qualitative research interview transcript example

Transcript Example (with Microsoft Word and PDF Templates)

This resource includes a transcript example from an interview, formatted in several different ways:

• Clean verbatim style
• True verbatim style
• Timestamps at regular intervals
• Timestamps at speaker or paragraph intervals

I made these .docx and PDF example transcripts for university students, educators, non-profits, journalists, podcasters, filmmakers, and transcriptionists.

Quick tip: If you’re not using it already, you can install free transcription software like Express Scribe to help you manually transcribe interviews much faster. The software lets you control audio playback using hotkeys so you don’t have to keep starting and stopping audio with your mouse.

If you want to go really fast, I also recommend getting a transcription foot pedal (I use the Infinity pedal ). Together, these two tools will save you hours upon hours of transcription time. (Or learn more about our interview transcription services .)

If you’re a professional content creator, you may also be interested in our posts about AI-powered tools for scaling up your audio and video production workflow:

• Best AI Video Upscaling Software
• Best AI Video Generators
• Best AI Video Editors

Now, on to the transcript examples!

This post may contain affiliate links. See my disclosure for more info.

Interview transcription format sample for Microsoft Word

Download this transcription format template for Microsoft Word for use with interviews and qualitative research projects:

Interview Transcription Template – Word (.docx)

Clean verbatim vs. true verbatim transcript examples

There are two main styles of transcription used in interviews and qualitative research:

• Clean verbatim (also called intelligent verbatim or non-verbatim).
• True verbatim (also called strict verbatim, or simply “verbatim”).

A clean verbatim transcript is a lightly edited version of the original audio. Typically, the following elements are removed:

• Filler speech, including “um,” “uh,” etc.
• Most non-speech sounds, including coughing and throat clearing
• False starts

A true verbatim transcript, on the other hand, attempts to capture every utterance of the speakers. These include stutters, meaningless filler speech, and false starts. Verbatim style may also include non-speech and background sounds, such as coughing and sneezing or a door closing.

While each transcription style is useful under certain circumstances, clean verbatim is used most often because the transcripts cost less and are easier to read.

However, true verbatim may be desirable for certain qualitative and market research projects and legal investigations, where it’s necessary to study not only what was said, but also the manner in which something was said.

Below, I’ve included examples of an interview transcribed in both verbatim and clean verbatim fashion.

Example transcript in true verbatim style

Here’s a sample interview transcript that demonstrates the true verbatim style:

Download the PDF version here: Interview Transcript Example – True Verbatim (PDF)

Example transcript in clean verbatim style

And here’s the same conversation from above, transcribed in clean verbatim:

Download the PDF version here: Interview Transcript Example – Clean Verbatim (PDF)

We made the following changes to the second (clean verbatim) transcript:

• We edited out stutters, partial words, and short incomplete sentences.
• We removed meaningless instances of words like “so” at the start of sentences, and “like” when used as filler speech. (However, we left in the word “like” where removing it would have made the meaning literal when it wasn’t intended to be – i.e., when Brad refers to his “like, two” Facebook friends.)
• We chose to leave in the laughter, as it helps capture the overall tone of the interview and the banter occurring between the speakers. We also left in nonsense exclamations like “Uh … phew,” because it helps set the context for what follows. However, we removed other non-speech sounds like coughing and throat clearing that do not contribute anything useful to the content.
• In this particular example, we opted to remove repetitive instances of the word “actually” spoken by Brad, the interviewee. Normally we leave longer words in, but in this case we felt it was a speaker idiosyncrasy that distracted from the content of the interview.

Clean verbatim style is not an exact science, and sometimes there may be overlap between non-verbatim and verbatim styles in a transcript. All in all, the changes we made here make for a cleaner, less distracting, and more valuable interview – without detracting anything meaningful from the original.

Sample transcript with timestamps at regular intervals

Some projects require timestamps to be placed at regular intervals in the transcript so the audio can be easily referenced later.

Below is an example of an interview transcript with timestamps:

Download the PDF version here: Interview Transcript Example – Timestamps at Regular Intervals (PDF)

Sample transcript with timestamps at speaker intervals

Another way to timestamp a document is to place the timecode markup at speaker or paragraph intervals, like in the following interview transcript sample:

Download the PDF version here: Interview Transcript Example – Timestamps at Speaker Intervals (PDF)

Transcript format tips

There are several formatting elements common to most transcripts. These include speaker labels, timestamps, inaudible and crosstalk tags, and markup for external sounds. Let’s look at how to handle each of these:

Speaker labels. Speakers are typically identified by first name, full name, title, or role. They can also be identified by generic descriptors, like “Male” or “Female,” when other information isn’t available.

In the above examples, the speakers’ names have been offset from the rest of the transcript for better readability. To use this formatting in your own transcripts, download the .docx template at the top of this article.

Timestamps. Timestamps, e.g. [01:27] , can be placed at regular intervals such as every 15 or 30 seconds, or they may be placed at the beginning or end of each paragraph or speaker. Examples of each style are shown above.

Inaudible tags. When words or phrases are unclear, mark them out with a timecode; e.g., [inaudible 00:27] . You can also include guesses (phonetic or otherwise) as to what was said – for example, [wing yard 00:27] .

Crosstalk tags. When two or more speakers are talking at the same time and it’s impossible to hear what’s being said, use a crosstalk tag, e.g. [crosstalk 01:27] .

Sounds. Non-speech and background sounds are notated in brackets; for example, [laughing] or [door slams] . No timestamp is necessary.

Finally, a note on consistency and style: It’s best to follow a style guide to ensure consistency among elements like numerals, dates, titles of works, etc. We generally follow AP style . Other common style methods include APA , MLA , and The Chicago Manual of Style .

If you’re thinking of starting a career in transcription, check out my complete guide on how to become a transcriptionist . I also recently posted this list of 75+ transcription jobs for beginners and pros.

If you have any questions about using the example transcripts above, leave a comment and I’ll do my best to help!

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23 comments.

thanks a lot for this. I appreciate th above lessons. at the moment lets keep the above into practice.

You’re very welcome! I’m glad you found it useful.

Very very helpful. For sure, God bless you.

Thank you. I’ve recently launched my own company in ghostwriting & editing, and typing & transcription services. These tips are GREAT reminders. God bless you.

Thank you, Mrs. Owens!

Handy for a beginner like me.

Thank you very much, really help me to do my assignment

I’m glad to hear that!

Hello, I don’t know how to thank you ,these instructions are very helpful and useful and real ,and how to contact you if I need any help.

I’m so happy you enjoyed the post! While I’m not always available to respond directly to questions, I always appreciate receiving suggestions about what kind of content you’d like to see me write about in the future. So if there’s a particular topic you have in mind, please feel free to reply and let me know. Thanks so much for commenting!

Your information is very valuable. My problem is, I need to find a resource that tells me how to set up the formatting in MSWord 2016. Setting the speaker tags and margins so it all lines up. If you have any link you could direct me to, or if you can explain how you do that, I would be forever grateful. Thanks, Lorri

I’ve been meaning to get a refresher on formatting myself and recently bookmarked this comprehensive tutorial on MS Word 2016: https://www.youtube.com/watch?v=TxLuuNprjXg

I haven’t watched it yet, but there’s a clickable table of contents in the video description and it has some sections on formatting and adjusting margins. I hope it helps!

how to name an interview transcript document?

If you’re doing the transcript for a client or professor, you should typically give the document the exact same name as its corresponding audio file; for example, “Interview with Sahar.mp3” would be titled “Interview with Sahar.docx”.

If you’re recording the audio yourself and there are a lot of files, it’s best practice to use some kind of file naming convention to keep everything organized. One easy way to do this is to use a date prefix; for example, 2019-05-30_Interview_with_Sahar.mp3.

I hope this helps!

Thank you so much for this guide. I am just about to embark on Transcription services as a full time activity and will be grateful for any mentoring and encouragement

You’re very welcome! Since you’re just getting started, I recommend visiting the following resources:

My complete guide on how to become a transcriptionist: https://www.mondayroadmap.com/how-to-become-a-transcriptionist/

My list of 75+ companies that hire work-from-home transcribers: https://www.mondayroadmap.com/online-transcription-jobs/

All the best in your new transcription career!

Thank you, this was very helpful.

Glad to hear it, Cony! Thanks for commenting.

This was really really helpful. Thank you so much.

Thank you for reading!

Hi, I’m just getting started transcribing hours of interviews. This article is a life saver. Really helpful, accessible, clear and the .pdfs are really useful allowing me to see what the finished transcription should look like. Thank you so very much.

You’re so welcome, Shaz! Thank you for reading!

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The Coding Manual for Qualitative Researchers

Student resources, three sample interview transcripts.

The following three transcripts have been provided to help you test your coding skills.  Please note these will open in a new window.

Interview Transcript: Digestive Disorders – Brenda

Interview transcript – a teacher’s observations of child oppression, interview transcript: digestive disorders – sam.

The following interview with Brenda [pseudonym] was conducted in April 2013 by Cody Goulder, a graduate student researching people with digestive disorders. Brenda is 25 years old and the transcription is as verbatim as possible.

As a coding and analysis exercise, review the transcript several times to become acquainted with the contents. Make jottings about passages that strike you and pre-code your initial work. Then separate the extended interview transcript into stanzas. Determine the most appropriate coding method(s) for the transcript to help examine the general research questions:

• What are the experiences of people with digestive disorders?
• How do people with digestive disorders cope with them?

Also consider comparing or combining the analysis of this transcript with Sam, the other case interview on digestive disorders.

B: Bowel disorders, it is what it is.

I: How old were you when you first started to realize you were having problems with your digestion?

B: I was, uh, 21 and a half, to be exact, yeah.

I: And do you suffer from celiac or, how would you define your discomfort?

B: My colonoscopy says no celiac and not inflammatory bowel disease. My blood marker test says I have inflammatory bowel disease. I would label myself definitely gluten intolerant.

I: And for the record, can you describe what that means? Gluten intolerance? As you would describe it.

B: Gluten intolerance means that you, your body just does not digest or break down or really absorb gluten. And that is a protein that is found in wheat. I would also say that I don’t handle processed wheat well either. Um, and the symptoms are across the board. For me personally, um, I get, I’ll get joint pains, exhaustion, um, and I just feel incredibly full. After four or five bites, if I’m having, say, pasta or something where it’s just, after four or five bites, I can’t eat anymore, feel nauseous. That’s actually where the symptoms really first started.

I: Was there anything else beyond that?  Say migraine headaches or …

B: Headaches. I have, and it’s gotten a lot better, I had, um, pretty bad hormonal acne, is what they would call it. Went across the board trying to treat it. I tried creams and antibiotics, retin-As, all that stuff. When I started to cut out gluten and wheats, my skin cleared up the best it’s ever been. I even went on Accutane and, I was on Accutane for five months and that is exactly when my symptoms would appear. I’ve been completely healthy my entire life.

I: Do you think there is a connection between …

B: Yes. I, well, studies have shown that if you possibly have Crohn’s disease or ulcerative colitis and you go on Accutane, there is research coming out that, it can set those diseases off. Um, and I just, I can’t, I think that’s what happened to me because of, like I said, I was completely healthy and then one day I’m having bowel issues and medications.

I: You said you’ve seen doctors, medical doctors, what was that process like of getting tested? What was the response?

B: Well, I went to, when I first got sick, I went to my internal medicine doctor and he’s like, “I don’t know if it’s acid reflux or what, so I’m gonna do a blood test on you.” And he did a blood panel, that’s when he said, “OK, according to these markers you have IBD, go to a gastrologist.”  And, I went to one that was recommended, um, and she was just like, “OK, I wanna scope you.”  I told her about all these symptoms and when I told her I’d been on Accutane, she kind of made a look like, “Oh, OK.” And then I have a family history, unfortunately, with inflammatory bowel disease. Both of my younger sisters have ulcerative colitis. I have an uncle who is deceased who had ulcerative colitis, and two or three second cousins that have ulcerative colitis and Crohn’s.

I: Can you describe what ulcerative colitis is, as you would describe it?

B: Um, it’s just your intestines not really absorbing the proper nutrients and inflammation, um, and that can be where, um, in any part of your gut. All the way to, Crohn’s can even burn your esophagus and mouth, all the way down through the rest of your body. It’s pretty intense. I was the healthy one. I didn’t have asthma or, not like my little sisters. The hell they went through in middle school with getting sick, I never had that.

I: Would you be willing to talk a little more about that?

B:  So, my first sister got sick right around middle school. Her symptoms were, any time she’d eat, she immediately would have to go to the bathroom, instant diarrhea. She’d break out in a sweat. She’d get [ unable to transcribe ], which is a kind of skin lesion, which is, we talked to the dermatologist and, but until you treat really the underlying problem, you don’t know what’s going on. Um, what else did she have? And just going from doctor to doctor. Um, they did a scope and there was a little inflammation that they did find. Um, but they still were very hesitant of saying, “Yes, you have ulcerative colitis” because she wasn’t on, your typical textbook case. I found that really hard for doctors. If it’s not black and white, they …

I: We’ve discussed in other interviews, before this, the fear of using labels in …

B: They’re terrified. I mean, I went through several doctors and then finally, um, I think kinda, and going through puberty, I and, while my sisters were going through puberty, it was really hard. With all the hormones and changing, It just kinda, I think, throws a lot of things off. And then my sister, she’s what would you call remission, but it’s never really going away. You’ll always still have it, but she been in remission for a while now. Um, found the right doctor and he didn’t label her until he started treating her.

I: So it was sort of a trial by fire?

B: Yeah, we’d kind of tell them, “Hey, can we try this? It’s not getting better.” And then my youngest sister, right around the same time, about sixth grade, she got sick as well. Different symptoms. Um, she didn’t have, she had ulcerative colitis. But, there can come blood when you go to the bathroom. And she went in, was severely sick, she went to the hospital. And filled up the little cup they have, completely, with blood. And when they went in to scope, they couldn’t find anything. But she had the blood. She had the joint ache. She has the rash. She’s trying to eat as much as she could, but her belly would distend. And they wanted to send my sister to the psych unit. They thought it was a mental thing and we’re like, “No, she’s filling up the cup.” Like, really? And it was just their reaction because they couldn’t figure out why because the gold standard in diagnosing these things is the colonoscopy. But it’s so hard with these diseases to find it.

I: Why do you think there seems to be a reluctance or a unwillingness in wanting to just get right to the point?

B: I’m not really sure. I don’t, I don’t know. I don’t know if they’re taught that in med school that, you know, that it’s not black and white. And we have found also that, when you are in a hospital setting, you don’t see the same doctor. You have a doctor for a week and then, you know, in all honesty, they weren’t all on the same page. They had their own egos and their own agendas. My sister was in there 21 days. Still, we were finally like, “This is enough. It’s not a psych problem, discharge her now.” And she was still bleeding, two weeks later, she was anemic. We ended up, by chance, being able to get into a different doctor at a different practice who would treat her as if. She was in remission for about three years, she’s out of it now, but she’s got good doctors. She’s still trying to figure out how to beat this beast.

I: Are both your sisters, and you as well, on prescription medication?

B: Um, yes. My little sister Tammy now, I think because she’s been in remission is on like a, something for acid reflux. My younger sister, she’s not on any medication. And my one sister, yes, but I don’t remember what she’s on.

I: And, none of these symptoms have been shown in your parents?

B: My mom, yeah. I remember growing up and her having bowel issues, yeah. And, it’s all on my mom’s side. My dad’s side doesn’t have any bowel issues. This gluten intolerance thing, I didn’t really understand it until I was taking a class with a friend and I was just telling her, “God, I really don’t like.” They labeled me as having GERD and put me on severe, pretty intense medication. I just don’t like the fact I have to take this medication. 

I: What is GERD?

B: It’s similar to the acid reflux disease. So, a lot of it is by diet. Little things can set it off.

I: Before all this, what was your favorite food?

B: I loved pizza and burgers.

I: Would you say you ate a pretty balanced diet? Not loading up on pasta …

B: No, but it’s funny ‘cause when I was sick, that’s all I wanted, you know? That sounded really good to eat bread and crackers.

I: Is that because it was a comfort basis?

B:  No, um, I think people with that, like sugars and complex stuff, especially like all the sugar that’s really not good for you, it’s addicting, you know?  The longer you are away from it, it’s easier to stay away. Have a little and it’s like I gotta have more. It’s difficult.

I: When you started to cut out gluten and bad sugars, what was the response?

B: From like a friend?

I: Yeah. Were you a partier?

B: No. I was so, no, it was weird. I kinda went through my drinking when I was underage. By the time I turned 21, I really didn’t enjoy it. Actually, last night, I feel it. Like, I didn’t drink that much and I feel like hell the next day. Two beers. But, say if I have food and water with it, it’s still mm-mm. So, when I cheat, I’m like, “You’re gonna pay for it the next day.” But it’s hard. Not wanting to go out with friends and, you know, it gets kinda, after a while, “Oh, I’ll just have salad cause that’s really all I can eat.” I can still eat stuff, but finding restaurants that are accommodating to eating to that.

I: Is there a feeling of being ostracized? Your friends or actually from the restaurant itself?

B: Yeah, it’s complicated. I just tell them now.

I: Do you have a specific experience that jumps out in your mind?

B: Yeah, I’d just gotten, a couple of times when you ask, “Do you have a gluten-free menu?” They’re getting much better at it, but I remember when I first started, like a year and a half ago, it was still kind of like [ rolls eyes ], “Oh, you’re one of those people.” Um, cause some people will cut out gluten because they think it will be great for them. But it really doesn’t hurt them. So, I don’t like to be grouped into that. It’d be cheaper. Probably be easier just to be able to go with the flow.

I: How does that make you feel when you talk to someone who says they’re cutting out gluten for my diet, but they can eat bread if they desperately wanted to?

B: Um, close friends, no. Not at all. I mean, because, well, they’ve seen me not do well. I’m just not very nice either because I don’t feel well. Um, but strangers, yeah, that don’t get it. You know, there’s kind of a judgment and they, “Why are you, are you doing it to lose weight or … ?” No, I’m doing it ’cause I feel miserable. But that’s also something that’s going around like in the media, I know, it’s being hyped up as, “Cut out gluten, it’ll make you lose weight.” I think that anything, if you’re just trying, doing it to lose weight, that won’t stick.

I: How do feel with all the mass market of gluten-free this, gluten-free that?

B: It’s a little overwhelming, to be honest. You really have to look at the food labels. Are they taking out this? I still, and trying to find stuff, um, at the grocery store that I can eat, but it takes forever. I try to, at least, read every label. Grocery experiences are long [ laughs ].

I: Is there a specific thing that you want, but know you can’t have?

B: Yeah, that’s my downfall. I mean, I’ve found some places that are gluten-free. But, you know, I haven’t found, has anyone found a gluten-free pizza that you can make at home, send it my way ’cause [ laughs ] …

I: In addition to reading labels and breakdown what I can and can’t eat in the moment, how has your lifestyle changed to feel comfort?

B: With gluten intolerance, I’ve done some research. But I’ve gotten to the point where I’ve, I’m taking a class with a friend and she’s like, “I have stomach issues. Why don’t you read this book? It’s called Eat Right for Your Blood Type .” I didn’t know my blood type at the time, so I started reading the type-O diet and I was like, “Oh my god.” It describes how, based on if you eat these foods, it’s what you have. It’s so me. I had to kinda look away. Is this really me? And it was. So for me, I follow the hunter-gatherer type, meat, fruits, and vegetables. Um, and so that alone, that book and I’m so grateful for my friend, because that brought a sense of comfort.

I: It sounds like you’ve got a lot of support around you.

I: And, have you been able to pass that along to your sisters? Did they ever talk to you about what it’s like to be in middle school and have, really feel, have these differences?

B:  Oh yeah, it was really, really tough. Kids, not so much kids, but I remember the teachers would not, being, not really getting it. And my mom would try so hard to, I mean, “Hey, this is what my daughters have. There are the type of medications, heavy medication at one point that they were on. Heavy steroids that make you, not really there. Um, she’s maybe not paying attention because her pain or she’s trying not to shit her pants.” And, um, yeah they had a really hard time finding kids that understood what they were going through. And, it’s a disease on the inside that doesn’t always manifest on the outside. And I think a lot of diseases are like that. Just being aware.

I: Especially when a lot of the symptoms are connected to other diseases? Are you concerned, have you thought about at all what this could lead to?

B: That’s why I changed my diet because I know the blood markers, so, in some ways that kind of means I’m a ticking time bomb. You know, I could get the flu really, really bad. And that could set off this disease. Um, but I’m doing everything that I can in my power as far as diet that I can to control it. Because that also can set it off. I’ve adapted this new lifestyle. Exercise like three, four times a week. Um, that’s been the hardest one, to really stay committed. I’ve conquered the food part, but not putting in the exercise as well. And doing yoga ’cause I stress easily. And, that’ll feed into it, that stress will lead me into making poor food choices. So, finding the balance is what I’m really focusing on.

I: Do you feel that, when you’ve had a bad day, it’s the emotional connection, or that emotion is tied to reactions? “I feel bad, I need comfort.”

B:  That’s something to be aware of, definitely. That’s happened to me.

I: Do you think there’s a danger in people becoming so emotion-oriented?

B: Oh yeah. Um, yeah you gotta find balance you know? And being aware, it’s all kind of connected.

I: Is there a point where you’ve had to battle and fears or overwhelming emotions? And you had to bring yourself back? Trigger or phrases that help keep you in balance?

B: Um, I have to stay in the present. And not, “God, what if this happens?” ’Cause that, you know, will set it off. And that’s where I need to be, in that present and just focus on that. And when I don’t, that’s when it gets me and stresses me out. And in listening to your body is the best thing. You are your best advocate for yourself. Not taking the medical. Being in tune. It’s clear if I’ve had a bad week. I eat foods I shouldn’t have been eating. I feel really lethargic and exhausted. If you don’t want to feel like this, don’t eat it. It’s pretty immediate.

I: Do you feel you’re leaning towards organic?

B: I have found, for me, the hunter-gatherer, animal protein. I’d watch documentaries on how animals are being treated, on what they’re given and what we’re absorbing and the cancer rate and all. So, I tried vegetarian, but that means I upped my soy. A lot of soy, had a lot of grains too, even lentils, which are supposed to be really good. And I felt miserable. And I gained a lot of weight. And, they, “You know, don’t eat meat and you’ll lose weight.” For me, I felt horrible. Like, my skin was breaking out, I gained weight. I think like everyone is honestly a little bit different. It’s unfair to the consumer. I gotta eat animal protein or I’m not a very nice woman. I’m cranky. Watch out! But, on the other side, I’ve got to pay more for grass-fed animal meat that’s not injected with hormones. I think that’s what’s causing the cancer and all these problems. It’s because of what they’re giving to the animals. And the hormones. Of course we’re gonna get sick. Of course. It’s infuriating, it really is. But you pay more, a little bit, for the great meat, you know, versus paying several years down the line severe medical bills. I’m not saying you couldn’t, one day, have cancer. But you’ve done everything in your power to not get it and I just got the short end of the stick, but at least I can be in control of, at least I’m eating this. Holds me accountable.

I: Last question, what’s it been like?

B: I have a really tough stomach. Yeah we, my sisters and I, do talk about it. Definitely check in and, our poor dad. We’re all so females that, sometimes, there’s a point we’re at dinner conversations and we talk about our bowel habits and what was going on. My poor dad. So, yeah, there’s definitely an open communication and you gotta have a sense of humor. You got these issues, you have to have a sense of humor.

I: What would say to someone that provides comfort? It’s OK, this is life?

B:  Um, we just, we just joke. “Hey, remember that one time when,” you know? You just have, you just kind of have a sense of humor about it, accepting what it is and try to stay positive is how we try to move forward. And be on top of it. And really choosing to have a say in relation to our digestion and stuff. Being aware. It’s different for everyone. Be in tune with what your symptoms are. You’re your best advocate. 

An interview was conducted with “Ms. D,” a female, fifth-grade, veteran elementary school classroom teacher in preparation for an action research project on school bullying. The research team interviewed fourth- and fifth-grade teachers at a lower middle-class suburban school site to learn about forms of oppression they saw and heard most often among their children.

As a coding and analysis exercise, review the transcript excerpt several times to become acquainted with the contents. Make jottings about passages that strike you and pre-code your initial work. Then separate the interview transcript into stanzas. Determine the most appropriate coding method(s) for the transcript to help examine the pre-action research question:

• What are the forms of child oppression?

Also compose an analytic memo that brainstorms the types of strategies that might be taken by an action research team to lessen the amount of child oppression in a school setting.

I: How do children in your classroom oppress each other?

MS. D: Well, they call each other names.

I: Like, what kinds of names?

MS. D: Oh, we’ve got a little girl in here, she looks different and she acts different, so they’ll make up some name that they call her. They, um, it’s the same kid, it seems like every year there’s one kid that gets picked on more than somebody else, because they’re different, because they might look different, they might act different. Say, for instance, she will say something or she gets very excited about something, they’ll tell her to “Sit down,” “Be quiet,” “Stop doing this,” they’re like on her case all the time. Then you’ve got another kid in here who, well he loses control of himself, and so he blurts stuff out or yells out, and the kids will turn around and yell back at him. And out on the playground they do tend to sometimes get pushy-shovy kinda stuff. Like with her [ pointing to a desk ] I’ve watched them actually walk by this little girl and purposely bump into her or something like that, but then even though you’re watching them, the kid’ll turn around and say, “Well, I didn’t do that” after you confront him. And it’s not everybody, it’s just a few, and it’s a few that have behavior problems that seek attention, and they don’t know how to get attention any other way besides a negative way.

I: How do the students deal with these conflicts?

MS. D: They come to me right away to tell me, so then I have to deal with it. I’ve told them to do it that way. I don’t want them taking means into their own hands, ’cause if they do then they’re causing more problems than, because they tend to get physical or it’s a taunting kind of thing that will take place all over the place. So if they come to me right away then I can deal with just the two people it involves and that way it doesn’t tend to get blown out of proportion. It stays right there rather than getting other kids involved in the situation.

I: What kinds of oppressions might your students deal with in their home environment?

MS. D: Oh, jeez. There’s some sad cases here. There’s this one boy who seeks attention because his mother is a drunken alcoholic. The mom says he’s her best buddy and works hard to get him what he wants. He’s had to meet with the school counselor. There was another girl who was taken away from a bad family situation in Philadelphia because of physical and verbal abuse, her mother was into witchcraft. She moved to live with some relatives here but the home situation here isn’t safe either, so the police had to be called in. But she seems to be settling in now. Her mom’s moved down here but the girl’s slowly evolving into one of the neighborhood kids. She’s the one they pick on a lot because she is a little different, but she’s had different experiences than a lot of kids, too.

I: What kinds of differences do kids tend to target?

MS. D: With this one student the kids seem to zero in because she did look different, and she …

I: Clothing-wise?

MS. D: No, just physically, she, she just, and she acted kind of strange, she would just rock back and forth in her chair, that this was a thing of the abuse, that kind of thing. And one of the girls said, “Stop it, stop it!” and I would have to go over to her and just put my hands on her, “Don’t do that now,” that kind of thing, and we had to have her meet with the school nurse. And she’s the type of kid who thinks she knows everything, so that was another thing that bugged the kids, that she would, and yet she does know a lot, but they just didn’t like it, that it was her . You know, once they had this idea that something’s wrong with them, or they don’t like them, then when they start to interact with the kids and the kids kind of, they’re not accepting. But most of the other kids in this room have been together for years, so she’s brand new, the other kid with problems is brand new, and so it’s the ones, they’re kind of not fitting in because they weren’t with this group as they moved on through school.

I: Like a newcomer?

MS. D: Uh-huh, I think it is like a newcomer thing. It’s basically the new ones. These two new ones were pretty outgoing and were put down by the others, but another newcomer moved quietly and she was easily accepted because she didn’t stand out. There’s another boy who’s obnoxious and the class gets upset with him. The kids pick up on attitude. Their whole thing is attention: how can I get attention and bring it to myself? Acting goofy or silly is a big thing, and some of the kids’ll say, “Oh, stop acting like that.”

The following interview with Sam [pseudonym] was conducted in April 2013 by Cody Goulder, a graduate student researching people with digestive disorders. Sam is in his early 30s and the transcription is as verbatim as possible.

Also consider comparing or combining the analysis of this transcript with Brenda, the other case interview on digestive disorders.

I: How old were you when you first realized you had something, celiac or, I should clarify: do you have celiac or is it a variation?

S: And I’ll clarify, too.

I: Yeah, absolutely.

S: A few things: I do energy healing and, um, as well as like, um, counseling of people like with diseases of these natures. So, because of that I also go to medical doctors or energy healers and nutritionists or people more off, off the beaten path, acupuncturists, things like that. And because of that, these doctors are hesitant to specifically name anything, because once you put a label on it, you give it power. You give it a consciousness and the more you, the more that consciousness is spread out, spread around like ADHD and all of that first came out. It gives it a negative connotation, so I was never told celiac. I was never told, the only thing I was ever told was, in the early stages was candida and parasites. And candida is a form of a parasite. Um, and other than that, they don’t address it to me and I don’t really ask. I’ve, I’ve asked, slipped up and asked, in the past, um, the doctors just like don’t worry about it. Because then, I’ll start to research it and buy into the symptoms.

I: Why do you think that is? Aside from not wanting to promote, for lack of a better term, hysteria, why do you think doctors are so reluctant to label …

S:  Um, I think medical doctors is because of the lawsuits. Per-, perhaps, and the liability. They don’t wanna, um, but, but the alternative doctors I go to, which are, I mean they’re also chiropractors, so they are doctors. Um, [ pause ] for one of the reasons I just mentioned so that my consciousness doesn’t buy into it and I create more of the disease, within my own body, which I, we all kinda tend to do anyway.

I: For the record, and certainly help clarify because, through this project, we’ve talked to other people we’re interviewing and we’ve heard different labels for it. So, can you help explain the variations?

S: If you went through my symptoms, you would say, you would say celiac. You would say there’s a lot of stuff. And I just saw something on Facebook, um, a medical doctor, I don’t know, I was trying to find it for you. I don’t know whose page it was, ’cause I have so many fan pages. It was a medical doctor that said, “What I used to, when I was practicing medicine, my patients would come to me and they had all these symptoms, which is fatigue, chronic fatigue, like all the, um, diarrhea, chronic diarrhea.” I’ve, you know, chronic stomach pains, intestinal pain, and things like that, um. Vision problems like floaters, um, I forgot what else she said in the list, but it’s like, “Oh, that’s all me.” There’s, there’s no name for that. But, she said, “When I finally would ask my patients what their body needs, because they went through all the protocols and all the testing and nothing would ever change. When I finally asked my patients what their body needs, some would say, you know, this medication or whatever.” That’s a small percentage of what this host said. The rest of the people, 98% would say I need to quit my job. I need to go do something that makes me happy. My body needs this. My body needs, you know, and it wasn’t related to anything that, food-wise or medical-wise, it was related to lifestyle choices. And, as a healer myself, that’s what I’ve learned as well and, you know, knowing this I should be able to heal myself and slowly, slowly, gradually I am. But, it’s, it’s easier said than done. Especially when you’re dealing with something that’s so emotionally tied into your, your system and your psyche. Does that make sense?

I: Yeah, it does.

S: And that kinda follows through with what, when I’ve started reading into the candida years ago, I was first diagnosed.

I: Can you explain a little more about candida? 

S: Candida is a yeast infection. And, when I first heard that, I’m thinking “Oh, which chick did I get it from?” [ laughs ] And so, I started like, after a while, after about a week, I’m like, you know, I’m gonna google this, and what it is is, we all have this natural yeast that occurs in our bodies. And, what happens over, it could be a traumatic issue. A traumatic occurrence or a thing like that, um, that happens in our lives and that yeast will, will, like, say we have X amount of yeast in our system. Let’s just, naturally good yeast. Quote unquote, good yeast.

I: On par with, say, the good bacteria living in our stomach.

S: Right. Well, when that good yeast expands to like double X or triple X or however, I’m just, I’m not, um, when it expands, that level, then it starts to become bad yeast. And it starts to take over and, it’s not, it’s only bad because it’s too much of it. And that yeast will affect your ability, and then the more sugar you have, the more you feed the yeast. The more gluten you have, the more wheat, the more things that, you know, have gluten in them, the more you’re gonna feed it. Um, and so forth until you get to the point where it’s like, you can, and I’ve read the diets and the diets, you can’t even, it’s almost impossible. They say it’s almost impossible to do. You have to do this diet to, to cut out all the yeast, you can’t even have carrots.

S: ’Cause of the sugar. But, then they say carrots are iffy because carrots also help kill the bacteria. It’s like there’s so much unknown about this, but it’s said it’s all, but the consensus that, I googled of all these websites that talked about candida is, it’s all emotional in origin. Hippocrates said the same thing. He’s the father of, you know, modern Western medicine. He said all disease is emotional in origin. As a healer, I know this. Because, even cancer starts as an emotion. And the more that emotion manifests, you get a tumor or something negative. Um, and I full-heartedly understand how that works. Because, especially in dealing with patients and myself, it’s like as soon as you get rid of that emotional counterpart, the disease goes away. Even if it’s cancer, I’ve seen it happen. They say it’s pretty amazing. Um, so, I’m sorry, what was your question?

I: What was candida?

S: Yeah, so, that’s what candida is in a nutshell. And so, that’s what my doctor started treating me for. My doctor, my healer, doctor, chiropractor started treating me for. And, and she told me to cut out all of, and this was probably about in oh-five [2005], it was about a year after I graduated [from university], getting my master’s. Um, it was, she treated me, she said no sugar, no caffeine, no dairy, I couldn’t do dairy either and no gluten, obviously. And, gradually I slowly weaned myself off, ’cause she was a vegetarian at the time, I slowly started weaning myself off of meat and stuff. I did eggs for protein. And what ended up and, I believe this was still, this was less than a year, about a year after my mom’s death, which was devastating for me, and I think …

I: What did she die of?

S: Oh, I can tell you the whole story. Can I?

I: Absolutely, we’ll circle back.

S. Yeah, um, and I believe that’s what started this manifestation in my stomach and my, my intestines ’cause I can tell the difference now. After a bowel moment I can, I’m just worn out. Um, so it was a year after my mom died and I went off all these things. Did the eggs for protein for about two months. I lost 40 pounds of muscle. And fat, but mostly muscle. So, I went from a size extra large shirts to mediums.

S: It was bad. It wasn’t, and I was also in depression and that’s why I want to preface that because I believe that depression plays a part in this all. Is that, whether we know it or not, you know?

I: There’s different levels of depression, period.

S: Exactly. And, there’s, and then there’s the fears that I constantly face like, within myself, and I think that contributed to it. I notice that when, like this HOA [Home Owners’ Association] thing and I think, I thought it was perfect that it was coming up. I hate the HOA, just like you were saying. And I was, I don’t know why I was having such anxiety over this meeting, ’cause once I had the meeting, it wasn’t a big deal. But like, there are certain people that I thought were going to be there, and that weren’t there, that I was like, I don’t wanna deal with these assholes, right? So, that, and that, and I was paying attention to what was happening, having anxiety this past week and it was going, it was going right to my gut. And, I’m like, well that’s not good for me. What am I doing to myself? But, like I can intellectualize it. But it’s, but until I like either do meditation or just like breathe and just get it through my system or just face it, which is what I did today, I, that’s why I went to the meeting, um, until you face that fear, you can’t, it’s almost impossible to get rid of it. Because once you face your vulnerability, that’s when, that’s when you empower yourself. But, most people are used to running away from their vulnerabilities. Does that make sense? 

I: Absolutely.

S: So, OK, you wanted to go back to my mom or, I kinda jump around so keep me …

I: No, it’s fine, I like to jump around. Um, so how does, let’s backtrack a bit to candida, trying to get a scope of these disorders?

S: I can tell you how candida manifested into other things if you …

I: Absolutely. Oh totally. Yes, so how does it differ from, say, someone who has celiac or has a general gluten or lactose or … ?

S: I think people that have celiac I, don’t quote me on this, but I, well, you can quote me on this.

I: I don’t have to use it.

S: I, I’m pretty sure people who have celi-, celiac also have candida issues. I’m pretty sure and, you know, chronic fatigue plays into all of that. I’m pretty sure that people who have gluten intolerances have the celiac, whether they were tested for it or not. I’m not sure that most medical doctors, some of them do ’cause I’ve been to a few that do, will test for celiac. There’s a spit test you can do. There’s all these other tests you can do that are, that don’t cost money. But how does it come, go into play? 

I: Is it sort of like …

S: I think it was, for me, I think it was the first stages. Um, at least as far as a diagnosis goes and my doctor slowly started treating me for celiac. Once she got that under control, then we started treating me for, like, if I have gluten I’m bleeding out my, you know, out my ass because, and I didn’t know that’s what celiac did. Because, my friend works, he’s a higher up at [a restaurant] and he works in the kitchen and he’s like, he’s like it’s very serious. In like, really, ’cause he, everyone calls it celiac ’cause it’s more widespread as a diagnosis and that’s what we label it.

S: In all intents and purposes, you could say I have that, but I don’t like to use that label.

I: Is that because you feel that, as a medical term, celiac is an easy way to create an umbrella over these conditions?

S: Absolutely. Its, it’s just like, back when they used to say ADD and ADHD they would come up with all these initials for that. You remember those, when that happened?

S: And I’m just like, that was us growing up. I was an A student, but it was still, we were, my little brother was way even more hyper. My mom didn’t know what to do with that. But she didn’t drug him because she didn’t want to deal with him. She just dealt with it. And now we call it something so we can put someone on drugs. But it doesn’t help them. You know what I’m saying, it’s like toxic to those kid that grew up, and now they’re adults, a functioning, and they’re like, that was the worst thing you can do to a kid is put them on the drugs, because they can’t access, access their creativity.

I: What are your feelings when you see gluten-free diets, everything’s being marketed as gluten-free this, gluten-free menus when you are in a restaurant?

S: I actually, honestly, I appreciate it. I don’t think of it as, as a bad thing. Like, what is it, on Picasso’s Pizza, Pan Gusto’s Pizza, which is one of the old Picasso’s, they’re, almost all organic and all gluten-free. Organic, I think, fits into it. If you’re gluten-free you’ve got to watch the pesticides you’re putting into your body. Um, and diet, we’re learning more slowly as a society that diet is the best, is a better medicine than actual drugs. Um, it’s what you put into your body, not just the preventative, but um, as a way, that when you do have something, as a way to get out, get yourself out of it. Um, and …

I: Because food is something that you need and you cannot operate without it.

S: Right, right. And if you’re eating stuff that is attributing and continuing exacerbating the issues that you have, whether it’s emotional or not, I mean there’s still, there’s something in your system that’s exacerbating the problem, then how, how is it that any amount of medicine or anything else going to help you? But if you eat stuff that promotes the good stuff to occur and helps you, help you feel better, helps you to feel more energetic and have energy to exercise, that alone and just a better outlook can push away most diseases in anyone’s body, whether that’s gluten or anything else.

S: Um, there’s so much more I was gonna say because, like, as I’m talking, I’m having all these thoughts.

I: If it comes up to you, just throw it out there.

S: I can send you some stuff from like, I see this happening on my pages every day. Like Socrates or Plato or like all these people or Doctor Freud.

I: That would be amazing if you were …

S: It’s some amazing stuff that, like these are all on my feeds that I hit “Like” on. But, it talks about like, all this stuff in different ways. And they, it’s just …

I: Are they posted on your Facebook page?

S: No, it’s just my feed.

S: Various feeds. And so, you know, as it comes, I’ll just forward it to you.

I: Absolutely. I’d love to see these.

S: OK. And, some of them I save and some of them I don’t. If I have any on my computer, I’ll just, yeah, because, and I’ll, it’ll help your, I think it’ll help your [research].

I: I think it will help this project a lot. Um, and just having information too, to know more about …

S: I mean, and you could hear me say, as a healer, like, when you hear other people that are famous, it’s almost kinda almost …

I: Well, it’s refreshing, I mean, it’s refreshing to get it from your perspective because, as you described it, a doctor is going to tell me something that I …

S: And I was at a doctor, um. OK, there’s something I wanna say and it’s all coming out at once, I was …

I: Take your time, we’re in no rush.

S: My, my chiropractor sent me to a doctor because she’s like, “I can’t prescribe medication but I really think, to kick this out of your system, we want to prescribe this,” and she told me that, what she wanted. So, she sends me to a person I know and a person that she knows and this doctor was just, she was a medical doctor but a quack. I’m just like, “You don’t know anything.” And, I’m like, she was testing, which is fine, testing me for all these, testing my blood, testing my liver and all this. And, she’s like, “Well, I don’t know what to do.” I’m like, “What about that medication, you know, doctor- she suggested?” “Well, I could put you on that and I think that’s the best thing, but I just don’t know what’s going on with you.” And, I’m like, it’s all like going back to the medieval days for me. It’s like, I’m like, I spent time with my doctor and we’ve been treating this and we want results to just kick it. But, she’s all, doctors have that ego. Like, “I’m God, I know better than anyone.” And it’s like, so I took the drugs. Literally, it happened Friday night until Sunday evening, I was in-, I was incapacitated. I’ve, I’ve never been, I can’t call it sick, I think I was in a coma. I could, the only thing I could do was get up to pee, I couldn’t even get water. It was, and what happened was, what I researched and what my chiropractor kind of already knew, she’s pretty intuitive, is it killed a parasite in my liver and it caused that reaction. Now had I known in ad-, had I actually known this in advance, and in hindsight, there’s a tea you can drink that’ll counter that and I would have been fine. But, you only know this stuff through experience. It’s who’s, and this is funny ’cause my mom was the same way. She would educate the doctors. And all my, all my uncles are doctors. Um, so my mom had, she, she was gluten-free later on in life, um, because of her, she had rheumatoid arthritis. But, mostly she, she got on a healthy diet because of the arthritis. She would educate my uncles in treating their patients. She’s like, they would argue with her, “This, this is not what we were, the medical books say this.” And, finally, like after, I was, I was a little kid going to [city], that’s where my cousins are. And that one year, they just switched. My mom was just so beside herself, “I’ve been saying this until I’m blue in the face, what made you see the light?” They’re like, “Our patients are demanding it from me.” And so I had to study it and learn that food is more important than medicine in a lot of cases. You know, you’ll never get them. They’re my uncles and I love, they, but they’ll never say that out loud. Because that’s just, it’s their careers and the, it’s the insurance companies. And I’m, I’m doing all of this out of pocket because my insurance company won’t pay for what I had. I got rid of my insurance. They wouldn’t pay for it.

I: Why wouldn’t the insurance company cover that?

S: They won’t pay for a chiropractor, they won’t pay for a nutritionist. They’re just something society doesn’t deem as important. Some insurance companies will. I have Blue Cross. And after, after several years of, after paying my, you know, paying my doctors out of pocket, I’m just, why have insurance? You know, and so my dad would get back because he’s an attorney, he was an attorney. And he would just, so he would pay it for me. And when he died, I was, just would, my dad, he cancel. [ slight laugh ] Because he had, but that’s because, how he was raised. They were taught growing up, is, you know, from grandparents and aunts and uncles that grew up in the Depression. You need insurance. You need this. You need that. And, this is how you live. You live in fear of the what-ifs.

I: That’s going to happen, you may need this.

S: And I, and what helped me change that attitude, because that’s how I was raised by these people. My dad, my grandfather, what changed, my mom wasn’t like that. She was the artist. She did a lot of coppers, but she did a lot of painting as well. But, um, that’s what she did later on in life. Artistic career. And then she became a realtor in the 80s. And that’s what she did until she, and then she kind of retired after all that, when they moved to [a new location]. But, um, so that’s what she did. Where was I going? I forgot what I was talking about.

I: We were discussing, where did we, we started with celiac umbrella term, and, last little blurb. Insurance. Why did you need insurance?

S: And so, I guess we were on a, a track. I was just saying that, you know, we train our society to grow up in these fear modes. I feel that the fear that you have like, that creates the fear of the what-ifs creates more of that happening. Like, what if my house flooded or what if there’s a tornado? Well, those are the people that attract that most to them. And I’ve known, just from my own experience that if you were to ask me this 10 years ago.

I: Is there a specific experience that jumps out to you?

S: Of me creating my own situation?

I: Or seeing it in someone else?

S: In my dad, yeah. He would create these fears and they would happen. Just like, if I didn’t have insurance then I’ll, then you look at someone like me who grew up in the same family, and I don’t have insurance, and even my doctor, my chiropractor, she doesn’t need. She’s like, “Sam, if I could live like you, I would. But, I still have that fear of society. And if you can let that go, if something happens, it happens.” But, if not, it’s, I, it’s like ever since I saw the movie, and I don’t, I’m just gonna throw this at you. I saw that movie, this is as I was going to join [a university degree program] and I, I didn’t want to bring up the girlfriend. She was a [student in the degree program]. Um, but she, she and I were going through a, insane shit. I won’t go into it, but if we …

I: I want you to know that this is a safe place, so if you want to go on a tangent, throw something out there, go for it.

S: Yeah, you could write my life story later, but I, this will [ laughs ], her and I were going through a, um, emotional upheaval that we’re told, um, ’cause we didn’t know what to do. I mean like, shit was, shit was flying around the room. It was like that kind of, like a, um, looking back was an emotional thing. It manifested itself in, there’s so much we don’t know. [ laughs ] That’s another conversation.

I: That’s another conversation for another project.

S: A major conversation. Um, it’s a major conversation. Not because it was personal but because um, but that kind of tied into it as far as, um, her and I saw this movie. I think it was separately because we were breaking up at the time.

I: What was the title?

S: It’s a famous movie. You’ll know it when I tell you it. It came, I can’t think of it. Not The Secret , the one before? [ pause ] But, anyway, it’s this movie, before I’ll, I’ll get it to you.

I: We’ll figure it out after …

S: If I IMDBed [Internet Movie Data Base] it, I’d find it. It’s a documentary. And once I saw that documentary, after this documentary, I’m like, this is stuff I knew in high school. But I would never say it because people thought I was, would think I was crazy. These were scientists that came up with all this stuff. Not gluten people, right? Um, and in the second half of the movie, it was just like, it was more story with Marlene [ sic ] Matlin in it. And, you know with, the deaf one. And you see her like taking all the drugs in her medicine cabinet and throwing them out because it was, it was her realizing that power not to need that. And I used to take Advil all the time for headaches or whatever. Especially going through [university], you understand how that is. I’m just like, you know what, I had such a rush of, after watching that movie, I took, I even threw out my Advils, and I’ve never needed them since. And so, that’s kind of, that’s an example of where I don’t need that insurance, I don’t have to go buy it. And, if I ever do have a headache, which is probably like three times in that eight-year, nine-year period, very minor.

I: Let’s tie it back to the food issue, because one of the theories running around out there is because so much of the food we consume is this genetically altered …

S: Monsanto.

I: Monsanto. There’s, corn is completely different, the amount of steroids and things they put into beer and chicken. Even the treatment of animals is a hot topic issue. It’s all over the place. How much of that do you think ties into these fears that we have? What I put into my body?

S: I think a lot of it does. The people who are against Monsanto and the pro-organic, whenever you’re against something you create a fear. So if I’m saying I’m against, um, non-organic food or I’m against GMOs, well then, you create that fear that these things are bad. I’m not saying they’re bad or good because I don’t know. We haven’t done enough tests on Monsanto. But by creating that fear even we, it’ll even get in my head that it’s, well, I’ve got to be careful I don’t buy GMO. Then, the more I create that myself, I limit the foods I can’t eat. You know, at least in my mind. In reality, could I eat Monsanto and probably be fine? Probably. But, if I knew it was and I was eating it, that would exacerbate the food. I mean, that would exacerbate the food I’m putting into my system. And, I’ve noticed within myself, if I’m focusing on negativity, if I’m pissed off at someone or in a situation where I’m pissed off and not eating, it’s just, I’m gonna, I’m gonna have diarrhea that night. It won’t be the next day, it’ll just go right through me because I’m eating with anger. Doesn’t that make sense?

S: I mean, I’m not sure how much you’re into this.

I: No, this is all good, I mean, we’ll cycle back in and through.

S: And these are all things I’ve learned since, it was either taught to me sometimes or either, but mostly, the way I’ve learned is, and I’ve always thought this was odd, especially going through [university], I would have a revelation or an epiphany or I would have the experience, learn that way. And then, maybe like a week, a month, a year later or two years later, I would have the validation. I mean like, why is that happening? But, I realized because the, it comes from a book, it doesn’t have as much power as coming from me having the experience first. And then I’d have the validation later. Because, I think, I’ve grown up very skeptical of all this shit, trust me. Even though my mom was very into health food, you know, tried to instill that into her children, it was still kinda feel like, oh, that’s just mom. That’s how we are with our parents. So, but because of my own experience, I’ve been able to develop my own ways of doing things, whereas if someone tells me something, then I’m just kind of like a puppet. Being pushed around and the, with the food industry, with Monsanto, people saying pros and cons. And as much as I try to stay out of that, you still see it on Facebook. It’s because of the places that I hit “Like” on.

I: Getting back to the experiences, I wanna circle back into your background, um, how old were you when you first …

S: Had stomach stuff?

S: [ pause ] Here’s where it gets interesting. I believe it was, if I could trace back all the symptoms, I believe it was probably like, when I was, um, probably in my 20s, maybe 21, 22. I remember talking to a friend on the phone, going and asking like, “Don’t you just feel like wiped out after you go to the bathroom? You know have a, have a bowel movement?” And he’s like, “No.” ’Cause I used to work out a lot back then and I’m like, and that happens to me now where I’d have a bowel movement and I’d just, I’d just be exhausted. I’d have to take a nap. I mean, literally, take a nap. Um, and, but no one, who’s to know back then? No one talked about any of this stuff so I wasn’t aware that’s what’s going on. So, I would say probably around 21 is when I felt it started. Um, now, going back before that, when I was in college at [a western university], 18, 19, 20, or maybe even in high school, I drank a lot. And I’m talking Jack Daniels in one hand, Bacardi in another and have a couple of beers for chasers. And the reason I elected to be social, it was because, it actually didn’t make me drunk back then. I would be the designated driver and I was drinking that much. Because people were like, “You’re, you’re sober.” After a while, I stopped arguing with them. My blood alcohol content probably didn’t say that, I could function, yeah. So, I just drank because it was the thing to be social. I think, in the physical world as opposed to the emotional world, I believe that is what helped destroy some of the good lining in my stomach, the bacterias. And I believe that’s where it started. Because one, every year in the spring, this time of year, March, April, May, a month, I would have a stomach issue. And that started so, so the symptoms started when I was 21 with being exhausted after the bowel movement. You know, like, 25, I’m back from school living here. 25, 26, I would notice, like every year, for about four or five years I would have these issues of one-month stomach issues. And that’s exactly what I’m currently going through. Um, and then like gradually, I would have like acid reflux, and so I would take whatever people would, and it always exacerbated with alcohol. So finally, and that’s why I don’t drink too much. I can go six months to a year without drinking a drop. You know, it just depends where I’m at. Because, I know it’s going to re-effect it. Just from experience, I try not to put the thought in there and it doesn’t.

I: How’d that change socially? Did you notice a change at all? Was there?

S: Socially, I had to make, I had to make the, I had to make this decision to stop drinking. And when that happens people feel, like you think your friends are just like, “Oh, c’mon,” it’s really like a tug of war. It’s like, why is my drinking affecting you? In me going through that, it made me a stronger person. In that, like, per-, pressure way. And even the gluten stuff is like, some friends of mine I can’t even be gluten-free around. It’s like, I won’t even eat dinner with you. Sorry. ’Cause it’s like, especially if I go over to their house …

I: What is that conversation like?

S: Most of my friends know now, but like initially, certain friends, especially the ones from [a western university] that aren’t sensitive, mostly guy friends: “You’re fucking weird or pussy,” stuff like that. It’s like, it’s kinda like, “Oh, c’mon.” And I’ll even drink water that doesn’t have ice in it. I thought my mom was crazy growing up, doing that. I couldn’t do that. But my doctor even said, “Don’t drink water with ice in it because what it does is, it makes your stomach and your system work that much harder to digest the coldness and make it warm, room temperature again.” So, if you already have digestive issues, and I take …

I: Don’t they say, in certain diets, that if you want to lose weight you should drink cold water?  One of those little tricks that they tell you? Same with eating peppers.

S: Peppers actually do help me. Certain peppers with the intestinal lining, which wore away gradually due to, they call it leaky gut syndrome. And like, all the toxins within your stool with, be passing through. You’re supposed to absorb the good stuff and the toxins go out. Well, all the toxins were getting into my blood because the gut lining was so thin it started going through the wall. That’s what they call a leaky gut, which was contributing to the, um, chronic fatigue. Which I, and I don’t like to label it but, for me, it was chronic fatigue. Back to what your question was, I’m sorry.

I: How it affected you socially.

S:  Um, so socially I, I don’t, I don’t go to bars and if do it’s tough.

I: What specifically? Is it just the …

S: Because one, I’m not drinking this. But two, because most bar food is fricking fried and it’s got gluten in it. And, even if it’s not fried, it’s not the most healthy, you know? So, my choices are eat beforehand, meet people, sit around and talk while they eat and drink and, you know, you can still have fun. Like, I have friends that are alcoholics who, you can still have fun and, but you can’t, I mean, I just gradually stopped going. Dwindling, so socially, it’s like, to answer your question it’s, I’ll just tell you, I literally, I haven’t lost friends, but I don’t hang out with them as much as I used to. I mean, not nearly as much. I was out every night. Now, it’s sometimes once a month.

I: And that’s not something one can find, almost like a support group or …

S: And, it’s one of the things I was just gonna address which is, it’s almost easier to say, “I’m an alcoholic” than “I’m gluten-free.” It’s all easier to say, “I’m an alcoholic” than say “I can’t drink alcohol because I choose to not drink alcohol with you.” Because when you’re an alcoholic, people like give you that respect. That just is. But when you’re, when you make a choice for your health, to eliminate something out of your diet, it’s like, it really affects other people. And I had to learn that that’s not my issue. Just because you want to drag me into your hell doesn’t mean that, and I had to learn that, how to be strong enough, to stand up for my own health, really. And that’s what it boiled down to. I mean, literally, and one of the guys I’m talking about, kinda referring to is, I see him once every year or six months now. We used to hang out all the time. But because he couldn’t let go of that, and even with his daughter, she, he had a three-year-old who’s had issues with gluten. And I, we were out at dinner and they order it special, non-dairy because no dairy ties in with gluten. As well as alcohol and all that stuff, sugar. Um, and he, he was getting on her, and his family’s practicing medicine too. His dad and uncles are doctors. The words that came out of his mouth were, “I want her to eat normal cheese because I don’t like it.” So, I can live my life and I’m just thinking, and I don’t like, I don’t like to chastise my friends ’cause that’s their choice how they want to raise their family and live. ’Cause, I don’t want to do to him what they’d do to me basically. But when they say that, it’s like you’d rather put your daughter on drugs and medicine that might affect her later on, at three years old, than just get her off gluten for a while? And have her just be healthy? So, I don’t know, it’s for me. And I see her face too, it’s the irony of that. And it’s kinda like that lady, Louise Hay, who I think it was from 73, 75, she made the decision, not because of her health, because of her health, but not because she was gluten intolerant or anything like that. It was a decision before it was even popular to do no sugar, no dairy, no alcohol, and no gluten. I think no caffeine too, like there’s those kind of four or five things that could kind of contribute to the issues. She’s almost 90 right now. I mean, and that’s amazing in our society and she’s got her own publishing company.

I: Especially when it is not with the assistance of a plastic heart. Or something that has been artificially put in.

S: Exactly, so, and there’s probably everyone for her age, there’s probably other people that are smokers and, you know, do drugs all the time. So, who knows? I mean, I’m just saying, yeah  right. Anyway. All these things they’ve found for cures have also proven harmful to your system. So, she actually wanted to learn how to be able to get out of bed during the day because of her arthritis. Because of the gluten at the time. The more she looked into the diet, the more she researched, she learned gluten could affect it all. Back then, all it was was rice, bread, and that’s it. It’s better for me to have brown rice than white because of the nutrients. In the food aspect, I’ve gotten to points where I’m like, I don’t want to eat any more. Like, literally, I, my situation is probably different than others. I eat out almost all the time. I will eat like raw foods, which I’ve found is much better on my system besides processed foods.

I: What is your favorite kind of food?

S: I don’t eat pizza anymore, unless it’s from Picasso’s because they do a great non-gluten, non-dairy pizza that tastes great.

I: Were you a big pizza buff before that?

S: I ate a lot of pizza. I knew it wasn’t good for you but I did it. I mean, it’s cheap. I would eat Taco Bell a lot, and there’s things that I would do in college that I would only do in college that I wouldn’t do when I was out. And that was smoke pot. Although, I didn’t really inhale. As soon as I graduated, I was done. If you put something in your system, make sure it’s good. My dad connected that with gourmet. My mom, she said organic. I like seafood. Just have to be careful it doesn’t have a thickened sauce with flour. Afterwards, no pizza. The dairy will affect me as much as the gluten, if not more. Sugar’s been the hardest one. I can cut it out and be cold turkey. But the little increments I can’t do. Sugar also contributes to cancer. And, they’d rather fight cancer with chemo than do it the right way. The candida was the first thing that we addressed with my treatments. And that was over the course of maybe six months to eight months. Maybe longer, I don’t know. This is my memory. But then after that, we started treating me for parasites. Whether it morphed or it’s just, I think she was doing the stages.

I: And this is when you were seeing the doctor?

S: The chiropractor. And this is all out of pocket. I was seeing and what literally brought, OK, I was seeing her and she got me to a place where I was stable. I stopped seeing her for about three years. Um, I came back to her. It was hard for me to come back to her, not because I didn’t like her, but because, um, I had gotten to a point where I, I would wake up in the morning, go to the bathroom, like you know take a shit, and I was exhausted because like, literally, it was my gut was leaking. So like all the toxins were coming out through and it would burn and it, it was like draining. I learned that your stomach is your power center, it’s where you hold most of your power, and if that’s affected, you’re wiped out. That’s from my experience, I found out research that proves it, but I, or otherwise I’m just telling you what someone else said. So, I’d wake up in the morning, take a shit, ah fuck, go back to bed. I’d get up. I’m like, my God, I’ve gotta eat. I, get this, this was going on for weeks. I’d get up, go downstairs, grab something out of the fridge or out of a cupboard, eat some food, that would wear me out. It’s like it’s wipe me the fuck out. And I would go back to bed. Then I would take a shit. Like, this was throughout the whole day. I would stare at the ceiling looking, thinking, really start talking to God, “Why the fuck am I here? If you want me to, like, what do you want me to do?” It’s like, it’s like you have that conversation and it’s like, just kill me or take me, you know, because I don’t know if I can, if I can’t function, then what’s my purpose here? I can write about this, but I can’t when I’m exhausted. So, I got to this point where I’m just like I have to go back to this doctor. Literally, like, she won’t say anything. She doesn’t want to alarm me, and she knows me, ’cause like, we had this understanding. It’s OK, don’t tell me. Um, literally, she had to treat me for parasites. For all this stuff and she would gradually do it, without explaining to me the process. And I never asked. I didn’t care, because it’s like I don’t want this part to interfere with this part of, you know? If that makes sense? The mind and the stomach. Um, so I started seeing her and literally it was like, but I knew I was ready to die. And she’s like, “You, you’ve had this for a long time” and she’s like “We’re past the point of me treating this for you. You just felt good and stopped seeing me.” OK, I get it. I started seeing her again and like stage by stage we’re treating me for allergies. For gluten allergies, for, I actually started getting some arthritis symptoms here and there and they’d go away once she started treating for, um, for arthritis. She treated me for leaky gut. But you can’t do it all at once. Gradually you can, but she wanted to treat one thing at a time, to make sure it was working. And it was, but, you like, she comes from an engineering background before she became a chiropractor. Intuitive. Nutritional. So we stated with candida, then we would treat me for parasites. Then we would treat me for allergies. Food allergies. And then something emotional would happen, and it would be just like, I’d be back at square one. Not square one, but it felt like I was back at square one. And, when that emotional situation would happen, I can’t remember specifically what incidents back then, but something would set it off and I would either get pissed or all my symptoms started coming back. It can be a physical or emotional stress. My triggers are people attacking me with words. It goes right to my gut and I haven’t gotten past that sensitivity, especially when it involves anger. So, I understand the emotional part. Like people aren’t making this stuff up. How can you agree with one part they say and not the other? People are nuts, man. It’s like you have to do what works for you. When you’re living in a hole where everyone wants to tell you what to do, they don’t know your system. The only one who knows it and can empower it is you. I’ve learned to be stronger, to be able to walk with more confidence as opposed to going around life getting pushed around like a pinball machine. No matter what kind of people try to steer me off course. It’s harder to talk to myself because then I have to listen to this shit. It’s easier for me to explain it to people. I get that. More full life. More satisfaction in life. We always want to be better than our parents and have our children better than us. I’m more in tune with what I’m doing. I’d rather not have gluten at all and cheat after a while. When you have too much of the same food, eventually, your body will reject it because you’re not, it’s just the tolerance for it decreases. Just like the antibiotic. I would take antibiotics to get rid of lingering stuff. I didn’t know there were natural cures. My mom would always say, “All the doctors I go to tell me, only do antibiotics if it’s life or death.” Why wouldn’t they have medicine if it wasn’t good for you? Immunity. I’d done way too much. If I had a fever, I’d take a hot bath, then I’d start throwing up and that would be enough to kick the system. It’d burn my stomach. It was alcohol, it was antibiotics, it was whatever was destroying the lining. I didn’t learn how to express my emotions as a child. We hold our emotions in our gut.

[The interview continued but the participant addressed content not related to the central research question.]

The Ultimate Guide to Qualitative Research - Part 2: Handling Qualitative Data

• Handling qualitative data
• Introduction

Introduction to transcripts in qualitative research

Understanding the transcription process, practical insights: transcription in action, using transcription services, challenges in transcription.

• Field notes
• Survey data and responses
• Visual and audio data
• Data organization
• Data coding
• Coding frame
• Auto and smart coding
• Organizing codes
• Qualitative data analysis
• Content analysis
• Thematic analysis
• Thematic analysis vs. content analysis
• Narrative research
• Phenomenological research
• Discourse analysis
• Grounded theory
• Deductive reasoning
• Inductive reasoning
• Inductive vs. deductive reasoning
• Qualitative data interpretation
• Qualitative analysis software

Research transcripts

Conducting qualitative interviews or focus groups is only the first part of data collection in a qualitative research project. For most qualitative data analysis , you need to turn those audio or video files into written transcripts. While this may seem self-evident to many researchers, much discussion has taken place about transcripts, best research practices for generating them, the debate between transcription services and human transcription, and so much more.

Qualitative data transcription holds a key role in research , acting as the building blocks from which findings are derived and conclusions are drawn. They are the textual representation of verbal data gathered through interviews , focus groups , and observational studies . Given their significance, it's essential to grasp why they are fundamental to qualitative research.

What is the importance of transcripts in research?

The importance of transcripts in research lies in their ability to convert spoken language into written form, making data analysis significantly more manageable. Transcripts act as the raw material for your analysis , creating a tangible record of the conversations and discussions that form the basis of your research. They provide a precise, detailed account of the verbal data collected, enabling researchers to review the information repeatedly and uncover layers of meaning that might be overlooked when listening to the recording .

Transcripts help researchers systematically organize and manage the data, especially when dealing with large volumes of information. They make it easier to search for specific themes, patterns, or keywords, thereby speeding up the data analysis process. Furthermore, transcripts facilitate the sharing of data among researchers, allowing for collaborative analysis and review. They also ensure the transparency of your research by providing a permanent record that can be scrutinized by other researchers, reviewers, or auditors.

How is transcribing used in qualitative research?

A transcript is used as a way to record and represent the rich, detailed, and complex data collected during qualitative studies such as interviews, focus groups, or observations. Without transcriptions, it would be challenging for researchers to dissect, understand, and interpret the in-depth experiences, perceptions, and opinions shared by the participants. Most research involving audio recordings of interviews requires recordings to undergo the transcription process in order for qualitative data analysis to proceed.

Transcribing, in qualitative research, doesn't merely involve verbatim transcription (the word-for-word rendering of verbal data into text). It can also encompass the translation of non-verbal cues such as laughter, pauses, or emotional expressions that can provide valuable context and insights into the participants' experiences and perspectives. By capturing these details, transcripts can help portray a fuller, more authentic picture of the data, enabling a more comprehensive and nuanced analysis.

In qualitative research, transcriptions are also used for data coding , a process where researchers label or categorize parts of the data based on their content, themes, or patterns. This step is critical for identifying trends and making sense of the data, and having a written transcript makes the coding process significantly more efficient and precise.

How are transcripts used in quantitative research?

Interview transcripts also have an important role in quantitative research , specifically in methods like content analysis and conversation analysis . Content analysis involves the systematic coding and quantifying of data within transcripts, such as the frequency of specific words or themes. This allows researchers to discern patterns and trends and gain insights into the prevalence of certain concepts or attitudes. For example, this could involve quantifying the occurrence of health-related discussions within interviews with healthcare providers.

On the other hand, conversation analysis , while often qualitative, can include quantifiable aspects. Transcripts record details of conversation structure and patterns, such as timing and sequence of speech. Quantitative measures like the count of certain conversational elements or the duration of pauses can be used to understand communication dynamics.

In essence, transcripts are not solely a tool for qualitative research methods but also provide a source of quantitative data and a foundation for quantitative analysis methods. They allow for a detailed, tangible record of spoken data, crucial for both qualitative understanding and quantitative measures, showcasing their versatility in the research field.

The transcription process is a critical stage in qualitative research . It refers to the conversion of recorded or observed speech into written text, turning the fluid and dynamic nature of spoken communication into a tangible and analyzable form . In this section, we will delve deeper into the process of transcription and how it is approached in qualitative research.

How do you create a research transcript?

Writing a research transcript starts with the raw data , usually an audio or video recording from interviews , focus groups , or observations . The first step is to carefully listen to the recording and begin writing down what is being said. This should be done with utmost accuracy, capturing not only the spoken words but also any significant pauses, laughter, or emotional expressions.

A crucial aspect of writing a transcript is deciding how detailed it should be. This varies depending on the research objectives and the nature of the data. For some research, a verbatim transcription, which includes every utterance, filler words, and non-verbal cues, is necessary. For other studies, a clean verbatim transcript, which omits irrelevant details like repeated words or stutters, is sufficient. After the initial transcription, the transcript should be reviewed and cross-checked with the recording for accuracy. During this revision process, the researcher may also add time stamps, annotations, or comments to enrich the transcript further.

Other details in transcripts

Depending on your research inquiry, you may consider more nuanced approaches to generating transcripts when you require the analysis of complex and multifaceted data. Apart from accurately rendering the spoken words into text, a qualitative research transcript can also capture the context, meaning, and nuances inherent in the spoken interaction.

This could involve noting the tone of voice, pauses, emotional expressions, body language, and interactions among participants. These non-verbal cues can provide rich insights into the participants' attitudes, emotions, and social dynamics, thus giving the researcher a deeper understanding of the data.

One unique aspect of transcribing qualitative data is the reflection and interpretative process embedded in it. Researchers often gain a deeper understanding of the data during transcription, as it forces them to engage closely with the data and notice details that might have been missed during the initial data collection.

How is data transcription done?

Data transcription can be done manually or with the assistance of transcription software. Manual transcription involves the researcher or a transcriptionist listening to the recording and typing out the conversation. This method is time-consuming but can lead to a higher level of accuracy and deeper immersion in the data.

Automated transcription software, on the other hand, uses automatic speech recognition (ASR) technology to transcribe audio recordings into text. While this method is faster and can handle large volumes of data, it may not be as accurate, especially when dealing with poor audio quality, heavy accents, or technical jargon.

Regardless of the method chosen, the transcribed data should be reviewed and edited for accuracy. This might involve repeated listening to the audio, making corrections, and refining the transcript until it accurately represents the original data.

In summary, the transcription process is a meticulous task that requires careful listening, accurate writing, and thoughtful interpretation. It is an essential step in transforming the raw data into a form suitable for in-depth analysis, thus laying the foundation for your qualitative research findings. By understanding how to write a research transcript, specifically a qualitative research transcript, and knowing how data transcription is done, you'll be well-equipped to handle this critical phase of your qualitative research process.

Types of data transcription in qualitative research

As qualitative data can be diverse and complex, it’s important to understand that not all transcripts are the same. Depending on the research objectives, data characteristics, and the resources available, researchers might opt for different types of transcriptions. Let's delve deeper into these different types and their applicability in qualitative research.

What are the different types of data transcription?

There are generally three main types of data transcription:

1. Verbatim transcription: This is the most detailed form of transcription. It involves transcribing every single word, including filler words (like "um," "uh," and "you know"), false starts, repetitions, and even non-verbal cues such as laughter, pauses, or sighs. Verbatim transcription is often used in research where the manner of speaking or the emotional context is as important as the content itself.

2. Clean verbatim transcription: This type of transcription also captures every word spoken but omits filler words, stutters, and false starts, resulting in a cleaner, more readable transcript. Clean verbatim transcription is usually preferred when the focus is on the content of the speech rather than the style or manner of speaking.

3. Intelligent transcription (or edited transcription): This form of transcription goes a step further in simplifying and clarifying the text. It not only removes filler words and repetitions but also corrects grammatical errors and may even rephrase sentences for clarity. Intelligent transcription is typically used for creating transcripts intended for publication or for audiences who are not directly involved in the research.

What are the different types of transcription in qualitative research?

In qualitative research, the type of transcription used often depends on the nature of the study and the level of detail required in the analysis.

For studies aiming to explore the content of the conversations, clean verbatim or intelligent transcriptions might be sufficient. These types provide a clear and concise account of the spoken data, allowing researchers to easily identify themes and patterns in the content.

However, for studies interested in the nuances of communication, such as sociolinguistic studies or discourse analysis, a verbatim transcription might be more appropriate. This type captures the exact words, speech patterns, and non-verbal cues, thus providing a richer and more authentic representation of the spoken interaction.

Choosing the right type of transcription for your qualitative research is crucial, as it can significantly impact the depth and quality of your data analysis . By understanding the different types of data transcription and their uses in qualitative research, you will be better positioned to make an informed decision that aligns with your research goals.

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Transcription is more than a technical process; it's a fundamental part of the journey from data collection to analysis in qualitative research . Understanding transcription in action means knowing how to do it, what to include, and how to record it for optimal use in your study.

What are examples of transcription?

Transcription can take various forms based on the nature of your research. For instance, a sociolinguistic study might require a detailed verbatim transcript, including non-verbal cues and speech anomalies.

Here's an example:

Interviewer: So, how are you feeling about the project? (in a concerned tone) Participant: Umm... Well, (laughs nervously) it's been a bit... um, overwhelming?

On the other hand, an interview transcript for a market research study might be a clean verbatim transcript, focusing on the content. Here's how it could look:

Interviewer: What do you like about our product? Participant: I really enjoy its user-friendly interface and the customer service is exceptional

How do you transcribe a research interview?

Transcribing a research interview involves several steps. First, ensure you have a good-quality audio or video recording of the interview . Listen to the recording carefully, typing out the conversation verbatim. You can also slow down the speed of the recording, and shortcut keys to rewind the recording a few seconds can be a great help. It's essential to maintain accuracy and include key details that might influence the interpretation of the data , such as significant pauses or emotional inflections.

Depending on your research aims, you may choose to transcribe in verbatim, clean verbatim, or intelligent transcription style. Once the initial transcription is complete, review and cross-check it against the recording for accuracy. Finally, anonymize the data if necessary to ensure participant confidentiality .

What should be included in an interview transcript?

An interview transcript should include everything that is said in the interview, but the level of detail can vary. Here are some elements that are typically included:

1. Identifiers: These help distinguish between different speakers. In the case of an interview, this would usually be the interviewer and the interviewee(s). 2. Verbal responses: All responses to the interview questions should be included in the transcript. 3. Non-verbal cues: Depending on the research objectives, non-verbal cues such as laughter, sighs, or pauses can provide additional context and should be included. 4. Time stamps: These help locate specific parts of the audio recording and can be very helpful during analysis. 5. Annotations: These might include comments or notes made by the transcriber about the context, the tone of voice, or background noises.

How do I record an interview transcript?

Recording an interview transcript starts with creating an audio or video recording of the interview. After the interview, use either manual transcription or automatic transcription software to convert the audio into written text. Make sure to include identifiers for each speaker, their verbal responses, and any relevant non-verbal cues. Review and revise the transcript for accuracy, adding time stamps or annotations as needed.

In summary, transcribing interviews is a meticulous task that requires careful attention to detail and accuracy. By understanding what to include in a transcript and how to record it, you'll be well-equipped to capture the richness and depth of your interview data, laying the groundwork for a robust analysis.

Benefits of transcription in qualitative research

In qualitative research , transcription represents more than a technical or administrative task. It’s the transformative process that turns spoken communication into a tangible, accessible text form that can be critically examined, dissected, and evaluated. This process forms the underpinning of the entire data analysis journey, creating the foundation upon which interpretations are built and conclusions are drawn.

Looking deeper into the benefits of transcription in qualitative research

Unearthing the multiple layers of transcription’s benefits in qualitative research reveals how it contributes to the efficacy and integrity of a study.

1. Facilitating data accessibility: One of the fundamental benefits of transcription is that it brings to life the spoken word, facilitating accessibility. It translates data into a format that is readable, searchable, and conducive to rigorous analysis. Transcripts can be reviewed multiple times, allowing researchers to revisit the data continually. They can be easily shared among team members or other researchers, enhancing the communicability of the study. Transcription also bridges barriers for those who are hearing-impaired or for whom the original language of the conversation might be a hurdle.

2. Enabling comprehensive analysis: Transcripts are the bedrock upon which qualitative analysis is built. They provide the raw material for various methods of qualitative data examination, whether it's the deep dive of a thematic analysis , the linguistic focus of discourse analysis , or the systematic categorization of content analysis . These written records allow researchers to delve into the data, identify recurring patterns, extract significant themes, and uncover insights that might be less discernible or entirely lost in the original audio or video format.

3. Promoting reflection and interpretation: Transcription is far from being a mechanical, dispassionate process. It necessitates active and continual engagement with the data , leading to a process of reflection and interpretation that forms the basis of qualitative analysis. During the act of transcribing, researchers can glean new insights, recognize overlooked details, and begin to make initial interpretations. It's often during this process that the data begin to speak, allowing researchers to discern their meaning and value.

4. Providing evidence and establishing an audit trail: Transcripts constitute a concrete, verifiable record of the data collected, the words expressed by the participants, their sentiments, and their experiences. This record acts as a form of evidence to substantiate the research findings, ensuring their credibility. Furthermore, they provide an audit trail, contributing to the transparency, accountability, and, thus, the overall trustworthiness of the study.

Justifying the use of transcription for qualitative data

The crucial role of transcription in qualitative research is underscored by its ability to capture the richness and multifaceted nature of spoken data and convert it into a format ripe for in-depth analysis. It provides a lens through which subtle nuances of communication - the ebb and flow of conversation, shifts in tone, or emotional expressions - can be understood. This is invaluable in qualitative research, where the aim is to capture and understand the depth and complexity of human experiences.

Transcripts also serve as a durable, enduring record of the data, preserving the words and voices of the participants. They ensure that the insights, stories, and experiences shared by participants are not transient but can be revisited, reviewed, and reinterpreted in future research.

Transcription services have revolutionized the way researchers process their data, offering a range of possibilities from manual transcription to advanced AI-driven software. These services often come with their own benefits and drawbacks, and understanding these is key to making an informed decision for your qualitative research project. This section will delve into the world of transcription services, helping you to explore your options and make the best choice for your research needs.

Types of transcription services

Broadly, transcription services fall into two main categories: human services and automated services.

Human transcription services employ professional transcribers to convert your audio or video files into text. These services often offer high-quality, accurate transcripts, as they benefit from the nuanced understanding and context interpretation abilities of a human transcriber.

Automated transcription services, on the other hand, use speech recognition software to transcribe audio or video files. They are typically faster and less expensive than human transcription services, but their accuracy can vary depending on the quality of the audio and the complexity of the language used.

Advantages and disadvantages of outside services

Choosing between human and automated transcription services often depends on your project's specific needs. Let's delve into some advantages and disadvantages of each.

Advantages of human services

1. Accuracy: Human transcribers can understand context, decipher accents, and make out words in poor-quality audio better than any software, ensuring high-quality transcripts.

2. Personalized service: They offer personalized service with attention to detail, including specific formatting requests or specialized transcription styles.

Disadvantages of human services

1. Time-consuming: Human transcription is slower than automated transcription, which can be an issue for projects with tight timelines.

2. Cost: Human transcription services can be expensive, especially for large volumes of data. Advantages of automated services

1. Speed: Automated services can transcribe audio or video files much faster than human transcribers.

2. Cost: They are usually more affordable than human transcription services, making them a good option for budget-conscious projects.

Disadvantages of automated services

1. Accuracy: While speech recognition technology has improved significantly, it still struggles with accents, poor audio quality, and complex terminology, which may lead to less accurate transcripts.

2. Lack of context: Automated services may not capture nuances in language or understand context the way a human transcriber can.

Tips for choosing the right service

Selecting the right transcription service should be based on the specific needs and constraints of your project. Here are a few tips to guide your choice:

1. Assess your needs: Consider the complexity of your data, the quality of your recordings, your budget, and your timeline.

2. Test the service: If possible, use a short sample of your data to test the service. This can give you a sense of the quality of the transcription and whether it meets your needs.

3. Read reviews: Check out reviews and ratings from other users to gauge the reliability and performance of the service.

These outside services can be a valuable resource in qualitative research, saving you time and effort. By understanding the benefits and drawbacks of human and automated services and evaluating your specific research needs, you can make an informed choice that best supports your research goals.

The transcription process, while invaluable to qualitative research , does not come without its fair share of challenges. The transformation of oral data into written format can be a complicated endeavor, particularly in cases where the audio quality is poor, speakers have heavy accents, or the conversation is filled with technical or specific jargon. Despite these hurdles, there are various strategies that can help you navigate these issues and ensure high-quality, accurate transcripts.

Audio quality

One of the most common challenges in transcription is dealing with poor audio quality. Background noise, low speaking volumes, or unclear pronunciations can make it difficult to distinguish what is being said. It's a good idea to invest in high-quality recording equipment and choose a quiet, controlled environment for your interviews or focus groups. Ensure that all participants speak clearly and loudly enough to be heard. If your data is already collected and the audio quality is poor, consider using noise-canceling software or hiring a professional transcription service that specializes in handling poor-quality audio.

Accents and dialects

Dealing with heavy accents or unfamiliar dialects can be challenging, particularly for automated transcription services that may not be programmed to handle a wide range of accents or dialects. Human transcribers can spend time familiarizing themselves with the accent or dialect to aid their comprehension. In some cases, it may be beneficial to engage a local transcriber who is familiar with the accent or dialect. For automated services, choosing a service that offers multilingual support or can handle a variety of accents can improve the accuracy of your transcripts.

Technical jargon and specific language

Transcribing conversations that include technical jargon, specific terminology, or industry-specific language can be a challenge, especially if the transcriber is not familiar with the terminology. If you are outsourcing your transcription to a human service, providing a glossary of terms to your transcriber can be very helpful. This can include definitions of technical terms, acronyms, or any specific language used in your study. If using an automated service, choose one that has capabilities to learn and adapt to specific terminology.

Time and resources

Transcription can be a time-consuming and resource-intensive process, especially for large volumes of data. Consider using transcription software or outsourcing to a transcription service to save time. If you’re transcribing manually, developing a systematic approach can increase efficiency. This can include using transcription software to speed up or slow down the audio, utilizing keyboard shortcuts, or creating a consistent formatting system.

Choose ATLAS.ti for your interview research

Analyze transcripts for interviews and focus groups with ATLAS.ti. Download a free trial today.

How to Transcribe Interviews for Qualitative Research

Saving time and effort with Notta, starting from today!

Collecting numerical data is as easy as clicking copy and paste. But what about the unique feedback, comments, and descriptions of qualitative data? Not so much. Once you’ve figured out your research objectives and conducted your interviews, everything else feels intimidating. How do you transcribe entire interviews if every participant talks about something different? How do you even measure answers in natural language with unique viewpoints?

I feel you. When I managed customer support for an online company a few years ago, a lot of our valuable feedback didn’t come from scores out of 10 on product surveys, but rather from customer emails, reviews, and social media comments telling us what they loved and where we could do better. I think that’s why transcribing interviews for qualitative research like this is so important. It’s the first step in organizing all kinds of information into groups and themes you can actually use.

Keep reading because I’ll explain more about how to transcribe an interview (and why you should), plus using transcription software for qualitative research to speed things up.

What is Qualitative Research?

Qualitative research is when you ask open questions that prompt people for descriptive answers. It encourages feedback and observations that you can’t measure with numbers. If quantitative research finds out the facts from numbers , qualitative research is the reason why people make specific choices or behave a certain way .

What is an Interview?

An interview is a great qualitative feedback method whereby you ask a series of open-ended questions to an interviewee to gain answers, feedback, and opinions in their own words. You can conduct interviews in person, over the phone, or on video, solo or in groups.

How to Prepare an Interview for Qualitative Research

1. Decide Important Information for Your Interview

Start with your research objectives and create questions based on these - what do you want to learn?

How will you structure your interview? For structured interviews, prepare a list of questions to ask. For unstructured interviews, list topics you want to talk about.

Use open-ended questions to help the interviewee express their thoughts in their own words.

Ask your team to review and approve the interview questions before you begin so you can tweak them if needed.

2. What You Need from Your Research Interview Transcription

How will you extract answers and comments from your transcripts? Coding answers for specific questions and connecting themes can help categorize the data.

Will you read through the entire transcript or condense the conversation into bullet points? You can format your transcript in three ways:

Full Verbatim : The conversation in a raw, unedited state including slang and false starts

Intelligent Verbatim : A cleaned-up version of the full transcript, written in a grammatically correct way without false starts or stuttering

Detailed notes : Summarizing the conversation into scannable notes that cover the main points of conversation

3. Have Your Tools Ready

Choose a good quality microphone and noise-canceling headset that provides clear audio for easy communication.

What device will you use to conduct the interview and write the transcript? Have your PC, Mac, or tablet up to date with software installed.

Settle on the transcription software you’ll use. If you’re typing the transcript manually, have your preferred text editor installed. For automatic transcription, set up your Notta account and log in.

How to Transcribe an Interview for Qualitative Research

Manually transcribe your interview.

Listen to the recorded interview all the way through to familiarize yourself with the content of the conversation.

Open your favorite text editor such as Microsoft Word or Notepad and begin writing the speech while you listen to the recording. Don’t worry about getting it perfect the first time, just write as much as possible.

Go through the transcript again while listening to the audio, this time adding in timestamps in [HH:MM:SS] format and speaker tags every time the interviewer and interviewee speak, with a tag such as [Rachel] or [Interviewer]. If the interviewee wishes to remain anonymous, you can use a general tag such as [Interviewee].

Save your document to your device and share with your research team. Repeat these steps for every interview.

Automatically Transcribe Qualitative Interviews with Notta

Upload an existing recording to notta.

Log into Notta and go to your Dashboard .

Click ‘ Import files ’. You can drag and drop your audio or video file or paste a Google Drive, Dropbox, or YouTube link in the ‘ Import from link ’ field.

Record a Live Meeting or Live Audio with Notta

Click ‘ Transcribe live meeting ’ and paste your meeting link from Zoom, Google Meet, Microsoft Teams, or Webex, if you’re conducting your meeting virtually. This invites Notta Bot to record and transcribe your conversation.

Click ‘ Record an Audio ’ if your interview is in person. This starts recording using your microphone and transcribes in real time.

Edit, Export, and Share Your Transcript

Click on the interview transcript under ‘ Recent Recordings ’ on your Notta dashboard.

Read through the full transcript. You can adjust the blocks of text by clicking your cursor and pressing ‘ Enter ’ or ‘ Delete ’ to join or separate transcript text.

Click a speaker’s name to change it. You can type their name and then decide whether you want to adjust it for this block of text only, or for the entire transcript. Remember, if an interviewee wants to remain anonymous, you can type a generic tag like ‘Interviewee’.

Correct transcription errors by typing directly into the transcript text. Click the highlighted words or phrases in blue and the audio playback will jump to this point.

Add written notes and images to specific points in your transcript using the floating toolbar. This is helpful if you want to add observations you made during the interview.

Click the ‘ Download ’ icon at the top of your transcript page and export in a variety of formats. Notta exports in MP3, TXT, SRT, PDF, DOCX, and XLSX. You can toggle timestamps, speakers, and more.

Share the transcript with people in your team by clicking the ‘ Share ’ button, then managing group and team permissions with the drop-down menus. Create a shareable link by toggling ‘ Share ’ on and copy the link provided.

How to Analyze the Interview Qualitative Data

At first glance, you might feel daunted by the prospect of arranging your qualitative data. After all, numerical and factual data is easy to organize. But what about unique answers, observations, and feedback? Don’t worry—here are some simple steps you can follow to analyze your findings without pulling your hair out.

Organize the Information You Collected at Interview

To study your interviews effectively, use the same method of collection for every interview. This means transcribing each interview in the same way and asking the same or similar questions to each participant. This way, you can stick to the same process when analyzing what data you’ve collected.

Summarize Insights Using Your Transcript

Reading through full transcripts takes a lot of time, so you may find it easier to condense the information into a summary. Use Notta AI to create a summary in a few moments.

Click the ‘ Magic wand ’ icon in your Notta transcript and then click ‘ Generate ’. Notta AI uses machine learning to create an AI summary with three useful parts:

AI Summary: A condensed version of your full transcript, highlighting the basic points

Chapters: A list of key moments and themes during the conversation

Action items: A list of next steps to take, according to the conversation

Explore the Data

Creating a coding system helps you categorize the data and make it easier to understand. Codes can vary and come in a variety of formats but here are some examples:

Descriptive codes : Providing context for the data such as ‘interview setting in coffee shop’.

In-Vivo codes : A verbatim phrase the interviewee used to describe a product or service such as ‘I couldn’t live without it’.

Themed codes : Describing an overarching theme or pattern relating to the interview questions such as ‘accessibility issues’.

Process codes : Identifies what stage of the process the interviewee is currently at in relation to your product or service, such as ‘canceled subscription’ or ‘I’ve heard of your product recently’.

It’s vital that everyone involved in research sticks to these pre-agreed codes to organize data efficiently. It’s okay if you need to revise your methods as you go, but keep everyone informed so there’s no confusion.

Present Your Research

To make your research findings easier to interpret, you can organize them in several ways. Here are some common methods to share your data:

Spreadsheets : arrange your data into a table

Graphs : Displays themes and patterns using their codes in visual graphs

Word clouds : Using In-Vivo codes, displays the most commonly used language by participants

Are There Any Other Qualitative Research Methods?

Interviews aren’t the only way to collect useful qualitative data. If you’re pressed for time or need a deeper understanding of a culture or group, you can try other options.

Observations : Observing peoples’ behaviors in their natural setting without directly interacting with them. Take detailed field notes to describe what you can see, hear, and encounter in terms of interactions.

Focus groups : Taking a small group of people and asking questions. Their answers and interactions with each other can provide verbal and non-verbal insights.

Ethnography : Immersing yourself in a culture or group of people to understand their behaviors, rituals, and perceptions. This is similar to observations but might require deeper and longer-term fieldwork.

Narrative analysis : Studying personal stories, biographies, and autobiographical data to understand the perceptions and meanings people give to certain experiences.

Surveys : Create a series of open-ended questions in a questionnaire to distribute to people, to get unique feedback in their own words.

Secondary research : Gathering different, pre-existing sources of feedback as qualitative data. This includes emails, texts, images, videos, audio recordings, documents, policies, and diaries.

Frequently Asked Questions about Transcription in Qualitative Research

What is a good example of qualitative data.

Qualitative data is valuable when it provides insights into a person’s reasoning behind certain behaviors and lived experiences. Some examples of good qualitative data could include:

Documents like contracts, notes, and emails that contain descriptive, non-numerical data

Social media post and forum comments expressing authentic discussions and opinions

Audio or video recordings of natural conversations

The best qualitative data provides real, descriptive feedback in a person’s natural language. It should express feelings, emotions, attitudes, and perceptions.

Is Qualitative Research Subjective?

Yes, qualitative research is subjective because it’s relative to that individual’s culture, experience, and perceptions. It’s based on opinions and thoughts. Quantitative data is objective because it deals with numerical facts. Both have a place in research, but the subjective nature of qualitative research provides reasoning behind behaviors and decisions.

Why Should You Choose Qualitative Research?

There are many reasons why qualitative research is valuable:

It’s unbiased, as participants can provide thoughts and opinions in their own words.

You can uncover new theories and hypotheses that you may not have known about previously. Collecting qualitative data is often unstructured, allowing people to express new ideas and themes

Gain a deeper understanding of trends. Participants using their own language allows you to find common patterns and insights on a particular issue.

You can discuss sensitive topics. Participants can broach subjects in their own words and share as much as they feel comfortable with.

What is the Difference Between Qualitative and Quantitative Data?

Quantitative data is fixed, numerical feedback. Examples can include annual income, number of people in a household, times a person has bought a specific item, and so on. Qualitative data provides non-numerical, descriptive feedback in natural language. Examples might look like thoughts about a brand’s new color scheme or favorite part of visiting a recent conference.

How Do I Record an Interview?

Here are some basic steps you can follow to prepare for recording an interview as part of your qualitative research:

Write out a list of open-ended questions or a list of topics you want to cover.

Check that the device you’re recording on is charged.

Plug in your microphone and headphones and test them.

Conduct your interview in a quiet environment.

Use the meeting software’s built-in recorder such as Zoom, or a meeting recorder such as Notta.

When the interview starts, set your interviewee at ease by asking some icebreaker questions about their day, their plans, and themselves to get to know each other better and build rapport.

Move onto your interview questions, leaving plenty of time for the interviewee to gather their thoughts and answer in their own words.

Listen and follow up to ask for clarification if needed.

Thank them for their time and let them know what the next steps are.

Check the recorded audio or video file to ensure it came out clearly, ready for transcription.

See? Transcribing an interview for qualitative research doesn’t have to be stressful or time-consuming when you have a plan! My biggest piece of advice here is to understand the goal of the interviews you’re conducting . Interviews with vague questions and no direction in relation to your research objective aren’t likely to garner you valuable information you can actually use. Once you know what insights you’re aiming to uncover, it makes the conversation feel more productive and your research interview transcription will be far easier to use when collecting the data.

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Qualitative Data Coding 101

How to code qualitative data, the smart way (with examples).

By: Jenna Crosley (PhD) | Reviewed by:Dr Eunice Rautenbach | December 2020

As we’ve discussed previously , qualitative research makes use of non-numerical data – for example, words, phrases or even images and video. To analyse this kind of data, the first dragon you’ll need to slay is  qualitative data coding  (or just “coding” if you want to sound cool). But what exactly is coding and how do you do it? 

Overview: Qualitative Data Coding

In this post, we’ll explain qualitative data coding in simple terms. Specifically, we’ll dig into:

• What exactly qualitative data coding is
• What different types of coding exist
• How to code qualitative data (the process)
• Moving from coding to qualitative analysis
• Tips and tricks for quality data coding

What is qualitative data coding?

Let’s start by understanding what a code is. At the simplest level,  a code is a label that describes the content  of a piece of text. For example, in the sentence:

“Pigeons attacked me and stole my sandwich.”

You could use “pigeons” as a code. This code simply describes that the sentence involves pigeons.

So, building onto this,  qualitative data coding is the process of creating and assigning codes to categorise data extracts.   You’ll then use these codes later down the road to derive themes and patterns for your qualitative analysis (for example, thematic analysis ). Coding and analysis can take place simultaneously, but it’s important to note that coding does not necessarily involve identifying themes (depending on which textbook you’re reading, of course). Instead, it generally refers to the process of  labelling and grouping similar types of data  to make generating themes and analysing the data more manageable. 

Makes sense? Great. But why should you bother with coding at all? Why not just look for themes from the outset? Well, coding is a way of making sure your  data is valid . In other words, it helps ensure that your  analysis is undertaken systematically  and that other researchers can review it (in the world of research, we call this transparency). In other words, good coding is the foundation of high-quality analysis.

What are the different types of coding?

Now that we’ve got a plain-language definition of coding on the table, the next step is to understand what types of coding exist. Let’s start with the two main approaches,  deductive  and  inductive   coding.

Deductive coding 101

With deductive coding, we make use of pre-established codes, which are developed before you interact with the present data. This usually involves drawing up a set of  codes based on a research question or previous research . You could also use a code set from the codebook of a previous study.

For example, if you were studying the eating habits of college students, you might have a research question along the lines of 

“What foods do college students eat the most?”

As a result of this research question, you might develop a code set that includes codes such as “sushi”, “pizza”, and “burgers”.  

Deductive coding allows you to approach your analysis with a very tightly focused lens and quickly identify relevant data . Of course, the downside is that you could miss out on some very valuable insights as a result of this tight, predetermined focus. 

Inductive coding 101 

But what about inductive coding? As we touched on earlier, this type of coding involves jumping right into the data and then developing the codes  based on what you find  within the data. 

For example, if you were to analyse a set of open-ended interviews , you wouldn’t necessarily know which direction the conversation would flow. If a conversation begins with a discussion of cats, it may go on to include other animals too, and so you’d add these codes as you progress with your analysis. Simply put, with inductive coding, you “go with the flow” of the data.

Inductive coding is great when you’re researching something that isn’t yet well understood because the coding derived from the data helps you explore the subject. Therefore, this type of coding is usually used when researchers want to investigate new ideas or concepts , or when they want to create new theories. 

A little bit of both… hybrid coding approaches

If you’ve got a set of codes you’ve derived from a research topic, literature review or a previous study (i.e. a deductive approach), but you still don’t have a rich enough set to capture the depth of your qualitative data, you can  combine deductive and inductive  methods – this is called a  hybrid  coding approach. 

To adopt a hybrid approach, you’ll begin your analysis with a set of a priori codes (deductive) and then add new codes (inductive) as you work your way through the data. Essentially, the hybrid coding approach provides the best of both worlds, which is why it’s pretty common to see this in research.

Need a helping hand?

How to code qualitative data

Now that we’ve looked at the main approaches to coding, the next question you’re probably asking is “how do I actually do it?”. Let’s take a look at the  coding process , step by step.

Both inductive and deductive methods of coding typically occur in two stages:  initial coding  and  line by line coding . 

In the initial coding stage, the objective is to get a general overview of the data by reading through and understanding it. If you’re using an inductive approach, this is also where you’ll develop an initial set of codes. Then, in the second stage (line by line coding), you’ll delve deeper into the data and (re)organise it according to (potentially new) codes. 

Step 1 – Initial coding

The first step of the coding process is to identify  the essence  of the text and code it accordingly. While there are various qualitative analysis software packages available, you can just as easily code textual data using Microsoft Word’s “comments” feature. 

Let’s take a look at a practical example of coding. Assume you had the following interview data from two interviewees:

What pets do you have?

I have an alpaca and three dogs.

Only one alpaca? They can die of loneliness if they don’t have a friend.

I didn’t know that! I’ll just have to get five more. 

I have twenty-three bunnies. I initially only had two, I’m not sure what happened. 

In the initial stage of coding, you could assign the code of “pets” or “animals”. These are just initial,  fairly broad codes  that you can (and will) develop and refine later. In the initial stage, broad, rough codes are fine – they’re just a starting point which you will build onto in the second stage. 

How to decide which codes to use

But how exactly do you decide what codes to use when there are many ways to read and interpret any given sentence? Well, there are a few different approaches you can adopt. The  main approaches  to initial coding include:

• In vivo coding 

Process coding

• Open coding

Descriptive coding

Structural coding.

• Value coding

Let’s take a look at each of these:

In vivo coding

When you use in vivo coding, you make use of a  participants’ own words , rather than your interpretation of the data. In other words, you use direct quotes from participants as your codes. By doing this, you’ll avoid trying to infer meaning, rather staying as close to the original phrases and words as possible. 

In vivo coding is particularly useful when your data are derived from participants who speak different languages or come from different cultures. In these cases, it’s often difficult to accurately infer meaning due to linguistic or cultural differences. 

For example, English speakers typically view the future as in front of them and the past as behind them. However, this isn’t the same in all cultures. Speakers of Aymara view the past as in front of them and the future as behind them. Why? Because the future is unknown, so it must be out of sight (or behind us). They know what happened in the past, so their perspective is that it’s positioned in front of them, where they can “see” it. 

In a scenario like this one, it’s not possible to derive the reason for viewing the past as in front and the future as behind without knowing the Aymara culture’s perception of time. Therefore, in vivo coding is particularly useful, as it avoids interpretation errors.

Next up, there’s process coding, which makes use of  action-based codes . Action-based codes are codes that indicate a movement or procedure. These actions are often indicated by gerunds (words ending in “-ing”) – for example, running, jumping or singing.

Process coding is useful as it allows you to code parts of data that aren’t necessarily spoken, but that are still imperative to understanding the meaning of the texts. 

An example here would be if a participant were to say something like, “I have no idea where she is”. A sentence like this can be interpreted in many different ways depending on the context and movements of the participant. The participant could shrug their shoulders, which would indicate that they genuinely don’t know where the girl is; however, they could also wink, showing that they do actually know where the girl is. 

Simply put, process coding is useful as it allows you to, in a concise manner, identify the main occurrences in a set of data and provide a dynamic account of events. For example, you may have action codes such as, “describing a panda”, “singing a song about bananas”, or “arguing with a relative”.

Descriptive coding aims to summarise extracts by using a  single word or noun  that encapsulates the general idea of the data. These words will typically describe the data in a highly condensed manner, which allows the researcher to quickly refer to the content. 

Descriptive coding is very useful when dealing with data that appear in forms other than traditional text – i.e. video clips, sound recordings or images. For example, a descriptive code could be “food” when coding a video clip that involves a group of people discussing what they ate throughout the day, or “cooking” when coding an image showing the steps of a recipe. 

Structural coding involves labelling and describing  specific structural attributes  of the data. Generally, it includes coding according to answers to the questions of “ who ”, “ what ”, “ where ”, and “ how ”, rather than the actual topics expressed in the data. This type of coding is useful when you want to access segments of data quickly, and it can help tremendously when you’re dealing with large data sets. 

For example, if you were coding a collection of theses or dissertations (which would be quite a large data set), structural coding could be useful as you could code according to different sections within each of these documents – i.e. according to the standard  dissertation structure . What-centric labels such as “hypothesis”, “literature review”, and “methodology” would help you to efficiently refer to sections and navigate without having to work through sections of data all over again. 

Structural coding is also useful for data from open-ended surveys. This data may initially be difficult to code as they lack the set structure of other forms of data (such as an interview with a strict set of questions to be answered). In this case, it would useful to code sections of data that answer certain questions such as “who?”, “what?”, “where?” and “how?”.

Let’s take a look at a practical example. If we were to send out a survey asking people about their dogs, we may end up with a (highly condensed) response such as the following: 

Bella is my best friend. When I’m at home I like to sit on the floor with her and roll her ball across the carpet for her to fetch and bring back to me. I love my dog.

In this set, we could code  Bella  as “who”,  dog  as “what”,  home  and  floor  as “where”, and  roll her ball  as “how”. 

Values coding

Finally, values coding involves coding that relates to the  participant’s worldviews . Typically, this type of coding focuses on excerpts that reflect the values, attitudes, and beliefs of the participants. Values coding is therefore very useful for research exploring cultural values and intrapersonal and experiences and actions.   

To recap, the aim of initial coding is to understand and  familiarise yourself with your data , to  develop an initial code set  (if you’re taking an inductive approach) and to take the first shot at  coding your data . The coding approaches above allow you to arrange your data so that it’s easier to navigate during the next stage, line by line coding (we’ll get to this soon). 

While these approaches can all be used individually, it’s important to remember that it’s possible, and potentially beneficial, to  combine them . For example, when conducting initial coding with interviews, you could begin by using structural coding to indicate who speaks when. Then, as a next step, you could apply descriptive coding so that you can navigate to, and between, conversation topics easily. 

Step 2 – Line by line coding

Once you’ve got an overall idea of our data, are comfortable navigating it and have applied some initial codes, you can move on to line by line coding. Line by line coding is pretty much exactly what it sounds like – reviewing your data, line by line,  digging deeper  and assigning additional codes to each line. 

With line-by-line coding, the objective is to pay close attention to your data to  add detail  to your codes. For example, if you have a discussion of beverages and you previously just coded this as “beverages”, you could now go deeper and code more specifically, such as “coffee”, “tea”, and “orange juice”. The aim here is to scratch below the surface. This is the time to get detailed and specific so as to capture as much richness from the data as possible. 

In the line-by-line coding process, it’s useful to  code everything  in your data, even if you don’t think you’re going to use it (you may just end up needing it!). As you go through this process, your coding will become more thorough and detailed, and you’ll have a much better understanding of your data as a result of this, which will be incredibly valuable in the analysis phase.

Moving from coding to analysis

Once you’ve completed your initial coding and line by line coding, the next step is to  start your analysis . Of course, the coding process itself will get you in “analysis mode” and you’ll probably already have some insights and ideas as a result of it, so you should always keep notes of your thoughts as you work through the coding.  

When it comes to qualitative data analysis, there are  many different types of analyses  (we discuss some of the  most popular ones here ) and the type of analysis you adopt will depend heavily on your research aims, objectives and questions . Therefore, we’re not going to go down that rabbit hole here, but we’ll cover the important first steps that build the bridge from qualitative data coding to qualitative analysis.

When starting to think about your analysis, it’s useful to  ask yourself  the following questions to get the wheels turning:

• What actions are shown in the data? 
• What are the aims of these interactions and excerpts? What are the participants potentially trying to achieve?
• How do participants interpret what is happening, and how do they speak about it? What does their language reveal?
• What are the assumptions made by the participants? 
• What are the participants doing? What is going on? 
• Why do I want to learn about this? What am I trying to find out? 
• Why did I include this particular excerpt? What does it represent and how?

Code categorisation

Categorisation is simply the process of reviewing everything you’ve coded and then  creating code categories  that can be used to guide your future analysis. In other words, it’s about creating categories for your code set. Let’s take a look at a practical example.

If you were discussing different types of animals, your initial codes may be “dogs”, “llamas”, and “lions”. In the process of categorisation, you could label (categorise) these three animals as “mammals”, whereas you could categorise “flies”, “crickets”, and “beetles” as “insects”. By creating these code categories, you will be making your data more organised, as well as enriching it so that you can see new connections between different groups of codes. 

Theme identification

From the coding and categorisation processes, you’ll naturally start noticing themes. Therefore, the logical next step is to  identify and clearly articulate the themes  in your data set. When you determine themes, you’ll take what you’ve learned from the coding and categorisation and group it all together to develop themes. This is the part of the coding process where you’ll try to draw meaning from your data, and start to  produce a narrative . The nature of this narrative depends on your research aims and objectives, as well as your research questions (sounds familiar?) and the  qualitative data analysis method  you’ve chosen, so keep these factors front of mind as you scan for themes. 

Tips & tricks for quality coding

Before we wrap up, let’s quickly look at some general advice, tips and suggestions to ensure your qualitative data coding is top-notch.

• Before you begin coding,  plan out the steps  you will take and the coding approach and technique(s) you will follow to avoid inconsistencies. 
• When adopting deductive coding, it’s useful to  use a codebook  from the start of the coding process. This will keep your work organised and will ensure that you don’t forget any of your codes. 
• Whether you’re adopting an inductive or deductive approach,  keep track of the meanings  of your codes and remember to revisit these as you go along.
• Avoid using synonyms  for codes that are similar, if not the same. This will allow you to have a more uniform and accurate coded dataset and will also help you to not get overwhelmed by your data.
• While coding, make sure that you  remind yourself of your aims  and coding method. This will help you to  avoid  directional drift , which happens when coding is not kept consistent. 
• If you are working in a team, make sure that everyone has  been trained and understands  how codes need to be assigned. 

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31 Comments

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How to Analyze Interview Transcripts in Qualitative Research

Rev › Blog › Transcription Blog › How to Analyze Interview Transcripts in Qualitative Research

Studies take time, accuracy, and a drive to provide excellent information, and qualitative research is a critical part of any successful study. You may be wondering how qualitative data adds to a paper or report, given that it’s not the hard “science” we often see highlighted the most often.

How Do You Analyze Qualitative Interviews?

There are two main approaches to qualitative analysis: inductive and deductive . What’s more, there are two types of inductive qualitative analysis to choose from. These are called thematic content analysis and narrative analysis, both of which call for an unstructured approach to research.

Inductive Methods of Analyzing Interview Transcripts

A thematic content analysis begins with weeding out biases and establishing your overarching impressions of the data. Rather than approaching your data with a predetermined framework, identify common themes as you search the materials organically. Your goal is to find common patterns across the data set.

A narrative analysis involves making sense of your interview respondents’ individual stories. Use this type of qualitative data analysis to highlight important aspects of their stories that will best resonate with your readers. And, highlight critical points you have found in other areas of your research.

Deductive Approach to Qualitative Analysis

Deductive analysis , on the other hand, requires a structured or predetermined approach. In this case, the researcher will build categories in advance of their analysis. Then, they’ll map connections in the data to those specific categories.

Each of these qualitative analysis methods lends its benefits to the research effort. Inductive analyses will produce more nuanced findings. Meanwhile, deductive analyses allow the researcher to point to key themes essential to their research.

Successful qualitative research hinges on the accuracy of your data. This can be harder to achieve than with quantitative research. It’s easy to lose important facts and meaning as you transition qualitative data from the source to your published content. This makes transcription a vital tool in maintaining integrity and relaying information in an unbiased way that’s useful for readers and adds appropriate context to the journal or study.

How to Transcribe a Qualitative Interview

Accurate transcription begins early in the interview process, even before you start interviewing. Here are the steps to transcribing a qualitative interview.

1. Collect Feedback for Qualitative Research

There are dozens of ways to gather qualitative data. Recording and accurately transcribing interviews is among the best methods to avoid inaccuracies and data loss, and researchers should consider this approach over simply taking notes firsthand.

Make sure you have a reliable way to record, whether the interview takes place in person, over the phone, or as part of a video call. Depending on the interview method, you may record a video or an audio-only format. Here are some tips depending on where the interview takes place:

• These apps can also be used for over-the-phone interviews.
• For video interviews , we recommend taking advantage of one of our transcription integrations , such as Zoom. Rev also has an API available for those who want to streamline their workflow even further by integrating Rev directly into their processes and platforms.

2. Organize Your Research Recordings

You should ensure that your audio or video files are easy to save, compile, and share. To do this, be sure to adopt easy-to-remember naming conventions as well to ensure they stay organized. An example of a naming convention that is simple to remember and recreate includes “Date.LastNameofSource.Topic”.

3. Transcribe All the Interviews and Focus Group Recordings

The next critical step is transcription. Done manually, this is a long and tedious process that can add hours, days, or even months to your report-writing process. There are dozens of pitfalls when performing transcriptions manually as well, as it can be hard to pick up words spoken in a heavy dialect or quiet tone. You also want to avoid having to transcribe all the “umms” and “ems” that occur when a source is speaking naturally.

Rev provides a variety of transcription services that take the tedium and guesswork out of the research process. You can choose to edit out all of the “umms,” while ensuring that heavy accents or muffled voices are picked up by the recording service.

You can order transcripts from Rev with both audio and video recordings. Once you’ve received your professional transcripts from Rev, you can begin your qualitative analysis.

The 6 Steps of Qualitative Interview Data Analysis

Among qualitative interview data analysis methods, thematic content analysis is perhaps the most common and effective method. It can also be one of the most trustworthy , increasing the traceability and verification of an analysis when done correctly. The following are the six main steps of a successful thematic analysis of your transcripts.

1. Read the Transcripts

By now, you will have accessed your transcript files as digital files in the cloud or have downloaded them to your computer for offline viewing. Start by browsing through your transcripts and making notes of your first impressions. You will be able to identify common themes. This will help you with your final summation of the data.

Next, read through each transcript carefully. Evidence of themes will become stronger, helping you to hone in on important insights.

You must identify bias during this step as well. Biases can appear in the data, among the interviewees, and even within your objectives and methodologies. According to SAGE Publishing , researchers should “acknowledge preconceived notions and actively work to neutralize them” at this early step.

2. Annotate the Transcripts

Annotation is the process of labeling relevant words, phrases, sentences, or sections with codes. These codes help identify important qualitative data types and patterns. Labels can be about actions, activities, concepts, differences, opinions, processes, or whatever you think is relevant.  Annotations will help you organize your data for dissemination .

Be generous with your annotations—don’t hold back. You will have an opportunity to eliminate or consolidate them later. It’s best to do more here, so you don’t have to come back to find more opportunities later.

3. Conceptualize the Data

Conceptualizing qualitative data is the process of aligning data with critical themes you will use in your published content. You will have identified many of these themes during your initial review of the transcripts.

To conceptualize,  create categories and subcategories  by grouping the codes you created during annotation. You may eliminate or combine certain codes rather than using all the codes you created. Keep only the codes you deem relevant to your analysis.

4. Segment the Data

Segmentation is the process of positioning and  connecting your categories . This allows you to establish the bulk of your data cohesively. Start by labeling your categories and then describe the connections between them.

You can use these descriptions to improve your final published content.

• Create a spreadsheet  to easily compile your data.
• Then, use the columns to structure important variables of your data analysis using codes as tools for reference.
• Create a separate tab for the front of the document that contains a coding table. This glossary contains important codes used in the segmentation process. This will help you and others quickly identify what the codes are referring to.

5. Analyze the Segments

You’re now ready to take a  deep dive into your data segments . Start by determining if there is a hierarchy among your categories. Determine if one is more important than the other, or draw a figure to summarize the results. At this stage, you may also want to align qualitative data with any quantitative data you collected.

6. Write the Results

Your analysis of the content is complete—you’re ready to transition your findings into the real body of your content. Use your insights to build and verify theories, answer key questions in your field, and back aims and objectives. Describe your categories and how they are connected using a neutral, objective voice.

Although you will pull heavily from your own research, be sure to publish content in the context of your field. Interpret your results in light of relevant studies, theories, and concepts related to your study.

Why Use Interviews for Qualitative Data

Unlike quantitative data, which is certainly important, a qualitative analysis adds color to academic and business reports. It offers perspective and can make a report more readable, add context, and inspire thoughtful discussion beyond the report.

As we’ve observed, transcribing qualitative interviews is crucial to getting less measurable data from direct sources. They allow researchers to provide relatable stories and perspectives and even quote important contributors directly. Lots of qualitative data from interviews enables authors to avoid embellishment and maintain the integrity of their content as well.

So, how do you conduct interview data analysis on qualitative data to pull key insights and strengthen your reports? Transcribing interviews is one of the most useful tools available for this task.

As a researcher, you need to make the most of recorded interviews . Interview transcripts allow you to use the best qualitative analysis methods. Plus, you can focus only on tasks that add value to your research effort.

Transcription is Essential to Qualitative Research Analysis

Qualitative data is often elusive to researchers. Transcripts allow you to capture original, nuanced responses from your respondents. You get their response naturally using their own words—not a summarized version in your notes.

You can also go back to the original transcript at any time to see what was said as you gain new context. The editable digital transcript files are incredibly easy to work with, saving you time and giving you speaker tags, time marks, and other tools to ensure you can find what you need within a transcript quickly.

When creating a report, accuracy matters, but efficiency matters, as well. Rev offers a seamless way of doing the transcription for you, saving you time and allowing you to focus on high-quality work instead. Consider Rev as your transcription service provider for qualitative research analysis — try Rev’s AI or Human Transcription services today.

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Qualitative Data Analysis: Transcription

• Atlas.ti web
• R for text analysis
• Microsoft Excel & spreadsheets
• Other options
• Planning Qual Data Analysis
• Free Tools for QDA
• QDA with NVivo
• QDA with Atlas.ti
• QDA with MAXQDA
• PKM for QDA
• QDA with Quirkos
• Working Collaboratively
• Qualitative Methods Texts
• Transcription
• Data organization
• Example Publications

Transcription as an Act of Analysis

While transcription is often treated as part of the data collection process, it is also an act of analysis (Woods, 2020). When you manually transcribe an interview, for example, you make choices about how to turn the recording of the interview into text, and these decisions shape the analysis you conduct. 

For example, if you host a focus group, a transcription that just includes the words spoken by the participants loses data about the interaction between them. You may decide to ensure that your transcription includes details on interactions (which would take more time or resources) or decide that interaction information is not relevant to your analysis. This decision is influenced by your methodology and research goals, and should be recognized as a part of your analysis process. 

Planning and communicating the transcription process is further complicated when the researcher works in a research team, asks participants to discuss sensitive topics, occurs in a cross-cultural environment, or when the transcript must be translated into another language (Clark et al, 2017). Published research reports rarely include significant detail about the transcription process, but if you find yourself in one of these situations, it may be worth seeking works in your discipline that address best practices for transcription, data management, participant relationships, and translation, such as Clark et al's (2017) work on developing a transcription and translation protocol for sensitive and cross-cultural team research. 

Transcription Tools

• Atlas.ti (Mac)
• Atlas.ti (Windows)
• NVivo (Windows)
• NVivo (Mac)
• Kaltura/Mediaspace
• Free transcription tools
• Paid transcription services
• Importing automatic transcripts into Atlas.ti (Mac) You can import transcripts and media files from Zoom, Teams, and other video meeting platforms. Atlas.ti links the video and automatic transcript, which allows you to watch the video and edit the transcript right in Atlas.
• Creating transcripts in Atlas.ti You can import media files to Atlas.ti and then create your own transcript within the program. This process will create a transcript that is synced with the media file.
• Link a transcript to media in Atlas.ti You can import existing media and transcripts to Atlas.ti in order to link them together and enable synchronous viewing of the media with links to the transcript.
• Importing automatic transcripts into Atlas.ti (Windows) You can import transcripts and media files from Zoom, Teams, and other video meeting platforms. Atlas.ti links the video and automatic transcript, which allows you to watch the video and edit the transcript right in Atlas.
• Create a transcript in Atlas.ti You can import media files to Atlas.ti and create your own transcript within the program. The transcript will be linked to the media for synchronous scrolling.
• Link a transcript to a media file If you transcript text already, you can upload a media file to Atlas.ti and link the text. This will allow you to use synchronized scrolling, which shows you the video and transcript at the same time.
• Create transcripts in NVivo You can create new transcriptions of media in your NVivo project using the edit mode.
• Import and link transcripts in NVivo Existing transcripts can be imported to NVivo and link the transcript with a media file.

The MAXQDA is the same across Mac and Windows devices. 

• Manual Transcription You can upload media files to MAXQDA and then create new transcripts using the Multimedia Browser.
• Link transcripts to a media file by creating timestamps If you already have transcript text, you can use the edit mode in MAXQDA to create timestamps and sync the transcript to the media file.
• Automatic transcription New to MAXQDA 24, you can now automatically transcribe your media.
• Downloading captions from Kaltura Video files you upload to Kaltura (including recorded Zoom meetings) are automatically captioned, though you'll need to edit the captions and publish them before they appear on your video. Once the file is created, you can download it from Kaltura to upload to other programs. See this page on captions in Kaltura for more information.
• Find and replace text in Word When you download captions from Zoom or Kaltura, it will come with timestamps. You can use the find and replace feature in Word to clear the timestamps for easier editing.
• OTranscribe OTranscribe is a free, open-source and web browser based tool for transcribing audio and video. You can upload media and use the tool to create citations. See the help pages for information.
• Google Docs Voice Typing You can use the voice typing feature to create rough transcriptions of audio as you collect data or by re-playing a recording into the microphone.
• Microsoft Word Dictate Typing Web and desktop versions of Microsoft Word include a dictation tool that will create a rough transcription while you collect data or when you play a recording near your device's microphone.

There are companies that will create transcripts from media files on your behalf, usually for a by-minute fee. 

If you decide to use one of these options, you should ensure that the security of data shared with these services is in compliance with your IRB protocol and consent obtained from any participants. 

Do you have experience with any paid transcription services that you think would be worth adding to this list? Please share your experience with me . 

• NVivo Transcription NVivo offers a paid transcription service, which can be purchased as a paid subscription or a pay-as-you-go service. Transcription is available in 42 languages including English, Spanish, Japanese, Hindi, Arabic and Korean.
• Rev Ref offers both automatic, rough transcription as well as more accurate transcription conducted by workers. Rev supports 36 languages including English, Spanish, Arabic, Mandarin, Japanese, Korean, and Hindi.
• Trint Trint is a paid transcription and analysis tool, with transcription available for 30+ languages , including English, Spanish, Chinese Mandarin, Korean, Hindi, and Korean. Trint also offers translation of text.

Cited on this page

Clark, L., Birkhead, A. S., Fernandez, C., & Egger, M. J. (2017). A transcription and translation protocol for sensitive cross-cultural team research . Qualitative Health Research , 27 (12), 1751–1764. https://doi.org/10.1177/1049732317726761

Woods, D. Presentation in: Christina Silver, Phd. (2020, December 4).  CAQDAS webinar 005 Transcription as an analytic act.  [Video].  https://www.youtube.com/watch?v=7X-s1r4l0QQ.  

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• Transcribing an Interview | 5 Steps & Transcription Software

Transcribing an Interview | 5 Steps & Transcription Software

Published on 6 May 2022 by Raimo Streefkerk .

Transcribing is converting speech to text word for word. Transcribing is a common practice when conducting interviews because it enables you to perform analysis.

How to transcribe an interview in five steps:

• Choose your preferred transcription method.
• Transcribe the audio (using transcription software ).
• Add speaker designation and time stamps.
• Clarify the transcript where needed.
• Proofread the transcript.

Transcription software comparison

Table of contents

Transcription methods, altering the transcript, example transcript, analysing interview transcripts, transcription software.

Before you start transcribing, you first need to determine what transcription method you want to use. The best method depends on the goal of your transcription.

Verbatim transcription

Write down every single word, including pauses, the expression of emotions such as laughter, stuttering, and hesitations such as ‘uh’.

This type of transcription is mostly used in the legal profession or in research where you’re not only interested in what is said but also how it is said.

Intelligent verbatim transcription (most common)

Write down every word, but without irrelevant fillers like ‘um’, ‘yeah’, and ‘you know’. To improve readability, you can also fix grammar mistakes, broken sentences, and long paragraphs.

This method is more readable than verbatim transcription, but some data – such as emotions, pauses and hesitation – is lost in the process.

Edited transcription

A summarised and edited version of an intelligent verbatim transcript. In addition to omitting fillers like ‘you know’, irrelevant sentences can be omitted if it doesn’t change the meaning of the story.

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If the audio quality is bad or the conversation itself needs clarification, you are allowed to make changes in the transcript. For instance:

• Adding a clarifying comment: ‘I showed him that this option [raising prices] would be beneficial for profitability.’
• Marking unclear or missing audio with ellipses: ‘I showed him … would be beneficial for profitability.’
• Emphasising words: ‘ Increasing prices is needed for profitability.’

There are no rules for formatting and structuring a transcript. However, most transcripts contain the following information:

• Names of the interviewer and interviewee (can be anonymised)
• Date and time when the interview took place
• Location of the interview
• Speaker designation (who says what?)
• Line numbers and time stamps (optional)

After transcribing the interview(s) it is time to start analysing. There are several techniques for doing this – coding and categorising is one of them.

This means that you link keywords (e.g., ‘understanding customer’) to the answers you’ve received to your questions. Based on these keywords you are able to find connections between the answers of different respondents.

You can also use methods such as content analysis , thematic analysis , or discourse analysis .

If you quote from an interview in your paper, make sure you correctly cite the source. Learn how to cite an interview in MLA and APA .

Transcribing interviews takes a lot of time, but luckily transcription software is developing quickly. Using transcription software can help you speed up the process.

Most software is able to accurately convert English speech to text. However, the audio quality must be good in order for the software to work. That means a noise-free background, no over-talk, clear accents and good microphones.

If the audio quality is too poor for automatic transcription, you unfortunately have to dictate it or transcribe it manually.

We tested and reviewed the transcription software below using the audio of a YouTube video in which Bill Gates is interviewed . The audio meets all the criteria listed above.

Happy Scribe

• Speaker recognition
• Clean and intuitive editor
• Omits ‘uhs’ and stuttering
• Correct capitalisation and use of full stops
• 25% student discount
• Doesn’t insert punctuation (except for full stops)

• Good speaker recognition
• Simple but powerful interface
• Comment and highlight feature
• Ignores intro music from video
• Easy to keep track of reviewing progress
• Some missing spaces

• Solid speaker recognition
• Very good capitalisation and punctuation (including commas)
• Much cheaper than other transcription software
• Just a 1-minute trial
• Dated editor with limited functionality
• Doesn’t connect audio and transcript
• $20 (approx. £16.25) annual licence fee

Cite this Scribbr article

If you want to cite this source, you can copy and paste the citation or click the ‘Cite this Scribbr article’ button to automatically add the citation to our free Reference Generator.

Streefkerk, R. (2022, May 06). Transcribing an Interview | 5 Steps & Transcription Software. Scribbr. Retrieved 15 April 2024, from https://www.scribbr.co.uk/research-methods/transcribing-an-interview/

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Guidelines and examples of transcription of qualitative data

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The UK Data Service has compiled a set of instructions and best practices to transcribe qualitative data from interviews. This guide seeks to provide advice to ensure methodological consistency and to increase the shareability and reuse of qualitative research data. It provides links to further instructions, examples and a template transcriber confidentiality agreement.

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In the new season of the podcast series Stories of Data: Open.Science.Talk, our representatives from the Horizon 2020 project EOSC-Pillar discuss the present and future of EOSC with a focus on EOSC-Pillar contributions, interviewing project partners and guests about all sorts of topics.

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Article Contents

Introduction, what are the aims of the research project, what level of detail is required, who should do the transcribing, what contextual detail is necessary to interpret data, how should data be represented, what equipment is needed, declaration.

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First steps in qualitative data analysis: transcribing

Bailey J. First steps in qualitative data analysis: transcribing. Family Practice 2008; 25: 127–131.

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Julia Bailey, First steps in qualitative data analysis: transcribing, Family Practice , Volume 25, Issue 2, April 2008, Pages 127–131, https://doi.org/10.1093/fampra/cmn003

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Qualitative research in primary care deepens understanding of phenomena such as health, illness and health care encounters. Many qualitative studies collect audio or video data (e.g. recordings of interviews, focus groups or talk in consultation), and these are usually transcribed into written form for closer study. Transcribing appears to be a straightforward technical task, but in fact involves judgements about what level of detail to choose (e.g. omitting non-verbal dimensions of interaction), data interpretation (e.g. distinguishing ‘I don't, no’ from ‘I don't know’) and data representation (e.g. representing the verbalization ‘hwarryuhh’ as ‘How are you?’).

Representation of audible and visual data into written form is an interpretive process which is therefore the first step in analysing data. Different levels of detail and different representations of data will be required for projects with differing aims and methodological approaches. This article is a guide to practical and theoretical considerations for researchers new to qualitative data analysis. Data examples are given to illustrate decisions to be made when transcribing or assigning the task to others.

Qualitative research can explore the complexity and meaning of social phenomena, 1 , 2 for example patients' experiences of illness 3 and the meanings of apparently irrational behaviour such as unsafe sex. 4 Data for qualitative study may comprise written texts (e.g. documents or field notes) and/or audible and visual data (e.g. recordings of interviews, focus groups or consultations). Recordings are transcribed into written form so that they can be studied in detail, linked with analytic notes and/or coded. 5

Word limits in medical journals mean that little detail is usually given about how transcribing is actually done. Authors' descriptions in papers convey the impression that transcribing is a straightforward technical task, summed up using terms such as ‘verbatim transcription’. 6 However, representing audible talk as written words requires reduction, interpretation and representation to make the written text readable and meaningful. 7 , 8 This article unpicks some of the theoretical and practical decisions involved in transcribing, for researchers new to qualitative data analysis.

Researchers' methodological assumptions and disciplinary backgrounds influence what are considered relevant data and how data should be analysed. To take an example, talk between hospital consultants and medical students could be studied in many different ways: the transcript of a teaching session could be analysed thematically, coding the content (topics) of talk. Analysis could also look at the way that developing an identity as a doctor involves learning to use language in particular ways, for example, using medical terminology in genres such as the ‘case history’. 9 The same data could be analysed to explore the construction of ‘truth’ in medicine: for example, a doctor saying ‘the patient's blood pressure is 120/80’ frames this statement as an objective, quantifiable, scientific truth. In contrast, formulating a patient's medical history with statements such as ‘she reports a pain in the left leg’ or ‘she denies alcohol use’ frames the patient's account as less trustworthy than the doctor's observations. 10 The aims of a project and methodological assumptions have implications for the form and content of transcripts since different features of data will be of analytic interest. 7

Making recordings involves reducing the original data, for example, selecting particular periods of time and/or particular camera angles. Selecting which data have significance reflects underlying assumptions about what count as data for a particular project, for example, whether social talk at the beginning and end of an interview is to be included or the content of a telephone call which interrupts a consultation.

Visual data

Verbal and non-verbal interaction together shape communicative meaning. 11 The aims of the project should dictate whether visual information is necessary for data interpretation, for example, room layout, body orientation, facial expression, gesture and the use of equipment in consultation. 12 However, visual data are more difficult to process since they take a huge length of time to transcribe, and there are fewer conventions for how to represent visual elements on a transcript. 5

Capturing how things are said

The meanings of utterances are profoundly shaped by the way in which something is said in addition to what is said. 13 , 14 Transcriptions need to be very detailed to capture features of talk such as emphasis, speed, tone of voice, timing and pauses but these elements can be crucial for interpreting data. 7

Dr 9: I would suggest yes paracetamol is a good symptomatic treatment, and you'll be fine Pt K: fine, okay, well, thank you very much.

Dr 9: (..) I would suggest (..) yes paracetamol or ibuprofen is a good (..) symptomatic treatment (..) um (.) (slapping hands on thighs) and you'll be fine Pt K: fine (..) okay (.) well (..) (shrugging shoulders and laughing) thank you very much

In the second representation of this interaction, both speakers pause frequently. The doctor slaps his thigh and uses the idiom ‘you'll be fine’ to wrap up his advice giving. In response, Patient K is hesitant and he uses the mitigation ‘well’, shrugs his shoulders and laughs, suggesting turbulence or difficulty in interaction. 15 Although the patient's words seem to indicate agreement, the way these words are said seem to indicate the opposite. 16

Dr 5: So let's just go back to this. So, so you've had this for a few weeks Pt F: yes

Dr 5: .hhh so let's just go back to this (.) so (..) so you've had this for a few w ee ks Pt F: yes (1.0) (left hand on throat, stroking with fingers)

Dr 5: I must ask you (.) why have you come in tod a y because it is a Saturday morning (1.0) it's for u rgent cases only that really have just st a rted Pt F: Yes because it has been troubling me since last last night (left hand still on neck)

This more detailed level of transcribing facilitates analysis of the social relationship between doctor and patient; in this example, the consequences for the doctor–patient interaction of consulting in an urgent surgery with ‘minor’ symptoms. 16

Data must inevitably be reduced in the process of transcribing, since interaction is hugely complex. Decisions therefore need to be made about which features of interaction to transcribe: the level of detail necessary depends upon the aims of a research project, and there is a balance to be struck between readability and accuracy of a transcript. 18

Transcribing is often delegated to a junior researcher or medical secretary for example, but this can be a mistake if the transcriber is inadequately trained or briefed. Transcription involves close observation of data through repeated careful listening (and/or watching), and this is an important first step in data analysis. This familiarity with data and attention to what is actually there rather than what is expected can facilitate realizations or ideas which emerge during analysis. 1 Transcribing takes a long time (at least 3 hours per hour of talk and up to 10 hours per hour with a fine level of detail including visual detail) 5 and this should be allowed for in project time plans, budgeting for researchers’ time if they will be doing the transcribing.

Recordings may be difficult to understand because of the recording quality (e.g. quiet volume, overlaps in speech, interfering noise) and differing accents or styles of speech. Utterances are interpretable through knowledge of their local context (i.e. in relation to what has gone before and what follows), 8 for example, allowing differentiation between ‘I don't, no’ and ‘I don't know'. Interaction is also understood in wider context such as understanding questions and responses to be part of an ‘interview’ or ‘consultation’ genre with particular expectations for speaker roles and the form and content of talk. 19 For example, the question ‘how are you?’ from a patient in consultation would be interpreted as a social greeting, while the same question from a doctor would be taken as an invitation to recount medical problems. 14 Contextual information about the research helps the transcriber to interpret recordings (if they are not the person who collected the data), for example, details about the project aims, the setting and participants and interview topic guides if relevant.

Dr 1: so what are your symptoms since yesterday (..) the aches Pt B: aches ere (..) in me arm (..) sneezing (..) edache Dr 1: ummm (..) okay (..) and have you tried anything for this (.) at all? Pt B: no (..) I ain't a believer of me- (.) medicine to tell you the truth

Although this attempts to represent linguistic variety, using a more literal spelling is difficult to read and runs the risk of portraying respondents as inarticulate and/or uneducated. 20 Even using standard written English, transcribed talk appears faltering and inarticulate. For example, verbal interaction includes false starts, repetitions, interruptions, overlaps, in- and out-breaths, coughs, laughs and encouraging noises (such as ‘mm’), and these features may be omitted to avoid cluttering the text. 18

If talk is mediated via an interpreter, decisions must be made about how to represent translation on a transcript, 8 for example, whether to translate ‘literally’, and then to interpret the meaning in terms of the second language and culture. For example, from French to English, ‘j'ai mal au coeur’ translates literally as ‘I have bad in the heart’, interpreted in English as ‘I feel sick’. Translation therefore adds an additional layer of interpretation to the transcribing process.

Written representations reflect researchers’ interpretations. For example, laughter could be transcribed as ‘he he he', ‘laughter (2 seconds)’, ‘nervous laughter’, ‘quiet laughter’ or ‘giggling’ and these representations convey different interpretations. The layout on paper and labelling also reflect analytic assumptions about data. 20 For example, labelling speakers as ‘patient’ and ‘doctor’ implies that their respective roles in a medical encounter are more salient than other attributes such as ‘man’, ‘mother’, ‘Spanish speaker’ or ‘advice giver’. Talk is often presented in speech turns, with a new line for the next speaker (as in the data examples given), but could also be laid out in a timeline, in columns or in stanzas like poetry, for example. 7 Transcripts are not therefore neutral records of events, but reflect researchers’ interpretations of data.

Presenting quotations in a research paper involves further steps in reduction and representation through the choice of which data to present and what to highlight. There is debate about what counts as relevant context in qualitative research. 21 , 22 For example, studies usually describe the setting in which data were collected and demographic features of respondents such as their age and gender, but relevant contextual information could also include historical, political and policy context, participants’ physical appearance, recent news events, details of previous meetings and so on. 23 Authors’ decisions on which data and what contextual information to present will lead to different framing of data.

Decisions about the level of detail needed for a project will inform whether video or audio recordings are needed. 24 Taking notes instead of making recordings is not sufficiently accurate or detailed for most qualitative projects. Digital audio and video recorders are rapidly replacing analogue equipment: digital recordings are generally better quality, but require computer software to store and process, and digital video files take up huge quantities of computer memory. It is usually necessary to playback recordings repeatedly: a foot-controlled transcription machine facilitates this for analogue audio tapes (see Fig. 1 ) and transcribing software is recommended for digital audio or video files, since this allows synchronous playback and typing (see Fig. 2 ).

Analogue audio recording equipment: dictaphone with microphone and mini-cassette tape and foot-pedal controlled transcription machine with headphones

Digital video recording equipment: video camera with firewire computer lead, mini DV cassette and Transana transcribing software

Representation of audible and visible data into written form is an interpretive process which involves making judgments and is therefore the first step in analysing data. Decisions about transcribing are guided by the methodological assumptions underpinning a particular research project, and there are therefore many different ways to transcribe the same data. Researchers need to decide which level of transcription detail is required for a particular project and how data are to be represented in written form.

Transcribing is an interpretive act rather than simply a technical procedure, and the close observation that transcribing entails can lead to noticing unanticipated phenomena. It is impossible to represent the full complexity of human interaction on a transcript and so listening to and/or watching the ‘original’ recorded data brings data alive through appreciating the way that things have been said as well as what has been said.

Funding: Primary Care Researcher Development award, Department of Health National Coordinating Centre for Research Capacity Development.

Ethical approval: East London and the City Ethical Committee.

Conflict of interest: None.

This paper derives from a PhD thesis written by Julia Bailey entitled ‘Doctor-patient consultations for upper respiratory tract infections: a discourse analysis’, which was supervised by Celia Roberts, Roger Jones and Jane Barlow. Thanks are due to doctors and patients who participated in the project, to practice staff, and to Anne Rouse for her advice on the practicalities of transcribing.

Transcription Conventions

(?) talk too obscure to transcribe.

Hhhhh audible out-breath

.hhh in-breath

[ overlapping talk begins

] overlapping talk ends

(.) silence, less than half a second

(..) silence, less than one second

(2.8) silence measured in 10 ths of a second

:::: lengthening of a sound

Becau- cut off, interruption of a sound

he says. Emphasis

= no silence at all between sounds

LOUD sounds

? rising intonation

(left hand on neck) body conduct

[notes, comments]

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Author notes

• consultation
• primary health care
• qualitative research
• interpretation of findings

Julia Bailey’s article on transcription of qualitative research data caught my attention because she gives the reader valuable advice regarding the theoretical and practical decisions involved in the process of transcription. For example, she emphasized the importance of focusing on the aim of the research project, on proper reduction of original data, on capturing the meaning of verbal and non-verbal interaction, and on the influence of the researcher’s interpretation of raw data on the outcome of the study (1).

Transcription is indeed a crucial process in any qualitative research project as it is the first step in the analysis of raw data. I agree with Bailey that investigators should be very careful with handling this process. I would like to add a few thoughts about the transcription process by reviewing some additional literature sources and by adding a few of my own experiences.

Marshall and Rossman (2) pointed out that we do not speak in paragraphs and do not give signals to researchers about punctuation during a conversation. Thus, transcribing qualitative data is challenging because the transcriber makes judgments and shapes the meaning of the written words. Sofaer (3) emphasized that the analysis and interpretation process should be deliberate and thorough in order to avoid the use of initial impressions. Bradley and Curry (4) discussed the importance of formatting and suggest the labeling of transcripts with a systematic file name and inserting line-numbering so that communication among members of the analysis team is easier, particularly when certain sections of an interview are being discussed later. They also suggest that once a transcript has been prepared, it should be read closely to gain a general understanding of the data. I found it personally quite helpful to read out loud my self-prepared transcripts for several times, which significantly improved my understanding of the qualitative data and also facilitated the subsequent development of coding categories.

Lichtman (5) discussed the issue of transcribing research data collected from a focus group interview with many people (e.g., 10 different voices). She pointed to the difficulty in transcribing those raw data because some people may speak at the same time, some may interrupt, and others may be talking so quietly that it is difficult to understand them. A solution to this problem is to listen and then extract themes rather than to attempt distinguishing one voice from another. I believe this is a good idea.

Transcribing recorded qualitative data is time-consuming and can be quite costly. Most literature sources I read indicate that self- transcribing original data has advantages over hiring a professional transcriber. However, this may not always be possible, particularly when large data sets need to be processed. Seidman (6) pointed out that an advantage of transcribing own tapes is that the investigator comes to know his/her interviews better. In case someone else is hired to transcribe the raw data, Bogdan and Biklen (7) suggest that the investigator should work closely together with the transcriber in order to make sure that the transcription is accurate. More specifically, when a professional transcriber is hired, the investigator should have prepared detailed written instructions for this person. As Seidman (6) puts it: “Writing out the instructions will improve the consistency of the process, encourage the researchers to think through all that is involved, and allow them to share their decision making with their readers at a later point.”

Another important issue relates to the length of the transcripts. Should everything be transcribed or only certain sections of it? Seidman (6) does not recommend preselecting particular parts of the tape for transcription and omitting others because this could lead to premature judgments about what is important and what is not. I have tried out both ways and came to the same conclusion.

The term “transcription” is well known in biology. In this scientific discipline, it relates to “gene-transcription,” a process that can be defined as using the DNA as a template in order to make RNA strands (the transcripts) from it (8). If the genes encoded in the DNA are not accurately transcribed, the deciphering of the transcripts will be difficult and may result in improper protein synthesis. This, in turn, can significantly impact cellular functions. I suggest that we recognize the significance of “accurate gene transcription” in biology and adopt it to the field of qualitative research. Accurate “qualitative data transcription” will allow us to obtain a readable text that has important meaning and can help us solve complex social phenomena, including those related to medicine, public health, and education.

1. Bailey J. First steps in qualitative data analysis: transcribing. Fam Pract. 2008; 25: 127-131.

2. Marshall C, Rossman GB. Designing Qualitative Research. 4th edn. Thousand Oaks, CA: Sage Publications, 2006.

3. Sofaer S. Qualitative research methods. Int J Qual Health Care. 2002; 14: 329-336.

4. Bradley EH, Curry LA. Codes to theory: a critical stage in qualitative analysis. In: Curry L, Shield R, Wetle T (eds.). Improving Aging and Public Health Research: Qualitative and Mixed Methods. Washington, DC: American Public Health Association, 2006: 91-102.

5. Lichtman M. Qualitative Research in Education: A User’s Guide. Thousand Oaks, CA: Sage Publications, 2006.

6. Seidman I. Interviewing as Qualitative Research: A Guide for Researchers in Education and the Social Sciences. 3rd edn. New York, NY: Teachers College Press, 2006.

7. Bogdan RC, Biklen SK. Qualitative Research for Education: An Introduction to Theories and Methods. 5th edn. Boston, MA: Pearson Education, 2007.

8. Starr C. Basic Concepts in Biology. 6th edn. Belmont, CA: Thomson Brook/Cole, 2006.

Conflict of Interest:

None declared

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Methodology

• Transcribing an Interview | 5 Steps & Transcription Software

Transcribing an Interview | 5 Steps & Transcription Software

Published on April 25, 2019 by Raimo Streefkerk . Revised on June 22, 2023.

Transcribing is converting speech to text word for word. Transcribing is a common practice when conducting interviews because it enables you to perform analysis.

How to transcribe an interview in five steps:

• Choose your preferred transcription method
• Transcribe the audio (using transcription software )
• Add speaker designation and time stamps
• Clarify the transcript where needed
• Proofread the transcript, looking out for any mistakes that can lead to information bias or omitted variable bias

Transcription software comparison

Table of contents

Transcription methods, altering the transcript, example transcript, analyzing interview transcripts, transcription software, other interesting articles.

Before you start transcribing, you first need to determine what transcription method you want to use. The best method depends on the goal of your transcription.

Verbatim transcription

Write down every single word, including pauses, the expression of emotions such as laughter, stuttering, and hesitations such as “uh”.

This type of transcription is mostly used in the legal profession or in research where you’re not only interested in what is said but also how it is said.

Intelligent verbatim transcription (most common)

Write down every word, but without irrelevant fillers like “uhm”, “yeah”, “you know” etc. To improve readability, you can also fix grammar mistakes, broken sentences and long paragraphs.

This method is more readable than verbatim transcription, but some data—such as emotions, pauses and hesitation—is lost in the process.

Edited transcription

A summarized and edited version of an intelligent verbatim transcript. In addition to omitting fillers like “you know”, irrelevant sentences can be omitted if it doesn’t change the meaning of the story.

If the audio quality is bad or the conversation itself needs clarification, you are allowed to make changes in the transcript. For instance:

• Adding a clarifying comment: “I showed him that this option [raising prices] would be beneficial for profitability.”
• Marking unclear / missing audio with ellipses: “I showed him … would be beneficial for profitability”
• Emphasizing words: “ Increasing prices is needed for profitability”

There are no rules for formatting and structuring a transcript. However, most transcripts contain the following information:

• Names of the interviewer and interviewee (can be anonymized)
• Date and time when the interview took place
• Location of the interview
• Speaker designation (who says what?)
• Line numbers and time stamps (optional)

After transcribing the interview(s) it is time to start analyzing. There are several techniques for doing this—coding and categorizing is one of them.

This means that you link keywords (e.g., “understanding customer”) to the answers you’ve received to your questions. Based on these keywords you are able to find connections between the answers of different respondents.

You can also use methods such as content analysis , thematic analysis or discourse analysis .

If you quote from an interview in your research paper , make sure you correctly cite the source. Learn how to cite an interview in MLA and APA .

Transcribing interviews takes a lot of time, but luckily transcription software is developing quickly! Using transcription software can help you speed up the process.

Most software is able to accurately convert English speech to text. However, the audio quality must be good in order for the software to work. That means a noise-free background, no over-talk, clear accents and good microphones.

If the audio quality is too poor for automatic transcription, you unfortunately have to dictate it or transcribe it manually.

We tested and reviewed the transcription software below using the audio of a YouTube video in which Bill Gates is interviewed . The audio meets all the criteria listed above.

Happy Scribe

• Speaker recognition
• Clean and intuitive editor
• Omits ‘uhs’ and stuttering
• Correct capitalization and use of periods
• 25% student discount
• Doesn’t insert punctuation (except for periods)

• Good speaker recognition
• Simple but powerful interface
• Comment and highlight feature
• Ignores intro music from video
• Easy to keep track of reviewing progress
• Some missing spaces

• Solid speaker recognition
• Very good capitalization and punctuation (including commas )
• Much cheaper than other transcription software
• Just a 1-minute trial
• Dated editor with limited functionality
• Doesn’t connect audio and transcript
• $20 annual license fee

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

• Normal distribution
• Measures of central tendency
• Chi square tests
• Confidence interval
• Quartiles & Quantiles
• Cluster sampling
• Stratified sampling
• Thematic analysis
• Cohort study
• Peer review
• Ethnography

Research bias

• Implicit bias
• Cognitive bias
• Conformity bias
• Hawthorne effect
• Availability heuristic
• Attrition bias
• Social desirability bias

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Constraints and Opportunities with Interview Transcription: Towards Reflection in Qualitative Research

Daniel g. oliver.

Ohio State University

Julianne M. Serovich

Tina l. mason.

In this paper we discuss the complexities of interview transcription. While often seen as a behind-the-scenes task, we suggest that transcription is a powerful act of representation. Transcription is practiced in multiple ways, often using naturalism, in which every utterance is captured in as much detail as possible, and/or denaturalism, in which grammar is corrected, interview noise (e.g., stutters, pauses, etc.) is removed and nonstandard accents (i.e., non-majority) are standardized. In this article, we discuss the constraints and opportunities of our transcription decisions and point to an intermediate, reflective step. We suggest that researchers incorporate reflection into their research design by interrogating their transcription decisions and the possible impact these decisions may have on participants and research outcomes.

Introduction

Despite its centrality in qualitative data collection, transcription practices remain superficially examined. It is not uncommon for transcription to be presented as a behind-the-scenes aspect of data management rather than as an object of study in its own right. As Agar (1996 :153) writes, “Transcription is a chore.” While certainly there are more stimulating aspects of research, in this paper we argue that transcription is a pivotal aspect of qualitative inquiry. Largely emerging in linguistics ( Ochs 1979 ) and linguistic anthropology ( Duranti 1997 ), scholars from diverse disciplines ( Lapadat and Lindsay 1999 ; Mishler 1984 ; Sandelowski 1994 ; Tilley 1998 ) have begun to recognize the centrality of transcription in qualitative research ( Poland 2002 ). From these scholars, we have learned how transcription can powerfully affect the way participants are understood, the information they share, and the conclusions drawn.

Transcription practices can be thought of in terms of a continuum with two dominant modes: naturalism, in which every utterance is transcribed in as much detail as possible, and denaturalism, in which idiosyncratic elements of speech (e.g., stutters, pauses, nonverbals, involuntary vocalizations) are removed. These two positions correspond to certain views about the representation of language. With a naturalized approach, language represents the real world. Therefore, the transcript reflects a verbatim depiction of speech ( Schegloff 1997 ). Denaturalized transcripts, however, suggest that within speech are meanings and perceptions that construct our reality ( Cameron 2001 ). These are but the bookends in a larger practice of transcription. Between these two methods are endless variations using elements of each to achieve certain analytical objectives and research goals. In this paper, it is not our purpose to pass judgment on the relative superiority of naturalism or denaturalism or to suggest that researchers must choose between the two. Both methods, and the many permutations of each, can be relevant to specific research questions. Rather, in this paper we illustrate the constraints and opportunities that different transcription styles can have on research outcomes and research participants. What is in question is the researcher’s decision-making. In the haste to begin data analysis, it can be easy to use a transcription style that fails to match one’s research objectives or concerns over participant confidentiality. In this paper, we advocate an intermediate step: a period of reflection that allows researchers to contemplate transcription choices and assess how these choices affect both participants and the goals of research. We do this in reference to our own experiences in a highly-sensitive, public health project.

Setting the Transcription Context

In this article, the constraints and opportunities of transcription practices are discussed with reference to on-going research examining the disclosure decisions of HIV-positive men who have sex with men (MSM). The qualitative portion of this mixed-methods study consisted of semi-structured interviews and focus groups with 57 participants about their disclosure practices to casual sexual partners. Data collected as part of this study were highly sensitive given disclosure legislation in many states. For example, in 2000, the Ohio legislature passed legislation stipulating that no person with knowledge that he or she has tested positive for HIV/AIDS can engage in sexual conduct with another person without disclosing their status prior to sex nor engage in sexual conduct with a person the offender knows or believes lacks the mental capacity to understand the significance of the offender’s infection ( Ohio HB. 100 2000 ). Violators can be prosecuted on a second degree felony assault charge and imprisoned up to eight years.

Participant recruitment moved quickly due to tight deadlines. We hired transcribers who were trained to replicate the taped interview, noting pauses, overlapping talk, incomprehensible speech and response/non-response tokens (e.g., Uh huh, Mm, Yeah , etc.). A community-based research team, including research scientists, HIV educators, consumers and graduate students, was formed to provide the first level of coding. When the initial transcripts were given to the research team, we faced an unexpected dilemma. While requesting accurate transcripts, the result was data that often exposed participants’ identities (i.e., as African-American, immigrant, Appalachian). This created two obvious problems. First it endangered participant confidentiality, particularly when combined with other sensitive information revealed in the interview. Second, knowledge about ethnic/class identity permitted the committee to make assumptions about the participant that were not conducive to collaborative data analysis. Given the legal environment that surrounded our participants, we became keenly aware of the need to take extraordinary measures to carefully represent participants’ stories. One of the ways we worked to accomplish this was through reflection on our methods. Upon reflection, we soon came to see transcription as a diverse practice with often competing objectives.

Transcription in Practice

Qualitative research often includes some form of transcription. This is not a new trend. The early ethnographies that took place in the South Pacific and Western America attempted to represent human and natural environments in field notes. Yet, even these early ventures in sustained, academic observation were fraught with representational difficulties. In Duranti (1997 : 122–123), Boas, whose participant observations occurred on American Indian reservations, wrote about these problems:

I am worrying now about the style of oratory because I do not yet know how to get it down. Anyways I have troubles with ordinary conversation. Narrative I can understand quite well, if they talk distinctly, but many have the Indian habit of slurring over the ends of their words – whispering – and that makes it difficult.

These are questions of validity that continue to haunt qualitative researchers. While the social sciences frequently overlook transcription as an important methodological step, there has been a lively debate in linguistics to help fill this gap.

Naturalized Transcription

Naturalized transcription, where utterances are transcribed in as much detail as possible, is most often seen in conversation analysis studies. Conversation analysis can be defined as the study of “talk-in-interaction.” ( Hutchby and Wooffitt 1998 : 13) The analysis is of actual speech patterns between people, that is, conversations. Conversation analysts focus on the tools used to coordinate a conversation (e.g., turn-taking, repairs, overlapping talk, response tokens) ( Edwards and Lampert 1993 ; Hutchby and Wooffitt 1998 ; Jefferson 1985 ; Ochs 1979 ). Attention is paid to describing the conversation and examining it for patterns. Researchers who are interested in the intricacies of spoken language often turn to naturalized transcription.

A naturalized view of conversation is captured both in the structure of the transcript and the representation of speech. This concerns the spatial organization of dialogue and the notation of speech, respectively ( Edwards 2001 ; Jefferson 1985 ; Ochs 1979 ). Concerning structure, the more common, basic transcript is prepared as a dramatic script ( Ochs 1979 ). Just as one reads a play or a page of prose, eyes move top to bottom and left to right. That which is written above and to the left occurs before that written below and to the right. Concerning data representation, an extensive, linguistic shorthand has arisen to suit the needs for verbatim depictions of speech data. (See Table 1 for a brief summary or Atkinson and Heritage (1999) for a more thorough description.)

Transcription Notation

The system provides the transcriber textual symbols to indicate, among other things, time gaps in tenths of a second (e.g., .1), drawn out syllables (e.g., jus:t) and emphasis (e.g., currently ). An example of this, drawn from an interview with an African-American participant, would be depicted as:

• Ok (.1) so you went to (.1) the (.1) Health Department =
• = and got tested then? Are you currently in a relationship?
• Um (.2) not so much (.3) an’thin’ (.1) at all. I jus:t casu:al

With the transcript constructed this way, the belief is that misrepresentation is lessoned, as one moves more closely to actually-existing speech. Ochs (1979) maintained, however, that these transcription conventions are preferences, but also biases about the representation of speech. In response, other transcript styles have been developed to reflect actually-existing speech.

Columnar and partiture formats are common alternatives used to more accurately present speech ( Edwards 1993 ). The first separates speakers into columns. Using the same data as before:

In this case, the speaker’s turns are noted vertically along the column. In addition to notation, overlapping speech is bracketed. Edwards (1993) noted that the advantage of columnar formats over the more common dramatic type is that it shows how conversational asymmetries exist between speakers. That is, the timing of dialogue can be preserved in the transcript, with overlapping talk and turn-taking more graphically depicted than in the basic format. Partiture is another method of attending to the timing of conversations, where the speech is presented horizontally. Ehlich (1993) described data in the partiture method as “semiotic events arrayed horizontally on a line [that] follow each other in time, while events on the same vertical axis represent simultaneous acoustic events.” (p. 129) Like the columnar form, partiture is an attempt to more naturalistically represent dialogue.

Dialogue is rarely the simple exchange of ideas, however. Talk is peppered with verbal and non-verbal signals that can change the tenor of conversations and meaning. The more common signals include overlapping speech, laughter, stuttering and response/non-response tokens (e.g., Yeah, Uh huh, Mm , etc,). These can be difficult to interpret and present the transcriber with difficult, representational decisions ( Bucholtz 2000 ). On one hand, such signals can set the tone of a conversation and/or offer insight into the participant’s affect ( Schegloff 1997 ). On the other hand, signals could have no bearing on the content of the interview at all, and instead obfuscate the participants’ meanings, misleading the analyst. Fundamentally, this is a question of validity and representation. That is, how does the transcriber represent the non-verbal or non-intelligible? For example, in our work with HIV-positive men, the research team read a transcript where the participant’s statement was continually interrupted by his sniffling, indicated in the transcript by (( sniff )). When the team met to discuss this transcript, the sniffling became confusing and the subject of some debate. Some thought the participant was crying during the interview, whereas others made assumptions about drug use. The confusion was settled when the interviewer explained that the participant was sick and his nose was running. Confusion such as this occupies anxieties over proper representation and data validity ( Borland 1991 ). For some, especially conversation analysts, this has meant increased attention to naturalized transcription, arguing that one can decrease this confusion by focusing on the details of the conversation ( Billig 1999a ). For others, it has meant a move towards denaturalism.

Denaturalized Transcription

Denaturalized transcription grows out of an interest in the informational content ( MacLean et al 2004 ) of speech and dissatisfaction with the empiricism of naturalized work ( Billig 1999a , 1999b ). A denaturalized approach to transcription also attempts a verbatim depiction of speech. Yet while still working for a “full and faithful transcription” (Cameron 1996: 33), denaturalism has less to do with depicting accents or involuntary vocalization. Rather, accuracy concerns the substance of the interview, that is, the meanings and perceptions created and shared during a conversation. This approach has found particular relevance in variants of ethnography ( Agar 1996 ; Carspecken 1996 ), grounded theory ( Charmaz 2000 ) and critical discourse analysis ( Fairclough 1993 ; van Dijk 1999 ). We address denaturalized transcription in reference to the latter two.

Critical discourse analysis is a mode of inquiry used to uncover the maneuverings of power. As the critical adjective suggests, its philosophical roots are in the Frankfurt School of critical sociology ( Crotty 1998 ). Whereas the conversation analyst wants to learn about talk, the critical discourse analyst wants to learn what this talk says about other aspects of the participant’s life ( Cameron 2001 ). The focus of critical discourse analysis is on the “ideological dimension” of speech, that is, the embodied discourses ( Cameron 2001 : 123). Interviews, and then the transcripts, are methodological tools used to capture these discourses.

Critical discourse analysts often turn to Foucault’s large body of work for theoretical support. Of particular interest to Foucault ([1972] 1982 , [1979] 1995) was the extent to which discourses permeated society. Discourses were presented as ubiquitous, and they structured how we understood reality. For Foucault ([1972] 1982) , the object of social analysis was to uncover these powerful discourses. He described this approach as archeological, to note an uncovering of discourse in everyday practices (e.g., sexual practices, mental health care, schooling). However, as Fairclough (1993) noted, researchers cannot turn to Foucault for help with transcription. Foucault never addressed the point or employed transcription in any of his work. Accordingly, a Foucauldian approach to discourse analysis can be criticized for being abstracted from real contexts of practice (e.g., interviews, observation). Fairclough (1993) , accordingly, has suggested that if researchers want to examine real practices (e.g., of power), they must analyze real texts. In that the understandings of power are often captured during interviews, one can collect this information in the transcript.

While it is difficult to find detailed guidance about the uses and misuses of transcription in critical discourse analysis, one can turn to actual critical discourse analyses to examine the method in use. For example, in looking at Fairclough’s transcription style, we see a dramatic format, devoid of notation other than for overlapping speech. Describing his transcription approach, he said it is “a fairly minimal type of transcription, which is adequate for many purposes. No system could conceivably show everything, and it is always a matter of judgment, given the nature of research questions, what sort of features to show and in how much detail.” (p.229) Fairclough, therefore, emphasized that researchers reflect on the purposes of the research. For Fairclough, the purpose was an analysis power. In that the maneuverings of power are often captured in the content of the interview rather than in the mechanics of the conversation, denaturalized transcription is typically the chosen method.

This portrayal of denaturalized approaches is not meant to suggest that if one chooses a naturalized approach, critical analyses are not possible. Recently, feminist and critical conversation analysts have focused on how power is implicated in the mechanics of speech. For example, Kitzinger and Frith (1999) used a feminist approach to conversation analysis to uncover the manner in which women refused unwanted sexual overtures. However, the important distinction between this and critical discourse analysis is that the focus of conversation analysis is how these ideas are conveyed in dialogue rather than the ideas themselves. This is a difference in research objectives – an interest in meaning or mechanics. As expressed throughout this paper, methods should reflect research questions. Therefore, if a researcher is interested in how speech is used to negotiate rape prevention, then a critical conversation analysis would be useful in addressing this interest. If, on the other hand, a researcher is interested in the meanings and perceptions attached to rape or rape prevention, it is likely that grounded theory, critical discourse analysis or one of the many variants of ethnography would be more useful.

Similar to critical discourse analysts, grounded theorists also employ a more denaturalized transcription style. Charmaz (2000 : 509) defined grounded theory methods as “systematic guidelines for collecting and analyzing data to build middle-range theoretical frameworks that explain the collected data.” That is, the researcher constructs a theory of the phenomenon being studied that is rooted in the information shared during interviews, observations and focus groups ( Glaser and Strauss 1967 ). The grounded theorist goes into data collection with an interest in meanings and perceptions.

As in critical discourse analysis, effort must be expended to find useful guidance about transcription in grounded theory. The researcher interested in approaches to transcription is less likely to find the extended discussions common to conversation analysis. In grounded theory research, discussions of transcription tend to occupy terse sections of manuscripts. Nevertheless, it is possible to piece together a sustained argument for denaturalized transcription by examining the actual practice of grounded theory. As in critical discourse analysis, the purpose of grounded theory is to get at emic points-of-view, or insider meanings, that are attached to social phenomena. The focus is less how one communicates perceptions (although this can be useful in capturing meanings, cf. Mehan 1999 ), but the perceptions themselves. For example, in MacLeod’s study, (1995) , he worked to express the perceptions attached to the life aspirations of poor, urban youth. Using key quotes from his participants, MacLeod revealed to readers the complex meanings participants had about growing up in poverty: some feeling confident they would escape their housing project, others feeling resigned to a life of poverty. Throughout the text, key quotes were presented in a denaturalized style. While he did not explain this choice, he did explain his interest in the experience of poverty. About his methodological choice, he writes (1995: 8), “The field methods employed in this study are not unlike those. . . in which the researcher attempts to understand a culture form an insider’s point of view.” That is, what did it mean for these young men to live in poverty?

Bennstam et al . (2004) handled their data very similarly to MacLeod. Using a grounded theory design, they analyzed focus group data concerning perceptions of tuberculosis infection in the Congo. Despite the likelihood of very specific geo-ethnic accents (e.g., both indigenous and colonial), their data were presented in a denaturalized format. Within these data were rich details about what it meant to contract TB, particularly the stigmatization and isolation associated with the disease. For MacLeod (1995) and Bennstam et al . (2004) , this had less to do with the mechanics of speech and more to do with the content of the interview. Therefore, the extensive detail of the naturalized transcript, replete with involuntary vocalizations and geo-ethnic accents, was missing from their account of these ethnically diverse participants.

Constraints and Opportunities in Transcription

Transcription choices reflect both explicit and implicit assumptions. In naturalized transcription, it can be argued that the analyst is presented with speech as it is spoken by the participant rather than overly-filtered through the transcriber. Schegloff (1997) states that when we attempt to stay true to the actual speech, we privilege participants’ words and avoid a priori assumptions. This is done, he wrote, “because it is the orientations, meanings, interpretations, understandings, etc. of the participants … it is those characterizations which are privileged in the constitution of social-interactional reality , and therefore have a prima facie claim to being privileged.” ( Schegloff 1997 : 166–167, emphasis in original) The focus is on presenting data in its natural environment, that is, objectively and precisely. Only after this, according to Schegloff (1997) , was it appropriate to apply theoretical filters. To do this before valid data collection is to commit, according to Schegloff (1997) , a kind of theoretical imperialism… a kind of hegemony of the intellectuals… whose theoretical apparatus gets to stipulate the terms by reference to which the world is to be understood – when there has already been a set of terms by reference to which the world was understood – by those… involved in its very coming to pass.” (p. 167, emphasis in original) Schegloff (1997) suggested researchers ask “to whom do the words in a transcript belong?” By keeping the transcript in its natural state, he argued, the participants are allowed to speak for themselves.

Naturalism is not without its critics. Of the more vocal are those in critical discourse analysis ( Billig 1999a , 1999b ; Fairclough 1993 ), who question efforts to ensure an unbiased depiction of speech. Conversation analysis and naturalized transcription, it is argued, are rooted in a naive realism that accepts empirical realities unproblematically ( Guba and Lincoln 1994 ). Critical discourse analysts suggest that this ignores the influence of society and ideology ( Billig 1999a , 1999b ; van Dijk 1999 ). Ignoring this, some argue, could work to misrepresent participants, their stories, and therefore the rigor of the interpretations made from the transcript ( Jaffe and Walton 2000 ; Preston 1982 ).

The effect naturalism can have on our understanding of the social context of speech and the speaker can be problematic. By transcribing a taped interview naturalistically, assumptions can be made about what is standard and what is non-standard. Preston (1982) described the tendency to represent non-standard English as “linguacentric” (p. 306), respelling the speech of African-Americans and southerners. Preston (1982) said this practice gave dialects a “shock folk status” (p. 306); accents were something exotic, if not collectible ( Wolfram and Schilling-Estes 1997 ). A hierarchy is implied with standard, American English placed above those that deviate from this norm.

Jaffe and Walton (2000) further noted that when these non-standard orthographies are read, they often denote race and class that can then be attached to prejudiced assumptions and analyses. As we mentioned earlier, this happened in our own research when committee members began to associate ethnic and class identities with certain social characteristics (e.g., internalized homophobia and lack of HIV/AIDS awareness). For example, a 43-year-old African-American man spoke of how his disclosure decisions are often based on whether his partners believe he has sex with women as well as men. If his male partners do not believe he has sex with women, he will often not disclose. About this he said:

I didn’t want to disclose [to] them because they didn’t think I had been with women. I have a daughter and a son. But with those guys, I used that as a [reason] for me to not disclose because they didn’t believe I was bisexual. Out of 35 [male partners] I told about 20, 25 of them. But the rest I didn’t. And that was due to them not believing that I had ever had sex with a woman.

Later in this interview, he added that his disclosure decisions are also based on his partner’s “character,” which turned out to mean his perception of their heterosexuality. About this he said:

It directs me to disclose and sometimes not to disclose. It’s according to their character…. If they’re not flamboyant…. I would say real flaming, real fagish, because I feel that’s my part. And if you’re the man… that turns me off. So I won’t disclose.

This was problematic for one community member on our research team. He argued that this man represented the internalized homophobia endemic to African-American communities. After this, his reading of the interview reflected disdain for the participant and impeded his ability to code the remainder of the interview in a productive way. We began to understand that knowledge of a participant’s ethnicity could compromise both the integrity of our analysis and confidentiality. This led us to pause and reflect on how to remediate this problem. Rather than removing valuable members of our research team, we began to think about removing certain indicators of ethnicity, including geo-ethnic accent and basic demographic data from all the transcripts community researchers would read.

In the end, transcription presents real challenges to qualitative researchers. Both naturalized and denaturalized approaches suit the purposes of certain research questions (e.g., dialogue patterns or meaning) or frameworks (e.g., conversation analysis or grounded theory) ( Lapadat and Lindsay 1999 ; Ochs 1979 ). While many researchers may be less likely to practice either pure naturalism or denaturalism, opting for something that borrows liberally from each, there are, nevertheless, real concerns that must be addressed in these methodological choices. In our research, we came to realize that a period of reflection was invaluable to creating trustworthy qualitative data, largely by creating safe spaces where our participants would feel free to explain sensitive parts of their lives without fear of the repercussions their words might have.

Towards Reflection in Transcription

At the heart of the debate are questions of research objectives. Conversation analysts focus on the empirical description and analysis of speech. Grounded theorists and critical discourse analysts, on the other hand, are more focused on the meanings contained in a transcript. While these sides are often placed at odds, very rarely have those embroiled in the debate discussed their transcription decisions in relation to their research questions. That is, what are we asking? And, how is what we ask addressed methodologically? Earlier in this paper we stated that one must pick the best method or set of methods that answer the question(s) being asked. This was the impetus for our reflective pause before transcription.

Reflection has gained increased popularity throughout the academy. It is, however, subject to various interpretations. Woolgar (1988) locates reflection within the wider reflexive turn in the social sciences ( Bourdieu and Wacquant 1992 ). Reflexivity is, as Haggerty (2003 : 158) writes “a performance that positions the author in relationship to the field, the act of research, writing and the production of knowledge more generally.” Woolgar (1988) goes on to suggest varieties of reflexivity that can be located on a continuum. At one end, is a radical reflexivity whereby knowledge creation is interdependent. That is, knowledge of an object becomes an act of representation filtered through an author’s or researcher’s preconceptions, experiences and bias. At the other end is a more introspective stance. Woolgar (1998 : 22) writes that such introspection is “a kind of reflexivity – perhaps more accurately designated reflection – [that] entails loose injunctions to ‘think about what we are doing.’” Citing Dewey, Carter (1999 : 28) further defined reflection as “an intentional endeavor to discover specific connections between something which we do and the consequences which result.” Schön (1983) provided yet another level of thinking in writing about reflection-in-action and reflection-on-action. The former referred to the ability to think-while-doing or ‘thinking-on-your-feet.’ The latter referred to the ability to think about one’s practice, after the fact, in an effort to improve, change or evaluate this practice. Schön emphasized that the two are not wholly distinct. That is, one reflects on his/her action which informs thinking-in-action. Taken together, the practitioner develops a repertoire of practices and frames of reference that help in making informed decisions. These discussions about reflection prove relevant in pointing to the processes of informed decision-making. This same impulse to pause and think about our practice emerged as we confronted obstacles to what we believed was useful data collection. Our reflection involved reconciling pitfalls of recorded speech data and its transcription with the objectives of our research.

Early into the project, several transcription-related problems were identified. Choosing a naturalized approach could provide detail that might obfuscate the substance of the interview. This could have an impact on the analysis (e.g., the sniffling participant may have been viewed differently due to a concern over illness or affectation). A denaturalized approach could result in white-washed data, which removed the fine-grained socio-cultural features of the data or even information that could improve the outcomes of the study (i.e., HIV disclosure intervention programs). Our team had reached a crossroad. Rather than choosing an approach and forging ahead, an intermediate step was added. We paused to reflect on our transcription methods. Although it delayed the project, this period of reflection was invaluable.

Language usage revealed itself as particularly problematic. This included (a) challenges with participant and interviewer pronunciation, (b) vocalizations and non-verbal communication, and (c) the use of irregular grammar. Each of these will be described, their challenges revealed, and options for remediation debated.

Pronunciation

How words are pronounced and then represented as text is complicated. Difficulties can occur due to participant’s and interviewer’s use of slang, language or diction. These transcription or interpretation errors can arise in different ways, both technological and human. The most obvious source of technological error emerges from hardware or software difficulties. For example, in our work we found numerous errors resulting from inadequate audio-taping hardware. Either the tape became difficult to hear or skipped during the interview 1 . These difficulties are troublesome but relatively easy to correct. Most other sources of error are human in nature. These can range from how the transcriber hears, interprets and records what he or she hears. This issue will be incorporated throughout the discussion of pronunciation issues.

All languages contain slang, lingo, idioms and euphemisms. In our work with HIV-positive MSM, slang tended to be sexual in nature. For example, a common reference to sexual positioning included referring to oneself as a “top” or “bottom,” “pitcher” or “catcher,” rather than the technical terminology of insertive or receptive partner. For the most part, common usages of slang are not problematic. However, more obscure terminology can be troublesome in that it is difficult to comprehend and may be rendered as something other than what was meant. Transcription errors can result from the transcriber’s naiveté regarding the meaning of the slang or intention of the participant for its usage. For example, when a participant said that his repertoire of sexual behaviors included “tossin’ the salad,” the transcriber was perplexed. Further along in the taped discussion, however, the interviewer probed about this term and learned this was slang used in prisons for oral-anal contact. While not intrinsically difficult to record, the meanings of such terminology frequently elude both the researcher and the transcriber. In these cases, the interviewer can request further description from the participant to ensure complete understanding and, therefore, proper transcription. In another interview, a participant used more personalized slang, referring to his anus as his “anie.” In this case, it was clear what the participant was referring to; however it does underscore that clarification is sometimes necessary.

Geo-ethnic Accent

There are three language issues that can arise when transcribing. These include navigating accents, English as a second language and Ebonics. Geo-ethnic accents can create misunderstanding and confusion in actual conversations, let alone in transcribing interviews. For example, Southern American and New England accents could require considerable effort to transcribe for those not indigenous to that region. Typically, the transcriber is left to decide whether to record the words exactly as they are pronounced or to ”translate” what the participant says into standard (i.e., majority) American English (SAE). For example, a participant of Asian descent pronounced his Vs with a hard B sound (e.g., “however” became “howeber” and “river” became “riber”). Typically in these situations there are cultural or ethnic differences between the participant and transcriber. That is, a transcriber hears the interview through his/her own cultural-linguistic filters. The interviewer and the transcriber are often aware of participant intentions. However, this affords the transcriber significant interpretive and representational power that could affect analysis and results.

Ebonics, or African American Vernacular English (AAVE), is any of the nonstandard varieties of English spoken by some African-American people throughout the world (American Heritage Dictionary 2000). While the media, linguists and educators have debated whether AAVE is improper English or the markings of culture, for the qualitative researcher the issue is largely how to transcribe AAVE ( Green 2002 ). In our study, the most common example was the use of “wif dat” rather than “with that.” Other examples included “ax” instead of “ask” and “bof uv em” instead of “both of them.”

In our study, transcription of AAVE was initially handled naturalistically, depicting it verbatim rather than in SAE. During our reflection sessions, however, the appropriateness of this strategy was debated. On the one hand, if a naturalized approach was adopted, during member check, participants could become offended that they were represented in an insensitive way. On the other hand, if we used a more denaturalized method and “cleaned up” the transcript of AAVE, valuable data might be lost. During reflection we asked ourselves if the transcript would look different if the participant was the transcriber. That is, would they write “wif dat” or “with that?” We wondered if our research was respectful. Equally, we wondered whose perspective was being honored. While Schegloff (1997) argues that naturalism always honors the participant, this assumes that the participant hears his/her voice just as the transcriber does or is comfortable when they do not. We also needed to consider the potential influence of naturalized transcription on research team members. As stated earlier, we found that when AAVE was handled naturalistically some team members made assumptions about education level and socioeconomic status of African-American participants, resulting in potentially biased data analysis. Therefore, we had twin concerns about representation and suitability to our research design.

The pronunciation and enunciation of words is typically described as diction. In qualitative research, diction concerns how interviewers and participants choose words, especially with regard to correctness, clearness or effectiveness. A common feature of diction is the dropping of the “g” behind words. Known in phonology as consonant cluster reduction , this describes the tendency in AAVE to drop the second consonant of a final consonant cluster ( Smitherman 1977 ). Examples from our data included: “I don’t want to give you somethin’ I got” and “I don’t want nothin’ that you got” and “It’s like havin’ a friend… You know what I’m sayin’?”

Another complicated feature of diction is the mispronunciation of words. For example, during an interview, a participant was asked about which types of sexual activities he practiced. To this he responded, “annual” sex.

Speaker A: So when the two of you entered the bathroom, what type of sexual activities did you engage in?

Speaker B: Annual .

This type of scenario presented difficulties that we had not anticipated. We assumed that the participant meant to say “anal,” yet wondered whether to correct this on the transcript. If he was to read “annual” while member checking would he be offended or embarrassed? Neither are reactions that any researcher would be comfortable eliciting.

Involuntary Vocalizations, Response Tokens and Nonverbal Vocalizations

Vocalizations and nonverbal interactions that occur during an interview are other transcription issues to consider. Vocalizations other than speech (e.g., laughing, coughing, stuttering, etc.) and nonverbals (e.g., hand-waving, smiling, etc.) are common in most conversations. Transcribing these features of speech can add to the context of the conversation/interview, offer clarity or create erroneous assumptions. For the purpose of this paper, we have classified such vocalizations into three distinct categories: involuntary vocalizations response/non-response tokens and non-verbal interactions.

Involuntary Vocalizations

Sounds such as coughing, sneezing, burping, sniffing, laughing and crying are considered involuntary noises. Involuntary sounds that occur during an interview can be meaningful or meaningless to the analyst. In an example mentioned earlier, sometimes the inclusion of noise (e.g., sniffling) can be misleading. In that example, the belief that the participant was crying was confirmed for the transcriber when the interviewer asked, “Do you need a moment?” and then, “Would you like a tissue?” Yet, when the interviewer reviewed the transcript, he reported that the participant actually had a cold and was not crying. In another example, a transcript captured a participant who laughed a great deal during the interview. Again, only the interviewer was able to explain to the transcriber that the participant was extremely nervous and that this was a nervous laugh. Training interviewers to give cues as to what is happening during the silence is helpful to the transcriber and analyst.

Response Tokens

Like involuntary vocalizations, there are other parts of speech that, while not quite words, are nevertheless language. Using certain mono- or bi-syllabic sounds, can relay both meaning and understanding to the interlocutors. Among the more common of these are Hm, Ok, Ah, Yeah, Um, Uh , and Uh huh/Nuh uh . Unlike involuntary noises, these vocalizations are intentional. There is meaning attached to them that can influence a conversation. Nevertheless, such vocalizations are often neglected as either inconsequential or extraneous. Research has shown, however, that such vocalizations can provide a great deal of insight into both the nature of conversation (i.e., how one converses), but also the informational content of the conversation ( Gardner 2001 ). Among those working in the ethnomethodological tradition of conversation analysis ( Heritage 1984 ; Jefferson 1984 ; Sacks 1992 ), these features of speech have been called response tokens. Gardner writes (2001 : 3), “Response tokens are difficult to describe, as they lack meaning in the conventional dictionary sense of the word.”

Nevertheless, tokens can capture meaning and emotion. Gardner (2001) offers researchers a typology of response tokens and an indication of their use and intent. Among the most common are three. First, continuers such as Mm hm , or Uh huh are used to note agreement with the speaker and give them back the primary role in the conversation. Second, acknowledgements, such as Mm and Yeah , work to express agreement or understanding between a speaker and a listener. Third are repairs, such as Huh , that ask the speaker to rephrase or repeat an idea or question. In many cases, tokens serve to add more detail and/or emotion to what the speaker is trying to express. A participant used a response token (e.g., Nuh uh to express “no”) in explaining his preferred sexual activities.

Speaker A: So you don’t insert into anybody at all?

Speaker B: Nuh uh. No. I’m considered a typical bottom. Yeah, female bottom.

Speaker A: Okay .

Speaker B : Drag queen bottom, I mean.

Speaker A : Okay, alright. Well some people that are…

Speaker B : I know, I know, I mean, Nuh uh, I just, I have had guys, just this other, like this other guy that I just met, he was talking to me and he’s positive, he was talking to me about having sex like that, and I was like, “No,” and he said he likes it too, and I’m like, “Nuh uh.” It was just, it’s not creepy, it’s just that it’s almost, like, a turn off.

As with involuntary vocalizations, these signals can be inessential, if not distracting, for the analyst. However, it is important to review the transcript to assess their importance before removing these potentially important data from subsequent analyses. Many researchers, particularly conversation analysts, have argued that by disregarding tokens one may fail to fully grasp the intricacies of dialogue. That is, tokens such as a thoughtful Hm or wistful Mm can serve as useful markers in speech, indicating participant discomfort or other affective states (e.g., distress, happiness, pride, etc.).

Non-verbal Vocalizations

Non-verbal communication includes actions, activities and interactions of both participant and interviewer. Gesticulations such as pointing, thought checking, fidgeting, head nodding and hand gestures are included as non-verbal interactions. As with the other forms of noise, non-verbal interactions can add context and explanation, or create misunderstandings for the analyst. For example, one participant likened his penis to a gun, intimating that HIV made it dangerous. In the following excerpt, he speaks about not disclosing his serostatus to a partner before sex, deciding to do so afterwards.

I remember the first time I [did not disclose] because it bugged the shit out of my conscience. I even went back to [him] afterwards and said, “Hey you know what? This is bugging me. I’m HIV positive. I should have told you up front. I totally apologize. I understand if you hate me. I understand if you want to beat the shit out of me. I’m really, really sorry.” He asked why and I said, “I was afraid you wouldn’t go home with me and I wanted you that bad that night.” Which, of course, he took as a total compliment. He thought that was absolutely the sweetest thing in the world, which is fine. But why play around with, (making gun gesture with hand) oh this gun is pretty! Let me just stick it in my mouth! It’s one of those things, like this is really pretty (making gun gesture with hand) it looks great next to your head ((laughing)). Here!

For the researcher, the decision can be to eliminate none, some or all non-verbals from the transcript. In some instances, these data may seem irrelevant and not worthy of including in the transcript. However, it could be argued that non-verbals, as with tokens, are as valuable as verbiage to achieving a deep understanding of the content of a conversation. One advantage of removing non-verbals and tokens is that transcripts become easier to read ( MacLean et al 2004 ). These features of speech can be distracting and make reading and following conversation threads more difficult. However, if non-verbals are removed, there is a risk of missing important conversational cues. The reader or analyst risks missing interviewer’s gestures of compassion, or participant’s movements of discomfort. That is, the rich detail of qualitative data could be lost if the transcript is purged of all non-verbals or tokens. One solution is to have the interviewer function as the transcriber, verifier or analyst. This allows for the inclusion of relevant speech data or the clarification of confusing noises in the transcript which could reduce misinterpretation.

A final language concern is the improper use of SAE. During interviews, it is likely that both interviewer and participant will make grammatical errors. The most common grammatical error we encountered was the use of “ain’t.” Transcribing grammatical errors verbatim is a likely protocol, however we found a more common problem with grammatical errors. For example, in the following excerpt, both the interviewer (Speaker A) and the participant (Speaker B) use incorrect grammar.

Speaker A : Were both of you laying on the couch?

Speaker B : Yeah, we were both laying on the couch.

When the interviewer is either the transcriber or the double checker, the tendency was to recognize the grammatical error and want to change “laying” to “lying” in their quote without disturbing the participant’s quote. Thus, the problem arises when corrections of grammatical errors are made for the interviewer but not for the participant.

Recommendations

As argued, a period of reflection is useful in addressing important transcription issues. This time affords researchers the ability to deliberate over transcription practices and how it affects participants and the goals of research. In relating these issues to research outcomes, it may be necessary to assess the constraints and opportunities of naturalized or denaturalized transcription. This concerns the nature of the research question and what is being sought in the data. In our project, we were interested in both contributing to the knowledge about disclosure practices but also in developing an HIV disclosure intervention. Therefore, issues of the meanings and perceptions attached to disclosure were important to us, less so the mechanics of our interview. This distinction was central to our decision to transcribe more denaturalistically.

Sensitivity to participants and the nature of their involvement with the research is also important to consider. In our project, we were aware that participants might be involved in member checking and our transcription decisions would be quickly apparent. Knowing this, it is important that researchers make decisions in a manner that shows respect for participants’ words and intentions ( Tilley 1998 ). For participants engaging in member checking, naturalized transcription could be seen as disrespectful if the participant would have written the words differently or perceived their grammar more accurately than portrayed in naturalized text.

That being said, there are merits to retaining much of the conversational mechanics captured in a naturalistic transcript. As discussed, conversation analysis provides a wealth of information that could add rich detail to the data. In that a niche of qualitative inquiry is the depth of analysis that statistical indicators cannot provide, it seems counterintuitive to remove the very details that qualitative inquiry is known and appreciated for. The pronunciation, non-verbals and irregular grammar that are parts of everyday speech can offer important insights into a participant’s life and meaning-making that could add richness that would otherwise be lost. For this reason, some qualitative researchers have advocated retaining two versions of the transcript. 2 The first of these would be a naturalized version, containing the many details common to conversation analysis. This copy could serve as a reference copy that the researcher could turn to if in-depth analysis of the conversation (i.e., accents, communication style and speech idiosyncrasies) needed to be examined. The second of these would be a denaturalized version. This transcript could be used both in member-checking (i.e., supplied to the participant) but also for different types of analyses. That is, if the researcher was not interested in the specifics of communication (e.g., repairs, response/non-response tokens, accent, etc.) but rather the informational content, then she/he could turn to this transcript.

Because large studies require numerous transcribers, transcription decisions have to be easily standardized. Transcribers can range from undergraduate volunteers to paid professionals, thus researchers are encouraged to consider a codebook which would aid in the equivalence of the transcription process ( Tilley 1998 ). For example, the codebook section for non-verbals might include references to the omission of sneezing but the inclusion of non-verbals related to affect such as (( crying )) or (( laughing )). Codebooks should be reviewed and updated as necessary.

Finally, transcription decisions should filter back to interviewers who might have to be retrained. As noted earlier, sexual slang was commonplace in our interviews. During reflection we acknowledged that such terminology would be important for later incorporation into an intervention. Therefore, this information was both necessary and desired. Directing interviewers to have participants define their slang could help alleviate many interpretive problems. This would reduce misunderstandings and offer participants the opportunity to clarify and provide their own meanings.

Transcription is a powerful act of representation. This representation can affect how data are conceptualized. Instead of being viewed as a behind-the-scenes task, we argue that the transcription process be incorporated more intimately into qualitative research designs and methodologies. Periods of reflection at crucial design and implementation points may provide a valuable exercise in honoring both the research process and participant’s voice.

Acknowledgments

This work was supported by a grant from the National Institute of Mental Health (R21 MH 067494) to the second author. The authors thank Sarah Smith, members of the Qualitative Research for the Human Sciences listserv and anonymous reviewers for their helpful suggestions. An earlier version of this paper was presented at the 10th annual Qualitative Health Research Conference, Banff, Alberta, Canada. The views expressed in this paper are solely those of the authors. Daniel G. Oliver is a PostDoctoral Research Fellow, Julianne M. Serovich is a Professor and Tina L. Mason is a Post-Doctoral Research Fellow in the Department of Human Development and Family Science at Ohio State University.

1 We did not use voice-activated recording during data collection. Tape skips that did occur during our recording of interviews were due to equipment failures (e.g., defective audiotapes and analog recorders).

2 We thank Rosalie Aroni and an anonymous reviewer for this suggestion.

Contributor Information

Daniel G. Oliver, Ohio State University.

Julianne M. Serovich, Ohio State University.

Tina L. Mason, Ohio State University .

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Healthcare team resilience during COVID-19: a qualitative study

• John W. Ambrose 1 ,
• Ken Catchpole 2 ,
• Heather L. Evans 3 ,
• Lynne S. Nemeth 1 ,
• Diana M. Layne 1 &
• Michelle Nichols 1  

BMC Health Services Research volume  24 , Article number:  459 ( 2024 ) Cite this article

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Resilience, in the field of Resilience Engineering, has been identified as the ability to maintain the safety and the performance of healthcare systems and is aligned with the resilience potentials of anticipation, monitoring, adaptation, and learning. In early 2020, the COVID-19 pandemic challenged the resilience of US healthcare systems due to the lack of equipment, supply interruptions, and a shortage of personnel. The purpose of this qualitative research was to describe resilience in the healthcare team during the COVID-19 pandemic with the healthcare team situated as a cognizant, singular source of knowledge and defined by its collective identity, purpose, competence, and actions, versus the resilience of an individual or an organization.

We developed a descriptive model which considered the healthcare team as a unified cognizant entity within a system designed for safe patient care. This model combined elements from the Patient Systems Engineering Initiative for Patient Safety (SEIPS) and the Advanced Team Decision Making (ADTM) models. Using a qualitative descriptive design and guided by our adapted model, we conducted individual interviews with healthcare team members across the United States. Data were analyzed using thematic analysis and extracted codes were organized within the adapted model framework.

Five themes were identified from the interviews with acute care professionals across the US ( N  = 22): teamwork in a pressure cooker , consistent with working in a high stress environment; healthcare team cohesion , applying past lessons to present challenges , congruent with transferring past skills to current situations; knowledge gaps , and altruistic behaviors , aligned with sense of duty and personal responsibility to the team. Participants’ described how their ability to adapt to their environment was negatively impacted by uncertainty, inconsistent communication of information, and emotions of anxiety, fear, frustration, and stress. Cohesion with co-workers, transferability of skills, and altruistic behavior enhanced healthcare team performance.

Working within the extreme unprecedented circumstances of COVID-19 affected the ability of the healthcare team to anticipate and adapt to the rapidly changing environment. Both team cohesion and altruistic behavior promoted resilience. Our research contributes to a growing understanding of the importance of resilience in the healthcare team. And provides a bridge between individual and organizational resilience.

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Introduction

The COVID-19 pandemic highlighted the complexity and dynamic nature of healthcare systems. It also created a unique opportunity to look at the concept of resilience through the lens of the healthcare team versus the more common approach of situating the concept within the individual or the organization. The early phase of the pandemic was marked by challenges, such as limited access to personal protective equipment, personnel shortages, drug shortages, and increased risks of infection [ 1 , 2 ]. Ensuring patient safety and proper functioning requires coordination and adaptation of the healthcare team and various processes across the health system infrastructure [ 3 , 4 ]. Resilience results from adaptive coordination which enables healthcare systems to maintain routine function in the face of all conditions [ 5 , 6 ].

Resilience in healthcare has been operationalized through resilience engineering, an interdisciplinary aspect of systems engineering focused on promotingpatient safety through the design, implementation, and management of healthcare systems [ 7 , 8 , 9 ] (e.g., how healthcare systems adapt and adjust to maneuver through the daily complexities and challenges to identify effective practices, prevent errors and maintain resilient performance) [ 6 , 8 , 9 , 10 , 11 ]. Resilient performance in healthcare is proposed to be the net result of reaching the threshold of four resilience capabilities within the system: anticipation, the ability to expect and prepare for the unexpected; monitoring, the ability to observe threats to daily system performance; responding, the ability to adapt how the performance is enacted; and learning, the ability to learn from present and past accomplishments within the system [ 12 ]. At present, there is a paucity of research on the resilience of the healthcare team as a cohesive, singular conscious source of knowledge in a highly complex healthcare system. While the resilience of both healthcare systems [ 11 , 13 ] and healthcare workers [ 14 ] has been investigated, there is a gap in knowledge specific to the resilience of the healthcare team as a unified singular consciousness. The circumstances surrounding the COVID-19 pandemic presented a unique opportunity to understand the resilience of the healthcare team in a highly complex system as a singular aware entity within the system; how it acknowledges itself, defines its purpose, and performs under extenuating circumstances. This shifts the emphasis of individual and organization resilience to the resilience in the interconnected healthcare team that extends beyond the boundary of any single person.

The adapted model situates the healthcare team as a cohesive singlular conscious source of knowledge within an intricate and highly complex system [ 15 ]. This model was designed as a bridge between resilience found in individuals within the healthcare system and the organization to emphasize the healthcare team as an aware, unified whole. Our model [ 15 ] combines the existing Systems Engineering Initiative for Patient Safety (SEIPS) model [ 16 ] (version 1), which is based on five domains (organization, person, tasks, technologies, and tools), and environment and the Advanced Team Decision Making Model [ 17 ], which includes components for team performance [ 17 , 18 , 19 ]. Team performance is comprised of team identity, team cognition, team competency, and team metacognition [ 17 , 18 , 19 ]. Team identity describes how the team identifies their purpose to help one another [ 17 ]. Team cognition describes the state of mind of the team, their focus, and common goals [ 17 ]. Team competency describes how well the team accomplishes tasks, and team metacognition describes problem solving and responsibility [ 17 , 19 ], Fig.  1 .

Healthcare Team as a cohesive, singular conscious source of knowledge in a highly complex system. The continuous variegated border represents the singularity and connectedness of the healthcare team within the system. The gears represent the processes, people, technology, and tasks within this highly dynamic healthcare system

The purpose of this qualitative research was to describe resilience in the healthcare team during the COVID-19 pandemic with the healthcare team situated as a singular conscious source of knowledge defined by its collective identity, purpose, competence, and actions. Additionally, we sought to identify factors that may facilitate or hinder the healthcare team from achieving the necessary capabilities to monitor, anticipate, adapt, and learn to meet the standard for resilient performance.

Methodology

A qualitative descriptive design [ 20 , 21 ] was employed. The interview guide was framed using the adapted model to explore various aspects of healthcare team performance (identity, purpose, competence, and cognition). These questions were pilot tested on the first 3 participants and no further changes were needed. Specifically, we aimed to investigate resilience capabilities, decision-making processes, and overall healthcare team performance.

Sampling strategy

A purposive snowball sample was used to identify healthcare team members who worked in U.S. acute care settings between January 2020–December 2020. This sampling method was used to ensure recruitment of participants most likely to have insight into the phenomenon of resilience in the acute care setting.

Inclusion criteria

To explore a wide range of interprofessional experience, participants were recruited across geographic regions and professional roles through personal contacts and social media [ 22 , 23 , 24 , 25 ]. Eligible participants included English-speaking individuals ages 20 and older with a valid personal email address, internet access, and the ability to participate in an online video interview. Potential participants had to be employed full or part-time for any period from January 2020–December 2020 in any of the following acute healthcare environments: emergency room (ER), intensive care unit (ICU), COVID- 19 ICU, COVID-19 floor, gastroenterology inpatient unit, endoscopy suite, operating room (OR), post anesthesia recovery room (PACU), pre-operative holding area, hospital administration, or inpatient medical and/or surgical patient care unit.

Exclusion criteria

Healthcare team members who did not complete the pre-screening survey or failed to schedule an interview were not enrolled.

National recruitment in the U.S

Upon approval by MUSC Institutional Review Board (IRB), registered under Pro00100917, fliers, social media posts on Twitter TM (version 9.34 IOS, San Francisco, California) and Facebook TM (version 390.1 IOS, Menlo Park, CA), and word of mouth were used to initiate recruitment efforts. Interested participants were sent a link to an electronic screening survey explaining the purpose of the study and verifying the respondents’ eligibility to participate. Informed consent was obtained from all subjects.

Data collection

Data were collected via an initial screening questionnaire to determine eligibility. Data were managed using REDCap™ (version 11.2.2) electronic data capture tools hosted at MUSC. Demographic data included age, sex, race, professional role, years of experience, geographic region, patient population served, practice specialty area, and deployment status during the pandemic. Deployment refers to the reassignment of personnel from their primary clinical area to another area to meet the demands of another clinical area without regard for the participant’s clinical expertise. Qualitative data were collected through semi-structured audio video recorded interviews to understand the healthcare team in their natural environment. Recorded interviews were conducted via Microsoft® Teams (version 1.5.00.17261, Microsoft Corporation) from the PIs private office to mitigate the risk of COVID-19 transmission and promote participation across the U.S.

Data monitoring and safety

The quality of the demographic data was monitored to ensure completeness. Potential participants who submitted incomplete responses on the questionnaire were excluded. Interviews were transcribed using software, transcriptions were reviewed and verified for accuracy, and then uploaded to MAXQDA Analytics Pro, Version 2022 (VERBI software) to facilitate data analysis. Transcripts were not returned to the participants. Qualitative codebooks, institutional review board (IRB) logs, and other study records were stored on a secure university server, with access limited to authorized study personnel. Adherence to Consolidated Criteria for Reporting Qualitative Research (COREQ) standards were maintained throughout the study and analysis [ 26 ].

Data analysis

Quantitative analysis.

Demographic data were analyzed using SPSS Statistics for MAC, version 28 (IBM). Both descriptive statistics for the continuous variables of age and years of experience (mean, standard deviation) and frequency tables (age, sex, race, role, geographic region, population served, deployment status) were analyzed.

Qualitative analysis

The Principal Investigator (PI) (JA) and senior mentor (MN) independently coded the interview transcripts. Open coding method was used to identify the categories of data [ 22 , 27 ]. Both a reflexive journal and audit trail were maintained. Codes were identified through induction from participant experiences and verified through weekly consensus meetings, while theoretical deductive analysis was guided by the adapted model and the four resilience capabilities (anticipation, monitoring, responding, learning [ 12 ]. Reflexive thematic analysis (TA) [ 28 , 29 , 30 , 31 ] was used to analyze the coded data and generate themes. Data were collected and categorized into the codebook until no further codes were identified by the PI and research mentor [ 22 , 27 ]. Participant checking was not employed.

Demographics

The eligibility pool was established based on survey completion. Eighty-nine healthcare team members opened the online screening survey; 21 were incomplete and eliminated from the dataset, which left a pool of 68 potential eligible participants. Eligible participants (100%) were contacted by email and phone to determine their interest in completing the study interview. Twenty-two participants completed screening surveys and study interviews between May–September 2021, equating to a 32.5% enrollment rate. Participant interviews lasted between 21 and 91 min with an average of 43 min. None of the interviews were repeated. Participant demographics, including descriptive statistic and role key, are noted in Tables  1 and 2 , respectively.

Five themes were identified: team work in a pressure cooker , healthcare team cohesion , applying past lessons to present challenges , knowledge gaps , and altruistic behaviors .

Teamwork in a pressure cooker

The theme teamwork in a pressure cooker describes the relentless pressures and emotional stressors (e.g., fear, anxiety, frustration, and stress) experienced by the healthcare team from the risks and potential threats associated with COVID-19 contamination and infection. Factors associated with these pressures included risk of COVID-19 exposure, lack of COVID-19 testing, rapid changes to policies and procedures from the standard, personnel shortages, limited physical space, and limited supplies. Exemplary quotes highlighting participant descriptions of these pressures or subthemes are noted in Table  3 .

The healthcare team described an unprecedented level of stress in the workplace as the healthcare team had to adjust to rapidly changing protocols. The lack of protective equipment, shortage of providers to perform patient care and a lack of a familiar clinical routine saturated them in overwhelming pressure and emotions that stuck to them as they navigated uncharted territory. Exemplary quotes highlighting the healthcare team’s descriptions of these emotions are noted in Table  4 .

“It was…uncharted territory for me.” (P1, DIR) “You were stuck in a situation you never— you didn’t know when it was going to end.” (P4, RN PACU) “They have not enough staff—they can’t do it—they—I don’t know what we’re going to do.” (P6, DIR). “When we deployed—trying to get re-accustomed to the changes—with the needs that had to be met was very difficult.” (P10, RN ENDO) “I wasn’t about to sign up for extra time working in under those stressful conditions.” (P17, RN PACU)

The fear of the unknown, combined with the constant need to adapt to rapidly changing circumstances, led to widespread stress, frustration, anxiety, and exhaustion within the healthcare team. This theme was characterized by the constant pressure both inside and outside of work experienced by the healthcare team.

“Driving to the hospital, crying, driving back from the hospital, crying, still doesn’t sum it up— surrounded by people who were just dying. And what could you do?” (P6, DIR) “It was constant. It was terrible. I couldn’t sleep at night. I’d wake up worried.” (P8, ER MD) “It was kind of like just keep sending the Calvary forward—and when one drops, you just walk over them.” (P17, RN PACU) “It was always there—COVID here, COVID there—you never could just completely get away from it. It was basically the center of everybody’s conversation everywhere you went or if you were on the phone with somebody.” (P18, RN COVID ICU) “I was having to call my parents before I’d leave my apartment to go into work— to vent to them and cry— to let out my frustration and my anxiety—and have them essentially convince me to go into work.” (P19, RN ICU). “Working so much— COVID was all that was on my brain—and it was a lot of pressure.” (P22, MGR)

Working during COVID-19 challenged the resilience of the healthcare team in the face of constant fear and uncertainty. The pressure to maintain team performance, while dealing with constant fear associated with the pandemic effected the healthcare team’s resilience.

“I have to tell you that after being in hospital—I don’t feel resilient right now— doing all the things I’ve done—I just want to be out of the hospital— [crying] I can tell you that it will stay with me the rest of my life— It will always stay with me.” (P6, DIR) “I feel like my team has used up all of their resilience. I don’t think there’s much left.” (P8, ER MD)

However, one team member stood out as an exception. They reported the pressures from the environment helped them to make decisions. This demonstrates that environmental pressures affect members of the healthcare team differently. They reported that the pressure and intensity of the situation sharpened their focus and allowed them to make choices more quickly and effectively.

“I make better decisions when I’m under pressure.” (P22, MGR)

Healthcare team cohesion

The theme healthcare team cohesion describes the unique experience of working together during the pandemic that created a means among the healthcare team to form close relationships and unite. This bond was characterized by the emergence of strong interpersonal connections among healthcare professionals during the COVID-19 pandemic. These connections shaped healthcare team relationships and were a factor in the collaborative decision-making processes within healthcare team for their day-to day functions. This cohesive bonding was fueled by the stress and uncertainty of the situation, which brought the healthcare team together illustrated by their solidarity, camaraderie, trust, and empowerment.

“All those decisions, important decisions were made together.” (P7, CRNA) “Everyone felt like they were they were, you know, in a in a battle zone and on the same side—and so that kind of brought people together.” (P8, ER MD) “I think our team worked as one.” (P11, CEO)

Solidarity described the sense of unity evident among the members of the healthcare team. This was characterized by connectedness and a sense of reliance on one another that promoted teamwork and resilience within the team from support both given and received. The sub-theme camaraderie described the close personal connection and support between the healthcare team that went beyond normal social interactions prior to the pandemic. These connections were filled with trust and respect for other healthcare team members.

“I think we were all trying to do the best we could do and help each other do the best they could do—I think early on just camaraderie helped a lot within the department and, you know, just relying on each other for support.” (P8, ER MD) “We knew that we can depend on each other and we all had different skill sets— I think that that was very important—that made us feel secure— rather than going alone.” (P10, RN ENDO) “We [The ICU Nurses] developed a sense of camaraderie that I mean, it’s nothing I’ve ever felt before, like we had to trust each other with our licenses, with our own health—my resiliency came from my coworkers.” (P14, CHG RN) “One of the things that I think the pandemic did in a positive—was—I believe that the teams that I worked for really started to solidify. We leaned on each other. I felt more of a team environment than I had had pre-pandemic—I felt that people were a bit better together. We all needed each other, and we all leaned on each other, and we gave each other support—more so than before COVID- 19.” (P15, CRNA) ”The nurses on the unit were always there for me—they became my friends— my family.” (P19, RN ICU)

The sub theme of empowerment referred to the ability of the healthcare team to confidently make decisions and assume responsibility for their actions within the healthcare setting. This process involved a sense of authority and the ability to exercise agency in decision-making together to respond and adapt to the demands the healthcare team experienced. The combination of solidarity, camaraderie, trust, and empowerment resulted in a strong sense of cohesion within the healthcare team which led to improved relationships and enhanced resilience in their performance.

“I felt that I felt that the team—we all needed each other and we all leaned on each other and we gave each other support—more so than before COVID.” (P15, CRNA) “How do you want to handle this? What’s the plan?—and we collaborated in the true sense of collaboration.” (P15, CRNA) “We just knew that we could count on each other—we knew that we could count on each other at any time if we had questions, because we all worked so closely together during this. We really became a really tight knit group, and it was great.” (P22, MGR)

The benefits of the cohesion found in the healthcare team were significant and apparent during the COVID-19 pandemic. The strengthened relationships and increased resilience allowed for improved communication and collaboration, leading to better patient care and outcomes. Despite these advantages, it was noted by one participant that the relationships developed were not sustained beyond the peak of the pandemic.

“Now that COVID is kind of at bay in our area, it’s kind of gone back to the same way it was— it has not stuck.” (P15, CRNA)

Applying past lessons to present challenges

The theme applying past lessons to present challenges describes how the knowledge and understanding gained from prior participant experiences was used to adapt to the novel clinical and infrastructural challenges faced during the pandemic. Past experiences facilitated the healthcare team to strategize ways to meet the demands of the healthcare system during this time.

Participants described two strategies the healthcare team used to improve the system’s ability to adapt and function effectively: changing roles and deploying personnel. The process of changing roles involved assigning new responsibilities to individuals based on priority-based initiatives, while deployment involved transferring clinical staff from areas with lower patient care needs to those with higher needs to optimize their utilization. Eleven participants (50%) were affected by these strategies. Of these, 73% were assigned to clinical areas for direct patient care, while the remaining 27% underwent a role change to support the operational needs of the system. The participants’ preexisting work relationships, specialized clinical expertise, and leadership abilities helped them adapt to their new clinical and non-clinical roles, which in turn enhanced the resilience of the healthcare team.

“We wanted to make sure that we were putting people into the right area where their skill set could be used the best.” (P1, DIR) “I’m known for moving people forward—I’m also well known for speaking up when I don’t think it is right and there was a lot of stuff that I didn’t think was right— and not only speaking up, I’m also going to come with the solution.” (P6, DIR)

Participants indicated the lessons learned from prior experience positively impacted team performance and improved patient care outcomes. There were two significant examples in the data: the perspective of a nurse who was redeployed to work in an obstetrics unit (P5, ENDO RN) and the perspective of a nursing director (P6, DIR) whose role was changed to develop a program to ensure adequate staffing.

“Because we [the team of interprofessionals] were all very familiar with what we had to do at the task, at handit [the experience of the provision of care] was very fluid—I think it’s because of our years of experience and working with each other for so long that it just worked out very well ”. (P5, ENDO RN) “Staff believed in me when I said I would do something— I could galvanize people because of my reputation of caring for staff, so I was chosen specifically because of my ability to move people forward in spite of things.” (P6, DIR)

Participants identified being assigned to unfamiliar clinical areas or working with unfamiliar patient populations as a barrier that hindered their ability to adapt to clinical situations. The lack of clinical competence among some personnel led to an increase in workload for other healthcare team members, who had to provide additional instruction and guidance on how to complete the task. Decision-makers who deployed nursing staff to a clinical area with higher staffing needs may have believed that the individual nurse had specific clinical skills that would be helpful in that area, and this was not the case.

“She [the patient] felt like it was that he [the new nurse]—really didn’t know what he was doing—not only were we kind of reintroduced to that role of caring for patients where we haven’t been recently, but we’re also in a teaching mode, too, for the new nurses—we had to prioritize how sick the patients were, from basic vital signs to wound dressings to respiratory, and help those new nurses know which to attend to first.” (P10, RN ENDO) “Nurses weren’t really put in a place with enough support and enough resources to be able to do a job, and to do a job that maybe they haven’t done for a few years.” (P10, RN ENDO)

The participants indicated that clinical competencies of a healthcare provider in one patient population may not necessarily be applicable to another patient group. For instance, a neonatal intensive care unit (NICU) nurse who has experience in managing Extra Corporeal Membranous Oxygen (ECMO) in newborns may not have the necessary skills to care for adult ECMO patients in an adult COVID-19 intensive care unit.

“The ECMO nurse was a NICU nurse, so she really could not help me.” (P14, CHG RN)

Knowledge gaps

The theme knowledge gaps refers to the disparity between the existing knowledge of the healthcare team and the knowledge required for the team to effectively respond and adapt to the needs of the healthcare system. The lack of COVID-19 specific knowledge led to gaps in the healthcare team’s understanding, while the lack of communication made it difficult for necessary information to be effectively conveyed and received (e.g., medical logistics, human resources, and other operational policies and procedures). This knowledge gap created a barrier to healthcare team resilience as their capacities to surveil, anticipate, and respond were diminished from the lack of knowledge.

“That [information] is pretty fundamental to how you [the healthcare team] function.” (P17, RN PACU) “I don’t think any amount of preparation could have actually prepared us for how bad COVID was—but we were very, very, very unprepared.” (P18, RN COVID ICU) “It was confusing, it was disruptive to the patients that we had there. They sensed that. And that’s— OK—screw with me, screw with my colleagues, but don’t screw with the patient.” (P21, RN ENDO)

All the participants in leadership roles during the COVID-19 pandemic emphasized the importance of having a thorough understanding of the information and effectively communicating it to the frontline healthcare team members most involved in providing patient care.

“There’s nothing worse than having to learn something in the moment and not being prepared for it.” (P1, DIR) “That made us communicate in multiple ways throughout a day because we all know people learn and adapt it could be in print. It could be in person; it could be a video. We tried to have multiple ways of getting messages out and knowing we needed to repeat messages because this was so unknown, and people were so stressed.” (P11, CEO)

One team member (P13, CRNA), highlighted areas where there were gaps in knowledge in greater detail.

“It was as if the unit was being run by all these sort of substitute teachers that were called in at the last minute. Nobody knew where stuff was—nobody knew what the protocol was—the communication was terrible.” (P13, CRNA)

The cumulative effect from the knowledge gaps contributed to the lack of a practical working knowledge for the healthcare team and affected the healthcare team’s ability to anticipate what needed to be done and adapt their performance to accomplish it. Despite knowledge gaps, healthcare team members reported their capability to learn was facilitated by incremental gains in practical knowledge through their experience over time.

“—people got to be experts at protecting patients and keeping themselves safe.” (P8, ER MD) “I think it kind of was like on the job training at that point, I felt like we were all just trying to survive—learning was like—you went out —then you came back, and you would share how things went.” (P15, CRNA) “You tried to educate yourself so you could be safe.” (P17, RN PACU)

The participant responses received from the leadership (CNO, Directors, and Manager) and front-line personnel (administrative staff, nurses, and physicians) regarding the importance of communication highlighted a difference in perspective. Leadership exhibited a strong commitment toward effective communication and made efforts to ensure all healthcare team members were well informed. On the other hand, the frontline participants indicated instances where communication strategies were not perceived as effective.

“I wasn’t contacted by a manager from the unit or anything to be able to reassure, reassure me that things were being followed through and it should be okay, so that was tough.” (P10, RN ENDO) “It really seemed like there was no communication between—like staffing and the floor—we would get up to the floor and they would say, who are you? What are you doing here? What are we supposed to do with you?” (P20, RN OR)

Altruistic behaviors

The theme altruistic behaviors , encompasses the participants’ perception of their obligation and accountability to their patients and healthcare team, and their steadfastness in supporting the healthcare team even if it meant facing personal or professional repercussions. This readiness to aid the healthcare team and accept consequences showcased their altruism and commitment to the healthcare team. The team’s dedication to both their patients and each other was a primary focus driven by a strong sense of responsibility and obligation.

“I want to be able to look myself in the mirror and feel like I did the right thing—.” (P6, DIR) “My resiliency came from my coworkers. I wanted to come back to work to help them.” (P14, RN COVID ICU) “People really looked out for each other—and people were really kind and compassionate to each other—we all were in this together.” (P15, CRNA) “I’m grateful for the experience that I had and all of the different patients that I was able to help in my time there definitely solidified that being a nurse is what I needed to do—and why I chose the profession is exactly what I should have been doing.” (P19, RN ICU) “You just have to go with what seems right—.” (P22, MGR)

A defining characteristic of this theme was a willingness to endure consequences for the benefit of the healthcare team. These consequences varied from contracting the virus, facing criticism from the healthcare team, to foregoing financial incentives, and even job loss.

“I felt like I was punished for speaking up and I was punished for doing the right thing for patients.” (P6, DIR) “I mean, I literally broke the law so many times. Do you know how many times I started pressors [vasoactive drugs to increase blood pressure] on patients that I had no orders for [because a physician would not enter the ICU]?” (P14, CHG RN)

We identified five key themes based on the coded data; namely teamwork in a pressure cooker , healthcare team cohesion , applying past lessons to present challenges , knowledge gaps , and altruistic behaviors . The researchers propose that stressors arising from the COVID-19 pandemic had an impact on the healthcare team’s resilience. In addition, strong healthcare team cohesion, selfless behaviors among the healthcare team, shared knowledge, and job competence within the healthcare team, enhanced resilient performance.

The healthcare team experienced significant stress and uncertainty, due to the COVID-19 pandemic. This is consistent with previous research that has shown that the unprecedented nature of the pandemic led to challenging working conditions, limited resources, lack of information, and concerns about infecting loved ones [ 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 ]. The collective global impact of COVID-19 on healthcare systems is likely a contributing factor to these stressors [ 45 , 46 , 47 , 48 ].

Our study, along with those conducted by Anjara et al. (2021)[ 49 ] and Kaye-Kauderer et al. (2022) [ 50 ], found that solidarity and camaraderie among healthcare professionals improve resilience. Specifically, Anjara et al. observed increased collaboration among the healthcare professionals they studied in Ireland during the COVID-19 pandemic, while Kaye-Kauderer et al. identified team camaraderie among their sample of front-line healthcare workers from New York. Kinsella et al. (2023) [ 51 ] reported that COVID − 19 offered frontline workers in the UK the opportunity to work together toward a common goal. Potential explanations for these findings align with the concepts of social capital proposed by Coleman [ 52 ] and social identification with other as proposed by Drury [ 54 ]. Coleman suggests an individual’s skills and capabilities are enhanced through their interdependent relationships with others [ 52 ]. Drury found in communities affected by disasters, mutual aid and support emerged from a shared social identity, which serves to strengthen the community [ 53 ]. Brooks et al. (2021) [ 54 ] conducted a study with healthcare, police, and commercial sectors in England. They found it was important for these individuals to receive support from and provide support to their colleagues to mitigate the psychological impact of disaster exposure [ 54 ]. In addition, like our findings, Aufegger and colleague’s 2019 systematic review [ 55 ] found that social support in acute care healthcare teams creates a supportive atmosphere where team members help each other communicate problems, fulfill needs, and deal with stress.

Our results are consistent with those of Liu et al. (2020) [ 32 ] and Banerjee et al. (2021) [ 44 ] who each found that healthcare professionals frequently feel a sense of personal responsibility to overcome challenges. One potential explanation for this may be the influence of collectivism in their cultures. Similarly, our study suggests the sense of camaraderie among healthcare professionals may also contribute to a sense of responsibility and increased altruistic behavior. However, other studies have highlighted different perspectives on healthcare professionals’ sense of responsibility and duty. Godkin and Markwell’s (2003) [ 56 ] revealed that healthcare professionals’ sense of responsibility during the Severe Acute Respiratory Syndrome (SARS) outbreak was dependent on the protective measures and support offered by the healthcare system where most SARS infected patients were hospitalized. More recently, Gray et al. (2021) reported that nurses’ sense of responsibility stems from their ethical obligations, regardless of potential personal or familial risks [ 57 ].

The altruistic behaviors described by our participants helped maintain the performance of the healthcare team. It is too soon to see the long-term impact from working in this high-pressure environment; however, past research by Liu et al. (2012) [ 58 ] and Wu (2009) [ 59 ] demonstrated that “altruistic-risk acceptance” during the SARS outbreak was shown to decrease depressive symptoms among hospital employees in China.

Our research on resilience has important implications for healthcare organizations and professionals. In order to ready themselves for forthcoming events, healthcare systems must emphasize the significance of shared knowledge and its influence on the healthcare team’s ability to foresee and monitor effectively. This knowledge can help the healthcare organization function as a unified entity, rather than as individuals in separate roles or clusters within the organization to improve healthcare team preparedness. Establishing a cohesive, clinically competent healthcare team benefits the organization and the patients served. Measures to enhance social support, improve communication and ensure clinical competence maintain healthcare team resilience.

There are several limitations to consider when interpreting the results of this study. First, the sample was obtained using purposive snowball sampling, which may have introduced sampling bias and may not accurately represent the larger population of healthcare team members who worked during the COVID-19, as 95% of the sample were white. Second, our study did not have equal representation of all interprofessional team members. It is possible that a more heterogenous sample regarding role, race and gender may have introduced additional codes. Additionally, the PI (JA) worked as a Certified Registered Nurse Anesthesiologist (CRNA) in acute care during the pandemic and personal experience may have introduced confirmation bias. Also, the focus of our research was to fill a gap in the existing knowledge of what is known about healthcare team resilience in pandemic disasters, and help to answer if and how it intersects with individual and organizational resilience. It is possible this novel conceptualization of healthcare team as a cohesive singular conscious source of knowledge did not adequately address this.

Steps to ensure rigor and mitigate any potential shortcomings of qualitative data analysis were the maintenance of a reflexive journal, a willingness of the PI to let go of unsupported ideas and constant verification of codes and themes with the research mentor (MN) for coherence and consistency within the coded data, selected methodology and research questions.

Overall, the extracted themes of teamwork in a pressure cooker; healthcare team cohesion; applying past lessons to present challenges; knowledge gaps; and altruistic behaviors illustrate comparable experiences within the healthcare team. As healthcare professionals and organizations continue to navigate the challenges of the COVID-19 pandemic and other crises, our findings provide valuable insights into how team cohesion, along with altruistic behaviors, may enhance resilience capabilities to create and maintain a unified resilient healthcare team.

Data availability

The data for this study are confidential as required by the IRB approval. To protect the anonymity of the participants, the data are not publicly available. Additional information about the research method, Interview questions, informant data, and the study in general can be requested from the corresponding author, J.A.

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Acknowledgements

The authors want to thank all the interviewed healthcare team participants for their time and sharing their personal stories and for their continued service during the COVID-19 pandemic. We would also like to acknowledge Ayaba Logan, the Research and Education Informationist, Mohan Madisetti, the MUSC College of Nursing Director of Research, the staff of the MUSC Center for Academic Excellence and the reviewers of this journal for their constructive criticism.

This research (software, transcription services, etc.) was solely funded by the Principal Investigator, J.A.

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Conceptualization J.A., K.C., L.N., D.L., H.E., and M.N.; methodology J.A. and M.N.; J.A. led the study, recruited the interviewees, conducted interviews, led the data analysis, and drafted the manuscript. J.A., and M.N. conducted the data analyses; review and editing K.C., H.E., D.L., and M.N.; supervision M.N.; research project administration J.A. and M.N.; funding acquisition J.A. All authors reviewed the manuscript.

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Ambrose, J.W., Catchpole, K., Evans, H.L. et al. Healthcare team resilience during COVID-19: a qualitative study. BMC Health Serv Res 24 , 459 (2024). https://doi.org/10.1186/s12913-024-10895-3

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Exploring perspectives on living through the COVID-19 pandemic for people experiencing homelessness and dealing with mental ill-health and/or substance use: qualitative study

Advances in Dual Diagnosis

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Article publication date: 16 April 2024

This study aims to explore the experiences of living through the COVID-19 pandemic for people who faced homelessness and dealt with mental health and/or substance use challenges.

Design/methodology/approach

This qualitative study was comprised of 26 1:1 interviews (16 men and 10 women), conducted between February and May 2021 with people who experienced homelessness in North East England during the COVID-19 pandemic. An inductive reflexive thematic analysis was undertaken, with input from individuals with lived experience who were involved throughout the study.

Four themes were developed. The first theme, lack of support and exacerbation of mental health and substance use difficulties, highlighted how the lack of in-person support and increased isolation and loneliness led to relapses or new challenges for many people’s mental health and substance use. The second theme, uncertainty and fear during the pandemic, explored how the “surreal” experience of the pandemic led to many people feeling uncertain about the future and when things would return to normal. The third theme, isolation and impacts on social networks, discussed how isolation and changes to relationships also played a role in mental health and substance use. Finally, opportunity for reflection and self-improvement for mental health and substance use, explored how some people used the isolated time to re-evaluate their recovery journey and focus on self-improvement.

Practical implications

The experiences shared within this study have important implications for planning the future delivery and commissioning of health and social care services for people facing homelessness, such as sharing information accessibly through clear, consistent and simple language.

Originality/value

As one of the few papers to involve people with lived experience as part of the research, the findings reflect the unique narratives of this population with a focus on improving services.

• Qualitative research
• Health inequalities
• Mental health
• Homelessness
• Substance use

Adams, E.A. , Hunter, D. , Kennedy, J. , Jablonski, T. , Parker, J. , Tasker, F. , Widnall, E. , O'Donnell, A.J. , Kaner, E. and Ramsay, S.E. (2024), "Exploring perspectives on living through the COVID-19 pandemic for people experiencing homelessness and dealing with mental ill-health and/or substance use: qualitative study", Advances in Dual Diagnosis , Vol. ahead-of-print No. ahead-of-print. https://doi.org/10.1108/ADD-06-2023-0014

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Copyright © 2024, Emma Audrey Adams, Desmond Hunter, Joanne Kennedy, Tony Jablonski, Jeff Parker, Fiona Tasker, Emily Widnall, Amy Jane O'Donnell, Eileen Kaner and Sheena E. Ramsay.

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The rapid emergence of the COVID-19 virus led to reactive changes internationally in an attempt to mitigate negative consequences and limit virus transmission. In many high- and middle-income countries, this meant identifying populations at increased risk of infection and implementing targeted protection measures in response ( Government of Canada, 2022 ; Public Health England, 2021 ; European Centre for Disease Prevention and Control, 2020 ; Centers for Disease Control and Prevention, 2022 ). With the introduction of “stay at home” measures during the pandemic, there became a growing concern for people experiencing homelessness who may have been unable to safely abide by these restrictions ( Rodriguez et al. , 2021 ; Allaria et al. , 2021 ; Cabinet Office, 2020 ). Global policy responses for homeless populations varied, but similarities existed around efforts to increase access to temporary accommodation solutions, either through creating new shelters, or repurposing existing hotels ( Martin et al. , 2020 ; O’Shea et al. , 2020 ; Kelly et al. , 2021 ; National Social Inclusion Office, 2020 ; Scallan et al. , 2022 ; Brown and Edwards, 2021 ). In England, such efforts were termed the “Everyone In” initiative ( Cromarty, 2021 ), marking the first national attempt at a coordinated offer of access to accommodation for people experiencing homelessness.

People who experience homelessness have high levels of physical and mental health needs compared to the general population, including co-occurring substance use ( Bramley et al. , 2015 ; Fazel et al. , 2008 ; Grant et al. , 2004 ). Yet although in most cases, offers of accommodation in England were paired with access to food, health and social care including drug and alcohol support, broader COVID-19 safety measures introduced during this period resulted in the closure of many face-to-face health and social care services and/or use of socially distanced or remote support often leveraging digital technology. Evidence suggests that people experiencing homelessness were disproportionately affected by these reductions in service provision and resultant social isolation ( Tsai and Wilson, 2020 ; Leifheit et al. , 2021 ; Rodriguez et al. , 2021 ). For example, qualitative studies based on a Scottish homeless service found that a reduction in services coupled with experiences of isolation and emotional impacts from the pandemic led to increased drug use, anxiety, depression and confusion/fear among some homeless people ( Parkes et al. , 2021b , Parkes et al. , 2021a ).

Although these trends are echoed elsewhere in the international literature, with increased rates of drug use and drug overdoses observed in Spain and America ( Appa et al. , 2021 ; Aguilar et al. , 2021 ; Tucker et al. , 2020 ) alongside a range of mental health challenges, including hopelessness, anxiety, loneliness, depression and sleep problems ( Tucker et al. , 2020 ), other studies report more positive outcomes. One Canadian case study reported periods of decreased drug use which was strongly related to periods of supported housing during the pandemic ( Scallan et al. , 2022 ). Another longitudinal study of young people experiencing homelessness found increased physical activity and improved mental well-being during the pandemic ( Thomas et al. , 2021 ). These contrasting negative and positive impacts on substance use and mental health in current evidence suggest further investigation is needed to understand the complexity of individuals’ experiences.

Qualitative research involving people with lived experience of homelessness has the potential to elucidate their unique experiences and perspective. We worked with people with lived experience of homelessness, mental ill-health and/or substance use to understand the perspectives of living through the COVID-19 pandemic for people experiencing homelessness and the challenges and benefits it presented them in dealing with mental ill-health and/or substance use.

Recognising that reality is subjective and socially constructed, this research was informed by an interpretivist paradigm and social constructivism ( Creswell and Poth, 2016 ). Thus, a qualitative methodology involving semi-structured interviews with people who experienced homelessness was used for this study conducted in North East England during the COVID-19 pandemic between February and May 2021.

People who have experienced homelessness, mental ill-health and/or substance use were involved in the design and conduct of our study, including collaboratively analysing the data, developing themes and co-writing the final paper. This led to the recruitment of three men (J.P., D.H., T.J.) and two women (J.K., F.T.) with lived experience of homelessness, substance use and/or mental ill-health from local lived experience groups. They became part of the core research project team as “Experts by Experience”. Approaches for involvement were determined collectively and based on best practices for community-based research with vulnerable populations ( Souleymanov et al. , 2016 ). Ethics approval for the study was granted by the Faculty of Medical Sciences Research Ethics Committee, part of Newcastle University’s Research Ethics Committee (ref: 2034/6698/2020).

Potential participants were initially purposively recruited through gatekeepers in housing and voluntary sectors alongside “Experts by Experience” networks in two areas in North East England (Newcastle upon Tyne and Gateshead). Recruited participants were then invited to share study information within their networks, a snowball strategy approach ( Johnson, 2014 ). Participants were aged 18 and over and self-identified as experiencing homelessness during the COVID-19 pandemic as well as mental health and/or substance use challenges. To recognise the breadth of homelessness in the region ( Shelter, 2021 ), a broad definition was used including rough sleeping, staying with friends or sofa surfing, in temporary accommodations and having approached the local government for housing ( Crisis, n.d. ). People who were interested in participating could contact the lead researcher (E.A.A.) by telephone, email or consent to a service provider sharing their contact details with the researcher. Information sheets were shared with potential participants at least 24 h in advance of the interview and had the opportunity to ask any questions before the interview.

Given the social distancing restrictions in place across England at the time of this study, all interviews were conducted by telephone. Adjustments were made to enable people to participate, which included rescheduling interviews, working with local hostels or housing providers to provide access to a designated phone for conversations and offering to conduct interviews outside of normal working hours. Once no new themes were identified within interviews (data sufficiency/saturation), active recruitment ended, and only those who had previously expressed interest were given a two-week window to participate.

access to mental health and substance use services; and

the impact of the COVID-19 pandemic on their lives, mental health and substance use.

All interviews were digitally recorded, transcribed, anonymised and checked for accuracy. At the end of interviews, participants were provided with a debrief sheet, which contained signposting to local services for housing, homelessness, mental health and substance use.

E.A.A. worked with the five “Experts by Experience” through a series of workshops to conduct the analysis, which was informed by Braun and Clarke’s (2006) inductive reflexive thematic analysis. All transcripts were reviewed by E.A.A. for familiarisation and a select number were reviewed by “Experts by Experience” independently. Initial codes were then developed for transcripts. Using initial coding, preliminary themes were developed collectively and reviewed to determine patterns of shared meaning across transcripts. Theme and subthemes were refined collaboratively and discussed with all co-authors before finalisation. The non-linear stages of analysis enabled early theme development based on central concepts within transcripts ( Braun and Clarke, 2021 ). Themes and subthemes related to access to mental health and substance use support are reported elsewhere ( Adams et al. , 2022 ).

lack of support and exacerbation of mental health and substance use difficulties;

uncertainty and fear during the pandemic;

isolation and impacts on social networks; and

opportunity for reflection and self-improvement for mental health and substance use.

Lack of support and exacerbation of mental health and substance use difficulties

Individuals spoke about how they felt that access to mental health and substance use support had been deprioritised while health and care system efforts focused on combatting the virus. Individuals felt frustrated that they could not access mental health and substance use support during this period, and, in some cases, this left them feeling helpless. Many people spoke about using drugs as a coping mechanism and others spoke about how they considered suicide in response to not being able to cope with their emotions and adversity.

I think it’s failing us the pandemic. Because people are starting to use excuses to say they can’t help you as much as they normally do. And mostly it’s failure. It seems like the system is failing us. (Male, 40s)

I’ve tried to take my life. Just not having the support and just feeling like I've been left. (Female, 30s)

People were further frustrated by the inconsistencies between easing of restrictions and which venues/places could reopen. There was particular frustration in relation to the challenges they faced accessing in-person support.

I can’t go to an AA meeting because of lockdown because of social distancing, yet I can go in a pub and get pissed out my skull. It’s really- it’s a bit of mind-bender for me, it really is. (Male, 40s)

Others spoke about how their present situations (such as inadequate housing or being unable to leave home) exacerbated pre-existing mental health challenges.

Yes, so it’s been a rollercoaster. It’s just been up and down, up and down. The full time I’m trying to live in a hostel system. […] It’s just been a rollercoaster of emotions. (Female, 40s)

I found it really, really scary, really difficult where the walls were closing in. I couldn’t watch the news. It started to a point where I just physically wouldn’t go out even if I just needed a loaf of bread, where I wouldn’t go to the local shop. (Female, 40s)

The isolation, loneliness and reduction in services brought about by the pandemic resulted in some relapses in participants’ mental health and substance use. People shared how they suddenly found themselves facing new mental health and substance use challenges. This meant, for some people who were using drugs, that they were suddenly requiring mental health support or those who had faced mental health challenges began to use drugs/alcohol.

I’ve basically went back to using drugs to deal with the loneliness and deal with the isolation and to deal with the solitude. People can think that’s an excuse, yes it is, it’s a bloody good one as well. It’s a bloody good excuse because I’m on my own, I'm isolated, I've got no outside communication. Hardly [any] contact with other people face to face much so I’m using drugs again to deal with it. Basically, everything I’ve achieved before the lockdown, which took years and years and years to achieve, like being stable on my script, not using, dealing with people, it has all been wiped away really because of lockdown. (Male, 30s)

I kind of really just bottle things up a lot and end up exploding and taking it out on myself and trying to commit suicide. (Female, 20s)

Uncertainty and fear during the pandemic

During interviews, people spoke about the large volume of information that was available from varying sources regarding the COVID-19 virus. Individuals felt overwhelmed with the amount of information about the virus and explained that it was often hard to determine the accuracy of the information provided. In addition, some participants spoke about “conspiracy theories” and concerns around misinformation. This was a particular concern given many had experienced mental health or substance use related paranoia or delusions and expressed distrust in the government. This led to some participants struggling to grasp the severity of the situation at the beginning of the pandemic.

It’s just, something that I’m not used to. I cannot understand it in a way. There’s too much information out there. It’s just all these conspiracy theories about it and I don’t know. […] You are listening to the news and the media and then you are listening to other stuff then you don’t know what’s right and what’s wrong. (Male, 30s)

Over time, and with continued information about the pandemic and its severity, many people transitioned into feeling afraid of catching the virus and the uncertainty of what catching the virus would entail. People also spoke about the realisation that they had existing vulnerabilities (such as pre-existing health conditions or post-surgery aftercare), which shaped their experience of the pandemic. Furthermore, the uncertainty on how long the pandemic would last, led to added concern and heightened anxiety.

Actually, I came out of the hospital in [date removed], but it was the start of the covid lockdown […] so, I was shielding at the time, but I still had to get out and get my shopping even though I wasn’t meant to. (Female, 40s)

Well, the scariest part is if we don’t find a cure for it basically. I know we’ve got these vaccinations now, but you never know, they say in some countries they’re having a third wave. […] I’m scared this vaccination might not work; it might mutate and I’m worried. (Male, 40s)

When mass vaccination began, people experiencing homelessness were a priority group. Although vaccination was not consistently discussed across interviews, one person explained they felt forced into getting a vaccine and expressed concerns about the contents of the vaccines and unknown long-term side effects, reiterating the lack of clarity around information during the pandemic.

I got the jab the other day. I didn’t want to have the vaccine, but I got it the other day after I was pressured by three doctors and the staff here to have it. I’d already said no in the first instance, but then they came back and they said, “ Well, you have to have it. Twenty-seven thousand people have had it. This one has had it, that one has had it”. I went, “ Fair enough, but I don’t have to have it. I don’t want to have it. Tell me what’s in it and I might have it”. You don’t know the effect that these vaccines are going to have on the body in ten/fifteen years’ time. (Male, 30s)

Isolation and impacts on social networks

During the early months of the pandemic, safety measures (such as social distancing and the “stay at home” order) and reductions in in-person service provision were introduced nationally to reduce the spread of the virus. With restrictions in place and fines introduced to encourage compliance with the “stay at home” order, many people were left feeling trapped; a particular concern for people who were housed in multiple unit occupancies (such as hostels) or even small single unit accommodations with minimum space.

I think before the lockdown, you know, you just took it for granted that you could get out […] I can’t get out all the time, I can’t go and visit people. You’re just stuck on your own, it’s horrible. (Female, 50s)

I Just felt like I was like a caged animal stuck in the flat. (Female, 40 s)

When speaking about changes over the last year, people recognised that the reasons they interacted with people have changed. It became clear that several individuals sought emotional and informal psychological support from family and friends, suggesting that the pandemic served to highlight the existence/lack of social networks.

So I’ve got a girlfriend now who comes and stays over, because I live by myself, I’ve created a bubble with her, and her family […] if I hadn’t met her, I think things would be a lot harder this time round, because with it being so cold, winter, dark, this third lockdown would have been really, really hard. (Male, 20s)

Like I met this lass in the last hostel I was in and like she’s like me best mate now. And she’s been through similar stuff uh, and we both help each other, so she’s a good support network. (Female, 20s)

In contrast, others spoke about losing people during the pandemic or being unable to seek support from family and friends as a result of pandemic restrictions/measures. This loss of social contact led to many people feeling alone and isolated which likely exacerbated existing mental health difficulties. In some cases, people spoke about how their housing officer or support worker would be the only person they would speak to.

I would’ve been able to call on family for housing support and somewhere to stay but my step dad [caught] Covid and had to go to hospital and mother tested positive so I've not been able to seek refuge or shelter due to the laws surrounding isolation and shielding which has worsened my situation considerably. (Male, 30s)

[…] No, I haven’t really been in touch with any- I haven’t really got any friends. (Female, 30s)

One participant described the negative impact of not having support and social interaction, explaining that no one would have noticed had he died.

[…] I could have taken my own life in here and I could have been lying on that bed for weeks and weeks, literally through the whole lockdown, and nobody would know. I know it sounds completely awful, depressing, but the only thing that would probably alert anybody was the smell of a decomposing body. (Male, 50s)

Opportunity for reflection and self-improvement for mental health and substance use

When discussing the impact of the COVID-19 pandemic on mental health and substance use, people reflected on how the pandemic has influenced their recovery journeys and acknowledged recovery as an ongoing process.

[…] if you’re not working on your recovery you’re working on your relapse. (Male, 30s)

I call it recovery because there is no cure. You are always recovering. Every day, if you get up every day, you are recovering. (Female, 40s)

Some individuals reflected on how the pandemic led to them seeing others face the same hardships they have been struggling with previously. This created some degree of validation and normalisation of the depression and mental health challenges individuals had experienced.

For the last few years before the pandemic, I was going through really, really, really hard times. I felt like I was the only one […] I felt very isolated and very sick due to depression, mental health and losing loved ones and things over the last few years. This last year, seeing people going through it. It’s strange, it’s almost like people have sort of joined me in what I was already going through. (Male, 20s)

Although many people experienced relapses or faced new challenges, others found the pandemic allowed them to reflect on and improve their mental health and substance use. Although there was recognition that the pandemic has been challenging, many people reported feeling that the forced isolation and distancing led them to be separated from others and reflect on their own well-being.

I’ve been clean for the last year. I’ll be a year in September. (Male, 40s)

I haven’t been able to see anybody really. I think that’s probably been a godsend to me because half my friends are all drug users or alcoholics and I’m ex for both of them so it’s probably a good thing I don’t get pulled back into it. (Male, 30s)

But before lockdown, it was just- I think we were all a bit fuzzy-headed, if that’s a word, before that. […] At one time, I didn’t have a TV or a phone or a radio in my room, I was sitting in my little room, and it was like a time for self-reflection. And obviously, it’s been so peaceful and quiet outside, I just loved it. (Female, 30s)

Some people reported finally receiving housing through new initiatives (such as the “Everyone In” programme) rolled out in response to the pandemic. This stability in accommodation was perceived to positively influence mental health and substance use.

Personally, for me, this year has actually been quite good. (Laughter) It sounds a bit daft because it’s been quite good because, obviously, I was homeless for, let’s say, six years and then the pandemic happened and I got put into shared accommodation and then I’ve obviously got my own flat through it so it’s been quite a good one for me. (Male, 20s)

This study explored the perspectives of people experiencing homelessness in North East England on living through the COVID-19 pandemic and the impact it had on their daily lives alongside mental health and/or substance use challenges. The findings highlight the unique circumstances of this population and their starkly contrasting experiences of the pandemic. The negative experiences shared regarding new and continued challenges for mental health and substance use among homeless people present potential target areas for future interventions, for example, the need for interventions around isolation and loneliness. The positive findings relating to improvements in mental health and substance use recovery and self-reflection could be important areas for future research and potential mechanisms for individual recovery journeys for people experiencing homelessness. The findings also highlight the importance of social and environmental circumstances, and access to both formal and informal support, in shaping individual experiences of the COVID-19 pandemic.

Previous studies have highlighted both the increases and decreases in mental health and substance use during the COVID-19 pandemic ( National Social Inclusion Office, 2020 ; Tucker et al. , 2020 ; Appa et al. , 2021 ; Aguilar et al. , 2021 ; Thomas et al. , 2021 ; Corey et al. , 2022 ). However, qualitative narratives capturing the lived experience and perspectives of people who experienced homelessness alongside mental health and substance use difficulties are missing from the current evidence base ( Rodriguez et al. , 2021 ; Parkes et al. , 2021a , Pixley et al. , 2022 ). Findings from our study provide a nuanced understanding for why changes occurred within this population or not.

One of the findings in our study related to negative mental health impacts of the pandemic among people experiencing homelessness of both new and existing difficulties. The loneliness, isolation and general sense of feeling left behind or forgotten by services led to many people facing relapses and experiencing new problems, including severe anxiety, depression, suicidal thoughts, drug use and drinking. Increases in mental ill-health and drug use during the pandemic has been noted in quantitative evidence ( Tucker et al. , 2020 ; Aguilar et al. , 2021 ; Scallan et al. , 2022 ). However, during the pandemic, these issues of depression, isolation, anxiety were experienced, not just by homeless populations, but much more widely by the general population ( Groarke et al. , 2020 ; Kwong et al. , 2021 ). Interestingly for some people, social restrictions were seen as a benefit, helping them separate themselves from people who were negative influences on their substance use or mental health, whereas for others it offered an opportunity to focus on their mental health and well-being. By stark contrast, there were others with limited social networks who spoke about severe isolation, coping with drug use and in some cases feeling suicidal. Similarly another cross-UK study found challenges during the pandemic were most acutely felt among people experiencing homelessness with limited social networks ( Dawes et al. , 2022 ). The relationship between social networks, homelessness trajectories and substance use patterns has been previously explored ( DiGuiseppi et al. , 2020 ; Neale and Stevenson, 2015 ; Neale and Brown, 2016 ; Hawkins and Abrams, 2007 ; Ravenhill, 2008 ).

Despite study participants all having mental health and substance use challenges, conversations highlighted the wider impacts of the COVID-19 pandemic on their lives and the role environmental circumstances (such as housing and having access to space). Many spoke about the struggles of balancing the uncertainty and restrictions the pandemic introduced, particularly around volume of (mis)information. Existing evidence has highlighted the poor communication and messaging of information surrounding COVID-19 and related regulations for people experiencing homelessness ( Rodriguez et al. , 2022 ). Our research builds on these findings by highlighting that the lack of clear communication and ambiguity often led to mistrust, confusion and paranoia among people experiencing homelessness. This is particularly concerning given the high rates of psychosis and more specifically paranoia often present among people experiencing homelessness ( Fazel et al. , 2008 ; Bebbington et al. , 2005 ; Powell and Maguire, 2018 ). These experiences were compounded by environmental circumstances such as access to adequate housing, space and not feeling confined. Some people spoke about the positives of finally being housed due to new COVID-19 housing initiatives (such as “Everyone In”); others spoke about how they lost their job or lost a family member, which led them to access hostel provision for the first time. Alongside other studies highlighting the complexity of individual situations for experiencing homelessness during the COVID-19 pandemic ( Dawes et al. , 2022 ; Parkin et al. , 2021 ), we recommend a need to recognise that the needs and priorities of those experiencing homelessness changed throughout the pandemic and will likely continue to change over their cycle of homelessness.

Strengths and limitations of the study

This study reported the experiences and views of people experiencing homelessness over one year after initial restrictions and pandemic measures were introduced in England. This allowed participants to reflect on changes across the year and in some cases reflect on longer-term impacts and consequences. The use of a broad definition and self-identification of homelessness allowed for narratives to be shared from voices who might have otherwise not been explored (e.g. those who experience more hidden forms of homelessness such as those sleeping on couches or staying with friends and family). The reflective process during analysis with those with lived experience led to a more nuanced understanding of the experiences and the development of themes ( Braun and Clarke, 2019 ), and was a unique aspect of this study compared to previously published research ( Tucker et al. , 2020 ; Appa et al. , 2021 ; Aguilar et al. , 2021 ; Thomas et al. , 2021 ; Parkes et al. , 2021b , Parkes et al. , 2021a ).

The findings should be considered with recognition of some limitations resulting from the design of the study. As participants were recruited from two urban regions in North East England, they may not reflect the experiences of those residing in rural or coastal areas or other parts of the globe. In addition, all participants in our study identified as White British and refugee populations were not included within the study’s definition of homelessness. Further research is needed to explore the experiences of refugee populations and those of other ethnicities.

Implications for practice and policy

Study findings will help providers and policymakers for health, social care and housing to better understand that the COVID-19 pandemic did not uniformly impact people experiencing homelessness. Findings also highlight that support will need to be adapted to support people who are new or returning to services and at different stages of their mental health and substance use recovery. With increased levels of isolation and loneliness among people who are homeless, services need to recognise there could be heightened stress and anxiety about accessing services in-person or in group-based settings. Efforts should be made to provide people with options for how they engage and access services moving forward to resolve any related anxiety. Many people shared confusion and frustration related to the amount of COVID-19 information and misinformation and having to navigate it. Future health-care campaigns should consider communicating issues in a way that uses clear, consistent and simple language to make it easily understandable. Working with people with lived experience of homelessness could reduce the risk of poor or inaccessible communication. As well, working with people with lived experience of homelessness or those who support them to identify ways to combat potential misinformation is key to ensuring people can make informed decisions and understand current health issues.

The pandemic placed existing and new adversity at the forefront for public health. Moving forward, policymakers and practitioners need to consider the immediate and longer-term impacts the pandemic has had on the lives of people experiencing homelessness. Future research should continue to explore the broader health impacts, aside from the virus itself, faced as a result of the pandemic for people experiencing homelessness.

Acknowledgements

The authors thank the members of our Advisory Group who provided input on initial theme development, Kate Dotsikas, Cassey Muir and Claire Smiles, and our colleagues in practice from Crisis Skylight Newcastle, Fulfilling Lives Newcastle Gateshead and Tyne Housing to name a few.

Declarations .

Ethics approval: Ethics approval for the study was granted by the Faculty of Medical Sciences Research Ethics Committee, part of Newcastle University’s Research Ethics Committee (ref: 2034/6698/2020). Verbal or written consent was obtained from participants before the interviews commenced.

Availability of data and materials: The data generated and/or analysed during the current study are not publicly available as due to the highly sensitive nature of the data and to protect participant’s confidentiality as they could contain potentially identifiable information, but summaries are available from the corresponding author on reasonable request.

Competing interests: All authors declare they have no competing interests.

Funding : This research was funded by the National Institute for Health and Care Research (NIHR) School for Public Health Research (SPHR) development fund for early career researchers (ECRs) (PD-SPH-2015), and by the NIHR Public Health Policy Research Unit (PH-PRU) (Grant Reference PHSEZQ47-21-A). EAA was supported by the NIHR School for Public Health Research (SPHR) Pre-doctoral Fellowship, Grant Reference Number PD- SPH-2015. EAA is now funded by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration (ARC) North East and North Cumbria (NENC) (NIHR200173). AO is an NIHR Advanced Fellow. EK is supported by an NIHR Senior Investigator award and is Director of the NIHR Applied Research Collaboration North East and North Cumbria. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. NIHR funding acknowledgement and disclaimer: This report is independent research commissioned and funded by the National Institute for Health and Care Research Policy Research Programme. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health and Care Research, the Department of Health and Social Care or its arm’s length bodies, and other Government Departments.

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• Analyzing qualitative research results effectively

In this article, we will explore how product managers can effectively use the outcomes of qualitative research.

Information obtained during interviews can help product managers and their collaborators better understand users and their needs. However, in order to use qualitative data effectively, it’s important to:

— Select the right technique for processing interviews (and related data);

— Draw accurate conclusions based on interviews (and related data).

Systematically analyzing in-depth interviews can help product managers identify trends, collaborate with stakeholders, and reduce subjective risk.

This guide is a result of our collaboration with experienced researchers: Anna Kon , co-founder of  TobyLab , a company dedicated to helping businesses research new markets worldwide Dmitriy Gubarev , UX expert

Interview objectives

In-depth interviews provide valuable opportunities for product managers to better understand their users’ needs, habits, problems, and expectations.

By gaining a detailed understanding of their users, product managers can identify common trends and patterns in user behavior (and important edge cases).

With this information, PMs can test their product hypotheses more effectively, and adapt their products to serve users’ most pressing needs. In some cases, research outcomes might lead a product manager to decide to discontinue a product or feature altogether.

If you’re unsure how to prepare and conduct in-depth interviews, check out “Qualitative research in product management: the guide” . Once you’re finished, you can return to this article.

Here, we’ll discuss why it’s important to analyze the results you’ve obtained from qualitative research, and how to do so. 

Analyzing qualitative data

Objectives of analyzing qualitative research results.

• Identify common trends

Reviewing research outcomes can help you understand important themes, trends, tendencies, and patterns in user behavior. Generating research summaries makes it easy to identify which problems users face while using the product, and which they face more generally. By establishing a baseline for user behavior, you can distinguish between urgent and non-urgent problems and identify opportunities for new feature development. This way, you’ll be empowered to solve problems that require immediate attention while working towards your product’s vision.

• Reduce subjectivity risk 

It’s impossible to completely eliminate our own influence on (and perception of) respondents and their contributions. That said, working systemically with the interview data you’ve collected will enable you to reduce the “ observer effect .” By analyzing and synthesizing qualitative data with care, you can understand it more objectively and schematically.

• Focus on the key goals of the research

During the data collection stage of a qualitative research project, it’s possible to gather a lot of interesting information that may spark new ideas. As a result, it’s easy to lose focus and stray from the original research objectives you’ve laid out. By conducting a careful analysis of your interviews (and other qualitative data), you can maintain fidelity to your research goals.

→ Test your product management and data skills with this free Growth Skills Assessment Test . → Learn data-driven product management in Simulator by GoPractice . → Learn growth and realize the maximum potential of your product in Product Growth Simulator .

Analyzing qualitative data by yourself

Below is a general process to follow when analyzing qualitative data:

• Step 1. Data Preparation: transcribe interview recordings.
• Step 2. Working with Data: structure transcripts, add tags.
• Step 3. Analysis: build a code tree / compile results.
• Step 4. Conclusion: formulate answers to research questions.

In the sections below, we’ll describe each step in detail. While this process is inspired by an academic approach to research, it’s worth acknowledging that professional researchers may simplify this process in practice.

Step 1 begins with transcription. After interviewing respondents, you’ll need to transcribe interview recordings in order to get raw data. In most cases, this requires converting video files into text files. Transcribing and saving interviews is useful for two main reasons.

• Firstly, if you’d like to locate a specific excerpt from a conversation, you can search your transcription file to find it. This way, you won’t need to spend extra time listening to the entire recording again.
• Secondly, creating a transcription habit can allow you to be more present during the interview process. When transcription is a key part of your research process, there’s no need to worry about taking notes during your conversation. This way, you can fully focus on the interviewee (and your research objectives).

The obtained data will form the basis for the final report

Experienced researchers experiment regularly with new tools in order to improve the quality of transcriptions or automate the transcription process. In our survey of researchers, Whisper , transkriptor.com , and sonix.ai were cited among the tools they use ( see this guide for an overview of all tools ).

After interview recordings are transcribed, they should be structured. Copying the structure of the questionnaire is the simplest way to do this.

Another option is to create codes (tags) that reflect the main ideas or themes present in an interview. This method allows researchers to organize their results, making it faster and easier to find important information after interviews have been conducted. 

Tags can be applied:

• To data generated during a specific research project
• Across all projects, to link the results of various research projects together

To start, create tags (codes) that reflect general categories of conversation with interviewees. For example, a set of tags might include general questions, user experience, product design, competitors’ solutions, and more.

Tags can (and should) be customized to fit the needs of your research objectives. Creating tags that relate to your interview questionnaire and research topics will help ensure that the results of your research are organized and clear. 

Above all, tags should be easy for you to work with. For more detailed instructions on how to create, maintain, and structure tag groups, refer to this guide .

Once you’ve created a group of tags, it’s important to maintain its structure for each interview. Tags can be especially useful if you plan to leverage interviews for additional persona work or other documentation. 

Scholars who use a ‘grounded theory’ approach to research will mark different parts of a text (such as an interview) with codes. For grounded theorists, groups of interrelated tags are often referred to as a “code tree.” This approach can be studied in detail in Anselm Strauss and Juliet Corbin’s book, “Basics of Qualitative Research: Grounded Theory Procedures and Techniques.”  

According to Strauss and Corbin, qualitative researchers can choose from three distinct coding methods: open, axial, and selective. The first option, open coding, does not involve applying predefined categories to text. Unlike open coding, an axial coding system establishes connections (e.g., causality) between categories or tags. The final system, selective coding, focuses on a central category around which a larger narrative or categorical system is constructed. Researchers who use selective coding methods can use tags to classify individual excerpts, and subsequently group these tags into broader categories.

Depending on their goals, researchers can use different tools to analyze qualitative data and generate reports. When analyzing interview transcripts in depth, work can be carried out within a word processor like Microsoft Word or Google Docs. Researchers who use Google Docs to analyze transcripts can take advantage of the Highlight Tool plugin in order to tag specific sections with ease. This plugin saves time by automatically generating a summary table complete with codes, quotes, and comments.

When compiling the results of usability tests for a designer, it’s often convenient to work in Miro, which makes it easy to add comments, recommendations, and quotes to a user interface (or “screen map”) . Similarly, Figma makes it easy to add comments to designs using stickers.

Useful tips

Feature quotes from interviewees whenever possible . When compiling a report on your research results, highlight specific quotes from respondents in order to support key conclusions or topic areas. These quotes will bring the user’s perspective to life, allowing the team to see things from their point of view.

Check qualitative data for trends and recurring patterns. Keep in mind that users might express the same problem in different words.

Separate the general from the specific . Remember, not every problem mentioned by a respondent is relevant to all users.

Compare and contrast data from different interview sections . To help identify trends and behavioral patterns, outline the similarities and differences in respondents’ answers to particular questions. For example, do users with similar financial means relate to your product in an analogous way? Are there dependencies present between their usage and their finances? Does the age or marital status of users affect the problems they are trying to solve with your product?

Remember the difference between facts and opinions . Users can be inconsistent, and their words may contradict their actions. For example, if a user encounters difficulties while performing a task, but describes the task as “simple”, pay extra attention.

Always keep research objectives in mind when interpreting results, drawing conclusions, and formulating recommendations based on your research. Whenever possible, separate primary problems from secondary problems. If a user mentions the criticality of a problem, give it special consideration. If users request small feature refinements or make comments that are tangentially related to your product, they may be secondary issues. 

Record possible solutions when they come to mind . Sometimes, researchers may come up with ideas for new solutions (or new research projects) while collecting and analyzing data. When inspiration strikes, take notes so you can remember your ideas when generating recommendations or planning future research.

Typical issues

As researchers, we often witness the same mistakes being made when working with qualitative data.

Lack (or misunderstanding) of context

Responses to interview questions may be misinterpreted when researchers misunderstand the context in which they were provided. For example, let’s say a user mentioned not receiving push notifications from a mobile app. Due to this failure, this user missed an important event. After asking several clarifying questions, the primary researcher discovered that the user had push notifications turned off in their phone settings. Without this context, another team member might conclude that problems within the mobile app itself caused the user to miss their appointment. In this way, a lack of context can lead to inaccurate conclusions.

To prevent this, ensure that you have a comprehensive view of a user’s particular situation. If a user highlights a problem using your product, it’s important to understand not only the problem itself, but also the circumstances in which they encountered it.

For example, interacting with a navigation app is fundamentally different for users sitting in an office as opposed to those driving a car. When driving, notifications that might be convenient in other circumstances may actually interfere with making the right turns. Pop-ups that are helpful in one context may be harmful in another.

When drafting research questions, it’s impossible to account for all the possible answers (and situations) that a respondent might mention. As such, sometimes it’s necessary to deviate from your interview script and ask additional questions in order to understand a user’s context.

Ignoring contradictions

Always remember the goals of your research. If you don’t consider the variety of respondents’ opinions, you may come to general conclusions that don’t fully reflect all points of view. Sometimes a respondent may contradict themselves–in other cases, the views of different participants may diverge greatly. These difficult scenarios need to be considered when drawing conclusions. 

Desire to quantify everything

Often, teams are overly focused on quantitative indicators (such as conversions and revenue), but forget that qualitative data can provide a deep understanding of the motives underlying the metrics. Qualitative research offers unique data that cannot be obtained from statistical analysis or other quantitative methods. The emotions, motivations, and preferences of users can help explain how users make decisions and why they use a product, which is incredibly valuable. That said, remember that qualitative methods do not guarantee (nor imply) a quantitative assessment.

By conducting a thorough analysis of interview data, you can identify patterns and better understand users’ needs and expectations. In particular, Interviews can be extremely useful for identifying causal factors. Qualitative data can help researchers understand the essence of a problem; not how often it occurs within a target group. For this reason, never present interview results as percentages, even though it’s tempting. Instead, use interview results to form a basis for structuring quantitative research projects in the future.

In-depth interviews are a useful tool for testing product hypotheses and developing an comprehensive understanding of users and their needs.

Analyzing the results of qualitative research allows researchers to reduce their subjectivity risk, highlight common issues and behavioral patterns, and identify important topics for further research or feature development.

The process of data analysis can be broken down into several stages: transcribing interview records, structuring data through tagging, identifying patterns, and formulating general conclusions.

When working with an array of collected data, check for recurring trends and patterns, and compare answers from different sections to find relationships and identify important user context.

Throughout this process, don’t forget about the original objectives you set out to achieve in your research. It’s important to distinguish information that will support hypothesis testing from unrelated user information and feedback. At the same time, it’s worth paying attention to instances where users speak freely about critical issues.

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• Qualitative research in product management: the guide

Home / Professions, skills, and teams / Analyzing qualitative research results effectively

• Open access
• Published: 16 April 2024

Experiences of support for people who access voluntary, community and social enterprise (VCSE) organisations for self-harm: a qualitative study with stakeholder feedback

• Joe Hulin 1 ,
• Vyv Huddy 2 ,
• Phillip Oliver 3 ,
• Jack Marshall 3 ,
• Aarti Mohindra 3 ,
• Brigitte Delaney 1 , 3 &
• Caroline Mitchell 3  

BMC Public Health volume  24 , Article number:  1059 ( 2024 ) Cite this article

Metrics details

Prevalence of self-harm In England is rising, however contact with statutory services remains relatively low. There is growing recognition of the potential role voluntary, community and social enterprise sector (VCSE) organisations have in the provision of self-harm support. We aimed to explore individuals’ experiences of using these services and the barriers and facilitators to accessing support.

Qualitative, online interviews with 23 adults (18+) who have accessed support from VCSE organisations for self-harm in the Yorkshire and the Humber region were undertaken. Interviews were audio recorded and transcribed verbatim. Thematic analysis was undertaken using NVivo software.

Participants described how a lack of service flexibility and the perception that their individual needs were not being heard often made them less likely to engage with both statutory and VCSE organisations. The complexity of care pathways made it difficult for them to access appropriate support when required, as did a lack of awareness of the types of support available. Participants described how engagement was improved by services that fostered a sense of community. The delivery of peer support played a key role in creating this sense of belonging. Education and workplace settings were also viewed as key sources of support for individuals, with a lack of mental health literacy acting as a barrier to access in these environments.

Conclusions

VCSE organisations can play a crucial role in the provision of support for self-harm, however, pathways into these services remain complex and links between statutory and non-statutory services need to be strengthened. The provision of peer support is viewed as a crucial component of effective support in VCSE organisations. Further supervision and training should be offered to those providing peer support to ensure that their own mental health is protected.

Peer Review reports

Self-harm is defined by the National Institute for Health and Care Excellence (NICE) in 2023 as ‘any act of self-poisoning or self-injury…. irrespective of motivation’ and is a major public health concern [ 1 ]. Self-harm has been identified as a key indicator for suicide risk; it is the strongest risk factor for suicide in children and young people and approximately 50% of individuals who take their own life have a history of self-harm [ 2 , 3 ]. In this context, self-harm has been highlighted as one of the 7 key areas requiring action as recommended by Public Health England in 2017 [ 4 ].

Research drawing on the British Psychiatric Morbidity Survey has found the prevalence of self-harm has increased, particularly in younger age groups, and in females [ 5 ]. This study reported that prevalence increased from 6.5% in 2000 to 19.7% in 2014, in females aged 16–24 years [ 5 ]. The same research has shown that the number of people seeking medical or psychological support from statutory services appears to be stagnant, and a majority do not seek formal help [ 5 ]. Barriers to accessing support across all age groups include short consultation times, stigma related to mental health issues and the idea of ‘attention seeking’, confidentiality concerns and GP consultation skills [ 6 , 7 , 8 ]. Older adults who self-harm also perceive that their physical health problems can feel prioritised over their mental health struggles due to time constraints in primary care [ 8 ]. A further barrier appears to be the perception that GP’s lack skills in working with mental health issues and that primary care professionals only view physical health problems as important [ 6 , 7 ].

Informal help can be defined as support from family, friends, peers, religious leaders or other non-health professions including non-statutory or voluntary sector organisations. Research on support for broad categories of mental health difficulties has found that this type of support is very widely used [ 9 ]. For example, data collected in 2008–2010, showed that 60% of 386 UK adults with common mental health disorders seeked informal help [ 9 ]. Despite this, little is known about the experiences of people who access such support for self-harm. A review of peer support groups for self-harm, published in 2022, found that such groups can have a therapeutic role, with social and emotional benefits [ 10 ]. However, the studies included in this review were mostly focused on on-line peer support and did not position the findings in the context of general experience of accessing support or why informal, VCSE organisations might be used.

Our study aimed to qualitatively explore the experiences of those accessing VCSE support in a group of adults with lived experience of self-harm to determine the barriers and facilitators to accessing and engaging with services.

Study design

A qualitative study was undertaken using semi-structured interviews with a purposive sample of individuals with lived experience of self-harm. A lived experience advisory group (LEAG) met regularly with researchers and contributed to all stages of the research process.

Participants and recruitment

We recruited individuals via 72 VCSE organisations providing support for individuals who self-harm in the Yorkshire and the Humber (YH) region. VCSE organisations across the region were contacted via phone or email by a member of the study team and asked to advertise the study in their services and via social media. The advert was co-created with our LEAG and participants received a £10 gift voucher for taking part.

Inclusion criteria for participants were:

aged 18 years or over.

self-identified as having lived experience of self-harm as defined by NICE [ 1 ].

living in the YH region.

Participants self-selected to take part by contacting a member of the study team via email or telephone. Eligible participants were provided with an information sheet and an online consent form. All participants were given the opportunity to ask questions about the research via email or through an informal discussion with a member of the research team. Participants were informed that their decision to participate would not impact on the support they were receiving from any organisation and that they could withdraw from the research at any stage. Consenting participants also completed a sociodemographic form which collected data on age, gender, ethnicity, education, employment, and location.

Purposive sampling was attempted when under-recruiting by key demographic characteristics. This included individuals from ethnic minority groups, males and adults aged over 55 years. Interviews continued until data saturation was achieved in a maximum variety sample.

Semi-structured, one to one interviews using a topic guide were undertaken online or via telephone by a member of the interdisciplinary research team (BD, JH, JM or AM) from October 2021 to April 2022. The content of the topic guide was informed from existing literature, policy documents and discussions with our LEAG. For the online interviews, the audio-visual and chat box messages were recorded using the in-built systems on Google Meet and Blackboard Collaborate Ultra. Visual recordings were converted to an mp3 format and the original mp4 recording deleted. Audio from telephone interviews was recorded using dedicated encrypted recording devices. All interviews were transcribed verbatim and interview transcripts were anonymised in order to protect the identity of participants (e.g. names of people, locations or services were redacted). All audio files were deleted following transcription and data was stored on a secure drive in accordace with University policy.

Data analysis

Thematic analysis, using NVivo software, was undertaken in accordance with Braun and Clarke’s framework [ 11 ]. This framework includes the following six phases: familiarisation, generating initial codes, searching for themes, reviewing themes, defining and naming themes and producing the report. In accordance with this framework, researchers (JM, AM and JH) read and re-read transcripts to familiarise themselves with the data and initial notes on impressions of the participants’ accounts were recorded. Researchers (JM, AM and JH) coded the transcripts separately before sorting codes into broader candidate themes and sub themes. These preliminary themes were subject to critical interpretive challenge during regular analysis workshops with the whole research team to achieve a coherent and consistent account of the data. The themes were also presented to the LEAG to be defined further and named. The final findings were presented for further feedback in an online workshop to the members of our LEAG and 70 key stakeholders, including mental health practitioners, public health practitioners, academics, and individuals working in VCSE organisations.

Involvement of the LEAG throughout the research study design allowed us to address the four key principles of validity of qualitative research [ 12 ]. For example, through presenting preliminary themes to individuals with lived experience of accessing support for self-harm, we were able to ensure we were not imposing our pre-conceived categories onto the data and consequently demonstrating “sensitivity to context” [ 12 ]. The principle of “commitment and rigour” [ 12 ] was also achieved through the iterative phases of data analysis, which enabled prolonged and in-depth engagement with the data. Demonstrating transparency is also highlighted as an indicator of quality in qualitative research [ 12 ], which was addressed by ensuring the themes were grounded in examples and quotes from participants. Finally, impact and importance were addressed by ensuring that key stakeholders were involved in the research from the design phase so that the research question would be of practical usefulness for organisations providing support. The online presentation of findings to members of our LEAG and other key stakeholders, also allowed the team to gain additional perspectives on the themes uncovered and use these stakeholder perspectives to develop implications for public health policy and practice.

Twenty three interviews were undertaken. The majority of participants were female ( n  = 17) and white British ( n  = 19) (see Table 1). All participants were aged over 18 years, with the majority of inividuals ( n  = 8) aged 26–35. Five participants were aged 56 and over. Twelve of the study population lived in areas falling within the 5th or higher index of multiple deprivation (IMD) decline. In terms of employment, 14 participants were employed and 5 were unemployed. One individual was a University student, one was retired and one participant preferred not to answer the question.

Whilst the focus of our research was on accessing support from VCSE organisations, general experiences of seeking support from all services were captured, allowing us to explore whether barriers and faciltators to access and engagement differed across statutory and non-statutory services. Four key themes were identified from the data: appropriate and timely support, fostering a sense of community, awareness of support and employment and education. Table 2 summarises these main themes and explanatory sub-themes. The theme of timely and appropriate support included two main sub themes relating to the need for person-centered care and additional support in navigating complex care pathways. What participants defined as appropriate support was also partially addressed in the second theme, which highlighted the need for services to foster a sense of community. In this theme participants highlighted the importance of shared experiences, across both in-person and online resources. The third theme covered the perception that there was a lack of information available on existing support across both statutory and non-statutory services. Finally, the importance of employment and education settings in providing support for self-harm was also emphasised.

Appropriate and timely support

This theme captured how individuals perceived a lack of person-centred services for self-harm, which provided support in a timely manner. Participants described the need for additional support in navigating complex care pathways, which included multiple referrals and lengthy delays in accessing support.

Tailored services

Participants described the importance of services being tailored to meet individual needs and how a lack of options made them less likely to engage with services. For example, one individual described how they were hesitant to access support from one VCSE organisation, because they felt their preferences for one-to-one support were not being heard by healthcare professionals:

I said I’ll think about it on the phone but when I thought about it I knew deep down I really wanted one to one. It kind of upset me a bit. I’m not sure why, maybe because I thought they were just going to get rid of me or something, I don’t know, but yeah that kind of threw me off. If I’d have wanted group therapy, I would have said it at the beginning. P20: White British Female, aged 26–35 years

An inability or unwillingness for services to tailor approaches to meet the needs of individuals with neurodevelopmental conditions, such as autism, was also highlighted:

It’s one size fits all, we don’t want to have any specialised services, we don’t want that because it’s too much trouble, too much expense. P16: White British Female, aged 56–65 years

Practical issues, such as the time in which sessions were being delivered, was another potential barrier. For example, one participant described how a lack of service flexibility made it difficult to access support from some VCSE organisations, particularly for those in full time employment:

groups are like three and a half hours a week with everything and I work full time, so it was kind of, like, you know, it’s stressful enough working without trying to suddenly find more time as well. P3: White British Female, aged 26–35 years

Accessibility to third sector support was also dependent on the location in which you live, with one individual describing how living in a more rural environment, with fewer transport links, meant appropriate support was not always available:

place X is really, really low in third sector availability and transport. That’s a particular issue for me; I live in a little village. Accessibility is a huge problem. P11: White British Female, aged 56–65 years

Navigating complex pathways

The complexity of care pathways also limited access to services. One individual described how “you’ve got to be the right sort of mad at the right time” (P11: White British Female, aged 56–65 years) to be able to receive appropriate support. Both statutory and non-statutory services were often viewed as fragmented, and some participants highlighted a perceived lack of support in helping navigate these care systems, leading to feelings of isolation:

So then I was a little bit sort of taken aback then, it’s like ‘well where do you want to go from here’ and I’m like ‘well I don’t really know, I was hoping you’d kind of help me’, but then, no, so then I was just kind of on my own again. P3: White British Female, aged 26–35 years

One participant felt that better communication between services could help staff or volunteers guide individuals through these care pathways more effectively, enabling smoother care transitions. The importance of building rapport through continuity of care was also viewed as a key component of care:

I think it’s better communication between the teams… like my facilitator in DBT (Dialectical Behaviour Therapy) is also on the crisis team so you sort of build, yeah you sort of build a rapport with that person. P13: White British Female, aged 26–35 years

Navigating pathways were also made more difficult as a result of waiting times following initial referrals:

So he was like ‘go away and try and some talking therapies and come back’, so I spent two years trying to access talking therapies, kept getting taken off the waiting list without being told, and then it’s probably, I’d say January this year, I went back to the GP and I was like ‘look, I can’t do anything about this, it’s worse’, so then she prescribed me some medication for my anxiety and then I was like ‘OK and what about anything else’ and then she was like ‘well you’ll just have to self-refer and you’ll just have to find something to keep you going, I can’t really refer you on or do anything about that, you’ll have to go and find somewhere to refer yourself to or somewhere to access support’. So I referred myself back to the Mental Welling being Service. That was in January, they said it would be an eight month wait to bet CBT (Cognitive Behavioural Therapy)– never heard back from them since. P5: White British Female, aged 18–25 years

The time required to access support was seen as a particular problem for some individuals, who felt that they needed more urgent responses from services to help with their self-harm. It was suggested that more immediate support was often facilitated through drop-in services:

I struggle with the waiting times, because it’s like by the time it comes around sometimes I might be OK and not be able to explain it properly, so with the drop-ins (via the University health service) you could literally just go when you wanted and you had the counselling service, which you did have to wait for a bit, but they still had this like wellbeing person that you drop in with and stuff. P3: White British Female, aged 26–35 years

Fostering a sense of community

Individuals were more likely to engage with support in settings which fostered a sense of belonging. Some individuals highlighted how being a valued member of a community aided their recovery:

People don’t recover in our institutions, they recover in community. Once you’ve been accepted within a community and welcomed within a community and seen a value asset within a community and that you’ve got a purpose of you’ve got something to give. P1: White and Black Caribbean Male, aged 46–55 years

Shared experiences

Environments which fostered a sense of community were often established through the inclusion of peer support, with individuals noting how they were more comfortable seeking support from those with shared experiences:

Group X (VCSE organisation), which is a peer support group which really helps me and it allows me to talk about my experiences without being ashamed of it, because there’s other people with similar experiences. So being part of Group X makes me feel as though I belong somewhere. P1: White and Black Caribbean Male, aged 46–55 years

One individual also discussed how being able to support others was also viewed as having a positive impact on their own wellbeing and mental health:

I find it quite helpful because it’s like I try to be the person that I needed when I was younger, that person who is safe to talk to who will fight for the underdog. P17: White British Female, aged 26–35 years

However, the potential burden this could have on those providing peer support in VCSE settings was also acknowledged, with one individual highlighting the fact that “you can’t hang everything on people who are struggling themselves”.

P11: White British Female, aged 56–65 years

Online communities

Participants also highlighted how a sense of community or belonging could often be created through engagement with others online:

“It’s like an online Big White Wall so with like post-it notes and different little forums where people can talk about stuff. And the main message is like “You’re not alone” which is a really important thing with self-harm; you do feel like “Oh my God, what’s going on with me? I’ve never experienced this before”. P22: White British Female, aged 18–25 years

Below one participant describes how coining of new phrases regarding a perceived lack of need for support helped them recognise that others share similar experiences:

She’s come up with this thing basically called ‘Baby Cut Syndrome’…. so it’s kind of, like, the whole baby cut, you think yours aren’t as deep as someone else sort of thing, so that’s quite a useful sort of term that kind of I feel I wouldn’t have known other people had until that came up and it suddenly sort of clicked and made sense… it’s just kind of a feeling that you think you always have on your own but then knowing that other people have that feeling too and there’s a name for it, that she’s come up with, is quite helpful, quite validating in a way. P3: White British Female, aged 26–35 years

However, it was recognised that shared experiences of mental health on social media can negatively impact individuals by acting as a “trigger” for their self-harm (P3: White British Female, aged 26–35 years).

Awareness of support

Some individuals felt that access to support was hindered by a lack of awareness of available services and by not being provided with a clear understanding of the support they would likely receive.

Knowledge of service availability

Participants described how they felt existing services were not clearly communicating the support available:

I think had I known where to go sooner and had it been talked about more, I might have stopped self-harming sooner or sought out services sooner. P22: White British Female, aged 18–25 years

One individual also described how they had a perception that self-harm would not be addressed in primary care:

…it feels like too small of an issue to go to a GP with, because I feel like depression is a big enough issue, any other mental illness is a big enough issue, but self-harm is like this tiny little subcategory where it’s like, you know, yeah, so I think I was like oh I’ll manage it. P7: Indian female, aged 18–25 years

This lack of awareness was also reported to be mirrored by those involved in delivering support:

…in the conversation with the receptionist I just said mental health and then she started panicking being ‘oh we’re not equipped to deal with this, we can’t…’, like, I kept it very, very general and then she was like ‘we’re not equipped to deal with this, you couldn’t be calling us, you should be calling someone else, blah blah blah’ and I was like, at the time, I was like ‘well it’s only anxiety, I’m pretty sure a GP can deal with that, but then because she had such a panic reaction, I was like well I’m not going to bother going about self-harm or anything like that, because she made it sound like they’re not equipped to deal with anything that could be classed as a bit more serious. P5: White British Female, aged 26–35 years

Lack of clarity

The lack of information on what services entailed also had a significant impact on engagement with support. One individual described how they did not know what to expect from service and this made them more reluctant to access care:

…a bit more clarity would be good, because I got told I was going to this core psychology and that I had this meeting, but I didn’t know what it was, how long it were going to be for, who it was with and it ended up being with a psychologist rather than a…like a counsellor or summat, I didn’t know whether it was going to be a weekly counselling thing or what or whether I’d meet her once and then I’d have to wait for something else…. P3: White British Female, aged 26–35 years

Education & employment

Participants described the importance of creating supportive environments in education and work settings for people who self harm. The role employment can play in creating a sense of meaning or purpose, which can help facilitate personal recovery, was also highlighted.

Creating supportive environments

Employment settings were highlighted as sources of support for some individuals. However, a lack of mental health literacy among employees and available resources was noted as a particular barrier to accessing support:

…my direct manager isn’t the most understanding person of mental health…she’s not able to recognise signs, symptoms of like people who are in crisis or whatever, you know, but her manager is a little bit more, so I’ve gone and spoken to her about stuff, and yeah so she recommended that I go to see the OTs (Occupational Therapists) and I’ve tried contacting them but they’ve never come back to me…even when you ask for that help they’re not always there. P17: White British Female, aged 26–35 years

Support in education settings was also seen as crucial for some individuals, especially when students felt academic pressure was having a negative impact on their mental health:

my tutor was brilliant as well and they were just really helpful because they didn’t– they let me have like extensions, they didn’t put pressure on me in terms of my work and things, they were just brilliant, can’t say a bad word about uni really. P3: White British Female, aged 26–35 years

Empowerment and self esteem

It was also noted how employment opportunities could play a role in improving individuals mental health and wellbeing and reducing experience of self-harm:

I’d been doing volunteering all along but then when I started to get into paid work, that was really massive for me in terms of like self esteem, self worth, like structure, routine, all of that kind of thing. P18: White British Female, aged 36–45 years

This sub theme, is closely related to the sub-theme of “Shared Experiences”, in which the positive impact on mental wellbeing through being able to provide peer support in VCSE organisations was highlighted.

In our study, participants highlighted a number of barriers to accessing both statutory and third sector organisations for support for self harm. These barriers included a perception that existing care pathways were fragmented and difficult to navigate and that services were not often suitable for individual patient needs. Participants also described how the availability of support services were not always clearly communicated. One of the perceived benefits of accessing VCSE organisations for support, was the unique sense of community or social connectedness gained in these settings. With some participants suggesting that being accepted within a community and being heard by others with similar experiences played an important role in recovery. Individuals often felt this sense of belonging was absent from primary and secondary mental health services.

The perceived social benefits of accessing VCSE support mirror findings from the recent review by Abou Seif and colleagues [ 10 ]. Both this review and the current study also demonstrated that the value of being able to provide and receive support from individuals with similar experiences was not limited to in person services, with online communities also being recognised as a source of meaningful engagement. However, the current study findings and existing literature [ 10 ] also acknowledge the potential risks associated with engaging with online content, with it being reported that some individuals may actively seek content which is likely to trigger their self-harm [ 13 ].

Participants called for greater flexibility from both statutory and VCSE organisations with regards to service access. Implementing this will require a careful balance between ensuring patient choice and customisation with protecting a feasible level of complexity within service structures; VCSE can draw on learning in statuary healthcare providers [ 14 ]. It might be also fruitful to consider a broader definition of what constitutes a provider to help provide capacity to deliver the required flexibility. Outside of the statutory and VCSE network the most visited healthcare providers are community pharmacies and there has been work exploring their potential role in supporting other services [ 15 ].

One means to achieve more connectedness and awareness of services is provided by resources that help organisations collaborate and network such as ‘sharing economies’ [ 16 ]. Cooperation can also be achieved by local authorities supporting forums for networking. For example, Tower Hamlets has such an organisation facilitated by a health lead who acts as a link between the VCSE sector and health and wellbeing boards [ 17 ]. This approach may be well placed to integrate service users and experts by experiences into resources on offer. It may also provide a means to increase resources to support volunteers, such as supervision and training.

The role education and employment settings can have in providing self-harm support was also highlighted by participants in our current study. Mental health provision in school and college settings continues to grow in the UK, with over 13,800 schools and colleges claiming grants to train new mental health leads between October 2021 to March 2023 [ 18 ]. From 2018 to 2023, there have also been 398 new Mental Health Support Teams introduced across England to help deliver mental health interventions [ 18 ]. However, there remains a lack of consensus on which type of interventions are effective in reducing mental health conditions [ 19 ]. A recent review on the effectiveness of school-based interventions to prevent self-harm, reported evidence of reduction in self-harm in 3/6 studies eligible for inclusion [ 20 ]. However, only one of these studies was deemed as methodologically sound [ 20 ]. As in the current study, recent qualitative research on facilitators to self-harm interventions in school settings, support the need for interventions to be tailored to individual needs [ 21 ]. An emphasis on the need for whole-school approaches to self-harm prevention was also noted, which is often defined by the inclusion of interventions at the whole-school level to create positive, mental health-promoting learning environments.

With regards to the provision of mental health support in the workplace, a recent review of reviews found some evidence that psychological interventions can be effective in reducing depression, anxiety and workplace stress [ 22 ]. However, there appears to be a paucity of evidence on how employment settings can effectively provide support specifically for self-harm.

Working closely with our members of our LEAG throughout the research process allowed us to develop recruitment strategy and interview procedure in which participants felt supported in sharing their experiences of non-statutory peer and community support for self-harm. This allowed us to explore a range of in-depth narratives to enable a better understanding of the importance of these services in improving public mental health and the potential barriers to accessing such support. However, despite consultation with the “Deep End” PPI panel, we acknowledge that further efforts could have been made to recruit a more diverse sample of participants, with the majority of the sample being White British, females. For example, the use of interpreters and options for in person interviews could have allowed us to further explore the voices of those which often go unheard in research on the provision of self-harm support.

Working closely with those involved in commissioning and delivering VCSE support and allowing for feedback from over 70 delegates at our stakeholder event was a key strength of the research. This allowed us to understand the implications of our results for services and the challenges of implementing service recommendations from the providers perspective.

Our study suggests that VCSE organisations can play an important role in the delivery of support for people who have self-harmed. These organisations can offer participants the opportunity to receive support from individuals with shared experiences, which in turn fosters a sense of belonging that helps facilitate engagement with services. However, it is vital that appropriate supervision and training is provided to these individuals providing support to ensure their own mental health and wellbeing is protected. Further work is also required to raise awareness of the types of services available to individuals, with better communication between statutory and non-statutory services required to help individuals navigate complex care pathways, which are often viewed as inflexible and fragmented.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to concerns of privacy and confidentiality, but some material can be available from the corresponding author on reasonable request.

Abbreviations

Voluntary community and social enterprise

General practitioner

Lived experience advisory group

Indices of multiple deprivation

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Acknowledgements

The author’s would like to express their thanks our lived experience advisory group and the Deep End Research Alliance for their time and input on the project.

The research was funded by the Yorkshire and the Humber Mental Health & Suicide Prevention Community of Improvement (Y&H MH&SP CoI) and Hull City Council.

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JH, VH, PO and CM conceptualized and designed the study. JH, JM, AM and BD contributed to the collection of data via interviews. All authors (JH, VH, PO, JM, AM, BD & CM) contributed to the data analysis and read and approved the final manuscript.

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Hulin, J., Huddy, V., Oliver, P. et al. Experiences of support for people who access voluntary, community and social enterprise (VCSE) organisations for self-harm: a qualitative study with stakeholder feedback. BMC Public Health 24 , 1059 (2024). https://doi.org/10.1186/s12889-024-18455-4

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How would you describe a mentally healthy college student based on Chinese culture? A qualitative research from the perspective of college students

• Mingjia Guo 1 ,
• Xiaoming Jia 1 &
• Wenqian Wang 1  

BMC Psychology volume  12 , Article number:  207 ( 2024 ) Cite this article

Metrics details

Promoting college students’ mental health remains a significant concern, necessitating a clear understanding of what constitutes good mental health. Variations in the conceptualizations of mental health across cultures, typically derived from academic and authoritative perspectives, have overlooked insights from laypeople. This study aims to investigate the characteristics of mentally healthy college students within Chinese cultural contexts, emphasizing perspectives provided by college students themselves.

Undergraduates with self-reported mental health scores ≥ 7 were randomly selected for in-depth interviews. The sample ( N  = 17, 59% female) had a mean age of 20.82 ± 1.33 years and represented diverse regions, backgrounds, and academic fields. Thematic analysis was used in the analysis of the qualitative data, involving initial coding to identify 168 manifestations of mental health among college students, followed by categorizing them into 18 characteristics through focused coding. These characteristics were then organized into five themes via core coding. The Delphi method was utilized to validate the themes with 3 experts, ensuring the trustworthiness of the final findings.

Eighteen characteristics of mentally healthy college students emerged from the interviews, categorized into 5 themes: (1)Value Pursuit (i.e. Having a sense of responsibility and mission and being willing to dedicate oneself to the country at any time.); (2)Life Attitude (i.e. Staying positive and having the ability and quality to cope with hardships.); (3)Interpersonal Ideals (i.e., Showing filial respect to parents appropriately.); (4)Behavior Ability(i.e., Studying diligently and learning well.); and (5)Self-cultivation (i.e., Possessing good qualities advocated by Confucianism, Buddhism, and Taoism coexist harmoniously.). Most of these characteristics directly reflect traditional Chinese culture or culture that has changed with the times. At the same time, some are a reflection of modern Chinese new culture.

Conclusions

On the whole, the characteristics of mentally healthy college students are diverse and with rich connotations, focusing on the individual’s relationship with the country, family, and others, and are good expressions of Chinese cultural features, such as the balance of Yin and Yang, the coexistence of Confucianism, Buddhism, and Taoism, and highlight moral attributes. In essence, these traits hold profound importance in advancing the mental health of Chinese college students.

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The period of undergraduate study is vital for individual development, physical and mental growth, knowledge reserve, and health literacy development. For undergraduate students, they are in the process of transitioning from late adolescence to early adulthood, navigating various physical, psychological, and social changes [ 1 ]. After entering the university, undergraduates, especially first-year students, are prone to various maladaptation problems due to changes in their living and learning environments [ 2 ]. Notably, a recent nationwide survey of 48,789 undergraduate students from 31 provinces and cities of China showed that 24.17% of undergraduates were at risk of depression, and 49.58% were at risk of anxiety [ 3 ].

Some studies have shown that these psychological problems are related to culture. As a Chinese proverb goes, “Nothing is more important than learning.” Before university, Chinese students focused solely on their studies, with their parents managing all aspects of life [ 4 ]. Consequently, they may lack the ability to independently resolve problems, particularly when confronted with many challenges in university life, often feeling helpless. Furthermore, admission to university is considered an honor to ancestors and a source of pride for parents in Chinese culture [ 5 ]. Attaining good grades and securing an ideal career post-graduation are seen as ways for college students to fulfill their filial duties, like supporting their parents, thus imposing familial and communal pressures.

Cultural influences also play a role in the mental health of college students. Wang et al. (2016) investigated how traditional Chinese philosophies—such as relationship harmony (advocated by Confucianism), dialectical coping (from Taoism), and non-attachment (rooted in Buddhism)—impact college students’ mental health. Their research demonstrated these philosophies’ negative correlation with psychological distress and negative emotions while displaying positive correlations with self-esteem, positive emotions, meaning of life, and happiness [ 6 ]. Another study indicated that Chinese college students scoring higher in Zhongyong thinking exhibit lower anxiety and depressive symptoms, along with higher self-esteem and life satisfaction, versus those with lower scores [ 7 ].

Since culture and mental health are mutually embedded [ 8 ], different cultures may interpret the same things differently. For instance, in Western cultures, pursuing a college education is often viewed as an individual pursuit, whereas in collectivist China, but in China, higher education is commonly sought to elevate social status and offer enhanced financial support to parents, such as securing a comfortable retirement home. In times of conflict, individuals in Chinese society tend to adopt the principle of “taking a step back and yielding vastness and spaciousness to others” [ 9 ], prioritizing long-term harmony over immediate gains by favoring conflict avoidance over confrontation. The values of “harmony is precious” and the practice of “forbearance” are revered in China, whereas in Western societies, it may be considered unhealthy, with individuals opting for direct expression of discontent [ 10 ].

In China, only 8% of the population hold bachelor’s degrees [ 11 ], and college students are seen as the nation’s hope and future [ 12 ], underscoring a heightened focus on their mental health. To enhance the mental health of Chinese college students effectively, it is imperative to grasp the cultural nuances defining mental health across various contexts.

Mental health has always been a focus in the field of psychology. Researchers from diverse backgrounds have extensively investigated mental health within various cultural frameworks. This includes the development of nuanced interpretations and pertinent theories regarding mental health across different cultural settings [ 13 , 14 ]. Moreover, scholars have localized measurement tools through meticulous adaptations [ 1 , 15 , 16 , 17 ] and delved into understanding the impact mechanisms between mental health and its associated determinants [ 18 , 19 ]. In terms of the connotation of mental health, aside from the various approaches of counseling and psychotherapy have their interpretations and definitions of mental health, various organizations and scholars have also put forward different perspectives of mental health from multifaceted viewpoints, clearly demonstrating the impact of culture.

According to the Concise Encyclopaedia Britannica, mental health is defined as “the state of optimal functioning of the individual psyche within the limits of its own and environmental conditions, but not as an absolute state of perfection” [ 20 ]. Meeks and Heit describe mental health as “the ability to perceive and express one’s emotions and state of mind; mental health is the ability to accept reality as it is” [ 21 ]. Meanwhile, Ryan and Deci propose that mental health involves “the ability to feel effective and agile, e.g., to have full self-fulfillment” [ 22 ]. The World Health Organization defines mental health as “a state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and can make a contribution to his or her community” [ 23 ]. These definitions illustrate how Western culture emphasizes individual capabilities, states of being, and overall well-being, focusing on fulfilling potential, fostering self-esteem, and reflecting a culture centered on the individual.

In the Dictionary of Psychology (Chinese version), mental health was defined as “a good state in which the individual’s mental state (e.g., general adaptability, soundness of personality) remains normal or at a good level, and in which harmony is maintained within the self (e.g., self-awareness, self-control, self-experience) and between the self and the environment” [ 24 ]. According to Zhang and Yang, mental health contains objective and subjective components [ 25 ]. An individual’s mental health is mainly expressed by the relationship between the individual and others in a group, so it contains social meaning. Hu suggests that mental health is about “following one’s heart and not exceeding the rules,” which has both its individual (developmental and autonomous) and social (adaptive and normative) aspects [ 26 ]. Yip defines mental health as a direction that suggests self-discipline and obedience to social order to maintain inner balance and external harmony with others [ 27 ]. Specifically, individuals can maintain this balance and harmony across three levels: personal, interpersonal, and moral/ethical. These definitions underscore Chinese scholars’ emphasis on the social aspects of the individual in conjunction with the proper functioning of mental faculties. They highlight Chinese culture’s focus on harmony, interpersonal relationships, societal connections, and moral/ethical considerations.

In summary, concepts and understandings of mental health are closely tied to culture [ 28 ], reflecting that the connotations of mental health defined by different cultural contexts can vary to some extent. Then, how is mental health related to culture? The theory of sociocultural models (TSCM) provides a perspective on the interaction between culture and the individual mind [ 29 ].

The primary thesis of the theory of sociocultural models (TSCM) is that the human mind and culture mutually constitute each other. During continued interactions, individuals internalize the social culture into their psychological realities to regulate their actions and interactions. Conversely, community members will externalize the psychological reality through enactment and instantiation, creating new social cultures through social interactions and co-construction with the existing social culture. The dialectical interactions of these two aspects constitute the mechanism of the sociocultural regulation of human actions and the construction of the sociocultural reality [ 29 ]. Consequently, social culture dictates varying expectations for mental health standards, while the characteristics associated with mental health are also culturally rooted and reflect social culture. Simultaneously, societal depictions of mentally healthy individuals contribute to the evolution of novel cultural norms in a reciprocal manner.

The Chinese culture has a long history of rich mental health concepts deeply rooted in philosophies such as Confucianism, Buddhism, and Taoism. Confucianism seeks to go into the society( Rushi ), i.e., “To ordain conscience for Heaven and Earth, to secure life and fortune for the populace, to carry on lost teachings of ancient sages, to build peace for posterity” (Zhang Zai: Heng Qu Yi Shuo ). When encountering setbacks, Confucianism advocates being adaptable to circumstances and maintaining mental health by being resilient and motivated. Taoism seeks to transcend the world( Chaoshi ) and advocates “letting go.”When encountering difficulties, people maintain mental health by going with the flow and doing what they should do. The philosophy also underscores the importance of balancing Yin and Yang, enabling individuals to perceive challenges holistically by acknowledging both positive and negative aspects. Buddhism seeks to jump out of the material world( Chushi ) and advocate “being free of worried thoughts” when encountering difficulties. As Hui Neng(the Sixth Patriarch of Zen) said in the Tan Jing, “Since everything is naught, where can dust gather?” Individuals can cope better with difficulties if they have a mindset that looks down on gains and losses and that everything is nothingness.

Popular anecdotes and proverbs in Chinese culture also dictate criteria for individuals’ mental health. For instance, the “Three Feet of Space” tale narrates an incident from ancient China where the Guo family faced a boundary dispute with their neighbor during house construction. Upon hearing of this issue, patriarch Guo Pu wisely proposed, “Sending letters a thousand miles just for a wall; why not give him three feet?” This led to the Guo family’s compromise, and finally, both families conceded three feet of space from their walls. This narrative underscores the cultural emphasis on fostering interpersonal harmony through mutual accommodation, viewing discordant relationships as signs of poor mental health.

Contemporary scholars have also endeavored to directly integrate key concepts from Chinese traditional culture into psychological counseling and therapy. Yang and his colleagues(2002) [ 30 ] created Taoist Cognitive Therapy to facilitate cognitive restructuring in psychologically distressed individuals by directly applying the 32 characteristics of the Taoist principle of health, that is: “Benefit without harm, but not disputing; abstinent contentment with little selfishness and desire; under the knowledge and the place, let gentleness overcome rigidity; recover the original simplicity, let it be.” Liu(2023) posits that “unity of universe and human” in Chinese culture is a core idea of mental health [ 31 ]. He pointed out that the psychological phenomenon corresponding to this concept is psychological nothingness. By fusing modern psychotherapy with the concept of “unity of universe and human,” Liu developed the technique of “Moving symptom’s symbol to nothingness” to fulfill the healing role of Chinese culture. These endeavors establish a robust framework for comprehending mental health through the lens of Chinese cultural perspectives.

Over the years, numerous scholars have delved into the attributes of mentally healthy college students. Prominent among these is Wang and Zhang’s widely recognized framework, which outlines eight characteristics drawing from personal experience: understanding and accepting oneself; accepting others and dealing well with them; facing reality squarely and accepting it; loving life and enjoying work; being able to coordinate and control emotions and being in a good state of mind; having a complete and harmonious personality; having normal intelligence; and having age-appropriate mental behavior [ 32 ]. However, this work has predominantly focused on psychological cognition, emotion, and intention, with limited consideration of the cultural context, particularly the influence of Chinese culture on mental health.

Subsequently, scholars such as Zeng and Lei, incorporating social, ethical, and moral perspectives, proposed a culturally nuanced framework emphasizing four main traits in mentally healthy college students: positive and controllable emotions, good moral values, comfortable coping with schoolwork, and healthy social interaction [ 33 ]. While valuable, this perspective primarily mirrors researchers’ subjective experiences and authority-driven viewpoints. It neglects insights from laypeople, omits identification of the aspects of Chinese culture showcasing characteristics of mentally healthy college students, and lacks differentiation between mentally healthy college students and other demographic groups. Consequently, there is a demand for exploring innovative methodologies to scrutinize the attributes of mentally healthy college students, particularly focusing on characteristics within Chinese culture.

Currently, there are various research paradigms for the study of mental health. Jiang (2004) categorized them and concluded that there are two main principles in evaluating mental health: the majority principle and the elite principle [ 34 ]. The majority principle refers to a research paradigm that selects research subjects through large samples and measures whether individuals deviate from the norm through the principle of statistical normal distribution [ 35 ]. An example is applying the Chinese version of Symptom Checklist-90 (SCL-90), one of the most often used self-report symptom inventories to measure the mental health of college students, and individuals scoring exceeding the norm were considered abnormal [ 36 ].

The elite principle refers to a research paradigm that focuses on elite samples, namely a small number of relatively outstanding individuals in the whole population who are at the tip of one side of the normal distribution, and primarily employs qualitative research methods to derive research findings [ 35 ]. For example, Maslow researched some great people in Western history( i.e., self-actualized people) using qualitative research methods such as biographical analysis, depicted 15 characteristics of self-actualized people, that is, “more efficient perception of reality and more comfortable relations with it,” “acceptance (self, others, nature),” “spontaneity; simplicity; naturalness,” “problem centering,” “the quality of detachment; the need for privacy,” “continued freshness of appreciation,” “autonomy; independence of culture and environment; will; active agents,” “the mystic experience: the peak experience,” “gemeinschaftsgefuhl,” “interpersonal relations,” “the democratic character structure,” “discrimination between means and ends, between good and evil,” “philosophical, unhostile sense of humor,” “creativeness,” “resistance to enculturation; the transcendence of any particular culture” [ 37 ].

Maslow’s findings profoundly influenced research on mental health definitions, standards, and interventions. While some researchers have embraced the characteristics of self-actualized people as an ideal standard of mental health [ 38 ], others have leveraged these characteristics by focusing on exceptional psychological qualities rather than normative behavioral performance [ 39 ], and many of these characteristics have been used as ideal indicators of mental health for the promotion of mental health among college students [ 40 ]. Additionally, these characteristics and the conditions that promote or inhibit self-actualization are also applied in methods and paths of healthy human development [ 41 ]. Furthermore, specific characteristics such as a “philosophical, unhostile sense of humor” have been directly applied by researchers to enhance humor quality among college students facing stress and embarrassment, aiming to uphold their mental well-being [ 42 ].

Despite significant value in both theory and practice, Maslow’s study is based on the Western culture and is not aimed at a specific group of college students. Consequently, its direct relevance to enhancing the mental well-being of Chinese college students may be limited, necessitating further investigation into mental health within the framework of Chinese culture. Nonetheless, Maslow’s study of the elite samples of self-actualized people also provides a new research paradigm for mental health research, which has greatly inspired this study.

In the past, most studies on the mental health of college students used quantitative studies based on the majority principle. While some qualitative studies inquiries delved into the characteristics of mentally healthy college students, these studies often focused on specific subgroups like those who experienced being left behind [ 43 ] or childhood trauma [ 44 ]. A gap exists in the mental health characteristics based on the Chinese culture of college students who are the elite samples, i.e., those who exhibit very good mental health. By utilizing the elite principle paradigm, researchers can gain insights into and depict the mental health characteristics of college students within the context of Chinese culture, with the ultimate aim of delineating the mental health characteristics of college students specific to this cultural framework.

This study will apply the elite principle to examine college students with very good mental health. Through a distinctly Chinese cultural lens, this research aims to delineate what mentally healthy college students look like and what characteristics they show. By focusing on college students’ personal experiences and Chinese culture, this study positions college students as knowledge generators, employing a qualitative research approach to uncover the characteristics of mentally healthy college students. The objective is to achieve a new understanding of college students’ mental health based on Chinese culture and provide a theoretical basis for new mental health standards and a reference for promoting, cultivating, and intervening in college students’ mental health.

In this study, mental health refers to the good psychological state of an individual. College students refer to the group of students who are receiving professional higher education. Chinese culture refers to the culture created by the Chinese over thousands of years of development, from ancient times to the present [ 45 ].

The study applied a participatory, exploratory, qualitative design. Qualitative methods are suitable for exploring the meaning of phenomena or life events to the interviewees and their inherent experiences from the subjectivity of the interviewees [ 46 ]. It also emphasizes the participants as a generator of knowledge and the acquisition of significant experiences from the participants [ 47 ]. Thus, it can help researchers to gain a deeper understanding of community members in a specific cultural-historical context. Moreover, qualitative methods hold particular promise for prioritizing participants’ voices, and they contribute to understanding human interaction with the environment in development and helping researchers build and expand new concepts and theories in specific cultural-historical contexts [ 48 ]. This study used semi-structured individual in-depth interviews to explore the characteristics of mentally healthy college students based on Chinese culture. Moreover, the procedure of the study is shown in Fig.  1 .

The procedure of the study

The development of the interview outline

The qualitative data for this study was collected through semi-structured interviews. Interviews serve as a tool to help reveal and understand participants’ perspectives and experiences. The interview outline for this study was based on the theory of sociocultural models [ 29 ], focusing on how the interviewed college students understood Chinese culture and which cultures were internalized as characteristics of mentally healthy college students.

The interview outline in the pre-interview includes questions such as “What do you think is mental health? What do you think a ‘mentally healthy’ college student is like? You can use yourself or your classmates as examples.” “What do you think is Chinese culture? What is your understanding of Chinese culture?” “What do you think is related to college students’ mental health in Chinese culture?” (Appendix 1 ).

Participant recruitment and selection

The selection criteria for the participants were: i) undergraduate students enrolled in colleges; ii) having a very good psychological status, with a self-assessment of mental health of 7 or more (out of 10); and iii) self-assessment anxiety/depression scores within the normal range.

The study recruited participants through postings in contact groups and forums among different colleges. Undergraduates who satisfied the selection criteria volunteered to participate in the study. At the time of self-referral, enrolled students rated their mental health with the term “Out of ten, how would you rate your mental health?” as well as filled out self-rated anxiety and depression scales [ 49 , 50 ].

The reasons for considering selection criteria are as follows. Firstly, the research objective is to identify the mental health characteristics of college students with good mental health. Therefore, following the elite principle and referencing Maslow’s self-actualization research paradigm [ 37 ], we have chosen exceptionally mentally healthy college students as elite samples for study. Given that statistical analysis commonly regards the top 27% as the criterion for high-score groups [ 51 , 52 ], a score of 7 out of 10 indicates high mental health levels. Consequently, the study interviewed college students scoring at least 7 points. Secondly, to eliminate individuals with significant biases in the self-assessment of mental health and those potentially experiencing psychological issues, we utilized scores from self-rating scales for depression and anxiety to exclude possible candidates with underlying psychological disorders.

Eventually, 17 college students who met the criteria were selected for interviews in this study. The selection of participants considered factors that might influence college students to develop different understandings of Chinese cultures, such as upbringing, family environment, and educational experiences. The total number of participants was determined based on thematic saturation, i.e., no significant themes emerged with new respondents [ 53 , 54 ]. Finally, 17 undergraduate students volunteered to participate in the formal interviews, and the self-reported mental health score of the interviewees was 8.11(SD = 0.90) (out of 10). Among the participants, seven were male, and ten were female. Their ages ranged from 19 to 23 years old (mean age = 20.82, SD = 1.33 years), five interviewees were from Double World-Class Project Universities in China, and 5 were first-year students, two sophomores, eight juniors, and two seniors. Participants came from different regions of China; 4 grew up in north China, 1 in northwest China, 2 in southwest China, 2 in south China, 1 in east China, and 7 in central China; 1 from an ethnic minority. 65% were from urban areas, and 29% had no siblings. Additional information on parents’ education level and occupation is shown in Table  1 .

After the interviews, participants were thanked for their participation and contribution and were offered 30 RMB (about 4 dollars) for participating.

The finalization of the interview outline

Before the formal interviews, three college students (one male and two female) who met the selection criteria were pre-interviewed, and the interview outline was adjusted based on the pre-interviews. Specifically, the researchers adjusted ambiguous expressions. For example, in the pre-interview, the researchers found that if they asked the interviewees, “What do you think is related to college students’ mental health in Chinese culture?” They answered how Chinese culture affects college students’ mental health rather than the characteristics of mentally healthy college students based on Chinese culture. Therefore, we adjusted the question to “What a ‘mentally healthy’ college student is like based on Chinese culture? You can take yourself or your classmates as an example” to obtain the characteristics of mental health that reflect Chinese culture. A formal interview outline was eventually formed (Appendix 2 ).

Data collection and analysis

The qualitative data was collected through in-depth personal interviews with eligible college students. Each interview lasted between 50- 100 min and was conducted by the researcher (MG), who possessed a doctoral background in psychology, had received training in qualitative research methods, and had three years of experience working in mental health education in universities. All participants signed informed consent forms prior to the interviews. In total, 1252 min of interviews were conducted with 17 participants, which were then manually transcribed by MG, resulting in 289,000 words of interview transcripts.

To accurately ascertain the true meaning expressed by the participants, this study employed manual analysis within the research team to code and analyze the interview transcripts word by word and sentence by sentence. Under the guidance of XJ (a clinical and counseling psychology professor), the research team completed all data analysis work. In addition to MG and WW, the team members included two doctoral students who are also full-time university psychological counselors and two master’s students specializing in mental health education.

The data analysis was conducted using thematic analysis [ 55 ]. The steps are as follows: first, the researcher transcribed each of the digitally recorded interviews, immersed within the data, and repeatedly read through the 289,000-word interview transcripts. Second, researchers identified meaningful texts and created open codes. Each meaningful sentence was marked with a “code number,” totaling 1,889. The study used “F” to represent female interviewees and “M” for male participants. The first number represents the interview orders of interviewees; the second number represents the order of the meaningful statements in the interview. For example, “M5-40” represents the 40th word, sentence, or paragraph spoken by the fifth male interviewee. Third, after contemplating the open codes repeatedly, 168 manifestations of mentally healthy college students were derived through initial coding. These manifestations were then summarized to establish 18 characteristics of psychologically healthy university students via focused coding. Subsequently, these 18 characteristics were further classified through core coding to derive five main themes. Fourth, we checked the themes and adjusted their structure until they met internal homogeneity and external heterogeneity criteria. Fifth, we defined and named the themes; 18 characteristics were obtained and coded into five themes.

The Delphi expert evaluation

Subsequently, three experts were invited to assess the appropriateness of naming, defining, and classifying the identified 18 characteristics and five themes above. These experts are professors in clinical and counseling psychology from institutions such as Beijing University of Chinese Medicine, with in-depth research in Chinese culture and mental health. They have published numerous related monographs and academic papers, such as “When Psychological Counseling Meets Traditional Culture” and “Mind Operations in Meditation.”

The evaluation comprised two rounds. The first round involved a focused group interview where the three experts individually reviewed each theme, characteristic, and original interview data, offering suggestions for revision. They generally approved of the theme divisions and most characteristics, with two main modifications: 1) the integration and categorization of specific characteristics, such as the initial characteristic “Having a pleasant disposition,” which was deemed by experts to contribute to a comfortable interpersonal state and thus was incorporated into “Interpersonal harmony and comfort.” 2) Adjustments to specific nomenclature, such as refining “Showing filial respect to parents” to “Showing filial respect to parents appropriately” to better emphasize the nuance of the characteristic.

The revised results were resent to the three experts for a second round of evaluation, leading to a consensus with no further modifications suggested, thus finalizing the research findings.

The trustworthiness of the data

Trustworthiness was achieved in several ways.

First, to minimize personal biases to the greatest extent possible, the researchers continuously reflect at each stage of the research project, remaining attentive to the influence of their own experiences and biases throughout all research and analysis phases. For instance, MG utilized a reflective journal [ 56 ] to document personal perspectives after each interview, consistently reminding herself to avoid preconceived notions.

Second, the selection of participants considered factors that might influence college students to develop different understandings of Chinese cultures to ensure the diversity of the participants. And, the total number of participants was determined based on thematic saturation [ 53 , 54 ]. In this study, after interviewing the F8(the 14th interviewee), no new significant themes emerged. Then, three more interviews were conducted (F9, F10, M7), and no significant themes emerged with the new respondents.

Third, the research performed investigator triangulation [ 57 ]. Independent researchers completed comparative analyses of individual findings, organized regular research team meetings to compare the analyses, and identified relevant themes. Moreover, XJ frequently reviewed interviews conducted by MG, her reactions to interviews, and the formulation of results. All the researchers discussed the coding and the corresponding original text until a consensus was obtained to bolster the study’s credibility and dependability.

Fourth, external audits are conducted to foster the accuracy or validity of a research study [ 57 ]. The research invited three experts above who have made achievements in Chinese culture and mental health to assess the appropriateness of naming, defining, and classifying the characteristics and themes in order to enhance the reliability of research findings.

College students’ understanding of Chinese culture

The interviewees’ understanding of Chinese culture was focused on the following four main aspects, and the participant’s identifier follows quotations.

Firstly, Chinese culture is undoubtedly distinct from other countries. For example, F1 believes that “Chinese culture is not just some fixed dynasties in history, or language, or what some literati or educators or some people said, it refers to some patterns of behavior or some ideas that distinguish people from other countries” (F1-66) and is unique to China (M3-110).

Secondly, Chinese culture includes both traditional and modern Chinese new cultures (e.g., revolutionary spirit, M2-95, M4-151, M7-85). Moreover, it is argued that Chinese culture is the essence of what has been left behind through history, including all aspects that have been handed down from ancient times to the present (M1-99; M5-128), and that it is a continuous transmission (F2-72, F4-92, F5-170, F7-137; F9-181; M6-132) and a fusion of the old and the new (F7-142). Chinese culture is implicitly formed and constantly influences and permeates everyone or their lives (F3-134; F7-138; M1-102; M3-111).

Thirdly, Chinese culture is a macro concept, encompassing both intangible and physical aspects. Intangible aspects include thoughts, spirits, and qualities (M2-95, M4-151, M5-131). The physical component includes not only literary works such as poetry (as perceived by all respondents) but also Chinese language and writing (Chinese characters, F2-75; oracle bone inscriptions, F9-184; calligraphy, F2-77, F5-170, F8-94), architecture (F3-148; F10-98), costume (F3-141; F10-101), and folkloric performances (drama, F2 -74; shadow puppets, F5-168; martial arts, F7-141), gastronomy (M5-132), art (painting, F8-93; paper-cutting, M1-100, M2-96, F5-169; china, M2-97; F2-75), traditional festivals and customs (M3-107; F3-138; F5-166; F7-140; F0-97. M7-87) and many others.

Fourthly, some important historical and modern figures mainly reflect Chinese culture’s ideological and spiritual aspects. For example, the famous statesman and literary figure Wen Tianxiang of the late Southern Song dynasty, whose poems “Everyone must die; let me but leave a loyal heart shining in the pages of history books” showed the interviewees his righteousness (M4-122), resilient, his moral integrity (F6-77), and his fearlessness in dedicating his life to his country (M2-72). There is also Zhou Enlai’s ambitious pursuit of “Reading for the rise of China” (M4-62), Mao Zedong’s sense of family and country and the importance he attached to learning (M5-43), and Qian Xuesen’s strict demands on himself during his research (M4-126). The interviewees also made many references to literary figures, such as Li Bai, a poet of the Tang dynasty, whom several interviewees mentioned for his free and ease in the face of frustration (M2-92, M6-30), and his ability to show his spontaneous side in life and learn things spontaneously(M5-54). As well as the ambition of Du Fu showed in his poem “When you are standing on the peak, you are on top of the world” (M5-36), and his sense of responsibility (M1-91, F3-56) reflected in his other poem, “To Emperor Yao and Shun, and to make the customs simple again” (M1-91, F3-56). They also talked about Su Shi’s open-mindedness (F8-79; M6-9) and cheerfulness (M5-29) in the face of adversity, who is a famous poet, calligrapher, gourmet, and hydraulic expert in the Northern Song Dynasty; and also the inner peace(M6-15) and indifference (F3-53) of Tao Yuanming (a famous idyllic poet in the Eastern Jin Dynasty) from his poem “I pick fence side asters at will; carefree I see the southern hill,” and so on.

In addition, the spirit of Chinese culture is also reflected in some allusions and some historical events in ancient and modern times, for example, “Mencius’ mother moves her home three times to better her son’s education” (F1-60), “Che Yin makes use of the light of fireflies or the reflected light by the snow to study” and “Kuang Heng dug a small hole on the wall in order to get some light from the neighbor’s house to read books” (F1-61; F8-34). These allusions convey the importance of studying hard even when conditions are limited. Also, the revolutionary spirit of the May Fourth Movement shows that young people are not afraid of sacrifice (M4-29), and the New Democratic and Industrial Revolution embodied the unity of the Chinese people (M7-91).

Characteristics of mentally healthy college students based on Chinese culture

There are eighteen characteristics of mentally healthy college students based on participants’ understanding of Chinese culture as described above, which is coded into five core themes: (1) value pursuit, (2) life attitude, (3) interpersonal ideal, (4) behavior ability, and (5) self-cultivation. It can be seen that the vast majority of the mental health characteristics reflect traditional Chinese culture, which is constantly being passed down and changed, with the remainder reflecting the influence of modern Chinese culture. The five themes and corresponding characteristics are shown in Table  2 . The results are presented below, and the participant’s identifier follows quotations.

Value pursuit

Value pursuit refers to an individual’s understanding and practice of life ideals and beliefs after integrating social consciousness, such as worldview, life view, and values. Participants described that mentally healthy college students based on Chinese culture have strong beliefs and goal pursuits of contributing to the motherland. They exhibit profound loyalty towards their motherland, viewing its service as their sacred duty, and are steadfast in their resolve to contribute through bold exploration, even in the face of daunting challenges or the prospect of personal sacrifice. This theme directly reflects the Chinese Confucian culture of “Self-cultivation is the starting point of several steps moving outward. The next step is managing family affairs, followed by governing the state. The final step is moving to provide peace and sound governance to all under heaven” and “To be the first in the country to worry about the affairs of the state and the last to enjoy oneself.” The following three subthemes were identified regarding students’ value pursuit.

(1) Loving their motherland and identifying with their culture

First and foremost, mentally healthy college students love their country and are firmly convinced that they want to identify with it. Twelve interviewees emphasize that mentally healthy college students should embody love for their country, cultural identification, and a profound sense of belonging and national pride. On the one hand, they are patriotic and loyal to their motherland and have high moral characters. For example, one participant said, “ like the patriotism in Yue Fei (a famous military man, strategist, calligrapher, poet, and national hero in Chinese history, and was the first of the Four generals rebuilding the Song dynasty). His patriotism and loyalty are also what a mentally healthy college student should have ” (#M6-54).

On the other hand, they identify with the country, nation, and culture from the heart and are proud of the motherland. Another participant said, “ Mentally healthy college students should have a real sense of cultural identity. Furthermore, a Chinese should identify with the traditional Chinese culture …… ” (#F3-110).

(2) Having a sense of responsibility and mission and being willing to dedicate oneself to the country at any time

In addition, mentally healthy college students have a firm sense of mission and responsibility to the motherland. Ten interviewees assert that mentally healthy college students should exhibit a sense of national responsibility, ambitious aspirations, and a readiness to devote themselves to their homeland wholeheartedly. Mentally healthy college students should have ambitious ambitions. As M1-75 said: “ ‘To ordain conscience for Heaven and Earth, to secure life and fortune for the populace, to carry on lost teachings of ancient sages, to build peace for posterity’ (Zhang Zai: Heng Qu Yi Shuo), which can also reflect the looks of a mentally healthy college student. ”

The most important thing is to be willing to contribute to their motherland, even at the expense of oneself. Another participant said, “ Mentally healthy college students do not think about personal gains and losses too much but put their country and nation before themselves, ……, ‘Death is not my concern should it benefit the country. How can I pick and choose for my loss or gains?’ (Lin Zexu) …… ” (#M7-22).

(3) Daring to criticize, explore, and innovate

At the same time, mentally healthy college students have the quest and conviction to keep climbing to the top. Sixteen interviewees believe that mentally healthy college students are enterprising, daring to criticize, explore, and innovate to contribute to their country’s development. Mentally healthy college students are active, enterprising, and have goals and plans. One participant said, “ I think mentally healthy college students should have goals and plans for themselves ” (#M6-3). They also have critical thinking and exploratory spirit and will keep innovating. As F7 said, “ If you are a mentally healthy college student, you also need some innovative spirit to break through …… ” (#F7-59). Also, they are willing to explore and contribute to the country’s development, as M4 said: “ Mentally healthy college students should be like Qian Xuesen (also known as Tsien Hsue-she), who has a strong spirit of patriotism. He devoted himself to scientific research, and after countless attempts and explorations, he finally launched the first atomic bomb for China …… ” (#M4-124).

Life Attitude

Life attitude is an individual’s understanding and reaction to things that happen in daily life. Participants highlighted that maintaining a positive, optimistic, dialectical, and open-minded stance towards setbacks and challenges is a key characteristic of mentally healthy college students. This theme directly reflects Chinese culture: “Someday, with my sail piercing the clouds, I will mount the wind, break the waves, and traverse the vast, rolling sea.” and “It is blessed to suffer losses.” The following four subthemes regarding students’ life attitudes were identified.

(1) Loving life and being positive

Mentally healthy college students hold positive attitudes about life. Fourteen interviewees believe that mentally healthy college students exhibit optimistic attitudes toward life. Mentally healthy college students approach life optimistically, viewing it as brimming with hope. As F9 mentioned, “ I think I am mentally healthy because I am quite positive and optimistic about life, and I will face it positively even if there are some bad things ” (#F9-149). Moreover, they love life and experience life from their heart, “ I think mentally healthy college students can live a good life. Particularly, they can still maintain a love for life, have something they want to do, have the energy to fight or to live. ” (#M2-2). They always think life is full of meaning. As F1 said, “ I think some of the cases (of mental ill health) are because they have lost hope in life and do not want to do anything ” (#F1-47).

(2) Staying positive and having the ability and quality to cope with hardships

Mentally healthy college students possess a positive attitude towards suffering and setbacks. All interviewees believe that mentally healthy college students have a positive view and the qualities of coping with suffering when facing life difficulties. They will not shy away from adversity; instead, they proactively address issues, surmount obstacles, and manage them with composure. When facing difficulties or setbacks, mentally healthy college students maintain constructive beliefs. As one participant said: “ ‘Just as heaven keeps moving forward vigorously, a man of virtue should strive continuously to strengthen himself’ (The Change of Book). And ‘When Heaven intends to confer a great responsibility upon a person, it first visits his mind and will with suffering, toils his sinews and bones, subjects his body to hunger, exposes him to poverty and confounds his projects. Through this, his mind is stimulated, his nature strengthened, and his inadequacies repaired’ (Mencius). A mentally healthy college student should be like as described in these statements. ” (#F9-25).

They also exhibit the qualities to cope with hardships, such as striving continuously to strengthen themselves, being indomitable, resilient, enterprising, and so on. “ I think indomitable also reflects the self-control mentioned earlier, that is, they will not give up even after experiencing more difficulties ” (#M4-136).

Furthermore, they can analyze and resolve problems amid adversity and challenges, effectively overcoming them. “ For a long time, when my friends and I encounter setbacks, crises, or challenges, I always use this phrase to encourage myself and others to handle it calmly, ‘to be unchanged in front of the collapse of the mountain Tai, and to face danger without being surprised when it suddenly comes in front of you.’ ” (#M7-6).

(3) Being flexible and dialectical

Mentally healthy college students have a dialectical attitude towards life. Ten interviewees noted that mentally healthy college students demonstrate critical thinking skills by approaching situations objectively, comprehensively, and dialectically. These dialectical concepts, attitudes, and behaviors when facing negative things in life are also characteristics of mentally healthy college students. One participant said, “ Mentally healthy college students should be as objective and comprehensive as possible when dealing with things ” (#F3-118). They do not dwell on the present and have a positive attitude toward the future, “ There are plenty of fish in the sea. Do not miss the whole forest because of a tree. Even if you are sad about a breakup, do not cling to the past, but try to live a new life ” (#M7-12).

Furthermore, they think dialectically and believe that all sufferings have its reward. As F1 said: “ A saying goes that ‘Someday This Pain Will Be Useful to You,’ which means that it is not always bad to suffer Loss; think long term. For example, one may sometimes feel that their interests are being threatened in interpersonal relationships. However, if they are particularly concerned about this, it will make them uncomfortable, while if they are generous or forgiving, their heart will become more open ” (#F1-24).

(4) Being inclusive and broad-minded

Mentally healthy college students have an open-minded attitude toward life. Sixteen interviewees believe mentally healthy college students are tolerant, broad-minded, and open-minded. Both for themselves and others, mentally healthy college students hold tolerant attitudes. A participant said, “ I may lack a little tolerance for others because I am always strict with myself, so I may sometimes be strict with others. So, from this point of view, I think my mental health level needs to be further improved ” (#M2-79). They are broad-minded (“ Be magnanimous, as the saying goes, ‘A prime minister’s mind should be broad enough for poling a boat,’ which is a sign of college students’ mental health, advising people to look at whatever things a little more openly ”, #F6-34).

Moreover, even in the face of life’s misfortunes, they are also very liberal and open-minded, able to accept them openly. As M6 mentioned, “ One should also have positive and healthy perceptions. Su Shi, a famous poet, calligrapher, gourmet, and hydraulic expert in the Northern Song Dynasty, openly accepted the fact that he was deprived of his official position. Instead of being depressed daily, he lived an easy and interesting life, free and relaxed ” (#M6-9).

Interpersonal ideal

Interpersonal ideals refer to the pursuit and aspiration of individuals to achieve the best in interpersonal communication and good relationships. According to these interviewees, the characteristics of mentally healthy college students can be divided into general and specific interpersonal relationships. Regarding general interpersonal relationships, mentally healthy college students are friendly and kind, and their interactions with others are harmonious and comfortable. When navigating specific relationships like those with parents, they are filial but have rational thinking; in terms of friendship and romantic partnerships, they pursue ideal and pure relationships. This theme is a direct reflection of Chinese culture: “benevolence,” “harmony is precious,” “The relations between men of virtue are plain like water,” “filial piety,” and so on. The following four subthemes were identified regarding students’ interpersonal ideals.

1） Being benevolent and kind

Mentally healthy college students are benevolent and kind in their interactions with others. Thirteen interviewees believe mentally healthy college students are kind-hearted, compassionate, sincere, caring, and helping others without discrimination. Mentally healthy college students are benevolent and have compassion for others; as M7 mentioned, “ When I met beggars on the road, …… whether they are pretending or be, I am always willing to give them some money…… ” (#M7-54). They are kind-hearted (“ I think a person should be at least kind-hearted; he may have that kind of empathy inside, have that kind of emotion for either other people or animals, ……, and have a softer heart, which also reflects the mental health of college students ,” #F6-45). They treat people gently and friendly (“ Laozi and Confucius look gentler than others, I feel that this characteristic in them also indicates the mental health of college students ,” #M3-73).

Furthermore, they are helpful and kind to others. As one participant said, “ Imagine this: You’re in a crowd, and a bike tumbles to the ground. Everyone is looking around, unsure of what happened. Now, you’re caught in a bind: Should you lend a hand or stay back to avoid being wrongly accused? Despite the chance of misunderstanding, I feel it’s crucial to step up and help. Ignoring the situation just doesn’t sit right with me—it goes against everything I believe in. ” (#F5-161).

2） Interpersonal harmony and comfort

Mentally healthy college students have a harmonious and comfortable interpersonal state. All interviewees agree that mentally healthy college students exhibit pleasant character and interpersonal adeptness, adhere to fundamental Chinese cultural values, and maintain a more harmonious and comfortable relational environment compared to their peers. Mentally healthy college students experience interpersonal harmony and comfort; one interviewee said, “ A mentally healthy college student has better interpersonal relationships, ……and has a comfortable social state ” (#F1-17). In interpersonal interaction, they prioritize harmony (“ I quite agree with the saying ‘Peace is of paramount importance. Since we are studying together, it is important to take care of each other and try to understand each other ”, #M3-49). Besides, they have good interpersonal interactions (“ ones’ mental health, I think, also shows more in whether they can deal with interpersonal relationships with people around them, …… whatever kind of people may meet, they can deal with the relationship well ”, #F6-9).

Moreover, they appreciate others (“ If other people have gained a certain amount of academic achievement, …… if he is (mentally) healthy, he may be happy for others’ success, achievement ”, #M7-33). Also, they can resolve conflicts or contradictions in interpersonal relationships (“ There is no perfect person; for example, if they cause harm to others, they can recognize their mistakes and apologize timely and honestly ,” #M6-101).

Furthermore, they follow many guidelines to create a harmonious and comfortable interpersonal state. As F3 mentioned, “ I think, when it comes to some unimportant things, it is important not to bother others like that…… one should have the sense of proportion ” (#F3-39).

3） Having a soul mate

Mentally healthy college students seek to have a soul mate in specific friendships or romantic partnerships. Nine interviewees suggest that mentally healthy college students possess the ability and quality to communicate and empathize with others on a deep spiritual level and form corresponding friendships or romantic relationships. Whether in friendship or romantic relationships, mentally healthy college students have the correct attitude toward interaction, as F8 said, “ For example, Zeng Gong and Wang Anshi (both politicians of the Northern Song Dynasty), …… They become good friends for life not based on interests, but on their appreciation of each other, and the same values, which I think mental health of college students should always be ” (#F8-67).

They emphasize the spiritual level of communication more than pursuing each other’s company. They have a more high-quality and pure relationship, in friendship or romantic relationships. As F6 said: “ ‘The friendship of a noble person is as pure as water.’ (Chuang-Tzu). Put simply, relationships should be genuine and straightforward, free from fame-seeking or ulterior motives; Just like the story of Boya and Ziqi, mentally healthy students might find a companion who truly gets them, connecting on a spiritual and empathetic level…… ” (#F6-38). It is the same with romantic relationships, as M6 mentioned, “ When you read the poem of Su Shi, for example, ‘Ten years parted, one living, one dead; Not thinking; Yet never forgetting; A thousand Li from her lonely grave; I have nowhere to tell my grief……’ The affection between him and his wife is so deep that it is enviable ” (#M6-42).

4） Showing filial respect to parents appropriately

Mentally healthy college students have rational conceptions of filial piety towards their parents and appropriate, respectful behavior. Eleven interviewees believe mentally healthy college students are filial and rational in their interactions with their parents. Mentally healthy college students show filial piety to their parents appropriately. On the one hand, they practice filial piety by accompanying their parents, communicating more with them, caring for them, repaying them, and so on. As F5 mentioned, “ ‘Our bodies—to every hair and bit of skin—are received by us from our parents’ (Xiao Jing). Mentally healthy college students are grateful and respectful, often care for their parents, and spend more time with them ” (#F5-109).

On the other hand, they also have rational thinking rather than unprincipled obedience regarding filial piety’s “cognition” aspect. As one participant said, “ Not just any kind of filial piety, that is, you should have your thinking and judgment…… ” (#F3-105). Another participant said, “ Proper filial piety is an aspect of college students’ mental health, not that they are obedient to their parents. When they disagree with parents, they can communicate more with parents and let themselves be understood ” (#M5-102).

Behavior ability

Behavior ability refers to the ability of an individual to behave appropriately. According to these interviewees, mentally healthy college students have a variety of behavioral abilities, such as adapting to different environments, learning well, and regulating their emotions. This theme directly reflects the Chinese culture: “Those who obey heaven survive, and those who defy heaven perish,” “learn without thinking is reckless, think without learning is dangerous,” and “When joy, anger, sorrow, and happiness are not yet expressed as a response to other things, they are in a state of balance. When they are expressed in words and deeds by the rites, harmony is achieved. “The following three subthemes were identified regarding students’ behavior ability.

(1) Adapting to the environment

Mentally healthy college students can adapt to the environment. Seven interviewees believe that mentally healthy college students can adapt to different environments. Adaptability is reflected on the one hand in the interpersonal aspects (“ There is also the adaptation to the university environment. Mentally healthy college students can integrate into groups and clubs, and actively participate in club activities ”, #F2-16). Also, they can adapt to different environments (“ I think social adaptability is quite important…… I went to work part-time this summer, but I feel that I have just been exposed to it ”, #F9-10). Moreover, they also show adaptability to adversity (“ I think mentally healthy college students also can adapt to adversity…… ”, #M5-70).

(2) Studying diligently and learning well

Mentally healthy college students can learn well. Thirteen interviewees suggest that mentally healthy college students exhibit a positive learning attitude, take ownership of their learning, maintain a continuous learning process, and demonstrate good study habits. They learn earnestly and diligently and have good learning attitudes (“ College students with good mental health will keep learning, have the initiative to learn, down-to-earth. Moreover, if they work by fits and starts (Cao Xueqin: The Dream of Red Mansions), there will not be a good result ”, #F5-64).

They also actively take responsibility for learning. As F10 said, “ Responsibility is fundamental. The primary task for students is studying. One should stay in one’s lane ” (#F10-83). Besides, they are good at learning (“ I think Lu Xun, who gave up medicine to pursue literature, …… has a powerful ability to learn ”, #F9-71). In addition, they study diligently and accumulate knowledge. As M2 mentioned, “ Since I have to prepare for the entrance examination, I have to memorize words and take lessons every day. That is, ‘But unless you pile up little steps, you can never journey a thousand li; unless you pile up tiny streams, you can never make a river or a sea.’ (Hsun-Tzu: Encouraging Learning), …… I realized that what I do daily is important ”, #M2-93).

(3) Being emotionally appropriate and can regulate emotions

Mentally healthy college students can regulate and manage their emotions. Nine interviewees posit that mentally healthy students display emotional appropriateness and stability, promptly and effectively managing their emotions. Emotions are often regarded as the signal light of mental health. Thus, mentally healthy college students are emotionally appropriate and relatively stable, “ A mentally healthy college student should be emotionally stable, …… ‘The master was mild, and yet dignified; majestic, and yet not fierce; respectful, and yet easy’ (The Analects). One should have a suitable emotion in which state ” (#F3-78).

Moreover, when encountering adverse events, they have the ability to regulate their emotions. As one participant mentioned, “ A mentally healthy college student can control his emotions and regulate his emotions ” (#F6-1). At the same time, they can adjust themselves in appropriate and healthy ways in time, “ when he meets some bad things, he can just communicate with others, exercise…… instead of drinking or even hurting himself ” (#F8-10).

Self-cultivation

Self-cultivation refers to the inner quality or state an individual constantly improves or achieves through long-term efforts and cultivation. According to the interviewees, mentally healthy college students advocate the continuous improvement of self-cultivation. They try to possess many excellent qualities of Confucianism, Buddhism, and Taoism and perfect them daily by having clear and objective self-knowledge and constantly reflecting on themselves to improve their cultivation. This is a direct reflection of the Chinese culture of “no end to learning” and “Seeing the virtuous and thinking of the wise, seeing the unwise and introspecting”, and so on. The following four subthemes regarding students’ self-cultivation were identified.

(1) Having an objective, positive perception of oneself and can accept one’s mediocrity

The constant improvement of mentally healthy college students’ self-cultivation first requires a clear perception of oneself. Eleven interviewees believe mentally healthy college students have a positive, comprehensive, and clear understanding of themselves. They know their strengths and weaknesses and can accept their mediocre and weak sides, “ For example, an Olympic weightlifter, he can only lift 50 pounds, but he had to go lift 100 pounds…… A mentally healthy person should clearly understand themselves and do according to one’s abilities… ”, #F8-33). They also have a positive view of themselves, “ ‘All things in their being are good for something’ (Li Bai: Invitation to Wine); one should not think too lightly of themselves when disillusioned. They can certainly play their usefulness in life, cannot improperly belittle oneself ” (#F9-35). Furthermore, they can also accept their mediocrity and weakness, “ I think there is also a significant point, which is to accept their mediocrity gradually…… ” (#F1-8).

(2) Being confident and also modest

The constant improvement of mentally healthy college students’ self-cultivation also requires an objective perception of oneself. Thirteen interviewees believe that mentally healthy college students are confident and able to stick to what they believe is correct while also being modest. According to a participant, mentally healthy college students believe in themselves, “ This point of believing in oneself in Qian Xuesen is probably also what a mentally healthy college student should have…… ”, #M4-128). They are assertive and can stand firm on their ideas (“ When faced with two choices, mentally healthy college students listen to others’ opinions and at the same time stick to their ow n,” #F4-77). At the same time, they are also modest (“ A saying goes that, ‘Modesty helps one go forward, whereas conceit makes one lag.’ In my opinion, mentally healthy students may not be so proud of themselves……”, #F5-36). Furthermore, they are not overly confident or modest (“Both confidence and modesty in a mentally healthy college student are appropriate and balanced, that is, I think it is necessary to be confident but also modest……, ” #F7-109).

(3) Focusing on introspection and contemplation to align with the sages

Mentally healthy college students improve themselves through constant introspection. Ten interviewees believe mentally healthy college students focus on introspection and are strict with themselves. They constantly check the gaps to seek progress and expand their horizon. Specifically, mentally healthy college students often reflect on themselves (“ ‘I daily examine myself on three points……’ (The Analects) which I think reflects the mental health of college students, that is, whether you are doing your best in the team…… ”, F2-35). They are also strict with themselves, “ As the sayings go, ‘You cannot expect a better world without cleaning your room first,’ although Du Fu (a famous poet of the Tang Dynasty) is said to be very talented, if one cannot do small things well, like cleaning the house, he can do nothing else well ” (#M5-52).

Moreover, they make constant progress and look to the virtuous, “ ‘When you see a person of virtue and capability, you should think of emulating and equaling the person; when you see a person of low caliber, you should reflect on your weak points’ (The Analects). Mentally healthy people also constantly learn from the strengths of others and reflect on their weaknesses ” (#M2-34).

(4) Possessing good qualities advocated by Confucianism, Buddhism, and Taoism, which coexist harmoniously

The highest level of self-cultivation for mentally healthy college students is to possess many good qualities of Confucianism, Buddhism, and Taoism, which together become the characteristics of mentally healthy college students. Sixteen interviewees suggest that mentally healthy college students exhibit strong moral characteristics and virtues from Confucianism, Buddhism, and Taoism, all coexisting harmoniously. Mentally healthy college students have the excellent qualities of Taoism, such as being calm and bland, indifferent to fame and fortune, and peaceful and happy. As the participants said, “ This sense of ordinariness, which I think may also be a necessity for mental health…… ” (#F7- 34); “ Mentally healthy college students are calm and relaxed, take the rough with the smooth; they have confidence in themselves and take it easy ” (#M7-35).

Moreover, they have the excellent virtues of Confucianism, such as benevolence, righteousness, rites, wisdom, and good faith. As F3 said, “ Mentally healthy college students must be good in these virtues, like ‘loyalty, filial piety, rites, wisdom, good faith, and courage’…… ” (#F3-90). Another participant mentioned, “ After comparing so many fictional characters, it is hard for me to use words to describe him (Qiao Feng), …… very filial and loyal, very righteous, …… doing things very fairly, … … ”, #M6-59).

Besides, they also obtain the main qualities of Buddhism, such as gratitude and kindness (“ ‘Moral character can be built by accumulating goodness’ (Hsun-Tzu: Encouraging Learning). A mentally healthy college student does good deeds, such as attending activities as a volunteer…… ” #F2-30). As F9 said, “ Also, mentally healthy college students often remember others’ kindness and are grateful, and then be nice to others, as the saying goes, ‘You throw a peach to me, I give you a white jade for friendship.’ (The Book of Songs) ”, #F9 -112).

The study identified five themes and 18 characteristics of mentally healthy college students within Chinese culture. These characteristics are deeply rooted in Chinese traditions, highlighting yin-yang balance and moral cultivation. They related closely to college students’ identity, learning stage, and age. Contrasting with characteristics of other cultural backgrounds, they showcase the impact of Chinese culture on college students, validating and expanding the theory of sociocultural models.

Comparison with previous studies

Firstly, compared to existing research on the characteristics of mentally healthy college students, this study presents novel findings and unique insights. Consistent with other related studies rooted in Chinese culture, both this study and previous research accentuate that the characteristics of mentally healthy college students encompass facets such as self-awareness, interpersonal relationships, emotional regulation, and positive learning traits. For instance, Wang (1992) posited that mentally healthy college students exhibit characteristics focusing on self-awareness, interpersonal adeptness, and emotional regulation [ 32 ]. Similarly, Zeng (2021) described the characteristics of mentally healthy college students, highlighting their emotional state, academic performance, and interpersonal skills [ 33 ].

Some characteristics revealed in our study diverge from those proposed in prior research concerning their specific connotations. Taking emotional regulation as an example, the research of Zeng (2021) and Wang (1992) primarily emphasized affirming positive emotions. They depicted mentally healthy college students as “positively emotional and controllable” or “possess the capacity to coordinate and manage emotions effectively, sustaining a positive mood.” In contrast, the characteristic identified in this study of “being emotionally appropriate and can regulate emotions” not only encompasses positive emotions but also includes negative feelings, emphasizing the timely and moderate expression of both. This directly reflects the Confucian concept of “Zhongyong” (doctrine of the mean) in Chinese culture, which advocates for moderation in all things, whether positive or negative. Therefore, it is evident that college students’ mental health is closely intertwined with the concept of moderation. Individuals can achieve mental health in various aspects by expressing emotions moderately, whether positive or negative.

Furthermore, this study has identified characteristics not previously mentioned by Chinese scholars, such as “showing filial respect to parents appropriately.” Filial piety is a unique social behavior within Chinese culture, embodying a comprehensive and intricate ethical framework [ 58 ]. Chinese society dramatically emphasizes family values, where treating parents well and acknowledging their upbringing is paramount. Therefore, if one is not filial, one cannot be said to be mentally healthy. However, with the evolution of societal norms, the essence of filial piety has transformed. Recent research reveals that contemporary society no longer adheres to traditional interpretations of filial piety solely through obedience to parents [ 59 ]. This shift signifies that mentally healthy college students now approach filial piety differently, manifesting altered perspectives, attitudes, and behaviors toward this concept. In ancient China, departing from one’s hometown to pursue education and personal growth was discouraged, as staying by one’s parents’ side was deemed the epitome of filial piety. As Confucius stated, “While the father and mother are living, do not wander afar” ( The Analects ). However, today, individuals are encouraged to venture afar to contribute meaningfully to their country and society [ 60 ]. As a result, modern manifestations of filial piety among mentally healthy college students involve not just reverence, care, and support for their parents but also underscore the significance of preserving autonomy and independence while fulfilling their familial duties.

Secondly, upon comparing our findings with research from other cultural backgrounds, it becomes apparent that our results diverge significantly from those of Western culture but align closely with research outcomes from Africa and Asia.

In the West, the understanding of mental health emphasizes enhancing personal belonging, satisfaction, and well-being, which is very different from Chinese culture, which emphasizes self-sacrifice and self-elimination [ 61 ]. Although this study was conducted in a qualitative study of a group of college students in very good mental health, a research perspective similar to Maslow’s research on self-actualizers, there were significant differences in the specific characteristics of these healthy individuals in different cultures. In particular, this study did not address the characteristics of self-actualizers noted by Maslow, such as “the mystic experience: the peak experience” and “philosophical, unhostile sense of humor,” which emphasize excellent personal features. The characteristics identified from this study emphasize individuals’ relationships with the country and family. Such as “loving their motherland and identifying with their culture,” “having a sense of responsibility and mission and being willing to dedicate oneself to the country at any time,” and “Showing filial respect to parents appropriately.” These characteristics are the direct expression of Chinese culture in terms of devoting oneself to the country and being filial to parents, which were not found in the results of Maslow’s study.

On the other hand, this study aligns more closely with research findings from African and Asian cultural backgrounds. For example, in the view of caregivers in Africa and Asia, mentally healthy individuals are people who contribute to the community and spend an enjoyable time in groups [ 28 ]. Thus, college students with good mental health can meet precise requirements at different levels: the individual and others, the individual and the family, and the individual and the nation, which is more of a relationship-oriented “big self” [ 62 ].

Thirdly, this research’s findings correspond with certain facets of the 24 character strengths and 6 virtues outlined in positive psychology, yet they also reveal disparities in specific aspects.

With the burgeoning of the positive psychology movement, some researchers have suggested that people with good mental health are not articulated merely as the absence of mental illness but as people who possess positive qualities, such as being highly resilient and well-being [ 63 ]. Seligman and colleagues summarized 6 virtues and 24 character strengths contributing to a good life [ 64 ], which have garnered wide attention. A point of convergence is that some positive psychological qualities emphasized by the characteristics identified in this study align with those highlighted in positive psychology. For instance, the characteristic of “being benevolent and kind” identified in this study emphasizes that mentally healthy college students are compassionate and kind. Similarly, one of the 6 virtues in positive psychology is humanity, which also focuses on kindness.

Nonetheless, notable distinctions exist between this study and the character strengths or virtues proposed by positive psychology. Firstly, in terms of the connotation of similar qualities, there are variations between the two. For example, the quality of “modesty” as a traditional Chinese virtue holds different implications than the Western perspective on “humility.” Modesty in Chinese culture carries much richer connotations than in the West, and core characteristics such as being open-minded, down-to-earth, and striving for improvement are unique to Chinese culture [ 65 ]. Additionally, while positive psychology views humility as an important but standalone character strength, this study found that mentally healthy college students are “being confident and also modest,” with modesty and confidence blending and coexisting harmoniously. This aligns with the encouragement of self-esteem, confidence, and self-improvement among the younger generation in China in recent years [ 66 ]. However, Chinese people still highly value modesty as a virtue while simultaneously emphasizing confidence. These seemingly contradictory qualities of confidence and modesty are valued, reflecting the dynamic balance of “yin and yang” in Chinese culture [ 67 ].

More importantly, this study has uncovered additional positive qualities beyond the 24 character strengths, such as “being inclusive and broad-minded”.These qualities carry strong moral attributes; in other words, possessing these moral qualities is essential for mental health. Confucianism emphasizes social morality, self-cultivation, and the development of a gentleman-like sage personality [ 68 ]. Self-cultivation is the basis for the ethical construction of family and society to perfect the ideal personality of governing the state and pacifying the world. The concept of “sageliness within and kingliness without” underscores this philosophy [ 69 ]. The characteristic “being inclusive and broad-minded” implies that mentally healthy college students exhibit tolerant and open-minded attitudes, embracing the principles of “Harmony, but Not Uniformity” and “The sea admits hundreds of rivers for its capacity to hold”(Chinese idioms) when encountering diverse viewpoints or adversity. Therefore, a mentally healthy college student possesses virtues such as tolerance and open-mindedness, showcasing solid moral values. In essence, college students’ mental health is intertwined with their moral attributes. A mentally healthy individual must embody essential moral qualities, which serve as markers of their overall well-being. Acknowledging the significance of moral virtues in defining and nurturing mental health among college students is crucial.

Validation and extension to the theory of sociocultural models

Firstly, this study validates the theory of sociocultural models. On one hand, this study confirms how culture influences individual psychology as proposed in the theory of sociocultural models. In this study, psychological entities represent the characteristics of mentally healthy college students that guide their thoughts, behaviors, and attitudes. According to the findings of this study, Chinese traditional culture plays a significant role in shaping these characteristics. For example, the patriotic sentiments of important historical figures such as Wen Tianxiang and Yue Fei, as well as the thoughts of traditional Chinese culture such as “Death is not my concern should it benefit the country. How can I pick and choose for my loss or gains?” (Lin Zexu: Two poems for family members on the way to the garrison ”) and “To ordain conscience for Heaven and Earth, to secure life and fortune for the populace, to carry on lost teachings of ancient sages, to build peace for posterity’ (Zhang Zai: Heng Qu Yi Shuo ) are internalized in the characteristics of “Having a sense of responsibility and mission and being willing to dedicate oneself to the country at any time.” The country cultivates college students as pillars of talent, and Confucianism teaches “To be the first in the country to worry about the affairs of the state and the last to enjoy oneself.” (Fan Zhongyan: The Yueyang Tower ). Thus, studying is not only for personal development but also for a sense of responsibility and contribution to the country, which arguably demonstrates the mental health characteristics of the specific group of college students with distinct traditional Chinese cultural connotations. Such findings align with the theory of sociocultural models, emphasizing how people internalize societal culture into their psychological entities to regulate their psychological activities.

On the other hand, this study validates how individual psychology externalizes and promotes the generation of new culture as proposed in the theory of sociocultural models. During China’s modernization, people have realized that only by daring to break through the shackles of existing ideas and exploring innovative development opportunities can the country move forward and develop sustainably. Many people have overcome difficulties and carried out the revolution, construction, and innovation in constructing Chinese socialism. Their love for the country and their sense of mission made them always meet the challenges of national reconstruction with high morale and perseverance [ 70 ]. Especially since the reform and opening-up, people’s minds have been fundamentally liberated, and the spring of scientific and technological progress has been ushered in. Their precious spiritual wealth, such as the characteristic of “daring to criticize, explore, and innovate,” has facilitated the development of new cultures like Chinese revolutionary and socialist cultures in modern times. Such findings align with the theory of sociocultural models, highlighting how group members externalize their psychological entities and transform them into new social cultures through social interactions and co-construction with existing social cultures.

Secondly, this study expands the content of the theory of sociocultural models. Due to a lack of specific pathways depicting the interaction between culture and psychology in the theory of sociocultural models, this study found that the significant carriers of interaction between culture and individual psychology are the spiritual world presented by historical and modern figures mentioned by the interviewees, as well as tangible worlds such as Chinese characters, poetry, martial arts, and art. These aspects of Chinese culture are internalized by college students as part of their psychological entities, guiding their words and actions and also shaping their perception of mental health. Conversely, the psychological entities of college students, such as the emergence of new concepts like “daring to criticize, explore, and innovate” in the construction of a new China, are transformed into emerging cultures, such as Chinese socialist culture through the role of figures like Qian Xuesen and stories as carriers.

Strengths, limitations, and future research

This study possesses several strengths. Firstly, it is the first attempt to systematically explore the characteristics of college students’ mental health entirely based on Chinese culture. The 18 identified characteristics directly convey or reflect aspects of Chinese culture, significantly enriching the comprehension of college students’ mental well-being within the context of Chinese culture. Secondly, the study adheres to the elite principle research paradigm by using elite samples as participants. Consequently, the outcomes comprehensively delineate the characteristics of mentally healthy college students possessing an excellent psychological state rooted in Chinese culture. These findings not only provide an ideal model for nurturing mental health among college students but also engender fresh insights into mental well-being, culminating in a novel benchmark for mental health standards. Thirdly, this study delves into the unique characteristics of mentally healthy college students within Chinese culture from the students’ firsthand experiences. In contrast, prior scholars predominantly offered personal opinions on the characteristics of mentally healthy individuals based on their experiences, lacking the direct perspectives of college students.

This study also has some limitations. As a qualitative study, the nature of this research inherently limits the applications of its conclusions. Focused primarily on college students, generalizing the findings to other groups in China (such as civil servants) may be constrained. Moreover, this study exclusively examines Chinese college students without conducting cross-cultural research. The absence of direct comparative studies fails to highlight variations in mentally healthy characteristics across diverse cultures. For instance, the absence of a comparative study between Chinese and students from other cultures (such as American college students) hindered exploration into the distinctive characteristics and differences of mentally healthy college students from varying cultures. Consequently, extrapolating the results of this study to other cultural contexts also has its limitations. Despite some similarities between Chinese culture and certain cultures in Asia and Africa, direct inferences also have significant constraints.

Furthermore, in terms of understanding culture, there is no conclusive definition of what culture is and what Chinese culture is. Scholars have put forward many understandings and definitions of Chinese culture from different perspectives. Understanding and defining Chinese culture are still in the exploratory stage, which challenges this study. The researcher’s understanding and mastery of existing relevant knowledge are somewhat limited regarding the formation of research results and the depth of analysis and discussion.

Future research could consider the following aspects. Firstly, a comparative study of the characteristics of mentally healthy people in different cultural groups can be conducted. Since individualistic/collectivistic cultures influence Americans and Chinese to be more expressive of private selves/collective selves, and religious cultures also influence individual self-esteem [ 71 ] and form religious selves [ 72 ]. Therefore, some comparative studies with students from different cultural backgrounds can be conducted in the future. For example, a comparative study with three groups of college students from the United States, China, and India can be considered to compare whether there are differences in the characteristics of mentally healthy college students from different cultures. Secondly, some quantitative studies can be considered. For example, future research could refine specific characteristics identified in the study, like “being flexible and dialectical,” for more specific operational definitions and develop a scale to measure the mental health of different groups to validate how these characteristics are manifested in university students or other groups so that more further research could be conducted using this new scale, which may help facilitate replication of the findings. Thirdly, based on continuous learning and accumulation of Chinese culture, future research can do in-depth excavation and exploration of the manifestation and nature of these mental health characteristics. For example, future research could select the characteristics reflecting the culture of filial piety or Zhongyong culture and explore how these cultures change and develop into mental health characteristics with the development of science and technology, the change of social structure, and the collision of Chinese and Western cultures, which may also be of great significance.

Practical implications

The Chinese culture has rich treasure resources and cultivated Chinese character traits, characteristics, and lifestyles. The results of this study show that many attitudes, ideas, and behaviors espoused by Chinese culture are manifestations of mental health. In particular, this study found the characteristics of mentally healthy college students based on Chinese culture, which is culturally applicable and more suitable for promoting the mental health of Chinese college students and can provide essential references and bases for mental health education and clinical practice.

On the one hand, this study can provide an overall theoretical framework for developing mental health courses for college students. Mental health courses are the most important and direct form of mental health education for college students in China, and they are also the primary way to improve the psychological quality of college students. The Ministry of Education requires colleges and universities to offer mandatory public courses on mental health for undergraduate students [ 73 ]. However, current mental health courses for Chinese college students rely mainly on Western mental health-related definitions, theories, and techniques for delivery [ 74 , 75 ]. The five themes and 18 characteristics discovered in this study are systematic, providing a comprehensive and systematic theoretical basis for college students’ mental health courses.

In particular, the five themes discovered in this study—values pursuit, life attitude, interpersonal ideals, behavioral ability, and self-cultivation—can be employed as the central pillars for teaching and setting objectives in a college student mental health course rooted in Chinese culture. Furthermore, the 18 identified characteristics can form each lesson’s fundamental content and learning goals, establishing a comprehensive framework. For instance, the characteristics “being confident and also modest” can be one of the key topics under the theme of “self-cultivation.” By comparing Western views of mental health (focused on confidence) with Chinese beliefs (valuing both confidence and modesty) and blending students’ self-awareness with Chinese cultural insights, the course can delve into the importance of confidence and modesty in Chinese culture. Strategies for cultivating these characteristics can be discussed, shedding light on the unique aspects of mental health development among college students within Chinese cultural contexts.

Secondly, this research offers valuable insights for fostering healthy personalities among college students in psychological counseling methods from the perspective of Chinese culture. On the one hand, this study has a guiding significance for setting goals in psychological counseling. Psychological counseling has traditionally emphasized decreasing negative emotions and boosting positive ones. Nevertheless, this study serves as a reminder for counselors to reassess this counseling objective. Throughout the counseling process, counselors should not only focus on diminishing negative emotions but also be wary of potential complications stemming from excessive positive emotions, stressing the importance of a moderate expression of positive and negative emotions.

On the other hand, the discoveries of this study could serve as a wellspring of inspiration for crafting indigenous approaches to psychological counseling. This research reveals that mentally healthy college students possess the characteristic “possessing good qualities advocated by Confucianism, Buddhism, and Taoism coexist harmoniously.” Within Chinese culture, the symbiotic interplay among Confucianism, Buddhism, and Taoism stands out as a cornerstone [ 76 ], where these philosophies coexist compatibly and mutually influence each other in shaping Chinese characters [ 77 ]. Future scholars might devise counseling methodologies rooted in the principle of harmonious coexistence found within Confucianism, Buddhism, and Taoism, potentially empowering individuals to bolster their mental health through these culturally embedded psychological counseling approaches.

This study explores the characteristics of mental health of college students with good psychological states from the perspective of Chinese culture and finds 18 characteristics, based on which five themes are formed: value pursuit, life attitude, interpersonal ideal, behavior ability, and self-cultivation. The 18 characteristics are typical of Chinese culture or its features, focusing on multi-level relationships with others, parents, and the country. They are also typical of Chinese culture with moral attributes, an emphasis on self-cultivation, a balance of Yin and Yang, and the coexistence of Confucianism, Buddhism, and Taoism. These findings help enrich the research on culture and mental health, highlight the Chinese cultural connotations of mental health, and help form an ideal standard of mental health for college students. Findings can serve as a theoretical foundation for improving the mental well-being of Chinese college students, act as a guiding light for enhancing students’ mental health, and be integrated directly into the mental health curriculum as course content. Mental health education activities based on these findings can help promote, maintain, and cultivate college students’ mental health literacy and healthy personalities to fulfill their potential and become the pillars of the nation.

Availability of data and materials

The datasets for this study are not readily available because they consist of interview data, for which confidentiality cannot be safeguarded. Therefore, the data will not be made available. Requests to access the datasets should be directed to XJ, [email protected].

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Acknowledgements

We appreciate Professor Tianjun Liu from Beijing University of Chinese Medicine, Professor Jianjun Zhu, and Professor Ming Li from Beijing Forestry University for their support in assessing the appropriateness of naming, defining, and classifying the 18 characteristics and five themes. We thank our research team and participants who shared their experiences and made this study possible. We thank Dr. Xiaofang Yao at Federation University Australia and Dr. Lixian Tu at Shanghai University of Political Science and Law for their support throughout the English translation.

This study is support by the BIT Research and Innovation Promoting Project (Grant No. 2022YCXY053).

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MG conducted the interviews, analyzed the data and wrote the manuscript under the guidance of XJ. XJ formulated this study and contributed to editing of the manuscript and critical revisions. WW assisted with the writing and editing of the final manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.

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Guo, M., Jia, X. & Wang, W. How would you describe a mentally healthy college student based on Chinese culture? A qualitative research from the perspective of college students. BMC Psychol 12 , 207 (2024). https://doi.org/10.1186/s40359-024-01689-7

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Development of Patient and Caregiver Conceptual Models Investigating the Health-Related Quality of Life Impacts of Malignant Pleural Mesothelioma

• Original Research Article
• Published: 15 April 2024

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• Adam E. J. Gibson 1 ,
• Waqas Ahmed 1 ,
• Louise Longworth 1 ,
• Bryan Bennett 2 ,
• Melinda Daumont 3 &
• Liz Darlison 4  

Malignant pleural mesothelioma (MPM) is a rare and usually fatal malignancy frequently linked to occupational asbestos exposures and associated with poor prognosis and considerable humanistic burden. The study aimed to develop conceptual models of the health-related quality of life (HRQoL) impact on patients with and receiving treatment for MPM, and the burden on their caregivers.

This multi-country study (Australia and United Kingdom) adopted a qualitative methodology to conduct semi-structured, independent interviews with people with MPM ( n = 26), current caregivers ( n = 20), and caregivers of people who had recently died because of MPM ( n = 4). Participants were recruited using a purposive sampling approach and interviews conducted via telephone between January 2021 and January 2022. Transcripts were analysed using thematic analysis and used to construct conceptual models.

Patient analysis yielded four overarching themes: (1) debilitating burden of breathlessness and fatigue; (2) physical mesothelioma symptoms experienced by patients; (3) distress of MPM on the self and family; and (4) treatment is worth ‘having a go’ despite the potential impact on symptoms. Caregiver analysis yielded five core themes: (1) daily life limited by caregiving duties; (2) emotional well-being and the need for support; (3) the relational role shift to caregiver; (4) time spent providing care negatively impacts work and productivity; and (5) positive aspects and outcomes of caregiving.

Conclusions

This study highlights the substantial daily and emotional HRQoL impact that MPM symptoms have on patients and caregivers. Both groups reduced work, productivity, and social and leisure activities. There was evidence of positive HRQoL impacts as a result of immunotherapy and radiotherapy, but less for chemotherapy. Caregiver impacts were intensified during the end-of-life period and persisted following patient death. Evident is a need for increased psychological support, information, and advice for caregivers, increased during the end-of-life period.

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Availability of data and materials

Participant data are not available for distribution due to confidentiality. Interview discussion guide and coding inquiries can be directed to [email protected].

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Acknowledgements

The authors would like to thank the patients and caregivers who participated for their valuable contributions and without whom this research would not have been possible.

This study was funded by Bristol-Myers Squibb.

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Adam E. J. Gibson, Waqas Ahmed & Louise Longworth

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Melinda Daumont

Mesothelioma UK, 235 Loughborough Road, Mountsorrel, Loughborough, Leicestershire, LE12 7AS, UK

Liz Darlison

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Contributions

AG contributed to the conception and design, data acquisition, data analysis, and data interpretation. WA contributed to data analysis and data interpretation. LL, BB, MD, and LD contributed to the conception and design, as well as data interpretation. All authors reviewed the manuscript.

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Correspondence to Adam E. J. Gibson .

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The authors declare no competing interests.

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The study design and conduct were reviewed and received ethical approval prior to commencement by an independent ethical review board, WIRB (WCG IRB, www.wcgirb.com ). All interviewees provided recorded consent to participate and for use of their data in this research and publication.

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Gibson, A.E.J., Ahmed, W., Longworth, L. et al. Development of Patient and Caregiver Conceptual Models Investigating the Health-Related Quality of Life Impacts of Malignant Pleural Mesothelioma. Patient (2024). https://doi.org/10.1007/s40271-024-00690-x

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Accepted : 11 March 2024

Published : 15 April 2024

DOI : https://doi.org/10.1007/s40271-024-00690-x

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