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The best superyacht hot tubs in the world

Crescent 117.

Found on 35.6 metre Crescent 117 ’s top deck is a grand four-person jetted hot tub. Although it's on the highest level of the superyacht, the hot tub is nestled cosily in a corner - perfect for when the weather’s at its most torrid.

Directly opposite sits a bar and barbecue, so guests can sit back and relax while the drinks are being delivered.

39 metre Flexplorer Aurelia ’s sundeck isn’t referred to in the conventional way, rather, her top deck is affectionately known as “the private Jacuzzi deck”.

The owner wanted it to be a small, exclusive space on top of the boat. “The 130 has a very peculiar layout because they didn’t even want a sundeck – just a small portion open with a Jacuzzi,” said Cantiere delle Marche’s Vasco Buonpensiere. “They created an alcove, a cosy place up there for the two of them, so the crew can’t go there.”

The sundeck aboard this 73 metre Feadship superyacht is the ideal spot for relaxation, and is outfitted more like the interior of a beach house than an outdoor patio. Loungers with optional shading sit aft, while forward is a spa pool with a bar and dining sofa. Designed inside and out by RWD, with space and on board living in mind, Lunasea encapsulates that ‘home away from home’ feeling.

More about this yacht

Skat’s standout feature is hard to miss, with the generous Jacuzzi and sun beds sitting forward of the spacious sundeck. Sitting atop this striking vessel, the sundeck draws attention and offers the best seat in the house for watching those sunsets and sunrises. The iconic, military-inspired Lürssen superyacht offers an unexpected calm and clean interior – something you wouldn’t expect from its exterior.

Long considered an essential item on board any proper superyacht, a bubbling spa pool is a sure sign that guests are in for a truly luxurious and relaxing experience. We round up some of the best examples from around the world, starting with the sundeck centrepiece of Andiamo ...

This 47.6 metre Baglietto T-Line yacht boasts a sprawling  superyacht sundeck that measures 140 square metres, offering chaise longues, armchairs, a bar area, games table and dining table. But the star of the show is undoubtedly the 2,200 litre glass-fronted pool, which is continually fed by a closed-circuit waterfall system that circulates water over a sloped pane of glass connected to the hardtop.

Photo: Emilio Bianchi

Yachts for charter

Delivered by Gulf Craft in March 2017, 47.6 metre Sehamia epitomises luxury living on a superyacht. The central feature of her aft deck is the enormous oval spa pool, which is ingeniously filled by an on-board waterfall. This imaginative design means that, when in use, a curtain of cascading water pours between the saloon and the upper deck on its way to fill the pool, simulating the sounds of a tropical waterfall. Relaxing in the pool therefore creates an effect of synaesthesia, engaging all of the senses for a superior experience. The second hull in the Majesty 155 series, Sehamia can accommodate up to 18 guests plus nine crew members.

When the owner of Polar Star  set about refitting this 63 metre Lürssen explorer yacht at MB92 in 2016, the spa pool was a key priority. Out went the old circular hexagonal tub, to be replaced by a more modern rectangular pool with a glass side that allows the effect of the underwater lighting to be appreciated by guests relaxing nearby.

Most superyacht hot tubs need to be drained when cruising and refilled when moored up, creating inconvenient delays for those looking to take a quick dip. The waiting time is trimmed to just 40 minutes on the 49.6 metre Admiral superyacht Ouranos , whose fast-filling hot tub holds a massive 4,000 litres of water — that's the equivalent of 50 average-sized bath tubs.

Photo: Olga Logvina

Having a great view out from your superyacht spa pool is essential, and guests on board 55 metre Amels yacht Elixir get a view that is hard to beat. With glass panels on all sides, the panoramic vistas from this ideal relaxation spot are impressive to say the least.

This spa pool can also be covered up when shade is needed, and when it’s time for liquid refreshment the backlit onyx bar is only a few steps away. Currently available for charter through Y.CO , Elixir boasts accommodation for 12 guests with a crew of 12 on hand to cater for your every whim.

Photo: Christopher Scholey

Pegasus VIII

Jump (literally) from this spectacular octagon-shaped hot tub aboard the 78.60 metre  Royal Denship Pegasus VIII to a nightclub, which accommodates up to 50 guests. Unwind with a glass of bubbly ahead of an evening spent on the raised dancefloor, complete with a smoke machine and two bars – or simply retreat the morning after the night’s dramas. Well, as much drama as you can have while on a near 80 metre superyacht...

Take a look at the best superyacht hot tubs, including Crescent 117's sheltered nook sundeck and Polar Star's private Jacuzzi deck...

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Yacht Tub Rentals: Floating Spa on the Willamette River

Relax in a heated Yacht Tub on the Willamette River with friends, featuring fresh water, a Bluetooth stereo, and stunning Portland views.

$399 for a 2-hour rental for up to 6 people; additional charges for special events

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Description

Experience the ultimate relaxation with a Yacht Tub rental on the Willamette River in Portland. This unique floating spa is designed for up to six people and includes a nearly silent electric motor for a serene journey. Start your adventure at Riverplace Marina and explore Portland's waterways, including the historic OMSI submarine and the iconic bridges of "Bridgetown". Each tub is filled with fresh, pre-heated water to match the weather, ensuring a comfortable soak. With an integrated Bluetooth stereo, you can enjoy your favorite music as you take in the beautiful skyline. Book your two-hour rental for $399 and enjoy amenities like a Bimini top for weather protection and optional plush towels for an extra $5 each.

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• Arrive at Riverplace Marina, Portland.
• Check-in and receive a brief orientation.
• Board your Yacht Tub and set sail using the easy joystick controls.
• Enjoy a two-hour soak with music and scenic views.
• Return to Riverplace Marina at the end of your rental.

315 S Montgomery St #140, Portland, OR 97201

Packing List

• Comfortable swimwear
• Sunglasses and hat for sun protection
• Towels (available for rent)
• Water bottles

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315 S Montgomery St, Portland , Oregon 97201 USA

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Learn more about this business on Yelp .

Reviewed by Shannon F.

Highly recommend! Incredibly fun! Easy to operate boat. Great staff will help you! Totally worth it! Read more

Reviewed by Nikki S.

This was an amazing experience, I'm so happy that I did this during my visit to Portland. The staff was very friendly and professional. Booking was simple and I think this is appropriately priced.... Read more

Reviewed by Carrie W.

I saw a sponsored ad on Instagram for this and immediately sent it to my friends. 5 of us booked a tub for a Sunday afternoon in July. Patricia and Chris were super welcoming and accommodating.... Read more

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Yacht With A Pool

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Life On A Yacht With A Pool

Doesn’t sound too shabby, right? A yacht with a pool is becoming more common among the top yachts for charter or purchase. We’re not talking about Olympic-size pools with a super high diving board, but then again, when you have the entire ocean at your beck and call, who needs one?

Related   What Is A Yacht Charter    |    Luxury Charter Yacht Events

Pool or Deck Jacuzzi

If all you really need is a quick dip or even a soothing hydro-massage, the on deck Jacuzzi typically acts as the pool on board. Water temperature can be regulated in most, so turning off the heat is an option if you need to cool down after an onboard workout. Either way, a yacht with a pool offers the ultimate in relaxation while you take in the vast views of the sea.

Exercise On A Yacht

If you’re a swimmer and enjoy challenges, a lap pool is not unheard of aboard some of the finest yachts. Equipped with an intense water jet stream, which is activated upon demand at different speeds, an artificial current disburses the resistance you crave for a full-body workout.

Yachts With Large Pools

Some onboard pools are large, and offer space for up to 12 people, so the whole charter party can socialize together, sipping custom cocktails and nibbling on tapas. The idea of a yacht with a pool starts to become more realistic when you picture yourself luxuriating with family and friends in the middle of the ocean.

Custom Yacht Pool

Almost anything seems possible when building a custom yacht with a pool. Some superyachts feature an infinity pool, making you feel at one with the ocean. A raised-deck pool broadens your views in all directions, unobstructed and expansive. Some yacht stylists can create intricate designs at the bottom and sides of a pool with mosaic tiles that can form some of the most elaborate patterns.

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how to write a qualitative research report

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• What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

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

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

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

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

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

Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

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

• Flexibility

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

• Natural settings

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

• Meaningful insights

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

• Generation of new ideas

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

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

• Unreliability

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

• Subjectivity

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

• Limited generalizability

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

• Labor-intensive

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

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

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

Research bias

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

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

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

There are five common approaches to qualitative research :

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

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

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

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

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

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• UNC Libraries
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Qualitative Research Resources: Writing Up Your Research

Created by health science librarians.

• What is Qualitative Research?
• Qualitative Research Basics
• Special Topics
• Training Opportunities: UNC & Beyond
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• Qualitative Software for Coding/Analysis
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About this Page

Writing conventions for qualitative research, sample size/sampling:.

• Integrating Qualitative Research into Systematic Reviews
• Publishing Qualitative Research
• Presenting Qualitative Research
• Qualitative & Libraries: a few gems
• Data Repositories

Why is this information important?

• The conventions of good writing and research reporting are different for qualitative and quantitative research.
• Your article will be more likely to be published if you make sure you follow appropriate conventions in your writing.

On this page you will find the following helpful resources:

• Articles with information on what journal editors look for in qualitative research articles.
• Articles and books on the craft of collating qualitative data into a research article.

These articles provide tips on what journal editors look for when they read qualitative research papers for potential publication.  Also see Assessing Qualitative Research tab in this guide for additional information that may be helpful to authors.

Belgrave, L., D. Zablotsky and M.A. Guadagno.(2002). How do we talk to each other? Writing qualitative research for quantitative readers . Qualitative Health Research , 12(10),1427-1439.

Hunt, Brandon. (2011) Publishing Qualitative Research in Counseling Journals . Journal of Counseling and Development 89(3):296-300.

Fetters, Michael and Dawn Freshwater. (2015). Publishing a Methodological Mixed Methods Research Article. Journal of Mixed Methods Research 9(3): 203-213.

Koch, Lynn C., Tricia Niesz, and Henry McCarthy. (2014). Understanding and Reporting Qualitative Research: An Analytic Review and Recommendations for Submitting Authors. Rehabilitation Counseling Bulletin 57(3):131-143.

Morrow, Susan L. (2005) Quality and Trustworthiness in Qualitative Research in Counseling Psychology ; Journal of Counseling Psychology 52(2):250-260.

Oliver, Deborah P. (2011) "Rigor in Qualitative Research." Research on Aging 33(4): 359-360.

Sandelowski, M., & Leeman, J. (2012). Writing usable qualitative health research findings . Qual Health Res, 22(10), 1404-1413.

Schoenberg, Nancy E., Miller, Edward A., and Pruchno, Rachel. (2011) The qualitative portfolio at The Gerontologist : strong and getting stronger. Gerontologist 51(3): 281-284.

Weaver-Hightower, M. B. (2019). How to write qualitative research . [e-book]

Sidhu, Kalwant, Roger Jones, and Fiona Stevenson (2017). Publishing qualitative research in medical journals. Br J Gen Pract ; 67 (658): 229-230. DOI: 10.3399/bjgp17X690821 PMID: 28450340

• This article is based on a workshop on publishing qualitative studies held at the Society for Academic Primary Care Annual Conference, Dublin, July 2016.

Smith, Mary Lee.(1987) Publishing Qualitative Research. American Educational Research Journal 24(2): 173-183.

Tong, Allison, Sainsbury, Peter, Craig, Jonathan ; Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups , International Journal for Quality in Health Care , Volume 19, Issue 6, 1 December 2007, Pages 349–357, https://doi.org/10.1093/intqhc/mzm042 .

Tracy, Sarah. (2010) Qualitative Quality: Eight 'Big-Tent' Criteria for Excellent Qualitative Research. Qualitative Inquiry 16(10):837-51.

Because reviewers are not always familiar with qualitative methods, they may ask for explanation or justification of your methods when you submit an article. Because different disciplines,different qualitative methods, and different contexts may dictate different approaches to this issue, you may want to consult articles in your field and in target journals for publication.  Additionally, here are some articles that may be helpful in thinking about this issue. 

Bonde, Donna. (2013). Qualitative Interviews: When Enough is Enough . Research by Design.

Guest, Greg, Arwen Bunce, and Laura Johnson. (2006) How Many Interviews are Enough?: An Experiment with Data Saturation and Variability. Field Methods 18(1): 59-82.

Hennink, Monique and Bonnie N. Kaiser. (2022) Sample Sizes for Saturation in Qualitative Research: A Systematic Review of Empirical Tests . Social Science & Medicine 292:114523. doi: 10.1016/j.socscimed.2021.114523. Epub 2021 Nov 2. PMID: 34785096.

Morse, Janice M. (2015) "Data Were Saturated..." Qualitative Health Research 25(5): 587-88 . doi:10.1177/1049732315576699.

Nelson, J. (2016) "Using Conceptual Depth Criteria: Addressing the Challenge of Reaching Saturation in Qualitative Research." Qualitative Research, December. doi:10.1177/1468794116679873.

Patton, Michael Quinn. (2015) "Chapter 5: Designing Qualitative Studies, Module 30 Purposeful Sampling and Case Selection. In Qualitative Research & Evaluation Methods: Integrating Theory and Practice, Fourth edition, pp. 264-72. Thousand Oaks, California: SAGE Publications, Inc. ISBN: 978-1-4129-7212-3

Small, Mario Luis. (2009) 'How Many Cases Do I Need?': On Science and the Logic of Case-Based Selection in Field-Based Research. Ethnography 10(1): 538.

Search the UNC-CH catalog for books about qualitative writing . Selected general books from the catalog are listed below. If you are a researcher at another institution, ask your librarian for assistance locating similar books in your institution's catalog or ordering them via InterLibrary Loan.  

Oft quoted and food for thought

• Morse, J. M. (1997). " Perfectly healthy, but dead": the myth of inter-rater reliability. DOI:10.1177/104973239700700401 Editorial
• Silberzahn, R., Uhlmann, E. L., Martin, D. P., Anselmi, P., Aust, F., Awtrey, E., ... & Carlsson, R. (2018). Many analysts, one data set: Making transparent how variations in analytic choices affect results. Advances in Methods and Practices in Psychologi
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• Next: Integrating Qualitative Research into Systematic Reviews >>
• Last Updated: Jul 28, 2024 4:11 PM
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The word qualitative implies an emphasis on the qualities of entities and on processes and meanings that are not experimentally examined or measured [if measured at all] in terms of quantity, amount, intensity, or frequency. Qualitative researchers stress the socially constructed nature of reality, the intimate relationship between the researcher and what is studied, and the situational constraints that shape inquiry. Such researchers emphasize the value-laden nature of inquiry. They seek answers to questions that stress how social experience is created and given meaning. In contrast, quantitative studies emphasize the measurement and analysis of causal relationships between variables, not processes. Qualitative forms of inquiry are considered by many social and behavioral scientists to be as much a perspective on how to approach investigating a research problem as it is a method.

Denzin, Norman. K. and Yvonna S. Lincoln. “Introduction: The Discipline and Practice of Qualitative Research.” In The Sage Handbook of Qualitative Research . Norman. K. Denzin and Yvonna S. Lincoln, eds. 3 rd edition. (Thousand Oaks, CA: Sage, 2005), p. 10.

Characteristics of Qualitative Research

Below are the three key elements that define a qualitative research study and the applied forms each take in the investigation of a research problem.

• Naturalistic -- refers to studying real-world situations as they unfold naturally; non-manipulative and non-controlling; the researcher is open to whatever emerges [i.e., there is a lack of predetermined constraints on findings].
• Emergent -- acceptance of adapting inquiry as understanding deepens and/or situations change; the researcher avoids rigid designs that eliminate responding to opportunities to pursue new paths of discovery as they emerge.
• Purposeful -- cases for study [e.g., people, organizations, communities, cultures, events, critical incidences] are selected because they are “information rich” and illuminative. That is, they offer useful manifestations of the phenomenon of interest; sampling is aimed at insight about the phenomenon, not empirical generalization derived from a sample and applied to a population.

The Collection of Data

• Data -- observations yield a detailed, "thick description" [in-depth understanding]; interviews capture direct quotations about people’s personal perspectives and lived experiences; often derived from carefully conducted case studies and review of material culture.
• Personal experience and engagement -- researcher has direct contact with and gets close to the people, situation, and phenomenon under investigation; the researcher’s personal experiences and insights are an important part of the inquiry and critical to understanding the phenomenon.
• Empathic neutrality -- an empathic stance in working with study respondents seeks vicarious understanding without judgment [neutrality] by showing openness, sensitivity, respect, awareness, and responsiveness; in observation, it means being fully present [mindfulness].
• Dynamic systems -- there is attention to process; assumes change is ongoing, whether the focus is on an individual, an organization, a community, or an entire culture, therefore, the researcher is mindful of and attentive to system and situational dynamics.

The Analysis

• Unique case orientation -- assumes that each case is special and unique; the first level of analysis is being true to, respecting, and capturing the details of the individual cases being studied; cross-case analysis follows from and depends upon the quality of individual case studies.
• Inductive analysis -- immersion in the details and specifics of the data to discover important patterns, themes, and inter-relationships; begins by exploring, then confirming findings, guided by analytical principles rather than rules.
• Holistic perspective -- the whole phenomenon under study is understood as a complex system that is more than the sum of its parts; the focus is on complex interdependencies and system dynamics that cannot be reduced in any meaningful way to linear, cause and effect relationships and/or a few discrete variables.
• Context sensitive -- places findings in a social, historical, and temporal context; researcher is careful about [even dubious of] the possibility or meaningfulness of generalizations across time and space; emphasizes careful comparative case study analysis and extrapolating patterns for possible transferability and adaptation in new settings.
• Voice, perspective, and reflexivity -- the qualitative methodologist owns and is reflective about her or his own voice and perspective; a credible voice conveys authenticity and trustworthiness; complete objectivity being impossible and pure subjectivity undermining credibility, the researcher's focus reflects a balance between understanding and depicting the world authentically in all its complexity and of being self-analytical, politically aware, and reflexive in consciousness.

Berg, Bruce Lawrence. Qualitative Research Methods for the Social Sciences . 8th edition. Boston, MA: Allyn and Bacon, 2012; Denzin, Norman. K. and Yvonna S. Lincoln. Handbook of Qualitative Research . 2nd edition. Thousand Oaks, CA: Sage, 2000; Marshall, Catherine and Gretchen B. Rossman. Designing Qualitative Research . 2nd ed. Thousand Oaks, CA: Sage Publications, 1995; Merriam, Sharan B. Qualitative Research: A Guide to Design and Implementation . San Francisco, CA: Jossey-Bass, 2009.

Basic Research Design for Qualitative Studies

Unlike positivist or experimental research that utilizes a linear and one-directional sequence of design steps, there is considerable variation in how a qualitative research study is organized. In general, qualitative researchers attempt to describe and interpret human behavior based primarily on the words of selected individuals [a.k.a., “informants” or “respondents”] and/or through the interpretation of their material culture or occupied space. There is a reflexive process underpinning every stage of a qualitative study to ensure that researcher biases, presuppositions, and interpretations are clearly evident, thus ensuring that the reader is better able to interpret the overall validity of the research. According to Maxwell (2009), there are five, not necessarily ordered or sequential, components in qualitative research designs. How they are presented depends upon the research philosophy and theoretical framework of the study, the methods chosen, and the general assumptions underpinning the study. Goals Describe the central research problem being addressed but avoid describing any anticipated outcomes. Questions to ask yourself are: Why is your study worth doing? What issues do you want to clarify, and what practices and policies do you want it to influence? Why do you want to conduct this study, and why should the reader care about the results? Conceptual Framework Questions to ask yourself are: What do you think is going on with the issues, settings, or people you plan to study? What theories, beliefs, and prior research findings will guide or inform your research, and what literature, preliminary studies, and personal experiences will you draw upon for understanding the people or issues you are studying? Note to not only report the results of other studies in your review of the literature, but note the methods used as well. If appropriate, describe why earlier studies using quantitative methods were inadequate in addressing the research problem. Research Questions Usually there is a research problem that frames your qualitative study and that influences your decision about what methods to use, but qualitative designs generally lack an accompanying hypothesis or set of assumptions because the findings are emergent and unpredictable. In this context, more specific research questions are generally the result of an interactive design process rather than the starting point for that process. Questions to ask yourself are: What do you specifically want to learn or understand by conducting this study? What do you not know about the things you are studying that you want to learn? What questions will your research attempt to answer, and how are these questions related to one another? Methods Structured approaches to applying a method or methods to your study help to ensure that there is comparability of data across sources and researchers and, thus, they can be useful in answering questions that deal with differences between phenomena and the explanation for these differences [variance questions]. An unstructured approach allows the researcher to focus on the particular phenomena studied. This facilitates an understanding of the processes that led to specific outcomes, trading generalizability and comparability for internal validity and contextual and evaluative understanding. Questions to ask yourself are: What will you actually do in conducting this study? What approaches and techniques will you use to collect and analyze your data, and how do these constitute an integrated strategy? Validity In contrast to quantitative studies where the goal is to design, in advance, “controls” such as formal comparisons, sampling strategies, or statistical manipulations to address anticipated and unanticipated threats to validity, qualitative researchers must attempt to rule out most threats to validity after the research has begun by relying on evidence collected during the research process itself in order to effectively argue that any alternative explanations for a phenomenon are implausible. Questions to ask yourself are: How might your results and conclusions be wrong? What are the plausible alternative interpretations and validity threats to these, and how will you deal with these? How can the data that you have, or that you could potentially collect, support or challenge your ideas about what’s going on? Why should we believe your results? Conclusion Although Maxwell does not mention a conclusion as one of the components of a qualitative research design, you should formally conclude your study. Briefly reiterate the goals of your study and the ways in which your research addressed them. Discuss the benefits of your study and how stakeholders can use your results. Also, note the limitations of your study and, if appropriate, place them in the context of areas in need of further research.

Chenail, Ronald J. Introduction to Qualitative Research Design. Nova Southeastern University; Heath, A. W. The Proposal in Qualitative Research. The Qualitative Report 3 (March 1997); Marshall, Catherine and Gretchen B. Rossman. Designing Qualitative Research . 3rd edition. Thousand Oaks, CA: Sage, 1999; Maxwell, Joseph A. "Designing a Qualitative Study." In The SAGE Handbook of Applied Social Research Methods . Leonard Bickman and Debra J. Rog, eds. 2nd ed. (Thousand Oaks, CA: Sage, 2009), p. 214-253; Qualitative Research Methods. Writing@CSU. Colorado State University; Yin, Robert K. Qualitative Research from Start to Finish . 2nd edition. New York: Guilford, 2015.

Strengths of Using Qualitative Methods

The advantage of using qualitative methods is that they generate rich, detailed data that leave the participants' perspectives intact and provide multiple contexts for understanding the phenomenon under study. In this way, qualitative research can be used to vividly demonstrate phenomena or to conduct cross-case comparisons and analysis of individuals or groups.

Among the specific strengths of using qualitative methods to study social science research problems is the ability to:

• Obtain a more realistic view of the lived world that cannot be understood or experienced in numerical data and statistical analysis;
• Provide the researcher with the perspective of the participants of the study through immersion in a culture or situation and as a result of direct interaction with them;
• Allow the researcher to describe existing phenomena and current situations;
• Develop flexible ways to perform data collection, subsequent analysis, and interpretation of collected information;
• Yield results that can be helpful in pioneering new ways of understanding;
• Respond to changes that occur while conducting the study ]e.g., extended fieldwork or observation] and offer the flexibility to shift the focus of the research as a result;
• Provide a holistic view of the phenomena under investigation;
• Respond to local situations, conditions, and needs of participants;
• Interact with the research subjects in their own language and on their own terms; and,
• Create a descriptive capability based on primary and unstructured data.

Anderson, Claire. “Presenting and Evaluating Qualitative Research.” American Journal of Pharmaceutical Education 74 (2010): 1-7; Denzin, Norman. K. and Yvonna S. Lincoln. Handbook of Qualitative Research . 2nd edition. Thousand Oaks, CA: Sage, 2000; Merriam, Sharan B. Qualitative Research: A Guide to Design and Implementation . San Francisco, CA: Jossey-Bass, 2009.

Limitations of Using Qualitative Methods

It is very much true that most of the limitations you find in using qualitative research techniques also reflect their inherent strengths . For example, small sample sizes help you investigate research problems in a comprehensive and in-depth manner. However, small sample sizes undermine opportunities to draw useful generalizations from, or to make broad policy recommendations based upon, the findings. Additionally, as the primary instrument of investigation, qualitative researchers are often embedded in the cultures and experiences of others. However, cultural embeddedness increases the opportunity for bias generated from conscious or unconscious assumptions about the study setting to enter into how data is gathered, interpreted, and reported.

Some specific limitations associated with using qualitative methods to study research problems in the social sciences include the following:

• Drifting away from the original objectives of the study in response to the changing nature of the context under which the research is conducted;
• Arriving at different conclusions based on the same information depending on the personal characteristics of the researcher;
• Replication of a study is very difficult;
• Research using human subjects increases the chance of ethical dilemmas that undermine the overall validity of the study;
• An inability to investigate causality between different research phenomena;
• Difficulty in explaining differences in the quality and quantity of information obtained from different respondents and arriving at different, non-consistent conclusions;
• Data gathering and analysis is often time consuming and/or expensive;
• Requires a high level of experience from the researcher to obtain the targeted information from the respondent;
• May lack consistency and reliability because the researcher can employ different probing techniques and the respondent can choose to tell some particular stories and ignore others; and,
• Generation of a significant amount of data that cannot be randomized into manageable parts for analysis.

Research Tip

Human Subject Research and Institutional Review Board Approval

Almost every socio-behavioral study requires you to submit your proposed research plan to an Institutional Review Board. The role of the Board is to evaluate your research proposal and determine whether it will be conducted ethically and under the regulations, institutional polices, and Code of Ethics set forth by the university. The purpose of the review is to protect the rights and welfare of individuals participating in your study. The review is intended to ensure equitable selection of respondents, that you have met the requirements for obtaining informed consent , that there is clear assessment and minimization of risks to participants and to the university [read: no lawsuits!], and that privacy and confidentiality are maintained throughout the research process and beyond. Go to the USC IRB website for detailed information and templates of forms you need to submit before you can proceed. If you are  unsure whether your study is subject to IRB review, consult with your professor or academic advisor.

Chenail, Ronald J. Introduction to Qualitative Research Design. Nova Southeastern University; Labaree, Robert V. "Working Successfully with Your Institutional Review Board: Practical Advice for Academic Librarians." College and Research Libraries News 71 (April 2010): 190-193.

Another Research Tip

Finding Examples of How to Apply Different Types of Research Methods

SAGE publications is a major publisher of studies about how to design and conduct research in the social and behavioral sciences. Their SAGE Research Methods Online and Cases database includes contents from books, articles, encyclopedias, handbooks, and videos covering social science research design and methods including the complete Little Green Book Series of Quantitative Applications in the Social Sciences and the Little Blue Book Series of Qualitative Research techniques. The database also includes case studies outlining the research methods used in real research projects. This is an excellent source for finding definitions of key terms and descriptions of research design and practice, techniques of data gathering, analysis, and reporting, and information about theories of research [e.g., grounded theory]. The database covers both qualitative and quantitative research methods as well as mixed methods approaches to conducting research.

SAGE Research Methods Online and Cases

NOTE :  For a list of online communities, research centers, indispensable learning resources, and personal websites of leading qualitative researchers, GO HERE .

For a list of scholarly journals devoted to the study and application of qualitative research methods, GO HERE .

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31 Writing Up Qualitative Research

Jane F. Gilgun, School of Social Work, University of Minnesota, Twin Cities

• Published: 04 August 2014
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This chapter provides guidelines for writing journal articles based on qualitative approaches. The guidelines are part of the tradition of the Chicago School of Sociology and the author’s experience as a writer and reviewer. The guidelines include understanding experiences in context, immersion, interpretations grounded in accounts of informants’ lived experiences, and research as action-oriented. The chapter also covers writing articles that report findings based on ethnographies, autoethnographies, performances, poetry, and photography and other graphic media.

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Commentary: Writing and Evaluating Qualitative Research Reports

Yelena p. wu.

1 Division of Public Health, Department of Family and Preventive Medicine, University of Utah,

2 Cancer Control and Population Sciences, Huntsman Cancer Institute,

Deborah Thompson

3 Department of Pediatrics-Nutrition, USDA/ARS Children’s Nutrition Research Center, Baylor College of Medicine,

Karen J. Aroian

4 College of Nursing, University of Central Florida,

Elizabeth L. McQuaid

5 Department of Psychiatry and Human Behavior, Brown University, and

Janet A. Deatrick

6 School of Nursing, University of Pennsylvania

Objective  To provide an overview of qualitative methods, particularly for reviewers and authors who may be less familiar with qualitative research. Methods  A question and answer format is used to address considerations for writing and evaluating qualitative research. Results and Conclusions  When producing qualitative research, individuals are encouraged to address the qualitative research considerations raised and to explicitly identify the systematic strategies used to ensure rigor in study design and methods, analysis, and presentation of findings. Increasing capacity for review and publication of qualitative research within pediatric psychology will advance the field’s ability to gain a better understanding of the specific needs of pediatric populations, tailor interventions more effectively, and promote optimal health.

The Journal of Pediatric Psychology (JPP) has a long history of emphasizing high-quality, methodologically rigorous research in social and behavioral aspects of children’s health ( Palermo, 2013 , 2014 ). Traditionally, research published in JPP has focused on quantitative methodologies. Qualitative approaches are of interest to pediatric psychologists given the important role of qualitative research in developing new theories ( Kelly & Ganong, 2011 ), illustrating important clinical themes ( Kars, Grypdonck, de Bock, & van Delden, 2015 ), developing new instruments ( Thompson, Bhatt, & Watson, 2013 ), understanding patients’ and families’ perspectives and needs ( Bevans, Gardner, Pajer, Riley, & Forrest, 2013 ; Lyons, Goodwin, McCreanor, & Griffin, 2015 ), and documenting new or rarely examined issues ( Haukeland, Fjermestad, Mossige, & Vatne, 2015 ; Valenzuela et al., 2011 ). Further, these methods are integral to intervention development ( Minges et al., 2015 ; Thompson et al., 2007 ) and understanding intervention outcomes ( de Visser et al., 2015 ; Hess & Straub, 2011 ). For example, when designing an intervention, qualitative research can identify patient and family preferences for and perspectives on desirable intervention characteristics and perceived needs ( Cassidy et al., 2013 ; Hess & Straub, 2011 ; Thompson, 2014 ), which may lead to a more targeted, effective intervention.

Both qualitative and quantitative approaches are concerned with issues such as generalizability of study findings (e.g., to whom the study findings can be applied) and rigor. However, qualitative and quantitative methods have different approaches to these issues. The purpose of qualitative research is to contribute knowledge or understanding by describing phenomenon within certain groups or populations of interest. As such, the purpose of qualitative research is not to provide generalizable findings. Instead, qualitative research has a discovery focus and often uses an iterative approach. Thus, qualitative work is often foundational to future qualitative, quantitative, or mixed-methods studies.

At the time of this writing, three of six current calls for papers for special issues of JPP specifically note that manuscripts incorporating qualitative approaches would be welcomed. Despite apparent openness to broadening JPP’s emphasis beyond its traditional quantitative approach, few published articles have used qualitative methods. For example, of 232 research articles published in JPP from 2012 to 2014 (excluding commentaries and reviews), only five used qualitative methods (2% of articles).

The goal of the current article is to present considerations for writing and evaluating qualitative research within the context of pediatric psychology to provide a framework for writing and reviewing manuscripts reporting qualitative findings. The current article may be especially useful to reviewers and authors who are less familiar with qualitative methods. The tenets presented here are grounded in the well-established literature on reporting and evaluating qualitative research, including guidelines and checklists ( Eakin & Mykhalovskiy, 2003 ; Elo et al., 2014 ; Mays & Pope, 2000 ; Tong, Sainsbury, & Craig, 2007 ). For example, the Consolidated Criteria for Reporting Qualitative Research checklist describes essential elements for reporting qualitative findings ( Tong et al., 2007 ). Although the considerations presented in the current manuscript have broad applicability to many fields, examples were purposively selected for the field of pediatric psychology.

Our goal is that this article will stimulate publication of more qualitative research in pediatric psychology and allied fields. More specifically, the goal is to encourage high-quality qualitative research by addressing key issues involved in conducting qualitative studies, and the process of conducting, reporting, and evaluating qualitative findings. Readers interested in more in-depth information on designing and implementing qualitative studies, relevant theoretical frameworks and approaches, and analytic approaches are referred to the well-developed literature in this area ( Clark, 2003 ; Corbin & Strauss, 2008 ; Creswell, 1994 ; Eakin & Mykhalovskiy, 2003 ; Elo et al., 2014 ; Mays & Pope, 2000 ; Miles, Huberman, & Saldaña, 2013 ; Ritchie & Lewis, 2003 ; Saldaña, 2012 ; Sandelowski, 1995 , 2010 ; Tong et al., 2007 ; Yin, 2015 ). Researchers new to qualitative research are also encouraged to obtain specialized training in qualitative methods and/or to collaborate with a qualitative expert in an effort to ensure rigor (i.e., validity).

We begin the article with a definition of qualitative research and an overview of the concept of rigor. While we recognize that qualitative methods comprise multiple and distinct approaches with unique purposes, we present an overview of considerations for writing and evaluating qualitative research that cut across qualitative methods. Specifically, we present basic principles in three broad areas: (1) study design and methods, (2) analytic considerations, and (3) presentation of findings (see Table 1 for a summary of the principles addressed in each area). Each area is addressed using a “question and answer” format. We present a brief explanation of each question, options for how one could address the issue raised, and a suggested recommendation. We recognize, however, that there are no absolute “right” or “wrong” answers and that the most “right” answer for each situation depends on the specific study and its purpose. In fact, our strongest recommendation is that authors of qualitative research manuscripts be explicit about their rationale for design, analytic choices, and strategies so that readers and reviewers can evaluate the rationale and rigor of the study methods.

Summary of Overarching Principles to Address in Qualitative Research Manuscripts

What Is Qualitative Research?

Qualitative methods are used across many areas of health research, including health psychology ( Gough & Deatrick, 2015 ), to study the meaning of people’s lives in their real-world roles, represent their views and perspectives, identify important contextual conditions, discover new or additional insights about existing social and behavioral concepts, and acknowledge the contribution of multiple perspectives ( Yin, 2015 ). Qualitative research is a family of approaches rather than a single approach. There are multiple and distinct qualitative methodologies or stances (e.g., constructivism, post-positivism, critical theory), each with different underlying ontological and epistemological assumptions ( Lincoln, Lynham, & Guba, 2011 ). However, certain features are common to most qualitative approaches and distinguish qualitative research from quantitative research ( Creswell, 1994 ).

Key to all qualitative methodologies is that multiple perspectives about a phenomenon of interest are essential, and that those perspectives are best inductively derived or discovered from people with personal experience regarding that phenomenon. These perspectives or definitions may differ from “conventional wisdom.” Thus, meanings need to be discovered from the population under study to ensure optimal understanding. For instance, in a recent qualitative study about texting while driving, adolescents said that they did not approve of texting while driving. The investigators, however, discovered that the respondents did not consider themselves driving while a vehicle was stopped at a red light. In other words, the respondents did approve of texting while stopped at a red light. In addition, the adolescents said that they highly valued being constantly connected via texting. Thus, what is meant by “driving” and the value of “being connected” need to be considered when approaching the issue of texting while driving with adolescents ( McDonald & Sommers, 2015 ).

Qualitative methods are also distinct from a mixed-method approach (i.e., integration of qualitative and quantitative approaches; Creswell, 2013b ). A mixed-methods study may include a first phase of quantitative data collection that provides results that inform a second phase of the study that includes qualitative data collection, or vice versa. A mixed-methods study may also include concurrent quantitative and qualitative data collection. The timing, priority, and stage of integration of the two approaches (quantitative and qualitative) are complex and vary depending on the research question; they also dictate how to attend to differing qualitative and quantitative principles ( Creswell et al., 2011 ). Understanding the basic tenets of qualitative research is preliminary to integrating qualitative research with another approach that has different tenets. A full discussion of the integration of qualitative and quantitative research approaches is beyond the scope of this article. Readers interested in the topic are referred to one of the many excellent resources on the topic ( Creswell, 2013b ).

What Are Typical Qualitative Research Questions?

Qualitative research questions are typically open-ended and are framed in the spirit of discovery and exploration and to address existing knowledge gaps. The current manuscript provides exemplar pediatric qualitative studies that illustrate key issues that arise when reporting and evaluating qualitative studies. Example research questions that are contained in the studies cited in the current manuscript are presented in Table 2 .

Example Qualitative Research Questions From the Pediatric Literature

What Are Rigor and Transparency in Qualitative Research?

There are several overarching principles with unique application in qualitative research, including definitions of scientific rigor and the importance of transparency. Quantitative research generally uses the terms reliability and validity to describe the rigor of research, while in qualitative research, rigor refers to the goal of seeking to understand the tacit knowledge of participants’ conception of reality ( Polanyi, 1958 ). For example, Haukeland and colleagues (2015) used qualitative analysis to identify themes describing the emotional experiences of a unique and understudied population—pediatric siblings of children with rare medical conditions such as Turner syndrome and Duchenne muscular dystrophy. Within this context, the authors’ rendering of the diverse and contradictory emotions experienced by siblings of children with these rare conditions represents “rigor” within a qualitative framework.

While debate exists regarding the terminology describing and strategies for strengthening scientific rigor in qualitative studies ( Guba, 1981 ; Morse, 2015a , 2015b ; Sandelowski, 1993a ; Whittemore, Chase, & Mandle, 2001 ), little debate exists regarding the importance of explaining strategies used to strengthen rigor. Such strategies should be appropriate for the specific study; therefore, it is wise to clearly describe what is relevant for each study. For example, in terms of strengthening credibility or the plausibility of data analysis and interpretation, prolonged engagement with participants is appropriate when conducting an observational study (e.g., observations of parent–child mealtime interactions; Hughes et al., 2011 ; Power et al., 2015 ). For an interview-only study, however, it would be more practical to strengthen credibility through other strategies (e.g., keeping detailed field notes about the interviews included in the analysis).

Dependability is the stability of a data analysis protocol. For instance, stepwise development of a coding system from an “a priori” list of codes based on the underlying conceptual framework or existing literature (e.g., creating initial codes for potential barriers to medication adherence based on prior studies) may be essential for analysis of data from semi-structured interviews using multiple coders. But this may not be the ideal strategy if the purpose is to inductively derive all possible coding categories directly from data in an area where little is known. For some research questions, the strategy may be to strengthen confirmability or to verify a specific phenomenon of interest using different sources of data before generating conclusions. This process, which is commonly referred to in the research literature as triangulation, may also include collecting different types of data (e.g., interview data, observational data), using multiple coders to incorporate different ways of interpreting the data, or using multiple theories ( Krefting, 1991 ; Ritchie & Lewis, 2003 ). Alternatively, another investigator may use triangulation to provide complementarity data ( Krefting, 1991 ) to garner additional information to deepen understanding. Because the purpose of qualitative research is to discover multiple perspectives about a phenomenon, it is not necessarily appropriate to attain concordance across studies or investigators when independently analyzing data. Some qualitative experts also believe that it is inappropriate to use triangulation to confirm findings, but this debate has not been resolved within the field ( Ritchie & Lewis, 2003 ; Tobin & Begley, 2004 ). More agreement exists, however, regarding the value of triangulation to complement, deepen, or expand understanding of a particular topic or issue ( Ritchie & Lewis, 2003 ). Finally, instead of basing a study on a sample that allows for generalizing statistical results to other populations, investigators in qualitative research studies are focused on designing a study and conveying the results so that the reader understands the transferability of the results. Strategies for transferability may include explanations of how the sample was selected and descriptive characteristics of study participants, which provides a context for the results and enables readers to decide if other samples share critical attributes. A study is deemed transferable if relevant contextual features are common to both the study sample and the larger population.

Strategies to enhance rigor should be used systematically across each phase of a study. That is, rigor needs to be identified, managed, and documented throughout the research process: during the preparation phase (data collection and sampling), organization phase (analysis and interpretation), and reporting phase (manuscript or final report; Elo et al., 2014 ). From this perspective, the strategies help strengthen the trustworthiness of the overall study (i.e., to what extent the study findings are worth heeding; Eakin & Mykhalovskiy, 2003 ; Lincoln & Guba, 1985 ).

A good example of managing and documenting rigor and trustworthiness can be found in a study of family treatment decisions for children with cancer ( Kelly & Ganong, 2011 ). The researchers describe how they promoted the rigor of the study and strengthening its credibility by triangulating data sources (e.g., obtaining data from children’s custodial parents, stepparents, etc.), debriefing (e.g., holding detailed conversations with colleagues about the data and interpretations of the data), member checking (i.e., presenting preliminary findings to participants to obtain their feedback and interpretation), and reviewing study procedure decisions and analytic procedures with a second party.

Transparency is another key concept in written reports of qualitative research. In other words, enough detail should be provided for the reader to understand what was done and why ( Ritchie & Lewis, 2003 ). Examples of information that should be included are a clear rationale for selecting a particular population or people with certain characteristics, the research question being investigated, and a meaningful explanation of why this research question was selected (i.e., the gap in knowledge or understanding that is being investigated; Ritchie & Lewis, 2003 ). Clearly describing recruitment, enrollment, data collection, and data analysis or extraction methods are equally important ( Dixon-Woods, Shaw, Agarwal, & Smith, 2004 ). Coherency among methods and transparency about research decisions adds to the robustness of qualitative research ( Tobin & Begley, 2004 ) and provides a context for understanding the findings and their implications.

Study Design and Methods

Is qualitative research hypothesis driven.

In contrast to quantitative research, qualitative research is not typically hypothesis driven ( Creswell, 1994 ; Ritchie & Lewis, 2003 ). A risk associated with using hypotheses in qualitative research is that the findings could be biased by the hypotheses. Alternatively, qualitative research is exploratory and typically guided by a research question or conceptual framework rather than hypotheses ( Creswell, 1994 ; Ritchie & Lewis, 2003 ). As previously stated, the goal of qualitative research is to increase understanding in areas where little is known by developing deeper insight into complex situations or processes. According to Richards and Morse (2013) , “If you know what you are likely to find, …  you should not be working qualitatively” (p. 28). Thus, we do not recommend that a hypothesis be stated in manuscripts presenting qualitative data.

What Is the Role of Theory in Qualitative Research?

Consistent with the exploratory nature of qualitative research, one particular qualitative method, grounded theory, is used specifically for discovering substantive theory (i.e., working theories of action or processes developed for a specific area of concern; Bryant & Charmaz, 2010 ; Glaser & Strauss, 1967 ). This method uses a series of structured steps to break down qualitative data into codes, organize the codes into conceptual categories, and link the categories into a theory that explains the phenomenon under study. For example, Kelly and Ganong (2011) used grounded theory methods to produce a substantive theory about how single and re-partnered parents (e.g., households with a step-parent) made treatment decisions for children with childhood cancer. The theory of decision making developed in this study included “moving to place,” which described the ways in which parents from different family structures (e.g., single and re-partnered parents) were involved in the child’s treatment decision-making. The resulting theory also delineated the causal conditions, context, and intervening factors that contributed to the strategies used for moving to place.

Theories may be used in other types of qualitative research as well, serving as the impetus or organizing framework for the study ( Sandelowski, 1993b ). For example, Izaguirre and Keefer (2014) used Social Cognitive Theory ( Bandura, 1986 ) to investigate self-efficacy among adolescents with inflammatory bowel disease. The impetus for selecting the theory was to inform the development of a self-efficacy measure for adolescent self-management. In another study on health care transition in youth with Type 1 Diabetes ( Pierce, Wysocki, & Aroian, 2016 ), the investigators adapted a social-ecological model—the Socio-ecological Model of Adolescent and Young Adult Transition Readiness (SMART) model ( Schwartz, Tuchman, Hobbie, & Ginsberg, 2011 )—to their study population ( Pierce & Wysocki, 2015 ). Pierce et al. (2016) are currently using the adapted SMART model to focus their data collection and structure the preliminary analysis of their data about diabetes health care transition.

Regardless of whether theory is induced from data or selected in advance to guide the study, consistent with the principle of transparency , its role should be clearly identified and justified in the research publication ( Bradbury-Jones, Taylor, & Herber, 2014 ; Kelly, 2010 ). Methodological congruence is an important guiding principle in this regard ( Richards & Morse, 2013 ). If a theory frames the study at the outset, it should guide and direct all phases. The resulting publication(s) should relate the phenomenon of interest and the research question(s) to the theory and specify how the theory guided data collection and analysis. The publication(s) should also discuss how the theory fits with the finished product. For instance, authors should describe how the theory provided a framework for the presentation of the findings and discuss the findings in context with the relevant theoretical literature.

A study examining parents’ motivations to promote vegetable consumption in their children ( Hingle et al., 2012 ) provides an example of methodological congruence. The investigators adapted the Model of Goal Directed Behavior ( Bagozzi & Pieters, 1998 ) for parenting practices relevant to vegetable consumption (Model of Goal Directed Vegetable Parenting Practices; MGDVPP). Consistent with the adapted theoretical model and in keeping with the congruence principle, interviews were guided by the theoretical constructs contained within the MGDVPP, including parents’ attitudes, subjective norms, and perceived behavioral control related to promoting vegetable consumption in children ( Hingle et al., 2012 ). The study discovered that the adapted model successfully identified parents’ motivations to encourage their children to eat more vegetables.

The use of the theory should be consistent with the basic goal of qualitative research, which is discovery. Alternatively stated, theories should be used as broad orienting frameworks for exploring topical areas without imposing preconceived ideas and biases. The theory should be consistent with the study findings and not be used to force-fit the researcher’s interpretation of the data ( Sandelowski, 1993b ). Divergence from the theory when it does not fit the study findings is illustrated in a qualitative study of hypertension prevention beliefs in Hispanics ( Aroian, Peters, Rudner, & Waser, 2012 ). This study used the Theory of Planned Behavior as a guiding theoretical framework but found that coding separately for normative and control beliefs was not the best organizing schema for presenting the study findings. When divergence from the original theory occurs, the research report should explain and justify how and why the theory was modified ( Bradbury-Jones et al., 2014 ).

What Are Typical Sampling Methods in Qualitative Studies?

Qualitative sampling methods should be “purposeful” ( Coyne, 1997 ; Patton, 2015 ; Tuckett, 2004 ). Purposeful sampling is based on the study purpose and investigator judgments about which people and settings will provide the richest information for the research questions. The logic underlying this type of sampling differs from the logic underlying quantitative sampling ( Patton, 2015 ). Quantitative research strives for empirical generalization. In qualitative studies, generalizability beyond the study sample is typically not the intent; rather, the focus is on deriving depth and context-embedded meaning for the relevant study population.

Purposeful sampling is a broad term. Theoretical sampling is one particular type of purposeful sampling unique to grounded theory methods ( Coyne, 1997 ). In theoretical sampling, study participants are chosen according to theoretical categories that emerge from ongoing data collection and analyses ( Bryant & Charmaz, 2010 ). Data collection and analysis are conducted concurrently to allow generating and testing hypotheses that emerge from analyzing incoming data. The following example from the previously mentioned qualitative interview study about transition from pediatric to adult care in adolescents with type 1 diabetes ( Pierce et al., 2016 ) illustrates the process of theoretical sampling: An adolescent study participant stated that he was “turned off” by the “childish” posters in his pediatrician’s office. He elaborated that he welcomed transitioning to adult care because his diabetes was discovered when he was 18, an age when he reportedly felt more “mature” than most pediatric patients. These data were coded as “developmental misfit” and prompted a tentative hypothesis about developmental stage at entry for pediatric diabetes care and readiness for health care transition. Examining this hypothesis prompted seeking study participants who varied according to age or developmental stage at time of diagnosis to examine the theoretical relevance of an emerging theme about developmental fit.

Not all purposeful sampling, however, is “theoretical.” For example, ethnographic studies typically seek to understand a group’s cultural beliefs and practices ( Creswell, 2013a ). Consistent with this purpose, researchers conducting an ethnographic study might purposefully select study participants according to specific characteristics that reflect the social roles and positions in a given group or society (e.g., socioeconomic status, education; Johnson, 1990 ).

Random sampling is generally not used in qualitative research. Random selection requires a sufficiently large sample to maximize the potential for chance and, as will be discussed below, sample size is intentionally small in qualitative studies. However, random sampling may be used to verify or clarify findings ( Patton, 2015 ). Validating study findings with a randomly selected subsample can be used to address the possibility that a researcher is inadvertently giving greater attention to cases that reinforce his or her preconceived ideas.

Regardless of the sampling method used, qualitative researchers should clearly describe the sampling strategy and justify how it fits the study when reporting study findings (transparency). A common error is to refer to theoretical sampling when the cases were not chosen according to emerging theoretical concepts. Another common error is to apply sampling principles from quantitative research (e.g., cluster sampling) to convince skeptical reviewers about the rigor or validity of qualitative research. Rigor is best achieved by being purposeful, making sound decisions, and articulating the rationale for those decisions. As mentioned earlier in the discussion of transferability , qualitative researchers are encouraged to describe their methods of sample selection and descriptive characteristics about their sample so that readers and reviewers can judge how the current sample may differ from others. Understanding the characteristics of each qualitative study sample is essential for the iterative nature of qualitative research whereby qualitative findings inform the development of future qualitative, quantitative, or mixed-methods studies. Reviewers should evaluate sampling decisions based on how they fit the study purpose and how they influence the quality of the end product.

What Sample Size Is Needed for Qualitative Research?

No definitive rules exist about sample size in qualitative research. However, sample sizes are typically smaller than those in quantitative studies ( Patton, 2015 ). Small samples often generate a large volume of data and information-rich cases, ultimately leading to insight regarding the phenomenon under study ( Patton, 2015 ; Ritchie & Lewis, 2003 ). Sample sizes of 20–30 cases are typical, but a qualitative sample can be even smaller under some circumstances ( Mason, 2010 ).

Sample size adequacy is evaluated based on the quality of the study findings, specifically the full development of categories and inter-relationships or the adequacy of information about the phenomenon under study ( Corbin & Strauss, 2008 ; Ritchie & Lewis, 2003 ). Small sample sizes are of concern if they do not result in these outcomes. Data saturation (i.e., the point at which no new information, categories, or themes emerge) is often used to judge informational adequacy ( Morgan, 1998 ; Ritchie & Lewis, 2003 ). Although enough participants should be included to obtain saturation ( Morgan, 1998 ), informational adequacy pertains to more than sample size. It is also a function of the quality of the data, which is influenced by study participant characteristics (e.g., cognitive ability, knowledge, representativeness) and the researcher’s data-gathering skills and analytical ability to generate meaningful findings ( Morse, 2015b ; Patton, 2015 ).

Sample size is also influenced by type of qualitative research, the study purpose, the sample, the depth and complexity of the topic investigated, and the method of data collection. In general, the more heterogeneous the sample, the larger the sample size, particularly if the goal is to investigate similarities and differences by specific characteristics ( Ritchie & Lewis, 2003 ). For instance, in a study to conduct an initial exploration of factors underlying parents’ motivations to use good parenting practices, theoretical saturation (i.e., the point at which no new information, categories, or themes emerge) was obtained with a small sample ( n  = 15), most likely because the study was limited to parents of young children ( Hingle et al., 2012 ). If the goal of the study had been, for example, to identify racial/ethnic, gender, or age differences in food parenting practices, a larger sample would likely be needed to obtain saturation or informational adequacy.

Studies that seek to understand maximum variation in a phenomenon might also need a larger sample than one that is seeking to understand extreme or atypical cases. For example, a qualitative study of diet and physical activity in young Australian men conducted focus groups to identify perceived motivators and barriers to healthy eating and physical activity and examine the influence of body weight on their perceptions. Examining the influence of body weight status required 10 focus groups to allow for group assignment based on body mass index ( Ashton et al., 2015 ). More specifically, 61 men were assigned to a healthy-weight focus group ( n  = 3), an overweight/obese focus group ( n  = 3), or a mixed-weight focus group ( n  = 4). Had the researcher not been interested in whether facilitators and barriers differed by weight status, its likely theoretical saturation could have been obtained with fewer groups. Depth of inquiry also influences sample size ( Sandelowski, 1995 ). For instance, an in-depth analysis of an intervention for children with cancer and their families included 16 family members from three families. Study data comprised 52 hrs of videotaped intervention sessions and 10 interviews ( West, Bell, Woodgate, & Moules, 2015 ). Depth was obtained through multiple data points and types of data, which justified sampling only a few families.

Authors of publications describing qualitative findings should show evidence that the data were “saturated” by a sample with sufficient variation to permit detailing shared and divergent perspectives, meanings, or experiences about the topic of inquiry. Decisions related to the sample (e.g., targeted recruitment) should be detailed in publications so that peer reviewers have the context for evaluating the sample and determining how the sample influenced the study findings ( Patton, 2015 ).

Qualitative Data Analysis

When conducting qualitative research, voluminous amounts of data are gathered and must be prepared (i.e., transcribed) and managed. During the analytic process, data are systematically transformed through identifying, defining, interpreting, and describing findings that are meant to comprehensively describe the phenomenon or the abstract qualities that they have in common. The process should be systematic ( dependability ) and well-documented in the analysis section of a qualitative manuscript. For example, Kelly and Ganong (2011) , in their study of medical treatment decisions made by families of children with cancer, described their analytic procedure by outlining their approach to coding and use of memoing (e.g., keeping careful notes about emerging ideas about the data throughout the analytic process), comparative analysis (e.g., comparing data against one another and looking for similarities and differences), and diagram drawing (e.g., pictorially representing the data structure, including relationships between codes).

How Should Researchers Document Coding Reliability?

Because the intent of qualitative research is to account for multiple perspectives, the goal of qualitative analysis is to comprehensively incorporate those perspectives into discernible findings. Researchers accustomed to doing quantitative studies may expect authors to quantify interrater reliability (e.g., kappa statistic) but this is not typical in qualitative research. Rather, the emphasis in qualitative research is on (1) training those gathering data to be rigorous and produce high-quality data and on (2) using systematic processes to document key decisions (e.g., code book), clear direction, and open communication among team members during data analysis. The goal is to make the most of the collective insight of the investigative team to triangulate or complement each other’s efforts to process and interpret the data. Instead of evaluating if two independent raters came to the same numeric rating, reviewers of qualitative manuscripts should judge to what extent the overall process of coding, data management, and data interpretation were systematic and rigorous. Authors of qualitative reports should articulate their coding procedures for others to evaluate. Together, these strategies promote trustworthiness of the study findings.

An example of how these processes are described in the report of a qualitative study is as follows:

The first two authors independently applied the categories to a sample of two interviews and compared their application of the categories to identify lack of clarity and overlap in categories. The investigators created a code book that contained a definition of categories, guidelines for their application, and excerpts of data exemplifying the categories. The first two authors independently coded the data and compared how they applied the categories to the data and resolved any differences during biweekly meetings. ATLAS.ti, version 6.2, was used to document and accommodate ongoing changes and additions to the coding structure ( Palma et al., 2015 , p. 224).

Do I Need to Use a Specialized Qualitative Data Software Program for Analysis?

Multiple computer software packages for qualitative data analysis are currently available ( Silver & Lewins, 2014 ; Yin, 2015 ). These packages allow the researcher to import qualitative data (e.g., interview transcripts) into the software program and organize data segments (e.g., delineate which interview excerpts are relevant to particular themes). Qualitative analysis software can be useful for organizing and sorting through data, including during the analysis phase. Some software programs also offer sophisticated coding and visualization capabilities that facilitate and enhance interpretation and understanding. For example, if data segments are coded by specific characteristics (e.g., gender, race/ethnicity), the data can be sorted and analyzed by these characteristics, which may contribute to an understanding of whether and/or how a particular phenomenon may vary by these characteristics.

The strength of computer software packages for qualitative data analysis is their potential to contribute to methodological rigor by organizing the data for systematic analyses ( John & Johnson, 2000 ; MacMillan & Koenig, 2004 ). However, the programs do not replace the researchers’ analyses. The researcher or research team is ultimately responsible for analyzing the data, identifying the themes and patterns, and placing the findings within the context of the literature. In other words, qualitative data analysis software programs contribute to, but do not ensure scientific rigor or “objectivity” in, the analytic process. In fact, using a software program for analysis is not essential if the researcher demonstrates the use of alternative tools and procedures for rigor.

Presentation of Findings

Should there be overlap between presentation of themes in the results and discussion sections.

Qualitative papers sometimes combine results and discussion into one section to provide a cohesive presentation of the findings along with meaningful linkages to the existing literature ( Burnard, 2004 ; Burnard, Gill, Stewart, Treasure, & Chadwick, 2008 ). Although doing so is an acceptable method for reporting qualitative findings, some journals prefer the two sections to be distinct.

When the journal style is to distinguish the two sections, the results section should describe the findings, that is, the themes, while the discussion section should pull the themes together to make larger-level conclusions and place the findings within the context of the existing literature. For instance, the findings section of a study of how rural African-American adolescents, parents, and community leaders perceived obesity and topics for a proposed obesity prevention program, contained a description of themes about adolescent eating patterns, body shape, and feedback on the proposed weight gain prevention program according to each subset of participants (i.e., adolescents, parents, community leaders). The discussion section then put these themes within the context of findings from prior qualitative and intervention studies in related populations ( Cassidy et al., 2013 ). In the Discussion, when making linkages to the existing literature, it is important to avoid the temptation to extrapolate beyond the findings or to over-interpret them ( Burnard, 2004 ). Linkages between the findings and the existing literature should be supported by ample evidence to avoid spurious or misleading connections ( Burnard, 2004 ).

What Should I Include in the Results Section?

The results section of a qualitative research report is likely to contain more material than customary in quantitative research reports. Findings in a qualitative research paper typically include researcher interpretations of the data as well as data exemplars and the logic that led to researcher interpretations ( Sandelowski & Barroso, 2002 ). Interpretation pertains to the researcher breaking down and recombining the data and creating new meanings (e.g., abstract categories, themes, conceptual models). Select quotes from interviews or other types of data (e.g., participant observation, focus groups) are presented to illustrate or support researcher interpretations. Researchers trained in the quantitative tradition, where interpretation is restricted to the discussion section, may find this surprising; however, in qualitative methods, researcher interpretations represent an important component of the study results. The presentation of the findings, including researcher interpretations (e.g., themes) and data (e.g., quotes) supporting those interpretations, adds to the trustworthiness of the study ( Elo et al., 2014 ).

The Results section should contain a balance between data illustrations (i.e., quotes) and researcher interpretations ( Lofland & Lofland, 2006 ; Sandelowski, 1998 ). Because interpretation arises out of the data, description and interpretation should be combined. Description should be sufficient to support researcher interpretations, and quotes should be used judiciously ( Morrow, 2005 ; Sandelowski, 1994 ). Not every theme needs to be supported by multiple quotes. Rather, quotes should be carefully selected to provide “voice” to the participants and to help the reader understand the phenomenon from the participant’s perspective within the context of the researcher’s interpretation ( Morrow, 2005 ; Ritchie & Lewis, 2003 ). For example, researchers who developed a grounded theory of sexual risk behavior of urban American Indian adolescent girls identified desire for better opportunities as a key deterrent to neighborhood norms for early sexual activity. They illustrated this theme with the following quote: “I don’t want to live in the ‘hood and all that…My sisters are stuck there because they had babies. That isn’t going to happen to me” ( Saftner, Martyn, Momper, Loveland-Cherry, & Low, 2015 , p. 372).

There is no precise formula for the proportion of description to interpretation. Both descriptive and analytic excess should be avoided ( Lofland & Lofland, 2006 ). The former pertains to presentation of unedited field notes or interview transcripts rather than selecting and connecting data to analytic concepts that explain or summarize the data. The latter pertains to focusing on the mechanics of analysis and interpretation without substantiating researcher interpretations with quotes. Reviewer requests for methodological rigor can result in researchers writing qualitative research papers that suffer from analytic excess ( Sandelowski & Barroso, 2002 ). Page limitations of most journals provide a safeguard against descriptive excess, but page limitations should not circumvent researchers from providing the basis for their interpretations.

Additional potential problems with qualitative results sections include under-elaboration, where themes are too few and not clearly defined. The opposite problem, over-elaboration, pertains to too many analytic distinctions that could be collapsed under a higher level of abstraction. Quotes can also be under- or over-interpreted. Care should be taken to ensure the quote(s) selected clearly support the theme to which they are attached. And finally, findings from a qualitative study should be interesting and make clear contributions to the literature ( Lofland & Lofland, 2006 ; Morse, 2015b ).

Should I Quantify My Results? (e.g., Frequency With Which Themes Were Endorsed)

There is controversy over whether to quantify qualitative findings, such as providing counts for the frequency with which particular themes are endorsed by study participants ( Morgan, 1993 ; Sandelowski, 2001 ). Qualitative papers usually report themes and patterns that emerge from the data without quantification ( Dey, 1993 ). However, it is possible to quantify qualitative findings, such as in qualitative content analysis. Qualitative content analysis is a method through which a researcher identifies the frequency with which a phenomenon, such as specific words, phrases, or concepts, is mentioned ( Elo et al., 2014 ; Morgan, 1993 ). Although this method may appeal to quantitative reviewers, it is important to note that this method only fits specific study purposes, such as studies that investigate the language used by a particular group when communicating about a specific topic. In addition, results may be quantified to provide information on whether themes appeared to be common or atypical. Authors should avoid using imprecise language, such as “some participants” or “many participants.” A good example of quantification of results to illustrate more or less typical themes comes from a manuscript describing a qualitative study of school nurses’ perceived barriers to addressing obesity with students and their families. The authors described that all but one nurse reported not having the resources they needed to discuss weight with students and families whereas one-quarter of nurses reported not feeling competent to discuss weight issues ( Steele et al., 2011 ). If quantification of findings is used, authors should provide justification that explains how quantification is consistent with the aims or goals of the study ( Sandelowski, 2001 ).

Conclusions

This article highlighted key theoretical and logistical considerations that arise in designing, conducting, and reporting qualitative research studies (see Table 1 for a summary). This type of research is vital for obtaining patient, family, community, and other stakeholder perspectives about their needs and interests, and will become increasingly critical as our models of health care delivery evolve. For example, qualitative research could contribute to the study of health care providers and systems with the goal of optimizing our health care delivery models. Given the increasing diversity of the populations we serve, qualitative research will also be critical in providing guidance in how to tailor health interventions to key characteristics and increase the likelihood of acceptable, effective treatment approaches. For example, applying qualitative research methods could enhance our understanding of refugee experiences in our health care system, clarify treatment preferences for emerging adults in the midst of health care transitions, examine satisfaction with health care delivery, and evaluate the applicability of our theoretical models of health behavior changes across racial and ethnic groups. Incorporating patient perspectives into treatment is essential to meeting this nation’s priority on patient-centered health care ( Institute of Medicine Committee on Quality of Health Care in America, 2001 ). Authors of qualitative studies who address the methodological choices addressed in this review will make important contributions to the field of pediatric psychology. Qualitative findings will lead to a more informed field that addresses the needs of a wide range of patient populations and produces effective and acceptable population-specific interventions to promote health.

Acknowledgments

The authors thank Bridget Grahmann for her assistance with manuscript preparation.

This work was supported by National Cancer Institute of the National Institutes of Health (K07CA196985 to Y.W.). This work is a publication of the United States Department of Agriculture/Agricultural Research Center (USDA/ARS), Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas. It is also a publication of the USDA/ARS, Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, and funded in part with federal funds from the USDA/ARS under Cooperative Agreement No. 58‐6250‐0‐008 (to D.T.). The contents of this publication do not necessarily reflect the views or policies of the USDA, nor does mention of trade names, commercial products, or organizations imply endorsement from the U.S. government. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Conflicts of interest : None declared.

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Guidelines for Preparing Qualitative Manuscripts

Authors submitting qualitative manuscripts to Psychology of Religion and Spirituality ( PRS ) should familiarize themselves with the Journal Article Reporting Standards for Qualitative Primary Research (JARS-Qual) and seek to adhere to them as much as possible.

In particular, the following JARS-Qual standards are deemed especially important for authors to uphold in their submissions of qualitative research submitted to PRS .

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Study Objectives/Aims/Research Goals

• State the purpose(s)/goal(s)/aim(s) of the study.
• Qualitative studies tend not to identify hypotheses, but research questions and goals.

Research Design Overview

• Summarize the research design (data-collection strategies, data-analytic strategies) and, if illuminating, approaches to inquiry (e.g., descriptive, interpretive, feminist, psychoanalytic, postpositivist, critical, postmodern or constructivist, pragmatic approaches).
• Provide the rationale for the design selected.

Researcher Description

• Describe the researchers' backgrounds in approaching the study, emphasizing their prior understandings of the phenomena under study. Prior understandings relevant to the analysis could include, but are not limited to, descriptions of researchers' demographic/cultural characteristics, credentials, experience with phenomena, training, values, or decisions in selecting archives or material to analyze.
• Describe how researchers' prior understandings of the phenomena under study were managed and/or influenced the research (e.g., enhancing, limiting, or structuring data collection and analysis).

Recruitment Process

• Describe the rationale for decision to halt data collection (e.g., saturation).
• Provide a rationale for the number of participants chosen.

Participant Selection

• Describe the participants/data sources selection process (e.g., purposive sampling methods such as maximum variation, diversity sampling, or convenience sampling methods such as snowball selection, theoretical sampling), inclusion/exclusion criteria.
• State the form of data collected (e.g., interviews, questionnaires, media, observation).
• Describe any alterations of data-collection strategy in response to the evolving findings or the study rationale.
• For interview and written studies, indicate the mean and range of the time duration in the data-collection process (e.g., "interviews were held for 75 to 110 min, with an average interview time of 90 min").
• Describe questions asked in data collection: Content of central questions, form of questions (e.g., open vs. closed).

Data-Analytic Strategies

• Describe the methods and procedures used and for what purpose/goal.
• Explicate in detail the process of analysis, including some discussion of the procedures (e.g., coding, thematic analysis, etc.) with a principle of transparency.
• Describe coders or analysts and their training, if not already described in the researcher description section (e.g., coder selection, collaboration groups).
• Identify whether coding categories emerged from the analyses or were developed a priori.
• Identify units of analysis (e.g., entire transcript, unit, text) and how units were formed, if applicable.
• Describe the process of arriving at an analytic scheme, if applicable (e.g., if one was developed before or during the analysis or was emergent throughout).
• Provide illustrations and descriptions of their development, if relevant.
• Indicate software, if used.

Methodological Integrity

The task force that developed JARS-Qual defines methodological integrity and its component processes as follows:

Methodological integrity can be evaluated through its two composite processes: fidelity to the subject matter and utility in achieving research goals. … Fidelity to the subject matter is the process by which researchers select procedures that develop and maintain allegiance to the phenomenon under study as it is conceived within their approach to inquiry (e.g., the phenomenon might be understood as a social construction). … The second composite process of methodological integrity, utility in achieving research goals is the process by which researchers select procedures that usefully answer their research questions and address their aims (e.g., raising critical consciousness, developing theory, deepening understanding, identifying social practices, forming conceptual frameworks, and developing local knowledge). (Levitt et al. [2018], Journal article reporting standards for qualitative primary, qualitative meta-analytic, and mixed methods research in psychology: The APA Publications and Communications Board Task Force report. American Psychologist, 73 (1), 26-46. P. 33).

• Demonstrate that the claims made from the analysis are warranted and have produced findings with methodological integrity. The procedures that support methodological integrity (i.e., fidelity and utility) typically are described across the relevant sections of a paper, but they could be addressed in a separate section when elaboration or emphasis would be helpful. Issues of methodological integrity include:
• Assess the adequacy of the data in terms of its ability to capture forms of diversity most relevant to the question, research goals, and inquiry approach.
• Describe how the researchers' perspectives were managed in both the data collection and analysis (e.g., to limit their effect on the data collection, to structure the analysis).
• Demonstrate that findings are grounded in the evidence (e.g., using quotes, excerpts, or descriptions of researchers' engagement in data collection).
• Demonstrate that the contributions are insightful and meaningful (e.g., in relation to the current literature and the study goal).
• Provide relevant contextual information for findings (e.g., setting of study, information about participant, presenting the interview question asked prior to presenting the excerpt, as needed).
• Present findings in a coherent manner that makes sense of contradictions or disconfirming evidence in the data (e.g., reconcile discrepancies, describe why a conflict might exist in the findings).
• Demonstrate consistency with regard to the analytic processes (e.g., analysts may use demonstrations of analyses to support consistency, describe their development of a stable perspective, interrater reliability, consensus) or describe responses to inconsistencies, as relevant (e.g., coders switching mid-analysis, an interruption in the analytic process). If alterations in methodological integrity were made for ethical reasons, explicate those reasons and the adjustments made.
• Describe how support for claims was supplemented by any checks added to the qualitative analysis. Examples of supplemental checks that can strengthen the research may include:
• Transcripts/data collected returned to participants for feedback.
• Triangulation across multiple sources of information, findings, or investigators.
• Checks on the interview thoroughness or interviewer demands.
• Consensus or auditing process.
• Member checks or participant feedback on findings.
• Data displays/matrices.
• In-depth thick description, case examples, illustrations.
• Structured methods of researcher reflexivity (e.g., sending memos, field notes, diary, log books, journals, bracketing).
• Checks on the utility of findings in responding to the study problem (e.g., an evaluation of whether a solution worked).
• Although findings may or may not include quantified information, depending upon the study's goals, approach to inquiry, and study characteristics, we encourage authors to include even simple quantified information about the qualitative findings (themes), recognizing that this will assist many readers in understanding the relative importance or frequency of themes.
• Identify the study's strengths and limitations (e.g., consider how the quality, source, or types of the data or the analytic processes might support or weaken its methodological integrity).
• Describe the limits of the scope of transferability (e.g., what should readers bear in mind when using findings across contexts).
• Consider the implications for future research, policy, or practice.

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Writing a qualitative research report

Affiliation.

• 1 School of Nursing and Midwifery Studies, University of Wales College of Medicine, Heath Park, Cardiff, UK. [email protected]
• PMID: 15234716
• DOI: 10.1016/j.aaen.2003.11.006

A research project in nursing or nursing education is probably only complete once the findings have been published. This paper offers a format for writing a qualitative research report for publication. It suggests, at least, the following sections: introduction, aims of the study, review of the literature, sample, data collection methods, data analysis methods, findings, discussion, conclusion, abstract. Each of these sections is addressed along with many written-out examples. In some sections, alternative approaches are suggested. The aim of the paper is to help the neophyte researcher to structure his or her report and for the experienced researcher to reflect on his or her current practice. References to other source material on qualitative research are given.

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How to Do Qualitative Research

Last Updated: October 26, 2022 Fact Checked

This article was co-authored by Jeremiah Kaplan . Jeremiah Kaplan is a Research and Training Specialist at the Center for Applied Behavioral Health Policy at Arizona State University. He has extensive knowledge and experience in motivational interviewing. In addition, Jeremiah has worked in the mental health, youth engagement, and trauma-informed care fields. Using his expertise, Jeremiah supervises Arizona State University’s Motivational Interviewing Coding Lab. Jeremiah has also been internationally selected to participate in the Motivational Interviewing International Network of Trainers sponsored Train the Trainer event. Jeremiah holds a BS in Human Services with a concentration in Family and Children from The University of Phoenix. There are 10 references cited in this article, which can be found at the bottom of the page. This article has been fact-checked, ensuring the accuracy of any cited facts and confirming the authority of its sources. This article has been viewed 751,131 times.

Qualitative research is a broad field of inquiry that uses unstructured data collections methods, such as observations, interviews, surveys and documents, to find themes and meanings to inform our understanding of the world. [1] X Trustworthy Source PubMed Central Journal archive from the U.S. National Institutes of Health Go to source Qualitative research tends to try to cover the reasons for behaviors, attitudes and motivations, instead of just the details of what, where and when. Qualitative research can be done across many disciplines, such as social sciences, healthcare and businesses, and it is a common feature of nearly every single workplace and educational environment.

Preparing Your Research

• The research questions is one of the most important pieces of your research design. It determines what you want to learn or understand and also helps to focus the study, since you can't investigate everything at once. Your research question will also shape how you conduct your study since different questions require different methods of inquiry.
• You should start with a burning question and then narrow it down more to make it manageable enough to be researched effectively. For example, "what is the meaning of teachers' work to teachers" is too broad for a single research endeavor, but if that's what you're interested you could narrow it by limiting the type of teacher or focusing on one level of education. For example, "what is the meaning of teachers' work to second career teachers?" or "what is the meaning of teachers' work to junior high teachers?"

Tip: Find the balance between a burning question and a researchable question. The former is something you really want to know about and is often quite broad. The latter is one that can be directly investigated using available research methods and tools.

• For example, if your research question focuses on how second career teachers attribute meaning to their work, you would want to examine the literature on second career teaching - what motivates people to turn to teaching as a second career? How many teachers are in their second career? Where do most second career teachers work? Doing this reading and review of existing literature and research will help you refine your question and give you the base you need for your own research. It will also give you a sense of the variables that might impact your research (e.g., age, gender, class, etc.) and that you will need to take into consideration in your own study.
• A literature review will also help you to determine whether you are really interested and committed to the topic and research question and that there is a gap in the existing research that you want to fill by conducting your own investigation.

For example, if your research question is "what is the meaning of teachers' work to second career teachers?" , that is not a question that can be answered with a 'yes' or 'no'. Nor is there likely to be a single overarching answer. This means that qualitative research is the best route.

• Consider the possible outcomes. Because qualitative methodologies are generally quite broad, there is almost always the possibility that some useful data will come out of the research. This is different than in a quantitative experiment, where an unproven hypothesis can mean that a lot of time has been wasted.
• Your research budget and available financial resources should also be considered. Qualitative research is often cheaper and easier to plan and execute. For example, it is usually easier and cost-saving to gather a small number of people for interviews than it is to purchase a computer program that can do statistical analysis and hire the appropriate statisticians.

• Action Research – Action research focuses on solving an immediate problem or working with others to solve problem and address particular issues. [7] X Research source
• Ethnography – Ethnography is the study of human interaction in communities through direct participation and observation within the community you wish to study. Ethnographic research comes from the discipline of social and cultural anthropology but is now becoming more widely used. [8] X Research source
• Phenomenology – Phenomenology is the study of the subjective experiences of others. It researches the world through the eyes of another person by discovering how they interpret their experiences. [9] X Research source
• Grounded Theory – The purpose of grounded theory is to develop theory based on the data systematically collected and analyzed. It looks at specific information and derives theories and reasons for the phenomena.
• Case Study Research – This method of qualitative study is an in-depth study of a specific individual or phenomena in its existing context. [10] X Research source

Collecting and Analyzing Your Data

• Direct observation – Direct observation of a situation or your research subjects can occur through video tape playback or through live observation. In direct observation, you are making specific observations of a situation without influencing or participating in any way. [12] X Research source For example, perhaps you want to see how second career teachers go about their routines in and outside the classrooms and so you decide to observe them for a few days, being sure to get the requisite permission from the school, students and the teacher and taking careful notes along the way.
• Participant observation – Participant observation is the immersion of the researcher in the community or situation being studied. This form of data collection tends to be more time consuming, as you need to participate fully in the community in order to know whether your observations are valid. [13] X Research source
• Interviews – Qualitative interviewing is basically the process of gathering data by asking people questions. Interviewing can be very flexible - they can be on-on-one, but can also take place over the phone or Internet or in small groups called "focus groups". There are also different types of interviews. Structured interviews use pre-set questions, whereas unstructured interviews are more free-flowing conversations where the interviewer can probe and explore topics as they come up. Interviews are particularly useful if you want to know how people feel or react to something. For example, it would be very useful to sit down with second career teachers in either a structured or unstructured interview to gain information about how they represent and discuss their teaching careers.
• Surveys – Written questionnaires and open ended surveys about ideas, perceptions, and thoughts are other ways by which you can collect data for your qualitative research. For example, in your study of second career schoolteachers, perhaps you decide to do an anonymous survey of 100 teachers in the area because you're concerned that they may be less forthright in an interview situation than in a survey where their identity was anonymous.
• "Document analysis" – This involves examining written, visual, and audio documents that exist without any involvement of or instigation by the researcher. There are lots of different kinds of documents, including "official" documents produced by institutions and personal documents, like letters, memoirs, diaries and, in the 21st century, social media accounts and online blogs. For example, if studying education, institutions like public schools produce many different kinds of documents, including reports, flyers, handbooks, websites, curricula, etc. Maybe you can also see if any second career teachers have an online meet group or blog. Document analysis can often be useful to use in conjunction with another method, like interviewing.

• Coding – In coding, you assign a word, phrase, or number to each category. Start out with a pre-set list of codes that you derived from your prior knowledge of the subject. For example, "financial issues" or "community involvement" might be two codes you think of after having done your literature review of second career teachers. You then go through all of your data in a systematic way and "code" ideas, concepts and themes as they fit categories. You will also develop another set of codes that emerge from reading and analyzing the data. For example, you may see while coding your interviews, that "divorce" comes up frequently. You can add a code for this. Coding helps you organize your data and identify patterns and commonalities. [15] X Research source tobaccoeval.ucdavis.edu/analysis-reporting/.../CodingQualitativeData.pdf
• Descriptive Statistics – You can analyze your data using statistics. Descriptive statistics help describe, show or summarize the data to highlight patterns. For example, if you had 100 principal evaluations of teachers, you might be interested in the overall performance of those students. Descriptive statistics allow you to do that. Keep in mind, however, that descriptive statistics cannot be used to make conclusions and confirm/disprove hypotheses. [16] X Research source
• Narrative analysis – Narrative analysis focuses on speech and content, such as grammar, word usage, metaphors, story themes, meanings of situations, the social, cultural and political context of the narrative. [17] X Research source
• Hermeneutic Analysis – Hermeneutic analysis focuses on the meaning of a written or oral text. Essentially, you are trying to make sense of the object of study and bring to light some sort of underlying coherence. [18] X Research source
• Content analysis / Semiotic analysis – Content or semiotic analysis looks at texts or series of texts and looks for themes and meanings by looking at frequencies of words. Put differently, you try to identify structures and patterned regularities in the verbal or written text and then make inferences on the basis of these regularities. [19] X Research source For example, maybe you find the same words or phrases, like "second chance" or "make a difference," coming up in different interviews with second career teachers and decide to explore what this frequency might signify.

Community Q&A

• Qualitative research is often regarded as a precursor to quantitative research, which is a more logical and data-led approach which statistical, mathematical and/or computational techniques. Qualitative research is often used to generate possible leads and formulate a workable hypothesis that is then tested with quantitative methods. [20] X Research source Thanks Helpful 0 Not Helpful 0
• Try to remember the difference between qualitative and quantitative as each will give different data. Thanks Helpful 4 Not Helpful 0

You Might Also Like

• ↑ https://www.ncbi.nlm.nih.gov/books/NBK470395/
• ↑ https://owl.purdue.edu/owl/research_and_citation/conducting_research/writing_a_literature_review.html
• ↑ https://academic.oup.com/humrep/article/31/3/498/2384737?login=false
• ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4275140/
• ↑ http://www.qual.auckland.ac.nz/
• ↑ http://www.socialresearchmethods.net/kb/qualapp.php
• ↑ http://www.socialresearchmethods.net/kb/qualdata.php
• ↑ tobaccoeval.ucdavis.edu/analysis-reporting/.../CodingQualitativeData.pdf
• ↑ https://statistics.laerd.com/statistical-guides/descriptive-inferential-statistics.php
• ↑ https://explorable.com/qualitative-research-design

About This Article

To do qualitative research, start by deciding on a clear, specific question that you want to answer. Then, do a literature review to see what other experts are saying about the topic, and evaluate how you will best be able to answer your question. Choose an appropriate qualitative research method, such as action research, ethnology, phenomenology, grounded theory, or case study research. Collect and analyze data according to your chosen method, determine the answer to your question. For tips on performing a literature review and picking a method for collecting data, read on! Did this summary help you? Yes No

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How to Write a Qualitative Research Paper

October 25, 2023

A qualitative research paper is a type of academic paper that focuses on exploring and understanding a phenomenon in depth, often using methods such as interviews, observations, and analysis of textual or visual data. Unlike quantitative research which relies on numerical data and statistical analysis, a qualitative research paper aims to provide detailed insights, interpretations, and subjective understandings of the research topic. The purpose of writing a qualitative research paper is to delve into the complexity of the subject matter and provide a rich and comprehensive understanding of it. To write a qualitative research paper effectively, it is crucial to carefully select a research topic, formulate pertinent research questions, conduct a thorough literature review, select an appropriate methodology, collect and analyze data, and present well-supported interpretations and conclusions.

Choosing a Research Topic

Choosing a research topic is a critical first step in writing a qualitative research paper. The topic should be of interest to the researcher and align with their expertise and passion. It is important to select a topic that is specific, manageable, and aligned with the research objectives. One approach is to identify gaps in existing literature and areas that require further exploration. Brainstorming, consulting with peers and mentors, and reviewing recent publications can help in generating ideas.

Once potential topics are identified, it is necessary to evaluate their feasibility and relevance. Consideration should be given to the availability of resources, access to data, ethical considerations, and potential impact. The research topic should be significant, addressing a research gap or contributing to the existing body of knowledge. It is also beneficial to choose a topic that allows for in-depth exploration and provides opportunities for meaningful analysis and interpretation.

Narrow down the topic by clarifying the research questions and objectives. This will refine the focus and guide the research process. It is essential to ensure that the chosen topic is ethically sound and aligns with the research guidelines and regulations. By carefully selecting a research topic, researchers can lay a solid foundation for their qualitative research paper and set themselves up for a successful and impactful study.

Qualitative Research Paper Topics Examples:

• The lived experiences of nursing home residents
• An exploration of the impact of social media on mental health
• Understanding the perspectives of parents of children with autism spectrum disorder
• The influence of cultural values on leadership styles in multinational organizations
• The role of spirituality in addiction recovery
• A phenomenological study of the experience of chronic pain
• Investigating the benefits and drawbacks of remote working for employees
• The experiences of international students in higher education
• The impact of mindfulness practices on stress and anxiety
• Exploring the factors that contribute to a positive work-life balance in healthcare professionals.

Formulating Research Questions and Objectives

Formulating clear research questions and objectives is a crucial step in writing a qualitative research paper. These questions and objectives guide the research process and provide focus for the study. Here are some tips for formulating research questions and objectives:

• Start with a broad research question: This will allow for exploration of the research topic and help in identifying key areas of focus.
• Refine the research question: Narrow down the research question by considering its relevance, feasibility, and practicality.
• Consider the research objectives: The research objectives should be specific, measurable, achievable, relevant, and time-bound. Use the SMART criteria to refine the research objectives.
• Ensure coherence between research questions and objectives: The research questions and objectives should work together to provide clarity and direction for the research.
• Use open-ended questions: Qualitative research involves exploring in-depth subjective experiences and perspectives. Open-ended questions allow for this exploration and provide rich data.
• Keep the target audience in mind: Formulate research questions and objectives that are relevant and meaningful to the intended audience.

Examples of research questions and objectives:

Research question: How do teachers cope with the challenges of remote teaching during the COVID-19 pandemic?

Research objectives:

• To explore the experiences of teachers with remote teaching during the pandemic.
• To identify the strategies used by teachers to overcome the challenges of remote teaching.
• To understand the impact of remote teaching on the well-being of teachers.

Conducting a Literature Review

Conducting a literature review is a critical aspect of writing a qualitative research paper. It involves reviewing existing literature on the chosen research topic and identifying gaps or areas that require further exploration. Here are some tips for conducting a literature review:

• Develop a search strategy: It is essential to develop a search strategy to ensure that relevant literature is captured. Databases such as PubMed, Scopus, and PsycINFO can be used to search for relevant literature.
• Use keywords: Keywords are essential for ensuring that relevant literature is identified. Start with a broad search, and then narrow down the search using specific keywords.
• Review the literature: Review the identified literature and assess its quality, relevance, and validity. Identify and summarize key themes, concepts, and findings.
• Identify gaps in the literature: Identify areas where further research is required. This will provide a basis for formulating research questions and objectives.
• Document all sources: Keep accurate records of all sources reviewed, including the author, title, publication date, and source.
• Evaluate the relevance of the literature: Ensure that reviewed literature is relevant by evaluating the date of publication and the credibility of the author and publisher.

Conducting a literature review is a crucial step in writing a qualitative research paper. The review provides a basis for understanding existing knowledge and identifying areas for future research. By carefully reviewing literature, researchers can ensure that their writing is informed and current, and that their research objectives are relevant and significant.

Selecting a Methodology

Selecting the appropriate methodology is a critical step in writing a qualitative research paper. The methodology chosen should align with the research questions and objectives and provide a suitable approach to collect relevant data. Qualitative research methodologies include ethnography, case study, grounded theory, phenomenology, and content analysis.

Researchers need to consider which methodology is best suited for their research questions and objectives. Ethnography and grounded theory are useful when researchers need to explore and describe complex social phenomena. Phenomenology is suited for understanding how individuals perceive or experience specific phenomena. Case study research is appropriate when researchers need to understand or explain a specific case or context. Content analysis is helpful when researchers need to analyze textual or visual data.

Selecting an appropriate methodology is essential to ensure high-quality research that can effectively answer the research questions and objectives. Careful consideration of the strengths and weaknesses of each methodology will ensure that the chosen methodology is best suited to the research project for writing a qualitative research paper.

Collecting Data

Collecting data is a crucial step in a qualitative research project. Data collection methods should be carefully chosen, based on the research questions, objectives, and methodology selected. The most common data collection methods in qualitative research include interviews, focus groups, observation, and document analysis.

Interviews are common in qualitative research and gather data through structured, semi-structured, or unstructured questions. Focus groups use group discussions to gather data from participants on specific topics. Observation involves collecting data through direct observation of behavior, while document analysis involves analyzing existing documents such as newspapers, journals, or reports.

When selecting a data collection method, it is essential to consider the research question and objective, the availability of participants, and the time and resources available. It is important to ensure that the data collection method is ethical and respects participants’ privacy and confidentiality.

In addition to collecting data, it is essential to document the data obtained. Data documentation should include information such as the date and time of data collection, the data collection method used, the participants’ demographics, and their responses. Further, it is crucial to ensure that the data collected is reliable and valid.

Overall, collecting data is a critical step in a qualitative research project, and researchers must carefully select appropriate data collection methods and document and analyze their data accurately.

Analyzing Data

Analyzing data is a crucial step in writing a qualitative research paper. It involves reviewing and interpreting the data collected to answer the research questions and objectives. Researchers must ensure that the data is analyzed consistently, systematically, and accurately.

Qualitative data analysis methods include thematic analysis, content analysis, and narrative analysis. Thematic analysis involves identifying themes and patterns within the data, while content analysis involves analyzing the frequency and distribution of specific words or phrases. Narrative analysis involves analyzing and interpreting the stories told by participants in the research project.

During data analysis, the researcher must document and track the findings and conclusions in a clear and concise manner. Writing can help to organize thoughts and ideas, making it easier to identify and summarize key themes and patterns.

It is essential to maintain transparency throughout the data analysis process, clearly outlining the steps taken to analyze the data. Researchers must also ensure that the analysis remains true to the data collected and avoid introducing personal bias.

Overall, analyzing data is a critical step in writing a qualitative research paper. By carefully analyzing and interpreting data, researchers can answer research questions and objectives and provide new insights into a specific topic or phenomenon. Writing is crucial throughout the process as it guides the analysis and ensures that the findings are documented and transparent.

Interpreting Results

Interpreting results is a crucial step in writing a qualitative research paper. It involves analyzing the data, identifying key themes, and drawing conclusions based on the findings. Researchers must ensure that the results are accurately and transparently reported.

During the interpretation of results, it is essential to keep an open mind, question assumptions, and support findings with strong evidence from the data collected. The analysis should consider different perspectives, such as the participants’ views and cultural background.

Qualitative research is often subjective, and interpretations of results can vary widely. Therefore, it is crucial to incorporate alternative interpretations and acknowledge any potential limitations or biases in the research process.

Researchers should use writing to convey the findings clearly and concisely, including a comprehensive summary of key themes and conclusions drawn from the data. The discussion of results should connect the research findings to previous literature and highlight the study’s contributions to the field.

In addition, researchers must also consider any practical implications of the research, including suggestions for future research and recommendations for policy or practice. Finally, researchers should ensure that the results are presented in a way that is accessible to a wide audience, including both academic and non-academic communities.

In conclusion, interpreting results from qualitative research is a multi-step process that involves analyzing the data collected, drawing conclusions and taking into account the research limitations, and presenting the findings in a clear, concise, and accessible manner.

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• Published: 26 August 2024

Health worker perspectives on barriers and facilitators of tuberculosis investigation coverage among index case contacts in rural Southwestern Uganda: a qualitative study

• Paddy Mutungi Tukamuhebwa 1 ,
• Pascalia Munyewende 1 ,
• Nazarius Mbona Tumwesigye 2 ,
• Juliet Nabirye 3 &
• Ntombizodwa Ndlovu 1  

BMC Infectious Diseases volume  24 , Article number:  867 ( 2024 ) Cite this article

Metrics details

In 2012, the World Health Organization recommended screening and investigation of contacts of index tuberculosis patients as a strategy to accelerate detection of tuberculosis (TB) cases. Nine years after the adoption of this recommendation, coverage of TB contact investigations in Uganda remains low. The objective of this study was to examine health care providers’ perceptions of factors influencing coverage of TB contact investigations in three selected rural health facilities in Mbarara district, southwestern Uganda.

This study identified provider opinions on the barriers and facilitators to implementation of TB contact investigation using the Consolidated Framework for Implementation Research. Using an exploratory qualitative study design, semi-structured interviews with 19 health workers involved in the TB program at district, health facility and community levels were conducted from April 2020 and July 2020. Analysis was conducted inductively using reflexive thematic analysis in six iterative steps: familiarizing with the data, creating initial codes, searching for themes, reviewing themes, developing theme definitions, and writing the report.

Nineteen health care workers participated in this study which translates to a 100% response rate. These included two district TB and leprosy supervisors, five nurses, five clinical officers, six village health team members and one laboratory technician. The three themes that emerged from the analysis were intervention-related, health system and contextual factors. Health system-related barriers included inadequate or delayed government funding for the TB program, shortage of human resources, insufficient personal protective equipment, and a stock-out of supplies such as Xpert MTB cartridges. Contextual barriers included steep terrain, poverty or low income, and the stigma associated with TB and COVID-19. Facilitators comprised increased knowledge and understanding of the intervention, performance review and on-the-job training of health workers.

This study found that most of the factors affecting TB contact investigations in this rural community were related to health system constraints such as inadequate or delayed funding and human resource shortages. This can be addressed by strengthening the foundational elements of the health system - health financing and human resources - to establish a comprehensive TB control program that will enable the efficient identification of missing TB patients.

Peer Review reports

Introduction

An estimated 10 million people suffer from active tuberculosis (TB) every year [ 1 ]. The disease continues to be the leading infectious cause of death globally, causing about 1.5 million deaths—95% of which occurred in low- and middle-income countries [ 2 , 3 ]. Although the African region has 9% of the world population, the region contributed 25% of all new TB cases in 2019, becoming the continent with the second-highest TB cases after South-East Asia. In Africa TB is mainly driven by the HIV pandemic, with about 50% of TB cases co-infected with HIV, and is the top cause of death among patients with HIV, causing more than 30% of all AIDS-related deaths [ 4 , 5 ].

In 2012, the WHO recommended the screening and evaluation of contacts of persons with infectious TB as an intervention for increasing TB case detection [ 6 ]. The intervention also provides an opportunity to diagnose latent TB and to scale-up TB preventive therapy among the eligible contacts, such as, children below five years, HIV positive patients, and other high-risk groups [ 7 , 8 ]. Five years later, in 2017, the Uganda Ministry of Health (MoH) adopted these WHO recommendations as high-level policy, and integrated them into the Manual for Management and Control of TB and Leprosy in Uganda [ 9 ]. Furthermore, in 2019, detailed operational guidelines were developed by the Uganda National Tuberculosis and Leprosy Program (NTLP) to guide and standardize TB contact investigation processes at health facility and community levels [ 8 ].

Despite the WHO policy guidance, coverage of TB contact investigation in many TB high burden countries such as Uganda, Kenya, Lao Republic, Pakistan and Yemen is still low [ 10 ]. A meta-analysis conducted in 2015 by Block et al., showed low TB contact investigation coverage in five countries (2.8% in the Lao Republic, 4.8% in Kenya, 14.9% in Pakistan and 15.1% in Uganda) and high coverage in one country (91.7% in the Democratic Republic of Congo) [ 10 ]. Armstrong et al. (2017), in a prospective multi-center observational study conducted in Kampala, Uganda, reported significant drop-out rates across the steps in the contact investigation cascade [ 11 ]. Among the 338 clients eligible for TB contact investigation, only 61% were scheduled for home visits, and only 50% of them were visited [ 11 ]. Furthermore, among the 131 people who were screened for TB and required definitive evaluation, only 20% were evaluated [ 11 ].

In rural Uganda, the coverage of TB contact investigation is much lower (15.1%) than that in urban areas such as Kampala (20%), and yet many of the missing TB cases are in such hard to reach and underserved rural areas [ 10 , 11 ]. This low coverage increases undiagnosed and untreated TB patients, thus perpetuating the TB pandemic. Furthermore, without TB contact investigation, many TB patients might infect other people in the household and the community, or die from TB related complications [ 12 ]. The low contact investigation coverage contributes to a high numbers of missed diagnoses in Uganda (400,000 in 2014), and high TB transmission rates, which hamper progress towards achievement of the third United Nations Sustainable Development Goal of ending the TB epidemic by 2030 [ 13 ].

Implementation research helps to connect research and practice by speeding-up the development and provision of public health interventions [ 14 ]. Given that urban settings have been the primary focus of the majority of implementation research studies in Africa and that the burden of TB differs between urban and rural areas [ 7 , 15 , 16 ], this study used implementation research tools to investigate the barriers to and enablers of TB contact investigation coverage in rural southwestern Uganda [ 3 ]. Although 82% of the Ugandan population lives in rural areas, there is inadequate information about TB contact investigation coverage, and its barriers and facilitators in rural settings [ 17 ]. The purpose of this study was to investigate the barriers and facilitators of investigation coverage among contacts of TB patients in rural Uganda.

The Consolidated Framework for Implementation Research (CFIR) by Damschroder et al. was used to explore barriers and facilitators of implementation in this study [ 18 ]. The framework consists of 39 constructs and five domains: characteristics of the intervention, inner setting, outer setting, individuals involved and implementation process [ 18 ]. The framework has been widely used across the globe to identify the barriers and facilitators of implementation outcomes in various healthcare settings, for example, evaluation of the online frailty tool in primary health care in Canada, integration of hypertension-HIV management in three Ugandan HIV clinics, examining the task shifting strategy for hypertension control at 32 hospitals and community health centers in Ghana and evaluating the implementation context of a quality improvement program for increasing vaccination coverage in Nigeria [ 19 , 20 , 21 , 22 ].

Study setting

This study was conducted in the rural district of Mbarara, located in the southwestern region of Uganda, about 270 km southwest of the capital city, Kampala. According to the 2014 population and housing census, the district had a population of 472,629 (Land area 1785.6 km 2 ), of which 59% resided in rural areas [ 23 ]. In total the district had 87 health facilities including 48 government owned, 26 private clinics and 13 nonprofit health facilities [ 24 ]. There were no data on TB contact investigation available at district level. Health Centres (HC) in Uganda are ranked II, III or IV based on the administrative zone served by the health facility with level II serving a parish, level III serving a sub-county and level IV serving a county [ 25 ]. A HC IV is expected to serve a population of at least 100,000 people. The services offered included general outpatient clinic (including TB and HIV care), immunization, antenatal care, maternity services, inpatient, laboratory, emergency surgery and blood transfusion [ 25 ].

The Ugandan health system operates on a referral basis, with the lowest level of health care provided by community health workers called Village Health Teams (VHTs) and the highest level of care offered at highly specialized hospitals called National Referral Hospitals. Levels of health care increase with complexity in terms of the packages of services offered, staffing levels, and the size of the population served. Three health facilities where the study was conducted were purposively selected due to their rural location, level of care (IV), and significant volume of patients compared to lower levels (II and III).

Coordination of TB services in the district was done by the District TB and Leprosy Supervisor (DTLS), who is responsible for 26 TB diagnostic and treatment centers. Regional coordination of TB activities is done by the Zonal TB and Leprosy Supervisor (ZTLS), while national level coordination and policy formulation is done by the National TB and Leprosy Program (NTLP) [ 15 ].

Study design and study population

A qualitative, exploratory study design was conducted to identify barriers and facilitators to implementing TB contact investigations between April and July 2020. Semi-structured interviews were conducted with all 19 health workers who were purposively selected based on their direct participation in the implementation of TB interventions since they were likely to have the most knowledge and experience with TB contact investigations. These included TB focal persons at the health facilities, clinical officers, nurses, laboratory staff, VHTs, and District TB and Leprosy Supervisors. Health workers who were not in the health facility during the data collection period were excluded from the study. The Consolidated criteria for reporting qualitative studies (COREQ) were applied to comply with the reporting standards (Table S2 ) [ 26 ].

Data collection

Semi-structured interview guides were developed and included background information about study participants and questions developed according to the five domains of the CFIR. The VHT interview guides were translated into the regional dialect and put through a pilot test to ensure that the questions were understood and to gauge how long the interviews would take. Two health facilities that provided comparable research sites in terms of staffing levels and services were used for the pilot testing.

Physical interviews for the study participants were conducted by the lead researcher (PT) in either English or Runyankore and each interview was tape recorded while a trained research assistant took field notes. Data collection for each category of study participants was continued until saturation was reached [ 27 ]. Since data collection took place during the first wave of the COVID-19 pandemic, precautions were taken to prevent COVID-19 cross-infection on both the researcher and the participants. Interviews were conducted at the selected health facilities in well-ventilated spaces, with both the interviewer and the participant wearing N-95 respirators, and surgical masks, respectively. Each interview lasted between 30 and 45 min and no repeat interviews were conducted.

Data management and analysis

Data were transcribed verbatim by the research team and the lead researcher listened to each audio recording while reading through the transcripts to correct errors in transcription and familiarize himself with the data. Transcripts were not given back to the participants for review or comments because evidence suggests that interviewee transcript review does not add value to the quality and rigor of qualitative research [ 28 ]. PT and JN reviewed the transcripts and made initial notes of interesting features or potential codes and themes in the data. The transcripts were then uploaded into MAXQDA 2020, and analyzed using reflexive thematic analysis in six iterative and recursive steps as described by Braun and Clarke [ 29 ]. The six steps included (1) familiarization with the data, (2) coding, (3) searching for themes, (4) reviewing the themes, (5) naming and defining the themes, and (6) writing the report [ 29 ]. The first step of the analysis was to look at the participants’ own words and expressions, without preconceived notions or classifications. The researchers then examined the language used by each participant in relation to the five domains of the CFIR. To ensure the reliability and credibility of the research analysis, both researchers PT and JN developed the themes by reading the transcripts independently to establish inter-coder agreement [ 30 ]. After the initial coding, the two-member team met to discuss the independently developed codes and themes and to reach an agreement on the themes. The transcribed texts and quotes were then grouped into themes, and the lead researcher used a reflexive approach to identify similarities or differences among CFIR domains and constructs. This iterative and recursive process provided space for reflexivity and ensured the credibility of the research findings. Themes were then defined and further refined to reflect the challenges and enablers of contact investigation coverage.

The research team and reflexivity

The field research team consisted of the principal investigator (PT), a male master’s student at the University of the Witwatersrand, and a female research assistant (GA), who is trained in population studies and monitoring and evaluation, and she was not employed at the time of this study. The principal investigator is a medical doctor who has training and experience in TB care and is familiar with WHO TB guidelines for contact investigations. He was not affiliated with the District Health Department or the Ministry of Health NTLP and is therefore unlikely to have influenced participant responses. Prior to the study, the principal investigator received training in qualitative research methods at the University of the Witwatersrand, so he was aware of how a researcher’s background, location, and assumptions can influence a qualitative study. The research team did not know the participants beforehand, and they were not directly involved in patient care in a way that would have influenced their responses.

Ethical considerations

This study was cleared by the Human Research Ethics Committees (Medical) at the University of the Witwatersrand (M200101), and Mbarara University of Science and Technology (MUREC 1/7). The Uganda National Council for Science and Technology granted permission to conduct the study in Uganda (HS569ES). Administrative approval was obtained from the District Health Officer, and the health facility managers of the respective study sites. Information about the study was shared with the participants before the interviews and written informed consent for participation and audio recording was obtained from each participant. To preserve participant privacy, interviews were conducted in a private space within the outpatient units, with only the researchers and the participants present.

Characteristics of study participants

Nineteen participants took part in semi-structured interviews with a response rate of 100% and 21.1% ( n  = 4) of them were male (Table  1 ). The sample comprised five clinical officers (26.3%), five nurses (26.3%), six VHT members (31.6%), one laboratory technician (5.2%), and two DTLs (10.5%). Eight of the participants (42.1%) had over three years’ experience in offering TB care. Clinical officers were paramedics with a diploma in clinical medicine, as opposed to nurses who had a bachelor’s degree in nursing, a diploma, or a nursing certificate. VHTs were lay health workers based in the community to aid with TB interventions in the local population. Laboratory technicians had a diploma in laboratory sciences, whereas DTLSs had one in nursing or clinical medicine.

Barriers and facilitators of TB contact investigation coverage

A reflective thematic analysis of the data gave rise to three themes: health system, contextual and intervention-related factors. The barriers and facilitators identified under each of the three themes (Table S3 ). Based on the WHO’s health system building blocks, the factors affecting the health system emerged under six sub-themes: human resources, commodities, service delivery, leadership and coordination, funding, and health information systems. Contextual factors were further categorized into geographic, social, and cultural, economic, and policy-related factors. Issues affecting TB contact investigations linked to the intervention itself were covered by the final theme (intervention-associated factors).

Barriers and facilitators

Domain 1: characteristics of the intervention.

The intervention related factors reported by the participants fell under three constructs, that is: evidence-base, intervention complexity and implementation cost.

Evidence-base

Out of the 19 healthcare workers involved in this research, 16 were aware of the intervention and its effectiveness in detecting, treating, and stopping the spread of tuberculosis in the community. Some of them had even engaged in relevant programs at the district, health facility, and community levels to improve uptake, such as support supervision, enlisting household contacts, home visits, health education, screening, and sputum sample collection. The DTLSs reported that training and regular orientation on several aspects of TB management, including TB contact investigation, provided easy access to knowledge and information. The district provided training on TB contact investigation to health workers in different platforms, including quarterly performance review meetings. As a result, they had the necessary information, abilities, or confidence to carry out contact investigation tasks.

“Even in meetings , we talk about contact tracing and investigation. Because for us we do meetings quarterly , all those meetings we…include a training in contact tracing and investigation” (Respondent 1—Nurse).

Intervention complexity

Three VHTs reported that TB contact investigations had multiple processes and therefore required a team to go for community visits, which interfered with other ongoing interventions at the health facility, such as TB screening at outpatient clinics, linking positive patients to treatment, providing community-based DOTs for patients on treatment, and following up with clients who defaulted on treatment. They also assisted with other medical services, such as immunizations, prenatal care, and providing ART refills to stable HIV patients. Therefore, during contact investigations, VHTs were mostly involved in community activities, leaving some of the basic facility-based interventions unattended.

“…it interferes with other programs… Now I am here working at the health facility , collecting sputum , screening and… I have many patients attending immunization , antenatal , ART (HIV clinic) , and I am the one who works on them too. And after that , I want to go and do contact tracing… Sometimes I ignore some of the facility activities so that I spare some time to go and do contact tracing in the community” (Respondent 4—VHT) .

Cost of the intervention

During TB contact investigations, it may be required to phone many patients or contacts. It is frequently necessary to call people who have appointments but do not show up at the health facility. Healthcare workers find it challenging to make these calls due to the high airtime requirements of this intervention and the associated cost.

“…some of these contacts need to be contacted on the phone several times because someone tells you he is coming tomorrow; and he doesn’t come. And the person keeps giving appointments without coming. And we do not have all that airtime…” (Respondent 5—Clinical Officer) .

Domain 2: outer setting

Funding from external entities: inadequate funding.

Multiple funding related challenges were reported at national, district and health facility levels. Funding for TB contact investigation was provided, through the Primary Health Care grants released from the Ministry of Health to public health facilities. Additional funds for contact investigation came from USAID through the Regional Health Integration to Enhance Services in Southwestern Uganda; a program for scaling up access to comprehensive HIV, TB and reproductive health services in the region.

Health workers believed that TB was not considered a priority by the Ministry of Health, which led to underfunding of the NTLP, and eventually underfunded TB work at district, health facility and community levels. TB interventions were not integrated into the annual budgeting processes like other interventions. For example, Malaria and sanitation interventions received funds, while TB remained unfunded, since 2014. The DTLS reported that the sanitation program was prioritized and funded better than the TB program, because of the advocacy by the sanitation program.

“…I think if the government says , ‘let us fight this disease’ , they need to put in (funds). Let them consider TB across the board. Let them budget for it like the way they budget for other conditions. Malaria is budgeted for , sanitation…receives money every quarter. But it is like six years (since 2014) when there was money for TB…and it was for only one quarter” (Respondent 1—Nurse).

The DTLSs reported insufficient funds for TB support supervision at the district level, which limited the amount of time the district TB supervisor spends in each health facility for supervision visits. Eventually, the quality of the supervision was compromised because teams did not have sufficient resources to train, mentor and supervise health facility teams.

“Because of the funds being little , we are forced , like in a day , to move to about four facilities. Remember , in TB , there are six indicators that you need to focus on and get to understand what the problem is. So , you find we do not have sufficient time to spend in the facility and support it.” (Respondent 2—Clinical Officer).

Health facility level funding challenges included delayed reimbursement of funds, and inadequate funds for home visits. In some cases, health facilities rely on NGOs for extra funds to conduct contact investigations, because of insufficient funds from the Primary Health Care (PHC) fund.

“…but when you do not have that NGO , things are challenging because you know that PHC money cannot be enough. You find that the PHC money is for only two patients , yet you have like six of them (to follow-up). So , when you do not have that money from NGOs , you cannot do it smoothly.” (Respondent 2—Clinical Officer) .

Some participants reported that they used their own money to trace index TB contacts; however, this money takes a long time to be refunded. Some participants even had a pay gap of about five months, which lowered their morale to continue with community visits.

“Most of the cases , we use our own money… you want to do your job , but transport facilitation (is missing)! Even…when they decide to refund it (money) , it takes so long…for example , since January we have never got that transport (money). We did contact tracing in January , February , March , April and May; we gave them reports , and they see that we are working , but we do not see our transport (refund)” (Respondent 16—VHT).

Critical incidents: COVID-19 pandemic related factors

This study was conducted during the first wave of the COVID-19 pandemic a lockdown policy was implemented by the government. This was characterized by suspension of public and private transportation, some health workers, TB patients and their contacts were unable to access health facilities. These restrictions affected the mobility of the health workers and patients to the health facility, and undermined TB contact investigation efforts. Besides lockdown measures, the COVID-19 pandemic was also associated with stigma among patients and health workers. Some TB contacts were afraid to report cough, in fear of being suspected of having COVID-19 and having to be quarantined for 14 days as per the MOH recommendations at the time. COVID-19 heightened the stigma associated with TB, because the two conditions have similar symptoms. Health workers could not tell who had COVID-19 or TB and, therefore, avoided anyone presenting with cough, because they feared it might be COVID-19. Some laboratory personnel declined to examine sputum samples because they were concerned that the samples might contain COVID-19 and increase their risk of getting the virus.

“Now with corona (COVID-19) , we would come here and not find any patient or health worker because they did not have transport means during the lockdown. Most of our people stayed at home. Even if you had your own motorcycle , they would not allow you to ride it…” (Respondent 13—Clinical officer).

Partnerships and connections: collaboration with NGOs and community-based organizations

Health workers and VHTs reported that the district and health facilities are networked with NGOs and community-based organizations which support the implementation of TB contact investigation and other health interventions. The primary implementing partner was Regional Health Integration to Enhance Services in Southwestern (RHITES-SW) Uganda, which supports the district with transportation and materials, while doing household visits.

Along with funding TB contact investigation, district-based NGOs also sponsored radio airtime to increase awareness and create demand for TB services.

“…RHITES-SW provides us with materials to use , like carrier bags. They provide us with transport to do contact tracing and the information. They normally update us on each and everything that is current in contact tracing and investigation” (Respondent 5—Clinical officer) . “Other stakeholders are working hand in hand with the government and our implementing partners. I see them working as a team to sponsor airtime on radios to create awareness and give some financial assistance.” (Respondent 12 , Clinical Officer).

Policies and laws: availability of updated operational guidelines

The district established favorable communication networks at district and health facility levels, facilitating efficient communication of guidelines, reference materials, and patients’ results. For example, the district had a WhatsApp group, specifically for the district TB team, to share information and monitor district activities.

“…we have a WhatsApp group of all the in charges and TB focal persons , where we discuss TB management and…share guidelines , so whoever needs guideline in TB management , he just goes there” (Respondent 1—Nurse).

Domain 3: inner setting

Available resources.

The barriers that emerged under available resources included, lack of personal protective equipment (PPE), stock-outs of Xpert MTB cartridges and shortage of human resources. Commodities that frequently went out of stock included toolkits for TB contact investigations and Xpert MTB cartridges for conducting Xpert MTB and RIF tests. At times health facilities spend about two months without cartridges, and health workers were notified by the laboratory team not to send sputum samples for analysis, which weighs down contact investigation efforts. Additionally, VHTs reported the lack of essential tools for community visits, especially during extreme weather. Health facilities also frequently ran short of PPE for home-based contact screening, such as masks and gloves, which discouraged them from doing community contact tracing out of fear of acquiring TB.

“…sometimes , there are no GeneXpert (Xpert MTB) cartridges; you find that we are not doing GeneXpert (tests) because cartridges are finished… , at times we take like a month or two without cartridges and…that is not good… , the lab people tell us , ‘do not send samples this month , we do not have (cartridges)’ , which means we are missing people (patients).” (Respondent 12—Clinical Officer). “At times you go to a difficult place…in a rainy season… , you climb a hill while it is raining on you. You do not have an umbrella; you do not have boots or a bag to carry the stuff (materials)…” (Respondent 4—VHT).

Human resource shortage was also reported as barrier. Sometimes, only one health worker was available to go for community visits, yet there are multiple tasks to do, including health education, screening, and sample collection. Therefore, this scarcity of human resources affects the quality of implementation since some of the tasks are left incomplete.

“…sometimes there is a lack of manpower because…the health workers are not enough at the facility , so you find that only one person is going for contact tracing , and the work there is huge , and that person cannot do all the work alone. So , most of the things are not done. They do part of the work and leave out some” (Respondent 15—Nurse).

Two facilitators were discussed under the construct of available resources: presence of a landline telephones to aid communication and a motorcycle to support transportation during community visits. The telephones were loaded with airtime for scheduling household visits and communicating Xpert MTB/RIF results from the hub laboratory while the motorcycle helped to reduce the cost of transportation since community visits only required fuel for the motorcycle.

“We have a health facility motorcycle , which does not force us to put in a lot of money… We just consider the distance we are covering and then put in fuel and move , which is easier than getting a boda-boda (motorcycle taxi).” (Respondent 16—VHT).

Structural characteristics: rugged terrain and poor road network, paper-based reporting systems, and hub and spoke laboratory system

All six VHTs reported that some patients came from hard-to-reach areas, characterized by rugged terrain, where vehicles or motorcycles cannot reach. This makes it hard for health workers to visit such communities for contact investigations. Additionally, some places have poor roads that are impassable during the rainy season, thus affecting service delivery. In such circumstances, health workers use boda-bodas (motorcycle taxis) to a certain point, and then walk the remaining distance. Sometimes the terrain is hilly and exhausting, which discourages teams from doing community visits. Large health facility catchment areas also made it more difficult for field teams to deliver contact investigation services to distant households. As a result, contacts of index TB cases from remote places were instead asked to come to the health facility for further evaluation, however, some of them did not come.

“…for those people who come from hard-to-reach areas , going to those homes is quite challenging. Sometimes we reach a point of walking on foot because we cannot reach there using a car or a motorcycle. So , we must climb a steep hill to look for those patients” (Respondent 4—VHT). “This is a big sub-county; people come from distant areas , even neighboring districts. And of course , as a health worker , you cannot reach every homestead. So , some (contacts) are called to come to the health facility. But because of the long distances , some fail to come.” (Respondent 4—VHT).

Another barrier was the use of the paper-based reporting system. One of the TB focal persons reported that TB contact investigation reports were submitted manually using a paper-based system which affects timeliness of reporting. Submission of reports had to wait for an opportunity when someone was going to the district headquarters, which causes a delay and eventually affects re-imbursement of the payments for activities.

“Sometimes , since we are sending the reports to Mbarara , they reach late because of transport issues. It becomes hard for someone to send the report since you cannot get any transport , so you get someone going to Mbarara , give them the reports , and tell that person where they should be delivering the reports. So , it also takes a bit of time” (Respondent 8—Nurse).

The laboratory system in the district used a “hub and spoke” system, where laboratory samples are collected in peripheral laboratories and transported by motorcycle riders to the central laboratory for analysis. However, participants reported that this system was dysfunctional because of the long results turn-around time, compromised early TB diagnosis and treatment and affected TB contact investigation coverage. In some cases, health workers spent up to two months, waiting for Xpert MTB results.

“And we have a challenge with hub riders… Sometimes , the hub riders take sputum samples to Mbarara , and if they do not go back to pick the results , you will never see them. And you end up spending around two months without results” (Respondent 12—Clinical Officer).

Domain 4: individuals involved

Under characteristics of the individuals involved, participants reported the presence of internal implementation leads called TB focal persons at health facility and DTLS at district level. These were responsible for coordinating the provision of TB services and technical leadership and supervision of the TB program and different levels of care. Additionally, health workers received adequate training on various aspects of TB management including TB contact investigation. Such training sessions supported them with the adequate knowledge and skills to confidently conduct contact investigation activities.

Domain 5: implementation process

The three constructs that emerged under implementation process were planning, engaging and reflection and evaluation.

The DTLSs reported that leaders at the Ministry of Health had transferred the planning, coordination, and funding of TB interventions, including TB contact investigation. Instead, this role was left to implementing partners, usually local and international Non-Governmental Organizations (NGOs), which negatively impacted the TB program at district level. Also, participants reported that implementing partners tend to have different priorities. For example, these organizations mainly focus on HIV interventions, and less on TB. Therefore, it is challenging to divert them from their preferences and focus them on district priorities, since their priorities are often guided by donor funding.

“Also , The Ministry of Health has deliberately left this work (TB contact investigation) …to implementing partners , and it has killed everything. And in that line , I think we can eradicate TB , but if the government is putting in (effort) , not leaving this disease for the implementing partners.” (Respondent 1—Nurse). “They tell you their priority is HIV , and you cannot shift them. They have their …operational guidelines that you cannot change.” (Respondent 1 , Nurse).

Reflection and evaluation

data use to inform program decisions by the district health team was identified as a facilitator. The district held quarterly performance and reflection meetings with the participation of the district’s NGOs, community-based organizations, district health management team, and healthcare providers from the various health centers. In these meetings, attendees discussed their performance, challenges across the different technical areas, and strategies for bridging the gaps.

the involvement of all stakeholders within the district, including health facility teams, district teams, NGOs, and community-based organizations involved in the TB program, in regular engagements to review implementation progress, performance, and plan improvement strategies was reported as a facilitator. Non-Governmental Organizations are actively involved in discussions regarding potential funding opportunities for specific activities.

“…we normally have the district stakeholders meeting , where they (external stakeholders) normally come here , and we discuss performance in different areas - MCH (maternal and child health) and HIV; TB is also given a platform. We tell them about our challenges.” (Respondent 1—Nurse) .

The stigma associated with TB was reported as a common challenge by all participants in this study. For this reason, index TB patients preferred not to be visited at home by a health worker, out of fear of being stigmatized if neighbors and other community members found out that they had TB. Some index TB patients even tried to avoid being visited by giving health workers incorrect phone numbers and physical addresses. Patients with TB and HIV co-infection have an increased fear of disclosing their status because of the misconception that every TB patient has HIV. Additionally, poverty among index TB patients was also found to be a challenge because contacts of TB patients lacked funds to transport them to the health facility for assessment, diagnosis, and treatment. As a result, it was necessary for health professionals to collect sputum samples from the community and bring them to the health facility for analysis. This, however, was not always feasible, leaving some of the contacts of TB patients unevaluated.

“…some patients give us wrong telephone contacts , we call the number , it is not on , or a different person picks it. So , we fail to trace that person. Some fear health workers going to their homes. Mostly when the index TB patient is also HIV positive , they do not want people in their villages to see any health care worker coming to their home because they may identify them” (Respondent 11—VHT).

This study explored the factors influencing TB contact investigation coverage in three rural, primary health facilities in Southwestern Uganda. The study is unique in its rural focus unlike previous studies in Uganda and Kenya, which were conducted in cities [ 7 , 15 , 31 ]. The barriers and facilitators identified in this study were diverse and covered all the five domains of the CFIR. Although some studies have used other implementation research tools to identify the barriers and facilitators to implementing TB contact investigation, this study used the CFIR to explore the factors influencing TB contact investigation coverage in Africa.

The key challenges that emerged from this study included health system challenges, such as the lack of funding for TB contact investigation, insufficient PPE and inadequate Xpert MTB equipment for diagnostic testing. The rugged terrain and poor road networks in rural communities also made it difficult for health workers to access patients in the community, and vice versa. Poverty, TB- and COVID19-related stigma were also perceived as barriers. On the other hand, the facilitators to TB contact investigation included an increased awareness of TB contact investigation, adequate knowledge of the Ugandan MoH guidelines, confidence in delivering the intervention and on-the-job training of health workers. In addition, the availability of a telephone and transport to schedule and make household visits were reported as facilitators. The support of key district stakeholders involved in TB contact investigations and quarterly performance review meetings also emerged as facilitators.

The health system barriers that emerged from this research were inadequate or irregular funding, human resource shortages, lack of PPE supplies (face masks, gloves, raincoats, and gumboots), out of stock of Xpert MTB cartridges and lack of airtime for communication. In addition, inadequate or inconsistent funding limited the frequency of the DTLS visits to health facilities for supervision and caused a delay in payment of travel and allowances to field teams, causing TB contact investigation operations to be hampered. This finding is in contrast with another study conducted in urban Kenya, which found that the TB program received sustainable funding for infrastructure and health workforce for contact investigation [ 32 ]. Furthermore, this Kenyan study used the WHO health systems framework. It focused on the stakeholder perspectives of the barriers and facilitators to optimizing TB contact investigation in Nairobi, the capital of Kenya. This funding disparity between rural and urban areas could be due to a higher TB prevalence in most urban settings thus attracting the attention of policy makers to allocate more resources there [ 33 ].

Consistent with this study, three studies conducted in Botswana, Ethiopia and Uganda reported human resource shortages as a considerable hindrance to TB contact investigation coverage [ 3 , 15 , 16 ]. In urban Uganda, health workers had other competing duties in the TB clinics, thus, they did not have sufficient time for community-level activities, including household contact tracing [ 15 ]. In this study, sometimes only one health worker was available for community visits, and they could not complete multiple tasks, such as health education, screening, sample collection, HIV testing and documentation in the registers. The staff shortage is partly attributed to a small number of staff trained in TB, and assigning them responsibilities in other units outside the TB unit [ 3 ].

Another challenge identified in this study was a lack of PPE materials such as masks, gloves, raincoats and gumboots for health workers to protect themselves against TB and other infectious diseases (such as COVID-19). Health staff were hesitant to conduct household contact investigations without wearing masks and gloves, to avoid contracting TB and COVID-19. Similarly, protective gear, such as raincoats and gumboots, to be used in harsh weather conditions, were not provided to health workers. There is limited literature on the influence of PPE materials on TB contact investigation coverage and this calls for more research in this area. These findings indicate that the supply chain management system for essential infection control materials is weak. These findings emphasize the need to strengthen mechanisms to guarantee sufficient PPE supplies and sustain the supply chain for these products.

The context within which an intervention is implemented, is recognized as a significant determinant of implementation success [ 18 ]. Contextual factors refer to issues about a person or their environment that can positively or negatively affect the delivery of an intervention [ 18 ]. Socio-economic, policy-related, and geographical barriers emerged as contextual barriers in this research. The socio-economic factors included poverty, lack of phones where patients can be contacted to confirm the appointment of household visits, stigma, and fear of reporting cough in fear of being labelled as having COVID-19.

In Botswana, Kenya, Ethiopia, and Uganda, the stigma associated with Tuberculosis has been reported as a barrier to TB contact investigation. [ 3 , 7 , 15 , 16 ]. Although these studies did not specifically focus on TB contact investigation coverage, stigma hindered household visits, because index TB patients avoided home visits by health workers, out of fear of their status being disclosed to the community and discrimination from them, which could eventually affect demand and coverage of the intervention. An important observation in our study was that stigma was aggravated by the misconception that every TB patient has HIV, and the emergence of the COVID-19 pandemic. Tuberculosis and COVID-19 have common respiratory symptoms (cough, fever, and breathing difficulties), making it difficult to distinguish the two. This causes diagnostic confusion, and the health workers may also avoid such patients, in fear of contracting COVID-19 [ 34 ]. Furthermore, because of the new COVID-19 stigma, patients with a chronic cough might fear coming to the health facilities for diagnosis, thus complicating the two pandemics [ 34 ].

The COVID-19 lockdown policy implemented in 2020 by the Government of Uganda posed significant challenges to TB contact investigation efforts. Both health staff and patients could not access health facilities, due to stringent lockdown measures, including travel restrictions and public and private transportation prohibitions. Additionally, health providers could not conduct home visits to screen the contacts. Similar findings were found in another study on the impact of COVID-19 on TB programs in Western Pacific nations [ 35 ]. Other COVID-19 related problems encountered in the Western Pacific study included a change in priorities towards the COVID-19 response, as demonstrated by the relocation of TB program staff to the COVID-19 response, and a reduced willingness of patients and contacts to visit health facilities [ 35 ]. Therefore, innovative strategies are required to streamline TB contact investigation in the context of the COVID-19 pandemic.

As reported by Cattamanchi et al., geographical challenges contribute to the failure of TB patients and contacts to present at health facilities for TB care [ 36 ]. In their study, health workers reported that the physical remoteness of patients’ homes from the health facility and the rugged terrain encountered during travel, was a challenge [ 36 ]. Likewise, in this study, health workers reported that some index TB patients and contacts came from distant and challenging areas, with steep hills and poor road networks, preventing access to health facilities. This challenge was aggravated by poverty, because patients and contacts from the periphery of the county could not travel to health facilities because of high transport costs.

Facilitators

All health workers interviewed in this study reported awareness of the intervention. They had even engaged in relevant programs to improve its uptake, including enlisting household contacts, home visits, screening, and sputum sample collection. In addition, the clarification of the various steps demonstrated health workers’ adherence to the organizational protocols for TB contact investigations. The increased awareness and fidelity to the guidelines may be attributed to the development and dissemination of local contact investigation guidelines through training and the use of electronic media, such as WhatsApp. Conversely, a similar study conducted in rural Ethiopia found that awareness and adherence to the guidelines were poor because of a lack of refresher training. [ 3 ].

The health system facilitators that emerged from this study include good provider knowledge and access to information, performance review meetings at the district level, and engagement of district stakeholders to obtain their support. In contrast to other studies in Uganda, Ethiopia, and the USA, provider knowledge and confidence (self-efficacy) worked as a facilitator in this study because staff involved in TB contact investigation had received on-the-job training on various aspects of TB management, including contact investigation, diagnosis, and management [ 3 , 15 , 37 ]. In this study, health workers reported that they had the knowledge, skills, and confidence to conduct TB contact investigations successfully. These results are partly attributed to the quarterly district performance review meetings, in which an orientation on TB contact investigation was done and guidelines were shared with health workers.

Reflection and evaluation in TB contact investigation performance were demonstrated by Karamagi et al., in a Quality Improvement study to improve case finding in Northern Uganda [ 38 ]. A review meeting was held to discuss progress on active case finding and develop scale-up plans for the intervention [ 38 ]. Similarly, this study found that quarterly district review meetings were held, to discuss district and health facility performance, challenges, and improvement strategies in various program components, including TB contact investigation. These reflection meetings involved district-based stakeholders such as NGOs, health workers, TB focal persons, and health facility managers, and this promoted ownership of the interventions, and helped in resource mobilization. These meetings were also used to review quarterly TB performance, and develop action plans to improve multiple TB indicators, including TB contact investigation.

Strengths and limitations of the study

This study had the following strengths. First, we included various health provider categories at different levels of the district healthcare system, including community, health facility and district levels, to obtain different perspectives from the participants. Second, this study used implementation science methods such as the CFIR to investigate the rural perceptions of the challenges and enablers of TB contact investigation coverage. The CFIR provided a framework for developing the semi-structured interview guides and interpretation of study findings and this promotes transferability of these results to other settings.

Some weaknesses were also observed. First, index TB patients and their contacts were not interviewed; therefore, some information on the challenges and enablers of contact investigation coverage from the patients’ and caregivers’ perspective may have been missed. Second, data collection was conducted during the COVID-19 lockdown, and some health workers were inaccessible, especially laboratory personnel involved in pandemic control activities at the time. Consequently, the laboratory may have challenges that were not identified in this study. Third, the COVID-19 pandemic may have aggravated some challenges, which were not so pronounced before the pandemic. Finally, the generalizability of our results to other geographical locations may be limited, because this study was conducted in one district in Uganda, which gives it a smaller scope. However, we included three health facilities in different counties, which may improve transferability to other settings.

This study explored health providers perceptions of the barriers and facilitators of TB contact investigation in rural Mbarara district, Southwestern Uganda. This study found that most of the challenges limiting TB contact investigations in rural communities are related to health system; for-example inadequate or delayed funding and human resource shortages. The Ministry of Health in Uganda therefore must strengthen the health system building blocks, particularly health financing and human resources to establish a robust TB control program that will enable the efficient identification of missing TB patients. It also demonstrated the unique challenges affecting the rural settings regarding tuberculosis contact investigation including lack of personal protective equipment, stock-out of Xpert MTB cartridges, shortage of airtime for communication, TB-related stigma, and inconsistent funding for TB contact investigation. Further research is needed to determine the effectiveness of potential implementation strategies for eliminating these barriers in rural communities. Also, having identified the disruptive nature of the COVID-19 pandemic to the achievement of optimal TB contact investigation coverage, there is a need to develop measures for integrating both COVID-19 and TB contact investigation interventions.

Data availability

The dataset used in the current study are available from the corresponding author on reasonable request.

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Acknowledgements

I acknowledge the contribution of Grace Ayebazibwe (GA), who supported me during the data collection and analysis by taking field notes, transcription, and translation of audio recordings.

This research work was supported by TDR, the Special Program for Research and Training in Tropical Diseases, which is hosted at the World Health Organization, and co-sponsored by UNICEF, UNDP, the World Bank and WHO. TDR grant number: B40299, first author ORCID ID: 0000-0001-9722-1202. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funder.

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PT, NN and PM participated in the conceptualization and design of the study, developing interview guides, writing the initial version of the manuscript, and reviewing subsequent versions, with substantial input from NMT. With assistance from NN and PM, PT and JN conducted the data analysis. Each author contributed to the writing of the manuscript, and they all reviewed and gave their approval for publishing of the final draft.

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Tukamuhebwa, P.M., Munyewende, P., Tumwesigye, N.M. et al. Health worker perspectives on barriers and facilitators of tuberculosis investigation coverage among index case contacts in rural Southwestern Uganda: a qualitative study. BMC Infect Dis 24 , 867 (2024). https://doi.org/10.1186/s12879-024-09798-9

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Gallery: Southeastern NC hit by heavy rain, flooding

WILMINGTON, N.C. (WECT) - A storm Monday morning brought heavy rain and lightning to the area, closing roads and knocking over some trees.

You can see photos of the storm impacts below and see video coverage of the storm at the top of this story.

New Hanover County

Brunswick County

Columbus County

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School schedule changes for Tuesday due to storm’s impacts

Multiple major highways closed in Brunswick County and other traffic impacts due to flooding

One injured in car wreck on Highway 210/17

Police: Over 3,000 doses of fentanyl, 1.5 kilograms of cocaine seized in investigation

Trump was the subject of an apparent assassination attempt at his Florida golf club, the FBI says

Feds arrest New Hanover County Moms for Liberty vice chair on Jan. 6 charges

First Alert Weather Team gives update on ongoing heavy rain in the Cape Fear

Latest news.

New Hanover and Pender Co. Schools issue statements on not canceling Monday classes

Hundreds stranded for hours after U.S. 17 closes due to historic rainfall

State of Emergency and mandatory curfews in Brunswick County & Southport

WECT announces third winner of the 2025 Collector’s Calendar Contest

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SIMILAR LUXURY YACHTS FOR CHARTER

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