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Background of The Study – Examples and Writing Guide

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Background of The Study

Definition:

Background of the study refers to the context, circumstances, and history that led to the research problem or topic being studied. It provides the reader with a comprehensive understanding of the subject matter and the significance of the study.

The background of the study usually includes a discussion of the relevant literature, the gap in knowledge or understanding, and the research questions or hypotheses to be addressed. It also highlights the importance of the research topic and its potential contributions to the field. A well-written background of the study sets the stage for the research and helps the reader to appreciate the need for the study and its potential significance.

How to Write Background of The Study

Here are some steps to help you write the background of the study:

Identify the Research Problem

Start by identifying the research problem you are trying to address. This problem should be significant and relevant to your field of study.

Provide Context

Once you have identified the research problem, provide some context. This could include the historical, social, or political context of the problem.

Review Literature

Conduct a thorough review of the existing literature on the topic. This will help you understand what has been studied and what gaps exist in the current research.

Identify Research Gap

Based on your literature review, identify the gap in knowledge or understanding that your research aims to address. This gap will be the focus of your research question or hypothesis.

State Objectives

Clearly state the objectives of your research . These should be specific, measurable, achievable, relevant, and time-bound (SMART).

Discuss Significance

Explain the significance of your research. This could include its potential impact on theory , practice, policy, or society.

Finally, summarize the key points of the background of the study. This will help the reader understand the research problem, its context, and its significance.

How to Write Background of The Study in Proposal

The background of the study is an essential part of any proposal as it sets the stage for the research project and provides the context and justification for why the research is needed. Here are the steps to write a compelling background of the study in your proposal:

• Identify the problem: Clearly state the research problem or gap in the current knowledge that you intend to address through your research.
• Provide context: Provide a brief overview of the research area and highlight its significance in the field.
• Review literature: Summarize the relevant literature related to the research problem and provide a critical evaluation of the current state of knowledge.
• Identify gaps : Identify the gaps or limitations in the existing literature and explain how your research will contribute to filling these gaps.
• Justify the study : Explain why your research is important and what practical or theoretical contributions it can make to the field.
• Highlight objectives: Clearly state the objectives of the study and how they relate to the research problem.
• Discuss methodology: Provide an overview of the methodology you will use to collect and analyze data, and explain why it is appropriate for the research problem.
• Conclude : Summarize the key points of the background of the study and explain how they support your research proposal.

How to Write Background of The Study In Thesis

The background of the study is a critical component of a thesis as it provides context for the research problem, rationale for conducting the study, and the significance of the research. Here are some steps to help you write a strong background of the study:

• Identify the research problem : Start by identifying the research problem that your thesis is addressing. What is the issue that you are trying to solve or explore? Be specific and concise in your problem statement.
• Review the literature: Conduct a thorough review of the relevant literature on the topic. This should include scholarly articles, books, and other sources that are directly related to your research question.
• I dentify gaps in the literature: After reviewing the literature, identify any gaps in the existing research. What questions remain unanswered? What areas have not been explored? This will help you to establish the need for your research.
• Establish the significance of the research: Clearly state the significance of your research. Why is it important to address this research problem? What are the potential implications of your research? How will it contribute to the field?
• Provide an overview of the research design: Provide an overview of the research design and methodology that you will be using in your study. This should include a brief explanation of the research approach, data collection methods, and data analysis techniques.
• State the research objectives and research questions: Clearly state the research objectives and research questions that your study aims to answer. These should be specific, measurable, achievable, relevant, and time-bound.
• Summarize the chapter: Summarize the chapter by highlighting the key points and linking them back to the research problem, significance of the study, and research questions.

How to Write Background of The Study in Research Paper

Here are the steps to write the background of the study in a research paper:

• Identify the research problem: Start by identifying the research problem that your study aims to address. This can be a particular issue, a gap in the literature, or a need for further investigation.
• Conduct a literature review: Conduct a thorough literature review to gather information on the topic, identify existing studies, and understand the current state of research. This will help you identify the gap in the literature that your study aims to fill.
• Explain the significance of the study: Explain why your study is important and why it is necessary. This can include the potential impact on the field, the importance to society, or the need to address a particular issue.
• Provide context: Provide context for the research problem by discussing the broader social, economic, or political context that the study is situated in. This can help the reader understand the relevance of the study and its potential implications.
• State the research questions and objectives: State the research questions and objectives that your study aims to address. This will help the reader understand the scope of the study and its purpose.
• Summarize the methodology : Briefly summarize the methodology you used to conduct the study, including the data collection and analysis methods. This can help the reader understand how the study was conducted and its reliability.

Examples of Background of The Study

Here are some examples of the background of the study:

Problem : The prevalence of obesity among children in the United States has reached alarming levels, with nearly one in five children classified as obese.

Significance : Obesity in childhood is associated with numerous negative health outcomes, including increased risk of type 2 diabetes, cardiovascular disease, and certain cancers.

Gap in knowledge : Despite efforts to address the obesity epidemic, rates continue to rise. There is a need for effective interventions that target the unique needs of children and their families.

Problem : The use of antibiotics in agriculture has contributed to the development of antibiotic-resistant bacteria, which poses a significant threat to human health.

Significance : Antibiotic-resistant infections are responsible for thousands of deaths each year and are a major public health concern.

Gap in knowledge: While there is a growing body of research on the use of antibiotics in agriculture, there is still much to be learned about the mechanisms of resistance and the most effective strategies for reducing antibiotic use.

Edxample 3:

Problem : Many low-income communities lack access to healthy food options, leading to high rates of food insecurity and diet-related diseases.

Significance : Poor nutrition is a major contributor to chronic diseases such as obesity, type 2 diabetes, and cardiovascular disease.

Gap in knowledge : While there have been efforts to address food insecurity, there is a need for more research on the barriers to accessing healthy food in low-income communities and effective strategies for increasing access.

Examples of Background of The Study In Research

Here are some real-life examples of how the background of the study can be written in different fields of study:

Example 1 : “There has been a significant increase in the incidence of diabetes in recent years. This has led to an increased demand for effective diabetes management strategies. The purpose of this study is to evaluate the effectiveness of a new diabetes management program in improving patient outcomes.”

Example 2 : “The use of social media has become increasingly prevalent in modern society. Despite its popularity, little is known about the effects of social media use on mental health. This study aims to investigate the relationship between social media use and mental health in young adults.”

Example 3: “Despite significant advancements in cancer treatment, the survival rate for patients with pancreatic cancer remains low. The purpose of this study is to identify potential biomarkers that can be used to improve early detection and treatment of pancreatic cancer.”

Examples of Background of The Study in Proposal

Here are some real-time examples of the background of the study in a proposal:

Example 1 : The prevalence of mental health issues among university students has been increasing over the past decade. This study aims to investigate the causes and impacts of mental health issues on academic performance and wellbeing.

Example 2 : Climate change is a global issue that has significant implications for agriculture in developing countries. This study aims to examine the adaptive capacity of smallholder farmers to climate change and identify effective strategies to enhance their resilience.

Example 3 : The use of social media in political campaigns has become increasingly common in recent years. This study aims to analyze the effectiveness of social media campaigns in mobilizing young voters and influencing their voting behavior.

Example 4 : Employee turnover is a major challenge for organizations, especially in the service sector. This study aims to identify the key factors that influence employee turnover in the hospitality industry and explore effective strategies for reducing turnover rates.

Examples of Background of The Study in Thesis

Here are some real-time examples of the background of the study in the thesis:

Example 1 : “Women’s participation in the workforce has increased significantly over the past few decades. However, women continue to be underrepresented in leadership positions, particularly in male-dominated industries such as technology. This study aims to examine the factors that contribute to the underrepresentation of women in leadership roles in the technology industry, with a focus on organizational culture and gender bias.”

Example 2 : “Mental health is a critical component of overall health and well-being. Despite increased awareness of the importance of mental health, there are still significant gaps in access to mental health services, particularly in low-income and rural communities. This study aims to evaluate the effectiveness of a community-based mental health intervention in improving mental health outcomes in underserved populations.”

Example 3: “The use of technology in education has become increasingly widespread, with many schools adopting online learning platforms and digital resources. However, there is limited research on the impact of technology on student learning outcomes and engagement. This study aims to explore the relationship between technology use and academic achievement among middle school students, as well as the factors that mediate this relationship.”

Examples of Background of The Study in Research Paper

Here are some examples of how the background of the study can be written in various fields:

Example 1: The prevalence of obesity has been on the rise globally, with the World Health Organization reporting that approximately 650 million adults were obese in 2016. Obesity is a major risk factor for several chronic diseases such as diabetes, cardiovascular diseases, and cancer. In recent years, several interventions have been proposed to address this issue, including lifestyle changes, pharmacotherapy, and bariatric surgery. However, there is a lack of consensus on the most effective intervention for obesity management. This study aims to investigate the efficacy of different interventions for obesity management and identify the most effective one.

Example 2: Antibiotic resistance has become a major public health threat worldwide. Infections caused by antibiotic-resistant bacteria are associated with longer hospital stays, higher healthcare costs, and increased mortality. The inappropriate use of antibiotics is one of the main factors contributing to the development of antibiotic resistance. Despite numerous efforts to promote the rational use of antibiotics, studies have shown that many healthcare providers continue to prescribe antibiotics inappropriately. This study aims to explore the factors influencing healthcare providers’ prescribing behavior and identify strategies to improve antibiotic prescribing practices.

Example 3: Social media has become an integral part of modern communication, with millions of people worldwide using platforms such as Facebook, Twitter, and Instagram. Social media has several advantages, including facilitating communication, connecting people, and disseminating information. However, social media use has also been associated with several negative outcomes, including cyberbullying, addiction, and mental health problems. This study aims to investigate the impact of social media use on mental health and identify the factors that mediate this relationship.

Purpose of Background of The Study

The primary purpose of the background of the study is to help the reader understand the rationale for the research by presenting the historical, theoretical, and empirical background of the problem.

More specifically, the background of the study aims to:

• Provide a clear understanding of the research problem and its context.
• Identify the gap in knowledge that the study intends to fill.
• Establish the significance of the research problem and its potential contribution to the field.
• Highlight the key concepts, theories, and research findings related to the problem.
• Provide a rationale for the research questions or hypotheses and the research design.
• Identify the limitations and scope of the study.

When to Write Background of The Study

The background of the study should be written early on in the research process, ideally before the research design is finalized and data collection begins. This allows the researcher to clearly articulate the rationale for the study and establish a strong foundation for the research.

The background of the study typically comes after the introduction but before the literature review section. It should provide an overview of the research problem and its context, and also introduce the key concepts, theories, and research findings related to the problem.

Writing the background of the study early on in the research process also helps to identify potential gaps in knowledge and areas for further investigation, which can guide the development of the research questions or hypotheses and the research design. By establishing the significance of the research problem and its potential contribution to the field, the background of the study can also help to justify the research and secure funding or support from stakeholders.

Advantage of Background of The Study

The background of the study has several advantages, including:

• Provides context: The background of the study provides context for the research problem by highlighting the historical, theoretical, and empirical background of the problem. This allows the reader to understand the research problem in its broader context and appreciate its significance.
• Identifies gaps in knowledge: By reviewing the existing literature related to the research problem, the background of the study can identify gaps in knowledge that the study intends to fill. This helps to establish the novelty and originality of the research and its potential contribution to the field.
• Justifies the research : The background of the study helps to justify the research by demonstrating its significance and potential impact. This can be useful in securing funding or support for the research.
• Guides the research design: The background of the study can guide the development of the research questions or hypotheses and the research design by identifying key concepts, theories, and research findings related to the problem. This ensures that the research is grounded in existing knowledge and is designed to address the research problem effectively.
• Establishes credibility: By demonstrating the researcher’s knowledge of the field and the research problem, the background of the study can establish the researcher’s credibility and expertise, which can enhance the trustworthiness and validity of the research.

Disadvantages of Background of The Study

Some Disadvantages of Background of The Study are as follows:

• Time-consuming : Writing a comprehensive background of the study can be time-consuming, especially if the research problem is complex and multifaceted. This can delay the research process and impact the timeline for completing the study.
• Repetitive: The background of the study can sometimes be repetitive, as it often involves summarizing existing research and theories related to the research problem. This can be tedious for the reader and may make the section less engaging.
• Limitations of existing research: The background of the study can reveal the limitations of existing research related to the problem. This can create challenges for the researcher in developing research questions or hypotheses that address the gaps in knowledge identified in the background of the study.
• Bias : The researcher’s biases and perspectives can influence the content and tone of the background of the study. This can impact the reader’s perception of the research problem and may influence the validity of the research.
• Accessibility: Accessing and reviewing the literature related to the research problem can be challenging, especially if the researcher does not have access to a comprehensive database or if the literature is not available in the researcher’s language. This can limit the depth and scope of the background of the study.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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What is the Background of the Study and How to Write It

What is the Background of the Study in Research? 

The background of the study is the first section of a research paper and gives context surrounding the research topic. The background explains to the reader where your research journey started, why you got interested in the topic, and how you developed the research question that you will later specify. That means that you first establish the context of the research you did with a general overview of the field or topic and then present the key issues that drove your decision to study the specific problem you chose.

Once the reader understands where you are coming from and why there was indeed a need for the research you are going to present in the following—because there was a gap in the current research, or because there is an obvious problem with a currently used process or technology—you can proceed with the formulation of your research question and summarize how you are going to address it in the rest of your manuscript.

Why is the Background of the Study Important?

No matter how surprising and important the findings of your study are, if you do not provide the reader with the necessary background information and context, they will not be able to understand your reasons for studying the specific problem you chose and why you think your study is relevant. And more importantly, an editor who does not share your enthusiasm for your work (because you did not fill them in on all the important details) will very probably not even consider your manuscript worthy of their and the reviewers’ time and will immediately send it back to you.

To avoid such desk rejections , you need to make sure you pique the reader’s interest and help them understand the contribution of your work to the specific field you study, the more general research community, or the public. Introducing the study background is crucial to setting the scene for your readers.

Table of Contents:

• What is “Background Information” in a Research Paper?
• What Should the Background of a Research Paper Include?
• Where Does the Background Section Go in Your Paper?

Background of the Study Structure

Before writing your study background, it is essential to understand what to include. The following elements should all be included in the background and are presented in greater detail in the next section:

• A general overview of the topic and why it is important (overlaps with establishing the “importance of the topic” in the Introduction)
• The current state of the research on the topic or on related topics in the field
• Controversies about current knowledge or specific past studies that undergird your research methodology
• Any claims or assumptions that have been made by researchers, institutions, or politicians that might need to be clarified
• Methods and techniques used in the study or from which your study deviated in some way

Presenting the Study Background

As you begin introducing your background, you first need to provide a general overview and include the main issues concerning the topic. Depending on whether you do “basic” (with the aim of providing further knowledge) or “applied” research (to establish new techniques, processes, or products), this is either a literature review that summarizes all relevant earlier studies in the field or a description of the process (e.g., vote counting) or practice (e.g., diagnosis of a specific disease) that you think is problematic or lacking and needs a solution.

Example s of a general overview

If you study the function of a Drosophila gene, for example, you can explain to the reader why and for whom the study of fly genetics is relevant, what is already known and established, and where you see gaps in the existing literature. If you investigated how the way universities have transitioned into online teaching since the beginning of the Covid-19 pandemic has affected students’ learning progress, then you need to present a summary of what changes have happened around the world, what the effects of those changes have been so far, and where you see problems that need to be addressed. Note that you need to provide sources for every statement and every claim you make here, to establish a solid foundation of knowledge for your own study. 

Describing the current state of knowledge

When the reader understands the main issue(s), you need to fill them in more specifically on the current state of the field (in basic research) or the process/practice/product use you describe (in practical/applied research). Cite all relevant studies that have already reported on the Drosophila gene you are interested in, have failed to reveal certain functions of it, or have suggested that it might be involved in more processes than we know so far. Or list the reports from the education ministries of the countries you are interested in and highlight the data that shows the need for research into the effects of the Corona-19 pandemic on teaching and learning.

Discussing controversies, claims, and assumptions

Are there controversies regarding your topic of interest that need to be mentioned and/or addressed? For example, if your research topic involves an issue that is politically hot, you can acknowledge this here. Have any earlier claims or assumptions been made, by other researchers, institutions, or politicians, that you think need to be clarified?

Mentioning methodologies and approaches

While putting together these details, you also need to mention methodologies : What methods/techniques have been used so far to study what you studied and why are you going to either use the same or a different approach? Are any of the methods included in the literature review flawed in such a way that your study takes specific measures to correct or update? While you shouldn’t spend too much time here justifying your methods (this can be summarized briefly in the rationale of the study at the end of the Introduction and later in the Discussion section), you can engage with the crucial methods applied in previous studies here first.

When you have established the background of the study of your research paper in such a logical way, then the reader should have had no problem following you from the more general information you introduced first to the specific details you added later. You can now easily lead over to the relevance of your research, explain how your work fits into the bigger picture, and specify the aims and objectives of your study. This latter part is usually considered the “ statement of the problem ” of your study. Without a solid research paper background, this statement will come out of nowhere for the reader and very probably raise more questions than you were planning to answer.   

Where does the study background section go in a paper?

Unless you write a research proposal or some kind of report that has a specific “Background” chapter, the background of your study is the first part of your introduction section . This is where you put your work in context and provide all the relevant information the reader needs to follow your rationale. Make sure your background has a logical structure and naturally leads into the statement of the problem at the very end of the introduction so that you bring everything together for the reader to judge the relevance of your work and the validity of your approach before they dig deeper into the details of your study in the methods section .

Consider Receiving Professional Editing Services

Now that you know how to write a background section for a research paper, you might be interested in our AI text editor at Wordvice AI. And be sure to receive professional editing services , including academic editing and proofreading , before submitting your manuscript to journals. On the Wordvice academic resources website, you can also find many more articles and other resources that can help you with writing the other parts of your research paper , with making a research paper outline before you put everything together, or with writing an effective cover letter once you are ready to submit.

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How to Write an Effective Background of the Study: A Comprehensive Guide

Table of Contents

The background of the study in a research paper offers a clear context, highlighting why the research is essential and the problem it aims to address.

As a researcher, this foundational section is essential for you to chart the course of your study, Moreover, it allows readers to understand the importance and path of your research.

Whether in academic communities or to the general public, a well-articulated background aids in communicating the essence of the research effectively.

While it may seem straightforward, crafting an effective background requires a blend of clarity, precision, and relevance. Therefore, this article aims to be your guide, offering insights into:

• Understanding the concept of the background of the study.
• Learning how to craft a compelling background effectively.
• Identifying and sidestepping common pitfalls in writing the background.
• Exploring practical examples that bring the theory to life.
• Enhancing both your writing and reading of academic papers.

Keeping these compelling insights in mind, let's delve deeper into the details of the empirical background of the study, exploring its definition, distinctions, and the art of writing it effectively.

What is the background of the study?

The background of the study is placed at the beginning of a research paper. It provides the context, circumstances, and history that led to the research problem or topic being explored.

It offers readers a snapshot of the existing knowledge on the topic and the reasons that spurred your current research.

When crafting the background of your study, consider the following questions.

• What's the context of your research?
• Which previous research will you refer to?
• Are there any knowledge gaps in the existing relevant literature?
• How will you justify the need for your current research?
• Have you concisely presented the research question or problem?

In a typical research paper structure, after presenting the background, the introduction section follows. The introduction delves deeper into the specific objectives of the research and often outlines the structure or main points that the paper will cover.

Together, they create a cohesive starting point, ensuring readers are well-equipped to understand the subsequent sections of the research paper.

While the background of the study and the introduction section of the research manuscript may seem similar and sometimes even overlap, each serves a unique purpose in the research narrative.

Difference between background and introduction

A well-written background of the study and introduction are preliminary sections of a research paper and serve distinct purposes.

Here’s a detailed tabular comparison between the two of them.

What is the relevance of the background of the study?

It is necessary for you to provide your readers with the background of your research. Without this, readers may grapple with questions such as: Why was this specific research topic chosen? What led to this decision? Why is this study relevant? Is it worth their time?

Such uncertainties can deter them from fully engaging with your study, leading to the rejection of your research paper. Additionally, this can diminish its impact in the academic community, and reduce its potential for real-world application or policy influence .

To address these concerns and offer clarity, the background section plays a pivotal role in research papers.

The background of the study in research is important as it:

• Provides context: It offers readers a clear picture of the existing knowledge, helping them understand where the current research fits in.
• Highlights relevance: By detailing the reasons for the research, it underscores the study's significance and its potential impact.
• Guides the narrative: The background shapes the narrative flow of the paper, ensuring a logical progression from what's known to what the research aims to uncover.
• Enhances engagement: A well-crafted background piques the reader's interest, encouraging them to delve deeper into the research paper.
• Aids in comprehension: By setting the scenario, it aids readers in better grasping the research objectives, methodologies, and findings.

How to write the background of the study in a research paper?

The journey of presenting a compelling argument begins with the background study. This section holds the power to either captivate or lose the reader's interest.

An effectively written background not only provides context but also sets the tone for the entire research paper. It's the bridge that connects a broad topic to a specific research question, guiding readers through the logic behind the study.

But how does one craft a background of the study that resonates, informs, and engages?

Here, we’ll discuss how to write an impactful background study, ensuring your research stands out and captures the attention it deserves.

Identify the research problem

The first step is to start pinpointing the specific issue or gap you're addressing. This should be a significant and relevant problem in your field.

A well-defined problem is specific, relevant, and significant to your field. It should resonate with both experts and readers.

Here’s more on how to write an effective research problem .

Provide context

Here, you need to provide a broader perspective, illustrating how your research aligns with or contributes to the overarching context or the wider field of study. A comprehensive context is grounded in facts, offers multiple perspectives, and is relatable.

In addition to stating facts, you should weave a story that connects key concepts from the past, present, and potential future research. For instance, consider the following approach.

• Offer a brief history of the topic, highlighting major milestones or turning points that have shaped the current landscape.
• Discuss contemporary developments or current trends that provide relevant information to your research problem. This could include technological advancements, policy changes, or shifts in societal attitudes.
• Highlight the views of different stakeholders. For a topic like sustainable agriculture, this could mean discussing the perspectives of farmers, environmentalists, policymakers, and consumers.
• If relevant, compare and contrast global trends with local conditions and circumstances. This can offer readers a more holistic understanding of the topic.

Literature review

For this step, you’ll deep dive into the existing literature on the same topic. It's where you explore what scholars, researchers, and experts have already discovered or discussed about your topic.

Conducting a thorough literature review isn't just a recap of past works. To elevate its efficacy, it's essential to analyze the methods, outcomes, and intricacies of prior research work, demonstrating a thorough engagement with the existing body of knowledge.

• Instead of merely listing past research study, delve into their methodologies, findings, and limitations. Highlight groundbreaking studies and those that had contrasting results.
• Try to identify patterns. Look for recurring themes or trends in the literature. Are there common conclusions or contentious points?
• The next step would be to connect the dots. Show how different pieces of research relate to each other. This can help in understanding the evolution of thought on the topic.

By showcasing what's already known, you can better highlight the background of the study in research.

Highlight the research gap

This step involves identifying the unexplored areas or unanswered questions in the existing literature. Your research seeks to address these gaps, providing new insights or answers.

A clear research gap shows you've thoroughly engaged with existing literature and found an area that needs further exploration.

How can you efficiently highlight the research gap?

• Find the overlooked areas. Point out topics or angles that haven't been adequately addressed.
• Highlight questions that have emerged due to recent developments or changing circumstances.
• Identify areas where insights from other fields might be beneficial but haven't been explored yet.

State your objectives

Here, it’s all about laying out your game plan — What do you hope to achieve with your research? You need to mention a clear objective that’s specific, actionable, and directly tied to the research gap.

How to state your objectives?

• List the primary questions guiding your research.
• If applicable, state any hypotheses or predictions you aim to test.
• Specify what you hope to achieve, whether it's new insights, solutions, or methodologies.

Discuss the significance

This step describes your 'why'. Why is your research important? What broader implications does it have?

The significance of “why” should be both theoretical (adding to the existing literature) and practical (having real-world implications).

How do we effectively discuss the significance?

• Discuss how your research adds to the existing body of knowledge.
• Highlight how your findings could be applied in real-world scenarios, from policy changes to on-ground practices.
• Point out how your research could pave the way for further studies or open up new areas of exploration.

Summarize your points

A concise summary acts as a bridge, smoothly transitioning readers from the background to the main body of the paper. This step is a brief recap, ensuring that readers have grasped the foundational concepts.

How to summarize your study?

• Revisit the key points discussed, from the research problem to its significance.
• Prepare the reader for the subsequent sections, ensuring they understand the research's direction.

Include examples for better understanding

Research and come up with real-world or hypothetical examples to clarify complex concepts or to illustrate the practical applications of your research. Relevant examples make abstract ideas tangible, aiding comprehension.

How to include an effective example of the background of the study?

• Use past events or scenarios to explain concepts.
• Craft potential scenarios to demonstrate the implications of your findings.
• Use comparisons to simplify complex ideas, making them more relatable.

Crafting a compelling background of the study in research is about striking the right balance between providing essential context, showcasing your comprehensive understanding of the existing literature, and highlighting the unique value of your research .

While writing the background of the study, keep your readers at the forefront of your mind. Every piece of information, every example, and every objective should be geared toward helping them understand and appreciate your research.

How to avoid mistakes in the background of the study in research?

To write a well-crafted background of the study, you should be aware of the following potential research pitfalls .

• Stay away from ambiguity. Always assume that your reader might not be familiar with intricate details about your topic.
• Avoid discussing unrelated themes. Stick to what's directly relevant to your research problem.
• Ensure your background is well-organized. Information should flow logically, making it easy for readers to follow.
• While it's vital to provide context, avoid overwhelming the reader with excessive details that might not be directly relevant to your research problem.
• Ensure you've covered the most significant and relevant studies i` n your field. Overlooking key pieces of literature can make your background seem incomplete.
• Aim for a balanced presentation of facts, and avoid showing overt bias or presenting only one side of an argument.
• While academic paper often involves specialized terms, ensure they're adequately explained or use simpler alternatives when possible.
• Every claim or piece of information taken from existing literature should be appropriately cited. Failing to do so can lead to issues of plagiarism.
• Avoid making the background too lengthy. While thoroughness is appreciated, it should not come at the expense of losing the reader's interest. Maybe prefer to keep it to one-two paragraphs long.
• Especially in rapidly evolving fields, it's crucial to ensure that your literature review section is up-to-date and includes the latest research.

Example of an effective background of the study

Let's consider a topic: "The Impact of Online Learning on Student Performance." The ideal background of the study section for this topic would be as follows.

In the last decade, the rise of the internet has revolutionized many sectors, including education. Online learning platforms, once a supplementary educational tool, have now become a primary mode of instruction for many institutions worldwide. With the recent global events, such as the COVID-19 pandemic, there has been a rapid shift from traditional classroom learning to online modes, making it imperative to understand its effects on student performance.

Previous studies have explored various facets of online learning, from its accessibility to its flexibility. However, there is a growing need to assess its direct impact on student outcomes. While some educators advocate for its benefits, citing the convenience and vast resources available, others express concerns about potential drawbacks, such as reduced student engagement and the challenges of self-discipline.

This research aims to delve deeper into this debate, evaluating the true impact of online learning on student performance.

Why is this example considered as an effective background section of a research paper?

This background section example effectively sets the context by highlighting the rise of online learning and its increased relevance due to recent global events. It references prior research on the topic, indicating a foundation built on existing knowledge.

By presenting both the potential advantages and concerns of online learning, it establishes a balanced view, leading to the clear purpose of the study: to evaluate the true impact of online learning on student performance.

As we've explored, writing an effective background of the study in research requires clarity, precision, and a keen understanding of both the broader landscape and the specific details of your topic.

From identifying the research problem, providing context, reviewing existing literature to highlighting research gaps and stating objectives, each step is pivotal in shaping the narrative of your research. And while there are best practices to follow, it's equally crucial to be aware of the pitfalls to avoid.

Remember, writing or refining the background of your study is essential to engage your readers, familiarize them with the research context, and set the ground for the insights your research project will unveil.

Drawing from all the important details, insights and guidance shared, you're now in a strong position to craft a background of the study that not only informs but also engages and resonates with your readers.

Now that you've a clear understanding of what the background of the study aims to achieve, the natural progression is to delve into the next crucial component — write an effective introduction section of a research paper. Read here .

Frequently Asked Questions

The background of the study should include a clear context for the research, references to relevant previous studies, identification of knowledge gaps, justification for the current research, a concise overview of the research problem or question, and an indication of the study's significance or potential impact.

The background of the study is written to provide readers with a clear understanding of the context, significance, and rationale behind the research. It offers a snapshot of existing knowledge on the topic, highlights the relevance of the study, and sets the stage for the research questions and objectives. It ensures that readers can grasp the importance of the research and its place within the broader field of study.

The background of the study is a section in a research paper that provides context, circumstances, and history leading to the research problem or topic being explored. It presents existing knowledge on the topic and outlines the reasons that spurred the current research, helping readers understand the research's foundation and its significance in the broader academic landscape.

The number of paragraphs in the background of the study can vary based on the complexity of the topic and the depth of the context required. Typically, it might range from 3 to 5 paragraphs, but in more detailed or complex research papers, it could be longer. The key is to ensure that all relevant information is presented clearly and concisely, without unnecessary repetition.

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Table of Contents

The background of a study is one of the most important components of a research paper. The quality of the background determines whether the reader will be interested in the rest of the study. Thus, to ensure that the audience is invested in reading the entire research paper, it is important to write an appealing and effective background. So, what constitutes the background of a study, and how must it be written?

What is the background of a study?

The background of a study is the first section of the paper and establishes the context underlying the research. It contains the rationale, the key problem statement, and a brief overview of research questions that are addressed in the rest of the paper. The background forms the crux of the study because it introduces an unaware audience to the research and its importance in a clear and logical manner. At times, the background may even explore whether the study builds on or refutes findings from previous studies. Any relevant information that the readers need to know before delving into the paper should be made available to them in the background.

How is a background different from the introduction?

The introduction of your research paper is presented before the background. Let’s find out what factors differentiate the background from the introduction.

• The introduction only contains preliminary data about the research topic and does not state the purpose of the study. On the contrary, the background clarifies the importance of the study in detail.
• The introduction provides an overview of the research topic from a broader perspective, while the background provides a detailed understanding of the topic.
• The introduction should end with the mention of the research questions, aims, and objectives of the study. In contrast, the background follows no such format and only provides essential context to the study.

How should one write the background of a research paper?

The length and detail presented in the background varies for different research papers, depending on the complexity and novelty of the research topic. At times, a simple background suffices, even if the study is complex. Before writing and adding details in the background, take a note of these additional points:

• Start with a strong beginning: Begin the background by defining the research topic and then identify the target audience.
• Cover key components: Explain all theories, concepts, terms, and ideas that may feel unfamiliar to the target audience thoroughly.
• Take note of important prerequisites: Go through the relevant literature in detail. Take notes while reading and cite the sources.
• Maintain a balance: Make sure that the background is focused on important details, but also appeals to a broader audience.
• Include historical data: Current issues largely originate from historical events or findings. If the research borrows information from a historical context, add relevant data in the background.
• Explain novelty: If the research study or methodology is unique or novel, provide an explanation that helps to understand the research better.
• Increase engagement: To make the background engaging, build a story around the central theme of the research

Avoid these mistakes while writing the background:

• Ambiguity: Don’t be ambiguous. While writing, assume that the reader does not understand any intricate detail about your research.
• Unrelated themes: Steer clear from topics that are not related to the key aspects of your research topic.
• Poor organization: Do not place information without a structure. Make sure that the background reads in a chronological manner and organize the sub-sections so that it flows well.

Writing the background for a research paper should not be a daunting task. But directions to go about it can always help. At Elsevier Author Services we provide essential insights on how to write a high quality, appealing, and logically structured paper for publication, beginning with a robust background. For further queries, contact our experts now!

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What Is Background in a Research Paper?

So you have carefully written your research paper  and probably ran it through your colleagues ten to fifteen times. While there are many elements to a good research article, one of the most important elements for your readers is the background of your study.

What is Background of the Study in Research

The background of your study will provide context to the information discussed throughout the research paper . Background information may include both important and relevant studies. This is particularly important if a study either supports or refutes your thesis.

Why is Background of the Study Necessary in Research?

The background of the study discusses your problem statement, rationale, and research questions. It links  introduction to your research topic  and ensures a logical flow of ideas.  Thus, it helps readers understand your reasons for conducting the study.

Providing Background Information

The reader should be able to understand your topic and its importance. The length and detail of your background also depend on the degree to which you need to demonstrate your understanding of the topic. Paying close attention to the following questions will help you in writing background information:

• Are there any theories, concepts, terms, and ideas that may be unfamiliar to the target audience and will require you to provide any additional explanation?
• Any historical data that need to be shared in order to provide context on why the current issue emerged?
• Are there any concepts that may have been borrowed from other disciplines that may be unfamiliar to the reader and need an explanation?

Related: Ready with the background and searching for more information on journal ranking? Check this infographic on the SCImago Journal Rank today!

Is the research study unique for which additional explanation is needed? For instance, you may have used a completely new method

How to Write a Background of the Study

The structure of a background study in a research paper generally follows a logical sequence to provide context, justification, and an understanding of the research problem. It includes an introduction, general background, literature review , rationale , objectives, scope and limitations , significance of the study and the research hypothesis . Following the structure can provide a comprehensive and well-organized background for your research.

Here are the steps to effectively write a background of the study.

1. Identify Your Audience:

Determine the level of expertise of your target audience. Tailor the depth and complexity of your background information accordingly.

2. Understand the Research Problem:

Define the research problem or question your study aims to address. Identify the significance of the problem within the broader context of the field.

3. Review Existing Literature:

Conduct a thorough literature review to understand what is already known in the area. Summarize key findings, theories, and concepts relevant to your research.

4. Include Historical Data:

Integrate historical data if relevant to the research, as current issues often trace back to historical events.

5. Identify Controversies and Gaps:

Note any controversies or debates within the existing literature. Identify gaps , limitations, or unanswered questions that your research can address.

6. Select Key Components:

Choose the most critical elements to include in the background based on their relevance to your research problem. Prioritize information that helps build a strong foundation for your study.

7. Craft a Logical Flow:

Organize the background information in a logical sequence. Start with general context, move to specific theories and concepts, and then focus on the specific problem.

8. Highlight the Novelty of Your Research:

Clearly explain the unique aspects or contributions of your study. Emphasize why your research is different from or builds upon existing work.

Here are some extra tips to increase the quality of your research background:

Example of a Research Background

Here is an example of a research background to help you understand better.

The above hypothetical example provides a research background, addresses the gap and highlights the potential outcome of the study; thereby aiding a better understanding of the proposed research.

What Makes the Introduction Different from the Background?

Your introduction is different from your background in a number of ways.

• The introduction contains preliminary data about your topic that  the reader will most likely read , whereas the background clarifies the importance of the paper.
• The background of your study discusses in depth about the topic, whereas the introduction only gives an overview.
• The introduction should end with your research questions, aims, and objectives, whereas your background should not (except in some cases where your background is integrated into your introduction). For instance, the C.A.R.S. ( Creating a Research Space ) model, created by John Swales is based on his analysis of journal articles. This model attempts to explain and describe the organizational pattern of writing the introduction in social sciences.

Points to Note

Your background should begin with defining a topic and audience. It is important that you identify which topic you need to review and what your audience already knows about the topic. You should proceed by searching and researching the relevant literature. In this case, it is advisable to keep track of the search terms you used and the articles that you downloaded. It is helpful to use one of the research paper management systems such as Papers, Mendeley, Evernote, or Sente. Next, it is helpful to take notes while reading. Be careful when copying quotes verbatim and make sure to put them in quotation marks and cite the sources. In addition, you should keep your background focused but balanced enough so that it is relevant to a broader audience. Aside from these, your background should be critical, consistent, and logically structured.

Writing the background of your study should not be an overly daunting task. Many guides that can help you organize your thoughts as you write the background. The background of the study is the key to introduce your audience to your research topic and should be done with strong knowledge and thoughtful writing.

The background of a research paper typically ranges from one to two paragraphs, summarizing the relevant literature and context of the study. It should be concise, providing enough information to contextualize the research problem and justify the need for the study. Journal instructions about any word count limits should be kept in mind while deciding on the length of the final content.

The background of a research paper provides the context and relevant literature to understand the research problem, while the introduction also introduces the specific research topic, states the research objectives, and outlines the scope of the study. The background focuses on the broader context, whereas the introduction focuses on the specific research project and its objectives.

When writing the background for a study, start by providing a brief overview of the research topic and its significance in the field. Then, highlight the gaps in existing knowledge or unresolved issues that the study aims to address. Finally, summarize the key findings from relevant literature to establish the context and rationale for conducting the research, emphasizing the need and importance of the study within the broader academic landscape.

The background in a research paper is crucial as it sets the stage for the study by providing essential context and rationale. It helps readers understand the significance of the research problem and its relevance in the broader field. By presenting relevant literature and highlighting gaps, the background justifies the need for the study, building a strong foundation for the research and enhancing its credibility.

The presentation very informative

It is really educative. I love the workshop. It really motivated me into writing my first paper for publication.

an interesting clue here, thanks.

thanks for the answers.

Good and interesting explanation. Thanks

Thank you for good presentation.

Hi Adam, we are glad to know that you found our article beneficial

The background of the study is the key to introduce your audience to YOUR research topic.

Awesome. Exactly what i was looking forwards to 😉

Hi Maryam, we are glad to know that you found our resource useful.

my understanding of ‘Background of study’ has been elevated.

Hi Peter, we are glad to know that our article has helped you get a better understanding of the background in a research paper.

thanks to give advanced information

Hi Shimelis, we are glad to know that you found the information in our article beneficial.

When i was studying it is very much hard for me to conduct a research study and know the background because my teacher in practical research is having a research so i make it now so that i will done my research

Very informative……….Thank you.

The confusion i had before, regarding an introduction and background to a research work is now a thing of the past. Thank you so much.

Thanks for your help…

Thanks for your kind information about the background of a research paper.

Thanks for the answer

Very informative. I liked even more when the difference between background and introduction was given. I am looking forward to learning more from this site. I am in Botswana

Hello, I am Benoît from Central African Republic. Right now I am writing down my research paper in order to get my master degree in British Literature. Thank you very much for posting all this information about the background of the study. I really appreciate. Thanks!

The write up is quite good, detailed and informative. Thanks a lot. The article has certainly enhanced my understanding of the topic.

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1 Introduction

Patricia Leavy Independent Scholar Kennebunk, ME, USA

• Published: 01 July 2014
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This chapter serves as the introduction to the Oxford Handbook of Qualitative Research . The first half of the chapter responds to two questions. First, the chapter addresses the question: What is qualitative research? In answering the question, the chapter reviews the major elements of research: paradigm, ontology, epistemology (which together form the philosophical basis of research), genre, methods, theory, methodology (which operate at the level of praxis), ethics, values, and reflexivity (which merge the philosophical and praxis dimensions of research). Second, the chapter addresses the question: Who are qualitative researchers? Leavy explains qualitative research as a form of bricolage and qualitative researchers as bricoleurs. The remainder of the chapter reviews the contents of the handbook, providing a chapter by chapter summary.

We shall not cease from exploration and the end of all our exploring will be to arrive where we started and know the place for the first time. – T. S. Eliot

I open the introduction to the Oxford Handbook of Qualitative Research with the preceding quote for two reasons. First, it captures the essence of qualitative inquiry as a way of understanding, describing, explaining, unraveling, illuminating, chronicling, and documenting social life—which includes attention to the everyday, to the mundane and ordinary, as much as the extraordinary. Qualitative research can involve the study of others, but also the self and the complex relationships between, within, and among people and groups, including our own entanglements. The second reason I have begun with this quote is because it opens Laurel Richardson’s book Fields of Play: Constructing an Academic Life (1997) . This is one of my favorite books, and, in it, Richardson expands the way we think of ourselves as researchers, writers, and knowers. What I intend to do by way of sharing this is to locate myself within the field and within this text—this is something that many qualitative researchers aim to do, in various ways. In qualitative research, we are not outside of our projects, but located and shifting within them. Qualitative research is an engaged way of building knowledge about the social world and human experience, and qualitative researchers are enmeshed in their projects.

What Is Qualitative Research?

Science is a conversation between rigor and imagination. ( Abbott, 2004 , p. 3)

Qualitative research is a way of learning about social reality. Qualitative approaches to research can be used across the disciplines to study a wide array of topics. In the social and behavioral sciences, these approaches to research are often used to explore, describe, or explain social phenomenon; unpack the meanings people ascribe to activities, situations, events, or artefacts; build a depth of understanding about some aspect of social life; build “thick descriptions” (see Clifford Geertz, 1973 ) of people in naturalistic settings; explore new or underresearched areas; or make micro–macro links (illuminate connections between individuals–groups and institutional and/or cultural contexts).

Qualitative research itself is an umbrella term for a rich array of research practices and products. Qualitative research is an expansive and continually evolving methodological field that encompasses a wide range of approaches to research, as well as multiple perspectives on the nature of research itself. It has been argued that qualitative research developed in an interdisciplinary, transdisciplinary, or counterdisciplinary field ( Denzin & Lincoln, 1998 ; Jovanic, 2011 ; Lorenz, 2010 ). This approach to inquiry is unique, in part because of its philosophical and methodological diversity, as well as because of the value system guiding research practice.

The diversity of the qualitative landscape, as well as the gestalt of qualitative practice, is also partly attributable to the context in which qualitative research developed. Chapter 2 in this handbook looks much more fully at the historical development of qualitative research, but I would like to briefly note the period of growth in the 1960s and 1970s because it bears directly on the richness of contemporary qualitative practice. 2

Although there were many pivotal works published prior to the 1960s, the social justice movements of the 1960s and 1970s—the civil rights, women’s, gay rights, and peace movements—culminated in major changes in the academic landscape, including the asking of new research questions and the reframing of many previously asked research questions and corresponding approaches to research. These movements in essence became sites for new ways of thinking and led to the critique of dominant methods of scientific practice, many of which relied on positivism ( Jovanic, 2011 ). There was a drive to include people historically excluded from social research or included in ways that reinforced stereotypes and justified relations of oppression, and researchers became more cognizant of power within the research process ( Hesse-Biber & Leavy, 2011 ). A couple of decades later, interdisciplinary area studies that developed in the context of critique—women’s studies, African-American studies, Chicana/Chicano studies—began emerging across academic institutions.

Because of the sociohistorical conditions in which it developed, the qualitative tradition can be characterized by its multiplicity of approaches to research as well as by its focus on the uses to which that research might be put . In this vein, there is a social justice undercurrent to qualitative practice, one that may be implicit or explicit depending on the positioning and goals of the practitioner and the project at hand.

Many qualitative researchers define qualitative research by comparing it to quantitative research. I myself have done this. However, instead of describing what something is by explaining what it isn’t, I focus on a discussion of the qualitative tradition as understood on its own merits. 3 One way of understanding qualitative research is by considering the key dimensions of any research practice and discussing them in terms of qualitative practice.

The Elements of Research

The main dimensions of research can be categorized under three general categories: philosophical, praxis, and ethics. The philosophical substructure of research consists of three elements: paradigm, ontology, and epistemology. At the level of praxis there are four key elements of research: genre, methods, theory, and methodology. The ethical compass (which combines philosophical and praxis dimensions) includes three main elements: ethics, values, and reflexivity (see Table 1.1 ).

The Philosophical Substructure of Qualitative Research

A range of beliefs guide research practice—beliefs about how research should proceed, what can be known, who can be a knower, and how we come to know. Together, these beliefs form the philosophical substructure of research and inform all aspects of the research from topic selection to research design to the final representation and dissemination of the research findings and all phases in between.

A paradigm is a worldview through which knowledge is filtered ( Kuhn, 1962 ). In other words, it is an overarching perspective that guides the research process. I think of paradigms as sunglasses, with different color lenses. When you put a pair on, it influences everything you see. Qualitative research is multiparadigmatic, with researchers working from different worldviews (such as post-positivism, interpretivism, and critical orientations), which makes it a highly diverse field of inquiry.

An ontology is a philosophical belief system about the nature of social reality, including what we can learn about this reality and how we can do so. In their classic definition, Egon Guba and Yvonna Lincoln explained the ontological question as: “What is the form and nature of reality and, therefore, what is there that can be known about it?” (1998, p. 201). Qualitative researchers adopt a perspective that suggests knowledge building is viewed as generative and process-oriented. The truth is not absolute and ready to be “discovered” by “objective” researchers, but rather it is contingent, contextual, and multiple ( Saldaña, 2011 ). Subjectivity is acknowledged and valued. Objectivity may be redefined and achieved through the owning and disclosing of one’s values system, not disavowing it ( Hesse-Biber & Leavy, 2011 ).

If the ontological question is “What can be known?” then the epistemological question is “Who can be a knower?” An epistemology is a philosophical belief system about how research proceeds as an embodied activity, how one embodies the role of researcher, and the relationship between the researcher and research participants ( Guba & Lincoln, 1998 ; Harding, 1987 ; Hesse-Biber & Leavy, 2004 ; 2011 ). Qualitative researchers work from many different epistemological positions. Researchers may work individually or as a part of a team with their participants in the co-creation of knowledge. From this perspective, researchers are not considered neutral or objective in the traditional sense. Rather, researchers acknowledge how their personal, professional, and political commitments influence all aspects of their research. Researchers are considered instruments in qualitative research ( Bresler, 2005 ; Saldaña, 2011 ). Research participants are valued and positioned as knowledge bearers and co-creators. This position rejects a hierarchical structure between the researcher and research participants or the idea that the researcher is the sole authority.

Together, the ontological and epistemological belief systems guiding the research practice serves as the philosophical basis or substructure of any research practice ( Hesse-Biber & Leavy, 2011 ). Although a researcher’s ontological and epistemological positions can vary across qualitative projects and may be influenced by a range of other factors, including theoretical and personal commitments, generally, qualitative researchers seek to build partial and contextualized truths in collaboration with their research participants or through reflexive engagement with their research texts.

Praxis: Approaches, Methods, and Theories in Action

Praxis is the doing of research—the practice of research. Approaches, methods, and theories come into being during praxis, as researchers build projects and execute on them, often making adjustments along the way.

Genres of research are overarching categories for different ways of approaching research ( Saldaña, 2011 ). Each genre lends itself to studying particular kinds of topics and includes a range of commonly used methods of data collection, analysis, and representation. Frequently used research genres include but are not limited to field research, interview, grounded theory, unobtrusive approaches, participatory research, community-based research, arts-based research, internet research, and multimethod and mixed-method approaches. This is not an exhaustive list. The genre within which a researcher works is motivated by a combination of factors, including the research topic, the research question(s), his or her methodological preferences and experiences, and the intended audience(s) for the research, as well as by a range of pragmatic considerations such as funding, time, and the researcher’s previous experience, skills, and personal preferences.

Research methods are tools for data collection. Research methods commonly used in qualitative practice include but are not limited to ethnography, autoethnography, duoethnography, narrative inquiry, in-depth interview, semistructured interview, focus group interview, oral history, document analysis, content analysis, historical-comparative methods, poetic inquiry, audiovisual methods, visual methods, photo-voice, case study, multiple case study, discourse analysis, conversation analysis, daily diary research, program evaluation, ethnodrama, ethnotheatre, ethnocinema, play building, and fiction-based research. As you can see, qualitative researchers use a range of tools for data collection. Research methods are selected because they are the best tools to gather the data sought for a particular study. The selection of research methods should be made in conjunction with the research question(s) and purpose or objective. In other words, depending on the research topic and how the research questions are framed, as well as more pragmatic issues such as access to participants or textual/preexisting data sources, time, and practical skills, researchers are guided to particular methods.

Each genre discussed earlier lends itself to the use of particular methods. For example, the genre of arts-based research lends itself to the use of ethnodrama, ethnotheatre, ethnocinema, play building, fiction-based research, poetic inquiry, audiovisual methods, photo-voice, or visual methods. The genre of interview research lends itself to the use of in-depth interview, semistructured interview, focus group interview, or oral history. Of course, these genres are all more complicated in practice. For example, discourse analysis is a method that may be employed in an interview study, document analysis, or narrative inquiry. Furthermore, depending on the context in which one employs a method, such as narrative inquiry, one might view it as an arts-based approach, interview approach, way of doing autoethnography, or a method of analysis. The intent is not to confuse matters but, given how large and diffuse the field of qualitative research is and the variety of ways that methods can be creatively employed, it is important to understand that you may come across these terms conceptualized in various ways in the literature. One of the reasons that methods can be conceptualized and employed in many different ways is because qualitative researchers also draw on multiple theories.

A theory is an account of social reality that is grounded in empirical data but extends beyond that data. Numerous theoretical perspectives may guide the research process, including but not limited to post-positivism, interpretive, symbolic interactionism, dramaturgy, phenomenology, ethnomethodology, social constructionism, post-structuralism, post-modernism, feminism, intersectionality theory, queer theory, and critical race theory. This is also not an exhaustive list and in most instances each of these theoretical perspectives are general categories for a range of more specific theories. A qualitative research study may also yield the development of a new theory. In these instances, theory develops inductively out of the research process. In other words, the study generates data out of which a theory is built—that theory is grounded in the empirical data from that study but extends beyond that data and can be applied to other situations.

A methodology is plan for how research will proceed—combining methods and theory. The methodology is what the researcher actually does once he or she has combined the different elements of research. The methodology is informed by the philosophical beliefs guiding the research, the selection of research methods, and the use of theory. One’s attention to ethics and their corresponding values system also influences how a study is designed and how methods are employed. Although two studies may use the same research method—for instance, a focus group interview—the researchers’ methodologies may be completely different. In other words, how they proceed with the research, based not only on their data collection tool but also on how they conceive of the use of that tool and thus structure the study, determines their methodology. The level of moderation and/or control a researcher exhibits during focus group interviews can vary greatly. Methodologies are not standardized nor are they typically etched in stone. Not only will methodological approaches to research vary across projects, but, even within a particular project, methodologies are often viewed as flexible and malleable. A qualitative researcher might adjust his or her methodology over the course of a project to facilitate new learning or new insights or to adapt to unanticipated challenges, obstacles, or opportunities. The malleability of qualitative methodologies is a strength of this approach to knowledge generation.

It is important to note that although I have reviewed methods for data collection as a part of methodology, there are also methods or strategies for qualitative data analysis, interpretation, representation, and dissemination of research findings. Similar to data collection tools and theories, these too are diverse, making the methodological possibilities rich.

Ethics: Beliefs and Practices

Ethics is an area that bridges the philosophical and praxis aspects of research. Ethics play a central role in any research practice. Typically, when we think about ethics in social research, particularly when working with human subjects, we are referring to issues such as preventing harm to the people or settings involved in the study, avoiding exploitation of research participants (with added attention in the case of vulnerable populations), disclosure of the nature of the study and how the findings will be used, the voluntary nature of participation, and confidentiality. Additionally, qualitative researchers have an ethical obligation to carefully consider how research participants are portrayed and to act sensitively.

Additional ethical issues are linked to a researcher’s ontological, epistemological, and practical imperatives, which together form a researcher’s values system. For instance, the real-world value or public usefulness of the research, the inclusion of underrepresented populations, the treatment of anomalous or contradictory data, and the way that the research findings are distributed to relevant stakeholders—these issues are also connected to ethical practice.

Reflexivity is also a core concept in the qualitative community and refers to one’s attention to how power and bias come to bear during all phases of the research. As D. Soyini Madison suggests, reflexivity is about “the politics of positionality” and acknowledging our power, privileges, and biases throughout the research process (2005, p. 6). The social justice imperative of many qualitative projects is a driver of reflexivity, as are critical and power-sensitive theoretical traditions. I suggest reflexivity is both a philosophical perspective and a way of doing or acting within the context of research, from start to finish (see Table 1.2 ).

Given the wide range of approaches, tools, and values that guide qualitative research, it is a rich and evolving tradition with innumerable possibilities for knowledge building and knowledge sharing. Researchers can build, craft, or construct many different kinds of projects to study a nearly limitless range of topics. For these reasons, many consider qualitative research a craft or form of bricolage.

Who Are Qualitative Researchers?

We are all interpretive bricoleurs stuck in the present working against the past as we move into a politically charged and challenging future. ( Norman K. Denzin, 2010 , p. 15)

The qualitative researcher can be thought of as a bricoleur—someone who comfortably draws on multiple bodies of scholarship, methods, and theories to do her or his work. The term bricoleur is attributed to Levi-Strauss (1966) ; however, Denzin and Lincoln popularized applying the term to the work of qualitative researchers. Thomas A. Schwandt (2001) writes:

As a bricoleur , the qualitative inquirer is capable of donning multiple identities—researcher, scientist, artist, critic, and performer—and engaging in different kinds of bricolage that consist of particular configurations of (or ways of relating) various fragments of inherited methodologies, methods, empirical materials, perspectives, understandings, ways of presentation, situated responsiveness, and so on into a coherent, reasoned approach to a research situation and problem. The bricolage appears to vary depending on one’s allegiance to different notions of interpretation, understanding, representation, and so on drawn from various intellectual and practice traditions. (p. 20) Table 1.2 Summary of key elements of research Element .  Philosophical or Praxis .  Definition .  Paradigm Philosophical Guiding worldview Ontology Philosophical The nature of social reality and what can be known about it Epistemology Philosophical The role of the researcher and researcher/participant relationship Genres Praxis Categories of ways of approaching research Methods Praxis Tools for data collection Theory Praxis Account of social reality that extends beyond data Methodology Praxis A plan for how research will proceed (combining methods, theory, and ethics) Ethics Philosophical and Praxis How one engages with, informs, and protects participants Values System Philosophical and Praxis Usefulness and distribution to the public, inclusion of underrepresented groups Reflexivity Philosophical and Praxis Attention to power, bias, and researcher positionality Element .  Philosophical or Praxis .  Definition .  Paradigm Philosophical Guiding worldview Ontology Philosophical The nature of social reality and what can be known about it Epistemology Philosophical The role of the researcher and researcher/participant relationship Genres Praxis Categories of ways of approaching research Methods Praxis Tools for data collection Theory Praxis Account of social reality that extends beyond data Methodology Praxis A plan for how research will proceed (combining methods, theory, and ethics) Ethics Philosophical and Praxis How one engages with, informs, and protects participants Values System Philosophical and Praxis Usefulness and distribution to the public, inclusion of underrepresented groups Reflexivity Philosophical and Praxis Attention to power, bias, and researcher positionality Open in new tab

Qualitative researchers may draw on scientific, humanistic, artistic, and other disciplinary forms. In this regard, qualitative research can be viewed as a scholarly, practical, and creative pursuit. Researchers need to be able to think analytically, symbolically, imaginatively, and metaphorically ( Saldaña, 2011 ). Moreover, projects often demand innovation, creativity, intuition, flexibility, and responsiveness (adapting to new learning or practical problems). This is a rigorous and often labor-intensive process. Qualitative research commonly requires working with others over an expanse of time and producing large amounts of data for analysis while also demanding sustained attention to ethics and values. It is also a creative process—allowing researchers to experiment, play, adapt, learn, and grow along the way.

Of course, pragmatic considerations come into play when designing a project: funding, time, access to needed participants or textual/preexisting data sources, and the researcher’s previous experience, skills, and personal preferences. Unfortunately, qualitative researchers are more often limited by practical issues than by their imaginative capabilities.

Despite these challenges, qualitative research is also a deeply rewarding process that may result in new learning about topics of import, increased self-awareness, the forging of meaningful relationships between co-creators of knowledge, the production of public scholarship, and the impetus for social change.

The Contents of This Handbook

As noted in the preface, no handbook can be all things to all people. It’s impossible to cover the entire field, and so I have approached the content with practicality in mind: what one learning about and/or embarking on qualitative research most needs to know, peppered with advanced material and prospective reviews intended to be of value to even the most experienced researchers.

Part 1 of this handbook, “The Qualitative Tradition,” offers a historical review of the field. Specifically, Part 1 presents an overview of the history of qualitative research in the social sciences and the ethical substructure of qualitative research practice.

In Chapter 2 , “Historical Overview of Qualitative Research in the Social Sciences,” Svend Brinkmann, Michael Hviid Jacobsen, and Søren Kristiansen provide a detailed history of qualitative research in the social sciences. As they note, this history is a complicated task because there is no agreed-upon version but rather a variety of perspectives. Accordingly, these authors present six histories of qualitative research: the conceptual history, the internal history, the marginalizing history, the repressed history, the social history, and the technological history. They also suggest that writing about history is necessarily tied up with writing about the future and thus conclude their contribution with a vision of the field. In Chapter 3 , “The History of Historical-Comparative Methods in Sociology,” Chares Demetriou and Victor Roudometof present an overview of the historical trajectory of comparative-historical sociology while considering the development of specific methodological approaches. Next is Anna Traianou’s chapter, “The Centrality of Ethics in Qualitative Research.” Attention to the ethical substructure of research is central to any qualitative practice and thus is given priority as the closing chapter in Part 1 . Traianou details the main ethical issues in qualitative practice, bearing in mind the changing sociohistorical climate in which research is carried out.

Part 2 of this handbook, “Approaches to Qualitative Research,” presents an array of philosophical approaches to qualitative research (all of which have implications for research praxis). Because qualitative research is a diverse tradition, it is impossible to adequately cover all of the approaches researchers may adopt. Nevertheless, Part 2 provides both an overview of the key approaches to qualitative research and detailed reviews of several commonly used approaches.

Part 2 opens with Renée Spencer, Julia M. Pryce, and Jill Walsh’s chapter, “Philosophical Approaches to Qualitative Research,” which provides a general view of the philosophical approaches that typically guide qualitative practice. They review post-positivism, constructivism, critical theory, feminism, and queer theory and offer a brief history of these approaches, considering the ontological, epistemological, and axiological assumptions on which they rest, and they detail some of their distinguishing features. They also identify three overarching, interrelated, and contested issues with which the field is being confronted: retaining the rich diversity that has defined the field, the articulation of recognizable standards for qualitative research, and the commensurability of differing approaches.

After the overview in Chapter 5 , we turn to in-depth treatments of specific approaches to qualitative research. In Chapter 6 , “Applied Interpretive Approaches,” Sally E. Thorne turns to the applied world of qualitative practice. Thorne considers how many applied scholars have been departing from established method to articulate approaches better suited to the questions of the applied world. This chapter considers the evolving relationship between the methods and their disciplinary origins and current trends in the direction of the applied interpretive qualitative project. Interpretive description is used as a methodological case in point to illustrate the kinds of departures that applied approaches are taking from their theoretical roots as they begin to advance knowledge development within applied contexts.

Chapter 7 , “The Grounded Theory Method” by Antony Bryant, reviews grounded theory, which, as Bryant notes, is itself a somewhat misleading term because it actually refers to a method that facilitates the development of new theoretical insights. Bryant’s suggestion about the complexity of the term itself is duly noted because this chapter could easily have been placed in Part 3 of this handbook. However, because grounded theory can be used in conjunction with more than one method of data collection, I have placed it in Part 2 as an approach to research. This chapter provides background information about the development of grounded theory as well as its main features, procedures outputs, and evaluation criteria.

The final three chapters in Part 2 tackle power-sensitive or social justice approaches to qualitative research that have emerged in the context of activist and scholarly work. In Chapter 8 , “Feminist Qualitative Research: Toward Transformation of Science and Society,” Maureen C. McHugh offers an in-depth treatment of feminist qualitative research, described in terms of its purposes of addressing women’s lives, advocacy for women, analysis of gender oppression, and transformation of society. The chapter covers topics including the feminist critiques of social science research, the transformation of science from empiricism to post-modernism (including intersectionality and double consciousness), reflexivity, collaboration, power analysis, advocacy, validity, and voice. Several qualitative approaches to research are described in relation to feminist research goals, with illustrations of feminist research. In Chapter 9 , “Critical Approaches to Qualitative Research,” Kum-Kum Bhavnani, Peter Chua, and Dana Collins reflect on critical strategies in qualitative research and examine the meanings and debates associated with the term “critical.” The authors contrast liberal and dialectical notions and practices in relations to social analysis and qualitative research. The chapter also explores how critical social research may be synonymous with critical ethnography in relation to issues of power, positionality, representation, and the production of situated knowledges. It uses Bhavnani’s (1993) framework to draw on Dana Collin’s research as a specific case to suggest how the notion of the “critical” relates to ethnographic research practices: ensuring feminist and queer accountability, resisting reinscription, and integrating lived experience. In Chapter 10 , “Decolonizing Research Practice: Indigenous Methodologies, Aboriginal Methods, and Knowledge/Knowing,” Mike Evans, Adrian Miller, Peter Hutchinson, and Carlene Dingwall review Indigenous approaches to research that are fundamentally rooted in the traditions and knowledge systems of Indigenous peoples themselves. The authors suggest Indigenous methodologies and methods have become both systems for generating knowledge and ways of responding to the processes of colonization. They describe two approaches drawn from the work of two Indigenous scholars with their communities in Australia and Canada. They hope this work leads not only to better, more pertinent research that is well disseminated but also to improvement in the situations of Indigenous communities and peoples.

The third section of this handbook, “Narrative Inquiry, Field Research, and Interview Methods,” provides chapters on a range of methods for collecting data directly from people (groups or individuals) or by systematically observing people engaged in activities in natural settings.

Part 3 begins with Chapter 11 , “Practicing Narrative Inquiry,” by Arthur P. Bochner and Nicholas A. Riggs. Arguably, this is a chapter that could have appeared just as easily in Part 2 because narrative is as much an approach to research as a method, or in Part 4 because narrative inquiry can be employed in the context of text- or arts-based research, or even in Part 6 as an approach to analysis. This chapter focuses on the development of the turn toward narrative in the human sciences. The authors trace the rise of narrative inquiry as it evolved in the aftermath of the crisis of representation in the social sciences, locating the explosion of interest in stories and storytelling in changing population demographics and the debunking of venerable notions about scientific knowledge. They show how narrative inquiry offered an opportunity to humanize the human sciences, placing people, meaning, and personal identity at the center of inquiry; inviting the development of reflexive, relational, dialogic, and interpretive methodologies; and drawing attention to the need to focus not only on the actual but also on the possible and the good. The chapter attempts to synthesize the changing methodological orientations of qualitative researchers associated with narrative inquiry, as well as their ethical commitments. In the second half of the chapter, the focus shifts to the divergent standpoints of small-story and big-story researchers; the differences between narrative analysis and narratives-under-analysis; and various narrative practices that seek to help people form better relationships, overcome oppressive canonical identities, amplify or reclaim moral agency, and cope better with contingencies and difficulties experienced over the course of life.

Chapter 12 , “Ethnography,” by Anthony Kwame Harrison, presents a new take on a classic method of qualitative research. Embracing the trope of ethnography-as-narrative, this chapter uses the mythic story of Bronislaw Malinowski’s—the reputed “founding father” of the ethnographic approach—early career and fieldwork as a vehicle through which to explore key aspects of ethnography’s history and development into a distinct form of qualitative research. Through a series of intervallic steps—in and out of Malinowski’s path from Poland to the “Cambridge School” and eventually to the western Pacific—Harrison traces the legacy of ethnography to its current position as a critical, historically informed, and unfailingly evolving research endeavor. Harrison suggests that, as a method continually reflected on and revised, ethnography is boundless.

In Chapter 13 , “The Purposes, Practices, and Principles of Autoethnographic Research,” Carolyn Ellis and Tony E. Adams define autoethnography according to their practice of the method, and they describe its history and emergence within qualitative social research and within psychology. They propose general guiding principles for those seeking to do autoethnography, such as using personal experience, acknowledging existing research, understanding and critiquing cultural experience, using insider knowledge, breaking silence, and maneuvering through pain, confusion, anger, and uncertainty. They present autoethnography as a process and as a product, one that can take a variety of representational forms. After offering ways to evaluate and critique autoethnography, they conclude with a discussion of autoethnography as an orientation to the living of life and an approach that has the potential of making life better—for the writer, reader, participant, and larger culture.

Switching gears from generating data from one’s own experiences to interviewing others, the next three chapters detail different methods of interview. Chapter 14 , “Unstructured and Semistructured Interviewing,” by Svend Brinkmann, provides an introduction to qualitative interviewing as a social practice with a cultural history. Issues addressed include different levels of structure, numbers of participants, media of interviewing, and also interviewer styles. A more detailed exposition of semistructured life world interviewing is offered, as Brinkmann suggests this is arguably the standard form of qualitative interviewing today. The next chapter is “Oral History Interviewing: Issues and Possibilities” by Valerie J. Janesick. As she explains, oral history resides in storytelling and involves the collection of stories, statements, and reminiscences of a person or persons who have firsthand knowledge of any number of experiences. Oral history offers qualitative researchers a way to capture the lived experiences of participants. The techniques of oral history may include interviews, document analysis, photographs, and video. Three major issues that emerge are those of social justice, arts-based approaches to oral history, and transdisciplinarity. Janesick notes that, in the current climate, there are endless possibilities in terms of using digital techniques for data presentation, data analysis, and dissemination. In Chapter 16 , “Focus Group Research: Retrospect and Prospect,” by George Kamberelis and Greg Dimitriadis, we turn to a method of group interviewing. First, the authors highlight the historical origins, tensions, and continuities/discontinuities of focus group research. Second, they suggest that focus group research embodies three primary, related functions: an inquiry function, a pedagogical function, and a political function. Third, they explore issues including mitigating the researcher’s authority; disclosing the constitutive power of discourse; approximating the natural; filling in knowledge gaps and saturating understanding; drawing out complexity, nuance, and contradiction; disclosing eclipsed connections; and creating opportunities for political activism. Fourth, they discuss contemporary threats to focus group work, and they conclude with what they see as new research frontiers for focus group research, especially in relation to new information technologies.

Part 3 concludes with Erica Tucker’s chapter “Museum Studies” which, as an entire area of study, arguably could have been placed in other sections of the handbook (such as the next section on multimethod research). However, given that museum studies often involve ethnographic observations in natural settings, I conclude Part 3 with this chapter. Tucker reviews the major research methods used to study museums, including gallery analyses and interviews with museum visitors, professionals, and stakeholders, as well as ethnographic fieldwork. Drawing from a range of case studies conducted by museum practitioners, anthropologists, historians, and other museum studies scholars, the author explores how these qualitative methods can be adapted to the study of exhibits, programs, and museums as knowledge-generating institutions. Approaches to research design, data analyses, and representation are also examined.

The next section of the handbook, “Text, Arts-Based, and Internet Methods,” considers how qualitative researchers work with nonliving data or through mediated forms. Although these methods are at times considered unobtrusive (because the data exist independent of the research; e.g., in the case of content analyzing newspapers), there are also many participatory approaches that are considered (such as participatory arts-based research).

Chapter 18 , “Content Analysis,” by Lindsay Prior, focuses on the ways in which content analysis can be used to investigate and describe interview and textual data. The author considers the method in both qualitative and quantitative social research. Examples of four different kinds of data are subjected to content analysis. Using a distinctive style of content analysis that calls on the notion of semantic networks, Prior shows how the method can be used either independently or in conjunction with other forms of inquiry (including various styles of discourse analysis) to analyze data and also how it can be used to verify and underpin claims that arise out of analysis. The chapter ends with an overview of the different ways in which the study of “content”—especially the study of document content—can be positioned in social scientific research projects.

Chapter 19 , “Photography as a Research Method,” by Gunilla Holm, reviews the development of photography as a research method in social sciences. Holm describes the different types of photographs used, such as archival photographs, photographs taken by the researcher, and photographs taken by participants. The uses of different approaches to obtain photographs and issues of interest concerning each approach are presented. The most common approaches to analyze photographs, such as content analysis, discourse analysis, and ethnographic analysis, are described. Questions surrounding interpretation and ethical practice are also considered.

Chapter 20 , “Arts-Based Research Practice: Merging Social Research and the Creative Arts,” by Gioia Chilton and Patricia Leavy, offers an overview of the emerging genre of arts-based research (ABR). ABR adapts the tenets of the creative arts in social research in order to approach research questions in new ways, ask new questions, and make research findings publicly accessible, evocative, and engaged. The authors provide a retrospective and prospective overview of the field, including a review of the some of the pioneers of ABR, methodological principles, robust examples of ABR within different artistic genres, assessment criteria, and the future of the field.

The final chapter in this section of the handbook is “Qualitative Approaches in Internet-Mediated Research: Opportunities, Issues, Possibilities” by Claire Hewson. Internet-mediated research (IMR) has grown expansively over the past decade, in both its scope and range of methodological possibilities and in its breadth of penetration across disciplines and research domains. However, the use of IMR approaches to support qualitative research has lagged behind its application in supporting quantitative methods. This chapter discusses the possibilities and scope for using IMR methods in qualitative research and considers some of the issues and debates that have led some qualitative researchers to be reluctant to consider this approach as a viable alternative to traditional offline methods. Hewson adopts an optimistic stance on the potential for qualitative IMR and outlines a range of possible methods and strategies, punctuated with examples of successful (as well as less successful) studies. The chapter also covers practical issues and offers a commentary on the possible future of IMR.

Part 5 of the handbook, “Multimethod, Mixed Method, and Participatory Designs,” focuses on approaches to research that typically rely on the use of more than one method of data collection and/or the participation of nonacademic stakeholders. Several of the chapters in this section could easily have been placed in Part 2 of the handbook because they can be viewed as “approaches” to research. Again, this illustrates how fluid the field of qualitative research is, with its overlaps in definitions and practice. Notwithstanding the suggestion that some of these chapters cover broad approaches to research, I have placed them in this section of the handbook because they generally involve the use of more than one method.

Chapter 22 , “Case Study Research: In-Depth Understanding in Context,” by Helen R. Simons, explores case study as a major approach to research and evaluation. After first noting various contexts in which case studies are commonly used, the chapter focuses on case study research directly. Strengths and potential problematic issues are outlined, as are key phases of the process. The chapter emphasizes how important it is to design the case, to collect and interpret data in ways that highlight the qualitative, to have an ethical practice that values multiple perspectives and political interests, and to report creatively to facilitate use in policy making and practice. Finally, the chapter explores how to generalize from the singular case. Concluding questions center on the need to think more imaginatively about design and the range of methods and forms of reporting available to persuade audiences to value qualitative ways of knowing in case study research.

In Chapter 23 , “Program Evaluation,” Paul R. Brandon and Anna L. Ah Sam offer a detailed overview of program evaluation situated in the historical context in which this practice has developed. The chapter includes discussion regarding the choice of methods, some of which are used primarily within evaluation approaches to conducting evaluation; the aspects of programs that evaluators typically address; the concept of value; the differences between evaluation and social science research; research on evaluation topics; and the major evaluation issues and concerns that have dominated discussion in the literature.

The following two chapters cover approaches to research that involve community participation. Chapter 24 “Community-Based Research: Understanding the Principles, Practices, Challenges, and Rationale,” by Margaret R. Boyd, reviews the inclusion of community members in research practice. This chapter is an introduction to the historical roots and subdivisions within community-based research (CBR) and discusses the core principles and skills useful when designing and working with community members in a collaborative, innovative, and transformative research partnership. The rationale for working within this research paradigm is discussed as are the challenges researchers and practitioners face when conducting CBR. Boyd suggests CBR challenges the traditional research paradigm by recognizing that complex social problems must involve multiple stakeholders in the research process—not as subjects but as co-investigators and co-authors. It is an “orientation to inquiry” rather than a methodology and reflects a transdisciplinary paradigm by including academics from many different disciplines, community members, activists, and often students in all stages of the research process. As the scholarship and practice of this form of research has increased dramatically over the past twenty years, this chapter looks at both new and emerging issues, as well as at founding questions that continue to draw debate in the contemporary discourse. In Chapter 25 , “Lineages: A Past, Present, and Future of Participatory Action Research,” Sarah Zeller-Berkman provides a historical overview of participatory action research (PAR). Like CBR, this is a social justice–oriented approach to research that transcends method but relies on a variety of qualitative methods. Zeller-Berkman writes that PAR in the twenty-first century asserts a democratization of who has the right to create knowledge, research social conditions, engage in participatory processes, and take action. People using PAR generally believe that knowledge has and will continue to be a source of power. Participatory research is an attempt to shift the balance of power back in favor of people who have historically been denied representational power.

The next chapter in the handbook covers the methodological work being done in the content area of disaster research. 4 In “Qualitative Disaster Research,” Brenda D. Phillips provides an overview of the history of qualitative disaster research since the 1920s. Challenges associated with conducting disaster research, particularly field-based studies, are presented. The chapter also discusses ethical challenges related to homeland security and the emotional impacts of disaster research on humans. Sections then lay out issues specific to the life cycle of disasters (preparedness, response, mitigation, and recovery), data gathering techniques commonly used (interviews, documents, observations, visual data), and strategies for data analysis. A final section links efforts to strengthen the trustworthiness and credibility of qualitative research to disaster studies.

The final chapter in this section of the handbook covers mixed-methods research. In Chapter 27 , “Conducting Mixed-Methods Research: Using Dialectical Pluralism and Social Psychological Strategies,” R. Burke Johnson, Tony Onwuegbuzie, Susan Tucker, and Marjorie L. Icenogle first summarize the philosophy of dialectical pluralism (DP). Ontologically, DP views reality as plural and changing. Epistemologically, DP follows a dialectical, dialogical, hermeneutical approach to listening, interacting, and learning from “the other.” Theoretically, DP integrates concepts especially from Rawls (e.g., procedural justice, reasonable pluralism, overlapping consensus, realistic utopia), Dewey (e.g., deliberative democracy, community, inquiry, growth), and Habermas (e.g., communicative rationality, deliberative democracy, discourse ethics, knowledge, public sphere). From empirical research, the authors draw on concepts and findings from social psychological literatures such as conflict management, negotiation, small-group psychology, group counseling, group dynamics, political diplomacy, deliberative democracy, and workplace justice. Dialectal pluralism requires purposeful construction of teams that include multiple/different values and perspectives and stakeholders from the most disadvantaged affected groups. The group process operates from the position of equal power, the use of social psychological strategies, and the working toward win-win solutions.

Part 6 of the handbook, “Analysis, Interpretation, Representation, and Evaluation,” covers a range of topics, including the analysis and interpretation of qualitative data, writing up qualitative research, and issues pertaining to evaluation.

The first two chapters in this section review qualitative data analysis. Chapter 28 , “Coding and Analysis Strategies,” by Johnny Saldaña, provides an overview of selected qualitative data analytic strategies, with a particular focus on codes and coding. Preparatory strategies for a qualitative research study and data management are first outlined. Six coding methods are then profiled using comparable interview data: process coding, in vivo coding, descriptive coding, values coding, dramaturgical coding, and versus coding. Strategies for constructing themes and assertions from the data then follow. Analytic memo writing is woven throughout the preceding as a method for generating additional analytic insight. Next, display- and arts-based strategies are provided, followed by recommended qualitative data analytic software programs and a discussion on verifying the researcher’s analytic findings. Chapter 29 , “Computer-Assisted Analysis of Qualitative Research,” by Christina Silver and Ann F. Lewins, picks up on the discussion of qualitative data analytic software programs (although it should be noted that this chapter also considers how technology can be used in data collection). Silver and Lewins focus on the current state of technological support for qualitative research practice. The chapter focuses on technology and how it assists three main aspects of qualitative research: data collection, preparation, and/or transcription; bibliographic management and systematic literature reviews; and data management and analysis. The main body of the chapter discusses the functionality, role, and implications of Computer Assisted Qualitative Data AnalysiS (CAQDAS) tools. Three recent trends in computer assistance are emphasized: support for visual analysis, support for mixed-methods approaches, and online solutions.

Moving from data analysis to interpretation, Chapter 30 , “Interpretation Strategies: Appropriate Concepts,” by Allen Trent and Jeasik Cho, presents a wide range of concepts related to interpretation in qualitative research. The chapter examines the meaning and importance of interpretation in qualitative inquiry and explores the ways methodology, data, and the self/researcher as instrument interact and impact interpretive processes. Additionally, the chapter presents a series of strategies for qualitative researchers engaged in the process of interpretation. The chapter closes by presenting a framework for qualitative researchers designed to inform their interpretations. The framework includes attention to the key qualitative research concepts transparency, reflexivity, analysis, validity, evidence, and literature. Four questions frame the chapter: What is interpretation and why are interpretive strategies important in qualitative research? How do methodology, data, and the researcher/self impact interpretation in qualitative research? How do qualitative researchers engage in the process of interpretation? And, in what ways can a framework for interpretation strategies support qualitative researchers across multiple methodologies and paradigms?

Chapter 31 , “Writing Up Qualitative Research,” by Jane Gilgun, provides guidelines for writing journal articles based on qualitative approaches. The guidelines are a part of the tradition of the Chicago School of Sociology and the author’s experience as an author and reviewer. The guidelines include understanding experiences in context, immersion, interpretations grounded in accounts of informants’ lived experiences, and conceiving of research as action-oriented. Gilgun suggests excellent write-ups have “grab”; that is, accounts that jump off the page and convey a sense of lived experiences. Although most of the chapter addresses the writing of conventional research reports, there is some coverage of writing articles that report findings resulting from ethnographies, autoethnographies, performances, poetry, and photography and other media.

The final chapter in this section of the handbook, “Evaluating Qualitative Research,” by Jeasik Cho and Allen Trent, addresses a wide range of theories and practices related to the evaluation of qualitative research (EQR). The authors present six categories of EQR: (1) a positivist category; (2) Lincoln and Guba’s alternative category; (3) a “subtle-realist” category developed by Hammersley, Atkinson, and Seale; (4) a general EQR category; (5) a category of post-criteriology; and (6) a post-validity category. The authors offer several evaluation strategies for EQR by providing a variety of examples. They also discuss a path forward for EQR. They conclude with a holistic view of EQR needed to collectively construct/confront inner and outer challenges to qualitative paradigms in the twenty-first century.

The final section of the handbook, “Conclusion: Politics and The Public,” offers some final thoughts about the politics of qualitative research, the importance of public scholarship, and the future of qualitative research in a transdisciplinary context.

In Chapter 33 , “The Politics of Research,” Michael D. Giardina and Joshua I. Newman critically interrogate the politics of research currently dominating US higher education, a politics that is shaped as much by theoretical and methodological questions and debates as it is by prevailing social, cultural, political, and economic forces. The authors’ arguments are guided by four primary questions: How and to what do the cultural and political priorities of the free-marketized, corporate university impact, direct, or confound the conduct of research? How and to what extent does politics situate methodologies? How and to what extent is the research act impinged on by such particularities as institutional review boards, national funding councils, scholarly journals, and the promotion and tenure process? And, how and where do we as academics fit into this new research climate? Giardina and Newman also provide a series of practical recommendations for professors and students alike who seek to actively confront and challenge the academic–industrial complex.

The closing chapter, “A Brief Statement on the Public and the Future of Qualitative Research,” offers some final comments about the future of qualitative research. I suggest that there is a widespread move from a disciplinary to a transdisciplinary research structure in which problems of importance are at the center of research practices (see Leavy, 2011 ). Within this context, qualitative researchers are well positioned to advance because of their ability to develop responsive and flexible research designs and present their work in multiple formats. Furthermore, I note how the broader move toward public scholarship is propelling both the practice of qualitative research and the teaching of qualitative methods.

Thank you to Dr. Tony Adams for providing his thoughtful and most helpful feedback on an earlier draft of this chapter.

There is qualitative work that can be pointed to in the late 1800s and early 1900s. However, it was the use of ethnography and related methods in the 1920s by researchers at the University of Chicago who were primarily studying urbanization (popularly deemed “The Chicago School of Sociology”) that prompted the use of qualitative methods in sociology departments around the United States. In the 1960s, the qualitative tradition fully emerged.

Chapter 2 of this handbook, “Historical Overview of Qualitative Research in the Social Sciences,” by Brinkmann, Jacobsen, and Kristiansen, provides a rich discussion of the history of qualitative research in relation to quantitative research.

There has been little documentation of the methodological work done in this field and therefore this chapter represents a significant contribution to the literature on both qualitative research and disaster studies.

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• USC Libraries
• Research Guides

Organizing Your Social Sciences Research Paper

• Background Information
• Purpose of Guide
• Design Flaws to Avoid
• Independent and Dependent Variables
• Glossary of Research Terms
• Reading Research Effectively
• Narrowing a Topic Idea
• Broadening a Topic Idea
• Extending the Timeliness of a Topic Idea
• Academic Writing Style
• Applying Critical Thinking
• Choosing a Title
• Making an Outline
• Paragraph Development
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• Executive Summary
• The C.A.R.S. Model
• The Research Problem/Question
• Theoretical Framework
• Citation Tracking
• Content Alert Services
• Evaluating Sources
• Primary Sources
• Secondary Sources
• Tiertiary Sources
• Scholarly vs. Popular Publications
• Qualitative Methods
• Quantitative Methods
• Insiderness
• Using Non-Textual Elements
• Limitations of the Study
• Common Grammar Mistakes
• Writing Concisely
• Avoiding Plagiarism
• Footnotes or Endnotes?
• Further Readings
• Generative AI and Writing
• USC Libraries Tutorials and Other Guides
• Bibliography

Background information identifies and describes the history and nature of a well-defined research problem with reference to contextualizing existing literature. The background information should indicate the root of the problem being studied, appropriate context of the problem in relation to theory, research, and/or practice , its scope, and the extent to which previous studies have successfully investigated the problem, noting, in particular, where gaps exist that your study attempts to address. Background information does not replace the literature review section of a research paper; it is intended to place the research problem within a specific context and an established plan for its solution.

Fitterling, Lori. Researching and Writing an Effective Background Section of a Research Paper. Kansas City University of Medicine & Biosciences; Creating a Research Paper: How to Write the Background to a Study. DurousseauElectricalInstitute.com; Background Information: Definition of Background Information. Literary Devices Definition and Examples of Literary Terms.

Importance of Having Enough Background Information

Background information expands upon the key points stated in the beginning of your introduction but is not intended to be the main focus of the paper. It generally supports the question, what is the most important information the reader needs to understand before continuing to read the paper? Sufficient background information helps the reader determine if you have a basic understanding of the research problem being investigated and promotes confidence in the overall quality of your analysis and findings. This information provides the reader with the essential context needed to conceptualize the research problem and its significance before moving on to a more thorough analysis of prior research.

Forms of contextualization included in background information can include describing one or more of the following:

• Cultural -- placed within the learned behavior of a specific group or groups of people.
• Economic -- of or relating to systems of production and management of material wealth and/or business activities.
• Gender -- located within the behavioral, cultural, or psychological traits typically associated with being self-identified as male, female, or other form of  gender expression.
• Historical -- the time in which something takes place or was created and how the condition of time influences how you interpret it.
• Interdisciplinary -- explanation of theories, concepts, ideas, or methodologies borrowed from other disciplines applied to the research problem rooted in a discipline other than the discipline where your paper resides.
• Philosophical -- clarification of the essential nature of being or of phenomena as it relates to the research problem.
• Physical/Spatial -- reflects the meaning of space around something and how that influences how it is understood.
• Political -- concerns the environment in which something is produced indicating it's public purpose or agenda.
• Social -- the environment of people that surrounds something's creation or intended audience, reflecting how the people associated with something use and interpret it.
• Temporal -- reflects issues or events of, relating to, or limited by time. Concerns past, present, or future contextualization and not just a historical past.

Background information can also include summaries of important research studies . This can be a particularly important element of providing background information if an innovative or groundbreaking study about the research problem laid a foundation for further research or there was a key study that is essential to understanding your arguments. The priority is to summarize for the reader what is known about the research problem before you conduct the analysis of prior research. This is accomplished with a general summary of the foundational research literature [with citations] that document findings that inform your study's overall aims and objectives.

NOTE : Research studies cited as part of the background information of your introduction should not include very specific, lengthy explanations. This should be discussed in greater detail in your literature review section. If you find a study requiring lengthy explanation, consider moving it to the literature review section.

ANOTHER NOTE : In some cases, your paper's introduction only needs to introduce the research problem, explain its significance, and then describe a road map for how you are going to address the problem; the background information basically forms the introduction part of your literature review. That said, while providing background information is not required, including it in the introduction is a way to highlight important contextual information that could otherwise be hidden or overlooked by the reader if placed in the literature review section.

Background of the Problem Section: What do you Need to Consider? Anonymous. Harvard University; Hopkins, Will G. How to Write a Research Paper. SPORTSCIENCE, Perspectives/Research Resources. Department of Physiology and School of Physical Education, University of Otago, 1999; Green, L. H. How to Write the Background/Introduction Section. Physics 499 Powerpoint slides. University of Illinois; Pyrczak, Fred. Writing Empirical Research Reports: A Basic Guide for Students of the Social and Behavioral Sciences . 8th edition. Glendale, CA: Pyrczak Publishing, 2014; Stevens, Kathleen C. “Can We Improve Reading by Teaching Background Information?.” Journal of Reading 25 (January 1982): 326-329; Woodall, W. Gill. Writing the Background and Significance Section. Senior Research Scientist and Professor of Communication. Center on Alcoholism, Substance Abuse, and Addictions. University of New Mexico.

Structure and Writing Style

Providing background information in the introduction of a research paper serves as a bridge that links the reader to the research problem . Precisely how long and in-depth this bridge should be is largely dependent upon how much information you think the reader will need to know in order to fully understand the problem being discussed and to appreciate why the issues you are investigating are important.

From another perspective, the length and detail of background information also depends on the degree to which you need to demonstrate to your professor how much you understand the research problem. Keep this in mind because providing pertinent background information can be an effective way to demonstrate that you have a clear grasp of key issues, debates, and concepts related to your overall study.

The structure and writing style of your background information can vary depending upon the complexity of your research and/or the nature of the assignment. However, in most cases it should be limited to only one to two paragraphs in your introduction.

Given this, here are some questions to consider while writing this part of your introduction :

• Are there concepts, terms, theories, or ideas that may be unfamiliar to the reader and, thus, require additional explanation?
• Are there historical elements that need to be explored in order to provide needed context, to highlight specific people, issues, or events, or to lay a foundation for understanding the emergence of a current issue or event?
• Are there theories, concepts, or ideas borrowed from other disciplines or academic traditions that may be unfamiliar to the reader and therefore require further explanation?
• Is there a key study or small set of studies that set the stage for understanding the topic and frames why it is important to conduct further research on the topic?
• Y our study uses a method of analysis never applied before;
• Your study investigates a very esoteric or complex research problem;
• Your study introduces new or unique variables that need to be taken into account ; or,
• Your study relies upon analyzing unique texts or documents, such as, archival materials or primary documents like diaries or personal letters that do not represent the established body of source literature on the topic?

Almost all introductions to a research problem require some contextualizing, but the scope and breadth of background information varies depending on your assumption about the reader's level of prior knowledge . However, despite this assessment, background information should be brief and succinct and sets the stage for the elaboration of critical points or in-depth discussion of key issues in the literature review section of your paper.

Writing Tip

Background Information vs. the Literature Review

Incorporating background information into the introduction is intended to provide the reader with critical information about the topic being studied, such as, highlighting and expanding upon foundational studies conducted in the past, describing important historical events that inform why and in what ways the research problem exists, defining key components of your study [concepts, people, places, phenomena] and/or placing the research problem within a particular context. Although introductory background information can often blend into the literature review portion of the paper, essential background information should not be considered a substitute for a comprehensive review and synthesis of relevant research literature.

Hart, Cris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage, 1998; Pyrczak, Fred. Writing Empirical Research Reports: A Basic Guide for Students of the Social and Behavioral Sciences . 8th edition. Glendale, CA: Pyrczak Publishing, 2014.

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Qualitative Research Writing

• First Online: 11 November 2020

Cite this chapter

• Seyyed-Abdolhamid Mirhosseini 2  

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This chapter focuses on the presentation of qualitative studies in writing. Although not part of the technicalities of the process of inquiry itself, the quality of reporting the process and outcomes of research plays a crucial role in completing the research endeavor. Apart from sharing the research findings, research writing can serve two other purposes. The very attempt at preparing an account of a study to be read by outsiders can help researchers distance themselves from the details of the project and notice the possible shortcomings. Moreover, a transparent presentation of the details of the research process and illustrating the findings in qualitative writing can facilitate corroboration and contribute to the overall process of taking care of the quality of qualitative research. The chapter also briefly addresses publishing qualitative language education research and introduces some related journals.

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Mirhosseini, SA. (2020). Qualitative Research Writing. In: Doing Qualitative Research in Language Education. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-030-56492-6_10

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Methodology

• What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

Published on June 19, 2020 by Pritha Bhandari . Revised on June 22, 2023.

Qualitative research involves collecting and analyzing non-numerical data (e.g., text, video, or audio) to understand concepts, opinions, or experiences. It can be used to gather in-depth insights into a problem or generate new ideas for research.

Qualitative research is the opposite of quantitative research , which involves collecting and analyzing numerical data for statistical analysis.

Qualitative research is commonly used in the humanities and social sciences, in subjects such as anthropology, sociology, education, health sciences, history, etc.

• How does social media shape body image in teenagers?
• How do children and adults interpret healthy eating in the UK?
• What factors influence employee retention in a large organization?
• How is anxiety experienced around the world?
• How can teachers integrate social issues into science curriculums?

Table of contents

Approaches to qualitative research, qualitative research methods, qualitative data analysis, advantages of qualitative research, disadvantages of qualitative research, other interesting articles, frequently asked questions about qualitative research.

Qualitative research is used to understand how people experience the world. While there are many approaches to qualitative research, they tend to be flexible and focus on retaining rich meaning when interpreting data.

Common approaches include grounded theory, ethnography , action research , phenomenological research, and narrative research. They share some similarities, but emphasize different aims and perspectives.

Note that qualitative research is at risk for certain research biases including the Hawthorne effect , observer bias , recall bias , and social desirability bias . While not always totally avoidable, awareness of potential biases as you collect and analyze your data can prevent them from impacting your work too much.

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Each of the research approaches involve using one or more data collection methods . These are some of the most common qualitative methods:

• Observations: recording what you have seen, heard, or encountered in detailed field notes.
• Interviews:  personally asking people questions in one-on-one conversations.
• Focus groups: asking questions and generating discussion among a group of people.
• Surveys : distributing questionnaires with open-ended questions.
• Secondary research: collecting existing data in the form of texts, images, audio or video recordings, etc.
• You take field notes with observations and reflect on your own experiences of the company culture.
• You distribute open-ended surveys to employees across all the company’s offices by email to find out if the culture varies across locations.
• You conduct in-depth interviews with employees in your office to learn about their experiences and perspectives in greater detail.

Qualitative researchers often consider themselves “instruments” in research because all observations, interpretations and analyses are filtered through their own personal lens.

For this reason, when writing up your methodology for qualitative research, it’s important to reflect on your approach and to thoroughly explain the choices you made in collecting and analyzing the data.

Qualitative data can take the form of texts, photos, videos and audio. For example, you might be working with interview transcripts, survey responses, fieldnotes, or recordings from natural settings.

Most types of qualitative data analysis share the same five steps:

• Prepare and organize your data. This may mean transcribing interviews or typing up fieldnotes.
• Review and explore your data. Examine the data for patterns or repeated ideas that emerge.
• Develop a data coding system. Based on your initial ideas, establish a set of codes that you can apply to categorize your data.
• Assign codes to the data. For example, in qualitative survey analysis, this may mean going through each participant’s responses and tagging them with codes in a spreadsheet. As you go through your data, you can create new codes to add to your system if necessary.
• Identify recurring themes. Link codes together into cohesive, overarching themes.

There are several specific approaches to analyzing qualitative data. Although these methods share similar processes, they emphasize different concepts.

Qualitative research often tries to preserve the voice and perspective of participants and can be adjusted as new research questions arise. Qualitative research is good for:

• Flexibility

The data collection and analysis process can be adapted as new ideas or patterns emerge. They are not rigidly decided beforehand.

• Natural settings

Data collection occurs in real-world contexts or in naturalistic ways.

• Meaningful insights

Detailed descriptions of people’s experiences, feelings and perceptions can be used in designing, testing or improving systems or products.

• Generation of new ideas

Open-ended responses mean that researchers can uncover novel problems or opportunities that they wouldn’t have thought of otherwise.

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Researchers must consider practical and theoretical limitations in analyzing and interpreting their data. Qualitative research suffers from:

• Unreliability

The real-world setting often makes qualitative research unreliable because of uncontrolled factors that affect the data.

• Subjectivity

Due to the researcher’s primary role in analyzing and interpreting data, qualitative research cannot be replicated . The researcher decides what is important and what is irrelevant in data analysis, so interpretations of the same data can vary greatly.

• Limited generalizability

Small samples are often used to gather detailed data about specific contexts. Despite rigorous analysis procedures, it is difficult to draw generalizable conclusions because the data may be biased and unrepresentative of the wider population .

• Labor-intensive

Although software can be used to manage and record large amounts of text, data analysis often has to be checked or performed manually.

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.

• Chi square goodness of fit test
• Degrees of freedom
• Null hypothesis
• Discourse analysis
• Control groups
• Mixed methods research
• Non-probability sampling
• Quantitative research
• Inclusion and exclusion criteria

Research bias

• Rosenthal effect
• Implicit bias
• Cognitive bias
• Selection bias
• Negativity bias
• Status quo bias

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

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

There are five common approaches to qualitative research :

• Grounded theory involves collecting data in order to develop new theories.
• Ethnography involves immersing yourself in a group or organization to understand its culture.
• Narrative research involves interpreting stories to understand how people make sense of their experiences and perceptions.
• Phenomenological research involves investigating phenomena through people’s lived experiences.
• Action research links theory and practice in several cycles to drive innovative changes.

Data collection is the systematic process by which observations or measurements are gathered in research. It is used in many different contexts by academics, governments, businesses, and other organizations.

There are various approaches to qualitative data analysis , but they all share five steps in common:

• Prepare and organize your data.
• Review and explore your data.
• Develop a data coding system.
• Assign codes to the data.
• Identify recurring themes.

The specifics of each step depend on the focus of the analysis. Some common approaches include textual analysis , thematic analysis , and discourse analysis .

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Qualitative research in education : Background information

• Background information

• SAGE researchmethods SAGE Research Methods is a tool created to help researchers, faculty and students with their research projects. Users can explore methods concepts to help them design research projects, understand particular methods or identify a new method, conduct their research, and write up their findings. Since SAGE Research Methods focuses on methodology rather than disciplines, it can be used across the social sciences, health sciences, and other areas of research.
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How to Write the Background of the Study in Research (Part 1)

Background of the Study in Research: Definition and the Core Elements it Contains

Before we embark on a detailed discussion on how to write the background of the study of your proposed research or thesis, it is important to first discuss its meaning and the core elements that it should contain. This is obviously because understanding the nature of the background of the study in research and knowing exactly what to include in it allow us to have both greater control and clear direction of the writing process.

So, what really is the background of the study and what are the core elements that it should contain?

The background of the study, which usually forms the first section of the introduction to a research paper or thesis, provides the overview of the study. In other words, it is that section of the research paper or thesis that establishes the context of the study. Its main function is to explain why the proposed research is important and essential to understanding the main aspects of the study.

The background of the study, therefore, is the section of the research paper or thesis that identifies the problem or gap of the study that needs to addressed and justifies the need for conducting the study. It also articulates the main goal of the study and the thesis statement, that is, the main claim or argument of the paper.

Given this brief understanding of the background of the study, we can anticipate what readers or thesis committee members expect from it. As we can see, the background of the study should contain the following major points:

1) brief discussion on what is known about the topic under investigation; 2) An articulation of the research gap or problem that needs to be addressed; 3) What the researcher would like to do or aim to achieve in the study ( research goal); 4) The thesis statement, that is, the main argument or contention of the paper (which also serves as the reason why the researcher would want to pursue the study); 5) The major significance or contribution of the study to a particular discipline; and 6) Depending on the nature of the study, an articulation of the hypothesis of the study.

Thus, when writing the background of the study, you should plan and structure it based on the major points just mentioned. With this, you will have a clear picture of the flow of the tasks that need to be completed in writing this section of your research or thesis proposal.

Now, how do you go about writing the background of the study in your proposed research or thesis?

The next lessons will address this question.

How to Write the Opening Paragraphs of the Background of the Study?

To begin with, let us assume that you already have conducted a preliminary research on your chosen topic, that is, you already have read a lot of literature and gathered relevant information for writing the background of your study. Let us also assume that you already have identified the gap of your proposed research and have already developed the research questions and thesis statement. If you have not yet identified the gap in your proposed research, you might as well go back to our lesson on how to identify a research gap.

So, we will just put together everything that you have researched into a background of the study (assuming, again, that you already have the necessary information). But in this lesson, let’s just focus on writing the opening paragraphs.

It is important to note at this point that there are different styles of writing the background of the study. Hence, what I will be sharing with you here is not just “the” only way of writing the background of the study. As a matter of fact, there is no “one-size-fits-all” style of writing this part of the research or thesis. At the end of the day, you are free to develop your own. However, whatever style it would be, it always starts with a plan which structures the writing process into stages or steps. The steps that I will share with below are just some of the most effective ways of writing the background of the study in research.

So, let’s begin.

It is always a good idea to begin the background of your study by giving an overview of your research topic. This may include providing a definition of the key concepts of your research or highlighting the main developments of the research topic.

Let us suppose that the topic of your study is the “lived experiences of students with mathematical anxiety”.

Here, you may start the background of your study with a discussion on the meaning, nature, and dynamics of the term “mathematical anxiety”. The reason for this is too obvious: “mathematical anxiety” is a highly technical term that is specific to mathematics. Hence, this term is not readily understandable to non-specialists in this field.

So, you may write the opening paragraph of your background of the study with this:

“Mathematical anxiety refers to the individual’s unpleasant emotional mood responses when confronted with a mathematical situation.”

Since you do not invent the definition of the term “mathematical anxiety”, then you need to provide a citation to the source of the material from which you are quoting. For example, you may now say:

“Mathematical anxiety refers to the individual’s unpleasant emotional mood responses when confronted with a mathematical situation (Eliot, 2020).”

And then you may proceed with the discussion on the nature and dynamics of the term “mathematical anxiety”. You may say:

“Lou (2019) specifically identifies some of the manifestations of this type of anxiety, which include, but not limited to, depression, helplessness, nervousness and fearfulness in doing mathematical and numerical tasks.”

After explaining to your readers the meaning, nature, and dynamics (as well as some historical development if you wish to) of the term “mathematical anxiety”, you may now proceed to showing the problem or gap of the study. As you may already know, the research gap is the problem that needs to be addressed in the study. This is important because no research activity is possible without the research gap.

Let us suppose that your research problem or gap is: “Mathematical anxiety can negatively affect not just the academic achievement of the students but also their future career plans and total well-being. Also, there are no known studies that deal with the mathematical anxiety of junior high school students in New Zealand.” With this, you may say:

“If left unchecked, as Shapiro (2019) claims, this problem will expand and create a total avoidance pattern on the part of the students, which can be expressed most visibly in the form of cutting classes and habitual absenteeism. As we can see, this will negatively affect the performance of students in mathematics. In fact, the study conducted by Luttenberger and Wimmer (2018) revealed that the outcomes of mathematical anxiety do not only negatively affect the students’ performance in math-related situations but also their future career as professionals. Without a doubt, therefore, mathematical anxiety is a recurring problem for many individuals which will negatively affect the academic success and future career of the student.”

Now that you already have both explained the meaning, nature, and dynamics of the term “mathematical anxiety” and articulated the gap of your proposed research, you may now state the main goal of your study. You may say:

“Hence, it is precisely in this context that the researcher aims to determine the lived experiences of those students with mathematical anxiety. In particular, this proposed thesis aims to determine the lived experiences of the junior high school students in New Zealand and identify the factors that caused them to become disinterested in mathematics.”

Please note that you should not end the first paragraph of your background of the study with the articulation of the research goal. You also need to articulate the “thesis statement”, which usually comes after the research goal. As is well known, the thesis statement is the statement of your argument or contention in the study. It is more of a personal argument or claim of the researcher, which specifically highlights the possible contribution of the study. For example, you may say:

“The researcher argues that there is a need to determine the lived experiences of these students with mathematical anxiety because knowing and understanding the difficulties and challenges that they have encountered will put the researcher in the best position to offer some alternatives to the problem. Indeed, it is only when we have performed some kind of a ‘diagnosis’ that we can offer practicable solutions to the problem. And in the case of the junior high school students in New Zealand who are having mathematical anxiety, determining their lived experiences as well as identifying the factors that caused them to become disinterested in mathematics are the very first steps in addressing the problem.”

If we combine the bits and pieces that we have written above, we can now come up with the opening paragraphs of your background of the study, which reads:

As we can see, we can find in the first paragraph 5 essential elements that must be articulated in the background of the study, namely:

1) A brief discussion on what is known about the topic under investigation; 2) An articulation of the research gap or problem that needs to be addressed; 3) What the researcher would like to do or aim to achieve in the study (research goal); 4) The thesis statement , that is, the main argument or claim of the paper; and 5) The major significance or contribution of the study to a particular discipline. So, that’s how you write the opening paragraphs of your background of the study. The next lesson will talk about writing the body of the background of the study.

How to Write the Body of the Background of the Study?

If we liken the background of the study to a sitting cat, then the opening paragraphs that we have completed in the previous lesson would just represent the head of the cat.

This means we still have to write the body (body of the cat) and the conclusion (tail). But how do we write the body of the background of the study? What should be its content?

Truly, this is one of the most difficult challenges that fledgling scholars faced. Because they are inexperienced researchers and didn’t know what to do next, they just wrote whatever they wished to write. Fortunately, this is relatively easy if they know the technique.

One of the best ways to write the body of the background of the study is to attack it from the vantage point of the research gap. If you recall, when we articulated the research gap in the opening paragraphs, we made a bold claim there, that is, there are junior high school students in New Zealand who are experiencing mathematical anxiety. Now, you have to remember that a “statement” remains an assumption until you can provide concrete proofs to it. This is what we call the “epistemological” aspect of research. As we may already know, epistemology is a specific branch of philosophy that deals with the validity of knowledge. And to validate knowledge is to provide concrete proofs to our statements. Hence, the reason why we need to provide proofs to our claim that there are indeed junior high school students in New Zealand who are experiencing mathematical anxiety is the obvious fact that if there are none, then we cannot proceed with our study. We have no one to interview with in the first. In short, we don’t have respondents.

The body of the background of the study, therefore, should be a presentation and articulation of the proofs to our claim that indeed there are junior high school students in New Zealand who are experiencing mathematical anxiety. Please note, however, that this idea is true only if you follow the style of writing the background of the study that I introduced in this course.

So, how do we do this?

One of the best ways to do this is to look for literature on mathematical anxiety among junior high school students in New Zealand and cite them here. However, if there are not enough literature on this topic in New Zealand, then we need to conduct initial interviews with these students or make actual classroom observations and record instances of mathematical anxiety among these students. But it is always a good idea if we combine literature review with interviews and actual observations.

Assuming you already have the data, then you may now proceed with the writing of the body of your background of the study. For example, you may say:

“According to records and based on the researcher’s firsthand experience with students in some junior high schools in New Zealand, indeed, there are students who lost interest in mathematics. For one, while checking the daily attendance and monitoring of the students, it was observed that some of them are not always attending classes in mathematics but are regularly attending the rest of the required subjects.”

After this sentence, you may insert some literature that will support this position. For example, you may say:

“As a matter of fact, this phenomenon is also observed in the work of Estonanto. In his study titled ‘Impact of Math Anxiety on Academic Performance in Pre-Calculus of Senior High School’, Estonanto (2019) found out that, inter alia, students with mathematical anxiety have the tendency to intentionally prioritize other subjects and commit habitual tardiness and absences.”

Then you may proceed saying:

“With this initial knowledge in mind, the researcher conducted initial interviews with some of these students. The researcher learned that one student did not regularly attend his math subject because he believed that he is not good in math and no matter how he listens to the topic he will not learn.”

Then you may say:

“Another student also mentioned that she was influenced by her friends’ perception that mathematics is hard; hence, she avoids the subject. Indeed, these are concrete proofs that there are some junior high school students in New Zealand who have mathematical anxiety. As already hinted, “disinterest” or the loss of interest in mathematics is one of the manifestations of a mathematical anxiety.”

If we combine what we have just written above, then we can have the first two paragraphs of the body of our background of the study. It reads:

“According to records and based on the researcher’s firsthand experience with students in some junior high schools in New Zealand, indeed there are students who lost interest in mathematics. For one, while checking the daily attendance and monitoring of the students, it was observed that some of them are not always attending classes in mathematics but are regularly attending the rest of the required subjects. As a matter of fact, this phenomenon is also observed in the work of Estonanto. In his study titled ‘Impact of Math Anxiety on Academic Performance in Pre-Calculus of Senior High School’, Estonanto (2019) found out that, inter alia, students with mathematical anxiety have the tendency to intentionally prioritize other subjects and commit habitual tardiness and absences.

With this initial knowledge in mind, the researcher conducted initial interviews with some of these students. The researcher learned that one student did not regularly attend his math subject because he believed that he is not good in math and no matter how he listens to the topic he will not learn. Another student also mentioned that she was influenced by her friends’ perception that mathematics is hard; hence, she avoids the subject. Indeed, these are concrete proofs that there are some junior high school students in New Zealand who have mathematical anxiety. As already hinted, “disinterest” or the loss of interest in mathematics is one of the manifestations of a mathematical anxiety.”

And then you need validate this observation by conducting another round of interview and observation in other schools. So, you may continue writing the body of the background of the study with this:

“To validate the information gathered from the initial interviews and observations, the researcher conducted another round of interview and observation with other junior high school students in New Zealand.”

“On the one hand, the researcher found out that during mathematics time some students felt uneasy; in fact, they showed a feeling of being tensed or anxious while working with numbers and mathematical problems. Some were even afraid to seat in front, while some students at the back were secretly playing with their mobile phones. These students also show remarkable apprehension during board works like trembling hands, nervous laughter, and the like.”

Then provide some literature that will support your position. You may say:

“As Finlayson (2017) corroborates, emotional symptoms of mathematical anxiety involve feeling of helplessness, lack of confidence, and being nervous for being put on the spot. It must be noted that these occasionally extreme emotional reactions are not triggered by provocative procedures. As a matter of fact, there are no personally sensitive questions or intentional manipulations of stress. The teacher simply asked a very simple question, like identifying the parts of a circle. Certainly, this observation also conforms with the study of Ashcraft (2016) when he mentions that students with mathematical anxiety show a negative attitude towards math and hold self-perceptions about their mathematical abilities.”

And then you proceed:

“On the other hand, when the class had their other subjects, the students show a feeling of excitement. They even hurried to seat in front and attentively participating in the class discussion without hesitation and without the feeling of being tensed or anxious. For sure, this is another concrete proof that there are junior high school students in New Zealand who have mathematical anxiety.”

To further prove the point that there indeed junior high school students in New Zealand who have mathematical anxiety, you may solicit observations from other math teachers. For instance, you may say:

“The researcher further verified if the problem is also happening in other sections and whether other mathematics teachers experienced the same observation that the researcher had. This validation or verification is important in establishing credibility of the claim (Buchbinder, 2016) and ensuring reliability and validity of the assertion (Morse et al., 2002). In this regard, the researcher attempted to open up the issue of math anxiety during the Departmentalized Learning Action Cell (LAC), a group discussion of educators per quarter, with the objective of ‘Teaching Strategies to Develop Critical Thinking of the Students’. During the session, one teacher corroborates the researcher’s observation that there are indeed junior high school students in New Zealand who have mathematical anxiety. The teacher pointed out that truly there were students who showed no extra effort in mathematics class in addition to the fact that some students really avoided the subject. In addition, another math teacher expressed her frustrations about these students who have mathematical anxiety. She quipped: “How can a teacher develop the critical thinking skills or ability of the students if in the first place these students show avoidance and disinterest in the subject?’.”

Again, if we combine what we have just written above, then we can now have the remaining parts of the body of the background of the study. It reads:

So, that’s how we write the body of the background of the study in research . Of course, you may add any relevant points which you think might amplify your content. What is important at this point is that you now have a clear idea of how to write the body of the background of the study.

How to Write the Concluding Part of the Background of the Study?

Since we have already completed the body of our background of the study in the previous lesson, we may now write the concluding paragraph (the tail of the cat). This is important because one of the rules of thumb in writing is that we always put a close to what we have started.

It is important to note that the conclusion of the background of the study is just a rehashing of the research gap and main goal of the study stated in the introductory paragraph, but framed differently. The purpose of this is just to emphasize, after presenting the justifications, what the study aims to attain and why it wants to do it. The conclusion, therefore, will look just like this:

“Given the above discussion, it is evident that there are indeed junior high school students in New Zealand who are experiencing mathematical anxiety. And as we can see, mathematical anxiety can negatively affect not just the academic achievement of the students but also their future career plans and total well-being. Again, it is for this reason that the researcher attempts to determine the lived experiences of those junior high school students in New Zealand who are experiencing a mathematical anxiety.”

If we combine all that we have written from the very beginning, the entire background of the study would now read:

If we analyze the background of the study that we have just completed, we can observe that in addition to the important elements that it should contain, it has also addressed other important elements that readers or thesis committee members expect from it.

On the one hand, it provides the researcher with a clear direction in the conduct of the study. As we can see, the background of the study that we have just completed enables us to move in the right direction with a strong focus as it has set clear goals and the reasons why we want to do it. Indeed, we now exactly know what to do next and how to write the rest of the research paper or thesis.

On the other hand, most researchers start their research with scattered ideas and usually get stuck with how to proceed further. But with a well-written background of the study, just as the one above, we have decluttered and organized our thoughts. We have also become aware of what have and have not been done in our area of study, as well as what we can significantly contribute in the already existing body of knowledge in this area of study.

Please note, however, as I already mentioned previously, that the model that I have just presented is only one of the many models available in textbooks and other sources. You are, of course, free to choose your own style of writing the background of the study. You may also consult your thesis supervisor for some guidance on how to attack the writing of your background of the study.

Lastly, and as you may already know, universities around the world have their own thesis formats. Hence, you should follow your university’s rules on the format and style in writing your research or thesis. What is important is that with the lessons that you learned in this course, you can now easily write the introductory part of your thesis, such as the background of the study.

• Open access
• Published: 02 April 2022

A qualitative study of rural healthcare providers’ views of social, cultural, and programmatic barriers to healthcare access

• Nicholas C. Coombs 1 ,
• Duncan G. Campbell 2 &
• James Caringi 1  

BMC Health Services Research volume  22 , Article number:  438 ( 2022 ) Cite this article

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Ensuring access to healthcare is a complex, multi-dimensional health challenge. Since the inception of the coronavirus pandemic, this challenge is more pressing. Some dimensions of access are difficult to quantify, namely characteristics that influence healthcare services to be both acceptable and appropriate. These link to a patient’s acceptance of services that they are to receive and ensuring appropriate fit between services and a patient’s specific healthcare needs. These dimensions of access are particularly evident in rural health systems where additional structural barriers make accessing healthcare more difficult. Thus, it is important to examine healthcare access barriers in rural-specific areas to understand their origin and implications for resolution.

We used qualitative methods and a convenience sample of healthcare providers who currently practice in the rural US state of Montana. Our sample included 12 healthcare providers from diverse training backgrounds and specialties. All were decision-makers in the development or revision of patients’ treatment plans. Semi-structured interviews and content analysis were used to explore barriers–appropriateness and acceptability–to healthcare access in their patient populations. Our analysis was both deductive and inductive and focused on three analytic domains: cultural considerations, patient-provider communication, and provider-provider communication. Member checks ensured credibility and trustworthiness of our findings.

Five key themes emerged from analysis: 1) a friction exists between aspects of patients’ rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US.

Conclusions

Inadequate access to healthcare is an issue in the US, particularly in rural areas. Rural healthcare consumers compose a hard-to-reach patient population. Too few providers exist to meet population health needs, and fragmented communication impairs rural health systems’ ability to function. These issues exacerbate the difficulty of ensuring acceptable and appropriate delivery of healthcare services, which compound all other barriers to healthcare access for rural residents. Each dimension of access must be monitored to improve patient experiences and outcomes for rural Americans.

Peer Review reports

Unequal access to healthcare services is an important element of health disparities in the United States [ 1 ], and there remains much about access that is not fully understood. The lack of understanding is attributable, in part, to the lack of uniformity in how access is defined and evaluated, and the extent to which access is often oversimplified in research [ 2 ]. Subsequently, attempts to address population-level barriers to healthcare access are insufficient, and access remains an unresolved, complex health challenge [ 3 , 4 , 5 ]. This paper presents a study that aims to explore some of the less well studied barriers to healthcare access, particularly those that influence healthcare acceptability and appropriateness.

In truth, healthcare access entails a complicated calculus that combines characteristics of individuals, their households, and their social and physical environments with characteristics of healthcare delivery systems, organizations, and healthcare providers. For one to fully ‘access’ healthcare, they must have the means to identify their healthcare needs and have available to them care providers and the facilities where they work. Further, patients must then reach, obtain, and use the healthcare services in order to have their healthcare needs fulfilled. Levesque and colleagues critically examined access conceptualizations in 2013 and synthesized all ways in which access to healthcare was previously characterized; Levesque et al. proposed five dimensions of access: approachability, acceptability, availability, affordability and appropriateness [ 2 ]. These refer to the ability to perceive, seek, reach, pay for, and engage in services, respectively.

According to Levesque et al.’s framework, the five dimensions combine to facilitate access to care or serve as barriers. Approachability indicates that people facing health needs understand that healthcare services exist and might be helpful. Acceptability represents whether patients see healthcare services as consistent or inconsistent with their own social and cultural values and worldviews. Availability indicates that healthcare services are reached both physically and in a timely manner. Affordability simplifies one’s capacity to pay for healthcare services without compromising basic necessities, and finally, appropriateness represents the fit between healthcare services and a patient’s specific healthcare needs [ 2 ]. This study focused on the acceptability and appropriateness dimensions of access.

Before the novel coronavirus (SARS-CoV-2; COVID-19) pandemic, approximately 13.3% of adults in the US did not have a usual source of healthcare [ 6 ]. Millions more did not utilize services regularly, and close to two-thirds reported that they would be debilitated by an unexpected medical bill [ 7 , 8 , 9 ]. Findings like these emphasized a fragility in the financial security of the American population [ 10 ]. These concerns were exacerbated by the pandemic when a sudden surge in unemployment increased un- and under-insurance rates [ 11 ]. Indeed, employer-sponsored insurance covers close to half of Americans’ total cost of illness [ 12 ]. Unemployment linked to COVID-19 cut off the lone outlet to healthcare access for many. Health-related financial concerns expanded beyond individuals, as healthcare organizations were unequipped to manage a simultaneous increase in demand for specialized healthcare services and a steep drop off for routine revenue-generating healthcare services [ 13 ]. These consequences of the COVID-19 pandemic all put additional, unexpected pressure on an already fragmented US healthcare system.

Other structural barriers to healthcare access exist in relation to the rural–urban divide. Less than 10% of US healthcare resources are located in rural areas where approximately 20% of the American population resides [ 14 ]. In a country with substantially fewer providers per capita compared to many other developed countries, persons in rural areas experience uniquely pressing healthcare provider shortages [ 15 , 16 ]. Rural inhabitants also tend to have lower household income, higher rates of un- or under-insurance, and more difficulty with travel to healthcare clinics than urban dwellers [ 17 ]. Subsequently, persons in rural communities use healthcare services at lower rates, and potentially preventable hospitalizations are more prevalent [ 18 ]. This disparity often leads rural residents to use services primarily for more urgent needs and less so for routine care [ 19 , 20 , 21 ].

The differences in how rural and urban healthcare systems function warranted a federal initiative to focus exclusively on rural health priorities and serve as counterpart to Healthy People objectives [ 22 ]. The rural determinants of health, a more specific expression of general social determinants, add issues of geography and topography to the well-documented social, economic and political factors that influence all Americans’ access to healthcare [ 23 ]. As a result, access is consistently regarded as a top priority in rural areas, and many research efforts have explored the intersection between access and rurality, namely within its less understood dimensions (acceptability and appropriateness) [ 22 ].

Acceptability-related barriers to care

Acceptability represents the dimension of healthcare access that affects a patient’s ability to seek healthcare, particularly linked to one’s professional values, norms and culture [ 2 ]. Access to health information is an influential factor for acceptable healthcare and is essential to promote and maintain a healthy population [ 24 ]. According to the Centers for Disease Control and Prevention, health literacy or a high ‘health IQ’ is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others, which impacts healthcare use and system navigation [ 25 ]. The literature indicates that lower levels of health literacy contribute to health disparities among rural populations [ 26 , 27 , 28 ]. Evidence points to a need for effective health communication between healthcare organizations and patients to improve health literacy [ 24 ]. However, little research has been done in this area, particularly as it relates to technologically-based interventions to disseminate health information [ 29 ].

Stigma, an undesirable position of perceived diminished status in an individual’s social position, is another challenge that influences healthcare acceptability [ 30 ]. Those who may experience stigma fear negative social consequences in relation to care seeking. They are more likely to delay seeking care, especially among ethnic minority populations [ 31 , 32 ]. Social media presents opportunities for the dissemination of misleading medical information; this runs further risk for stigma [ 33 ]. Stigma is difficult to undo, but research has shown that developing a positive relationship with a healthcare provider or organization can work to reduce stigma among patients, thus promoting healthcare acceptability [ 34 ].

A provider’s attempts to engage patients and empower them to be active decision-makers regarding their treatment has also been shown to improve healthcare acceptability. One study found that patients with heart disease who completed a daily diary of weight and self-assessment of symptoms, per correspondence with their provider, had better care outcomes than those who did not [ 35 ]. Engaging with household family members and involved community healers also mitigates barriers to care, emphasizing the importance of a team-based approach that extends beyond those who typically provide healthcare services [ 36 , 37 ]. One study, for instance, explored how individuals closest to a pregnant woman affect the woman’s decision to seek maternity care; partners, female relatives, and community health-workers were among the most influential in promoting negative views, all of which reduced a woman’s likelihood to access care [ 38 ].

Appropriateness-related barriers to care

Appropriateness marks the dimension of healthcare access that affects a patient’s ability to engage, and according to Levesque et al., is of relevance once all other dimensions (the ability to perceive, seek, reach and pay for) are achieved [ 2 ]. The ability to engage in healthcare is influenced by a patient’s level of empowerment, adherence to information, and support received by their healthcare provider. Thus, barriers to healthcare access that relate to appropriateness are often those that indicate a breakdown in communication between a patient with their healthcare provider. Such breakdown can involve a patient experiencing miscommunication, confrontation, and/or a discrepancy between their provider’s goals and their own goals for healthcare. Appropriateness represents a dimension of healthcare access that is widely acknowledged as an area in need of improvement, which indicates a need to rethink how healthcare providers and organizations can adapt to serve the healthcare needs of their communities [ 39 ]. This is especially true for rural, ethnic minority populations, which disproportionately experience an abundance of other barriers to healthcare access. Culturally appropriate care is especially important for members of minority populations [ 40 , 41 , 42 ]. Ultimately, patients value a patient-provider relationship characterized by a welcoming, non-judgmental atmosphere [ 43 , 44 ]. In rural settings especially, level of trust and familiarity are common factors that affect service utilization [ 45 ]. Evidence suggests that kind treatment by a healthcare provider who promotes patient-centered care can have a greater overall effect on a patient’s experience than a provider’s degree of medical knowledge or use of modern equipment [ 46 ]. Of course, investing the time needed to nurture close and caring interpersonal connections is particularly difficult in under-resourced, time-pressured rural health systems [ 47 , 48 ].

The most effective way to evaluate access to healthcare largely depends on which dimensions are explored. For instance, a population-based survey can be used to measure the barrier of healthcare affordability. Survey questions can inquire directly about health insurance coverage, care-related financial burden, concern about healthcare costs, and the feared financial impacts of illness and/or disability. Many national organizations have employed such surveys to measure affordability-related barriers to healthcare. For example, a question may ask explicitly about financial concerns: ‘If you get sick or have an accident, how worried are you that you will not be able to pay your medical bills?’ [ 49 ]. Approachability and availability dimensions of access are also studied using quantitative analysis of survey questions, such as ‘Is there a place that you usually go to when you are sick or need advice about your health?’ or ‘Have you ever delayed getting medical care because you couldn’t get through on the telephone?’ In contrast, the remaining two dimensions–acceptability and appropriateness–require a qualitative approach, as the social and cultural factors that determine a patient’s likelihood of accepting aspects of the services that are to be received (acceptability) and the fit between those services and the patient’s specific healthcare needs (appropriateness) can be more abstract [ 50 , 51 ]. In social science, qualitative methods are appropriate to generate knowledge of what social events mean to individuals and how those individuals interact within them; these methods allow for an exploration of depth rather than breadth [ 52 , 53 ]. Qualitative methods, therefore, are appropriate tools for understanding the depth of healthcare providers’ experiences in the inherently social context of seeking and engaging in healthcare.

In sum, acceptability- and appropriateness-related barriers to healthcare access are multi-layered, complex and abundant. Ensuring access becomes even more challenging if structural barriers to access are factored in. In this study, we aimed to explore barriers to healthcare access among persons in Montana, a historically underserved, under-resourced, rural region of the US. Montana is the fourth largest and third least densely populated state in the country; more than 80% of Montana counties are classified as non-core (the lowest level of urban/rural classification), and over 90% are designated as health professional shortage areas [ 54 , 55 ]. Qualitative methods supported our inquiry to explore barriers to healthcare access related to acceptability and appropriateness.

Participants

Qualitative methods were utilized for this interpretive, exploratory study because knowledge regarding barriers to healthcare access within Montana’s rural health systems is limited. We chose Montana healthcare providers, rather than patients, as the population of interest so we may explore barriers to healthcare access from the perspective of those who serve many persons in rural settings. Inclusion criteria required study participants to provide direct healthcare to patients at least one-half of their time. We defined ‘provider’ as a healthcare organization employee with clinical decision-making power and the qualifications to develop or revise patients’ treatment plans. In an attempt to capture a group of providers with diverse experience, we included providers across several types and specialties. These included advanced practice registered nurses (APRNs), physicians (MDs and DOs), and physician assistants (PAs) who worked in critical care medicine, emergency medicine, family medicine, hospital medicine, internal medicine, pain medicine, palliative medicine, pediatrics, psychiatry, and urgent care medicine. We also included licensed clinical social workers (LCSWs) and clinical psychologists who specialize in behavioral healthcare provision.

Recruitment and Data Collection

We recruited participants via email using a snowball sampling approach [ 56 ]. We opted for this approach because of its effectiveness in time-pressured contexts, such as the COVID-19 pandemic, which has made healthcare provider populations hard to reach [ 57 ]. Considering additional constraints with the pandemic and the rural nature of Montana, interviews were administered virtually via Zoom video or telephone conferencing with Zoom’s audio recording function enabled. All interviews were conducted by the first author between January and September 2021. The average length of interviews was 50 min, ranging from 35 to 70 min. There were occasional challenges experienced during interviews (poor cell phone reception from participants, dropped calls), in which case the interviewer remained on the line until adequate communication was resumed. All interviews were included for analysis and transcribed verbatim into NVivo Version 12 software. All qualitative data were saved and stored on a password-protected University of Montana server. Hard-copy field notes were securely stored in a locked office on the university’s main campus.

Data analysis included a deductive followed by an inductive approach. This dual analysis adheres to Levesque’s framework for qualitative methods, which is discussed in the Definition of Analytic Domains sub-section below. Original synthesis of the literature informed the development of our initial deductive codebook. The deductive approach was derived from a theory-driven hypothesis, which consisted of synthesizing previous research findings regarding acceptability- and appropriateness-related barriers to care. Although the locations, patient populations and specific type of healthcare services varied by study in the existing literature, several recurring barriers to healthcare access were identified. We then operationalized three analytic domains based on these findings: cultural considerations, patient-provider communication, and provider-provider communication. These domains were chosen for two reasons: 1) the terms ‘culture’ and ‘communication’ were the most frequently documented characteristics across the studies examined, and 2) they each align closely with the acceptability and appropriateness dimensions of access to healthcare, respectively. In addition, ‘culture’ is included in the definition of acceptability and ‘communication’ is a quintessential aspect of appropriateness. These domains guided the deductive portion of our analysis, which facilitated the development of an interview guide used for this study.

Interviews were semi-structured to allow broad interpretations from participants and expand the open-ended characterization of study findings. Data were analyzed through a flexible coding approach proposed by Deterding and Waters [ 58 ]. Qualitative content analysis was used, a method particularly beneficial for analyzing large amounts of qualitative data collected through interviews that offers possibility of quantifying categories to identify emerging themes [ 52 , 59 ]. After fifty percent of data were analyzed, we used an inductive approach as a formative check and repeated until data saturation, or the point at which no new information was gathered in interviews [ 60 ]. At each point of inductive analysis, interview questions were added, removed, or revised in consideration of findings gathered [ 61 ]. The Standards for Reporting Qualitative Research (SRQR) was used for reporting all qualitative data for this study [ 62 ]. The first and third authors served as primary and secondary analysts of the qualitative data and collaborated to triangulate these findings. An audit approach was employed, which consisted of coding completed by the first author and then reviewed by the third author. After analyses were complete, member checks ensured credibility and trustworthiness of findings [ 63 ]. Member checks consisted of contacting each study participant to explain the study’s findings; one-third of participants responded and confirmed all findings. All study procedures were reviewed and approved by the Human Subjects Committee of the authors’ institution’s Institutional Review Board.

Definitions of Analytic Domains

Cultural considerations.

Western health systems often fail to consider aspects of patients’ cultural perspectives and histories. This can manifest in the form of a providers’ lack of cultural humility. Cultural humility is a process of preventing imposition of one’s worldview and cultural beliefs on others and recognizing that everyone’s conception of the world is valid. Humility cultivates sensitive approaches in treating patients [ 64 ]. A lack of cultural humility impedes the delivery of acceptable and appropriate healthcare [ 65 ], which can involve low empathy or respect for patients, or dismissal of culture and traditions as superstitions that interfere with standard treatments [ 66 , 67 ]. Ensuring cultural humility among all healthcare employees is a step toward optimal healthcare delivery. Cultural humility is often accomplished through training that can be tailored to particular cultural- or gender-specific populations [ 68 , 69 ]. Since cultural identities and humility have been marked as factors that can heavily influence patients’ access to care, cultural considerations composed our first analytic domain. To assess this domain, we asked participants how they address the unique needs of their patients, how they react when they observe a cultural behavior or attitude from a patient that may not directly align with their treatment plan, and if they have received any multicultural training or training on cultural considerations in their current role.

Patient-provider communication

Other barriers to healthcare access can be linked to ineffective patient-provider communication. Patients who do not feel involved in healthcare decisions are less likely to adhere to treatment recommendations [ 70 ]. Patients who experience communication difficulties with providers may feel coerced, which generates disempowerment and leads patients to employ more covert ways of engagement [ 71 , 72 ]. Language barriers can further compromise communication and hinder outcomes or patient progress [ 73 , 74 ]. Any miscommunication between a patient and provider can affect one’s access to healthcare, namely affecting appropriateness-related barriers. For these reasons, patient-provider communication composed our second analytic domain. We asked participants to highlight the challenges they experience when communicating with their patients, how those complications are addressed, and how communication strategies inform confidentiality in their practice. Confidentiality is a core ethical principle in healthcare, especially in rural areas that have smaller, interconnected patient populations [ 75 ].

Provider-Provider Communication

A patient’s journey through the healthcare system necessitates sufficient correspondence between patients, primary, and secondary providers after discharge and care encounters [ 76 ]. Inter-provider and patient-provider communication are areas of healthcare that are acknowledged to have some gaps. Inconsistent mechanisms for follow up communication with patients in primary care have been documented and emphasized as a concern among those with chronic illness who require close monitoring [ 68 , 77 ]. Similar inconsistencies exist between providers, which can lead to unclear care goals, extended hospital stays, and increased medical costs [ 78 ]. For these reasons, provider-provider communication composed our third analytic domain. We asked participants to describe the approaches they take to streamline communication after a patient’s hospital visit, the methods they use to ensure collaborative communication between primary or secondary providers, and where communication challenges exist.

Healthcare provider characteristics

Our sample included 12 providers: four in family medicine (1 MD, 1 DO, 1 PA & 1 APRN), three in pediatrics (2 MD with specialty in hospital medicine & 1 DO), three in palliative medicine (2 MDs & 1 APRN with specialty in wound care), one in critical care medicine (DO with specialty in pediatric pulmonology) and one in behavioral health (1 LCSW with specialty in trauma). Our participants averaged 9 years (range 2–15) as a healthcare provider; most reported more than 5 years in their current professional role. The diversity of participants extended to their patient populations as well, with each participant reporting a unique distribution of age, race and level of medical complexity among their patients. Most participants reported that a portion of their patients travel up to five hours, sometimes across county- or state-lines, to receive care.

Theme 1: A friction exists between aspects of patients’ rural identities and healthcare systems

Our participants comprised a collection of medical professions and reported variability among health-related reasons their patients seek care. However, most participants acknowledged similar characteristics that influence their patients’ challenges to healthcare access. These identified factors formed categories from which the first theme emerged. There exists a great deal of ‘rugged individualism’ among Montanans, which reflects a self-sufficient and self-reliant way of life. Stoicism marked a primary factor to characterize this quality. One participant explained:

True Montanans are difficult to treat medically because they tend to be a tough group. They don’t see doctors. They don’t want to go, and they don’t want to be sick. That’s an aspect of Montana that makes health culture a little bit difficult.

Another participant echoed this finding by stating:

The backwoods Montana range guy who has an identity of being strong and independent probably doesn’t seek out a lot of medical care or take a lot of medications. Their sense of vitality, independence and identity really come from being able to take care and rely on themselves. When that is threatened, that’s going to create a unique experience of illness.

Similar responses were shared by all twelve participants; stoicism seemed to be heavily embedded in many patient populations in Montana and serves as a key determinant of healthcare acceptability. There are additional factors, however, that may interact with stoicism but are multiply determined. Stigma is an example of this, presented in this context as one’s concern about judgement by the healthcare system. Respondents were openly critical of this perception of the healthcare system as it was widely discussed in interviews. One participant stated:

There is a real perception of a punitive nature in the medical community, particularly if I observe a health issue other than the primary reason for one’s hospital visit, whether that may be predicated on medical neglect, delay of care, or something that may warrant a report to social services. For many of the patients and families I see, it’s not a positive experience and one that is sometimes an uphill barrier that I work hard to circumnavigate.

Analysis of these factors suggest that low use of healthcare services may link to several characteristics, including access problems. Separately, a patient’s perceived stigma from healthcare providers may also impact a patient’s willingness to receive services. One participant put it best by stating

Sometimes, families assume that I didn’t want to see them because they will come in for follow up to meet with me but end up meeting with another provider, which is frustrating because I want to maintain patients on my panel but available time and resource occasionally limits me from doing so. It could be really hard adapting to those needs on the fly, but it’s an honest miss.

When a patient arrives for a healthcare visit and experiences this frustration, it may elicit a patient’s perceptions of neglect or disorganization. This ‘honest miss’ may, in turn, exacerbate other acceptable-related barriers to care.

Theme 2: Facilitating access to healthcare requires application of and respect for cultural differences

The biomedical model is the standard of care utilized in Western medicine [ 79 , 80 ]. However, the US comprises people with diverse social and cultural identities that may not directly align with Western conceptions of health and wellness. Approximately 11.5% of the Montana population falls within an ethnic minority group. 6.4% are of American Indian or Alaska Native origin, 0.5% are of Black or African American origin, 0.8% are of Asian origin and 3.8% are of multiple or other origins. [ 81 ]. Cultural insensitivity is acknowledged in health services research as an active deterrent for appropriate healthcare delivery [ 65 ]. Participants for this study were asked how they react when a patient brings up a cultural attitude or behavior that may impact the proposed treatment plan. Eight participants noted a necessity for humility when this occurs. One participant conceptualized this by stating:

When this happens, I learn about individuals and a way of life that is different to the way I grew up. There is a lot of beauty and health in a non-patriarchal, non-dominating, non-sexist framework, and when we can engage in such, it is really expansive for my own learning process.

The participants who expressed humility emphasized that it is best to work in tandem with their patient, congruently. Especially for those with contrasting worldviews, a provider and a patient working as a team poses an opportunity to develop trust. Without it, a patient can easily fall out of the system, further hindering their ability to access healthcare services in the future. One participant stated:

The approach that ends up being successful for a lot of patients is when we understand their modalities, and they have a sense we understand those things. We have to show understanding and they have to trust. From there, we can make recommendations to help get them there, not decisions for them to obey, rather views based on our experiences and understanding of medicine.

Curiosity was another reaction noted by a handful of participants. One participant said:

I believe patients and their caregivers can be engaged and loving in different ways that don’t always follow the prescribed approach in the ways I’ve been trained, but that doesn’t necessarily mean that they are detrimental. I love what I do, and I love learning new things or new approaches, but I also love being surprised. My style of medicine is not to predict peoples’ lives, rather to empower and support what makes life meaningful for them.

Participants mentioned several other characteristics that they use in practice to prevent cultural insensitivity and support a collaborative approach to healthcare. Table 1 lists these facilitating characteristics and quotes to explain the substance of their benefit.

Consensus among participants indicated that the use of these protective factors to promote cultural sensitivity and apply them in practice is not standardized. When asked, all but two participants said they had not received any culturally-based training since beginning their practice. Instead, they referred to developing skills through “on the job training” or “off the cuff learning.” The general way of medicine, one participant remarked, was to “throw you to the fire.” This suggested that use of standardized cultural humility training modules for healthcare providers was not common practice. Many attributed this to time constraints.

Individual efforts to gain culturally appropriate skills or enhance cultural humility were mentioned, however. For example, three participants reported that they attended medical conferences to discuss cultural challenges within medicine, one participant sought out cultural education within their organization, and another was invited by Native American community members to engage in traditional peace ceremonies. Participants described these additional efforts as uncommon and outside the parameters of a provider’s job responsibilities, as they require time commitments without compensation.

Additionally, eight participants said they share their personal contact information with patients so they may call them directly for medical needs. The conditions and frequency with which this is done was variable and more common among providers in specialized areas of medicine or those who described having a manageable patient panel. All who reported that they shared their personal contact information described it as an aspect of rural health service delivery that is atypical in other, non-rural healthcare systems.

Theme 3: Communication between healthcare providers is systematically fragmented

Healthcare is complex and multi-disciplinary, and patients’ treatment is rarely overseen by a single provider [ 82 ]. The array of provider types and specialties is vast, as is the range of responsibilities ascribed to providers. Thus, open communication among providers both within and between healthcare systems is vital for the success of collaborative healthcare [ 83 ]. Without effective communication achieved between healthcare providers, the appropriate delivery of healthcare services may be become compromised. Our participants noted that they face multiple challenges that complicate communication with other providers. Miscommunication between departments, often implicating the Emergency Department (ED), was a recurring point noted among participants. One participant who is a primary care physician said:

If one of my patients goes to the ER, I don’t always get the notes. They’re supposed to send them to the patient’s primary care doc. The same thing happens with general admissions, but again, I often find out from somebody else that my patient was admitted to the hospital.

This failure to communicate can negatively impact the patient, particularly if time sensitivity or medical complexity is essential to treatment. A patient’s primary care physician is the most accurate source of their medical history; without an effective way to obtain and synthesize a patient’s health information, there may be increased risk of medical error. One participant in a specialty field stated:

One of the biggest barriers I see is obtaining a concise description of a patient’s history and needs. You can imagine if you’re a mom and you’ve got a complicated kid. You head to the ER. The ER doc looks at you with really wide eyes, not knowing how to get information about your child that’s really important.

This concern was highlighted with a specific example from a different participant:

I have been unable to troubleshoot instances when I send people to the ER with a pretty clear indication for admission, and then they’re sent home. For instance, I had an older fellow with pretty severe chronic kidney disease. He presented to another practitioner in my office with shortness of breath and swelling and appeared to have newly onset decompensated heart failure. When I figured this out, I sent him to the ER, called and gave my report. The patient later came back for follow up to find out not only that they had not been admitted but they lost no weight with outpatient dialysis . I feel like a real opportunity was missed to try to optimize the care of the patient simply because there was poor communication between myself and the ER. This poor guy… He ended up going to the ER four times before he got admitted for COVID-19.

In some cases, communication breakdown was reported as the sole cause of a poor outcome. When communication is effective, each essential member of the healthcare team is engaged and collaborating with the same information. Some participants called this process ‘rounds’ when a regularly scheduled meeting is staged between a group of providers to ensure access to accurate patient information. Accurate communication may also help build trust and improve a patient’s experience. In contrast, ineffective communication can result in poor clarity regarding providers’ responsibilities or lost information. Appropriate delivery of healthcare considers the fit between providers and a patient’s specific healthcare needs; the factors noted here suggest that provider-provider miscommunication can adversely affect this dimension of healthcare access.

Another important mechanism of communication is the sharing of electronic medical records (EMRs), a process that continues to shift with technological advances. Innovation is still recent enough, however, for several of our study participants to be able to recall a time when paper charts were standard. Widespread adoption and embrace of the improvements inherent in electronic medical records expanded in the late 2000’s [ 84 ]. EMRs vastly improved the ability to retain, organize, safeguard, and transfer health information. Every participant highlighted EMRs at one point or another and often did so with an underlying sense of anger or frustration. Systematic issues and problems with EMRs were discussed. One participant provided historical context to such records:

Years back, the government aimed to buy an electronic medical record system, whichever was the best, and a number of companies created their own. Each were a reasonable system, so they all got their checks and now we have four completely separate operating systems that do not talk to each other. The idea was to make a router or some type of relay that can share information back and forth. There was no money in that though, so of course, no one did anything about it. Depending on what hospital, clinic or agency you work for, you will most likely work within one of these systems. It was a great idea; it just didn’t get finished.

Seven participants confirmed these points and their impacts on making coordination more difficult, relying on outdated communication strategies more often than not. Many noted this even occurs between facilities within the same city and in separate small metropolitan areas across the state. One participant said:

If my hospital decides to contract with one EMR and the hospital across town contracts with another, correspondence between these hospitals goes back to traditional faxing. As a provider, you’re just taking a ‘fingered crossed’ approach hoping that the fax worked, is picked up, was put in the appropriate inbox and was actually looked at. Information acquisition and making sure it’s timely are unforeseen between EMRs.

Participants reported an “astronomic” number of daily faxes and telephone calls to complete the communication EMRs were initially designed to handle. These challenges are even more burdensome if a patient moves from out of town or out of state; obtaining their medical records was repeatedly referred to as a “chore” so onerous that it often remains undone. Another recurring concern brought up by participants regarded accuracy within EMRs to lend a false sense of security. They are not frequently updated, not designed to be family-centered and not set up to do anything automatically. One participant highlighted these limitations by stating:

I was very proud of a change I made in our EMR system [EPIC], even though it was one I never should have had to make. I was getting very upset because I would find out from my nursing assistant who read the obituary that one of my patients had died. There was a real problem with the way the EMR was notifying PCP’s, so I got an EPIC-level automated notification built into our EMR so that any time a patient died, their status would be changed to deceased and a notification would be sent to their PCP. It’s just really awful to find out a week later that your patient died, especially when you know these people and their families really well. It’s not good care to have blind follow up.

Whether it be a physical or electronic miscommunication between healthcare providers, the appropriate delivery of healthcare can be called to question

Theme 4: Time and resource constraints disproportionately harm rural health systems

Several measures of system capacity suggest the healthcare system in the US is under-resourced. There are fewer physicians and hospital beds per capita compared to most comparable countries, and the growth of healthcare provider populations has stagnated over time [ 15 ]. Rural areas, in particular, are subject to resource limitations [ 16 ]. All participants discussed provider shortages in detail. They described how shortages impact time allocation in their day-to-day operations. Tasks like patient intakes, critical assessments, and recovering information from EMRs take time, of which most participants claimed to not have enough of. There was also a consensus in having inadequate time to spend on medically complex cases. Time pressures were reported to subsequently influence quality of care. One participant stated:

With the constant pace of medicine, time is not on your side. A provider cannot always participate in an enriching dialogue with their patients, so rather than listen and learn, we are often coerced into the mindset of ‘getting through’ this patient so we can move on. This echoes for patient education during discharge, making the whole process more arduous than it otherwise could be if time and resources were not as sparse.

Depending on provider type, specialty, and the size of patient panels, four participants said they have the luxury of extending patient visits to 40 + minutes. Any flexibility with patient visits was regarded as just that: a luxury. Very few providers described the ability to coordinate their schedules as such. This led some study participants to limit the number of patients they serve. One participant said:

We simply don’t have enough clinicians, which is a shame because these people are really skilled, exceptional, brilliant providers but are performing way below their capacity. Because of this, I have a smaller case load so I can engage in a level of care that I feel is in the best interest of my patients. Everything is a tradeoff. Time has to be sacrificed at one point or another. This compromise sets our system up to do ‘ok’ work, not great work.

Of course, managing an overly large number of patients with high complexity is challenging. Especially while enduring the burden of a persisting global pandemic, participants reflected that the general outlook of administering healthcare in the US is to “do more with less.” This often forces providers to delegate responsibilities, which participants noted has potential downsides. One participant described how delegating patient care can cause problems.

Very often will a patient schedule a follow up that needs to happen within a certain time frame, but I am unable to see them myself. So, they are then placed with one of my mid-level providers. However, if additional health issues are introduced, which often happens, there is a high-risk of bounce-back or need to return once again to the hospital. It’s an inefficient vetting process that falls to people who may not have specific training in the labs and imaging that are often included in follow up visits. Unfortunately, it’s a forlorn hope to have a primary care physician be able to attend all levels of a patient’s care.

Several participants described how time constraints stretch all healthcare staff thin and complicate patient care. This was particularly important among participants who reported having a patient panel exceeding 1000. There were some participants, however, who praised the relationships they have with their nurse practitioners and physician’s assistants and mark transparency as the most effective way to coordinate care. Collectively, these clinical relationships were built over long standing periods of time, a disadvantage to providers at the start of their medical career. All but one participant with over a decade of clinical experience mentioned the usefulness of these relationships. The factors discussed in Theme 4 are directly linked to the Availability dimension of access to healthcare. A patient’s ability to reach care is subject to the capacity of their healthcare provider(s). Additionally, further analysis suggests these factors also link to the Appropriateness dimension because the quality of patient-provider relationships may be negatively impacted if a provider’s time is compromised.

Theme 5: Profits are prioritized over addressing barriers to healthcare access in the US.

The US healthcare system functions partially for-profit in the public and private sectors. The federal government provides funding for national programs such as Medicare, but a majority of Americans access healthcare through private employer plans [ 85 ]. As a result, uninsurance rates influence healthcare access. Though the rate of the uninsured has dropped over the last decade through expansion of the Affordable Care Act, it remains above 8 percent [ 86 ]. Historically, there has been ethical criticism in the literature of a for-profit system as it is said to exacerbate healthcare disparities and constitute unfair competition against nonprofit institutions. Specifically, the US healthcare system treats healthcare as a commodity instead of a right, enables organizational controls that adversely affect patient-provider relationships, undermines medical education, and constitutes a medical-industrial complex that threatens influence on healthcare-related public policy [ 87 ]. Though unprompted by the interviewer, participants raised many of these concerns. One participant shared their views on how priorities stand in their practice:

A lot of the higher-ups in the healthcare system where I work see each patient visit as a number. It’s not that they don’t have the capacity to think beyond that, but that’s what their role is, making sure we’re profitable. That’s part of why our healthcare system in the US is as broken as it is. It’s accentuated focus on financially and capitalistically driven factors versus understanding all these other barriers to care.

Eight participants echoed a similar concept, that addressing barriers to healthcare access in their organizations is largely complicated because so much attention is directed on matters that have nothing to do with patients. A few other participants supported this by alluding to a “cherry-picking” process by which those at the top of the hierarchy devote their attention to the easiest tasks. One participant shared an experience where contrasting work demands between administrators and front-line clinical providers produces adverse effects:

We had a new administrator in our hospital. I had been really frustrated with the lack of cultural awareness and curiosity from our other leaders in the past, so I offered to meet and take them on a tour of the reservation. This was meant to introduce them to kids, families and Tribal leaders who live in the area and their interface with healthcare. They declined, which I thought was disappointing and eye-opening.

Analysis of these factors suggest that those who work directly with patients understand patient needs better than those who serve in management roles. This same participant went on to suggest an ulterior motive for a push towards telemedicine, as administrators primarily highlight the benefit of billing for virtual visits instead of the nature of the visits themselves.

This study explored barriers and facilitators to healthcare access from the perspective of rural healthcare providers in Montana. Our qualitative analysis uncovered five key themes: 1) a friction exists between aspects of patients’ rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US. Themes 2 and 3 were directly supported by earlier qualitative studies that applied Levesque’s framework, specifically regarding healthcare providers’ poor interpersonal quality and lack of collaboration with other providers that are suspected to result from a lack of provider training [ 67 , 70 ]. This ties back to the importance of cultural humility, which many previous culture-based trainings have referred to as cultural competence. Cultural competence is achieved through a plethora of trainings designed to expose providers to different cultures’ beliefs and values but induces risk of stereotyping and stigmatizing a patient’s views. Therefore, cultural humility is the preferred idea, by which providers reflect and gain open-ended appreciation for a patient’s culture [ 88 ].

Implications for Practice

Perhaps the most substantial takeaway is how embedded rugged individualism is within rural patient populations and how difficult that makes the delivery of care in rural health systems. We heard from participants that stoicism and perceptions of stigma within the system contribute to this, but other resulting factors may be influential at the provider- and organizational-levels. Stoicism and perceived stigma both appear to arise, in part, from an understandable knowledge gap regarding the care system. For instance, healthcare providers understand the relations between primary and secondary care, but many patients may perceive both concepts as elements of a single healthcare system [ 89 ]. Any issue experienced by a patient when tasked to see both a primary and secondary provider may result in a patient becoming confused [ 90 ]. This may also overlap with our third theme, as a disjointed means of communication between healthcare providers can exacerbate patients’ negative experiences. One consideration to improve this is to incorporate telehealth programs into an existing referral framework to reduce unnecessary interfacility transfers; telehealth programs have proven effective in rural and remote settings [ 91 ].

In fact, telehealth has been rolled out in a variety of virtual platforms throughout its evolution, its innovation matched with continued technological advancement. Simply put, telehealth allows health service delivery from a distance; it allows knowledge and practice of clinical care to be in a different space than a patient. Because of this, a primary benefit of telehealth is its impact on improving patient-centered outcomes among those living in rural areas. For instance, text messaging technology improves early infant diagnosis, adherence to recommended diagnostic testing, and participant engagement in lifestyle change interventions [ 92 , 93 , 94 ]. More sophisticated interventions have found their way into smartphone-based technology, some of which are accessible even without an internet connection [ 95 , 96 ]. Internet accessibility is important because a number of study participants noted internet connectivity as a barrier for patients who live in low resource communities. Videoconferencing is another function of telehealth that has delivered a variety of health services, including those which are mental health-specific [ 97 ], and mobile health clinics have been used in rural, hard-to-reach settings to show the delivery of quality healthcare is both feasible and acceptable [ 98 , 99 , 100 ]. While telehealth has potential to reduce a number of healthcare access barriers, it may not always address the most pressing healthcare needs [ 101 ]. However, telehealth does serve as a viable, cost-effective alternative for rural populations with limited physical access to specialized services [ 102 ]. With time and resource limitations acknowledged as a key theme in our study, an emphasis on expanding telehealth services is encouraged as it will likely have significant involvement on advancing healthcare in the future, especially as the COVID-19 pandemic persists [ 103 ].

Implications for Policy

One could argue that most of the areas of fragmentation in the US healthcare system can be linked to the very philosophy on which it is based: an emphasis on profits as highest priority. Americans are, therefore, forced to navigate a health service system that does not work solely in their best interests. It is not surprising to observe lower rates of healthcare usage in rural areas, which may be a result from rural persons’ negative views of the US healthcare system or a perception that the system does not exist to support wellness. These perceptions may interact with ‘rugged individualism’ to squelch rural residents’ engagement in healthcare. Many of the providers we interviewed for this study appeared to understand this and strived to improve their patients’ experiences and outcomes. Though these efforts are admirable, they may not characterize all providers who serve in rural areas of the US. From a policy standpoint, it is important to recognize these expansive efforts from providers. If incentives were offered to encourage maximum efforts be made, it may lessen burden due to physician burnout and fatigue. Of course, there is no easy fix to the persisting limit of time and resources for providers, problems that require workforce expansion. Ultimately, though, the current structure of the US healthcare system is failing rural America and doing little to help the practice of rural healthcare providers.

Implications for Future Research

It is important for future health systems research efforts to consider issues that arise from both individual- and system-level access barriers and where the two intersect. Oftentimes, challenges that appear linked to a patient or provider may actually stem from an overarching system failure. If failures are critically and properly addressed, we may refine our understanding of what we can do in our professional spaces to improve care as practitioners, workforce developers, researchers and advocates. This qualitative study was exploratory in nature. It represents a step forward in knowledge generation regarding challenges in access to healthcare for rural Americans. Although mental health did not come up by design in this study, future efforts exploring barriers to healthcare access in rural systems should focus on access to mental healthcare. In many rural areas, Montana included, rates of suicide, substance use and other mental health disorders are highly prevalent. These characteristics should be part of the overall discussion of access to healthcare in rural areas. Optimally, barriers to healthcare access should continue to be explored through qualitative and mixed study designs to honor its multi-dimensional stature.

Strengths and Limitations

It is important to note first that this study interviewed healthcare providers instead of patients, which served as both a strength and limitation. Healthcare providers were able to draw on numerous patient-provider experiences, enabling an account of the aggregate which would have been impossible for a patient population. However, accounts of healthcare providers’ perceptions of barriers to healthcare access for their patients may differ from patients’ specific views. Future research should examine acceptability- and appropriateness-related barriers to healthcare access in patient populations. Second, study participants were recruited through convenience sampling methods, so results may be biased towards healthcare providers who are more invested in addressing barriers to healthcare access. Particularly, the providers interviewed for this study represented a subset who go beyond expectations of their job descriptions by engaging with their communities and spending additional uncompensated time with their patients. It is likely that a provider who exhibits these behavioral traits is more likely to participate in research aimed at addressing barriers to healthcare access. Third, the inability to conduct face-to-face interviews for our qualitative study may have posed an additional limitation. It is possible, for example, that in-person interviews might have resulted in increased rapport with study participants. Notwithstanding this possibility, the remote interview format was necessary to accommodate health risks to the ongoing COVID-19 pandemic. Ultimately, given our qualitative approach, results from our study cannot be generalizable to all rural providers’ views or other rural health systems. In addition, no causality can be inferred regarding the influence of aspects of rurality on access. The purpose of this exploratory qualitative study was to probe research questions for future efforts. We also acknowledge the authors’ roles in the research, also known as reflexivity. The first author was the only author who administered interviews and had no prior relationships with all but one study participant. Assumptions and pre-dispositions to interview content by the first author were regularly addressed throughout data analysis to maintain study integrity. This was achieved by conducting analysis by unique interview question, rather than by unique participant, and recoding the numerical order of participants for each question. Our commitment to rigorous qualitative methods was a strength for the study for multiple reasons. Conducting member checks with participants ensured trustworthiness of findings. Continuing data collection to data saturation ensured dependability of findings, which was achieved after 10 interviews and confirmed after 2 additional interviews. We further recognize the heterogeneity in our sample of participants, which helped generate variability in responses. To remain consistent with appropriate means of presenting results in qualitative research however, we shared minimal demographic information about our study participants to ensure confidentiality.

The divide between urban and rural health stretches beyond a disproportionate allocation of resources. Rural health systems serve a more complicated and hard-to-reach patient population. They lack sufficient numbers of providers to meet population health needs. These disparities impact collaboration between patients and providers as well as the delivery of acceptable and appropriate healthcare. The marker of rurality complicates the already cumbersome challenge of administering acceptable and appropriate healthcare and impediments stemming from rurality require continued monitoring to improve patient experiences and outcomes. Our qualitative study explored rural healthcare providers’ views on some of the social, cultural, and programmatic factors that influence access to healthcare among their patient populations. We identified five key themes: 1) a friction exists between aspects of patients’ rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US. This study provides implications that may shift the landscape of a healthcare provider’s approach to delivering healthcare. Further exploration is required to understand the effects these characteristics have on measurable patient-centered outcomes in rural areas.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to individual privacy could be compromised but are available from the corresponding author on reasonable request.

Ethics approval and consent to participate.

All study procedures and methods were carried out in accordance with relevant guidelines and regulations from the World Medical Association Declaration of Helsinki. Ethics approval was given by exempt review from the Institutional Review Board (IRB) at the University of Montana (IRB Protocol No.: 186–20). Participants received oral and written information about the study prior to interview, which allowed them to provide informed consent for the interviews to be recorded and used for qualitative research purposes. No ethical concerns were experienced in this study pertaining to human subjects.

Consent for publication.

The participants consented to the publication of de-identified material from the interviews.

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Acknowledgements

This research was supported by the Center for Biomedical Research Excellence award (P20GM130418) from the National Institute of General Medical Sciences of the National Institute of Health. The first author was also supported by the University of Montana Burnham Population Health Fellowship. We would like to thank Dr. Christopher Dietrich, Dr. Jennifer Robohm and Dr. Eric Arzubi for their contributions on determining inclusion criteria for the healthcare provider population used for this study.

 This research did not receive any specific grant from funding agencies in the public, commercial, and not-for-profit sectors. 

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Coombs, N.C., Campbell, D.G. & Caringi, J. A qualitative study of rural healthcare providers’ views of social, cultural, and programmatic barriers to healthcare access. BMC Health Serv Res 22 , 438 (2022). https://doi.org/10.1186/s12913-022-07829-2

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Women’s experiences of attempted suicide in the perinatal period (ASPEN-study) – a qualitative study

• Kaat De Backer   ORCID: orcid.org/0000-0001-5202-2808 1 ,
• Alexandra Pali   ORCID: orcid.org/0009-0009-5817-156X 1 , 2 ,
• Fiona L. Challacombe   ORCID: orcid.org/0000-0002-3316-8155 3 ,
• Rosanna Hildersley   ORCID: orcid.org/0000-0002-1850-6101 3 ,
• Mary Newburn   ORCID: orcid.org/0000-0001-9471-0908 4 ,
• Sergio A. Silverio   ORCID: orcid.org/0000-0001-7177-3471 5 , 6 ,
• Jane Sandall   ORCID: orcid.org/0000-0003-2000-743X 1 ,
• Louise M. Howard   ORCID: orcid.org/0000-0001-9942-744X 3 &
• Abigail Easter   ORCID: orcid.org/0000-0002-4462-6537 1  

BMC Psychiatry volume  24 , Article number:  255 ( 2024 ) Cite this article

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Suicide is a leading cause of maternal death during pregnancy and the year after birth (the perinatal period). While maternal suicide is a relatively rare event with a prevalence of 3.84 per 100,000 live births in the UK [ 1 ], the impact of maternal suicide is profound and long-lasting. Many more women will attempt suicide during the perinatal period, with a worldwide estimated prevalence of 680 per 100,000 in pregnancy and 210 per 100,000 in the year after birth [ 2 ]. Qualitative research into perinatal suicide attempts is crucial to understand the experiences, motives and the circumstances surrounding these events, but this has largely been unexplored.

Our study aimed to explore the experiences of women and birthing people who had a perinatal suicide attempt and to understand the context and contributing factors surrounding their perinatal suicide attempt.

Through iterative feedback from a group of women with lived experience of perinatal mental illness and relevant stakeholders, a qualitative study design was developed. We recruited women and birthing people ( N  = 11) in the UK who self-reported as having undertaken a suicide attempt. Interviews were conducted virtually, recorded and transcribed. Using NVivo software, a critical realist approach to Thematic Analysis was followed, and themes were developed.

Three key themes were identified that contributed to the perinatal suicide attempt. The first theme ‘Trauma and Adversities’ captures the traumatic events and life adversities with which participants started their pregnancy journeys. The second theme, ‘Disillusionment with Motherhood’ brings together a range of sub-themes highlighting various challenges related to pregnancy, birth and motherhood resulting in a decline in women’s mental health. The third theme, ‘Entrapment and Despair’, presents a range of factors that leads to a significant deterioration of women’s mental health, marked by feelings of failure, hopelessness and losing control.

Conclusions

Feelings of entrapment and despair in women who are struggling with motherhood, alongside a background of traumatic events and life adversities may indicate warning signs of a perinatal suicide. Meaningful enquiry around these factors could lead to timely detection, thus improving care and potentially prevent future maternal suicides.

Peer Review reports

Pregnancy, childbirth, and the postnatal period are a positive and empowering experience for many women and birthing people Footnote 1 . Yet it is widely accepted that the perinatal period is also a time of significant stress, with one in four women experiencing mental health difficulties during this time [ 3 ]. Evidence on the impact of perinatal mental ill-health on the mother [ 4 ], her children [ 5 ], the wider family [ 6 ] and society [ 7 ] has grown in the last decade and worldwide, maternal suicide has been identified as a global public health issue [ 8 ]. In European countries with enhanced surveillance systems for maternal mortality maternal suicide has been identified as one of the leading causes of maternal death [ 9 ]. In the UK, the Confidential Enquiries into Maternal Deaths (MBRRACE-UK) have repeatedly highlighted similar findings, leading to the development and expansion of specialist perinatal mental health services in the UK [ 10 ]. Despite this, there has been no sign of a reduction in suicide rates [ 11 , 12 , 13 , 14 ]. The UK Government has therefore identified pregnant women and new mothers for the first time as a priority group in the recent Suicide Prevention Strategy [ 15 ].

While maternal suicide is a relatively rare event with a prevalence of 3.84 per 100,000 live births (95% CI 2.55–5.55) in the UK [ 1 ], many more women will attempt suicide during pregnancy and the year after birth. Worldwide, the pooled prevalence of perinatal suicide attempts has been estimated to be 680 per 100,000 (95% CI 0.10–4.69%) during pregnancy and 210 per 100,000 (95% CI 0.01–3.21%) during the first-year postpartum [ 2 ]. As well as distressing in their own right, perinatal suicide attempts are known to increase the risk of future fatal acts [ 16 ]. Antenatal [ 17 ] and postnatal suicide attempts [ 18 ] are also associated with increased maternal and neonatal morbidity, adverse birth outcomes, and further suicide attempts.

It is important to note that terminology in suicide research has been a contentious issue and a wide range of definitions have been used in various contexts. The US National Center for Injury and Control issued guidance on uniform definitions in the context of self-directed violence’ [ 19 ], which has informed our study definition of ‘suicide attempt’: “a non-fatal, self-directed, potentially injurious behaviour with intent to die as a result of the behaviour. A suicide attempt might not result in injury”. This definition contains three components worth highlighting, i.e. (1) suicidal ideation, (2) suicidal intent and (3) suicidal behaviour. ‘Suicidal ideation’, also known as ‘suicidality’ (i.e. thoughts of engaging in suicide-related behaviour) [ 19 ] is a known risk factor for suicide [ 20 ] but does not necessarily lead to suicidal behaviours (e.g., behaviour that is self-directed and deliberately results in injury or the potential for injury to oneself, with implicit or explicit evidence of suicidal intent’) [ 19 ]. ‘Suicide attempt’ must also be distinguished from ‘near-fatal deliberate self-harm’, which was defined by Douglas et al (2004) as ‘an act of self-harm using a method that would usually lead to death, or self-injury to a “vital” body area, or self-poisoning that requires admission to an intensive care unit or is judged to be potentially lethal [ 21 ]’. This definition does not contain an element of ‘suicidal intent’, ie. explicit or implicit evidence that at the time of injury the individual intended to kill self or wished to die, and that the individual understood the probable consequences of his or her actions [ 19 ].

To date, perinatal suicide research has predominately been based on case note reviews [ 1 ], retrospective cohort studies [ 22 ], or qualitative studies focussing on suicidal ideation [ 23 ]. Research into suicide attempts in the perinatal period is therefore acutely needed, to gain a better understanding of the circumstances surrounding maternal suicide, the support available to perinatal women and how future deaths can be avoided. To our knowledge, no studies in the UK have used qualitative methods to explore the experiences of women who undertook a suicide attempt in pregnancy or during the postnatal period, yet survived. A better understanding of these events could help refine support and early interventions for women and birthing people at risk.

Aim of the study

The aim of this study was to explore the experiences of women and birthing people who had undertaken one or more suicide attempts during the perinatal period.

Study design

The ASPEN-study (Attempted Suicide during the PEriNatal period) utilised a qualitative design, using semi-structured interviews, to allow for an in-depth understanding of the contextual factors of perinatal suicide attempts, and to demystify the taboos and misunderstanding that are enshrouding this phenomenon [ 24 ]. Qualitative methods are particularly helpful to study sensitive topics [ 25 ] and can facilitate a deeper understanding of suicide attempts, beyond merely explaining [ 26 ]. We adopted a critical realist ontology, meaning participants’ accounts were seen as ‘truths’, even when their reported recall might have been impacted by serious mental illness and/or distress at the time of events [ 27 ]. We also adopted an objectivist epistemological stance meaning our belief system of how we acquire knowledge is one of reality existing and not being constructed, thus enabling an approach to participants’ narratives with no preconceived notions of how the participants may experience the phenomenon of interest [ 28 ]. Drawing on our epistemological and ontological positions, a critical realist approach to Thematic Analysis was best aligned with our philosophical underpinnings. Critical realist TA is an alternative approach to Thematic Analysis, that differs from codebook TA with its positivistic assumptions [ 29 ], or reflexive TA that is grounded in philosophical constructivism [ 30 , 31 ]. Critical realist TA is an explanatory approach that aims to produce causal knowledge through qualitative research on phenomena in the world around us [ 32 , 33 ]. We wanted to go beyond merely ‘exploring’ the phenomenon of perinatal suicide attempt, but aimed to understand what women had experienced during this time, such as any significant life course events they identified as relevant to their perinatal suicide attempt, the specific circumstances in the lead-up to the suicide attempt, their views of motherhood and how this impacted their mental health and any key elements or milestones that made a substantial difference on their journey to recovery. As such, this approach informed our development and structure of the interview schedule and analysis of the data to ensure that this was captured.

Participants and recruitment

The study was advertised through social media and third sector organisations in the field of perinatal mental health and suicide prevention (see Acknowledgements). Interested participants were included if they: (1) were 18 years of age or older; (2) had one or more suicide attempts during the perinatal period (i.e. from pregnancy up to the first year after giving birth), including when the attempt was prevented by self, a loved one or a member of the public; (3) and this happened less than 10 years ago; (4) were residing in the UK; and (5) were not receiving inpatient psychiatric care or experiencing an acute episode of a psychiatric disorder at the time of recruitment. The latter exclusion criterium was adopted in line with our safety protocol, to prevent delays in recovery by addressing such a difficult event outside a therapeutic environment. We used both convenience sampling and purposive sampling techniques: we interviewed anyone who responded to our recruitment materials, met the inclusion criteria and wanted to participate in the study after reading the participant information sheet (convenience sampling). Simultaneously, we also made concerted efforts through intense collaboration with community leaders and third sector organisations to recruit a diverse sample of women and birthing people from different ethnic, cultural, socio-economic and religious backgrounds (purposive sampling). A total of twelve women and birthing people contacted the research team with an interest in the study. Eligibility for the study was explored in a sensitive way, against the overall inclusion criteria and the three components of the study’s definition of ‘suicide attempt’ (suicidal ideation, intent and behaviour). Where in doubt, eligibility was discussed with the wider supervision team. In total, eleven interviews were conducted. A twelfth interested participant did not attend the (online) interview and did not respond to any follow-up emails. Recruitment was finalised when no new themes were being generated from data analysis of the last two interviews [ 34 ]. Participants received reimbursement of £50 for their time to complete the interview and a short demographic survey.

Data collection and analysis

Semi-structured interviews lasted between 38 and 115 min ( MTime  = 65 min) and were conducted via video-conference software (Microsoft Teams) by one researcher (KDB) between October 2022 and April 2023. Interviews were audio-recorded, transcribed and de-identified by a professional transcription company. Field notes were taken during the interview. Transcriptions were checked for accuracy by two researchers (KDB, AP). The interview schedule, which was co-designed with a panel of women with lived experience of perinatal mental illness, aimed to explore experiences of mental health difficulties prior to and during the perinatal period, the circumstances in the lead-up to the suicide attempt, and those following the suicide attempt. The interview schedule was used flexibly and did not prevent participants from sharing their story in the order they preferred, but instead, was used as an aid to prompt where required. Interview data was so rich that a secondary analysis focusing on social support prior and after women’s suicide attempts was undertaken, to be published separately.

Thematic Analysis (TA) [ 30 , 31 , 33 ] of the interview data was conducted using NVivo software while adopting a critical realist approach to Thematic Analysis [ 30 , 31 , 33 ]. The process of data analysis is rarely a linear event, and guided by Fryer’s previous work on critical realist TA [ 33 ], our approach to data analysis is presented in Fig.  1 and can best be described as follows:

Display of critical realist approach to thematic analysis

Public and patient involvement and engagement (PPIE)

An established advisory panel of women with lived experience of perinatal mental illness was consulted during different phases of the study with additional feedback sought from key stakeholders in the field of perinatal mental illness (see Acknowledgements). The process of PPIE during the study design and data collection phase of this study has been documented elsewhere [ 35 ]. A draft manuscript was shared with research participants to sense-check findings and comment on the manuscript. Participants were also given the opportunity to select a pseudonym of their choice. A total of 8 participants reviewed the draft manuscript and their feedback was incorporated in the final version of this paper.

The study team and reflexivity

The research team are a multidisciplinary team of researchers and clinical academics, with backgrounds in psychology (FLC, AE, RH, SAS, AP), psychiatry (LMH), and midwifery (KDB, JS), and several had clinical experience of supporting women who attempted suicide during the perinatal period (KDB, FLC, LMH). Within the research team, there was a balance between those who were parents and those who did not have children and researchers were at different stages of their life, spanning nearly three generations. The phenomenon of suicidality in the perinatal period was familiar to most of the research team, through extensive clinical experience and/or previous research in the field of perinatal mental health. Our positionality is therefore best described as ‘hybrid’, concordant with our critical realist ontology, as we aimed to align our existing knowledge and understanding (i.e. being embedded in the data) with the uniqueness and unfamiliarity of each individual story that was shared with us as a ‘truth’ (i.e. being an objective onlooker), in order to analyse the data in a coherent and sensitive matter [ 36 ]. Data were collected by one researcher (KDB) who was trained in advanced qualitative research techniques as well as having clinical experience as a perinatal mental health midwife. Analysis was conducted by the same researcher and a MSc Student with a background in clinical psychology (AP). Regular team meetings were held throughout the data collection and analysis phase to discuss and sense-check the developing themes and sub-themes.

Participant safety and researcher wellbeing

The safety and emotional wellbeing of all participants was key throughout the study. Thus, we adopted key elements of trauma-informed care into our study design [ 37 ]. A robust safety protocol, with clear pathways for escalation if required, was developed with the input of the PPIE advisory panel [ 38 ]. The study team undertook bespoke training in trauma-informed interviewing and the interview schedule was developed with this in mind. A safety check prior and after the interview was carried out by the same researcher (KDB), either via email or by phone and all participants were offered a confidential de-brief session with an independent clinical psychologist. The psychological safety of the researchers was also considered [ 25 ] and supported by access to regular reflective supervision sessions provided by a clinical psychologist and regular debrief sessions with supervisors to process any difficult emotions arising from conducting the interviews [ 39 ]. We were acutely aware of the potentially triggering content of the audio files and raised this with the transcription company [ 40 ]. When sending audio recordings for transcription, a summary of triggering content was provided to ensure the transcription would be appropriately allocated.

The majority of our sample ( N  = 11) were White British women ( n  = 10), with one woman from a mixed ethnic background. Participants were predominantly married ( n  = 8) and had higher education qualifications ( n  = 7). All but one participant had received a mental health diagnosis by a doctor or other healthcare professional in the past although the demographic survey did not allow to ascertain when this diagnosis had been given. More than half of the participants in our sample were given multiple diagnoses, indicating a high level of complexity in mental health presentation. In most cases, pregnancies had been planned ( n  = 9). All but two women were multiparous, with half of the sample having two children ( n  = 6), and three participants having three or more children. Two women were first-time mothers at the time of the attempt. Four women undertook their suicide attempt during pregnancy, with a fifth woman being pregnant whilst her older child was still under the age of one. The remaining six women undertook a suicide attempt within the year after giving birth. Four participants had a stay in an inpatient psychiatric Mother and Baby Unit (MBU), and for three of them the admission was preceded by their suicide attempt. For one participant, the admission in the Mother and Baby Unit was subsequently followed by an admission in a general psychiatric hospital, where she undertook the actual suicide attempt. A full table of demographic and clinical information can be found in Table  1 .

Qualitative analysis resulted in the identification of three key themes that played a significant role in the deterioration of women’s mental health during the perinatal period, ultimately culminating into a suicide attempt. Saturation for all themes and sub-themes was achieved after nine interviews when no new themes or subthemes were generated. Data from the remaining two interviews confirmed our analysis and provided additional depth and detail [ 34 ]. The three overarching themes are presented in Fig.  2 : Theme 1 ‘Trauma and Adversities’ , consisting of family history of perinatal mental illness and psycho-social adversities, including grief and trauma; Theme 2 ‘Disillusionment with Motherhood’ , marked by a variety of challenges that arose during pregnancy or the postnatal period; and Theme 3 ‘Entrapment and Despair’ , where multiple stressors piled up with no respite or support available, leading to a severe deterioration of mental ill-health, and ultimately, the suicide attempt.

Display of themes and sub-themes

Qualitative data is presented below, with the most representative quotations in text and an additional table of supplementary of quotations included in Supplementary Material 1 .

Theme 1: trauma and adversities

All respondents in our sample started their pregnancy journeys with a range of vulnerabilities, such as previous mental health difficulties, loss, trauma, or social risk factors including domestic abuse and substance misuse. Nevertheless, participants were not always aware of the profound impact these would have on their mental health later in pregnancy and in the postnatal period. Subthemes contributing to this were:

Psycho-social adversities

Many women had experienced mental health difficulties at some point in their life, and most were fully aware of their potentially devastating impact. Some had experienced poor mental health during adolescence and young adulthood and anticipated mental health problems during the perinatal period.

“I’ve had some terrible things happen in my life about failed marriage and fertility problems. Big, big things that I’ve sort of managed with a strength of mine that I perhaps didn’t have in my late teens or early 20s to overcome. So I guess it was always on my radar knowing the stats around you are more likely to have perinatal mental health problems if you’ve had bouts of depression in the past.” – Rosy .

In contrast, others had dealt with traumatic experiences in their life, but could not see how this would be relevant to their mental health during pregnancy and the postnatal period. They started their pregnancy unaware of any potential risks to their mental health.

“I lost my brother when he was 18. […] And I didn’t get a lot of time off work, I was kind of straight back into work. I’m a [professional role in mental health], so I was working in acute psychiatry. Back to work, dealing with other people’s trauma and I don’t think I really dealt with my own particularly well. And it was kind of I think eight months later I had an episode of depression, just very low mood, apathy, poor motivation, poor concentration, was treated briefly with antidepressants and then just kind of did okay after that. So there had been nothing.” – Simone .

Previous trauma was reported by almost all respondents, whether it being through a bereavement, or traumatic life experiences, such as miscarriage and infertility, domestic abuse, fractured relationships, or suicide of a loved one. Two women reported having experienced domestic abuse. One of them reported the abuse, which she described as a ‘punishment’, only started after informing her partner of the pregnancy.

“It was a punishment actually that I dared to be pregnant even though he knew I wasn’t on any contraception or anything. And it really shocked me because he had never ever been like that before.” – Lauren .

For the other respondent, the domestic abuse had been long-lasting and led her to seek coping strategies to deal with the trauma and pain. Being in an abusive relationship created the worst possible start for pregnancy, with no support available.

“Well, it was my first pregnancy. I was 24 so I still hadn’t grown up properly, and I was in a really bad domestic violence relationship so there was a lot going on around that. I was getting no support [for] my pregnancy. I was also using as well which I regret profoundly, but I was drinking, like I drank occasionally because of my mental health, and my mental health was just all over the place; I was really, really unwell.” – Selina .

For some, their previous mental health difficulties were related to an earlier pregnancy or birth experience:

“I had huge amounts of birth trauma from my first, which I had a debrief for from the hospital, which was incredibly unhelpful. And it ended in emergency caesarean [section], after nine days of labour, and being in hospital, as a very naïve 19-year-old, having her first baby; looking back on it, feeling quite coerced by doctors, but not realising at the time that that’s what was happening. And that has impacted me for the rest of my life.” – Sam .

The severity of previous perinatal mental health problems was varied, with one woman having experienced postpartum psychosis after the birth of her first child. Going into the second pregnancy, the risk of relapse was hanging over her like a dark cloud:

“I remember sort of going to the 12-week scan with [second pregnancy] and getting the picture and thinking like shit, it’s really real now and it could all happen again. So I was really scared about that. Because the reccurrence rates are quite high for psychosis, so it’s quite likely that I was going to become unwell. So I was worried, yes, I was really concerned.” – Marie .

This feeling of worry was also reported by women with mild to moderate mental health difficulties and was compounded by a fear of being dismissed and not being able to access support if they would require it.

“I think there was something about the anxiousness of doing it all again, because I think I had some prenatal depression with my first, that wasn’t picked up, and then postnatal anxiety through the roof, that was also never picked up, and was told that was normal.” – Sam .

Family history of perinatal mental illness

Several respondents had a family history of perinatal mental illness and were vigilant that they might experience something similar. To mitigate this risk, they actively sought perinatal mental health support at the earliest opportunity.

“My mum had severe perinatal mental illness, she was hospitalised after my older brother for a year without him […]. At the time they didn’t really have Mother and Baby Units. Then I came [a few] years later and she was hospitalised again but with me for six months, and she passed away […] So my dad said she was saying the same things as each time she’d been sectioned; she would present with very religious ideation and stuff like this, so it was exactly the same stuff, and she died by suicide. So because of that collective history, when we were trying to get pregnant we thought “We need to let someone know we’re trying to get pregnant,” and so I was referred then to a Perinatal Psychiatrist before we got pregnant” - Sarah .

For others, this family history was not something which was spoken about prior to their own experiences of perinatal mental illness. One respondent mentioned she had never been aware of her mother’s history of postnatal depression until she herself started to experience postnatal depression.

“I didn’t know that my mum had postnatal depression. That’s not anything that she’d shared until… I knew that my brother cried a lot and I think he had a cows’ milk protein intolerance, but I didn’t know that my mum…” – Rosy .

Theme 2: disillusionment with motherhood

While previous mental health challenges or trauma were present in the background, all women were profoundly disillusioned with motherhood which contributed to a deterioration in their mental health. This theme of ‘Disillusionment with Motherhood’ captures three sub-themes that reflect a discrepancy between what women thought or hoped motherhood would be like, and the crushing reality they found themselves in. Together, these sub-themes compounded each other and became a catalyst for worsening mental health. The following sub-themes address the various areas of disillusionment that women in our sample reported: in their bodies, in their identity and in the bond with their baby.

The physical and mental struggle of pregnancy and birth

All participants held hopes and expectations of what their pregnancy, birth or the postnatal period would be like. For some first-time mothers, it soon became clear that the societal rosy-hued image of pregnancy was very far removed from their own experience of pregnancy. As they came to grips with how pregnancy was unfolding, the harsh contrast between expectation and reality was so high that many struggled to adjust to this:

“There’s all this thing about pregnancy you’re supposed to be glowing and it’s all marvellous and you’ve got these wonderful hormones, but I was just beached on the sofa feeling hot and sweaty thinking when is this baby going to come out, when’s it going to come out?” – Simone .

For those who had been pregnant before, the reality of another pregnancy, knowing full well what was in store, started to dawn on them:

“I don’t know, it hit me like a ton of bricks. Like oh shit, I’m doing this again. I’m pregnant again.” – Liv .

In addition to these psychological adjustments to reality, respondents mentioned how the physical toll of pregnancy and childbirth played a significant role in the deterioration of their mental health. This close correlation between physical issues and mental health decline was abundantly clear across the sample.

“I was horribly, horribly sick [hyperemesis]; that got worse each pregnancy. I don’t know if that’s normal; I’d heard it is. But horribly sick, which makes you absolutely miserable anyway.” – Sam . “I just sort of couldn’t wait for it [the pregnancy] to end. Yes, I just wanted to give birth. So when they said that they were going to induce me at 40 weeks I thought thank goodness, because my sickness started again quite late on. Again, I don’t know if it was because of the pre-eclampsia. But yes, I was just very ready, very ready to have little one.” – Hannah .

In the most extreme cases, pregnancy was not viewed as something to be enjoyed, but something that left women feeling repulsive.

“So since the pregnancy, just my life fell apart really, I was unemployed, and I just felt the whole way through not just sick and ill, absolutely physically repulsive, like I just felt like an absolute filthy animal. I can’t describe the disgust I felt for myself and the bigger my bump grew, the more disgusting I felt. And I don’t know, it’s just everything was awful, every day was awful.” – Lauren .

For other women physical injuries as a result of childbirth left them unable to function and to enjoy the things they were looking forward to as a new mother.

“I had some tearing and I’d had an episiotomy and they hadn’t healed, so my episiotomy had opened up and there were lots of A&E [Accidents and Emergency] visits and an operation eventually, but I think that really didn’t help my mental health because obviously if you’re in pain all the time then, it just drags you down, doesn’t it? So I wasn’t able to do my normal stuff, I wasn’t able to just carry on with life because I was in pain, I couldn’t sit and I felt like I couldn’t do mummy things.” – Mel .

Apart from the physical repercussions of pregnancy and childbirth, it was the trauma of giving birth and its psychological sequalae which triggered a marked deterioration in the mental health of several women in our sample.

“It was just sort of like you couldn’t expect it to happen, it was like a poor pregnancy and sort of felt like, you know, the birth went wrong as well.” – Hannah . “I had a premature baby. And I went on, I don’t know, like trauma response. Like totally numb. I suppose the adrenalin, the shock, everything…” – Liv .

Invalidation of identity and self-sacrifice

Almost all respondents encountered negative experiences with healthcare professionals at some point during pregnancy or the postnatal period and felt invalidated and dismissed by these. Women reported they were not seen as a person, with a complete identity, but reduced to a vessel for their baby, with little consideration given to their own feelings. This led to a profound loss of identity, exacerbating feelings of being invisible, inadequate and unimportant.

“It was never about me. And I know it’s not all about me, but when I’m wanting to commit suicide, it is very much about me and not one person asked me if I was alright, they were more concerned if the baby was alright, which I was as well, but they just completely bypassed that there was any reason I would do it.“ – Selina .

There seemed to be a lack of professional inquisitiveness to understand why a mother(-to-be) would consider suicide. Instead, all attention was directed towards the well-being of the baby, leading to multiple missed opportunities for timely care and support. In some cases, women reached out but their calls for help were simply ignored while their mood was rapidly deteriorating. These experiences would have devastating consequences on their further help-seeking behaviour.

“What really killed me, what was like the punch in the face that I needed was when I had my midwife appointment at, I don’t know, eight, ten weeks, something like that, and I told her ‘you know what, I’m not feeling right. There’s something bubbling inside me that is not alright, is not correct. I feel more anxious than normal, I can’t sleep, it’s all very weird’. And she just said ‘okay, I’m going to pin that down here to talk about in your next appointment. But we’re not going to do anything right now’. I never saw her again, by the way.” – Liv .

Invalidating encounters like the one described above would have a profound impact on how women viewed healthcare professionals as a source of support and whether they would reach out to them and share the extent of their mental health problems.

“I just felt like nobody was listening at all, just not heard one bit.” – Anna .

For some, the invalidating experience would almost become a motivator to succeed in their suicide plans, as they felt the severity of their mental health problems was brushed under the carpet. One participant sought help after a first suicide attempt through a medication overdose and shared the following:

“So then I think a few more weeks went by and I went back to the doctor’s. I said to the doctor, ’I want to kill myself’. My medication and stuff, I was honest with him, I said the medications and stuff that he was put… I think he tried me on Zopiclone as well with not sleeping and he said, ‘Well if you wanted to kill yourself, you would have done it by now’. I was just… I sort of felt then I’ve got something to prove.” – Hannah .

The loss of identity made respondents feel invisible to healthcare professionals and went hand in hand with exhausting themselves to be the best possible mother for their baby. Women described feelings of total self-sacrifice to meet this perceived standard of ‘the perfect mother’.

“I think I sort of went into supermum mode when I came home, like I had something to prove, and again, it’s that background of failure. I think I’m quite hard on myself anyway and I’m quite… If something goes wrong, I’m probably harder on myself in my head than somebody else would be and I maybe got a bit of a perfectionist trait, so I really didn’t want to rely on anybody, I didn’t ask for help with anything regarding my little boy, and I had a really, really strong bond with him which was really positive, but I think I was sort of going like overkill with not asking for help.” – Hannah .

However, as women started to experience the hard reality of caring for a newborn, they felt unable to meet this impossible standard. The perceived pressure to achieve (unrealistic) goals as well as their feelings of failure to do so started to take a significant strain on their mental health.

“No one had ever told me that before. No one had ever said that you don’t just have to drop everything and run to your child. Because I thought that that was what a secure bond was; and obviously now I’ve learnt about attachment theory and things. I thought that, for her to be securely bonded with me, I had to give every last drop of myself to be her mum.” – Sam .

‘It wasn’t like starry-eyed love’

Closely linked with the previous sub-theme, was the realisation for many women that they did not feel an instant rush of love for their baby. Several women reported feeling unsettled and flawed as a mother when they felt distant and detached from their baby. Women tried their very best to ‘act as a mother’ and do whatever their baby required, but this did not mean they also ‘felt like a mother’.

“So, at the beginning it was very strange. It, because like I said, I was determined to do anything in my power to get that baby out of NICU [Neonatal Intensive Care Unit]. Like whatever it takes, whatever the cost. So it never felt like oh, it’s my baby. I would have jumped in front of a train for him but it was not like a starry-eyed love. And that kept going.” – Liv . “In terms of motherhood, yes, I don’t know whether I just felt I was failing at it or… [pause] I don’t know, I felt very not connected to the baby. I had felt very, very bonded and very connected, and then I wasn’t at all.” – Sarah .

Sadly, for some, this lack of bonding with their baby persisted for a long time, with enduring consequences on their mental health and family happiness, leading to feelings of guilt and shame with which they still are coming to terms with.

“I had no attachment to him probably for about five years, nothing at all, just this ongoing sense of regret and I remember thinking daily I’ve made such a massive mistake in my life and almost this like realisation you are never going to get back what you had before, so just this real hopelessness actually at life.” – Lauren . “I just couldn’t, I couldn’t bond with, I couldn’t. Even still now I love her to pieces but we’re not like mother and daughter, we’re not.” – Anna .

Theme 3: entrapment and despair

In the final phase leading up to the suicide attempt, women experienced an accumulation of stressors, unleashing an overwhelming feeling of hopelessness and entrapment, with seemingly no way out of the situation they found themselves in. The sub-themes identified under this theme of ‘Entrapment and Despair’ left women no breathing space or respite. A perfect storm was brewing, for which women only started to see one way out, and that was by taking their own life.

Feeling like a failure

All respondents expressed a pervasive feeling of utter failure, intersecting their different identifies as a woman, mother and partner. Their perceived inability to meet expectations, whether this related to giving birth, feeding their baby, or functioning as a mother and partner stood in sharp contrast with how they viewed other mothers, who seemed to be effortlessly successful in doing so.

“You sort of just blame yourself. So I can just remember looking at him when he was asleep thinking like, ’Oh you’ve failed, I can’t do this, I’ve already failed at being a mum, but I can’t do this’, and I can just remember just thinking that, looking at him. So I think even though I know it wasn’t my fault, you really felt like a failure and I felt like it was me, like there was something wrong with me, because a lot of women around me, like even family, they never really had experiences like that, they would have like a good pregnancy, like a vaginal birth, a normal birth, so I really felt like I had failed and I really blamed myself for that.” – Hannah .

This feeling of being a total failure created a sense of dread, leaving them fearful every day that their inability and incompetence as a mother would be further exposed.

“I remember seeing the light coming in through the curtains in the morning and just thinking “Oh my god, no, I can’t, I can’t do another day,” like my heart would go, and it was that dread, that whole dread would come over me and I’d think “I can’t do another day today, I just can’t do it. I can’t do it.” It was like a… Yes, it was really hard. I just felt like I don’t know, it felt like I just wasn’t good enough for her, I wasn’t good enough. […] It just felt like I wasn’t good enough to be her mum.” – Mel .

This overwhelming sense of incompetence erased feelings of love, enjoyment or hope and instilled a feeling that their baby and loved ones would be better off without them.

“So it just escalated. This what was going on in my head about, you know, me not being good enough, a failure, just escalated even more, that now I was thinking they are going to take him away, everyone will know how rubbish I am. So it was later that week where I still wasn’t sleeping and I just thought, do you know what, the both of them would be better off without me, because I’ve just failed, I’m just a failure. They will be better off without me.” – Simone . “…That just made me feel so, so low that I think that spiral of internalised feelings and negativity compounded with this sort of isolation and lack of sleep just led me to think they’d be better off without me around, they’d have a parent maybe or a family that would be able to meet their needs.” – Rosy .

Intense intrusive thoughts and abnormal experiences

More than half of the women in our sample reported intrusive ideas or unsettling experiences in the period preceding their suicide attempt. For many, this came as a total surprise as they were unaware this could happen and they felt unable to express the extent of their intrusive thoughts to anyone.

“I remember getting up and going to the bathroom to brush my teeth and then started hearing voices. So this voice, I didn’t recognise it, was just chanting, ‘stinky [name of baby], stinky [name of baby]’, which is my baby’s name and I was like why’s that happening? I don’t understand. Where’s that coming from? And then later that day I remember looking at my husband and thinking you’re the father of this baby, but I’m not its mother. It was a really odd thought, because I was like I know I’ve been pregnant and I know I’ve just been through all that labour, but I look at this baby and it’s not mine, but I know you are the dad. It was really odd.”- Simone . “They [the intrusive thoughts] were really, really scary. And totally uncontrollable as well. They were so vivid and they used to make me feel really upset because they happened quite early on, probably when she was only a few weeks old and I remembering googling them and reading loads of things about it didn’t mean that you were not coping, it didn’t meant that you were going to hurt your baby, it didn’t mean that you were depressed, but I think maybe I should have perhaps seen that as a bit of a sign that I needed to get some help because it was weeks and weeks later that I finally did. But yes, they did upset me and I only told my mum, I didn’t tell anybody else because I just felt as though are people going to think that I’m going to hurt her? Am I going to hurt her if I talk about it more? Yes, they were really scary.” – Rosy .

For some, these ideas were extremely horrific and a symptom of their psychotic illness at the time. Unfortunately, this was left undiagnosed and untreated, leaving them totally desperate and isolated while these unsettling thoughts became their lived reality.

“[…] I started to think ‘oh I’ve committed all these awful crimes in my life’ and I was kind of struggling to process what they were and I was thinking have I killed people and maybe buried them and I don’t know where they are or have I kind of done a big theft or something but not been able to quite work out where I’d stolen the money from. But I was kind of panicking that I’d either buried these bodies or hidden this money and I couldn’t remember where they were, so I was panicking someone else is going to find them and then I’m going to be put in prison. So I had this kind of I want to die because I’m scared I’m going to go to prison because I’ve done all these awful things. And I just felt absolutely desperate.” – Lauren .

Alone in this world

While these distressing experiences of failure and intrusive thoughts invaded women’s mindset, women felt profoundly alone and isolated. Social isolation was reported as a catalyst for their suicide attempt by every woman in the sample. For some, it was a continuation of the situation they had already been in, but during this stage everything felt more desperate, more alone.

“I think by that point I wasn’t talking to anybody at all, not family, certainly not the kids’ dad. The kids’ dad… […] I just totally blocked his number and I wasn’t seeing anybody else. And actually, in some ways, I don’t think anybody wanted to see me because they were just like, “Why have you had another kid?” So the only people that I saw were my own kids, maybe the odd school teacher at pickup but that was it. No one from work. No friends really.” – Lauren .

For others, it was the absence of their partner, who had to return to work after paternity leave, that served as a lever for an acute deterioration of their mental health.

“Everything was fine until about three weeks after the birth and we were back at home, and my husband went back to work; it was him going back to work and I just, yes, fell apart.” – Sarah .

Some respondents had their baby during one of the COVID-19 pandemic lockdowns, when social restrictions meant they were unable to meet with friends or family or seek peer support from other mothers. Instead, they felt cooped up inside their house, alone and isolated, with their suicidal thoughts.

“Completely isolated. Not being able to, like I could have been going to, I don’t know, prenatal yoga. Or breastfeeding groups or toddler groups. Anything else that would take me out of that loop. So I think obviously that made it a lot worse. I don’t think that it would have been… – I don’t know.” – Liv . “So she was three or four months old when Covid hit and it was the whole lockdown and yes, everything just got ten times worse because I couldn’t do anything then; I couldn’t go and talk to my mum, I couldn’t go out, I couldn’t even have doctor’s appointments, I couldn’t have hospital appointments which made me worry even more, and my husband’s a key worker so I was just on my own all the time. Yes, and I think that’s when it got to the point where I just felt like I couldn’t cope anymore.” – Mel .

Several respondents recalled how this feeling of loneliness instilled a determination in them to retreat into isolation further. This meant they no longer wanted to speak to or be around others, even when they had a supportive network in place. An unstoppable cycle of isolation and socially avoidant behaviour was set in motion.

“I just stopped talking to people. That’s when I stopped talking to anybody and I got really ill with my mental health because of it, but I thought “Well, why am I going to talk to people when they don’t listen to me anyway?”- Selina . “I knew exactly what I was doing. I knew how I was going to do it. I just wanted it done. So I thought I have to tell him. I have to tell him. But I couldn’t tell him that I was off to kill myself.” – Simone .

‘Tired’ and ‘wired’

All but two respondents mentioned sleep deprivation as a major contributing factor to the accumulation of despair in the days or weeks before the suicide attempt. The sheer exhaustion they felt prevented them from thinking clearly or having the energy to face their circumstances and get better.

“My little boy slept really well from, gosh, about three weeks, maybe less than that, he would sleep through the night which was really, really lucky, but I couldn’t sleep and I think, yes, the problems of not sleeping had a snowball effect.” – Hannah .

This level of hypervigilance and restlessness was for many women the reason why they were unable to sleep. While women reported to feel exhausted on one hand, they also reported to experience an unhealthy level of drive, anger or arousal, leaving them ‘tired and wired’.

“I stopped sleeping entirely; I was so angry all the time – it’s all the textbook depression symptoms, but I was so angry all the time. I was so tired all the time, but just wired, couldn’t sleep.”- Sam . “I remember thinking I’m just so tired, I just want to go to sleep. I just want to be asleep and not be disturbed. But my mind was just so busy.” – Simone .

Some displayed agitated and manic behaviour to such an extent that they struggled to understand how this went unnoticed.

“I live three miles from the hospital and after they sent me home the next day, I walked back to the hospital with [the] kids and I was mowing the lawn five days after he was born and cleaning the house from top to bottom and driving all over the city after a [caesarean] section and you kind of just think like why did nobody notice? How can you think that that’s normal behaviour? Because I just felt this constant need, like I’ve got to be constantly doing things, constantly cleaning things, constantly walking places or doing things, alongside this absolute anger.” – Lauren .

The irreversibility of motherhood

A majority of respondents described they came to a very agonising realisation that they were unable to get out of being a mother and that they found themselves in an irreversible situation, with no going back. The feeling of being ‘stuck’ was so pervasive, that many expressed they wanted either the pregnancy to end, or to not wake up. The irreversibility of motherhood was surrounded by feelings of deep regret and an admission that this had been their own fault and responsibility.

“I remember actually hoping he would be stillborn towards the end, I think after the bridge. I just really wanted for him to be stillborn because if he was then it would all be over but it wouldn’t be my fault, and then I couldn’t go back. I think there was this constant sense of wanting to go back before any of it had happened and I just have my [older] children and I was working and I was happy and I kept seeking these ways just to go back and there weren’t any and I just got more and more desperate as time went on.” – Lauren .

Many respondents shared their conflicting emotions towards their baby, who they viewed as the cause of their distress on the one hand, and as the reason to stay alive on the other.

“[…] I simply could not do it anymore. Help, or don’t help. Whatever. I’m just not going to be around. And it’s almost like this feeling of, you want someone to take the baby off you, so that the baby’s not around, or that’s how I felt. The baby is your reason to stay alive, but the baby’s also the thing that’s causing you so much anguish. And that conflict is just so hard.” – Sam .

Women were desperate to get a grip on the situation, yet it all felt in vain, with no improvement in sight. An overwhelming feeling of hopelessness took over, leaving women with no light at the end of the tunnel and only one option: taking their own life.

“I don’t know how to explain it. I was feeling like all the things that I had to do were like water in my hands. I could see it. I could feel it. I could hold it. But it was coming through my fingers and I couldn’t do anything about it.” – Liv .

Our study identified three overarching themes, marking different phases during which women’s mental health gradually deteriorated. Whilst not all sub-themes under these themes were necessarily reported by every respondent, they paint a comprehensive picture of the distressing feelings and contributing factors that women experienced in the days and weeks prior to their suicide attempt. Nearly half of our sample undertook a suicide attempt during pregnancy. This is in line with evidence suggesting antepartum suicide attempts are an important complication of pregnancy [ 2 ] and act as a strong predictor for postnatal suicidal behaviour, including completed suicide [ 41 ]. In addition, participants in our sample whose suicide attempt occurred during the postnatal period reported suicidal ideation had started during pregnancy, making the antenatal period a critical period for both antenatal and postnatal suicide prevention.

Our first theme, ‘Trauma and adversities’, captures vulnerabilities prior to conception and during pregnancy and has two key elements: (1) psycho-social adversities, including grief and trauma and (2) having a family history of perinatal mental health difficulties. Women with previous mental health difficulties, in particular those with a history of depression and mood disorders, are known to have an increased risk of fatal and non-fatal perinatal suicide attempts [ 3 , 42 , 43 ]. In addition, previous adverse life events and abuse, especially when these occurred during childhood, [ 44 , 45 ], perinatal bereavement and infertility [ 46 ], comorbid substance use disorders and intimate partner violence [ 47 ], have also been associated with an increased risk of perinatal suicidal thoughts and suicidal behaviour. While the need for trauma-informed maternity services has become a public health priority [ 37 ], it is not always matched by a general awareness of the importance to raise these issues during pregnancy or the postnatal period [ 48 ]. This is reflected in our findings, where several of the respondents had experienced significant trauma and adverse life events prior to becoming pregnant but did not feel this was particularly relevant. Similarly, for some respondents a significant family history of perinatal mental health problems was unbeknown to them until their own mental health deteriorated. In contrast, those respondents who started pregnancy with an alertness of the risk of perinatal mental health problems in light of their own previous mental health difficulties or those of close relatives, reported to have prophylactic support measures in place, for instance by accessing a community perinatal mental health service during pregnancy. While this did not prevent their mental health from deteriorating, it did shorten the referral and escalation times when they reached a point of crisis. Having meaningful conversations about the prevalence of perinatal mental ill-health early on in pregnancy and undertaking a thorough assessment of mental health-related risk factors, such as previous mental health history, domestic abuse, substance misuse, previous trauma, among others, at every contact with maternity services is therefore essential to mitigate these pre-existing vulnerabilities [ 49 ].

In our second theme, ‘Disillusionment with Motherhood’, we identified a range of triggering factors that caused women’s mental health to decline. A first and often overlooked sub-theme that we identified was the impact of a physically and mentally challenging pregnancy and birth and their role in a subsequent mental health deterioration. This was often exacerbated when women received unkind, disrespectful care, which made them feel invisible. Whilst there are no studies to our knowledge that directly associate birth trauma with an increased risk of perinatal suicide, the association between birth trauma and postpartum post-traumatic stress disorder (PTSD) is well established [ 50 , 51 , 52 , 53 ]. Postpartum PTSD in turn is associated with poor coping and stress and highly co-morbid with depression [ 50 ]. Less evidence is available on the association between pregnancy and birth complications and perinatal suicide risk. One study found no association between maternal complications in pregnancy and during birth with hospitalisation for a suicide attempt [ 54 ]. Yet, as illustrated by our study sample, not all suicide attempts will result in an admission to a general hospital for medical treatment. Thus, further evidence is needed to understand the role of physical health complications, both during pregnancy, childbirth and the postnatal period, and their role in mood deterioration.

The subsequent sub-themes of ‘Invalidation of identify and self-sacrifice’ and ‘It wasn’t like starry-eyed love’ are closely intertwined and bring the complexity of women’s conflicting emotions towards motherhood to light [ 55 ]. The desire to be a good mother as a newly found identify often came to the detriment of their own personal self, with many women reporting situations of total self-sacrifice [ 56 ]. These daily struggles, of trying to be the perfect mother on the one hand, while trying to bond with their baby on the other hand, was in many cases fertile soil to start feeling obsolete as a person and feeling disillusioned in motherhood. Our findings build on previous work from Reid et al. (2022), who identified key factors in the context of a perinatal suicide attempt, such as a strained mother-infant bond, lack of social support, loneliness and hopelessness [ 44 ]. This resonates with our sub-themes of “Feeling like a failure”, “Alone in this world” and “Irreversibility of motherhood”. Our final theme “Entrapment and Despair” is in line with Reid et al. (2022)’s final phase, called ‘Darkness Descends’ [ 23 ] and is marked by pervasive feelings of hopelessness and failed motherhood. Under this theme, a turbulent accumulation of negative factors resulting in a fast deterioration of their mental health was reported by all respondents. These feelings of hopelessness and being totally entrapped were so all-encompassing, that participants felt no other way out than by attempting to take their own life. However, in this third stage, women did not just feel disillusioned, they felt totally incompetent as a mother, to a point they believed their baby and family would be better off without them. The finality of motherhood, with no way to turn back time or to escape their fate (‘Irreversibility of Motherhood’), drove them further to despair [ 55 ]. The MBRRACE-UK reports have repeatedly raised such feelings of incompetence as a mother and estrangement of the infant as a ‘red flag’ which should be taken seriously to prevent future maternal deaths by suicide [ 1 , 13 , 57 ].

Another factor we identified in this phase was the occurrence of intrusive thoughts and unsettling (psychotic) experiences, brought together in the subtheme ‘Intense intrusive thoughts and abnormal experiences’. The majority of our respondents reported abnormal experiences that were very unsettling to them. For some, these could be described as intrusive thoughts in the context of Obsessive Compulsive Disorder. Although intrusive thoughts are common among new parents, such experiences are often misunderstood, surrounded by stigma, and sometimes being misdiagnosed or over-normalised and dismissed, preventing timely and effective intervention [ 58 ]. For others in our sample, these experiences may have been delusions or hallucinations as part of a psychotic presentation. For all respondents who had them, the experiences were intense, frightening and difficult to understand at the time. Practitioner knowledge, sensitive risk assessment and careful diagnostic consideration about the nature and type of internal experiences is fundamental to appropriately treat women experiencing these upsetting experiences [ 59 ]. Yet equally important is increased public awareness on the occurrence and impact of such experiences, so women can seek timely support when they experience these frightening thoughts or delusions.

A third common factor we identified was sleep deprivation during pregnancy and the postnatal period and its profound impact on women’s mental health. Sleep disturbance is very common in relation to mental illness, and was highlighted in the most recent MBRRACE-UK report as marked and persistent in those women who died by suicide, even when treated with hypnotic medication [ 1 ]. A recent systematic review by Palagini et al. (2023) showed insomnia and poor sleep quality increased the odds of suicidal risk in pregnant and postpartum women by more than threefold, independently from psychiatric comorbidity [ 60 ]. Especially in a context of onset of psychotic illness, such as bipolar disorder, insomnia often precipitates other psychotic symptoms such as restlessness, irritability and rapid mood changes [ 61 ]. Unfortunately, as sleep loss is generally accepted as a common ‘side effect’ of pregnancy and having a newborn baby, its severity and potential devastating consequences are poorly understood and often minimised. Overall, the theme of ‘Entrapment and Despair’ captures the sheer hopelessness and inability to gain control over a rapidly escalating situation, in line with Klonsky and May’s Three-Step-Theory of suicide [ 62 ]. This theoretical model of suicide considers three steps to suicide. Being in pain and hopelessness leads to suicidal ideation (Step 1), which can be exacerbated by isolation or countered by connectedness (Step 2). The final step is marked by one’s capability of attempting suicide (Step 3). The pervasive feeling of hopelessness and lack of control gradually paved the way for a solid belief it would be better to no longer be here. Participants in our sample shared how they accepted this belief and waited for an opportunity to carry out their suicide plan. This combination of hopelessness and rejection of motherhood, a belief that death would be preferred and an opportunity to act on these thoughts has been previously theorised as a culmination of factors for perinatal suicide [ 23 ]. In line with findings from previous MBRRACE-UK reports, the vast majority of respondents in our sample turned to violent methods for suicide, such as jumping, hanging, suffocation, using sharp objects or stepping in front of traffic, reflecting the high level of distress women found themselves in and the determination with which they wanted to carry out their plan.

Strengths and limitation

Our study is the first to our knowledge to focus on suicide attempts during the perinatal period and offers a rich understanding of women’s experiences surrounding these highly distressing events. A strength of this study is the recruitment of participants across the UK, rather than one geographical area, with diversity in the sample regarding age, parity, psychiatric morbidity, social support, educational attainment and socio-economic status. Significant efforts were made to recruit women from diverse ethnic, cultural, and religious backgrounds, through invitations and meetings with community leaders and designated support groups. Despite our efforts, we did not achieve diversity regarding ethnic and cultural background, one of the limitations of this study. Ethnicity data from the latest MBRRCACE-UK report showed that women who died by suicide were predominately white (86%), with no further ethnicity details on the remaining 14% [ 1 ]. As a result, although this was never our intention, we are aware our study findings are focusing on the experiences of White women in the UK and not transferrable to an ethnically and culturally more diverse sample, or to other countries across the globe. In addition, our sample consisted predominantly of participants with higher educational qualification, in positions of employment. Therefore, our analysis was unable to explore the impact of poverty on women’s suicidality, which is known to be an important driver of poor (perinatal) mental health [ 63 , 64 ]. We are aware a more ethnically, culturally, religiously and socio-economically heterogenous sample is likely to represent a diversity of perspectives, highlighting these issues. Another limitation was the design of the demographic survey, which did not specifically differentiate between mental health diagnosis given during the life course or specifically at the time of the suicide attempt. Suicide research, especially in a perinatal context, is notorious for its recruitment challenges. Saturation for all themes and sub-themes was achieved well within the available sample and is one of the strengths of this study. Another strength of our study is the sensitivity and rigour of patient and public involvement throughout the various phases of the study. This was crucial to do justice to the courage which participants had shown by sharing their stories and to keep respondents safe throughout their research participation.

Implications for clinical practice and care and future research

Our study highlights the importance of routine inquiry of previous mental health difficulties and family history of perinatal mental health problems at the first encounter during pregnancy. Yet, such an assessment needs to be more comprehensive than a tick-box exercise and should be accompanied by a personalised conversation about prevalence of perinatal mental health problems and potential triggers, including trauma and grief. Professionals should be given adequate time during antenatal encounters to explore this in depth and, where required, receive additional training in perinatal mental health to build confidence in doing so. The perinatal period is often described as a ‘window of opportunity’, but this goes both ways: While every encounter creates opportunity for screening, detection and support, it also has the potential for invoking or deepening trauma. Our study revealed the devastating and long-lasting impact of unkind, careless and dismissive remarks by healthcare professionals on women’s mental health, thus instilling a feeling of failure by throw-away comments that would ripple on weeks and months after they were uttered. Perinatal healthcare professionals need to understand the weight of their words, how they can provide hope when women are struggling, but equally how they can push women further into isolation and despair. Culturally aware and trauma-informed clinical practice is essential to achieve this, whilst also recognising the impact of burn-out and carer’s fatigue in an overstretched and under-resourced healthcare service. Healthcare professionals need to be cautious about the difference between normalising and dismissing distressing feelings. In addition, professionals need to fully understand the profound impact of physical, social and psychological risk factors as identified by our study. The physical and mental challenge of pregnancy and childbirth, often in combination with a traumatic birth experience should not be underestimated. An impaired mother-infant dyad, feelings of resentment of motherhood, and the discrepancy between women’s expectations and their lived reality are all key triggers that should be discussed, identified and addressed at the earliest opportunity, in a non-judgemental and sensitive way to avoid further escalation. Women need to be validated and reassured by professionals when disclosing these feelings, and be informed that support is available to help them transition into motherhood. Continuity of care throughout the perinatal period, if done with sensitivity and person-centredness, can foster trusting relationship so women feel safe and supported to disclose distressing feelings. Similarly, insomnia and sleep disturbance, albeit in combination with restlessness and irritability, intrusive thoughts and feelings of lack of control and failure are red flags for severe and rapid mental health deterioration that required prompt and effective action. More than anything, women need to feel safe and listened to, so they can share their feelings with healthcare professionals without fear of judgement, shame and stigma. Our study showed that women will often retreat into silence prior to a suicide attempt and in that moment more than ever rely on attentive, educated and compassionate support networks to avoid a suicide attempt.

Future research into perinatal suicide attempt should focus on developing effective preventative interventions and public health strategies, both in an antenatal and postnatal context, with their distinct healthcare professionals’ involvement and resource challenges. By using implementation science methods, these interventions should be tested and evaluated on their efficacy and effectiveness, in order to reduce future maternal suicides.

This study is the first UK-based qualitative study looking at suicide attempts during the perinatal period. Our findings identified three themes with several contributing factors which led women to undertake a suicide attempt. It is important to understand the impact of previous trauma and life adversity when going through pregnancy and the postnatal period. Feelings of disillusionment with motherhood and feeling entrapped in a hopeless situation were key phases women experienced in the lead-up to their suicide attempt. Our study findings have important implications for clinical practice and healthcare professionals should be aware of warning signs, to improve timely detection and facilitate meaningful inquiry, in order to improve care and prevent future maternal suicide deaths.

Data availability

The datasets generated and analysed during the current study are not publicly available due to the privacy of the participants in the study and the sensitive nature of the data. Further inquiries can be directed to the corresponding author ([email protected]).

We acknowledge not all people who give birth and go through the perinatal period identity as women, female or mothers. While this paper utilises predominantly the terms women and mothers, we aim to include also those who identify as transgender, non-binary or any other gender identity.

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Acknowledgements

We would like to thank all the women and birthing people who took part in this study, for their time, their bravery and the honesty with which they shared their story. Their commitment to improve care for others who find themselves in a similar position was a privilege to witness. We thank Dr Clare Dolman, the Patient Advisory Group at the Section for Women’s Mental Health at King’s College London, the South London Applied Research Collaboration Maternity and Perinatal Mental Health theme Patient and Public Involvement and Engagement group for their suggestions and feedback throughout the different stages of this study. We also like to thank the third sector partners that were closely involved in the study journey, such as Maternal Mental Health Alliance, Mothers for Mothers, the Institute of Health Visiting, the Motherhood Group, REFORM, National Childbirth Trust (NCT), and Maternity Action.

This work was supported by the National Institute for Health and Care Research (NIHR) South London Applied Research Collaboration (NIHR200152). Patient and public involvement engagement activities undertaken for this study were funded through a King’s Engaged Research Network (KERN) Public Engagement Small Grant Award. Kaat De Backer, Sergio A. Silverio, Professor Jane Sandall and Dr Abigail Easter are supported by the NIHR Applied Research Collaboration South London (NIHR ARC South London) at King’s College Hospital NHS Foundation Trust. Kaat De Backer (King’s College London) is also in receipt of an NIHR Doctoral Research Fellowship (NIHR302565). Sergio A. Silverio (King’s College London) is currently in receipt of a Personal Doctoral Fellowship from the NIHR ARC South London Capacity Building Theme [NIHR-INF-2170]. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

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Contributions

AE, LMH, JS, RH, KDB conceived the work and designed the study. SAS and MN contributed to the development of the design. MN led the Public and Patient Involvement and Engagement. KDB, AP, AE, FLC contributed to data acquisition. KDB, AP, AE, FLC interpreted the data. KDB drafted the manuscript and incorporated revisions from all other authors. All authors read and approved the final manuscript.

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Ethical approvals were sought and granted by the King’s College London Health Faculties Research Ethics Committee, in January 2021 (reference HR-20/21-20092), with a further amendment in June 2022, after further feedback from the advisory panel and stakeholder meeting (reference MOD-21/22-20092). The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

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De Backer, K., Pali, A., Challacombe, F.L. et al. Women’s experiences of attempted suicide in the perinatal period (ASPEN-study) – a qualitative study. BMC Psychiatry 24 , 255 (2024). https://doi.org/10.1186/s12888-024-05686-3

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DOI : https://doi.org/10.1186/s12888-024-05686-3

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• Martha Vazquez Corona   ORCID: orcid.org/0000-0003-2061-9540 1 ,
• Ana Pilar Betrán   ORCID: orcid.org/0000-0002-5631-5883 3 ,
• Newton Opiyo   ORCID: orcid.org/0000-0003-2709-3609 3 ,
• Caroline S. E. Homer   ORCID: orcid.org/0000-0002-7454-3011 4 &
• Meghan A. Bohren   ORCID: orcid.org/0000-0002-4179-4682 1  

BMC Public Health volume  23 , Article number:  1851 ( 2023 ) Cite this article

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Caesarean section (CS) rates are increasing globally, posing risks to women and babies. To reduce CS, educational interventions targeting pregnant women have been implemented globally, however, their effectiveness is varied. To optimise benefits of these interventions, it is important to understand which intervention components influence success. In this study, we aimed to identify essential intervention components that lead to successful implementation of interventions focusing on pregnant women to optimise CS use.

We re-analysed existing systematic reviews that were used to develop and update WHO guidelines on non-clinical interventions to optimise CS. To identify if certain combinations of intervention components (e.g., how the intervention was delivered, and contextual characteristics) are associated with successful implementation, we conducted a Qualitative Comparative Analysis (QCA). We defined successful interventions as interventions that were able to reduce CS rates. We included 36 papers, comprising 17 CS intervention studies and an additional 19 sibling studies (e.g., secondary analyses, process evaluations) reporting on these interventions to identify intervention components. We conducted QCA in six stages: 1) Identifying conditions and calibrating the data; 2) Constructing truth tables, 3) Checking quality of truth tables; 4) Identifying parsimonious configurations through Boolean minimization; 5) Checking quality of the solution; 6) Interpretation of solutions. We used existing published qualitative evidence synthesis to develop potential theories driving intervention success.

We found successful interventions were those that leveraged social or peer support through group-based intervention delivery, provided communication materials to women, encouraged emotional support by partner or family participation, and gave women opportunities to interact with health providers. Unsuccessful interventions were characterised by the absence of at least two of these components.

We identified four key essential intervention components which can lead to successful interventions targeting women to reduce CS. These four components are 1) group-based delivery, 2) provision of IEC materials, 3) partner or family member involvement, and 4) opportunity for women to interact with health providers. Maternal health services and hospitals aiming to better prepare women for vaginal birth and reduce CS can consider including the identified components to optimise health and well-being benefits for the woman and baby.

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Introduction

In recent years, caesarean section (CS) rates have increased globally [ 1 , 2 , 3 , 4 ]. CS can be a life-saving procedure when vaginal birth is not possible; however, it comes with higher risks both in the short- and long-term for women and babies [ 1 , 5 ]. Women with CS have increased risks of surgical complications, complications in future pregnancies, subfertility, bowel obstruction, and chronic pain [ 5 , 6 , 7 , 8 ]. Similarly, babies born through CS have increased risks of hypoglycaemia, respiratory problems, allergies and altered immunity [ 9 , 10 , 11 ]. At a population level, CS rates exceeding 15% are unlikely to reduce mortality rates [ 1 , 12 ]. Despite these risks, an analysis across 154 countries reported a global average CS rate of 21.1% in 2018, projected to increase to 28.5% by 2030 [ 3 ].

There are many reasons for the increasing CS rates, and these vary between and within countries. Increasingly, non-clinical factors across different societal dimensions and stakeholders (e.g. women and communities, health providers, and health systems) are contributing to this increase [ 13 , 14 , 15 , 16 , 17 ]. Women may prefer CS over vaginal birth due to fear of labour or vaginal birth, previous negative experience of childbirth, perceived increased risks of vaginal birth, beliefs about an auspicious or convenient day of birth, or beliefs that caesarean section is safer, quick, and painless compared to vaginal birth [ 13 , 14 , 15 ].

Interventions targeting pregnant women to reduce CS have been implemented globally. A Cochrane intervention review synthesized evidence from non-clinical interventions targeting pregnant women and family, providers, and health systems to reduce unnecessary CS, and identified 15 interventions targeting women [ 18 ]. Interventions targeting women primarily focused on improving women’s knowledge around birth, improving women’s ability to cope during labour, and decreasing women’s stress related to labour through childbirth education, and decision aids for women with previous CS [ 18 ]. These types of interventions aim to reduce the concerns of pregnant women and their partners around childbirth, and prepare them for vaginal birth.

The effectiveness of interventions targeting women in reducing CS is mixed [ 18 , 19 ]. Plausible explanations for this limited success include the multifactorial nature of the factors driving increases in CS, as well as the contextual characteristics of the interventions, which may include the study environment, participant characteristics, intensity of exposure to the intervention and method of implementation. Understanding which intervention components are essential influencers of the success of the interventions is conducive to optimising benefits. This study used a Qualitative Comparative Analysis (QCA) approach to re-analyse evidence from existing systematic reviews to identify essential intervention components that lead to the successful implementation of non-clinical interventions focusing on pregnant women to optimise the use of CS. Updating and re-analysing existing systematic reviews using new analytical frameworks may help to explore the heterogeneity in effects and ascertain why some studies appear to be effective while others are not.

Data sources, case selection, and defining outcomes

Developing a logic model.

We developed a logic model to guide our understanding of different pathways and intervention components potentially leading to successful implementation (Additional file 1 ). The logic model was developed based on published qualitative evidence syntheses and systematic reviews [ 18 , 20 , 21 , 22 , 23 , 24 ]. The logic model depicts the desired outcome of reduced CS rates in low-risk women (at the time of admission for birth, these women are typically represented by Robson groups 1–4 [ 25 ] and are women with term, cephalic, singleton pregnancies without a previous CS) and works backwards to understand what inputs and processes are needed to achieve the desired outcome. Our logic model shows multiple pathways to success and highlights the interactions between different levels of factors (women, providers, societal, health system) (Additional file 1 ). Based on the logic model, we have separated our QCA into two clusters of interventions: 1) interventions targeting women, and 2) interventions targeting health providers. The results of analysis on interventions targeting health providers have been published elsewhere [ 26 ]. The logic model was also used to inform the potential important components that influence success.

Identifying data sources and selecting cases

We re-analysed the systematic reviews which were used to inform the development and update of World Health Organization (WHO) guidelines. In 2018, WHO issued global guidance on non-clinical interventions to reduce unnecessary CS, with interventions designed to target three different levels or stakeholders: women, health providers, and health systems [ 27 ]. As part of the guideline recommendations, a series of systematic reviews about CS interventions were conducted: 1) a Cochrane intervention review of effectiveness by Chen et al. (2018) [ 18 ] and 2) three qualitative evidence syntheses exploring key stakeholder perspectives and experiences of interventions focusing on women and communities, health professionals, and health organisations, facilities and systems by Kingdon et al. (2018) [ 20 , 21 , 22 ]. Later on, Opiyo and colleagues (2020) published a scoping review of financial and regulatory interventions to optimise the use of CS [ 23 ].

Therefore, the primary data sources of this QCA are the intervention studies included in Chen et al. (2018) [ 18 ] and Opiyo et al. (2020) [ 23 ]. We used these two systematic reviews as not only they are comprehensive, but they were also used to inform the WHO guidelines development. A single intervention study is referred to as a “case”. Eligible cases were intervention studies focusing on pregnant women and aimed to reduce or optimise the use of CS. No restrictions on study design were imposed in the QCA. Therefore, we also assessed the eligibility of intervention studies excluded from Chen et al. (2018) [ 18 ] and Opiyo et al. (2020) [ 23 ] due to ineligible study designs (such as cohort study, uncontrolled before and after study, interrupted time series with fewer than three data points), as these studies could potentially show other pathways to successful implementation. We complemented these intervention studies with additional intervention studies published since the last review updates in 2018 and 2020, to include intervention studies that are likely to meet the review inclusion criteria for future review updates. No further search was conducted as QCA is suitable for medium-N cases, approximately around 10–50 cases, and inclusion of more studies may threaten study rigour [ 28 ].

Once eligible studies were selected, we searched for their ‘sibling studies’. Sibling studies are studies linked to the included intervention studies, such as formative research or process evaluations which may have been published separately. Sibling studies can provide valuable additional information about study context, intervention components, and implementation outcomes (e.g. acceptability, fidelity, adherence, dosage), which may not be well described in a single article about intervention effectiveness. We searched for sibling studies using the following steps: 1) reference list search of the intervention studies included in Chen et al. (2018) [ 18 ] and Opiyo et al. (2020) [ 23 ], 2) reference list search of the qualitative studies included in Kingdon et al. (2018) reviews [ 20 , 21 , 22 ]; and 3) forward reference search of the intervention studies (through “Cited by” function) in Scopus and Web of Science. Sibling studies were included if they included any information on intervention components or implementation outcomes, regardless of the methodology used. One author conducted the study screening independently (RIZ), and 10% of the screening was double-checked by a second author (MAB). Disagreements during screening were discussed until consensus, and with the rest of the author team if needed.

Defining outcomes

We assessed all outcomes related to the mode of birth in the studies included in the Chen et al. (2018) [ 18 ] and Opiyo et al. (2020) [ 23 ] reviews. Based on the consistency of outcome reporting, we selected “overall CS rate” as the primary outcome of interest due to its presence across studies. We planned to rank the rate ratio across these studies to select the 10 most successful and unsuccessful intervention studies. However, due to heterogeneity in how CS outcomes were reported across studies (e.g. odds ratios, rate ratios, percentages across different intervention stages), the final categorisation of successful or unsuccessful interventions is based on whether the CS rate decreased, based on the precision of the confidence interval or p-value (successful, coded as 1), or CS rate increased or did not change (unsuccessful, coded as 0).

Assessing risk of bias in intervention studies

All intervention studies eligible for inclusion were assessed for risk of bias. All studies included in Chen et al. (2018) and Opiyo et al. (2020) already had risk of bias assessed and reported [ 18 , 23 ], and we used these assessments. Additional intervention studies outside the included studies on these reviews were assessed using the same tools depending on the type of evidence (two randomized controlled trials and one uncontrolled before and after study), and details of the risk of bias assessment results can be found in Additional file 2 . We excluded studies with a high risk of bias to ensure that the analysis was based on high-quality studies and to enhance the ability of researchers to develop deep case knowledge by limiting the overall number of studies.

Qualitative comparative analysis (QCA)

QCA was first developed and used in political sciences and has since been extended to systematic reviews of complex health interventions [ 24 , 29 , 30 , 31 ]. Despite the term “qualitative”, QCA is not a typical qualitative analysis, and is often conceptualised as a methodology that bridges qualitative and quantitative methodologies based on its process, data used and theoretical standpoint [ 24 ]. Here, QCA is used to identify if certain configurations or combinations of intervention components (e.g. participants, types of interventions, contextual characteristics, and intervention delivery) are associated with the desired outcome [ 31 ]. These intervention components are referred to as “conditions” in the QCA methodology. Whilst statistical synthesis methods may be used to examine intervention heterogeneity in systematic reviews, such as meta-regression, QCA is a particularly suitable method to understand complex interventions like those aiming to optimise CS, as it allows for multiple overlapping pathways to causality [ 31 ]. Moreover, QCA allows the exploration of different combinations of conditions, rather than relying on a single condition leading to intervention effectiveness [ 31 ]. Although meta-regression allows for the assessment of multiple conditions, a sufficient number of studies may not be available to conduct the analysis. In complex interventions, such as interventions aiming to optimise the use of CS, single condition or standard meta-analysis may be less likely to yield usable and nuanced information about what intervention components are more or less likely to yield success [ 31 ].

QCA uses ‘set theory’ to systematically compare characteristics of the cases (e.g. intervention in the case of systematic reviews) in relation to the outcomes [ 31 , 32 ]. This means QCA compares the characteristics of the successful ‘cases’ (e.g. interventions that are effective) to those unsuccessful ‘cases’ (e.g. interventions that are not effective). The comparison is conducted using a scoring system based on ‘set membership’ [ 31 , 32 ]. In this scoring, conditions and outcomes are coded based on the extent to which a certain feature is present or absent to form set membership scores [ 31 , 32 ]. There are two scoring systems in QCA: 1) crisp set QCA (csQCA) and 2) fuzzy set QCA (fsQCA). csQCA assigns binary scores of 0 (“fully out” to set membership for cases with certain conditions) and 1 (“fully in” to set membership for cases with certain conditions), while fsQCA assigns ordinal scoring of conditions and outcomes, permitting partial membership scores between 0 and 1 [ 31 , 32 ]. For example, using fsQCA we may assign a five-level scoring system (0, 0.33, 0.5, 0.67, 1), where 0.33 would indicate “more out” than “in” to the set of membership, and 0.67 would indicate “more in” than “out”, and 0.5 would indicate ambiguity (i.e. a lack of information about whether a case was “in” or “out”) [ 31 , 32 ]. In our analysis, we used the combination of both csQCA and fsQCA to calibrate our data. This approach was necessary because some conditions were better suited to binary options using csQCA, while others were more complex, depending on the distribution of cases, and required fsQCA to capture the necessary information. In our final analysis, however, the conditions run on the final analysis were all using the csQCA scoring system.

Two relationships can be investigated using QCA [ 24 , 31 ]. First, if all instances of successful interventions share the same condition(s), this suggests these features are ‘necessary’ to trigger successful outcomes [ 24 , 31 ]. Second, if all instances of a particular condition are associated with successful interventions, this suggests these conditions are ‘sufficient’ for triggering successful outcomes [ 24 , 31 ]. In this QCA, we were interested to explore the relationship of sufficiency: that is, to assess the various combinations of intervention components that can trigger successful outcomes. We were interested in sufficiency because our logic model (explained further below) highlighted the multiple pathways that can lead to a CS and different interventions that may optimise the use of CS along those pathways, which suggested that it would be unlikely for all successful interventions to share the same conditions. We calculated the degree of sufficiency using consistency measures, which evaluate the frequency in which conditions are present when the desired outcome is achieved [ 31 , 32 ]. The conditions with a consistency score of at least 0.8 were considered sufficient in triggering successful interventions [ 31 , 32 ]. At present, there is no tool available for reporting guidelines in the re-analysis of systematic reviews using QCA, however, CARU-QCA is currently being developed for this purpose [ 33 ]. QCA was conducted using R programming software with a package developed by Thiem & Duşa (2013) and QCA with R guidebook [ 32 ]. QCA was conducted in six stages based on Thomas et al. (2014) [ 31 ] and explained below.

QCA stage 1: Identifying conditions, building data tables and calibration

We used a deductive and inductive process to determine the potential conditions (intervention components) that may trigger successful implementation. Conditions were first derived deductively using the developed logic model (Additional file 1 ). We then added additional conditions inductively using Intervention Component Analysis from the intervention studies [ 34 ], and qualitative evidence (“view”) synthesis [ 22 ] using Melendez-Torres’s (2018) approach [ 35 ]. Intervention Component Analysis is a methodological approach that examines factors affecting implementation through reflections from the trialist, which is typically presented in the discussion section of a published trial [ 34 ]. Examples of conditions identified in the Intervention Component Analysis include using an individualised approach, interaction with health providers, policies that encourage CS and acknowledgement of women’s previous birth experiences. After consolidating or merging similar conditions, a total of 52 conditions were selected and extracted from each included intervention and analysed in this QCA (Details of conditions and definitions generated for this study can be found in Additional files 3 and 4 ). We adapted the coding framework from Harris et al. (2019) [ 24 ] by adapting coding rules and six domains that were used, to organize the 52 conditions and make more sense of the data. These six domains are broadly classified as 1) context and participants, 2) intervention design, 3) program content, 4) method of engagement, 5) health system factors, and 6) process outcomes.

One author (RIZ) extracted data relevant to the conditions for each included study into a data table, which was then double-reviewed by two other authors (MVC, MAB). The data table is a matrix in which each case is represented in a row, and columns are used to represent the conditions. Following data extraction, calibration rules using either csQCA or fsQCA (e.g. group-based intervention delivery condition: yes = 1 (present), no = 0 (absent)) were developed through consultation with all authors. We developed a table listing the conditions and rules of coding the conditions, by either direct or transformational assignment of quantitative and qualitative data [ 24 , 32 ] (Additional file 3 depicts the calibration rules). The data tables were then calibrated by applying scores, to explore the extent to which interventions have ‘set membership’ with the outcome or conditions of interest. During this iterative process, the calibration criteria were explicitly defined, emerging from the literature and the cases themselves. It is important to note, that maximum ambiguity is typically scored as 0.5 in QCA, however, we decided it would be more appropriate to assume that if a condition was not reported it was unlikely to be a feature of the intervention, so we treated not reported as “absence” that is we coded it 0.

QCA stage 2: Constructing truth tables

Truth tables are an analytical tool used in QCA to analyse associations between configurations of conditions and outcomes. Whereas the data table represents individual cases (rows) and individual conditions (columns) – the truth table synthesises this data to examine configurations – with each row representing a different configuration of the conditions. The columns indicate a) which conditions are featured in the configuration in that row, b) how many of the cases are represented by that configuration, and c) their association with the outcome.

We first constructed the truth tables based on context and participants, intervention designs, program content, and method of engagement; however, no configurations to trigger successful interventions were observed. Instead, we observed limited diversity, meaning there were many instances in which the configurations were unsupported by cases, likely due to the presence of too many conditions in the truth tables. We used the learning from these truth tables to return to the literature to explore potential explanatory theories about what conditions are important from the perspectives of participants and trialists to trigger successful interventions (adhering to the ‘utilisation of view’ perspective [ 35 ]). Through this process, we found that women and communities liked to learn new information about childbirth, and desired emotional support from partners and health providers while learning [ 22 ]. They also appreciated educational interventions that provide opportunities for discussion and dialogue with health providers and align with current clinical practice and advice from health providers [ 22 ]. Therefore, three models of truth tables were iteratively constructed and developed based on three important hypothesised theories about how the interventions should be delivered: 1) how birth information was provided to women, 2) emotional support was provided to women (including interactions between women and providers), and 3) a consolidated model examining the interactions of important conditions identified from model 1 and 2. We also conducted a sub-analysis of interventions targeting both women and health providers or systems (‘multi-target interventions’). This sub-analysis was conducted to explore if similar conditions were observed in triggering successful interventions in multi-target interventions, among the components for women only. Table 1 presents the list of truth tables that were iteratively constructed and refined.

QCA stage 3: Checking quality of truth tables

We iteratively developed and improved the quality of truth tables by checking the configurations of successful and unsuccessful interventions, as recommended by Thomas et al. (2014) [ 31 ]. This includes by assessing the number of studies clustering to each configuration, and exploring the presence of any contradictory results between successful and unsuccessful interventions. We found contradictory configurations across the five truth tables, which were resolved by considering the theoretical perspectives and iteratively refining the truth tables.

QCA stage 4: Identifying parsimonious configurations through Boolean minimization

Once we determined that the truth tables were suitable for further analysis, we used Boolean minimisation to explore pathways resulting in successful intervention through the configurations of different conditions [ 31 ]. We simplified the “complex solution” of the pathways to a “parsimonious solution” and an “intermediate solution” by incorporating logical remainders (configurations where no cases were observed) [ 36 ].

QCA stage 5: Checking the quality of the solution

We presented the intermediate solution as the final solution instead of the most parsimonious solution, as it is most closely aligned with the underlying theory. We checked consistency and coverage scores to assess if the pathways identified were sufficient to trigger success. We also checked the intermediate solution by negating the outcome to see if it predicts the observed solutions.

QCA stage 6: Interpretation of solutions

We iteratively interpreted the results of the findings through discussions among the QCA team. This reflexive approach ensured that the results of the analysis considered the perspectives from the literature discourse, methodological approach, and that the results were coherent with the current understanding of the phenomenon.

Overview of included studies

Out of 79 intervention studies assessed by Chen et al. (2018) [ 18 ] and Opiyo et al. (2020) [ 23 ], 17 intervention studies targeted women and are included, comprising 11 interventions targeting only women [ 37 , 38 , 39 , 40 , 41 , 42 , 43 ] and six interventions targeting both women and health providers or systems [ 44 , 45 , 46 , 47 , 48 , 49 ]. From 17 included studies, 19 sibling studies were identified [ 43 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 ]. Thus, a total of 36 papers from 17 intervention studies are included in this QCA (See Fig.  1 : PRISMA Flowchart).

PRISMA flowchart. *Sibling studies: studies that were conducted in the same settings, participants, and timeframe; **Intervention components: information on intervention input, activities, and outputs, including intervention context and other characteristics

The 11 interventions targeting women comprised of five successful interventions [ 37 , 68 , 69 , 70 , 71 ] and six unsuccessful interventions [ 37 , 38 , 39 , 40 , 41 , 42 , 43 ] in reducing CS. Sixteen sibling studies were identified, from five out of 11 included interventions [ 37 , 41 , 43 , 70 , 71 ]. Included studies were conducted in six countries across North America (2 from Canada [ 38 ] and 1 from United States of America [ 71 ]), Asia–Pacific (1 from Australia [ 41 ]), 5 from Iran [ 39 , 40 , 68 , 69 , 70 ]), Europe (2 from Finland [ 37 , 42 ], 1 from United Kingdom [ 43 ]). Six studies were conducted in high-income countries, while five studies were conducted in upper-middle-income countries (all from Iran). All 11 studies targeted women, with three studies also explicitly targeting women’s partners [ 68 , 69 , 71 ]. One study delivering psychoeducation allowed women to bring any family members to accompany them during the intervention but did not specifically target partners [ 37 ]. All 11 studies delivered childbirth education, with four delivering general antenatal education [ 38 , 40 , 68 , 69 ], six delivering psychoeducation [ 37 , 39 , 41 , 42 , 70 , 71 ], and one implementing decision aids [ 43 ]. All studies were included in Chen et al. (2018), and some risks of bias were identified [ 18 ] (Additional file 2).

The multi-target interventions consisted of five successful interventions [ 44 , 45 , 46 , 47 , 48 ] and one unsuccessful intervention [ 49 ]. Sibling studies were only identified from one study [ 48 ]. The interventions were delivered in five countries across: South America (1 from Brazil [ 46 ]), Asia–Pacific (4 from China [ 44 , 45 , 47 , 49 ]), Europe (1 from Italy [ 48 ], 1 from Ireland [ 48 ], and 1 from Germany [ 48 ]). Three studies were conducted in high-income countries and five studies in upper middle-income countries. The multi-target interventions targeted women, health providers and health organisations. For this analysis, however, we only consider the components of the intervention that targeted women, which was typically childbirth education. One study came from Chen et al. (2018) [ 18 ] and was graded as having some concerns [ 47 ], two studies from Opiyo et al. (2020) [ 23 ] were graded as having no serious concerns [ 45 , 46 ], and three studies are newly published studies assessed as low [ 44 ] and some concerns about risk of bias [ 48 , 49 ] Table 2 and 3 show characteristics of included studies.

The childbirth education interventions included information about mode of birth, birth process, mental health and coping strategies, pain relief methods, and partners’ roles in birth. Most interventions were delivered in group settings, and only in three studies they were delivered on a one-to-one basis [ 38 , 41 , 42 ]. Only one study explicitly stated that the intervention was individualised to a woman’s unique needs and experiences [ 38 ].

Overall, there was limited theory used to design interventions among the included studies: less than half of interventions (7/17) explicitly used theory in designing the intervention. Among the seven interventions that used theory in intervention development, the theories included the health promotion-disease prevention framework [ 38 ], midwifery counselling framework [ 41 ], cognitive behavioural therapy [ 42 ], Ost’s applied relaxation [ 70 ], conceptual model of parenting [ 71 ], attachment and social cognitive theories [ 37 ], and healthcare improvement scale-up framework [ 46 ]. The remaining 10 studies only relied on previously published studies to design the interventions. We identified very limited process evaluation or implementation outcome evidence related to the included interventions, which is a limitation of the field of CS and clinical interventions more broadly.

• Qualitative comparative analysis

Model 1 – How birth information was provided to women

Model 1 is constructed based on the finding from Kingdon et al. (2018) [ 22 ] that women and communities enjoy learning new birth information, as it opens up new ways of thinking about vaginal birth and CS. Learning new information allows them to understand better the benefits and risks of CS and vaginal births, as well as increase their knowledge about CS [ 22 ].

We used four conditions in constructing model 1 truth table: 1) the provision of information, education, and communication (IEC) materials on what to expect during labour and birth, 2) type of education delivered (antenatal education or psychoeducation), and 3) group-based intervention delivery. We explored this model considering other conditions, such as type of information provided (e.g. information about mode of birth including birth process, mental health and coping strategies, pain relief), delivery technique (e.g. didactic, practical) and frequency and duration of intervention delivery; however these additional conditions did not result in configurations.

Of 16 possible configurations, we identified seven configurations (Table 4 ). The first two row shows perfect consistency of configurations (inclusion = 1) in five studies [ 37 , 68 , 69 , 70 , 71 ] in which all conditions are present, except antenatal education or psychoeducation. The remaining configurations are unsuccessful interventions. Interestingly, when either IEC materials or group-based intervention delivery are present (but not both), implementation is likely to be unsuccessful (rows 3–7).

Boolean minimisation identified two intermediate pathways to successful interventions (Fig.  2 ). The two pathways are similar, except for one condition: type of education. The antenatal education or psychoeducation materials is the content tailored to the type of women they target. Therefore, from the two pathways, we can see that the presence of distribution of IEC materials on birth information and group-based intervention delivery of either antenatal education to the general population of women (e.g. not groups of women with specific risks or conditions) or psychoeducation to women with fear of birth trigger successful interventions. From this solution, we can see that the successful interventions are consistently characterised by the presence of both IEC materials and group-based intervention delivery.

Intermediate pathways from model 1 that trigger successful interventions targeting pregnant women to optimise CS. In QCA, asterisk (*) denotes an ‘AND’ relationship; Inclusion score (InclS), also known as consistency, indicates the degree to which the evidence is consistent with the hypothesis that there is sufficient relation between the configuration and the outcome; Proportional Reduction in Inconsistency (PRI) refers to the extent in which a configuration is sufficient in triggering successful outcome as well as the negation of the outcome; Coverage score (CovS) refers to percentage of cases in which the configuration is valid

Model 2 – Emotional support was provided to women

Model 2 was constructed based on the theory that women desire emotional support alongside the communication of information about childbirth [ 22 ]. This includes emotional support from husbands or partners, health professional, or doulas [ 22 ]. Furthermore, Kingdon et al. (2018) describe the importance of two-way conversation and dialogue between women and providers during pregnancy care, particularly to ensure the opportunity for discussion [ 22 ]. Interventions may generate more questions than they answered, creating the need and desire of women to have more dialogue with health professionals [ 22 ]. Women considered intervention content to be most useful when it complements clinical care, is consistent with advice from health professionals and provides a basis for more informed, meaningful dialogue between women and care providers [ 22 ].

Based on this underlying theory, we constructed model 3 truth table by considering three conditions representative of providing emotional support to women, including partner or family member involvement, group-based intervention delivery which provide social or peer support to women, and opportunity for women to interact with health providers. Of 8 possible configurations, we identified six configurations (Table 5 ). The first three rows represent successful interventions with perfect consistency (inclusion = 1). The first row shows successful interventions with all conditions present. The second and third row shows successful interventions with all conditions except partner or family member involvement or interaction with health providers. The remaining rows represent unsuccessful interventions, where at least two conditions are absent.

Boolean minimisation identified two intermediate pathways to successful interventions (Fig.  3 ). In the first pathway, the partner or family members involvement and group-based intervention delivery enable successful interventions. In the second pathway, however, when partner or family members are not involved, successful interventions can happen only when interaction with health providers is included alongside group-based intervention. From these two pathways, we can see that group-based intervention, involvement of partner and family member, and opportunity for women to interact with providers seem to be important in driving intervention success.

Intermediate pathways from model 2 that trigger successful interventions targeting pregnant women to optimise CS. In QCA, asterisk (*) denotes an ‘AND’ relationship; Inclusion score (InclS), also known as consistency, indicates the degree to which the evidence is consistent with the hypothesis that there is sufficient relation between the configuration and the outcome; Proportional Reduction in Inconsistency (PRI) refers to the extent in which a configuration is sufficient in triggering successful outcome as well as the negation of the outcome; Coverage score (CovS) refers to percentage of cases in which the configuration is valid

Consolidated model – Essential conditions to prompt successful interventions focusing on women

Using the identified important conditions observed in models 1 and 2, we constructed a consolidated model to examine the final essential conditions which could prompt successful educational interventions targeting women. We merged and tested four conditions: the provision of IEC materials on what to expect during labour and birth, group-based intervention delivery, partner or family member involvement, and opportunity for interaction between women and health providers.

Of the 16 possible configurations, we identified six configurations (Table 6 ). The first three rows show configurations resulting in successful interventions with perfect consistency (inclusion = 1). The first row shows successful interventions with all conditions present; the second and third rows show successful interventions with all conditions present except interaction with health providers or partner or family member involvement. The remaining three rows are configurations of unsuccessful interventions, missing at least two conditions, including the consistent absence of partner or family member involvement.

Boolean minimisation identified two intermediate pathways to successful intervention (Fig.  4 ). The first pathway shows that the opportunity for women to interact with health providers, provision of IEC materials, and group-based intervention delivery prompts successful interventions. The second pathway, however, shows that when there is no opportunity for women to interact with health providers, it is important to have partner or family member involvement alongside group-based intervention delivery and provision of IEC materials. These two pathways suggest that the delivery of educational interventions accompanied by provision of IEC materials and presence of emotional support for women during the intervention is important to trigger successful interventions. These pathways also emphasise that emotional support for women during the intervention can come from either partner, family member, or health provider. For the consolidated model, we did not simplify the solution further, as the intermediate solution is more theoretically sound compared to the most parsimonious solution.

Intermediate pathways from consolidated model that trigger successful interventions targeting pregnant women to optimise CS.  In QCA, asterisk (*) denotes an ‘AND’ relationship; Inclusion score (InclS), also known as consistency, indicates the degree to which the evidence is consistent with the hypothesis that there is sufficient relation between the configuration and the outcome; Proportional Reduction in Inconsistency (PRI) refers to the extent in which a configuration is sufficient in triggering successful outcome as well as the negation of the outcome; Coverage score (CovS) refers to percentage of cases in which the configuration is valid.

Sub-analysis – Interventions targeting both women and health providers or systems

In this sub-analysis, we run the important conditions identified from the consolidated model, added condition of multi-target intervention, and applied it to 17 interventions: 11 interventions targeting women, and six interventions targeting both women and health providers or systems (multi-target interventions).

Of 32 possible configurations, we identified eight configurations (Table 7 ). The first four rows show configurations with successful interventions with perfect consistency (inclusion = 1). The first row is where all the multi-target interventions are clustered, except the unsuccessful intervention Zhang (2020) [ 49 ], and where all the conditions are present. All the conditions in the second to fourth rows are present, except multi-target interventions (all rows), interaction with health providers (third row) and partner and family member involvement (fourth row). The remaining rows are all configurations to unsuccessful interventions, where at least three conditions are missing, except row 8, which is a single case row. This case is the only multi-target intervention that is unsuccessful and in which partner or family members were not involved.

The Boolean minimisation identified two intermediate pathways (Fig.  5 ). The first pathway shows that partner or family involvement, provision of IEC materials, and group-based intervention delivery prompt successful interventions. The first pathway is comprised of all five successful multi-target interventions [ 44 , 45 , 46 , 47 , 48 ] and four of 11 interventions targeting only women [ 37 , 68 , 69 , 71 ]. The second pathway shows that when multi-target interventions are absent, but when interaction with health providers is present, alongside provision of IEC materials and group-based intervention delivery, it prompts successful interventions (3/11 interventions targeting women only [ 37 , 69 , 70 ]). The first pathway shows that there are successful configurations with and without multi-target interventions. Therefore, similar to the interventions targeting women, when implementing multi-target interventions, intervention components targeting women are more likely to be successful when partners or family members are involved, interventions are implemented through group-based intervention delivery, IEC materials were provided, and there is an opportunity for women to interact with health providers.

Intermediate pathways from multi-target interventions sub-analysis that trigger successful interventions targeting pregnant women to optimise CS. In QCA, asterisk (*) denotes an ‘AND’ relationship; Inclusion score (InclS), also known as consistency, indicates the degree to which the evidence is consistent with the hypothesis that there is sufficient relation between the configuration and the outcome; Proportional Reduction in Inconsistency (PRI) refers to the extent in which a configuration is sufficient in triggering successful outcome as well as the negation of the outcome; Coverage score (CovS) refers to percentage of cases in which the configuration is valid

To summarise, there are four essential intervention components which trigger successful educational interventions focusing on pregnant women to reduce CS, this includes 1) group-based intervention delivery, 2) provision of IEC materials on what to expect during labour and birth, 3) partner or family member involvement on the intervention, and 4) opportunity for women to interact with health providers. These conditions do not work in siloed or independently but instead work jointly as parts of configurations to enable successful interventions.

Our extensive QCA identified configurations of essential intervention components which are sufficient to trigger successful interventions to optimised CS. Educational interventions focusing on women were successful by: 1) leveraging social or peer support through group-based intervention delivery, 2) improving women’s knowledge and awareness of what to expect during labour and birth, 3) ensuring women have emotional support through partner or family participation in the intervention, and 4) providing opportunities for women to interact with health providers. We found that the absence of two or more of the above characteristics in an intervention result in unsuccessful interventions. Unlike our logic model, which predicted engagement strategies (i.e. intensity, frequency, technique, recruitment, incentives) to be essential to intervention success, we found that “support” seems to be central in maximising benefits of interventions targeting women.

Group-based intervention delivery is present across all four truth tables and eight pathways leading to successful intervention implementation, suggesting that group-based intervention delivery is an essential component of interventions targeting women. Despite this, we cannot conclude that group-based intervention delivery is a necessary condition, as there may be other pathways not captured in this QCA. The importance of group-based intervention delivery may be due to the group setting providing women with a sense of confidence through peer support and engagement. In group-based interventions, women may feel more confident when learning with others and peer support may motivate women. Furthermore, all group-based interventions in our included studies are conducted at health facilities, which may provide women with more confidence that information is aligned with clinical recommendations. Evidence on benefits of group-based interventions involving women who are pregnant has been demonstrated previously [ 72 , 73 ]. Women reported that group-based interventions reduce their feelings of isolation, provide access to group support, and allow opportunities for them to share their experiences [ 72 , 74 , 75 , 76 ]. This is aligned with social support theory, in which social support through a group or social environment may provide women with feelings of reassurance, compassion, reduce feelings of uncertainty, increase sense of control, access to new contacts to solve problems, and provision of instrumental support, which eventually influence positive health behaviours [ 72 , 77 ]. Women may resolve their uncertainties around mode of birth by sharing their concerns with others and learning at the same time how others cope with it. These findings are consistent with the benefits associated with group-based antenatal care, which is recommended by WHO [ 78 , 79 ].

Kingdon et al. (2018) reported that women and communities liked learning new birth information, as it opens new ways of thinking about vaginal birth and CS, and educates about benefits of different modes of birth, including risks of CS. Our QCA is aligned with this finding where provision of information about birth through education delivery leads to successful interventions but with certain caveats. That is, provision of birth information should be accompanied by IEC materials and through group-based intervention delivery. There is not enough information to distinguish what type of IEC materials lead to successful intervention; however, it is important to note that the format of the IEC materials (such as paper-based or mobile application) may affect success. More work is needed to understand how women and families react to format of IEC materials; for example, will paper-based IEC materials be relegated over more modern methods of reaching women with information through digital applications? The QUALI-DEC (Quality decision-making (QUALI-DEC) by women and healthcare providers for appropriate use of caesarean section) study is currently implementing a decision-analysis tool to help women make an informed decision on preferred mode of birth using both a paper-based and mobile application that may shed some light on this [ 80 ].

Previous research has shown that women who participated in interventions aiming to reduce CS desired emotional support (from partners, doulas or health providers) alongside the communication about childbirth [ 22 ]. Our QCA is aligned with this finding in which emotional support from partners or family members is highly influential in leading to successful interventions. Partner involvement in maternity care has been extensively studied and has been demonstrated to improve maternal health care utilisation and outcomes [ 81 ]. Both women and their partners perceived that partner involvement is crucial as it facilitates men to learn directly from providers, thus promoting shared decision-making among women and partners and enabling partners to reinforce adherence to any beneficial suggestions [ 82 , 83 , 84 , 85 , 86 ]. Partners provide psychosocial support to women, for example through being present during pregnancy and the childbirth process, as well as instrumental support, which includes supporting women financially [ 82 , 83 , 84 ]. Despite the benefits of partner involvement, partner's participation in maternity care is still low [ 82 ], as reflected in this study where only four out of 11 included interventions on this study involved partner or family member involvement. Reasons for this low participation, which include unequal gender norms and limited health system capability [ 82 , 84 , 85 , 86 ], should be explored and addressed to ensure the benefits of the interventions.

Furthermore, our QCA demonstrates the importance of interaction with health providers to trigger successful interventions. The interaction of women with providers in CS decision-making, however, is on a “nexus of power, trust, and risk”, where it may be beneficial but can also reinforce the structural oppression of women [ 13 ]. A recent study on patient-provider interaction in CS decision-making concluded that the interaction between providers who are risk-averse, and women who are cautious about their pregnancies in the health system results in discouragement of vaginal births [ 87 ]. However, this decision could be averted by meaningful communication between women and providers where CS risks and benefits are communicated in an environment where vaginal birth is encouraged [ 87 ]. Furthermore, the reasons women desire interaction with providers can come from opposite directions. Some women see providers as the most trusted and knowledgeable source, in which women can trust the judgement and ensure that the information learned is reliable and evidenced-based [ 22 ]. On the other hand, some women may have scepticism towards providers where women understand that providers’ preference may negatively influence their preferred mode of birth [ 22 ]. Therefore, adequate, two-way interaction is important for women to build a good rapport with providers.

It is also important to note that we have limited evidence (3/17 intervention studies) involving women with previous CS. Vaginal birth after previous CS (VBAC) can be a safe and positive experience for some women, but there are also potential risks depending on their obstetric history [ 88 , 89 , 90 ]. Davis (2020) found that women were motivated to have VBAC due to negative experiences of CS, such as the difficult recovery, and that health providers' roles served as pivotal drivers in motivating women towards VBAC [ 91 ]. Other than this, VBAC also requires giving birth in a suitably staffed and equipped maternity unit, with staff trained on VBAC, equipment for labour monitoring, and resources for emergency CS if needed [ 89 , 90 ]. There is comparatively less research conducted on VBAC and trial of labour after CS [ 88 ]. Therefore, more work is needed to explore if there are potentially different pathways that lead to successful intervention implementation for women with previous CS. It may be more likely that interventions targeting various stakeholders are more crucial in this group of women. For example, both education for women and partners or families, as well as training to upskill health providers might be needed to support VBAC.

Strength and limitations

We found many included studies had poor reporting of the interventions, including the general intervention components (e.g. presence of policies that may support interventions) and process evaluation components, which is reflective of the historical approach to reporting trial data. This poor reporting means we could not engage further in the interventions and thus may have missed important conditions that were not reported. However, we have attempted to compensate for limited process evaluation components by identifying all relevant sibling studies that could contribute to a better understanding of context. Furthermore, there are no studies conducted in low-income countries, despite rapidly increasing CS rates in these settings. Lastly, we were not able to conduct more nuanced analyses about CS, such as exploring how CS interventions impacted changes to emergency versus elective CS, VBAC, or instrumental birth, due to an insufficient number of studies and heterogeneity in outcome measurements. Therefore, it is important to note that we are not necessarily measuring the optimal outcome of interest—reducing unnecessary CS. However, it is unlikely that these non-clinical interventions will interfere with a decision of CS based on clinical indications.

Despite these limitations, this is the first study aiming to understand how certain interventions can be successful in targeting women to optimise CS use. We used the QCA approach and new analytical frameworks to re-analyse existing systematic review evidence to generate new knowledge. We ensure robustness through the use of a logic model and worked backwards in understanding what aspects are different in the intervention across different outcomes. The use of QCA and qualitative evidence synthesis ensured that the results are theory-driven, incorporate participants’ perspectives into the analysis, and explored iteratively to find the appropriate configurations, reducing the risk of data fishing. Lastly, this QCA extends the understanding of effectiveness review conducted by Chen et al. (2018) [ 18 ] by explaining the potential intervention components which may influence heterogeneity.

Implications for practice and research

To aid researchers and health providers to reduce CS in their contexts and designing educational interventions targeting women during pregnancy, we have developed a checklist of key components or questions to consider when designing the interventions that may help lead to successful implementation:

Is the intervention delivered in a group setting?

Are IEC materials on what to expect during labour and birth disseminated to women?

Are women’s partners or families involved in the intervention?

Do women have opportunities to interact with health providers?

We have used this checklist to explore the extent to which the included interventions in our QCA include these components using a matrix model (Fig.  6 ).

Matrix model assessing the extent to which the included intervention studies have essential intervention components identified in the QCA

Additionally, future research on interventions to optimise the use of CS should report the intervention components implemented, including process outcomes such as fidelity, attrition, contextual factors (e.g. policies, details of how the intervention is delivered), and stakeholder factors (e.g. women’s perceptions and satisfaction). These factors are important in not just evaluating whether the intervention is successful or not, but also in exploring why similar interventions can work in one but not in another context. There is also a need for more intervention studies implementing VBAC to reduce CS, to understand how involving women with previous CS may result in successful interventions. Furthermore, more studies understanding impact of the interventions targeting women in LMICs are needed.

This QCA illustrates crucial intervention components and potential pathways that can trigger successful educational interventions to optimise CS, focusing on pregnant women. The following intervention components are found to be sufficient in triggering successful outcomes: 1) group-based delivery, 2) provision of IEC materials, 3) partner or family member involvement, and 4) opportunity for women to interact with health providers. These intervention components do not work in siloed or independently but instead work jointly as parts of configurations to enable successful interventions. Researchers, trialists, hospitals, or other institutions and stakeholders planning interventions focusing on pregnant women can consider including these components to ensure benefits. More studies understanding impact of the interventions targeting women to optimise CS are needed from LMICs. Researchers should clearly describe and report intervention components in trials, and consider how process evaluations can help explain why trials were successful or not. More robust trial reporting and process evaluations can help to better understand mechanisms of action and why interventions may work in one context yet not another.

Availability of data and materials

Additional information files have been provided and more data may be provided upon request to [email protected].

Abbreviations

Coverage score

• Caesarean section

Crisp set qualitative comparative analysis

Fuzzy set qualitative comparative analysis

Information, education, and communication

Inclusion score

Low- and middle-income countries

Proportional reduction in inconsistency

Quality decision-making by women and healthcare providers for appropriate use of caesarean section

Vaginal birth after previous caesarean section

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Acknowledgements

We extend our thanks to Jim Berryman (Brownless Medical Library, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne) for his help in refining the search strategy for sibling studies.

This research was made possible with the support of UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a co-sponsored programme executed by the World Health Organization (WHO). RIZ is supported by Melbourne Research Scholarship and Human Rights Scholarship from The University of Melbourne. CSEH is supported by a National Health and Medical Research Council (NHMRC) Principal Research Fellowship. MAB’s time is supported by an Australian Research Council Discovery Early Career Researcher Award (DE200100264) and a Dame Kate Campbell Fellowship (University of Melbourne Faculty of Medicine, Dentistry, and Health Sciences). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The contents of this publication are the responsibility of the authors and do not reflect the views of the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization.

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Additional file 1..

Logic model in optimizing CS use.

Additional file 2.

Risk of bias assessments.

Additional file 3.

Coding framework and calibration rules.

Additional file 4.

Coding framework as applied to each intervention (data table).

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Zahroh, R.I., Sutcliffe, K., Kneale, D. et al. Educational interventions targeting pregnant women to optimise the use of caesarean section: What are the essential elements? A qualitative comparative analysis. BMC Public Health 23 , 1851 (2023). https://doi.org/10.1186/s12889-023-16718-0

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A Practical Guide to Writing Quantitative and Qualitative Research Questions and Hypotheses in Scholarly Articles

Edward barroga.

1 Department of General Education, Graduate School of Nursing Science, St. Luke’s International University, Tokyo, Japan.

Glafera Janet Matanguihan

2 Department of Biological Sciences, Messiah University, Mechanicsburg, PA, USA.

The development of research questions and the subsequent hypotheses are prerequisites to defining the main research purpose and specific objectives of a study. Consequently, these objectives determine the study design and research outcome. The development of research questions is a process based on knowledge of current trends, cutting-edge studies, and technological advances in the research field. Excellent research questions are focused and require a comprehensive literature search and in-depth understanding of the problem being investigated. Initially, research questions may be written as descriptive questions which could be developed into inferential questions. These questions must be specific and concise to provide a clear foundation for developing hypotheses. Hypotheses are more formal predictions about the research outcomes. These specify the possible results that may or may not be expected regarding the relationship between groups. Thus, research questions and hypotheses clarify the main purpose and specific objectives of the study, which in turn dictate the design of the study, its direction, and outcome. Studies developed from good research questions and hypotheses will have trustworthy outcomes with wide-ranging social and health implications.

INTRODUCTION

Scientific research is usually initiated by posing evidenced-based research questions which are then explicitly restated as hypotheses. 1 , 2 The hypotheses provide directions to guide the study, solutions, explanations, and expected results. 3 , 4 Both research questions and hypotheses are essentially formulated based on conventional theories and real-world processes, which allow the inception of novel studies and the ethical testing of ideas. 5 , 6

It is crucial to have knowledge of both quantitative and qualitative research 2 as both types of research involve writing research questions and hypotheses. 7 However, these crucial elements of research are sometimes overlooked; if not overlooked, then framed without the forethought and meticulous attention it needs. Planning and careful consideration are needed when developing quantitative or qualitative research, particularly when conceptualizing research questions and hypotheses. 4

There is a continuing need to support researchers in the creation of innovative research questions and hypotheses, as well as for journal articles that carefully review these elements. 1 When research questions and hypotheses are not carefully thought of, unethical studies and poor outcomes usually ensue. Carefully formulated research questions and hypotheses define well-founded objectives, which in turn determine the appropriate design, course, and outcome of the study. This article then aims to discuss in detail the various aspects of crafting research questions and hypotheses, with the goal of guiding researchers as they develop their own. Examples from the authors and peer-reviewed scientific articles in the healthcare field are provided to illustrate key points.

DEFINITIONS AND RELATIONSHIP OF RESEARCH QUESTIONS AND HYPOTHESES

A research question is what a study aims to answer after data analysis and interpretation. The answer is written in length in the discussion section of the paper. Thus, the research question gives a preview of the different parts and variables of the study meant to address the problem posed in the research question. 1 An excellent research question clarifies the research writing while facilitating understanding of the research topic, objective, scope, and limitations of the study. 5

On the other hand, a research hypothesis is an educated statement of an expected outcome. This statement is based on background research and current knowledge. 8 , 9 The research hypothesis makes a specific prediction about a new phenomenon 10 or a formal statement on the expected relationship between an independent variable and a dependent variable. 3 , 11 It provides a tentative answer to the research question to be tested or explored. 4

Hypotheses employ reasoning to predict a theory-based outcome. 10 These can also be developed from theories by focusing on components of theories that have not yet been observed. 10 The validity of hypotheses is often based on the testability of the prediction made in a reproducible experiment. 8

Conversely, hypotheses can also be rephrased as research questions. Several hypotheses based on existing theories and knowledge may be needed to answer a research question. Developing ethical research questions and hypotheses creates a research design that has logical relationships among variables. These relationships serve as a solid foundation for the conduct of the study. 4 , 11 Haphazardly constructed research questions can result in poorly formulated hypotheses and improper study designs, leading to unreliable results. Thus, the formulations of relevant research questions and verifiable hypotheses are crucial when beginning research. 12

CHARACTERISTICS OF GOOD RESEARCH QUESTIONS AND HYPOTHESES

Excellent research questions are specific and focused. These integrate collective data and observations to confirm or refute the subsequent hypotheses. Well-constructed hypotheses are based on previous reports and verify the research context. These are realistic, in-depth, sufficiently complex, and reproducible. More importantly, these hypotheses can be addressed and tested. 13

There are several characteristics of well-developed hypotheses. Good hypotheses are 1) empirically testable 7 , 10 , 11 , 13 ; 2) backed by preliminary evidence 9 ; 3) testable by ethical research 7 , 9 ; 4) based on original ideas 9 ; 5) have evidenced-based logical reasoning 10 ; and 6) can be predicted. 11 Good hypotheses can infer ethical and positive implications, indicating the presence of a relationship or effect relevant to the research theme. 7 , 11 These are initially developed from a general theory and branch into specific hypotheses by deductive reasoning. In the absence of a theory to base the hypotheses, inductive reasoning based on specific observations or findings form more general hypotheses. 10

TYPES OF RESEARCH QUESTIONS AND HYPOTHESES

Research questions and hypotheses are developed according to the type of research, which can be broadly classified into quantitative and qualitative research. We provide a summary of the types of research questions and hypotheses under quantitative and qualitative research categories in Table 1 .

Research questions in quantitative research

In quantitative research, research questions inquire about the relationships among variables being investigated and are usually framed at the start of the study. These are precise and typically linked to the subject population, dependent and independent variables, and research design. 1 Research questions may also attempt to describe the behavior of a population in relation to one or more variables, or describe the characteristics of variables to be measured ( descriptive research questions ). 1 , 5 , 14 These questions may also aim to discover differences between groups within the context of an outcome variable ( comparative research questions ), 1 , 5 , 14 or elucidate trends and interactions among variables ( relationship research questions ). 1 , 5 We provide examples of descriptive, comparative, and relationship research questions in quantitative research in Table 2 .

Hypotheses in quantitative research

In quantitative research, hypotheses predict the expected relationships among variables. 15 Relationships among variables that can be predicted include 1) between a single dependent variable and a single independent variable ( simple hypothesis ) or 2) between two or more independent and dependent variables ( complex hypothesis ). 4 , 11 Hypotheses may also specify the expected direction to be followed and imply an intellectual commitment to a particular outcome ( directional hypothesis ) 4 . On the other hand, hypotheses may not predict the exact direction and are used in the absence of a theory, or when findings contradict previous studies ( non-directional hypothesis ). 4 In addition, hypotheses can 1) define interdependency between variables ( associative hypothesis ), 4 2) propose an effect on the dependent variable from manipulation of the independent variable ( causal hypothesis ), 4 3) state a negative relationship between two variables ( null hypothesis ), 4 , 11 , 15 4) replace the working hypothesis if rejected ( alternative hypothesis ), 15 explain the relationship of phenomena to possibly generate a theory ( working hypothesis ), 11 5) involve quantifiable variables that can be tested statistically ( statistical hypothesis ), 11 6) or express a relationship whose interlinks can be verified logically ( logical hypothesis ). 11 We provide examples of simple, complex, directional, non-directional, associative, causal, null, alternative, working, statistical, and logical hypotheses in quantitative research, as well as the definition of quantitative hypothesis-testing research in Table 3 .

Research questions in qualitative research

Unlike research questions in quantitative research, research questions in qualitative research are usually continuously reviewed and reformulated. The central question and associated subquestions are stated more than the hypotheses. 15 The central question broadly explores a complex set of factors surrounding the central phenomenon, aiming to present the varied perspectives of participants. 15

There are varied goals for which qualitative research questions are developed. These questions can function in several ways, such as to 1) identify and describe existing conditions ( contextual research question s); 2) describe a phenomenon ( descriptive research questions ); 3) assess the effectiveness of existing methods, protocols, theories, or procedures ( evaluation research questions ); 4) examine a phenomenon or analyze the reasons or relationships between subjects or phenomena ( explanatory research questions ); or 5) focus on unknown aspects of a particular topic ( exploratory research questions ). 5 In addition, some qualitative research questions provide new ideas for the development of theories and actions ( generative research questions ) or advance specific ideologies of a position ( ideological research questions ). 1 Other qualitative research questions may build on a body of existing literature and become working guidelines ( ethnographic research questions ). Research questions may also be broadly stated without specific reference to the existing literature or a typology of questions ( phenomenological research questions ), may be directed towards generating a theory of some process ( grounded theory questions ), or may address a description of the case and the emerging themes ( qualitative case study questions ). 15 We provide examples of contextual, descriptive, evaluation, explanatory, exploratory, generative, ideological, ethnographic, phenomenological, grounded theory, and qualitative case study research questions in qualitative research in Table 4 , and the definition of qualitative hypothesis-generating research in Table 5 .

Qualitative studies usually pose at least one central research question and several subquestions starting with How or What . These research questions use exploratory verbs such as explore or describe . These also focus on one central phenomenon of interest, and may mention the participants and research site. 15

Hypotheses in qualitative research

Hypotheses in qualitative research are stated in the form of a clear statement concerning the problem to be investigated. Unlike in quantitative research where hypotheses are usually developed to be tested, qualitative research can lead to both hypothesis-testing and hypothesis-generating outcomes. 2 When studies require both quantitative and qualitative research questions, this suggests an integrative process between both research methods wherein a single mixed-methods research question can be developed. 1

FRAMEWORKS FOR DEVELOPING RESEARCH QUESTIONS AND HYPOTHESES

Research questions followed by hypotheses should be developed before the start of the study. 1 , 12 , 14 It is crucial to develop feasible research questions on a topic that is interesting to both the researcher and the scientific community. This can be achieved by a meticulous review of previous and current studies to establish a novel topic. Specific areas are subsequently focused on to generate ethical research questions. The relevance of the research questions is evaluated in terms of clarity of the resulting data, specificity of the methodology, objectivity of the outcome, depth of the research, and impact of the study. 1 , 5 These aspects constitute the FINER criteria (i.e., Feasible, Interesting, Novel, Ethical, and Relevant). 1 Clarity and effectiveness are achieved if research questions meet the FINER criteria. In addition to the FINER criteria, Ratan et al. described focus, complexity, novelty, feasibility, and measurability for evaluating the effectiveness of research questions. 14

The PICOT and PEO frameworks are also used when developing research questions. 1 The following elements are addressed in these frameworks, PICOT: P-population/patients/problem, I-intervention or indicator being studied, C-comparison group, O-outcome of interest, and T-timeframe of the study; PEO: P-population being studied, E-exposure to preexisting conditions, and O-outcome of interest. 1 Research questions are also considered good if these meet the “FINERMAPS” framework: Feasible, Interesting, Novel, Ethical, Relevant, Manageable, Appropriate, Potential value/publishable, and Systematic. 14

As we indicated earlier, research questions and hypotheses that are not carefully formulated result in unethical studies or poor outcomes. To illustrate this, we provide some examples of ambiguous research question and hypotheses that result in unclear and weak research objectives in quantitative research ( Table 6 ) 16 and qualitative research ( Table 7 ) 17 , and how to transform these ambiguous research question(s) and hypothesis(es) into clear and good statements.

a These statements were composed for comparison and illustrative purposes only.

b These statements are direct quotes from Higashihara and Horiuchi. 16

a This statement is a direct quote from Shimoda et al. 17

The other statements were composed for comparison and illustrative purposes only.

CONSTRUCTING RESEARCH QUESTIONS AND HYPOTHESES

To construct effective research questions and hypotheses, it is very important to 1) clarify the background and 2) identify the research problem at the outset of the research, within a specific timeframe. 9 Then, 3) review or conduct preliminary research to collect all available knowledge about the possible research questions by studying theories and previous studies. 18 Afterwards, 4) construct research questions to investigate the research problem. Identify variables to be accessed from the research questions 4 and make operational definitions of constructs from the research problem and questions. Thereafter, 5) construct specific deductive or inductive predictions in the form of hypotheses. 4 Finally, 6) state the study aims . This general flow for constructing effective research questions and hypotheses prior to conducting research is shown in Fig. 1 .

Research questions are used more frequently in qualitative research than objectives or hypotheses. 3 These questions seek to discover, understand, explore or describe experiences by asking “What” or “How.” The questions are open-ended to elicit a description rather than to relate variables or compare groups. The questions are continually reviewed, reformulated, and changed during the qualitative study. 3 Research questions are also used more frequently in survey projects than hypotheses in experiments in quantitative research to compare variables and their relationships.

Hypotheses are constructed based on the variables identified and as an if-then statement, following the template, ‘If a specific action is taken, then a certain outcome is expected.’ At this stage, some ideas regarding expectations from the research to be conducted must be drawn. 18 Then, the variables to be manipulated (independent) and influenced (dependent) are defined. 4 Thereafter, the hypothesis is stated and refined, and reproducible data tailored to the hypothesis are identified, collected, and analyzed. 4 The hypotheses must be testable and specific, 18 and should describe the variables and their relationships, the specific group being studied, and the predicted research outcome. 18 Hypotheses construction involves a testable proposition to be deduced from theory, and independent and dependent variables to be separated and measured separately. 3 Therefore, good hypotheses must be based on good research questions constructed at the start of a study or trial. 12

In summary, research questions are constructed after establishing the background of the study. Hypotheses are then developed based on the research questions. Thus, it is crucial to have excellent research questions to generate superior hypotheses. In turn, these would determine the research objectives and the design of the study, and ultimately, the outcome of the research. 12 Algorithms for building research questions and hypotheses are shown in Fig. 2 for quantitative research and in Fig. 3 for qualitative research.

EXAMPLES OF RESEARCH QUESTIONS FROM PUBLISHED ARTICLES

• EXAMPLE 1. Descriptive research question (quantitative research)
• - Presents research variables to be assessed (distinct phenotypes and subphenotypes)
• “BACKGROUND: Since COVID-19 was identified, its clinical and biological heterogeneity has been recognized. Identifying COVID-19 phenotypes might help guide basic, clinical, and translational research efforts.
• RESEARCH QUESTION: Does the clinical spectrum of patients with COVID-19 contain distinct phenotypes and subphenotypes? ” 19
• EXAMPLE 2. Relationship research question (quantitative research)
• - Shows interactions between dependent variable (static postural control) and independent variable (peripheral visual field loss)
• “Background: Integration of visual, vestibular, and proprioceptive sensations contributes to postural control. People with peripheral visual field loss have serious postural instability. However, the directional specificity of postural stability and sensory reweighting caused by gradual peripheral visual field loss remain unclear.
• Research question: What are the effects of peripheral visual field loss on static postural control ?” 20
• EXAMPLE 3. Comparative research question (quantitative research)
• - Clarifies the difference among groups with an outcome variable (patients enrolled in COMPERA with moderate PH or severe PH in COPD) and another group without the outcome variable (patients with idiopathic pulmonary arterial hypertension (IPAH))
• “BACKGROUND: Pulmonary hypertension (PH) in COPD is a poorly investigated clinical condition.
• RESEARCH QUESTION: Which factors determine the outcome of PH in COPD?
• STUDY DESIGN AND METHODS: We analyzed the characteristics and outcome of patients enrolled in the Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension (COMPERA) with moderate or severe PH in COPD as defined during the 6th PH World Symposium who received medical therapy for PH and compared them with patients with idiopathic pulmonary arterial hypertension (IPAH) .” 21
• EXAMPLE 4. Exploratory research question (qualitative research)
• - Explores areas that have not been fully investigated (perspectives of families and children who receive care in clinic-based child obesity treatment) to have a deeper understanding of the research problem
• “Problem: Interventions for children with obesity lead to only modest improvements in BMI and long-term outcomes, and data are limited on the perspectives of families of children with obesity in clinic-based treatment. This scoping review seeks to answer the question: What is known about the perspectives of families and children who receive care in clinic-based child obesity treatment? This review aims to explore the scope of perspectives reported by families of children with obesity who have received individualized outpatient clinic-based obesity treatment.” 22
• EXAMPLE 5. Relationship research question (quantitative research)
• - Defines interactions between dependent variable (use of ankle strategies) and independent variable (changes in muscle tone)
• “Background: To maintain an upright standing posture against external disturbances, the human body mainly employs two types of postural control strategies: “ankle strategy” and “hip strategy.” While it has been reported that the magnitude of the disturbance alters the use of postural control strategies, it has not been elucidated how the level of muscle tone, one of the crucial parameters of bodily function, determines the use of each strategy. We have previously confirmed using forward dynamics simulations of human musculoskeletal models that an increased muscle tone promotes the use of ankle strategies. The objective of the present study was to experimentally evaluate a hypothesis: an increased muscle tone promotes the use of ankle strategies. Research question: Do changes in the muscle tone affect the use of ankle strategies ?” 23

EXAMPLES OF HYPOTHESES IN PUBLISHED ARTICLES

• EXAMPLE 1. Working hypothesis (quantitative research)
• - A hypothesis that is initially accepted for further research to produce a feasible theory
• “As fever may have benefit in shortening the duration of viral illness, it is plausible to hypothesize that the antipyretic efficacy of ibuprofen may be hindering the benefits of a fever response when taken during the early stages of COVID-19 illness .” 24
• “In conclusion, it is plausible to hypothesize that the antipyretic efficacy of ibuprofen may be hindering the benefits of a fever response . The difference in perceived safety of these agents in COVID-19 illness could be related to the more potent efficacy to reduce fever with ibuprofen compared to acetaminophen. Compelling data on the benefit of fever warrant further research and review to determine when to treat or withhold ibuprofen for early stage fever for COVID-19 and other related viral illnesses .” 24
• EXAMPLE 2. Exploratory hypothesis (qualitative research)
• - Explores particular areas deeper to clarify subjective experience and develop a formal hypothesis potentially testable in a future quantitative approach
• “We hypothesized that when thinking about a past experience of help-seeking, a self distancing prompt would cause increased help-seeking intentions and more favorable help-seeking outcome expectations .” 25
• “Conclusion
• Although a priori hypotheses were not supported, further research is warranted as results indicate the potential for using self-distancing approaches to increasing help-seeking among some people with depressive symptomatology.” 25
• EXAMPLE 3. Hypothesis-generating research to establish a framework for hypothesis testing (qualitative research)
• “We hypothesize that compassionate care is beneficial for patients (better outcomes), healthcare systems and payers (lower costs), and healthcare providers (lower burnout). ” 26
• Compassionomics is the branch of knowledge and scientific study of the effects of compassionate healthcare. Our main hypotheses are that compassionate healthcare is beneficial for (1) patients, by improving clinical outcomes, (2) healthcare systems and payers, by supporting financial sustainability, and (3) HCPs, by lowering burnout and promoting resilience and well-being. The purpose of this paper is to establish a scientific framework for testing the hypotheses above . If these hypotheses are confirmed through rigorous research, compassionomics will belong in the science of evidence-based medicine, with major implications for all healthcare domains.” 26
• EXAMPLE 4. Statistical hypothesis (quantitative research)
• - An assumption is made about the relationship among several population characteristics ( gender differences in sociodemographic and clinical characteristics of adults with ADHD ). Validity is tested by statistical experiment or analysis ( chi-square test, Students t-test, and logistic regression analysis)
• “Our research investigated gender differences in sociodemographic and clinical characteristics of adults with ADHD in a Japanese clinical sample. Due to unique Japanese cultural ideals and expectations of women's behavior that are in opposition to ADHD symptoms, we hypothesized that women with ADHD experience more difficulties and present more dysfunctions than men . We tested the following hypotheses: first, women with ADHD have more comorbidities than men with ADHD; second, women with ADHD experience more social hardships than men, such as having less full-time employment and being more likely to be divorced.” 27
• “Statistical Analysis
• ( text omitted ) Between-gender comparisons were made using the chi-squared test for categorical variables and Students t-test for continuous variables…( text omitted ). A logistic regression analysis was performed for employment status, marital status, and comorbidity to evaluate the independent effects of gender on these dependent variables.” 27

EXAMPLES OF HYPOTHESIS AS WRITTEN IN PUBLISHED ARTICLES IN RELATION TO OTHER PARTS

• EXAMPLE 1. Background, hypotheses, and aims are provided
• “Pregnant women need skilled care during pregnancy and childbirth, but that skilled care is often delayed in some countries …( text omitted ). The focused antenatal care (FANC) model of WHO recommends that nurses provide information or counseling to all pregnant women …( text omitted ). Job aids are visual support materials that provide the right kind of information using graphics and words in a simple and yet effective manner. When nurses are not highly trained or have many work details to attend to, these job aids can serve as a content reminder for the nurses and can be used for educating their patients (Jennings, Yebadokpo, Affo, & Agbogbe, 2010) ( text omitted ). Importantly, additional evidence is needed to confirm how job aids can further improve the quality of ANC counseling by health workers in maternal care …( text omitted )” 28
• “ This has led us to hypothesize that the quality of ANC counseling would be better if supported by job aids. Consequently, a better quality of ANC counseling is expected to produce higher levels of awareness concerning the danger signs of pregnancy and a more favorable impression of the caring behavior of nurses .” 28
• “This study aimed to examine the differences in the responses of pregnant women to a job aid-supported intervention during ANC visit in terms of 1) their understanding of the danger signs of pregnancy and 2) their impression of the caring behaviors of nurses to pregnant women in rural Tanzania.” 28
• EXAMPLE 2. Background, hypotheses, and aims are provided
• “We conducted a two-arm randomized controlled trial (RCT) to evaluate and compare changes in salivary cortisol and oxytocin levels of first-time pregnant women between experimental and control groups. The women in the experimental group touched and held an infant for 30 min (experimental intervention protocol), whereas those in the control group watched a DVD movie of an infant (control intervention protocol). The primary outcome was salivary cortisol level and the secondary outcome was salivary oxytocin level.” 29
• “ We hypothesize that at 30 min after touching and holding an infant, the salivary cortisol level will significantly decrease and the salivary oxytocin level will increase in the experimental group compared with the control group .” 29
• EXAMPLE 3. Background, aim, and hypothesis are provided
• “In countries where the maternal mortality ratio remains high, antenatal education to increase Birth Preparedness and Complication Readiness (BPCR) is considered one of the top priorities [1]. BPCR includes birth plans during the antenatal period, such as the birthplace, birth attendant, transportation, health facility for complications, expenses, and birth materials, as well as family coordination to achieve such birth plans. In Tanzania, although increasing, only about half of all pregnant women attend an antenatal clinic more than four times [4]. Moreover, the information provided during antenatal care (ANC) is insufficient. In the resource-poor settings, antenatal group education is a potential approach because of the limited time for individual counseling at antenatal clinics.” 30
• “This study aimed to evaluate an antenatal group education program among pregnant women and their families with respect to birth-preparedness and maternal and infant outcomes in rural villages of Tanzania.” 30
• “ The study hypothesis was if Tanzanian pregnant women and their families received a family-oriented antenatal group education, they would (1) have a higher level of BPCR, (2) attend antenatal clinic four or more times, (3) give birth in a health facility, (4) have less complications of women at birth, and (5) have less complications and deaths of infants than those who did not receive the education .” 30

Research questions and hypotheses are crucial components to any type of research, whether quantitative or qualitative. These questions should be developed at the very beginning of the study. Excellent research questions lead to superior hypotheses, which, like a compass, set the direction of research, and can often determine the successful conduct of the study. Many research studies have floundered because the development of research questions and subsequent hypotheses was not given the thought and meticulous attention needed. The development of research questions and hypotheses is an iterative process based on extensive knowledge of the literature and insightful grasp of the knowledge gap. Focused, concise, and specific research questions provide a strong foundation for constructing hypotheses which serve as formal predictions about the research outcomes. Research questions and hypotheses are crucial elements of research that should not be overlooked. They should be carefully thought of and constructed when planning research. This avoids unethical studies and poor outcomes by defining well-founded objectives that determine the design, course, and outcome of the study.

Disclosure: The authors have no potential conflicts of interest to disclose.

Author Contributions:

• Conceptualization: Barroga E, Matanguihan GJ.
• Methodology: Barroga E, Matanguihan GJ.
• Writing - original draft: Barroga E, Matanguihan GJ.
• Writing - review & editing: Barroga E, Matanguihan GJ.

This paper is in the following e-collection/theme issue:

Published on 9.4.2024 in Vol 8 (2024)

Implementation of Video-Based Care in Interdisciplinary Primary Care Settings at the Veterans Health Administration: Qualitative Study

Authors of this article:

Original Paper

• Claudia Der-Martirosian 1, 2 * , PhD   ; 
• Cynthia Hou 1 * , MS   ; 
• Sona Hovsepian 1 * , LCSW   ; 
• Maia Diarra Carter 3 * , MPH, MD   ; 
• Leonie Heyworth 4, 5 * , MPH, MD   ; 
• Aram Dobalian 2, 6 , MPH, JD, PhD   ; 
• Lucinda Leung 1, 7 , MPH, MD, PhD  

1 Veterans Affairs Greater Los Angeles Healthcare System Center for the Study of Healthcare Innovation, Implementation, and Policy, Los Angeles, CA, United States

2 Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA, United States

3 Office of Primary Care/Patient Care Services, Veterans Health Administration, Washington, DC, United States

4 Office of Connected Care/Telehealth Services, Veterans Health Administration, Washington, DC, United States

5 Department of Medicine, University of California San Diego School of Medicine, San Diego, CA, United States

6 Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, United States

7 Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA David Geffen School of Medicine, Los Agneles, CA, United States

*these authors contributed equally

Corresponding Author:

Claudia Der-Martirosian, PhD

Veterans Affairs Greater Los Angeles Healthcare System Center for the Study of Healthcare Innovation, Implementation, and Policy

16111 Plummer St

Los Angeles, CA, 91343

United States

Phone: 1 818 984 4596

Email: [email protected]

Background: With the rapid shift to telehealth, there remains a knowledge gap in how video-based care is implemented in interdisciplinary primary care (PC) settings.

Objective: The objective of this study was to gain an in-depth understanding of how video telehealth services were implemented in PC from the perspectives of patients and interdisciplinary PC team members at the Veterans Health Administration (VHA) 2 years after the onset of the COVID-19 pandemic.

Methods: We applied a positive and negative deviance approach and selected the 6% highest (n=8) and the 6% lowest (n=8) video-using PC sites in 2022 from a total of 130 VHA medical centers nationally. A total of 12 VHA sites were included in the study, where 43 PC interdisciplinary team members (August-October 2022) and 25 patients (February-May 2023) were interviewed. The 5 domains from the diffusion of innovation theory and the nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework guided the development of the 2 study interview guides (provider and patient). We identified themes that emerged across all interviews that were associated with the implementation of video-based care in interdisciplinary PC settings, using directed-content rapid analysis of the interview transcripts. The analysis was guided by 5 a priori NASSS domains: (1) patient condition or characteristic, (2) technology, (3) adopter system, (4) health care organization, and (5) adaptation over time.

Results: The study findings include the following common themes and factors, organized by the 5 NASSS domains: (1) patient condition or characteristic—visit type or purpose (eg, follow-up visits that do not require physical examination), health condition (eg, homebound or semihomebound patients), and sociodemographic characteristic (eg, patients who have a long commute time); (2) technology—key features (eg, access to video-enabled devices), knowledge (eg, how to use videoconferencing software), and technical support for patients and providers; (3) adopter system—changes in staff roles and clinical practice (eg, coordination of video-based care), provider and patient preference or comfort to use video-based care, and caregiver’s role (eg, participation of caregivers during video visits); (4) health care organization—leadership support and access to resources, scheduling for video visits (eg, schedule or block off digital half or full days), and training and telehealth champions (eg, hands-on or on-site training for staff, patients, or caregivers); (5) adaptation over time—capacity to improve all aspects of video-based care and provide continued access to resources (eg, effective communication about updates).

Conclusions: This study identified key factors associated with the implementation of video-based services in interdisciplinary PC settings at the VHA from the perspectives of PC team members and patients. The identified multifaceted factors may inform recommendations on how to sustain and improve the provision of video-based care in VHA PC settings as well as non-VHA patient-centered medical homes.

Introduction

With the rapid expansion of telehealth services since the onset of the COVID-19 pandemic, numerous studies have focused on health care clinicians’ perspectives on telehealth service implementation in primary care (PC). These studies primarily focused on satisfaction [ 1 - 4 ] and barriers to and benefits of telehealth services [ 5 - 24 ]. Regarding barriers to PC telehealth implementation, some clinicians have experienced challenges [ 5 - 14 ], such as technical issues with video and patient portals, privacy or confidentiality concerns, workflow and scheduling changes, low reimbursement rates, improper telecommunication infrastructure, inability to conduct physical examinations, difficulty maintaining the therapeutic relationship with patients, skill and comfort with technology, and access to technology [ 5 - 24 ]. However, clinicians and patients have shared several benefits of PC telehealth implementation [ 21 , 25 - 34 ], such as reducing infection and communicable disease exposure, eliminating commute time and patients’ transportation expenses, improved medication management, better evaluation of patients’ home environment, continuity of outpatient care, flexibility in scheduling appointments, and effective screening and triaging [ 5 - 9 , 21 , 25 - 34 ].

Despite its barriers and challenges, during the COVID-19 pandemic, video-based care has garnered high levels of satisfaction among health care clinicians and patients [ 1 - 4 ]. However, little is known about telehealth implementation at the national level, its use among interdisciplinary PC team members, and its sustainment beyond the initial phases of the pandemic. To address these knowledge gaps, the diffusion of innovation theory and the nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework [ 35 ], an evidence-based, theory-informed, pragmatic model, are used to help understand the factors associated with the implementation of a technology-supported health care program. The NASSS framework builds on the work of the diffusion of innovation theory [ 36 ] and addresses the success of telehealth services, referred to in this study as video-based care. Guided by 5 NASSS domains and the corresponding subdomains, this study identifies the common factors (across patients, providers, and sites) that are associated with achieving fully mainstreamed implementation of video-based care.

The main objective of this study is to understand PC team members’ and patients’ perspectives on the implementation of video-based services within the Veterans Health Administration (VHA) 2 years after the onset of the COVID-19 pandemic. VHA PC is based on a patient-centered medical home model that includes interdisciplinary team members (physicians, nurse practitioners, physician assistants, nurses, social workers, clinical pharmacists, and mental health specialists) who work together to coordinate the provision of care, including video-based care. The VHA is well-suited to examine these issues given its over 2 decades of experience in video-based care [ 37 - 40 ] and its rapid expansion of video-based services in PC at the onset of the COVID-19 pandemic [ 41 ].

Study Setting, Site Selection, and Recruitment

To have a greater understanding of the interdisciplinary PC team members’ and patients’ perspectives on the use of video-based services at the VHA, we applied a positive and negative deviance approach [ 42 , 43 ] and selected the 6% highest (n=8) and the 6% lowest (n=8) video-using PC sites in 2022 from a total of 130 VHA medical centers nationally. For each of the 16 selected VHA sites, we contacted the medical directors and chiefs of staff through email and shared the study materials, such as the study information sheet and study approvals. We specified in the study information sheet that participation in the study was voluntary, and if they decided to participate, they could withdraw from the study at any time or refuse to answer any question. VHA medical center directors and chiefs of staff from 12 sites (6 low and 6 high) agreed to participate in the study. The 12 study sites represent all 5 US regions (3 West, 3 Midwest, 2 Southwest, 2 Southeast, and 2 Northeast), where 9 are urban and 3 are rural.

For the provider interviews, the inclusion criteria to participate was to be a member of a VHA interdisciplinary PC team at any of the 12 study sites. After receiving approval at the 12 VHA sites, we were then referred to the PC chief of staff at each site, who assisted with the recruitment process by sharing the study information sheet with their PC team members. Interested PC team members (n=53; 3-5 per site) contacted our study team to express that they wanted to participate in a 30-minute interview. Up to 3 follow-up emails were sent to schedule the study interviews. A total of 43 PC staff members (3-4 per site) were interviewed by 2 study members remotely through Microsoft Teams during August-October 2022. All interviews were audio-recorded and transcribed.

For the patient interviews, we began the recruitment process in January 2023 by randomly selecting a total of 120 VHA PC patients (10 per site) using the VHA electronic health records. The study inclusion criteria included (1) at least 1 PC visit during the past 2 years (2021-2022), (2) a valid US postal address, and (3) a phone number. We first mailed the study recruitment letters to all potential study participants, explaining the purpose of the study, that study participation was voluntary, and that all collected interview data would be kept confidential. We also explained that they had the option to opt out by calling a designated study phone number, and if they chose not to opt out, we may contact them (by phone) in 2-3 weeks to schedule a 30-minute phone interview. To minimize the burden on the 2 study members, we mailed the recruitment letters in 2 batches (60 letters in January 2023 and 60 letters in February 2023). We contacted 83 recruited patients by phone (up to 3 phone calls) with the following results: (1) 42 (51%) voice messages (no answer), (2) 7 (8%) wrong phone numbers, (3) 9 (11%) refusals, and (4) 25 (30%) completed phone interviews (2-3 per site) during February-May 2023. The response rate for patient interviews was 33% ([25/(83-7)] × 100). We stopped recruiting patients after reaching data saturation [ 44 ]. All interviews were audio-recorded and transcribed.

Semistructured Interview Guide

For this study, 2 semistructured interview guides (provider and patient) with open-ended questions were used. Both interview guides were developed based on 5 of the NASSS domains [ 35 ] pertaining to telehealth implementation: (1) patient conditions, illness, and characteristic; (2) technology; (3) adopter system; (4) health care organization; and (5) adaptation over time (see Table 1 for details).

Study Population

A total of 43 PC team members and 25 PC patients were interviewed remotely. PC team members represented different roles in the PC team, including 16 primary care providers (PCPs), which included physicians, physician assistants, and nurse practitioners; 12 nurses; 3 clinical pharmacists; 3 social workers; 2 mental health specialists (eg, psychiatrists and clinical psychologists); 4 scheduling clerks or supervisors; and 3 health care leadership team members. A diverse group of patients with respect to age, gender, race, ethnicity, and place of residence (rural or urban) were interviewed.

We identified emerged themes and factors across all provider and patient interviews that were associated with the implementation of video-based care in interdisciplinary PC settings, using directed-content rapid analysis [ 45 , 46 ] of the interview transcripts. This analysis was based on substantive significance [ 47 ], and it was guided by 5 a priori NASSS domains (mentioned above). A structured template was created to summarize data from each interview, with 3 team members (CH, SH, and CDM) revising the template after independently analyzing a single transcript and reviewing the others’ templates for consistency. A summary matrix of the summaries was then used to consolidate all the interview findings. Key points were transposed and sorted into NASSS framework–identified themes, then reviewed and validated by 2 project team members (CH, SH, or CDM).

Ethical Considerations

This study was part of an ongoing quality improvement effort, and hence it was exempt from review by the institutional review board at the VHA Greater Los Angeles Healthcare System. Following study protocols, audio-recorded verbal consent was sufficient for participation in the study. To protect the privacy of study participants, all collected study information was deidentified and kept confidential. Each patient interviewee received a US $30 VHA canteen voucher after completing the interview. Provider interviewees did not receive any monetary incentives since their participation in the study was during the workday.

In this section, the emerged themes and factors from the directed-content rapid analysis of provider and patient qualitative interviews are discussed in detail. The emerged or identified themes (or identified factors) were common across all patient and provider types. Table 2 displays the study findings for each of the 5 NASSS domains and the corresponding subdomains.

Patient Condition, Illness, and Characteristic

Visit type or purpose.

Video-based care was considered most suitable for follow-ups to routine care, particularly for patients with chronic conditions. Seeing new patients and care requiring a physical assessment was preferably done in-person. A patient explained:

If I need a quick medicine change or something along those lines where I don’t need to be physically examined then I would, yes, use a video call. [Patient 18]

Moreover, video visits allow providers to assess patients’ home environment.

Video appointments give much more insights to the patients’ home status, their pride, their pets... their current living conditions that we can discuss about. [Leadership 1]

I do believe the best place to take care of the patient is in their home… so, the more video we could do, I think the better we would be at taking care of Veterans. We could touch them more often. [Physician 15]

Video visits also allowed better medication reconciliation, as patients could just show their bottles through the video camera.

They’re at home with their pills. They can pull them all out. They don’t have to drag them into the appointment. [Clinical pharmacist 3]

Video-based care is conducive for explaining new medications or laboratory results to patients. Blood pressure readings were cited as being video-appropriate, as patients usually have their own equipment and can be overseen by their clinician while taking their own blood pressure at home. Mental health specialists felt comfortable using the technology for telemental health sessions, stating the proven effectiveness and comparability of video to in-person care.

Health Condition, Illness, or Patient Type

For older patients with difficulty ambulating and those who depend on family members for transportation to the clinic, video-based care is a viable option. Similarly, for established patients who have been with the same PCP for many years, and for patients who cannot come to the clinic for a variety of reasons (eg, substance abuse and anxiety), video-based care might be a good alternative. Moreover, video-based care is appropriate for patients in palliative care, COVID-19–positive patients, and recently discharged patients. One patient explained:

Following up from emergency room visits or hospital stays, those are pretty easy to do over the phone or video because you should be okay. You shouldn’t have any other issues, or if you are having issues, as long as they’re not extreme and you don’t need to go back to the ER. [Patient 17]

Sociodemographic Characteristics

Even though younger patients might be more amenable to video-based care, age is arbitrary when understanding how to use telehealth technology.

We still live in a reality where people think that elderly people are not technologically savvy, and I don’t think that is correct. [Physician 7]

It’s our older population that are not working that I think we see more of them in the virtual appointments than anything. [Nurse 8]

Therefore, age should not be an exclusion criterion, but it often is. A social worker further explained that, at times, it is unrealistic for patients to be expected to come into the clinic when there is no need for them to make that extra effort.

Patients with long commutes to their local VHA clinics appreciated video visits. This allowed them to save time and money on gas and transportation. For patients who are traveling within the continental United States and who need continuity of care, video-based care can be a good option. Similarly, patients who work, have family obligations or go to school and accordingly have a hard time scheduling a clinic or in-person visit found video care to be beneficial. One patient explained:

Sometimes, I’ll set my appointment when I’m picking up my son and I’m waiting outside… and it’s usually a really good time. I’m in my car and it’s very quiet. [Patient 21]

Key Features of Videoconferencing Technology

Access to video-enabled devices (either a smartphone or laptop), as well as high-speed broadband and stable internet connectivity, is necessary for video-based care. At times, patients living in rural areas lacked the wireless bandwidth to take video calls. Homeless-experienced or low-income patients lacked suitable equipment (eg, a smartphone) for video services, but this issue was ameliorated by the Digital Divide Consult program that provided VHA-issued iPads or tablets for qualified patients. Yet some patients who received iPads still faced barriers to video-based care and did not use them because of internet connectivity issues or a lack of broadband access.

I saw that also happen with one of my Veterans. He wouldn’t show up on his video appointments. And I know he had a VA-issued iPad. [Physician 10]

Knowledge About Technology

Even though video-based care might be more suitable for tech-savvy patients and providers who can use video-enabled devices, it is still important for both patients and providers to conduct at least 1 test call before using the VHA video-based technology for the first time (eg, download the app ahead of time and test the video links).

Technical Support

IT support is available for PC team members at the office or when teleworking. IT support for patients is also available, which can help patients ensure everything is prepared for their upcoming videoconferencing visit. A video test call can be done with the IT help desk or a live web-based chatbot to ensure patients’ devices are compatible with the videoconferencing software, but often these services are underused by patients.

Adopter System (Staff, Patient, and Caregiver)

Changes in staff roles and clinical practice.

There have been challenges in video-based care coordination, as some aspects and processes of in-person visits are not easily transferable to video-based visits. For example, after a nurse conducted the initial video-based check-in (eg, going over vitals and the patient’s medication list), the video call was dropped during the transfer, and the PCP was unable to join the video visit. Creating processes and procedures to manage video-based care coordination among PC team members is key for providing team-based video care.

Additionally, video-based care can provide staffing flexibility. For example, video-based providers float and provide coverage at other clinics. Regarding clinical practice, there is a need to set up video-based care protocols and guidelines for different departments, services, and types of care, so there is guidance as to when video visits are appropriate.

Provider and Patient Preference or Comfort

Video-based visits provide flexibility for patients and providers to connect remotely. Provider and patient preferences regarding video-based care are important factors, given that there were strong opinions among providers against video-based care.

We have some providers that refuse to conduct video appointments… they just don’t like change. [Nurse 5]

Regarding patient preference and comfort coming into the clinic, video-based care offers a less stressful option for patients to connect with their providers. One patient explained:

I was back in the comfort of my personal space where I feel safe, and I can open up and talk better than at an office where you’re not as comfortable because it’s not your space… And I feel that I was able to open up more and really benefit from the mental healthcare than when I go to the office because I’m already like stressed because I’m there and I’m in a hospital environment and I don’t like hospitals at all. [Patient 23]

However, there was a concern with distracted patients during video visits.

Sometimes the patient does not engage enough with you, or they get distracted by the environment. [Physician 2]

They might log on, but they’re busy doing their hair. It’s almost like they’re face timing of a friend or a family member. [Mental health specialist 03]

Overall, patients preferred occasional in-person visits to feel like they were receiving adequate attention and care. Generally, patients have strong opinions either for or against video-based care.

The ones that wanted to do it, it was a really good process. The ones that didn’t want to do it didn’t want to hear anything about it. [Nurse 5]

Caregiver’s Role

In some instances, it is important for caregivers to be present during the visit and be involved in the patient’s care, such as providing emotional support, having a better understanding of the health condition, and sharing information about what the patient is going through. Video-based visits can provide more opportunities for caregivers to get more involved with patient care. One patient explained:

I think it’s wonderful because it gave my wife a better feel for what was going on with me. [Patient 14]

Another patient shared:

I did have one session with my husband because I was trying to get him qualified as a caregiver. So, we had a video appointment for that. It was very convenient and a great option because, at the time, I was bedridden with a back injury before I had back surgery. And he was pretty much taking full time care of me to get me out of bed, showered, dressed, the whole thing. It was very helpful to have that option that we could all meet and have that evaluation done. [Patient 22]

In another instance, a social worker explained:

They’d [adult son] rather just schedule that time to be at their parent’s house and sign into the video than come in person. [Social worker 3]

Health Care Organization

Leadership support and resources.

Leadership support at all levels (eg, PC chief of staff and clinic or medical director) and from all departments (eg, PCPs, nursing, scheduling, and pharmacy) is key for the successful implementation of video-based care in PC. Additionally, having a designated physical space (eg, a private quiet space with no distractions or interruptions) and computer hardware, such as video-enabled devices, are a necessity for the successful implementation of video-based care.

Scheduling, Reminders, and Day of Video Appointment

Before scheduling a video-based PC visit, schedulers or clerks ask patients a series of questions about the types of devices they own to determine if a video visit is feasible. The scheduler or clerk also sends the patient the video link and creates the follow-up appointment. Before the day of the video appointment, reminders through SMS text messages as well as email are sent. Automatically enrolling new patients for video visits is also an option, which makes scheduling for video-based visits easier. In-person or clinic visits are still the most frequently scheduled across clinics. However, after the provider puts in the video request that the patient agreed to, some schedulers or clerks failed to follow through with scheduling the video-based appointment.

Video clinics are being underutilized, not because of lack of patient interest. It’s being underutilized because schedulers are not calling patients to make the appointment in the video clinic. [Physician 2]

There is also the option to block off half or full days for video visits. Patients shared that video visits were more timely and easier to schedule compared to in-person appointments. Video-based visits should be treated just the same as an in-person visit. As such, patients need to dress appropriately, prepare a list of questions, have their medication list ready to review and find a quiet place for the video call.

Trainings and Telehealth Champions

Video-based care training for PC team members is done through formal web-based training. However, hands-on training or trial-and-error is the best way to learn how to use the VHA video technology.

I think the best way people can walk somebody else through it is if they do it themselves. [Physician 13]

Training should be tailored for each clinic and team member, so each can understand their role in the video-based care process. VHA leadership noted that they combined multiple video training courses into 1 web-based course for new providers. An optional 1-day intensive training course is also available. Ultimately, having a telehealth champion who provides hands-on, personalized training and updates to PC team members can be critical to effectively educating the PC team on how to use video-based care.

We did have a super user in the clinic who was able to go in and show everyone how to do it [ie, use VA video technology]. [Nurse 3]

For patients, training for video-based visits usually falls on the nurses, schedulers, clerks, technicians, or other clinic staff who enroll patients in video-based scheduling for the first time. Having a patient telehealth champion, for example, a veteran sharing how they benefited from a video visit, might be helpful in providing peer-to-peer mentoring and promoting video-based visits. Overall, it seems that patients choose to have more telehealth appointments after being trained.

Once we get it set up for them [patients] and they feel comfortable with the whole [thing]—they’re utilizing it [VA video technology] quite a bit. [Nurse 8]

Adaptation Over Time (Capacity to Improve and Continued Access to Resources)

Suggestions for improving video-based care at the VHA centered around 5 main areas: technological resources, personnel support, training, care coordination, and scheduling. Regarding resources, video-based care should be connected to the patient’s electronic health care records for easier access to the web-based appointment link. Accessibility of video on cellular devices, like using SMS text messages to quickly communicate with patients. There is a need to hire more clerical staff to assist with video-based care scheduling and technical support (eg, a telehealth enrollment coordinator role on the team or a telehealth help center to assist veterans with technical issues). Beyond personnel support, there is a need for more physical space in clinics, so they could have privacy to conduct telehealth visits. Other suggestions included having more resources to support video technology, such as choosing site-specific internet networks and improving network coverage overall.

Recommendations to improve training focused on having nonclinical staff administer patient education in group and in-person settings. Patients need adequate training to use VHA video technology.

We need to teach them. We need to take the time and put the investment… but too often, we blame the patient, I think inappropriately. [Physician 11]

When asked about care coordination, the video care process should mimic the flow of in-person care while striving for “care management and the same depth of treatment.”

Regarding scheduling, providers asked for separate days designated for video and face-to-face appointments. It is important to have 1 centralized platform or web-based grid where all types of appointments, telehealth and in-person, can be scheduled. Schedulers or clerks should have a script or checklist to ensure that patients understand their video-based care options. Finally, site-specific telehealth management is needed, acknowledging that regional differences and specific site needs may affect each VHA clinic’s telehealth or video adoption and implementation.

In this study, the 5 NASSS domains that pertained to the implementation of telehealth services guided the qualitative analysis and identified key factors associated with the implementation of video-based services in PC from interdisciplinary team members’ and patients’ perspectives 2 years after the onset of the COVID-19 pandemic. In terms of patient condition, illness, and characteristics, the study findings concurred with previous studies that video-based care is most appropriate for follow-up visits that do not require physical examinations, and in some cases, it might be well-suited for follow-up visits for chronic care management [ 48 , 49 ]. This study corroborated findings from previous studies that video visits are appropriate for semi- or fully homebound patients with mobility issues who benefit from having a caregiver present at their medical appointments [ 50 , 51 ]. Similar to previous studies, convenient access to video-based care was needed for patients with full-time jobs, family obligations, transportation difficulties, and long travel distances for in-person care [ 5 - 24 ]. Regarding age, the study findings illustrated that it is important not to assume that older patients are disinterested or not qualified in using video-based care.

This study focused on video-based care; therefore, the key features of videoconferencing technology, knowledge on how to use the VHA video technology, as well as the availability of technical support, were key factors in supporting video-based care at the VHA. This study did not examine the extent to which phone was the preferred mode of video-based care as compared to video or the extent to which video visits switched to phone visits because of technical issues or other barriers. A recent study of 4691 Medicare beneficiaries [ 52 ] found that phone visits were more common when patients were given the option to use video or phone, especially among those with less access to technology and information about telehealth services. Therefore, future studies should examine the extent to which it is important to offer both options of video-based care, phone (audio-only), or video, while also addressing technological barriers to video use.

Regarding the adopter system, the study findings illustrated that there are challenges for video-based care coordination to mirror (or mimic) the workflow of routine (in-person) care (eg, the nurse conducts the initial part of the video visit and then the PCP joins the video visit). Accordingly, more research is needed to identify better ways of integrating all PC team members in the coordination and provision of video-based visits. Additionally, as illustrated in previous studies [ 5 - 24 ], this study also found that patient and provider preferences, as well as comfort level, influence the use of video-based care. As stated previously [ 25 - 34 ], video-based care offers providers and patients flexibility. During video visits, patients have the flexibility to not only connect from the comfort of their homes but to also include their caregivers during video visits if needed or desired.

For health care organization factors, leadership support at clinic and departmental levels is needed to provide the resources necessary for the successful implementation of telehealth services. Additionally, the role of schedulers or clerks in video care is critical, especially for a large integrated health care system such as the VHA. Schedulers or clerks help introduce patients to video-based care options and assist patients in navigating the VHA web-based platform. Additional research is needed to identify best practices to improve the scheduling process of video-based visits. In terms of trainings, in addition to VHA web-based video-based care trainings, which are available to all PC team members at the national level, it is still important to have patient and provider telehealth champions at the local site or clinic level who can encourage use and provide peer-to-peer, hands-on, site- or clinic-specific trainings.

Study participants shared many areas of improvement that can help sustain telehealth adaptation over time. Like previous studies [ 53 ], the study findings highlighted that it is important for health care organizations to have the capacity to improve technological resources, personnel support, training, and video-based care coordination and continue to provide access to these resources. In addition, the study findings also highlight the importance of improving scheduling processes and platforms to better meet the needs of all providers and patients. Finally, it is important to acknowledge that site-specific telehealth management is needed, since regional differences and specific site needs may affect how each VHA clinic implements telehealth or video-based care in PC settings.

Limitations

The major strengths of this study are the following: first, the study included 12 VHA medical centers located in geographically diverse settings. Second, these study sites, including 9 urban and 3 rural, had varying rates of video use, ranging from lowest to highest. Third, the directed-content rapid analysis, guided by a priori NASSS domains, identified emerged themes or factors across all interviews (43 PC team members and 25 PC patients). Despite this, the study has several limitations. First, this study did not examine the differences between patient types, appointment types, provider types, and sites. Instead, the factors that were identified in this study were common across all patients, all PC team members, and all sites. Future studies should consider which factors differentiate between sites (eg, urban vs rural), provider types (eg, mental health specialists vs PCPs), patient types (eg, male vs female and with diabetes vs without diabetes), as well as appointment types (mental health visit vs PC visit). Second, since this study did not use probability sampling strategies to select the study sites or the provider study sample, the generalizability of the study findings to all VHA PC clinics and providers is limited. Furthermore, even though simple random sampling was used to select the patient study sample, the study’s main purpose was to have an in-depth understanding of the implementation process of video-based care at the selected VHA study sites. Hence, the generalizability of the study findings to all VHA patients is limited. Third, the generalizability of study findings may be limited in non-VHA health care systems for various reasons, including that VHA clinicians do not have the same cross-state licensure restrictions, especially since the passage of the Anywhere-to-Anywhere Act (in May 2018) [ 54 , 55 ], where VHA expanded telehealth services by allowing health care clinicians to treat patients across state lines; and VHA has a capitated payment system, which makes it easier to implement telehealth since it is not subject to third-party payer arrangements [ 54 ]. However, recent COVID-19 telehealth waivers have increased non-VHA health care providers’ and clinics’ telehealth capability, such as allowing telehealth services across state lines. Therefore, there are more similarities now between VHA and non-VHA telehealth services than even in the recent past. As such, study findings may still be applicable to non-VHA clinical settings and contribute to the growing evidence base surrounding factors most salient to the successful implementation of telehealth services at PC clinics.

Conclusions

Given that VHA PC is based on a patient-centered medical home model that includes interdisciplinary team members who work together to coordinate the provision of care, including video-based care, we examined the implementation of video-based care in interdisciplinary PC settings from the perspectives of PC team members as well as patients at 12 different VHA health care settings (9 urban and 3 rural). Guided by 5 a priori NASSS domains and the corresponding subdomains, we identified common factors (across patients and PC team members) that were associated with the implementation of video-based care in interdisciplinary PC settings. The identified multifaceted factors that resulted from the qualitative analysis of the collected interview data may help inform recommendations on how to sustain and improve video-based care in VHA PC settings and other non-VHA patient-centered medical homes.

Acknowledgments

This material was supported by the United States Department of Veterans Affairs, Veterans Health Administration, Office of Connected Care (XVA 65-127), Health Services Research and Development (PPO 21-247), and the Veterans Emergency Management Evaluation Center. The views expressed in this manuscript are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

Data Availability

The data sets that were generated and analyzed during this study are not publicly available because the collected information might compromise the privacy of the study participants. The data that support the findings of this study are available from the corresponding author (CD-M) on reasonable request.

Conflicts of Interest

None declared.

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Abbreviations

Edited by A Mavragani; submitted 16.09.23; peer-reviewed by C Pankhurst; comments to author 25.01.24; revised version received 13.02.24; accepted 07.03.24; published 09.04.24.

©Claudia Der-Martirosian, Cynthia Hou, Sona Hovsepian, Maia Diarra Carter, Leonie Heyworth, Aram Dobalian, Lucinda Leung. Originally published in JMIR Formative Research (https://formative.jmir.org), 09.04.2024.

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