qualitative research skills needed

In order to ensure that the industry and its practitioners continue to develop and mature, it is essential to have a shared and explicit definition of the specific elements that comprise “professional competency.” This set of eight Core Competencies (an update of our 2003 edition) outlines the key skills that are required to demonstrate proficiency as a qualitative research professional in today’s world, and QRCA urges the entire qualitative research industry to adopt these competencies as a significant step toward maintaining the level of professionalism in qualitative research.

Want to Learn More?

All content in QRCA’s Qualology Learning Hub is categorized into one or more of these areas. Click on any area above or below to learn more and link to relevant Qualology content. We further encourage the global qualitative research community to use these criteria to: 

• Identify and define the skills, traits and practices that constitute the professional conduct of qualitative research professionals 
• Provide those who work in qualitative research with a framework for self- or employee-evaluation, identifying areas of accomplishment and opportunity for continued growth 
• Create a framework for education by developing and evaluating curricula in an ever-expanding and diversifying global society 

Thank you for your interest and happy learning!

Core Competencies:

Develop this Competency

Research professionals competent in Research Design:

• Have the ability to recast an organization’s stated problem into relevant research objectives then design appropriate research strategies and tactics that address and answer the stakeholder’s research issue.​
• Execute research strategy with screener design, guide development, interview approaches, and report expectations.
• ​Are responsive to study budget and timeline limitations.​
• Are aware of and understand all available research methodologies, along with a keen understanding of the pros and cons of each, so that the best suited methods are recommended. Have the ability to apply methods to a wide variety of problem types and design effective research methodologies.

Research professionals competent in Project Management can:

• Set up, implement and monitor complex projects, either alone or with colleagues, staff, contractors and stakeholders in timely and cost-efficient ways to meet research objectives.​
• Plan and manage projects from inception to completion.​
• Utilize different project management approaches adjusted to the needs of the project. (e.g., innovation projects, long -term projects, iterative projects, multinational projects, etc.).
• Manage project risks; anticipate and respond to problems as they arise.​
• Create and utilize a variety of project management systems.

Research professionals competent in Moderating/Facilitation can:

• Create rapport with participants from all walks of life, with sensitivity to culture and context and the many variables that can influence study dynamics. They show unconditional positive regard and respect for all participants.​
• Work to elicit respondent’s deepest beliefs, assumptions, and feelings. They have the ability to manage and facilitate interviews and observational research, both in-person and online.​
• Manage and facilitate qualitative research sessions of varying sizes in a wide variety of settings, including on-site, in-facility, and virtual environments. 

Research professionals competent in A nalysis and Reporting can:

• Compile and effectively summarize qualitative data, extracting underlying themes that address the stakeholder’s objective.​
• Draw on relevant disciplines for interpretive models.​
• Weave themes into a coherent and integrated view of the data and how it relates to the research issues, including the psychological and social factors influencing behavior in reference to the stakeholder’s objective.

Research professionals competent in Communication can:

• Listen to and understand all parties in the research process, communicating effectively with them in multiple modalities, including presentations .  ​
• Produce clear, insightful, and engaging written reports and instructions for a variety of audiences (e.g., other parties to the research process and end users at different levels of the organization).​
• Give effective oral presentations in a variety of modalities, both spontaneous and planned.

Research professionals competent in Consulting can:

• Understand and define stakeholder problem situations, formulate problem statements and goals, and develop strategic and tactical plans for reaching those goals.​
• Anticipate unspoken stakeholder needs and wants.​
• Identify breakthrough opportunities. ​
• Make realistic recommendations that incorporate the research findings, but also go beyond the findings based on synthesis of learning across disciplines and organizations.​
• Have a general knowledge of business, health care or social policy as well as relevant disciplines (e.g., psychology).

Research professionals competent in Business Practices can:

• Operate an economically sustainable business or department, either independently or within a larger organization.​
• Understand the economic components of qualitative research projects (potential benefits, cost to deliver and sustain).
• ​Identify effective strategies to recommend ongoing opportunities for qualitative research to provide business insights and market information for stakeholders​.
• Develop and sustain mutually beneficial business relationships both inside and outside an organization.​
• Understand the basics of contracts, current purchasing processes, and good faith negotiations. 

Research professionals competent in Professionalism can:

• Maintain a personal commitment to honesty, integrity, and professional ethics with all parties to the research process, including stakeholders, suppliers and colleagues, which help to grow the profession.​
• Understand the strengths and limitations of qualitative research and one’s own knowledge and experience.​
• Build and maintain a repertoire of resources (people, skills, techniques, technology) for reference, learning, and sharing.​
• Recognize the actual and potential ethical issues in a project through design and implementation and identify appropriate responses to those issues. This includes knowledge of and adherence to relevant privacy regulations as well as understanding and adhering to the principles in the QRCA Code of Member Ethics and Professional Practices. ​
• Seek out opportunities to mentor, guide and inspire the next generation of qualitative research professionals, and to advocate for the value of qualitative as a business solution.

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• v.67(6); Nov-Dec 2014

Qualitative Research: Getting Started

Introduction.

As scientifically trained clinicians, pharmacists may be more familiar and comfortable with the concept of quantitative rather than qualitative research. Quantitative research can be defined as “the means for testing objective theories by examining the relationship among variables which in turn can be measured so that numbered data can be analyzed using statistical procedures”. 1 Pharmacists may have used such methods to carry out audits or surveys within their own practice settings; if so, they may have had a sense of “something missing” from their data. What is missing from quantitative research methods is the voice of the participant. In a quantitative study, large amounts of data can be collected about the number of people who hold certain attitudes toward their health and health care, but what qualitative study tells us is why people have thoughts and feelings that might affect the way they respond to that care and how it is given (in this way, qualitative and quantitative data are frequently complementary). Possibly the most important point about qualitative research is that its practitioners do not seek to generalize their findings to a wider population. Rather, they attempt to find examples of behaviour, to clarify the thoughts and feelings of study participants, and to interpret participants’ experiences of the phenomena of interest, in order to find explanations for human behaviour in a given context.

WHAT IS QUALITATIVE RESEARCH?

Much of the work of clinicians (including pharmacists) takes place within a social, clinical, or interpersonal context where statistical procedures and numeric data may be insufficient to capture how patients and health care professionals feel about patients’ care. Qualitative research involves asking participants about their experiences of things that happen in their lives. It enables researchers to obtain insights into what it feels like to be another person and to understand the world as another experiences it.

Qualitative research was historically employed in fields such as sociology, history, and anthropology. 2 Miles and Huberman 2 said that qualitative data “are a source of well-grounded, rich descriptions and explanations of processes in identifiable local contexts. With qualitative data one can preserve chronological flow, see precisely which events lead to which consequences, and derive fruitful explanations.” Qualitative methods are concerned with how human behaviour can be explained, within the framework of the social structures in which that behaviour takes place. 3 So, in the context of health care, and hospital pharmacy in particular, researchers can, for example, explore how patients feel about their care, about their medicines, or indeed about “being a patient”.

THE IMPORTANCE OF METHODOLOGY

Smith 4 has described methodology as the “explanation of the approach, methods and procedures with some justification for their selection.” It is essential that researchers have robust theories that underpin the way they conduct their research—this is called “methodology”. It is also important for researchers to have a thorough understanding of various methodologies, to ensure alignment between their own positionality (i.e., bias or stance), research questions, and objectives. Clinicians may express reservations about the value or impact of qualitative research, given their perceptions that it is inherently subjective or biased, that it does not seek to be reproducible across different contexts, and that it does not produce generalizable findings. Other clinicians may express nervousness or hesitation about using qualitative methods, claiming that their previous “scientific” training and experience have not prepared them for the ambiguity and interpretative nature of qualitative data analysis. In both cases, these clinicians are depriving themselves of opportunities to understand complex or ambiguous situations, phenomena, or processes in a different way.

Qualitative researchers generally begin their work by recognizing that the position (or world view) of the researcher exerts an enormous influence on the entire research enterprise. Whether explicitly understood and acknowledged or not, this world view shapes the way in which research questions are raised and framed, methods selected, data collected and analyzed, and results reported. 5 A broad range of different methods and methodologies are available within the qualitative tradition, and no single review paper can adequately capture the depth and nuance of these diverse options. Here, given space constraints, we highlight certain options for illustrative purposes only, emphasizing that they are only a sample of what may be available to you as a prospective qualitative researcher. We encourage you to continue your own study of this area to identify methods and methodologies suitable to your questions and needs, beyond those highlighted here.

The following are some of the methodologies commonly used in qualitative research:

• Ethnography generally involves researchers directly observing participants in their natural environments over time. A key feature of ethnography is the fact that natural settings, unadapted for the researchers’ interests, are used. In ethnography, the natural setting or environment is as important as the participants, and such methods have the advantage of explicitly acknowledging that, in the real world, environmental constraints and context influence behaviours and outcomes. 6 An example of ethnographic research in pharmacy might involve observations to determine how pharmacists integrate into family health teams. Such a study would also include collection of documents about participants’ lives from the participants themselves and field notes from the researcher. 7
• Grounded theory, first described by Glaser and Strauss in 1967, 8 is a framework for qualitative research that suggests that theory must derive from data, unlike other forms of research, which suggest that data should be used to test theory. Grounded theory may be particularly valuable when little or nothing is known or understood about a problem, situation, or context, and any attempt to start with a hypothesis or theory would be conjecture at best. 9 An example of the use of grounded theory in hospital pharmacy might be to determine potential roles for pharmacists in a new or underserviced clinical area. As with other qualitative methodologies, grounded theory provides researchers with a process that can be followed to facilitate the conduct of such research. As an example, Thurston and others 10 used constructivist grounded theory to explore the availability of arthritis care among indigenous people of Canada and were able to identify a number of influences on health care for this population.
• Phenomenology attempts to understand problems, ideas, and situations from the perspective of common understanding and experience rather than differences. 10 Phenomenology is about understanding how human beings experience their world. It gives researchers a powerful tool with which to understand subjective experience. In other words, 2 people may have the same diagnosis, with the same treatment prescribed, but the ways in which they experience that diagnosis and treatment will be different, even though they may have some experiences in common. Phenomenology helps researchers to explore those experiences, thoughts, and feelings and helps to elicit the meaning underlying how people behave. As an example, Hancock and others 11 used a phenomenological approach to explore health care professionals’ views of the diagnosis and management of heart failure since publication of an earlier study in 2003. Their findings revealed that barriers to effective treatment for heart failure had not changed in 10 years and provided a new understanding of why this was the case.

ROLE OF THE RESEARCHER

For any researcher, the starting point for research must be articulation of his or her research world view. This core feature of qualitative work is increasingly seen in quantitative research too: the explicit acknowledgement of one’s position, biases, and assumptions, so that readers can better understand the particular researcher. Reflexivity describes the processes whereby the act of engaging in research actually affects the process being studied, calling into question the notion of “detached objectivity”. Here, the researcher’s own subjectivity is as critical to the research process and output as any other variable. Applications of reflexivity may include participant-observer research, where the researcher is actually one of the participants in the process or situation being researched and must then examine it from these divergent perspectives. 12 Some researchers believe that objectivity is a myth and that attempts at impartiality will fail because human beings who happen to be researchers cannot isolate their own backgrounds and interests from the conduct of a study. 5 Rather than aspire to an unachievable goal of “objectivity”, it is better to simply be honest and transparent about one’s own subjectivities, allowing readers to draw their own conclusions about the interpretations that are presented through the research itself. For new (and experienced) qualitative researchers, an important first step is to step back and articulate your own underlying biases and assumptions. The following questions can help to begin this reflection process:

• Why am I interested in this topic? To answer this question, try to identify what is driving your enthusiasm, energy, and interest in researching this subject.
• What do I really think the answer is? Asking this question helps to identify any biases you may have through honest reflection on what you expect to find. You can then “bracket” those assumptions to enable the participants’ voices to be heard.
• What am I getting out of this? In many cases, pressures to publish or “do” research make research nothing more than an employment requirement. How does this affect your interest in the question or its outcomes, or the depth to which you are willing to go to find information?
• What do others in my professional community think of this work—and of me? As a researcher, you will not be operating in a vacuum; you will be part of a complex social and interpersonal world. These external influences will shape your views and expectations of yourself and your work. Acknowledging this influence and its potential effects on personal behaviour will facilitate greater self-scrutiny throughout the research process.

FROM FRAMEWORKS TO METHODS

Qualitative research methodology is not a single method, but instead offers a variety of different choices to researchers, according to specific parameters of topic, research question, participants, and settings. The method is the way you carry out your research within the paradigm of quantitative or qualitative research.

Qualitative research is concerned with participants’ own experiences of a life event, and the aim is to interpret what participants have said in order to explain why they have said it. Thus, methods should be chosen that enable participants to express themselves openly and without constraint. The framework selected by the researcher to conduct the research may direct the project toward specific methods. From among the numerous methods used by qualitative researchers, we outline below the three most frequently encountered.

DATA COLLECTION

Patton 12 has described an interview as “open-ended questions and probes yielding in-depth responses about people’s experiences, perceptions, opinions, feelings, and knowledge. Data consists of verbatim quotations and sufficient content/context to be interpretable”. Researchers may use a structured or unstructured interview approach. Structured interviews rely upon a predetermined list of questions framed algorithmically to guide the interviewer. This approach resists improvisation and following up on hunches, but has the advantage of facilitating consistency between participants. In contrast, unstructured or semistructured interviews may begin with some defined questions, but the interviewer has considerable latitude to adapt questions to the specific direction of responses, in an effort to allow for more intuitive and natural conversations between researchers and participants. Generally, you should continue to interview additional participants until you have saturated your field of interest, i.e., until you are not hearing anything new. The number of participants is therefore dependent on the richness of the data, though Miles and Huberman 2 suggested that more than 15 cases can make analysis complicated and “unwieldy”.

Focus Groups

Patton 12 has described the focus group as a primary means of collecting qualitative data. In essence, focus groups are unstructured interviews with multiple participants, which allow participants and a facilitator to interact freely with one another and to build on ideas and conversation. This method allows for the collection of group-generated data, which can be a challenging experience.

Observations

Patton 12 described observation as a useful tool in both quantitative and qualitative research: “[it involves] descriptions of activities, behaviours, actions, conversations, interpersonal interactions, organization or community processes or any other aspect of observable human experience”. Observation is critical in both interviews and focus groups, as nonalignment between verbal and nonverbal data frequently can be the result of sarcasm, irony, or other conversational techniques that may be confusing or open to interpretation. Observation can also be used as a stand-alone tool for exploring participants’ experiences, whether or not the researcher is a participant in the process.

Selecting the most appropriate and practical method is an important decision and must be taken carefully. Those unfamiliar with qualitative research may assume that “anyone” can interview, observe, or facilitate a focus group; however, it is important to recognize that the quality of data collected through qualitative methods is a direct reflection of the skills and competencies of the researcher. 13 The hardest thing to do during an interview is to sit back and listen to participants. They should be doing most of the talking—it is their perception of their own life-world that the researcher is trying to understand. Sophisticated interpersonal skills are required, in particular the ability to accurately interpret and respond to the nuanced behaviour of participants in various settings. More information about the collection of qualitative data may be found in the “Further Reading” section of this paper.

It is essential that data gathered during interviews, focus groups, and observation sessions are stored in a retrievable format. The most accurate way to do this is by audio-recording (with the participants’ permission). Video-recording may be a useful tool for focus groups, because the body language of group members and how they interact can be missed with audio-recording alone. Recordings should be transcribed verbatim and checked for accuracy against the audio- or video-recording, and all personally identifiable information should be removed from the transcript. You are then ready to start your analysis.

DATA ANALYSIS

Regardless of the research method used, the researcher must try to analyze or make sense of the participants’ narratives. This analysis can be done by coding sections of text, by writing down your thoughts in the margins of transcripts, or by making separate notes about the data collection. Coding is the process by which raw data (e.g., transcripts from interviews and focus groups or field notes from observations) are gradually converted into usable data through the identification of themes, concepts, or ideas that have some connection with each other. It may be that certain words or phrases are used by different participants, and these can be drawn together to allow the researcher an opportunity to focus findings in a more meaningful manner. The researcher will then give the words, phrases, or pieces of text meaningful names that exemplify what the participants are saying. This process is referred to as “theming”. Generating themes in an orderly fashion out of the chaos of transcripts or field notes can be a daunting task, particularly since it may involve many pages of raw data. Fortunately, sophisticated software programs such as NVivo (QSR International Pty Ltd) now exist to support researchers in converting data into themes; familiarization with such software supports is of considerable benefit to researchers and is strongly recommended. Manual coding is possible with small and straightforward data sets, but the management of qualitative data is a complexity unto itself, one that is best addressed through technological and software support.

There is both an art and a science to coding, and the second checking of themes from data is well advised (where feasible) to enhance the face validity of the work and to demonstrate reliability. Further reliability-enhancing mechanisms include “member checking”, where participants are given an opportunity to actually learn about and respond to the researchers’ preliminary analysis and coding of data. Careful documentation of various iterations of “coding trees” is important. These structures allow readers to understand how and why raw data were converted into a theme and what rules the researcher is using to govern inclusion or exclusion of specific data within or from a theme. Coding trees may be produced iteratively: after each interview, the researcher may immediately code and categorize data into themes to facilitate subsequent interviews and allow for probing with subsequent participants as necessary. At the end of the theming process, you will be in a position to tell the participants’ stories illustrated by quotations from your transcripts. For more information on different ways to manage qualitative data, see the “Further Reading” section at the end of this paper.

ETHICAL ISSUES

In most circumstances, qualitative research involves human beings or the things that human beings produce (documents, notes, etc.). As a result, it is essential that such research be undertaken in a manner that places the safety, security, and needs of participants at the forefront. Although interviews, focus groups, and questionnaires may seem innocuous and “less dangerous” than taking blood samples, it is important to recognize that the way participants are represented in research can be significantly damaging. Try to put yourself in the shoes of the potential participants when designing your research and ask yourself these questions:

• Are the requests you are making of potential participants reasonable?
• Are you putting them at unnecessary risk or inconvenience?
• Have you identified and addressed the specific needs of particular groups?

Where possible, attempting anonymization of data is strongly recommended, bearing in mind that true anonymization may be difficult, as participants can sometimes be recognized from their stories. Balancing the responsibility to report findings accurately and honestly with the potential harm to the participants involved can be challenging. Advice on the ethical considerations of research is generally available from research ethics boards and should be actively sought in these challenging situations.

GETTING STARTED

Pharmacists may be hesitant to embark on research involving qualitative methods because of a perceived lack of skills or confidence. Overcoming this barrier is the most important first step, as pharmacists can benefit from inclusion of qualitative methods in their research repertoire. Partnering with others who are more experienced and who can provide mentorship can be a valuable strategy. Reading reports of research studies that have utilized qualitative methods can provide insights and ideas for personal use; such papers are routinely included in traditional databases accessed by pharmacists. Engaging in dialogue with members of a research ethics board who have qualitative expertise can also provide useful assistance, as well as saving time during the ethics review process itself. The references at the end of this paper may provide some additional support to allow you to begin incorporating qualitative methods into your research.

CONCLUSIONS

Qualitative research offers unique opportunities for understanding complex, nuanced situations where interpersonal ambiguity and multiple interpretations exist. Qualitative research may not provide definitive answers to such complex questions, but it can yield a better understanding and a springboard for further focused work. There are multiple frameworks, methods, and considerations involved in shaping effective qualitative research. In most cases, these begin with self-reflection and articulation of positionality by the researcher. For some, qualitative research may appear commonsensical and easy; for others, it may appear daunting, given its high reliance on direct participant– researcher interactions. For yet others, qualitative research may appear subjective, unscientific, and consequently unreliable. All these perspectives reflect a lack of understanding of how effective qualitative research actually occurs. When undertaken in a rigorous manner, qualitative research provides unique opportunities for expanding our understanding of the social and clinical world that we inhabit.

Further Reading

• Breakwell GM, Hammond S, Fife-Schaw C, editors. Research methods in psychology. Thousand Oaks (CA): Sage Publications Ltd; 1995. [ Google Scholar ]
• Strauss A, Corbin J. Basics of qualitative research. Thousand Oaks (CA): Sage Publications Ltd; 1998. [ Google Scholar ]
• Willig C. Introducing qualitative research in psychology. Buckingham (UK): Open University Press; 2001. [ Google Scholar ]
• Guest G, Namey EE, Mitchel ML. Collecting qualitative data: a field manual for applied research. Thousand Oaks (CA): Sage Publications Ltd; 2013. [ Google Scholar ]
• Ogden R. Bias. In: Given LM, editor. The Sage encyclopedia of qualitative research methods. Thousand Oaks (CA): Sage Publications Inc; 2008. pp. 61–2. [ Google Scholar ]

This article is the seventh in the CJHP Research Primer Series, an initiative of the CJHP Editorial Board and the CSHP Research Committee. The planned 2-year series is intended to appeal to relatively inexperienced researchers, with the goal of building research capacity among practising pharmacists. The articles, presenting simple but rigorous guidance to encourage and support novice researchers, are being solicited from authors with appropriate expertise.

Previous article in this series:

Bond CM. The research jigsaw: how to get started. Can J Hosp Pharm . 2014;67(1):28–30.

Tully MP. Research: articulating questions, generating hypotheses, and choosing study designs. Can J Hosp Pharm . 2014;67(1):31–4.

Loewen P. Ethical issues in pharmacy practice research: an introductory guide. Can J Hosp Pharm. 2014;67(2):133–7.

Tsuyuki RT. Designing pharmacy practice research trials. Can J Hosp Pharm . 2014;67(3):226–9.

Bresee LC. An introduction to developing surveys for pharmacy practice research. Can J Hosp Pharm . 2014;67(4):286–91.

Gamble JM. An introduction to the fundamentals of cohort and case–control studies. Can J Hosp Pharm . 2014;67(5):366–72.

Competing interests: None declared.

Exploring Qualitative Researcher Skills: What They Are and How to Develop Them?

Qualitative research entails gathering and evaluating non-numerical data to gain deeper insights into thoughts, concepts, and opinions.

Recognizing essential qualitative research skills is crucial for understanding researchers’ needs and enhancing personal proficiency.

Qualitative Research Skills

Qualitative researchers engage in surveys, conversations, and interviews with subjects, emphasizing strong interpersonal and communication skills.

What skills does qualitative researcher needs?

1. framing questions.

For instance, they could ask follow-up inquiries or seek clarification regarding a response.

2. Listening

Key components of good listening skills include actively responding to comments and queries, treating the speaker with respect, and showing curiosity to get deeper into their insights.

3. Data collection

4. building rapport.

Building rapport quickly is a critical skill in qualitative research as it makes a sense of comfort and ease for the subject during conversations.

Techniques for establishing rapport include using non-threatening body language, mirroring the subject’s gestures, and maintaining an approachable demeanor that encourages easy communication.

Tips for improving qualitative researcher skills

1. enroll in training courses.

For instance, sales training can enhance qualities like empathy, active listening, and effective communication, which are valuable in qualitative research. Additionally, consider courses that focus on technical aspects such as data gathering and sharing findings.

2. Consult with Experienced Researchers

Learning from professionals in the field can offer valuable insights into your strengths and areas for development.

3. Conduct Your Own Research

4. create qualitative research projects.

If you’re not currently engaged in a role involving qualitative research, take the initiative to create or accept projects that allow you to practice and enhance your skills.

5. Request Feedback

When conducting qualitative research, it’s beneficial to seek feedback from those you’ve engaged with.

Workplace Qualitative Research Skills

Qualitative research plays a crucial role in achieving various objectives within the workplace, such as enhancing relationships, presenting information effectively, and managing project logistics.

Highlighting Qualitative Researcher Skills

1. qualitative researcher skills for resume.

Some examples of qualitative research skills to showcase on your resume include:

2. Qualitative Researcher Skills for Cover Letter

3. qualitative researcher skills for job interview.

During the interview, effectively demonstrate your qualitative researcher skills with real-life examples.

Emphasizing your achievements will substantiate your qualitative researcher skills and showcase your ability to drive positive outcomes.

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Qualitative Research Definition

Qualitative research methods and examples, advantages and disadvantages of qualitative approaches, qualitative vs. quantitative research, showing qualitative research skills on resumes, what is qualitative research methods and examples.

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Table of Contents

Qualitative research seeks to understand people’s experiences and perspectives by studying social organizations and human behavior. Data in qualitative studies focuses on people’s beliefs and emotional responses. Qualitative data is especially helpful when a company wants to know how customers feel about a product or service, such as in user experience (UX) design or marketing . 

Researchers use qualitative approaches to “determine answers to research questions on human behavior and the cultural values that drive our thinking and behavior,” says Margaret J. King, director at The Center for Cultural Studies & Analysis in Philadelphia.

Data in qualitative research typically can’t be assessed mathematically — the data is not sets of numbers or quantifiable information. Rather, it’s collections of images, words, notes on behaviors, descriptions of emotions, and historical context. Data is collected through observations, interviews, surveys, focus groups, and secondary research. 

However, a qualitative study needs a “clear research question at its base,” notes King, and the research needs to be “observed, categorized, compared, and evaluated (along a scale or by a typology chart) by reference to a baseline in order to determine an outcome with value as new and reliable information.”

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Who Uses Qualitative Research?

Researchers in social sciences and humanities often use qualitative research methods, especially in specific areas of study like anthropology, history, education, and sociology. 

Qualitative methods are also applicable in business, technology , and marketing spaces. For example, product managers use qualitative research to understand how target audiences respond to their products. They may use focus groups to gain insights from potential customers on product prototypes and improvements or surveys from existing customers to understand what changes users want to see. 

Other careers that may involve qualitative research include: 

• Marketing analyst
• UX and UI analyst
• Market researcher
• Statistician
• Business analyst
• Data analyst
• Research assistant
• Claims investigator

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Good research begins with a question, and this question informs the approach used by qualitative researchers. 

Grounded Theory

Grounded theory is an inductive approach to theory development. In many forms of research, you begin with a hypothesis and then test it to see if you’re correct. In grounded theory, though, you go in without any assumptions and rely on the data you collect to form theories. You start with an open question about a phenomenon you are studying and collect and analyze data until you can form a fully-fledged theory from the information. 

Example: A company wants to improve its brand and marketing strategies. The company performs a grounded theory approach to solving this problem by conducting interviews and surveys with past, current, and prospective customers. The information gathered from these methods helps the company understand what type of branding and marketing their customer-base likes and dislikes, allowing the team to inductively craft a new brand and marketing strategy from the data. 

Action Research

Action research is one part study and one part problem-solving . Through action research, analysts investigate a problem or weakness and develop practical solutions. The process of action research is cyclical —- researchers assess solutions for efficiency and effectiveness, and create further solutions to correct any issues found. 

Example: A manager notices her employees struggle to cooperate on group projects. She carefully reviews how team members interact with each other and asks them all to respond to a survey about communication. Through the survey and study, she finds that guidelines for group projects are unclear. After changing the guidelines, she reviews her team again to see if there are any changes to their behavior.  

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Phenomenological Research

Phenomenological research investigates a phenomenon in depth, looking at people’s experiences and understanding of the situation. This sort of study is primarily descriptive and seeks to broaden understanding around a specific incident and the people involved. Researchers in phenomenological studies must be careful to set aside any biases or assumptions because the information used should be entirely from the subjects themselves. 

Example : A researcher wants to better understand the lived experience of college students with jobs. The purpose of this research is to gain insights into the pressures of college students who balance studying and working at the same time. The researcher conducts a series of interviews with several college students, learning about their past and current situations. Through the first few interviews, the researcher builds a relationship with the students. Later discussions are more targeted, with questions prompting the students to discuss their emotions surrounding both work and school and the difficulties and benefits arising from their situation. The researcher then analyzes these interviews, and identifies shared themes to contextualize the experiences of the students.

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Skills you’ll build: Feedback giving, communication skills, empowering with insights, basics of lean, process mapping, continuous improvement tools, dataset handling in Excel

Ethnography

Ethnography is an immersive study of a particular culture or community. Through ethnographic research, analysts aim to learn about a group’s conventions, social dynamics, and cultural norms. Some researchers use active observation methods, finding ways to integrate themselves into the culture as much as possible. Others use passive observation, watching closely from the outside but not fully immersing themselves. 

Example: A company hires an external researcher to learn what their company’s culture is actually like. The researcher studies the social dynamics of the employees and may even look at how these employees interact with clients and with each other outside of the office. The goal is to deliver a comprehensive report of the company’s culture and the social dynamics of its employees.

Case Studies

A case study is a type of in-depth analysis of a situation. Case studies can focus on an organization, belief system, event, person, or action. The goal of a case study is to understand the phenomenon and put it in a real-world context. Case studies are also commonly used in marketing and sales to highlight the benefits of a company’s products or services. 

Example: A business performs a case study of its competitors’ strategies. This case study aims to show why the company should adopt a specific business strategy. The study looks at each competitor’s business structure, marketing campaigns, product offerings, and historical growth trends. Then, using this data on other businesses, the researcher can theorize how that strategy would benefit their company.

>>MORE: Learn how companies use case study interviews to assess candidates’ research and problem-solving skills. 

Qualitative research methods are great for generating new ideas. The exploratory nature of qualitative research means uncovering unexpected information, which often leads to new theories and further research topics. Additionally, qualitative findings feel meaningful. These studies focus on people, emotions, and societies and may feel closer to their communities than quantitative research that relies on more mathematical and logical data. 

However, qualitative research can be unreliable at times. It’s difficult to replicate qualitative studies since people’s opinions and emotions can change quickly. For example, a focus group has a lot of variables that can affect the outcome, and that same group, asked the same questions a year later, may have entirely different responses. The data collection can also be difficult and time-consuming with qualitative research. Ultimately, interviewing people, reviewing surveys, and understanding and explaining human emotions can be incredibly complex.

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While qualitative research deals with data that isn’t easily manipulated by mathematics, quantitative research almost exclusively involves numbers and numerical data. Quantitative studies aim to find concrete details, like units of time, percentages, or statistics. 

Besides the types of data used, a core difference between quantitative and qualitative research is the idea of control and replication. 

“Qualitative is less subject to control (as in lab studies) and, therefore, less statistically measurable than quantitative approaches,” says King.

One person’s interview about a specific topic can have completely different responses than every other person’s interview since there are so many variables in qualitative research. On the other hand, quantitative studies can often be replicated. For instance, when testing the effects of a new medication, quantifiable data, like blood test results, can be repeated. Qualitative data, though, like how people feel about the medication, may differ from person to person and from moment to moment.

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You can show your experience with qualitative research on your resume in your skills or work experience sections and your cover letter . 

• In your skills section , you can list types of qualitative research you are skilled at, like conducting interviews, performing grounded theory research, or crafting case studies. 
• In your work or internship experience descriptions , you can highlight specific examples, like talking about a time you used action research to solve a complex issue at your last job. 
• In your cover letter , you can discuss in-depth qualitative research projects you’ve completed. For instance, say you spent a summer conducting ethnographic research or a whole semester running focus groups to get feedback on a product. You can talk about these experiences in your cover letter and note how these skills make you a great fit for the job. 

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8 most important skills and abilities for qualitative researchers

As a senior leader in qualitative research here at Magid, I’ve led a wide range of market research strategies and applications across many industries with a primary focus on the entertainment industry – including television, movies, marketing/promotion, streaming content/OTT, apps/websites, and gaming.

I’m constantly having the opportunity to work with a diverse set of audiences from preschool age to adult, and kids and family research has become an area of specialty for me over the years. It’s interesting, particularly in the entertainment industry so we can deliver a more holistic understanding of what kids and families are doing-thinking-buying-changing-wishing for across their entire entertainment ecosystem.

I employ a wide range of different methods to approach UX issues, based on client questions, the platform, and the intended audience. Common approaches include everything from straightforward one-on-one UI interviews, dyads and triads with family or friend cohort groups, focus groups, longitudinal online communities, ethnographies or even creative consumer sessions.

Regardless of the method, certain skills are fundamental to providing a set of insights or recommendations that will result in a good outcome for our clients.

• Aptitude for listening with intention Being a good listener above all – listening beyond just what a user is saying to figure out where they are coming from and what they are really getting at.
• Ability to establish rapport quickly Especially in a one-on-one setting.
• Intuitiveness About how things work and how people think.
• Framing Knowing how to ask the right questions in the right way.
• Iterate in the moment When appropriate, given the client and their expectations, the ability to come up with and test alt language, flow, etc., in the moment with users.
• Think and articulate both big and small Ability to internalize the big picture questions, as well as the small details of the concept, feature, or content in question, so you have the ability to think quickly and adapt in real time.
• Articulate the findings Summarize key findings and make actionable recommendations that are user-centered.
• Democratically represent the consumer Be the voice of the user back to your clients – stand up for them.

This space continues to evolve just as technology and human behavior do. We’ve just come out of field with our own proprietary study exploring voice technology (Amazon Alexa, Google Home, etc.) with current owners/users and potential users. Voice is a unique UX and will have an impact on many different industries, including entertainment. We’re going into the study wanting to be poised and ready with an understanding of the current user experience, as well as what expectations and desires there are for the future of voice.

While evolution is inevitable in today’s rapidly changing world, applying fundamental skills to qualitative research will never go out of style.

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The Five Keys Skills Required to Be a Great Qualitative Researcher

There are already lots of articles out there exploring what it takes to be a great qualitative researcher, so why on earth do we need another one?

Well, the problem with many of those articles is that they focus exclusively on the skills required to actually undertake research moderation and in reality, moderation (most typically of focus groups, depth interviews and online communities) typically accounts for no more than 25% of the qualitative researcher’s working week.

In this article we’re going to include the often ignored 75% of the role!

But firstly – what exactly is qualitative research?

Before jumping in to a detailed description of the qualities required to be a ‘super-qualie’, it’s worth spending a bit of time considering what qualitative research actually is – and its role within marketing.

Qualitative research involves the non-numerical and creative exploration and assessment of people’s attitudes, opinions, feelings, priorities and behaviours. It’s conducted either in-person or online.

Within a commercial context, qualitative research agencies are typically commissioned to conduct research capable of informing the development of a client’s brand (e.g. Nintendo), product or service (e.g. a new soft drink or music app), marketing communication (e.g. TV , press or online ads, direct mail campaigns or billboards) or customer experience delivery (both online and bricks and mortar).

However, in isolation, qualitative research simply delivers interesting qualitative findings . It is the expert analysis and interpretation of those findings within a wider context that may enable them to be turned in to powerful insights capable of changing the dynamics of a marketing campaign, a brand, or an entire business.

The wider responsibilities of the qualitative researcher

For many qualies this catalytic process is what the role of is all about.

Yet, within the researcher’s working week there will typically be a lot of other ‘stuff’ that needs urgent attention, much of it rewarding in its own right.

This includes:

• Prospecting

Research design

• Proposal writing – including costing
• Client relationship management
• Research scheduling
• Discussion guide generation
• Respondent recruitment specification
• Stimulus material generation
• 3 rd party supplier relationship management (e.g. recruiters, facilities providers)
• Analysing the output and writing the debrief
• Presenting the debrief to the client

To make it easier to identify the full range of attributes required to be a super-qualie, the above list can be broken down in to 5 distinct areas:

• Managing relationships (e.g. the relationship with the client and with suppliers)
• Managing project logistics (e.g. client management, 3 rd party supplier management)
• Managing the research (e.g. project design, discussion guide and stimulus material generation, moderation of research)
• Analysing the research findings and compiling the presentation
• Presenting to the client

In the remainder of this article we’ll take a look at the core, qualitative research attributes required in each one.

1. Managing relationships

At the end of the day, the key thing to remember is that, as a research supplier, its all about the client. This means that the researcher’s ability to manage that relationship is key.

For starters, it requires great communication and relationship skills , combined with a natural sense of authority if the client is to feel they are in safe hands .

However, to really stand out in the area of relationship management the researcher also needs to be proactive, helping the client stay ahead of the competition by regularly bringing to their attention the latest research thinking, relevant new research methodologies and news pieces.

2. Managing project logistics

Unless the research agency has staff dedicated to managing project logistics, the role of project manager will typically fall to the researcher as well.

For any given research project this role may involve:

• Managing the development of appropriate research stimulus material
• Specifying and recruiting research respondents via a recruitment agency partner
• Booking of suitable research facilities (e.g. bespoke research viewing facilities, hotel meeting rooms or private homes) in which to hold any face-to-face research
• Arranging video links for research clients who are unable to attend but wish to accompany the face-to-face research in real time
• Sorting out the means by which research respondents will be paid for their participation in the research
• Ensuring that all aspects of the qualitative research conform to GDPR regulation and the Market Research Society’s Code of Conduct

Such tasks require the researcher to be highly organised and have a real eye for detail, particularly as that individual may well be running 2 or more projects simultaneously, meaning the logistical tasks really begin to pile up.

When this happens, the ability to compartmentalise each separate project becomes a sanity-preserving skill!

3. Running the research

For our super-qualie running the research isn’t just about moderation! Its highly likely that our qualitative hero or heroine will also be responsible for identifying the appropriate qualitative methodology at the outset, costing it and then writing the research proposal around it:

Not surprisingly, the researcher’s ability to identify the most effective, qualitative research approach is critical to the project’s success.

Not only will the qualitative approach determine the project’s overall cost, it will also decide the extent to which the research is ultimately able to address the strategic and commercial objectives of the client.

It requires experience, judgement and real understanding of which sort of approach will resonate most the client on the part of the researcher.

Moderating the focus group, depth interview, online community…..

Whether the focus of the client’s business is B2C or B2B, both the qualitative research agency and researcher will typically be expected to have a good grasp of the subject matter – particularly if it is technical in nature.

However, to actually run the research session effectively and get the most out of it, it is an altogether softer set of skills that are required, including:

i) Natural curiosity

It’s a fairly obvious one, but if you aren’t the sort of person who is interested in others, what they think and why they behave the way that they do, then this isn’t going to be the career for you!

Similarly, if you find it difficult to accept, cultures, points of view or lifestyles that may be different from your own then walk on by!

ii) Approachability and empathy

The success of any form of qualitative research depends on the willingness of participants to contribute (and keep contributing) to a qualitative discussion in a way that is honest, thoughtful and constructive.

This can be particularly challenging if the subject matter is complex or in some way sensitive.

To encourage respondents to keep on contributing under such conditions the moderator needs to have an ability to put people at their ease and voice thoughts and opinions they might not normally feel confident expressing.

Ironically, the greater the moderator’s success in getting respondents to open up, the harder it can then be to then keep the discussion on-track – particularly if it is on a topic that the moderator also finds engrossing!

An experienced moderator will keep the project’s commercial objectives in his or her mind at all times, to ensure that conversation doesn’t become an enjoyable but irrelevant distraction.

iv) Objectivity

In projects that address socially or culturally sensitive topics the moderator will often find that the views of the respondents are completely at odds with his or her own.

Whilst such situations can be extremely challenging it is up to the moderator to maintain total objectivity, revealing no bias whatsoever.

v) Sensitivity

Sensitivity is crucial. Not just sensitivity in terms of managing individuals and groups, but also in terms of being able to pick up on sub-texts, body language other the non-verbal nuances which can reveal a very different story from the one the respondents are actually telling.

vi) Resoluteness

Moderators need to be resolute in different ways.

For example, in a focus group situation, individual respondents may occasionally monopolise the conversation and prevent others from voicing their thoughts and opinions.

On such occasions it is the job of the moderator to tactfully ‘manage’ that individual’s contributions. If not, the whole dynamic of the group can be ruined for the rest of the session.

Very infrequently it can also be the case that a particularly disruptive individual must be asked to leave the group prematurely. This obviously requires an approach that combines resoluteness with high levels of tact!

vii). Mental dexterity

Whatever the form of qualitative research being undertaken, the moderator will have prepared some form of discussion guide designed to ensure that all the research topics are covered appropriately.

However, when the research is actually underway it may turn out that sections of the guide lack relevance as the discussion takes a different turn.

In these instances the moderator needs to be able to swiftly identify the issue and be prepared to go ‘off-piste’, in order to steer the conversation towards more relevant, fertile (but potentially unprepared) subject matter.

viii) Boundless energy

The qualitative researcher’s job is a physically demanding one, meaning that stamina is required!

In addition to spending a full day at work, qualitative researchers will often find themselves moderating research sessions in the evening – possibly up to 11.00 pm. During exceptionally busy periods this can happen 3-4 days per week.

Many agencies will have time-in-lieu arrangements to compensate their qualitative researchers for working such long, anti-social hours.

4. Analysing the research findings and compiling the presentation

Qualitative research is an inherently messy business and its probably at its most messy at the beginning of the research analysis phase!

Analysis of the research findings

When the research fieldwork has finished the moderator must start to comb through possibly hours of research recordings, transcripts or web pages in order to identify and isolate the relevant, clips, comments and insights.

At this point the researcher’s greatest asset is arguably his or her ability to see the wood for the trees , finding and extracting real insight from a tangled mass of (often contradictory) qualitative data.

Once extracted, the researcher’s next task is to work out if and how these insight ‘fragments’ fit together, the story they and what that story means in terms of the client’s strategic and commercial objectives.

The approach must be systematic, whilst the moderator will need to apply an eclectic blend of social and cultural awareness, interpretive skill, objectivity and commercial-mindedness if they are to create order out of the research chaos!

Composition of the research debrief

No matter how compelling the researcher’s insights, conclusions and recommendations might be, if the debrief isn’t able to convey them with simplicity and impact their power is undermined.

Story-telling becomes key at the debrief stage, as does the researcher’s ability to put themselves in the shoes of the debrief audience , to understand what their debrief priorities and expectations will be and then to compile the debrief with that understanding clearly in mind.

This will avoid any focus on the superfluous or merely interesting, at the expense of what is actually relevant and important.

5. Presenting to the client

Typically, a debrief presentation slot will last 1-2 hours. It will involve the client’s core project team and may also include more senior client directors who haven’t had hands-on involvement in the project to this point.

Unfortunately, a presenter who lacks confidence in front of an audience can do much to undermine the power of the research and its findings and it is up to the research agency to ensure that more junior researchers aren’t exposed in this way.

Presenting skills will be learned over time, but there are several practical steps that junior researchers can take to increase their confidence – and the quality of their presentation. These include:

• Learning the content of the debrief inside out
• Anticipating the real needs and expectations of the audience so they can identify any obvious questions or objections – and prepare for them
• Ensuring the first five minutes of the presentation are pacey and engaging. It is during this short period of time that many in the audience will be evaluating the quality of the research – and the style of the presenter.
• Using respondents’ quotes and video footage to help substantiate more challenging points made in the debriefing. It’s very hard to argue with the end customer!

If you are reading this article because you are considering a career in qualitative research you may be feeling daunted by what you have just read.

If so, please don’t!

The reality is, with such a long and eclectic list of left-brain-meets-right-brain attributes required to be a super-qualie, no one is going to tick all the boxes, even after years of experience.

However, If you find that are endlessly curious about what makes people, cultures, and brands tick, then a career in qualitative research might well be the one for you.

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Qualitative research examples: How to unlock, rich, descriptive insights

Qualitative research uncovers in-depth user insights, but what does it look like? Here are seven methods and examples to help you get the data you need.

Armin Tanovic

Behind every what, there’s a why . Qualitative research is how you uncover that why. It enables you to connect with users and understand their thoughts, feelings, wants, needs, and pain points.

There’s many methods for conducting qualitative research, and many objectives it can help you pursue—you might want to explore ways to improve NPS scores, combat reduced customer retention, or understand (and recreate) the success behind a well-received product. The common thread? All these metrics impact your business, and qualitative research can help investigate and improve that impact.

In this article, we’ll take you through seven methods and examples of qualitative research, including when and how to use them.

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7 Qualitative research methods: An overview

There are various qualitative UX research methods that can help you get in-depth, descriptive insights. Some are suited to specific phases of the design and development process, while others are more task-oriented.

Here’s our overview of the most common qualitative research methods. Keep reading for their use cases, and detailed examples of how to conduct them.

1. User interviews

A user interview is a one-on-one conversation between a UX researcher, designer or Product Manager and a target user to understand their thoughts, perspectives, and feelings on a product or service. User interviews are a great way to get non-numerical data on individual experiences with your product, to gain a deeper understanding of user perspectives.

Interviews can be structured, semi-structured, or unstructured . Structured interviews follow a strict interview script and can help you get answers to your planned questions, while semi and unstructured interviews are less rigid in their approach and typically lead to more spontaneous, user-centered insights.

When to use user interviews

Interviews are ideal when you want to gain an in-depth understanding of your users’ perspectives on your product or service, and why they feel a certain way.

Interviews can be used at any stage in the product design and development process, being particularly helpful during:

• The discovery phase: To better understand user needs, problems, and the context in which they use your product—revealing the best potential solutions
• The design phase: To get contextual feedback on mockups, wireframes, and prototypes, helping you pinpoint issues and the reasons behind them
• Post-launch: To assess if your product continues to meet users’ shifting expectations and understand why or why not

How to conduct user interviews: The basics

• Draft questions based on your research objectives
• Recruit relevant research participants and schedule interviews
• Conduct the interview and transcribe responses
• Analyze the interview responses to extract insights
• Use your findings to inform design, product, and business decisions

💡 A specialized user interview tool makes interviewing easier. With Maze Interview Studies , you can recruit, host, and analyze interviews all on one platform.

User interviews: A qualitative research example

Let’s say you’ve designed a recruitment platform, called Tech2Talent , that connects employers with tech talent. Before starting the design process, you want to clearly understand the pain points employers experience with existing recruitment tools'.

You draft a list of ten questions for a semi-structured interview for 15 different one-on-one interviews. As it’s semi-structured, you don’t expect to ask all the questions—the script serves as more of a guide.

One key question in your script is: “Have tech recruitment platforms helped you find the talent you need in the past?”

Most respondents answer with a resounding and passionate ‘no’ with one of them expanding:

“For our company, it’s been pretty hit or miss honestly. They let just about anyone make a profile and call themselves tech talent. It’s so hard sifting through serious candidates. I can’t see any of their achievements until I invest time setting up an interview.”

You begin to notice a pattern in your responses: recruitment tools often lack easily accessible details on talent profiles.

You’ve gained contextual feedback on why other recruitment platforms fail to solve user needs.

2. Focus groups

A focus group is a research method that involves gathering a small group of people—around five to ten users—to discuss a specific topic, such as their’ experience with your new product feature. Unlike user interviews, focus groups aim to capture the collective opinion of a wider market segment and encourage discussion among the group.

When to use focus groups

You should use focus groups when you need a deeper understanding of your users’ collective opinions. The dynamic discussion among participants can spark in-depth insights that might not emerge from regular interviews.

Focus groups can be used before, during, and after a product launch. They’re ideal:

• Throughout the problem discovery phase: To understand your user segment’s pain points and expectations, and generate product ideas
• Post-launch: To evaluate and understand the collective opinion of your product’s user experience
• When conducting market research: To grasp usage patterns, consumer perceptions, and market opportunities for your product

How to conduct focus group studies: The basics

• Draft prompts to spark conversation, or a series of questions based on your UX research objectives
• Find a group of five to ten users who are representative of your target audience (or a specific user segment) and schedule your focus group session
• Conduct the focus group by talking and listening to users, then transcribe responses
• Analyze focus group responses and extract insights
• Use your findings to inform design decisions

The number of participants can make it difficult to take notes or do manual transcriptions. We recommend using a transcription or a specialized UX research tool , such as Maze, that can automatically create ready-to-share reports and highlight key user insights.

Focus groups: A qualitative research example

You’re a UX researcher at FitMe , a fitness app that creates customized daily workouts for gym-goers. Unlike many other apps, FitMe takes into account the previous day’s workout and aims to create one that allows users to effectively rest different muscles.

However, FitMe has an issue. Users are generating workouts but not completing them. They’re accessing the app, taking the necessary steps to get a workout for the day, but quitting at the last hurdle.

Time to talk to users.

You organize a focus group to get to the root of the drop-off issue. You invite five existing users, all of whom have dropped off at the exact point you’re investigating, and ask them questions to uncover why.

A dialog develops:

Participant 1: “Sometimes I’ll get a workout that I just don’t want to do. Sure, it’s a good workout—but I just don’t want to physically do it. I just do my own thing when that happens.”

Participant 2: “Same here, some of them are so boring. I go to the gym because I love it. It’s an escape.”

Participant 3: “Right?! I get that the app generates the best one for me on that specific day, but I wish I could get a couple of options.”

Participant 4: “I’m the same, there are some exercises I just refuse to do. I’m not coming to the gym to do things I dislike.”

Conducting the focus groups and reviewing the transcripts, you realize that users want options. A workout that works for one gym-goer doesn’t necessarily work for the next.

A possible solution? Adding the option to generate a new workout (that still considers previous workouts)and the ability to blacklist certain exercises, like burpees.

3. Ethnographic research

Ethnographic research is a research method that involves observing and interacting with users in a real-life environment. By studying users in their natural habitat, you can understand how your product fits into their daily lives.

Ethnographic research can be active or passive. Active ethnographic research entails engaging with users in their natural environment and then following up with methods like interviews. Passive ethnographic research involves letting the user interact with the product while you note your observations.

When to use ethnographic research

Ethnographic research is best suited when you want rich insights into the context and environment in which users interact with your product. Keep in mind that you can conduct ethnographic research throughout the entire product design and development process —from problem discovery to post-launch. However, it’s mostly done early in the process:

• Early concept development: To gain an understanding of your user's day-to-day environment. Observe how they complete tasks and the pain points they encounter. The unique demands of their everyday lives will inform how to design your product.
• Initial design phase: Even if you have a firm grasp of the user’s environment, you still need to put your solution to the test. Conducting ethnographic research with your users interacting with your prototype puts theory into practice.

How to conduct ethnographic research:

• Recruit users who are reflective of your audience
• Meet with them in their natural environment, and tell them to behave as they usually would
• Take down field notes as they interact with your product
• Engage with your users, ask questions, or host an in-depth interview if you’re doing an active ethnographic study
• Collect all your data and analyze it for insights

While ethnographic studies provide a comprehensive view of what potential users actually do, they are resource-intensive and logistically difficult. A common alternative is diary studies. Like ethnographic research, diary studies examine how users interact with your product in their day-to-day, but the data is self-reported by participants.

⚙️ Recruiting participants proving tough and time-consuming? Maze Panel makes it easy, with 400+ filters to find your ideal participants from a pool of 3 million participants.

Ethnographic research: A qualitative research example

You're a UX researcher for a project management platform called ProFlow , and you’re conducting an ethnographic study of the project creation process with key users, including a startup’s COO.

The first thing you notice is that the COO is rushing while navigating the platform. You also take note of the 46 tabs and Zoom calls opened on their monitor. Their attention is divided, and they let out an exasperated sigh as they repeatedly hit “refresh” on your website’s onboarding interface.

You conclude the session with an interview and ask, “How easy or difficult did you find using ProFlow to coordinate a project?”

The COO answers: “Look, the whole reason we turn to project platforms is because we need to be quick on our feet. I’m doing a million things so I need the process to be fast and simple. The actual project management is good, but creating projects and setting up tables is way too complicated.”

You realize that ProFlow ’s project creation process takes way too much time for professionals working in fast-paced, dynamic environments. To solve the issue, propose a quick-create option that enables them to move ahead with the basics instead of requiring in-depth project details.

4. Qualitative observation

Qualitative observation is a similar method to ethnographic research, though not as deep. It involves observing your users in a natural or controlled environment and taking notes as they interact with a product. However, be sure not to interrupt them, as this compromises the integrity of the study and turns it into active ethnographic research.

When to qualitative observation

Qualitative observation is best when you want to record how users interact with your product without anyone interfering. Much like ethnographic research, observation is best done during:

• Early concept development: To help you understand your users' daily lives, how they complete tasks, and the problems they deal with. The observations you collect in these instances will help you define a concept for your product.
• Initial design phase: Observing how users deal with your prototype helps you test if they can easily interact with it in their daily environments

How to conduct qualitative observation:

• Recruit users who regularly use your product
• Meet with users in either their natural environment, such as their office, or within a controlled environment, such as a lab
• Observe them and take down field notes based on what you notice

Qualitative observation: An qualitative research example

You’re conducting UX research for Stackbuilder , an app that connects businesses with tools ideal for their needs and budgets. To determine if your app is easy to use for industry professionals, you decide to conduct an observation study.

Sitting in with the participant, you notice they breeze past the onboarding process, quickly creating an account for their company. Yet, after specifying their company’s budget, they suddenly slow down. They open links to each tool’s individual page, confusingly switching from one tab to another. They let out a sigh as they read through each website.

Conducting your observation study, you realize that users find it difficult to extract information from each tool’s website. Based on your field notes, you suggest including a bullet-point summary of each tool directly on your platform.

5. Case study research

Case studies are a UX research method that provides comprehensive and contextual insights into a real-world case over a long period of time. They typically include a range of other qualitative research methods, like interviews, observations, and ethnographic research. A case study allows you to form an in-depth analysis of how people use your product, helping you uncover nuanced differences between your users.

When to use case studies

Case studies are best when your product involves complex interactions that need to be tracked over a longer period or through in-depth analysis. You can also use case studies when your product is innovative, and there’s little existing data on how users interact with it.

As for specific phases in the product design and development process:

• Initial design phase: Case studies can help you rigorously test for product issues and the reasons behind them, giving you in-depth feedback on everything between user motivations, friction points, and usability issues
• Post-launch phase: Continuing with case studies after launch can give you ongoing feedback on how users interact with the product in their day-to-day lives. These insights ensure you can meet shifting user expectations with product updates and future iterations

How to conduct case studies:

• Outline an objective for your case study such as examining specific user tasks or the overall user journey
• Select qualitative research methods such as interviews, ethnographic studies, or observations
• Collect and analyze your data for comprehensive insights
• Include your findings in a report with proposed solutions

Case study research: A qualitative research example

Your team has recently launched Pulse , a platform that analyzes social media posts to identify rising digital marketing trends. Pulse has been on the market for a year, and you want to better understand how it helps small businesses create successful campaigns.

To conduct your case study, you begin with a series of interviews to understand user expectations, ethnographic research sessions, and focus groups. After sorting responses and observations into common themes you notice a main recurring pattern. Users have trouble interpreting the data from their dashboards, making it difficult to identify which trends to follow.

With your synthesized insights, you create a report with detailed narratives of individual user experiences, common themes and issues, and recommendations for addressing user friction points.

Some of your proposed solutions include creating intuitive graphs and summaries for each trend study. This makes it easier for users to understand trends and implement strategic changes in their campaigns.

6. Secondary research

Secondary research is a research method that involves collecting and analyzing documents, records, and reviews that provide you with contextual data on your topic. You’re not connecting with participants directly, but rather accessing pre-existing available data. For example, you can pull out insights from your UX research repository to reexamine how they apply to your new UX research objective.

Strictly speaking, it can be both qualitative and quantitative—but today we focus on its qualitative application.

When to use secondary research

Record keeping is particularly useful when you need supplemental insights to complement, validate, or compare current research findings. It helps you analyze shifting trends amongst your users across a specific period. Some other scenarios where you need record keeping include:

• Initial discovery or exploration phase: Secondary research can help you quickly gather background information and data to understand the broader context of a market
• Design and development phase: See what solutions are working in other contexts for an idea of how to build yours

Secondary research is especially valuable when your team faces budget constraints, tight deadlines, or limited resources. Through review mining and collecting older findings, you can uncover useful insights that drive decision-making throughout the product design and development process.

How to conduct secondary research:

• Outline your UX research objective
• Identify potential data sources for information on your product, market, or target audience. Some of these sources can include: a. Review websites like Capterra and G2 b. Social media channels c. Customer service logs and disputes d. Website reviews e. Reports and insights from previous research studies f. Industry trends g. Information on competitors
• Analyze your data by identifying recurring patterns and themes for insights

Secondary research: A qualitative research example

SafeSurf is a cybersecurity platform that offers threat detection, security audits, and real-time reports. After conducting multiple rounds of testing, you need a quick and easy way to identify remaining usability issues. Instead of conducting another resource-intensive method, you opt for social listening and data mining for your secondary research.

Browsing through your company’s X, you identify a recurring theme: many users without a background in tech find SafeSurf ’s reports too technical and difficult to read. Users struggle with understanding what to do if their networks are breached.

After checking your other social media channels and review sites, the issue pops up again.

With your gathered insights, your team settles on introducing a simplified version of reports, including clear summaries, takeaways, and step-by-step protocols for ensuring security.

By conducting secondary research, you’ve uncovered a major usability issue—all without spending large amounts of time and resources to connect with your users.

7. Open-ended surveys

Open-ended surveys are a type of unmoderated UX research method that involves asking users to answer a list of qualitative research questions designed to uncover their attitudes, expectations, and needs regarding your service or product. Open-ended surveys allow users to give in-depth, nuanced, and contextual responses.

When to use open-ended surveys

User surveys are an effective qualitative research method for reaching a large number of users. You can use them at any stage of the design and product development process, but they’re particularly useful:

• When you’re conducting generative research : Open-ended surveys allow you to reach a wide range of users, making them especially useful during initial research phases when you need broad insights into user experiences
• When you need to understand customer satisfaction: Open-ended customer satisfaction surveys help you uncover why your users might be dissatisfied with your product, helping you find the root cause of their negative experiences
• In combination with close-ended surveys: Get a combination of numerical, statistical insights and rich descriptive feedback. You’ll know what a specific percentage of your users think and why they think it.

How to conduct open-ended surveys:

• Design your survey and draft out a list of survey questions
• Distribute your surveys to respondents
• Analyze survey participant responses for key themes and patterns
• Use your findings to inform your design process

Open-ended surveys: A qualitative research example

You're a UX researcher for RouteReader , a comprehensive logistics platform that allows users to conduct shipment tracking and route planning. Recently, you’ve launched a new predictive analytics feature that allows users to quickly identify and prepare for supply chain disruptions.

To better understand if users find the new feature helpful, you create an open-ended, in-app survey.

The questions you ask your users:

• “What has been your experience with our new predictive analytics feature?"
• “Do you find it easy or difficult to rework your routes based on our predictive suggestions?”
• “Does the predictive analytics feature make planning routes easier? Why or why not?”

Most of the responses are positive. Users report using the predictive analytics feature to make last-minute adjustments to their route plans, and some even rely on it regularly. However, a few users find the feature hard to notice, making it difficult to adjust their routes on time.

To ensure users have supply chain insights on time, you integrate the new feature into each interface so users can easily spot important information and adjust their routes accordingly.

💡 Surveys are a lot easier with a quality survey tool. Maze’s Feedback Surveys solution has all you need to ensure your surveys get the insights you need—including AI-powered follow-up and automated reports.

Qualitative research vs. quantitative research: What’s the difference?

Alongside qualitative research approaches, UX teams also use quantitative research methods. Despite the similar names, the two are very different.

Here are some of the key differences between qualitative research and quantitative research .

Before selecting either qualitative or quantitative methods, first identify what you want to achieve with your UX research project. As a general rule of thumb, think qualitative data collection for in-depth understanding and quantitative studies for measurement and validation.

Conduct qualitative research with Maze

You’ll often find that knowing the what is pointless without understanding the accompanying why . Qualitative research helps you uncover your why.

So, what about how —how do you identify your 'what' and your 'why'?

The answer is with a user research tool like Maze.

Maze is the leading user research platform that lets you organize, conduct, and analyze both qualitative and quantitative research studies—all from one place. Its wide variety of UX research methods and advanced AI capabilities help you get the insights you need to build the right products and experiences faster.

Frequently asked questions about qualitative research examples

What is qualitative research?

Qualitative research is a research method that aims to provide contextual, descriptive, and non-numerical insights on a specific issue. Qualitative research methods like interviews, case studies, and ethnographic studies allow you to uncover the reasoning behind your user’s attitudes and opinions.

Can a study be both qualitative and quantitative?

Absolutely! You can use mixed methods in your research design, which combines qualitative and quantitative approaches to gain both descriptive and statistical insights.

For example, user surveys can have both close-ended and open-ended questions, providing comprehensive data like percentages of user views and descriptive reasoning behind their answers.

Is qualitative or quantitative research better?

The choice between qualitative and quantitative research depends upon your research goals and objectives.

Qualitative research methods are better suited when you want to understand the complexities of your user’s problems and uncover the underlying motives beneath their thoughts, feelings, and behaviors. Quantitative research excels in giving you numerical data, helping you gain a statistical view of your user's attitudes, identifying trends, and making predictions.

What are some approaches to qualitative research?

There are many approaches to qualitative studies. An approach is the underlying theory behind a method, and a method is a way of implementing the approach. Here are some approaches to qualitative research:

• Grounded theory: Researchers study a topic and develop theories inductively
• Phenomenological research: Researchers study a phenomenon through the lived experiences of those involved
• Ethnography: Researchers immerse themselves in organizations to understand how they operate

• Open access
• Published: 21 August 2024

Patient perspectives on the Tailored intervention for Anxiety and Depression Management in COPD (TANDEM): a qualitative evaluation

• Ratna Sohanpal 1 ,
• Kristie-Marie Mammoliti 2 ,
• Amy Barradell 3 ,
• Moira Kelly 1 ,
• Sian Newton 1 ,
• Liz Steed 1 ,
• Vari Wileman 4 ,
• Vickie Rowland 5 ,
• Clarisse Dibao-Dina 6 ,
• Anna Moore 7 ,
• Hilary Pinnock 8 &
• Stephanie J. C. Taylor 1  

BMC Health Services Research volume  24 , Article number:  960 ( 2024 ) Cite this article

Metrics details

Chronic obstructive pulmonary disease (COPD) is commonly associated with anxiety/depression which can affect self-management and quality of life. The TANDEM trial evaluated a cognitive behavioural approach intervention targeting COPD-related symptoms of anxiety and/or depression, comprising up to eight one-to-one sessions delivered by respiratory healthcare professionals prior to pulmonary rehabilitation (PR). The intervention showed no improvement in anxiety/depression or uptake/completion of PR. We present patient perspectives of the intervention to help understand these results.

Semi-structured individual interviews, using a semi-structured topic guide informed by Sekhon’s Theoretical Framework of Acceptability, were conducted with 19 patients between September 2019 and April 2020. The interviews were audio-recorded, transcribed verbatim and analysed thematically.

The following could have limited the impact of the intervention: (1) The lives of patients were complex and commonly affected by competing comorbidities or other external stressors which they managed through previously adopted long-standing coping strategies. (2) Some patients were reluctant to talk about their mood despite the Facilitators' training and person centred-skills which aimed to enable patients to talk freely about mood. (3) The intervention handouts and ‘home-practice’ were perceived as helpful for some, but not suitable for all. (4) Many patients perceived improvements in their physical and mental health, but this was not sustained due to a mix of personal and external factors, and some did not perceive any benefits. (5) PR non-attendance/non-completion was a result of personal and PR service-related reasons. (6) Discussing COPD and mental health with the Facilitator was a novel experience. Many patients felt that TANDEM could be of benefit if it was offered earlier on/at different time points in the COPD illness journey.

We found the delivery of TANDEM prior to PR was not helpful for patients with advanced COPD often experiencing other comorbidities, and/or difficult personal/external events. These patients already utilised long-standing coping strategies to manage their COPD. Holistic interventions, that address the impact of COPD in relation to wider aspects of a patients’ life, may be more beneficial.

Trial registration

ISRCTN Registry 59,537,391. Registration date 20 March 2017.

Peer Review reports

Introduction

Patients with long-term conditions, such as chronic obstructive pulmonary disease (COPD), are two to three times more likely to experience mental health problems compared to the general population [ 1 ]. Patients with COPD suffer from physically disabling symptoms such as breathlessness, chronic cough and sputum production [ 2 ], and typically have one or more comorbidities such as anxiety and depression [ 1 , 3 , 4 , 5 ]. The mean prevalence of anxiety and depression in patients living with COPD are estimated at 36% (range 6%-74%) and 40% (range 8%-80%), respectively [ 6 ]. These comorbidities reduce patients’ ability to manage COPD effectively, affecting physical activity and quality of life and increasing their susceptibility to exacerbations, hospital admissions and readmissions [ 6 , 7 , 8 ] at major cost to health and care services [ 9 ].

There is a clear relationship between breathlessness and anxiety and/or depression, where one can negatively influence the other and a vicious cycle can develop [ 5 , 6 , 10 , 11 , 12 ] resulting in poorer health outcomes. This emphasises the importance of individually-targeted holistic treatments rather than purely focusing on the disease [ 13 ].

Unmet physical and psychological well-being needs [ 14 ], could be a result of patient and professional barriers [ 15 ]. Patients’ reluctance to ask for – or accept—support offered by health services may be due to stigma, reluctance to talk about emotional problems, physical symptoms masking mood symptoms [ 15 ], or having already adapted to the progressive and fluctuating nature of their COPD and comorbidities; [ 16 , 17 , 18 ] conversely, they may want to seek support but lack knowledge of mental health issues, treatment options, where to seek help, or have difficulty in accessing the support they need [ 14 , 15 , 19 ] further increasing the burden of disease/s [ 1 , 2 , 20 ].

The goals of non-pharmacological self-management interventions in COPD include reducing physical symptoms and functional impairments in daily life and improving emotional well-being [ 21 ]. Completion of evidence-based supervised exercise and self-management support programmes such as pulmonary rehabilitation (PR) is known to improve both physical and emotional well-being among patients with COPD [ 22 ]. However, anxiety or depression being associated with reduced uptake and completion of PR, remain [ 6 ]. Evidence of effective strategies to improve referral to, or uptake and completion of, PR treatment is limited [ 23 ]. Psychological treatment using cognitive-behavioural therapy (CBT) is an effective treatment for anxiety and depression but there is less evidence of benefit in COPD-related depression [ 24 , 25 ] and anxiety [ 25 , 26 ]. A systematic review by Coventry [ 27 ] found some improvement in anxiety and depression from interventions combining exercise with psychological and lifestyle interventions in COPD, and there have been calls for more high quality research into this [ 24 , 26 ].

In response to calls for further research, we developed a tailored, psychological cognitive behavioural approach intervention for patients with moderate to very severe COPD and mild to moderate anxiety and/or depression, to be delivered prior to patient attendance in PR, for evaluation in the TANDEM (Tailored intervention for Anxiety and Depression Management in COPD) randomised controlled trial [ 28 ]. We hypothesised that the intervention (referred to as the TANDEM intervention) delivered by trained respiratory health care professionals (referred to as TANDEM ‘Facilitators’) prior to patient’s attendance in PR would improve anxiety and/or depression (intervention aim and primary trial outcome) which in turn would improve patients’ uptake and completion of PR which would further improve both their physical and mental health (included in the secondary trial outcomes). The respiratory professionals involved in delivery of the TANDEM sessions were not involved in PR sessions delivery. Table 1 shows the patient inclusion/exclusion criteria in the TANDEM trial.

Table 2 describes the content of the TANDEM intervention. The intervention delivery comprised 6–8 weekly individual, face-to-face sessions with practice of skills between sessions to embed them in everyday life. Weekly or fortnightly telephone support calls to patients prior to patients starting PR and then weekly/fortnightly over the course of PR and for two weeks after completion of PR ensured continuity of support until the end of PR. The TANDEM intervention was designed as a precursor to PR but it was also developed to function as a stand-alone intervention in recognition of the fact that not all participants would want to or be able to take up the opportunity to attend PR. Patients who did not take up previous offers of PR, or who had previously dropped out of PR, were eligible for inclusion in the study. Addressing PR-related barriers was just one of the topic covered in the TANDEM intervention. In the UK, following patient referral to PR, the timeline of patients attending the PR assessment appointment following referral can take 4–9 weeks and from assessment to first attendance at a PR session can take a further 1–8 weeks. We worked with PR study sites that could accommodate our recruitment and intervention delivery timeline. In addition, to ensure patients had sufficient time to receive the intervention prior to starting PR, we included patients who had at least 4 weeks before starting the PR exercise class.

The TANDEM trial comprised a parallel health economic evaluation and a process evaluation using qualitative and quantitative methods to inform the implementation of the TANDEM intervention if the trial is positive, or assist interpretation of the findings if it was negative [ 28 , 31 ]. The intervention did not reduce anxiety and/or depression and there was no improvement in uptake/completion of PR [ 29 ].

Specific to this qualitative evaluation, the objectives of the study, developed a priori, were to explore from a patient perspective: [ 31 ].

The acceptability of the intervention among patients, considering intervention content (in session, home practice); therapeutic alliance; and practicalities (location, timing).

Experiences of the intervention, including: its impact on health, quality of care and post-trial implementation.

Any unintended consequences of the intervention.

The qualitative study was conducted between September 2019 and April 2020.

Sampling and participant recruitment

As part of trial recruitment, consent from patients to be approached for an interview was obtained. Those with scores suggestions severe anxiety/depression were ineligible and were referred to their general practitioner for more intensive mental health support. We planned to conduct 20 interviews with patients in the intervention group to meet sampling requirements to help address the research aim and to meet the trial timelines [ 31 , 32 ]. We reviewed the sampling during data collection to help decide if saturation was reached and whether there was need to conduct more interviews or stop data collection. Purposive sampling [ 33 ], using a sampling frame (Table  3 ), was used to identify patients who completed/dropped out of the TANDEM intervention and/or PR. The interviews were planned after the 6-month (i.e., after intervention delivery)) or 12-month (i.e., after PR delivery) follow up assessment during the trial. Patients were contacted by telephone to request an interview.

Data collection

Semi-structured interviews were conducted to explore patients’ perceptions of the intervention and its potential usefulness for future service development. It was led by a topic guide (Table  4 ) informed by the conceptual framework for the TANDEM process evaluation [ 31 ] and Sekhon’s theoretical framework of acceptability [ 34 ]. See Supplementary file 1 for the interview topic guide used in the interviews.

The interviews were conducted face-to-face, in the patients’ home or by telephone, at a date, location and time that suited the patient or in accordance with COVID regulations (mid-March 2020-April 2020). Interviews were audio-recorded using a digital encrypted recorder. They were conducted by three mixed-method researchers, KMM (Global Health Development, MSc), AB (Health Psychology, MSc), RS (Health Services Researcher, PhD). The researchers were involved in trial recruitment and data collection and were experienced in conducting qualitative interviews and were part of the patient working group within the wider process evaluation team and were involved in the discussions that informed the methods of the study. The researchers were not known to the interviewees. The interview planning was coordinated between the researchers in line with the trial milestones.

Data analysis

Audio-recordings of interviews were transcribed verbatim. Nvivo (version 12) data management software was used to support data analysis. Thematic analysis was conducted [ 35 , 36 ]. Researchers (KMM, AB, RS) independently used inductive, semantic, and latent coding to analyse two transcripts and prepare an initial coding framework. The researchers discussed this to reach consensus on the coding framework. The remaining transcripts were individually coded in line with the coding framework and new codes were added to the framework as required, with consensus. Once all transcripts were coded, the researchers jointly reviewed patterns and relationship within the data to generate potential themes and sub-themes. These were discussed with the wider process evaluation team [ 31 ] with the correct experience and expertise [ 37 ] to finalise the content and themes (Table  5 ).

Public involvement

Public involvement was incorporated in the design and delivery of the TANDEM trial [ 31 ]. Specific to this qualitative enquiry, patient and public involvement (PPI) colleagues (people with COPD, carers of people with COPD) provided comments and feedback to support the clarity, readability, and acceptability of the interview process specified in the participant documents. PPI colleagues reviewed the findings in relation to the main trial results and provided feedback, which supported our interpretations of the results.

Patient characteristics

Of the 29 patients invited for interview, 19 agreed to participate. Data collection occurred between September 2019 to April 2020. Due to the Covid-19 pandemic (19 March 2020—1 April 2020), eight interviews were conducted by telephone. The interview duration was between 30–60 min.

Table 6 presents the patient characteristics. Eleven were male. Two were in the 35–55-year age-group, five in 56–65 year age-group, seven in 66–75 year age-group and two in 76–85 year age group. Three interviewees did not provide their age. Thirteen patients had moderate COPD, six had severe/very severe COPD. Ten had both symptoms of anxiety and depression, five had symptoms of depression only and four had symptoms of anxiety only. Regarding other comorbidities, fifteen patients mentioned other comorbidities namely Heart disease, Stroke, High blood pressure, Parkinson’s, Diabetes, Kidney disease, Fatigue, Epilepsy, Diabetes, Pain and Cancer. Interview participants were comparable to main trial participants in terms of age, gender, COPD severity and other comorbidities, although as a group fewer of the interviewees reported comorbidities (79%) than amongst all the trial participants (90%).

Reasons for non-participation were family bereavement ( n  = 1), difficulty with hearing on the telephone ( n  = 1), uncontactable ( n  = 4), not interested ( n  = 3) and busy ( n  = 1). Those who declined taking part in the interview were mostly from the TANDEM intervention completion group ( n  = 7).

Over-arching findings

The findings generated four themes and nine subthemes, three themes related to intervention acceptability in line with Sekhon’s [ 34 ] theoretical framework of acceptability (TFA). The findings are exemplified with quotes. Theme 1 ‘Patient lives are complex’ encompasses patients living with and managing their COPD alongside other comorbidities and ongoing life/social situations, the challenging interplay of external situations, their own needs, and the adoption-refinement of self-coping strategies over time. Theme 2 ‘Relationship with the TANDEM Facilitator and engagement in the intervention sessions’ highlights the building of rapport and partnership between the patient and Facilitator to deliver the TANDEM intervention sessions and patient engagement with the intervention. This theme links with the Affective attitude TFA construct where patients spoke about how they felt about the intervention and with the Intervention coherence TFA construct where patients understood the purpose of the intervention, what was expected of them to engage in the intervention and spoke about their experience of engagement with the intervention materials [ 34 ]. Theme 3 ‘Impact of the TANDEM intervention sessions’ explores the perceived benefits (or lack of sustained benefit), from the intervention in relation to patients’ physical, mental, and social health. In this theme, patients, through their understanding of the intervention (Intervention coherence TFA construct); how they felt about the intervention (Affective attitude TFA construct); and whether they were able to apply the learnt skills following receipt of the intervention (Self-efficacy TFA construct) clearly stated whether they benefitted or not from the intervention (Perceived effectiveness TFA construct) [ 34 ]. Theme 4 ‘Distinguishing TANDEM in COPD care’ discusses lack of previous provision of psychological support and that TANDEM type of care should be offered to patients earlier in their illness journey. This theme links with the Burden TFA construct where patients spoke about their ease of being able to participate in the intervention. We have not presented the themes under the TFA constructs as these constructs are interlinked and overlapped in how patients spoke about their experience of the intervention.

Core themes and subthemes

Patient lives are complex, impact of copd and competing comorbidities/other external stressors.

Patients described how the fluctuation of COPD symptoms, suffering from exacerbations, several other health conditions and negative life events could have a cumulative effect on their physical, psychological, and social health. Many patients had previous experience of bad days, “frightening” breathlessness, and chest infections. Several mentioned the combination of COPD symptoms, along with symptoms of other comorbidities, resulted in low mood. Getting a new diagnosis (e.g., cancer), experiencing a sudden injury (e.g., a fall), an exacerbation of COPD symptoms, or other long-term comorbidities (e.g., stroke, diabetes, sepsis, dementia) made patients feel they could not fully recover physically and mentally.

“The thing that gets me down is I’ve got Parkinson’s as well, which is making walking difficult at the moment. It’s got much worse recently. And I get out of breath when I’m… Although I’m walking slowly it takes a lot of effort. So I get out of breath as well.” (Male, 66–75, Depressed, Moderate COPD, PAT5)

They described the adjustments/adaptations (e.g., sitting and resting) they made to manage their condition. Others described having become resigned to what they could or could not do (e.g., avoiding going out of the house).

“I used to go out a lot. And now I just don’t go out. I even used to do my own shopping with a relative or something. But I don’t even do that now. It’s just too much even with the help of a trolley. Walking around supermarkets, it’s just too much.” (Male, 56–65, Anxious and depressed, Severe COPD, PAT1)

Some patients felt that their COPD or its limitations were not always visible or well understood by others and this caused embarrassment and frustration. A few patients prioritised needs of others over their own health needs.

“….Well, I was outside trying to jet wash, and of course it takes it out of you. Always having a job breathing. Of course, I stopped to get my breath back. And it started to rain. Come on, get inside [partner said]. Hang on [I said], let me bloody breathe will you. Just let me try and breathe, and then I might be able to do something. But yeah. Don’t you realise I have difficulty breathing? …” (Male, 76–85, Anxious and depressed, Moderate COPD, PAT15)

Stoicism and self management

Patients described living with COPD and/or other comorbidities or life events as “I live with it and put up with it” . Several patients had learnt to adapt and developed coping strategies either alone or with the help of family and friends to overcome their physical limitations and anxiety, panic state or mood.

“…it was one of the guys, he lives across the road from me,… He said to me, … the way to look at your breathing is smell the roses and blow out the candles. And that’s always stuck. So when I do feel a bit anxious or panicky I think smell the roses and blow out the candles.” (Female, Age unknown, Anxious and depressed, Moderate COPD, PAT12)

Relationship with the TANDEM facilitator and engagement in the intervention sessions

Knowledge, skills and open communicative partnership.

The patients developed a good rapport and a positive relationship with their Facilitator over the course of the TANDEM intervention sessions. The positive relationship was nurtured by the Facilitator’s knowledge and skills, delivery of weekly sessions and the Facilitator’s ability to tailor content to the patient. Their adaptability to modify home practice to suit the patient’s level of health literacy and providing practical examples to enhance understanding of a topic was valued.

“Anything to do with writing, I’d just wait until she came and we did it. I didn’t do that bit.” (Female, 35–55, Anxious, Severe COPD, PAT2)

Patients praised the Facilitator’s knowledge of both COPD and mental health and their strong communication and counselling skills. Patients felt that their Facilitator was friendly, empathetic, supportive, and genuinely interested in them. They felt listened to and gently encouraged to speaking openly about their mood which for some was related to their social situations and not COPD.

“Yeah, and maybe asked questions that I would’ve not fancied talking about possibly. So she did probe. But it wasn’t putting me on the spot. Then it made me think, oh yeah, I don’t mind talking about that.” (Female, 56–65, Anxious and depressed, Very severe COPD, PAT18)

However, some patients did find it difficult to talk about their anxiety or mood with the Facilitator and preferred to discuss other things in the sessions.

“We discussed a little bit of anxiety, because the anxiety, I don’t really like to discuss my anxiety, because it just gets to me after a while when I’m talking about it.” (Male, 66–75, Anxious and depressed, Moderate COPD, PAT7)

Some patients who lived alone described enjoying the Facilitator’s company and the continued opportunity to discuss their illness. A few said that it was like conversing with a friend.

“…And like I say, people are probably the same as me, more benefits with just having that person coming for the company as well as talking about a specific illness.” (Male, 56–65, Anxious and depressed, Severe COPD, PAT1)

Engagement with the TANDEM intervention materials and sessions

Most patients understood that the TANDEM study was about education and discussions around their physical and/or emotional health with a focus on improving it. Patients recalled receiving various study-related materials such as leaflet/s, handouts, DVDs, and worksheets for home-practice and setting goals. Some patients had difficulty remembering the home-practice requirements. A few patients chose not to watch the DVD due to lack of interest or lost interest shortly after starting because it felt too repetitive and replicated the handouts/leaflets provided or the exercises shown were not deemed suitable to them.

“The CD was pretty boring. It was very repetitive and I lost interest quite quickly I’m afraid.” (Male, 66–75, Depressed, Moderate COPD, PAT5)

Two patients stopped receiving the intervention after two and three sessions because they described not being affected by their mood and were already familiar with the information provided. The third patient chose to discontinue after receiving two sessions because their sessions began to overlap with PR and they wanted to prioritise PR instead.

“Yeah, it was sort of a joint decision. If I had any problems I could give her a ring. But then I more or less carried on with the breathing thing [PR programme], so I did see people over at this breathing session. So any questions and the information you got from that at the beginning was very good Interviewer: And how soon did you join that exercise class after your one-to-one sessions? More or less straightaway.” (Male, Age unknown, Anxious, Severe COPD, PAT11)

Two patients did not complete any sessions and had no recollection of the intervention.

Impact of the TANDEM intervention sessions

Perceived benefits and the lack of perceived benefits.

The effects of the TANDEM intervention sessions on thoughts, feelings, behaviours and/or symptom management were varied and wide-ranging. Several patients described improvements to their mental health and had adopted positive coping strategies. They described the intervention having helped to shift negative thoughts to positive ones, feel more at ease and able to take control of their anxiety.

“I’ve got to be honest, when I had this chest infection I thought I was suffocating. My ribs, I thought they were breaking with this cough. And so it [TANDEM sessions] helped me a sense up here [thoughts], keep the anxiety [under control]. Because I was struggling to breathe at one stage.” (Female, 56–65, Anxious and depressed, Very severe COPD, PAT18)

Patients felt they made connections between their physical and mental health by acknowledging the presence of depression or anxiety. Patients realised the value of self-reflection. Some adopted a resilient mindset, refusing to let breathlessness, anxiety and/or depression stop them. Instead, they emphasised the importance of not giving up, setting goals, accepting help, and being kind to themselves. This realisation gave them confidence to move forward and see the value of life again.

“I didn’t realise I was depressed at the time because I was going to the bed most days in the afternoon, and that was more because I was… I retired last year, so I think it’s because I’d recently retired. I was just bored. So I was going to bed in the afternoons just to kill time. And then I realised through talking to [Facilitator] that that was more me being depressed….I’m going to say it [the TANDEM project] changed my outlook on life. … helped me realise if I get a little bit fitter I’ll be a lot happier and I’ll probably increase my…not going to say I’m going to live longer, but the years I’ve got to live I’ll be fitter, happier…” (Male, age group unknown, Anxious, Moderate COPD, PAT6)

Many patients described learning skills, techniques and adopting healthy behaviours to enhance their daily management of COPD/COPD-related breathlessness and COPD-related anxiety such as relaxation techniques (e.g., mindfulness, distraction, breathing techniques). These techniques were successfully applied during daily activities, such as walking, climbing stairs, gardening, getting to the car, and shopping. The perceived benefits varied for different individuals and comprised, an increase in knowledge, confidence, acceptance of condition and improvements to social life.

“Well I slow down a bit. I have a lady, [facilitator], from your research team come down last year. And she took me out for little walks, and she discovered that I was taking in too much air. So she did me little techniques of when I go out for a little walk, like doing things in your head, like counting odd numbers or counting from 100 backwards. Little bits like that to get your breathing under control.” (Female, 56–65, Depressed, Severe COPD, PAT8)

For a few patients, the sessions did not provide any new material but helped to reaffirm their existing knowledge about their condition and its management or reminded them of techniques/behaviours that could help them to effectively manage their condition. Others did not perceive any benefits from the intervention. One patient did not expect to learn anything new whilst another patient explained they knew most of what was being covered and that they were used to doing things on their own.

“Interviewer: Do you think your confidence levels have changed? “No, I don’t think so. No.” Interviewer: … Are there any other changes in your social life? No, not really…. I see my friends, at least once a week, sometimes twice. So yeah, I mean I don’t want to stay indoors, or watch TV. I do go out and see my friends.” (Male, 56–65, Anxious, Moderate COPD, PAT4)

Attendance and completion of pulmonary rehabilitation

Patients recalled discussions with their Facilitator regarding PR, specifically focusing on how PR could potentially benefit them and what they could anticipate from attending the programme. Some patients mentioned they always planned to attend PR despite the TANDEM sessions, whilst others were encouraged to attend PR following receipt of the TANDEM sessions. The reasons given by those who did not attend/complete PR were competing comorbidities which needed prioritisation, and health service-related reasons.

“I’ve done the pulmonary rehab before and I did go to an appointment but they wanted…because I was waiting for an ECG. They wanted to wait for the results for that, and that kept getting pushed back and pushed back…” (Female, 35–55, Anxious and depressed, Moderate COPD, PAT9)

Difficulties keeping up learnt skills or new activity due to personal or external factors

The application of learnt skills/techniques by patients varied over time with the perceived benefits not viewed as sustainable by some patients. Whereas others stated their learnings from the intervention had become in-built and they now knew what to do to manage their condition.

“Emotionally I was quite low, no self-esteem before I saw [facilitator], but afterwards I felt quite a lot better and I’ve still kept feeling more positive and more confident in those quite a few months since I saw her. I’ve not slipped back into my old way of thinking and everything.” (Female, 66–75, Anxious and depressed, Moderate COPD, PAT13)

For various reasons, some patients were unable to maintain changes they had adopted due to internal or external factors. (e.g., injury, new diagnosis with poor prognosis, new disabling symptoms from COPD, disabling comorbidities affected patient mood negatively; reduced motivation to be physically active, increased gym costs or changes made to the gym made it unsuitable to attend led patients unable to start or keep up with their physical activity; and Covid-19 restrictions affected both mood and physical activity negatively). Some patients attributed their worsening physical and mental health specifically to the Covid-19 lockdown and reduced access to services, whilst others described coping well and trying to continue activities at home, albeit on a much smaller scale to their usual routine.

“I think my breathing’s actually got worse …because now we can’t go out. So it’s…yeah, it’s… I’m definitely wheezing a lot more than I was before and get breathless. …if I sit still it’s fine. It’s when I start moving around. So I think it’s probably because I was going out literally every day. I was going out for a half hour walk, I was doing exercises. And of course now you’re stuck in the house and you can’t get out. So yeah…” (Female, Age unknown, Anxious and depressed, Moderate COPD, PAT12)

Distinguishing TANDEM in COPD care

Tandem is different to current care.

Patients described the intervention as incomparable to other currently available COPD services. Most interviewees had never previously received any psychological therapy for anxiety/depression. Some had undergone counselling (e.g., for grief, stress) but felt the counselling was not specific to their COPD. One patient who had previously received CBT felt the TANDEM sessions were more helpful.

“I’ve spoken to my GP just about general depression, not to do with my COPD. And I’ve had a couple of CBT appointments. But I didn’t really find those too helpful. They just seemed to give me one of these assessment sheets every time and I had to write down in the boxes how I felt about each situation. And then they were just adding my score up, oh, this week you’ve scored a bit higher than last week. They didn’t really offer me any advice as to how to improve the situation.” Interviewer: And what was different from the one-to-one sessions you had with [Facilitator]? I was able to talk through all sorts of problems that I’ve had over the last couple of years to do with my COPD and to do with personal stuff as well.” (Female, 66–75, Anxious and depressed, Moderate COPD, PAT13)

Having flexibility in the location (e.g., patient’s home, GP practice or local hospital) for intervention delivery was highly valued. This flexibility recognised the physical limitations experienced by people living with COPD and was conducive in creating a safe, comfortable, and private environment. Some patients expressed appreciation for not being excluded from receiving the intervention just because they were unable to leave their home. Others preferred the sessions at a GP practice or a public space to avoid distractions at home.

“…Because I said I don’t drive, I can’t afford the taxi fare. I can’t use public transport…So having the opportunity to have her [facilitator] come to the house was a god send, because otherwise I don’t think I would’ve done it. I couldn’t have done. I couldn’t have got anywhere to do it.” (Female, Age unknown, Anxious and depressed, Moderate COPD, PAT12)

Need for psychological support at different time points of the illness journey

Several patients suggested that the sessions would be helpful at diagnosis because some felt they were given insufficient information or support at this time point. Whilst others recommended the sessions at differing stages of their illness because symptoms can evolve over time or be influenced by external life events.

“I think it’s the whole package that matters. The cognitive therapy, you might just need that, mightn’t you? … So I just embraced it. It’s obviously valuable, and I suppose they’ll roll it out one day if you have got COPD or have an operation, it’ll be offered to you. It’s down to the individual.” The same participant continued “See generally it’s going to be older people doing this thing, I think. I mean younger people there might be more benefit. So a lot of them brought up to keep it…they can’t express their emotions. So I wonder…this might be for future generations. But older people are a bit reluctant to talk about themselves. It’s like get on with it.” (Female, 56–65, Anxious and depressed, Very severe COPD, PAT18)

Despite the overall acceptability for TANDEM, a few patients were considerate of the cost and the time impact upon NHS services. However, it was made very clear that the flexibility of intervention delivery (e.g., at home) should not be compromised.

“I think [home visits] should never be dropped and it should be moved to a place where it’s set for you to save money. Because that’s when everything starts going down hill then. And people trying to cut corners and then we have a meeting maybe every six months. And they say well, this never used to happen when we used to do one-on-ones at home. And now it is happening. So I think you should carry on exactly the way you are doing.” (Male, 56–65, Anxious and depressed, Severe COPD, PAT1)

As part of an integrated process evaluation of the TANDEM intervention, we explored patients’, experience of intervention receipt and acceptability to help us understand the trial findings. We found the fluctuation of patients’ COPD symptoms combined with comorbidities, and challenging social circumstances meant many patients had already developed coping strategies, including stoicism. Positive experiences of the intervention were attributed to the Facilitator’s knowledge in COPD and mental health, their supportive, empathetic, and person-centred communication skills. This enabled many patients to talk freely about their mental health, acknowledge the connection between their physical and mental health, and disclose interacting social circumstances. Some, but not all, patients found the intervention materials and home practice helpful. Most completers of the intervention perceived improvements in their mood/mental health, physical and social benefits. Sustaining these benefits was challenging for many due to personal, health-related, and external factors (including Covid-19). Patients described the intervention as novel, they valued the flexibility in how it could be delivered. Some patients suggested making the intervention sessions available ‘on demand’ throughout the illness trajectory so the patient could take them up when needed.

Comparison with other literature

We found only one qualitative study [ 38 ] exploring experiences of a home-based psychoeducation intervention within a trial, however, the structure and delivery were different to TANDEM. The intervention targeted symptoms related to breathlessness and anxiety [ 39 ] among patients with advanced COPD who reported perceived benefits such as anxiety becoming more manageable and taking control of cognitions [ 38 ]. TANDEM intervention completers also perceived improvements such as coping better with anxiety, feeling more content and at ease with oneself, and experiencing a shift from negative thoughts to a more positive outlook. Additionally, patients cited increase in knowledge, confidence, acceptance of condition and improvements to social life/daily activities.

However, the perceived improvements were not sustained and may therefore explain the trial outcomes. In Bove’s trial [ 39 ], the timing of the outcome assessment was one month and three-month post intervention delivery. Bove explained that this duration was a period for new knowledge and skills to be integrated into everyday life and was the right time for qualitative exploration. In contrast, the outcome assessments for TANDEM were at six- and twelve-months post intervention, [ 28 ], recommended for COPD self-management interventions [ 40 ]. Our findings show that several personal factors and external events prevented patients from long-term application or adherence of their TANDEM learnings. Non-adherence to learnt self-management skills is known to result in worse health outcomes [ 41 ]. Part of our intervention delivery occurred during the Covid-19 pandemic meaning some patients were unable to attend PR or continue their planned physical/social activities and this may have impacted the trial outcomes. The negative impact of Covid-19 on physical activity, social isolation and mental health has been shown in advanced respiratory disease [ 42 ]. A recent COPD study [ 43 ] reported initial gains made by an intervention were lost without content teaching about how to maintain health behaviours even in times of stress. Although we included problem solving as a topic, for future iterations of TANDEM, it may be useful to include a session involving specific discussions about the likelihood of setbacks/external stressors and practical strategies for dealing with them, possibly as a ‘booster’ session or ‘on demand’ during times of stress. It may also have been possible to deliver TANDEM alongside PR rather than as a precursor, however this would have increased patient burden and was not in line with our programme theory that reduction in depression and/or anxiety would be helpful to increased uptake and completion of PR.

Another explanation for the perceived lack of sustained benefits could be the severity of disease and disabling experience of patients from the burden of COPD and interacting comorbidities [ 44 , 45 ]. Many patients in this study talked about the fluctuating and unpredictable nature of COPD symptoms and the negative impact of ongoing comorbidities. Recognising the comorbidities in COPD, a study [ 46 ] discussing future interventions in COPD has suggested inclusion of a ‘feedback loop’ to assess progress of desired outcomes and treatment expectations related to comorbidities among patients. However, before this, further work is required to understand how comorbidities impact on/interact with COPD [ 47 ] and what outcomes are important to this patient group to support intervention development and its assessment in research for better health outcomes. Managing and adapting to the fluctuating nature of ongoing health conditions and its limitations and interactions with the surrounding social environment made achieving ‘normality’ out of reach for some patients. The perceived lack of understanding about COPD among family members and wider society, was felt to affect mood for some patients. One study, with comparable findings to ours, found difficult living situations, other life events and comorbidities negatively influence COPD-related distress [ 48 ]. The Facilitators reported working through problems (social, psychological, physical) with patients that were unrelated to COPD which shifted the focus away from the intervention targeting mood related to COPD symptoms/breathlessness [ 49 ]. The latter was perceived as a challenge during intervention delivery [ 49 ] and could contribute to explaining the trial outcomes, although overall fidelity to the intervention has been reported to be high [ 49 ]. Focusing on the physical/social environment of patients with COPD is important for future interventions in COPD [ 50 ], but will require gaining better understanding of the social environment and its impact on individuals [ 51 ].

Several patients in our study were stoic, and the stance taken was ‘to get on with it’. Stoicism can make patients hold on to strategies they perceive are working for them, they may be reluctant towards the treatment or they may have less realistic expectations of treatment benefits [ 52 ] which could have affected the trial outcomes. Some patients found the intervention unsuitable for their needs or failing to meet their expectations. The lack of perceived benefits amongst some is not surprising as, needs, expectations and preferences will vary among individuals. Some patients felt that they had not learnt anything new, whilst for some the intervention helped to reinforce strategies they were already using to manage their condition which will have reduced the potential for improvement in trial outcomes. A person-centred approach, only offering intervention to those with perceived need to reduce anxiety/depression may be more appropriate.

Although not reflected in the trial outcome analysis, a positive experience of the TANDEM intervention was that the patients particularly valued the therapeutic relationship with the Facilitator (a key element of the TANDEM intervention) [ 30 ]. The intervention sessions gave patients an opportunity to reflect on what COPD meant to them, recognise their actions were a result of anxiety and/or depression, make connections between their physical and mental health, and adopt home-practice activities which helped to improve their physical activity and symptoms. Despite the trial outcomes, the positive experiences of patients suggest that it might be useful to provide opportunities in practice to enable patients to reflect on the relationship between their physical and mental health [ 49 , 53 ]. An explanation for the lack of improvement in outcomes, supported by these findings, is that some patients did not do any independent home-practice between intervention sessions because they did not like to write things down or read. Not doing the home-practice may have made it difficult to embed the learning from the TANDEM sessions. The latter could be attributed to comorbidities or poor health literacy previously reported for this population [ 54 ]. It has been suggested that not doing CBT-related homework can lead to negative health outcomes [ 55 , 56 ]. A recent review [ 57 ] assessing the efficacy of psychosocial interventions on physical and psychological outcomes in COPD highlighted that older age may yield limited effects as they would be less adept to learn skills and techniques taught in a psychosocial intervention. The median age of patients in the TANDEM trial was 69 years and there were high intervention uptake and completion rates [ 29 ], so the offer of psychosocial interventions should continue among this population regardless of their age [ 57 ]. However, assessment of health literacy needs should be considered for interventions comprising written materials [ 43 , 46 , 50 , 54 ]. Production of intervention materials needs to be more creative than paper-based materials and need to be available in various formats to match patient choice, preferences and literacy levels.

Some patients in our study were reluctant to talk about their mood, which could be due to such discussion being unfamiliar within a healthcare setting. Few had received any psychological support previously for their mental health in relation to their COPD. The new treatment and the lack of familiarity of this psychological approach may have had an impact on trial outcomes. This could be related to the perceived stigmatisation of COPD [ 24 ] and mental health [ 48 ] or that having a one-off, short-term intervention may not be enough. There are reports of limited screening of mental health issues, and limited review of mental health issues as part of routine COPD review appointments, leading to under-diagnosis and consequently under-treatment [ 6 , 15 ]. A recent review [ 57 ] concluded that more research is needed to identify the ideal duration, or regularity of a psychosocial intervention in COPD, as long duration can have small effects due to waning of the effect or becoming dependent on the therapist. The duration of the TANDEM intervention was not a perceived problem for our interviewees, but they suggested offering TANDEM at diagnosis or at different timepoints in line with the illness journey allowing the opportunity for the patient to take it up when needed. The TANDEM Facilitators felt that offering TANDEM earlier on in the illness trajectory might be more suitable for patients with less complex needs [ 49 ]. This highlights the need for more mental health support to be available for patients with COPD.

Strengths and limitations

This study forms one part of the process evaluation work of the TANDEM trial and has provided an insight into why the TANDEM intervention may have not worked. The findings, via Sekhon’s acceptability framework [ 34 ], highlighted that most patients found the intervention acceptable but the acceptability of the intervention and the positive experiences were not translated into improvement in the trial outcome measures relative to controls. The reported positive and negative experiences of the TANDEM intervention might be useful for researchers and clinicians looking to improve mental health comorbidities in COPD and beyond COPD/COPD-related breathlessness.

We only interviewed patients in the intervention arm and conducted more interviews with those who had completed the intervention. We achieved data saturation among our sample of patients that had completed the TANDEM intervention with and without completion of pulmonary rehabilitation. We would have liked to speak to more patients who dropped out of the intervention as two patients did not attend any TANDEM intervention sessions and could not recall the reasons for non-attendance. However, we were unable to invite more patients due to administrative delays. Despite this we were able to show a balance of views among the interviewees to help explain the trial findings. A few trial participants had received the intervention by telephone due to the pandemic, but this was not anticipated and hence they were not interviewed.

Implications

More opportunities need to be created in practice to ask about mental health by professionals trained in person-centred skills, psychological skills, knowledge about COPD and common comorbidities associated with/linked to COPD. This is because patients may not be able to ask for treatment or it might not be the right time to seek treatment due to competing demands resulting from the fluctuating and unpredictable nature of COPD, the influence of individual social contexts and interaction with other conditions. Cognitive behavioural approach treatments may be more suited for patients earlier on in their COPD illness journey with built-in sustained follow up, allowing patients to include the learnt skills into their coping mechanisms for improved outcomes.

There is an increased need for co-production work among patients with COPD and comorbidities to develop intervention materials related to cognitive behaviour approach treatments suitable for patients at varying literacy levels, including those who do not like to read any materials or engage in independent home-practice. There is scope to develop interventions that consider an individual’s primary symptoms and interacting social environment to improve the physical and mental health outcomes of patients living with moderate to very severe COPD and anxiety and depression. Future research could look into the role of assistive technology interventions (e.g. adaptive and telecare equipment) [ 58 ] in COPD [ 29 ] that are relevant to improve function, independence, wellbeing and quality of life, particularly technology (e.g. personal digital assistant device) targeted at people with psychosocial disability including anxiety and depression with some evidence of benefit [ 59 ].

This study provides an insight into why a person-centred psychological intervention, evaluated in a randomised controlled trial, did not improve symptoms of anxiety/depression brought on by COPD symptoms, particularly breathlessness in patients with moderate to very severe COPD and did not improve uptake/completion of PR. Patients in our study were affected by other comorbidities or difficult social situations that caused anxiety/depression not necessarily related to COPD. Patients had learnt to manage their conditions or situations through long-established coping strategies. Patients who had not received any psychological treatment specific to COPD and mental health previously felt the intervention might be more suited to people earlier on in their illness journey or at different time points to gain benefits. There were patients who did not want to talk about mood, did not perceive any benefits from the intervention and did not want to use the intervention materials or do any home practice work independently. Our study further highlights that the time spent with the skilled Facilitator led some patients to talk freely about their mental health and they perceived improvements in their health including mental health through discussions, use of intervention materials and home practice work but the benefits were not sustainable due to personal/external factors. To improve the mental health of patients with advanced COPD, more opportunities need to be created to discuss mental health in routine assessments for COPD/for multimorbidity with availability of a sustained intervention that considers the holistic and dynamic nature of social and clinical complexities in COPD.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

We are deeply grateful to the study participants that took part in the study.

The study is funded by the NIHR Health Technology Assessment programme (project number 13/146/02). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

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R.S., K.M.M., A.B. were involved in data collection, data analysis and interpretation of data. R.S. was the major contributor in writing the manuscript and K.M.M. and A.B. contributed to the revision of the manuscript. S.J.C., H.P. were chief investigators and S.J.C., H.P., M.K., L.S., V.W., V.R., R.S., A.B., K.M.M., C.D.D., A.M. formed the process evaluation team for the TANDEM trial and designed the study. S.J.C., H.P., M.K., L.S., V.W., V.R., C.D.D. K.M.M. and A.M. contributed to the data analysis, data interpretation and the revision of the manuscript. All authors read and approved the final manuscript.

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Sohanpal, R., Mammoliti, KM., Barradell, A. et al. Patient perspectives on the Tailored intervention for Anxiety and Depression Management in COPD (TANDEM): a qualitative evaluation. BMC Health Serv Res 24 , 960 (2024). https://doi.org/10.1186/s12913-024-11370-9

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Updating a conceptual model of effective symptom management in palliative care to include patient and carer perspective: a qualitative study

• Emma J. Chapman 1 ,
• Carole A. Paley 1 ,
• Simon Pini 2 &
• Lucy E. Ziegler 1  

BMC Palliative Care volume  23 , Article number:  208 ( 2024 ) Cite this article

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A conceptual model of effective symptom management was previously developed from interviews with multidisciplinary healthcare professionals (HCP) working in English hospices. Here we aimed to answer the question; does a HCP data-derived model represent the experience of patients and carers of people with advanced cancer?

Semi-structured interviews were undertaken with six patients with advanced cancer and six carers to gain an in-depth understanding of their experience of symptom management. Analysis was based on the framework method; transcription, familiarisation, coding, applying analytical framework (conceptual model), charting, interpretation. Inductive framework analysis was used to align data with themes in the existing model. A deductive approach was also used to identify new themes.

The experience of patients and carers aligned with key steps of engagement, decision making, partnership and delivery in the HCP-based model. The data aligned with 18 of 23 themes. These were; Role definition and boundaries, Multidisciplinary team decision making, Availability of services/staff, Clinician-Patient relationship/rapport, Patient preferences, Patient characteristics, Quality of life versus treatment need, Staff time/burden, Psychological support -informal, Appropriate understanding, expectations, acceptance and goals- patients, Appropriate understanding, expectations, acceptance and goals-HCPs, Appropriate understanding, expectations, acceptance and goals- family friends, carers, Professional, service and referral factors, Continuity of care, Multidisciplinary team working, Palliative care philosophy and culture, Physical environment and facilities, Referral process and delays. Four additional patient and carer-derived themes were identified: Carer Burden, Communication, Medicines management and COVID-19. Constructs that did not align were Experience (of staff), Training (of staff), Guidelines and evidence, Psychological support (for staff) and Formal psychological support (for patients).

Conclusions

A healthcare professional-based conceptual model of effective symptom management aligned well with the experience of patients with advanced cancer and their carers. Additional domains were identified. We make four recommendations for change arising from this research. Routine appraisal and acknowledgement of carer burden, medicine management tasks and previous experience in healthcare roles; improved access to communication skills training for staff and review of patient communication needs. Further research should explore the symptom management experience of those living alone and how these people can be better supported.

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A conceptual model of effective symptom management was previously developed from qualitative data derived from interviews with healthcare professionals working in English hospices to elicit their views about the barriers and facilitators of effective symptom management [ 1 ]. The model delineated the successful symptom management experience into four steps of: engagement, decision-making, partnership and delivery. Constructs contributing to these were identified (Table 1 ).

Our original model was based solely on Healthcare professional (HCP) input. However, the perception of professionals may vary from that of patients and carers. A recent patient and professional survey of needs assessments in an oncology inpatient unit showed discrepancies between perception of unmet needs between staff and patients [ 2 ]. For this reason, we were concerned that what was deemed important by HCP working in palliative care may not mirror the concerns and experience of patients and carers.

Here we aimed to answer the question; does an HCP data-derived model represent the experience of patients and carers of people with advanced cancer?. If necessary, the original conceptual model of effective symptom management will be updated.

Qualitative, semi-structured interviews were chosen to gain an in-depth understanding of the experience from the perspective of a range of patients and carers. All methods were carried out in accordance with the principles of the Declaration of Helsinki. Ethical approval was granted by a UK research ethics committee ( North of Scotland [ 2 ] Research Ethics Committee (20/NS/0086)). Verbal, recorded informed consent was given using a verbal consent script (Supplementary information 1). Our original intention had been to conduct interviews face to face facilitated by a set of laminated prompt cards based upon those used in the HCP interviews. However, adaptation to telephone interviews in patient’s homes was necessary due to COVID-19 restrictions and it became apparent that the card exercise did not work well remotely. We continued interviews based on the interview schedule but without the use of prompt cards. EC is a female, non-clinical senior research fellow in palliative care. She has experience of qualitative interviews and led the development of the original HCP-based model of effective symptom management [ 1 ]. Audio recordings were transcribed verbatim by a senior academic secretary.

Recruitment

Participants who met the inclusion criteria were identified by a research nurse at the participating hospice. Eligible patients were those who met all 5 criteria:

Diagnosed with advanced disease (i.e., cancer that is considered to be incurable).

Had been referred to the participating hospice.

Were 18 years of age or over.

Were able to speak and understand English.

Were able to give informed consent.

Eligible carers were people who met all 4 criteria:

Were the informal carer of an eligible patient (who may or may not also be participating in the study).

Patients or carers were excluded if they:

Exhibited cognitive dysfunction which would impede their being able to give informed consent and take part in the study.

Were deemed by hospice staff to be too ill or distressed.

Access to the inpatient unit was not possible at this time due to Covid-19 restrictions. The research nurse introduced the study, provided a participant information sheet and completed a consent to contact form. The first contact with the researcher was made by telephone to confirm (or not) interest in participation and answer questions. An interview time not less than 48 h after provision of the participant information sheet, was scheduled. The researcher and the participant information sheet explained the overall aim of the RESOLVE research programme to improve health status and symptom experience for people living with advanced cancer (Supplementary information 2). The verbal consent statements made it clear that this was a conversation for research purposes only and would not have any impact on the care the patient received (Supplementary information 3). Permission was granted that the researcher may contact the clinical team at the hospice if there was a serious concern for welfare that required urgent attention. Verbal informed consent was collected, and audio recorded at the start of the interview with participants answering yes or no to each of the statements in the verbal consent script (Supplementary information 3). Participants were told that we had already interviewed HCPs about what helped or hindered effective symptom management and now we wanted to understand their perspective too.

Data Collection

Interview topic guides (Supplementary information 4 and 5) were used. Interviews were conducted by EC over the telephone and audio recorded onto an encrypted Dictaphone. Files were downloaded onto a secure University of Leeds drive and then deleted from the Dictaphone. No video was recorded. The researcher made brief field notes directly after the interview on impression, emotion and participant backgrounds that were disclosed.

An Excel spreadsheet was used to facilitate data management. We explored the constructs of patient and carer experience as defined by our existing model. An inductive framework analysis was used to align data with themes in the existing conceptual model. A deductive approach was also used to identify new themes not included in the original model. Two researchers (EC and CP) independently conducted framework analysis on all transcripts. Data was then compared and discussed until a consensus data set was developed. The study is reported in accordance with Standards for Reporting Qualitative Research (SRQR) recommendations [ 11 ].

Twelve participants were interviewed in their own homes by telephone. In five interviews a family member or friend was also present, and they were interviewed as a dyad. One interview was with a carer of a patient (patient not interviewed) and one interview was with a patient alone. Interviews lasted between 21 and 45 min. Basic self-declared demographic information was collected (Table 2 ).

One person was approached by a research nurse and provided with participant information sheet. However, when they spoke with the researcher on the telephone it was clear that they had not read the participant information sheet. The individual declined for the information to be read out loud with them. Informed consent could therefore not be given and an interview was not carried out. Upon reflection, this person was keen to informally chat to the researcher but was perhaps seeking social interaction rather than research participation. All other participants completed the interview as planned.

Participant background was relevant as one carer and one patient, had experience of working in healthcare and this may have shaped their experience and understanding. Analysis was based on the framework method; transcription, familiarisation, coding, applying analytical framework (conceptual model), charting, interpretation.

Data aligned with 18 of 23 constructs in the professional based model (Table 3 ). Pseudonyms are used to protect confidentiality.

Four constructs that had featured in the healthcare professional based model did not feature in the patient and carer derived data. These were perhaps not unexpectedly related to characteristics of staff; Experience (of staff), Training (of staff), Psychological support (for staff) and the provision of formal psychological support (for patients). One construct ‘Guidelines and Evidence’ was not explicitly mentioned by patients and carers. However, a carer did comment that at time of referral to the hospice, the patient had been on two different does of co-codamol simultaneously ‘ You were on co-codamol, the 500/8 plus co-codamol 500/30’ (Patricia, carer) which suggested to the researchers that the patient had been taking the medication in a way contrary to guidelines. Medications were then optimised by hospice staff. Four additional patient and carer-derived themes were identified: Carer Burden, Communication, Medicines management and Impact of COVID-19 (Fig. 1 ).

The conceptual model of effective symptom management in palliative care was updated to also reflect patient and carer perspective. Specifically, the need for support with communication and medicines management plus consideration of the carer burden were included

Carer burden

Our HCP-based conceptual model identified a role for the carer in shaping symptom management experience in either a positive or negative way [ 1 ]. The patient and carer derived data presented here provides additional insight into their role and the activities required of them. Carer burden is a multifaceted experience, however our interview schedule specifically asked about symptom management experience.

The carer was sometimes responsible for raising concerns and initiating the referral for specialist palliative cares support ‘it was at some stage earlier in this year when I was a little anxious about your health and contacted the chemo wing at (hospital) and one of the nurses there thought it would be helpful to me and Patient to put us in touch with (the hospice) (Kathleen, carer).

Carers were enmeshed into the disease and symptom experience of the patient, referring to ‘we’ when talking about the patient’s cancer treatment, pain and referral to hospice.

Olivia (carer): Immune therapy we’d had a reaction to and we’d resolved the reaction but it concluded in stopping any treatment and we then went to a situation where we were not able to manage the pain from the cancer successfully and it was recommended by our oncologist that (the hospice) may have some expertise that we could….

Olivia (carer): Tap into…as I say that was a difficult decision for us to agree for Anthony to go into (the hospice).

However, on occasion the insight from the carer was not acted upon leading to a delay in support for distressing symptoms ‘ I kept saying to people, he’s losing weight, he’s in pain and they just kept saying well he shouldn’t be in this amount of pain ‘cos of what his bloods are like. And I kept saying well what you’re saying he should be like, I can tell you he’s not like and we’re not ones to you know erm (he) isn’t one to be bothering the doctor.’ (Sandra, carer).

Once the patient was receiving palliative care the carer took responsibility for obtaining and retaining knowledge either because the patient could not, due to memory problems from medication, or their condition, or they were not willing to do this for themselves.

Martin (patient): ‘she knows better than me ‘cos I’m always, I’m not very good at remembering stuff’

Martin (patient): I’m not interested no I understand you do have a very important role and she’s taken the lead on it now, that’s definitely the case’

And with another couple

Terry (patient): Sorry I’ve got my wife at the side of me ‘cos she knows better than me ‘cos I’m always, I’m not very good at remembering stuff.

Stacey (carer): I’m usually present yeah, I’m usually around. I tend to be the one that asks more questions.

However, in our interviews occasionally discordance between patient and carer opinion was seen with the carer rating the symptoms more troublesome than the patient’s recollection.

Interviewer: So was it (the pain) stopping you doing any activities that you had been able to do?

Marti, (patient): Oh I see, not particularly no

Mary (carer): I would probably disagree with that sorry. I would say that Martin’s management of the pain and our management of the pain and everything was kind of a constant thing, that’s all we, you know if felt like we were talking about it all the time, his pain’.

Despite an integral role in facilitating effective symptom management carers could feel unacknowledged, specifically by hospital staff. ‘ at the same time they’re telling me I’m not a carer and yet you know Wendy would be in a very sorry state if I wasn’t on the ball all the time’ (Patricia, carer). Specialist palliative care staff were better at providing acknowledgement and consideration of individual capabilities.

Patricia (carer): ‘So they understand that I’m not sort of hale and hearty and I’ve got my limitations….and it’s just lovely them knowing and actually accepting that I am caring for patient, we are doing the best that we can and that they are there for us.’. This simple step of acknowledgement was appreciated and a factor in allowing the carer to continue to support the patient.

Olivia (carer): ‘You know I do feel that it’s about me as well, it’s not just about Anthony which, it is really all about Anthony but you know it’s important that I continue with my wellbeing in order that I can support and look after him’ .

Communication

The impact of communication of effective symptom management occurred at different levels. As would be expected, communication needed to be tailored to the background, previous experience and outlook of the individual. In particular, we noted that a patient who had a healthcare background themselves welcomed more in-depth discussion and input into decision making.

Andrew (patient): I’ve dealt with people with cancers and terminal illnesses. Yeah, I know about syringe drives and everything…The important thing is to be able to discuss it and with my knowledge of medication as well, I mean I can discuss it in depth.’ .

Interestingly, this person also equated being admitted to the hospice with the use of a syringe driver and end of life, illustrating that regardless of the patient’s professional background, a thorough explanation without any assumptions on understanding would still be necessary. Andrew (patient):  ‘I mean I could go into (the hospice) at any time knowing this but with my work record and everything else, I know what it all entails I mean I’d probably go in and they’d probably want to put me on a syringe drive with Oramorph and Midazolam and Betamethasone and everything else and I know that is the beginning of the end once you start on the syringe driver and everything because it just puts you to sleep and just makes you comfortable and you don’t really have no quality of life’ .

Patients and carers valued being able to get in contact with someone when difficulties arose. Kathleen (carer): ‘Ease of communication is important to us so it’s easy to get in touch with somebody’ .

For some people, at the earlier stages after referral to the palliative care team, the only support that they required was just telephone contact.

Kathleen (carer): ‘What we have at the moment is a phone number to call and another lady, a nurse who actually rings us probably about once a fortnight yeah to check if we have any anxieties, problems.’ .

Palliative care professionals had a key role in mediating communication between patients and carers and other services. Kathleen (carer):  ‘she said yes, do you think Harry would mind us contacting the GP you know and I said I’m sure he would, if I think it’s a good idea he’d go along with it so that’s what we did, she did, she contacted our GP which meant that we got a telephone appointment and something happened very quickly’ .

This extended to explaining the purpose and results of tests such as X-rays.

Stacey (carer): Yeah he went when he was admitted he went for an Xray and that was the hospice, it was (clinical nurse specialist) that had organised that. We didn’t really know what was happening in the hospital but we came home again and he didn’t really know why he’d had the Xray or anything.

So when he spoke to the nurse at (the hospice), she sort of went through it all with him and talked him through it and that was really informative and helpful

There was a feeling that communication was better in specialist palliative care compared to the general National Health Service (NHS).

Olivia (carer): ‘There is an awful lot to be learned from the NHS about liaising and communications they could learn an awful lot from the way that the palliative care is operating and running’.

The carer also became an advocate for the patient’s needs and relaying information about symptoms and concerns to the healthcare professionals which the patient may not have themselves. Andrew (patient): ‘ I mean she (partner) tells (hospice nurse) things that I don’t’ cos‘ I mean I sometimes bottle quite a few things up and don’t say nothing but (partner) notices these things and then she will tell (hospice nurse) about them’.

This was also seen during a research interview, where the patient was willing for the carer to ‘tell the story’ on their behalf.

Mary (carer): Sorry I’m doing all the talking.

Martin (patient): Well no you need to because I’m useless.

We identified that patients had unmet needs in communicating about their condition ‘ Yeah, erm, again it’s, people are very reticent to use the word cancer. So they balk at saying the word’ (Wendy, patient)  and symptom experience with family and friends other than their regular carer.

Wendy (patient): I don’t know where she’s (my sister) at in terms of knowing about my symptoms and about the treatment I’m having, well no I do tell her actually, it’s not that I don’t but she has very bad arthritis…so I don’t push that too much because I’m thinking she’s actually in as much pain as I might be.’

This lack of communication could come from a position of wishing to protect the feelings of family members:

Wendy (patient): ‘Oh it’s been very difficult with family. You don’t know how much you want to tell them and you don’t know how far down the line you are anyway. I think over the years, I’ve been protecting my family’ )

Sometimes there were other important conversations that had not been held with family members.

Martin (patient): ‘I suppose my point in bringing up was because they’re particularly good kids and they are particularly, although I wouldn’t like them to hear me say it but they are, very good’ .

The work of medicines management

Medicines management was a time consuming and complex task, even for carers who has a background working in healthcare.

Sandra (carer): ‘I’m having to ring back my fourth phone call today to see is it a week off or have they forgotten to give him it. The communication isn’t great and I kind of think you know I’m kind of used to the NHS I’m, I know to ring and that sort of thing but I do think, I think if someone isn’t, got a health background or that sort of background there’s a lot of left to guesswork’ .

Commonly, the responsibility of managing the medicines could be delegated to the carer due to the side effects of the medication on the patient’s memory. It was felt that the patient would not have been able to manage by themselves. Mary (carer): ‘ a lot of the medication has made him not so aware, maybe a little bit muddled at times and his memory’s not as good as it was….you know he does forget quite easily so I wouldn’t, I have to say I wouldn’t trust him with his medication at all.’.

Carers took responsibility for ensuring medications were taken on time. As previously reported, this carer viewed this a joint endeavour with the patient.

Patricia (carer): I wake (patient) at 9 o’clock and make sure that she has her Lansoprazole and that she has her 12 hourly Longtech tablet. I generally am doing everything and as I say, we put the injection in at lunchtime every day and at night I remind her, not that she doesn’t, she doesn’t really need reminding but at 9 o’clock, I say have you had your tablets?’ .

The carer (who did not have a healthcare background) had developed an understanding of complex concepts such as the different modes of metabolism of medication for pain.

Patricia (carer): ‘So she’s now on a different set of pain relief which, the morphine was better but not better for her. So the pain killing stuff that she’s on is processed through the liver rather than through the kidneys and the kidney function has stabilised.’ .

Impact of COVID-19

Interviewees were asked about whether COVID-19 had impacted upon their experience. It seemed that for this selected group of patients and carers the impact was minimal.

Patricia (carer): ‘Can I just add that Covid seems to have, people have been complaining that this has stopped and that’s stopped whereas with Wendy her appointments, they’ve always wanted face to face and we’ve done phone appointments when it’s been appropriate and the care has been absolutely marvelous’.

Availably of hospice staff sometimes filled the gap in other services.

Kathleen (carer): ‘Because of lockdown and the virus and everything obviously all that (GP support) changed and you did start to feel a bit isolated and alone ‘cos you don’t always want to have to get in the car and drive to (hospital) for something if it’s not absolutely necessary and so therefore having someone else to talk to who knew more about things because obviously we’re learning as we go along Harry and I, it was very helpful’.

Problems were attributed to the general NHS system rather than being COVID-19 specific.

Sandra (carer): ‘I think as far as forthcoming information, I don’t think Covid has any bearing on that to be honest. You know, it just, I think it’s just an age-old problem in the NHS is communication.’ .

The close alignment of this patient and carer data with our HCP-based conceptual model provides additional reinforcement of the importance of multidisciplinary working and continuity of care in shaping symptom management experience. Indeed, the ability to see preferred member of general practices staff was recently reported as a factor associated with satisfaction with ends of life care in England [ 3 ].

Palliative care takes a holistic view of the patient and carer, the concerns of both being intertwined and interdependent. The observation that carers and patients viewed themselves as a single unit and talked about ‘we’ when describing the experience of symptoms and service referral, aligns with the dimension of the carer ‘living in the patients world’ and living in ‘symbiosis’ recently described by Borelli et al [ 4 ] and in earlier qualitative work with advanced cancer patients [ 5 ]. Carer opinion can be a close but not always perfect proxy of patient voice, even in this small sample we observed some discordance between patient and carer perception of symptom burden. However, carers were vitally important for communication with healthcare providers, relaying concerns, managing medication and generally advocating for the patient when they were unable or willing to do so. In the UK in 2022, the number of people living alone was 8.3 million. Since 2020, the number of people over 65 years old living alone has also increased [ 6 ]. Household composition is not a general indicator of wider social support networks, but these data do suggest that there could be a considerable number of people with palliative care needs without live-in carer support. This raises the questions of whether the experience of those living without a supportive carer can be equitable and how services might better facilitate this.

Home-based palliative care is thought to reduce symptom burden for patients with cancer [ 7 ]. To enable this, it is therefore vital that carers are adequately supported. Carer burden is a multifaceted experience, however our interview schedule specifically asked about symptom management experience. In agreement with the term ‘role strain’ in the review by Choi and Seo [ 8 ] we saw carers involvement in symptom management and in mediating communication between the patient and healthcare providers. Additional aspects reported by Choi et Seo include physical symptoms of the carer, psychological distress, impaired social relationships, spiritual distress, financial crisis, disruption of daily life and uncertainty [ 8 ] and these will not have all been probed by our interview topic guide.

Although in our original study HCPs talked about medicines from their perspective, the role of the carer was not discussed. Medicines management was an important way that carers facilitated effective symptom management but is a complex task. One carer commented: ‘I have to say that would be a nightmare if I wasn’t a nurse by background’ . Our data on the difficulties with medicine management are not novel and closely mirror the report of Pollock et al., [ 9 ]. Our findings echo and support their conclusions that managing medicine at home during end-of-life care could be improved by reducing the work of medicines management and improving co-ordination and communication in health care and we echo their calls for further research in the area.

We identified that patients and carers viewed mediating communication as an important role for healthcare professionals. This could be enabling communication between patients and carers and other healthcare professionals, for example arranging follow-up care or explaining information received. There was also a need for better communication between patients and their family members. As reviewed and synthesised by Murray et al., (2014) the importance of effective communication in palliative care has been long recognised [ 10 ]. In our study, an opportunity for HCPs to facilitate better communication about symptom experience between patients and their wider family was identified. Our previous survey of English hospices found that healthcare professionals, particularly nurses and allied health professionals felt that they needed more training in basic and advanced communication skills [ 11 ]. Having relevant experience and if the appropriate training was provided, staff may be well placed to support patients with developing an approach to these potentially difficult conversations. Participants were offered a choice of joint or individual interviews, but most chose to be interviewed as a dyad. It is possible that being interviewed as a pair may have altered the information disclosed. Although the aim was to discuss factors that impacted upon effective symptom management, discussions at times deviated to a more general appraisal of a participant’s experiences and all data collected may not be relevant to the research question.

When data was collected that lead to the development of the HCP-based model of effective symptom management (May to November 2019) a global pandemic was unforeseen. At the time of the patient and carer interview described here (October to December 2020), COVID-19 restrictions were in place in the UK. The patients and carers we interviewed were already receiving specialist palliative care support as outpatients. For these individuals it appeared that the impact of COVID-19 pandemic had had minimal impact on their care. The availability and reassurance of telephone support from hospice staff seemed in part to ameliorate the reduced support available from other services such as GPs. This contrasts sharply with the negative impact of COVID-19 on the experience of patients and carers in the more immediate end of life phase [ 12 ], receiving oncology care [ 13 ] or with cancer more generally [ 14 ]. Selection bias is likely as patients and carers with the capacity and willingness to participate in our research study possibly reflect those where the illness is in a more stable phase and immediate needs were being met. Indeed, participants talked about difficulties before referral to specialist palliative care and with other services but were overwhelmingly positive about the support currently being provided by the hospice.

Limitations

Due to the constraints of conducting a research study during the COVID-19 lockdown, more purposive sampling was not possible, this led to a lack of diversity in our sample. All participants identified themselves as of white British or white Scottish ethnicity which potentially means issues related to diverse ethnicities were not captured. All the patients who participated (and the non-participating patient whose carer was interviewed) lived with another person and had carer/family support. The experience of those managing their symptoms in isolation was therefore not captured. All participants were currently accessing support from a single hospice, the experience of those not yet receiving specialist support or receiving support from a different organisation may differ. The sample were diverse in age and included males and females, but all carers were female. Demographic information was not collected on socioeconomic background. COVID-19 restrictions necessitated the use of telephone interviews which may have lost subtle communications cues such as body language or conversely may have facilitated candid description. The transcripts do suggest that participants felt comfortable to tell their experience and they mostly spoke freely with limited prompting. One participant mentioned that he found it very difficult to leave the house, and therefore a telephone interview might have facilitated his inclusion. In some interviews more data was derived from the opinion of the carer than the patient, with the pair agreeing that the carer took responsibility for many tasks involved in managing the condition. We cannot be certain that carer interpretation accurately matches patient experience for all symptoms [ 15 ].

We set out to answer the question; does a healthcare professional data derived model represent the experience of patients and carers of people with advanced cancer? Overall, the answer was yes, as our healthcare professional based conceptual model of effective symptom management aligned well with the experience of patients with advanced cancer and their carers. Domains that did not align were those specifically related to professionals; experience (of staff), training (of staff), guidelines and evidence, psychological support (for staff) and the provision of formal psychological support (for patients), a resource patients and carers might be unaware of. Additional domains of carer burden, communication, medicine management and the impact of COVID-19 were identified. We make four recommendations arising from this research.

Routine appraisal and acknowledgement of carer burden, medicine management tasks and previous experience in healthcare roles.

Increased access to communication skills training for staff caring for palliative care patients and their families.

Review of patient communication needs with support provided where needed.

Further research into the symptom management experience of those living alone and exploration of how these people can be better supported.

Availability of data and materials

Original recordings generated and analysed during the current study are not publicly available due to protection of confidentiality. Anonymised transcripts with identifiable information removed may be available from the corresponding author on reasonable request.

Abbreviations

Coronavirus disease 2019

Healthcare professional

National Health Service

United Kingdom

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Acknowledgements

We are grateful to the patients and carers who in giving valuable time to share their experiences, made this research possible. We thank research nurses Kath Black and Angela Wray for their support with recruitment.

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this work was supported by Yorkshire Cancer Research programme grant L412, RESOLVE: “Improving health status and symptom experience for people living with advanced cancer”. The sponsor had no role in study design or the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.

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Original idea, EC and SP; Data collection, EC; Data Analysis, EC and CP; Data interpretation, All, Methodological oversight, SP and LZ; writing the manuscript, All. All authors contributed to the development of the updated conceptual model and approved the final submission.

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Chapman, E.J., Paley, C.A., Pini, S. et al. Updating a conceptual model of effective symptom management in palliative care to include patient and carer perspective: a qualitative study. BMC Palliat Care 23 , 208 (2024). https://doi.org/10.1186/s12904-024-01544-x

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Challenges in institutionalizing evidence-informed priority setting for health service packages: a qualitative document and interview analysis from Iran

• Haniye Sadat Sajadi   ORCID: orcid.org/0000-0003-0897-4080 1 ,
• Hamidreza Safikhani   ORCID: orcid.org/0000-0001-5459-1326 2 ,
• Alireza Olyaeemanesh   ORCID: orcid.org/0000-0002-7417-2417 3 &
• Reza Majdzadeh   ORCID: orcid.org/0000-0003-3989-4470 4  

Health Research Policy and Systems volume  22 , Article number:  110 ( 2024 ) Cite this article

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Setting and implementing evidence-informed health service packages (HSPs) is crucial for improving health and demonstrating the effective use of evidence in real-world settings. Despite extensive training for large groups on evidence generation and utilization and establishing structures such as evidence-generation entities in many countries, the institutionalization of setting and implementing evidence-informed HSPs remains unachieved. This study aims to review the actions taken to set the HSP in Iran and to identify the challenges of institutionalizing the evidence-informed priority-setting process.

Relevant documents were obtained through website search, Google queries, expert consultations and library manual search. Subsequently, we conducted nine qualitative semi-structured interviews with stakeholders. The participants were purposively sampled to represent diverse backgrounds relevant to health policymaking and financing. These interviews were meticulously audio-recorded, transcribed and reviewed. We employed the framework analysis approach, guided by the Kuchenmüller et al. framework, to interpret data.

Efforts to incorporate evidence-informed process in setting HSP in Iran began in the 1970s in the pilot project of primary health care. These initiatives continued through the Health Transformation Plan in 2015 and targeted disease-specific efforts in 2019 in recent years. However, full institutionalization remains a challenge. The principal challenges encompass legal gaps, methodological diversity, fragile partnerships, leadership changeovers, inadequate financial backing of HSP and the dearth of an accountability culture. These factors impede the seamless integration and enduring sustainability of evidence-informed practices, hindering collaborative decision-making and optimal resource allocation.

Conclusions

Technical aspects of using evidence for policymaking alone will not ensure sustainability unless it achieves the necessary requirements for institutionalization. While addressing all challenges is crucial, the primary focus should be on required transparency and accountability, public participation with an intersectionality lens and making this process resilience to shocks. It is imperative to establish a robust legal framework and a strong and sustainable political commitment to embrace and drive change, ensuring sustainable progress.

Peer Review reports

Universal health coverage (UHC) is a global commitment to effective coverage of needed services and ensuring no one left behind them, a target all nations have pledged to achieve certain targets by 2030. However, the most recent annual reports on UHC monitoring paint a disheartening picture [ 1 ]. Countries still have a considerable distance to reach UHC targets for 2030, raising concerns about whether health resources are sufficiently allocated to attain the UHC.

One of the fundamental aspects of UHC is service coverage. By its very definition, UHC explicitly emphasizes providing needed services with adequate quality to everyone without financial hardship [ 2 ]. Therefore, one of the primary strategies for moving towards UHC is to understand the list of needed services through setting a health service package (HSP) considering country’s financial realities and social preferences [ 3 ].

Experiences across various nations suggest that many are striving to set HSP. However, health needs are evolving, technologies and services are advancing and financial resources are also undergoing changes. It demands ongoing updates to the HSP. Consequently, the institutionalization of its setting and implementation is of significant importance. Recent reviews of countries’ endeavours in setting HSP also highlight that institutionalization poses a challenge for most nations [ 4 , 5 ].

The health system in Iran underwent significant transformation after the Islamic Revolution of 1979. This revolution, which led to the overthrowing of the Pahlavi Dynasty and the establishment of the Islamic Republic, fostered a greater focus on justice and attention to underserved rural areas [ 6 ]. The primary health care (PHC) model, which had been piloted and developed in a region of Iran before the revolution, was scaled up and expanded nationwide in the early 1980s, providing a HSP across the country, particularly in rural areas [ 7 ].

From the beginning, the provision of services based on the needs of society, especially the vulnerable, has been a principal and was included in the HSP setting [ 8 ]. The same principle (coverage of needed services and financial protection) has been followed in forming a diagnostic and treatment services package. However, despite the significant achievements of Iran’s health system in increasing life expectancy and improving the population’s health [ 9 , 10 ], the concern of low efficiency (high costs compared with outputs) has been seriously raised [ 11 ]. This issue has been exacerbated by the economic crisis caused by imposed economic sanctions and the COVID-19 pandemic in recent years [ 12 ] and seriously escalated the need to revise the HSP [ 13 ].

The history of measures taken to set HSP shows successes in generating local knowledge for prioritization, capacity building in related fields and establishing institutions to govern health technology assessment (HTA) and HSP setting. For example, the willingness to pay for gaining health [ 14 ] and social health insurance [ 15 ] were studied. In prioritization methodologies, the Technique for Order of Preference by Similarity to Ideal Solution (AHP-TOPSIS) approach was applied to some technologies [ 16 ]. In addition, several criteria were identified through experts’ opinions, including efficiency/effectiveness, safety, population size, vulnerable population size, availability of alternative technologies, cost-effectiveness, budget impact, financial protection and quality of evidence [ 17 ]. Another work assessed the public perspective regarding prioritization criteria and recognized disease severity, age, daily care needs, number of alternative interventions, individuals’ economic status and diseases with absence from work [ 18 ]. Despite all efforts, which some of them also are elaborated in the result section of the current paper, producing and using evidence to prioritize health services are not yet well embedded in Iran’s health system [ 19 , 20 , 21 ].

Lack of attention to taking effective initiatives to strengthen institutional capacities can hinder using evidence to develop HSP [ 22 ]. Institutionalization can be defined as the process by which a set of activities becomes an integral and sustainable part of a formal system. It can be seen as a sequence of events leading to ‘new practices becoming standard practice’ [ 23 ]. Institutionalization plays an important role in using evidence to support decisions that can help improve the health policy development processes and ultimately strengthen health systems [ 24 ]. In fact, due to the complex individualized, organizational and system relations of health organizations and the contextual circumstance [ 25 ], it is not easy to institutionalize using evidence to set and implement HSP [ 4 ]. Hence, the aims of this study are (1) to review the measures undertaken over the past four decades to establish the HSP in Iran and (2) to identify the obstacles encountered in institutionalizing evidence-informed priority setting for HSP. Notably, we have employed the Kuchenmüller et al. framework [ 23 ], which focuses on the Institutionalization of evidence-informed policymaking, to evaluate its applicability empirically for the first time.

Study design: The study was qualitatively based on document analysis and semi-structured interviews with key stakeholders. We employed document analysis as a data collection method for systematic collection, documentation, analysis, interpretation and organization of printed or electronic data [ 26 , 27 ] to mainly describe the actions taken to set the HSP and clarify the current situation in Iran. Additionally, we chose interviews to get an in-depth understanding of stakeholders’ various perceptions, particularly regarding the challenges of institutionalizing the evidence-informed prioritization efforts in Iran. We utilized the Standards for Reporting Qualitative Research (SRQR) checklist to present this study.

Reflexivity statement: In this study, all researchers are experienced in setting and implementing HSP within a low- and middle-income countries’ context. Among the researchers, one is female. Our professional backgrounds span health research policy and systems, epidemiology, health policy and financing. We collectively believe that health interventions funded by public resources should be set through a scientific and participatory approach, specifically a deliberative, evidence-informed process. While this approach is suitable for defining the HSP, its institutionalization and integration into the health system pose significant challenges and can be considered a crucial health reform necessary for moving toward UHC.

Study setting: Iran, with a population exceeding 85 million, was classified as a lower-middle-income country, at the time of study, in West Asia. Over the past decades, Iran has faced significant political events, including revolution, war and economic sanctions. Despite these shocks, the country has made notable progress in literacy, urbanization and investments in the transportation and food industries. In the health sector, various policies have been implemented across primary, secondary and tertiary care, as well as in medical education and research, to ensure ‘health for all’ [ 9 ]. While there have been improvements in health outcomes, several challenges persist, including the need for a sustainable financing mechanism to support effective health interventions.

Theoretical perspective: We found that the Kuchenmüller et al. [ 23 ] framework of institutionalizing evidence-informed health policymaking is useful as a practical lens to understand key stakeholders’ perspectives on key challenges for the successful institutionalization of evidence-informed prioritization. Based on this framework, there are six domains for a successful institutionalization, including: (1) governance; (2) standards and routinized processes; (3) partnership, collective action and support; (4) leadership and commitment; (5) resources; and (6) culture.

Document selection: Potentially, documents were identified through the following methods: (1) relevant government bodies and ministries website searches (e.g. Ministry of Health and Medical Education (MoHME), Ministry of Welfare, Parliament, Management and Planning Organization, Health Insurance Organizations), (2) Google search, (3) expert consultation with key informants and (4) hand searching in libraries.

Two authors (HSS and RM) reviewed the retrieved documents to validate the accuracy of their data and sources. To be eligible for inclusion, the documents had to meet the following criteria: (1) published after 1985 (the year of establishment of the MoHME); (2) relevant to HSP activities, including health need assessments, prioritization, pooling, fund allocation, budgeting, and health monitoring and evaluation; and (3) document types included books, papers, national development plans and policies, general health policies, bylaws, legal documents, technical reports and official guides. Documents were excluded if they did not specifically outline events and actions related to defining and implementing HSP or if a more recent version of the same document was available. Finally, 98 documents were included.

Data extraction: The details of included documents were entered into a data extraction matrix developed in Microsoft Excel, including the title, type, timeframe, main actions and events related to HSP development or implementation and the factors that have enabled or hindered this process. One author (HSS) extracted the data.

Study participants: We aimed to achieve diverse perspectives in our study. We employed a purposive sampling strategy, combining maximum variation sampling with a snowballing approach. It allowed us to identify potential participants with varying backgrounds in health policymaking, health financing, health sector reforms and health management. Given our relatively homogenous study populations and narrowly defined objectives [ 28 ], our sample consisted of nine individuals, ensuring data saturation. Documents and participants’ information is provided in Table  1 .

Interview procedure: We performed qualitative, in-depth interviews that lasted 30–50 min between February and July 2022. Two authors (HSS and RM) with experience in qualitative research conducted all interviews. We developed an interview guide with open questions for the semi-structured interviews. We slightly adapted the initial interview guide after conducting two interviews. The stakeholders were asked to explain what has been done in the last 40 years to define/revise the package in Iran, share their experiences about how these initiatives have strengthened the health system’s functions, what have been the impacts or consequences of these initiatives and express their ideas on the main challenges of institutionalizing the evidence-informed prioritization to set the HSP. Invitations, a consent form and study information were emailed. We used audio-recorded video or phone calls for the interviews and took field notes during the interviews. The audio files were then transcribed verbatim. Summaries of the interviews were emailed to stakeholders for revision and completion if necessary.

Data analysis: The same two authors who conducted the interviews also analysed the data using the framework analysis approach, guided by the Kuchenmüller et al. framework [ 23 ] as the analytical framework. The approach consists of seven stages: transcription, familiarization with the interviews, coding, development of a working analytical framework, application of the analytical framework, charting and data interpretation [ 29 ]. We imported the content from relevant documents and the transcripts of interviews into ATLAS-ti 8, a qualitative data analysis software. Subsequently, we immersed ourselves in the data by iteratively listening to the interview audiotape recordings and reading the interview transcripts and documents. During this immersion process, we annotated and coded key ideas and concepts. Our coding approach combined both inductive and deductive methods. We then organized the codes into categories and subcategories, which revealed the main challenges in institutionalizing evidence-informed priority setting. Through an iterative process, we developed a working analytical framework. This framework was applied to index subsequent transcripts and documents using the existing categories and subcategories. The resulting categories were charted into framework matrices to summarize the findings in a structured manner. Finally, we interpreted the data through discussions with all co-authors, resolving discrepancies through consensus.

The documents and interviews that were included were originally in Persian. The code descriptions and quotations, extracted from the interview transcripts and documents, were subsequently translated from Persian into English.

In our study, we employed Guba and Lincoln’s criteria to evaluate the trustworthiness of our work. These criteria are widely recognized in qualitative research and provide a robust framework for assessing the rigour and credibility of findings [ 30 ]. To this end, the credibility was established by prolonged engagement with participants and member checking. Besides, selecting participants with diverse experiences increases the possibility of shedding light on the research question from different aspects. Dependability and conformability were achieved through an auditing process. Two auditors examined the analytical process and the records of meetings for accuracy and then assessed whether all analytical techniques of the grounded theory had been used. The auditors reviewed the analysis of the descriptive, axial and selective codes to ensure whether they followed the study data. The research team documented all study data and described the participants and the research process to help assess the present findings’ transferability.

Ethical consideration

In our study, we secured informed oral consent from all participants, emphasizing their voluntary participation without coercion. Before data collection, we transparently communicated the study’s purpose, procedures, potential risks and benefits. Participants were fully informed and had the opportunity to seek clarification or ask questions. To safeguard privacy, we rigorously maintained participant confidentiality. Identifying information was meticulously removed during data analysis and reporting. Our commitment to confidentiality extended to securely storing data, ensuring that only authorized researchers had access.

Evolution of setting HSP in Iran

Iran’s HSP comprises two primary components, each with distinct characteristics and significant events shaping their development, including preventive and PHC Services and diagnostic and therapeutic Services.

Preventive and PHC services: At the first level of care, preventive and primary services are provided, focusing primarily on health promotion and prevention, with some surgical, pharmaceutical and diagnostic services included. Funded by the government, these services are freely accessible to the entire population [ 31 , 32 ]. The private offices are the main providers of the first level of care, particularly in urban areas and populated cities where basic insurance schemes cover their services. The main policies and reforms that influenced the development and evolution of PHC services in Iran were as follows:

1970s – PHC pilot project: The initial phase involved a limited number of rural health houses. HSP focused on mothers and children, as well as environmental health and infectious disease services provided by community health workers. Target diseases were selected on the basis of hospital admissions and mortality causes, following WHO and UNICEF recommendations [ 33 , 34 , 35 ].

2000s – PHC scale-up: This phase included a comprehensive review of the HSP to expand service coverage. New services related to family and school health, noncommunicable diseases (NCDs), oral health, mental health and more were defined. Consideration was given to human resource needs and integrating different health system levels to maintain continuity of care through a referral system [ 33 ].

2005 − Family physician plan: Implemented in rural and nomadic areas, this plan introduced family physicians and established a referral system and rural health insurance [ 36 , 37 ].

2015 – Updating PHC package of services: As part of Iran’s health reform aimed at achieving UHC, Health Transformation Plan (HTP) [ 38 ], the PHC services were revised to focus on specific population groups (children, adolescents, middle-aged, elderly and pregnant mothers). The revision included mental health, NCDs, nutrition, infectious diseases and environmental and occupational health services [ 39 , 40 ].

Diagnostic and therapeutic services: This component encompasses diagnostic and para clinical services, clinical interventions, medicines, medical equipment and specialized care primarily provided in hospitals and ambulatory care centres. Significant initiatives in this area include:

1995 – Passive purchasing by basic insurance funds: The establishment of the Supreme Council of Health Insurance (SCHI) [ 31 ] marked the beginning of efforts to coordinate insurance organizations. One of the first major actions by SCHI was the publication of a negative list of non-covered services, including cosmetic surgeries, organ transplants and infertility treatments.

“The beginning of the modern stage of the setting HSP in Iran goes back to 1994 when the issue of hospitals autonomy program was raised, and it was decided that the health insurance organization would be formed and the Universal Health Insurance Law was approved. In that law, it was the first place where we formally talked about the service package.” P4

“32 items have been excluded from the HSP under the title of additional and supplementary insurances, such as canes, walkers, and glasses.” P3

2007 – HTA: HTA was introduced to facilitate strategic purchasing. Several HTA projects have been conducted [ 41 ]. However, a review of completed HTA projects indicated that the application of HTA evidence was unsatisfactory, and HTA was not fully institutionalized in the decision-making process [ 21 ].

2015 – Strengthening strategic purchasing through Disease Control Priorities 3 (DCP3): During the monitoring of the HTP, several inefficiencies in the basic services insurance package were identified. Efforts were made to build capacity and move towards strengthening strategic purchasing to address these inefficiencies [ 10 ].

“Lately, it was the same DCP3 approach that was started in departments such as maternal health, NCD, and AIDS, but it did not reach a result.” P8

The importance of DCP3 lies in its role as a global initiative advocating for the use of a prioritized list of cost-effective interventions, tailored for resource-constrained nations, endorsed by international organizations and promoted for use in these countries [ 4 ]. A country initiative was established to translate DCP3 for use in Iran. The initial assessment of this initiative indicated that DCP3 has limited added value in Iran, as the services provided in DCP3 are more appropriate for countries with limited service coverage.

2018 – Use of evidence-informed deliberative processes: The service package and medicines related to multiple sclerosis (MS) [ 42 ] and diabetes [ 43 ] were reviewed and endorsed by the SCHI in 2021 for implementation. In this process, three pillars were identified and used, which were: quality of care (effectiveness and safety), necessity (out of pocket payment and alternative availability) and sustainability (budget impact) [ 42 ].

Challenges of institutionalizing evidence-informed prioritization to set HSP in Iran

After data analysis, six main categories emerged. According to participants’ statements, the barriers encompassed 23 subcategories (Table  2 ). In the following section, the most critical challenges of institutionalization are explained according to Iran’s experience in developing and revising the service package.

Our study revealed that the need to revise the HSP, particularly at the second and third levels of care, is not acknowledged as an essential component of the health system’s goal to achieve UHC. Participants highlighted that although revising the HSP through evidence-informed process has been incorporated into upstream policies, this approach has not been consistently implemented. It is largely attributed to the perception of such revisions as standalone endeavors rather than integral steps towards realizing UHC.

Participants further emphasized that this perception has led to the adoption of varying approaches in setting HSP across different levels of care, including inter-sectoral interventions, primary health care and secondary and tertiary care. It was also noted that these approaches do not form a cohesive package to promote health and ensure health equity for the entire society. It was emphasized that the current HSP lacks comprehensive addressing for implementing the general health policies (GHPs), per UHC principles.

The setting of these packages lack a systematic and integrated approach. There are instances of overlap or remnants of certain services, and the overall structure is unclear. The lack of a sustained and rigorous scientific approach to prioritizing health interventions results in limited access to essential and affordable services for vulnerable populations. It, coupled with substantial out-of-pocket expenses, undermines their financial protection.

Participants emphasized another obstacle which is the absence of a legal framework that endorses the use of evidence in prioritizing services. Nevertheless, sustainability of any advancements in this area would be challenging without sufficient enforcement and regulatory backing.

Another challenge identified is the lack of a well-defined organizational structure essential for deliberative evidence-informed prioritization. Participants noted that despite the establishment of structures such as the secretariat of the SCHI, the PHC Network Development Center and the HTA office, there are still deficiencies in the institutional arrangement. The roles, responsibilities and levels of authority within these units lack clarity. Furthermore, there are shortcomings in the composition of members, which impacts the involvement of relevant stakeholders and the definition of their roles.

Standards and routinized processes

Participants strongly believed that the main barrier to institutionalizing evidence in setting HSP was a lack of well-defined and clear processes. That is why there were different approaches for defining or revising the HSP. They described that most preventive and PHC services are recommendations of international agencies. In contrast, different criteria have been considered for assessing the eligibility of diagnostic and therapeutic services over time, including disease burden, effectiveness, safety and financial burden. They pointed out that decisions were made by consensus or voting, and criteria were not scored.

According to the participants, Iran has been setting HSP for decades, using different methodologies that are not usually clear. The process has traditionally relied on experts’ opinions, initially implicitly and explicitly, for the past 15 years. The criteria used have evolved in line with the changes and advancements in methodologies worldwide.

The study participants highlighted that apart from the inadequate process and criteria for prioritizing, there is also a notable absence of a defined process for effectively implementing the HSP. Additionally, the lack of a reliable mechanism for monitoring the outcomes of HSP implementation emerged as a significant challenge. Moreover, the participants expressed genuine concern about the inadequacy of a robust accountability mechanism to oversee the revision of the HSP, as endorsed in the country’s development plans and GHPs. Overall, these issues present considerable difficulties in providing quality and accessible services to the population, and policymakers must address these concerns and work towards strengthening governance and accountability mechanisms in the health sector to improve health outcomes for all.

Partnership, collective action and support

Regarding collaboration, participants highlighted a significant challenge in institutionalizing evidence uptake for setting HSP: conflicts of interest. The output of the HSP definition and revision processes influences the interests of diverse professional groups. However, it remains unclear why certain services are included in the HSP without clear engagement processes and mechanisms for stakeholders. Participants emphasized that the interests of powerful groups have manipulated the current HSP. One of the challenges lies in HTA offices outsourcing evidence production to the private sector and requesting them to fund studies. This practice increases the likelihood of conflicts of interest. Additionally, the diversity among licensing bodies for health technologies introduces complexities and may influence the final decision by interest groups.

In partnership, participants highlighted a significant challenge related to people’s preferences. From their perspective, there is no well-defined mechanism for actively listening to people’s voice. Some policymakers even question the eligibility of individuals to express their opinions. One participant pointed out that ignoring people’s voices and the existing conflict of interest has led to people increasingly valuing services provided by specialists. As a result, specialization has come to dominate the service-seeking behaviour.

Lack of collaboration within the organizations involved in setting HSP was a significant barrier to the institutionalization of using evidence in priority-setting. One of the key observations from experts in this field is that many organizations operate in silos and do not communicate effectively with each other. This lack of collaboration leads to duplication of efforts, conflicting priorities and the generation of unreliable or incomplete data. Participants specified that the absence of a culture of collaboration makes it difficult for organizations to share information, knowledge and resources necessary for producing high-quality evidence. As a result, using evidence in decision-making becomes ad hoc and less effective. The institutionalization of using evidence requires a culture of collaboration among stakeholders, including policymakers, researchers, health professionals and community members.

Leadership and commitment

The participants identified a significant challenge to effectively institutionalizing the prioritizing HSP: a lack of awareness among health managers and senior leaders about the benefits of evidence-informed methods. According to the participants, many of these managers are clinical service providers with limited knowledge of management science and economics. As a result, they tend to rely on traditional methods of prioritizing services based on their clinical expertise rather than incorporating evidence-informed approaches. This shortage of awareness and commitment among managers hinders the sustainability of change efforts and perpetuates the use of less effective, outdated methods.

The participants also identified a lack of necessary leadership skills as another obstacle to effectively institutionalizing use of evidence-informed approaches for HSP. Institutionalizing this change in the health system requires strong, charismatic leadership to guide, motivate and provide ongoing support. The shift from traditional methods is a fundamental change, and Iran’s successful experience in implementing PHC highlights the potential for another significant shift with powerful leadership. However, the participants noted that such leadership has been scarce in recent years, which is unfortunate for the health system and the people it serves.

The participants identified political considerations as another obstacle. In a such political environment, policymakers showcase their achievements to the public during election. However, since the benefits of evidence-informed approaches may not be immediately visible to the public and sometimes it results conflict with the interest of certain groups, policymakers may be hesitant to challenge themselves to prioritize it.

Some participants emphasized the challenge of management changes. Specifically, they shared their experiences of encountering managers who supported using evidence only to have them suddenly replaced for political reasons. These changes often occur without regard for technical knowledge or expertise, which makes it challenging to sustain an evidence-informed approach to service prioritization. Frequent management changes cultivate confusion, uncertainty and inconsistency within the organization, interfering with the successful implementation and institutionalization of evidence-informed strategies.

The managers’ and key decision-makers value systems were another significant obstacle reported by participants. From their perspective, most decision-makers do not believe the benefits of evidence-informed approaches, rely more on intuition and established habits when making decisions. This reluctance to embrace evidence-informed practices is a common issue that has been observed in various health systems across the world.

Participants highlighted that the most significant obstacle to institutionalizing the use of evidence in developing HSP was related to financial resources. They acknowledged that dedicated and sustainable financial resources are key to (1) implementing HSP and (2) establishing evidence-informed priority setting. Unfortunately, despite increased resources within the health sector, participants found that this approach was not prioritized in the actual allocation of financial resources. They added that allocating financial resources for short-term projects was insufficient and could not support the institutionalization of evidence-informed priority setting. Without a sustainable financial plan, integrating and maintaining an evidence-informed approach is challenging.

According to many participants, there has been a significant investment in capacity building in Iran to produce and utilize evidence for health policies. From their perspective, the quantity and quality of these resources are sufficient to institutionalize the use of evidence-informed practices. However, the cultural aspect remains an obstacle in terms of the lack of the necessary skills to work in multidisciplinary groups.

Participants acknowledged the importance of human resources from a wide range of fields, including economics, management, politics, social sciences and methodological sciences, to effectively institutionalize the use of evidence in different stages of policy development. However, it appears that the formation and activity of these groups are still in the early stages.

Participants recognized that Iran’s health information systems have improved. However, they indicated that the registration systems, routine data systems and data from national studies are not integrated enough to provide the necessary data for developing or revising the packages. Furthermore, these systems lack the capability to demonstrate changes in health system indicators resulting from implementing these packages, making monitoring and evaluating their implementation challenging. In other words, there is a gap in the health information system’s capacity to provide data relevant to evaluating the impact of evidence-informed practices in health policies.

The lack of an accountability culture was identified as a significant cultural barrier to using evidence in health policymaking. Participants noted that health managers have not been held accountable for not incorporating evidence in HSP development, and there is no mechanism to track the use or non-use of evidence. In addition, many managers do not view evidence as a critical component in developing HSP, which diminishes the motivation to adopt evidence-informed practices. This lack of accountability is not only limited to managers as users of evidence but also includes producers of evidence. Participants observed a lack of motivation among evidence producers to generate essential evidence required for package formulation due to the deliberative nature of the process.

As observed in the ‘Leadership and commitment’ section, another significant cultural barrier to using evidence in policy formulation is the lack of belief and habit of utilizing evidence. Participants noted that, in society, there is a greater emphasis on solving problems in the shortest time rather than obtaining and utilizing evidence to inform decisions. This approach overlooks the importance of evidence in improving health outcomes and undermines the value of evidence-informed practices. Moreover, as there is no accountability system in place, there is little concern for the impact of these decisions on the people affected.

Setting and implementing HSP, drawing upon both global and local evidence, exemplifies the use of evidence in policymaking. Beyond mere evidence utilization, HSP development necessitates active stakeholder engagement and alignment with local values to yield meaningful outcomes. However, pursuing UHC through HSPs is a gradual, long-term endeavour that does not yield immediate results [ 44 ].

The finding demonstrated that several efforts have been made to perpetuate evidence-informed prioritization process in health systems, starting in the 1970s and continuing in the 2000s, 2015 and 2019. However, they have yet to be institutionalized. Without robust institutionalization, the decision-making process underlying HSP prioritization may remain unstable and potentially ineffective, resulting in a wish list of services which does not have any real world implication for the countries. Therefore, a critical factor emphasized in setting and implementing HSP is institutionalization in achieving programmatic goals and advancing towards UHC. Furthermore, experience underscores those countries facing constant political instability or shock conditions need resilient decision-making processes, which can only be achieved through effective institutionalization [ 4 , 5 ].

Institutionalization is a complex endeavour that necessitates careful consideration of contextual strengths and weaknesses to identify optimal solutions for addressing critical areas. Our study identified several key challenges in this process, including legal gaps, methodological diversity, fragile partnerships, leadership transitions, insufficient financial support and a culture of lack of accountability. While addressing all these challenges remains crucial, we contend that the primary focus areas should involve establishing transparent and accountable mechanisms and fostering public participation to strengthen partnerships, enhance collaboration and amplify the voices of vulnerable populations.

Moreover, it is imperative to establish a robust legal framework and a transparent process aligned with it to ensure comprehensive implementation. Realizing these measures demands high political commitment, persistent effort and effective mobilization of enduring resources to implement the results defined by the HSP.

As our findings highlighted, one of the significant challenges in the design and implementation of the HSP is the conflict of interest. To address this issue, it is imperative to establish or strengthen transparency and accountability processes. Recent service package review activities for MS and diabetes have emphasized transparency [ 42 , 43 ], which is crucial for the success of these reviews and has been a persistent challenge in the recent HTA in the country [ 21 ]. A study in Iran highlighted the necessity of establishing accountability mechanisms to ensure policymakers make informed decisions [ 45 ]. Without these mechanisms to monitor actions and enforce appropriate rewards or penalties, the benefits of evidence-based prioritization cannot be realized. Implementing policies and decisions related to the HSP based on rigorous studies and expert opinions while reducing political influence, especially for costly technologies and medicines, are additional measures to enhance transparency and accountability.

Another notable challenge lies in disregarding the perspectives of vulnerable communities. Reviews of the HSP frequently show that public participation has either been neglected or considered superficially. Moreover, the principle of including vulnerable populations in developing the HSP has been ignored in all aspects of HSP [ 3 ]. Therefore, it is crucial to establish a platform for the participation of disadvantaged groups, allowing their voices to be heard. This approach incorporates the concept of intersectionality in public participation to institutionalize the HSP [ 46 ]. Especially in times of shocks and crises, when vulnerable groups are the first to be affected, it is crucial to consider intersectionality with a systemic approach [ 47 ]. In Iran, legal frameworks for public participation in policymaking exist but have largely been overlooked by policymakers. Public participation structures in Iran are defined in two forms: the health participation house and the health assembly. The health participation house serves as a broker between people and managers, facilitating communication and collaboration, while the health assembly involves the public directly in policymaking processes [ 48 ]. These structures can be leveraged to institutionalize public participation or similar mechanisms in the evidence-informed deliberative prioritization process of the HSP.

Beyond transparency and accountability, two other pivotal dimensions of institutionalization involve establishing a legal framework for evidence-informed prioritization and consolidating processes. It ensures a well-defined approach to priority-setting that incorporates empirical data and actively engages relevant stakeholders. In this context, revising the HSP is perceived as an integral part of achieving UHC. Without such deliberate efforts, sporadic interventions remain isolated and cannot effectively contribute to the defined goals. Drawing from the Iranian experience, an initial focus on specific disease groups or programs can mitigate sensitivities, promote sustainability and pave the way for broader optimization. For example, optimizing MS services ensures efficient resource utilization, preventing patient and provider disruptions. However, a comprehensive revision of the HSP remains essential for achieving UHC and enhancing overall health system efficiency [ 49 ]. Therefore, it should foster commitment and motivation among policymakers and ministries, emphasizing that evidence-informed decisions for public health funding are essential for ensuring health for all.

The prerequisites for institutionalizing evidence use in HSP become feasible when strong leadership and ample resources are in place. High levels of political commitment and sustained effort are essential for mobilizing the necessary resources and supporting the continuous development and implementation of the HSP [ 4 ]. Achieving this requires a fundamental shift in policymakers’ attitudes to ensure sustainable political backing for evidence-informed decision-making processes related to service packages. Without this transformation, persistent health system challenges—financing and service delivery—will continue exacerbating, hindering progress towards UHC [ 5 ].

Strengths and limitations

In terms of methodology, we employed triangulation through document review and interview methods. Based on the convergence of responses, it can be asserted that the study demonstrates a suitable level of rigour. We used the framework proposed by Kuchenmüller et al. for data gathering and analysis. Empirical data validated this framework. While the framework proves helpful, it is essential to acknowledge its limitations. Notably, the framework lacks clear boundaries in critical areas such as governance and partnership, collective action and support, suggesting areas for improvement. Considering the findings, the significance of the work extends beyond optimizing HSP institutionalization and moving towards UHC. It also holds broader potential for institutionalizing evidence-informed policymaking.

However, our work has a notable limitation: we did not specifically address how the institutionalization of evidence-informed approaches may differ in countries experiencing conflict. The turbulent economic, social and political circumstances resulting from conflicts pose significant challenges to effective evidence-informed prioritization in health. Therefore, there is a call for more targeted investigations to implement effective and equitable health priority settings tailored to the unique contexts of conflict-affected countries.

In general, it can be learned that in the context of HSP, what is referred to as technical cooperation should strongly emphasize sustainability. Defining the HSP and its implementation, which involves changes in resource allocation methods and power dynamics, is indeed a political-economic issue. Merely addressing it as a strategic purchasing topic or conducting a comprehensive economic evaluation falls short. Attention must be paid to the readiness for change in countries, and thorough preparations for implementation are essential.

A strategic approach is necessary to foster linkage and exchange between policymakers and technical assistance providers. It includes seizing windows of opportunity for policy change. Additionally, capacity-building efforts should focus on strengthening leadership skills and avoiding conflicts of interest. Institutionalizing service prioritization and evidence-informed policymaking demands attention to various dimensions.

International organizations and academic institutions from high-income countries, if aiming to assist low and middle-income countries in the field of HSP, should prioritize institutional strengthening. Technical cooperation alone will not ensure sustainability unless it achieves the necessary institutionalization. Therefore, guidance and capacity-building initiatives are essential for successful institutionalization alongside the existing framework.

Data availability

The data that support the findings of this study are available from the corresponding author, [RM], upon reasonable request.

Abbreviations

Analytic Hierarchy Process Technique for Order of Preference by Similarity to Ideal Solution

Disease Control Priorities

General Health Policies

Health Service Package

Health Technology Assessment

Health Transformation Plan

Ministry of Health and Medical Education

Multiple Sclerosis

Non-Communicable Diseases

Primary Health Care

Supreme Council of Health Insurance

Standards for Reporting Qualitative Research

Universal Health Coverage

United Nations Children’s Fund

World Health Organization

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Acknowledgements

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This study was conducted with the financial support of Tehran University of Medical Sciences (grant number: 56639). We disclose that the study design and collection, analysis, data interpretation and manuscript writing were independent of the granting body.

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HSS: conceptualization, investigation, project administration, writing – original draft and review and editing. HS: data gathering, formal analysis, review and editing. AO: data gathering, formal analysis, review and editing. RM: conceptualization, supervision, analysis, interpretation, writing, review and editing. All authors have read and approved the final version of the manuscript.

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HS and AO have, at times, worked in the MOHME and have been members of the Secretariat for SCHI. The other authors declare that they have no competing interests.

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Sajadi, H.S., Safikhani, H., Olyaeemanesh, A. et al. Challenges in institutionalizing evidence-informed priority setting for health service packages: a qualitative document and interview analysis from Iran. Health Res Policy Sys 22 , 110 (2024). https://doi.org/10.1186/s12961-024-01207-6

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The impact of study habits and personal factors on the academic achievement performances of medical students

• Mohammed A. Aljaffer 1 ,
• Ahmad H. Almadani 1 ,
• Abdullah S. AlDughaither 2 ,
• Ali A. Basfar 2 ,
• Saad M. AlGhadir 2 ,
• Yahya A. AlGhamdi 2 ,
• Bassam N. AlHubaysh 2 ,
• Osamah A. AlMayouf 2 ,
• Saleh A. AlGhamdi 3 ,
• Tauseef Ahmad 4 &
• Hamza M. Abdulghani 5  

BMC Medical Education volume  24 , Article number:  888 ( 2024 ) Cite this article

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Academic achievement is essential for all students seeking a successful career. Studying habits and routines is crucial in achieving such an ultimate goal.

This study investigates the association between study habits, personal factors, and academic achievement, aiming to identify factors that distinguish academically successful medical students.

A cross-sectional study was conducted at the College of Medicine, King Saud University, Riyadh, Saudi Arabia. The participants consisted of 1st through 5th-year medical students, with a sample size of 336. The research team collected study data using an electronic questionnaire containing three sections: socio-demographic data, personal characteristics, and study habits.

The study results indicated a statistically significant association between self-fulfillment as a motivation toward studying and academic achievement ( p  = 0.04). The results also showed a statistically significant correlation between recalling recently memorized information and academic achievement ( p  = 0.05). Furthermore, a statistically significant association between preferring the information to be presented in a graphical form rather than a written one and academic achievement was also found ( p  = 0.03). Students who were satisfied with their academic performance had 1.6 times greater chances of having a high-grade point average (OR = 1.6, p  = 0.08).

The results of this study support the available literature, indicating a correlation between study habits and high academic performance. Further multicenter studies are warranted to differentiate between high-achieving students and their peers using qualitative, semi-structured interviews. Educating the students about healthy study habits and enhancing their learning skills would also be of value.

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Introduction

Academic performance is a common indicator used to measure student achievement [ 1 , 2 ]. It is a compound process influenced by many factors, among which is study habits [ 2 , 3 ]. Study habit is defined as different individual behavior in relation to studying, and is a combination of study methods and skills [ 2 , 3 , 4 ]. Put differently, study habits involve various techniques that would increase motivation and transform the study process into an effective one, thus enhancing learning [ 5 ]. Students’ perspectives and approaches toward studying were found to be the key factors in predicting their academic success [ 6 , 7 ]. However, these learning processes vary from one student to another due to variations in the students’ cognitive processing [ 8 ].

The study habits of students are the regular practices and habits they exhibit during the learning process [ 9 , 10 ]. Over time, several study habits have been developed, such as time management, setting appropriate goals, choosing a comfortable study environment, taking notes effectively, choosing main ideas, and being organized [ 11 ]. Global research shows that study habits impact academic performance and are the most important predictor of it [ 12 ]. It is difficult for medical students to organize and learn a lot of information, and they need to employ study skills to succeed [ 1 , 2 , 5 , 13 ].

Different lifestyle and social factors could affect students’ academic performance. For instance, Jafari et al. found that native students had better study habits compared to dormitory students [ 1 ]. This discrepancy between native and dormitory students was also indicated by Jouhari et al. who illustrated that dormitory students scored lower in attitude, test strategies, choosing main ideas, and concentration [ 10 ]. Regarding sleeping habits, Curcio G et al. found that students with a regular and adequate sleeping pattern had higher Grade Point Average (GPA) scores [ 14 ]. Lifestyle factors, such as watching television and listening to music, were shown to be unremarkable in affecting students’ grades [ 15 , 16 ]. Social media applications, including WhatsApp, Facebook, and Twitter, distract students during learning [ 16 , 17 ].

Motivation was found to be a major factor in students’ academic success. Bonsaksen et al. found that students who chose “to seek meaning” when studying were associated with high GPA scores [ 18 ]. In addition, low scores on “fear of failure” and high scores on “achieving” correlated with a higher GPA [ 8 , 18 ].

Resource-wise, Alzahrani et al. found that 82.7% of students relied on textbooks assigned by the department, while 46.6% mainly relied on the department’s lecture slides [ 19 ]. The study also indicated that 78.8% perceived that the scientific contents of the lectures were adequate [ 19 ]. Another study found that most students relied on the lecture slides (> 83%) along with their notes, followed by educational videos (76.1%), and reference textbooks (46.1%) [ 20 ]. Striking evidence in that study, as well as in another study, indicated that most students tended to avoid textbooks and opted for lecture slides, especially when preparing for exams [ 20 , 21 ].

Several researchers studied the association between different factors and academic performance; however, more is needed to know about this association in the process of education among medical students [ 15 , 20 , 22 ], with some limitations to the conducted studies. Such limitations include the study sample and using self-reported questionnaires, which may generate inaccurate results. Moreover, in Saudi Arabia in particular, the literature concerning the topic remains limited. Since many students are unsatisfied with their performance and seek improvement [ 10 ], the present study was designed and conducted.

Unlike other studies in the region, this study aims to investigate the relationship between study habits and personal factors and measure their influence on academic achievement. The results of this study could raise awareness regarding the effect of study habits and personal factors on students’ performance and would also guide them toward achieving academic success. The study also seeks to identify the factors that distinguish academically successful students from their peers.

Study design, setting, and participants

This observational cross-sectional study, which took place between June and December 2022, was conducted among students attending the College of Medicine at King Saud University (KSU), Riyadh, Saudi Arabia. Its targeted population included all male and female medical students (first to fifth years) attending KSU during the academic year 2021/2022. Whereas, students at other colleges and universities, those who failed to complete the questionnaire, interns (the students who already graduated), and those who were enrolled in the university’s preparatory year, were all excluded from the current study. The sample size was calculated based on a study conducted in 2015 by Lana Al Shawwa [ 15 ]. Using the sample size formula for a single proportion (0.79), the required sample size was 255 using a confidence interval of 95% and a margin of error of 5%. After adding a 20% margin to accommodate non-responses and incomplete responses, the calculated sample size required for this study was 306. However, our research team collected a total of 336 participants for this study to ensure complete representation.

Study instrument

The research team developed and used an electronic questionnaire. The rationale is that no standardized questionnaire measuring the study objectives was found in the literature. However, the questionnaire was tested on a pilot of 15 students to test its clarity and address any possible misconceptions and ambiguity. The study questionnaire was distributed randomly to this cohort, who were asked to fill out the questionnaire. The students reported a complete understanding of the questionnaire’s contents, so the same questionnaire was used without any modifications. The questionnaire, written in English, consisted of three parts. The first part included eleven questions about the socio-demographic status of the participants. The second part contained twenty-one questions examining personal factors such as sleep and caffeine consumption. The last part included twenty-one questions regarding students’ study habits. The questionnaire was constructed based on an ordinal Likert scale which had: strongly agree, agree, neutral, disagree, and strongly disagree as possible answers. The questionnaire was sent to participants through email and social media applications like Twitter and WhatsApp to increase the study response. An informed consent that clearly states the study’s purpose was taken from all participants at the beginning of the questionnaire. In addition, all participants were assured that the collected data would be anonymous and confidential. Each participant was represented by a code for the sole purpose of analyzing the data. Furthermore, no incentives or rewards were given to the participants for their participation.

Study variables

Socio-demographic information (such as age, gender, and academic year), and personal factors (such as motivation, sleeping status, caffeine consumption, and self-management) were the independent variables. Study habits such as attendance, individual versus group study, memorization techniques, revision, learning style, and strategies were also independent variables.

Academic achievement refers to a student’s success in gaining knowledge and understanding in various subjects, as well as the ability to apply that knowledge effectively [ 23 ]. It is a measure of the student’s progress throughout the educational journey, encompassing both academic achievements and personal growth [ 3 , 24 ]. Academic achievement is judged based on the student’s GPA or performance score. In this study, students’ GPA scores, awareness, and satisfaction regarding their academic performance were the dependent variables.

We divided the study sample into two groups based on the GPA. We considered students with high GPAs to be exposed (i.e. exposed to the study habits we are investigating), and students with low GPAs to be the control group. The purpose of this study was to determine why an exposed group of students gets high grades and what study factors they adopt. Based on this exposure (high achieving students), we concluded what methods they used to achieve higher grades. Those in the first group had a GPA greater or equal to 4.5 (out of 5), while those in the second group had a GPA less than 4.5. The students’ data were kept confidential and never used for any other purpose.

Data analysis

The data collected were analyzed by using IBM SPSS Statistical software for Windows version 24.0. Descriptive statistics such as frequency and percentage were used to describe the socio-demographic data in a tabular form. Furthermore, data for categorical variables, including different study habits, motivation factors, memorizing and revising factors, and lifestyle factors, were tabulated and analyzed using the odds ratio test. Finally, we calculated the odds ratio statistic and a p-value of 0.05 to report the statistical significance of our results.

Ethical approval and consent to Participate

Before conducting the study, the research team obtained the Ethics Committee Approval from the Institutional Review Board of the College of Medicine, KSU, Riyadh, Saudi Arabia (project No. E-22-7044). Participants’ agreement/consent to participate was guaranteed by choosing “agree” after reading the consent form at the beginning of the questionnaire. Participation was voluntary, and consent was obtained from all participants. The research team carried out all methods following relevant guidelines and regulations.

The total 336 medical students participated in the study. All participants completed the study questionnaire, and there were no missing or incomplete data, with all of them being able to participate. As shown in Table  1 9.3% of participants were between 18 and 20, 44.9% were between the ages of 21 and 22, and 35.8% were 23–28 years old. In the current study, 62.5% of the participants were males and 37.5% were females. The proportion of first-year students was 21.4%, 20.8% of second-year students, 20.8% of third-year students, 18.2% of fourth-year students, and 18.8% of fifth-year students, according to academic year levels. Regarding GPA scores, 36.9% scored 4.75-5 and 32.4% scored 4.5–4.74. 23.8% achieved 4-4.49, 6.5% achieved 3-3.99, and only 0.4% achieved 2.99 or less. Participants lived with their families in 94.6% of cases, with friends in 1.2% of cases, and alone in 4.2% of cases. For smoking habits, 86.3% did not smoke, 11% reported using vapes, 2.1% used cigarettes, and 0.6% used Shisha. 91.4% of the participants did not report any chronic illnesses; however, 8.6% did. In addition, 83% had no mental illness, 8.9% had anxiety, 6% had depression, and 2.1% reported other mental illnesses.

Table  2 shows motivational factors associated with academic performance. There was a clear difference in motivation factors between students with high and low achievement in the current study. Students with high GPAs were 1.67 times more motivated toward their careers (OR = 1.67, p  = 0.09) than those with low GPAs. Furthermore, significant differences were found between those students who had self-fulfillment or ambitions in life they had ~ 2 times higher (OR = 1.93, p  = 0.04) GPA scores than low GPA students. Exam results did not motivate exposed or high GPA students (46%) or control students with low GPA students (41%), but the current study showed test results had little impact on low achiever students (OR = 1.03, p  = 0.88). Furthermore, 72.6% of high achievers were satisfied with their academic performance, while only 41% of low achiever students were satisfied. Therefore, students who were satisfied with their academic performance had 1.6 times greater chances of a higher GPA (OR = 1.6, p  = 0.08). Students who get support and help from those around them are more likely to get high GPAs (OR = 1.1, p  = 0.73) than those who do not receive any support. When students reported feeling a sense of family responsibility, the odds (odds ratio) of their receiving higher grades were 1.15 times higher (OR = 1.15, p  = 0.6) compared to those who did not feel a sense of family responsibility. The p-value, which indicates the level of statistical significance, was 0.6.

Table  3 shows the study habits of higher achiever students and low achiever students. Most of the high-achieving students (79.0%) attended most of the lectures and had 1.6 times higher chances of getting higher grades (OR = 1.6, p  = 0.2) than those who did not attend regular lectures. The current study found that studying alone had no significant impact on academic achievement in either group. However, those students who had studied alone had lower GPAs (OR = 1.07, p  = 0.81). The current study findings reported 29.8% of students walk or stand while studying rather than sit, and they had 1.57 times higher GPA chances compared to students with lower GPAs (OR = 0.73, p  = 0.27). High achievers (54.0%) preferred studying early in the morning, and these students had higher chances of achieving good GPAs (OR = 1.3, p  = 0.28) than low achiever groups of students. The number of students with high achievement (39.5%) went through the lecture before the lesson was taught. These students had 1.08 times higher chances of achieving than low achiever groups of students. Furthermore, students who made a weekly study schedule had 1.3 times higher chances of being good academic achievers than those who did not (OR = 1.3, p  = 0.37). Additionally, high-achieving students paid closer attention to the lecturer (1.2 times higher). In addition, students with high GPAs spent more time studying when exam dates approached (OR = 1.3, p  = 0.58).

Table  4 demonstrates the relationship between memorizing and revising with high and low GPA students. It was found that high achiever students (58.9%) studied lectures daily and had 1.4 times higher chances of achieving high grades (OR = 1.4, p  = 0.16) than the other group. It was found that most of the high achievers (62.1%) skim the lecture beforehand before memorizing it, which led to 1.8 times higher chances of getting good grades in this exam (OR = 1.8, p  = 0.06). One regular activity reported by high GPA students (82.3%) was recalling what had just been memorized. For this recalling technique, we found a significant difference between low-achieving students (OR = 0.8, p  = 0.63) and high-achieving students (OR = 1.83, p  = 0.05). A high achiever student writes notes before speaking out for the memorizing method, which gives 1.2 times greater chances of getting high grades (OR = 1.2, p  = 0.55) than a student who does not write notes. A major difference in the current study was that high GPA achievers (70.2%) revise lectures more frequently than low GPA achievers (57.1%). They had 1.5 times more chances of getting high grades if they practiced and revised this method (OR = 1.5, p  = 0.13).

Table  5 illustrates the relationship between negative lifestyle factors and students’ academic performance. The current study found that students are less likely to get high exam grades when they smoke. Students who smoke cigarettes and those who vape are 1.14 and 1.07 times respectively more likely to have a decrease in GPA than those who do not smoke. Those students with chronic illnesses had 1.22 times higher chances of a downgrade in the exam (OR = 1.22, p  = 0.49). Additionally, students with high GPAs had higher mental pressures (Anxiety = 1.2, Depression = 1.18, and other mental pressures = 1.57) than those with low GPAs.

Learning is a multifaceted process that evolves throughout our lifetimes. The leading indicator that sets students apart is their academic achievement. Hence, it is crucial to investigate the factors that influence it. The present study examined the relationship between different study habits, personal characteristics, and academic achievement among medical students. In medical education, and more so in Saudi Arabia, there needs to be more understanding regarding such vital aspects.

Regarding motivational factors, the present study found some differences between high and low achievers. Students with high GPA scores were more motivated toward their future careers (OR = 1.67, p  = 0.09). The study also indicated that students who had ambitions and sought self-fulfillment were more likely to have high GPA scores, which were statistically significant (OR = 1.93, p  = 0.04). This was consistent with Bin Abdulrahman et al. [ 20 ], who indicated that the highest motivation was self-fulfillment and satisfying family dreams, followed by a high educational level, aspirations to join a high-quality residency program, and high income. Their study also found that few students were motivated by the desire to be regarded as unique students. We hypothesize that this probably goes back to human nature, where a highly rewarding incentive becomes the driving force of our work. Hence, schools should utilize this finding in exploring ways to enhance students’ motivation toward learning.

The present study did not find a significant effect of previous exam results on academic performance (OR = 1.03, p  = 0.88). However, some studies reported that more than half of the high-achieving students admitted that high scores acquired on previous assessments are an important motivational factor [ 15 , 25 , 26 ]. We hypothesize that as students score higher marks, they become pleased and feel confident with their study approach. This finding shows how positive measurable results influence the students’ mentality.

The present study also explored the social environment surrounding medical students. The results indicated that those who were supported by their friends or family were slightly more likely to score higher GPAs (OR = 1.1, p  = 0.73); however, the results did not reach a statistical significance. We hypothesize that a supportive and understanding environment would push the students to be patient and look for a brighter future. Our study results were consistent with previous published studies, which showed an association [ 3 , 27 , 28 , 29 , 30 ]. We hypothesize that students who spend most of their time with their families had less time to study, which made their study time more valuable. The findings of this study will hopefully raise awareness concerning the precious time that students have each day.

The association of different study habits among medical students with high and low GPAs was also studied in our study. It was noted that the high-achieving students try to attend their lectures compared to the lower achievers. This was in line with the previous published studies, which showed that significant differences were observed between the two groups regarding the attendance of lectures, tutorials, practical sessions, and clinical teachings [ 31 , 32 ]. The present study found that most students prefer to study alone, regardless of their level of academic achievement (82.1%). This finding is consistent with the study by Khalid A Bin Abdulrahman et al., which also showed that most students, regardless of their GPA, favored studying alone [ 20 ].

The present study findings suggest that a small number of students (29.8%) prefer to walk or stand while studying rather than sit, with most being high achievers (OR = 1.57, P  = 0.15). A study reported that 40.3% of students with high GPAs seemed to favor a certain posture or body position, such as sitting or lying on the floor [ 15 ]. These contradictory findings might indicate that which position to adopt while studying should come down to personal preference and what feels most comfortable to each student. The present study also found that high achievers are more likely to prefer studying early in the morning (OR = 1.3, P  = 0.28). The authors did not find similar studies investigating this same association in the literature. However, mornings might allow for more focused studying with fewer distractions, which has been shown to be associated with higher achievement in medical students [ 3 , 15 , 33 ].

Our study also found that 39.5% of the academically successful students reviewed pre-work or went through the material before they were taught it (OR = 1.08, p  = 0.75), and 25% were neutral. Similar findings were reported in other studies, showing that academically successful students prepared themselves by doing their pre-work, watching videos, and revising slides [ 3 , 9 , 34 ]. Our study showed that 75% of high-achieving students tend to listen attentively to the lecturer (OR = 1.2, p  = 0.48). Al Shawa et al. found no significant differences between the high achievers and low achievers when talking about attending lectures [ 15 ]. This could be due to the quality of teachers and the environment of the college or university.

Regarding the relationship between memorizing and revising with high and low GPA students, the present study found that students who study lectures daily are more likely to score higher than those who do not (OR = 1.4, p  = 0.16). This finding is consistent with other studies [ 3 , 19 , 35 ]. For skimming lectures beforehand, an appreciable agreement was noted by high GPA students (62.1%), while only (42%) of low GPA students agreed to it. Similarly, previous published studies also found that highlighting and reading the content before memorization were both common among high-achieving students [ 15 , 36 ]. Furthermore, the present study has found recalling what has just been memorized to be statistically significantly associated with high GPA students (OR = 1.83, p  = 0.05). Interestingly, we could not find any study that investigated this as an important factor, which could be justified by the high specificity of this question. Besides, when it comes to writing down/speaking out what has just been memorized, our study has found no recognizable differences between high-achieving students (75%) and low-achieving students (69%), as both categories had remarkably high percentages of reading and writing while studying.

The present study has found no statistical significance between regularly revising the lectures and high GPA ( p  > 0.05), unlike the study conducted by Deborah A. Sleight et al. [ 37 ]. The difference in findings between our study and Deborah A. Sleight et al. might be due to a limitation of our study, namely the similar backgrounds of our participants. Another explanation could be related to curricular differences between the institutions where the two studies were conducted. Moreover, a statistically significant correlation between not preferring the data being presented in a written form instead of a graphical form and high GPA scores have been found in their study ( p  < 0.05). However, a study conducted by Deborah A. Sleight et al. indicated that 66% of high achievers used notes prepared by other classmates compared to 84% of low achievers. Moreover, their study showed that only 59% of high achievers used tables and graphs prepared by others compared to 92% of low achievers. About 63% and 61% of the students in their study reported using self-made study aids for revision and memory aids, respectively [ 37 ].

The present study also examined the effects of smoking and chronic and mental illness, but found no statistical significance; the majority of both groups responded by denying these factors’ presence in their life. A similar finding by Al Shawwa et al. showed no statistical significance of smoking and caffeine consumption between low GPA and high GPA students [ 15 ]. We hypothesize that our findings occurred due to the study’s broad approach to examining such factors rather than delving deeper into them.

High-achieving students’ habits and factors contributing to their academic achievement were explored in the present study. High-achieving students were found to be more motivated and socially supported than their peers. Moreover, students who attended lectures, concentrated during lectures, studied early in the morning, prepared their weekly schedule, and studied more when exams approached were more likely to have high GPA scores. Studying techniques, including skimming before memorizing, writing what was memorized, active recall, and consistent revision, were adopted by high-achievers. To gain deeper insight into students’ strategies, it is recommended that qualitative semi-structured interviews be conducted to understand what distinguishes high-achieving students from their peers. Future studies should also explore differences between public and private university students. Additionally, further research is needed to confirm this study’s findings and provide guidance to all students. Future studies should collect a larger sample size from a variety of universities in order to increase generalizability.

Limitations and recommendations

The present study has some limitations. All the study’s findings indicated possible associations rather than causation; hence, the reader should approach the results of this study with caution. We recommend in-depth longitudinal studies to provide more insight into the different study habits and their impact on academic performance. Another limitation is that the research team created a self-reported questionnaire to address the study objectives, which carries a potential risk of bias. Hence, we recommend conducting interviews and having personal encounters with the study’s participants to reduce the risk of bias and better understand how different factors affect their academic achievement. A third limitation is that the research team only used the GPA scores as indicators of academic achievement. We recommend conducting other studies and investigating factors that cannot be solely reflected by the GPA, such as the student’s clinical performance and skills. Lastly, all participants included in the study share one background and live in the same environment. Therefore, the study’s findings do not necessarily apply to students who do not belong to such a geographic area and point in time. We recommend that future studies consider the sociodemographic and socioeconomic variations that exist among the universities in Saudi Arabia.

Availability of data materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Grade Point Average

King Saud University

Institutional review board

Statistical package for the social sciences

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Aljaffer, M.A., Almadani, A.H., AlDughaither, A.S. et al. The impact of study habits and personal factors on the academic achievement performances of medical students. BMC Med Educ 24 , 888 (2024). https://doi.org/10.1186/s12909-024-05889-y

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