qualitative research in psychology journal

Qualitative Research in Psychology

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Psychology (miscellaneous)

Taylor and Francis Ltd.

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14780887, 14780895

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The SAGE Handbook of Qualitative Research in Psychology

Carla Willig - City University, London, UK
Wendy Stainton Rogers - The Open University, UK
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The second edition of the SAGE Handbook of Qualitative Research is an extraordinary compendium of the central current issues in qualitative research in psychology. Capturing the diversity and plurality of qualitative methods of investigation, this updated handbook also considers matters such as ethics and reflexivity shared across methods. Newly revised to include recent work in the burgeoning field of qualitative inquiry, it will be an essential companion for both new and experienced qualitative researchers. Qualitative researchers in psychology owe a debt of gratitude to these editors for pulling this together.

This is a very welcome and timely second edition of the highly-regarded SAGE Handbook of Qualitative Research in Psychology . In the nine years since it was first published in 2008, qualitative research in psychology has flourished into a rich, diverse and vibrant field. As the Editors of this Handbook note, there is a sense of sophistication that has evolved throughout these recent developments. There is also an increased confidence that can be seen across this updated Handbook, from the editors’ valuable framing of the field at the start through to the revised chapters and the inclusion of three new chapters. Notable additions to the Handbook include a chapter devoted to interpretation issues in qualitative research, new approaches to thematic analysis, developments and progress around metasynthesis, netnography and the implications of rapidly developing information and communication technologies for qualitative research.

This Handbook will be highly valuable for a range of audiences, including for students in psychology and other social science disciplines, but also for academics, practitioners and activists (and indeed essential reading for many). It provides a comprehensive overview of the current state-of-play in qualitative research in psychology, covers a range of diverse methodologies, outlines key approaches and perspectives, and describes applications to specific subfields of psychology. It doesn’t shy away from the many big questions, tensions, complexities and debates that are involved in qualitative research, including the range of positions and approaches that exist regarding epistemology, ethics and politics, and the varying priorities that different people bring to research. Rather it engages with these issues directly and in an accessible and welcoming manner, ensuring this Handbook will function as the clear and reliable guide for both novices and experienced researchers. In this sense it is highly successful in meeting its purpose to “help its readers to gain a sense of the territory and to enable them to make well-informed methodological theoretical and ideological choices” (Stainton Rogers & Willig, p4).

The Sage Handbook of Qualitative Research in Psychology is comprehensive and bold, celebrating the wide range of methods, approaches, perspectives and applications among qualitative research in psychology. Written by leading psychologists, this handbook covers what are now well established qualitative methods while considering methodological changes required by contemporary developments, such as social media and the routine recording of people at work, blurring the distinctions between public and private and research and everyday practice.

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What is Qualitative in Qualitative Research

Patrik aspers.

1 Department of Sociology, Uppsala University, Uppsala, Sweden

2 Seminar for Sociology, Universität St. Gallen, St. Gallen, Switzerland

3 Department of Media and Social Sciences, University of Stavanger, Stavanger, Norway

What is qualitative research? If we look for a precise definition of qualitative research, and specifically for one that addresses its distinctive feature of being “qualitative,” the literature is meager. In this article we systematically search, identify and analyze a sample of 89 sources using or attempting to define the term “qualitative.” Then, drawing on ideas we find scattered across existing work, and based on Becker’s classic study of marijuana consumption, we formulate and illustrate a definition that tries to capture its core elements. We define qualitative research as an iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied. This formulation is developed as a tool to help improve research designs while stressing that a qualitative dimension is present in quantitative work as well. Additionally, it can facilitate teaching, communication between researchers, diminish the gap between qualitative and quantitative researchers, help to address critiques of qualitative methods, and be used as a standard of evaluation of qualitative research.

If we assume that there is something called qualitative research, what exactly is this qualitative feature? And how could we evaluate qualitative research as good or not? Is it fundamentally different from quantitative research? In practice, most active qualitative researchers working with empirical material intuitively know what is involved in doing qualitative research, yet perhaps surprisingly, a clear definition addressing its key feature is still missing.

To address the question of what is qualitative we turn to the accounts of “qualitative research” in textbooks and also in empirical work. In his classic, explorative, interview study of deviance Howard Becker ( 1963 ) asks ‘How does one become a marijuana user?’ In contrast to pre-dispositional and psychological-individualistic theories of deviant behavior, Becker’s inherently social explanation contends that becoming a user of this substance is the result of a three-phase sequential learning process. First, potential users need to learn how to smoke it properly to produce the “correct” effects. If not, they are likely to stop experimenting with it. Second, they need to discover the effects associated with it; in other words, to get “high,” individuals not only have to experience what the drug does, but also to become aware that those sensations are related to using it. Third, they require learning to savor the feelings related to its consumption – to develop an acquired taste. Becker, who played music himself, gets close to the phenomenon by observing, taking part, and by talking to people consuming the drug: “half of the fifty interviews were conducted with musicians, the other half covered a wide range of people, including laborers, machinists, and people in the professions” (Becker 1963 :56).

Another central aspect derived through the common-to-all-research interplay between induction and deduction (Becker 2017 ), is that during the course of his research Becker adds scientifically meaningful new distinctions in the form of three phases—distinctions, or findings if you will, that strongly affect the course of his research: its focus, the material that he collects, and which eventually impact his findings. Each phase typically unfolds through social interaction, and often with input from experienced users in “a sequence of social experiences during which the person acquires a conception of the meaning of the behavior, and perceptions and judgments of objects and situations, all of which make the activity possible and desirable” (Becker 1963 :235). In this study the increased understanding of smoking dope is a result of a combination of the meaning of the actors, and the conceptual distinctions that Becker introduces based on the views expressed by his respondents. Understanding is the result of research and is due to an iterative process in which data, concepts and evidence are connected with one another (Becker 2017 ).

Indeed, there are many definitions of qualitative research, but if we look for a definition that addresses its distinctive feature of being “qualitative,” the literature across the broad field of social science is meager. The main reason behind this article lies in the paradox, which, to put it bluntly, is that researchers act as if they know what it is, but they cannot formulate a coherent definition. Sociologists and others will of course continue to conduct good studies that show the relevance and value of qualitative research addressing scientific and practical problems in society. However, our paper is grounded in the idea that providing a clear definition will help us improve the work that we do. Among researchers who practice qualitative research there is clearly much knowledge. We suggest that a definition makes this knowledge more explicit. If the first rationale for writing this paper refers to the “internal” aim of improving qualitative research, the second refers to the increased “external” pressure that especially many qualitative researchers feel; pressure that comes both from society as well as from other scientific approaches. There is a strong core in qualitative research, and leading researchers tend to agree on what it is and how it is done. Our critique is not directed at the practice of qualitative research, but we do claim that the type of systematic work we do has not yet been done, and that it is useful to improve the field and its status in relation to quantitative research.

The literature on the “internal” aim of improving, or at least clarifying qualitative research is large, and we do not claim to be the first to notice the vagueness of the term “qualitative” (Strauss and Corbin 1998 ). Also, others have noted that there is no single definition of it (Long and Godfrey 2004 :182), that there are many different views on qualitative research (Denzin and Lincoln 2003 :11; Jovanović 2011 :3), and that more generally, we need to define its meaning (Best 2004 :54). Strauss and Corbin ( 1998 ), for example, as well as Nelson et al. (1992:2 cited in Denzin and Lincoln 2003 :11), and Flick ( 2007 :ix–x), have recognized that the term is problematic: “Actually, the term ‘qualitative research’ is confusing because it can mean different things to different people” (Strauss and Corbin 1998 :10–11). Hammersley has discussed the possibility of addressing the problem, but states that “the task of providing an account of the distinctive features of qualitative research is far from straightforward” ( 2013 :2). This confusion, as he has recently further argued (Hammersley 2018 ), is also salient in relation to ethnography where different philosophical and methodological approaches lead to a lack of agreement about what it means.

Others (e.g. Hammersley 2018 ; Fine and Hancock 2017 ) have also identified the treat to qualitative research that comes from external forces, seen from the point of view of “qualitative research.” This threat can be further divided into that which comes from inside academia, such as the critique voiced by “quantitative research” and outside of academia, including, for example, New Public Management. Hammersley ( 2018 ), zooming in on one type of qualitative research, ethnography, has argued that it is under treat. Similarly to Fine ( 2003 ), and before him Gans ( 1999 ), he writes that ethnography’ has acquired a range of meanings, and comes in many different versions, these often reflecting sharply divergent epistemological orientations. And already more than twenty years ago while reviewing Denzin and Lincoln’ s Handbook of Qualitative Methods Fine argued:

While this increasing centrality [of qualitative research] might lead one to believe that consensual standards have developed, this belief would be misleading. As the methodology becomes more widely accepted, querulous challengers have raised fundamental questions that collectively have undercut the traditional models of how qualitative research is to be fashioned and presented (1995:417).

According to Hammersley, there are today “serious treats to the practice of ethnographic work, on almost any definition” ( 2018 :1). He lists five external treats: (1) that social research must be accountable and able to show its impact on society; (2) the current emphasis on “big data” and the emphasis on quantitative data and evidence; (3) the labor market pressure in academia that leaves less time for fieldwork (see also Fine and Hancock 2017 ); (4) problems of access to fields; and (5) the increased ethical scrutiny of projects, to which ethnography is particularly exposed. Hammersley discusses some more or less insufficient existing definitions of ethnography.

The current situation, as Hammersley and others note—and in relation not only to ethnography but also qualitative research in general, and as our empirical study shows—is not just unsatisfactory, it may even be harmful for the entire field of qualitative research, and does not help social science at large. We suggest that the lack of clarity of qualitative research is a real problem that must be addressed.

Towards a Definition of Qualitative Research

Seen in an historical light, what is today called qualitative, or sometimes ethnographic, interpretative research – or a number of other terms – has more or less always existed. At the time the founders of sociology – Simmel, Weber, Durkheim and, before them, Marx – were writing, and during the era of the Methodenstreit (“dispute about methods”) in which the German historical school emphasized scientific methods (cf. Swedberg 1990 ), we can at least speak of qualitative forerunners.

Perhaps the most extended discussion of what later became known as qualitative methods in a classic work is Bronisław Malinowski’s ( 1922 ) Argonauts in the Western Pacific , although even this study does not explicitly address the meaning of “qualitative.” In Weber’s ([1921–-22] 1978) work we find a tension between scientific explanations that are based on observation and quantification and interpretative research (see also Lazarsfeld and Barton 1982 ).

If we look through major sociology journals like the American Sociological Review , American Journal of Sociology , or Social Forces we will not find the term qualitative sociology before the 1970s. And certainly before then much of what we consider qualitative classics in sociology, like Becker’ study ( 1963 ), had already been produced. Indeed, the Chicago School often combined qualitative and quantitative data within the same study (Fine 1995 ). Our point being that before a disciplinary self-awareness the term quantitative preceded qualitative, and the articulation of the former was a political move to claim scientific status (Denzin and Lincoln 2005 ). In the US the World War II seem to have sparked a critique of sociological work, including “qualitative work,” that did not follow the scientific canon (Rawls 2018 ), which was underpinned by a scientifically oriented and value free philosophy of science. As a result the attempts and practice of integrating qualitative and quantitative sociology at Chicago lost ground to sociology that was more oriented to surveys and quantitative work at Columbia under Merton-Lazarsfeld. The quantitative tradition was also able to present textbooks (Lundberg 1951 ) that facilitated the use this approach and its “methods.” The practices of the qualitative tradition, by and large, remained tacit or was part of the mentoring transferred from the renowned masters to their students.

This glimpse into history leads us back to the lack of a coherent account condensed in a definition of qualitative research. Many of the attempts to define the term do not meet the requirements of a proper definition: A definition should be clear, avoid tautology, demarcate its domain in relation to the environment, and ideally only use words in its definiens that themselves are not in need of definition (Hempel 1966 ). A definition can enhance precision and thus clarity by identifying the core of the phenomenon. Preferably, a definition should be short. The typical definition we have found, however, is an ostensive definition, which indicates what qualitative research is about without informing us about what it actually is :

Qualitative research is multimethod in focus, involving an interpretative, naturalistic approach to its subject matter. This means that qualitative researchers study things in their natural settings, attempting to make sense of, or interpret, phenomena in terms of the meanings people bring to them. Qualitative research involves the studied use and collection of a variety of empirical materials – case study, personal experience, introspective, life story, interview, observational, historical, interactional, and visual texts – that describe routine and problematic moments and meanings in individuals’ lives. (Denzin and Lincoln 2005 :2)

Flick claims that the label “qualitative research” is indeed used as an umbrella for a number of approaches ( 2007 :2–4; 2002 :6), and it is not difficult to identify research fitting this designation. Moreover, whatever it is, it has grown dramatically over the past five decades. In addition, courses have been developed, methods have flourished, arguments about its future have been advanced (for example, Denzin and Lincoln 1994) and criticized (for example, Snow and Morrill 1995 ), and dedicated journals and books have mushroomed. Most social scientists have a clear idea of research and how it differs from journalism, politics and other activities. But the question of what is qualitative in qualitative research is either eluded or eschewed.

We maintain that this lacuna hinders systematic knowledge production based on qualitative research. Paul Lazarsfeld noted the lack of “codification” as early as 1955 when he reviewed 100 qualitative studies in order to offer a codification of the practices (Lazarsfeld and Barton 1982 :239). Since then many texts on “qualitative research” and its methods have been published, including recent attempts (Goertz and Mahoney 2012 ) similar to Lazarsfeld’s. These studies have tried to extract what is qualitative by looking at the large number of empirical “qualitative” studies. Our novel strategy complements these endeavors by taking another approach and looking at the attempts to codify these practices in the form of a definition, as well as to a minor extent take Becker’s study as an exemplar of what qualitative researchers actually do, and what the characteristic of being ‘qualitative’ denotes and implies. We claim that qualitative researchers, if there is such a thing as “qualitative research,” should be able to codify their practices in a condensed, yet general way expressed in language.

Lingering problems of “generalizability” and “how many cases do I need” (Small 2009 ) are blocking advancement – in this line of work qualitative approaches are said to differ considerably from quantitative ones, while some of the former unsuccessfully mimic principles related to the latter (Small 2009 ). Additionally, quantitative researchers sometimes unfairly criticize the first based on their own quality criteria. Scholars like Goertz and Mahoney ( 2012 ) have successfully focused on the different norms and practices beyond what they argue are essentially two different cultures: those working with either qualitative or quantitative methods. Instead, similarly to Becker ( 2017 ) who has recently questioned the usefulness of the distinction between qualitative and quantitative research, we focus on similarities.

The current situation also impedes both students and researchers in focusing their studies and understanding each other’s work (Lazarsfeld and Barton 1982 :239). A third consequence is providing an opening for critiques by scholars operating within different traditions (Valsiner 2000 :101). A fourth issue is that the “implicit use of methods in qualitative research makes the field far less standardized than the quantitative paradigm” (Goertz and Mahoney 2012 :9). Relatedly, the National Science Foundation in the US organized two workshops in 2004 and 2005 to address the scientific foundations of qualitative research involving strategies to improve it and to develop standards of evaluation in qualitative research. However, a specific focus on its distinguishing feature of being “qualitative” while being implicitly acknowledged, was discussed only briefly (for example, Best 2004 ).

In 2014 a theme issue was published in this journal on “Methods, Materials, and Meanings: Designing Cultural Analysis,” discussing central issues in (cultural) qualitative research (Berezin 2014 ; Biernacki 2014 ; Glaeser 2014 ; Lamont and Swidler 2014 ; Spillman 2014). We agree with many of the arguments put forward, such as the risk of methodological tribalism, and that we should not waste energy on debating methods separated from research questions. Nonetheless, a clarification of the relation to what is called “quantitative research” is of outmost importance to avoid misunderstandings and misguided debates between “qualitative” and “quantitative” researchers. Our strategy means that researchers, “qualitative” or “quantitative” they may be, in their actual practice may combine qualitative work and quantitative work.

In this article we accomplish three tasks. First, we systematically survey the literature for meanings of qualitative research by looking at how researchers have defined it. Drawing upon existing knowledge we find that the different meanings and ideas of qualitative research are not yet coherently integrated into one satisfactory definition. Next, we advance our contribution by offering a definition of qualitative research and illustrate its meaning and use partially by expanding on the brief example introduced earlier related to Becker’s work ( 1963 ). We offer a systematic analysis of central themes of what researchers consider to be the core of “qualitative,” regardless of style of work. These themes – which we summarize in terms of four keywords: distinction, process, closeness, improved understanding – constitute part of our literature review, in which each one appears, sometimes with others, but never all in the same definition. They serve as the foundation of our contribution. Our categories are overlapping. Their use is primarily to organize the large amount of definitions we have identified and analyzed, and not necessarily to draw a clear distinction between them. Finally, we continue the elaboration discussed above on the advantages of a clear definition of qualitative research.

In a hermeneutic fashion we propose that there is something meaningful that deserves to be labelled “qualitative research” (Gadamer 1990 ). To approach the question “What is qualitative in qualitative research?” we have surveyed the literature. In conducting our survey we first traced the word’s etymology in dictionaries, encyclopedias, handbooks of the social sciences and of methods and textbooks, mainly in English, which is common to methodology courses. It should be noted that we have zoomed in on sociology and its literature. This discipline has been the site of the largest debate and development of methods that can be called “qualitative,” which suggests that this field should be examined in great detail.

In an ideal situation we should expect that one good definition, or at least some common ideas, would have emerged over the years. This common core of qualitative research should be so accepted that it would appear in at least some textbooks. Since this is not what we found, we decided to pursue an inductive approach to capture maximal variation in the field of qualitative research; we searched in a selection of handbooks, textbooks, book chapters, and books, to which we added the analysis of journal articles. Our sample comprises a total of 89 references.

In practice we focused on the discipline that has had a clear discussion of methods, namely sociology. We also conducted a broad search in the JSTOR database to identify scholarly sociology articles published between 1998 and 2017 in English with a focus on defining or explaining qualitative research. We specifically zoom in on this time frame because we would have expect that this more mature period would have produced clear discussions on the meaning of qualitative research. To find these articles we combined a number of keywords to search the content and/or the title: qualitative (which was always included), definition, empirical, research, methodology, studies, fieldwork, interview and observation .

As a second phase of our research we searched within nine major sociological journals ( American Journal of Sociology , Sociological Theory , American Sociological Review , Contemporary Sociology , Sociological Forum , Sociological Theory , Qualitative Research , Qualitative Sociology and Qualitative Sociology Review ) for articles also published during the past 19 years (1998–2017) that had the term “qualitative” in the title and attempted to define qualitative research.

Lastly we picked two additional journals, Qualitative Research and Qualitative Sociology , in which we could expect to find texts addressing the notion of “qualitative.” From Qualitative Research we chose Volume 14, Issue 6, December 2014, and from Qualitative Sociology we chose Volume 36, Issue 2, June 2017. Within each of these we selected the first article; then we picked the second article of three prior issues. Again we went back another three issues and investigated article number three. Finally we went back another three issues and perused article number four. This selection criteria was used to get a manageable sample for the analysis.

The coding process of the 89 references we gathered in our selected review began soon after the first round of material was gathered, and we reduced the complexity created by our maximum variation sampling (Snow and Anderson 1993 :22) to four different categories within which questions on the nature and properties of qualitative research were discussed. We call them: Qualitative and Quantitative Research, Qualitative Research, Fieldwork, and Grounded Theory. This – which may appear as an illogical grouping – merely reflects the “context” in which the matter of “qualitative” is discussed. If the selection process of the material – books and articles – was informed by pre-knowledge, we used an inductive strategy to code the material. When studying our material, we identified four central notions related to “qualitative” that appear in various combinations in the literature which indicate what is the core of qualitative research. We have labeled them: “distinctions”, “process,” “closeness,” and “improved understanding.” During the research process the categories and notions were improved, refined, changed, and reordered. The coding ended when a sense of saturation in the material arose. In the presentation below all quotations and references come from our empirical material of texts on qualitative research.

Analysis – What is Qualitative Research?

In this section we describe the four categories we identified in the coding, how they differently discuss qualitative research, as well as their overall content. Some salient quotations are selected to represent the type of text sorted under each of the four categories. What we present are examples from the literature.

Qualitative and Quantitative

This analytic category comprises quotations comparing qualitative and quantitative research, a distinction that is frequently used (Brown 2010 :231); in effect this is a conceptual pair that structures the discussion and that may be associated with opposing interests. While the general goal of quantitative and qualitative research is the same – to understand the world better – their methodologies and focus in certain respects differ substantially (Becker 1966 :55). Quantity refers to that property of something that can be determined by measurement. In a dictionary of Statistics and Methodology we find that “(a) When referring to *variables, ‘qualitative’ is another term for *categorical or *nominal. (b) When speaking of kinds of research, ‘qualitative’ refers to studies of subjects that are hard to quantify, such as art history. Qualitative research tends to be a residual category for almost any kind of non-quantitative research” (Stiles 1998:183). But it should be obvious that one could employ a quantitative approach when studying, for example, art history.

The same dictionary states that quantitative is “said of variables or research that can be handled numerically, usually (too sharply) contrasted with *qualitative variables and research” (Stiles 1998:184). From a qualitative perspective “quantitative research” is about numbers and counting, and from a quantitative perspective qualitative research is everything that is not about numbers. But this does not say much about what is “qualitative.” If we turn to encyclopedias we find that in the 1932 edition of the Encyclopedia of the Social Sciences there is no mention of “qualitative.” In the Encyclopedia from 1968 we can read:

Qualitative Analysis. For methods of obtaining, analyzing, and describing data, see [the various entries:] CONTENT ANALYSIS; COUNTED DATA; EVALUATION RESEARCH, FIELD WORK; GRAPHIC PRESENTATION; HISTORIOGRAPHY, especially the article on THE RHETORIC OF HISTORY; INTERVIEWING; OBSERVATION; PERSONALITY MEASUREMENT; PROJECTIVE METHODS; PSYCHOANALYSIS, article on EXPERIMENTAL METHODS; SURVEY ANALYSIS, TABULAR PRESENTATION; TYPOLOGIES. (Vol. 13:225)

Some, like Alford, divide researchers into methodologists or, in his words, “quantitative and qualitative specialists” (Alford 1998 :12). Qualitative research uses a variety of methods, such as intensive interviews or in-depth analysis of historical materials, and it is concerned with a comprehensive account of some event or unit (King et al. 1994 :4). Like quantitative research it can be utilized to study a variety of issues, but it tends to focus on meanings and motivations that underlie cultural symbols, personal experiences, phenomena and detailed understanding of processes in the social world. In short, qualitative research centers on understanding processes, experiences, and the meanings people assign to things (Kalof et al. 2008 :79).

Others simply say that qualitative methods are inherently unscientific (Jovanović 2011 :19). Hood, for instance, argues that words are intrinsically less precise than numbers, and that they are therefore more prone to subjective analysis, leading to biased results (Hood 2006 :219). Qualitative methodologies have raised concerns over the limitations of quantitative templates (Brady et al. 2004 :4). Scholars such as King et al. ( 1994 ), for instance, argue that non-statistical research can produce more reliable results if researchers pay attention to the rules of scientific inference commonly stated in quantitative research. Also, researchers such as Becker ( 1966 :59; 1970 :42–43) have asserted that, if conducted properly, qualitative research and in particular ethnographic field methods, can lead to more accurate results than quantitative studies, in particular, survey research and laboratory experiments.

Some researchers, such as Kalof, Dan, and Dietz ( 2008 :79) claim that the boundaries between the two approaches are becoming blurred, and Small ( 2009 ) argues that currently much qualitative research (especially in North America) tries unsuccessfully and unnecessarily to emulate quantitative standards. For others, qualitative research tends to be more humanistic and discursive (King et al. 1994 :4). Ragin ( 1994 ), and similarly also Becker, ( 1996 :53), Marchel and Owens ( 2007 :303) think that the main distinction between the two styles is overstated and does not rest on the simple dichotomy of “numbers versus words” (Ragin 1994 :xii). Some claim that quantitative data can be utilized to discover associations, but in order to unveil cause and effect a complex research design involving the use of qualitative approaches needs to be devised (Gilbert 2009 :35). Consequently, qualitative data are useful for understanding the nuances lying beyond those processes as they unfold (Gilbert 2009 :35). Others contend that qualitative research is particularly well suited both to identify causality and to uncover fine descriptive distinctions (Fine and Hallett 2014 ; Lichterman and Isaac Reed 2014 ; Katz 2015 ).

There are other ways to separate these two traditions, including normative statements about what qualitative research should be (that is, better or worse than quantitative approaches, concerned with scientific approaches to societal change or vice versa; Snow and Morrill 1995 ; Denzin and Lincoln 2005 ), or whether it should develop falsifiable statements; Best 2004 ).

We propose that quantitative research is largely concerned with pre-determined variables (Small 2008 ); the analysis concerns the relations between variables. These categories are primarily not questioned in the study, only their frequency or degree, or the correlations between them (cf. Franzosi 2016 ). If a researcher studies wage differences between women and men, he or she works with given categories: x number of men are compared with y number of women, with a certain wage attributed to each person. The idea is not to move beyond the given categories of wage, men and women; they are the starting point as well as the end point, and undergo no “qualitative change.” Qualitative research, in contrast, investigates relations between categories that are themselves subject to change in the research process. Returning to Becker’s study ( 1963 ), we see that he questioned pre-dispositional theories of deviant behavior working with pre-determined variables such as an individual’s combination of personal qualities or emotional problems. His take, in contrast, was to understand marijuana consumption by developing “variables” as part of the investigation. Thereby he presented new variables, or as we would say today, theoretical concepts, but which are grounded in the empirical material.

Qualitative Research

This category contains quotations that refer to descriptions of qualitative research without making comparisons with quantitative research. Researchers such as Denzin and Lincoln, who have written a series of influential handbooks on qualitative methods (1994; Denzin and Lincoln 2003 ; 2005 ), citing Nelson et al. (1992:4), argue that because qualitative research is “interdisciplinary, transdisciplinary, and sometimes counterdisciplinary” it is difficult to derive one single definition of it (Jovanović 2011 :3). According to them, in fact, “the field” is “many things at the same time,” involving contradictions, tensions over its focus, methods, and how to derive interpretations and findings ( 2003 : 11). Similarly, others, such as Flick ( 2007 :ix–x) contend that agreeing on an accepted definition has increasingly become problematic, and that qualitative research has possibly matured different identities. However, Best holds that “the proliferation of many sorts of activities under the label of qualitative sociology threatens to confuse our discussions” ( 2004 :54). Atkinson’s position is more definite: “the current state of qualitative research and research methods is confused” ( 2005 :3–4).

Qualitative research is about interpretation (Blumer 1969 ; Strauss and Corbin 1998 ; Denzin and Lincoln 2003 ), or Verstehen [understanding] (Frankfort-Nachmias and Nachmias 1996 ). It is “multi-method,” involving the collection and use of a variety of empirical materials (Denzin and Lincoln 1998; Silverman 2013 ) and approaches (Silverman 2005 ; Flick 2007 ). It focuses not only on the objective nature of behavior but also on its subjective meanings: individuals’ own accounts of their attitudes, motivations, behavior (McIntyre 2005 :127; Creswell 2009 ), events and situations (Bryman 1989) – what people say and do in specific places and institutions (Goodwin and Horowitz 2002 :35–36) in social and temporal contexts (Morrill and Fine 1997). For this reason, following Weber ([1921-22] 1978), it can be described as an interpretative science (McIntyre 2005 :127). But could quantitative research also be concerned with these questions? Also, as pointed out below, does all qualitative research focus on subjective meaning, as some scholars suggest?

Others also distinguish qualitative research by claiming that it collects data using a naturalistic approach (Denzin and Lincoln 2005 :2; Creswell 2009 ), focusing on the meaning actors ascribe to their actions. But again, does all qualitative research need to be collected in situ? And does qualitative research have to be inherently concerned with meaning? Flick ( 2007 ), referring to Denzin and Lincoln ( 2005 ), mentions conversation analysis as an example of qualitative research that is not concerned with the meanings people bring to a situation, but rather with the formal organization of talk. Still others, such as Ragin ( 1994 :85), note that qualitative research is often (especially early on in the project, we would add) less structured than other kinds of social research – a characteristic connected to its flexibility and that can lead both to potentially better, but also worse results. But is this not a feature of this type of research, rather than a defining description of its essence? Wouldn’t this comment also apply, albeit to varying degrees, to quantitative research?

In addition, Strauss ( 2003 ), along with others, such as Alvesson and Kärreman ( 2011 :10–76), argue that qualitative researchers struggle to capture and represent complex phenomena partially because they tend to collect a large amount of data. While his analysis is correct at some points – “It is necessary to do detailed, intensive, microscopic examination of the data in order to bring out the amazing complexity of what lies in, behind, and beyond those data” (Strauss 2003 :10) – much of his analysis concerns the supposed focus of qualitative research and its challenges, rather than exactly what it is about. But even in this instance we would make a weak case arguing that these are strictly the defining features of qualitative research. Some researchers seem to focus on the approach or the methods used, or even on the way material is analyzed. Several researchers stress the naturalistic assumption of investigating the world, suggesting that meaning and interpretation appear to be a core matter of qualitative research.

We can also see that in this category there is no consensus about specific qualitative methods nor about qualitative data. Many emphasize interpretation, but quantitative research, too, involves interpretation; the results of a regression analysis, for example, certainly have to be interpreted, and the form of meta-analysis that factor analysis provides indeed requires interpretation However, there is no interpretation of quantitative raw data, i.e., numbers in tables. One common thread is that qualitative researchers have to get to grips with their data in order to understand what is being studied in great detail, irrespective of the type of empirical material that is being analyzed. This observation is connected to the fact that qualitative researchers routinely make several adjustments of focus and research design as their studies progress, in many cases until the very end of the project (Kalof et al. 2008 ). If you, like Becker, do not start out with a detailed theory, adjustments such as the emergence and refinement of research questions will occur during the research process. We have thus found a number of useful reflections about qualitative research scattered across different sources, but none of them effectively describe the defining characteristics of this approach.

Although qualitative research does not appear to be defined in terms of a specific method, it is certainly common that fieldwork, i.e., research that entails that the researcher spends considerable time in the field that is studied and use the knowledge gained as data, is seen as emblematic of or even identical to qualitative research. But because we understand that fieldwork tends to focus primarily on the collection and analysis of qualitative data, we expected to find within it discussions on the meaning of “qualitative.” But, again, this was not the case.

Instead, we found material on the history of this approach (for example, Frankfort-Nachmias and Nachmias 1996 ; Atkinson et al. 2001), including how it has changed; for example, by adopting a more self-reflexive practice (Heyl 2001), as well as the different nomenclature that has been adopted, such as fieldwork, ethnography, qualitative research, naturalistic research, participant observation and so on (for example, Lofland et al. 2006 ; Gans 1999 ).

We retrieved definitions of ethnography, such as “the study of people acting in the natural courses of their daily lives,” involving a “resocialization of the researcher” (Emerson 1988 :1) through intense immersion in others’ social worlds (see also examples in Hammersley 2018 ). This may be accomplished by direct observation and also participation (Neuman 2007 :276), although others, such as Denzin ( 1970 :185), have long recognized other types of observation, including non-participant (“fly on the wall”). In this category we have also isolated claims and opposing views, arguing that this type of research is distinguished primarily by where it is conducted (natural settings) (Hughes 1971:496), and how it is carried out (a variety of methods are applied) or, for some most importantly, by involving an active, empathetic immersion in those being studied (Emerson 1988 :2). We also retrieved descriptions of the goals it attends in relation to how it is taught (understanding subjective meanings of the people studied, primarily develop theory, or contribute to social change) (see for example, Corte and Irwin 2017 ; Frankfort-Nachmias and Nachmias 1996 :281; Trier-Bieniek 2012 :639) by collecting the richest possible data (Lofland et al. 2006 ) to derive “thick descriptions” (Geertz 1973 ), and/or to aim at theoretical statements of general scope and applicability (for example, Emerson 1988 ; Fine 2003 ). We have identified guidelines on how to evaluate it (for example Becker 1996 ; Lamont 2004 ) and have retrieved instructions on how it should be conducted (for example, Lofland et al. 2006 ). For instance, analysis should take place while the data gathering unfolds (Emerson 1988 ; Hammersley and Atkinson 2007 ; Lofland et al. 2006 ), observations should be of long duration (Becker 1970 :54; Goffman 1989 ), and data should be of high quantity (Becker 1970 :52–53), as well as other questionable distinctions between fieldwork and other methods:

Field studies differ from other methods of research in that the researcher performs the task of selecting topics, decides what questions to ask, and forges interest in the course of the research itself . This is in sharp contrast to many ‘theory-driven’ and ‘hypothesis-testing’ methods. (Lofland and Lofland 1995 :5)

But could not, for example, a strictly interview-based study be carried out with the same amount of flexibility, such as sequential interviewing (for example, Small 2009 )? Once again, are quantitative approaches really as inflexible as some qualitative researchers think? Moreover, this category stresses the role of the actors’ meaning, which requires knowledge and close interaction with people, their practices and their lifeworld.

It is clear that field studies – which are seen by some as the “gold standard” of qualitative research – are nonetheless only one way of doing qualitative research. There are other methods, but it is not clear why some are more qualitative than others, or why they are better or worse. Fieldwork is characterized by interaction with the field (the material) and understanding of the phenomenon that is being studied. In Becker’s case, he had general experience from fields in which marihuana was used, based on which he did interviews with actual users in several fields.

Grounded Theory

Another major category we identified in our sample is Grounded Theory. We found descriptions of it most clearly in Glaser and Strauss’ ([1967] 2010 ) original articulation, Strauss and Corbin ( 1998 ) and Charmaz ( 2006 ), as well as many other accounts of what it is for: generating and testing theory (Strauss 2003 :xi). We identified explanations of how this task can be accomplished – such as through two main procedures: constant comparison and theoretical sampling (Emerson 1998:96), and how using it has helped researchers to “think differently” (for example, Strauss and Corbin 1998 :1). We also read descriptions of its main traits, what it entails and fosters – for instance, an exceptional flexibility, an inductive approach (Strauss and Corbin 1998 :31–33; 1990; Esterberg 2002 :7), an ability to step back and critically analyze situations, recognize tendencies towards bias, think abstractly and be open to criticism, enhance sensitivity towards the words and actions of respondents, and develop a sense of absorption and devotion to the research process (Strauss and Corbin 1998 :5–6). Accordingly, we identified discussions of the value of triangulating different methods (both using and not using grounded theory), including quantitative ones, and theories to achieve theoretical development (most comprehensively in Denzin 1970 ; Strauss and Corbin 1998 ; Timmermans and Tavory 2012 ). We have also located arguments about how its practice helps to systematize data collection, analysis and presentation of results (Glaser and Strauss [1967] 2010 :16).

Grounded theory offers a systematic approach which requires researchers to get close to the field; closeness is a requirement of identifying questions and developing new concepts or making further distinctions with regard to old concepts. In contrast to other qualitative approaches, grounded theory emphasizes the detailed coding process, and the numerous fine-tuned distinctions that the researcher makes during the process. Within this category, too, we could not find a satisfying discussion of the meaning of qualitative research.

Defining Qualitative Research

In sum, our analysis shows that some notions reappear in the discussion of qualitative research, such as understanding, interpretation, “getting close” and making distinctions. These notions capture aspects of what we think is “qualitative.” However, a comprehensive definition that is useful and that can further develop the field is lacking, and not even a clear picture of its essential elements appears. In other words no definition emerges from our data, and in our research process we have moved back and forth between our empirical data and the attempt to present a definition. Our concrete strategy, as stated above, is to relate qualitative and quantitative research, or more specifically, qualitative and quantitative work. We use an ideal-typical notion of quantitative research which relies on taken for granted and numbered variables. This means that the data consists of variables on different scales, such as ordinal, but frequently ratio and absolute scales, and the representation of the numbers to the variables, i.e. the justification of the assignment of numbers to object or phenomenon, are not questioned, though the validity may be questioned. In this section we return to the notion of quality and try to clarify it while presenting our contribution.

Broadly, research refers to the activity performed by people trained to obtain knowledge through systematic procedures. Notions such as “objectivity” and “reflexivity,” “systematic,” “theory,” “evidence” and “openness” are here taken for granted in any type of research. Next, building on our empirical analysis we explain the four notions that we have identified as central to qualitative work: distinctions, process, closeness, and improved understanding. In discussing them, ultimately in relation to one another, we make their meaning even more precise. Our idea, in short, is that only when these ideas that we present separately for analytic purposes are brought together can we speak of qualitative research.

Distinctions

We believe that the possibility of making new distinctions is one the defining characteristics of qualitative research. It clearly sets it apart from quantitative analysis which works with taken-for-granted variables, albeit as mentioned, meta-analyses, for example, factor analysis may result in new variables. “Quality” refers essentially to distinctions, as already pointed out by Aristotle. He discusses the term “qualitative” commenting: “By a quality I mean that in virtue of which things are said to be qualified somehow” (Aristotle 1984:14). Quality is about what something is or has, which means that the distinction from its environment is crucial. We see qualitative research as a process in which significant new distinctions are made to the scholarly community; to make distinctions is a key aspect of obtaining new knowledge; a point, as we will see, that also has implications for “quantitative research.” The notion of being “significant” is paramount. New distinctions by themselves are not enough; just adding concepts only increases complexity without furthering our knowledge. The significance of new distinctions is judged against the communal knowledge of the research community. To enable this discussion and judgements central elements of rational discussion are required (cf. Habermas [1981] 1987 ; Davidsson [ 1988 ] 2001) to identify what is new and relevant scientific knowledge. Relatedly, Ragin alludes to the idea of new and useful knowledge at a more concrete level: “Qualitative methods are appropriate for in-depth examination of cases because they aid the identification of key features of cases. Most qualitative methods enhance data” (1994:79). When Becker ( 1963 ) studied deviant behavior and investigated how people became marihuana smokers, he made distinctions between the ways in which people learned how to smoke. This is a classic example of how the strategy of “getting close” to the material, for example the text, people or pictures that are subject to analysis, may enable researchers to obtain deeper insight and new knowledge by making distinctions – in this instance on the initial notion of learning how to smoke. Others have stressed the making of distinctions in relation to coding or theorizing. Emerson et al. ( 1995 ), for example, hold that “qualitative coding is a way of opening up avenues of inquiry,” meaning that the researcher identifies and develops concepts and analytic insights through close examination of and reflection on data (Emerson et al. 1995 :151). Goodwin and Horowitz highlight making distinctions in relation to theory-building writing: “Close engagement with their cases typically requires qualitative researchers to adapt existing theories or to make new conceptual distinctions or theoretical arguments to accommodate new data” ( 2002 : 37). In the ideal-typical quantitative research only existing and so to speak, given, variables would be used. If this is the case no new distinction are made. But, would not also many “quantitative” researchers make new distinctions?

Process does not merely suggest that research takes time. It mainly implies that qualitative new knowledge results from a process that involves several phases, and above all iteration. Qualitative research is about oscillation between theory and evidence, analysis and generating material, between first- and second -order constructs (Schütz 1962 :59), between getting in contact with something, finding sources, becoming deeply familiar with a topic, and then distilling and communicating some of its essential features. The main point is that the categories that the researcher uses, and perhaps takes for granted at the beginning of the research process, usually undergo qualitative changes resulting from what is found. Becker describes how he tested hypotheses and let the jargon of the users develop into theoretical concepts. This happens over time while the study is being conducted, exemplifying what we mean by process.

In the research process, a pilot-study may be used to get a first glance of, for example, the field, how to approach it, and what methods can be used, after which the method and theory are chosen or refined before the main study begins. Thus, the empirical material is often central from the start of the project and frequently leads to adjustments by the researcher. Likewise, during the main study categories are not fixed; the empirical material is seen in light of the theory used, but it is also given the opportunity to kick back, thereby resisting attempts to apply theoretical straightjackets (Becker 1970 :43). In this process, coding and analysis are interwoven, and thus are often important steps for getting closer to the phenomenon and deciding what to focus on next. Becker began his research by interviewing musicians close to him, then asking them to refer him to other musicians, and later on doubling his original sample of about 25 to include individuals in other professions (Becker 1973:46). Additionally, he made use of some participant observation, documents, and interviews with opiate users made available to him by colleagues. As his inductive theory of deviance evolved, Becker expanded his sample in order to fine tune it, and test the accuracy and generality of his hypotheses. In addition, he introduced a negative case and discussed the null hypothesis ( 1963 :44). His phasic career model is thus based on a research design that embraces processual work. Typically, process means to move between “theory” and “material” but also to deal with negative cases, and Becker ( 1998 ) describes how discovering these negative cases impacted his research design and ultimately its findings.

Obviously, all research is process-oriented to some degree. The point is that the ideal-typical quantitative process does not imply change of the data, and iteration between data, evidence, hypotheses, empirical work, and theory. The data, quantified variables, are, in most cases fixed. Merging of data, which of course can be done in a quantitative research process, does not mean new data. New hypotheses are frequently tested, but the “raw data is often the “the same.” Obviously, over time new datasets are made available and put into use.

Another characteristic that is emphasized in our sample is that qualitative researchers – and in particular ethnographers – can, or as Goffman put it, ought to ( 1989 ), get closer to the phenomenon being studied and their data than quantitative researchers (for example, Silverman 2009 :85). Put differently, essentially because of their methods qualitative researchers get into direct close contact with those being investigated and/or the material, such as texts, being analyzed. Becker started out his interview study, as we noted, by talking to those he knew in the field of music to get closer to the phenomenon he was studying. By conducting interviews he got even closer. Had he done more observations, he would undoubtedly have got even closer to the field.

Additionally, ethnographers’ design enables researchers to follow the field over time, and the research they do is almost by definition longitudinal, though the time in the field is studied obviously differs between studies. The general characteristic of closeness over time maximizes the chances of unexpected events, new data (related, for example, to archival research as additional sources, and for ethnography for situations not necessarily previously thought of as instrumental – what Mannay and Morgan ( 2015 ) term the “waiting field”), serendipity (Merton and Barber 2004 ; Åkerström 2013 ), and possibly reactivity, as well as the opportunity to observe disrupted patterns that translate into exemplars of negative cases. Two classic examples of this are Becker’s finding of what medical students call “crocks” (Becker et al. 1961 :317), and Geertz’s ( 1973 ) study of “deep play” in Balinese society.

By getting and staying so close to their data – be it pictures, text or humans interacting (Becker was himself a musician) – for a long time, as the research progressively focuses, qualitative researchers are prompted to continually test their hunches, presuppositions and hypotheses. They test them against a reality that often (but certainly not always), and practically, as well as metaphorically, talks back, whether by validating them, or disqualifying their premises – correctly, as well as incorrectly (Fine 2003 ; Becker 1970 ). This testing nonetheless often leads to new directions for the research. Becker, for example, says that he was initially reading psychological theories, but when facing the data he develops a theory that looks at, you may say, everything but psychological dispositions to explain the use of marihuana. Especially researchers involved with ethnographic methods have a fairly unique opportunity to dig up and then test (in a circular, continuous and temporal way) new research questions and findings as the research progresses, and thereby to derive previously unimagined and uncharted distinctions by getting closer to the phenomenon under study.

Let us stress that getting close is by no means restricted to ethnography. The notion of hermeneutic circle and hermeneutics as a general way of understanding implies that we must get close to the details in order to get the big picture. This also means that qualitative researchers can literally also make use of details of pictures as evidence (cf. Harper 2002). Thus, researchers may get closer both when generating the material or when analyzing it.

Quantitative research, we maintain, in the ideal-typical representation cannot get closer to the data. The data is essentially numbers in tables making up the variables (Franzosi 2016 :138). The data may originally have been “qualitative,” but once reduced to numbers there can only be a type of “hermeneutics” about what the number may stand for. The numbers themselves, however, are non-ambiguous. Thus, in quantitative research, interpretation, if done, is not about the data itself—the numbers—but what the numbers stand for. It follows that the interpretation is essentially done in a more “speculative” mode without direct empirical evidence (cf. Becker 2017 ).

Improved Understanding

While distinction, process and getting closer refer to the qualitative work of the researcher, improved understanding refers to its conditions and outcome of this work. Understanding cuts deeper than explanation, which to some may mean a causally verified correlation between variables. The notion of explanation presupposes the notion of understanding since explanation does not include an idea of how knowledge is gained (Manicas 2006 : 15). Understanding, we argue, is the core concept of what we call the outcome of the process when research has made use of all the other elements that were integrated in the research. Understanding, then, has a special status in qualitative research since it refers both to the conditions of knowledge and the outcome of the process. Understanding can to some extent be seen as the condition of explanation and occurs in a process of interpretation, which naturally refers to meaning (Gadamer 1990 ). It is fundamentally connected to knowing, and to the knowing of how to do things (Heidegger [1927] 2001 ). Conceptually the term hermeneutics is used to account for this process. Heidegger ties hermeneutics to human being and not possible to separate from the understanding of being ( 1988 ). Here we use it in a broader sense, and more connected to method in general (cf. Seiffert 1992 ). The abovementioned aspects – for example, “objectivity” and “reflexivity” – of the approach are conditions of scientific understanding. Understanding is the result of a circular process and means that the parts are understood in light of the whole, and vice versa. Understanding presupposes pre-understanding, or in other words, some knowledge of the phenomenon studied. The pre-understanding, even in the form of prejudices, are in qualitative research process, which we see as iterative, questioned, which gradually or suddenly change due to the iteration of data, evidence and concepts. However, qualitative research generates understanding in the iterative process when the researcher gets closer to the data, e.g., by going back and forth between field and analysis in a process that generates new data that changes the evidence, and, ultimately, the findings. Questioning, to ask questions, and put what one assumes—prejudices and presumption—in question, is central to understand something (Heidegger [1927] 2001 ; Gadamer 1990 :368–384). We propose that this iterative process in which the process of understanding occurs is characteristic of qualitative research.

Improved understanding means that we obtain scientific knowledge of something that we as a scholarly community did not know before, or that we get to know something better. It means that we understand more about how parts are related to one another, and to other things we already understand (see also Fine and Hallett 2014 ). Understanding is an important condition for qualitative research. It is not enough to identify correlations, make distinctions, and work in a process in which one gets close to the field or phenomena. Understanding is accomplished when the elements are integrated in an iterative process.

It is, moreover, possible to understand many things, and researchers, just like children, may come to understand new things every day as they engage with the world. This subjective condition of understanding – namely, that a person gains a better understanding of something –is easily met. To be qualified as “scientific,” the understanding must be general and useful to many; it must be public. But even this generally accessible understanding is not enough in order to speak of “scientific understanding.” Though we as a collective can increase understanding of everything in virtually all potential directions as a result also of qualitative work, we refrain from this “objective” way of understanding, which has no means of discriminating between what we gain in understanding. Scientific understanding means that it is deemed relevant from the scientific horizon (compare Schütz 1962 : 35–38, 46, 63), and that it rests on the pre-understanding that the scientists have and must have in order to understand. In other words, the understanding gained must be deemed useful by other researchers, so that they can build on it. We thus see understanding from a pragmatic, rather than a subjective or objective perspective. Improved understanding is related to the question(s) at hand. Understanding, in order to represent an improvement, must be an improvement in relation to the existing body of knowledge of the scientific community (James [ 1907 ] 1955). Scientific understanding is, by definition, collective, as expressed in Weber’s famous note on objectivity, namely that scientific work aims at truths “which … can claim, even for a Chinese, the validity appropriate to an empirical analysis” ([1904] 1949 :59). By qualifying “improved understanding” we argue that it is a general defining characteristic of qualitative research. Becker‘s ( 1966 ) study and other research of deviant behavior increased our understanding of the social learning processes of how individuals start a behavior. And it also added new knowledge about the labeling of deviant behavior as a social process. Few studies, of course, make the same large contribution as Becker’s, but are nonetheless qualitative research.

Understanding in the phenomenological sense, which is a hallmark of qualitative research, we argue, requires meaning and this meaning is derived from the context, and above all the data being analyzed. The ideal-typical quantitative research operates with given variables with different numbers. This type of material is not enough to establish meaning at the level that truly justifies understanding. In other words, many social science explanations offer ideas about correlations or even causal relations, but this does not mean that the meaning at the level of the data analyzed, is understood. This leads us to say that there are indeed many explanations that meet the criteria of understanding, for example the explanation of how one becomes a marihuana smoker presented by Becker. However, we may also understand a phenomenon without explaining it, and we may have potential explanations, or better correlations, that are not really understood.

We may speak more generally of quantitative research and its data to clarify what we see as an important distinction. The “raw data” that quantitative research—as an idealtypical activity, refers to is not available for further analysis; the numbers, once created, are not to be questioned (Franzosi 2016 : 138). If the researcher is to do “more” or “change” something, this will be done by conjectures based on theoretical knowledge or based on the researcher’s lifeworld. Both qualitative and quantitative research is based on the lifeworld, and all researchers use prejudices and pre-understanding in the research process. This idea is present in the works of Heidegger ( 2001 ) and Heisenberg (cited in Franzosi 2010 :619). Qualitative research, as we argued, involves the interaction and questioning of concepts (theory), data, and evidence.

Ragin ( 2004 :22) points out that “a good definition of qualitative research should be inclusive and should emphasize its key strengths and features, not what it lacks (for example, the use of sophisticated quantitative techniques).” We define qualitative research as an iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied. Qualitative research, as defined here, is consequently a combination of two criteria: (i) how to do things –namely, generating and analyzing empirical material, in an iterative process in which one gets closer by making distinctions, and (ii) the outcome –improved understanding novel to the scholarly community. Is our definition applicable to our own study? In this study we have closely read the empirical material that we generated, and the novel distinction of the notion “qualitative research” is the outcome of an iterative process in which both deduction and induction were involved, in which we identified the categories that we analyzed. We thus claim to meet the first criteria, “how to do things.” The second criteria cannot be judged but in a partial way by us, namely that the “outcome” —in concrete form the definition-improves our understanding to others in the scientific community.

We have defined qualitative research, or qualitative scientific work, in relation to quantitative scientific work. Given this definition, qualitative research is about questioning the pre-given (taken for granted) variables, but it is thus also about making new distinctions of any type of phenomenon, for example, by coining new concepts, including the identification of new variables. This process, as we have discussed, is carried out in relation to empirical material, previous research, and thus in relation to theory. Theory and previous research cannot be escaped or bracketed. According to hermeneutic principles all scientific work is grounded in the lifeworld, and as social scientists we can thus never fully bracket our pre-understanding.

We have proposed that quantitative research, as an idealtype, is concerned with pre-determined variables (Small 2008 ). Variables are epistemically fixed, but can vary in terms of dimensions, such as frequency or number. Age is an example; as a variable it can take on different numbers. In relation to quantitative research, qualitative research does not reduce its material to number and variables. If this is done the process of comes to a halt, the researcher gets more distanced from her data, and it makes it no longer possible to make new distinctions that increase our understanding. We have above discussed the components of our definition in relation to quantitative research. Our conclusion is that in the research that is called quantitative there are frequent and necessary qualitative elements.

Further, comparative empirical research on researchers primarily working with ”quantitative” approaches and those working with ”qualitative” approaches, we propose, would perhaps show that there are many similarities in practices of these two approaches. This is not to deny dissimilarities, or the different epistemic and ontic presuppositions that may be more or less strongly associated with the two different strands (see Goertz and Mahoney 2012 ). Our point is nonetheless that prejudices and preconceptions about researchers are unproductive, and that as other researchers have argued, differences may be exaggerated (e.g., Becker 1996 : 53, 2017 ; Marchel and Owens 2007 :303; Ragin 1994 ), and that a qualitative dimension is present in both kinds of work.

Several things follow from our findings. The most important result is the relation to quantitative research. In our analysis we have separated qualitative research from quantitative research. The point is not to label individual researchers, methods, projects, or works as either “quantitative” or “qualitative.” By analyzing, i.e., taking apart, the notions of quantitative and qualitative, we hope to have shown the elements of qualitative research. Our definition captures the elements, and how they, when combined in practice, generate understanding. As many of the quotations we have used suggest, one conclusion of our study holds that qualitative approaches are not inherently connected with a specific method. Put differently, none of the methods that are frequently labelled “qualitative,” such as interviews or participant observation, are inherently “qualitative.” What matters, given our definition, is whether one works qualitatively or quantitatively in the research process, until the results are produced. Consequently, our analysis also suggests that those researchers working with what in the literature and in jargon is often called “quantitative research” are almost bound to make use of what we have identified as qualitative elements in any research project. Our findings also suggest that many” quantitative” researchers, at least to some extent, are engaged with qualitative work, such as when research questions are developed, variables are constructed and combined, and hypotheses are formulated. Furthermore, a research project may hover between “qualitative” and “quantitative” or start out as “qualitative” and later move into a “quantitative” (a distinct strategy that is not similar to “mixed methods” or just simply combining induction and deduction). More generally speaking, the categories of “qualitative” and “quantitative,” unfortunately, often cover up practices, and it may lead to “camps” of researchers opposing one another. For example, regardless of the researcher is primarily oriented to “quantitative” or “qualitative” research, the role of theory is neglected (cf. Swedberg 2017 ). Our results open up for an interaction not characterized by differences, but by different emphasis, and similarities.

Let us take two examples to briefly indicate how qualitative elements can fruitfully be combined with quantitative. Franzosi ( 2010 ) has discussed the relations between quantitative and qualitative approaches, and more specifically the relation between words and numbers. He analyzes texts and argues that scientific meaning cannot be reduced to numbers. Put differently, the meaning of the numbers is to be understood by what is taken for granted, and what is part of the lifeworld (Schütz 1962 ). Franzosi shows how one can go about using qualitative and quantitative methods and data to address scientific questions analyzing violence in Italy at the time when fascism was rising (1919–1922). Aspers ( 2006 ) studied the meaning of fashion photographers. He uses an empirical phenomenological approach, and establishes meaning at the level of actors. In a second step this meaning, and the different ideal-typical photographers constructed as a result of participant observation and interviews, are tested using quantitative data from a database; in the first phase to verify the different ideal-types, in the second phase to use these types to establish new knowledge about the types. In both of these cases—and more examples can be found—authors move from qualitative data and try to keep the meaning established when using the quantitative data.

A second main result of our study is that a definition, and we provided one, offers a way for research to clarify, and even evaluate, what is done. Hence, our definition can guide researchers and students, informing them on how to think about concrete research problems they face, and to show what it means to get closer in a process in which new distinctions are made. The definition can also be used to evaluate the results, given that it is a standard of evaluation (cf. Hammersley 2007 ), to see whether new distinctions are made and whether this improves our understanding of what is researched, in addition to the evaluation of how the research was conducted. By making what is qualitative research explicit it becomes easier to communicate findings, and it is thereby much harder to fly under the radar with substandard research since there are standards of evaluation which make it easier to separate “good” from “not so good” qualitative research.

To conclude, our analysis, which ends with a definition of qualitative research can thus both address the “internal” issues of what is qualitative research, and the “external” critiques that make it harder to do qualitative research, to which both pressure from quantitative methods and general changes in society contribute.

Acknowledgements

Financial Support for this research is given by the European Research Council, CEV (263699). The authors are grateful to Susann Krieglsteiner for assistance in collecting the data. The paper has benefitted from the many useful comments by the three reviewers and the editor, comments by members of the Uppsala Laboratory of Economic Sociology, as well as Jukka Gronow, Sebastian Kohl, Marcin Serafin, Richard Swedberg, Anders Vassenden and Turid Rødne.

Biographies

is professor of sociology at the Department of Sociology, Uppsala University and Universität St. Gallen. His main focus is economic sociology, and in particular, markets. He has published numerous articles and books, including Orderly Fashion (Princeton University Press 2010), Markets (Polity Press 2011) and Re-Imagining Economic Sociology (edited with N. Dodd, Oxford University Press 2015). His book Ethnographic Methods (in Swedish) has already gone through several editions.

is associate professor of sociology at the Department of Media and Social Sciences, University of Stavanger. His research has been published in journals such as Social Psychology Quarterly, Sociological Theory, Teaching Sociology, and Music and Arts in Action. As an ethnographer he is working on a book on he social world of big-wave surfing.

Publisher’s Note

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Patrik Aspers, Email: [email protected] .

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Qualitative Research in Psychology

Brendan Gough - Leeds Metropolitan University, UK
Description

This five-volume collection maps the terrain of qualitative psychology, using classic papers from the last 25 years to document key principles, orientations and virtues, and drawing on more recent papers to delineate current trends, innovations, and debates. Although qualitative research has featured within the discipline of psychology throughout its history, the past 25 years has witnessed an avalanche of journals and textbooks, conferences, national and international associations all devoted to qualitative research, which means that this major work couldn’t be timelier. The volumes are structured chronologically to enable understanding of developments and trends in field, running from the foundations (volume 1) to contemporary issues (volume 5). This major work is designed to serve students, faculty, practitioners, and educators with an interest in qualitative research within psychology and other social science disciplines.

Volume One: Foundations

Volume Two: Qualitative data collection

Volume Three: Methodologies 1: From experiential to constructionist approaches

Volume Four: Methodologies 2: Discursive and critical approaches

Volume Five: Contemporary issues and innovations

"Brendan Gough has taken on the unenviable task of distilling out the "most interesting and influential papers" on qualitative research over the last 20-30 years. His selection of 79 papers could, and probably will, be debated but there is no doubt that he has succeeded in assembling a coherent and valuable collection of articles. The logical, systematic organisation of the five volumes, around methods and issues, allows for easy location of readings of interest on a wide variety of topics. This collection will be highly useful as core resource readings, for both those new to and those more experienced in qualitative research."

"With this collection, qualitative psychology has truly come of age. The 5 volumes map out the field, from its origins and foundations through to the most recent innovations and debates. Brendan Gough has done a fantastic job in bringing together the voices of qualitative psychologists who have shaped the discipline and give it its present direction. Inspirational and informative, this major work constitutes an indispensable addition to any research methods library ."

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Published: 21 May 2024

The bright side of sports: a systematic review on well-being, positive emotions and performance

David Peris-Delcampo 1 ,
Antonio Núñez 2 ,
Paula Ortiz-Marholz 3 ,
Aurelio Olmedilla 4 ,
Enrique Cantón 1 ,
Javier Ponseti 2 &
Alejandro Garcia-Mas 2

BMC Psychology volume 12 , Article number: 284 ( 2024 ) Cite this article

Metrics details

The objective of this study is to conduct a systematic review regarding the relationship between positive psychological factors, such as psychological well-being and pleasant emotions, and sports performance.

This study, carried out through a systematic review using PRISMA guidelines considering the Web of Science, PsycINFO, PubMed and SPORT Discus databases, seeks to highlight the relationship between other more ‘positive’ factors, such as well-being, positive emotions and sports performance.

The keywords will be decided by a Delphi Method in two rounds with sport psychology experts.

Participants

There are no participants in the present research.

The main exclusion criteria were: Non-sport thema, sample younger or older than 20–65 years old, qualitative or other methodology studies, COVID-related, journals not exclusively about Psychology.

Main outcomes measures

We obtained a first sample of 238 papers, and finally, this sample was reduced to the final sample of 11 papers.

The results obtained are intended to be a representation of the ‘bright side’ of sports practice, and as a complement or mediator of the negative variables that have an impact on athletes’ and coaches’ performance.

Conclusions

Clear recognition that acting on intrinsic motivation continues to be the best and most effective way to motivate oneself to obtain the highest levels of performance, a good perception of competence and a source of personal satisfaction.

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Introduction

In recent decades, research in the psychology of sport and physical exercise has focused on the analysis of psychological variables that could have a disturbing, unfavourable or detrimental role, including emotions that are considered ‘negative’, such as anxiety/stress, sadness or anger, concentrating on their unfavourable relationship with sports performance [ 1 , 2 , 3 , 4 ], sports injuries [ 5 , 6 , 7 ] or, more generally, damage to the athlete’s health [ 8 , 9 , 10 ]. The study of ‘positive’ emotions such as happiness or, more broadly, psychological well-being, has been postponed at this time, although in recent years this has seen an increase that reveals a field of study of great interest to researchers and professionals [ 11 , 12 , 13 ] including physiological, psychological, moral and social beneficial effects of the physical activity in comic book heroes such as Tintin, a team leader, which can serve as a model for promoting healthy lifestyles, or seeking ‘eternal youth’ [ 14 ].

Emotions in relation to their effects on sports practice and performance rarely go in one direction, being either negative or positive—generally positive and negative emotions do not act alone [ 15 ]. Athletes experience different emotions simultaneously, even if they are in opposition and especially if they are of mild or moderate intensity [ 16 ]. The athlete can feel satisfied and happy and at the same time perceive a high level of stress or anxiety before a specific test or competition. Some studies [ 17 ] have shown how sports participation and the perceived value of elite sports positively affect the subjective well-being of the athlete. This also seems to be the case in non-elite sports practice. The review by Mansfield et al. [ 18 ] showed that the published literature suggests that practising sports and dance, in a group or supported by peers, can improve the subjective well-being of the participants, and also identifies negative feelings towards competence and ability, although the quantity and quality of the evidence published is low, requiring better designed studies. All these investigations are also supported by the development of the concept of eudaimonic well-being [ 19 ], which is linked to the development of intrinsic motivation, not only in its aspect of enjoyment but also in its relationship with the perception of competition and overcoming and achieving goals, even if this is accompanied by other unpleasant hedonic emotions or even physical discomfort. Shortly after a person has practised sports, he will remember those feelings of exhaustion and possibly stiffness, linked to feelings of satisfaction and even enjoyment.

Furthermore, the mediating role of parents, coaches and other psychosocial agents can be significant. In this sense, Lemelin et al. [ 20 ], with the aim of investigating the role of autonomy support from parents and coaches in the prediction of well-being and performance of athletes, found that autonomy support from parents and coaches has positive relationships with the well-being of the athlete, but that only coach autonomy support is associated with sports performance. This research suggests that parents and coaches play important but distinct roles in athlete well-being and that coach autonomy support could help athletes achieve high levels of performance.

On the other hand, an analysis of emotions in the sociocultural environment in which they arise and gain meaning is always interesting, both from an individual perspective and from a sports team perspective. Adler et al. [ 21 ] in a study with military teams showed that teams with a strong emotional culture of optimism were better positioned to recover from poor performance, suggesting that organisations that promote an optimistic culture develop more resilient teams. Pekrun et al. [ 22 ] observed with mathematics students that individual success boosts emotional well-being, while placing people in high-performance groups can undermine it, which is of great interest in investigating the effectiveness and adjustment of the individual in sports teams.

There is still little scientific literature in the field of positive emotions and their relationship with sports practice and athlete performance, although their approach has long had its clear supporters [ 23 , 24 ]. It is comforting to observe the significant increase in studies in this field, since some authors (e.g [ 25 , 26 ]). . , point out the need to overcome certain methodological and conceptual problems, paying special attention to the development of specific instruments for the evaluation of well-being in the sports field and evaluation methodologies.

As McCarthy [ 15 ] indicates, positive emotions (hedonically pleasant) can be the catalysts for excellence in sport and deserve a space in our research and in professional intervention to raise the level of athletes’ performance. From a holistic perspective, positive emotions are permanently linked to psychological well-being and research in this field is necessary: firstly because of the leading role they play in human behaviour, cognition and affection, and secondly, because after a few years of international uncertainty due to the COVID-19 pandemic and wars, it seems ‘healthy and intelligent’ to encourage positive emotions for our athletes. An additional reason is that they are known to improve motivational processes, reducing abandonment and negative emotional costs [ 11 ]. In this vein, concepts such as emotional intelligence make sense and can help to identify and properly manage emotions in the sports field and determine their relationship with performance [ 27 ] that facilitates the inclusion of emotional training programmes based on the ‘bright side’ of sports practice [ 28 ].

Based on all of the above, one might wonder how these positive emotions are related to a given event and what role each one of them plays in the athlete’s performance. Do they directly affect performance, or do they affect other psychological variables such as concentration, motivation and self-efficacy? Do they favour the availability and competent performance of the athlete in a competition? How can they be regulated, controlled for their own benefit? How can other psychosocial agents, such as parents or coaches, help to increase the well-being of their athletes?

This work aims to enhance the leading role, not the secondary, of the ‘good and pleasant side’ of sports practice, either with its own entity, or as a complement or mediator of the negative variables that have an impact on the performance of athletes and coaches. Therefore, the objective of this study is to conduct a systematic review regarding the relationship between positive psychological factors, such as psychological well-being and pleasant emotions, and sports performance. For this, the methodological criteria that constitute the systematic review procedure will be followed.

Materials and methods

This study was carried out through a systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews) guidelines considering the Web of Science (WoS) and Psycinfo databases. These two databases were selected using the Delphi method [ 29 ]. It does not include a meta-analysis because there is great data dispersion due to the different methodologies used [ 30 ].

The keywords will be decided by the Delphi Method in two rounds with sport psychology experts. The results obtained are intended to be a representation of the ‘bright side’ of sports practice, and as a complement or mediator of the negative variables that have an impact on athletes’ and coaches’ performance.

It was determined that the main construct was to be psychological well-being, and that it was to be paired with optimism, healthy practice, realisation, positive mood, and performance and sport. The search period was limited to papers published between 2000 and 2023, and the final list of papers was obtained on February 13 , 2023. This research was conducted in two languages—English and Spanish—and was limited to psychological journals and specifically those articles where the sample was formed by athletes.

Each word was searched for in each database, followed by searches involving combinations of the same in pairs and then in trios. In relation to the results obtained, it was decided that the best approach was to group the words connected to positive psychology on the one hand, and on the other, those related to self-realisation/performance/health. In this way, it used parentheses to group words (psychological well-being; or optimism; or positive mood) with the Boolean ‘or’ between them (all three refer to positive psychology); and on the other hand, it grouped those related to performance/health/realisation (realisation; or healthy practice or performance), separating both sets of parentheses by the Boolean ‘and’’. To further filter the search, a keyword included in the title and in the inclusion criteria was added, which was ‘sport’ with the Boolean ‘and’’. In this way, the search achieved results that combined at least one of the three positive psychology terms and one of the other three.

Results (first phase)

The mentioned keywords were cross-matched, obtaining the combination with a sufficient number of papers. From the first research phase, the total number of papers obtained was 238. Then screening was carried out by 4 well-differentiated phases that are summarised in Fig. 1 . These phases helped to reduce the original sample to a more accurate one.

Phases of the selection process for the final sample. Four phases were carried out to select the final sample of articles. The first phase allowed the elimination of duplicates. In the second stage, those that, by title or abstract, did not fit the objectives of the article were eliminated. Previously selected exclusion criteria were applied to the remaining sample. Thus, in phase 4, the final sample of 11 selected articles was obtained

Results (second phase)

The first screening examined the title, and the abstract if needed, excluding the papers that were duplicated, contained errors or someone with formal problems, low N or case studies. This screening allowed the initial sample to be reduced to a more accurate one with 109 papers selected.

Results (third phase)

This was followed by the second screening to examine the abstract and full texts, excluding if necessary papers related to non-sports themes, samples that were too old or too young for our interests, papers using qualitative methodologies, articles related to the COVID period, or others published in non-psychological journals. Furthermore, papers related to ‘negative psychological variables’’ were also excluded.

Results (fourth phase)

At the end of this second screening the remaining number of papers was 11. In this final phase we tried to organise the main characteristics and their main conclusions/results in a comprehensible list (Table 1 ). Moreover, in order to enrich our sample of papers, we decided to include some articles from other sources, mainly those presented in the introduction to sustain the conceptual framework of the concept ‘bright side’ of sports.

The usual position of the researcher of psychological variables that affect sports performance is to look for relationships between ‘negative’ variables, first in the form of basic psychological processes, or distorting cognitive behavioural, unpleasant or evaluable as deficiencies or problems, in a psychology for the ‘risk’ society, which emphasises the rehabilitation that stems from overcoming personal and social pathologies [ 31 ], and, lately, regarding the affectation of the athlete’s mental health [ 32 ]. This fact seems to be true in many cases and situations and to openly contradict the proclaimed psychological benefits of practising sports (among others: Cantón [ 33 ], ; Froment and González [ 34 ]; Jürgens [ 35 ]).

However, it is possible to adopt another approach focused on the ‘positive’ variables, also in relation to the athlete’s performance. This has been the main objective of this systematic review of the existing literature and far from being a novel approach, although a minority one, it fits perfectly with the definition of our area of knowledge in the broad field of health, as has been pointed out for some time [ 36 , 37 ].

After carrying out the aforementioned systematic review, a relatively low number of articles were identified by experts that met the established conditions—according to the PRISMA method [ 37 , 38 , 39 , 40 ]—regarding databases, keywords, and exclusion and inclusion criteria. These precautions were taken to obtain the most accurate results possible, and thus guarantee the quality of the conclusions.

The first clear result that stands out is the great difficulty in finding articles in which sports ‘performance’ is treated as a well-defined study variable adapted to the situation and the athletes studied. In fact, among the results (11 papers), only 3 associate one or several positive psychological variables with performance (which is evaluated in very different ways, combining objective measures with other subjective ones). This result is not surprising, since in several previous studies (e.g. Nuñez et al. [ 41 ]) using a systematic review, this relationship is found to be very weak and nuanced by the role of different mediating factors, such as previous sports experience or the competitive level (e.g. Rascado, et al. [ 42 ]; Reche, Cepero & Rojas [ 43 ]), despite the belief—even among professional and academic circles—that there is a strong relationship between negative variables and poor performance, and vice versa, with respect to the positive variables.

Regarding what has been evidenced in relation to the latter, even with these restrictions in the inclusion and exclusion criteria, and the filters applied to the first findings, a true ‘galaxy’ of variables is obtained, which also belong to different categories and levels of psychological complexity.

A preliminary consideration regarding the current paradigm of sport psychology: although it is true that some recent works have already announced the swing of the pendulum on the objects of study of PD, by returning to the study of traits and dispositions, and even to the personality of athletes [ 43 , 44 , 45 , 46 ], our results fully corroborate this trend. Faced with five variables present in the studies selected at the end of the systematic review, a total of three traits/dispositions were found, which were also the most repeated—optimism being present in four articles, mental toughness present in three, and finally, perfectionism—as the representative concepts of this field of psychology, which lately, as has already been indicated, is significantly represented in the field of research in this area [ 46 , 47 , 48 , 49 , 50 , 51 , 52 ]. In short, the psychological variables that finally appear in the selected articles are: psychological well-being (PWB) [ 53 ]; self-compassion, which has recently been gaining much relevance with respect to the positive attributional resolution of personal behaviours [ 54 ], satisfaction with life (balance between sports practice, its results, and life and personal fulfilment [ 55 ], the existence of approach-achievement goals [ 56 ], and perceived social support [ 57 ]). This last concept is maintained transversally in several theoretical frameworks, such as Sports Commitment [ 58 ].

The most relevant concept, both quantitatively and qualitatively, supported by the fact that it is found in combination with different variables and situations, is not a basic psychological process, but a high-level cognitive construct: psychological well-being, in its eudaimonic aspect, first defined in the general population by Carol Ryff [ 59 , 60 ] and introduced at the beginning of this century in sport (e.g., Romero, Brustad & García-Mas [ 13 ], ; Romero, García-Mas & Brustad [ 61 ]). It is important to note that this concept understands psychological well-being as multifactorial, including autonomy, control of the environment in which the activity takes place, social relationships, etc.), meaning personal fulfilment through a determined activity and the achievement or progress towards goals and one’s own objectives, without having any direct relationship with simpler concepts, such as vitality or fun. In the selected studies, PWB appears in five of them, and is related to several of the other variables/traits.

The most relevant result regarding this variable is its link with motivational aspects, as a central axis that relates to different concepts, hence its connection to sports performance, as a goal of constant improvement that requires resistance, perseverance, management of errors and great confidence in the possibility that achievements can be attained, that is, associated with ideas of optimism, which is reflected in expectations of effectiveness.

If we detail the relationships more specifically, we can first review this relationship with the ‘way of being’, understood as personality traits or behavioural tendencies, depending on whether more or less emphasis is placed on their possibilities for change and learning. In these cases, well-being derives from satisfaction with progress towards the desired goal, for which resistance (mental toughness) and confidence (optimism) are needed. When, in addition, the search for improvement is constant and aiming for excellence, its relationship with perfectionism is clear, although it is a factor that should be explored further due to its potential negative effect, at least in the long term.

The relationship between well-being and satisfaction with life is almost tautological, in the precise sense that what produces well-being is the perception of a relationship or positive balance between effort (or the perception of control, if we use stricter terminology) and the results thereof (or the effectiveness of such control). This direct link is especially important when assessing achievement in personally relevant activities, which, in the case of the subjects evaluated in the papers, specifically concern athletes of a certain level of performance, which makes it a more valuable objective than would surely be found in the general population. And precisely because of this effect of the value of performance for athletes of a certain level, it also allows us to understand how well-being is linked to self-compassion, since as a psychological concept it is very close to that of self-esteem, but with a lower ‘demand’ or a greater ‘generosity’, when we encounter failures, mistakes or even defeats along the way, which offers us greater protection from the risk of abandonment and therefore reinforces persistence, a key element for any successful sports career [ 62 ].

It also has a very direct relationship with approach-achievement goals, since precisely one of the central aspects characterising this eudaimonic well-being and differentiating it from hedonic well-being is specifically its relationship with self-determined and persistent progress towards goals or achievements with incentive value for the person, as is sports performance evidently [ 63 ].

Finally, it is interesting to see how we can also find a facet or link relating to the aspects that are more closely-related to the need for human affiliation, with feeling part of a group or human collective, where we can recognise others and recognise ourselves in the achievements obtained and the social reinforcement of those themselves, as indicated by their relationship with perceived social support. This construct is very labile, in fact it is common to find results in which the pressure of social support is hardly differentiated, for example, from the parents of athletes and/or their coaches [ 64 ]. However, its relevance within this set of psychological variables and traits is proof of its possible conceptual validity.

Analysing the results obtained, the first conclusion is that in no case is an integrated model based solely on ‘positive’ variables or traits obtained, since some ‘negative’ ones appear (anxiety, stress, irrational thoughts), affecting the former.

The second conclusion is that among the positive elements the variable coping strategies (their use, or the perception of their effectiveness) and the traits of optimism, perfectionism and self-compassion prevail, since mental strength or psychological well-being (which also appear as important, but with a more complex nature) are seen to be participated in by the aforementioned traits.

Finally, it must be taken into account that the generation of positive elements, such as resilience, or the learning of coping strategies, are directly affected by the educational style received, or by the culture in which the athlete is immersed. Thus, the applied potential of these findings is great, but it must be calibrated according to the educational and/or cultural features of the specific setting.

Limitations

The limitations of this study are those evident and common in SR methodology using the PRISMA system, since the selection of keywords (and their logical connections used in the search), the databases, and the inclusion/exclusion criteria bias the work in its entirety and, therefore, constrain the generalisation of the results obtained.

Likewise, the conclusions must—based on the above and the results obtained—be made with the greatest concreteness and simplicity possible. Although we have tried to reduce these limitations as much as possible through the use of experts in the first steps of the method, they remain and must be considered in terms of the use of the results.

Future developments

Undoubtedly, progress is needed in research to more precisely elucidate the role of well-being, as it has been proposed here, from a bidirectional perspective: as a motivational element to push towards improvement and the achievement of goals, and as a product or effect of the self-determined and competent behaviour of the person, in relation to different factors, such as that indicated here of ‘perfectionism’ or the potential interference of material and social rewards, which are linked to sports performance—in our case—and that could act as a risk factor so that our achievements, far from being a source of well-being and satisfaction, become an insatiable demand in the search to obtain more and more frequent rewards.

From a practical point of view, an empirical investigation should be conducted to see if these relationships hold from a statistical point of view, either in the classical (correlational) or in the probabilistic (Bayesian Networks) plane.

The results obtained in this study, exclusively researched from the desk, force the authors to develop subsequent empirical and/or experimental studies in two senses: (1) what interrelationships exist between the so called ‘positive’ and ‘negative’ psychological variables and traits in sport, and in what sense are each of them produced; and, (2) from a global, motivational point of view, can currently accepted theoretical frameworks, such as SDT, easily accommodate this duality, which is becoming increasingly evident in applied work?

Finally, these studies should lead to proposals applied to the two fields that have appeared to be relevant: educational and cultural.

Application/transfer of results

A clear application of these results is aimed at guiding the training of sports and physical exercise practitioners, directing it towards strategies for assessing achievements, improvements and failure management, which keep them in line with well-being enhancement, eudaimonic, intrinsic and self-determined, which enhances the quality of their learning and their results and also favours personal health and social relationships.

Data availability

There are no further external data.

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Integrating qualitative research within a clinical trials unit: developing strategies and understanding their implementation in contexts

Jeremy Segrott ORCID: orcid.org/0000-0001-6215-0870 1 ,
Sue Channon 2 ,
Amy Lloyd 4 ,
Eleni Glarou 2 , 3 ,
Josie Henley 5 ,
Jacqueline Hughes 2 ,
Nina Jacob 2 ,
Sarah Milosevic 2 ,
Yvonne Moriarty 2 ,
Bethan Pell 6 ,
Mike Robling 2 ,
Heather Strange 2 ,
Julia Townson 2 ,
Qualitative Research Group &
Lucy Brookes-Howell 2

Trials volume 25 , Article number: 323 ( 2024 ) Cite this article

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Background/aims

The value of using qualitative methods within clinical trials is widely recognised. How qualitative research is integrated within trials units to achieve this is less clear. This paper describes the process through which qualitative research has been integrated within Cardiff University’s Centre for Trials Research (CTR) in Wales, UK. We highlight facilitators of, and challenges to, integration.

We held group discussions on the work of the Qualitative Research Group (QRG) within CTR. The content of these discussions, materials for a presentation in CTR, and documents relating to the development of the QRG were interpreted at a workshop attended by group members. Normalisation Process Theory (NPT) was used to structure analysis. A writing group prepared a document for input from members of CTR, forming the basis of this paper.

Actions to integrate qualitative research comprised: its inclusion in Centre strategies; formation of a QRG with dedicated funding/roles; embedding of qualitative research within operating systems; capacity building/training; monitoring opportunities to include qualitative methods in studies; maximising the quality of qualitative research and developing methodological innovation. Facilitators of these actions included: the influence of the broader methodological landscape within trial/study design and its promotion of the value of qualitative research; and close physical proximity of CTR qualitative staff/students allowing sharing of methodological approaches. Introduction of innovative qualitative methods generated interest among other staff groups. Challenges included: pressure to under-resource qualitative components of research, preference for a statistical stance historically in some research areas and funding structures, and difficulties faced by qualitative researchers carving out individual academic profiles when working across trials/studies.

Conclusions

Given that CTUs are pivotal to the design and conduct of RCTs and related study types across multiple disciplines, integrating qualitative research into trials units is crucial if its contribution is to be fully realised. We have made explicit one trials unit’s experience of embedding qualitative research and present this to open dialogue on ways to operationalise and optimise qualitative research in trials. NPT provides a valuable framework with which to theorise these processes, including the importance of sense-making and legitimisation when introducing new practices within organisations.

Peer Review reports

The value of using qualitative methods within randomised control trials (RCTs) is widely recognised [ 1 , 2 , 3 ]. Qualitative research generates important evidence on factors affecting trial recruitment/retention [ 4 ] and implementation, aiding interpretation of quantitative data [ 5 ]. Though RCTs have traditionally been viewed as sitting within a positivist paradigm, recent methodological innovations have developed new trial designs that draw explicitly on both quantitative and qualitative methods. For instance, in the field of complex public health interventions, realist RCTs seek to understand the mechanisms through which interventions generate hypothesised impacts, and how interactions across different implementation contexts form part of these mechanisms. Proponents of realist RCTs—which integrate experimental and realist paradigms—highlight the importance of using quantitative and qualitative methods to fully realise these aims and to generate an understanding of intervention mechanisms and how context shapes them [ 6 ].

A need for guidance on how to conduct good quality qualitative research is being addressed, particularly in relation to feasibility studies for RCTs [ 7 ] and process evaluations embedded within trials of complex interventions [ 5 ]. There is also guidance on the conduct of qualitative research within trials at different points in the research cycle, including development, conduct and reporting [ 8 , 9 ].

A high proportion of trials are based within or involve clinical trials units (CTUs). In the UK the UKCRC Registered CTU Network describes them as:

… specialist units which have been set up with a specific remit to design, conduct, analyse and publish clinical trials and other well-designed studies. They have the capability to provide specialist expert statistical, epidemiological, and other methodological advice and coordination to undertake successful clinical trials. In addition, most CTUs will have expertise in the coordination of trials involving investigational medicinal products which must be conducted in compliance with the UK Regulations governing the conduct of clinical trials resulting from the EU Directive for Clinical Trials.

Thus, CTUs provide the specialist methodological expertise needed for the conduct of trials, and in the case of trials of investigational medicinal products, their involvement may be mandated to ensure compliance with relevant regulations. As the definition above suggests, CTUs also conduct and support other types of study apart from RCTs, providing a range of methodological and subject-based expertise.

However, despite their central role in the conduct and design of trials, (and other evaluation designs) little has been written about how CTUs have integrated qualitative work within their organisation at a time when such methods are, as stated above, now recognised as an important aspect of RCTs and evaluation studies more generally. This is a significant gap, since integration at the organisational level arguably shapes how qualitative research is integrated within individual studies, and thus it is valuable to understand how CTUs have approached the task. There are different ways of involving qualitative work in trials units, such as partnering with other departments (e.g. social science) or employing qualitative researchers directly. Qualitative research can be imagined and configured in different ways—as a method that generates data to inform future trial and intervention design, as an embedded component within an RCT or other evaluation type, or as a parallel strand of research focusing on lived experiences of illness, for instance. Understanding how trials units have integrated qualitative research is valuable, as it can shed light on which strategies show promise, and in which contexts, and how qualitative research is positioned within the field of trials research, foregrounding the value of qualitative research. However, although much has been written about its use within trials, few accounts exist of how trials units have integrated qualitative research within their systems and structures.

This paper discusses the process of embedding qualitative research within the work of one CTU—Cardiff University’s Centre for Trials Research (CTR). It highlights facilitators of this process and identifies challenges to integration. We use the Normalisation Process Theory (NPT) as a framework to structure our experience and approach. The key gap addressed by this paper is the implementation of strategies to integrate qualitative research (a relatively newly adopted set of practices and processes) within CTU systems and structures. We acknowledge from the outset that there are multiple ways of approaching this task. What follows therefore is not a set of recommendations for a preferred or best way to integrate qualitative research, as this will comprise diverse actions according to specific contexts. Rather, we examine the processes through which integration occurred in our own setting and highlight the potential value of these insights for others engaged in the work of promoting qualitative research within trials units.

Background to the integration of qualitative research within CTR

The CTR was formed in 2015 [ 10 ]. It brought together three existing trials units at Cardiff University: the South East Wales Trials Unit, the Wales Cancer Trials Unit, and the Haematology Clinical Trials Unit. From its inception, the CTR had a stated aim of developing a programme of qualitative research and integrating it within trials and other studies. In the sections below, we map these approaches onto the framework offered by Normalisation Process Theory to understand the processes through which they helped achieve embedding and integration of qualitative research.

CTR’s aims (including those relating to the development of qualitative research) were included within its strategy documents and communicated to others through infrastructure funding applications, annual reports and its website. A Qualitative Research Group (QRG), which had previously existed within the South East Wales Trials Unit, with dedicated funding for methodological specialists and group lead academics, was a key mechanism through which the development of a qualitative portfolio was put into action. Integration of qualitative research within Centre systems and processes occurred through the inclusion of qualitative research in study adoption processes and representation on committees. The CTR’s study portfolio provided a basis to track qualitative methods in new and existing studies, identify opportunities to embed qualitative methods within recently adopted studies (at the funding application stage) and to manage staff resources. Capacity building and training were an important focus of the QRG’s work, including training courses, mentoring, creation of an academic network open to university staff and practitioners working in the field of healthcare, presentations at CTR staff meetings and securing of PhD studentships. Standard operating procedures and methodological guidance on the design and conduct of qualitative research (e.g. templates for developing analysis plans) aimed to create a shared understanding of how to undertake high-quality research, and a means to monitor the implementation of rigorous approaches. As the QRG expanded its expertise it sought to develop innovative approaches, including the use of visual [ 11 ] and ethnographic methods [ 12 ].

Understanding implementation—Normalisation Process Theory (NPT)

Normalisation Process Theory (NPT) provides a model with which to understand the implementation of new sets of practices and their normalisation within organisational settings. The term ‘normalisation’ refers to how new practices become routinised (part of the everyday work of an organisation) through embedding and integration [ 13 , 14 ]. NPT defines implementation as ‘the social organisation of work’ and is concerned with the social processes that take place as new practices are introduced. Embedding involves ‘making practices routine elements of everyday life’ within an organisation. Integration takes the form of ‘sustaining embedded practices in social contexts’, and how these processes lead to the practices becoming (or not becoming) ‘normal and routine’ [ 14 ]. NPT is concerned with the factors which promote or ‘inhibit’ attempts to embed and integrate the operationalisation of new practices [ 13 , 14 , 15 ].

Embedding new practices is therefore achieved through implementation—which takes the form of interactions in specific contexts. Implementation is operationalised through four ‘generative mechanisms’— coherence , cognitive participation , collective action and reflexive monitoring [ 14 ]. Each mechanism is characterised by components comprising immediate and organisational work, with actions of individuals and organisations (or groups of individuals) interdependent. The mechanisms operate partly through forms of investment (i.e. meaning, commitment, effort, and comprehension) [ 14 ].

Coherence refers to how individuals/groups make sense of, and give meaning to, new practices. Sense-making concerns the coherence of a practice—whether it ‘holds together’, and its differentiation from existing activities [ 15 ]. Communal and individual specification involve understanding new practices and their potential benefits for oneself or an organisation. Individuals consider what new practices mean for them in terms of tasks and responsibilities ( internalisation ) [ 14 ].

NPT frames the second mechanism, cognitive participation , as the building of a ‘community of practice’. For a new practice to be initiated, individuals and groups within an organisation must commit to it [ 14 , 15 ]. Cognitive participation occurs through enrolment —how people relate to the new practice; legitimation —the belief that it is right for them to be involved; and activation —defining which actions are necessary to sustain the practice and their involvement [ 14 ]. Making the new practices work may require changes to roles (new responsibilities, altered procedures) and reconfiguring how colleagues work together (changed relationships).

Third, Collective Action refers to ‘the operational work that people do to enact a set of practices’ [ 14 ]. Individuals engage with the new practices ( interactional workability ) reshaping how members of an organisation interact with each other, through creation of new roles and expectations ( relational interaction ) [ 15 ]. Skill set workability concerns how the work of implementing a new set of practices is distributed and the necessary roles and skillsets defined [ 14 ]. Contextual integration draws attention to the incorporation of a practice within social contexts, and the potential for aspects of these contexts, such as systems and procedures, to be modified as a result [ 15 ].

Reflexive monitoring is the final implementation mechanism. Collective and individual appraisal evaluate the value of a set of practices, which depends on the collection of information—formally and informally ( systematisation ). Appraisal may lead to reconfiguration in which procedures of the practice are redefined or reshaped [ 14 , 15 ].

We sought to map the following: (1) the strategies used to embed qualitative research within the Centre, (2) key facilitators, and (3) barriers to their implementation. Through focused group discussions during the monthly meetings of the CTR QRG and in discussion with the CTR senior management team throughout 2019–2020 we identified nine types of documents (22 individual documents in total) produced within the CTR which had relevant information about the integration of qualitative research within its work (Table 1 ). The QRG had an ‘open door’ policy to membership and welcomed all staff/students with an interest in qualitative research. It included researchers who were employed specifically to undertake qualitative research and other staff with a range of study roles, including trial managers, statisticians, and data managers. There was also diversity in terms of career stage, including PhD students, mid-career researchers and members of the Centre’s Executive team. Membership was therefore largely self-selected, and comprised of individuals with a role related to, or an interest in, embedding qualitative research within trials. However, the group brought together diverse methodological perspectives and was not solely comprised of methodological ‘champions’ whose job it was to promote the development of qualitative research within the centre. Thus whilst the group (and by extension, the authors of this paper) had a shared appreciation of the value of qualitative research within a trials centre, they also brought varied methodological perspectives and ways of engaging with it.

All members of the QRG ( n = 26) were invited to take part in a face-to-face, day-long workshop in February 2019 on ‘How to optimise and operationalise qualitative research in trials: reflections on CTR structure’. The workshop was attended by 12 members of staff and PhD students, including members of the QRG and the CTR’s senior management team. Recruitment to the workshop was therefore inclusive, and to some extent opportunistic, but all members of the QRG were able to contribute to discussions during regular monthly group meetings and the drafting of the current paper.

The aim of the workshop was to bring together information from the documents in Table 1 to generate discussion around the key strategies (and their component activities) that had been adopted to integrate qualitative research into CTR, as well as barriers to, and facilitators of, their implementation. The agenda for the workshop involved four key areas: development and history of the CTR model; mapping the current model within CTR; discussing the structure of other CTUs; and exploring the advantages and disadvantages of the CTR model.

During the workshop, we discussed the use of NPT to conceptualise how qualitative research had been embedded within CTR’s systems and practices. The group produced spider diagrams to map strategies and actions on to the four key domains (or ‘generative mechanisms’ of NPT) summarised above, to aid the understanding of how they had functioned, and the utility of NPT as a framework. This is summarised in Table 2 .

Detailed notes were made during the workshop. A core writing group then used these notes and the documents in Table 1 to develop a draft of the current paper. This was circulated to all members of the CTR QRG ( n = 26) and stored within a central repository accessible to them to allow involvement and incorporate the views of those who were not able to attend the workshop. This draft was again presented for comments in the monthly CTR QRG meeting in February 2021 attended by n = 10. The Standards for QUality Improvement Reporting Excellence 2.0 (SQUIRE) guidelines were used to inform the structure and content of the paper (see supplementary material) [ 16 ].

In the following sections, we describe the strategies CTR adopted to integrate qualitative research. These are mapped against NPT’s four generative mechanisms to explore the processes through which the strategies promoted integration, and facilitators of and barriers to their implementation. A summary of the strategies and their functioning in terms of the generative mechanisms is provided in Table 2 .

Coherence—making sense of qualitative research

In CTR, many of the actions taken to build a portfolio of qualitative research were aimed at enabling colleagues, and external actors, to make sense of this set of methodologies. Centre-level strategies and grant applications for infrastructure funding highlighted the value of qualitative research, the added benefits it would bring, and positioned it as a legitimate set of practices alongside existing methods. For example, a 2014 application for renewal of trials unit infrastructure funding stated:

We are currently in the process of undertaking […] restructuring for our qualitative research team and are planning similar for trial management next year. The aim of this restructuring is to establish greater hierarchical management and opportunities for staff development and also provide a structure that can accommodate continuing growth.

Within the CTR, various forms of communication on the development of qualitative research were designed to enable staff and students to make sense of it, and to think through its potential value for them, and ways in which they might engage with it. These included presentations at staff meetings, informal meetings between project teams and the qualitative group lead, and the visibility of qualitative research on the public-facing Centre website and Centre committees and systems. For instance, qualitative methods were included (and framed as a distinct set of practices) within study adoption forms and committee agendas. Information for colleagues described how qualitative methods could be incorporated within funding applications for RCTs and other evaluation studies to generate new insights into questions research teams were already keen to answer, such as influences on intervention implementation fidelity. Where externally based chief investigators approached the Centre to be involved in new grant applications, the existence of the qualitative team and group lead enabled the inclusion of qualitative research to be actively promoted at an early stage, and such opportunities were highlighted in the Centre’s brochure for new collaborators. Monthly qualitative research network meetings—advertised across CTR and to external research collaborators, were also designed to create a shared understanding of qualitative research methods and their utility within trials and other study types (e.g. intervention development, feasibility studies, and observational studies). Training events (discussed in more detail below) also aided sense-making.

Several factors facilitated the promotion of qualitative research as a distinctive and valuable entity. Among these was the influence of the broader methodological landscape within trial design which was promoting the value of qualitative research, such as guidance on the evaluation of complex interventions by the Medical Research Council [ 17 ], and the growing emphasis placed on process evaluations within trials (with qualitative methods important in understanding participant experience and influences on implementation) [ 5 ]. The attention given to lived experience (both through process evaluations and the move to embed public involvement in trials) helped to frame qualitative research within the Centre as something that was appropriate, legitimate, and of value. Recognition by research funders of the value of qualitative research within studies was also helpful in normalising and legitimising its adoption within grant applications.

The inclusion of qualitative methods within influential methodological guidance helped CTR researchers to develop a ‘shared language’ around these methods, and a way that a common understanding of the role of qualitative research could be generated. One barrier to such sense-making work was the varying extent to which staff and teams had existing knowledge or experience of qualitative research. This varied across methodological and subject groups within the Centre and reflected the history of the individual trials units which had merged to form the Centre.

Cognitive participation—legitimising qualitative research

Senior CTR leaders promoted the value and legitimacy of qualitative research. Its inclusion in centre strategies, infrastructure funding applications, and in public-facing materials (e.g. website, investigator brochures), signalled that it was appropriate for individuals to conduct qualitative research within their roles, or to support others in doing so. Legitimisation also took place through informal channels, such as senior leadership support for qualitative research methods in staff meetings and participation in QRG seminars. Continued development of the QRG (with dedicated infrastructure funding) provided a visible identity and equivalence with other methodological groups (e.g. trial managers, statisticians).

Staff were asked to engage with qualitative research in two main ways. First, there was an expansion in the number of staff for whom qualitative research formed part of their formal role and responsibilities. One of the three trials units that merged to form CTR brought with it a qualitative team comprising methodological specialists and a group lead. CTR continued the expansion of this group with the creation of new roles and an enlarged nucleus of researchers for whom qualitative research was the sole focus of their work. In part, this was linked to the successful award of projects that included a large qualitative component, and that were coordinated by CTR (see Table 3 which describes the PUMA study).

Members of the QRG were encouraged to develop their own research ideas and to gain experience as principal investigators, and group seminars were used to explore new ideas and provide peer support. This was communicated through line management, appraisal, and informal peer interaction. Boundaries were not strictly demarcated (i.e. staff located outside the qualitative team were already using qualitative methods), but the new team became a central focus for developing a growing programme of work.

Second, individuals and studies were called upon to engage in new ways with qualitative research, and with the qualitative team. A key goal for the Centre was that groups developing new research ideas should give more consideration in general to the potential value and inclusion of qualitative research within their funding applications. Specifically, they were asked to do this by thinking about qualitative research at an early point in their application’s development (rather than ‘bolting it on’ after other elements had been designed) and to draw upon the expertise and input of the qualitative team. An example was the inclusion of questions on qualitative methods within the Centre’s study adoption form and representation from the qualitative team at the committee which reviewed new adoption requests. Where adoption requests indicated the inclusion of qualitative methods, colleagues were encouraged to liaise with the qualitative team, facilitating the integration of its expertise from an early stage. Qualitative seminars offered an informal and supportive space in which researchers could share initial ideas and refine their methodological approach. The benefits of this included the provision of sufficient time for methodological specialists to be involved in the design of the proposed qualitative component and ensuring adequate costings had been drawn up. At study adoption group meetings, scrutiny of new proposals included consideration of whether new research proposals might be strengthened through the use of qualitative methods where these had not initially been included. Meetings of the QRG—which reviewed the Centre’s portfolio of new studies and gathered intelligence on new ideas—also helped to identify, early on, opportunities to integrate qualitative methods. Communication across teams was useful in identifying new research ideas and embedding qualitative researchers within emerging study development groups.

Actions to promote greater use of qualitative methods in funding applications fed through into a growing number of studies with a qualitative component. This helped to increase the visibility and legitimacy of qualitative methods within the Centre. For example, the PUMA study [ 12 ], which brought together a large multidisciplinary team to develop and evaluate a Paediatric early warning system, drew heavily on qualitative methods, with the qualitative research located within the QRG. The project introduced an extensive network of collaborators and clinical colleagues to qualitative methods and how they could be used during intervention development and the generation of case studies. Further information about the PUMA study is provided in Table 3 .

Increasing the legitimacy of qualitative work across an extensive network of staff, students and collaborators was a complex process. Set within the continuing dominance of quantitative methods with clinical trials, there were variations in the extent to which clinicians and other collaborators embraced the value of qualitative methods. Research funding schemes, which often continued to emphasise the quantitative element of randomised controlled trials, inevitably fed through into the focus of new research proposals. Staff and external collaborators were sometimes uncertain about the added value that qualitative methods would bring to their trials. Across the CTR there were variations in the speed at which qualitative research methods gained legitimacy, partly based on disciplinary traditions and their influences. For instance, population health trials, often located within non-health settings such as schools or community settings, frequently involved collaboration with social scientists who brought with them experience in qualitative methods. Methodological guidance in this field, such as MRC guidance on process evaluations, highlighted the value of qualitative methods and alternatives to the positivist paradigm, such as the value of realist RCTs. In other, more clinical areas, positivist paradigms had greater dominance. Established practices and methodological traditions across different funders also influenced the ease of obtaining funding to include qualitative research within studies. For drugs trials (CTIMPs), the influence of regulatory frameworks on study design, data collection and the allocation of staff resources may have played a role. Over time, teams gained repeated experience of embedding qualitative research (and researchers) within their work and took this learning with them to subsequent studies. For example, the senior clinician quoted within the PUMA case study (Table 3 below) described how they had gained an appreciation of the rigour of qualitative research and an understanding of its language. Through these repeated interactions, embedding of qualitative research within studies started to become the norm rather than the exception.

Collective action—operationalising qualitative research

Collective action concerns the operationalisation of new practices within organisations—the allocation and management of the work, how individuals interact with each other, and the work itself. In CTR the formation of a Qualitative Research Group helped to allocate and organise the work of building a portfolio of studies. Researchers across the Centre were called upon to interact with qualitative research in new ways. Presentations at staff meetings and the inclusion of qualitative research methods in portfolio study adoption forms were examples of this ( interactive workability ). It was operationalised by encouraging study teams to liaise with the qualitative research lead. Development of standard operating procedures, templates for costing qualitative research and methodological guidance (e.g. on analysis plans) also helped encourage researchers to interact with these methods in new ways. For some qualitative researchers who had been trained in the social sciences, working within a trials unit meant that they needed to interact in new and sometimes unfamiliar ways with standard operating procedures, risk assessments, and other trial-based systems. Thus, training needs and capacity-building efforts were multidirectional.

Whereas there had been a tendency for qualitative research to be ‘bolted on’ to proposals for RCTs, the systems described above were designed to embed thinking about the value and design of the qualitative component from the outset. They were also intended to integrate members of the qualitative team with trial teams from an early stage to promote effective integration of qualitative methods within larger trials and build relationships over time.

Standard Operating Procedures (SOPs), formal and informal training, and interaction between the qualitative team and other researchers increased the relational workability of qualitative methods within the Centre—the confidence individuals felt in including these methods within their studies, and their accountability for doing so. For instance, study adoption forms prompted researchers to interact routinely with the qualitative team at an early stage, whilst guidance on costing grants provided clear expectations about the resources needed to deliver a proposed set of qualitative data collection.

Formation of the Qualitative Research Group—comprised of methodological specialists, created new roles and skillsets ( skill set workability ). Research teams were encouraged to draw on these when writing funding applications for projects that included a qualitative component. Capacity-building initiatives were used to increase the number of researchers with the skills needed to undertake qualitative research, and for these individuals to develop their expertise over time. This was achieved through formal training courses, academic seminars, mentoring from experienced colleagues, and informal knowledge exchange. Links with external collaborators and centres engaged in building qualitative research supported these efforts. Within the Centre, the co-location of qualitative researchers with other methodological and trial teams facilitated knowledge exchange and building of collaborative relationships, whilst grouping of the qualitative team within a dedicated office space supported a collective identity and opportunities for informal peer support.

Some aspects of the context in which qualitative research was being developed created challenges to operationalisation. Dependence on project grants to fund qualitative methodologists meant that there was a continuing need to write further grant applications whilst limiting the amount of time available to do so. Similarly, researchers within the team whose role was funded largely by specific research projects could sometimes find it hard to create sufficient time to develop their personal methodological interests. However, the cultivation of a methodologically varied portfolio of work enabled members of the team to build significant expertise in different approaches (e.g. ethnography, discourse analysis) that connected individual studies.

Reflexive monitoring—evaluating the impact of qualitative research

Inclusion of questions/fields relating to qualitative research within the Centre’s study portfolio database was a key way in which information was collected ( systematisation ). It captured numbers of funding applications and funded studies, research design, and income generation. Alongside this database, a qualitative resource planner spreadsheet was used to link individual members of the qualitative team with projects and facilitate resource planning, further reinforcing the core responsibilities and roles of qualitative researchers within CTR. As with all staff in the Centre, members of the qualitative team were placed on ongoing rather than fixed-term contracts, reflecting their core role within CTR. Planning and strategy meetings used the database and resource planner to assess the integration of qualitative research within Centre research, identify opportunities for increasing involvement, and manage staff recruitment and sustainability of researcher posts. Academic meetings and day-to-day interaction fulfilled informal appraisal of the development of the group, and its position within the Centre. Individual appraisal was also important, with members of the qualitative team given opportunities to shape their role, reflect on progress, identify training needs, and further develop their skillset, particularly through line management systems.

These forms of systematisation and appraisal were used to reconfigure the development of qualitative research and its integration within the Centre. For example, group strategies considered how to achieve long-term integration of qualitative research from its initial embedding through further promoting the belief that it formed a core part of the Centre’s business. The visibility and legitimacy of qualitative research were promoted through initiatives such as greater prominence on the Centre’s website. Ongoing review of the qualitative portfolio and discussion at academic meetings enabled the identification of areas where increased capacity would be helpful, both for qualitative staff, and more broadly within the Centre. This prompted the qualitative group to develop an introductory course to qualitative methods open to all Centre staff and PhD students, aimed at increasing understanding and awareness. As the qualitative team built its expertise and experience it also sought to develop new and innovative approaches to conducting qualitative research. This included the use of visual and diary-based methods [ 11 ] and the adoption of ethnography to evaluate system-level clinical interventions [ 12 ]. Restrictions on conventional face-to-face qualitative data collection due to the COVID-19 pandemic prompted rapid adoption of virtual/online methods for interviews, observation, and use of new internet platforms such as Padlet—a form of digital note board.

In this paper, we have described the work undertaken by one CTU to integrate qualitative research within its studies and organisational culture. The parallel efforts of many trials units to achieve these goals arguably come at an opportune time. The traditional designs of RCTs have been challenged and re-imagined by the increasing influence of realist evaluation [ 6 , 18 ] and the widespread acceptance that trials need to understand implementation and intervention theory as well as assess outcomes [ 17 ]. Hence the widespread adoption of embedded mixed methods process evaluations within RCTs. These broad shifts in methodological orthodoxies, the production of high-profile methodological guidance, and the expectations of research funders all create fertile ground for the continued expansion of qualitative methods within trials units. However, whilst much has been written about the importance of developing qualitative research and the possible approaches to integrating qualitative and quantitative methods within studies, much less has been published on how to operationalise this within trials units. Filling this lacuna is important. Our paper highlights how the integration of a new set of practices within an organisation can become embedded as part of its ‘normal’ everyday work whilst also shaping the practices being integrated. In the case of CTR, it could be argued that the integration of qualitative research helped shape how this work was done (e.g. systems to assess progress and innovation).

In our trials unit, the presence of a dedicated research group of methodological specialists was a key action that helped realise the development of a portfolio of qualitative research and was perhaps the most visible evidence of a commitment to do so. However, our experience demonstrates that to fully realise the goal of developing qualitative research, much work focuses on the interaction between this ‘new’ set of methods and the organisation into which it is introduced. Whilst the team of methodological specialists was tasked with, and ‘able’ to do the work, the ‘work’ itself needed to be integrated and embedded within the existing system. Thus, alongside the creation of a team and methodological capacity, promoting the legitimacy of qualitative research was important to communicate to others that it was both a distinctive and different entity, yet similar and equivalent to more established groups and practices (e.g. trial management, statistics, data management). The framing of qualitative research within strategies, the messages given out by senior leaders (formally and informally) and the general visibility of qualitative research within the system all helped to achieve this.

Normalisation Process Theory draws our attention to the concepts of embedding (making a new practice routine, normal within an organisation) and integration —the long-term sustaining of these processes. An important process through which embedding took place in our centre concerned the creation of messages and systems that called upon individuals and research teams to interact with qualitative research. Research teams were encouraged to think about qualitative research and consider its potential value for their studies. Critically, they were asked to do so at specific points, and in particular ways. Early consideration of qualitative methods to maximise and optimise their inclusion within studies was emphasised, with timely input from the qualitative team. Study adoption systems, centre-level processes for managing financial and human resources, creation of a qualitative resource planner, and awareness raising among staff, helped to reinforce this. These processes of embedding and integration were complex and they varied in intensity and speed across different areas of the Centre’s work. In part this depended on existing research traditions, the extent of prior experience of working with qualitative researchers and methods, and the priorities of subject areas and funders. Centre-wide systems, sometimes linked to CTR’s operation as a CTU, also helped to legitimise and embed qualitative research, lending it equivalence with other research activity. For example, like all CTUs, CTR was required to conform with the principles of Good Clinical Practice, necessitating the creation of a quality management system, operationalised through standard operating procedures for all areas of its work. Qualitative research was included, and became embedded, within these systems, with SOPs produced to guide activities such as qualitative analysis.

NPT provides a helpful way of understanding how trials units might integrate qualitative research within their work. It highlights how new practices interact with existing organisational systems and the work needed to promote effective interaction. That is, alongside the creation of a team or programme of qualitative research, much of the work concerns how members of an organisation understand it, engage with it, and create systems to sustain it. Embedding a new set of practices may be just as important as the quality or characteristics of the practices themselves. High-quality qualitative research is of little value if it is not recognised and drawn upon within new studies for instance. NPT also offers a helpful lens with which to understand how integration and embedding occur, and the mechanisms through which they operate. For example, promoting the legitimacy of a new set of practices, or creating systems that embed it, can help sustain these practices by creating an organisational ambition and encouraging (or requiring) individuals to interact with them in certain ways, redefining their roles accordingly. NPT highlights the ways in which integration of new practices involves bi-directional exchanges with the organisation’s existing practices, with each having the potential to re-shape the other as interaction takes place. For instance, in CTR, qualitative researchers needed to integrate and apply their methods within the quality management and other systems of a CTU, such as the formalisation of key processes within standard operating procedures, something less likely to occur outside trials units. Equally, project teams (including those led by externally based chief investigators) increased the integration of qualitative methods within their overall study design, providing opportunities for new insights on intervention theory, implementation and the experiences of practitioners and participants.

We note two aspects of the normalisation processes within CTR that are slightly less well conceptualised by NPT. The first concerns the emphasis within coherence on identifying the distinctiveness of new practices, and how they differ from existing activities. Whilst differentiation was an important aspect of the integration of qualitative research in CTR, such integration could be seen as operating partly through processes of de-differentiation, or at least equivalence. That is, part of the integration of qualitative research was to see it as similar in terms of rigour, coherence, and importance to other forms of research within the Centre. To be viewed as similar, or at least comparable to existing practices, was to be legitimised.

Second, whilst NPT focuses mainly on the interaction between a new set of practices and the organisational context into which it is introduced, our own experience of introducing qualitative research into a trials unit was shaped by broader organisational and methodological contexts. For example, the increasing emphasis placed upon understanding implementation processes and the experiences of research participants in the field of clinical trials (e.g. by funders), created an environment conducive to the development of qualitative research methods within our Centre. Attempts to integrate qualitative research within studies were also cross-organisational, given that many of the studies managed within the CTR drew together multi-institutional teams. This provided important opportunities to integrate qualitative research within a portfolio of studies that extended beyond CTR and build a network of collaborators who increasingly included qualitative methods within their funding proposals. The work of growing and integrating qualitative research within a trials unit is an ongoing one in which ever-shifting macro-level influences can help or hinder, and where the organisations within which we work are never static in terms of barriers and facilitators.

The importance of utilising qualitative methods within RCTs is now widely recognised. Increased emphasis on the evaluation of complex interventions, the influence of realist methods directing greater attention to complexity and the widespread adoption of mixed methods process evaluations are key drivers of this shift. The inclusion of qualitative methods within individual trials is important and previous research has explored approaches to their incorporation and some of the challenges encountered. Our paper highlights that the integration of qualitative methods at the organisational level of the CTU can shape how they are taken up by individual trials. Within CTR, it can be argued that qualitative research achieved high levels of integration, as conceptualised by Normalisation Process Theory. Thus, qualitative research became recognised as a coherent and valuable set of practices, secured legitimisation as an appropriate focus of individual and organisational activity and benefitted from forms of collective action which operationalised these organisational processes. Crucially, the routinisation of qualitative research appeared to be sustained, something which NPT suggests helps define integration (as opposed to initial embedding). However, our analysis suggested that the degree of integration varied by trial area. This variation reflected a complex mix of factors including disciplinary traditions, methodological guidance, existing (un)familiarity with qualitative research, and the influence of regulatory frameworks for certain clinical trials.

NPT provides a valuable framework with which to understand how these processes of embedding and integration occur. Our use of NPT draws attention to the importance of sense-making and legitimisation as important steps in introducing a new set of practices within the work of an organisation. Integration also depends, across each mechanism of NPT, on the building of effective relationships, which allow individuals and teams to work together in new ways. By reflecting on our experiences and the decisions taken within CTR we have made explicit one such process for embedding qualitative research within a trials unit, whilst acknowledging that approaches may differ across trials units. Mindful of this fact, and the focus of the current paper on one trials unit’s experience, we do not propose a set of recommendations for others who are working to achieve similar goals. Rather, we offer three overarching reflections (framed by NPT) which may act as a useful starting point for trials units (and other infrastructures) seeking to promote the adoption of qualitative research.

First, whilst research organisations such as trials units are highly heterogenous, processes of embedding and integration, which we have foregrounded in this paper, are likely to be important across different contexts in sustaining the use of qualitative research. Second, developing a plan for the integration of qualitative research will benefit from mapping out the characteristics of the extant system. For example, it is valuable to know how familiar staff are with qualitative research and any variations across teams within an organisation. Thirdly, NPT frames integration as a process of implementation which operates through key generative mechanisms— coherence , cognitive participation , collective action and reflexive monitoring . These mechanisms can help guide understanding of which actions help achieve embedding and integration. Importantly, they span multiple aspects of how organisations, and the individuals within them, work. The ways in which people make sense of a new set of practices ( coherence ), their commitment towards it ( cognitive participation ), how it is operationalised ( collective action ) and the evaluation of its introduction ( reflexive monitoring ) are all important. Thus, for example, qualitative research, even when well organised and operationalised within an organisation, is unlikely to be sustained if appreciation of its value is limited, or people are not committed to it.

We present our experience of engaging with the processes described above to open dialogue with other trials units on ways to operationalise and optimise qualitative research in trials. Understanding how best to integrate qualitative research within these settings may help to fully realise the significant contribution which it makes the design and conduct of trials.

Availability of data and materials

Some documents cited in this paper are either freely available from the Centre for Trials Research website or can be requested from the author for correspondence.

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Acknowledgements

Members of the Centre for Trials Research (CTR) Qualitative Research Group were collaborating authors: C Drew (Senior Research Fellow—Senior Trial Manager, Brain Health and Mental Wellbeing Division), D Gillespie (Director, Infection, Inflammation and Immunity Trials, Principal Research Fellow), R Hale (now Research Associate, School of Social Sciences, Cardiff University), J Latchem-Hastings (now Lecturer and Postdoctoral Fellow, School of Healthcare Sciences, Cardiff University), R Milton (Research Associate—Trial Manager), B Pell (now PhD student, DECIPHer Centre, Cardiff University), H Prout (Research Associate—Qualitative), V Shepherd (Senior Research Fellow), K Smallman (Research Associate), H Stanton (Research Associate—Senior Data Manager). Thanks are due to Kerry Hood and Aimee Grant for their involvement in developing processes and systems for qualitative research within CTR.

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Segrott, J., Channon, S., Lloyd, A. et al. Integrating qualitative research within a clinical trials unit: developing strategies and understanding their implementation in contexts. Trials 25 , 323 (2024). https://doi.org/10.1186/s13063-024-08124-7

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Research Article

“It’s like your days are empty and yet there’s life all around”: A mixed methods, multi-site study exploring boredom during and following homelessness

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft

* E-mail: [email protected]

Affiliation Social Justice in Mental Health Research Lab, School of Occupational Therapy, Western University, London, Ontario, Canada

Roles Data curation, Formal analysis, Writing – review & editing

Affiliations Social Justice in Mental Health Research Lab, School of Occupational Therapy, Western University, London, Ontario, Canada, School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canada

Roles Formal analysis, Writing – review & editing

Roles Conceptualization, Methodology, Writing – review & editing

Affiliation School of Rehabilitation Science, Queen’s University, Kingston, Ontario, Canada

Roles Conceptualization, Funding acquisition, Investigation, Methodology, Resources, Supervision, Writing – review & editing

Affiliation School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canada

Carrie Anne Marshall,
Abrial Cooke,
Julia Holmes,
Jordana Bengall,
Suliman Aryobi,
Brooke Phillips,
Rosemary Lysaght,
Rebecca Gewurtz

Published: May 23, 2024
https://doi.org/10.1371/journal.pone.0302900
Reader Comments

To identify experiences of boredom and associations with psychosocial well-being during and following homelessness.

Using a convergent, mixed-methods explanatory design, we conducted quantitative interviews with 164 participants) (n = 102 unhoused; n = 62 housed following homelessness) using a 92-item protocol involving demographic components and seven standardized measures of psychosocial well-being. A sub-sample (n = 32) was approached to participate in qualitative interviews. Data were analyzed by group (unhoused; housed). Quantitative data were analyzed using descriptive statistics designed to generate insights into boredom, meaningful activity engagement, and their associations with psychosocial well-being during and following homelessness. Qualitative data were analyzed using thematic analysis. Quantitative and qualitative findings were integrated at the stage of discussion.

Quantitative analyses revealed small to moderate correlations between boredom and increased hopelessness (rs = .376, p < .01), increased drug use (rs = .194, p < .05), and lowered mental well-being (rs = -.366, p < .01). There were no statistically significant differences between unhoused and housed participants on any standardized measures. Hierarchical regression analyses revealed that housing status was not a significant predictor of boredom or meaningful activity engagement ( p >.05). Qualitative interviews revealed profound boredom during and following homelessness imposing negative influences on mental well-being and driving substance use.

Conclusions

Boredom and meaningful activity are important outcomes that require focused attention in services designed to support individuals during and following homelessness. Attention to this construct in future research, practice, and policy has the potential to support the well-being of individuals who experience homelessness, and to contribute to efforts aimed at homelessness prevention.

Citation: Marshall CA, Cooke A, Holmes J, Bengall J, Aryobi S, Phillips B, et al. (2024) “It’s like your days are empty and yet there’s life all around”: A mixed methods, multi-site study exploring boredom during and following homelessness. PLoS ONE 19(5): e0302900. https://doi.org/10.1371/journal.pone.0302900

Editor: Alan Farrier, University of Central Lancashire, UNITED KINGDOM

Received: July 12, 2023; Accepted: April 15, 2024; Published: May 23, 2024

Copyright: © 2024 Marshall et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data underlying the results presented in the study are available from the Western University Research Ethics Board at [email protected] . Only researchers with the credentials to access and manage confidential data will be provided with data given the sensitive nature of interviews.

Funding: This study was funded by an Insight Development Grant awarded to the principal investigator (CM) by the Social Sciences and Humanities Research Council of Canada ( https://www.sshrc-crsh.gc.ca/home-accueil-eng.aspx ) in 2019 [Grant number: 430-2018-00050]. Co-investigators also named on this grant include RL and RG. The funder did not inform the study design, processes for data collection and analysis, decision to publish or preparation of this manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Identifying and evaluating approaches aimed at supporting individuals to secure and sustain a tenancy has been the focus of much literature on homelessness; however, less attention has been devoted to targeting indices of psychosocial well-being after securing a tenancy [ 1 ]. Recent research exploring what is needed for thriving following homelessness has highlighted that meaningful activity engagement is a key outcome [ 1 – 3 ]. Persons with experiences of homelessness are frequently excluded from opportunities to engage in activities that are meaningful due to the structural and institutional contexts in which they are embedded [ 4 – 7 ]. Exclusion from meaningful activity can result in deep degrees of boredom that pervade the lives of persons with experiences of homelessness, resulting in lowered mental well-being, profound hopelessness, and questioning one’s very existence [ 8 ]. There is an intimate relationship between boredom and meaningful activity engagement in that a lack of activity that is meaningful as defined by the person, can result in the emergence of boredom [ 4 , 5 , 8 , 10 ]. To date, research on boredom with persons with experiences of homelessness has been largely exploratory, conducted with small sample sizes, and focused primarily on boredom experienced during homelessness [ 4 , 7 , 9 ].

Boredom and its history in academic discourse

Boredom is defined as “the aversive experience of wanting, but being unable, to engage in satisfying activity” [ 10 ] (p. 482), or a lack of challenge or meaning in the activities in which one is engaged [ 11 ]. As such, a person can be engaged in an activity that they regard as lacking meaning or may be unoccupied entirely–both of which can result in the emergence of boredom. While meaningful activity entails a description of how a person can use their time, boredom can be viewed as the outcome of whether a person is engaged sufficiently in activities which are experienced as meaningful. Research on this construct indicates that boredom is distinct from apathy, anhedonia or depression [ 12 ]. Boredom can be experienced as a state , arising from a lack of stimulation in one’s environment, or a trait wherein boredom is experienced by virtue of one’s personality across environmental contexts [ 13 ]. Historically, it was regarded as a nuisance and form of existential suffering primarily experienced by the upper-classes who were privileged enough to not have to work to generate an income [ 14 , 15 ]. In recent years, however, researchers have recognized boredom to be a phenomenon that disproportionately affects persons who experience economic oppression [ 16 , 17 ], including homelessness [ 7 , 8 ]. This construct has long been of interest to philosophers including Kant [ 18 ], Schopenhauer [ 19 ], Kierkegaard [ 20 ], Nietzsche [ 21 ] and Heidegger [ 22 , 23 ], and has recently garnered interest in the social sciences, particularly psychology and occupational therapy. Growing interest in this construct in recent years has resulted in the development of the interdisciplinary field of ‘Boredom Studies’ which includes philosophers, anthropologists, psychologists, sociologists and occupational therapists [ 24 , 25 ].

Boredom and its influence on psychosocial well-being

Interdisciplinary research with a range of populations suggests that boredom can impose both positive and negative influences on psychosocial well-being. Researchers have demonstrated, for instance, that the presence of boredom can elicit curiosity and creativity, which are seen to be facilitative of mental health [ 26 ]. Much of this literature, however, suggests that boredom has deleterious effects on well-being. High levels of boredom have been associated with increased engagement in substance use [ 27 – 29 ], low self-reported physical and mental health [ 30 ], low motivation [ 31 ], and involvement in criminal activity [ 32 , 33 ]. While research with clinical populations is relatively limited, research with inpatient psychiatric populations suggests that boredom arising from few opportunities to engage in meaningful activity may lead to increased smoking, aggression, abscondment, and poorer mental health [ 34 ]. This negative impact is concerning in light of the high levels of boredom reported by persons with experiences of homelessness in existing research combined with the disproportionately high prevalence of mental illness and substance use disorder in this population [ 35 ].

Boredom as it relates to homelessness

While research suggests that some boredom is facilitative of mental well-being [ 26 ], the boredom experienced by persons with experiences of homelessness has been reported to be profound and pervasive, imposing negative effects on psychosocial well-being [ 4 – 8 ]. Much of this research, however, has been conducted in the context of exploring other phenomena [ 8 ], with only a few empirical studies focusing on boredom as it relates to this population specifically [ 4 – 7 ]. While the findings of these studies provide a glimpse into how boredom is experienced, they are few in number, and have been conducted with small sample sizes [ 4 – 7 ]. Only one study has focused on how boredom is experienced in the transition to housing following homelessness with only two participants [ 5 ]. Further, these studies have focused on limited geographic contexts and represent only one city in Canada [ 4 , 5 ] and one in Romania [ 6 , 7 ]. There is a need to generate data describing how boredom is experienced, and how it may change in the transition to housing following homelessness with larger sample sizes and in multiple contexts. Such findings will produce more generalizable data that can be used to inform policy and practice.

The current study

The presence of profound boredom in the lives of persons with experiences of homelessness is a serious social justice and health equity issue [ 4 , 5 , 7 – 9 ]. More research aimed at understanding this experience, how it emerges, and the ways in which it is associated with indices of psychosocial well-being during and following homelessness, is needed. We conducted this research, guided by the lenses of social justice [ 36 ] and health equity [ 37 ], and the research question: What is the experience of boredom and its association with indices of psychosocial well-being during and following homelessness?

Materials and methods

We conducted a convergent, mixed-methods study, defined by Creswell and Plano-Clark as collecting and analyzing both qualitative and quantitative data simultaneously [ 38 ]. As such, our research is situated within a pragmatic philosophy [ 38 ], informed by the belief that findings generated from both qualitative and quantitative methods are equally valuable for understanding a construct of interest. This study builds on pilot research conducted by our team using a similar protocol [ 4 , 5 ]. While our original intention was to conduct a longitudinal study, a high degree of attrition in our pilot work at follow-up led to choosing a cross-sectional design for the current study.

Recruitment

After obtaining ethics approval from Western University, we recruited participants over a one-year period from June 19, 2019 to March 13, 2020. Participants were recruited in shelters, drop-in centres, housing case management, and permanent and transitional housing programs in three cities in Ontario, Canada (Kingston, London, and Hamilton). We recruited by: 1) placing advertisements in the common areas of organizations used by persons with experiences of homelessness that provided contact information for the research team and times during which interviewers would be present to conduct interviews; and 2) by asking staff and leadership in these organizations to provide contact information for the research team to potential interviewees. We recruited participants from two groups: 1) persons who were currently unhoused; and 2) persons housed following homelessness.

Inclusion and exclusion criteria

Using a combination of convenience, snowball, and purposive sampling methods, we recruited two groups of participants who were over the age of 18: 1) persons who were currently unhoused; and 2) persons housed following homelessness. Unhoused participants were included if they had been unhoused for at least one month in their current episode of homelessness. Housed participants were recruited if they had been housed in market, public, transitional, or permanent supportive housing for less than two years following at least one month of homelessness. We recruited individuals who had a history of being “emergency sheltered” or “unsheltered” using the Canadian Definition of Homelessness [ 39 ].

Participants who satisfied inclusion criteria met with an interviewer in a private interview space. Each participant was engaged in an informed consent procedure after which they were assigned a participant number to protect their confidentiality. All participants were engaged in quantitative interviews. From this sample, we purposively recruited a smaller diverse sub-sample to engage in qualitative interviews. The letter of information, informed consent, and all interview questions were read aloud during interviews to overcome the possibility of poor literacy. Participants were provided with a visual stimulus identifying the response options for each standardized measure to limit respondent fatigue. The informed consent and all interview questions were translated into a survey using Qualtrics [ 40 ], and responses to all quantitative interview questions were recorded by a member of our research team on a tablet computer during interviews. Participants involved in qualitative interviews were asked to identify a pseudonym to assign to their quotes to protect their confidentiality. A list linking participant identifiers and pseudonyms with participants’ real names was created by our research team and kept separate from participants’ data during analysis as per standard processes established by Western University’s Research Ethics Board. Participants were compensated $20 for participating in quantitative interviews, and $40 for participating in mixed interviews.

Instruments

Quantitative interview..

Participants were engaged in a 92-item quantitative interview conducted by one of five members of our research team (CM, RG, AC, JB, JH). Interviews were composed of demographic elements (gender, age, sexual orientation, race/ethnicity, marital status, employment status, income source), housing and health status, and seven standardized measures. Each standardized measure and associated internal consistency for the current study and previous research is detailed in Table 1 .

PPT PowerPoint slide
PNG larger image
TIFF original image

https://doi.org/10.1371/journal.pone.0302900.t001

Qualitative interview.

Following quantitative interviews, a purposive sub-sample of participants were engaged in semi-structured qualitative interviews aimed at identifying experiences of boredom during and following homelessness. Participants in this sub-sample were selected to obtain a diverse sample based on age, gender, housing status and geographic location. A list of demographic characteristics of qualitative participants was completed after each qualitative interview, and new participants were approached based on the developing composition of the sample to maximize the diversity of qualitative participants. Interviews were recorded on a digital recording device and transcribed verbatim. Qualitative interview questions posed to participants are provided in Table 2 .

https://doi.org/10.1371/journal.pone.0302900.t002

Quantitative.

Using SPSS 28, we calculated descriptive statistics for all variables. Demographic, housing and health characteristics were calculated for both unhoused and housed participants and for the full sample. Summary scores were generated for each standardized measure using processes described by the test authors. As we planned to identify any differences on standardized measures between unhoused and housed groups, we conducted analyses to determine any significant differences in demographic, housing or health characteristics that would explain these relationships using Mann-Whitney U, Chi-Square, and Fisher’s Exact Tests as indicated.

Our quantitative analyses were informed by four research sub-objectives, with associated statistical analyses. We opted to use non-parametric tests when possible, given that several sub-tests used ordinal scales. We conducted: 1) Spearman correlations to identify any statistically significant associations between boredom (MSBS-8) and meaningful activity engagement (EMAS) with indices of psychosocial well-being ; 2) one-sample Wilcoxon Signed-Rank tests to identify how participants’ scores on standardized measures differed from norms and threshold scores reported in existing literature ; 3) Mann-Whitney U tests to determine whether boredom , meaningful activity , and indices of psychosocial well-being were significantly different for participants who were unhoused or housed following homelessness ; and 4) two hierarchical multiple regression analyses to determine whether months housed or unhoused (in the past year) predicted boredom (MSBS-8) and meaningful activity engagement (EMAS) , while controlling for the effects of age, gender, and recruitment site. Assumptions of normality, linearity, multicollinearity and homoscedasticity were assessed prior to conducting our analyses and were determined not to have been violated. When conducting these regression statistics, the same independent variables were entered for both analyses. In block one, we entered age, gender and recruitment site. In block two, we entered months housed, and months unhoused in the past year. The dependent variable for the first analysis was total MSBS-8 score, and total EMAS score for the second. During analysis, when data was missing in full or in part in a participant’s response on a specific standardized test, we eliminated that participant from the analysis involving that test. Significance was set to p < .05 for all statistical tests.

Qualitative.

Transcripts were separated by group (unhoused; housed following homelessness) and uploaded to Dedoose [ 41 ], a qualitative data management program, to facilitate cross-site collaboration and analysis. Transcripts were coded abductively, informed by the lenses of social justice and health equity, by several members of our research team (CM, AC, JB, JH, SA, BP, RG). Using thematic analysis [ 42 ], our team met on several occasions to arrange codes into themes. Following recommendations of Braun & Clarke [ 42 ], we identified an overarching essence describing participant narratives from both groups, and also an essence that captured experiences of boredom for both unhoused and housed participants.

Trustworthiness . Trustworthiness was established using criteria described by Lincoln & Guba [ 43 ] including: 1) prolonged engagement with the population of interest, established by our research team’s extensive involvement in research and practice related to homelessness; 2) peer debriefing among our research team during the conduct of interviews, and in the process of analyzing our data; 3) recording interviews; 4) accurate transcription; 5) intercoder consensus (see analysis); and 6) use of a computer program to organize qualitative data.

Reflexivity . Collectively, the principal investigator and all members of our research team have decades of experience in research and practice with individuals who experience mental illness, substance use disorders and homelessness. Our extensive involvement in research and practice in this area has informed the design of this study, and how we’ve analyzed our qualitative data. We have embraced this knowledge and believe that these background experiences have enabled us to analyze the narratives of participants with greater depth and sensitivity.

Participants

Our full sample consisted of 164 participants, of which 102 were unhoused, and 62 were housed. We intended to recruit similar sample sizes for both groups; however, the COVID-19 pandemic interrupted our recruitment efforts. At the time, our team determined that public health regulations imposed early in the pandemic would significantly influence our findings given our focus on boredom and meaningful activity engagement, and we made the difficult decision to cease recruitment to avoid cohort effects. As such, none of the participants in the current study were interviewed during or after physical distancing restrictions were imposed during the COVID-19 pandemic in the province of recruitment. The demographic characteristics of participants in our sample are provided in Table 3 , and the housing and health characteristics of our sample are provided in Table 4 .

https://doi.org/10.1371/journal.pone.0302900.t003

https://doi.org/10.1371/journal.pone.0302900.t004

Housed and unhoused participants were mostly similar on demographic characteristics, with significant differences in marital status ( p < .05) and type of social assistance received ( p < .01; p < .05) (see Table 2 ). There were no statistically significant differences between groups in terms of housing history other than participants’ current housing status. With respect to health, the groups were mostly similar with a significantly greater number of participants living with respiratory conditions ( p < .05) and diabetes ( p < .01) in the unhoused group (see Table 3 ).

Quantitative findings

Associations between boredom, meaningful activity, and indices of psychosocial well-being..

A statistically significant negative correlation between boredom and meaningful activity was observed ( rs = -.222, p < .01). Using criteria established by Cohen [ 44 ], the strength of this correlation was small. Higher EMAS scores were significantly correlated with increased physical community integration ( rs = .237, p < .01, small), decreased drug use ( rs = -.289, p < .01, small), and increased mental well-being ( rs = .468, p < .01, moderate). Greater reported boredom was associated with increased reported hopelessness ( rs = .376, p < .01, moderate), increased drug use ( rs = .194, p < .05, small), and decreased mental well-being ( rs = -.366, p < .01, moderate). No statistically significant correlations were reported between boredom and meaningful activity engagement with psychological community integration or alcohol use. See Table 5 .

https://doi.org/10.1371/journal.pone.0302900.t005

Differences between boredom, meaningful activity engagement and indices of psychosocial well-being from published norms and threshold scores.

Norms and threshold scores were available only for measures of boredom (MSBS-8), meaningful activity (EMAS), mental well-being (SWEMWBS, BHS), and substance use (AUDIT-10, DAST-10). Significant differences across all measures were observed. Compared with norms reported in existing literature, participants in our study reported: significantly higher boredom on the MSBS ( z = 9.909, p < .0001); significantly lower engagement in meaningful activity on the EMAS ( z = -6,765, p < .0001); lower mental well-being on the SWEMWBS ( z = -7.029, p < .0001); and higher degrees of hopelessness on the BHS ( z = -8.361, p < .0001). When compared with threshold scores established by the test authors for substance use, participants in our study were engaged in alcohol use that was significantly lower than a ‘hazardous’ threshold score on the AUDIT-10 [ 45 ], and significantly lower than a ‘low-moderate’ range on the DAST-10 [ 46 ]. All of these differences were associated with moderate to large effect sizes. See Table 6 .

https://doi.org/10.1371/journal.pone.0302900.t006

Differences between boredom, meaningful activity, and indices of psychosocial well-being during and following homelessness.

There were no statistically significant differences on measures of boredom (MSBS-8), meaningful activity (EMAS), mental well-being (SWEMWBS, BHS), substance use (AUDIT-10, DAST-10), and community integration (physical integration, psychological integration) between unhoused and housed groups. Persons who were housed reported higher levels of psychological integration in their communities, however, this finding only approached statistical significance [Unhoused (Mdn = 10, n = 98); Housed (Mdn = 11.5, n = 62), U = 2502, z = -1.895, p = .058, r = .15)]. See Table 7 .

https://doi.org/10.1371/journal.pone.0302900.t007

Housing status and associations with boredom and meaningful activity engagement.

We conducted two hierarchical regression analyses. In the first analysis, we sought to identify how boredom (measured by total MSBS-8 score) was predicted by housing status (months unhoused/months housed in the past year) while controlling for the effects of age, gender, and recruitment site. This model was found to be non-significant ( p >.05). Age, gender, and site were entered in block one, explaining 6% of the variance in MSBS-8 scores. After entering months housed and months unhoused (in the past year) in block two, the total variance explained by the model as a whole was 6.4%, F (6, 149) = 1.7, p = .125. The two independent variables (months housed and months unhoused) explained an additional 0.4% of the variance in MSBS-8 scores, R squared change = .004, F change (2, 149) = .311, p = .733. In the final model, only one recruitment site (London) was statistically significant (beta = .20, p < .05).

In the second analysis, we sought to identify how engagement in meaningful activity (measured by the EMAS) was predicted by housing status (months unhoused/months housed in the past year) while controlling for the effects of age, gender and recruitment site. This model was found to be non-significant ( p >.05). Age, gender, and site were entered in block one, explaining 1.2% of the variance in EMAS scores. After entering months housed and months unhoused (in the past year) into block two, the total variance explained by the model as a whole was 2%, F (6, 149) = .505. The two independent variables (months housed and months unhoused) explained an additional 0.8% of the variance in EMAS scores, R squared change = .008, F change (2, 149) = .636. In the final model, none of the independent variables were significantly associated with EMAS scores.

Qualitative findings

Participants..

From the larger sample, we interviewed 32 participants using our qualitative interview protocol (n = 18 unhoused; n = 14 housed). Participants in the unhoused group included nine women (50%) and nine men (50%) ranging in age from 18–56 (Mdn = 38; IQR = 11). Participants in the housed group included six women (43%) and eight men (57%) ranging in age from 23–77 (Mdn = 39; IQR = 28). None of the participants in these two groups identified as non-binary or with other genders.

Overarching essence—Boredom is “like being caught in a tornado.”.

The essence of our analysis across both housed and unhoused groups represented the feeling of boredom described by participants, which permeated much of their days during and following homelessness. During homelessness, participants described how their time use was restricted to activities that enabled survival, and the rules and hours of operation of the programs that they accessed. These influences restricted their time use and resulted in long periods where time was relatively unoccupied: “ There’s too much time on my hands , here ” [Serina, Unhoused]. Following homelessness, participants’ time use was determined by finances, the presence of social relationships, and stigma. Restrictions imposed by these factors led to experiencing boredom “ almost every moment of the day ” [Andrew, Housed]. Both during and following homelessness, participants felt trapped in the deep degrees of boredom that they experienced. One participant described the feeling of relentless boredom in his life as “ like being caught in a tornado ” [Shawn, Unhoused]. This metaphor describes the calm in the centre of a tornado, surrounded by chaos and fast-moving wind. Participants described feeling like they were caught in a tornado by being embedded in a society that they could not access and in which they had few opportunities to participate. The environments in which they were embedded severely limited opportunities for participating in activities that were meaningful resulting in a feeling of unwelcome stillness. This feeling persisted while movement, people and opportunities surrounded them that they could only observe as an outsider.

We generated two ‘essences’ to describe participants’ experiences of boredom during and following homelessness. For unhoused participants, this essence was “ it’s kind of like being in jail .” For housed participants, the essence was “ it’s like your day is empty and there’s life all around .” A visual depiction of this theme structure is provided in Fig 1 .

https://doi.org/10.1371/journal.pone.0302900.g001

During homelessness—“It’s kind of like being in jail” . Participants who were unhoused described how they were included within social networks in shelters and on the street, where they described being a part of a “ street family ” [Street Jesus, Unhoused]. While they were included in these social networks, they described how they were largely excluded from society: “ You know , you have to remember–you’ve been kicked out of the club . You’re not part of society anymore ” [Niel, Unhoused]. This profound social exclusion and having little money to occupy one’s time led to restrictions in opportunities for meaningful activity, leading to pervasive boredom: “ it costs too damn much to do anything…we’re bored , we’re sick , and we’re tired of it ” [Susan, Unhoused]. Rules imposed on their time use by shelters and other organizations that they accessed compounded this problem: “ In jail , there’s not a lot to do…I find it’s like being in jail . Like you gotta sign up for things . You gotta ask permission to do things ” [Jimmy Hat, Unhoused]. As a result, they spent their days either engaged in meeting their survival needs or “ just sitting around ” [Bud, Unhoused]. This essence was expressed through three themes generated in our analysis: “Survival first, getting things done, and then you’re out of time”; “bored til lunch, bored til dinner, then bored til bed”; and “I’m doing to get by”.

“Survival first , getting things done , and then you’re out of time . ” Unhoused participants discussed at length how their time use was dictated by their survival needs, and how boredom emerged because their time use was taken up by activities that they didn’t choose to do but in which they needed to participate to survive:

It feels like…there’s no time for anything . I’m not doing anything , though , so it is boredom , I guess…like nothing is going forward , and I can’t do anything about it…cause you gotta eat . Like you don’t have time to do any quality things ‘cause you still think , ‘like where to get out of the cold’ , or ‘what are you gonna eat ? ’ [Louise, Unhoused]

After completing survival activities, there was little choice in how participants could spend the time that was left given institutional, social, and financial constraints: “ there’s lots of things that I want to do , but can’t do ” [Louise, Unhoused]. They either spent this time engaged in activities that lacked meaning or did nothing at all: “ what we work on here is distraction . It’s not meaningful exercises…or meaningful endeavours . At least most of us…[are] just basically doing them to try and fill time ” [Niel, Unhoused].

“Bored til lunch , bored til dinner , then bored til bed . ” Living in a state of survival and being situated in environments that limited engagement in meaningful activity led to boredom that lasted for much of the day. For many, it felt like the rule, rather than the exception: “ after breakfast is over , it’s bored til lunch , bored til dinner , then bored til bed ” [Shawn Foster, Unhoused]; “ I’m bored all the time ” [Apple, Unhoused]. For some, this felt like they had too much time: “ boredom , to me , feels like time is extended…[if] they had some way of stimulating your mind here , the time would go by faster ” [Niel, Unhoused]. For others, boredom felt like being trapped, like “ sitting in a jail cell ” [Peanut, Unhoused], or being “ sucked into the void…getting sucked into this all-encompassing , nothing-to-do . There’s no way to get out ” [Shawn Foster, Unhoused]. The boredom that participants described caused the days to meld together, and when they described this experience, it was as if they were suspended in a liminal space, sometimes due to the loss of important roles and relationships in their lives: “ I’m alone and I don’t have my kids…I feel like every day just blends . I had meaning before ” [Denver, Unhoused].

Participants described the impacts of this unrelenting boredom on their mental health, particularly. They frequently associated boredom with anxiety and depression: “ I’ll just be like sitting over there doing nothing . I’m seeing everybody come and go , and it’s like well , what am I doing ? And I just get sad cause I’m not doing anything ” [Taylor, Unhoused]. This boredom led to a loss of motivation, hopelessness and a loss of purpose in their lives: “ So I feel like really I’m stuck . I’m in a hole , and I can’t get out of it ” [Louise, Unhoused]. Participants also discussed how having long periods of unoccupied time led to thinking deeply about their pasts, causing traumas to re-surface. Being alone with these thoughts with little opportunity for emotional processing gave rise to distress:

You get flashbacks and stuff , right ? You think about your past , and what you could’ve done , so you don’t end up here … You just got a lot of thinking time , I guess…that’s what I experience when I get bored . I just have a lot of thinking time , right ? So I try not to be bored . [Bud, Unhoused]

“I’m doing to get by” . Participants who were unhoused identified that they coped with the boredom that pervaded their lives by trying to find anything to do that might help them to escape the relentlessness of this experience. They felt a pressing “ need to just keep doing something ” [Niel, Unhoused]. They described constantly “ thinking of what to do next , like where to go next ” [Syres, Unhoused], and thinking “ a lot more about what I could do to bide the time away ” [Jimmy Hat, Unhoused]. Participants described how they coped with boredom primarily through the use of substances, which were widely available in shelters and on the street. When asked how she coped with boredom, Louise responded: “ I drink and drink as much as I can ” [Louise, Unhoused]. Speedy had a similar response and added: “ beer and weed actually speeds up the day ” [Speedy, Unhoused]. One participant indicated that when boredom was overwhelming:

99% of the time , I find some good drugs…and get really fucking high for a day or two , and forget that you even exist…you roll yourself into getting as high as possible so you can stare at the sky , at the stars , and pretend you’re flying through them or something because life sucks…you need an escape . [Shawn, Unhoused].

Participants also coped with the trauma that resurfaced during periods of boredom through substance use: “for me, I want to use mostly when I start thinking of bad things. I start thinking of my kids and I can’t stop those thoughts, right? So I need something to kind of distract” [Peanut, Unhoused].

Following homelessness—“It’s like your day is empty and there’s life all around . ” Participants who were housed following homelessness described how the boredom that they had experienced during homelessness persisted and became even more profound once they were housed. Boredom arose from a total lack of stimulation in their housing: “ the most noise I get is from pigeons on the balcony ” [Sandy, Housed]. The need to engage in survival activities lessened, and with few opportunities to engage in other activities, boredom often deepened: “ it’s hard to sit at home all day and do nothing . Like I don’t do anything ” [Rogo, Housed]. This led to feeling deeply disconnected: “ I become very numb and kind of forget that I’m even there or a person . Like literally , I forget I’m existing ” [April, Housed]. This profound boredom was associated with a sense of hopelessness and came as a surprise to participants as they hoped their transition to housing would be easier:

There’s nothing to look forward to . It’s like your days are empty and yet there’s life all around . You don’t want to do anything . Like , my apartment is so quiet…and there’s people . Angry yelling , talking to themselves , around . Music’s playing , blasting usually . In all directions…Because my place is so quiet , it feels like I’m the only one who’s experienced such hollowness…this is the first time I’m on my own…as nice as it is , it’s very boring . [Sandy, Housed]

This essence was expressed through three themes generated in our analysis: adapting to new possibilities and restrictions following homelessness; boredom emerging from and determining well-being; and belonging through activity.

Adapting to new restrictions and possibilities following homelessness . Participants described experiencing a lack of personal agency in how they could spend their time following homelessness. This lack of agency arose from the presence of ongoing poverty, poor social integration, and stigma. Living on a limited income was a serious barrier to engaging in their communities, which contributed to the boredom that they experienced: “ Having no money… It’s not having money…we’re really prevented from doing anything , so we sit around bored ” [Andrew, Housed].

For individuals living with mental illness, disclosure of their mental health condition became a difficult and calculated decision when trying to build new social networks that would provide access to meaningful activities after securing housing: “ I got a mental illness , but you don’t want too many people to know…and when you say that word … people will look at you a little different . Even if it’s just a little bit ” [Rogo, Housed]. Others felt that their ability to participate in activities in the community was influenced by feelings of safety in their new neighbourhoods: “ for me , personally , I have to take into account where I’m going , what I am doing . It’s like , is this place gonna be a safe place for me as a gay person ?” [Andrew, Housed].

Having stable housing enabled participants to think about their plans for the future, and many discussed the desire to return to work and school to increase their incomes and also to avoid boredom: “ at least I know that 10–12 hours of my day during the week I’m not bored ” [Nick Wilson, Housed]. Many faced barriers to returning to work and school, however, and discussed the need for accessible opportunities that accounted for their histories of homelessness and substance use. John described how he was engaged in a volunteer position that he wanted but had to leave because it was too difficult to manage so early after the transition to housing “ Somehow , they got me doing like an eight-hour day . And I was just up early in the morning and it was just…too much out of nowhere…once you spend your days drunk , you can’t just go back to one day waking up at five o’clock in the morning ” [John, Housed].

Boredom emerging from and determining well-being . Participants indicated that boredom pervaded their lives following homelessness and that disabilities associated with health conditions influenced the extent to which they experienced boredom. Mostly, participants described deleterious impacts of boredom on their well-being: “ I’ve spent a whole day just playing solitaire on my bed with the cards…I’ve sat there for literally eight hours and done it…I felt like I’m here wasting ” [Grandpa, Housed]. Participants also discussed how the presence of boredom led to the re-emergence of traumatic memories that caused distress: “ it plays on my head . It plays on my thoughts…too much time just sitting and doing nothing ” [Mia, Housed]. Some participants, however, recognized that boredom simultaneously imposed both positive and negative influences: “ I actually don’t mind a second of boredom , because then I can think creatively about what I’m going to do for the next little while to not be bored , or what I need to accomplish…but boredom , I think…can get you in trouble ” [Jude, Housed].

Similar to participants who were unhoused, housed participants described how the presence of boredom led to a desire to use substances for stimulation when opportunities for engagement in meaningful activity were limited: “ I’ve engaged in some drug use to deal with boredom , like crystal methamphetamine usage . Yeah . That’s a consequence of boredom…it’s just feeling fun . Feelings of pleasure . Normal everyday activities are just interesting to do ” [Andrew, Housed]. Participants who were housed also associated the experience of boredom with hopelessness and distress: “ it plays on my head . It plays on my thoughts , and it can be too much time just sitting doing nothing… Nothing . And not doing anything meaningful…it doesn’t feel good when there’s nothing ” [Mia, Housed].

While boredom influenced well-being, it also resulted from activity limitations caused by the presence of health conditions. For one participant living with physical disabilities, when asked if she experienced boredom, she responded:

All day , everyday . Even at night when I’m awake…There’s not very much to do…and it’s hot . You know , you can’t go for walks because I have asthma…and I have to have a double knee replacement , so I’m in pain all the time . I can’t even walk . It’s just so hot that I would have to use my puffer constantly…to even go a couple of blocks . [Grams, Housed]

Belonging through activity . Participants described how they experienced deep degrees of loneliness following homelessness and struggled to engage in their communities, leading to the emergence of boredom: “ I don’t know anybody here , so it’s just me by myself . And of course , I’m experiencing boredom . I just go walking and come back home ” [Max, Housed]. Being integrated in their communities was seen as critically important by participants: “ Without some form of community , you disappear ” [Andrew, Housed]. They saw meaningful activity, however, as an opportunity to belong in their communities, and some made active attempts to build on their social networks following homelessness. Sandy described how she had begun to serve coffee and tea to her neighbours as a way of mitigating boredom and connecting with others in her building:

I go out and buy coffee , and Coffee Mate , sugar , things I need for serving coffee , and I serve coffee from 9 : 30 at night ‘til 1 : 00 in the morning . Just like a bar . And people are loving it . I’ve got a lot of customers … and they told me they really look forward to their coffee every night and their tea or whatever…one lady last night , she donated cookies and different things…and everybody gets together , and they talk…we have a lot of laughs , and we watch the news . [Sandy, Housed]

We conducted this study to identify experiences of boredom, meaningful activity engagement, and their associations with key indices of psychosocial well-being during and following homelessness. Our findings build on published literature and provide further evidence of the pervasiveness of boredom in the lives of individuals during and following homelessness, and its serious, primarily detrimental, influence on psychosocial well-being [ 4 , 6 – 8 ]. Beyond our pilot study, which included only two participants [ 5 ], this is the only known study which has focused on boredom in the transition to housing following homelessness. The findings of this study not only validate the findings of previous research but build on existing evidence by presenting an analysis representing a much larger sample across a broader range of urban contexts. This research furthers a growing body of literature which emphasizes the importance of meaningful activity in the lives of individuals during and following homelessness [ 47 – 53 ], and can be used to inform policy and practice aimed at addressing barriers to participation in meaningful activity to mitigate the deep degrees of boredom often experienced by individuals during homelessness and after securing a tenancy.

Our findings demonstrate the intimate relationship between boredom and psychosocial well-being among persons who experience homelessness. Participants in this study reported significantly higher boredom and lower engagement in meaningful activity than other populations, and poorer psychosocial well-being overall. In this study, boredom was associated with increased drug use, increased hopelessness, and lowered mental well-being, while conversely, engagement in meaningful activity was associated with lowered drug use, and increased mental well-being. These findings were consistent with qualitative interviews, both during and following homelessness, where participants emphasized the deleterious influence that boredom imposed upon their mental health. Further, participants described how substances enabled them to cope with the presence of boredom, and the trauma that re-surfaced during long periods of unoccupied time. These are important findings that provide a unique glimpse into the dynamics of substance use for persons who experience homelessness and explain one of the many contributors to the poor mental health typically observed in this population [ 35 , 54 ]. While it is unlikely that engagement in meaningful activity will address all of the mental health and substance use challenges experienced by individuals during and following homelessness, our findings suggest that mitigating boredom may help to address some of these challenges.

A surprising and novel finding of this research was how boredom and meaningful activity were experienced following homelessness. Our quantitative analyses demonstrated that there were no differences in housed or unhoused participants on reported boredom or meaningful activity, and that the number of months of being housed, or unhoused in the past year did not predict boredom or meaningful activity engagement. Further, there were no statistically significant differences in these groups on other indices of psychosocial well-being. This suggests that meaningful activity engagement and boredom continue following homelessness, and that the psychosocial well-being of individuals leaving homelessness may not improve upon obtaining housing alone. Our qualitative analyses substantiated and contextualized these findings, with housed participants describing similar challenges with boredom and meaningful activity engagement as persons who were unhoused. Restrictions in meaningful activity engagement occurred for some of the same reasons for unhoused and housed participants and included ongoing poverty and social exclusion; however, different challenges emerged for participants who were housed. While having stable housing changed participants’ routines and provided them with a foundation on which they could participate in more meaningful activities, having limited social networks, living in ongoing poverty and being socially isolated following homelessness limited possibilities for meaningful engagement and resulted in boredom that was just as, or more profound, as when they were unhoused. This qualitative evidence, combined with the fact that our quantitative data illustrated no differences between unhoused and housed groups is a critically important finding, particularly with regard to homelessness prevention. If individuals have access to deeply affordable housing, and are experiencing wellness following homelessness, including having opportunities to participate in activities that are meaningful, it can be argued that such a person will be more likely to sustain their tenancy in the long term. While this study demonstrates the importance of meaningful activity engagement following homelessness, more research is needed to determine whether meaningful activity engagement can predict tenancy sustainment.

Research and practice implications

For good reason, a large majority of research and practice in the area of homelessness is focused primarily on tenancy sustainment. While this is a critical goal, the findings of this study challenge the common assumption that housing alone necessarily leads to improvements in psychosocial well-being. This study emphasizes the need for greater research and practice attention on a broader range of indices of psychosocial well-being following homelessness that include meaningful time use. Research findings and practice evidence have given rise to a growing mass of researchers and practitioners who are calling for targeting a broader range of outcomes following homelessness, and a focus on targeting and measuring indices of thriving rather than simply sustaining a tenancy [ 1 , 55 – 58 ]. While practice resources emphasize the inclusion of meaningful time use [ 59 , 60 ], this outcome is rarely measured in the evaluation of interventions in research and practice. Measures of thriving following homelessness that include attention to boredom and meaningful activity engagement are needed, and are currently in development [ 61 ]. The availability of these measures will support researchers and service providers to attend to boredom and meaningful activity in their research and practice and will add to the growing body of evidence in this area.

Future research aimed at developing a more thorough understanding of the relationship between boredom, trauma and substance use is needed. Homelessness is recognized as a traumatic experience and persons who experience homelessness are known to experience high degrees of trauma both before and during homelessness [ 62 , 63 ]. Trauma is also broadly recognized as a strong predictor of substance use [ 64 ]. Participants in this study described how the presence of pervasive boredom evoked the need to use substances simply to feel a sense of stimulation that was lacking in their lives, and to cope with the trauma that resurfaced during periods of unoccupied time. While we did not measure trauma quantitatively, participants associated boredom with trauma consistently across qualitative interviews. Future research focused on the relationship between boredom and substance use among individuals who experience homelessness is needed to uncover the ways in which boredom, trauma and substance use are related. Such research can inform the development and evaluation of practice and policy aimed at supporting persons who use substances and experience homelessness. Incorporating an understanding of how boredom and meaningful activity engagement factor into the substance use patterns of persons who experience homelessness is a novel contribution, and critically important given the high rates of substance use and trauma in this population [ 35 , 54 ].

Overall, our findings suggest that interventions aimed at engaging individuals in meaningful activity are a serious gap in existing services. In a recent systematic review focused on the effectiveness of interventions for engaging individuals experiencing homelessness in meaningful activity, only nine moderate-high quality studies were identified [ 65 ]. The dire lack of intervention research in this area combined with the findings of this study suggest that future research aimed at developing and evaluating such interventions is needed. Participatory research that incorporates the perspectives of persons with experiences of homelessness, service providers and researchers may be an important strategy for co-designing and evaluating interventions designed to increase participation in meaningful activity.

Finally, persons with histories of homelessness are known to experience a high prevalence of mental illness [ 54 ], substance use disorder [ 35 ], and brain injuries [ 66 ]. These conditions are associated with the presence of cognitive challenges that may make boredom more likely irrespective of opportunities for engagement in meaningful activity (i.e. trait boredom). In this study, only a quantitative measure of state boredom was used (MSBS-8). Future research should incorporate measures of trait boredom that can help to identify whether boredom is related more or less to individual factors or the environmental contexts in which persons who experience homelessness are situated. This information will be critically important for informing the development of strategies aimed at mitigating the pervasiveness of this experience.

Policy implications

Policymakers may consider the importance of meaningful activity engagement in evaluating and funding programs designed to support individuals who experience homelessness. The relentlessness of boredom in the lives of persons who are unhoused and housed following homelessness represents a serious social justice issue that has been associated with indices of well-being in this study and previous research [ 4 – 8 ]. Most of the participants in this study were receiving income support in the form of general and disability-related social assistance. Repeatedly, participants indicated that the income received from these programs is insufficient for meeting their daily needs, and prevented them from participating in meaningful activity, which ultimately gave rise to experiences of pervasive boredom. Social assistance rates in the province in which participants were recruited have been criticized for being insufficient for most [ 67 ]. Policymakers may consider increasing social assistance rates both to prevent homelessness, and to enable individuals living in low income to pay for their basic needs, which includes accessing meaningful activity. For some, this will mean increasing participation in employment. Only 15.2% of participants in the current study were employed. Previous research indicates that a large majority of persons who experience homelessness are unemployed, despite expressing the desire to work [ 68 ]. Services are needed to increase the accessibility of employment programs for persons with histories of homelessness that account for the high prevalence of disabilities that they experience. Finally, policymakers should be aware that the meaning of activities is highly subjective and phenomenological. As such, policies that are developed, and programs that are funded to increase participation in meaningful activities for persons who experience homelessness need to offer choice for this population in how their time is occupied.

Limitations

The findings of this research represent the experiences of individuals during and following homelessness in three predominantly English-speaking, urban contexts in a high-income country. Further, the participants in both unhoused and housed groups in this study were primarily White and heterosexual. Transferring or generalizing the findings of this study to racialized, non-heterosexual groups should account for how these underrepresented groups may experience boredom, meaningful activity, and homelessness differently. Further, while the reliability of most of the standardized measures used in this study was satisfactory, internal consistency for the CIS subscales were in the ‘questionable’ range [ 69 ], and this should be accounted for when interpreting quantitative findings related to community integration in this study. Finally, it should be noted that the quotes provided to describe our themes in this article represent only a small fraction of the many quotes from interviews that could have been used to provide evidence of the themes highlighted in our findings. This should be acknowledged in any interpretation of the findings of this paper.

Research pertaining to persons with experiences of homelessness has primarily focused on what is needed to support the security and maintenance of a tenancy and less on targeting thriving following homelessness. The findings of this research suggest that boredom and meaningful activity are important outcomes that should be accounted for in future research, practice, and policy related to supporting individuals following homelessness. The findings of this study suggest that this is not an outcome that is achieved through securing housing alone. Identifying existing and novel intervention strategies designed to increase participation in meaningful activities is an essential goal given the findings of this study. Future research designed to identify the nature of boredom (i.e. state vs. trait boredom) experienced by persons with histories of homelessness is needed to inform the development of these approaches. Finding ways to address boredom following homelessness is likely to promote thriving and may contribute to existing strategies for health promotion and homelessness prevention.

Acknowledgments

We would like to thank the participants in this research who shared their important perspectives during the course of this study. We hope that presenting their voices in this research will influence research, policy and practice in services aimed at improving the lives of persons who experience homelessness and housing precarity. We also thank the peer reviewers for their valuable contributions during the publication process.

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Open access
Published: 27 May 2024

Shaping and shifting schemas on supervised injectable opioid treatment: findings from a cross-sectional qualitative study in two German treatment facilities

Zoe Friedmann ORCID: orcid.org/0000-0002-0225-2231 1 ,
Hans-Tilmann Kinkel 2 ,
Claudia Kühner 3 ,
Andreas Zsolnai 3 ,
Annette Binder 4 na1 &
Inge Mick 5 na1

Addiction Science & Clinical Practice volume 19 , Article number: 45 ( 2024 ) Cite this article

Metrics details

Supervised injectable opioid treatment (SIOT) is a promising alternative for people living with opioid use disorder (OUD) who have not sufficiently benefitted from oral opioid substitution treatment. Yet, SIOT utilization remains limited in Germany. We propose that this is due to beliefs, or schemas, on SIOT among people living with OUD. Drawing from medical sociology and social psychology, this study explores the emergence and evolution of such schemas on SIOT.

We conducted semi-structured interviews with 34 individuals currently in or eligible for SIOT in two German outpatient treatment facilities and paralleled an inductive qualitative content analysis with the exploration of individual cases.

The analysis revealed that peer-to-peer interaction and individuals’ practical experiences in therapy are crucial in constructing and changing idiosyncratic and shared schemas of SIOT. When facing ambiguous information, cognitive strategies like subtyping served to mitigate uncertainty.

This research has important practical implications for integrating experiential knowledge into clinical care and improve information sharing among people living with OUD. A nuanced understanding of the complex network of informal advice-seeking and -giving among people living with OUD is indispensable to adequately expand treatment modalities of proven effectiveness.

Introduction

Opioid Agonist Therapy (OAT) remains the most effective intervention for individuals living with opioid use disorder (OUD) [ 1 , 2 ]. Yet not all people satisfyingly respond to conventional forms of OAT with oral methadone, morphine, or buprenorphine [ 3 ]. Supervised Injectable Opioid Treatment (SIOT) is a promising alternative for people living with OUD who have not sufficiently benefitted from oral OAT. Individuals previously considered treatment-refractory have been shown to improve their health status and social functioning, increase treatment retention and reduce criminal activities and street heroin use when in SIOT [ 4 ].

Patients in SIOT inject their substitute (diamorphine, DAM, or hydromorphone) in specialized outpatient clinics under the supervision of healthcare staff. Unlike other forms of OAT, including injectable formulations like extended-release buprenorphine, bolus injections of DAM in SIOT offer a temporary surge rather than sustained stability of mu-receptor agonism. So far, the therapy has been implemented in Canada and several European countries for individuals with severe OUD who fulfil certain eligibility criteria [ 5 ]. To be eligible for SIOT in Germany, individuals must be 23 years or older, have used opioids for at least five years, present ongoing intravenous use, have previously attempted treatment for OUD twice, one of which no less than 6 months in oral OAT and have additional health impairments due to continued drug use [ 6 ]. Although DAM-based SIOT has been available in Germany since 2009, the estimated need of SIOT is currently not met in Germany. In total, there are only 14 SIOT-clinics in 7 of the 16 federal states in Germany. Further perpetuating this access gap, there is no standardized path to recruit individuals into treatment and relatively few eligible people choose to initiate SIOT [ 7 , 8 ]. We propose that the underutilization can in part be explained by SIOT’s cultural schema, or how the therapy is understood among people living with OUD.

It has been shown that beliefs about a given substitute are highly influential in patients’ decisions to initiate and maintain OAT [ 9 , 10 ]. For instance, stigma and misinformation on OAT often lead to the underutilization of effective treatment modalities [ 11 , 12 ]. Research has predominantly focused on the prevalence and effects of (mis-)beliefs on OAT. The limited evidence on the formation of beliefs about OAT suggests that general societal views, first-hand experiences and a treatment’s perceived effects on peers are important sources of attitudes on OAT among people living with OUD [ 13 , 14 ]. In this regard, Gryczynski et al. (15:289) describe a highly influential “street narrative […] emerging from a mix of personal experiences and second-hand lore” which is more important than service delivery structure or scientific evidence for engaging people living with OUD in care. Goldsmith et al. [ 16 ] explain the importance of information obtained from peers with the heavy reliance of people living with OUD on “street news” about heroin and drug effects before entering OAT. They suggest that even when engaged in treatment, individuals give greater importance to their peers’ accounts than professionals’ knowledge. Similarly, Hunt et al. (17:1753) highlight the significance of methadone’s “street image”, which is “likely to be influenced by the norms and values of the addict subculture”. Yet, there is limited research on how “street images” on OAT are constructed or transmitted and how people living with OUD react to the information they obtain from their peers. Furthermore, despite the substantive scholarship demonstrating the significance of stigma on OAT, little is known on how to change stigmatizing beliefs [ 12 ].

With the aim to fill this gap in the literature and better understand the underutilization of effective treatment modalities like SIOT, we translate insights from medical sociology and social psychology to the context of OAT. Specifically, we conceptualize SIOT’s “street image” among people living with OUD as its cultural schema- the therapy’s socially shared representation governing how it is utilized [ 18 ]. To investigate dynamics of peer-to-peer knowledge transfer, we add the concept of experiential knowledge, or truth derived from personal experience [ 19 ]. In this regard, we understand peer- or social groups as affiliative networks of people who have a comparable status and experience similar situations. In the following sections, we will first introduce our theoretical framework and then turn to the empirical part of this article.

Conceptual framework

On a basic level, schemas are learned and deeply internalized explanatory frameworks which mediate how persons understand and act upon past and current experiences [ 20 ]. Schemas are mainly deployed through automatic cognition and thus lead to fast, intuitive interpretations occurring with little conscious awareness [ 21 ]. There are idiosyncratic schemas unique to an individual and cultural schemas, which are intersubjectively shared between members of a social group [ 22 ]. Cultural schemas emerge through individual first-hand experience and social interaction, which can be direct (e.g., face-to-face conversation or observation) or mediated (e.g., written accounts) [ 23 ]. Once established, cultural schemas are prone to interpersonal reconstruction, which is influenced by group members’ experiences, conditions of the social contact and contingent action. As such, schemas that initially emerged from social interaction can later be reinterpreted by individuals considering their own practical experiences [ 24 , 25 ]. Conversely, pre-existing schemas and experiences guide whether individuals seek and how they are affected by social interaction [ 26 ]. This leads to mutually influencing first-hand experiences, schemas, social interaction and contingent behaviors. According to Strauss and Quinn [ 23 ], schemas are thus “flexibly adaptive” rather than fixed.

Despite agreements on their flexible nature, it remains contested how and under which circumstances schemas change. Generally, social interaction and individual experience may either disconfirm or corroborate existing schemas [ 27 , 28 ]. On a group level, the potential of social contact to change stigmatizing beliefs, a type of cultural schemas [ 29 ], is well-documented [ 30 ]. Yet, research suggests that in general, cultural schemas are durable in individuals and through time [ 31 ]. Even when confronted with contradictory evidence, schemas tend to persevere due to several cognitive and interpersonal processes working against change [ 27 , 32 ]. For instance, pre-existing schemas influence the uptake of new information and often lead to schema-consistent interpretation and re-transmission [ 33 , 34 ].

Distinctions between schemas vs. non-schemas are often gradual rather than definitive [ 35 :536]. Despite conceptual inconsistencies, schemas are useful explanatory frameworks in multiple disciplines in and beyond sociology [ 36 ]. Some scholars describe associative neural networks making up cultural schemas on an algorithmic level. Building on insights from this approach, we analyze schemas on a “functional level” [ 21 ] to explore the construction and evolution of schemas on SIOT among people living with OUD. As scholarship on cultural schemas has often focused on social macro-processes, it is useful to also consider work on the practical co-construction and transfer of knowledge in subcultures, which we turn to now.

Experiential knowledge

Our theoretical framework also includes the concept of experiential knowledge, which has gained much attention in the past decades in healthcare [ 37 ] and beyond [ 38 , 39 ]. In contrast to established occupations ’ systematically accumulated professional knowledge, experiential knowledge is derived from personal experience [ 19 ]. This includes vicarious experiential knowledge gained from talking with and observing others dealing with a particular situation [ 40 ]. Abel and Browner [ 41 ], for instance, distinguish “embodied” knowledge obtained through one’s own, direct bodily experience and “empathetic” knowledge gained through close emotional ties with those experiencing a phenomenon. Upon individual reflection and organization, initially implicit experiences are transformed into re-countable experiential knowledge. Individuals’ experiential knowledge is fluent across time and context [ 42 ], which leads Boardman [ 43 ] to differentiate between cumulative experiential knowledge shaped by linear, “quasi-paradigmatic shifts” and fragmented experiential knowledge, where “different, but equally accurate” truths can coexist.

Despite their differences, experiential and professional knowledge are neither inherently conflicting nor mutually exclusive. Rather, they can complement and co-shape one another both on an individual and group level [ 44 , 45 , 46 ]. However, frictions arise when discordant information is presented about the same phenomena (19:448). In the medical context, power differences inherent in the doctor-patient relationship [ 47 ] suggest that professional knowledge trumps experimental knowledge when tensions arise. Yet, resistance to professional in favor of experiential knowledge is highly context-specific and rather gradual than definitive [ 48 , 49 ], particularly in the context of OST [ 50 ].

According to Noorani [ 51 :65], experiential knowledge relies on “collective meaning-making” between members of a peer group. Examples of such groups include Alcoholics Anonymous, mutual aid groups for single parents or for people who stutter and patient organizations of people living with fibromyalgia or chronic fatigue syndrome [ 37 ]. In the process of “collective meaning making”, individuals share their experiential knowledge and subject it to interpersonal evaluation, whereby it obtains validity through its embeddedness in real-life experience and assumed representativeness for those who find themselves in similar situations [ 52 ]. Sharing and validating individuals’ experiences is facilitated by “the feeling of being understood as well as the open, natural communication between those with similar experiences” (19:450). Eventually, this leads to the production of a collectivized pool of knowledge. Particularly for potentially stigmatized and vulnerable groups, pools of experiential knowledge can be important resources to mediate decision-making processes in uncertain situations [ 53 , 54 ]. Yet, as Halloy et al. [ 37 ] point out, the transfer and uptake of experiential knowledge is highly context specific, cognitively challenging and a matter of degree- regardless of how similar individuals’ situations might be. Mazanderani et al. [ 55 ], for instance, provide a rich account of the “identity work” necessary to transfer others’ experiences onto one’s individual situation and highlight the plurality of experiential knowledge of people living with the same diagnosis. While the co-production and utilization of experiential knowledge can occur in a variety of mediation spaces, prior research has focused on organized forms of collective meaning-making, e.g., in self-help groups or internet fora [ 37 ]. Little attention has been paid to informal networks as described among people living with OUD.

Spoken discourse can be understood as “the external matrix of all deeply internalized cultural schemas” (18:230). Although schemas and their effects are seldomly formulated as explicit declarative propositions [ 20 ], they can thus be reconstructed through linguistic data [ 56 ]. This makes interviews a suitable method to explore individuals’ schemas and the dynamics underlying their formation.

This article builds on data from a qualitative interview study with people currently in or eligible for SIOT. Specifically, we investigated the patient perspective on barriers and enabling factors for SIOT-initiation and -maintenance and on how to improve the therapy [ 10 , 57 ]. Inclusion criteria for the interview study were purposefully broad to include different experiences with and perspectives on SIOT. All people currently receiving OAT who fulfilled German eligibility criteria for SIOT [ 6 ], had an adequate level of English or German and were able to provide informed consent were eligible. Our research was approved by the ethics committee of Landesärztekammer Baden-Württemberg (AZ: F-2022-002). We followed the consolidated criteria for reporting qualitative studies [ 58 ] and provide further information regarding our methods in supplementary material 1.

To develop our semi-structured interview guides, authors 1, 2 and 3 first screened the existing literature on the initiation and maintenance of OAT and barriers to care to identify common themes, key issues, and potential areas of interest related to our research objectives. The specific interview questions were additionally informed by relevant qualitative research exploring individuals’ experiences with both oral and injectable OAT and the extensive clinical experience in OUD-care of several members of the research team. Prior to data collection, the interview guides and the study’s purpose were discussed in a focus group including people living with OUD and persons providing psychosocial support in the Berlin clinic. This was to ensure that the study design was feasible, non-judgmental and of relevance for people with lived experiences [ 59 ]. As the feedback obtained during the focus group session was affirmatory, it did not result in significant changes.

Participants

We recruited participants from two German outpatient SIOT-clinics. One clinic, located in Stuttgart, is the sole provider of SIOT in the German federal state of Baden-Württemberg. It accommodates 260 patients in oral OAT and 140 in SIOT. The other clinic, situated in Berlin where two SIOT-clinics exist, has 220 patients in oral OAT and 103 in SIOT. While most patients reside in Stuttgart and Berlin, some also travel from adjacent areas to access SIOT. Both clinics allow for interaction and knowledge transfer among patients in oral OAT and SIOT, e.g., in the clinics’ surroundings. Stuttgart, situated in the south of Germany, has a population of approximately 650,000 inhabitants. In contrast, Berlin, located in the east of Germany, has around 3.8 million inhabitants.

All patients of the respective clinics were screened for eligibility and grouped into currently being in SIOT or currently being in oral OAT. For people in oral treatment, we differentiated between individuals ever and never having been in SIOT. Stratified by age and self-assigned gender to reflect the study clinics’ patient population, eligible people were randomly selected from the respective groups. Selected individuals were offered to participate in the study by the clinics’ staff and provided with a study information and consent form.

Guided by previous experience from members of the research team, the consultation of outside qualitative researchers during the planning phase of the study and the concept of information power [ 60 ], we set an initial number of participants to 16 individuals currently in SIOT and 12 currently in oral OAT. These numbers evolved throughout data gathering and preliminary analyses. For instance, we did not expect patients’ enthusiasm to participate and initially over-sampled people in SIOT. Yet, all sampled individuals wanted to participate, and we continued to schedule interviews until no new topics kept emerging. Conversely, we were not able to recruit 12 individuals in oral OAT eligible for SIOT. Finally, 23 participants currently in SIOT and 11 participants currently in oral treatment, of which 4 had ever received SIOT, were included in the study.

Data collection

One-on-one semi-structured interviews were conducted by author 1, a female medical student trained in qualitative research who was unknown to participants prior to data collection and not providing care at the study sites. The interviews were held between May and August of 2022 in private rooms in the respective clinics. Prior to all interviews, author 1 again explained the study’s purpose, her position and confidentiality protocols. It was stressed that participation was voluntary and the decision to take part unrelated to participants’ care at the clinic. Upon informed written and verbal consent, the interviews were audio-recorded and supplemented with field notes (e.g., on participants’ non-verbal cues, contextual information and author 1’s personal reflections).

Interviews ranged from 18 to 61 min. All interviews started with an open question inviting participants to reflect upon their initiation of SIOT and/or oral OAT. Participants who had ever been in SIOT were asked about their experiences in treatment and thoughts on discontinuing treatment. Depending on their individual circumstances, participants currently in oral OAT were asked if and why they would or would not (re)enroll in SIOT. All participants were asked if they had any suggestions to improve SIOT and encouraged to share any further thoughts upon ending the interview. While the questions were broad and invited participants to lead the course of the interviews, author 1 used follow up and probing questions when deemed appropriate. After the interviews, participants were invited to contact author 1 for any further inquiries or having transcripts of their interviews returned to them. All participants (including those consulted prior to data collection and publication) were given a compensation of 20€, which was self-financed by the research team. We took measures to mitigate potential conflicts of interest arising from this arrangement (e.g., repeated critical reflections and consulting Charité’s Office for Research Integrity ).

Data analysis

All data were analyzed in German. The illustrative quotations for this article were translated from German to English in forwards-backwards technique by bilingual academics (IS, GS) for concurrent validity [ 61 ]. Assisted by NVivo transcription-software, pseudonymized interviews were transcribed verbatim and identifying information was removed. For systematic coding, transcripts and fieldnotes were imported into MaxQDA (2022) software. We included data from all participant interviews in the analysis, which was informed by qualitative content analysis in a structured-thematic approach [ 62 , 63 ] and commenced after completing the first 4 interviews. Following repeated close reading of the transcripts, author 1 inductively derived initial major categories (e.g., perceptions of SIOT). A paper describing the content of different perceptions on SIOT and how these influence therapy-initiation has been published elsewhere [ 10 ].

In an iterative, cyclical approach supplemented by reflexive memo-writing, author 1 derived increasingly differentiated sub-categories (e.g., factors influencing perceptions of SIOT, differentiated in e.g., embodied experiences and interactions with peers). The emerging category system was refined during independent coding by author 1 and the research supporter, where discrepancies were discussed until consensus was reached. The final category system guiding the analyses presented in this paper was applied independently to about 20% of the material and can be found in supplementary material 1. During qualitative content analysis, author 1 noticed overlapping elements with work from the social sciences. Alternating between theory and our empirical material, we consequently developed our theoretical framework. This allowed us to better understand dynamics and relationships between our categories and surpass the descriptive stage of qualitative content analysis. Paralleling cross-case analyses, author 1 reviewed schemas on SIOT in individual cases to compare emerging dynamics across interviews with those of individual accounts and identify disconfirming cases. Thus, the model guiding the interpretations of our results (Fig. 1 ) emerged as a synthesis of individual and cross-case analyses and was present in all cases in different specificities.

Interaction and embodied experiences shaping schemas on SIOT. SIOT: Supervised Injectable Opioid Treatment

To facilitate critical reflexivity, author 1 kept a log of all methodological and analytical steps made during the research process. In regular verification meetings, author 1 discussed the category system and analytical approaches with variable members of the research team. During these meetings, researchers providing care to study participants only reviewed de-identified illustrative quotes. We continuously reflected upon the appropriateness of our theoretical framework and presented our analytical approaches at interdisciplinary interpretation groups and colloquia for intersubjective validation. We acknowledge that the data we gathered in interviews were co-created by the researchers and participants [ 64 ]. Prior to publication, we individually discussed this article’s summary results with 3 people living with OUD. They affirmed that the interpretations we made aligned with their informed lived experiences.

Most participants’ schemas of SIOT emerged from the information they derived from direct interactions with peers and their own experiences in treatment, as shown in Fig. 1 . Less frequently mentioned sources of knowledge were mediated accounts of experiential knowledge such as SIOT-clients’ testimonials in magazines or online. When participants obtained knowledge about SIOT from medical professionals or social workers, they often described corroborating this by observing and talking to their peers. Rather than shaping schemas on SIOT, professionals were depicted as managing the treatment of co-morbidities, practical gatekeepers and a source of psychosocial support. The importance given to information gathered through interactions with peers stemmed from a feeling of mutual understanding, facing similar problems, previous and/or ongoing negative experiences with healthcare professionals and the ubiquity of informal exchanges among peers in- and outside of the clinic.

In the following sections, we explore how interactions with peers and embodied experiences in treatment influenced participants’ schemas of SIOT. As we describe dynamics between categories, the presentation of our results does not follow the structure of our initial category system. We will first outline accounts in which participants entirely changed their understanding of SIOT considering information that conflicted with their prior schema. We then turn to more ambiguous situations where conflicting views coexist. While some participants comfortably accommodated partly contradicting information in their schemas, others expressed uncertainty arising from this. Several participants developed cognitive strategies to make sense of conflicting information by isolating individual accounts from one another or devalued their peers’ credibility. We end this section with participants’ practical suggestions for accurate and adequate information transfer. Participants whose anonymized data are presented below were assigned gender appropriate pseudonyms and selected because they most clearly capture our key findings.

Consistent schematic changes

Several participants described profound schematic changes resulting from the embodied experiences they made in treatment. Angela, a female in her 40s, has been in SIOT for 2 years after a long period of uncertainty on enrolling. Before SIOT, she has been on and off oral OAT for over 10 years, where -like most participants- she has never been able to control her co-use of street drugs. In SIOT, she feels satisfied and that her life has become more stable. In her case, information from peers influenced her initial schema of SIOT, which she then questioned considering conflicting empathetic experiential knowledge. Finally, her embodied experience invalidated and replaced her initial schema.

“You have to have x therapies, nothing can help you anymore, you have to be totally f*cked up to even get into the [SIOT] program”. Rumors like that were going around and that discourages you from entering the program. And actually, it’s not like that now at all. If you look at some of the people upstairs in our area, you wouldn’t think that they are in the program. They go to work normally and everything. Yes, but that scares people on the scene. Because they have totally different ideas if they don’t know someone [in SIOT] themselves. And also, when you say, “the program”- and I was also like “no way I’m going, I would never go in”. And because [boyfriend] was in there and another mate, that’s when you start- I also saw how [boyfriend], how it did him good and everything. And then I just went along.

While social interaction profoundly shaped Angela’s schema, this was not as clear for other participants. Nadine, a female in her 40s, has been in SIOT for 8 months after being unstably treated in oral OAT for nearly 20 years. She radically changed her schema of SIOT following positive embodied experiences in treatment. Although Nadine had several close friends in SIOT who told her that they were greatly benefitting from the treatment and encouraged her to initiate SIOT as well, she actively blocked these influences until she felt like there was no other way to control her co-use. She explains:

I’m really a patient who goes from “no way” to “10 stars”. And I wouldn’t have thought that myself. Really, honestly. Thank God [my friend] convinced me. So, I often think to myself “Yes, I should have done that much earlier”. Because even back then [my friends] were saying to me, “Come on Nadine, you should go into the diamorphine program, you always smuggle your sh*t out here [to inject your oral substitute]”. And I couldn’t help it, I was always like “Whoa, now stop doing this, for real!” and stuff like that. And then I always played tricks with the masks and ah, really stupid. I was like, “No, I never want to do that, get lost!”

Nadine could not clearly depict the source of her initial schema. When inquired on why she held a negative image on SIOT, she responded:

I just don’t know; I think that was really pure ignorance […]. That came from me. Like, that was my attitude.

As many participants whose embodied experiences paradigmatically changed their schema on SIOT, Nadine even reversed her image of methadone treatment. She now juxtapositions SIOT-patients (including herself) with individuals in methadone maintenance and says that

I still know and see far too many people in the methadone program. That sh*t should actually be scrapped. […] I just think that the clinics that offer methadone should think about whether [providing SIOT] might not make more sense.

Integrating conflicting information and avoiding uncertainty

Another group of interviewees did not report such radical schematic shifts when confronted with new information. These participants often had to accommodate conflicting, but coexisting information from interactions and embodied experiences. Uwe, a male in his 50s who started oral OAT in the 1980s, was in SIOT for about a year and liked many aspects of the treatment. He went back to oral OAT after “turning blue” and having to be oxygenated twice in SIOT. Notwithstanding his negative embodied experiences, he maintained a positive view of SIOT.

The substitute itself, that’s good. But I wanted to- I’m a bit fond of it, even if it’s not as great as it could be. But I don’t want to die because of it. And that’s why I left the program.

Not all participants could easily integrate conflicting information. Stefan, a male in his 40s, started SIOT because other patients conveyed a positive schema of the therapy. However, he felt uncomfortable in SIOT and decided to go back on oral OAT after a month. Despite expressing a consistently negative opinion towards SIOT, he had trouble to integrate his embodied experience with the information he obtained from peers.

I don’t know many dropouts. I don’t really know anyone, except myself. So, I don’t know what they all find so great about it. […] I can’t see anything good about it. For me, it was all just bad.

This trouble was also evident in the accounts of many interviewees eligible for but never having been in SIOT. Unable to construct a consistent schema on SIOT, they faced uneasiness in their decision-making processes regarding the therapy. Katrin, a female in her 30s in oral OAT who feels burdened by her co-use of cocaine and alcohol, repeatedly expressed insecurity arising from the information she obtains from her peers.

I have seen or- or know many people who take [DAM] and really only the very smallest percentage is fully satisfied with it, and a few do really well with it […]. But like I said, the ones who maybe find it positive, you don’t see them anymore. So, I don’t know what to think about it. In the end, it would have to help me.

Several participants developed strategies to avoid uncertainty and discomfort when facing conflicting information. Some individualized and subtyped the input they got and refrained from general inferences. Bettina, a female in her 30s currently in oral OAT whose brother discontinued SIOT, said that

many aren’t on the streets anymore. They all take diamorphine and are happy with it. Many say “It’s good for us. I’m satisfied. So, I try to go about my regular day that way”. It varies. You can’t put everything on one person […]. But I just say [SIOT] is not for me. It’s much too strong, I saw that with my brother. That’s what made me scared of it.

Additionally, interviewees frequently individualized and contrasted their embodied experiences with those of their peers to maintain consistency. Thomas, a male in his 40s who has been in SIOT for 4 years, stated that

I do great with it. There are some people who also do great with it, but others don’t do so well. So, it’s different for- it’s different for each person with diamorphine.

Another group of participants dealt with conflicting information by devaluating their peers’ accounts. Sascha, a male in his 40s, initiated SIOT to avoid a prison sentence despite the negative view on the therapy he adapted from his peers. The positive embodied experiences he made in treatment changed not only his schema on SIOT but also how he evaluates what he heard from his peers.

Now, looking back on it, if I’d known that before, I probably would have come sooner. It’s just that I got misinformation from other people about [SIOT]. […] But those people aren’t even in diamorphine and they already have preconceptions against it. And then they say something like that about it.

Participants’ suggestions for improvement

While most participants depicted interactions with peers as their primary source of knowledge, they also problematized misinformation circulating among people living with OUD and suggested educational interventions to combat this. Participants advocated for including people with lived experiences and greater interpersonal exchange between patients, medical personnel, social workers and individuals currently not engaged in treatment. Sebastian, a male in his 30s who has been in SIOT for the past 7 years, explains:

If I had had someone at [harm reduction NGO] or something who were using themselves, who could tell me about it first-hand or from whom I could pick up tips, where I knew “hey, they’ve got the sh- They were also on the street once, they’ve been injecting long enough themselves”. Maybe I would have picked up one or two tips from them.

Practical suggestions to improve interpersonal exchange regarded “patient advocates” in the clinic to mediate between medical personnel and patients, patient-led group sessions and inviting people into the clinic to get their own impression on SIOT. Julia, a female in her 30s who has been in SIOT for one year, suggested

that we are asked more often. I mean, we are the ones who have to go there and need it. And yes, I think it would also be nice to publicly […]. People should be shown what’s happening here and what kind of people are coming here.

Building on work from medical sociology and social psychology, this study investigates the. social construction of schemas on SIOT in two German outpatient OAT-clinics. We find that peer-to-peer interaction and embodied experiences are the predominant influences on participants’ schemas regarding SIOT. This is in line with prior work from the social sciences [ 21 ] and addiction medicine [ 15 ]. Focusing on the context of OUD, our findings contribute to the growing literature that examines the production, spread and utility of experiential knowledge.

The importance of vicarious experiential knowledge in developing schemas

Prior to treatment-initiation, we found vicarious experiential knowledge on SIOT (both second-hand and empathetic) as highly influential in the development of participants’ schemas. This contextualizes recent findings on the relational qualities of treatment engagement in SIOT, where several participants initiated SIOT due to the experiences their partners had made in treatment [ 65 ]. Interestingly, work on buprenorphine found that individuals formed their opinion on the medication mainly through embodied experiences after obtaining it illegally on the street and only partly through interactions with peers [ 15 ]. This difference is likely caused by the supervised application in SIOT, which makes the diversion of a relevant amount of injectable DAM improbable and restricts first-hand experiences to clinical settings [ 66 ]. Such unique nuances in the delivery of different OAT modalities may engender further distinct patterns in the formation of treatment schemas. Thus, more context-specific research is needed to better understand the influence of peer experiences on treatment perceptions in OAT modalities beyond SIOT.

Strikingly, only a minority of participants based their schemas and decisions regarding SIOT on professional forms of knowledge. Generally, participants neither explicitly devalued nor mistrusted professional knowledge, as previous work on OAT [ 50 ] and experiential knowledge [ 37 ] suggests. The reliance on informal interactions with peers might be a residual habit from before entering and stabilizing in treatment [ 16 ]. Another probable explanation are the “different conceptual worlds” [ 67 ] patients and medical professionals operate in, which is particularly pronounced in treating OUD [ 68 ]. Coupled with the unique feeling of mutual understanding and “natural communication” among peers [ 19 ], this might render professional knowledge less relevant. Although beyond the scope of this study, disentangling individuals’ reasons for (not) relying on professional knowledge regarding OAT is an important avenue for future research. Simultaneously, peer-to-peer knowledge transfer must be considered in all efforts to engage individuals in treatment.

Adapting schemas

Over time, participants described frequent adaptations of their idiosyncratic schemas and situated decision-making processes. Generally, embodied experiences in SIOT that put pre-existing schemas to the test were the most prominent stimuli for change. This mainly regarded changes towards more positive, but also towards mixed or negative schemas, which complements previous quantitative [ 69 ] and qualitative [ 70 ] findings on patients’ variable satisfaction-trajectories in SIOT. We did not find that individuals who initially held negative schemas on SIOT maintained these in treatment. This goes against studies on methadone, where patients kept negative attitudes toward the substance in therapy even when they thought that methadone has had a positive effect on their lives [ 17 , 71 ].

Additionally, participants adapted their schemas considering social interactions with peers, which is in line with prior research [ 30 ]. In this process, they gave varying importance to the information they obtained. Our findings concur with Mazanderani et al. [ 55 ] and Borkman [ 19 ], who argue that the assumed representativeness and uptake of vicarious experiential knowledge is situationally and temporally contingent. Furthermore, social learning and schema theorists propose that the selective internalization and interpretation of new, potentially ambiguous information serves to construct coherent and eventually durable cultural schemas [ 23 , 72 ]. In this regard, cognitive mechanisms such as subtyping and individualization [ 27 ] were utilized by many participants in our study.

Yet, our findings on incongruent schemas on the individual and group level suggest that factors beyond schema-consistency should be considered. Here, we found that some participants prioritized emotionally demanding and affectively laden interactions, as suggested by Hunzaker [ 73 ]. Furthermore, the “friendship potential” and repeated interaction among patients in the same clinic likely mitigated schema-consistent interpretations and allowed for change [ 26 ]. We can only speculate about additional influences (e.g., the selective uptake of information due to social hierarchies within treatment and recovery settings [ 74 ]). To reach comprehensive conclusions, future studies should systematically evaluate how people living with OUD prioritize the information they obtain from their peers.

Fragmented experiential knowledge as a resource

Our results disagree with studies on the utility of experiential knowledge in uncertain situations [ 53 ]. Rather than serving as a valuable resource, conflicting experiential knowledge and second-hand accounts caused insecurity in decision-making on SIOT, which is more in line with Boardman [ 75 ]. This might be because, in our context, we found no organized collective pool of experiential knowledge or consistent cultural schema, but an inconsistent, informally transmitted agglomeration. Boardman [ 43 ] argues that experiential knowledge can take paradigmatic shifts or contain fragmented, partially contradictory information. For Boardman [ 43 ], however, intraindividual fragmentation characterizes experiential knowledge as a “living” resource. We rather found fragmentation to produce uneasiness for many participants. Considering these differences, further research in the context of OUD is needed to tap the potential of experiential knowledge and peer-to-peer informational exchange and improve SIOT-engagement.

Practice implications

Our findings on peer-to-peer transmissions of experiential knowledge and the suggestions made by participants have several practical implications. It would be wise to enhance peer-to-peer support and the organized sharing of experiential knowledge in clinical care for OUD [ 76 ]. While evidence on peer support is limited and shows only modest impacts [ 77 ], this might be due to barriers towards the meaningful implementation of experiential knowledge in healthcare services [ 78 , 79 , 80 ]. In particular, tokenism [ 52 ], exploitation [ 81 , 82 ] and the commodification [ 83 ] of people with lived experiences must be avoided through careful planning and realization [ 84 ]. Enhanced sharing of experiential knowledge among peers is no panacea against the spread of misinformation and distrust [ 85 , 86 ]. Thus, simultaneous efforts should be made to mitigate problematic beliefs and promote accurate information sharing among staff, patients and patients’ social networks [ 87 , 88 ]. Social contact interventions, e.g., inviting people into the clinic to get their own impression on SIOT, as some participants suggested, might be a way to reach individuals beyond patients’ direct networks [ 89 ] and reduce inner-group stigma [ 90 ]. However, one must be wary of potential unintended consequences of these interventions (e.g., perpetuating perceptions of dangerousness or increasing self-stigma) [ 91 ]. Thus, while implementing such interventions, careful consideration of both their potential impact and strategies to mitigate any negative outcomes is crucial.

Another consideration regards eligibility criteria for SIOT, which were frequently mentioned as a presumably objective source of stigmatizing schemas. The high costs and elevated rates of adverse events in SIOT necessitate thorough considerations on who to enroll [ 92 ]. Nevertheless, regulations on OAT are not isolated from larger socio-political contexts and can reinforce structural stigma [ 93 , 94 ]. Our findings highlight that regulations must be carefully communicated, frequently re-evaluated and potentially adapted to not enhance prejudice, marginalization and the underutilization of effective treatment modalities.

Strengths and limitations

A strength of our research is its diverse study population. We went beyond previous work by including people eligible for, previously in and currently in SIOT. Participants had various treatment trajectories and could speak to interpersonal dynamics both in- and outside of therapy. The importance of informal knowledge transfer among peers in out-of-care populations found in this study and previous research suggests that, to some extent, our findings are transferable to OAT modalities beyond SIOT and to individuals currently not engaged in treatment. Furthermore, coupled with the coherence of accounts from both study sites, it is likely that our findings are transferable to geographical regions beyond our study sites. Just like most previous research on OAT, however, we conducted our study in urban areas and cannot necessarily speak to rural regions.

A further important limitation of this study is that we solely relied on cross-sectional interviews. A longitudinal design would have mitigated recall biases and might have allowed us to explore dynamics in individuals’ schemas over time more rigorously. Additional qualitative methods, e.g., participant observation, might have enriched our analyses and shed light, for instance, on the configuration of interpersonal networks underlying the dynamics we investigated [ 95 ]. Because we focused on the experiences of people living with severe OUD on the individual and group level, we cannot necessarily speak to processes on higher societal levels (e.g., the public creation of stigma on OAT), which likely interact with what we found on the micro-level [ 27 ].

Furthermore, presenting our findings in English introduces some constraints. It is possible that certain nuances inherent in the original German data have been modified or overlooked during the translation process. To mitigate this risk and ensure that the English version remains close to the original German data, we employed forward-backward translation and deliberated on all translation decisions both within and outside the research team. Finally, we integrated people with lived experiences only on a “consult” level due to ethical and practical considerations [ 59 ]. While this allowed different stakeholders’ priorities and reflections to be implemented into our study, the main responsibility remained within the research team and social desirability responses might have affected the affirmatory outcome of our consultations with people living with OUD.

This study explored how schemas on SIOT are built, transmitted and transformed among people living with OUD. Peer-to-peer interactions and embodied experiences were the predominant influences on participants’ schemas regarding SIOT. Thus, effective interventions must be based on an understanding of the complex social dynamics involved in (not) seeking treatment and peer-to-peer knowledge transfer should be acknowledged in all considerations on SIOT. In this regard, the accumulation and sharing of experiential knowledge should be supported. Informal exchanges should be supplemented with organized information sharing and measures to mitigate problematic beliefs that might produce insecurity and harm. In all these efforts, individual preferences and strategies of knowledge-seeking must be respected to meaningfully improve service provision for people living with severe OUD and assist them to achieve their individual treatment goals.

Data availability

The data that support the findings of this study are not openly available due to reasons of confidentiality. Anonymized data can be made available from the corresponding author upon reasonable request.

Abbreviations

Diamorphine

Opioid Agonist Therapy

Opioid Use Disorder

Supervised injectable opioid treatment

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Acknowledgements

We are grateful to all the participants in this study for sharing their time and experiences with us. We also thank Paula Tigges for her assistance during independent coding and Genia Schuemer as well as Ioni Schumer-Lawrence for their assistance during translation of illustrative quotations.

The study was self-financed by the research team and did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Open Access funding enabled and organized by Projekt DEAL.

Author information

Annette Binder and Inge Mick contributed equally to this work and shared the last authorship in the author list.

Authors and Affiliations

Charité Universitätsmedizin Berlin (Medical University Hospital Charité Berlin), Charitéplatz 1, 10117, Berlin, Germany

Zoe Friedmann

Praxiskombinat Neubau, Schwerpunktpraxis für Suchtmedizin (outpatient clinic for addiction medicine), Ruschestraße 103, 10365, Berlin, Germany

Hans-Tilmann Kinkel

Schwerpunktpraxis für Suchtmedizin Stuttgart (outpatient clinic for addiction medicine), Kriegsbergstraße 40, 70174, Stuttgart, Germany

Claudia Kühner & Andreas Zsolnai

Universitätsklinikum Tuebingen, Sektion Suchtmedizin und Suchtforschung (addiction medicine and addiction research department, Medical University Hospital Tuebingen, University of Tuebingen), Calwerstraße 14, 72076, Tuebingen, Germany

Annette Binder

Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin (Medical University Hospital Charité Berlin), Charitéplatz 1, 10117, Berlin, Germany

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Contributions

Zoe Friedmann: Conceptualization, Data Curation, Formal Analysis (lead), Investigation (lead), Methodology, Project Administration (lead), Visualization (lead), Writing – Original Draft Preparation (lead), Writing – Review & Editing.

Hans-Tilmann Kinkel: Conceptualization (lead), Project Administration, Resources, Supervision, Writing – Review & Editing.

Andreas Zsolnai: Conceptualization, Resources, Writing – Review & Editing.

Claudia Kühner: Conceptualization, Project Administration, Resources, Writing – Review & Editing.

Annette Binder*: Methodology, Formal Analysis, Supervision, Visualization, Writing – Review & Editing.

Inge Maria Mick*: Conceptualization, Validation, Supervision, Writing – Review & Editing.

*Shared last authorship: these authors contributed equally to this work.

Research support:

Paula Tigges: Formal Analysis, Validation.

Corresponding author

Correspondence to Zoe Friedmann .

Ethics declarations

Ethical approval.

Our research was approved by the ethics committee of Landesärztekammer Baden-Württemberg (AZ: F-2022-002). All participants gave written and verbal informed consent prior to data collection and publication.

Conflict of interest

Zoe Friedmann: Financial and non-monetary stipend from Studienstiftung des Deutschen Volkes (scholarship program from the German government).

Hans-Tilmann Kinkel: Medical head and director of an outpatient clinic for addiction medicine (Praxiskombinat Neubau Berlin); Speaker’s fees from Accente BizzComm GmbH, AbbVie Deutschland GmbH & Co. KG, and GILEAD Sciences GmbH; conference travel and attendance fees from GILEAD Sciences GmbH.

Claudia Kühner: Psychologist at an outpatient clinic for addiction medicine (Schwerpunktpraxis für Suchtmedizin Stuttgart).

Andreas Zsolnai: Medical head and director of an outpatient clinic for addiction medicine (Schwerpunktpraxis für Suchtmedizin Stuttgart).

Annette Binder: Member of Deutsche Gesellschaft für Suchtforschung und Suchttherapie e.V. (German society of addiction research and addiction therapy); medical residency in addiction medicine at Medical University Hospital Tuebingen.

Inge Mick: Senior physician in general adult psychiatry (including care for addictive behaviors) at Charité Berlin.

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Friedmann, Z., Kinkel, HT., Kühner, C. et al. Shaping and shifting schemas on supervised injectable opioid treatment: findings from a cross-sectional qualitative study in two German treatment facilities. Addict Sci Clin Pract 19 , 45 (2024). https://doi.org/10.1186/s13722-024-00475-5

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Qualitative methods of research contribute valuable information to our understanding and expanding knowledge of psychological phenomena. This updated edition of Qualitative Research in Psychology builds upon the groundwork laid by its acclaimed predecessor, bringing together a diverse group of scholars to illuminate the value that qualitative methods bring to studying psychological phenomena ...
Qualitative Research in Psychology
Top authors and change over time. The top authors publishing in Qualitative Research in Psychology (based on the number of publications) are: Jonathan A. Smith (8 papers) published 1 paper at the last edition,; Victoria Clarke (8 papers) published 1 paper at the last edition,; Rachel L. Shaw (8 papers) absent at the last edition,; Virginia Braun (7 papers) published 1 paper at the last edition,
Integrating qualitative research within a clinical trials unit
The value of using qualitative methods within clinical trials is widely recognised. How qualitative research is integrated within trials units to achieve this is less clear. This paper describes the process through which qualitative research has been integrated within Cardiff University's Centre for Trials Research (CTR) in Wales, UK. We highlight facilitators of, and challenges to, integration.
A Qualitative Exploration of Chinese Rural College ...
However, there has been scant research on their career development from a vocational psychology perspective. Drawing from the Psychology of Working Theory (PWT), we examined the contextual and personal factors that shape their work volition and perceptions of future decent work.
"It's like your days are empty and yet there's life all around": A
Purpose To identify experiences of boredom and associations with psychosocial well-being during and following homelessness. Methods Using a convergent, mixed-methods explanatory design, we conducted quantitative interviews with 164 participants) (n = 102 unhoused; n = 62 housed following homelessness) using a 92-item protocol involving demographic components and seven standardized measures of ...
Reporting Qualitative Research in Psychology, Revised Edition
Heidi M. Levitt, PhD, is a professor of clinical psychology in the Department of Psychology at the University of Massachusetts Boston. She was chair of the APA Publications and Communications Board Working Group on Journal Article Reporting Standards for Qualitative Research (JARS-Qual Working Group; Levitt et al., 2018).
Shaping and shifting schemas on supervised injectable opioid treatment
Drawing from medical sociology and social psychology, this study explores the emergence and evolution of such schemas on SIOT. ... Explore journals Get published ... Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-57. ...
Full article: Qualitative research in psychology: Attitudes of
Qualitative methods have been present in psychology since its founding in 1879 (Wertz, Citation 2011), with seminal researchers such as William James and Sigmund Freud utilising qualitative approaches to form the basis of psychological knowledge (Willig & Stainton‐Rogers, Citation 2008).Despite its early use, and the acceptance of dual qualitative and quantitative research cultures within ...
PiE Editorial March 2024 42(1)
Perspectives in Education (PiE) is is a fully open access journal, which means that all articles are freely available on the internet immediately upon publication. PiE is also a professional, peer-reviewed journal that encourages the submission of previously unpublished articles on contemporary educational issues. As a journal that represents a variety of cross-disciplinary interests, both ...

Qualitative Research in Psychology

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The SAGE Handbook of Qualitative Research in Psychology

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What is Qualitative in Qualitative Research

Towards a Definition of Qualitative Research

Analysis – What is Qualitative Research?

Qualitative and Quantitative

Qualitative Research

Grounded Theory

Defining Qualitative Research

Distinctions

Improved Understanding

Acknowledgements

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Qualitative Research in Psychology

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The bright side of sports: a systematic review on well-being, positive emotions and performance

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Introduction

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BMC Psychology

Integrating qualitative research within a clinical trials unit: developing strategies and understanding their implementation in contexts

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Conclusions

Background to the integration of qualitative research within CTR

Understanding implementation—Normalisation Process Theory (NPT)

Coherence—making sense of qualitative research

Cognitive participation—legitimising qualitative research

Collective action—operationalising qualitative research

Reflexive monitoring—evaluating the impact of qualitative research

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“It’s like your days are empty and yet there’s life all around”: A mixed methods, multi-site study exploring boredom during and following homelessness

Conclusions

Introduction

Boredom and its history in academic discourse

Boredom and its influence on psychosocial well-being

Boredom as it relates to homelessness

The current study

Materials and methods

Recruitment

Inclusion and exclusion criteria

Instruments