article on qualitative research

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• Published: 27 May 2020

How to use and assess qualitative research methods

• Loraine Busetto   ORCID: orcid.org/0000-0002-9228-7875 1 ,
• Wolfgang Wick 1 , 2 &
• Christoph Gumbinger 1  

Neurological Research and Practice volume  2 , Article number:  14 ( 2020 ) Cite this article

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This paper aims to provide an overview of the use and assessment of qualitative research methods in the health sciences. Qualitative research can be defined as the study of the nature of phenomena and is especially appropriate for answering questions of why something is (not) observed, assessing complex multi-component interventions, and focussing on intervention improvement. The most common methods of data collection are document study, (non-) participant observations, semi-structured interviews and focus groups. For data analysis, field-notes and audio-recordings are transcribed into protocols and transcripts, and coded using qualitative data management software. Criteria such as checklists, reflexivity, sampling strategies, piloting, co-coding, member-checking and stakeholder involvement can be used to enhance and assess the quality of the research conducted. Using qualitative in addition to quantitative designs will equip us with better tools to address a greater range of research problems, and to fill in blind spots in current neurological research and practice.

The aim of this paper is to provide an overview of qualitative research methods, including hands-on information on how they can be used, reported and assessed. This article is intended for beginning qualitative researchers in the health sciences as well as experienced quantitative researchers who wish to broaden their understanding of qualitative research.

What is qualitative research?

Qualitative research is defined as “the study of the nature of phenomena”, including “their quality, different manifestations, the context in which they appear or the perspectives from which they can be perceived” , but excluding “their range, frequency and place in an objectively determined chain of cause and effect” [ 1 ]. This formal definition can be complemented with a more pragmatic rule of thumb: qualitative research generally includes data in form of words rather than numbers [ 2 ].

Why conduct qualitative research?

Because some research questions cannot be answered using (only) quantitative methods. For example, one Australian study addressed the issue of why patients from Aboriginal communities often present late or not at all to specialist services offered by tertiary care hospitals. Using qualitative interviews with patients and staff, it found one of the most significant access barriers to be transportation problems, including some towns and communities simply not having a bus service to the hospital [ 3 ]. A quantitative study could have measured the number of patients over time or even looked at possible explanatory factors – but only those previously known or suspected to be of relevance. To discover reasons for observed patterns, especially the invisible or surprising ones, qualitative designs are needed.

While qualitative research is common in other fields, it is still relatively underrepresented in health services research. The latter field is more traditionally rooted in the evidence-based-medicine paradigm, as seen in " research that involves testing the effectiveness of various strategies to achieve changes in clinical practice, preferably applying randomised controlled trial study designs (...) " [ 4 ]. This focus on quantitative research and specifically randomised controlled trials (RCT) is visible in the idea of a hierarchy of research evidence which assumes that some research designs are objectively better than others, and that choosing a "lesser" design is only acceptable when the better ones are not practically or ethically feasible [ 5 , 6 ]. Others, however, argue that an objective hierarchy does not exist, and that, instead, the research design and methods should be chosen to fit the specific research question at hand – "questions before methods" [ 2 , 7 , 8 , 9 ]. This means that even when an RCT is possible, some research problems require a different design that is better suited to addressing them. Arguing in JAMA, Berwick uses the example of rapid response teams in hospitals, which he describes as " a complex, multicomponent intervention – essentially a process of social change" susceptible to a range of different context factors including leadership or organisation history. According to him, "[in] such complex terrain, the RCT is an impoverished way to learn. Critics who use it as a truth standard in this context are incorrect" [ 8 ] . Instead of limiting oneself to RCTs, Berwick recommends embracing a wider range of methods , including qualitative ones, which for "these specific applications, (...) are not compromises in learning how to improve; they are superior" [ 8 ].

Research problems that can be approached particularly well using qualitative methods include assessing complex multi-component interventions or systems (of change), addressing questions beyond “what works”, towards “what works for whom when, how and why”, and focussing on intervention improvement rather than accreditation [ 7 , 9 , 10 , 11 , 12 ]. Using qualitative methods can also help shed light on the “softer” side of medical treatment. For example, while quantitative trials can measure the costs and benefits of neuro-oncological treatment in terms of survival rates or adverse effects, qualitative research can help provide a better understanding of patient or caregiver stress, visibility of illness or out-of-pocket expenses.

How to conduct qualitative research?

Given that qualitative research is characterised by flexibility, openness and responsivity to context, the steps of data collection and analysis are not as separate and consecutive as they tend to be in quantitative research [ 13 , 14 ]. As Fossey puts it : “sampling, data collection, analysis and interpretation are related to each other in a cyclical (iterative) manner, rather than following one after another in a stepwise approach” [ 15 ]. The researcher can make educated decisions with regard to the choice of method, how they are implemented, and to which and how many units they are applied [ 13 ]. As shown in Fig.  1 , this can involve several back-and-forth steps between data collection and analysis where new insights and experiences can lead to adaption and expansion of the original plan. Some insights may also necessitate a revision of the research question and/or the research design as a whole. The process ends when saturation is achieved, i.e. when no relevant new information can be found (see also below: sampling and saturation). For reasons of transparency, it is essential for all decisions as well as the underlying reasoning to be well-documented.

Iterative research process

While it is not always explicitly addressed, qualitative methods reflect a different underlying research paradigm than quantitative research (e.g. constructivism or interpretivism as opposed to positivism). The choice of methods can be based on the respective underlying substantive theory or theoretical framework used by the researcher [ 2 ].

Data collection

The methods of qualitative data collection most commonly used in health research are document study, observations, semi-structured interviews and focus groups [ 1 , 14 , 16 , 17 ].

Document study

Document study (also called document analysis) refers to the review by the researcher of written materials [ 14 ]. These can include personal and non-personal documents such as archives, annual reports, guidelines, policy documents, diaries or letters.

Observations

Observations are particularly useful to gain insights into a certain setting and actual behaviour – as opposed to reported behaviour or opinions [ 13 ]. Qualitative observations can be either participant or non-participant in nature. In participant observations, the observer is part of the observed setting, for example a nurse working in an intensive care unit [ 18 ]. In non-participant observations, the observer is “on the outside looking in”, i.e. present in but not part of the situation, trying not to influence the setting by their presence. Observations can be planned (e.g. for 3 h during the day or night shift) or ad hoc (e.g. as soon as a stroke patient arrives at the emergency room). During the observation, the observer takes notes on everything or certain pre-determined parts of what is happening around them, for example focusing on physician-patient interactions or communication between different professional groups. Written notes can be taken during or after the observations, depending on feasibility (which is usually lower during participant observations) and acceptability (e.g. when the observer is perceived to be judging the observed). Afterwards, these field notes are transcribed into observation protocols. If more than one observer was involved, field notes are taken independently, but notes can be consolidated into one protocol after discussions. Advantages of conducting observations include minimising the distance between the researcher and the researched, the potential discovery of topics that the researcher did not realise were relevant and gaining deeper insights into the real-world dimensions of the research problem at hand [ 18 ].

Semi-structured interviews

Hijmans & Kuyper describe qualitative interviews as “an exchange with an informal character, a conversation with a goal” [ 19 ]. Interviews are used to gain insights into a person’s subjective experiences, opinions and motivations – as opposed to facts or behaviours [ 13 ]. Interviews can be distinguished by the degree to which they are structured (i.e. a questionnaire), open (e.g. free conversation or autobiographical interviews) or semi-structured [ 2 , 13 ]. Semi-structured interviews are characterized by open-ended questions and the use of an interview guide (or topic guide/list) in which the broad areas of interest, sometimes including sub-questions, are defined [ 19 ]. The pre-defined topics in the interview guide can be derived from the literature, previous research or a preliminary method of data collection, e.g. document study or observations. The topic list is usually adapted and improved at the start of the data collection process as the interviewer learns more about the field [ 20 ]. Across interviews the focus on the different (blocks of) questions may differ and some questions may be skipped altogether (e.g. if the interviewee is not able or willing to answer the questions or for concerns about the total length of the interview) [ 20 ]. Qualitative interviews are usually not conducted in written format as it impedes on the interactive component of the method [ 20 ]. In comparison to written surveys, qualitative interviews have the advantage of being interactive and allowing for unexpected topics to emerge and to be taken up by the researcher. This can also help overcome a provider or researcher-centred bias often found in written surveys, which by nature, can only measure what is already known or expected to be of relevance to the researcher. Interviews can be audio- or video-taped; but sometimes it is only feasible or acceptable for the interviewer to take written notes [ 14 , 16 , 20 ].

Focus groups

Focus groups are group interviews to explore participants’ expertise and experiences, including explorations of how and why people behave in certain ways [ 1 ]. Focus groups usually consist of 6–8 people and are led by an experienced moderator following a topic guide or “script” [ 21 ]. They can involve an observer who takes note of the non-verbal aspects of the situation, possibly using an observation guide [ 21 ]. Depending on researchers’ and participants’ preferences, the discussions can be audio- or video-taped and transcribed afterwards [ 21 ]. Focus groups are useful for bringing together homogeneous (to a lesser extent heterogeneous) groups of participants with relevant expertise and experience on a given topic on which they can share detailed information [ 21 ]. Focus groups are a relatively easy, fast and inexpensive method to gain access to information on interactions in a given group, i.e. “the sharing and comparing” among participants [ 21 ]. Disadvantages include less control over the process and a lesser extent to which each individual may participate. Moreover, focus group moderators need experience, as do those tasked with the analysis of the resulting data. Focus groups can be less appropriate for discussing sensitive topics that participants might be reluctant to disclose in a group setting [ 13 ]. Moreover, attention must be paid to the emergence of “groupthink” as well as possible power dynamics within the group, e.g. when patients are awed or intimidated by health professionals.

Choosing the “right” method

As explained above, the school of thought underlying qualitative research assumes no objective hierarchy of evidence and methods. This means that each choice of single or combined methods has to be based on the research question that needs to be answered and a critical assessment with regard to whether or to what extent the chosen method can accomplish this – i.e. the “fit” between question and method [ 14 ]. It is necessary for these decisions to be documented when they are being made, and to be critically discussed when reporting methods and results.

Let us assume that our research aim is to examine the (clinical) processes around acute endovascular treatment (EVT), from the patient’s arrival at the emergency room to recanalization, with the aim to identify possible causes for delay and/or other causes for sub-optimal treatment outcome. As a first step, we could conduct a document study of the relevant standard operating procedures (SOPs) for this phase of care – are they up-to-date and in line with current guidelines? Do they contain any mistakes, irregularities or uncertainties that could cause delays or other problems? Regardless of the answers to these questions, the results have to be interpreted based on what they are: a written outline of what care processes in this hospital should look like. If we want to know what they actually look like in practice, we can conduct observations of the processes described in the SOPs. These results can (and should) be analysed in themselves, but also in comparison to the results of the document analysis, especially as regards relevant discrepancies. Do the SOPs outline specific tests for which no equipment can be observed or tasks to be performed by specialized nurses who are not present during the observation? It might also be possible that the written SOP is outdated, but the actual care provided is in line with current best practice. In order to find out why these discrepancies exist, it can be useful to conduct interviews. Are the physicians simply not aware of the SOPs (because their existence is limited to the hospital’s intranet) or do they actively disagree with them or does the infrastructure make it impossible to provide the care as described? Another rationale for adding interviews is that some situations (or all of their possible variations for different patient groups or the day, night or weekend shift) cannot practically or ethically be observed. In this case, it is possible to ask those involved to report on their actions – being aware that this is not the same as the actual observation. A senior physician’s or hospital manager’s description of certain situations might differ from a nurse’s or junior physician’s one, maybe because they intentionally misrepresent facts or maybe because different aspects of the process are visible or important to them. In some cases, it can also be relevant to consider to whom the interviewee is disclosing this information – someone they trust, someone they are otherwise not connected to, or someone they suspect or are aware of being in a potentially “dangerous” power relationship to them. Lastly, a focus group could be conducted with representatives of the relevant professional groups to explore how and why exactly they provide care around EVT. The discussion might reveal discrepancies (between SOPs and actual care or between different physicians) and motivations to the researchers as well as to the focus group members that they might not have been aware of themselves. For the focus group to deliver relevant information, attention has to be paid to its composition and conduct, for example, to make sure that all participants feel safe to disclose sensitive or potentially problematic information or that the discussion is not dominated by (senior) physicians only. The resulting combination of data collection methods is shown in Fig.  2 .

Possible combination of data collection methods

Attributions for icons: “Book” by Serhii Smirnov, “Interview” by Adrien Coquet, FR, “Magnifying Glass” by anggun, ID, “Business communication” by Vectors Market; all from the Noun Project

The combination of multiple data source as described for this example can be referred to as “triangulation”, in which multiple measurements are carried out from different angles to achieve a more comprehensive understanding of the phenomenon under study [ 22 , 23 ].

Data analysis

To analyse the data collected through observations, interviews and focus groups these need to be transcribed into protocols and transcripts (see Fig.  3 ). Interviews and focus groups can be transcribed verbatim , with or without annotations for behaviour (e.g. laughing, crying, pausing) and with or without phonetic transcription of dialects and filler words, depending on what is expected or known to be relevant for the analysis. In the next step, the protocols and transcripts are coded , that is, marked (or tagged, labelled) with one or more short descriptors of the content of a sentence or paragraph [ 2 , 15 , 23 ]. Jansen describes coding as “connecting the raw data with “theoretical” terms” [ 20 ]. In a more practical sense, coding makes raw data sortable. This makes it possible to extract and examine all segments describing, say, a tele-neurology consultation from multiple data sources (e.g. SOPs, emergency room observations, staff and patient interview). In a process of synthesis and abstraction, the codes are then grouped, summarised and/or categorised [ 15 , 20 ]. The end product of the coding or analysis process is a descriptive theory of the behavioural pattern under investigation [ 20 ]. The coding process is performed using qualitative data management software, the most common ones being InVivo, MaxQDA and Atlas.ti. It should be noted that these are data management tools which support the analysis performed by the researcher(s) [ 14 ].

From data collection to data analysis

Attributions for icons: see Fig. 2 , also “Speech to text” by Trevor Dsouza, “Field Notes” by Mike O’Brien, US, “Voice Record” by ProSymbols, US, “Inspection” by Made, AU, and “Cloud” by Graphic Tigers; all from the Noun Project

How to report qualitative research?

Protocols of qualitative research can be published separately and in advance of the study results. However, the aim is not the same as in RCT protocols, i.e. to pre-define and set in stone the research questions and primary or secondary endpoints. Rather, it is a way to describe the research methods in detail, which might not be possible in the results paper given journals’ word limits. Qualitative research papers are usually longer than their quantitative counterparts to allow for deep understanding and so-called “thick description”. In the methods section, the focus is on transparency of the methods used, including why, how and by whom they were implemented in the specific study setting, so as to enable a discussion of whether and how this may have influenced data collection, analysis and interpretation. The results section usually starts with a paragraph outlining the main findings, followed by more detailed descriptions of, for example, the commonalities, discrepancies or exceptions per category [ 20 ]. Here it is important to support main findings by relevant quotations, which may add information, context, emphasis or real-life examples [ 20 , 23 ]. It is subject to debate in the field whether it is relevant to state the exact number or percentage of respondents supporting a certain statement (e.g. “Five interviewees expressed negative feelings towards XYZ”) [ 21 ].

How to combine qualitative with quantitative research?

Qualitative methods can be combined with other methods in multi- or mixed methods designs, which “[employ] two or more different methods [ …] within the same study or research program rather than confining the research to one single method” [ 24 ]. Reasons for combining methods can be diverse, including triangulation for corroboration of findings, complementarity for illustration and clarification of results, expansion to extend the breadth and range of the study, explanation of (unexpected) results generated with one method with the help of another, or offsetting the weakness of one method with the strength of another [ 1 , 17 , 24 , 25 , 26 ]. The resulting designs can be classified according to when, why and how the different quantitative and/or qualitative data strands are combined. The three most common types of mixed method designs are the convergent parallel design , the explanatory sequential design and the exploratory sequential design. The designs with examples are shown in Fig.  4 .

Three common mixed methods designs

In the convergent parallel design, a qualitative study is conducted in parallel to and independently of a quantitative study, and the results of both studies are compared and combined at the stage of interpretation of results. Using the above example of EVT provision, this could entail setting up a quantitative EVT registry to measure process times and patient outcomes in parallel to conducting the qualitative research outlined above, and then comparing results. Amongst other things, this would make it possible to assess whether interview respondents’ subjective impressions of patients receiving good care match modified Rankin Scores at follow-up, or whether observed delays in care provision are exceptions or the rule when compared to door-to-needle times as documented in the registry. In the explanatory sequential design, a quantitative study is carried out first, followed by a qualitative study to help explain the results from the quantitative study. This would be an appropriate design if the registry alone had revealed relevant delays in door-to-needle times and the qualitative study would be used to understand where and why these occurred, and how they could be improved. In the exploratory design, the qualitative study is carried out first and its results help informing and building the quantitative study in the next step [ 26 ]. If the qualitative study around EVT provision had shown a high level of dissatisfaction among the staff members involved, a quantitative questionnaire investigating staff satisfaction could be set up in the next step, informed by the qualitative study on which topics dissatisfaction had been expressed. Amongst other things, the questionnaire design would make it possible to widen the reach of the research to more respondents from different (types of) hospitals, regions, countries or settings, and to conduct sub-group analyses for different professional groups.

How to assess qualitative research?

A variety of assessment criteria and lists have been developed for qualitative research, ranging in their focus and comprehensiveness [ 14 , 17 , 27 ]. However, none of these has been elevated to the “gold standard” in the field. In the following, we therefore focus on a set of commonly used assessment criteria that, from a practical standpoint, a researcher can look for when assessing a qualitative research report or paper.

Assessors should check the authors’ use of and adherence to the relevant reporting checklists (e.g. Standards for Reporting Qualitative Research (SRQR)) to make sure all items that are relevant for this type of research are addressed [ 23 , 28 ]. Discussions of quantitative measures in addition to or instead of these qualitative measures can be a sign of lower quality of the research (paper). Providing and adhering to a checklist for qualitative research contributes to an important quality criterion for qualitative research, namely transparency [ 15 , 17 , 23 ].

Reflexivity

While methodological transparency and complete reporting is relevant for all types of research, some additional criteria must be taken into account for qualitative research. This includes what is called reflexivity, i.e. sensitivity to the relationship between the researcher and the researched, including how contact was established and maintained, or the background and experience of the researcher(s) involved in data collection and analysis. Depending on the research question and population to be researched this can be limited to professional experience, but it may also include gender, age or ethnicity [ 17 , 27 ]. These details are relevant because in qualitative research, as opposed to quantitative research, the researcher as a person cannot be isolated from the research process [ 23 ]. It may influence the conversation when an interviewed patient speaks to an interviewer who is a physician, or when an interviewee is asked to discuss a gynaecological procedure with a male interviewer, and therefore the reader must be made aware of these details [ 19 ].

Sampling and saturation

The aim of qualitative sampling is for all variants of the objects of observation that are deemed relevant for the study to be present in the sample “ to see the issue and its meanings from as many angles as possible” [ 1 , 16 , 19 , 20 , 27 ] , and to ensure “information-richness [ 15 ]. An iterative sampling approach is advised, in which data collection (e.g. five interviews) is followed by data analysis, followed by more data collection to find variants that are lacking in the current sample. This process continues until no new (relevant) information can be found and further sampling becomes redundant – which is called saturation [ 1 , 15 ] . In other words: qualitative data collection finds its end point not a priori , but when the research team determines that saturation has been reached [ 29 , 30 ].

This is also the reason why most qualitative studies use deliberate instead of random sampling strategies. This is generally referred to as “ purposive sampling” , in which researchers pre-define which types of participants or cases they need to include so as to cover all variations that are expected to be of relevance, based on the literature, previous experience or theory (i.e. theoretical sampling) [ 14 , 20 ]. Other types of purposive sampling include (but are not limited to) maximum variation sampling, critical case sampling or extreme or deviant case sampling [ 2 ]. In the above EVT example, a purposive sample could include all relevant professional groups and/or all relevant stakeholders (patients, relatives) and/or all relevant times of observation (day, night and weekend shift).

Assessors of qualitative research should check whether the considerations underlying the sampling strategy were sound and whether or how researchers tried to adapt and improve their strategies in stepwise or cyclical approaches between data collection and analysis to achieve saturation [ 14 ].

Good qualitative research is iterative in nature, i.e. it goes back and forth between data collection and analysis, revising and improving the approach where necessary. One example of this are pilot interviews, where different aspects of the interview (especially the interview guide, but also, for example, the site of the interview or whether the interview can be audio-recorded) are tested with a small number of respondents, evaluated and revised [ 19 ]. In doing so, the interviewer learns which wording or types of questions work best, or which is the best length of an interview with patients who have trouble concentrating for an extended time. Of course, the same reasoning applies to observations or focus groups which can also be piloted.

Ideally, coding should be performed by at least two researchers, especially at the beginning of the coding process when a common approach must be defined, including the establishment of a useful coding list (or tree), and when a common meaning of individual codes must be established [ 23 ]. An initial sub-set or all transcripts can be coded independently by the coders and then compared and consolidated after regular discussions in the research team. This is to make sure that codes are applied consistently to the research data.

Member checking

Member checking, also called respondent validation , refers to the practice of checking back with study respondents to see if the research is in line with their views [ 14 , 27 ]. This can happen after data collection or analysis or when first results are available [ 23 ]. For example, interviewees can be provided with (summaries of) their transcripts and asked whether they believe this to be a complete representation of their views or whether they would like to clarify or elaborate on their responses [ 17 ]. Respondents’ feedback on these issues then becomes part of the data collection and analysis [ 27 ].

Stakeholder involvement

In those niches where qualitative approaches have been able to evolve and grow, a new trend has seen the inclusion of patients and their representatives not only as study participants (i.e. “members”, see above) but as consultants to and active participants in the broader research process [ 31 , 32 , 33 ]. The underlying assumption is that patients and other stakeholders hold unique perspectives and experiences that add value beyond their own single story, making the research more relevant and beneficial to researchers, study participants and (future) patients alike [ 34 , 35 ]. Using the example of patients on or nearing dialysis, a recent scoping review found that 80% of clinical research did not address the top 10 research priorities identified by patients and caregivers [ 32 , 36 ]. In this sense, the involvement of the relevant stakeholders, especially patients and relatives, is increasingly being seen as a quality indicator in and of itself.

How not to assess qualitative research

The above overview does not include certain items that are routine in assessments of quantitative research. What follows is a non-exhaustive, non-representative, experience-based list of the quantitative criteria often applied to the assessment of qualitative research, as well as an explanation of the limited usefulness of these endeavours.

Protocol adherence

Given the openness and flexibility of qualitative research, it should not be assessed by how well it adheres to pre-determined and fixed strategies – in other words: its rigidity. Instead, the assessor should look for signs of adaptation and refinement based on lessons learned from earlier steps in the research process.

Sample size

For the reasons explained above, qualitative research does not require specific sample sizes, nor does it require that the sample size be determined a priori [ 1 , 14 , 27 , 37 , 38 , 39 ]. Sample size can only be a useful quality indicator when related to the research purpose, the chosen methodology and the composition of the sample, i.e. who was included and why.

Randomisation

While some authors argue that randomisation can be used in qualitative research, this is not commonly the case, as neither its feasibility nor its necessity or usefulness has been convincingly established for qualitative research [ 13 , 27 ]. Relevant disadvantages include the negative impact of a too large sample size as well as the possibility (or probability) of selecting “ quiet, uncooperative or inarticulate individuals ” [ 17 ]. Qualitative studies do not use control groups, either.

Interrater reliability, variability and other “objectivity checks”

The concept of “interrater reliability” is sometimes used in qualitative research to assess to which extent the coding approach overlaps between the two co-coders. However, it is not clear what this measure tells us about the quality of the analysis [ 23 ]. This means that these scores can be included in qualitative research reports, preferably with some additional information on what the score means for the analysis, but it is not a requirement. Relatedly, it is not relevant for the quality or “objectivity” of qualitative research to separate those who recruited the study participants and collected and analysed the data. Experiences even show that it might be better to have the same person or team perform all of these tasks [ 20 ]. First, when researchers introduce themselves during recruitment this can enhance trust when the interview takes place days or weeks later with the same researcher. Second, when the audio-recording is transcribed for analysis, the researcher conducting the interviews will usually remember the interviewee and the specific interview situation during data analysis. This might be helpful in providing additional context information for interpretation of data, e.g. on whether something might have been meant as a joke [ 18 ].

Not being quantitative research

Being qualitative research instead of quantitative research should not be used as an assessment criterion if it is used irrespectively of the research problem at hand. Similarly, qualitative research should not be required to be combined with quantitative research per se – unless mixed methods research is judged as inherently better than single-method research. In this case, the same criterion should be applied for quantitative studies without a qualitative component.

The main take-away points of this paper are summarised in Table 1 . We aimed to show that, if conducted well, qualitative research can answer specific research questions that cannot to be adequately answered using (only) quantitative designs. Seeing qualitative and quantitative methods as equal will help us become more aware and critical of the “fit” between the research problem and our chosen methods: I can conduct an RCT to determine the reasons for transportation delays of acute stroke patients – but should I? It also provides us with a greater range of tools to tackle a greater range of research problems more appropriately and successfully, filling in the blind spots on one half of the methodological spectrum to better address the whole complexity of neurological research and practice.

Availability of data and materials

Not applicable.

Abbreviations

Endovascular treatment

Randomised Controlled Trial

Standard Operating Procedure

Standards for Reporting Qualitative Research

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• Published: 05 October 2018

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

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• J. Baillie 2  

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

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

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

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

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

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Introduction.

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

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

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

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

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

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

Overview of qualitative research

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

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

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

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

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

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

Types of interview

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

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

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

Conducting an interview

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

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

Greeting and explaining the project/interview

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

Asymmetry between the researcher and participant talking

Expressing interest and cultural ignorance

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

Creating hypothetical situations

Asking friendly questions

Knowing when to leave.

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

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

Box 1: Example of a topic guide

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

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

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

Why did you start cleaning their teeth at that point?

How often do you brush their teeth?

What do you use to brush their teeth and why?

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

Do you find anything difficult?

What makes cleaning their teeth easier for you?

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

Has it become easier or harder?

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

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

What do they enjoy about having their teeth cleaned?

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

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

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

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

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

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

Focus groups

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

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

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

Focus group considerations

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

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

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

Focus group management

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

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

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

Discussions within the group are confidential to the group

Only one person can speak at a time

All participants should have sufficient opportunity to contribute

There should be no unnecessary interruptions while someone is speaking

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

Challenging contrary opinions is appropriate, but ridiculing is not.

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

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

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

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

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

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

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Accepted : 02 July 2018

Published : 05 October 2018

Issue Date : 12 October 2018

DOI : https://doi.org/10.1038/sj.bdj.2018.815

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American Journal of Qualitative Research (AJQR)  is a quarterly peer-reviewed academic journal that publishes qualitative research articles from a number of social science disciplines such as psychology, health science, sociology, criminology, education, political science, and administrative studies. The journal is an international and interdisciplinary focus and greatly welcomes papers from all countries. The journal offers an intellectual platform for researchers, practitioners, administrators, and policymakers to contribute and promote qualitative research and analysis.

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Call for Papers- American Journal of Qualitative Research

American Journal of Qualitative Research (AJQR) welcomes original research articles and book reviews for its next issue. The AJQR is a quarterly and peer-reviewed journal published in February, May, August, and November.

We are seeking submissions for a forthcoming issue published in February 2024. The paper should be written in professional English. The length of 6000-10000 words is preferred. All manuscripts should be prepared in MS Word format and submitted online: https://www.editorialpark.com/ajqr

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Submission Deadline: November 15, 2023

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Dear AJQR Readers, 

Due to the high volume of submissions in the American Journal of Qualitative Research , the editorial board decided to publish quarterly since 2023.

Volume 8, Issue 2

Current issue - in progress.

The COVID-19 pandemic has highlighted and exacerbated the difficult juggling act women in the U.S. have to do between parenting their children and working outside the home. The pandemic has also led to a decline in maternal mental health, particularly among mothers with young children, mothers of color, and those with previous mental health issues. The authors noted these experiences in their own lives as mothers with children and observed them in the lives of the women around them. These observations informed the design of this narrative inquiry study, in which we used semi-structured interviews to explore mothers’ shifting ideas and experiences of mothering, work, and family life during a global pandemic. We used creative analytic practice (CAP) to compose reflexive researcher conversations around the interview data that enabled us to highlight nuances in the data, show more transparently our meaning-making, make visible our researcher subjectivities, show uncertainties about aspects of data interpretation, and create a more accessible data representation.

Keywords: Mothering, COVID-19 pandemic, U.S. women, Narrative inquiry, Creative analytic practice.

The COVID-19 pandemic put France’s healthcare system under extreme tension and led to significant levels of stress among healthcare professionals in general and nurses in particular. Research has shown how these elements affected nurses’ physical and psychological health and manifested as insomnia, anxiety, and depressive syndromes. The present qualitative study aimed to explore the lived experiences of France’s nurses as a function of their level of exposure to the virus and whether they worked in the hospital sector or practiced privately in the community during the pandemic’s first wave. It also sought to describe the resources nurses used to maintain their overall health. We administered 19 qualitative interviews to 19 nurses in the autumn of 2021. The present study revealed that nurses were subjected to significant stress during the pandemic. Our data analysis enabled us to draw out three principal themes: 1) Being on the edge in stormy period ; 2) Personal impact on several levels and 3) Floating together and learning. There were no significant differences between the groups that were subjected to different levels of exposure to COVID-19. All the groups were affected by the pandemic that struck a healthcare system that was already systematically fragile. Nurses were severely tested by the COVID-19 pandemic, but their consciousness of the importance of their role grew, despite questioning what meaning there was to their profession, perhaps even to their lives . The trauma still felt fresh 18 months later, during the interviews, and this cannot be ignored in future healthcare policymaking .

Keywords: COVID-19, nurses, salutogenesis, stressors, health resources.

Annual mammography screening is recommended by the US Preventive Services Task Force (USPSTF) and American Cancer Society (ACS) to reduce mortality through early detection of breast cancer. In rural Appalachia, rates of later-stage breast cancer incidence and mortality are higher than national averages. We explored the ways that providers and staff at breast cancer screening facilities employed novel approaches to overcome patient- and facility-level barriers to access to breast cancer screening in the Appalachian region. We conducted 23 semi-structured interviews with 28 clinical providers and staff of breast health facilities in Appalachia. Themes reflect how limiting features of breast screening facilities influenced access to care; the way patient-level barriers presented challenges to access to breast screening; and that external and regulatory forces presented obstacles to access to care. In addition, the unique geographical and geographical attributes of the Appalachian region shaped access and adherence to mammography screening recommendations. Thematic findings highlight that facilities implemented patient-centered strategies to overcome access-related barriers. Results may inform the ways breast cancer screening facilities address suboptimal access to breast health screening. They may also inform future resource allocations to enable facilities to reach breast cancer screening performance goals.

Keywords: rural health, breast cancer, preventive health care, women’s health.

Paternal parenting affects child development; hence, the father’s absence has a deleterious effect on the male child. The literature on parenting shows limited focus on how parenting impacts children by gender. This qualitative hermeneutic phenomenological study investigated the key question, “How does a father’s absence during childhood influence a man’s subsequent parenting of his son(s)?” An integrated theoretical framework was used to guide the study: Parenting Style Theory, Social-Cognitive Theory, and Bioecological Systems Theory. Nine Trinidadian males aged 20 to 35 years who were parenting sons were recruited to participate using snowball sampling. Data on men’s adverse childhood experiences were gathered using semi-structured interviews. Content and thematic analyses were done using DELVE software. Key findings include the influence of stereotypical cultural constructs, the church’s critical role in addressing childhood trauma, the transmission of father absence across generations, and the relationship between neurodevelopment and adverse childhood experiences. Implications of these findings will benefit child and adolescent advocacy, inform policymaking, aid professional intervention in mental health and education, and strengthen familial systems and ecclesiastical contexts. Future research should explore the lived experiences of men who crave emotional connection with their sons yet struggle with the stereotypical cultural perception of manhood.

Keywords: father absence, brain development, childhood trauma, intergenerational, the transmission of behavior.

The purpose of this qualitative transcendental phenomenological study was to understand the essence of the shared lived experiences of undergraduate college students with anxiety disorders at two universities in the Southeastern United States. Ellis’s cognitive theory, rational emotive behavior therapy, guided the study which took place at a mid-sized, public nonsectarian university and a small, private liberal arts college. The central research question elicited rich data regarding the shared lived experiences of the study participants. The four research sub-questions address participants’ perceptions regarding the impact of their disorders on their lifestyles and academic performance. A purposeful criterion sample was used to select the participants who completed a questionnaire, open-ended individual interviews, a single focus group interview, and participant journals. Phenomenological reduction was used to create a composite integration of meaning and the essence of the lived experience of the participants. Data results identified five themes: (a) social fears, (b) stressor issues, (c) generational issues, (d) academic performance barriers, and (e) institutional education and accommodation preferences.

Keywords: Alexithymia, anxiety, disorder, qualitative, stressors

School shootings are traumatic events that can lead to anxiety, depression, and post-traumatic stress disorder among students who experience these events. It is important to find effective strategies to help students cope with their return to school, as well as their anxiety and stress levels while on campus. There exists a gap in the literature on the effects of therapy dogs on students who have witnessed a school shooting. This current study used a retrospective mixed-methods survey that was sent to recent graduates of Marjory Stoneman Douglas High School (located in Parkland, Florida) who witnessed the February 2018 shooting. Data were collected to assess how the therapy dogs affected students' willingness to return to school and their stress/anxiety levels while on campus. Identified themes indicated that the therapy dogs helped with anxiety levels, stress levels, and overall moods of Marjory Stoneman Douglas High School students. These findings provide important implications for community leaders and school administrators who want to promote healing and well-being in a community that has experienced violence.

Keywords: Therapy dog, school shooting, community violence.

Identifying the relation between the processes of programming and foreign language writing may lead to new directions for programming language and natural language focused instructional design. The present qualitative case study supported by quantitative data investigated foreign language writing experiences of computer engineering students taking an object-oriented programming course. Forty-five sophomores learning programming and academic English simultaneously in a foundation university in Ankara, Turkey, were selected purposefully for the case study. There were two data sources (students’ opinions and documents) and three data collection tools (a semi-structured interview, a short diary, and a composition. In terms of the findings of the research, four themes were obtained; however, only the use of metacognitive strategies will be explained in detail due to the length of the study. Participants stated that they feel the positive effects of programming experience on the use of self-evaluation strategy and that there are similarities and differences between the processes of programming and foreign language writing. Participants’ views on the effect of programming on foreign language writing did not differ according to their writing and programming performance scores. Participants stated that programming experience may have an effect on the use of metacognitive language learning strategies in the writing process. Upon analyzing participants’ comments, it is understood that programming experience does not hinder the use of metacognitive strategies but has a role in supporting and reinforcing their use. It is suggested that multiple case studies be done for similar views on the effects of programming and that each finding be proven by quantitative studies.

Keywords: programming, foreign language writing, metacognitive strategies.

The significance of participatory decision-making in educational institutions is widely acknowledged as essential in school management and administration. This study aimed to determine how involved teachers are in making decisions in their schools and what role they think they play in shaping different parts of school policies and procedures. It also looked at their perspectives on how decisions made by others are carried out in schools. Semi-structured interviews with 10 secondary school teachers focused on teachers' role in decision-making related to their routine school tasks, strategic decision-making, participatory role in making school decisions, and their willingness to participate in decision-making. This study showed that teachers' low participation is attributed to their shared desire to be involved in school management and administration-related decisions. Teachers expressed that participatory school-based decision-making can promote collaboration and collectivism among the school staff, and it plays a significant role in shaping their work satisfaction and motivation. By gaining insights into teachers' perspectives, this study aims to contribute to the broader understanding of participatory school decision-making in the Rwandan secondary education system and communicate potential improvements for fostering a more collaborative and inclusive educational environment.

Keywords: teachers’ perceptions, qualitative research, decision-making, secondary schools.

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• Open access
• Published: 04 May 2024

Identifying gaps in healthcare: a qualitative study of Ukrainian refugee experiences in the German system, uncovering differences, information and support needs

• Kristin Rolke 1 ,
• Johanna Walter 1 ,
• Klaus Weckbecker 1 ,
• Eva Münster 1 &
• Judith Tillmann 1  

BMC Health Services Research volume  24 , Article number:  585 ( 2024 ) Cite this article

Metrics details

The 5.8 million Ukrainian refugees arriving in European countries must navigate varying healthcare systems and different and often unknown languages in their respective host countries. To date, there has been little exploration of the experiences, perceived differences, information and support needs of these refugees regarding the use of healthcare in Germany.

We conducted ten qualitative interviews with Ukrainian refugees living in Germany from February to May 2023, using Ukrainian, English and German language. The transcribed interviews were analysed using the qualitative content analysis method according to Kuckartz and Rädiker with the MAXQDA software.

In general, participants consistently had a positive experience of the German healthcare system, particularly regarding the quality of treatments and insurance. Differences have been reported in the structure of the healthcare systems. The Ukrainian healthcare system is divided into private and state sectors, with no mandatory insurance and frequent out-of-pocket payments. Pathways differ and tend to focus more on clinics and private doctors. General practitioners, often working in less well-equipped offices, have only recently gained prominence due to healthcare system reforms. Initiating contact with doctors is often easier, with much shorter waiting times compared to Germany. Interviewees often found the prescription requirements for many medications in Germany to be unusual. However, the mentioned differences in healthcare result in unmet information needs among the refugees, especially related to communication, navigating the healthcare system, health insurance, waiting times and medication access. These needs were often addressed through personal internet research and informal (social media) networks because of lacking official information provided during or after their arrival.

Conclusions

Despite the positive experiences of Ukrainian refugees in the German healthcare system, differences in the systems and language barriers led to barriers using healthcare and information needs among refugees. The dissemination of information regarding characteristics of the German health care system is crucial for successful integration but is currently lacking.

Trial Registration

German Clinical Trials Register: DRKS00030942, date of registration: 29.12.2022.

Peer Review reports

Since the beginning of the war in Ukraine on 24th February 2022, more than 5.8 million people from Ukraine have been registered as refugees in European countries; in Germany, the number is estimated at more than one million in 2023 [ 1 ]. 80% of adult refugees in Germany are women, nearly half of them came to Germany with their minor children and live mostly in private accommodations [ 2 ]. Since June 2022, refugees from Ukraine are not required to go through an asylum procedure due to the Temporary Protection Directive (2001/55/EG), but receive temporary protection in the European Union for up to three years after registration in the Central Register of Foreigners. They are thus entitled to medical care according to the catalog of the statutory health insurance (SHI) [ 3 ]. In Germany, around 90% of the population is covered by SHI [ 4 ]. There is an obligation to be insured in a SHI up to a fixed income limit. Earners above this limit and some professional groups can opt for private health insurance. Healthcare is primarily financed by contributions from citizens and employers, as along with subsidies from tax revenue [ 5 ]. In Germany, the Standing Committee on Vaccination (STIKO) makes recommendations on the implementation of vaccinations in accordance with § 20 (2) of the Infectious Diseases Protection Act (IfSG). Vaccination is only compulsory for measles for all children aged one year and above who attend community facilities such as kindergartens or schools, as well as some occupational groups. The healthcare system in Germany is divided into outpatient care, the hospital sector and rehabilitation facilities. The general practitioner is often the first point of contact in case of health problems and refers patients to other specialists if necessary; patients can also consult other specialists directly without a referral.

Ukrainian refugees have rarely been prepared for the contact with healthcare in Germany, which can be attributed to the rapid outbreak of war and the sudden flight. German health professionals can often look back on a long history of experience in treating refugees. Nevertheless they now face new regulations due to the EU mass influx directive [ 3 ] and also a lack of information flow, e.g. in regard of information for practice teams and a lack of networking with psychotherapeutic services, contact points, medication databases and regional interpreter services [ 6 ]. Differences in the healthcare systems, such as their structure and initial contacts/pathways in case of illness, prescription rules of medication, and coping with diseases may play a role in becoming familiar with another healthcare system.

Differences in the healthcare system are rarely described in the literature or health data. Findings include, for example, corruption problems with procurement of medication [ 7 ], low vaccination coverage rates e.g. regarding polio or COVID-19, and one of the highest burdens in Europe of chronic infectious diseases such as tuberculosis and HIV in Ukraine [ 8 , 9 ]. Life expectancy at birth in Ukraine is on average 65.2 years for men (Germany: 78.6 years), significantly lower than for women with 74.4 years (Germany: 83.4 years) [ 10 , 11 ]. The Ukrainian healthcare system is underfunded, which leads to high out-of-pocket expenditure on the part of the population in order to achieve adequate care, although formally the healthcare system provides free care in public healthcare facilities. Besides, taking out health insurance is voluntary [ 12 , 13 ].

In 2018 the state healthcare system in Ukraine was reformed. The reform of general practitioner (GP) care in Ukraine has included a free choice of doctor and stronger gatekeeping by the GP in the form of a referral system-similar to that in Germany [ 7 , 13 ]. Literature from UK and Poland indicate that Ukrainian refugees are in need of healthcare services, especially for chronic diseases, gynecological and obstetric treatments as well as mental health [ 14 , 15 ].

Experiences and challenges in contact with Ukrainian refugees in Germany from the viewpoint ofGPs have been researched in 2022 in a quantitative study. Communication, lack of information on previous illnesses, refugees’ expectations of services to be provided (e.g. routine unsubstantiated blood tests, thyroid tests, prescription of multivitamin supplements), and drug prescription due to unavailable or unknown medication were mentioned by GPs as the most common challenges [ 6 ]. A publication from Poland on health system differences between Ukraine and Poland indicates differences in immunization programs and prevalence of some infectious diseases [ 16 ]. However, the experiences and needs of Ukrainian refugees themselves in other healthcare systems, especially the German one, have rarely been studied and are of high current relevance. They are essential to understand patients’ points of view and to develop solutions to improve care and facilitate the arrival and integration of refugees in the German healthcare system.

That is why we focus on this topic in the following study (RefUGe-P) and aim to answer the following research questions in this publication:

How do Ukrainian refugees experience healthcare in Germany regarding major differences to the system in Ukraine and which information and support needs can be identified?

The methodological elaboration of the study was carried out taking into account the COREQ guideline [ 17 ].

Study design

For this study, ten Ukrainian refugees from four cities in the German region of North-Rhine-Westphalia (NRW) were interviewed in person in German, English and Ukrainian. Theoretical saturation was reached after ten interviews were conducted, so no further interview participants were recruited. The two German and two English interviews were conducted by the project staff. The six interviews in Ukrainian were conducted with the help of interpreters who translated in the interview from Ukrainian to German and vice versa. The interpreters worked on a voluntary basis, but had a lot of experience in interpreting for Ukrainian refugees at medical appointments. Additionally, information materials and consent forms were translated into the respective languages and handed out before participation.

The interview participants were recruited in various ways, mostly face-to face, via multipliers (responsible municipal employees, employees of welfare organisations, people of Ukrainian origin who volunteer to translate for refugees in the federal state of North Rhine-Westphalia) known to the project staff in four cities. The multipliers received detailed information about the planned study as well as information about the necessary inclusion criteria for participation, both orally and through a project flyer and a study information sheet. The aforementioned information materials were made available to the multipliers for their workplace and they approached refugees about the project. Interested persons were then able to contact the project staff directly or informed the multipliers about their interest for participation. The prerequisite for participation was that the interviewees were at least 18 years old and had visited a general practitioner in Germany at least once after their arrival. Additionally, it was aimed to achieve diversity among participants in terms of age, gender, family situation and health status. One potential participant was excluded because he/she had not seen a GP himself/herself as a patient.

Participants received an information sheet about the study with information on data protection and filled in a short questionnaire about sociodemographic information. These documents were also explained to every participant in person by the interviewer. All participants were fully informed by the interviewers about the study, data protection and signed written informed consent forms.

The development of the interview guide was based on the guidelines developed by Helfferich [ 18 ] and began with open narrative stimuli (opening question Appendix 1) before progressing to more specific questions. Since the research interest included different topic-specific aspects, the interview form of the problem-centered interview according to Witzel [ 19 ] was considered during guide development.

Additionally, an expert advisory board consisting of five representatives from various disciplines (including general practice, local authorities, welfare organisations and interpreters) was established to accompany the project and was involved in the preparation of the interview guide and preparation and interpretation of results. The interview guide has been newly developed for this study and is available as supplementary material (appendix 1). The main topics of the semi-structured interviews are shown there. The interview guide was pretested in two interview situations. One pretest was conducted in German, one in English whereby no adjustments had to be made.

All interviews were conducted between February and May 2023 and lasted an average of 45 min (35 min to 1 h and 10 min). They were audio-recorded and fully transcribed by an external service provider in German and English and coded in these languages. Interview protocols were written after each interview, noting special incidents and details about the interview location and atmosphere which were included in the analyses.

Data analysis

The transcribed interviews were analysed using the qualitative content analysis method according to Kuckartz and Rädiker [ 20 ] with the computer software MAXQDA version 20 and 22. The content analysis according to Kuckartz and Rädiker can be carried out in three forms (to structure content, to evaluate it or to form types) [ 20 ]. The former was used for this project in order to be able to analyse the material in terms of content and topic.

The codes were developed through both deductive and inductive methods (Fig.  1 ). Deductive categories were formed by the subject areas that had already been recorded in the interview guide. Inductive categories were developed directly from the material.

Coding tree with relevant categories for this article, RefUGe-P

The interviews were independently coded by two authors and the results were subsequently compared and discussed. This process aimed to improve the quality of results and mitigate the influence of subjective perspectives. One of these authors is a public health scientist with a PhD and several years of work experience in the field of migration and health and the other is a psychologist and medical student.

Sample characteristics

A total of ten interviews were conducted with seven female and three male participants. The participants had an average age of 47.6 years (min. 29 years, max. 70 years). Additional participant characteristics are presented in Table  1 .

Refugees constitute a vulnerable group of people and this was considered during the study’s conception and research design. The interview questions were checked in advance to ensure that personal events and memories related to the flight experience were not discussed, thus minimizing the potential for retraumatization during the interviews. One interviewer was experienced in working with interview partners who had refugee experiences through prior project experience and workshops regarding this topic. The second interviewer received information and exchange of experiences via the project team. The multipliers assisting with recruitment had established positive relationships with the participants. They personally introduced the interviewers, contributing to the development of trust.

The Ethics Committee of the University Witten/Herdecke, Germany, granted approval for this study (reference number: S-219/2022).

In general, the participants’ experience of the German healthcare system was consistently positive. Interviewees positively mentioned the good and thorough treatment, as well as the extensive technical equipment of the doctors’ offices and health insurance. In particular, the inclusion of patients in treatment decisions and the information provided, for example in the case of upcoming surgical procedures, were positively emphasized in the interviews. Likewise, the reminder of the possibility to participate in preventive check-ups in old age was appreciated.

“So the first thing that comes to my mind and I think is very good, I got the insurance and immediately got the invitations for examinations. Mammography and colonoscopy. What I have never experienced in Ukraine like this.” (I5)

Differences between the German and the Ukrainian healthcare system

Pathways and structure of the healthcare system.

The interviewees reported that the healthcare system in Ukraine consists of a private and a state system, which exist side by side. Since there is no mandatory health insurance in Ukraine, according to the interviewees, citizens have the freedom to choose the services they want to use. Financial viability plays a major role in their decision-making. While many services provided by the state system are free of charge, those provided by private institutions must be paid for privately. The interviewees therefore reported different utilization patterns, which can be summarized in three scenarios: Exclusive use of the state system, exclusive use of the private system, or use of both systems.

“ I had a GP in Ukraine and then another private doctor and I communicated with both of them. Depending on the time (…) and then, because I had money, I got insurance also. ” (I5)

In case of illness, the participants in Ukraine usually went to a (poly)clinic containing many specialized medical fields, presented their concerns and were referred to the appropriate department. Some went to a physician assigned to them according to their place of residence. In urgent cases, private physicians could be visited directly on the same day. Home visits were also common in this context. Patients could request and pay for blood tests at laboratories and could immediately access their test results after processing.

“So suppose you call and it is said that the doctor can only come the day after tomorrow, but you urgently want him to come today, then you can pay money so that he comes today. Which is also not very expensive, so the equivalent of about ten euros.” (I6)

Some of the private institutions were considered to be of higher quality, both in medical treatment and in the equipment. Participants often had the mobile phone number of their doctors and could contact them around the clock. They got a diagnosis from remote and started treatment as suggested.

“If I have a fever or something then I can contact my doctor conveniently via Viber or WhatsApp. I text my doctor, my daughter is sick, she can’t eat and drink and she has a fever, what should I do, and the doctor writes what I should do. For example, you have to go to the hospital now, or go to the pharmacy and buy such tablets.” (I2)

In Ukraine a general practitioner system was also established in 2018. However, according to the interviewees, this has not yet been established everywhere across the country and private payments still exist.

Health insurance

Interviewees reported that health insurance covering major health treatment in case of illness likewise in Germany is not common in Ukraine and just a minority can afford it. Therefore, services are used when needed, often in the private sector, in order to be treated immediately. Surgeries in particular were described as very expensive and often unaffordable. Many Ukrainians save money for years in order to pay a medical treatment. The need for regular medication and its acquisition is described to be particularly challenging for elderly people due to the low pensions.

“(…) I don’t have this system in Ukraine because we don’t have obligatory health insurance. People in Ukraine don’t have this system. That’s why they can pay money for the first visit or for next visits and just came to the doctor and have health (…) treatment. (…) You just need to pay money and go to doctor.” (I1)

Some of the interviewees also reported that since the reform of the healthcare system in Ukraine, health insurance with fixed monthly rates has been introduced, but that it is not functioning effectively. However, state care is often described to be of lower quality and private payments to doctors are still frequent. In Germany, they experienced the insurance system as better and medical care as more affordable.

“Concerning the pediatrician. I can always call him and somehow ask him what medication I have to give my children now or what I should do when she feels ill. But I always send money in return. That means it’s always about money. And if you don’t do it, then nobody cares about you in the health system.” (I7)

Waiting times

All of the interviewees were initially surprised by the long waiting times in Germany. Waiting for months to get specialist appointments and long waiting times in doctor’s offices and clinics were unfamiliar to the refugees. Some found these long waiting times to be stressful and problematic. Furthermore, concerns were expressed about not receiving help quickly enough in case of emergency. Interviewees also reported difficulties in finding a GP who was not busy and still accepting new patients.

“(…) So this is long, long, long everywhere. You need to wait for an appointment, you need to wait in a waiting room. You will need to wait. Yeah, I understand. It’s different from Ukrainian system, but, yes, sometimes it’s exhausting.” (I1)

As a result, some of the interview participants thought about returning to Ukraine for treatment or knew other people who did this.

“She called several doctors nearby, dermatology yes, and the earliest appointment was only in three months. And what did she do? She went to Ukraine. We can go to Ukraine. And she bought a ticket in the bus, and went to city A by bus, and she did everything for one day. In the clinic she made laser, she had all blood tests. In the morning she had all the results.” (I2)

Prescription of medication and vaccination

The requirement for a prescription to obtain medication in Germany was unfamiliar to some interviewees. In Ukraine, various medicines were bought without a prescription, including antibiotics. The interviewees also observed that German doctors prescribe fewer medications than Ukrainian ones and they often recommend alternatives for symptoms like fever and headaches.

“But in Ukraine it is really common (…) when my kids are sick, I always got a prescription with total list of pills, even if it is like common fever or something like that.” (I1)

In addition to people who experienced this as positive, there were also negative statements, for example when antibiotics were not prescribed for infections and therefore then ordered in Ukraine. Additionally, individual reports highlighted differences in medication quality (better in Germany), and availability (certain Ukrainian combination medications were not available in Germany).

“She (the GP) said to me that my daughter must drink more tea and I will be honest with you, I called to my friends. They lived in (city in Germany) and I asked them to call my doctor in Ukraine so I can find an antibiotic.” (I9)

The mothers interviewed also wondered about the vaccinations given to their children, which they did not know from Ukraine. Most Ukrainian participants were also unaware of adult booster vaccinations. The majority was vaccinated only in childhood. Several interviewees reported that there is no structured approach to adult immunization in Ukraine. One person said that he/she did not know where to go as an adult to get vaccinations in Ukraine.

“But what I did here, for example, the doctor here immediately offered to do so and so many vaccinations. After sixty years. And we never got such an offer in Ukraine.” (I3)

Information and support needs

Most of the interviewees did not receive information about the German healthcare system, medical care and insurance in Germany. Instead, they had to seek information themselves, often by doing their own research on the internet. Frequently friends, relatives, hosts, language course teachers, interpreters, etc. were asked for information. Some of the interviewees described this process as difficult. Often they asked other Ukrainians in their place of residence, e.g. through Telegram or other online Ukrainian community groups. There, doctors were recommended, lists were shared, information was spread, questions were asked and translation help was offered or requested. Interpreters are searched for through these networks as well to overcome language barriers.

“We have some webs, there is this group in Telegram (…) and we have the big, big list and people ask maybe who knows some gynecologist or something like this and people help.” (I9)

Table  2 specifies frequently mentioned information needs and improvement requests from refugees in Germany, along with selected quotes.

Our study identified perceived differences between the German and Ukrainian healthcare systems with the Ukrainian system still being shaped by out-of-pocket payments, private care, no mandatory insurance, and a GP system only gaining prominence in the recent years before the war. Easier contact to doctors with shorter waiting times and less prescription requirements for some medications have been reported about Ukraine. These differences in combination with lacking official information provided during or after arrival lead to unmet information and support needs among Ukrainian refugees living in Germany.

The results are particularly relevant in light of the fact that many Ukrainians would like to live in Germany in the long term, recorded in current surveys [ 2 ]. Therefore, it is crucial to ensure the successful integration of this patient group and a mutual understanding of their needs to provide equal healthcare opportunities. Some of the results of this article may also be of interest to other countries, as the findings on the structure and characteristics of the Ukrainian healthcare sector can be compared regionally. In addition, the results show parallels to studies on refugees from other countries of origin in Germany, e.g. persisting communication problems [ 21 , 22 ].

Pathways in the healthcare system and waiting times

In Ukraine, fast access to healthcare, especially if the services are privately paid for, results in short waiting times and easy access to doctors. Therefore, Ukrainians in the German system are not used to experience long waiting times and not to have the ability to expedite the processes themselves. As reported from the interviewees in Ukraine, patients often commission, pay for and receive their own medical analyses. In the interviews it became clear that the different approach and the different circumstances in Germany can cause a feeling of loss of control and unpredictability. As patients in Ukraine, they were able to act in a self-determined manner and, for example, pay money in order to be treated more quickly. In Germany, faster access to care is particularly important in the case of acute or life-threatening conditions. It might be perceived as impatience or high expectations, but it primarily stems from differences in healthcare systems, habits and the lack of information dissemination. Ukrainian-language information on the German healthcare system should be provided to the refugees as soon as they arrive.

Prescription of medication and prevention

The respondents were often unfamiliar with preventive care services and booster vaccinations in adulthood. This lack of awareness may be attributed to the low vaccination rates in Ukraine prior to the war, which led to outbreaks of vaccine-preventable diseases such as measles and polio between 2017 and 2020 [ 23 ]. Despite a national vaccination schedule provided by the Ministry of health in Ukraine [ 24 ], vaccination rates are among the lowest in Europe. Preventive measures in Germany (e.g. cancer screening) were welcomed after information and explanation in our study. At the same time, people with a migration background have an on average lower level of health literacy with regard to preventive care services in Germany compared to people without a migration background [ 25 ]. Therefore, it can be useful to inform and educate patients about this approach to healthcare and to increase health literacy in general.

Participants also reported differences about how medication is prescribed and taken like quick prescription of medications by Ukrainian doctors. Since antibiotics were also sold over-the-counter in Ukraine until recently [ 26 ], self-medication occurred frequently. Having a large number of different medications were not rare in households. This old practice was criticized among some younger respondents and they appreciate the new reform regulations in Ukraine and feel comfortable with the treatment approach in Germany. It is essential for doctors and medical staff to be aware of these differences to address misconceptions and raise awareness about (in)effectiveness of medications.

Participants valued their membership in the German SHI as it provided them with a sense of security. However, not all participants were accustomed to this, as they often had to save up the required amount for healthcare. Because of this difference, the respondents wished to receive more information about the scope of medical services provided by the SHI, as it was not clear to them that most costs of necessary medication are included, whilst dental treatment, for example, partially requires private payment. This information should be made available upon arrival in Germany.

None of our interviewees received information about the German healthcare system or healthcare in general through official channels. The fact that information about the health care system is often obtained via informal channels is also reported in other (inter-)national studies [ 22 , 27 ]. This should be changed urgently to improve care and facilitate access for the refugees. As there is a lot of Ukrainian and Russian information online created for example by the Federal Office for Migration and Refugees ( www.germany4ukraine.de ), but it does not seem to reach the refugees, the distribution should be improved. This should already be done upon arrival, e.g. at registration at the Foreigners’ Registration Office or at the Citizens’ Registration Office in case of residence registration, but can also be useful in doctor’s offices.

As also identified in other studies [ 6 , 16 , 28 ], refugees in our study perceived some information and support needs to healthcare regarding communication. In many cases, the treating physicians demanded that an interpreting person must be present. Refugees, on the one hand, are therefore under pressure to find interpreters, who are often rare, in a country and system they often do not know and on the other hand, they always have to seek help. This situation also led them to bypass the issue and seek out Russian-speaking doctors. Still, the costs for professional interpreters are generally not reimbursed in GP practices and have to be paid by the patient [ 29 ]. There is a need for interpreters, preferably paid and professional, both when making and taking advantage of appointments. This has already been demanded for general practice and practices in general [ 30 , 31 , 32 ]. Biddle et al. [ 21 ] also emphasize the expansion of high-quality interpreting services in Germany. It cannot be the task of the refugees to look for and pay for interpreters. This should be urgently organized by the state, for example through (municipal) contact points for interpreter seekers and (telephone or video) interpreter services for medical consultations.

Limitations

Around half of the interviews were conducted with the help of interpreters. The real-time translation by interpreters demands a high level of concentration. An exact reproduction of all interview content is hardly possible, so that a loss of information cannot be prevented [ 33 ]. The interpreters were known to the patients from previous medical appointments and had already established a relationship of trust with them. However, multipliers, researchers and interpreters involved made it clear that participation was voluntary and emphasised the aims of the research work. Furthermore, the interviews were solely conducted in NRW, Germany’s most populous federal state. The study could therefore be expanded throughout Germany and with more participants in order to gain further insights - including into regional differences. However, through the broad spread of age groups, gender, locations, diseases and the inclusion of several multipliers, we have attempted to get a broad picture.

This study provides important and new information about the healthcare experiences of Ukrainian refugees in Germany, differences in the healthcare systems and resulting information and support needs from the perspective of refugees.

Participants’ experiences of the German healthcare system were predominantly positive, especially because of the quality of treatments and health insurance. Nonetheless, health system differences in pathways, responsibilities, structure, insurance and costs, quality, medication and prevention as well as waiting times are noticeable for Ukrainian refugees in the German healthcare system, and influence their utilization of services. On top of this, the language barrier is a huge and still unsolved problem. Disseminating information about the new healthcare system shortly after the arrival of Ukrainian refugees in Germany, conducting educational efforts and tackling language barriers are essential for successful integration, but are lacking in Germany.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

general practitioner

North Rhine-Westphalia

statutory health insurance

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Acknowledgements

We would like to thank all interview partners for their openness and very informative conversations. We would also like to thank all the experts of our advisory board for the deep and insightful discussions during the meetings and the engagement beyond, especially the two interpreters. We also thank the University of Witten/Herdecke for the financial support of the study.

This research received funding from the internal grant program (project IFF 2023-68) of the Faculty of Health at Witten/Herdecke University, Germany.

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KR developed the interview guide with team support, recruited participants with the assistance of multipliers, conducted the majority of the interviews, wrote big parts of the manuscript. JT mainly devised the basic idea and research concept, conducted background research on the topic, contributed essentially to the development of the interview guide, analysed the interviews in collaboration with JW, wrote big parts of the manuscript and provided guidance as the project leader throughout all phases. JW conducted essential research on the topic, conducted part of the interviews, jointly analysed them with JT and wrote parts of the results section. KW devised the basic idea, provided practical medical expertise and made significant contribution to data interpretation. EM contributed to the discussion section and significantly contribution to data interpretation. All authors read and approved the final manuscript and are accountable for all aspects of the work.

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In recent years, qualitative research methods in criminology have experienced a notable resurgence. This is evidenced by various scholarly endeavors, including the publication of works such as ‘Qualitative Research in Criminology: Cutting-Edge Methods’ (edited by Faria & Dodge, 2022 ), ‘ Liquid Criminology. Doing imaginative criminological research ’ (edited by Hviid Jacobsen & Walklate, 2016 ), ‘The Routledge Handbook of Qualitative Criminology ’ (edited by Copes & Miller, 2015 ), ‘ Qualitative Research in Criminology’ (Treadwell, 2019 ). The establishment of journals such as Qualitative Criminology and initiatives like the Working Group on Qualitative Research Methodologies and Epistemologies at the European Society of Criminology, or the the Qualitative Research Network in Criminology & Criminal Justice (QRN-CCJ) also signify a renewed recognition of the importance of qualitative approaches in understanding complex criminologically relevant phenomena. More recently, the CrimRxiv Consortium started a curation hub on qualitative criminology aimed at spotlighting studies based on non-numeric data.

Diverse criminological subfields such as global and green criminology, cultural criminology, and narrative criminology, have not only enriched our understanding of the respective topics but have also paved the way for innovative qualitative methodologies. Creative, reflexive and interventionist epistemologies and methodologies proved to be prerequisite, in order to imaginatively (Mills, 1959 ; Young, 2011 ) understand the contemporary social harms of dislocation, surveillance, incarceration, impoverishment, mind-numbing consumerism, experiences of uprooting and existential uncertainty, environmental degradation, global pandemics, the dynamics of social movements, and polarization. Moreover, research into the ever more present online world and online identities, the call for new approaches to data collection and analysis, the use of sensory methods, co-creation strategies, appeals to sensitivity to diversity and reflexivity from researchers - all of this has influenced greatly the panorama in qualitative research, particularly so in the study of crime and deviance, victimization and harm, crime control and related topics.

However, despite many innovations, qualitative researchers continue to grapple with numerous challenges. This includes navigating ethical considerations and the relatively recent data protection regulations, accessing and recruiting participants for studies on sensitive topics, and overcoming difficulties in publishing (Dodge & Parker, 2023 ). Qualitative research remains labor-intensive and requires tailor-made approaches. Numbers still push policy, the field of criminology still suffers from ‘methodological fetisjism’ and is easily seduced by actuarial tendencies, in which dominant research methods contribute to mystification of social realities and the politics of everyday life (Ferrell, 2009 ; Young, 2011 ). To complement knowledge produced employing rather detached methods of criminological inquiry, the aim of qualitative approaches is to foreground meaning, performance, unpredictability, engagement, reflexivity, creativity and, eventually, progressive transformations. Of course, such approaches exhibit great variation across different subfields, epistemological traditions, and geographical contexts. This diversity highlights the need to critically interrogate familiar epistemological frameworks and research agendas shaped by Global-North perspectives. Therefore, this special issue of Crime Law and Social Change focuses on qualitative research ‘from the periphery.’

By periphery, we refer not only to marginalized topics and populations within criminological discourse but also to innovative methodological approaches and underrepresented geographic traditions. The collection of papers featured in this special issue embodies this commitment to exploring the ‘periphery’ of qualitative criminological research, explicitly offering broadly relevant methodological insights, drawing on authors’ research experiences. More subtly, it also intends to red flag the peripheric interest that scientific journals have in qualitative research.

The first paper, A farewell to the lone hero researcher: Team research and writing , Sveinung Sandberg and Lucero Ibarra Rojas challenge the archetype of the lone hero researcher and advocate for collaborative approaches to qualitative research. Drawing upon their experiences in Mexico and Norway, the authors argue for the importance of team research and writing, as a means of addressing power differentials and promoting diversity.

In Rich scholar, poor scholar: inequalities in research capacity, “knowledge” abysses, and the value of unconventional approaches to research David Rodriguez Goyes and May-Len Skilbrei examine material inequalities in research capacity and propose unconventional approaches to data collection. Their paper highlights the global disparities in knowledge production and advocates for innovative methods that democratize access to meaningful data, using examples from their research in Colombia and Russia.

Janeille Zorina Matthews’ contribution titled Creating the Demand for Better Crime Policy: Qualitative Frame Analysis as a Vehicle for Social Transformation explores the potential of Qualitative Frame Analysis (QFA) as a tool for shaping crime discourse and informing policy. By analyzing framing strategies in Antigua and Barbuda, Matthews demonstrates the transformative power of qualitative methodologies in challenging dominant narratives.

In Ethnographic semantics and documentary method in criminology. A combination of reconstructive approaches using the example of Municipal Law Enforcement Services Ina Hennen introduces the documentary method and ethnographic semantics as two complementary approaches, based on her research with German Municipal Law Enforcement Services. Through an ethnomethodological design, Hennen illustrates how these methodologies deepen our understanding of security practices in public spaces.

Next, in their Mapmaking as visual storytelling: The movement and emotion of managing sex work in the urban landscape , Sara Jordenö and Amber Horning-Ruf foreground visual storytelling methods. Their interdisciplinary approach combines psychogeography and mapmaking to elucidate the emotional and spatial dynamics of sex work in urban landscapes, offering insights into the lived experiences and social relations of sex workers.

Finally, an original approach is presented in Lorenzo Natali’s The social perception of environmental victimization. A visual and sensory methodological proposal . Natali proposes a visual and sensory methodology for studying environmental victimization, highlighting the perspectives of those affected by environmental harm and employs photo elicitation and itinerant soliloquy to deepen our understanding and challenge familiar perspectives.

The reality in which we set up our inquiries is ever evolving and so does the need to understand and respond to the current complexities of crime, control, conflicts, and threats. From the specter of totalitarianism to the existential threat of global warming, radicalization, and the challenges of artificial intelligence, the current sociopolitical landscape underscores the urgency of mobilizing engaged qualitative research to understand and address pressing issues. The ever-shifting nature of current social, political, and technological phenomena needs to be addressed by qualitative methods which, by their nature, are especially well-suited to offer new theories and explanations based on detailed and nuanced accounts of complex phenomena. In that sense, discussions of critical and creative qualitative methodologies such as the ones presented in this special issue serve, in the first place, as meeting spaces for researchers working on seemingly distant topics, as fora for addressing epistemological and ethical questions and reimagining the boundaries of qualitative criminological research. Only last and least as mere methodological-technical discussions.

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Treadwell, J. (2019). Qualitative Research in Criminology, In P. Atkinson, S. Delamont, A. Cernat, J.W. Sakshaug, & R.A. Williams (Eds.), SAGE Research Methods Foundations https://doi.org/10.4135/9781526421036847209 .

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Energy & Environmental Science

Reconfiguring european industry for net-zero: a qualitative review of hydrogen and carbon capture utilization and storage benefits and implementation challenges †.

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a Professor of Earth and Environment, Boston University, USA

b Center for Energy Technologies, Department of Business Development and Technology, Aarhus University, Denmark

c Bennett Institute for Innovation and Policy Acceleration, University of Sussex Business School, Jubilee 367, Brighton, UK E-mail: [email protected]

d Khalifa University, United Arab Emirates

Based on a rich corpus of original mixed-methods research, this paper explores the benefits, barriers, and justice impacts of industrial decarbonization via hydrogen and carbon capture utilization and storage (CCUS) via European industrial firms located in UK clusters. It asks: (1) what are the technology dynamics and drivers of both hydrogen and CCUS in a real-world deployment context, including the state of deployment plans? (2) what are the possible benefits of CCUS and hydrogen deployment? (3) What are the most significant barriers and challenges facing CCUS and hydrogen implementation? (4) Who stands to “win” the most from deployment, who stands to “lose,” what possible inequitable community impacts could emerge, and what impact will deployment have on vulnerable groups? We offer answers to these four questions based on extensive semi-structured research interviews ( N = 111) triangulated with site visits to industrial clusters ( N = 52) as well as an extensive secondary review of the academic literature. We conclude with clear policy insights that are now prevalent across UK and European industrial clusters as well as emerging and context-specific recommendations concerning the adoption of hydrogen and CCUS to achieve net-zero industry globally.

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B. K. Sovacool, D. F. Del Rio, K. Herman, M. Iskandarova, J. M. Uratani and S. Griffiths, Energy Environ. Sci. , 2024, Advance Article , DOI: 10.1039/D3EE03270A

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What It Means To Be Asian in America

The lived experiences and perspectives of asian americans in their own words.

Asians are the fastest growing racial and ethnic group in the United States. More than 24 million Americans in the U.S. trace their roots to more than 20 countries in East and Southeast Asia and the Indian subcontinent.

The majority of Asian Americans are immigrants, coming to understand what they left behind and building their lives in the United States. At the same time, there is a fast growing, U.S.-born generation of Asian Americans who are navigating their own connections to familial heritage and their own experiences growing up in the U.S.

In a new Pew Research Center analysis based on dozens of focus groups, Asian American participants described the challenges of navigating their own identity in a nation where the label “Asian” brings expectations about their origins, behavior and physical self. Read on to see, in their own words, what it means to be Asian in America.

• Introduction

Table of Contents

This is how i view my identity, this is how others see and treat me, this is what it means to be home in america, about this project, methodological note, acknowledgments.

No single experience defines what it means to be Asian in the United States today. Instead, Asian Americans’ lived experiences are in part shaped by where they were born, how connected they are to their family’s ethnic origins, and how others – both Asians and non-Asians – see and engage with them in their daily lives. Yet despite diverse experiences, backgrounds and origins, shared experiences and common themes emerged when we asked: “What does it mean to be Asian in America?”

In the fall of 2021, Pew Research Center undertook the largest focus group study it had ever conducted – 66 focus groups with 264 total participants – to hear Asian Americans talk about their lived experiences in America. The focus groups were organized into 18 distinct Asian ethnic origin groups, fielded in 18 languages and moderated by members of their own ethnic groups. Because of the pandemic, the focus groups were conducted virtually, allowing us to recruit participants from all parts of the United States. This approach allowed us to hear a diverse set of voices – especially from less populous Asian ethnic groups whose views, attitudes and opinions are seldom presented in traditional polling. The approach also allowed us to explore the reasons behind people’s opinions and choices about what it means to belong in America, beyond the preset response options of a traditional survey.

The terms “Asian,” “Asians living in the United States” and “Asian American” are used interchangeably throughout this essay to refer to U.S. adults who self-identify as Asian, either alone or in combination with other races or Hispanic identity.

“The United States” and “the U.S.” are used interchangeably with “America” for variations in the writing.

Multiracial participants are those who indicate they are of two or more racial backgrounds (one of which is Asian). Multiethnic participants are those who indicate they are of two or more ethnicities, including those identified as Asian with Hispanic background.

U.S. born refers to people born in the 50 U.S. states or the District of Columbia, Puerto Rico, or other U.S. territories.

Immigrant refers to people who were not U.S. citizens at birth – in other words, those born outside the U.S., Puerto Rico or other U.S. territories to parents who were not U.S. citizens. The terms “immigrant,” “first generation” and “foreign born” are used interchangeably in this report.  

Second generation refers to people born in the 50 states or the District of Columbia with at least one first-generation, or immigrant, parent.

The pan-ethnic term “Asian American” describes the population of about 22 million people living in the United States who trace their roots to more than 20 countries in East and Southeast Asia and the Indian subcontinent. The term was popularized by U.S. student activists in the 1960s and was eventually adopted by the U.S. Census Bureau. However, the “Asian” label masks the diverse demographics and wide economic disparities across the largest national origin groups (such as Chinese, Indian, Filipino) and the less populous ones (such as Bhutanese, Hmong and Nepalese) living in America. It also hides the varied circumstances of groups immigrated to the U.S. and how they started their lives there. The population’s diversity often presents challenges . Conventional survey methods typically reflect the voices of larger groups without fully capturing the broad range of views, attitudes, life starting points and perspectives experienced by Asian Americans. They can also limit understanding of the shared experiences across this diverse population.

Across all focus groups, some common findings emerged. Participants highlighted how the pan-ethnic “Asian” label used in the U.S. represented only one part of how they think of themselves. For example, recently arrived Asian immigrant participants told us they are drawn more to their ethnic identity than to the more general, U.S.-created pan-ethnic Asian American identity. Meanwhile, U.S.-born Asian participants shared how they identified, at times, as Asian but also, at other times, by their ethnic origin and as Americans.

Another common finding among focus group participants is the disconnect they noted between how they see themselves and how others view them. Sometimes this led to maltreatment of them or their families, especially at heightened moments in American history such as during Japanese incarceration during World War II, the aftermath of 9/11 and, more recently, the COVID-19 pandemic. Beyond these specific moments, many in the focus groups offered their own experiences that had revealed other people’s assumptions or misconceptions about their identity.

Another shared finding is the multiple ways in which participants take and express pride in their cultural and ethnic backgrounds while also feeling at home in America, celebrating and blending their unique cultural traditions and practices with those of other Americans.

This focus group project is part of a broader research agenda about Asians living in the United States. The findings presented here offer a small glimpse of what participants told us, in their own words, about how they identify themselves, how others see and treat them, and more generally, what it means to be Asian in America.

Illustrations by Jing Li

Publications from the Being Asian in America project

• Read the data essay: What It Means to Be Asian in America
• Watch the documentary: Being Asian in America
• Explore the interactive: In Their Own Words: The Diverse Perspectives of Being Asian in America
• View expanded interviews: Extended Interviews: Being Asian in America
• About this research project: More on the Being Asian in America project
• Q&A: Why and how Pew Research Center conducted 66 focus groups with Asian Americans

One of the topics covered in each focus group was how participants viewed their own racial or ethnic identity. Moderators asked them how they viewed themselves, and what experiences informed their views about their identity. These discussions not only highlighted differences in how participants thought about their own racial or ethnic background, but they also revealed how different settings can influence how they would choose to identify themselves. Across all focus groups, the general theme emerged that being Asian was only one part of how participants viewed themselves.

The pan-ethnic label ‘Asian’ is often used more in formal settings

“I think when I think of the Asian Americans, I think that we’re all unique and different. We come from different cultures and backgrounds. We come from unique stories, not just as a group, but just as individual humans.” Mali , documentary participant

Many participants described a complicated relationship with the pan-ethnic labels “Asian” or “Asian American.” For some, using the term was less of an active choice and more of an imposed one, with participants discussing the disconnect between how they would like to identify themselves and the available choices often found in formal settings. For example, an immigrant Pakistani woman remarked how she typically sees “Asian American” on forms, but not more specific options. Similarly, an immigrant Burmese woman described her experience of applying for jobs and having to identify as “Asian,” as opposed to identifying by her ethnic background, because no other options were available. These experiences highlight the challenges organizations like government agencies and employers have in developing surveys or forms that ask respondents about their identity. A common sentiment is one like this:

“I guess … I feel like I just kind of check off ‘Asian’ [for] an application or the test forms. That’s the only time I would identify as Asian. But Asian is too broad. Asia is a big continent. Yeah, I feel like it’s just too broad. To specify things, you’re Taiwanese American, that’s exactly where you came from.”

–U.S.-born woman of Taiwanese origin in early 20s

Smaller ethnic groups default to ‘Asian’ since their groups are less recognizable

Other participants shared how their experiences in explaining the geographic location and culture of their origin country led them to prefer “Asian” when talking about themselves with others. This theme was especially prominent among those belonging to smaller origin groups such as Bangladeshis and Bhutanese. A Lao participant remarked she would initially say “Asian American” because people might not be familiar with “Lao.”

“​​[When I fill out] forms, I select ‘Asian American,’ and that’s why I consider myself as an Asian American. [It is difficult to identify as] Nepali American [since] there are no such options in forms. That’s why, Asian American is fine to me.”

–Immigrant woman of Nepalese origin in late 20s

“Coming to a big country like [the United States], when people ask where we are from … there are some people who have no idea about Bhutan, so we end up introducing ourselves as being Asian.”

–Immigrant woman of Bhutanese origin in late 40s

But for many, ‘Asian’ as a label or identity just doesn’t fit

Many participants felt that neither “Asian” nor “Asian American” truly captures how they view themselves and their identity. They argue that these labels are too broad or too ambiguous, as there are so many different groups included within these labels. For example, a U.S.-born Pakistani man remarked on how “Asian” lumps many groups together – that the term is not limited to South Asian groups such as Indian and Pakistani, but also includes East Asian groups. Similarly, an immigrant Nepalese man described how “Asian” often means Chinese for many Americans. A Filipino woman summed it up this way:

“Now I consider myself to be both Filipino and Asian American, but growing up in [Southern California] … I didn’t start to identify as Asian American until college because in [the Los Angeles suburb where I lived], it’s a big mix of everything – Black, Latino, Pacific Islander and Asian … when I would go into spaces where there were a lot of other Asians, especially East Asians, I didn’t feel like I belonged. … In media, right, like people still associate Asian with being East Asian.”

–U.S.-born woman of Filipino origin in mid-20s

Participants also noted they have encountered confusion or the tendency for others to view Asian Americans as people from mostly East Asian countries, such as China, Japan and Korea. For some, this confusion even extends to interactions with other Asian American groups. A Pakistani man remarked on how he rarely finds Pakistani or Indian brands when he visits Asian stores. Instead, he recalled mostly finding Vietnamese, Korean and Chinese items.

Among participants of South Asian descent, some identified with the label “South Asian” more than just “Asian.” There were other nuances, too, when it comes to the labels people choose. Some Indian participants, for example, said people sometimes group them with Native Americans who are also referred to as Indians in the United States. This Indian woman shared her experience at school:

“I love South Asian or ‘Desi’ only because up until recently … it’s fairly new to say South Asian. I’ve always said ‘Desi’ because growing up … I’ve had to say I’m the red dot Indian, not the feather Indian. So annoying, you know? … Always a distinction that I’ve had to make.”

–U.S.-born woman of Indian origin in late 20s

Participants with multiethnic or multiracial backgrounds described their own unique experiences with their identity. Rather than choosing one racial or ethnic group over the other, some participants described identifying with both groups, since this more accurately describes how they see themselves. In some cases, this choice reflected the history of the Asian diaspora. For example, an immigrant Cambodian man described being both Khmer/Cambodian and Chinese, since his grandparents came from China. Some other participants recalled going through an “identity crisis” as they navigated between multiple identities. As one woman explained:

“I would say I went through an identity crisis. … It’s because of being multicultural. … There’s also French in the mix within my family, too. Because I don’t identify, speak or understand the language, I really can’t connect to the French roots … I’m in between like Cambodian and Thai, and then Chinese and then French … I finally lumped it up. I’m just an Asian American and proud of all my roots.”

–U.S.-born woman of Cambodian origin in mid-30s

In other cases, the choice reflected U.S. patterns of intermarriage. Asian newlyweds have the highest intermarriage rate of any racial or ethnic group in the country. One Japanese-origin man with Hispanic roots noted:

“So I would like to see myself as a Hispanic Asian American. I want to say Hispanic first because I have more of my mom’s culture in me than my dad’s culture. In fact, I actually have more American culture than my dad’s culture for what I do normally. So I guess, Hispanic American Asian.”

–U.S.-born man of Hispanic and Japanese origin in early 40s

Other identities beyond race or ethnicity are also important

Focus group participants also talked about their identity beyond the racial or ethnic dimension. For example, one Chinese woman noted that the best term to describe her would be “immigrant.” Faith and religious ties were also important to some. One immigrant participant talked about his love of Pakistani values and how religion is intermingled into Pakistani culture. Another woman explained:

“[Japanese language and culture] are very important to me and ingrained in me because they were always part of my life, and I felt them when I was growing up. Even the word itadakimasu reflects Japanese culture or the tradition. Shinto religion is a part of the culture. They are part of my identity, and they are very important to me.”

–Immigrant woman of Japanese origin in mid-30s

For some, gender is another important aspect of identity. One Korean participant emphasized that being a woman is an important part of her identity. For others, sexual orientation is an essential part of their overall identity. One U.S.-born Filipino participant described herself as “queer Asian American.” Another participant put it this way:

“I belong to the [LGBTQ] community … before, what we only know is gay and lesbian. We don’t know about being queer, nonbinary. [Here], my horizon of knowing what genders and gender roles is also expanded … in the Philippines, if you’ll be with same sex, you’re considered gay or lesbian. But here … what’s happening is so broad, on how you identify yourself.”

–Immigrant woman of Filipino origin in early 20s

Immigrant identity is tied to their ethnic heritage

Participants born outside the United States tended to link their identity with their ethnic heritage. Some felt strongly connected with their ethnic ties due to their citizenship status. For others, the lack of permanent residency or citizenship meant they have stronger ties to their ethnicity and birthplace. And in some cases, participants said they held on to their ethnic identity even after they became U.S. citizens. One woman emphasized that she will always be Taiwanese because she was born there, despite now living in the U.S.

For other participants, family origin played a central role in their identity, regardless of their status in the U.S. According to some of them, this attitude was heavily influenced by their memories and experiences in early childhood when they were still living in their countries of origin. These influences are so profound that even after decades of living in the U.S., some still feel the strong connection to their ethnic roots. And those with U.S.-born children talked about sending their kids to special educational programs in the U.S. to learn about their ethnic heritage.

“Yes, as for me, I hold that I am Khmer because our nationality cannot be deleted, our identity is Khmer as I hold that I am Khmer … so I try, even [with] my children today, I try to learn Khmer through Zoom through the so-called Khmer Parent Association.”

–Immigrant man of Cambodian origin in late 50s

Navigating life in America is an adjustment

Many participants pointed to cultural differences they have noticed between their ethnic culture and U.S. culture. One of the most distinct differences is in food. For some participants, their strong attachment to the unique dishes of their families and their countries of origin helps them maintain strong ties to their ethnic identity. One Sri Lankan participant shared that her roots are still in Sri Lanka, since she still follows Sri Lankan traditions in the U.S. such as preparing kiribath (rice with coconut milk) and celebrating Ramadan.

For other participants, interactions in social settings with those outside their own ethnic group circles highlighted cultural differences. One Bangladeshi woman talked about how Bengalis share personal stories and challenges with each other, while others in the U.S. like to have “small talk” about TV series or clothes.

Many immigrants in the focus groups have found it is easier to socialize when they are around others belonging to their ethnicity. When interacting with others who don’t share the same ethnicity, participants noted they must be more self-aware about cultural differences to avoid making mistakes in social interactions. Here, participants described the importance of learning to “fit in,” to avoid feeling left out or excluded. One Korean woman said:

“Every time I go to a party, I feel unwelcome. … In Korea, when I invite guests to my house and one person sits without talking, I come over and talk and treat them as a host. But in the United States, I have to go and mingle. I hate mingling so much. I have to talk and keep going through unimportant stories. In Korea, I am assigned to a dinner or gathering. I have a party with a sense of security. In America, I have nowhere to sit, and I don’t know where to go and who to talk to.”

–Immigrant woman of Korean origin in mid-40s

And a Bhutanese immigrant explained:

“In my case, I am not an American. I consider myself a Bhutanese. … I am a Bhutanese because I do not know American culture to consider myself as an American. It is very difficult to understand the sense of humor in America. So, we are pure Bhutanese in America.”

–Immigrant man of Bhutanese origin in early 40s

Language was also a key aspect of identity for the participants. Many immigrants in the focus groups said they speak a language other than English at home and in their daily lives. One Vietnamese man considered himself Vietnamese since his Vietnamese is better than his English. Others emphasized their English skills. A Bangladeshi participant felt that she was more accepted in the workplace when she does more “American” things and speaks fluent English, rather than sharing things from Bangladeshi culture. She felt that others in her workplace correlate her English fluency with her ability to do her job. For others born in the U.S., the language they speak at home influences their connection to their ethnic roots.

“Now if I go to my work and do show my Bengali culture and Asian culture, they are not going to take anything out of it. So, basically, I have to show something that they are interested in. I have to show that I am American, [that] I can speak English fluently. I can do whatever you give me as a responsibility. So, in those cases I can’t show anything about my culture.”

–Immigrant woman of Bangladeshi origin in late 20s

“Being bi-ethnic and tri-cultural creates so many unique dynamics, and … one of the dynamics has to do with … what it is to be Americanized. … One of the things that played a role into how I associate the identity is language. Now, my father never spoke Spanish to me … because he wanted me to develop a fluency in English, because for him, he struggled with English. What happened was three out of the four people that raised me were Khmer … they spoke to me in Khmer. We’d eat breakfast, lunch and dinner speaking Khmer. We’d go to the temple in Khmer with the language and we’d also watch videos and movies in Khmer. … Looking into why I strongly identify with the heritage, one of the reasons is [that] speaking that language connects to the home I used to have [as my families have passed away].”

–U.S.-born man of Cambodian origin in early 30s

Balancing between individualistic and collective thinking

For some immigrant participants, the main differences between themselves and others who are seen as “truly American” were less about cultural differences, or how people behave, and more about differences in “mindset,” or how people think . Those who identified strongly with their ethnicity discussed how their way of thinking is different from a “typical American.” To some, the “American mentality” is more individualistic, with less judgment on what one should do or how they should act . One immigrant Japanese man, for example, talked about how other Japanese-origin co-workers in the U.S. would work without taking breaks because it’s culturally inconsiderate to take a break while others continued working. However, he would speak up for himself and other workers when they are not taking any work breaks. He attributed this to his “American” way of thinking, which encourages people to stand up for themselves.

Some U.S.-born participants who grew up in an immigrant family described the cultural clashes that happened between themselves and their immigrant parents. Participants talked about how the second generation (children of immigrant parents) struggles to pursue their own dreams while still living up to the traditional expectations of their immigrant parents.

“I feel like one of the biggest things I’ve seen, just like [my] Asian American friends overall, is the kind of family-individualistic clash … like wanting to do your own thing is like, is kind of instilled in you as an American, like go and … follow your dream. But then you just grow up with such a sense of like also wanting to be there for your family and to live up to those expectations, and I feel like that’s something that’s very pronounced in Asian cultures.”

–U.S.-born man of Indian origin in mid-20s

Discussions also highlighted differences about gender roles between growing up in America compared with elsewhere.

“As a woman or being a girl, because of your gender, you have to keep your mouth shut [and] wait so that they call on you for you to speak up. … I do respect our elders and I do respect hearing their guidance but I also want them to learn to hear from the younger person … because we have things to share that they might not know and that [are] important … so I like to challenge gender roles or traditional roles because it is something that [because] I was born and raised here [in America], I learn that we all have the equal rights to be able to speak and share our thoughts and ideas.”

U.S. born have mixed ties to their family’s heritage

“I think being Hmong is somewhat of being free, but being free of others’ perceptions of you or of others’ attempts to assimilate you or attempts to put pressure on you. I feel like being Hmong is to resist, really.” Pa Houa , documentary participant

How U.S.-born participants identify themselves depends on their familiarity with their own heritage, whom they are talking with, where they are when asked about their identity and what the answer is used for. Some mentioned that they have stronger ethnic ties because they are very familiar with their family’s ethnic heritage. Others talked about how their eating habits and preferred dishes made them feel closer to their ethnic identity. For example, one Korean participant shared his journey of getting closer to his Korean heritage because of Korean food and customs. When some participants shared their reasons for feeling closer to their ethnic identity, they also expressed a strong sense of pride with their unique cultural and ethnic heritage.

“I definitely consider myself Japanese American. I mean I’m Japanese and American. Really, ever since I’ve grown up, I’ve really admired Japanese culture. I grew up watching a lot of anime and Japanese black and white films. Just learning about [it], I would hear about Japanese stuff from my grandparents … myself, and my family having blended Japanese culture and American culture together.”

–U.S.-born man of Japanese origin in late 20s

Meanwhile, participants who were not familiar with their family’s heritage showed less connection with their ethnic ties. One U.S.-born woman said she has a hard time calling herself Cambodian, as she is “not close to the Cambodian community.” Participants with stronger ethnic ties talked about relating to their specific ethnic group more than the broader Asian group. Another woman noted that being Vietnamese is “more specific and unique than just being Asian” and said that she didn’t feel she belonged with other Asians. Some participants also disliked being seen as or called “Asian,” in part because they want to distinguish themselves from other Asian groups. For example, one Taiwanese woman introduces herself as Taiwanese when she can, because she had frequently been seen as Chinese.

Some in the focus groups described how their views of their own identities shifted as they grew older. For example, some U.S.-born and immigrant participants who came to the U.S. at younger ages described how their experiences in high school and the need to “fit in” were important in shaping their own identities. A Chinese woman put it this way:

“So basically, all I know is that I was born in the United States. Again, when I came back, I didn’t feel any barrier with my other friends who are White or Black. … Then I got a little confused in high school when I had trouble self-identifying if I am Asian, Chinese American, like who am I. … Should I completely immerse myself in the American culture? Should I also keep my Chinese identity and stuff like that? So yeah, that was like the middle of that mist. Now, I’m pretty clear about myself. I think I am Chinese American, Asian American, whatever people want.”

–U.S.-born woman of Chinese origin in early 20s

Identity is influenced by birthplace

“I identified myself first and foremost as American. Even on the forms that you fill out that says, you know, ‘Asian’ or ‘Chinese’ or ‘other,’ I would check the ‘other’ box, and I would put ‘American Chinese’ instead of ‘Chinese American.’” Brent , documentary participant

When talking about what it means to be “American,” participants offered their own definitions. For some, “American” is associated with acquiring a distinct identity alongside their ethnic or racial backgrounds, rather than replacing them. One Indian participant put it this way:

“I would also say [that I am] Indian American just because I find myself always bouncing between the two … it’s not even like dual identity, it just is one whole identity for me, like there’s not this separation. … I’m doing [both] Indian things [and] American things. … They use that term like ABCD … ‘American Born Confused Desi’ … I don’t feel that way anymore, although there are those moments … but I would say [that I am] Indian American for sure.”

–U.S.-born woman of Indian origin in early 30s

Meanwhile, some U.S.-born participants view being American as central to their identity while also valuing the culture of their family’s heritage.

Many immigrant participants associated the term “American” with immigration status or citizenship. One Taiwanese woman said she can’t call herself American since she doesn’t have a U.S. passport. Notably, U.S. citizenship is an important milestone for many immigrant participants, giving them a stronger sense of belonging and ultimately calling themselves American. A Bangladeshi participant shared that she hasn’t received U.S. citizenship yet, and she would call herself American after she receives her U.S. passport.

Other participants gave an even narrower definition, saying only those born and raised in the United States are truly American. One Taiwanese woman mentioned that her son would be American since he was born, raised and educated in the U.S. She added that while she has U.S. citizenship, she didn’t consider herself American since she didn’t grow up in the U.S. This narrower definition has implications for belonging. Some immigrants in the groups said they could never become truly American since the way they express themselves is so different from those who were born and raised in the U.S. A Japanese woman pointed out that Japanese people “are still very intimidated by authorities,” while those born and raised in America give their opinions without hesitation.

“As soon as I arrived, I called myself a Burmese immigrant. I had a green card, but I still wasn’t an American citizen. … Now I have become a U.S. citizen, so now I am a Burmese American.”

–Immigrant man of Burmese origin in mid-30s

“Since I was born … and raised here, I kind of always view myself as American first who just happened to be Asian or Chinese. So I actually don’t like the term Chinese American or Asian American. I’m American Asian or American Chinese. I view myself as American first.”

–U.S.-born man of Chinese origin in early 60s

“[I used to think of myself as] Filipino, but recently I started saying ‘Filipino American’ because I got [U.S.] citizenship. And it just sounds weird to say Filipino American, but I’m trying to … I want to accept it. I feel like it’s now marry-able to my identity.”

–Immigrant woman of Filipino origin in early 30s

For others, American identity is about the process of ‘becoming’ culturally American

Immigrant participants also emphasized how their experiences and time living in America inform their views of being an “American.” As a result, some started to see themselves as Americans after spending more than a decade in the U.S. One Taiwanese man considered himself an American since he knows more about the U.S. than Taiwan after living in the U.S. for over 52 years.

But for other immigrant participants, the process of “becoming” American is not about how long they have lived in the U.S., but rather how familiar they are with American culture and their ability to speak English with little to no accent. This is especially true for those whose first language is not English, as learning and speaking it without an accent can be a big challenge for some. One Bangladeshi participant shared that his pronunciation of “hot water” was very different from American English, resulting in confusions in communication. By contrast, those who were more confident in their English skills felt they can better understand American culture and values as a result, leading them to a stronger connection with an American identity.

“[My friends and family tease me for being Americanized when I go back to Japan.] I think I seem a little different to people who live in Japan. I don’t think they mean anything bad, and they [were] just joking, because I already know that I seem a little different to people who live in Japan.”

–Immigrant man of Japanese origin in mid-40s

“I value my Hmong culture, and language, and ethnicity, but I also do acknowledge, again, that I was born here in America and I’m grateful that I was born here, and I was given opportunities that my parents weren’t given opportunities for.”

–U.S.-born woman of Hmong origin in early 30s

During the focus group discussions about identity, a recurring theme emerged about the difference between how participants saw themselves and how others see them. When asked to elaborate on their experiences and their points of view, some participants shared experiences they had with people misidentifying their race or ethnicity. Others talked about their frustration with being labeled the “model minority.” In all these discussions, participants shed light on the negative impacts that mistaken assumptions and labels had on their lives.

All people see is ‘Asian’

For many, interactions with others (non-Asians and Asians alike) often required explaining their backgrounds, reacting to stereotypes, and for those from smaller origin groups in particular, correcting the misconception that being “Asian” means you come from one of the larger Asian ethnic groups. Several participants remarked that in their own experiences, when others think about Asians, they tend to think of someone who is Chinese. As one immigrant Filipino woman put it, “Interacting with [non-Asians in the U.S.], it’s hard. … Well, first, I look Spanish. I mean, I don’t look Asian, so would you guess – it’s like they have a vision of what an Asian [should] look like.” Similarly, an immigrant Indonesian man remarked how Americans tended to see Asians primarily through their physical features, which not all Asian groups share.

Several participants also described how the tendency to view Asians as a monolithic group can be even more common in the wake of the COVID-19 pandemic.

“The first [thing people think of me as] is just Chinese. ‘You guys are just Chinese.’ I’m not the only one who felt [this] after the COVID-19 outbreak. ‘Whether you’re Japanese, Korean, or Southeast Asian, you’re just Chinese [to Americans]. I should avoid you.’ I’ve felt this way before, but I think I’ve felt it a bit more after the COVID-19 outbreak.”

–Immigrant woman of Korean origin in early 30s

At the same time, other participants described their own experiences trying to convince others that they are Asian or Asian American. This was a common experience among Southeast Asian participants.

“I have to convince people I’m Asian, not Middle Eastern. … If you type in Asian or you say Asian, most people associate it with Chinese food, Japanese food, karate, and like all these things but then they don’t associate it with you.”

–U.S.-born man of Pakistani origin in early 30s

The model minority myth and its impact

“I’ve never really done the best academically, compared to all my other Asian peers too. I never really excelled. I wasn’t in honors. … Those stereotypes, I think really [have] taken a toll on my self-esteem.” Diane , documentary participant

Across focus groups, immigrant and U.S.-born participants described the challenges of the seemingly positive stereotypes of Asians as intelligent, gifted in technical roles and hardworking. Participants often referred to this as the “model minority myth.”

The label “model minority” was coined in the 1960s and has been used to characterize Asian Americans as financially and educationally successful and hardworking when compared with other groups. However, for many Asians living in the United States, these characterizations do not align with their lived experiences or reflect their socioeconomic backgrounds. Indeed, among Asian origin groups in the U.S., there are wide differences in economic and social experiences. 

Academic research on the model minority myth has pointed to its impact beyond Asian Americans and towards other racial and ethnic groups, especially Black Americans, in the U.S. Some argue that the model minority myth has been used to justify policies that overlook the historical circumstances and impacts of colonialism, slavery, discrimination and segregation on other non-White racial and ethnic groups.

Many participants noted ways in which the model minority myth has been harmful. For some, expectations based on the myth didn’t match their own experiences of coming from impoverished communities. Some also recalled experiences at school when they struggled to meet their teachers’ expectations in math and science.

“As an Asian person, I feel like there’s that stereotype that Asian students are high achievers academically. They’re good at math and science. … I was a pretty mediocre student, and math and science were actually my weakest subjects, so I feel like it’s either way you lose. Teachers expect you to fit a certain stereotype and if you’re not, then you’re a disappointment, but at the same time, even if you are good at math and science, that just means that you’re fitting a stereotype. It’s [actually] your own achievement, but your teachers might think, ‘Oh, it’s because they’re Asian,’ and that diminishes your achievement.”

–U.S.-born woman of Korean origin in late 20s

Some participants felt that even when being Asian worked in their favor in the job market, they encountered stereotypes that “Asians can do quality work with less compensation” or that “Asians would not complain about anything at work.”

“There is a joke from foreigners and even Asian Americans that says, ‘No matter what you do, Asians always do the best.’ You need to get A, not just B-plus. Otherwise, you’ll be a disgrace to the family. … Even Silicon Valley hires Asian because [an] Asian’s wage is cheaper but [they] can work better. When [work] visa overflow happens, they hire Asians like Chinese and Indian to work in IT fields because we are good at this and do not complain about anything.”

–Immigrant man of Thai origin in early 40s

Others expressed frustration that people were placing them in the model minority box. One Indian woman put it this way:

“Indian people and Asian people, like … our parents or grandparents are the ones who immigrated here … against all odds. … A lot of Indian and Asian people have succeeded and have done really well for themselves because they’ve worked themselves to the bone. So now the expectations [of] the newer generations who were born here are incredibly unrealistic and high. And you get that not only from your family and the Indian community, but you’re also getting it from all of the American people around you, expecting you to be … insanely good at math, play an instrument, you know how to do this, you know how to do that, but it’s not true. And it’s just living with those expectations, it’s difficult.”

–U.S.-born woman of Indian origin in early 20s

Whether U.S. born or immigrants, Asians are often seen by others as foreigners

“Being only not quite 10 years old, it was kind of exciting to ride on a bus to go someplace. But when we went to Pomona, the assembly center, we were stuck in one of the stalls they used for the animals.” Tokiko , documentary participant

Across all focus groups, participants highlighted a common question they are asked in America when meeting people for the first time: “Where are you really from?” For participants, this question implied that people think they are “foreigners,” even though they may be longtime residents or citizens of the United States or were born in the country. One man of Vietnamese origin shared his experience with strangers who assumed that he and his friends are North Korean. Perhaps even more hurtful, participants mentioned that this meant people had a preconceived notion of what an “American” is supposed to look like, sound like or act like. One Chinese woman said that White Americans treated people like herself as outsiders based on her skin color and appearance, even though she was raised in the U.S.

Many focus group participants also acknowledged the common stereotype of treating Asians as “forever foreigners.” Some immigrant participants said they felt exhausted from constantly being asked this question by people even when they speak perfect English with no accent. During the discussion, a Korean immigrant man recalled that someone had said to him, “You speak English well, but where are you from?” One Filipino participant shared her experience during the first six months in the U.S.:

“You know, I spoke English fine. But there were certain things that, you know, people constantly questioning you like, oh, where are you from? When did you come here? You know, just asking about your experience to the point where … you become fed up with it after a while.”

–Immigrant woman of Filipino origin in mid-30s

U.S.-born participants also talked about experiences when others asked where they are from. Many shared that they would not talk about their ethnic origin right away when answering such a question because it often led to misunderstandings and assumptions that they are immigrants.

“I always get that question of, you know, ‘Where are you from?’ and I’m like, ‘I’m from America.’ And then they’re like, ‘No. Where are you from-from ?’ and I’m like, ‘Yeah, my family is from Pakistan,’ so it’s like I always had like that dual identity even though it’s never attached to me because I am like, of Pakistani descent.”

–U.S.-born man of Pakistani origin in early 20s

One Korean woman born in the U.S. said that once people know she is Korean, they ask even more offensive questions such as “Are you from North or South Korea?” or “Do you still eat dogs?”

In a similar situation, this U.S.-born Indian woman shared her responses:

“I find that there’s a, ‘So but where are you from?’ Like even in professional settings when they feel comfortable enough to ask you. ‘So – so where are you from?’ ‘Oh, I was born in [names city], Colorado. Like at [the hospital], down the street.’ ‘No, but like where are you from?’ ‘My mother’s womb?’”

–U.S.-born woman of Indian origin in early 40s

Ignorance and misinformation about Asian identity can lead to contentious encounters

“I have dealt with kids who just gave up on their Sikh identity, cut their hair and groomed their beard and everything. They just wanted to fit in and not have to deal with it, especially [those] who are victim or bullied in any incident.” Surinder , documentary participant

In some cases, ignorance and misinformation about Asians in the U.S. lead to inappropriate comments or questions and uncomfortable or dangerous situations. Participants shared their frustration when others asked about their country of origin, and they then had to explain their identity or correct misunderstandings or stereotypes about their background. At other times, some participants faced ignorant comments about their ethnicity, which sometimes led to more contentious encounters. For example, some Indian or Pakistani participants talked about the attacks or verbal abuse they experienced from others blaming them for the 9/11 terrorist attacks. Others discussed the racial slurs directed toward them since the COVID-19 pandemic in 2020. Some Japanese participants recalled their families losing everything and being incarcerated during World War II and the long-term effect it had on their lives.

“I think like right now with the coronavirus, I think we’re just Chinese, Chinese American, well, just Asian American or Asians in general, you’re just going through the same struggles right now. Like everyone is just blaming whoever looks Asian about the virus. You don’t feel safe.”

–U.S.-born man of Chinese origin in early 30s

“At the beginning of the pandemic, a friend and I went to celebrate her birthday at a club and like these guys just kept calling us COVID.”

–U.S.-born woman of Korean origin in early 20s

“There [were] a lot of instances after 9/11. One day, somebody put a poster about 9/11 [in front of] my business. He was wearing a gun. … On the poster, it was written ‘you Arabs, go back to your country.’ And then someone came inside. He pointed his gun at me and said ‘Go back to your country.’”

–Immigrant man of Pakistani origin in mid-60s

“[My parents went through the] internment camps during World War II. And my dad, he was in high school, so he was – they were building the camps and then he was put into the Santa Anita horse track place, the stables there. And then they were sent – all the Japanese Americans were sent to different camps, right, during World War II and – in California. Yeah, and they lost everything, yeah.”

–U.S.-born woman of Japanese origin in mid-60s

As focus group participants contemplated their identity during the discussions, many talked about their sense of belonging in America. Although some felt frustrated with people misunderstanding their ethnic heritage, they didn’t take a negative view of life in America. Instead, many participants – both immigrant and U.S. born – took pride in their unique cultural and ethnic backgrounds. In these discussions, people gave their own definitions of America as a place with a diverse set of cultures, with their ethnic heritage being a part of it.

Taking pride in their unique cultures

“Being a Pakistani American, I’m proud. … Because I work hard, and I make true my dreams from here.” Shahid , documentary participant

Despite the challenges of adapting to life in America for immigrant participants or of navigating their dual cultural identity for U.S.-born ones, focus group participants called America their home. And while participants talked about their identities in different ways – ethnic identity, racial (Asian) identity, and being American – they take pride in their unique cultures. Many also expressed a strong sense of responsibility to give back or support their community, sharing their cultural heritage with others on their own terms.

“Right now it has been a little difficult. I think it has been for all Asians because of the COVID issue … but I’m glad that we’re all here [in America]. I think we should be proud to be here. I’m glad that our families have traveled here, and we can help make life better for communities, our families and ourselves. I think that’s really a wonderful thing. We can be those role models for a lot of the future, the younger folks. I hope that something I did in the last years will have impacted either my family, friends or students that I taught in other community things that I’ve done. So you hope that it helps someplace along the line.”

“I am very proud of my culture. … There is not a single Bengali at my workplace, but people know the name of my country. Maybe many years [later] – educated people know all about the country. So, I don’t have to explain that there is a small country next to India and Nepal. It’s beyond saying. People after all know Bangladesh. And there are so many Bengali present here as well. So, I am very proud to be a Bangladeshi.”

Where home is

When asked about the definition of home, some immigrant participants said home is where their families are located. Immigrants in the focus groups came to the United States by various paths, whether through work opportunities, reuniting with family or seeking a safe haven as refugees. Along their journey, some received support from family members, their local community or other individuals, while others overcame challenges by themselves. Either way, they take pride in establishing their home in America and can feel hurt when someone tells them to “go back to your country.” In response, one Laotian woman in her mid-40s said, “This is my home. My country. Go away.”

“If you ask me personally, I view my home as my house … then I would say my house is with my family because wherever I go, I cannot marry if I do not have my family so that is how I would answer.”

–Immigrant man of Hmong origin in late 30s

“[If somebody yelled at me ‘go back to your country’] I’d feel angry because this is my country! I live here. America is my country. I grew up here and worked here … I’d say, ‘This is my country! You go back to your country! … I will not go anywhere. This is my home. I will live here.’ That’s what I’d say.”

–Immigrant woman of Laotian origin in early 50s

‘American’ means to blend their unique cultural and ethnic heritage with that in the U.S.

“I want to teach my children two traditions – one American and one Vietnamese – so they can compare and choose for themselves the best route in life.” Helen , documentary participant (translated from Vietnamese)

Both U.S.-born and immigrant participants in the focus groups shared their experiences of navigating a dual cultural environment between their ethnic heritage and American culture. A common thread that emerged was that being Asian in America is a process of blending two or more identities as one.

“Yeah, I want to say that’s how I feel – because like thinking about it, I would call my dad Lao but I would call myself Laotian American because I think I’m a little more integrated in the American society and I’ve also been a little more Americanized, compared to my dad. So that’s how I would see it.”

–U.S.-born man of Laotian origin in late 20s

“I mean, Bangladeshi Americans who are here, we are carrying Bangladeshi culture, religion, food. I am also trying to be Americanized like the Americans. Regarding language, eating habits.”

–Immigrant man of Bangladeshi origin in mid-50s

“Just like there is Chinese American, Mexican American, Japanese American, Italian American, so there is Indian American. I don’t want to give up Indianness. I am American by nationality, but I am Indian by birth. So whenever I talk, I try to show both the flags as well, both Indian and American flags. Just because you make new relatives but don’t forget the old relatives.”

–Immigrant man of Indian origin in late 40s

Pew Research Center designed these focus groups to better understand how members of an ethnically diverse Asian population think about their place in America and life here. By including participants of different languages, immigration or refugee experiences, educational backgrounds, and income levels, this focus group study aimed to capture in people’s own words what it means to be Asian in America. The discussions in these groups may or may not resonate with all Asians living in the United States. Browse excerpts from our focus groups with the interactive quote sorter below, view a video documentary focused on the topics discussed in the focus groups, or tell us your story of belonging in America via social media. The focus group project is part of a broader research project studying the diverse experiences of Asians living in the U.S.

Read sortable quotes from our focus groups

Browse excerpts in the interactive quote sorter from focus group participants in response to the question “What does it mean to be [Vietnamese, Thai, Sri Lankan, Hmong, etc.] like yourself in America?” This interactive allows you to sort quotes from focus group participants by ethnic origin, nativity (U.S. born or born in another country), gender and age.

Video documentary

Videos throughout the data essay illustrate what focus group participants discussed. Those recorded in these videos did not participate in the focus groups but were sampled to have similar demographic characteristics and thematically relevant stories.

Watch the full video documentary and watch additional shorter video clips related to the themes of this data essay.

Share the story of your family and your identity

Did the voices in this data essay resonate? Share your story of what it means to be Asian in America with @pewresearch. Tell us your story by using the hashtag #BeingAsianInAmerica and @pewidentity on Twitter, as well as #BeingAsianInAmerica and @pewresearch on Instagram.

This cross-ethnic, comparative qualitative research project explores the identity, economic mobility, representation, and experiences of immigration and discrimination among the Asian population in the United States. The analysis is based on 66 focus groups we conducted virtually in the fall of 2021 and included 264 participants from across the U.S. More information about the groups and analysis can be found in this appendix .

Pew Research Center is a subsidiary of The Pew Charitable Trusts, its primary funder. This data essay was funded by The Pew Charitable Trusts, with generous support from the Chan Zuckerberg Initiative DAF, an advised fund of the Silicon Valley Community Foundation; the Robert Wood Johnson Foundation; the Henry Luce Foundation; The Wallace H. Coulter Foundation; The Dirk and Charlene Kabcenell Foundation; The Long Family Foundation; Lu-Hebert Fund; Gee Family Foundation; Joseph Cotchett; the Julian Abdey and Sabrina Moyle Charitable Fund; and Nanci Nishimura.

The accompanying video clips and video documentary were made possible by The Pew Charitable Trusts, with generous support from The Sobrato Family Foundation and The Long Family Foundation.

We would also like to thank the Leaders Forum for its thought leadership and valuable assistance in helping make this study possible. This is a collaborative effort based on the input and analysis of a number of individuals and experts at Pew Research Center and outside experts.

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ORIGINAL RESEARCH article

This article is part of the research topic.

Challenges and Prospects for Conservation Genetics at XXI Century

Developing a DNA metabarcoding method to identify diet taxa in Neotropical foxes Provisionally Accepted

• 1 Facultad de Medicina, Universidad de la República, Uruguay
• 2 Instituto de Investigaciones Biológicas Clemente Estable (IIBCE), Uruguay
• 3 Pasteur Institute of Montevideo, Uruguay

The final, formatted version of the article will be published soon.

Pampas and crab-eating foxes are medium-sized canids living in sympatry in the middle east of South America. Studies on the diet composition of these species provide a deep understanding of their ecological roles in the ecosystem structure and regulation. Using the metabarcoding technique, we analyzed the diet of both fox species in order to identify the vertebrate taxa included as food items. A fragment of the 12S ribosomal gene of the mtDNA was amplified using DNA extracted from 27 scat samples collected in south-central Uruguay during cold (June 2015) and warm (January -April 2016) seasons. A fox DNA blocking primer was designed to minimize the host amplicon products, and pooled samples were sequenced through paired-end reads (100 bp library) on a MiSeq Illumina Platform. The generated sequences were compared to a reference database built with sequences available in GenBank. In concordance with previous studies using traditional methods, we found that the most common food taxon were rodents. Qualitative differences in diet composition between both fox species were identified. Armadillo species were only found in pampas fox diet, while a greater variety of amphibians and birds were detected in crab-eating fox feces. Additionally, an innovative approach to differentiate between real and artifact sequences was employed. This method was based on comparing mutations at conserved and non-conserved positions within the secondary structure of the 12S rRNA, combined with network sequence reconstruction. Our results demonstrate the efficacy of the methodology in detecting the food species present in both fox diets, enabling the evaluation of intraspecific diversity among these species and facilitating the discarding of sequencing errors. This makes the methodology applicable to a wide range of studies.

Keywords: Non-invasive genetic techniques, High-throughput sequencing (HTS), Molecular Ecology, environmental DNA, Wild canids

Received: 23 Dec 2023; Accepted: 29 Apr 2024.

Copyright: © 2024 Mannise, Cosse, Greif, Bou, Robello, Gonzalez and Iriarte. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Dr. Mariana Cosse, Instituto de Investigaciones Biológicas Clemente Estable (IIBCE), Montevideo, 11600, Uruguay Prof. Andres Iriarte, Facultad de Medicina, Universidad de la República, Montevideo, 11800, Uruguay

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