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This review aims to synthesize a published set of evaluative criteria for good qualitative research. The aim is to shed light on existing standards for assessing the rigor of qualitative research encompassing a range of epistemological and ontological standpoints. Using a systematic search strategy, published journal articles that deliberate criteria for rigorous research were identified. Then, references of relevant articles were surveyed to find noteworthy, distinct, and well-defined pointers to good qualitative research. This review presents an investigative assessment of the pivotal features in qualitative research that can permit the readers to pass judgment on its quality and to condemn it as good research when objectively and adequately utilized. Overall, this review underlines the crux of qualitative research and accentuates the necessity to evaluate such research by the very tenets of its being. It also offers some prospects and recommendations to improve the quality of qualitative research. Based on the findings of this review, it is concluded that quality criteria are the aftereffect of socio-institutional procedures and existing paradigmatic conducts. Owing to the paradigmatic diversity of qualitative research, a single and specific set of quality criteria is neither feasible nor anticipated. Since qualitative research is not a cohesive discipline, researchers need to educate and familiarize themselves with applicable norms and decisive factors to evaluate qualitative research from within its theoretical and methodological framework of origin.

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Criteria for Good Qualitative Research: A Comprehensive Review

2021, The Asia-Pacific Education Researcher

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Evaluative criteria for qualitative research in health care: controversies and recommendations

Affiliation.

1 Department of Family Medicine, Research Division, University of Medicine and Dentistry, Robert Wood Johnson Medical School, Somerset, New Jersey 08873, USA. [email protected]
PMID: 18626033
PMCID: PMC2478498
DOI: 10.1370/afm.818

Purpose: We wanted to review and synthesize published criteria for good qualitative research and develop a cogent set of evaluative criteria.

Methods: We identified published journal articles discussing criteria for rigorous research using standard search strategies then examined reference sections of relevant journal articles to identify books and book chapters on this topic. A cross-publication content analysis allowed us to identify criteria and understand the beliefs that shape them.

Results: Seven criteria for good qualitative research emerged: (1) carrying out ethical research; (2) importance of the research; (3) clarity and coherence of the research report; (4) use of appropriate and rigorous methods; (5) importance of reflexivity or attending to researcher bias; (6) importance of establishing validity or credibility; and (7) importance of verification or reliability. General agreement was observed across publications on the first 4 quality dimensions. On the last 3, important divergent perspectives were observed in how these criteria should be applied to qualitative research, with differences based on the paradigm embraced by the authors.

Conclusion: Qualitative research is not a unified field. Most manuscript and grant reviewers are not qualitative experts and are likely to embrace a generic set of criteria rather than those relevant to the particular qualitative approach proposed or reported. Reviewers and researchers need to be aware of this tendency and educate health care researchers about the criteria appropriate for evaluating qualitative research from within the theoretical and methodological framework from which it emerges.

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Criteria for Good Qualitative Research: A Comprehensive Review

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Ann Fam Med
v.6(4); 2008 Jul

Evaluative Criteria for Qualitative Research in Health Care: Controversies and Recommendations

Deborah j. cohen.

Department of Family Medicine, Research Division, University of Medicine and Dentistry, Robert Wood Johnson Medical School, Somerset, New Jersey

Benjamin F. Crabtree

PURPOSE We wanted to review and synthesize published criteria for good qualitative research and develop a cogent set of evaluative criteria.

METHODS We identified published journal articles discussing criteria for rigorous research using standard search strategies then examined reference sections of relevant journal articles to identify books and book chapters on this topic. A cross-publication content analysis allowed us to identify criteria and understand the beliefs that shape them.

RESULTS Seven criteria for good qualitative research emerged: (1) carrying out ethical research; (2) importance of the research; (3) clarity and coherence of the research report; (4) use of appropriate and rigorous methods; (5) importance of reflexivity or attending to researcher bias; (6) importance of establishing validity or credibility; and (7) importance of verification or reliability. General agreement was observed across publications on the first 4 quality dimensions. On the last 3, important divergent perspectives were observed in how these criteria should be applied to qualitative research, with differences based on the paradigm embraced by the authors.

CONCLUSION Qualitative research is not a unified field. Most manuscript and grant reviewers are not qualitative experts and are likely to embrace a generic set of criteria rather than those relevant to the particular qualitative approach proposed or reported. Reviewers and researchers need to be aware of this tendency and educate health care researchers about the criteria appropriate for evaluating qualitative research from within the theoretical and methodological framework from which it emerges.

INTRODUCTION

Until the 1960s, the scientific method—which involves hypothesis testing through controlled experimentation—was the predominant approach to research in the natural, physical, and social sciences. In the social sciences, proponents of qualitative research argued that the scientific method was not an appropriate model for studying people (eg, Cicourel, 1 Schutz, 2 , 3 and Garfinkel 4 ), and such methods as observation and interviewing would lead to a better understanding of social life in its naturally occurring, uncontrolled form. Biomedical and clinical research, with deep historical roots in quantitative methods, particularly observational epidemiology 5 and clinical trials, 6 was on the periphery of this debate. It was not until the late 1960s and 1970s that anthropologists and sociologists began introducing qualitative research methods into the health care field. 4 , 7 – 14

Since that time, qualitative research methods have been increasingly used in clinical and health care research. Today, both journals (eg, Qualitative Health Research ) and books are dedicated to qualitative methods in health care, 15 – 17 and a vast literature describes basic approaches of qualitative research, 18 , 19 as well as specific information on focus groups, 20 – 23 qualitative content analysis, 24 observation and ethnography, 25 – 27 interviewing, 28 – 32 studying stories 33 , 34 and conversation, 35 – 37 doing case study, 38 , 39 and action research. 40 , 41 Publications describe strategies for sampling, 42 – 45 analyzing, reporting, 45 – 49 and combining qualitative and quantitative methods 50 ; and a growing body of health care research reports findings from studies using in-depth interviews, 51 – 54 focus groups, 55 – 57 observation, 58 – 60 and a range of mixed-methods designs. 61 – 63

As part of a project to evaluate health care improvements, we identified a need to help health care researchers, particularly those with limited experience in qualitative research, evaluate and understand qualitative methodologies. Our goals were to review and synthesize published criteria for “good” qualitative research and develop a cogent set of evaluative criteria that would be helpful to researchers, reviewers, editors, and funding agencies. In what follows, we identify the standards of good qualitative research articulated in the health care literature and describe the lessons we learned as part of this process.

A series of database searches were conducted to identify published journal articles, books, and book chapters offering criteria for evaluating and identifying rigorous qualitative research.

Data Collection and Management

With the assistance of a librarian, a search was conducted in December 2005 using the Institute for Science (ISI) Web of Science database, which indexes a wide range of journals and publications from 1980 to the present. Supplemental Appendix 1, available online-only at http://www.annfammed.org/cgi/content/full/6/4/331/DC1 , describes our search strategy. This search yielded a preliminary database of 4,499 publications. Citation information, abstracts, and the number of times the article was cited by other authors were exported to a Microsoft Excel file and an Endnote database.

After manually reviewing the Excel database, we found and removed a large number of irrelevant publications in the physical and environmental sciences (eg, forestry, observational studies of crystals), and further sorted the remaining publications to identify publications in health care. Among this subset, we read abstracts and further sorted publications into (1) publications about qualitative methods, and (2) original research using qualitative methods. For the purposes of this analysis, we reviewed in detail only publications in the first category. We read each publication in this group and further subdivided the group into publications that (1) articulated criteria for evaluating qualitative research, (2) addressed techniques for doing a particular qualitative method (eg, interviewing, focus groups), or (3) described a qualitative research strategy (eg, sampling, analysis). Subsequent analyses focused on the first category; however, among publications in the second category, a number of articles addressed the issue of quality in, for example, case study, 39 interviewing, 28 focus groups, 22 , 64 , 65 discourse, 66 and narrative 67 , 68 research that we excluded as outside the scope of our analysis.

Books and book chapters could not be searched in the same way because a database cataloging these materials did not exist. Additionally, few books on qualitative methods are written specifically for health care researchers, so we would not be able to determine whether a book was or was not contributing to the discourse in this field. To overcome these challenges, we used a snowball technique, identifying and examining books and book chapters cited in the journal articles retrieved. Through this process, a number of additional relevant journal articles were identified as frequently cited but published in non–health care or nonindexed journals (eg, online journals). These articles were included in our analysis.

We read journal articles and book chapters and prepared notes recording the evaluative criteria that author(s) posited and the world view or belief system in which criteria were embedded, if available. When criteria were attributed to another work, this information was noted. Books were reviewed and analyzed differently. We read an introductory chapter or two to understand the authors’ beliefs about research and prepared summary notes. Because most books contained a section discussing evaluative criteria, we identified and read this section, and prepared notes in the manner described above for journal articles and book chapters.

An early observation was that not all publications offered explicit criteria. Publications offering explicit evaluative criteria were treated as a group. Publications by the same author were analyzed and determined to be sufficiently similar to cluster. We examined evaluative criteria across publications, listing similar criteria in thematic clusters (eg, importance of research, conducting ethically sound research), identifying the central principle or theme of the cluster, and reviewing and refining clusters. Publications that discussed evaluative criteria for qualitative research but did not offer explicit criteria were analyzed separately.

Preliminary findings were synthesized into a Web site for the Robert Wood Johnson Foundation ( http://www.qualres.org ). This Web site was reviewed by Mary Dixon-Woods, PhD, a health care researcher with extensive expertise in qualitative research, whose feedback regarding the implications of endorsing or positing a unified set of evaluative criteria encouraged our reflection and influenced this report.

We identified 29 journal articles 19 , 26 , 45 , 69 – 94 and 16 books or book chapters 95 – 110 that offered explicit criteria for evaluating the quality of qualitative research. Supplemental Appendix 2, available online-only at http://www.annfammed.org/cgi/content/full/6/4/331/DC1 , contains a table listing citation information and criteria posited in these works. An additional 29 publications were identified that did not offer explicit criteria but informed discourse on this topic and our analysis. 111 – 139

Seven evaluative criteria were identified: (1) carrying out ethical research; (2) importance of the research; (3) clarity and coherence of the research report; (4) use of appropriate and rigorous methods; (5) importance of reflexivity or attending to researcher bias; (6) importance of establishing validity or credibility; and (7) importance of verification or reliability. There was general agreement observed across publications on the first 4 quality dimensions; however, on the last 3 criteria, disagreement was observed in how the concepts of researcher bias, validity, and reliability should be applied to qualitative research. Differences in perspectives were grounded in paradigm debates regarding the nature of knowledge and reality, with some arguing from an interpretivist perspective and others from a more pragmatic realist perspective. Three major paradigms and their implications are described in Table 1 ▶ .

Common Paradigms in Health Care Research


Positivism	There is a real world of objects apart from people
	Researchers can know this reality and use symbols to accurately describe, represent and explain this reality
	Researchers can compare their claims against this objective reality. This allows for prediction, control, and empirical verification
Realism	There are real-world objects apart from people
	Researchers can only know reality from their perspective of it
	We cannot separate ourselves from what we know; however, objectivity is an ideal researchers strive for through careful sampling and specific techniques
	It is possible to evaluate the extent to which objectivity or truth is attained. This can be evaluated by a community of scholars and those who are studied
Interpretivism	Reality as we know it is constructed intersubjectively. Meaning and under- standing are developed socially and experientially
	We cannot separate ourselves from what we know. Who we are and how we understand the world are linked
	Researchers’ values are inherent in all phases of research. Truth is negotiated through dialogue
	Findings or knowledge claims are created as an investigation proceeds and emerge through dialogue and negotiations of meanings among community members (both scholars and the community at large)
	All interpretations are located in a particular context, setting, and moment

Fundamental Criteria

It was widely agreed that qualitative research should be ethical, be important, be clearly and coherently articulated, and use appropriate and rigorous methods. Conducting ethically sound research involved carrying out research in a way that was respectful, 69 humane, 95 and honest, 77 and that embodied the values of empathy, collaboration, and service. 77 , 84 Research was considered important when it was pragmatically and theoretically useful and advanced the current knowledge base. * Clarity and coherence of the research report were criteria emphasizing that the report itself should be concise and provide a clear and adequate description of the research question, background and contextual material, study design (eg, study participants, how they were chosen, how data are collected and analyzed), and rationale for methodological choices. Description of the data should be unexaggerated, and the relationship between data and interpretation should be understandable. †

Researcher Bias

The majority of publications discussed issues of researcher bias, recognizing researchers’ preconceptions, motivations, and ways of seeing shape the qualitative research process. (It should be noted there is ample evidence to suggest researcher motivations and preconceptions shape all research.) 140 One perspective (interpretivist) viewed researcher subjectivity as “something used actively and creatively through the research process” rather than as a problem of bias. 72 A hallmark of good research was understanding and reporting relevant preconceptions through reflexive processing (ie, reflective journal-keeping). ‡ A second perspective (realist) viewed researcher bias as a problem affecting the trustworthiness, truthfulness, or validity of the account. In addition to understanding researchers’ motivations and preconceptions, value and rigor were enhanced by controlling bias through techniques to verify and confirm findings, as discussed in more detail below. * Thus, whereas all publications agreed that researcher bias was an important consideration, the approach for managing bias was quite different depending on the paradigm grounding the work.

A number of publications framed the concept of validity in the context of quantitative research, where it typically refers to the “best available approximation to the truth or falsity of propositions.” 142 (p37) Internal validity refers to truth about claims made regarding the relationship between 2 variables. External validity refers to the extent to which we can generalize findings. Across publications, different ideas emerged.

Understanding the concept of validity requires understanding beliefs about the nature of reality. One may believe that there can be multiple ways of understanding social life and reality, even multiple realities. This view of reality emerges from an interpretivist perspective. Hallmarks of high-quality qualitative research include producing a rich, substantive account with strong evidence for inferences and conclusions and then reporting the lived experiences of those observed and their perspectives on social reality, while recognizing that these could be multiple and complex and that the researcher is intertwined in the portrayal of this experience. The goal is understanding and providing a meaningful account of the complex perspectives and realities studied. †

In contrast, research may be based on the belief that there is one reality that can be observed, and this reality is knowable through the process of research, albeit sometimes imperfectly. This perspective is typically associated with a positivist paradigm that underlies quantitative research, but also with the realist paradigm found in some qualitative research. Qualitative research based on this view tends to use alternative terms for validity (eg, adequacy, trustworthiness, accuracy, credibility) and emphasizes striving for truth through the qualitative research process, for example, by having outside auditors or research participants validate findings. An important dimension of good qualitative research, therefore, is plausibility and accuracy. ‡

Verification or Reliability

Divergent perspectives were observed on the appropriateness of applying the concept of verifiability or reliability when evaluating qualitative research. As is validity, this concept is rooted in quantitative and experimental methods and refers to the extent to which measures and experimental treatments are standardized and controlled to reduce error and decrease the chance of obtaining differences. 142 Two distinct approaches to evaluating the reliability of qualitative research were articulated. In the first, verification was a process negotiated between researchers and readers, where researchers were responsible for reporting information (eg, data excerpts, how the researcher dealt with tacit knowledge, information about the interpretive process) so readers could discern for themselves the patterns identified and verify the data, its analysis and interpretation. § This interpretivist perspective contrasts with the second, realist, perspective. Rather than leaving the auditing and confirming role to the reader, steps to establish dependability should be built into the research process to repeat and affirm researchers’ observations. In some cases, special techniques, such as member checking, peer review, debriefing, and external audits to achieve reliability, are recommended and posited as hallmarks of quality in qualitative research. || In Table 2 ▶ we provide a brief description of these techniques.

Verification Techniques Used in Qualitative Research


Triangulation	Using multiple data sources in an investigation to produce understanding
Peer review/ debriefing	The “process of exposing oneself to a disinterested peer in a manner paralleling an analytical session and for the purpose of exploring aspects of the inquiry that might otherwise remain only implicit within the inquirer’s mind”
External audits/ auditing	Auditing involves having a researcher not involved in the research process examine both the process and product of the research study. The purpose is to evaluate the accuracy and evaluate whether the findings, interpretations, and conclusions are supported by the data
Member checking	Data, analytic categories, interpretations, and conclusions are tested with members of those groups from whom the data were originally obtained. This can be done both formally and informally, as opportunities for member checks may arise during the normal course of observation and conversation

Perspectives on the Value of Criteria

Health care researchers also discuss the usefulness of evaluative criteria. We observed 3 perspectives on the utility of having unified criteria for assessing qualitative research.

One perspective recognized the importance of validity and reliability as criteria for evaluating qualitative research. 132 , 133 Morse et al make the case that without validity and reliability, qualitative research risks being seen as nonscientific and lacking rigor. 88 , 125 Their argument is compelling and suggests reliability and validity should not be evaluated at the end of the project, but should be goals that shape the entire research process, influencing study design, data collection, and analysis choices. A second approach is to view the criteria of validity and reliability as inappropriate for qualitative research, and argue for the development of alternative criteria relevant for assessing qualitative research. *

This position is commonly based on the premise that the theoretical and methodological beliefs informing quantitative research (from whence the criteria of reliability and validity come) are not the same as the methodological and theoretical beliefs informing qualitative research and are, therefore, inappropriate. 136 Cogent criteria for evaluating qualitative research are needed. Without well-defined, agreed-upon, and appropriate standards, qualitative research risks being evaluated by quantitative standards, which can lead to assimilation, preferences for qualitative research that are most compatible with quantitative standards, and rejection of more radical methods that do not conform to quantitative criteria. 94 From this perspective emerged a number of alternative criteria for evaluating qualitative research.

Alternative criteria have been open to criticism. We observed such criticism in publications challenging the recommendation that qualitative research using such techniques as member checking, multiple coding, external audits, and triangulation is more reliable, valid, and of better quality. 72 , 82 , 90 , 91 , 112 , 127 , 143 Authors challenging this recommendation show how techniques such as member checking can be problematic. For example, it does not make sense to ask study participants to check or verify audio-recorded transcribed data. In other situations, study participants asked to check or verify data may not recall what they said or did. Even when study participants recall their responses, there are a number of factors that may account for discrepancies between what participants recall and the researcher’s data and preliminary findings. For instance, the purpose of data analysis is to organize individual statements into themes that produce new, higher-order insights. Individual contributions may not be recognizable to participants, and higher-order insights might not make sense. 82 Similar issues have been articulated about the peer-review and auditing processes 127 , 143 and some uses of triangulation. 130 Thus, alternative criteria for evaluating qualitative research have been posited and criticized on the grounds that such criteria (1) cannot be applied in a formulaic manner; (2) do not necessarily lead to higher-quality research, particularly if these techniques are poorly implemented; and (3) foster the false expectation among evaluators of research that use of one or more of these techniques in a study is a mark of higher quality. 72 , 81 , 90 , 91 , 112 , 123 , 127

A third approach suggests the search for a cogent set of evaluative criteria for qualitative research is misguided. The field of qualitative research is broad and diverse, not lending itself to evaluation by one set of criteria. Instead, researchers need to recognize each study is unique in its theoretical positioning and approach, and different evaluative criteria are needed. To fully understand the scientific quality of qualitative research sometimes requires a deep understanding of the theoretical foundation and the science of the approach. Thus, evaluating the scientific rigor of qualitative research requires learning, understanding, and using appropriate evaluative criteria. 123 , 124 , 135 , 137

There are a number of limitations of this analysis to be acknowledged. First, although we conducted a comprehensive literature review, it is always possible for publications to be missed, particularly with our identification of books and book chapters, which relied on a snowball technique. In addition, relying on publications and works cited within publications to understand the dialogue about rigor in qualitative methods is imperfect. Although these discussions manifest in the literature, they also arise at conferences, grant review sessions, and hallway conversations. One’s views are open to revision (cf, Lincoln’s 103 , 144 ), and relationships with editors and others shape our ideas and whom we cite. In this analysis, we cannot begin to understand these influences.

Our perspectives affect this report. Both authors received doctoral training in qualitative methods in social science disciplines (sociology/communication and anthropology) and have assimilated these values into health care as reviewers, editors, and active participants in qualitative health care studies. Our training shapes our beliefs, so we feel most aligned with interpretivism. This grounding influences how we see qualitative research, as well as the perspectives and voices we examine in this analysis. We have been exposed to a wide range of theoretical and methodological approaches for doing qualitative research, which may make us more inclined to notice the generic character of evaluative criteria emerging in the health care community and take note of the potential costs of this approach.

In addition, we use 3 common paradigms—interpretivism, realism, and positivism—in our analysis. It is important to understand that paradigms and debates about paradigms are political and used to argue for credibility and resources in the research community. In this process, underlying views about the nature of knowledge and reality have been simplified, sometimes even dichotomized (interpretivism vs positivism). We recognize our use of these paradigms as an oversimplification and limitation of our work, but one that is appropriate if only because these categories are so widely used in the works we analyze.

Our analysis reveals some common ground has been negotiated with regard to establishing criteria for rigorous qualitative research. It is important to notice that the criteria that have been widely accepted—carrying out ethical research and important research, preparing a clear and coherent research report, and using appropriate and rigorous methods—are applicable to all research. Divergent perspectives were observed in the field with regard to 3 criteria: researcher bias, validity, and verification or reliability. These criteria are more heavily influenced by quantitative and experimental approaches 142 and, not surprisingly, have met with resistance. To understand the implications of these influences, our analysis suggests the utility of examining how these criteria are embedded in beliefs about the nature of knowledge and reality.

Central to the interpretivist paradigm, which historically grounds most qualitative traditions, is the assumption that realities are multiple, fluid, and co-constructed, and knowledge is taken to be negotiated between the observer and participants. From this framework emerge evaluative criteria valuing research that illuminates subjective meanings and understands and articulates multiple ways of seeing a phenomenon. Rich substance and content, clear delineation of the research process, evidence of immersion and self-reflection, and demonstration of the researcher’s way of knowing, particularly with regard to tacit knowledge, are essential features of high-quality research.

In contrast, fundamental to a positivist paradigm, which historically grounds most quantitative approaches, is the assumption that there is a single objective reality and the presumption that this reality is knowable. The realist paradigm softens this belief by suggesting knowledge of reality is always imperfect. Within the realist framework the goal of qualitative research is to strive for attaining truth, and good research is credible, confirmable, dependable, and transferable. Thus, rigorous qualitative research requires more than prolonged engagement, persistent observation, thick description, and negative case analysis, but it should use such techniques as triangulation, external auditing, and member checking to promote attainment of truth or validity through the process of verifying findings.

One reason for the centrality of the realist paradigm in health care research may be its ability to assimilate the values, beliefs, and criteria for rigorous research that emerge from the positivist paradigm. In a community that values biomedical bench research, sees the randomized controlled trial as a reference standard, holds a belief in an objective reality, and values research that is reliable, valid, and generalizable (typically positivist ideals), it is not surprising that realist views with regard to qualitative research have found favor. Unlike interpretivism, realism adopts a philosophy of science not at odds with the commonly held ideals of positivism. By maintaining a belief in an objective reality and positing truth as an ideal qualitative researchers should strive for, realists have succeeded at positioning the qualitative research enterprise as one that can produce research which is valid, reliable, and generalizable, and therefore, of value and import equal to quantitative biomedical research.

Although qualitative research emerging from a realist paradigm may have successfully assimilated into the clinical research community (as it has in other disciplines), it may be at a cost. Qualitative approaches most compatible with traditional values of quantitative research may be most likely to be accepted (published and funded). More radical methods (eg, feminist standpoint research, critical postmodern research), which can make innovative contributions to the field, may be marginalized because they do not fit the evaluative criteria that have emerged in the health care community. 94 , 115 In addition, doing rigorous qualitative research in the way realists prescribe involves using a number of techniques that may foster the appearance of validity and reliability, but can be problematic if inappropriately applied. *

The search for a single set of criteria for good qualitative research is grounded in the assumption that qualitative research is a unified field. 124 , 135 , 137 , 145 Qualitative research is grounded in a range of theoretical frameworks and uses a variety of methodological approaches to guide data collection and analysis. Because most manuscript and grant reviewers are not qualitative experts, they are likely to embrace a generic set of criteria. Reviewers and researchers need to be aware of the 7 criteria for good qualitative research, but also they need to be aware that applying the same standards across all qualitative research is inappropriate. Helping reviewers understand how an unfamiliar qualitative approach should be executed and standards for evaluating quality are essential, because reviewers, even qualitative experts, might not be well-versed in the particular qualitative method being used or proposed. Panel organizers and editors need to recognize that a qualitative expert may have only a very narrow range of expertise. Moreover, some researchers may be so entrenched in the dogma of their own approach that they are unable to value qualitative methods dissimilar from their own. This type of ax grinding harms not only the efforts of qualitative researchers, but the field more generally.

Future work needs to focus on educating health care researchers about the criteria for evaluating qualitative research from within the appropriate theoretical and methodological framework. Although the ideas posited here suggest there may be a connection between how quality is defined and the kind of work published or funded, this assumption is worthy of empirical examination. In addition, the field needs to reflect on the value of qualitative health care research and consider whether we have the space and models for adequately reporting interpretive research in our medical journals.

Acknowledgments

We are indebted to Mary Dixon-Woods, PhD, for her insightful comments on earlier versions of this work.

Conflicts of interest: none reported

Funding support: Preparation of this report was supported by a grant from the Robert Wood Johnson Foundation (#053512).

* References 26 , 69 , 70 , 73 , 77 , 80 , 94 , 95 , 98 , 106 .

† References 19 , 26 , 69 , 70 , 73 , 75 , 77 , 84 , 85 , 87 , 95 , 107 .

‡ References 19 , 69 , 70 , 72 , 73 , 77 , 80 – 82 , 87 , 94 , 103 , 105 .

* References 19 , 45 , 71 , 74 , 78 , 79 , 83 , 87 , 96 , 101 – 106 , 108 , 141 .

† References 69 , 72 , 76 , 77 , 80 – 82 , 89 , 95 , 96 .

‡ References 45 , 70 , 71 , 73 , 74 , 78 , 79 , 83 , 86 , 87 , 90 , 91 , 93 , 96 , 98 , 100 – 108 , 141 .

§ References 69 , 70 , 72 , 81 , 82 , 89 , 95 , 109 , 110 .

|| References 19 , 45 , 71 , 73 , 74 , 76 , 78 , 80 , 83 , 84 , 86 , 87 , 93 , 96 , 100 – 106 , 108 , 141 .

* References 72 , 81 , 82 , 85 , 94 , 114 , 118 , 129 , 136 .

* References 72 , 81 , 90 , 91 , 112 , 123 , 127 , 145 .

DOI: 10.1370/afm.818
Corpus ID: 207358433

Evaluative Criteria for Qualitative Research in Health Care: Controversies and Recommendations

D. Cohen , B. Crabtree
Published in Annals of Family Medicine 1 July 2008

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Criteria for Good Qualitative Research: A Comprehensive Review

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Yadav, D. (2022). Criteria for Good Qualitative Research: A Comprehensive Review. Asia-Pacific Education Researcher , 31 (6), 679–689. https://doi.org/10.1007/s40299-021-00619-0

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Criteria for Good Qualitative Research: A Comprehensive Review

The Asia-Pacific Education Researcher , Sep 2021

Yadav, Drishti

This review aims to synthesize a published set of evaluative criteria for good qualitative research. The aim is to shed light on existing standards for assessing the rigor of qualitative research encompassing a range of epistemological and ontological standpoints. Using a systematic search strategy, published journal articles that deliberate criteria for rigorous research were identified. Then, references of relevant articles were surveyed to find noteworthy, distinct, and well-defined pointers to good qualitative research. This review presents an investigative assessment of the pivotal features in qualitative research that can permit the readers to pass judgment on its quality and to condemn it as good research when objectively and adequately utilized. Overall, this review underlines the crux of qualitative research and accentuates the necessity to evaluate such research by the very tenets of its being. It also offers some prospects and recommendations to improve the quality of qualitative research. Based on the findings of this review, it is concluded that quality criteria are the aftereffect of socio-institutional procedures and existing paradigmatic conducts. Owing to the paradigmatic diversity of qualitative research, a single and specific set of quality criteria is neither feasible nor anticipated. Since qualitative research is not a cohesive discipline, researchers need to educate and familiarize themselves with applicable norms and decisive factors to evaluate qualitative research from within its theoretical and methodological framework of origin.

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Yadav, Drishti. Criteria for Good Qualitative Research: A Comprehensive Review , The Asia-Pacific Education Researcher, 2021, pp. 1-11, DOI: 10.1007/s40299-021-00619-0

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Progress in remote sensing and gis-based fdi research based on quantitative and qualitative analysis.

1. Introduction

2. research methods and data, 2.1. research methods, 2.2. data sources and screening, 2.3. data processing, 3. subject categories and publication trends, 3.1. subject evolution, 3.2. trends in the number and cited times of published papers, 4. the intellectual structure, 4.1. quantitative analysis, 4.2. qualitative analysis, 4.2.1. macro-environmental research at national, regional, and city scales, 4.2.2. global industrial development and layout, 4.2.3. research on global value chains, 4.2.4. micro-information geography of tncs, 4.2.5. internationalization and commercialization of geo-information industry, 4.2.6. multiple data and interdisciplinary approaches, 5. discussions and conclusions, data availability statement, acknowledgments, conflicts of interest.

1	(accessed on 13 July 2024). One date of launch is missing from the data set, but this has a minimal impact on the overall trend.
2	, accessed on 13 July 2024) is selected as the primary quantitative analysis tool in this paper.

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Step	Description	Details
1	Topic identification	Identify a knowledge domain using the broadest possible terms
2	Data collection	Collect data of commonly used sources of scientific literature
3	Terms extract	Extract research front terms
4	Time slicing	Build time series models over time
5	Outcome layout	Analyze domains and generate visualizations

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Open access
Published: 19 August 2024

Collaboration for implementation of decentralisation policy of multi drug-resistant tuberculosis services in Zambia

Malizgani Paul Chavula ORCID: orcid.org/0000-0003-1189-7194 1 , 2 ,
Tulani Francis L. Matenga 3 ,
Patricia Maritim 4 , 5 ,
Margarate N. Munakampe 4 , 5 ,
Batuli Habib 3 ,
Namakando Liusha 6 ,
Jeremiah Banda 7 ,
Ntazana N. Sinyangwe 8 ,
Hikabasa Halwiindi 1 ,
Chris Mweemba 4 ,
Angel Mubanga 9 ,
Patrick Kaonga 7 ,
Mwimba Chewe 4 ,
Henry Phiri 9 &
Joseph Mumba Zulu 3 , 4

Health Research Policy and Systems volume 22 , Article number: 112 ( 2024 ) Cite this article

72 Accesses

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Multi-drug-resistant tuberculosis (MDR-TB) infections are a public health concern. Since 2017, the Ministry of Health (MoH) in Zambia, in collaboration with its partners, has been implementing decentralised MDR-TB services to address the limited community access to treatment. This study sought to explore the role of collaboration in the implementation of decentralised multi drug-resistant tuberculosis services in Zambia.

A qualitative case study design was conducted in selected provinces in Zambia using in-depth and key informant interviews as data collection methods. We conducted a total of 112 interviews involving 18 healthcare workers, 17 community health workers, 32 patients and 21 caregivers in healthcare facilities located in 10 selected districts. Additionally, 24 key informant interviews were conducted with healthcare workers managers at facility, district, provincial, and national-levels. Thematic analysis was employed guided by the Integrative Framework for Collaborative Governance.

The principled engagement was shaped by the global health agenda/summit meeting influence on the decentralisation of TB, engagement of stakeholders to initiate decentralisation, a supportive policy environment for the decentralisation process and guidelines and quarterly clinical expert committee meetings. The factors that influenced the shared motivation for the introduction of MDR-TB decentralisation included actors having a common understanding, limited access to health facilities and emergency transport services, a shared understanding of challenges in providing optimal patient monitoring and review and their appreciation of the value of evidence-based decision-making in the implementation of MDR- TB decentralisation. The capacity for joint action strategies included MoH initiating strategic partnerships in enhancing MDR-TB decentralisation, the role of leadership in organising training of healthcare workers and of multidisciplinary teams, inadequate coordination, supervision and monitoring of laboratory services and joint action in health infrastructural rehabilitation.

Conclusions

Principled engagement facilitated the involvement of various stakeholders, the dissemination of relevant policies and guidelines and regular quarterly meetings of clinical expert committees to ensure ongoing support and guidance. A shared motivation among actors was underpinned by a common understanding of the barriers faced while implementing decentralisation efforts. The capacity for joint action was demonstrated through several key strategies, however, challenges such as inadequate coordination, supervision and monitoring of laboratory services, as well as the need for collaborative efforts in health infrastructural rehabilitation were observed. Overall, collaboration has facilitated the creation of a more responsive and comprehensive TB care system, addressing the critical needs of patients and improving health outcomes.

Peer Review reports

Introduction

Multi-drug-resistant tuberculosis (MDR-TB) infection is a major global public health concern, with TB remaining as one of the top 10 leading causes of morbidity and mortality, especially in low- and middle-income countries (LMICs) [ 1 ]. In 2022, the global MDR-TB burden estimate was at 410 000 cases (CI 370 000–450 000) and only 176 000 (43%) were initiated on treatment [ 2 ]. The burden of MDR-TB infection and disease is unevenly distributed globally, with LMICs disproportionally affected due to high poverty levels [ 1 ]. Zambia is among 30 other countries with the highest MDR-TB burden in the world [ 1 ]. In 2022, Zambia had an estimated burden of 1900 MDR-TB cases, but only initiated treatment in 362 cases in the same year (WHO 2023 Global TB Report). The country recorded a treatment success rate for MDR-TB of 79% for the same year, which was lower than the treatment success rate for drug-susceptible TB, which was at 92%. The sub-optimal treatment success for MDR-TB cases is attributed to the complexity of the TB bacterium called Mycobacterium tuberculosis, as it undergoes mutations, rendering it resistant to first-line drugs crucial for TB treatment, hence requiring a more comprehensive and multifaceted approach during treatment and care [ 3 ].

Studies have highlighted risks and susceptibility factors, which drive MDR-TB infection. These include gender, residence, history of previous TB treatment, lack of knowledge and poor adherence to treatment, treatment failure, presence of MDR-TB in the family and low economic status [ 5 , 6 ]. Further, treatment success is hindered by adverse events that may arise during treatment, including vomiting, skin rash, anaemia and peripheral neuropathy [ 7 ]. Drivers for unsuccessful treatment outcomes include social stigma, negative experiences of physical and emotional trauma, lack of social support and non-responsiveness to healthcare services [ 8 ]. Therefore, while MDR-TB is driven by various factors such as gender and social support, its successful treatment faces challenges from both side effects and patient experiences.

Prevention of MDR-TB infection is part of the global agenda of Sustainable Development Goal (SDG) 3 (Good Health and Well-being), thus, in practical terms, the aim is to dismantle inequalities and increase universal health coverage [ 9 ]. Many countries are adopting decentralisation of MDR-TB services through health systems strengthening as a critical way of ensuring timely service delivery to all people. Global partners and international organisations are playing a critical role in strengthening the health systems through resource mobilisation, and investment into improving infrastructure, diagnostics, health information and human resources for health development, to enhance service delivery [ 10 ].

Studies have revealed that decentralisation of MDR-TB healthcare services has had significant advantages including improved accessibility, and timely delivery of care particularly for rural areas [ 11 ]. In Bangladesh, decentralisation contributed to enhanced collaboration in localising MDR-TB medical services, adapting them to local preferences and needs [ 12 ]. However, governance issues such as fragmentation and poor coordination remain significant gaps limiting equitable resource distribution for MDR-TB services, including infrastructure inadequacy. Many other challenges, however, are faced by many countries in trying to combat TB and attain the WHO global target to eliminate TB by 2030, through the End TB Strategy [ 10 ]. In South Africa, healthcare providers reported anxiety over the abrupt introduction of MDR-TB care, limited support and inadequate communication and collaboration during the service implementation [ 7 ]. These challenges are exacerbated by socio-economic and political factors including declining funding towards TB services .

In 2017, Zambia’s Ministry of Health introduced a policy to decentralise MDR-TB services through the 2017–2021 National Strategic Plan for Tuberculosis and Leprosy Prevention, Care, and Control, which was aligned to the National Health Strategic Plan and the WHO Global End TB Strategy [ 13 ]. The MDR-TB service delivery has, since 2017, been decentralised from the two national-level hospitals to about 100 sites across all 10 provinces in the country, including regional and local hospitals. The Ministry of Health has been collaborating with local and international organisations to support the delivery of decentralised TB services. Some of the funding agencies working with the Ministry of Health in supporting the decentralisation process include the Global Fund, the United States Government through the United States Agency for International Development (USAID) and Centers for Disease Control and Prevention (CDC), WHO, Japan Anti-Tuberculosis Association (JATA) and many others. Local partners such as civil society organisations (CSOs), TB survivor groups, faith-based organisations and many others have also been key in enhancing the decentralisation process in the country. In line with this strategic direction, collaboration has the potential to create an opportunity to strengthen the health system through increasing coverage, expanding access and improving the comprehensive availability of MDR-TB services across the country.

Collaboration is a participatory process of engaging key actors in addressing complex problems that cannot be handled by a single entity. Some studies have been conducted in LMICs on collaborative governance of tuberculosis control programmes (West Africa and Bangladesh) [ 14 , 15 ]. The Ministry of Health in Zambia, in collaboration with partners, is implementing the decentralisation of MDR-TB services. There is inadequate evidence on the optimal implementation of decentralised MDR services in the country with available literature only focusing on the general TB and human immunodeficiency virus (HIV) programme collaborative activities [ 16 ]. Most studies conducted have not addressed how system context issues and capacity for joint action as aspects of collaboration affect the effective or successful decentralisation of MDR-TB services. This study sought to explore the role of collaboration in the implementation of the decentralisation policy of multi-drug-resistant tuberculosis services in Zambia.

Conceptual framework: integrative collaborative governance

To address the research question, we adopted an integrated framework for collaborative governance to analyse the findings according to Emerson et al. [ 17 ]. Collaborative governance is defined as “the processes and structures of public policy decision-making, and management that engage people constructively across the boundaries of public agencies, levels of government, and/or the public, private and civic spheres to carry out a public purpose that could not otherwise be accomplished” [ 5 ]. We adopted the integrative framework for collaborative governance by Emerson et al. [ 17 ] to analyse the role of collaboration in the implementation of the decentralisation policy of multi-drug-resistant tuberculosis services in Zambia. The framework consists of key components (layers) including system context, collaborative governance regime, drivers and collaborative dynamics (principled engagement, shared motivation and capacity for joint action) [ 2 ] as shown in Fig. 1 . However, this paper focussed on exploring how collaboration dynamics namely principled engagement, shared motivation and capacity for joint action c hinder or support the implementation decentralisation policy of MDR-TB services in Zambia. The interaction and intersectionality of contextual actors including the political, social and legal environment are some of the key drivers influencing collaboration dynamics. The concept of principled engagement entails a process that unfolds over time, involving various stakeholders who may participate at different stages and in different settings, such as face-to-face or virtual meetings, cross-organisational networks or public and private gatherings. In this study, stakeholders engage through principled discussion to define the purpose, guidelines and roles necessary to govern the collaboration. The degree of shared motivation among actors influences the nature and pattern of collaboration in the delivery of MDR-TB services. Furthermore, capacity for joint action refers to the actor’s ability to collectively decentralise the delivery of MDR-TB services. The stakeholders collectively, through regular joint meetings, mobilise resources to facilitate implementation of MDR-TB services using existing networks and community structures [ 3 ].

Integrated framework for collaborative governance Emerson et al. [ 17 ]

Study context

This study was conducted in selected health facilities in Zambia, where the burden of TB, particularly MDR-TB, is high. The contributing factors to the higher prevalence include poverty, rapid urbanisation, population growth and exposure to silica in mining settlements [ 17 ]. In response to this situation, the Ministry of Health (Zambia), in collaboration with partners, implemented the decentralised treatment and management of TB from two national health facilities (in Lusaka and Ndola) to other facilities in all 10 provinces. The decentralisation of TB services was implemented in alignment with the 2022–2026 Zambia National Health Strategic Plan for Tuberculosis, which stresses the significance of adopting the primary healthcare approach in eliminating MDR-TB by 2030 [ 12 ]. The study was conducted in various selected healthcare facilities, including provincial and district hospitals, both public and private across the nation (Lusaka, eastern, southern, western, central and Copperbelt provinces). The study sites were selected on the basis of their higher volumes of MDR-TB case notifications, with decentralisation of TB services already being implemented in these sites.

Study design

A qualitative case study design was adopted to investigate the influence of collaboration on decentralising drug-resistant tuberculosis services in Zambia. The application of this approach enabled a comprehensive analysis of the collaboration in the implementation process. We used a case study approach to get a detailed understanding of the collaboration within the context of MDR-TB. Case studies are useful when conducting a detailed exploration of an issue in its real-life context, such as collaboration in the implementation of MDR-TB, and was relevant to facilitate unpacking of substantive real-life contexts, interactions and complexities [ 18 ]. The study utilised this design to understand how collaboration influenced the success and challenges of the decentralisation process.

Data collection methods and sampling strategy

In this study, we employed key informant and in-depth interviews as methods of understanding collaboration for the implementation of decentralisation policy of multi-drug-resistant tuberculosis services in Zambia. We conducted a total of 112 interviews with healthcare workers (18), community health workers (17), patients (32) and caregivers (21) in select healthcare facilities located in 10 selected districts and key informant interviews with facility, district, provincial, and nationallevel based managers (24). We engaged 10 trained research assistants who conducted various study activities under the supervision of the study team. The research assistants were divided into groups and collected data from the different facilities. Study participants were purposively sampled based on their involvement in the treatment and management of TB at different levels. Table 1 summarises the qualitative interviews per category of respondents.

Data management and analysis

The collected interviews were transcribed word for word and managed using NVivo software plus 14. We adopted an integrative collaborative governance framework focussing on collaboration dynamics to guide the analysis. A codebook was developed in NVivo and trained research assistants then used the NVivo software and coded the transcripts on the basis of the pre-determined coding framework. Subsequently, the coded projects were integrated into a unified project. The coding process enabled us to identify codes, which were later grouped into substantive themes. These substantive themes were later aligned with the respective domains under collaboration dynamics including principled engagement, shared motivation and capacity for joint action [ 19 ]. Our analysis approach was guided by the thematic data analysis method [ 19 ].

Trustworthiness of the study

To ensure the credibility and trustworthiness of the study, transcripts were coded by different coders. After coding, the authors verified the coded work to ensure that the quotes were representative of the developed codes. Additionally, quality assurance of transcripts was conducted through the sharing of transcripts with study team members and audio recordings. Furthermore, we held meetings with stakeholders who participated in the study to discuss the findings. However, this did not affect the interpretation of the themes as participants confirmed or could relate to these findings.

This section presents collaboration dynamics strategies shaping the implementation of the decentralisation policy of MDR-TB services. The results have been presented around the integrative collaborative governance domains, including principled engagement, shared motivation and capacity joint action, as highlighted in Table 2 below.

Domain 1: Principled engagement

Principled engagement was shaped by the global health agenda/summit meeting influence on decentralisation of TB, political will to support the introduction of decentilisation, engagement of stakeholders to initiate decentralisation, and a supportive policy environment for decentralisation of MDR-TB services.

Global health agenda/summit meeting influence on decentralisation of TB

The local government leadership interaction with the global community on health reignited the desire to create systems that increase access to health. Participants narrated that the global meeting on health for all heads of state on sustainable development was held. Goal number three was appreciated by heads of state, including the available leadership at the time. The notion of decentralising health governance, including the delivery of services, was adopted as part of the government’s agenda. The Zambian Government also committed itself to urgently address gaps in access to TB services. The Ministry of Health was tasked with finding mechanisms to address TB access-related challenges.

[In] 2015 there was a high-level meeting where heads of state were called at the UN summit and subscribed to the sustainable development goal number three and malaria, TB and HIV were picked globally for contributing as causes of mortalities, so the summit recognised the need to do something about it… (KII, government official 1).

Political will to support the introduction of decentralisation

The documented challenges on centralisation received government support, and this was a catalyst for decentralisation of TB services in Zambia. Some participants noted that there was a great push from the Ministry of Health that played a crucial role in preparing for decentralisation. Furthermore, the political will and ownership of appreciation of the value of decentralisation was also enhanced by the global agenda on health where the fight against TB was one of the priorities.

The government, through the Ministry of Health, emphasises zero cost on the part of the patient who has come to access TB services. There's caution to make sure that patient incur zero (or minimal) cost. So, when we look at these things and certainly say, how can we stop someone from travelling from [the provincial capital] all the way to UTH to seek treatment? (KII, TB government official 2).

Engagement of stakeholders to initiate decentralisation

The Ministry conducted capacity building to secure stakeholder buy-in for decentralisation, fostering community support and promoting integration, organisational capacity building, staff recruitment maintenance and ensuring a fertile climate for community support. Respondents indicated that obtaining explicit buy-in from critical stakeholders was necessary to foster a supportive environment through community sensitisation and capacity-building. Partnerships between the Ministry of Health and some implementing partners including local NGOs were essential to enhancing the provision of resources such as funding, equipment and training.

We built capacities, then we also conducted a lot of sensitisations, in promoting decentralisation, amongst other healthcare workers as well as amongst the patients, we assured the patients that service flow would continue smoothly, they shouldn’t be worried about those people who would be attending to them. They are capable (KII, government official 3).

Furthermore, organisational capacity was conducted to enhance institutional and structural health systems governance, and overall abilities to deliver quality services effectively and efficiently. Organisational capacity was conducted through recruiting and training new staff, equipping staff, improving infrastructure and increasing access to resources. As one interviewee stated:

So, now we actually started ah… are equipping, doing capacity-building to health workers in these other facilities which highlights the importance of investing in the development of human resources to improve the overall capacity of the healthcare system (KII, government official 4).

Supportive policy environment for the decentralisation process

The government, through the Ministry of Health, introduced policies including the 2017–2021 Zambia National Strategic Plan (NSP) on TB and Leprosy Management and Control in Zambia. To this effect, the Ministry of Health introduced the MDR decentralisation across the provinces in a phased approach. The services were decentralised first in Lusaka and the Copperbelt, and subsequently to other provinces including the Eastern, Western, North-western and Central provinces. However, little was mentioned about the impact that these policies had on operations at various levels.

There is a strategic document that we have called national strategic document for TB so that once again gives the overall guidance, and it runs for a period of 5 years so that is the mother document. The implementation part is the guideline, where everything is well documented and even algorithms are an extract from the guideline. Even when you go to the lab it will tell you an algorithm to use (KII, government official 5).

However, interviewees were of the view that the lack of stakeholder involvement during the decentralisation process may have contributed to the removal of critical policy and program features required for the successful implementation of the MDR-TB programme. They felt that engaging stakeholders, particularly healthcare practitioners, would assist them grasp the programme’s importance, build appreciation and allow for talks about how to incorporate the program into their daily activities. The absence of stakeholder participation in these talks may have resulted in missed opportunities.

I observed the relaxed support to decentralisation program by the district leadership, when you go to the district to do mentorship, our expectation was that the district leadership in most cases were supposed to be with us and just maybe even just participate for 10 minutes, even see what’s happening and have a word with a local team, but in most districts we did not see that, so this resulted in health workers not taking the program to be serious because health workers take the program to be serious when they see the top leadership is also involved (KII, government official 6).

Quarterly clinical expert committee meetings

Strengthened healthcare providers’ collaboration was recognised as a strategic approach to improving MDR-TB healthcare reform that could lead to improved patient outcomes. Expert committees were present at national, provincial and district levels. Peer-to-peer data reviews in the districts were felt to be effective. However, the capacity of provincial expert committees to go around districts providing technical assistance and facilitation for the implementation of decentralised services was reliant on the available services such as diagnosis and screening. This has led to a reduced number of visits in the last few years. The TB experts gave midweekly reviews of the performance of the decentralised MDR-TB services and identified strategies to improve them. Clinical expert committee meetings at national and provincial levels were held quarterly to review difficult cases and technical support provided on the best patient management strategies.

We also hold the quarterly clinical expert committee meetings where we review difficult TB cases pertaining to patients. Each district was given a chance to make a presentation on difficult cases that they have had in that quarter both for MDR and drug susceptibility so in that platform we build capacity, and we have a team of experts that now advise on how that patient can be managed and we have really improved in the treatment outcome for DR patients (KII, government official 7).

Domain 2: Shared motivation

Several factors influenced shared motivation in the decentralisation of MDR-TB, including actors having a common understanding, limited access to health facilities and emergency transport services, shared understanding of challenges in providing optimal patient monitoring and review, and their appreciation of the value of evidence-based decision-making in adopting the MDR-TB decentralisation.

A common understanding of the challenges faced by MDR-TB: limited access to health facilities and emergency transport services

The centralisation of TB services brought about patient discontentment regarding poor service delivery due to the poor accessibility of TB services. The patients were required to travel long distances to selected health facilities for treatment. Some patients with inadequate financial resources could not afford transportation fees to health facilities, accommodation and food while seeking care at the health facilities. The challenges contributed to socio-economic inequalities concerning access to health services. The respondents narrated that there was a great need for the government to adequately deliver these services, especially in provinces such as Eastern and North-western provinces where the decentralisation process was happening at a slow pace and had patients that still experienced difficulties travelling to health facilities.

I stayed in Lusaka for treatment for 5 months, the sixth month they said the remaining 1 month you should go and finish from home. So, when I came back home the medicine I got from Lusaka was not here the whole week and in the second week I found the medicine, and it happened that the cough came back again. When I thought of coming back to the clinic, I had no transport because where I live........ there is a distance (Patient with TB).

Centralisation also affected the emergency transport services as more patients were required to be taken to only two facilities in the country. Hence, before decentralisation, health facilities experienced challenges in referring patients. Sometimes, the unavailability of ambulances or transport limited the capacity of health facilities to deliver services to patients in time. During the decentralisation phase, more patients were attended to promptly because several health facilities across districts were offering services to patients with MDR-TB.

Before decentralisation, so, first a case could be identified by facility, and the facility would communicate to the district, then the district needed to find transport to take that patient to the central treatment centre, yet the district does not have any capacity to transport that patient (KII, government official 8).

The adoption of decentralisation facilitates opportunities for local health systems to collaborate with existing partners to provide emergency services to the nearest hospital. Compared with taking the patients to the two national treatment centres, the decentralised model reduces costs such as travel costs which were associated with TB management/services before decentralisation.

I can mention here that for us, we can’t afford a vehicle to go and pick up a client from a facility to the general hospital so our partners will provide the vehicle to move the patient and even if we want to go and visit a patient, our partners will provide transport/logistics (KII, government official 9).

Shared understanding of challenges in providing optimal patient monitoring and review

The centralisation of MDR-TB services was perceived to be affecting the monitoring and care of patients. Healthcare workers in the centralised system experienced heavy workloads due to huge numbers of patients, thus making the monitoring of patients challenging and sometimes impossible. Furthermore, seeing many patients and managing patient health information was problematic, furthering the gap in ensuring that patients are effectively monitored. The government and implementing actors recognised the multifaceted challenges and supported the decentralisation process to contribute to a reduction of the problem.

Patient overload, distance to the facility, poor record keeping and follow-ups were not being done and maybe even monitoring of these patients was difficult, so they figured out that if we decentralise maybe things will be done more orderly. So even patient care was compromised, so when they decentralised care and treatment improved because services were brought closer to home (KII, government official 10).

Appreciation of the value of evidence-based decision-making in adopting MDR-TB decentralisation

The capacity readiness assessment included evaluating the size and composition of health facilities, the availability of human resources, diagnostic and laboratory capabilities and the availability of data collection tools. These facilitated an understanding of facilities’ readiness to implement and manage MDR-TB treatment at the facility level. Key informants narrated that human resource for health were identified as a crucial factor, and facilities needed to have at least one medical doctor and a dedicated clinician or nurse trained in DR-TB management to handle the patients. Diagnostic services also had to be available to make an accurate diagnosis of MDR-TB. The decentralisation process was gradual, starting with larger hospitals in 2014 and fully decentralising to districts in 2018. There was also an imperative need for adequate drug stocks, which were crucial in ensuring that facilities could continue providing treatment and care for patients with MDR-TB. The success of the decentralisation process of TB services depended heavily on these preparatory measures, with manpower development being a key factor as one interviewee stated:

So, we did have a tool that was assessing certain things that should be in place for a site to be set to be related to start treating patients. It has to be a diagnostic site, it must have a preferred medical officer who’s also trained in drug-resistant TB (KII, government official 11).

Domain 3: Capacity for joint action

The capacity for joint action strategies included leadership roles in communicating the implementation plan, MoH initiating strategic partnerships in enhancing MDR-TB decentraliation, leadership capacity role in organiing training for healthcare workers, training of multidisciplinary teams, inadequate coordination, supervision and monitoring of laboratory services and joint action in health infrastructural rehabilitation.

Leadership capacity in communicating the implementation plan

The selected sites were assessed using a tool to ensure that each region had the necessary resources to treat patients with MDR-TB. This strategy allowed for a targeted and context-specific approach to implementing decentralised MDR-TB treatment in Zambia, rather than a one-size-fits-all plan. The communicating of the plan to all relevant implementing partners was crucial to ensuring that they were all informed and guided. Another KII participant stated:

We have to have different strategies for different provinces because the capacity of one province is not the same as the capacity of another province (KII, government official 12) I think one last important area where we are involved is to make sure that the community TB program is also supported and coordinated so that as a province, we do make sure that drug-resistant TB at the community level is implemented, where volunteers are supported. …. provide services on DRTB by for instance supporting DRTB patients at the community level. (…) even giving education at the community level for people who are coughing or people who may be on treatment but they are not getting any better so communities are involved, so in a nutshell that’s what I can say the degree to which am involved in DRTB program (KII, government official 17).

MoH initiating strategic partnerships in enhancing MDR-TB decentralisation

Strategic partner identification was critical to the successful execution of the MDR-TB decentralisation strategy. As a result, several partners were identified to assist with staffing specific facilities, sourcing equipment and providing assistance at the district or facility levels. It has been stated that increased collaboration in healthcare is a strategic approach to reform that can improve patient outcomes, such as reducing preventable adverse drug reactions, lowering morbidity and mortality rates and optimising pharmaceutical dosages.

The Ministry of Health alone cannot manage to sufficiently do a lot of things [on its own] but when you collaborate with other organisations, it helps because for example, the training which we have been having, they were supported by CIDRZ. So, then they will support those activities. In addition, when we are doing some of the community activities, they also support the communities (KII, government official 13).

Creating health partnerships extends to supporting the implementation of community-based activities. It was also important to assess which institutions were capable of offering preparatory services to assist with the decentralisation process. For instance, the [general hospital] was identified in the [province] as a training site to train health workers in MDR-TB diagnosis and treatment. For some areas, collaboration with external partners helped them not only train staff members but also led to the rehabilitation of structural facilities that would lead to a smooth decentralisation process of MDR-TB management.

The [general hospital] is a training and internship site… so we train a lot of interns in MDR TB, of course, our understanding is that as we build capacity, wherever they’ll go, they’ll carry that capacity… we trained pharmacy, trained lab, nurse, clinical people ahh we trained them and trained environmental health for public health purposes (KII, government official 14).

Leadership in organising and implementing the training for healthcare workers

The availability of trained human resources for health contributes to their increased knowledge and skills to improve the delivery of TB services. Some healthcare workers reported that after receiving the training, they were now more actively involved in the planning, implementation and monitoring of the delivery of TB services compared with the pre-decentralisation period. However, due to limited funding, several healthcare providers were not trained in the management of MDR-TB.

So, now we actually started…are equipping, doing capacity building to health workers in these other facilities, which highlights the importance of investing in the development of human resources to improve the overall capacity of the healthcare system (KII, government official).

Formation of multidisciplinary teams

The interviewees underscored that creating MDR-TB implementation teams was a crucial step in the decentralisation efforts, at the national, provincial, district, and health facility levels. In this regard, committees and expert teams were formed to spearhead the process. The National Clinical Expert Committee is composed of specialists in internal medicine, and infectious diseases including MDR TB, pharmacy, paediatrics, gynaecology, nutrition, social work and other supporting partners. Collaboration and teamwork were essential for ensuring successful decentralisation efforts, but it was not the same across regions and sites. As one interviewee stated:

You feel (the patient) is not responding well to treatment, there is a committee that the client is subjected to. They analyse the patient, analyse the drugs, should we switch, should we change maybe from second line treatment…third line treatment. That committee has been there maybe I don’t see any change I don’t think there is something that has changed if there are changes maybe it’s the number of times that probably this committee should sit…the number of times that this committee should look at the patients, discuss the patients… (KII, government official 14).

Collaborating with external partners in support decentralisation

For some areas, collaboration with external partners not only helped train health workers but also led to the rehabilitation of existing health facilities’ infrastructure, facilitating the smooth decentralisation process of MDR-TB services and management.

In 2017, we first started having visitations with NTLP to see what was on the ground… I think the major partner was FHI-360 under the challenge TB program. So, FHI-360 through the challenge TB program conducted the prevention and control training for the entire institution targeting all the workers in all the major departments… and providing infectious control guidelines and activities in each working space in the clinical area as well as in the non-clinical. They brought in partners under USAID and lobbied for us to have an MDR ward rehabilitated. That was done at UTH, here [Kabwe], Ndola and Kitwe, not sure about other provinces if something was done to that effect (KII, health facility staff 1).

Joint action in health infrastructural rehabilitation

Furthermore, the collaboration between the Ministry of Health and partners also contributed to improving infrastructure. For some areas, collaboration with external partners helped not only train staff members, but also led to the rehabilitation of structural facilities that would lead to a smooth decentralisation process of MDR-TB management. In some cases, new structures were built for MDR TB management. However, the support was limited as many health facilities required adequate health infrastructure development that remains unmet.

They brought in partners under USAID and World Bank lobbied for us to have an MDR ward rehabilitated (KII, health facility staff 2).

This study explored how collaboration influences the effective decentraliation implementation of MDR-TB in Zambia to enhance access and care quality. The principled engagement was shaped by the global health agenda/summit meeting’s influence on the decentralisation of TB, engagement of stakeholders to initiate decentralisation, supportive policy environment and quarterly clinical expert committee meetings. The study underscores the value of collaboration among stakeholders in policy development and implementation, shaping their joint capacity and shared motivation to train healthcare providers and engage communities, ultimately influencing successful treatment outcomes.

The study has revealed that the lack of TB service decentralisation in Zambia led to limited access, hindering eligible patients and clients from conveniently accessing care. However, a Pakistani study showed that expanding the centralised TB healthcare services contributed to increased adverse effects for rural and peri-urban populations [ 20 ]. The limited access to TB services in rural and peri-urban areas was attributed to limited or lack of healthcare infrastructure where patients could easily get tested. This highlights the major constraining factors that contributed to limited access to health facilities. They included emergency services transport for referring patients for MDR-TB services, constraining access to health facilities owing to long distances and challenges in providing optimal patient monitoring and review, as motivating factors.

The study suggests that a supportive decentralisation policy and governance environment plays a crucial role in health systems strengthening in MDR-TB in Zambia. The political leadership appreciated the pressing challenges, particularly poor access to MDR-TB services. Therefore, they advocated with political will for a policy shift from centralisation to decentralisation. Similarly, a South African study also showed that the health reform pertaining decentralisation of MDR-TB services was done to enhance access to care by placing TB care closer to communities, and improving TB-care success rates [ 21 ]. In addition, studies conducted on health policy and systems reforms also show how critical leadership and power are in driving collective decision-making on health system and policy development and reform [ 22 , 23 , 24 ]. The Ministry of Health realised that creating an enabling policy environment would contribute to addressing the limited access to MDR-TB services in Zambia. Therefore, taking services closer to the people promotes equity and contributes to dismantling health inequalities.

The supportive policy health environment spelt out the government’s agenda, direction and commitment to scaling up the decentralisation of MDR-TB services. This roadmap was essential not only in helping health managers, providers and partners understand the policy, but also in giving authority to key stakeholders to hold the government accountable for the status of the delivery of services. An Indian-based study showed that social accountability mechanisms empowered the community to collective negotiations resulting in demands for changes from the health leadership [ 25 ]. However, top leadership, in some cases, limited sustained momentum in the decentralisation process. This creates an impression whereby local health actors may fail to appreciate the health reform, contributing to a lack of ownership as they will only be waiting for the superiors to direct the implementation of the process. This study highlights that shared motivation is critical in making the stakeholders understand the programme, facilitate their buy-in and support the creation of the MDR-TB decentralisation structure and plan. Therefore, collaboration is key in facilitating stakeholder engagement through decentralised delivery of TB services to improve accessibility by clients to health facilities and the provision of quality services for a broader population.

Furthermore, this study has highlighted the importance of collaboration in the decentralisation of multi-drug-resistant tuberculosis services. Collaboration plays a crucial role in capacity-building and training among healthcare providers. In South Africa, trained human resources for healthcare are limited, thereby impacting optimal service delivery. Stakeholders, including NGOs’ collaboration and collective action, improved healthcare workers’ delivery of TB services through the provision of specialised healthcare and psychological social support [ 21 , 26 , 27 ]. Furthermore, through joint efforts, healthcare providers can receive specialised training to stay updated with the latest treatment options and management techniques, thus enhancing their proficiency in handling MDR-TB cases.

This study also highlighted that strategic partnerships are essential through capacity-building and training of healthcare providers by contributing to more effective patient care and enhanced treatment outcomes. This finding is in line with other studies, which suggest that collaborative efforts in delivering patient-centred decentralised approaches enable healthcare providers to navigate therapeutic options and provide effective care, ultimately contributing to improved treatment outcomes [ 4 ]. Collaboration helps healthcare workers to continue providing services through community structures [ 28 , 29 , 30 ]. However, inadequate human resources for health in Zambia is contributing to limiting healthcare provider’s involvement in the treatment of patients. Many healthcare facilities are not fully equipped to handle TB. In addition, they have a limited number of healthcare providers who have heavy workloads with marginal involvement of others in the management of patients.

Some studies have, however, shown that collaboration in delivering a patient-centred decentralised approach where healthcare providers collaborate in delivering TB services helps in navigating therapeutic options and enhances effective care [ 5 ]. Furthermore, this study shows that training healthcare providers is key to the decentralisation of TB services. The training equips the officers with specialisation on the latest treatment options in the operations and management of TB. Similarly, evidence from an African study found that equipping healthcare providers in the management of TB and adopting locally appropriate strategies enhances the implementation of the decentralisation policy [ 31 ].

Supportive collective community-based MDR-TB interventions were found to be crucial in creating awareness and improving patient treatment outcomes. It was apparent that community health actors, with the involvement of community health workers, contributed to improved awareness, enhanced case detection and strengthened referral systems and monitoring of patients [ 32 ]. The findings of the study show that there was inadequate involvement of community-based actors in the delivery of TB services, which might be contributing to low levels of knowledge and inadequate support from the community.

Limitations and strengths of the study

One of the limitations is the absence of stakeholders from supporting partners, including international organisations. This leaves a gap in understanding engagements during the decentralisation process. This could potentially limit the scope of the insights shaping decentralisation. Another limitation of this study is that we only focussed on collaborative dynamics to understand the key factors shaping the decentralisation policy of MDR-TB services, as it is crucial to provide in-depth knowledge of the key lessons influencing the implementation of these services. Despite this limitation, our study strength includes conducting inclusive interviews with stakeholders at the national, provincial, district and community levels, such as healthcare providers and managers at different levels, patients and caregivers, which facilitated an in-depth understanding of collaboration for implementation of decentralisation policy of multi-drug-resistant tuberculosis services in Zambia. The collaboration of researchers with backgrounds in health, social science and TB programs enhanced the analysis and quality interpretation of the findings.

The decentralisation of multi-drug-resistant tuberculosis services in Zambia was propelled by collaborative efforts aimed at addressing access to multifaceted challenges arising from the centralised management of TB health services. Collaboration dynamics, including principled engagement, shared motivation and the capacity for joint action, played a crucial role in involving stakeholders to tackle issues such as limited access, transportation barriers and patient monitoring challenges. The shift in policy was grounded in evidence-based decision-making, influenced by political determination and facilitated by supportive policies. However, more capacity-building trainings are needed to increase the number of healthcare workers involved in the delivery of MDR-TB services. The study also identified associated healthcare challenges, including infrastructure and service delivery limitations. Therefore, enhancing stakeholders’ collaboration will create opportunities to expand the current infrastructure and support the optimal decentralised delivery of MDR-TB services.

Data availability

The study data can be requested from the authors. The articles for this review can be made available upon request.

Abbreviations

Non-governmental organisations

Tuberculosis

Multi-drug-resistant tuberculosis

World Health Organisation

United States Government via United States Agency for International Development

Centres for Disease Control and Prevention

Japan Anti-Tuberculosis Association

Civil society organisations

National Tuberculosis and Leprosy Programme

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Acknowledgements

We would like to thank the Ministry of Health managers for facilitating easy data collection process. We also appreciate the participants for sacrificing the time in providing information on this study.

Open access funding provided by Umea University. We would like to thank the Ministry of Health through Global Fund of Zambia for providing financial support to implement this study.

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Contributions

M.P.C., T.F.L.M., P.M., M.N.M., B.H. and J.M.Z. contributed towards the development of study design, review of data, analysis and synthesis. M.P.C. drafted the manuscript and all authors contributed towards its revision. All authors (M.P.C., T.F.L.M., P.M., M.N.M., B.H., N.L., J.B., N.N.S., H.H., C.M., A.M., P.K., M.C., H.P. and J.M.Z.) reviewed and approved the final manuscript.

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Correspondence to Malizgani Paul Chavula .

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This study followed comprehensive ethical considerations. Ethics approval was sought from the University of Zambia Biomedical Research—UNZABREC (ref. no. 3003-2022) and protocol was further registered and approved by the Zambia National Health Research Authority. Informed consent was obtained from all participants to ensure confidentiality and clear information about the study’s purpose, risks and benefits. To protect research assistants and participants, health safety protocols, including provision of N95 masks, hand sensitising and ensuring that they maintain a safe distance during interviews, were followed.

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Chavula, M.P., Matenga, T.F.L., Maritim, P. et al. Collaboration for implementation of decentralisation policy of multi drug-resistant tuberculosis services in Zambia. Health Res Policy Sys 22 , 112 (2024). https://doi.org/10.1186/s12961-024-01194-8

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Collaboration for implementation of decentralisation policy of multi drug-resistant tuberculosis services in Zambia

Conclusions

Introduction

Conceptual framework: integrative collaborative governance

Study context

Study design

Data collection methods and sampling strategy

Data management and analysis

Trustworthiness of the study

Domain 1: Principled engagement

Global health agenda/summit meeting influence on decentralisation of TB

Political will to support the introduction of decentralisation

Engagement of stakeholders to initiate decentralisation

Supportive policy environment for the decentralisation process

Quarterly clinical expert committee meetings

Domain 2: Shared motivation

A common understanding of the challenges faced by MDR-TB: limited access to health facilities and emergency transport services

Shared understanding of challenges in providing optimal patient monitoring and review

Appreciation of the value of evidence-based decision-making in adopting MDR-TB decentralisation

Domain 3: Capacity for joint action

Leadership capacity in communicating the implementation plan

MoH initiating strategic partnerships in enhancing MDR-TB decentralisation

Leadership in organising and implementing the training for healthcare workers

Formation of multidisciplinary teams

Collaborating with external partners in support decentralisation

Joint action in health infrastructural rehabilitation

Limitations and strengths of the study

Data availability

Abbreviations

Acknowledgements

Author information

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