qualitative research generalizability

Criteria for Good Qualitative Research: A Comprehensive Review

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• Published: 18 September 2021
• Volume 31 , pages 679–689, ( 2022 )

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This review aims to synthesize a published set of evaluative criteria for good qualitative research. The aim is to shed light on existing standards for assessing the rigor of qualitative research encompassing a range of epistemological and ontological standpoints. Using a systematic search strategy, published journal articles that deliberate criteria for rigorous research were identified. Then, references of relevant articles were surveyed to find noteworthy, distinct, and well-defined pointers to good qualitative research. This review presents an investigative assessment of the pivotal features in qualitative research that can permit the readers to pass judgment on its quality and to condemn it as good research when objectively and adequately utilized. Overall, this review underlines the crux of qualitative research and accentuates the necessity to evaluate such research by the very tenets of its being. It also offers some prospects and recommendations to improve the quality of qualitative research. Based on the findings of this review, it is concluded that quality criteria are the aftereffect of socio-institutional procedures and existing paradigmatic conducts. Owing to the paradigmatic diversity of qualitative research, a single and specific set of quality criteria is neither feasible nor anticipated. Since qualitative research is not a cohesive discipline, researchers need to educate and familiarize themselves with applicable norms and decisive factors to evaluate qualitative research from within its theoretical and methodological framework of origin.

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Introduction

“… It is important to regularly dialogue about what makes for good qualitative research” (Tracy, 2010 , p. 837)

To decide what represents good qualitative research is highly debatable. There are numerous methods that are contained within qualitative research and that are established on diverse philosophical perspectives. Bryman et al., ( 2008 , p. 262) suggest that “It is widely assumed that whereas quality criteria for quantitative research are well‐known and widely agreed, this is not the case for qualitative research.” Hence, the question “how to evaluate the quality of qualitative research” has been continuously debated. There are many areas of science and technology wherein these debates on the assessment of qualitative research have taken place. Examples include various areas of psychology: general psychology (Madill et al., 2000 ); counseling psychology (Morrow, 2005 ); and clinical psychology (Barker & Pistrang, 2005 ), and other disciplines of social sciences: social policy (Bryman et al., 2008 ); health research (Sparkes, 2001 ); business and management research (Johnson et al., 2006 ); information systems (Klein & Myers, 1999 ); and environmental studies (Reid & Gough, 2000 ). In the literature, these debates are enthused by the impression that the blanket application of criteria for good qualitative research developed around the positivist paradigm is improper. Such debates are based on the wide range of philosophical backgrounds within which qualitative research is conducted (e.g., Sandberg, 2000 ; Schwandt, 1996 ). The existence of methodological diversity led to the formulation of different sets of criteria applicable to qualitative research.

Among qualitative researchers, the dilemma of governing the measures to assess the quality of research is not a new phenomenon, especially when the virtuous triad of objectivity, reliability, and validity (Spencer et al., 2004 ) are not adequate. Occasionally, the criteria of quantitative research are used to evaluate qualitative research (Cohen & Crabtree, 2008 ; Lather, 2004 ). Indeed, Howe ( 2004 ) claims that the prevailing paradigm in educational research is scientifically based experimental research. Hypotheses and conjectures about the preeminence of quantitative research can weaken the worth and usefulness of qualitative research by neglecting the prominence of harmonizing match for purpose on research paradigm, the epistemological stance of the researcher, and the choice of methodology. Researchers have been reprimanded concerning this in “paradigmatic controversies, contradictions, and emerging confluences” (Lincoln & Guba, 2000 ).

In general, qualitative research tends to come from a very different paradigmatic stance and intrinsically demands distinctive and out-of-the-ordinary criteria for evaluating good research and varieties of research contributions that can be made. This review attempts to present a series of evaluative criteria for qualitative researchers, arguing that their choice of criteria needs to be compatible with the unique nature of the research in question (its methodology, aims, and assumptions). This review aims to assist researchers in identifying some of the indispensable features or markers of high-quality qualitative research. In a nutshell, the purpose of this systematic literature review is to analyze the existing knowledge on high-quality qualitative research and to verify the existence of research studies dealing with the critical assessment of qualitative research based on the concept of diverse paradigmatic stances. Contrary to the existing reviews, this review also suggests some critical directions to follow to improve the quality of qualitative research in different epistemological and ontological perspectives. This review is also intended to provide guidelines for the acceleration of future developments and dialogues among qualitative researchers in the context of assessing the qualitative research.

The rest of this review article is structured in the following fashion: Sect.  Methods describes the method followed for performing this review. Section Criteria for Evaluating Qualitative Studies provides a comprehensive description of the criteria for evaluating qualitative studies. This section is followed by a summary of the strategies to improve the quality of qualitative research in Sect.  Improving Quality: Strategies . Section  How to Assess the Quality of the Research Findings? provides details on how to assess the quality of the research findings. After that, some of the quality checklists (as tools to evaluate quality) are discussed in Sect.  Quality Checklists: Tools for Assessing the Quality . At last, the review ends with the concluding remarks presented in Sect.  Conclusions, Future Directions and Outlook . Some prospects in qualitative research for enhancing its quality and usefulness in the social and techno-scientific research community are also presented in Sect.  Conclusions, Future Directions and Outlook .

For this review, a comprehensive literature search was performed from many databases using generic search terms such as Qualitative Research , Criteria , etc . The following databases were chosen for the literature search based on the high number of results: IEEE Explore, ScienceDirect, PubMed, Google Scholar, and Web of Science. The following keywords (and their combinations using Boolean connectives OR/AND) were adopted for the literature search: qualitative research, criteria, quality, assessment, and validity. The synonyms for these keywords were collected and arranged in a logical structure (see Table 1 ). All publications in journals and conference proceedings later than 1950 till 2021 were considered for the search. Other articles extracted from the references of the papers identified in the electronic search were also included. A large number of publications on qualitative research were retrieved during the initial screening. Hence, to include the searches with the main focus on criteria for good qualitative research, an inclusion criterion was utilized in the search string.

From the selected databases, the search retrieved a total of 765 publications. Then, the duplicate records were removed. After that, based on the title and abstract, the remaining 426 publications were screened for their relevance by using the following inclusion and exclusion criteria (see Table 2 ). Publications focusing on evaluation criteria for good qualitative research were included, whereas those works which delivered theoretical concepts on qualitative research were excluded. Based on the screening and eligibility, 45 research articles were identified that offered explicit criteria for evaluating the quality of qualitative research and were found to be relevant to this review.

Figure  1 illustrates the complete review process in the form of PRISMA flow diagram. PRISMA, i.e., “preferred reporting items for systematic reviews and meta-analyses” is employed in systematic reviews to refine the quality of reporting.

PRISMA flow diagram illustrating the search and inclusion process. N represents the number of records

Criteria for Evaluating Qualitative Studies

Fundamental criteria: general research quality.

Various researchers have put forward criteria for evaluating qualitative research, which have been summarized in Table 3 . Also, the criteria outlined in Table 4 effectively deliver the various approaches to evaluate and assess the quality of qualitative work. The entries in Table 4 are based on Tracy’s “Eight big‐tent criteria for excellent qualitative research” (Tracy, 2010 ). Tracy argues that high-quality qualitative work should formulate criteria focusing on the worthiness, relevance, timeliness, significance, morality, and practicality of the research topic, and the ethical stance of the research itself. Researchers have also suggested a series of questions as guiding principles to assess the quality of a qualitative study (Mays & Pope, 2020 ). Nassaji ( 2020 ) argues that good qualitative research should be robust, well informed, and thoroughly documented.

Qualitative Research: Interpretive Paradigms

All qualitative researchers follow highly abstract principles which bring together beliefs about ontology, epistemology, and methodology. These beliefs govern how the researcher perceives and acts. The net, which encompasses the researcher’s epistemological, ontological, and methodological premises, is referred to as a paradigm, or an interpretive structure, a “Basic set of beliefs that guides action” (Guba, 1990 ). Four major interpretive paradigms structure the qualitative research: positivist and postpositivist, constructivist interpretive, critical (Marxist, emancipatory), and feminist poststructural. The complexity of these four abstract paradigms increases at the level of concrete, specific interpretive communities. Table 5 presents these paradigms and their assumptions, including their criteria for evaluating research, and the typical form that an interpretive or theoretical statement assumes in each paradigm. Moreover, for evaluating qualitative research, quantitative conceptualizations of reliability and validity are proven to be incompatible (Horsburgh, 2003 ). In addition, a series of questions have been put forward in the literature to assist a reviewer (who is proficient in qualitative methods) for meticulous assessment and endorsement of qualitative research (Morse, 2003 ). Hammersley ( 2007 ) also suggests that guiding principles for qualitative research are advantageous, but methodological pluralism should not be simply acknowledged for all qualitative approaches. Seale ( 1999 ) also points out the significance of methodological cognizance in research studies.

Table 5 reflects that criteria for assessing the quality of qualitative research are the aftermath of socio-institutional practices and existing paradigmatic standpoints. Owing to the paradigmatic diversity of qualitative research, a single set of quality criteria is neither possible nor desirable. Hence, the researchers must be reflexive about the criteria they use in the various roles they play within their research community.

Improving Quality: Strategies

Another critical question is “How can the qualitative researchers ensure that the abovementioned quality criteria can be met?” Lincoln and Guba ( 1986 ) delineated several strategies to intensify each criteria of trustworthiness. Other researchers (Merriam & Tisdell, 2016 ; Shenton, 2004 ) also presented such strategies. A brief description of these strategies is shown in Table 6 .

It is worth mentioning that generalizability is also an integral part of qualitative research (Hays & McKibben, 2021 ). In general, the guiding principle pertaining to generalizability speaks about inducing and comprehending knowledge to synthesize interpretive components of an underlying context. Table 7 summarizes the main metasynthesis steps required to ascertain generalizability in qualitative research.

Figure  2 reflects the crucial components of a conceptual framework and their contribution to decisions regarding research design, implementation, and applications of results to future thinking, study, and practice (Johnson et al., 2020 ). The synergy and interrelationship of these components signifies their role to different stances of a qualitative research study.

Essential elements of a conceptual framework

In a nutshell, to assess the rationale of a study, its conceptual framework and research question(s), quality criteria must take account of the following: lucid context for the problem statement in the introduction; well-articulated research problems and questions; precise conceptual framework; distinct research purpose; and clear presentation and investigation of the paradigms. These criteria would expedite the quality of qualitative research.

How to Assess the Quality of the Research Findings?

The inclusion of quotes or similar research data enhances the confirmability in the write-up of the findings. The use of expressions (for instance, “80% of all respondents agreed that” or “only one of the interviewees mentioned that”) may also quantify qualitative findings (Stenfors et al., 2020 ). On the other hand, the persuasive reason for “why this may not help in intensifying the research” has also been provided (Monrouxe & Rees, 2020 ). Further, the Discussion and Conclusion sections of an article also prove robust markers of high-quality qualitative research, as elucidated in Table 8 .

Quality Checklists: Tools for Assessing the Quality

Numerous checklists are available to speed up the assessment of the quality of qualitative research. However, if used uncritically and recklessly concerning the research context, these checklists may be counterproductive. I recommend that such lists and guiding principles may assist in pinpointing the markers of high-quality qualitative research. However, considering enormous variations in the authors’ theoretical and philosophical contexts, I would emphasize that high dependability on such checklists may say little about whether the findings can be applied in your setting. A combination of such checklists might be appropriate for novice researchers. Some of these checklists are listed below:

The most commonly used framework is Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007 ). This framework is recommended by some journals to be followed by the authors during article submission.

Standards for Reporting Qualitative Research (SRQR) is another checklist that has been created particularly for medical education (O’Brien et al., 2014 ).

Also, Tracy ( 2010 ) and Critical Appraisal Skills Programme (CASP, 2021 ) offer criteria for qualitative research relevant across methods and approaches.

Further, researchers have also outlined different criteria as hallmarks of high-quality qualitative research. For instance, the “Road Trip Checklist” (Epp & Otnes, 2021 ) provides a quick reference to specific questions to address different elements of high-quality qualitative research.

Conclusions, Future Directions, and Outlook

This work presents a broad review of the criteria for good qualitative research. In addition, this article presents an exploratory analysis of the essential elements in qualitative research that can enable the readers of qualitative work to judge it as good research when objectively and adequately utilized. In this review, some of the essential markers that indicate high-quality qualitative research have been highlighted. I scope them narrowly to achieve rigor in qualitative research and note that they do not completely cover the broader considerations necessary for high-quality research. This review points out that a universal and versatile one-size-fits-all guideline for evaluating the quality of qualitative research does not exist. In other words, this review also emphasizes the non-existence of a set of common guidelines among qualitative researchers. In unison, this review reinforces that each qualitative approach should be treated uniquely on account of its own distinctive features for different epistemological and disciplinary positions. Owing to the sensitivity of the worth of qualitative research towards the specific context and the type of paradigmatic stance, researchers should themselves analyze what approaches can be and must be tailored to ensemble the distinct characteristics of the phenomenon under investigation. Although this article does not assert to put forward a magic bullet and to provide a one-stop solution for dealing with dilemmas about how, why, or whether to evaluate the “goodness” of qualitative research, it offers a platform to assist the researchers in improving their qualitative studies. This work provides an assembly of concerns to reflect on, a series of questions to ask, and multiple sets of criteria to look at, when attempting to determine the quality of qualitative research. Overall, this review underlines the crux of qualitative research and accentuates the need to evaluate such research by the very tenets of its being. Bringing together the vital arguments and delineating the requirements that good qualitative research should satisfy, this review strives to equip the researchers as well as reviewers to make well-versed judgment about the worth and significance of the qualitative research under scrutiny. In a nutshell, a comprehensive portrayal of the research process (from the context of research to the research objectives, research questions and design, speculative foundations, and from approaches of collecting data to analyzing the results, to deriving inferences) frequently proliferates the quality of a qualitative research.

Prospects : A Road Ahead for Qualitative Research

Irrefutably, qualitative research is a vivacious and evolving discipline wherein different epistemological and disciplinary positions have their own characteristics and importance. In addition, not surprisingly, owing to the sprouting and varied features of qualitative research, no consensus has been pulled off till date. Researchers have reflected various concerns and proposed several recommendations for editors and reviewers on conducting reviews of critical qualitative research (Levitt et al., 2021 ; McGinley et al., 2021 ). Following are some prospects and a few recommendations put forward towards the maturation of qualitative research and its quality evaluation:

In general, most of the manuscript and grant reviewers are not qualitative experts. Hence, it is more likely that they would prefer to adopt a broad set of criteria. However, researchers and reviewers need to keep in mind that it is inappropriate to utilize the same approaches and conducts among all qualitative research. Therefore, future work needs to focus on educating researchers and reviewers about the criteria to evaluate qualitative research from within the suitable theoretical and methodological context.

There is an urgent need to refurbish and augment critical assessment of some well-known and widely accepted tools (including checklists such as COREQ, SRQR) to interrogate their applicability on different aspects (along with their epistemological ramifications).

Efforts should be made towards creating more space for creativity, experimentation, and a dialogue between the diverse traditions of qualitative research. This would potentially help to avoid the enforcement of one's own set of quality criteria on the work carried out by others.

Moreover, journal reviewers need to be aware of various methodological practices and philosophical debates.

It is pivotal to highlight the expressions and considerations of qualitative researchers and bring them into a more open and transparent dialogue about assessing qualitative research in techno-scientific, academic, sociocultural, and political rooms.

Frequent debates on the use of evaluative criteria are required to solve some potentially resolved issues (including the applicability of a single set of criteria in multi-disciplinary aspects). Such debates would not only benefit the group of qualitative researchers themselves, but primarily assist in augmenting the well-being and vivacity of the entire discipline.

To conclude, I speculate that the criteria, and my perspective, may transfer to other methods, approaches, and contexts. I hope that they spark dialog and debate – about criteria for excellent qualitative research and the underpinnings of the discipline more broadly – and, therefore, help improve the quality of a qualitative study. Further, I anticipate that this review will assist the researchers to contemplate on the quality of their own research, to substantiate research design and help the reviewers to review qualitative research for journals. On a final note, I pinpoint the need to formulate a framework (encompassing the prerequisites of a qualitative study) by the cohesive efforts of qualitative researchers of different disciplines with different theoretic-paradigmatic origins. I believe that tailoring such a framework (of guiding principles) paves the way for qualitative researchers to consolidate the status of qualitative research in the wide-ranging open science debate. Dialogue on this issue across different approaches is crucial for the impending prospects of socio-techno-educational research.

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Yadav, D. Criteria for Good Qualitative Research: A Comprehensive Review. Asia-Pacific Edu Res 31 , 679–689 (2022). https://doi.org/10.1007/s40299-021-00619-0

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Validity, reliability, and generalizability in qualitative research

Affiliation.

• 1 Department of Family Medicine, Queen's University, Kingston, Ontario, Canada ; Centre of Studies in Primary Care, Queen's University, Kingston, Ontario, Canada.
• PMID: 26288766
• PMCID: PMC4535087
• DOI: 10.4103/2249-4863.161306

In general practice, qualitative research contributes as significantly as quantitative research, in particular regarding psycho-social aspects of patient-care, health services provision, policy setting, and health administrations. In contrast to quantitative research, qualitative research as a whole has been constantly critiqued, if not disparaged, by the lack of consensus for assessing its quality and robustness. This article illustrates with five published studies how qualitative research can impact and reshape the discipline of primary care, spiraling out from clinic-based health screening to community-based disease monitoring, evaluation of out-of-hours triage services to provincial psychiatric care pathways model and finally, national legislation of core measures for children's healthcare insurance. Fundamental concepts of validity, reliability, and generalizability as applicable to qualitative research are then addressed with an update on the current views and controversies.

Keywords: Controversies; generalizability; primary care research; qualitative research; reliability; validity.

Understanding Generalizability and Transferability

In this chapter, we discuss generalizabililty, transferability, and the interrelationship between the two. We also explain how these two aspects of research operate in different methodologies, demonstrating how researchers may apply these concepts throughout the research process.

Generalizability Overview

Generalizability is applied by researchers in an academic setting. It can be defined as the extension of research findings and conclusions from a study conducted on a sample population to the population at large. While the dependability of this extension is not absolute, it is statistically probable. Because sound generalizability requires data on large populations, quantitative research -- experimental for instance -- provides the best foundation for producing broad generalizability. The larger the sample population, the more one can generalize the results. For example, a comprehensive study of the role computers play in the writing process might reveal that it is statistically probable that students who do most of their composing on a computer will move chunks of text around more than students who do not compose on a computer.

Transferability Overview

Transferability is applied by the readers of research. Although generalizability usually applies only to certain types of quantitative methods, transferability can apply in varying degrees to most types of research . Unlike generalizability, transferability does not involve broad claims, but invites readers of research to make connections between elements of a study and their own experience. For instance, teachers at the high school level might selectively apply to their own classrooms results from a study demonstrating that heuristic writing exercises help students at the college level.

Interrelationships

Generalizability and transferability are important elements of any research methodology, but they are not mutually exclusive: generalizability, to varying degrees, rests on the transferability of research findings. It is important for researchers to understand the implications of these twin aspects of research before designing a study. Researchers who intend to make a generalizable claim must carefully examine the variables involved in the study. Among these are the sample of the population used and the mechanisms behind formulating a causal model. Furthermore, if researchers desire to make the results of their study transferable to another context, they must keep a detailed account of the environment surrounding their research, and include a rich description of that environment in their final report. Armed with the knowledge that the sample population was large and varied, as well as with detailed information about the study itself, readers of research can more confidently generalize and transfer the findings to other situations.

Generalizability

Generalizability is not only common to research, but to everyday life as well. In this section, we establish a practical working definition of generalizability as it is applied within and outside of academic research. We also define and consider three different types of generalizability and some of their probable applications. Finally, we discuss some of the possible shortcomings and limitations of generalizability that researchers must be aware of when constructing a study they hope will yield potentially generalizable results.

In many ways, generalizability amounts to nothing more than making predictions based on a recurring experience. If something occurs frequently, we expect that it will continue to do so in the future. Researchers use the same type of reasoning when generalizing about the findings of their studies. Once researchers have collected sufficient data to support a hypothesis, a premise regarding the behavior of that data can be formulated, making it generalizable to similar circumstances. Because of its foundation in probability, however, such a generalization cannot be regarded as conclusive or exhaustive.

While generalizability can occur in informal, nonacademic settings, it is usually applied only to certain research methods in academic studies. Quantitative methods allow some generalizability. Experimental research, for example, often produces generalizable results. However, such experimentation must be rigorous in order for generalizable results to be found.

An example of generalizability in everyday life involves driving. Operating an automobile in traffic requires that drivers make assumptions about the likely outcome of certain actions. When approaching an intersection where one driver is preparing to turn left, the driver going straight through the intersection assumes that the left-turning driver will yield the right of way before turning. The driver passing through the intersection applies this assumption cautiously, recognizing the possibility that the other driver might turn prematurely.

American drivers also generalize that everyone will drive on the right hand side of the road. Yet if we try to generalize this assumption to other settings, such as England, we will be making a potentially disastrous mistake. Thus, it is obvious that generalizing is necessary for forming coherent interpretations in many different situations, but we do not expect our generalizations to operate the same way in every circumstance. With enough evidence we can make predictions about human behavior, yet we must simultaneously recognize that our assumptions are based on statistical probability.

Consider this example of generalizable research in the field of English studies. A study on undergraduate instructor evaluations of composition instructors might reveal that there is a strong correlation between the grade students are expecting to earn in a course and whether they give their instructor high marks. The study might discover that 95% of students who expect to receive a "C" or lower in their class give their instructor a rating of "average" or below. Therefore, there would be a high probability that future students expecting a "C" or lower would not give their instructor high marks. However, the results would not necessarily be conclusive. Some students might defy the trend. In addition, a number of different variables could also influence students' evaluations of an instructor, including instructor experience, class size, and relative interest in a particular subject. These variables -- and others -- would have to be addressed in order for the study to yield potentially valid results. However, even if virtually all variables were isolated, results of the study would not be 100% conclusive. At best, researchers can make educated predictions of future events or behaviors, not guarantee the prediction in every case. Thus, before generalizing, findings must be tested through rigorous experimentation, which enables researchers to confirm or reject the premises governing their data set.

Considerations

There are three types of generalizability that interact to produce probabilistic models. All of them involve generalizing a treatment or measurement to a population outside of the original study. Researchers who wish to generalize their claims should try to apply all three forms to their research, or the strength of their claims will be weakened (Runkel & McGrath, 1972).

In one type of generalizability, researchers determine whether a specific treatment will produce the same results in different circumstances. To do this, they must decide if an aspect within the original environment, a factor beyond the treatment, generated the particular result. This will establish how flexibly the treatment adapts to new situations. Higher adaptability means that the treatment is generalizable to a greater variety of situations. For example, imagine that a new set of heuristic prewriting questions designed to encourage freshman college students to consider audience more fully works so well that the students write thoroughly developed rhetorical analyses of their target audiences. To responsibly generalize that this heuristic is effective, a researcher would need to test the same prewriting exercise in a variety of educational settings at the college level, using different teachers, students, and environments. If the same positive results are produced, the treatment is generalizable.

A second form of generalizability focuses on measurements rather than treatments. For a result to be considered generalizable outside of the test group, it must produce the same results with different forms of measurement. In terms of the heuristic example above, the findings will be more generalizable if the same results are obtained when assessed "with questions having a slightly different wording, or when we use a six-point scale instead of a nine-point scale" (Runkel & McGrath, 1972, p.46).

A third type of generalizability concerns the subjects of the test situation. Although the results of an experiment may be internally valid, that is, applicable to the group tested, in many situations the results cannot be generalized beyond that particular group. Researchers who hope to generalize their results to a larger population should ensure that their test group is relatively large and randomly chosen. However, researchers should consider the fact that test populations of over 10,000 subjects do not significantly increase generalizability (Firestone,1993).

Potential Limitations

No matter how carefully these three forms of generalizability are applied, there is no absolute guarantee that the results obtained in a study will occur in every situation outside the study. In order to determine causal relationships in a test environment, precision is of utmost importance. Yet if researchers wish to generalize their findings, scope and variance must be emphasized over precision. Therefore, it becomes difficult to test for precision and generalizability simultaneously, since a focus on one reduces the reliability of the other. One solution to this problem is to perform a greater number of observations, which has a dual effect: first, it increases the sample population, which heightens generalizability; second, precision can be reasonably maintained because the random errors between observations will average out (Runkel and McGrath, 1972).

Transferability

Transferability describes the process of applying the results of research in one situation to other similar situations. In this section, we establish a practical working definition of transferability as it's applied within and outside of academic research. We also outline important considerations researchers must be aware of in order to make their results potentially transferable, as well as the critical role the reader plays in this process. Finally, we discuss possible shortcomings and limitations of transferability that researchers must be aware of when planning and conducting a study that will yield potentially transferable results.

Transferability is a process performed by readers of research. Readers note the specifics of the research situation and compare them to the specifics of an environment or situation with which they are familiar. If there are enough similarities between the two situations, readers may be able to infer that the results of the research would be the same or similar in their own situation. In other words, they "transfer" the results of a study to another context. To do this effectively, readers need to know as much as possible about the original research situation in order to determine whether it is similar to their own. Therefore, researchers must supply a highly detailed description of their research situation and methods.

Results of any type of research method can be applied to other situations, but transferability is most relevant to qualitative research methods such as ethnography and case studies. Reports based on these research methods are detailed and specific. However, because they often consider only one subject or one group, researchers who conduct such studies seldom generalize the results to other populations. The detailed nature of the results, however, makes them ideal for transferability.

Transferability is easy to understand when you consider that we are constantly applying this concept to aspects of our daily lives. If, for example, you are an inexperienced composition instructor and you read a study in which a veteran writing instructor discovered that extensive prewriting exercises helped students in her classes come up with much more narrowly defined paper topics, you could ask yourself how much the instructor's classroom resembled your own. If there were many similarities, you might try to draw conclusions about how increasing the amount of prewriting your students do would impact their ability to arrive at sufficiently narrow paper topics. In doing so, you would be attempting to transfer the composition researcher's techniques to your own classroom.

An example of transferable research in the field of English studies is Berkenkotter, Huckin, and Ackerman's (1988) study of a graduate student in a rhetoric Ph.D. program. In this case study, the researchers describe in detail a graduate student's entrance into the language community of his academic program, and particularly his struggle learning the writing conventions of this community. They make conclusions as to why certain things might have affected the graduate student, "Nate," in certain ways, but they are unable to generalize their findings to all graduate students in rhetoric Ph.D. programs. It is simply one study of one person in one program. However, from the level of detail the researchers provide, readers can take certain aspects of Nate's experience and apply them to other contexts and situations. This is transferability. First-year graduate students who read the Berkenhotter, Huckin, and Ackerman study may recognize similarities in their own situation while professors may recognize difficulties their students are having and understand these difficulties a bit better. The researchers do not claim that their results apply to other situations. Instead, they report their findings and make suggestions about possible causes for Nate's difficulties and eventual success. Readers then look at their own situation and decide if these causes may or may not be relevant.

When designing a study researchers have to consider their goals: Do they want to provide limited information about a broad group in order to indicate trends or patterns? Or do they want to provide detailed information about one person or small group that might suggest reasons for a particular behavior? The method they choose will determine the extent to which their results can be transferred since transferability is more applicable to certain kinds of research methods than others.

Thick Description: When writing up the results of a study, it is important that the researcher provide specific information about and a detailed description of her subject(s), location, methods, role in the study, etc. This is commonly referred to as "thick description" of methods and findings; it is important because it allows readers to make an informed judgment about whether they can transfer the findings to their own situation. For example, if an educator conducts an ethnography of her writing classroom, and finds that her students' writing improved dramatically after a series of student-teacher writing conferences, she must describe in detail the classroom setting, the students she observed, and her own participation. If the researcher does not provide enough detail, it will be difficult for readers to try the same strategy in their own classrooms. If the researcher fails to mention that she conducted this research in a small, upper-class private school, readers may transfer the results to a large, inner-city public school expecting a similar outcome.

The Reader's Role: The role of readers in transferability is to apply the methods or results of a study to their own situation. In doing so, readers must take into account differences between the situation outlined by the researcher and their own. If readers of the Berkenhotter, Huckin, and Ackerman study are aware that the research was conducted in a small, upper-class private school, but decide to test the method in a large inner-city public school, they must make adjustments for the different setting and be prepared for different results.

Likewise, readers may decide that the results of a study are not transferable to their own situation. For example, if a study found that watching more than 30 hours of television a week resulted in a worse GPA for graduate students in physics, graduate students in broadcast journalism may conclude that these results do not apply to them.

Readers may also transfer only certain aspects of the study and not the entire conclusion. For example, in the Berkenhotter, Huckin, and Ackerman study, the researchers suggest a variety of reasons for why the graduate student studied experienced difficulties adjusting to his Ph.D. program. Although composition instructors cannot compare "Nate" to first-year college students in their composition class, they could ask some of the same questions about their own class, offering them insight into some of the writing difficulties the first-year undergraduates are experiencing. It is up to readers to decide what findings are important and which may apply to their own situation; if researchers fulfill their responsibility to provide "thick description," this decision is much easier to make.

Understanding research results can help us understand why and how something happens. However, many researchers believe that such understanding is difficult to achieve in relation to human behaviors which they contend are too difficult to understand and often impossible to predict. "Because of the many and varied ways in which individuals differ from each other and because these differences change over time, comprehensive and definitive experiments in the social sciences are not possible...the most we can ever realistically hope to achieve in educational research is not prediction and control but rather only temporary understanding" (Cziko, 1993, p. 10).

Cziko's point is important because transferability allows for "temporary understanding." Instead of applying research results to every situation that may occur in the future, we can apply a similar method to another, similar situation, observe the new results, apply a modified version to another situation, and so on. Transferability takes into account the fact that there are no absolute answers to given situations; rather, every individual must determine their own best practices. Transferring the results of research performed by others can help us develop and modify these practices. However, it is important for readers of research to be aware that results cannot always be transferred; a result that occurs in one situation will not necessarily occur in a similar situation. Therefore, it is critical to take into account differences between situations and modify the research process accordingly.

Although transferability seems to be an obvious, natural, and important method for applying research results and conclusions, it is not perceived as a valid research approach in some academic circles. Perhaps partly in response to critics, in many modern research articles, researchers refer to their results as generalizable or externally valid. Therefore, it seems as though they are not talking about transferability. However, in many cases those same researchers provide direction about what points readers may want to consider, but hesitate to make any broad conclusions or statements. These are characteristics of transferable results.

Generalizability is actually, as we have seen, quite different from transferability. Unfortunately, confusion surrounding these two terms can lead to misinterpretation of research results. Emphasis on the value of transferable results -- as well as a clear understanding among researchers in the field of English of critical differences between the conditions under which research can be generalized, transferred, or, in some cases, both generalized and transferred -- could help qualitative researchers avoid some of the criticisms launched by skeptics who question the value of qualitative research methods.

Generalizability and Transferability: Synthesis

Generalizability allows us to form coherent interpretations in any situation, and to act purposefully and effectively in daily life. Transferability gives us the opportunity to sort through given methods and conclusions to decide what to apply to our own circumstances. In essence, then, both generalizability and transferability allow us to make comparisons between situations. For example, we can generalize that most people in the United States will drive on the right side of the road, but we cannot transfer this conclusion to England or Australia without finding ourselves in a treacherous situation. It is important, therefore, to always consider context when generalizing or transferring results.

Whether a study emphasizes transferability or generalizability is closely related to the goals of the researcher and the needs of the audience. Studies done for a magazine such as Time or a daily newspaper tend towards generalizability, since the publishers want to provide information relevant to a large portion of the population. A research project pointed toward a small group of specialists studying a similar problem may emphasize transferability, since specialists in the field have the ability to transfer aspects of the study results to their own situations without overt generalizations provided by the researcher. Ultimately, the researcher's subject, audience, and goals will determine the method the researcher uses to perform a study, which will then determine the transferability or generalizability of the results.

A Comparison of Generalizability and Transferability

Although generalizability has been a preferred method of research for quite some time, transferability is relatively a new idea. In theory, however, it has always accompanied research issues. It is important to note that generalizability and transferability are not necessarily mutually exclusive; they can overlap.

From an experimental study to a case study, readers transfer the methods, results, and ideas from the research to their own context. Therefore, a generalizable study can also be transferable. For example, a researcher may generalize the results of a survey of 350 people in a university to the university population as a whole; readers of the results may apply, or transfer, the results to their own situation. They will ask themselves, basically, if they fall into the majority or not. However, a transferable study is not always generalizable. For example, in case studies , transferability allows readers the option of applying results to outside contexts, whereas generalizability is basically impossible because one person or a small group of people is not necessarily representative of the larger population.

Controversy, Worth, and Function

Research in the natural sciences has a long tradition of valuing empirical studies; experimental investigation has been considered "the" way to perform research. As social scientists adapted the methods of natural science research to their own needs, they adopted this preference for empirical research. Therefore, studies that are generalizable have long been thought to be more worthwhile; the value of research was often determined by whether a study was generalizable to a population as a whole. However, more and more social scientists are realizing the value of using a variety of methods of inquiry, and the value of transferability is being recognized.

It is important to recognize that generalizability and transferability do not alone determine a study's worth. They perform different functions in research, depending on the topic and goals of the researcher. Where generalizable studies often indicate phenomena that apply to broad categories such as gender or age, transferability can provide some of the how and why behind these results.

However, there are weaknesses that must be considered. Researchers can study a small group that is representative of a larger group and claim that it is likely that their results are applicable to the larger group, but it is impossible for them to test every single person in the larger group. Their conclusions, therefore, are only valid in relation to their own studies. Another problem is that a non-representative group can lead to a faulty generalization. For example, a study of composition students'; revision capabilities which compared students' progress made during a semester in a computer classroom with progress exhibited by students in a traditional classroom might show that computers do aid students in the overall composing process. However, if it were discovered later that an unusually high number of students in the traditional classrooms suffered from substance abuse problems outside of the classroom, the population studied would not be considered representative of the student population as a whole. Therefore, it would be problematic to generalize the results of the study to a larger student population.

In the case of transferability, readers need to know as much detail as possible about a research situation in order to accurately transfer the results to their own. However, it is impossible to provide an absolutely complete description of a situation, and missing details may lead a reader to transfer results to a situation that is not entirely similar to the original one.

Applications to Research Methods

The degree to which generalizability and transferability are applicable differs from methodology to methodology as well as from study to study. Researchers need to be aware of these degrees so that results are not undermined by over-generalizations, and readers need to ensure that they do not read researched results in such a way that the results are misapplied or misinterpreted.

Applications of Transferability and Generalizability: Case Study

Research Design Case studies examine individuals or small groups within a specific context. Research is typically gathered through qualitative means: interviews, observations, etc. Data is usually analyzed either holistically or by coding methods.

Assumptions In research involving case studies, a researcher typically assumes that the results will be transferable. Generalizing is difficult or impossible because one person or small group cannot represent all similar groups or situations. For example, one group of beginning writing students in a particular classroom cannot represent all beginning student writers. Also, conclusions drawn in case studies are only about the participants being observed. With rare exceptions, case studies are not meant to establish cause/effect relationships between variables. The results of a case study are transferable in that researchers "suggest further questions, hypotheses, and future implications," and present the results as "directions and questions" (Lauer & Asher 32).

Example In order to illustrate the writing skills of beginning college writers, a researcher completing a case study might single out one or more students in a composition classroom and set about talking to them about how they judge their own writing as well as reading actual papers, setting up criteria for judgment, and reviewing paper grades/teacher interpretation.

Results of a Study In presenting the results of the previous example, a researcher should define the criteria that were established in order to determine what the researcher meant by "writing skills," provide noteworthy quotes from student interviews, provide other information depending on the kinds of research methods used (e.g., surveys, classroom observation, collected writing samples), and include possibilities for furthering this type of research. Readers are then able to assess for themselves how the researcher's observations might be transferable to other writing classrooms.

Applications of Transferability and Generalizability: Ethnography

Research Design Ethnographies study groups and/or cultures over a period of time. The goal of this type of research is to comprehend the particular group/culture through observer immersion into the culture or group. Research is completed through various methods, which are similar to those of case studies, but since the researcher is immersed within the group for an extended period of time, more detailed information is usually collected during the research. (Jonathon Kozol's "There Are No Children Here" is a good example of this.)

Assumptions As with case studies, findings of ethnographies are also considered to be transferable. The main goals of an ethnography are to "identify, operationally define, and interrelate variables" within a particular context, which ultimately produce detailed accounts or "thick descriptions" (Lauer & Asher 39). Unlike a case study, the researcher here discovers many more details. Results of ethnographies should "suggest variables for further investigation" and not generalize beyond the participants of a study (Lauer & Asher 43). Also, since analysts completing this type of research tend to rely on multiple methods to collect information (a practice also referred to as triangulation), their results typically help create a detailed description of human behavior within a particular environment.

Example The Iowa Writing Program has a widespread reputation for producing excellent writers. In order to begin to understand their training, an ethnographer might observe students throughout their degree program. During this time, the ethnographer could examine the curriculum, follow the writing processes of individual writers, and become acquainted with the writers and their work. By the end of a two year study, the researcher would have a much deeper understanding of the unique and effective features of the program.

Results of a Study Obviously, the Iowa Writing Program is unique, so generalizing any results to another writing program would be problematic. However, an ethnography would provide readers with insights into the program. Readers could ask questions such as: what qualities make it strong and what is unique about the writers who are trained within the program? At this point, readers could attempt to "transfer" applicable knowledge and observations to other writing environments.

Applications of Transferability and Generalizability: Experimental Research

Research Design A researcher working within this methodology creates an environment in which to observe and interpret the results of a research question. A key element in experimental research is that participants in a study are randomly assigned to groups. In an attempt to create a causal model (i.e., to discover the causal origin of a particular phenomenon), groups are treated differently and measurements are conducted to determine if different treatments appear to lead to different effects.

Assumptions Experimental research is usually thought to be generalizable. This methodology explores cause/effect relationships through comparisons among groups (Lauer & Asher 152). Since participants are randomly assigned to groups, and since most experiments involve enough individuals to reasonably approximate the populations from which individual participants are drawn, generalization is justified because "over a large number of allocations, all the groups of subjects will be expected to be identical on all variables" (155).

Example A simplified example: Six composition classrooms are randomly chosen (as are the students and instructors) in which three instructors incorporate the use of electronic mail as a class activity and three do not. When students in the first three classes begin discussing their papers through e-mail and, as a result, make better revisions to their papers than students in the other three classes, a researcher is likely to conclude that incorporating e-mail within a writing classroom improves the quality of students' writing.

Results of a Study Although experimental research is based on cause/effect relationships, "certainty" can never be obtained, but rather results are "probabilistic" (Lauer and Asher 161). Depending on how the researcher has presented the results, they are generalizable in that the students were selected randomly. Since the quality of writing improved with the use of e-mail within all three classrooms, it is probable that e-mail is the cause of the improvement. Readers of this study would transfer the results when they sorted out the details: Are these students representative of a group of students with which the reader is familiar? What types of previous writing experiences have these students had? What kind of writing was expected from these students? The researcher must have provided these details in order for the results to be transferable.

Applications of Transferability and Generalizability: Survey

Research Design The goal of a survey is to gain specific information about either a specific group or a representative sample of a particular group. Survey respondents are asked to respond to one or more of the following kinds of items: open-ended questions, true-false questions, agree-disagree (or Likert) questions, rankings, ratings, and so on. Results are typically used to understand the attitudes, beliefs, or knowledge of a particular group.

Assumptions Assuming that care has been taken in the development of the survey items and selection of the survey sample and that adequate response rates have been achieved, surveys results are generalizable. Note, however, that results from surveys should be generalized only to the population from which the survey results were drawn.

Example For instance, a survey of Colorado State University English graduate students undertaken to determine how well French philosopher/critic Jacques Derrida is understood before and after students take a course in critical literary theory might inform professors that, overall, Derrida's concepts are understood and that CSU's literary theory class, E615, has helped students grasp Derrida's ideas.

Results of a Study The generalizability of surveys depends on several factors. Whether distributed to a mass of people or a select few, surveys are of a "personal nature and subject to distortion." Survey respondents may or may not understand the questions being asked of them. Depending on whether or not the survey designer is nearby, respondents may or may not have the opportunity to clarify their misunderstandings.

It is also important to keep in mind that errors can occur at the development and processing levels. A researcher may inadequately pose questions (that is, not ask the right questions for the information being sought), disrupt the data collection (surveying certain people and not others), and distort the results during the processing (misreading responses and not being able to question the participant, etc.). One way to avoid these kinds of errors is for researchers to examine other studies of a similar nature and compare their results with results that have been obtained in previous studies. This way, any large discrepancies will be exposed. Depending on how large those discrepancies are and what the context of the survey is, the results may or may not be generalizable. For example, if an improved understanding of Derrida is apparent after students complete E615, it can be theorized that E615 effectively teaches students the concepts of Derrida. Issues of transferability might be visible in the actual survey questions themselves; that is, they could provide critical background information readers might need to know in order to transfer the results to another context.

The Qualitative versus Quantitative Debate

In Miles and Huberman's 1994 book Qualitative Data Analysis , quantitative researcher Fred Kerlinger is quoted as saying, "There's no such thing as qualitative data. Everything is either 1 or 0" (p. 40). To this another researcher, D. T. Campbell, asserts "all research ultimately has a qualitative grounding" (p. 40). This back and forth banter among qualitative and quantitative researchers is "essentially unproductive" according to Miles and Huberman. They and many other researchers agree that these two research methods need each other more often than not. However, because typically qualitative data involves words and quantitative data involves numbers, there are some researchers who feel that one is better (or more scientific) than the other. Another major difference between the two is that qualitative research is inductive and quantitative research is deductive. In qualitative research, a hypothesis is not needed to begin research. However, all quantitative research requires a hypothesis before research can begin.

Another major difference between qualitative and quantitative research is the underlying assumptions about the role of the researcher. In quantitative research, the researcher is ideally an objective observer that neither participates in nor influences what is being studied. In qualitative research, however, it is thought that the researcher can learn the most about a situation by participating and/or being immersed in it. These basic underlying assumptions of both methodologies guide and sequence the types of data collection methods employed.

Although there are clear differences between qualitative and quantitative approaches, some researchers maintain that the choice between using qualitative or quantitative approaches actually has less to do with methodologies than it does with positioning oneself within a particular discipline or research tradition. The difficulty of choosing a method is compounded by the fact that research is often affiliated with universities and other institutions. The findings of research projects often guide important decisions about specific practices and policies. The choice of which approach to use may reflect the interests of those conducting or benefitting from the research and the purposes for which the findings will be applied. Decisions about which kind of research method to use may also be based on the researcher's own experience and preference, the population being researched, the proposed audience for findings, time, money, and other resources available (Hathaway, 1995).

Some researchers believe that qualitative and quantitative methodologies cannot be combined because the assumptions underlying each tradition are so vastly different. Other researchers think they can be used in combination only by alternating between methods: qualitative research is appropriate to answer certain kinds of questions in certain conditions and quantitative is right for others. And some researchers think that both qualitative and quantitative methods can be used simultaneously to answer a research question.

To a certain extent, researchers on all sides of the debate are correct: each approach has its drawbacks. Quantitative research often "forces" responses or people into categories that might not "fit" in order to make meaning. Qualitative research, on the other hand, sometimes focuses too closely on individual results and fails to make connections to larger situations or possible causes of the results. Rather than discounting either approach for its drawbacks, though, researchers should find the most effective ways to incorporate elements of both to ensure that their studies are as accurate and thorough as possible.

It is important for researchers to realize that qualitative and quantitative methods can be used in conjunction with each other. In a study of computer-assisted writing classrooms, Snyder (1995) employed both qualitative and quantitative approaches. The study was constructed according to guidelines for quantitative studies: the computer classroom was the "treatment" group and the traditional pen and paper classroom was the "control" group. Both classes contained subjects with the same characteristics from the population sampled. Both classes followed the same lesson plan and were taught by the same teacher in the same semester. The only variable used was the computers. Although Snyder set this study up as an "experiment," she used many qualitative approaches to supplement her findings. She observed both classrooms on a regular basis as a participant-observer and conducted several interviews with the teacher both during and after the semester. However, there were several problems in using this approach: the strict adherence to the same syllabus and lesson plans for both classes and the restricted access of the control group to the computers may have put some students at a disadvantage. Snyder also notes that in retrospect she should have used case studies of the students to further develop her findings. Although her study had certain flaws, Snyder insists that researchers can simultaneously employ qualitative and quantitative methods if studies are planned carefully and carried out conscientiously.

Annotated Bibliography

Babbie, Earl R. (1979). The practice of social research . Belmont: Wadsworth Publishing Company, Inc.

A comprehensive review of social scientific research, including techniques for research. The logic behind social scientific research is discussed.

Berkenkotter, C., Huckin, T.N., & Ackerman, J. (1988). Conventions, conversations, and the writer: Case study of a student in a rhetoric Ph.D. program. Research in the Teaching of English 22 (1), 9-44.

Describes a case study of a beginning student in a Ph.D. program. Looks at the process of his entry into an academic discourse community.

Black, Susan. (1996). Redefining the teacher's role. Executive Educator,18 (8), 23-26.

Discusses the value of well-trained teacher-researchers performing research in their classrooms. Notes that teacher-research focuses on the particular; it does not look for broad, generalizable principles.

Blank, Steven C. (1984). Practical business research methods . Westport: AVI Publishing Company, Inc.

A comprehensive book of how to set up a research project, collect data, and reach and report conclusions.

Bridges, David. (1993). Transferable Skills: A Philosophical Perspective. Studies in Higher Education 18 (1), 43-51.

Transferability of skills in learning is discussed, focusing on the notions of cross-disciplinary, generic, core, and transferable skills and their role in the college curriculum.

Brookhart, Susan M. & Rusnak, Timothy G. (1993). A pedagogy of enrichment, not poverty: Successful lessons of exemplary urban teachers. Journal of Teacher Education, 44 (1), 17-27.

Reports the results of a study that explored the characteristics of effective urban teachers in Pittsburgh. Suggests that the results may be transferable to urban educators in other contexts.

Bryman, Alan. (1988). Quantity and quality in social research . Boston: Unwin Hyman Ltd.

Butcher, Jude. (1994, July). Cohort and case study components in teacher education research. Paper presented at the annual conference of the Australian Teacher Education Association, Brisbane, Queensland, Australia.

Argues that studies of teacher development will be more generalizable if a broad set of methods are used to collect data, if the data collected is both extensive and intensive, and if the methods used take into account the differences in people and situations being studied.

Carter, Duncan. (1993). Critical thinking for writers: Transferable skills or discipline-specific strategies? Composition Studies/Freshman English News, 21 (1), 86-93.

Questions the context-dependency of critical thinking, and whether critical thinking skills are transferable to writing tasks.

Carter, Kathy. (1993). The place of story in the study of teaching and teacher education. Educational Researcher, 22 (1), 5-12.

Discusses the advantages of story-telling in teaching and teacher education, but cautions instructors, who are currently unfamiliar with story-telling in current pedagogical structures, to be careful in implementing this method in their teaching.

Clonts, Jean G. (1992, January). The concept of reliability as it pertains to data from qualitative studies. Paper presented at the annual meeting of the Southwest Educational Research Association, Houston, TX.

Presents a review of literature on reliability in qualitative studies and defines reliability as the extent to which studies can be replicated by using the same methods and getting the same results. Strategies to enhance reliability through study design, data collection, and data analysis are suggested. Generalizability as an estimate of reliability is also explored.

Connelly, Michael F. & Clandinin D. Jean. (1990). Stories of experience and narrative inquiry. Educational Researcher, 19. (5), 2-14.

Describes narrative as a site of inquiry and a qualitative research methodology in which experiences of observer and observed interact. This form of research necessitates the development of new criteria, which may include apparency, verisimilitude, and transferability (7).

Crocker, Linda & Algina, James. (1986). Introduction to classical & modern test theory. New York: Holt, Rinehart and Winston.

Discusses test theory and its application to psychometrics. Chapters range from general overview of major issues to statistical methods and application.

Cronbach, Lee J. et al. (1967). The dependability of behavioral measurements: multifaceted studies of generalizability. Stanford: Stanford UP.

A technical research report that includes statistical methodology in order to contrast multifaceted generalizability with classical reliability.

Cziko, Gary A. (1992). Purposeful behavior as the control of perception: implications for educational research. Educational Researcher, 21 (9), 10-18. El-Hassan, Karma. (1995). Students' Rating of Instruction: Generalizability of Findings. Studies in Educational Research 21 (4), 411-29.

Issues of dimensionality, validity, reliability, and generalizability of students' ratings of instruction are discussed in relation to a study in which 610 college students who evaluated their instructors on the Teacher Effectiveness Scale.

Feingold, Alan. (1994). Gender differences in variability in intellectual abilities: a cross-cultural perspective. Sex Roles: A Journal of Research 20 (1-2), 81-93.

Feingold conducts a cross-cultural quantitative review of contemporary findings of gender differences in variability in verbal, mathematical, and spatial abilities to assess the generalizability of U.S. findings that males are more variable than females in mathematical and spatial abilities, and the sexes are equally variable in verbal ability.

Firestone,William A. (1993). Alternative arguments for generalizing from data as applied to qualitative research. Educational Researcher, 22 (4), 16-22.

Focuses on generalization in three areas of qualitative research: sample to population extrapolation, analytic generalization, and case-to-case transfer (16). Explains underlying principles, related theories, and criteria for each approach.

Fyans, Leslie J. (Ed.). (1983). Generalizability theory: Inferences and practical applications. In New Directions for Testing and Measurement: Vol. 18. San Francisco: Jossey-Bass.

A collection of articles on generalizability theory. The goal of the book is to present different aspects and applications of generalizability theory in a way that allows the reader to apply the theory.

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Hathaway says that the choice between using qualitative or quantitative approaches is less about methodology and more about aligning oneself with particular theoretical and academic traditions. He concluded that the two approaches address questions in very different ways, each one having its own advantages and drawbacks.

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Discusses causality and causal analysis in terms of sociological research. Provides equations and explanations.

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Explains the selection of subjects, formulation of hypotheses or questions, data collection, data analysis, and variable identification through discussion of each design.

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Explores the five types of validity used in qualitative research, including generalizable validity, and examines possible threats to research validity.

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Validity, reliability, and generalizability in qualitative research.

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Journal of Family Medicine and Primary Care , 01 Jul 2015 , 4(3): 324-327 https://doi.org/10.4103/2249-4863.161306   PMID: 26288766  PMCID: PMC4535087

Abstract 

Free full text , validity, reliability, and generalizability in qualitative research, lawrence leung.

1 Department of Family Medicine, Queen's University, Kingston, Ontario, Canada

2 Centre of Studies in Primary Care, Queen's University, Kingston, Ontario, Canada

In general practice, qualitative research contributes as significantly as quantitative research, in particular regarding psycho-social aspects of patient-care, health services provision, policy setting, and health administrations. In contrast to quantitative research, qualitative research as a whole has been constantly critiqued, if not disparaged, by the lack of consensus for assessing its quality and robustness. This article illustrates with five published studies how qualitative research can impact and reshape the discipline of primary care, spiraling out from clinic-based health screening to community-based disease monitoring, evaluation of out-of-hours triage services to provincial psychiatric care pathways model and finally, national legislation of core measures for children's healthcare insurance. Fundamental concepts of validity, reliability, and generalizability as applicable to qualitative research are then addressed with an update on the current views and controversies.

• Nature of Qualitative Research versus Quantitative Research

The essence of qualitative research is to make sense of and recognize patterns among words in order to build up a meaningful picture without compromising its richness and dimensionality. Like quantitative research, the qualitative research aims to seek answers for questions of “how, where, when who and why” with a perspective to build a theory or refute an existing theory. Unlike quantitative research which deals primarily with numerical data and their statistical interpretations under a reductionist, logical and strictly objective paradigm, qualitative research handles nonnumerical information and their phenomenological interpretation, which inextricably tie in with human senses and subjectivity. While human emotions and perspectives from both subjects and researchers are considered undesirable biases confounding results in quantitative research, the same elements are considered essential and inevitable, if not treasurable, in qualitative research as they invariable add extra dimensions and colors to enrich the corpus of findings. However, the issue of subjectivity and contextual ramifications has fueled incessant controversies regarding yardsticks for quality and trustworthiness of qualitative research results for healthcare.

• Impact of Qualitative Research upon Primary Care

In many ways, qualitative research contributes significantly, if not more so than quantitative research, to the field of primary care at various levels. Five qualitative studies are chosen to illustrate how various methodologies of qualitative research helped in advancing primary healthcare, from novel monitoring of chronic obstructive pulmonary disease (COPD) via mobile-health technology,[ 1 ] informed decision for colorectal cancer screening,[ 2 ] triaging out-of-hours GP services,[ 3 ] evaluating care pathways for community psychiatry[ 4 ] and finally prioritization of healthcare initiatives for legislation purposes at national levels.[ 5 ] With the recent advances of information technology and mobile connecting device, self-monitoring and management of chronic diseases via tele-health technology may seem beneficial to both the patient and healthcare provider. Recruiting COPD patients who were given tele-health devices that monitored lung functions, Williams et al. [ 1 ] conducted phone interviews and analyzed their transcripts via a grounded theory approach, identified themes which enabled them to conclude that such mobile-health setup and application helped to engage patients with better adherence to treatment and overall improvement in mood. Such positive findings were in contrast to previous studies, which opined that elderly patients were often challenged by operating computer tablets,[ 6 ] or, conversing with the tele-health software.[ 7 ] To explore the content of recommendations for colorectal cancer screening given out by family physicians, Wackerbarth, et al. [ 2 ] conducted semi-structure interviews with subsequent content analysis and found that most physicians delivered information to enrich patient knowledge with little regard to patients’ true understanding, ideas, and preferences in the matter. These findings suggested room for improvement for family physicians to better engage their patients in recommending preventative care. Faced with various models of out-of-hours triage services for GP consultations, Egbunike et al. [ 3 ] conducted thematic analysis on semi-structured telephone interviews with patients and doctors in various urban, rural and mixed settings. They found that the efficiency of triage services remained a prime concern from both users and providers, among issues of access to doctors and unfulfilled/mismatched expectations from users, which could arouse dissatisfaction and legal implications. In UK, a care pathways model for community psychiatry had been introduced but its benefits were unclear. Khandaker et al. [ 4 ] hence conducted a qualitative study using semi-structure interviews with medical staff and other stakeholders; adopting a grounded-theory approach, major themes emerged which included improved equality of access, more focused logistics, increased work throughput and better accountability for community psychiatry provided under the care pathway model. Finally, at the US national level, Mangione-Smith et al. [ 5 ] employed a modified Delphi method to gather consensus from a panel of nominators which were recognized experts and stakeholders in their disciplines, and identified a core set of quality measures for children's healthcare under the Medicaid and Children's Health Insurance Program. These core measures were made transparent for public opinion and later passed on for full legislation, hence illustrating the impact of qualitative research upon social welfare and policy improvement.

• Overall Criteria for Quality in Qualitative Research

Given the diverse genera and forms of qualitative research, there is no consensus for assessing any piece of qualitative research work. Various approaches have been suggested, the two leading schools of thoughts being the school of Dixon-Woods et al. [ 8 ] which emphasizes on methodology, and that of Lincoln et al. [ 9 ] which stresses the rigor of interpretation of results. By identifying commonalities of qualitative research, Dixon-Woods produced a checklist of questions for assessing clarity and appropriateness of the research question; the description and appropriateness for sampling, data collection and data analysis; levels of support and evidence for claims; coherence between data, interpretation and conclusions, and finally level of contribution of the paper. These criteria foster the 10 questions for the Critical Appraisal Skills Program checklist for qualitative studies.[ 10 ] However, these methodology-weighted criteria may not do justice to qualitative studies that differ in epistemological and philosophical paradigms,[ 11 , 12 ] one classic example will be positivistic versus interpretivistic.[ 13 ] Equally, without a robust methodological layout, rigorous interpretation of results advocated by Lincoln et al. [ 9 ] will not be good either. Meyrick[ 14 ] argued from a different angle and proposed fulfillment of the dual core criteria of “transparency” and “systematicity” for good quality qualitative research. In brief, every step of the research logistics (from theory formation, design of study, sampling, data acquisition and analysis to results and conclusions) has to be validated if it is transparent or systematic enough. In this manner, both the research process and results can be assured of high rigor and robustness.[ 14 ] Finally, Kitto et al. [ 15 ] epitomized six criteria for assessing overall quality of qualitative research: (i) Clarification and justification, (ii) procedural rigor, (iii) sample representativeness, (iv) interpretative rigor, (v) reflexive and evaluative rigor and (vi) transferability/generalizability, which also double as evaluative landmarks for manuscript review to the Medical Journal of Australia. Same for quantitative research, quality for qualitative research can be assessed in terms of validity, reliability, and generalizability.

Validity in qualitative research means “appropriateness” of the tools, processes, and data. Whether the research question is valid for the desired outcome, the choice of methodology is appropriate for answering the research question, the design is valid for the methodology, the sampling and data analysis is appropriate, and finally the results and conclusions are valid for the sample and context. In assessing validity of qualitative research, the challenge can start from the ontology and epistemology of the issue being studied, e.g. the concept of “individual” is seen differently between humanistic and positive psychologists due to differing philosophical perspectives:[ 16 ] Where humanistic psychologists believe “individual” is a product of existential awareness and social interaction, positive psychologists think the “individual” exists side-by-side with formation of any human being. Set off in different pathways, qualitative research regarding the individual's wellbeing will be concluded with varying validity. Choice of methodology must enable detection of findings/phenomena in the appropriate context for it to be valid, with due regard to culturally and contextually variable. For sampling, procedures and methods must be appropriate for the research paradigm and be distinctive between systematic,[ 17 ] purposeful[ 18 ] or theoretical (adaptive) sampling[ 19 , 20 ] where the systematic sampling has no a priori theory, purposeful sampling often has a certain aim or framework and theoretical sampling is molded by the ongoing process of data collection and theory in evolution. For data extraction and analysis, several methods were adopted to enhance validity, including 1 st tier triangulation (of researchers) and 2 nd tier triangulation (of resources and theories),[ 17 , 21 ] well-documented audit trail of materials and processes,[ 22 , 23 , 24 ] multidimensional analysis as concept- or case-orientated[ 25 , 26 ] and respondent verification.[ 21 , 27 ]

• Reliability

In quantitative research, reliability refers to exact replicability of the processes and the results. In qualitative research with diverse paradigms, such definition of reliability is challenging and epistemologically counter-intuitive. Hence, the essence of reliability for qualitative research lies with consistency.[ 24 , 28 ] A margin of variability for results is tolerated in qualitative research provided the methodology and epistemological logistics consistently yield data that are ontologically similar but may differ in richness and ambience within similar dimensions. Silverman[ 29 ] proposed five approaches in enhancing the reliability of process and results: Refutational analysis, constant data comparison, comprehensive data use, inclusive of the deviant case and use of tables. As data were extracted from the original sources, researchers must verify their accuracy in terms of form and context with constant comparison,[ 27 ] either alone or with peers (a form of triangulation).[ 30 ] The scope and analysis of data included should be as comprehensive and inclusive with reference to quantitative aspects if possible.[ 30 ] Adopting the Popperian dictum of falsifiability as essence of truth and science, attempted to refute the qualitative data and analytes should be performed to assess reliability.[ 31 ]

• Generalizability

Most qualitative research studies, if not all, are meant to study a specific issue or phenomenon in a certain population or ethnic group, of a focused locality in a particular context, hence generalizability of qualitative research findings is usually not an expected attribute. However, with rising trend of knowledge synthesis from qualitative research via meta-synthesis, meta-narrative or meta-ethnography, evaluation of generalizability becomes pertinent. A pragmatic approach to assessing generalizability for qualitative studies is to adopt same criteria for validity: That is, use of systematic sampling, triangulation and constant comparison, proper audit and documentation, and multi-dimensional theory.[ 17 ] However, some researchers espouse the approach of analytical generalization[ 32 ] where one judges the extent to which the findings in one study can be generalized to another under similar theoretical, and the proximal similarity model, where generalizability of one study to another is judged by similarities between the time, place, people and other social contexts.[ 33 ] Thus said, Zimmer[ 34 ] questioned the suitability of meta-synthesis in view of the basic tenets of grounded theory,[ 35 ] phenomenology[ 36 ] and ethnography.[ 37 ] He concluded that any valid meta-synthesis must retain the other two goals of theory development and higher-level abstraction while in search of generalizability, and must be executed as a third level interpretation using Gadamer's concepts of the hermeneutic circle,[ 38 , 39 ] dialogic process[ 38 ] and fusion of horizons.[ 39 ] Finally, Toye et al. [ 40 ] reported the practicality of using “conceptual clarity” and “interpretative rigor” as intuitive criteria for assessing quality in meta-ethnography, which somehow echoed Rolfe's controversial aesthetic theory of research reports.[ 41 ]

• Food for Thought

Despite various measures to enhance or ensure quality of qualitative studies, some researchers opined from a purist ontological and epistemological angle that qualitative research is not a unified, but ipso facto diverse field,[ 8 ] hence any attempt to synthesize or appraise different studies under one system is impossible and conceptually wrong. Barbour argued from a philosophical angle that these special measures or “technical fixes” (like purposive sampling, multiple-coding, triangulation, and respondent validation) can never confer the rigor as conceived.[ 11 ] In extremis, Rolfe et al. opined from the field of nursing research, that any set of formal criteria used to judge the quality of qualitative research are futile and without validity, and suggested that any qualitative report should be judged by the form it is written (aesthetic) and not by the contents (epistemic).[ 41 ] Rolfe's novel view is rebutted by Porter,[ 42 ] who argued via logical premises that two of Rolfe's fundamental statements were flawed: (i) “The content of research report is determined by their forms” may not be a fact, and (ii) that research appraisal being “subject to individual judgment based on insight and experience” will mean those without sufficient experience of performing research will be unable to judge adequately – hence an elitist's principle. From a realism standpoint, Porter then proposes multiple and open approaches for validity in qualitative research that incorporate parallel perspectives[ 43 , 44 ] and diversification of meanings.[ 44 ] Any work of qualitative research, when read by the readers, is always a two-way interactive process, such that validity and quality has to be judged by the receiving end too and not by the researcher end alone.

In summary, the three gold criteria of validity, reliability and generalizability apply in principle to assess quality for both quantitative and qualitative research, what differs will be the nature and type of processes that ontologically and epistemologically distinguish between the two.

Source of Support: Nil.

Conflict of Interest: None declared.

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Students’ and junior doctors’ perspectives on radiology education in medical school: a qualitative study in the Netherlands

• Frederike S. Harthoorn 1 , 2 ,
• Sascha W. J. Scharenborg 1 , 2 ,
• Monique Brink 2 ,
• Liesbeth Peters-Bax 2 &
• Dylan J. H. A. Henssen 2  

BMC Medical Education volume  24 , Article number:  479 ( 2024 ) Cite this article

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Modern medicine becomes more dependent on radiologic imaging techniques. Over the past decade, radiology has also gained more attention in the medical curricula. However, little is known with regard to students’ perspectives on this subject. Therefore, this study aims to gain insight into the thoughts and ideas of medical students and junior doctors on radiology education in medical curricula.

A qualitative, descriptive study was carried out at one medical university in the Netherlands. Participants were recruited on social media and were interviewed following a predefined topic list. The constant comparative method was applied in order to include new questions when unexpected topics arose during the interviews. All interviews were transcribed verbatim and coded. Codes were organized into categories and themes by discussion between researchers.

Fifteen participants (nine junior doctors and six students) agreed to join. From the coded interviews, four themes derived from fifteen categories arose: (1) The added value of radiology education in medical curricula, (2) Indispensable knowledge on radiology, (3) Organization of radiology education and (4) Promising educational innovations for the radiology curriculum.

This study suggests that medical students and junior doctors value radiology education. It provides insights in educational topics and forms for educational improvement for radiology educators.

• Ultrasound was suggested to integrate within radiology education in medical curricula.

• Integration of applied radiology in a longitudinal learning community could be explored.

• Regardless of their personal interests, participants valued radiology education in medical curricula.

Peer Review reports

Can you imagine practicing medicine without using radiologic imaging techniques, such as chest radiographs, CT-scans or ultrasound? It would be almost inconceivable in modern medicine [ 1 ]. Coherent to this increasing role of radiology in healthcare, education of radiology in medical curricula has been a topic of discussion with proponents among both clinicians and students for more radiology education [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 ]. The results of a recent review on the role of radiology in medical student teaching reflect this, showing a significant increase in medical articles published over the past decade [ 10 ].

Regarding the learning objectives of radiology education, not only consensus between radiologists and clinicians is needed [ 11 , 12 , 13 , 14 ], but also between students and these groups [ 9 , 15 , 16 ]. The studies of Subramaniam et al. were the only ones that investigated the opinions of clinicians and medical students in a study of three papers to create an overview of the opinions of the different groups on this subject [ 15 , 17 , 18 ]. When focusing on students’ opinions regarding radiology education, various studies investigated these by use of surveys with closed-ended questions [ 9 ] and open-ended questions [ 15 , 16 ]. These studies reported that students recognized the importance of radiology as an educational topic, especially with regard to reading radiographs and the detection of gross abnormalities on medical images [ 15 , 16 ]. Additionally, students in these studies also stated to have little knowledge regarding the possible health effects of ionizing radiation and MRI safety [ 9 ]. Although interesting, these results need further clarification: what exactly do students expect by “reading radiographs”, what pathologies should we consider “gross abnormalities” and how should we teach these subjects to students? To gain deeper insights in quantitative data, a qualitative research method is needed [ 19 ]. Therefore, this study sets out to further elucidate students’ perspectives on radiology education in medical curricula by use of individual interviews.

A qualitative, descriptive study with semi-structured interviews was performed. Prior to conducting these interviews, a list of topics was assembled based on relevant scientific literature, discussion sessions between two researchers (F.H. and D.H) and the educational experiences of the research team. Interviews were performed following an inductive iterative process using the constant comparative method [ 20 ]. This study was approved by the ethics committee of the Netherlands Association of Medical Education (NVMO, case number 2023.2.9).

Participants

Master’s students from the Radboud University Nijmegen, The Netherlands, and junior doctors were recruited between August 2020 and October 2020 by placing public advertisements on social media including electronic student environments and Facebook and by contacting students personally, to reach as many students as possible. These ways of recruitment was since no other ways were facilitated. To be included in this study, students needed to be enrolled in the master’s Medicine program of the Radboud University Nijmegen, implying that they had at least some clinical experience. Furthermore, students who followed an elective internship in Radiology were encouraged to participate to gain insights in their experience of an internship.

Data collection

Interviewees participated in one-on-one semi-structured interviews which were conducted in person, via electronic telecommunication software (e.g. Skype version 8.65.0.78; Skype Technologies, Luxembourg City, Luxembourg Palo Alto, CA, United States ) or by telephone with one of the researchers (F.H.). Semistructured interviews were conducted to obtain nuanced descriptions and extensive, salient data regarding the perspectives on radiology education. The interview schedule was derived from literature-dependent topics and discussions between the researchers. This resulted in a predefined topic list.

During the interviews, participants were encouraged to speak openly about their thoughts and considerations on the subject using open-ended questions. Therefore, it was highlighted that the interviewer had no relations with the board of examiners, the university medical center educational board or any other educational management team.

To ensure reliable data, all interviews were audio- and/or video-recorded, facilitating the transcription of these interviews verbatim afterwards. Prior to the interview, informed consent was obtained from all participants. The transcription of the interviews immediately started after the first interview. When information saturation occurred, two additional interviews were held to control data saturation. When it was confirmed that saturation was achieved, no new subjects were included as this would not result in new insights.

Data analysis

The transcribed data was thereafter analyzed via direct content analysis [ 21 ]. The inductive iterative process was performed using the constant comparative method. Data analysis started after completion of the first interview. Codes derived from the previous interview were used as starting point for coding the next one and additional codes were added when needed. Two researchers (F.H. and D.H) analyzed four interviews independently in order to compare the coding process. Discrepancies in coding were solved by discussion and concession. Thereafter, one researcher (F.H.) coded the remaining interviews. The coding process was performed using Atlas.ti software, version 8.2.29.0 (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). As a result, the created coding list was used to make an overview of categories and themes as a final product.

Sixteen subjects responded to the recruitment, one student was excluded due to not yet being enrolled in the master’s program, resulting in a total of fifteen participants who were interviewed. Tables  1 and 2 give an overview of the characteristics of the participants. All answers were collected via interviews; nine via Skype, one via Facetime, three via telephone and two in person. The interviews lasted between 25 and 50 min.

Four themes derived from fifteen categories arose from the qualitative data: (1) the added value of radiology education in medical curricula, (2) indispensable knowledge on radiology, (3) organization of radiology education and (4) promising educational innovations for the radiology curriculum (Fig.  1 ).

Summary of students’ perspectives on radiology education in medical curricula organized in themes and categories

The added value of radiology education in medical curricula

Current radiology education in medical curricula.

Interviewees expressed a heterogeneous exposure to radiology education moments, due to their preferences (e.g. attending elective courses) and changes in the medical curriculum. However, all interviewees stated that they received education on interpretating chest radiographs. Despite that, the medical curriculum paid little attention to it and interviewees felt ill-prepared to perform this task adequately. Additionally, participants expressed that systematic reading of chest radiographs, once taught, was easily forgotten due to a lack of repetition.

Interviewees considered radiology education fragmented throughout the study program and lacking proper structure. Participants also believed that radiological images were rather used as a tool to support other educational moments and indicated that they were often not aware of the relevance of gaining knowledge in radiology.

Integration of radiology in other internships

Participants expressed greater exposure to radiological images during their internships compared to their theoretical courses. Nonetheless, most interviewees experienced little or no expectations from supervisors regarding radiologic knowledge. Therefore, almost all their radiologic knowledge was acquired via self-study and critical evaluation of radiologic knowledge by an expert was lacking. Participants expressed that they did master different skills, dependent on their clinical exposure during the internships. This includes balancing pros and cons when choosing a radiologic exam, how to write a decent question for the radiologist and systematically reviewing chest radiographs.

Radiology during the work of junior doctors

Although the exposure of radiology varied in the participants’ jobs, several aspects of knowledge in radiology were described as advantageous for their work. For example: understanding and interpretating a radiologic report or conclusion, knowledge in different imaging techniques and useful skills for requesting a radiologic exam. This knowledge was considered important for night shifts, when junior doctors have little supervision. Participants appointed that this knowledge was gained via clinical practice and experiences and not through received education.

The added value of radiology education

There were no opponents for radiology education among the interviewees. The majority believed that knowledge in radiology would be beneficial for all medical students as radiology is an omnipresent, important diagnostic tool in medical disciplines. Therefore, they considered it important to integrate into medical curricula.

One participant questioned if other disciplines deserve more time in the already crowded medical curricula instead of radiology. Several participants expressed that specific radiologic knowledge for certain specialisms should be gained during residency. However, they dismissed this consideration since the wide occurrence of radiology in various specialisms is also the reason that basic knowledge in radiology would be beneficial for (almost) all medical students. Consequently, participants experienced a need for more education in the basics of radiology.

“For me [as a medical advisor for insurance] it is not that relevant anymore to know all that. But yes, most of the students will obviously work in the clinical sector or will end up in the treatment sector” – Junior doctor .

Indispensable knowledge on Radiology

Knowledge of anatomy was considered of great importance in order to understand a radiologic image and to distinguish normal images from abnormal ones. CT-scans and radiographs were thought to be imaging techniques on which students should be able to recognize anatomy. Whether the same applies to MRI was a point of discussion, because of the complexity of the imaging technique itself.

“If you do not understand the anatomy, you will not understand the image and vice versa […] so you will not be able to assess an image without knowing the anatomy” – Student .

Skills in interpretation

The interpretation of chest radiographs was considered a potential learning topic, but discussion arose to what extent this topic should be taught. Beliefs varied from interpretating the whole radiologic image with an own conclusion, to only systematically reviewing, to questioning if this should be taught at all during medical school. Interpretation of other imaging modalities (i.e. MRI and CT) was seen as a specialistic skill that should not be a learning goal in medical curricula. However, opinions differed as to which depth a student should be able to recognize certain anatomical landmarks and/or abnormalities.

Overall, it was considered important that students can differentiate normal from abnormal whilst looking at a radiologic image. Furthermore, participants indicated the importance of recognizing the most prevalent anomalies on the most commonly used modalities (Fig.  2 ) and the abnormalities that need rapid medical intervention. Two frequently given examples were recognizing fractures and pneumonia on (chest)radiographs.

A list of mentioned structures or 1 abnormalities that junior doctors should recognize according to the respondents

“…I believe that you should be able to assess the acute pathologies of every modality. This enables you to get ahead in the clinical decision-making process, when no radiologist is present on short notice” – Junior Doctor .

Basic technological background

Participants expressed that basic technological background of radiological images should be less prominent in medical curricula. It was experienced that there is too much focus on these theoretical aspects, which are too specific for junior doctors. However, interviewees did indicate that a certain (basic) knowledge is required to understand an image.

“You need basic understanding of how the modality works…At the beginning of the curriculum, our education focuses mainly on the different techniques. I just miss the clinical application” – Student .

(Contra-)indications, strengths and limitations of the different modalities

Knowledge of (contra-)indications of the different techniques was considered important by the majority of the interviewees. They believed it to be an important part of the clinical reasoning process. Additionally, differentiation in indication between available techniques such as CT, MRI or ultrasound was believed to be important.

“…it is paramount to learn the most important indications for the different radiological examinations for the most frequently encountered pathologies during every internship” – Junior Doctor .

These thoughts were accompanied by the idea that a student must know the strengths and limitations of commonly used radiologic exams. Knowledge on radiation, patient characteristics, influence of timing on accuracy of an image, sensitivity and specificity and false-positivity and false-negativity were suggested. There was a discrepancy in whether this is essential to teach or just good to know between participants.

“Knowing not to order an ultrasound for a heavily obese patient” – Student .

Application and outcome

The application of radiologic studies was considered an important educational topic. This included the added value of implications and consequences of the outcome of a radiologic study, the costs of different modalities, knowing which tests are available in specific circumstances and knowing what to mention when requesting a radiologic study.

Radiological imaging is getting better, fancier and clearer, but consequently it also getting more expensive. …When I believe that it is important to know something, I need to consider whether it will change my course of action for a patient. Only then, I must order the radiological examination – Junior Doctor .

Knowledge in the use of outcome of a study was regarded to be important as well. This included items such as understanding the terminology, looking critically at the conclusion and the role as a clinician to create a link between the clinical case and the image.

Lastly the role of the radiologists was mentioned. Interviewees believed that the ability to consult a radiologist should always be present when in doubt, for both application and outcome. Additionally, it was found important to create more insight into the tasks of a radiologist, so it would become clearer what can be asked and expected, and what is important information to provide when requesting a radiologic examination.

“That would be very interesting indeed, to know what the radiologist considers important regarding an application. I do not know that at all actually. I write down what the symptoms are and what diseases I am suspicious of, but I am not sure whether this is actually knowledge the radiologist needs. I can imagine that there is a lot to gain in that area” – Junior Doctor .

Organization of Radiology Education

Timing and emphasizing responsibilities.

It was believed that radiology education would be more useful if taught in the master’s phase, since students would be able to understand the value of this knowledge in a clinical context. Furthermore, interviewees believed repetition to be the key for both creating a better learning environment and ensuring less time investment in the overcrowded medical curriculum. Some participants suggested an integrated radiology curriculum including only basic topics while others advised against a separate radiology course.

Accompanied by this view, it was believed that radiology education should be integrated within other internships. Interviewees suggested teaching specific modalities before the start of different internships. For example, formal education on how to read radiological examinations of the brain (i.e. MRI and/or CT) should be organized prior to neurology rotations and principles of ultrasound should be taught prior to the gynecology internship. Education on indications and application was suggested to be taught during the last year of the master’s phase. This is because in the Netherlands a medical student is only allowed to perform this task during this last phase of the master. Recapitulating some radiology teaching material prior to starting the elective internships was also suggested.

“Before starting my surgery internship, I wanted to have some education about reading radiographs of fractures. We did receive some education on this topic, but it was really short, and it was not really about radiology. That might be a good addition.” – Student .

Educational forms

Participants suggested an integrated, repetitive radiology curriculum within the courses and internships of other specialties. Within this curriculum, students would like to see applied radiology and applied anatomy integrated in clinical cases, as well as a combination between self-study and practice. Other suggested teaching forms were working groups, computer guided education, e-learnings, self-study assessments, education in the dissection room and radiology meetings.

“I believe that it would be best if radiology education is integrated in the education preparing a student for a specific internship: these are the investigations that you will see encounter during this internship.” – Junior Doctor .

Although digital education (e-learnings and computer-guided education) was considered a good tool to learn recognizing images and to teach the basics of radiology, interviewees also had a negative view towards these teaching forms. They highlighted the pitfalls of having no feedback or possibility to ask questions, resulting in a passive learning style.

“I consider e-learnings useful to learn about the basics, but I think lectures or small group assignments are more useful for clinical discussions as you can have interaction with a professional.” – Student .

The majority of the participants had a positive view towards interactive education forms. In Fig.  3 an overview of the proposed educational forms per educational topic is shown. Additionally, the importance of having good references present was highlighted.

“It is better to use radiologic images that are examples of the really obvious during medical education. Usually, you will encounter complicated pathologies and as a beginning intern you need to study more simple pathologies, for example pneumonia on chest radiographs.” – Student .

Suggested educational forms per educational topic

Potential areas of improvement for a better learning environment

Interviewees believed that teaching radiology before starting a new internship would be beneficial to their radiologic knowledge and could result in increased self-esteem. Linking radiology education to a specific specialty and aligning the education with clinical practice was considered important. It was believed essential that students understand why certain topics are discussed. Other suggestions to enhance the learning environment were: enough exposure and repetition, providing feedback on questions in e-learnings and aligning learning objectives with the changing tasks of students during the years of their internships.

“You will have to implement your knowledge right after learning a radiological principle. Thereby, you will use the acquired knowledge which will result in better recall” – Student .

Promising educational innovation for the radiology curriculum

Internship in radiology.

While some participants suggested a regular (mini-)internship in radiology, the majority of the interviewees believed an elective internship in radiology to be better for personal deepening, also including the student’s personal learning objectives. Integration of a couple (internship)days of radiology in regular internships was also proposed.

However, if an internship would be created, participants suggested a duration of two weeks with integrated educational moments. The educational objectives of the internship were difficult to come up with and ideas on timing in the medical curriculum differed from before the start of the regular internships to the last year. By providing the internship in the first master year, the gained knowledge would come in handy during the next internships. On the other hand, there would be a danger that students would not understand the importance of this knowledge and could potentially have too little foreknowledge to help them assess and interpret the images.

Longitudinal educational curriculum

The idea of a longitudinal learning community (LLC) was pitched among participants as a new type of radiology education in the medical curriculum. This was described as a community-based approach to learning that stimulates meaningful student interaction via repetitive small-group learning and peer-group evaluation during a time period of more than one year. All participants were advocates for the suggested LLC and believed it would be a great addition to the current medical curriculum. One student suggested facilitating the LLC and withdrawing the internship in radiology. The aforementioned topics were proposed to be incorporated in the LLC.

“I think that it is a really good idea to have a continuous process of learning activities which helps you to expand your knowledge. And indeed, radiological imaging is somewhat different for different internships as some techniques are more often used than others in different settings” – Junior Doctor .

It was believed that the LCC would increase the attention for radiology education during other internships. It was noted that the complexity of the study materials taught in the LLC could progress over time. Although, it was disclosed that fragmentation could also be a pitfall of an LLC in radiology.

“You could embed an afternoon or day of radiology into other internships. So that during the neurology internship, you will observe the work of the neuro-radiologist. Then you will have more exposure.” – Student .

Ultrasound education

Interviewees noted that ultrasound is an emerging modality and believed education in ultrasound to be attractive. Discussions arose on both the added value of the theoretical aspects (including interpretation) as well as the practical aspects of ultrasound education.

“Good ultrasound education is lacking in the medical curriculum. Whereas ultrasound, in my opinion, is the bedside diagnostic tool of the future, especially with the hand-held ultrasounds which fit in your pocket.” – Student .

For ultrasound education to become useful, participants believed repetition and basic educational topics to be essential components. It was believed that these topics should be the same as other radiologic modalities. Regions that were suggested to teach were the abdomen and heart. As for teaching forms it was suggested to either use a separate course consisting of a combination of computer-guided education and self-study or integrate the study material via clinical cases (applied radiology).

However, there was disagreement on teaching practical sonography skills. Opponents mainly stated that this would be too specialized, while an advocate highlighted that it would be beneficial to master this skill since ultrasound is a dynamic examination.

“Performing an ultrasound examination properly and interpreting those images adequately, that is not something you will learn in one group session. For that, you would really need more time in the medical curriculum, to teach it consequently”- Student .

This study suggests that medical students and junior doctors value radiology education in medical curricula as they see it as a relevant topic, regardless of personal interests. However, radiology education in its current form was criticized. Adaptions to facilitate a more integrated and applied form of radiology education were suggested, in order to establish the skills a junior doctor should master. An elective radiology internship was suggested for those more interested.

Our results are in line with outcomes reported by Subramaniam and colleagues [ 15 ]. They found that medical students considered (1) learning to systematically analyze radiographs, (2) distinguishing normal from abnormal and (3) identifying gross abnormalities important learning goals. However, several new topics arose from our study. For example, we found that students believe that less time should be invested in the theoretical background of the radiologic techniques. Nevertheless, in a previous study, students also reported the lowest mean score for “Basic knowledge of radiation protection, including timing of organogenesis and radiation effects”. This indicates that students regard this learning goal least interesting [ 15 ]. In our study, on the other hand, the students detail their comments and provide insights on how to implement this theoretical aspect of radiology in daily educational practice; For example by in-time learning and using clinical cases to teach radiology in a more applied way. In addition, our study suggested that students have nuanced views on the depth of their knowledge with regard to different topics. Also, students suggest in this paper that more time should be created for learning applied radiology, and that ultrasound education should be implemented more broadly. Nevertheless, this study was unable to investigate the nuanced views of students and junior doctors on each topic. Regarding the basic technological background, further research should aim to provide a detailed overview of the benefits and limitations as perceived by students and junior doctors regarding this subject. Such a detailed overview of the topics described in this study could help to further shape radiology education of the future.

Participants suggested integrating ultrasound as an imaging technique within the medical curriculum. Discussion arose if this should also include practical skills. This increased interest in ultrasound education has been shown in literature [ 22 , 23 ]. Although the theoretical aspect of this technology is getting more implemented in medical curricula in Europe, and ultrasonography is practically taught in some countries, not all universities have developed an ultrasound curriculum to teach the practical skills [ 24 ]. One explanation that could help understand why such an ultrasound curriculum is not ubiquitous within modern medical curricula, could be that a well-designed ultrasound curriculum is needed for optimal integration that meets students’ expectations and matches the existing clinical needs. Nonetheless, a recent study did provide recommendations for such an ultrasound curriculum in medical school [ 25 ], although further investigation of the learning outcomes would be paramount [ 26 , 27 , 28 , 29 ]. Positive outcomes on teaching anatomy have been reported, though the impact of ultrasound education on clinical examination skills of medical students is less clear and needs further investigation [ 29 , 30 ].

The possibility of developing an LLC to improve radiology curricula was positively reviewed by participants. Literature showed examples of national radiology curricula that were developed in the UK, Australia and Germany [ 23 , 31 ]. However, it was unclear whether these curricula are also integrated in medical curricula. To our knowledge no national LLC curriculum has yet been developed in the Netherlands. Since positive outcomes have been reported of an integrated imaging curriculum [ 23 , 32 ], we believe it would be beneficial to explore this educational form of radiology education. It has been reported that a vertically integrated “virtual” radiology internship is as effective as a freestanding internship [ 33 ]. The remark of the interviewees that a radiology internship should be elective when a LLC is applied is in line with these findings.

This study has several strengths and limitations. The qualitative research design provided a detailed insight into students’ perspectives on radiology education in medical curricula. By including junior doctors, more insight into the gaps of the current radiology education and the challenges of radiology in daily clinical work was obtained. The group of participants varied in personal interests and interest in future specialties, which was essential to get insight into whether every medical student would benefit from radiology education, and which topics should be taught. Lastly, some participants followed an elective internship in radiology and others did not. This information was used to obtain more information if an internship in radiology would be useful, either mandatory or elective.

The generalizability of these data is affected by the small group of included participants. This should be seen as a limitation of this study. Second, representativeness could have been affected by the method of recruiting students and junior doctors, creating selection bias. Third, only students from one University Centre in the east of the Netherlands were included, potentially creating responses that are not representative for students participating in other Dutch curricula. Finally, the fact that only junior doctors were included might have led to unbalanced answers when it comes to professional needs later in their medical career and to the costs of suggested improvements. Although we have no reason to assume that the interviewees cannot reflect the large group of medical students, more qualitative research on the importance of radiology education is warranted to confirm the presented findings.

This study suggests that medical students and junior doctors consider radiology education important within medical school curricula and provided insight into educational topics and ways to improve the current curriculum. Participants were positive about an integrated radiology curriculum that included applied radiology and incorporating more ultrasound education in the medical curriculum. The implementation of a LLC in radiology, incorporating ultrasound education, could be investigated. Overall, more research is needed to get information from more students on these specific subjects and get an agreement between clinicians and students on these topics.

Data availability

The dataset which was generated from the interviews and analyzed during the current study is not publicly available since individual privacy could potentially be compromised. Data are however available from the corresponding author on reasonable request.

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FH contributed to the design of the study, the acquisition, analysis and interpretation of data and drafted the work. SS and MB have substantively revised the work. LPB designed the study and substantively revised the work. DH supervised the whole project and consequently contributed to the design of the study and to revisions of the work. All authors approve the submitted version of this article and have agreed to both to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated, resolved and the resolution is documented in the literature.

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Harthoorn, F.S., Scharenborg, S.W., Brink, M. et al. Students’ and junior doctors’ perspectives on radiology education in medical school: a qualitative study in the Netherlands. BMC Med Educ 24 , 479 (2024). https://doi.org/10.1186/s12909-024-05460-9

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Factors influencing breast cancer screening practices among women worldwide: a systematic review of observational and qualitative studies

• Banafsheh Tavakoli 1 ,
• Awat Feizi 2 ,
• Fereshteh Zamani-Alavijeh 3 &
• Hossein Shahnazi 3  

BMC Women's Health volume  24 , Article number:  268 ( 2024 ) Cite this article

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Metrics details

The variation in breast cancer incidence rates across different regions may reflect disparities in breast cancer screening (BCS) practices. Understanding the factors associated with these screening behaviors is crucial for identifying modifiable elements amenable to intervention. This systematic review aims to identify common factors influencing BCS behaviors among women globally.

Relevant papers were sourced from PubMed, Scopus, Embase, and Google Scholar. The included studies were published in English in peer-reviewed journals from January 2000 to March 2023 and investigated factors associated with BCS behaviors.

From an initial pool of 625 articles, 34 studies (comprising 29 observational and 5 qualitative studies) with 36,043 participants were included. Factors influencing BCS behaviors were categorized into nine groups: socio-demographic factors, health status history, knowledge, perceptions, cultural factors, cues to action, motivation, self-efficacy, and social support. The quality appraisal scores of the studies ranged from average to high.

Conclusions

This systematic review highlights factors pivotal for policy-making at various levels of breast cancer prevention and assists health promotion professionals in designing more effective interventions to enhance BCS practices among women.

Peer Review reports

Breast cancer stands as the most commonly diagnosed cancer among women worldwide, affecting both developed and developing countries [ 1 ]. Statistical analyses indicate that while wealthier nations report higher breast cancer incidence rates, less developed countries suffer from higher relative mortality rates [ 2 ].

In high-income countries, including the United Kingdom, Australia, and Eastern Europe, over 60% of women are diagnosed at stages one and two of the disease, significantly improving their survival rates. Conversely, women in low-income countries often seek treatment at advanced disease stages when it has metastasized to other organs [ 3 ].

Differences in cancer incidence rates across populations may be attributable to the variance in risk factor prevalence and the implementation or uptake of screening programs [ 4 ].

Routine screening is pivotal in detecting breast cancer at an early, more treatable stage, significantly reducing mortality rates [ 5 ]. The primary methods of screening include breast self-examination (BSE), clinical breast examination (CBE) by a healthcare professional, and mammography (MMG), all of which have been demonstrated to lower mortality rates from breast cancer in various studies [ 6 , 7 , 8 , 9 ].

Despite numerous interventions and educational efforts aimed at promoting participation in BCS programs, recent studies indicate a continuing rise in mortality rates and a persistently low participation rate among women, particularly in less developed countries [ 1 , 10 ]. For instance, recent figures show that only 13.6% of Malaysian, 0.3% of Egyptian, and 3.8% of Ethiopian women have undergone MMG in the past two years, compared to 81%, 88%, and 70% in Belgium, Australia, and the United States, respectively [ 11 , 12 , 13 , 14 , 15 , 16 ]. These disparities highlight the crucial need for developing and implementing effective strategies based on scientific and reliable research to enhance screening behaviors across different societies.

Given the significance of BCS and the dire predictions that both morbidity and mortality from breast cancer will more than double by 2035 [ 3 ], it becomes imperative to conduct a comprehensive review of the published literature. This systematic review aims to [ 1 ] summarize current knowledge on factors influencing BCS behaviors and [ 2 ] identify factors relevant to enhancing screening behaviors among women worldwide. Achieving these objectives and leveraging the findings of this research could empower policymakers, researchers, and health promotion professionals to devise more effective prevention policies and interventions, thereby improving BCS behaviors through well-informed strategies.

This systematic review was registered with PROSPERO under the registration number CRD42023432810. The presentation of findings adheres to the PRISMA checklist standards (Additional file 1 ).

Search Strategy

The research question, structured according to the PICOS framework, was: “What are the factors impacting BCS behaviors among women worldwide?”

The PICOS elements defined were as follows:

Population: Healthy individuals aged 15 years or older, encompassing all genders, races, and geographic locations.

Intervention (Influential Factors): This includes socio-demographic factors, health history, knowledge, perceptions, cultural factors, cues to action, motivation, self-care, and social support.

Comparison Group: Subpopulations and subgroups differentiated by socio-demographic variables.

Outcome: Practices related to BCS.

Study Design: The review included cross-sectional, retrospective, prospective, and qualitative studies.

Four key search concepts and their synonyms (Table  1 ) were identified for the search. The international databases searched included PubMed, Scopus, Science Direct, Embase, and Google Scholar. Berenguer and Sakellariou’s search strategy [ 17 ] was adopted. The search concepts, along with their synonyms (utilizing truncations and wildcards, as indicated in Tables  1 and Additional file 2 ), where the asterisk ‘*’ was applied where appropriate, and subject heading terms were combined using the Boolean operators ‘OR’ within concepts, and ‘AND’ to combine concepts, thus developing the final search strategy (Additional file 2 ).

Inclusion and exclusion criteria

Studies were included if they:

Reported on MMG, CBE, or BSE as methods for BCS, in alignment with recommendations by international health organizations.

Were published in peer-reviewed journals between January 2000 and March 2023.

Addressed factors associated with BCS behaviors, focusing on associated factors rather than the effects of interventions.

Employed quantitative or qualitative research designs.

Included participants aged 15 years or older.

The exclusion criteria for the studies were:

Duplicate publications across databases.

Non-original research articles, including dissertations, reviews, case reports, editorials, oral and poster presentations, and book chapters.

Publications in languages other than English.

Preprints are not subjected to peer review.

Studies focusing on general cancer screening are not specific to breast cancer.

The research concentrated on other preventative behaviors or early detection methods unrelated to BCS.

Studies focused on factors associated with the second BCS participation round.

Research involving women with specific conditions, such as those who are sick or vulnerable.

Study selection

The selection followed PRISMA guidelines. Initially, duplicates across databases were removed. Titles and abstracts were then reviewed for relevance, and articles not meeting the inclusion criteria were discarded. Subsequently, full texts of the remaining studies were evaluated for relevance, with any further non-compliant studies excluded. This review process was independently conducted by two researchers, with any discrepancies resolved through discussion.

Quality assessment

Following numerous academics’ recommendations, the methodological quality of the included studies was assessed, and a Methodological Quality Score (MQS) was assigned. Experts evaluated each study’s conceptual and methodological rigor, resolving discrepancies by consensus. Based on Bernstein’s standards [ 18 ] and as explained by Patton [ 19 ], the assessment criteria included theoretical framework usage, study design, sample size, measurement instruments, data analysis, and reporting on reliability and validity. Quantitative studies were scored on a scale from 0 to 19, and qualitative studies from 0 to 14, with higher scores indicating higher methodological quality. Studies scoring below 60% were excluded.

Data extraction and synthesis

Data were independently extracted by two researchers (BT and HSH), using a pre-designed tool to collect methodological details, including first author, publication year, study design, data source, study location, sampling strategy, sample size, data collection techniques, participant age, BCS method, and conceptual framework. For quantitative studies, additional data on screening participation rates and identified factors associated with BCS behaviors were noted. Qualitative studies included thematic information extracted for analysis.

An initial search yielded 625 articles from the specified databases. After removing duplicates and screening titles and abstracts, 118 papers were selected for full-text evaluation. Ultimately, 34 papers comprising 29 observational studies and 5 qualitative studies, with 36,043 participants, were included in the final review. The study selection process is illustrated in Fig.  1 .

PRISMA flow diagram of the study selection procedure

Quality of included studies

None of the studies achieved the highest possible score. A majority of the studies were cross-sectional designs (82.4%), and over half (64.7%) included large samples (more than 300 participants). Furthermore, 67.7% of the studies grounded their findings in specific theoretical frameworks. Approximately half reported the psychometric properties of their assessment instruments. A significant portion (85.3%, N  = 29) of the studies were quantitative and utilized both descriptive and advanced statistical analyses, such as t-tests, multiple regression, logistic regression, and multivariate analysis. The qualitative studies (14.7%, N  = 5) primarily employed content and thematic analysis. All quantitative studies assessed the statistical significance of factors associated with BCS behaviors (Table  2 ).

Characteristics of included studies

The 34 articles that met the inclusion and exclusion criteria were geographically diverse: 20 studies were conducted in Asia [ 10 , 11 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 ], 5 in America [ 16 , 38 , 39 , 40 , 41 ], 4 in Europe [ 14 , 42 , 43 , 44 ], 4 in Africa [ 12 , 13 , 45 , 46 ], and 1 in Australia [ 15 ].

The sample sizes ranged from 8 to 11,409 participants, with the age of participants spanning from 15 to 82 years. Except for one qualitative study focusing on Arab men’s perceptions of female BCS [ 34 ], all participants were women.

There was variability in the BCS methods and the measurement of related factors across studies. Eleven studies identified CBE, BSE, or MMG as the screening methods [ 13 , 20 , 22 , 29 , 30 , 32 , 34 , 36 , 37 , 41 , 46 ]; four defined BSE or MMG [ 12 , 25 , 31 , 35 ]; one mentioned CBE or MMG [ 11 ]; one mentioned CBE or BSE [ 24 ]; one specified CBE alone [ 39 ]; six identified BSE alone [ 23 , 26 , 28 , 33 , 45 , 47 ]; and ten focused solely on MMG [ 14 , 15 , 16 , 27 , 38 , 40 , 42 , 43 , 44 , 48 ].

The reported BCS rates varied significantly across studies, from 0.3 to 62% for BSE, 2.5–41% for CBE, and 0.3–88.1% for MMG (Table  3 ).

Factors associated with BCS behaviors

The question of “What factors impact BCS behaviors in women worldwide?” is comprehensively answered through the analysis presented in Tables  4 ,  5  and 6 . These tables delineate the factors influencing BSE, CBE, and MMG, respectively, as identified in the 34 reviewed articles.

The factors identified are categorized into nine key areas:

Socio-demographic Factors: This includes age, education level, income, marital status, and employment status, highlighting how these variables influence screening behaviors.

Health History: Past health experiences, family history of breast cancer, and personal health beliefs play a significant role in an individual’s decision to undergo screening.

Knowledge: The awareness and understanding of breast cancer and the benefits of early detection through screening methods.

Perceptions: Women’s beliefs and attitudes towards breast cancer risk, the effectiveness of screening, and the healthcare system’s role in cancer detection.

Cultural Factors: How cultural beliefs, norms, and societal expectations shape attitudes towards breast health and screening practices.

Cues to Action: External prompts, such as recommendations from healthcare professionals, health campaigns, or peers’ experiences, encourage women to seek screening.

Motivation: The intrinsic and extrinsic motivators drive women to participate in screening activities.

Self-care: The degree to which women prioritize their health and well-being, including the proactive pursuit of health screenings.

Social Support: The influence of family, friends, and community networks in supporting or hindering screening behaviors.

The primary goal of this study was to identify the universal factors influencing BCS behaviors among women globally. Although most countries offer BCS programs [ 17 ], the nature and implementation of these programs vary significantly across different health systems and populations [ 49 ]. Consequently, the BCS methods examined in this review varied, reflecting these disparities. MMG, recognized for its efficacy in clinical studies, is predominantly used in developed countries due to its higher costs [ 8 ]. Conversely, in developing countries, BSE stands out as a widely adopted, cost-effective method for early detection [ 50 ].

Moreover, the rates of screening methods reported in the literature show considerable international variation. Countries like Sweden, Belgium, the USA, and Australia report high MMG screening rates [ 14 , 15 , 16 , 43 ], whereas BSE is more prevalent in countries like Egypt, Ethiopia, Turkey, Iran, and Iraq [ 12 , 13 , 25 , 26 , 32 ], often falling below the WHO’s recommended screening rates [ 49 ].

The WHO underscores the importance of high participation rates in screening programs to enhance their effectiveness [ 49 ]. Understanding the factors influencing participation enables health systems to adopt comprehensive strategies for prevention, early diagnosis, and BCS promotion.

Over half of the studies reviewed focused on socio-demographic factors as determinants of screening behaviors, identified in previous research as facilitators and barriers [ 51 , 52 ]. Findings indicate that demographic variables such as age, education level, income, and employment status significantly influence screening rates.

While socio-demographic status is recognized as a crucial determinant of access to BCS in both high-income [ 51 , 52 ] and middle-income countries [ 10 , 17 ], studies in European countries with organized screening programs report no correlation between screening participation and socio-demographic variables [ 53 ]. A 2011 study exploring the impact of socioeconomic inequalities on screening participation highlighted that such disparities exist even without financial barriers [ 54 ]. These variations necessitate careful interpretation, considering women’s diverse challenges in accessing screening services worldwide, including geographical, economic, and cultural obstacles.

For instance, despite Qatar’s provision of comprehensive medical services at no cost, including BCS, cultural barriers have led to only a third of eligible women utilizing these services [ 34 ]. Thus, offering organized screening programs with equitable access could gradually mitigate socioeconomic disparities.

The review also highlights that beyond a family history of breast cancer and personal breast health issues, fertility-related challenges, such as infertility and hormonal imbalances, influence screening behaviors. This finding aligns with systematic reviews from China and the USA, which examined screening factors among different populations [ 55 , 56 ]. Women with personal or familial health histories may perceive a higher susceptibility to breast cancer, thereby increasing their utilization of healthcare services for screening and diagnostic tests. This heightened awareness and concern about breast cancer risk can motivate women to adopt preventive measures, including screening. However, it is notable that many women may not pursue screening until symptomatic or following the discovery of breast cancer in close relatives [ 57 , 58 ].

The findings of the study reveal that women with comprehensive knowledge about breast cancer risk factors, symptoms, and screening methods are more likely to participate in screening programs. Conversely, women who have not undergone screening often lack awareness or believe that once screened, repeat screenings are unnecessary [ 59 ]. This lack of knowledge has been identified as a critical barrier to screening participation among Iranian and Asian women and as a predictive factor for the late diagnosis of breast cancer in Canada [ 10 , 60 , 61 ]. However, Schlueter’s study found no correlation between the level of knowledge and screening behaviors [ 62 ], indicating the complexity of this relationship.

Educational interventions targeting breast cancer awareness and screening guidelines are crucial for improving women’s knowledge and participation rates.

Perceptual factors significantly influence screening behaviors, including fewer perceived barriers and higher self-efficacy. A Chinese study highlighted reduced perceived barriers as a predictive factor for screening participation [ 55 ]. Main barriers identified include fear [ 34 , 42 , 46 , 48 ], anxiety [ 29 , 30 ], worry [ 22 , 63 ], religious beliefs and fatalism [ 32 , 46 , 48 ], financial constraints [ 34 ], language barriers [ 29 , 39 , 40 ], and embarrassment [ 63 ]. Although fear can motivate screening behavior in some contexts [ 56 ], it is predominantly an emotional barrier in the findings.

Types of fear recognized include the fear of mastectomy, diagnosis of cancer, and stigmatization [ 34 , 46 , 48 ]. Consedine et al. noted that while fear of cancer could facilitate screening, specific fears—such as those associated with medical procedures or diagnosis—often deter women from participating [ 64 ]. A meta-analysis further linked fear of breast cancer to screening behaviors [ 65 ], suggesting that mitigating fear through education and positive screening experiences could enhance participation rates.

Cultural factors, particularly religious beliefs, and fatalism, notably impact screening behaviors. Some Muslim women believe BCS is unnecessary, viewing cancer as a divine challenge or part of destiny [ 63 ]. This fatalistic view, a belief in the health locus of control being external (chance or divine will), can lead to passive health behaviors [ 66 ]. While some studies show no significant impact of religious beliefs on screening behaviors [ 67 ], the intertwined nature of these beliefs with culture and religion necessitates nuanced interventions.

Effective strategies might involve integrating breast cancer awareness and early diagnosis information within the framework of existing belief systems leveraging religious leaders to promote health messages aligned with spiritual teachings. Such approaches, using religious and spiritual elements in health messaging, have been shown to encourage screening behaviors among women [ 11 ].

The results of this review highlight that women are more likely to engage in BCS behaviors when they receive information from healthcare teams, social media, or other sources compared to those who do not consult with healthcare professionals or use social media for health information. Jones et al. emphasized that recommendations and reminders from healthcare providers are among the most effective means of directing women toward MMG and other screening tests [ 68 ]. A 2019 study further showed that ignoring cues to action, such as letters, messages, and reminder calls, correlates with lower MMG participation rates [ 69 ].

In the modern era, widespread access to information through digital media, advancements in technology, and the introduction of electronic health tools have facilitated the use of these platforms in cancer screening campaigns. For instance, smartphone applications that remind users about screening schedules and provide preventive advice through text, images, and videos represent an innovative approach to enhancing screening participation.

This review also underscores a significant link between motivation and BCS behaviors. Khazaee-Pool et al. found that motivational solid factors, such as valuing life and health responsibility, significantly encourage screening participation [ 21 ]. Moreover, studies among diverse racial and ethnic groups have identified a clear association between motivation and increased screening activities [ 70 ].

Various socio-psychological barriers, including attitudes, cultural beliefs, and communication issues, have been identified as impediments to motivation [ 71 ]. Factors contributing to low motivation for MMG include the perceived unimportance of testing, lack of support, time constraints, cost concerns, familial obligations, and a busy lifestyle [ 48 ]. Therefore, interventions aimed at enhancing motivational self-efficacy could significantly improve screening participation.

As part of self-care practices, regular health check-ups have been shown to predict screening behaviors. Reviews have highlighted a correlation between infrequent mammograms and breast exams among Asian and Korean-American women with irregular gynecological visits [ 51 , 59 ]. Although MMG can be performed without direct referrals in some countries [ 59 ], the lack of commitment to regular check-ups remains a barrier. As Pasket et al. reported, while 75% of women acknowledged the importance of periodic exams, 67% indicated that their physicians did not actively encourage MMG [ 72 ].

Improving knowledge about self-care and self-regulation is crucial for fostering regular health examination habits. The health system’s role in scheduling periodic health assessments and encouraging adherence is also vital, as demonstrated by research from the Netherlands, which linked pre-scheduled appointments and proactive general practitioner involvement to higher screening rates [ 49 ].

Regarding social support, assistance from healthcare teams and family members significantly influences screening behaviors. Lack of partner support and fear of familial disruption post-diagnosis have been noted as significant barriers among African-American women [ 68 ]. Support from family and friends, providing both financial and emotional backing, can bolster confidence, reduce fear, and encourage screening participation [ 21 , 59 , 73 ].

The review also points out that women’s financial independence and employment status in certain regions are critical in health decision-making. Conversely, many women rely on male family members to make health decisions, a group that requires targeted support from health teams for emotional, instrumental, and informational needs. Leong et al. found that social support not only reduces depression but also promotes healthier behaviors [ 74 ]. Thus, establishing support networks and self-help groups can enhance women’s knowledge, experience, and motivation regarding BCS, ultimately fostering a community of mutual encouragement and support.

This systematic review meticulously evaluated the quality of included studies to ensure their reliability and relevance. A unique aspect of the analysis is the consideration of men’s attitudes and perceptions toward BCS, acknowledging the influence of gender dynamics on screening behaviors. A comprehensive approach was undertaken, analyzing factors affecting BCS behaviors across quantitative and qualitative studies and categorizing them based on their impact on three distinct screening behaviors: BSE, CBE, and MMG. This nuanced categorization provides a detailed understanding of the diverse influences on BCS practices.

Limitations

This research was confined to online studies, potentially overlooking valuable research indexed in databases such as PubMed, Scopus, Embase, and Google Scholar or available only in print. The restriction to English-language publications may have excluded pertinent non-English studies, introducing language bias. The review’s predominance of cross-sectional studies limits the ability to ascertain causal relationships between the factors studied and screening behaviors. Additionally, the reliance on self-reported data raises concerns about the accuracy of the findings, given the potential for recall bias or the desire of participants to present themselves in a socially desirable light.

The heterogeneity of the included studies—in terms of study design, geographic location, methodological approach, demographic characteristics, sample size, screening methods employed, and the intervals between screenings—complicates direct comparisons and may affect the generalizability of the findings.

This systematic review synthesizes a broad array of research on the factors influencing BCS behaviors among women worldwide. By examining various screening methods and participation rates, along with identifying determinants of screening behavior, this study contributes valuable insights to the field of public health. The findings highlight the complex interplay of factors affecting screening behaviors and provide evidence-based guidance for policymakers and health promotion professionals. This knowledge is crucial for developing targeted interventions that can effectively encourage BCS practices, ultimately contributing to breast cancer prevention and early detection.

Availability of data and materials

This published article and its supplementary information files include all data generated or analyzed during this study.

Abbreviations

Breast cancer screening

Breast self-examination

Clinical breast examination

Mammography

Methodological quality score

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

World Health Organization

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Acknowledgements

We thank the Isfahan University of Medical Sciences and the Isfahan School of Health for their support. Our thanks also go to all who contributed to the conceptualization, execution, and analysis of this work.

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Banafsheh Tavakoli

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Fereshteh Zamani-Alavijeh & Hossein Shahnazi

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B.T. and H.S. conceived the project; B.T. and H.S. performed the literature search; all authors contributed to the literature analysis and synthesis of data; F.Z. and A.F. created the figures and tables; B.T. and H.S. wrote the review. All authors were involved in further editing and finalizing the manuscript.

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Tavakoli, B., Feizi, A., Zamani-Alavijeh, F. et al. Factors influencing breast cancer screening practices among women worldwide: a systematic review of observational and qualitative studies. BMC Women's Health 24 , 268 (2024). https://doi.org/10.1186/s12905-024-03096-x

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Received : 28 June 2023

Accepted : 16 April 2024

Published : 27 April 2024

DOI : https://doi.org/10.1186/s12905-024-03096-x

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