interview protocol qualitative research example

Sample Interview Protocol Form

Faculty interview protocol.

Institutions: _____________________________________________________

Interviewee (Title and Name): ______________________________________

Interviewer: _____________________________________________________

Survey Section Used:

_____ A: Interview Background _____ B: Institutional Perspective _____ C: Assessment _____ D: Department and Discipline _____ E: Teaching and Learning _____ F: Demographics (no specific questions)

Other Topics Discussed:____________________________________________

________________________________________________________________

Documents Obtained: _____________________________________________

Post Interview Comments or Leads:

Teaching, Learning, and Assessment Interviews

Introductory Protocol

To facilitate our note-taking, we would like to audio tape our conversations today. Please sign the release form. For your information, only researchers on the project will be privy to the tapes which will be eventually destroyed after they are transcribed. In addition, you must sign a form devised to meet our human subject requirements. Essentially, this document states that: (1) all information will be held confidential, (2) your participation is voluntary and you may stop at any time if you feel uncomfortable, and (3) we do not intend to inflict any harm. Thank you for your agreeing to participate.

We have planned this interview to last no longer than one hour. During this time, we have several questions that we would like to cover. If time begins to run short, it may be necessary to interrupt you in order to push ahead and complete this line of questioning.

Introduction

You have been selected to speak with us today because you have been identified as someone who has a great deal to share about teaching, learning, and assessment on this campus. Our research project as a whole focuses on the improvement of teaching and learning activity, with particular interest in understanding how faculty in academic programs are engaged in this activity, how they assess student learning, and whether we can begin to share what we know about making a difference in undergraduate education. Our study does not aim to evaluate your techniques or experiences. Rather, we are trying to learn more about teaching and learning, and hopefully learn about faculty practices that help improve student learning on campus.

A. Interviewee Background

How long have you been …

_______ in your present position? _______ at this institution?

Interesting background information on interviewee:

What is your highest degree? ___________________________________________

What is your field of study? ____________________________________________

1. Briefly describe your role (office, committee, classroom, etc.) as it relates to student learning and assessment (if appropriate).

Probes: How are you involved in teaching, learning, and assessment here?

How did you get involved?

2. What motivates you to use innovative teaching and/or assessment techniques in your teaching?

B. Institutional Perspective

1. What is the strategy at this institution for improving teaching, learning, and assessment?

Probes: Is it working – why or why not?

Purpose, development, administration, recent initiatives

2. What resources are available to faculty for improving teaching and assessment techniques?

3. What rewards do faculty receive from the institution for engaging in innovative teaching/learning and assessment strategies?

Probe: Do you see a widening of the circle of participants here on campus?

4. What is changing about teaching, learning, and assessment on this campus?

Probe: What is being accomplished through campus-based initiatives?

What kinds of networks do you see developing surrounding teaching/learning reforms?

5. Have you or your colleagues encountered resistance to these reforms in your department? . . . on campus?

C. Assessment

1. How do you go about assessing whether students grasp the material you present in class?

Probe: Do you use evidence of student learning in your assessment of classroom strategies?

2. What kinds of assessment techniques tell you the most about what students are learning?

Probe: What kinds of assessment most accurately capture what students are learning?

3. Are you involved in evaluating teaching, learning, and assessment practices at either the department or campus level? How is this achieved?

4. How is the assessment of student learning used to improve teaching/learning in your department? …. on campus?

D. Department and Discipline

1. What are some of the major challenges your department faces in attempting to change teaching, learning, and assessment practices? What are the major opportunities?

Probes: How can barriers be overcome?

How can opportunities be maximized?

2. To what extent are teaching-related activities evaluated at your institutions? . . . in your department?

Probe: How is “good teaching” rewarded?

3. To what extent is teaching and assessment valued within your discipline?

E. Teaching and Learning

1. Describe how teaching, learning, and assessment practices are improving on this campus

Probe: How do you know? (criteria, evidence)

2. Is the assessment of teaching and learning a major focus of attention and discussion here?

Probe: why or why not? (reasons, influences)

3. What specific new teaching or assessment practices have you implemented in your classes?

4. Are there any particular characteristics that you associate with faculty who are interested in innovative teaching/learning initiatives?

5. What types of faculty development opportunities do you see emerging on your campus that focus on teaching and learning strategies for the classroom? (Institutional or disciplinary?)

Probes: What motivates you to participate in instructional development programs on campus?

How frequently do you attend such programs?

How are these programs advertised to faculty?

F. Demographics

Post Interview Comments and/or Observations:

Interview Protocol Sample Interview Protocol Form

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PDF Version of the Sample Interview Protocol Form

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Interview protocol design

On this page you will find our recommendations for creating an interview protocol for both structured and semi-structured interviews. Your protocol can be viewed as a guide for the interview: what to say at the beginning of the interview to introduce yourself and the topic of the interview, how to collect participant consent, interview questions, and what to say when you end the interview. These tips have been adapted from  Jacob and Furgerson’s (2012) guide to writing interview protocols and conducting interviews for those new to qualitative research. Your protocol may have more questions if you are planning a structured interview. However, it may have fewer and more open-ended questions if you are planning a semi-structured interview, in order to allow more time for participants to elaborate on their responses and for you to ask follow-up questions.

Interview protocol design accordion widget

Use a script to open and close the interview.

This will allow you to share all of the relevant information about your study and critical details about informed consent before you begin the interview. It will also allow a space to close the interview and give the participant an opportunity to share additional thoughts that haven’t yet been discussed in the interview.

Collect informed consent

The most common (and encouraged) means of gaining informed consent is by giving the participant a participant information sheet as well as an informed consent form to read through and then sign before you begin the interview. You can find the template for participant information sheets  and informed consent form on the Imperial College London Education Ethics Review Process (EERP) webpage . Other resources for the EERP process can also be found on this website.

Start with the basics

To help build rapport and a comfortable space for the participant, start out with questions that ask for some basic background information. This could include asking their name, their course year, how they are doing, whether they have any interesting things happening at the moment, their likes and interests etc. (although be careful not to come across as inauthentic). This will help both you and the participant to have an open conversation throughout the interview.

Create open-ended questions

Open-ended questions enable more time and space for the participant to open up and share more detail about their experiences. Using phrases like “Tell me about…” rather than “Did you ever experience X?” will be less likely to elicit only “yes” or “no” answers, which do not provide rich data. If a participant does give a “yes” or “no” answer, but you would like to know more, you can ask, “Can you tell me why?” or “Could you please elaborate on that answer a bit more?” For example, if you are interviewing a student about their sense of belonging at Imperial, you could ask, “Can you tell me about a time when you felt a real sense that you belonged at Imperial College London?”

Ensure your questions are informed by existing research

Before creating your interview questions, conduct a thorough review of the literature about the topic you are investigating through interviews. For example, research on the topic of “students’ sense of belonging” has emphasised the importance of students feeling respected by other members of the university. Therefore, it would be a good idea to include a question about “respect” if you are interested in your students’ sense of belonging at Imperial or within their departments and study areas (e.g. the classroom). See our sense of belonging interview protocol for an idea.

Begin with questions that are easier to answer, then move to more difficult or abstract questions

Be aware that even if you have explained your topic to the participant, you should not assume that they have the same understanding of the topic as you. Resist the temptation to simply ask your research questions to your participants directly, particularly at the beginning of the interview, as these will often be too conceptual and abstract for them to answer easily. Asking abstract questions too early on can alienate your participant. By asking more concrete questions that participants can answer easily, you will build rapport and trust more quickly. Start by asking questions about concrete experiences, preferably ones that are very recent or ongoing. For example, if you are interested in students’ sense of belonging, do not start by asking whether a student “belongs” or how they perceive their “belonging.” Rather, try asking about how they have felt in recent modules to give them the opportunity to raise any positive or negative experiences themselves. Later, you can ask questions which specifically address concepts related to sense of belonging, for example whether they always feel “respected” (to follow on from our earlier example). Then, at the end of the interview, you could ask your participant to reflect more directly and generally on your topic. For example, it may be good to end an interview by asking the participant to summarise the extent to which they feel they ‘belong’ and what the main factors are. Note that this advice is particularly important if dealing with topics that may be difficult to form an opinion on, such as topics which require students to remember things from the distant past, or which deal with controversial topics.  

Use prompts

If you are asking open-ended questions, the intention is that the participant will use that as an opportunity to provide you with rich qualitative detail about their experiences and perceptions. However, participants sometimes need prompts to get them going. Try to anticipate what prompts you could give to help someone answer each of your open-ended questions (Jacob & Furgerson, 2012). For example, if you are investigating sense of belonging and the participant is struggling to respond to the question “What could someone see about you that would show them that you felt like you belonged?”, you might prompt them to think about their clothes or accessories (for example do they wear or carry anything with the Imperial College London logo) or their activities (for example membership in student groups), and what meaning they attach to these. 

Be prepared to revise your protocol during and after the interview

During the interview, you may notice that some additional questions might pop into your mind, or you might need to re-order the questions, depending on the response of the participant and the direction in which the interview is going. This is fine, as it probably means the interview is flowing like a natural conversation. You might even find that this new order of questions should be adopted for future interviews, and you can adjust the protocol accordingly.

Be mindful of how much time the interview will take

When designing the protocol, keep in mind that six to ten well-written questions may make for an interview lasting approximately one hour. Consider who you are interviewing, and remember that you are asking people to share their experiences and their time with you, so be mindful of how long you expect the interview to last.

Pilot test your questions with a colleague

Pilot testing your interview protocol will help you to assess whether your interview questions make sense. Pilot testing gives you the chance to familiarise yourself with the order and flow of the questions out loud, which will help you to feel more comfortable when you begin conducting the interviews for your data collection.

Jacob, S. A., & Furgerson, S. P. (2012). Writing Interview Protocols and Conducting Interviews: Tips for Students New to the Field of Qualitative Research. The Qualitative Report, 17 (2), 1-10.

Welch, C., & Piekkari, R. (2006). Crossing Language Boundaries:. Management International Review, 46 , 417-437. Retrieved from https://link.springer.com/content/pdf/10.1007%2Fs11575-006-0099-1.pdf

Prompts, Not Questions: Four Techniques for Crafting Better Interview Protocols

• Published: 05 June 2021
• Volume 44 , pages 507–528, ( 2021 )

Cite this article

• Tomás R. Jiménez 1 &
• Marlene Orozco 2  

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A Correction to this article was published on 05 August 2023

This article has been updated

We offer effective ways to write interview protocol “prompts” that are generative of the most critical types of information researchers wish to learn from interview respondents: salience of events, attributes, and experiences; the structure of what is normal; perceptions of cause and effect; and views about sensitive topics. We offer tips for writing and putting into practice protocol prompts that we have found to be effective at obtaining each of these kinds of information. In doing so, we encourage researchers to think of an interview protocol as a series of prompts, rather than a list of questions, for respondents to talk about certain topics related to the main research question(s). We provide illustrative examples from our own research and that of our students and professional colleagues to show how generally minor tweaks to typical interview prompts result in richer interview data.

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Acknowledgements

We would like to thank our colleagues who supported this work and provided examples from their research: Emily Carian, Molly King, Tagart Sobotka, and Chloe Hart. Special thanks to Forrest Stuart for his input on several drafts. We would also like to thank the participants of the Migration, Ethnicity, Race and Nation workshop at Stanford for their comments on the manuscript.

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Jiménez, T.R., Orozco, M. Prompts, Not Questions: Four Techniques for Crafting Better Interview Protocols. Qual Sociol 44 , 507–528 (2021). https://doi.org/10.1007/s11133-021-09483-2

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Appendix: Qualitative Interview Design

Daniel W. Turner III and Nicole Hagstrom-Schmidt

Qualitative Interview Design: A Practical Guide for Novice Investigators

Qualitative research design can be complicated depending upon the level of experience a researcher may have with a particular type of methodology. As researchers, many aspire to grow and expand their knowledge and experiences with qualitative design in order to better utilize a variety of research paradigms. One of the more popular areas of interest in qualitative research design is that of the interview protocol. Interviews provide in-depth information pertaining to participants’ experiences and viewpoints of a particular topic. Oftentimes, interviews are coupled with other forms of data collection in order to provide the researcher with a well-rounded collection of information for analyses. This paper explores the effective ways to conduct in-depth, qualitative interviews for novice investigators by expanding upon the practical components of each interview design.

Categories of Qualitative Interview Design

As common with quantitative analyses, there are various forms of interview design that can be developed to obtain thick, rich data utilizing a qualitative investigational perspective. [1] For the purpose of this examination, there are three formats for interview design that will be explored which are summarized by Gall, Gall, and Borg:

• Informal conversational interview,
• General interview guide approach,
• Standardized open-ended interview. [2]

In addition, I will expand on some suggestions for conducting qualitative interviews which includes the construction of research questions as well as the analysis of interview data. These suggestions come from both my personal experiences with interviewing as well as the recommendations from the literature to assist novice interviewers.

Informal Conversational Interview

The informal conversational interview is outlined by Gall, Gall, and Borg for the purpose of relying “…entirely on the spontaneous generation of questions in a natural interaction, typically one that occurs as part of ongoing participant observation fieldwork.” [3] I am curious when it comes to other cultures or religions and I enjoy immersing myself in these environments as an active participant. I ask questions in order to learn more about these social settings without having a predetermined set of structured questions. Primarily the questions come from “in the moment experiences” as a means for further understanding or clarification of what I am witnessing or experiencing at a particular moment. With the informal conversational approach, the researcher does not ask any specific types of questions, but rather relies on the interaction with the participants to guide the interview process. [4] Think of this type of interview as an “off the top of your head” style of interview where you really construct questions as you move forward. Many consider this type of interview beneficial because of the lack of structure, which allows for flexibility in the nature of the interview. However, many researchers view this type of interview as unstable or unreliable because of the inconsistency in the interview questions, thus making it difficult to code data. [5] If you choose to conduct an informal conversational interview, it is critical to understand the need for flexibility and originality in the questioning as a key for success.

General Interview Guide Approach

The general interview guide approach is more structured than the informal conversational interview although there is still quite a bit of flexibility in its composition. [6] The ways that questions are potentially worded depend upon the researcher who is conducting the interview. Therefore, one of the obvious issues with this type of interview is the lack of consistency in the way research questions are posed because researchers can interchange the way he or she poses them. With that in mind, the respondents may not consistently answer the same question(s) based on how they were posed by the interviewer. [7] During research for my doctoral dissertation, I was able to interact with alumni participants in a relaxed and informal manner where I had the opportunity to learn more about the in-depth experiences of the participants through structured interviews. This informal environment allowed me the opportunity to develop rapport with the participants so that I was able to ask follow-up or probing questions based on their responses to pre-constructed questions. I found this quite useful in my interviews because I could ask questions or change questions based on participant responses to previous questions. The questions were structured, but adapting them allowed me to explore a more personal approach to each alumni interview.

According to McNamara, the strength of the general interview guide approach is the ability of the researcher “…to ensure that the same general areas of information are collected from each interviewee; this provides more focus than the conversational approach, but still allows a degree of freedom and adaptability in getting information from the interviewee.” [8] The researcher remains in the driver’s seat with this type of interview approach, but flexibility takes precedence based on perceived prompts from the participants.

You might ask, “What does this mean anyway?” The easiest way to answer that question is to think about your own personal experiences at a job interview. When you were invited to a job interview in the past, you might have prepared for all sorts of curve ball-style questions to come your way. You desired an answer for every potential question. If the interviewer were asking you questions using a general interview guide approach, he or she would ask questions using their own unique style, which might differ from the way the questions were originally created. You as the interviewee would then respond to those questions in the manner in which the interviewer asked which would dictate how the interview continued. Based on how the interviewer asked the question(s), you might have been able to answer more information or less information than that of other job candidates. Therefore, it is easy to see how this could positively or negatively influence a job candidate if the interviewer were using a general interview guide approach.

Standardized Open-Ended Interviews

The standardized open-ended interview is extremely structured in terms of the wording of the questions. Participants are always asked identical questions, but the questions are worded so that responses are open-ended. [9] This open-endedness allows the participants to contribute as much detailed information as they desire and it also allows the researcher to ask probing questions as a means of follow-up. Standardized open-ended interviews are likely the most popular form of interviewing utilized in research studies because of the nature of the open-ended questions, allowing the participants to fully express their viewpoints and experiences. If one were to identify weaknesses with open-ended interviewing, they would likely identify the difficulty with coding the data. [10] Since open-ended interviews in composition call for participants to fully express their responses in as much detail as desired, it can be quite difficult for researchers to extract similar themes or codes from the interview transcripts as they would with less open-ended responses. Although the data provided by participants are rich and thick with qualitative data, it can be a more cumbersome process for the researcher to sift through the narrative responses in order to fully and accurately reflect an overall perspective of all interview responses through the coding process. However, according to Gall, Gall, and Borg, this reduces researcher biases within the study, particularly when the interviewing process involves many participants. [11]

Suggestions for Conducting Qualitative Interviews

Now that we know a few of the more popular interview designs that are available to qualitative researchers, we can more closely examine various suggestions for conducting qualitative interviews based on the available research. These suggestions are designed to provide the researcher with the tools needed to conduct a well constructed, professional interview with their participants. Some of the most common information found within the literature relating to interviews, according to Creswell [12] :

• The preparation for the interview,
• The constructing effective research questions,
• The actual implementation of the interview(s). [13]

Preparation for the Interview

Probably the most helpful tip with the interview process is that of interview preparation. This process can help make or break the process and can either alleviate or exacerbate the problematic circumstances that could potentially occur once the research is implemented. McNamara suggests the importance of the preparation stage in order to maintain an unambiguous focus as to how the interviews will be erected in order to provide maximum benefit to the proposed research study. [14] Along these lines Chenail provides a number of pre-interview exercises researchers can use to improve their instrumentality and address potential biases. [15] McNamara applies eight principles to the preparation stage of interviewing which includes the following ingredients:

• Choose a setting with little distraction;
• Explain the purpose of the interview;
• Address terms of confidentiality;
• Explain the format of the interview;
• Indicate how long the interview usually takes;
• Tell them how to get in touch with you later if they want to;
• Ask them if they have any questions before you both get started with the interview;
• Don’t count on your memory to recall their answers. [16]

Selecting Participants

Creswell discusses the importance of selecting the appropriate candidates for interviews. He asserts that the researcher should utilize one of the various types of sampling strategies such as criterion based sampling or critical case sampling (among many others) in order to obtain qualified candidates that will provide the most credible information to the study. [17] Creswell also suggests the importance of acquiring participants who will be willing to openly and honestly share information or “their story.” [18] It might be easier to conduct the interviews with participants in a comfortable environment where the participants do not feel restricted or uncomfortable to share information.

Pilot Testing

Another important element to the interview preparation is the implementation of a pilot test. The pilot test will assist the research in determining if there are flaws, limitations, or other weaknesses within the interview design and will allow him or her to make necessary revisions prior to the implementation of the study. [19] A pilot test should be conducted with participants that have similar interests as those that will participate in the implemented study. The pilot test will also assist the researchers with the refinement of research questions, which will be discussed in the next section.

Constructing Effective Research Questions

Creating effective research questions for the interview process is one of the most crucial components to interview design. Researchers desiring to conduct such an investigation should be careful that each of the questions will allow the examiner to dig deep into the experiences and/or knowledge of the participants in order to gain maximum data from the interviews. McNamara suggests several recommendations for creating effective research questions for interviews which includes the following elements:

• Wording should be open-ended (respondents should be able to choose their own terms when answering questions);
• Questions should be as neutral as possible (avoid wording that might influence answers, e.g., evocative, judgmental wording);
• Questions should be asked one at a time;
• Questions should be worded clearly (this includes knowing any terms particular to the program or the respondents’ culture); and
• Be careful asking “why” questions. [20]

Examples of Useful and Not-So Useful Research Questions

To assist the novice interviewer with the preparation of research questions, I will propose a useful research question and a not so useful research question. Based on McNamara’s suggestion, it is important to ask an open-ended question. [21] So for the useful question, I will propose the following: “How have your experiences as a kindergarten teacher influenced or not influenced you in the decisions that you have made in raising your children”? As you can see, the question allows the respondent to discuss how his or her experiences as a kindergarten teacher have or have not affected their decision-making with their own children without making the assumption that the experience has influenced their decision-making. On the other hand, if you were to ask a similar question, but from a less than useful perspective, you might construct the same question in this manner: “How has your experiences as a kindergarten teacher affected you as a parent”? As you can see, the question is still open-ended, but it makes the assumption that the experiences have indeed affected them as a parent. We as the researcher cannot make this assumption in the wording of our questions.

Follow-Up Questions

Creswell also makes the suggestion of being flexible with research questions being constructed. [22] He makes the assertion that respondents in an interview will not necessarily answer the question being asked by the researcher and, in fact, may answer a question that is asked in another question later in the interview. Creswell believes that the researcher must construct questions in such a manner to keep participants on focus with their responses to the questions. In addition, the researcher must be prepared with follow-up questions or prompts in order to ensure that they obtain optimal responses from participants. When I was an Assistant Director for a large division at my University a couple of years ago, I was tasked with the responsibility of hiring student affairs coordinators at our off-campus educational centers. Throughout the interviewing process, I found that interviewees did indeed get off topic with certain questions because they either misunderstood the question(s) being asked or did not wish to answer the question(s) directly. I was able to utilize Creswell’s suggestion [23] by reconstructing questions so that they were clearly assembled in a manner to reduce misunderstanding and was able to erect effective follow-up prompts to further understanding. This alleviated many of the problems I had and assisted me in extracting the information I needed from the interview through my follow-up questioning.

Implementation of Interviews

As with other sections of interview design, McNamara makes some excellent recommendations for the implementation stage of the interview process. He includes the following tips for interview implementation:

• Occasionally verify the tape recorder (if used) is working;
• Ask one question at a time;
• Attempt to remain as neutral as possible (that is, don’t show strong emotional reactions to their responses;
• Encourage responses with occasional nods of the head, “uh huh”s, etc.;
• Be careful about the appearance when note taking (that is, if you jump to take a note, it may appear as if you’re surprised or very pleased about an answer, which may influence answers to future questions);
• Provide transition between major topics, e.g., “we’ve been talking about (some topic) and now I’d like to move on to (another topic);”
• Don’t lose control of the interview (this can occur when respondents stray to another topic, take so long to answer a question that times begins to run out, or even begin asking questions to the interviewer). [24]

Interpreting Data

The final constituent in the interview design process is that of interpreting the data that was gathered during the interview process. During this phase, the researcher must make “sense” out of what was just uncovered and compile the data into sections or groups of information, also known as themes or codes. [25] These themes or codes are consistent phrases, expressions, or ideas that were common among research participants. [26] How the researcher formulates themes or codes vary. Many researchers suggest the need to employ a third party consultant who can review codes or themes in order to determine the quality and effectiveness based on their evaluation of the interview transcripts. [27] This helps alleviate researcher biases or potentially eliminate where over-analyzing of data has occurred. Many researchers may choose to employ an iterative review process where a committee of nonparticipating researchers can provide constructive feedback and suggestions to the researcher(s) primarily involved with the study.

From choosing the appropriate type of interview design process through the interpretation of interview data, this guide for conducting qualitative research interviews proposes a practical way to perform an investigation based on the recommendations and experiences of qualified researchers in the field and through my own personal experiences. Although qualitative investigation provides a myriad of opportunities for conducting investigational research, interview design has remained one of the more popular forms of analyses. As the variety of qualitative research methods become more widely utilized across research institutions, we will continue to see more practical guides for protocol implementation outlined in peer reviewed journals across the world.

This text was derived from

Turner, Daniel W., III. “Qualitative Interview Design: A Practical Guide for Novice Investigators.” The Qualitative Report 15, no. 3 (2010): 754-760. https://doi.org/10.46743/2160-3715/2010.1178 . Licensed under a  Creative Commons Attribution-Noncommercial-Share Alike 4.0 International License .

It is edited and reformatted by Nicole Hagstrom-Schmidt.

• John W. Creswell, Qualitative Inquiry and Research Design: Choosing Among Five Approaches , 2nd ed. (Thousand Oaks, CA: Sage, 2007). ↵
• M.D. Gall, Walter R. Borg, and Joyce P. Gall, Educational Research: An Introduction , 7th ed. (Boston, MA: Pearson, 2003). ↵
• M.D. Gall, Walter R. Borg, and Joyce P. Gall, Educational Research: An Introduction , 7th ed (Boston, MA: Pearson, 2003), 239. ↵
• Carter McNamara, “General Guidelines for Conducting Interviews,” Free Management Library , accessed January 11, 2010, https://managementhelp.org/businessresearch/interviews.htm. ↵
• M.D. Gall, Walter R. Borg, and Joyce P. Gall, Educational Research: An Introduction , 7th ed (Boston, MA: Pearson, 2003). ↵
• Carter McNamara, “General Guidelines for Conducting Interviews,” Free Management Library , accessed January 11, 2010, https://managementhelp.org/businessresearch/interviews.htm . ↵
• Carter McNamara, “General Guidelines for Conducting Interviews,” Free Management Library , “Types of Interviews” section, para. 1, accessed January 11, 2010, https://managementhelp.org/businessresearch/interviews.htm . ↵
• John W. Creswell, Research Design: Qualitative, Quantitative, and Mixed Methods Approaches , 3rd ed. (Thousand Oaks, CA: Sage, 2003); John W. Creswell, Qualitative Inquiry and Research Design: Choosing Among Five Approaches , 2nd ed. (Thousand Oaks, CA: Sage, 2007). ↵
• Ronald J. Chenail, “Interviewing the Investigator: Strategies for Addressing Instrumentation and Researcher Bias Concerns in Qualitative Research,” The Qualitative Report 16, no. 1 (2011): 255–262, https://nsuworks.nova.edu/tqr/vol16/iss1/16/ . ↵
• Carter McNamara, “General Guidelines for Conducting Interviews,” Free Management Library , “Preparation for Interview section,” para. 1, accessed January 11, 2010, https://managementhelp.org/businessresearch/interviews.htm . ↵
• John W. Creswell, Qualitative Inquiry and Research Design: Choosing Among Five Approaches , 2nd ed. (Thousand Oaks, CA: Sage, 2007), 133. ↵
• Steinar Kvale, Doing Interviews (London and Thousand Oaks, CA: Sage, 2007) https://doi.org/10.4135/9781849208963 . ↵
• Carter McNamara, “General Guidelines for Conducting Interviews,” Free Management Library , “Wording of Questions” section, para. 1, accessed January 11, 2010, https://managementhelp.org/businessresearch/interviews.htm . ↵
• Carter McNamara, “General Guidelines for Conducting Interviews,” Free Management Library , “Conducting Interview” section, para 1, accessed January 11, 2010, https://managementhelp.org/businessresearch/interviews.htm . ↵
• Steinar Kvale, Doing Interviews (London and Thousand Oaks, CA: Sage, 2007) https://doi.org/10.4135/9781849208963 ↵

Appendix: Qualitative Interview Design Copyright © 2022 by Daniel W. Turner III and Nicole Hagstrom-Schmidt is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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Qualitative Research 101: Interviewing

5 Common Mistakes To Avoid When Undertaking Interviews

By: David Phair (PhD) and Kerryn Warren (PhD) | March 2022

Undertaking interviews is potentially the most important step in the qualitative research process. If you don’t collect useful, useable data in your interviews, you’ll struggle through the rest of your dissertation or thesis.  Having helped numerous students with their research over the years, we’ve noticed some common interviewing mistakes that first-time researchers make. In this post, we’ll discuss five costly interview-related mistakes and outline useful strategies to avoid making these.

Overview: 5 Interviewing Mistakes

• Not having a clear interview strategy /plan
• Not having good interview techniques /skills
• Not securing a suitable location and equipment
• Not having a basic risk management plan
• Not keeping your “ golden thread ” front of mind

1. Not having a clear interview strategy

The first common mistake that we’ll look at is that of starting the interviewing process without having first come up with a clear interview strategy or plan of action. While it’s natural to be keen to get started engaging with your interviewees, a lack of planning can result in a mess of data and inconsistency between interviews.

There are several design choices to decide on and plan for before you start interviewing anyone. Some of the most important questions you need to ask yourself before conducting interviews include:

• What are the guiding research aims and research questions of my study?
• Will I use a structured, semi-structured or unstructured interview approach?
• How will I record the interviews (audio or video)?
• Who will be interviewed and by whom ?
• What ethics and data law considerations do I need to adhere to?
• How will I analyze my data? 

Let’s take a quick look at some of these.

The core objective of the interviewing process is to generate useful data that will help you address your overall research aims. Therefore, your interviews need to be conducted in a way that directly links to your research aims, objectives and research questions (i.e. your “golden thread”). This means that you need to carefully consider the questions you’ll ask to ensure that they align with and feed into your golden thread. If any question doesn’t align with this, you may want to consider scrapping it.

Another important design choice is whether you’ll use an unstructured, semi-structured or structured interview approach . For semi-structured interviews, you will have a list of questions that you plan to ask and these questions will be open-ended in nature. You’ll also allow the discussion to digress from the core question set if something interesting comes up. This means that the type of information generated might differ a fair amount between interviews.

Contrasted to this, a structured approach to interviews is more rigid, where a specific set of closed questions is developed and asked for each interviewee in exactly the same order. Closed questions have a limited set of answers, that are often single-word answers. Therefore, you need to think about what you’re trying to achieve with your research project (i.e. your research aims) and decided on which approach would be best suited in your case.

It is also important to plan ahead with regards to who will be interviewed and how. You need to think about how you will approach the possible interviewees to get their cooperation, who will conduct the interviews, when to conduct the interviews and how to record the interviews. For each of these decisions, it’s also essential to make sure that all ethical considerations and data protection laws are taken into account.

Finally, you should think through how you plan to analyze the data (i.e., your qualitative analysis method) generated by the interviews. Different types of analysis rely on different types of data, so you need to ensure you’re asking the right types of questions and correctly guiding your respondents.

Simply put, you need to have a plan of action regarding the specifics of your interview approach before you start collecting data. If not, you’ll end up drifting in your approach from interview to interview, which will result in inconsistent, unusable data.

2. Not having good interview technique

While you’re generally not expected to become you to be an expert interviewer for a dissertation or thesis, it is important to practice good interview technique and develop basic interviewing skills .

Let’s go through some basics that will help the process along.

Firstly, before the interview , make sure you know your interview questions well and have a clear idea of what you want from the interview. Naturally, the specificity of your questions will depend on whether you’re taking a structured, semi-structured or unstructured approach, but you still need a consistent starting point . Ideally, you should develop an interview guide beforehand (more on this later) that details your core question and links these to the research aims, objectives and research questions.

Before you undertake any interviews, it’s a good idea to do a few mock interviews with friends or family members. This will help you get comfortable with the interviewer role, prepare for potentially unexpected answers and give you a good idea of how long the interview will take to conduct. In the interviewing process, you’re likely to encounter two kinds of challenging interviewees ; the two-word respondent and the respondent who meanders and babbles. Therefore, you should prepare yourself for both and come up with a plan to respond to each in a way that will allow the interview to continue productively.

To begin the formal interview , provide the person you are interviewing with an overview of your research. This will help to calm their nerves (and yours) and contextualize the interaction. Ultimately, you want the interviewee to feel comfortable and be willing to be open and honest with you, so it’s useful to start in a more casual, relaxed fashion and allow them to ask any questions they may have. From there, you can ease them into the rest of the questions.

As the interview progresses , avoid asking leading questions (i.e., questions that assume something about the interviewee or their response). Make sure that you speak clearly and slowly , using plain language and being ready to paraphrase questions if the person you are interviewing misunderstands. Be particularly careful with interviewing English second language speakers to ensure that you’re both on the same page.

Engage with the interviewee by listening to them carefully and acknowledging that you are listening to them by smiling or nodding. Show them that you’re interested in what they’re saying and thank them for their openness as appropriate. This will also encourage your interviewee to respond openly.

Need a helping hand?

3. Not securing a suitable location and quality equipment

Where you conduct your interviews and the equipment you use to record them both play an important role in how the process unfolds. Therefore, you need to think carefully about each of these variables before you start interviewing.

Poor location: A bad location can result in the quality of your interviews being compromised, interrupted, or cancelled. If you are conducting physical interviews, you’ll need a location that is quiet, safe, and welcoming . It’s very important that your location of choice is not prone to interruptions (the workplace office is generally problematic, for example) and has suitable facilities (such as water, a bathroom, and snacks).

If you are conducting online interviews , you need to consider a few other factors. Importantly, you need to make sure that both you and your respondent have access to a good, stable internet connection and electricity. Always check before the time that both of you know how to use the relevant software and it’s accessible (sometimes meeting platforms are blocked by workplace policies or firewalls). It’s also good to have alternatives in place (such as WhatsApp, Zoom, or Teams) to cater for these types of issues.

Poor equipment: Using poor-quality recording equipment or using equipment incorrectly means that you will have trouble transcribing, coding, and analyzing your interviews. This can be a major issue , as some of your interview data may go completely to waste if not recorded well. So, make sure that you use good-quality recording equipment and that you know how to use it correctly.

To avoid issues, you should always conduct test recordings before every interview to ensure that you can use the relevant equipment properly. It’s also a good idea to spot check each recording afterwards, just to make sure it was recorded as planned. If your equipment uses batteries, be sure to always carry a spare set.

4. Not having a basic risk management plan

Many possible issues can arise during the interview process. Not planning for these issues can mean that you are left with compromised data that might not be useful to you. Therefore, it’s important to map out some sort of risk management plan ahead of time, considering the potential risks, how you’ll minimize their probability and how you’ll manage them if they materialize.

Common potential issues related to the actual interview include cancellations (people pulling out), delays (such as getting stuck in traffic), language and accent differences (especially in the case of poor internet connections), issues with internet connections and power supply. Other issues can also occur in the interview itself. For example, the interviewee could drift off-topic, or you might encounter an interviewee who does not say much at all.

You can prepare for these potential issues by considering possible worst-case scenarios and preparing a response for each scenario. For instance, it is important to plan a backup date just in case your interviewee cannot make it to the first meeting you scheduled with them. It’s also a good idea to factor in a 30-minute gap between your interviews for the instances where someone might be late, or an interview runs overtime for other reasons. Make sure that you also plan backup questions that could be used to bring a respondent back on topic if they start rambling, or questions to encourage those who are saying too little.

In general, it’s best practice to plan to conduct more interviews than you think you need (this is called oversampling ). Doing so will allow you some room for error if there are interviews that don’t go as planned, or if some interviewees withdraw. If you need 10 interviews, it is a good idea to plan for 15. Likely, a few will cancel , delay, or not produce useful data.

5. Not keeping your golden thread front of mind

We touched on this a little earlier, but it is a key point that should be central to your entire research process. You don’t want to end up with pages and pages of data after conducting your interviews and realize that it is not useful to your research aims . Your research aims, objectives and research questions – i.e., your golden thread – should influence every design decision and should guide the interview process at all times. 

A useful way to avoid this mistake is by developing an interview guide before you begin interviewing your respondents. An interview guide is a document that contains all of your questions with notes on how each of the interview questions is linked to the research question(s) of your study. You can also include your research aims and objectives here for a more comprehensive linkage. 

You can easily create an interview guide by drawing up a table with one column containing your core interview questions . Then add another column with your research questions , another with expectations that you may have in light of the relevant literature and another with backup or follow-up questions . As mentioned, you can also bring in your research aims and objectives to help you connect them all together. If you’d like, you can download a copy of our free interview guide here .

Recap: Qualitative Interview Mistakes

In this post, we’ve discussed 5 common costly mistakes that are easy to make in the process of planning and conducting qualitative interviews.

To recap, these include:

If you have any questions about these interviewing mistakes, drop a comment below. Alternatively, if you’re interested in getting 1-on-1 help with your thesis or dissertation , check out our dissertation coaching service or book a free initial consultation with one of our friendly Grad Coaches.

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Methodology

• Types of Interviews in Research | Guide & Examples

Types of Interviews in Research | Guide & Examples

Published on March 10, 2022 by Tegan George . Revised on June 22, 2023.

An interview is a qualitative research method that relies on asking questions in order to collect data . Interviews involve two or more people, one of whom is the interviewer asking the questions.

There are several types of interviews, often differentiated by their level of structure.

• Structured interviews have predetermined questions asked in a predetermined order.
• Unstructured interviews are more free-flowing.
• Semi-structured interviews fall in between.

Interviews are commonly used in market research, social science, and ethnographic research .

Table of contents

What is a structured interview, what is a semi-structured interview, what is an unstructured interview, what is a focus group, examples of interview questions, advantages and disadvantages of interviews, other interesting articles, frequently asked questions about types of interviews.

Structured interviews have predetermined questions in a set order. They are often closed-ended, featuring dichotomous (yes/no) or multiple-choice questions. While open-ended structured interviews exist, they are much less common. The types of questions asked make structured interviews a predominantly quantitative tool.

Asking set questions in a set order can help you see patterns among responses, and it allows you to easily compare responses between participants while keeping other factors constant. This can mitigate   research biases and lead to higher reliability and validity. However, structured interviews can be overly formal, as well as limited in scope and flexibility.

• You feel very comfortable with your topic. This will help you formulate your questions most effectively.
• You have limited time or resources. Structured interviews are a bit more straightforward to analyze because of their closed-ended nature, and can be a doable undertaking for an individual.
• Your research question depends on holding environmental conditions between participants constant.

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Semi-structured interviews are a blend of structured and unstructured interviews. While the interviewer has a general plan for what they want to ask, the questions do not have to follow a particular phrasing or order.

Semi-structured interviews are often open-ended, allowing for flexibility, but follow a predetermined thematic framework, giving a sense of order. For this reason, they are often considered “the best of both worlds.”

However, if the questions differ substantially between participants, it can be challenging to look for patterns, lessening the generalizability and validity of your results.

• You have prior interview experience. It’s easier than you think to accidentally ask a leading question when coming up with questions on the fly. Overall, spontaneous questions are much more difficult than they may seem.
• Your research question is exploratory in nature. The answers you receive can help guide your future research.

An unstructured interview is the most flexible type of interview. The questions and the order in which they are asked are not set. Instead, the interview can proceed more spontaneously, based on the participant’s previous answers.

Unstructured interviews are by definition open-ended. This flexibility can help you gather detailed information on your topic, while still allowing you to observe patterns between participants.

However, so much flexibility means that they can be very challenging to conduct properly. You must be very careful not to ask leading questions, as biased responses can lead to lower reliability or even invalidate your research.

• You have a solid background in your research topic and have conducted interviews before.
• Your research question is exploratory in nature, and you are seeking descriptive data that will deepen and contextualize your initial hypotheses.
• Your research necessitates forming a deeper connection with your participants, encouraging them to feel comfortable revealing their true opinions and emotions.

A focus group brings together a group of participants to answer questions on a topic of interest in a moderated setting. Focus groups are qualitative in nature and often study the group’s dynamic and body language in addition to their answers. Responses can guide future research on consumer products and services, human behavior, or controversial topics.

Focus groups can provide more nuanced and unfiltered feedback than individual interviews and are easier to organize than experiments or large surveys . However, their small size leads to low external validity and the temptation as a researcher to “cherry-pick” responses that fit your hypotheses.

• Your research focuses on the dynamics of group discussion or real-time responses to your topic.
• Your questions are complex and rooted in feelings, opinions, and perceptions that cannot be answered with a “yes” or “no.”
• Your topic is exploratory in nature, and you are seeking information that will help you uncover new questions or future research ideas.

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Depending on the type of interview you are conducting, your questions will differ in style, phrasing, and intention. Structured interview questions are set and precise, while the other types of interviews allow for more open-endedness and flexibility.

Here are some examples.

• Semi-structured
• Unstructured
• Focus group
• Do you like dogs? Yes/No
• Do you associate dogs with feeling: happy; somewhat happy; neutral; somewhat unhappy; unhappy
• If yes, name one attribute of dogs that you like.
• If no, name one attribute of dogs that you don’t like.
• What feelings do dogs bring out in you?
• When you think more deeply about this, what experiences would you say your feelings are rooted in?

Interviews are a great research tool. They allow you to gather rich information and draw more detailed conclusions than other research methods, taking into consideration nonverbal cues, off-the-cuff reactions, and emotional responses.

However, they can also be time-consuming and deceptively challenging to conduct properly. Smaller sample sizes can cause their validity and reliability to suffer, and there is an inherent risk of interviewer effect arising from accidentally leading questions.

Here are some advantages and disadvantages of each type of interview that can help you decide if you’d like to utilize this research method.

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.

• Student’s  t -distribution
• Normal distribution
• Null and Alternative Hypotheses
• Chi square tests
• Confidence interval
• Quartiles & Quantiles
• Cluster sampling
• Stratified sampling
• Data cleansing
• Reproducibility vs Replicability
• Peer review
• Prospective cohort study

Research bias

• Implicit bias
• Cognitive bias
• Placebo effect
• Hawthorne effect
• Hindsight bias
• Affect heuristic
• Social desirability bias

The four most common types of interviews are:

• Structured interviews : The questions are predetermined in both topic and order. 
• Semi-structured interviews : A few questions are predetermined, but other questions aren’t planned.
• Unstructured interviews : None of the questions are predetermined.
• Focus group interviews : The questions are presented to a group instead of one individual.

The interviewer effect is a type of bias that emerges when a characteristic of an interviewer (race, age, gender identity, etc.) influences the responses given by the interviewee.

There is a risk of an interviewer effect in all types of interviews , but it can be mitigated by writing really high-quality interview questions.

Social desirability bias is the tendency for interview participants to give responses that will be viewed favorably by the interviewer or other participants. It occurs in all types of interviews and surveys , but is most common in semi-structured interviews , unstructured interviews , and focus groups .

Social desirability bias can be mitigated by ensuring participants feel at ease and comfortable sharing their views. Make sure to pay attention to your own body language and any physical or verbal cues, such as nodding or widening your eyes.

This type of bias can also occur in observations if the participants know they’re being observed. They might alter their behavior accordingly.

A focus group is a research method that brings together a small group of people to answer questions in a moderated setting. The group is chosen due to predefined demographic traits, and the questions are designed to shed light on a topic of interest. It is one of 4 types of interviews .

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.

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Prompts, Not Questions: Four Techniques for Crafting Better Interview Protocols

We offer effective ways to write interview protocol “prompts” that are generative of the most common types of information researchers wish to learn from interview respondents: the salience of events, attributes, and experiences; the structure of what is normal; perceptions of cause and effect; and views about sensitive topics. We offer tips for writing and putting into practice protocol prompts that we have found to be effective at obtaining each of these kinds of information. In doing so, we encourage researchers to think of an interview protocol as a series of prompts, rather than a list of questions, for respondents to talk about certain topics related to the main research question(s). We provide illustrative examples from our own research to show how generally minor tweaks to typical interview prompts result in richer interview data.

• Corpus ID: 148312093

Preparing for Interview Research: The Interview Protocol Refinement Framework

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• Published 1 May 2016
• The Qualitative Report

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• Published: 05 October 2018

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

• P. Gill 1 &
• J. Baillie 2  

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

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

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

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

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

You have full access to this article via your institution.

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Interviews in the social sciences

Professionalism in dentistry: deconstructing common terminology

A review of technical and quality assessment considerations of audio-visual and web-conferencing focus groups in qualitative health research, introduction.

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

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

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

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

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

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

Overview of qualitative research

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

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

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

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

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

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

Types of interview

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

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

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

Conducting an interview

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

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

Greeting and explaining the project/interview

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

Asymmetry between the researcher and participant talking

Expressing interest and cultural ignorance

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

Creating hypothetical situations

Asking friendly questions

Knowing when to leave.

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

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

Box 1: Example of a topic guide

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

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

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

Why did you start cleaning their teeth at that point?

How often do you brush their teeth?

What do you use to brush their teeth and why?

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

Do you find anything difficult?

What makes cleaning their teeth easier for you?

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

Has it become easier or harder?

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

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

What do they enjoy about having their teeth cleaned?

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

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

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

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

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

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

Focus groups

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

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

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

Focus group considerations

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

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

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

Focus group management

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

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

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

Discussions within the group are confidential to the group

Only one person can speak at a time

All participants should have sufficient opportunity to contribute

There should be no unnecessary interruptions while someone is speaking

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

Challenging contrary opinions is appropriate, but ridiculing is not.

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

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

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

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

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

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

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Pre-exposure prophylaxis (PrEP) is a highly effective pharmaceutical intervention that prevents HIV infection, but PrEP uptake across the US has been slow among men who have sex with men (MSM), especially among Black/African American (B/AA) and Hispanic /Latino (H/L) MSM. This study investigates the acceptability and essential components of a peer-driven intervention (PDI) for promoting PrEP uptake among MSM, with a specific focus on B/AA and H/L communities.

We conducted 28 semi-structured, qualitative interviews with MSM in southern New England to explore the components of a PDI, including attitudes, content, and effective communication methods. A purposive sampling strategy was used to recruit diverse participants who reflect the communities with the highest burden of HIV infection.

Of 28 study participants, the median age was 28 years (interquartile range [IQR]: 25, 35). The sample comprised B/AA (39%, n  = 11) and H/L (50%, n  = 14) individuals. Notably, nearly half of the participants (46%) were current PrEP users. We found that many participants were in favor of using a PDI approach for promoting PrEP. Additionally, several participants showed interest in becoming peer educators themselves. They emphasized the need for strong communication skills to effectively teach others about PrEP. Moreover, participants noted that peer education should cover key topics like how PrEP works, how effective it is, and any possible side effects.

Conclusions

Our study shows that effective PDIs, facilitated by well-trained peers knowledgeable about PrEP, could enhance PrEP uptake among MSM, addressing health disparities and potentially reducing HIV transmission in B/AA and H/L communities.

Peer Review reports

Introduction

In 2021, gay, bisexual, and other men who have sex with men (MSM) accounted for 67% of all new HIV infections in the United States (US) [ 1 ]. Black/African American (B/AA) MSM are the most affected subpopulation, followed by Hispanic/Latino (H/L) MSM [ 1 ]. B/AA and H/L MSM each represent less than 1% of the population [ 2 ], but account for 25% and 22% of all new HIV diagnoses in 2021, respectively [ 1 ]. Given this concentrated epidemic, the 2025 National HIV/AIDS Strategy lists MSM as one of the high-priority populations for HIV initiatives, in particular Black, Latino, and American Indian/Alaska Native men, as focusing resources on these populations would reduce HIV incidence disparities among MSM and achieve greater impact in reducing HIV incidence overall [ 3 ].

Pre-exposure prophylaxis (PrEP) — a highly effective pharmaceutical intervention against new HIV infection [ 4 , 5 , 6 ]— has the potential to dramatically reduce HIV incidence among MSM in the US [ 7 , 8 ]. Despite the proven efficacy and recommendation by the Centers for Disease Control and Prevention (CDC) that all sexually active persons at risk of HIV acquisition could benefit from PrEP, PrEP uptake has been slow across the US, especially among B/AA and H/L MSM [ 9 , 10 , 11 ]. In 2021, B/AA individuals comprised 14%, H/L individuals made up 17%, while White individuals accounted for 65% of all persons prescribed PrEP in the US [ 12 ]. Other studies have found that B/AA and H/L MSM who initiate PrEP are significantly less likely to be retained in care at three months relative to white MSM [ 13 , 14 ]. B/AA and H/L MSM are also more likely to have limited awareness about PrEP [ 15 ], low perceived HIV risk [ 16 ], medical mistrust [ 17 ], and experience stigma [ 18 ] and financial burdens [ 19 ]; all of which contribute to suboptimal PrEP uptake and retention in PrEP care [ 20 , 21 , 22 , 23 , 24 , 25 ].

Community-based outreach approaches and peer-driven interventions (PDI) have the potential to mitigate these barriers and enhance PrEP uptake among MSM, especially B/AA and H/L MSM. PDIs involve recruiting peer educators and then encouraging them to educate and motivate members of their social network(s) for PrEP uptake. Research demonstrates that PDIs are both cost-effective for engaging hard-to-reach populations [ 26 , 27 ], and efficient for disseminating HIV education, promoting condom use, and expanding HIV testing among MSM [ 28 , 29 ]. However, there is limited research on the feasibility of a PDI for PrEP promotion, apart from a pilot study conducted by the authors from 2018 to 2019 [ 30 ]. Most of the 15 participants in the pilot study viewed positively a PDI to promote PrEP. The current study investigated the acceptability and effectiveness of PDIs for PrEP uptake among MSM, focusing on B/AA and H/L subgroups. Acknowledging their distinct needs, the study aimed to identify PDI components tailored to each group, addressing specific barriers in PrEP adoption. Findings from this study can inform the development and implementation of future PDIs for PrEP promotion in the US.

Study population and recruitment

Our research staff conducted 28 in-depth interviews with MSM between October 6th, 2020, and September 2nd, 2022. Participants were recruited from multiple venues, including clinical outreach at The Miriam Hospital (TMH) Immunology Center; lesbian, gay, bisexual, transgender, and LGBTQ + bars and community-based organizations in Providence, Rhode Island; and LGBTQ + email-based listservs in southern New England (Rhode Island, Connecticut, and Massachusetts). Participants were eligible if they: (a) were 18 years of age or older, (b) were assigned male at birth and identified as a man, (c) had sex with men in the past three months, and (d) had a HIV negative status. Our sampling approach was purposive, aiming to encompass a wide range of experiences among B/AA and H/L MSM with different PrEP statuses, including both current users and non-users [ 31 , 32 , 33 ].

Interviews and data collection

Twenty-eight eligible study participants were invited to participate in a 45–60-minute one-on-one interview with a trained researcher. Study staff decided to conduct all interviews via Zoom, a HIPPA-compliant online meeting platform, due to the coronavirus disease 2019 (COVID-19) pandemic. Interviewers referred to an interview guide that they developed specifically for the purpose of the current study (Supplementary File 1 ). Interview questions covered the following topics: (1) awareness and acceptability of PrEP; (2) social network characteristics (including both physical and virtual interactions) and acceptability of promoting PrEP through these networks; (3) facilitators and barriers to PrEP uptake; (4) potential peer-delivered intervention components and related content to support PrEP initiation; (5) characteristics of ideal PrEP educators (e.g., leadership, responsibility, and passion and commitment to HIV prevention); and (6) cultural nuances about PrEP. As PDIs are based on existing social networks to reach individuals who may be at high risk of HIV infection, it is crucial to understand the dynamics of these networks and provide insights into how individuals are connected both directly and indirectly. Enrollment ended when preliminary data analysis reflected thematic saturation [ 34 ]. Specifically, we continued enrolling participants until data saturation was achieved, a point at which additional interviews ceased to yield novel insights or significantly alter our understanding of the research topic. Each participant was compensated $50 for their time. The Institutional Review Board at The Miriam Hospital approved the study (IRB number:1594759).

Data analysis

Interviews were digitally recorded and then transcribed verbatim by an external HIPAA-certified transcription company. Following transcription, research staff meticulously reviewed the transcripts to ensure they accurately reflected the recorded content, paying close attention to linguistic nuances and context-specific details. In addition to conducting interviews, research staff took notes, completed standardized debriefing forms immediately following the interview, and reviewed these forms with study investigators during weekly team meetings. Qualitative data were analyzed iteratively during data collection by a trained research assistant, and the interview guides were adapted as needed to address any unanticipated, emergent themes. The primary themes were organized and distilled into the primary findings presented here. This method allowed us to determine when we reached saturation in data collection. Qualitative and mixed methods data analysis was conducted using Dedoose, a versatile software platform designed for analyzing qualitative and mixed methods research data. Dedoose facilitates the organization, coding, and interpretation of complex datasets, enhancing the efficiency and depth of analysis [ 35 ]. The study team developed a coding scheme based on the interview protocol and transcripts of 28 interviews. After an initial round of coding, the research team met to discuss the coding and revise the codebook. Three independent qualitative analysts coded the transcripts. Discrepancies in the coding between any two analysts were resolved by the third analyst who assigned the final code. We used a thematic analysis strategy to analyze the data [ 36 ]. The research team reviewed and analyzed data to identify themes within the domains from the interview guide.

Demographic characteristics

Of the 28 study participants, the median age was 28 years old (interquartile range [IQR]: 25, 35). The majority reported having a college education or above (78%), having health insurance (93%), identifying same-sex sexual orientation (79%), and being single (57%). B/AA and H/L individuals accounted for 39% ( N  = 11) and 50% ( N  = 14) of all participants, respectively. Thirteen individuals (46%) reported currently taking PrEP; five individuals (18%) reported previous PrEP use; nine individuals (32%) had never taken PrEP before; and one individual (4%) had never heard of PrEP (Table  1 ).

Themes identified during interviews

Thematic analysis suggested several key themes for informing the development and implementation of a PDI to promote PrEP uptake among MSM, especially B/AA and H/L individuals. Table  2 presents a list of the themes generated from participant interviews, including: (1) characteristics of social networks; (2) the role of peers in increasing PrEP awareness and knowledge; (3) attitudes towards a PrEP PDI; (4) ideal characteristics of PrEP peer educators; (5) key components of PrEP education; (6) suggested approaches for initiating conversations about PrEP; (7) cultural barriers to initiating PrEP; (8) barriers to initiating PrEP for young adults; (9) suggestions for PrEP education content for peer educators; and (10) the impact of COVID-19 on social and sexual behaviors. These themes are described below along with illustrative quotes.

Social network characteristics

Most participants reported having racially and ethnically diverse social networks. They usually considered less than ten people to be very important in their lives; among those they considered important, they mentioned family members, people with whom they had grown up, or more recent connections made at college, work, or through mutual friends. The majority of participants saw or communicated frequently with two to three individuals.

“It really is a mix. I have white friends. My best friend is actually Palestinian , and , yeah , Asian friends , Mexican friends. It’s a mix…That’s the overall ethnic diagnosis. [Laughter] Well , yeah , I just meet friends , and they come in all flavors.” - Asian/non-Hispanic male , mid-twenties .

Most participants had several friends who self-identified as gay or bisexual men.

“[I have] quite a few [gay and bisexual friends]. I don’t know in terms of numbers…but I would probably say probably around 20 or 30 people. This is all from goin’ to college and some people from back home. In terms of my close-knit circle of friends that identify as gay and bisexual , I would probably say around five or six… Maybe ten max.” - Black/Hispanic male , early-twenties .

The role of peers in raising PrEP awareness

Of 28 participants, seven reported that they first heard about PrEP from their peers. Their interest in PrEP was sparked by the knowledge and experience their peers shared, motivating them to explore and learn more about PrEP.

“There was a friend of mine who told me that he was taking it. I asked what it was , and he told me… I was like , “Oh , okay.” Then , I looked it up on the internet and that’s when I saw and learned a little more about it.” – Black/non-Hispanic male , late-twenties .

Of thirteen individuals who were currently taking PrEP, eight reported already playing the role of a peer educator within their social network. This included having conversations about PrEP with LGBTQ friends, straight friends, and sexual partners.

“From my friends’ circle , three of my college friends have gone into PrEP after I have talked to them. The three of them identify as African Americans…Every knowledge that I gain that will affect [my friend group] , I will try to share that [knowledge with them] as much as I can.” - Black/Hispanic male , late-twenties . “I am an advocate for PrEP…I talk to people about it. All of my gay friends I’ve spoken to about it , partners that I have hooked up with in the past I’ve spoken to about it…I think it’s something we should all know is available as an option.” – White/Hispanic male , mid-thirties .

Attitude toward a PDI approach

All participants had a positive attitude toward using a PDI approach for PrEP promotion. Many thought that members of their own communities would be a reliable source for disseminating PrEP knowledge and capable of motivating their peers to seek PrEP counseling and care.

“I think [a community member] is helpful because you would trust that person , so I think it’s important ‘cause—yeah. I think it’s more effective and more impactful than just reading something online.” – Asian/Hispanic male , mid-twenties .

Most interviewees reported that they would be willing to be a peer educator to improve PrEP awareness and reduce rates of HIV infection in their communities.

“I’d love to take action within the queer community and help support HIV prevention…that would be something I’d be very interested in. Do I have enough education about it? No. But it’s definitely something that I feel like I’d love to learn more about and be able to pass that on.” – White/non-Hispanic male , early-twenties .

Characteristics of peer educators

Most participants stated that peer educators should have strong communication skills to effectively approach members of their social network for PrEP education. In addition, participants expected PrEP educators to be friendly, outgoing, respectful towards others, and willing to listen. According to participants, PrEP educators should also be able to ensure members in their social network are comfortable, be trustworthy, and highly knowledgeable about HIV and PrEP.

“I think characteristics they should have is that they should be , first of all , social. Obviously , they have to be able to communicate to people , be willing to give people the information , be patient with their questions…and treat people with respect when answering the questions.” - Black/non-Hispanic male , late-twenties . “I think a PrEP promoter should be outgoing , engaging. They should also be willing to listen because there are a number of people , especially in the African American community , who are going to be distrustful of someone who’s pushing a medicine on them. I think that a PrEP promoter should also be willing to hear a ‘no’ and not want to immediately get defensive or get argumentative.” - Black/non-Hispanic male , mid-thirties . “I think [peer educators] should know the effectiveness of [PrEP]. They should know who is considered high risk and who are the ones that should probably be taking it. Definitely should know what some of the side effects of it can be. I think [a peer educator] should be someone who’s actually taking it themselves , because then they have the firsthand—I get that everyone’s body is different , but it’s a little bit more comforting hearing it from someone who’s actually taking it. I think that they should just know general things about HIV.” – Black/non-Hispanic male , late-twenties .

Critical components for PrEP education

Participants identified components that are critical to include when providing PrEP education. The efficacy of PrEP, how it works in the body, and PrEP side effects were common suggestions for PrEP education content. Since there are several forms of PrEP available, including multiple daily oral formulations and long-acting injectable formulations, participants wanted to learn more about these different options. A few participants also mentioned that PrEP education should underscore the high risk of HIV acquisition for MSM, especially B/AA and H/L individuals, as well as emphasize the importance of taking PrEP as prescribed.

“I think you know the things that you probably wanna cover. It’s like , the risk—people knowin’ their risk , one; two , the options that they can take. There’s Truvada and there’s Descovy. You mentioned those two things. What’s the difference between them and how they both basically benefit the same thing.” – Black/Hispanic male , early-twenties . “I should definitely know about both the good and the bad cases of people who have taken it. People who have experienced negative side effects , what they were and what the percentage of that is if they have those statistics. Then , like I said , just the effectiveness of if you take it every day like you’re supposed to.” - Black/non-Hispanic male , late-twenties .

Some participants stated that they would like to learn more information about PrEP’s efficacy and that being equipped with this knowledge would help them feel more comfortable in playing a role as a PrEP peer educator.

“I think the best way to help someone like me to promote this would be to give me the information. If I had all the information that I’m curious about , it’d be a lot easier for me to spread the message of what PrEP is and why it’s important…For me , again , like I mentioned , I’m all about the facts. I need to know the science behind it. I need to know the truth. I don’t wanna know your opinion , how you feel about it. Show me the paperwork. If it’s on paper , it’s good to go for me.” - White/Hispanic male , mid-thirties .

Since many participants noted that cost was a major barrier to PrEP uptake, some suggested including information about how to pay for PrEP in the intervention, including available financial assistance programs.

“The training that I think I would need is I would want to have more information on the how it can be affected by insurance , ‘cause that’s another big question , is how can people afford it? I’m not gonna lie , I know about my personal insurance , but I know everyone’s different and there’s different things , we’ve got different tiers. I think that that’s a big one , because that’s gonna be a question , I feel like , everyone’s gonna ask is , ‘Financially , is it realistic for me to do this?’” – Black/non-Hispanic male , late-twenties .

Approaches to initiate PrEP conversation

We asked participants about how best to initiate a conversation about PrEP with peers in their social network. A range of approaches were identified such as: letting the conversation occur naturally, asking their peers directly if they have heard about PrEP and then providing more information if they have not, sharing personal experiences related to PrEP, providing an informational sheet about PrEP without first discussing it at-length, and only providing information if someone asks about it first.

“I think it just comes up casually , I don’t think that there is an intended approach. If I’m talking to my friends—for example , yesterday…my friends asked , “Hey , so what are you up to today?” I said , “Well , I have my PrEP appointment at this time.” Then , the conversation organically flows from that…I don’t go out of my way to say , “Wait , what about PrEP?” It doesn’t come like that. It’s usually more like a casual conversation.” – Hispanic male , mid-thirties . “I would probably just ask them ‘have they heard of it.’ Then , from there , gauge what they knew of PrEP. Then , probably in that , hear any concerns they would have , and just try to use my experience to help them gain access to it.” - Black/non-Hispanic male , early-thirties . “As opposed to having a long conversation [with someone you don’t know] , when you don’t know if someone’s interested in that conversation , you can very easily give them a card and just say , “Think about this.” I think it’s a good way to do it.” – Black/non-Hispanic male , early-twenties .

Participants identified text messaging, social media, and in-person meetings as preferred methods to deliver a PrEP PDI. Some suggested text messaging as an easier and more convenient delivery method of information than meeting in-person and identified social media as being able to reach a large audience quickly.

“I think , in this day and age , social media and texting is probably the best way to get in contact with people. That’s definitely how I would approach it , just a friendly little message in text or social media.” - Black/non-Hispanic male , early-thirties . “Maybe a social network would be a really good way to spread that message because you can spread one thing—you can share one thing on , let’s say Facebook. Within one hours that one message you’ve just shared could reach the other side of the world. Hundreds and thousands of people on the other side of the world.” – White/Hispanic male , mid-thirties .

However, some participants demonstrated a strong preference for in-person approaches, stating they believed it would be more effective in establishing a connection.

“The best way would be in-person. I think all the best conversations are face-to-face conversations.” - White/non-Hispanic male , late-seventies . “I’m old fashioned. I do the in-person just ‘cause I think that does capture everything. Sometimes via text or calling , you do lose some of that situational reaction. You lose a lot , you lose facial expression , you lose a lot of different things that can eventually help an individual make the right step in their life.” – White/Hispanic male , mid-twenties .

Cultural beliefs impact on PrEP uptake

Participants generally agreed that cultural beliefs may act as barriers to initiating PrEP. For example, some cultures do not accept same-sex relationships, and therefore those who belong to these cultures may find it uncomfortable to talk about sexual health and be unable to pursue PrEP.

“I definitely think there are some cultures that are not open to same-sex relationships or sex before marriage and things like that. That shame and stuff , I’m sure , can trickle in for individuals when it comes to taking something like PrEP.” - Black/non-Hispanic male , early-thirties .

One participant who identified as B/AA discussed how internalized stigma and low self-esteem, resulting from structural racism within our society, can act as a barrier to initiating PrEP. In addition, according to this participant there may be a misconception among some B/AA MSM that PrEP is not as applicable to them as it is for White MSM.

“I think we live in a culture that still is reckoning with racism. I think one of the effects of that is that if someone has a hard time seeing themselves as valuable or worthy of being treated well and being healthy , then they’re also less likely to practice—have good sex practices. That strikes me as a pretty big cultural barrier. …I also think , just in terms of how segregated people are , I think there is still an image of PrEP as something that mostly white gay men do. I think that’s a piece of it too.” - Black/non-Hispanic male , early-thirties .

Some H/L participants shared their experiences on being from a community where conversations about sexual health may not be normalized, and how that creates a barrier to initiating PrEP.

“I think sex sometimes is one of those where , in a lot of Hispanic countries , or not countries itself , but little communities…You don’t talk about sex at a dinner table. You don’t talk about sex with your friends. You only talk about sex with your spouse , or whatever the case is. In some cases , your parents won’t even talk to you about sex because it’s taboo , and you shouldn’t. They don’t even refer to genitalia as penis and vagina. They just go , like—they call it by other cutesy names , because they’re embarrassed to talk about sex. I think , culturally , there is a lot of barriers , and I think that could be a struggle when it comes to PrEP knowledge. Because a lot of—whether it’s a Hispanic gay man , or a Hispanic straight male , they may not be willing to talk about it. They even may think they don’t need it.”- Hispanic male , mid-thirties .

Unique barriers for young adults interested in PrEP

One young adult participant mentioned that being on their parents’ insurance was a key barrier to initiating PrEP. They started to take PrEP only once they were on their own health plan.

“I wanted to make sure that I was on my own insurance , ‘cause I’m not out to my parents. I don’t think we had that insurance where I would get on somethin’ and they would notify them , but I’m a very private person when it comes to a lot of things in my life. That was one of the main factors for me [to start PrEP] , that I was off my parent’s insurance and I had my own insurance and I was able to afford it.”- Black/Hispanic male , early-twenties .

Another young adult, recently graduated from college, reported a lack of comprehensive sexual health education and PrEP resources available through their school.

I think a lot of [sexual health education] came from , honestly , off-campus resources , once I started going to a clinic outside of my college campus….my college campus was the one who recommended [PrEP] for me , but they told me to go off campus to supply it. – White/non-Hispanic male , early twenties .

The impact of COVID on PrEP use and access

All participants reported that the COVID-19 pandemic drastically changed the way they socialize and communicate, and their sexual activity. During the COVID-19 pandemic, most individuals had minimal in-person social activities and reduced sexual activity as well.

“Pre-COVID…I had more sexual partners for sure. Now , during COVID , if I chat with someone—you add the question on top of like , “Hey , what’s your status?” …You’re not necessarily just asking these days for what’s your HIV status , you’re also asking what’s your COVID status? Are you negative? Are you safe? Some people will just give you different answers. I have chosen not to engage in too many sexual encounters in 2020.”- Hispanic male , mid-thirties .

Due to reduced sexual activity and lower perceived risk of HIV acquisition during the pandemic, some participants chose to temporarily discontinue PrEP.

“At the beginning of the pandemic , I had stopped taking it , ’cause there was no need. I wasn’t having any sexual activity for a few months…Once restriction and things were loosening up a bit , that’s when I was being sexually active again. That’s when I started [PrEP] back up.” –Black/non-Hispanic male , early-thirties .

The COVID-19 pandemic often negatively impacted participants’ access to medical care, including PrEP appointments and routine testing.

“There was interruptions…at the height of COVID , so the very early stages where a lot of medical or health organizations or providers were going teletherapy. You were able to do your consulting or your check-in appointment , but unless you had symptoms of something , they were like , “Okay , don’t go to the doctor. Don’t do the three-month blood work of whether it’s your kidney or your STD bloodwork , ” or whatever. It became very like , okay…so that’s kinda why I got off of it.”- White/Hispanic male , mid-thirties .

Several participants reported having prescription refills delivered at-home to mitigate COVID-related barriers to PrEP access.

“The pills usually get delivered to my…so it’s usually pretty straight forward. I’m home all the time , so I can’t really miss a dose.” – Hispanic male , mid-thirties .

However, a couple participants who received their PrEP refills via at-home delivery reported major issues with the delivery service that negatively affected their adherence to PrEP.

“There was two weeks where I just wasn’t getting it delivered. I called the people and said , “Hey , I signed up for delivery. Why haven’t you sent it?” They eventually just signed me up for delivery permanently. Now I get it delivered automatically , which is good…I did have a two-week gap that one time. Since then , I’ve been covered.” – Black/non-Hispanic male , early-twenties . “The process in which I can reach and get [PrEP] is a bit hard. Because they are not found in the nearby stores , I need to order online and delivery sometimes is delayed , so that’s a big challenge to me.” – Black/non-Hispanic male , late-twenties .

This study is one of the first to explore the acceptability and potential components of a PDI for PrEP among MSM. Our findings highlighted a positive perception of a PDI for PrEP among participants, with a willingness to both educate and learn from their peers. This is consistent with previous studies that have explored the effectiveness of PDIs in promoting various HIV prevention measures, such as adherence to antiretroviral therapy (ART) and increased condom use, particularly within populations disproportionately affected by HIV [ 27 , 37 , 38 , 39 ]. These findings are also consistent with the pilot study conducted by the authors on a PDI for PrEP uptake among MSM [ 30 ]. This current study had nearly double the participants of the pilot, with no participants that were involved in both studies, and was conducted during and post-COVID, which has allowed us to capture a broader range of perspectives and analyze how the COVID-19 pandemic has changed our study population’s social interactions, sexual behaviors, and PrEP access. Given the alignment of our study’s findings with existing literature and the urgent need for PrEP promotion, especially among B/AA and H/L MSM who face a disproportionate burden of HIV infection, a PDI approach holds significant promise to reducing this burden among the most affected populations [ 25 , 29 ]. Our study suggests that PDIs have the potential to address disparities in PrEP uptake and contribute to reducing HIV transmission within these communities.

We conducted an in-depth exploration of the essential components necessary for an effective implementation of a PDI to promote uptake of PrEP. This exploration encompassed various topics, including shared characteristics of social networks among MSM, the role of peers in raising PrEP awareness, general attitudes toward a PDI approach, desired attributes and formal trainings of peer educators, approaches to initiate conversations about PrEP, and cultural barriers to PrEP initiation. Through identifying and investigating these themes, our results have important implications for understanding the various elements that should be in place for a PDI tailored to PrEP promotion to succeed.

Most study participants reported having a diverse group of friends with varied racial and ethnic backgrounds. They also mentioned having a close-knit circle of friends who identified as MSM. This diverse network facilitated open and comfortable discussions about sex, HIV, and drug-related topics among their social connections. Participants’ ability to engage in such conversations was influenced by characteristics of their social network, and if they had access to an environment where important health-related discussions could take place without fear of judgment or stigma. However, it’s important to recognize that this sample may not reflect the wider Black and Hispanic MSM populations, even in our study setting. Caution is warranted when extrapolating that such supportive discussions are uniformly prevalent in diverse networks across these communities. Additionally, as indicated by responses in the study, many Hispanic and Black communities face significant sex- and racism-related stigma. This stigma poses a substantial, yet not unassailable, obstacle to the effectiveness of interventions. The findings underscore the need for nuanced approaches to health promotion that consider the complex interplay of cultural, social, and individual factors. Our participants highlighted the importance of selecting peer educators who are outgoing, personable, and skilled in effective communication. Moreover, peer educators should exhibit a strong knowledge base and enthusiasm for PrEP and be willing to educate individuals within their own social circles. Furthermore, peer educators who share experiences or backgrounds with participants were seen as having an advantage in building trust and rapport. This aligns with existing research demonstrating that individuals at the center of social networks exert greater influence over the health behavior of others within their network [ 40 ].

Participants identified several critical components to be included in PrEP education content. They stressed the need to emphasize the higher HIV risk among MSM compared to heterosexuals and suggested presenting current HIV data during sessions to underscore this. They also wanted to see evidence from previous studies demonstrating PrEP’s effectiveness in HIV prevention. Additionally, they emphasized the importance of discussing adherence to maximize PrEP’s effectiveness and desired more information on how PrEP functions in the body, available PrEP options, and candid discussions about potential side effects. Lastly, many participants suggested that it would be beneficial for peers providing PrEP education to include information about financial assistance programs for PrEP and how to navigate insurance when initiating PrEP. Given that neither of the two uninsured participants were currently on PrEP, it is likely that the existence of PrEP financial assistance programs for uninsured individuals is not widespread knowledge. Therefore, to fill this gap in PrEP coverage of uninsured patients, future peer-based interventions should include information about these programs and assist patients in applying for them.

It is crucial that PDI approaches include culturally appropriate content and address the cultural barriers mentioned by B/A and H/L participants. Given that several participants voiced they would be more comfortable with a peer educator with whom they shared an identity or cultural background, it may be highly beneficial for a PrEP PDI to select peer educators who are B/AA or H/L MSM currently on PrEP or with prior PrEP experience. Training for peer educators should also include how to approach conversations about PrEP with a focus on navigating cultural barriers that may inhibit sexual health conversations as well as the effects of internalized stigma. Such cultural competence will ensure that the intervention resonates with the targeted population.

Many participants suggested and preferred in-person meetings for PDIs. Some participants expressed a strong preference for face-to-face interactions, emphasizing the efficacy of personal engagement in providing information and addressing concerns. Conversely, other participants exhibited a greater openness to digital modes of communication. Nevertheless, it’s worth noting that the evolving landscape of social interactions influenced by the COVID-19 pandemic has prompted a shift in preferences, with some participants preferring virtual modes of engagement.

We also found that young adults face unique barriers when considering PrEP initiation, as highlighted by some participants in our study. For one individual, a key obstacle was enrollment on their parent’s insurance plan. For young adults still on a parental insurance plan, navigating sensitive conversations with their parents regarding their sexual health choices can pose a daunting challenge, in particular for those with parents unaware or unsupportive of their sexual orientation. Another participant disclosed that their university health services were not equipped to prescribe or provide PrEP, and that sexual health education and resources through their university were lacking. These experiences underscore the need for tailored interventions and support systems to address the unique concerns of young adults, including college students, interested in PrEP.

The COVID-19 pandemic caused significant changes in participants’ social and sexual behaviors. Lockdowns and social distancing measures led to reduced in-person social activities and fewer sexual encounters. Consequently, some participants temporarily stopped taking PrEP as they perceived their risk of HIV acquisition to be low. The pandemic posed challenges to consistent PrEP access and adherence due to disruptions in healthcare services and personal circumstances. Fear of COVID-19 infection also deterred participants from visiting healthcare facilities for PrEP prescriptions. Despite efforts like at-home medication delivery, some participants faced issues that hindered their adherence. HIV prevention initiatives should enhance PrEP accessibility through measures such as affordability without insurance and improved delivery options.

In our study, we employed purposive sampling based on PrEP status and race/ethnicity to explore attitudes towards a PDI on PrEP promotion among individuals with varying PrEP experiences and racial/ethnic backgrounds. This sampling methodology may have influenced our observation that B/AA MSM had a higher likelihood of PrEP usage in this study, a finding that diverges from the predominant trends reported in existing literature [ 41 ]. It is reasonable to consider that B/AA MSM who are currently taking PrEP could be more motivated to participate in a study focusing on PrEP-related interventions. Given that the primary aim of our study was to explore knowledge of and perspectives on PrEP, this potential sampling bias is unlikely to significantly detract from the validity of our findings. Indeed, capturing the insights of active PrEP users is integral to understanding the nuances of PrEP promotion strategies within diverse communities.

Nonetheless, it is important to consider the limitations of this study. The insights presented here are based on interviews conducted in the state of Rhode Island and variations in perspectives may exist in different geographical and cultural settings. While we employed purposive sampling to capture diverse viewpoints, the findings may not fully represent the broader MSM population, especially B/AA and H/L MSM. Additionally, the study was conducted during the COVID-19 pandemic, which may have impacted preferences for in-person meetings and social interactions. Aware of the potential for social desirability bias, we employed a non-judgmental and supportive interview approach, reassuring participants that all responses were valid without any ‘correct’ answers, to mitigate this effect.

In conclusion, this study suggests ways to develop a tailored PDI approach for promoting PrEP uptake among MSM populations, in particular B/AA and H/L MSM. Our findings suggest that the success of PDIs will be feasible and acceptable but their success will depend on careful selection of peer educators, comprehensive training, culturally-sensitive content, and the acknowledgment of unique challenges related to HIV and PrEP within these communities.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to risk of compromising privacy of the qualitative interview participants but are available from the corresponding author on reasonable request.

Abbreviations

Pre-exposure prophylaxis

• Peer-driven intervention
• Black/African American
• Hispanic/Latino

Men who have sex with men

Centers for Disease Control and Prevention

Human immunodeficiency virus

Lesbian, gay, bisexual, transgender, queer

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Acknowledgements

I extend my deepest gratitude to Dr. Nancy Barnett whose mentorship has been invaluable throughout the course of this research. Dr. Barnett’s guidance, support, and expert insights have not only shaped this work but have also significantly contributed to my professional growth and development as a researcher. Dr. Barnett’s dedication to excellence and her unwavering commitment to nurturing my potential were pivotal in the successful completion of this manuscript. I am profoundly thankful for the opportunity to work with her in this study.

This research was funded by the National Institute of Mental Health (K01MH19660).

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Jun Tao, Hannah Parent, Harrison Martin & Philip A. Chan

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JT designed the study and conducted the participant interviews, with assistance and guidance from PC. SAM acted as our qualitative research expert and led the training of research assistants for interview coding and analysis. JK, IK, HP, and HM coded the interviews. IK led the thematic analysis, with support from SAM and JT. JT, HP, HM, and IK majorly contributed to the writing and revision of the article. HP prepared Tables 1 and 2. BM, HR, LM, SAM and AN contributed to further revisions. All authors read and approved the final manuscript.

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Tao, J., Parent, H., Karki, I. et al. Perspectives on a peer-driven intervention to promote pre-exposure prophylaxis (PrEP) uptake among men who have sex with men in southern New England: a qualitative study. BMC Health Serv Res 24 , 1023 (2024). https://doi.org/10.1186/s12913-024-11461-7

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• Volume 14, Issue 9
• Mixed-methods protocol for the WiSSPr study: Women in Sex work, Stigma and psychosocial barriers to Pre-exposure prophylaxis in Zambia
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• http://orcid.org/0000-0002-4570-6686 Ramya Kumar 1 , 2 ,
• http://orcid.org/0000-0003-4076-0170 Deepa Rao 3 ,
• http://orcid.org/0000-0002-8189-0732 Anjali Sharma 1 ,
• Jamia Phiri 1 ,
• Martin Zimba 4 ,
• Maureen Phiri 4 ,
• Ruth Zyambo 5 ,
• Gwen Mulenga Kalo 5 ,
• Louise Chilembo 5 ,
• Phidelina Milambo Kunda 6 ,
• Chama Mulubwa 1 ,
• Benard Ngosa 1 ,
• http://orcid.org/0000-0001-5208-7468 Kenneth K Mugwanya 7 ,
• Wendy E Barrington 8 ,
• http://orcid.org/0000-0002-3629-3867 Michael E Herce 1 , 9 ,
• http://orcid.org/0000-0001-9968-7540 Maurice Musheke 1
• 1 Centre for Infectious Disease Research in Zambia , Lusaka , Zambia
• 2 Epidemiology , University of Washington School of Public Health , Seattle , Washington , USA
• 3 University of Washington School of Public Health , Seattle , Washington , USA
• 4 Zambia Sex Workers Alliance , Lusaka , Zambia
• 5 Tithandizeni Umoyo Network , Lusaka , Zambia
• 6 Lusaka District Health Office , Zambia Ministry of Health , Lusaka , Zambia
• 7 Epidemiology, Global Health , University of Washington School of Public Health , Seattle , Washington , USA
• 8 Epidemiology; Child, Family, and Population Health Nursing; Health Systems and Population Health , University of Washington School of Public Health , Seattle , Washington , USA
• 9 Institute for Global Health and Infectious Diseases , University of North Carolina at Chapel Hill , Chapel Hill , North Carolina , USA
• Correspondence to Dr Ramya Kumar; ramya.kumar.mlk{at}gmail.com

Introduction Women engaging in sex work (WESW) have 21 times the risk of HIV acquisition compared with the general population. However, accessing HIV pre-exposure prophylaxis (PrEP) remains challenging, and PrEP initiation and persistence are low due to stigma and related psychosocial factors. The WiSSPr (Women in Sex work, Stigma and PrEP) study aims to (1) estimate the effect of multiple stigmas on PrEP initiation and persistence and (2) qualitatively explore the enablers and barriers to PrEP use for WESW in Lusaka, Zambia.

Methods and analysis WiSSPr is a prospective observational cohort study grounded in community-based participatory research principles with a community advisory board (CAB) of key population (KP) civil society organi sations (KP-CSOs) and the Ministry of Health (MoH). We will administer a one-time psychosocial survey vetted by the CAB and follow 300 WESW in the electronic medical record for three months to measure PrEP initiation (#/% ever taking PrEP) and persistence (immediate discontinuation and a medication possession ratio). We will conduct in-depth interviews with a purposive sample of 18 women, including 12 WESW and 6 peer navigators who support routine HIV screening and PrEP delivery, in two community hubs serving KPs since October 2021. We seek to value KP communities as equal contributors to the knowledge production process by actively engaging KP-CSOs throughout the research process. Expected outcomes include quantitative measures of PrEP initiation and persistence among WESW, and qualitative insights into the enablers and barriers to PrEP use informed by participants’ lived experiences.

Ethics and dissemination WiSSPr was approved by the Institutional Review Boards of the University of Zambia (#3650-2023) and University of North Carolina (#22-3147). Participants must give written informed consent. Findings will be disseminated to the CAB, who will determine how to relay them to the community and stakeholders.

• MENTAL HEALTH
• HIV & AIDS
• EPIDEMIOLOGIC STUDIES
• Health Equity
• QUALITATIVE RESEARCH
• SOCIAL MEDICINE

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https://doi.org/10.1136/bmjopen-2023-080218

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STRENGTHS AND LIMITATIONS OF THIS STUDY

The Women in Sex work, Stigma and PrEP (WiSSPr) study uses a mixed-methods approach which is ideal for intersectional stigma research because it allows quantitative research to be grounded in the lived experiences of people, while ensuring that aspects of stigma that emerge at the intersections of identities are measured in testable ways.

Qualitative aim enrolls peer navigators to capture the perspectives of women who are at the unique interface of recipients of care as sex workers themselves, and supporters of health service delivery.

Uses core principles of community-based participatory research which value key populations as equal contributors to the knowledge production process.

Limitations include an inability to longitudinally assess the alignment of pre-exposure prophylaxis (PrEP) adherence and persistence with HIV risk, and limitations in measuring PrEP adherence by self-report and pharmacy dispensations instead of by drug biomarkers.

Introduction

Women engaging in sex work (WESW) are a key population (KP) that experiences an unacceptably high risk of HIV infection. In 2019, the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimate WESW have 21 times the risk of HIV acquisition compared with the general population of adults aged 15 – 49 years old. 1 In Southern and East Africa, KPs and their sexual partners account for 25% of all new HIV infections. 2 To reduce the burden of HIV in Africa, HIV prevention strategies tailored to the unique needs of WESW are critical to safeguarding their health, as well as the health of people in their sexual networks. 3 4

While HIV pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV infection, its real-world efficacy is closely linked to adherence, which is a complex process for WESW. A systematic review of PrEP usage and adherence among WESW reveals complex interrelationships between individual perceptions of HIV risk, social support and fear of healthcare provider stigma. 5 WESW may experience multiple stigmatised identities, conditions or behaviours, such as participating in sex work, having a substance use disorder, and taking HIV prevention medication. 6

Zambia has a generalised HIV epidemic, and the capital city of Lusaka is a major regional transit hub attracting WESW from the region. Approximately 3,396 live in Lusaka with over half (53%) living with HIV, underscoring the need to urgently tailor prevention strategies for this population. 7 WESW in Zambia are subject to violence and discrimination in the form of verbal, physical and sexual abuse from strangers, acquaintances, clients, intimate partners and even law enforcement. 8 Surveys among WESW in Zambia have identified healthcare provider stigma and discrimination, as well as a lack of confidential care as main barriers to HIV prevention services at public health facilities. 7 9 Therefore, a better understanding of the multiple stigmas that WESW experience is a critical first step to designing interventions to meet their HIV prevention needs.

In recent years, Zambia has made significant progress in reaching WESW and providing them with comprehensive HIV prevention services. Since May 2019, the PEPFAR-funded Key Population Investment Fund (KPIF) has been successfully engaging with KP in Lusaka Province and providing them with community-based HIV prevention and treatment services. KPIF is implemented by the Centre for Infectious Disease Research in Zambia (CIDRZ) in partnership with the Zambian Ministry of Health (MoH), US Centers for Disease Control and Prevention and importantly, key population civil society organisations (KP-CSOs). A key objective of the KPIF programme is to improve PrEP initiation, persistence and adherence for HIV-negative WESW. For this study, we propose to leverage existing KPIF infrastructure to enhance study feasibility and ensure its real-world relevance to achieving this key objective.

Although PrEP initiations are high in the KPIF programme, they may not accurately reflect PrEP effectiveness. 10 A systematic review of 41 studies found high discontinuation rates at 1 month. 11 Despite WHO recommendations and national PrEP guidelines for regular HIV testing and follow-up visits, maintaining client engagement with PrEP has been challenging. 12 13 This has resulted in a lack of data on short-term PrEP persistence among WESW in Zambia. Assessing the percentage of clients who do not return for their first follow-up visit is crucial for determining PrEP effectiveness. Current prevention strategies do not adequately address the multiple stigmas and psychosocial stress that hinder PrEP persistence.

Specific objectives

The Women in Sex work, Stigma and PrEP (WiSSPr) mixed-methods study aims to (1) measure the association between multiple stigmas on PrEP initiation and persistence among HIV-negative adult WESW and (2) qualitatively explore the enablers and barriers (interpersonal, psychosocial and structural) to initiating and persisting on PrEP. The qualitative aim will complement and contextualise 14–16 findings from the quantitative results. We hypothesize that WESW with high levels of any type of stigma will be less likely to initiate and persist on PrEP.

Conceptual framework

Interview guides will be informed by the Community, Opportunity, Motivation – Behaviour (COM-B) framework to assess how these components drive engagement with PrEP services. 17 18 The COM-B model is commonly used in HIV prevention because it offers a framework to guide the development and implementation of targeted interventions, thereby enhancing the efficacy and reach of HIV prevention programmes. 19 This framework will guide us to identify deficits in knowledge or skills (Capability), environmental and social contexts (Opportunity), and personal motivations and attitudes (Motivation). This integrated approach ensures that all relevant aspects of behaviour change are considered, leading to more effective and sustainable health outcomes.

Directed acyclic graph

Directed acyclic graphs (DAG) visually synthesise a priori knowledge about the hypothesised relationships between variables of interest, helping to identify causal pathways and potential confounders that could bias the results. We propose confounders based on their known association with stigmas and PrEP persistence, using evidence from published studies addressing similar questions. Controlling for the following variables will be sufficient to block any unconditionally open, non-causal backdoor paths that could lead to confounding: age, community hub, duration of sex work, and education ( figure 1 ).

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Directed acyclic graph illustrating the causal effect of stigma on PrEP persistence. PrEP, pre-exposure prophylaxis.

Methods and analysis

Study design.

We will use a prospective observational cohort study design with mixed methods to characterise PrEP outcomes for HIV-negative WESW in Lusaka, Zambia. Trained research assistants will administer a one-time, 75-item psychosocial survey to participants and follow them prospectively in the electronic medical record. For the qualitative aim, we will conduct in-depth interviews (IDIs) with WESW to get perspectives of prevention services with peer navigators who are both recipients of care and supporters of health service delivery.

Mixed-methods integration

We will use the NIH ‘Best Practices for Mixed Methods’ guidelines to design, analyse and interpret qualitative and quantitative data in mixed-methods research. 20 Specifically, we will employ a convergent parallel design that collects both qualitative and quantitative data concurrently and separately, prioritising both the quantitative and qualitative strands equally but keeping them independent during analysis. We will interpret the extent to which the two sets of results converge, diverge, relate to each other and/or combine to create a better understanding in response to the study’s overall purpose. 20

Study setting

The study population is composed of adult WESW who are living or working within the catchment areas of two community hubs located within urban Lusaka. Based on CIDRZ’s prior published work, we anticipate that the study population will be comprised largely (63%) of younger women (18 – 29 years old). 10

Study exposures and outcomes

Table 1 identifies the primary outcomes of PrEP initiation and persistence from pharmacy dispensations records in the last 90 days for survey participants. Several studies have accessed this data from the national electronic medical record system SmartCare. 21 22 CIDRZ is a key Smartcare implementing partner and routinely leveraging this data to optimise service delivery for KP in KPIF in order to better understand outcomes for HIV treatment and prevention in the national HIV programme. 23–28 Table 2 identifies the independent variables of interest including sociodemographic history, intersectional stigma (everyday discrimination scale), 29 substance use (ASSIST), 30 depressive symptoms (Patient Health Questionnaire, PHQ), 31 as well as sex work, HIV and PrEP-related stigmas and resulting discrimination using established questionnaires. 32–34 The qualitative outcomes are insights into the enablers and barriers to PrEP use informed by participants’ lived experiences according to the COM-B model.

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WiSSPr study outcomes

WiSSPr study independent variables

Sample size

We determined the minimum sample size using Demidenko’s method for logistic regression with binary interactions, informed by effect size and variance data from Witte et al ’s study on PrEP acceptability among women in Uganda. 35–37 Sample size considerations are based on our primary outcome of PrEP initiation and informed by preliminary programmatic data that formed assumptions about baseline HIV prevalence and estimated PrEP initiations. Each site tests an average of 200 WESW per month, which will allow an estimated 800 women to be tested during the 2-month enrolment period. We project approximately 56% (448) will test HIV-negative, and of these, we estimate 403 (90%) will be eligible, and 350 (87%) will agree to initiate PrEP. Due to time and resource limitations, we seek to enroll a sample of 300 eligible WESW. Assuming 5% of participant medical records cannot be found, a total cohort of 285 PrEP users would allow us to estimate the prevalence ratio of stigma on PrEP initiation of 1.98 or higher (positive association), or 0.50 or lower (negative association) at 80% power with a significance level of 0.05. We aim to recruit 18 participants for IDIs, based on prior research with this population and qualitative methodology guidelines suggesting that 6 – 10 interviews per subgroup are sufficient to reach thematic saturation 14 20

Participant recruitment

The study will start in July 2023. WiSSPr will recruit 300 participants from a convenience sample of WESW who are receiving HIV services from two community-based hubs which have been functioning as MoH drop-in wellness centres since October 2021. All HIV testing and prevention services at these community hubs are led by teams of KP and MoH staff. Outreach activities take place in venues where WESW socialise, such as brothels, bars, or the home of a KP. Recruitment activities will take place during these outreach activities. KPIF programming leverages KP social networks to mobilise WESW for recruitment into the study. A total of 18 participants, including 6 peer navigators, 6 WESW who discontinue PrEP after initiation, and 6 WESW who continue on PrEP, will be purposively sampled for IDIs, or until we achieve thematic saturation. 38 Qualitative data collection will take place at least 30 days after the quantitative recruitment begins, in order to sample women who initiate a 30 day supply of PrEP but do not return to pick up another refill. Figure 2 outlines the WiSSPr study recruitment process.

The WiSSPr study flow diagram summarises the stages of participant recruitment and follow-up. PrEP, pre-exposure prophylaxis; WiSSPr, Women in Sex work, Stigma and PrEP.

Recruitment will end when 300 participants have been enrolled for the survey and 18 participants enrolled for interviews. PrEP event data will be abstracted from SmartCare approximately 3 months after the final participant’s enrollment. Study activities, including qualitative data collection, data quality control and assurance, and data analysis, are anticipated to continue until the planned end of the study in September 2024.

We will engage the community advisory board (CAB) in collaborative decision-making on: (1) how best to conduct outreach to venues that WESW frequent, (2) how to engage leaders in the sex work community to inform them about this study, and (3) to encourage WESW participation in a way that minimises social harms. Box 1 identifies the inclusion and exclusion criteria for the study. Written informed consent in English or local languages (ChiNyanja or IchiBemba) will be obtained before enrollment. As an added measure of protection for this marginalised population, participants must complete an informed consent quiz to ensure that they understand the potential risks of study participation. Participants will receive the Zambia Kwacha equivalent of US$5 per survey and interview as compensation for their time.

Inclusion and exclusion criteria

Cohort inclusion and exclusion criteria are as follows:

Inclusion criteria: (1) identify as a cis-gendered or transgendered woman, (2) age ≥ 18 years, (3) earns a significant amount of income from exchanging sex for money or goods in the last 3 months, (4) HIV-negative status and eligible for PrEP according to national guidelines, (5) not planning to transfer care to another site within the next 30 days, (6) speaks English or ChiNyanja or IchiBemba and (7) willing and able to provide written informed consent

Exclusion criteria: (1) do not identify as a woman, (2) age < 18 years old, (3) has not earned a significant amount of income from exchanging sex for money or goods or has earned for < 3 months, (4) HIV-positive status or status is unknown or ineligible for PrEP, (5) planning to transfer care to another site within the next 30 days, (6) unable to speak English or ChiNyanja or IchiBemba and (7) not willing or able to provide written informed consent

In-depth interviews will be conducted with cohort members, as well as peer navigators. The inclusions and exclusion criteria for peer navigators is as follows:

Inclusion criteria: (1) age ≥ 18 years old, (2) history working as a peer health navigator, (3) history of providing HIV services to women engaging in sex work, (4) speaks English or ChiNyanja or IchiBemba and (5) willing and able to provide written informed consent.

Exclusion criteria: (1) age < 18 years, (2) does not have a history working as a peer health navigator, (3) does not have a history of providing HIV services to women engaging in sex work, (4) unable to speak English or ChiNyanja or IchiBemba and (5) not willing or able to provide written informed consent.

Quantitative data collection

A team of 3–5 trained research assistants will administer a tablet-based survey ( online supplemental file 1 ) for quicker data entry, real-time quality control and logic checks to reduce data entry errors and immediate data backup compared with paper. Surveys, estimated to take 60 min each, will be conducted in English, ChiNyanja or IchiBemba, based on participant preference. The survey tool will be piloted with CAB members and peer navigators. Patient medical records are routinely entered by KPIF programme staff into a secure, standardised electronic data capture system, from which we will extract relevant deidentified data using the participants’ SmartCare ID numbers.

Supplemental material

Qualitative data collection.

We will use a semi-structured interview guide ( online supplemental file 1 ) with open-ended questions and probes to explore specific themes related to HIV prevention and intersectional stigma. This guide allows some flexibility for participants to follow topics of interest to them. The themes we will explore are informed by the COM-B conceptual framework which include perceived and enacted stigma, the impact of intersectional stigmas on health service utilisation service needs, enablers such as psychosocial support or the trustworthiness of the healthcare system. The guide also includes modules on PrEP where the interviewer will explain oral and long-acting injectable PrEP and assess participants perceptions of the advantages and disadvantages and willingness to use these different PrEP options. Participants will be asked about their own perceptions as well as their perceived opinions of their peers, as this approach has yielded richer responses in previous studies. 39 Interviews are estimated to take 60 minutes and will be conducted in English, ChiNyanja, or IchiBemba in a private location at a community safe space or other similarly secure location determined by participant preference. We will request permission to audio record interviews for transcription and translation. All interviews will be conducted by a single trained interviewer. The interview guides will be piloted with CAB members before implementation.

Data management

SmartCare serves as a repository of clinical data for WESW accessing KPIF services. A secure server will be used to store encrypted study data, including the study database. Quantitative data collected on tablets will be transmitted to the server at the end of each day. To ensure data safety, there will be daily backups, and data will also be stored on secure drives.

All IDIs will be audio recorded. Audio recordings will be transcribed verbatim and then translated into English in a single step by qualified research staff. The audio recordings will not be marked with any identifying information. Instead, interviewers will use unique participant codes to label the audio recordings. No personal identifiers will be used, and any identifiers inadvertently mentioned during interviews will be purged from the transcripts prior to analysis.

All medical records that contain participant identities are treated as confidential in accordance with the Zambian Data Protection Act. All study documents related to the participants will only include an assigned participant code. Only research staff will have access to linkable information, which will be kept strictly confidential. All records will be archived in a secure storage facility for 3 years after the completion of the study per local regulatory guidelines, after which time all electronic data will be deleted from project servers and hard drives, and all paper-based records will be disposed of.

Quantitative data analysis

We will conduct univariable analyses to examine whether there are differences in the levels of stigma, discrimination, depressive symptoms and substance use disorders among those who initiate PrEP versus those who do not, stratified by community hub. We will report the prevalences of HIV and PrEP stigmas, discrimination due to intersectional stigma identified by the Everyday Discrimination scale, depression and suicidal ideation identified by PHQ, and substance use disorders identified by ASSIST. We will sum all items within a screener to a total score before collapsing data into categorical variables. For cases where missing data are more limited (approximately < 5%), for single items and measures, we will use mean imputation to derive a score. If there is substantial missingness (> 10%) then we will use missing data methods such as multiple imputation.

A PHQ-9 score ≥ 10 is commonly used in primary care settings as a cut-off for probable major depression. 40 PHQ-9 cut-off scores of 5, 10, 15 and 20 will be categorised as mild, moderate, moderately severe and severe depression, respectively. The ASSIST gives 10 risk scores for tobacco, alcohol, cannabis, cocaine, amphetamine-type stimulants, inhalants, sedatives, hallucinogens, opioids and other drugs. The score is higher the more frequently the participant reports using substances. For alcohol use, we will use cut-offs of 11 and 27 for moderate and high risk of substance use disorder. For all other substances cut-offs of 4, and 27 for moderate and high risk. 30

PrEP initiation will be calculated using the total number of individuals initiated on PrEP over the total number of HIV-negative individuals who were enrolled and eligible for PrEP. We refer to the complement of discontinuation as PrEP persistence. 41 We define immediate discontinuation for those who initiate a 30 day supply of PrEP and do not return for any refills over the 108 day observation period in alignment with national antiretroviral therapy (ART) programme guidelines on continuity of care and management of missed appointments. 21 42 We will calculate a medication possession ratio (MPR) of total days with medication in patient possession to the observation period, as a measure of engagement in services and report both the MPR and IQR ( table 1 ).

We will use Stata (V.16.1, StataCorp) for analysis, reporting descriptive statistics to characterise the study population and bivariate associations between key exposures and immediate discontinuation with Pearson’s χ 2 statistics. We will fit Poisson regression models, which will estimate prevalence ratios of discrimination, PrEP stigma and HIV stigma on immediate discontinuation of PrEP over a 3-month follow-up period, controlling for confounders identified by the DAG. Adjusted prevalence ratio estimates will be reported with 95% CIs and p-values at the alpha = 0.05 significance level.

Qualitative data analysis

We will analyse the qualitative data using established analytical software (NVivo, QSR International, Melbourne, Australia) through deductive reasoning based on our conceptual model and inductive reasoning to identify major and minor themes emerging from audio recordings and transcripts. The process of eliciting themes will involve familiarisation with interview transcripts and noting emergent themes, adapting our conceptual framework as necessary, performing open coding, developing a codebook, performing data reduction, data display using matrices and/or tables, and interpretation to map out relationships in the data. Two coders will review these data, independently identify emergent themes, and confer to agree on final coding and findings. We will apply established qualitative research principles in our analyses, including negative case analysis and respondent validation. 43 44

Participant attitudes and preferences relating to elements of future stigma-reduction intervention, psychosocial support provision and long-acting injectable PrEP will be described qualitatively. We will strive for critical reflexivity by outlining our point of view in relation to the interviewees of the study during data collection and will state how positionality and context may have affected the findings. The credibility and trustworthiness of qualitative data will be assured through member-checking by participants themselves. 45

Ethics and dissemination

WiSSPr was approved by the Institutional Review Boards of the University of Zambia (#3650 -2023) and University of North Carolina, the Zambia National Health Research Authority and the Lusaka Provincial and District Health Offices. A final study notification will be sent on completion of the study, or in the event of early termination. Participants are free to withdraw from the study at any time without affecting their right to medical care.

The study findings will be disseminated to KP community members, providers, researchers and policy-makers. The CAB will review preliminary results and advise on meaningful dissemination to the KP community, National AIDS Council, National HIV and Mental Health Technical Working Groups, investigators and stakeholders. The information will be presented at conferences or published in peer-reviewed journals. Participants’ personal information will not be included in any publications.

Patient and public involvement

We will use principles of community-based participatory research (CBPR) to ensure patient and public involvement in this study. CBPR is a research paradigm that focuses on relationships between academic and community partners, with principles of co-learning, mutual benefit and long-term commitment. 46 CBPR incorporates community theories, participation, and practices into the research efforts and plays a role in expanding the reach of implementation science to influence practice and policies for eliminating health disparities. 46 47

To collaboratively develop this study with clients and the public, we will use CBPR principles and create a CAB with Lusaka District Health Office and two KP-CSOs working in the study sites: Zambia Sex Workers Alliance and Tithandizeni Umoyo Network. As a study team, our first priority is to develop trust with people engaging in sex work. Trust development is a construct of CBPR and has also emerged as a synthesising theory. 48 49 Trust types are ordered along a relative continuum from least (trust deficit) to most (critical reflective) trust which reflects an ability to discuss and move on after a misstep. 48 Given the historical marginalisation and stigmatisation of WESW in Zambia, we anticipate a trust deficit and have allocated time and budget to nurture and develop trust along this continuum. We will build trust through ‘role-based trust’ as researchers, ‘proxy trust’ from the reputation of CIDRZ and KP CSO team members’ work with KPs in Zambia, and ultimately aim to establish ‘critical reflective’ trust.

The research questions and outcome measures were developed in collaboration with the CAB, ensuring they reflect the priorities, experiences and preferences of the sex worker community. Input from the CAB helped tailor the study to address the most pressing issues identified by the community. The study team will work with the CAB to adapt the study within complex systems of organisational and cultural context and knowledge. Collaborative decision-making will occur prior to the study launch, throughout the recruitment period, and during dissemination. The CAB will provide feedback on the potential burden of the intervention and the time required for participation, so that the study minimises inconvenience and respected participants’ time constraints. All partners will decide what it means to have a ‘collaborative, equitable partnership’ and how to make that happen. 50 The CAB will advise on which community hub to recruit from first, and how to work with community leaders to adapt study standard operating procedures to not disrupt service implementation at study sites. They will also advise on how to minimise potential risks to participants, including ways to reduce emotional distress and ensure physical safety. Participants experiencing emotional distress will be referred for psychosocial support with evidence-based mental health therapy specialised for those with depression and substance abuse, with the KPIF providing transportation and a peer navigator accompanying them to the facility providing these services. The CAB will be actively involved in planning the dissemination of study results to participants and the wider community, helping decide what information to share, the timing of the dissemination and the most appropriate formats for communicating the findings.

The WiSSPr study is significant as it addresses the limitations of HIV interventions that focus solely on HIV-related stigma, without considering co-occurring stigmas linked to other identities or conditions. This study will inform the design of PrEP service delivery programmes for WESW in Zambia and the region. Understanding stigmas and related psychosocial factors is crucial for developing effective, evidence-based stigma-reduction interventions for WESW in Africa. Our long-term goal is to optimise person-centred HIV prevention by implementing inclusive, affirming practices for individuals facing multiple barriers.

Strengths of this study include (1) a mixed-methods approach which grounds quantitative research in the lived experiences of people and measures aspects of stigma that emerge at the intersections of identities, (2) qualitative data from peer navigators capturing perspectives of women at the unique interface of being recipients of care as sex workers as well as direct supporters of health service delivery, and (3) incorporation of core principles of CBPR which value KP-CSOs as equal contributors to the knowledge production process.

Several methodological limitations are also inherent in the study. First, we are unable to longitudinally assess the alignment of PrEP adherence and persistence with HIV risk. We will be limited to measuring PrEP adherence by self-report and pharmacy dispensations instead of by biomarkers of tenofovir use. Secondly, recruitment might fall short at some sites, necessitating expansion to additional community outreach venues leveraging our network of KPs. Lastly, cohort studies may have bias, due to recall and social desirability bias of self-reported measures, and missing data.

Ethics statements

Patient consent for publication.

Not applicable.

Acknowledgments

The authors would like to acknowledge the infrastructure support provided by the Centre for Infectious Disease Research in Zambia (CIDRZ) and the Key Populations Investment Fund (KPIF) programme. The authors would also like to thank peer navigators and leaders in the sex work community for their assistance in developing the study approach and recruiting study participants.

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MEH and MM are joint senior authors.

X @idlidosa2, @kenmugwanya, @webarrington

Contributors RK, DR, AS, MM, MH, KKM and WB conceived and designed the study. RK, DR, AS, MM, MH, JP, MZ, MP, RZ, GMK, LC, PMK, CM and BN created the interview guides and survey. All authors revised drafts and gave final approval for publication. MM is the guarantor of the study and accepts full responsibility for the finished work and the conduct of the study, had access to the data and controlled the decision to publish.

Funding The study is being supported by the NIH Fogarty Global Health Fellowship awarded by the NIH Fogarty International Center Grant #D43TW009340.

Competing interests None declared.

Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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