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• What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

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

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

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

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

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

Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

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

• Flexibility

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

• Natural settings

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

• Meaningful insights

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

• Generation of new ideas

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

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

• Unreliability

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

• Subjectivity

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

• Limited generalizability

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

• Labor-intensive

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

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

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

Research bias

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

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

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

There are five common approaches to qualitative research :

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

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

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

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

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

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Qualitative Research : Definition

Qualitative research is the naturalistic study of social meanings and processes, using interviews, observations, and the analysis of texts and images.  In contrast to quantitative researchers, whose statistical methods enable broad generalizations about populations (for example, comparisons of the percentages of U.S. demographic groups who vote in particular ways), qualitative researchers use in-depth studies of the social world to analyze how and why groups think and act in particular ways (for instance, case studies of the experiences that shape political views).   

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• Introduction to NVivo Have you just collected your data and wondered what to do next? Come join us for an introductory session on utilizing NVivo to support your analytical process. This session will only cover features of the software and how to import your records. Please feel free to attend any of the following sessions below: April 25th, 2024 12:30 pm - 1:45 pm Green Library - SVA Conference Room 125 May 9th, 2024 12:30 pm - 1:45 pm Green Library - SVA Conference Room 125
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The Oxford Handbook of Qualitative Research (2nd edn)

Patricia Leavy Independent Scholar Kennebunk, ME, USA

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The Oxford Handbook of Qualitative Research, second edition, presents a comprehensive retrospective and prospective review of the field of qualitative research. Original, accessible chapters written by interdisciplinary leaders in the field make this a critical reference work. Filled with robust examples from real-world research; ample discussion of the historical, theoretical, and methodological foundations of the field; and coverage of key issues including data collection, interpretation, representation, assessment, and teaching, this handbook aims to be a valuable text for students, professors, and researchers. This newly revised and expanded edition features up-to-date examples and topics, including seven new chapters on duoethnography, team research, writing ethnographically, creative approaches to writing, writing for performance, writing for the public, and teaching qualitative research.

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• UConn Library
• Scientific Research and Communication
• Qualitative Research: What is it?

Scientific Research and Communication — Qualitative Research: What is it?

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• The Scientific Method
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• Quantitative Research: What Is It?
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What is qualitative research?

"Qualitative research is a type of research that explores and provides deeper insights into real-world problems. [1]  Instead of collecting numerical data points or intervene or introduce treatments just like in quantitative research, qualitative research helps generate hypotheses as well as further investigate and understand quantitative data."

"Qualitative research at its core, ask open-ended questions whose answers are not easily put into numbers such as ‘how’ and ‘why’. [2]  Due to the open-ended nature of the research questions at hand, qualitative research design is often not linear in the same way quantitative design is. [2]  One of the strengths of qualitative research is its ability to explain processes and patterns of human behavior that can be difficult to quantify. [3]  Phenomena such as experiences, attitudes, and behaviors can be difficult to accurately capture quantitatively, whereas a qualitative approach allows participants themselves to explain how, why, or what they were thinking, feeling, and experiencing at a certain time or during an event of interest."

• Qualitative Study - Steven Tenny; Grace D. Brannan; Janelle M. Brannan; Nancy C. Sharts-Hopko. This article details what qualitative research is, and some of the methodologies used.

Examples of Qualitative Research

• Quantitative vs Qualitative Chart Chart showing examples of quantitative vs. qualitative research.

EBooks on Qualitative Research Methodology

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Research methods--quantitative, qualitative, and more: qualitative research.

• Quantitative Research
• Qualitative Research
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• Get Data, Get Help!

About Qualitative Data

Qualitative data are data representing information and concepts that are not represented by numbers. They are often gathered from interviews and focus groups, personal diaries and lab notebooks, maps, photographs, and other printed materials or observations. Qualitative data are distinguished from  quantitative data , which focus primarily on data that can be represented with numbers. 

Qualitative data can be analyzed in multiple ways. One common method is data coding, which refers to the process of transforming the raw collected data into a set of meaningful categories that describe essential concepts of the data. Qualitative data and methods may be used more frequently in humanities or social science research and may be collected in descriptive studies.

(From the Data Glossary , National Center for Data Services, National Library of Medicine)

Methods Texts

Below are some methods texts recommended by qualitative workshop leaders from the UC Berkeley Library and the D-Lab: 

Workshops and Training

• Managing qualitative data 101 Tips on managing qualitative materials from your qualitative research librarian.
• D-Lab workshops Free online workshops on quant and qualitative skills, including coding and using qualitative analysis software.
• Institute for the Study of Societal Issues (ISSI) Training Ethnographic methods workshop from a campus institute.
• Qualitative Methods classes Filter to upcoming semesters and look for qualitative methods classes; the Graduate School of Education and School of Public Health offer extensive methods training.

Qualitative Data Analysis Software

Unfortunately, Berkeley does not yet have a sitewide license for any qualitative analysis software.

If you are a student, you can find affordable student licenses with a web search.

If you are a faculty member, instructor, lecturer, or visiting scholar without grant funding, unfortunately software is quite expensive.

You can find reviews of many qualitative software packages at this University of Surrey link:

• Choosing an Appropriate CAQDAS package .

You can also check out the websites of several major options below: 

• Taguette Taguette has fewer features than other qualitative analysis software, but is free and open-source.
• Atlas.ti Atlas.ti is a major qualitative analysis software, and has affordable licenses for students.
• MaxQDA MaxQDA is a major qualitative analysis software, with affordable student licenses. The D-Lab often teaches workshops on this software.
• NVIVO NVIVO is an established QDA software, with affordable student licenses.
• Dedoose Dedoose supports qualitaive and mixed methods research, using an online interface. Students pay $11 per month.

Resources for Qualitative Data Management

• Managing and Sharing Qualitative Data 101 This page from Berkeley's research data management website offers several things to consider.
• Tutorials on Ethnographic Data Management This curricula includes eight presentations and accompanying exercises for you to think through your qualitative data project--or coach others to do the same.
• Support Your Data: Evaluation Rubric Download the evaluation rubric on this page to assess where you are with qualitative data management, and consider areas to explore next.
• The Qualitative Data Repository (QDR) QDR is one of the top US-based repositories focused on the challenges of managing, storing, and sharing qualitative research materials.
• Research Data @ Berkeley Email Research Data for a consultation about how to set up your qualitative data management plan; they can help you locate other resources on campus.

Mixed Methods Research

Interpretations related to mixed (sometimes called merged) methods vary; be wary of jargon!  Gery Ryan, of the Kaiser Permanente School of Medicine, gives these definitions, while arguing that we should be thinking of the purposes of the research rather than the methodological labels:

Mixed methods research : “Combines elements of qualitative and quantitative research approaches (e. g., use of qualitative and quantitative viewpoints, data collection, analysis, inference techniques) for the broad purposes of breadth and depth of understanding and corroboration.”

Multimethod research : “Either solely combine multiple qualitative approaches or solely combine multiple quantitative approaches.”

Data triangulation : “Uses multiple sources of data or multiple approaches to analyzing data to enhance the credibility of a research study.”

(From " Mixed Methods Research Designs and Data Triangulation " by Gery Ryan, Kaiser Permanente School of Medicine)

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An Overview of Qualitative Research Methods

Direct Observation, Interviews, Participation, Immersion, Focus Groups

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Qualitative research is a type of social science research that collects and works with non-numerical data and that seeks to interpret meaning from these data that help understand social life through the study of targeted populations or places.

People often frame it in opposition to quantitative research , which uses numerical data to identify large-scale trends and employs statistical operations to determine causal and correlative relationships between variables.

Within sociology, qualitative research is typically focused on the micro-level of social interaction that composes everyday life, whereas quantitative research typically focuses on macro-level trends and phenomena.

Key Takeaways

Methods of qualitative research include:

• observation and immersion
• open-ended surveys
• focus groups
• content analysis of visual and textual materials
• oral history

Qualitative research has a long history in sociology and has been used within it for as long as the field has existed.

This type of research has long appealed to social scientists because it allows the researchers to investigate the meanings people attribute to their behavior, actions, and interactions with others.

While quantitative research is useful for identifying relationships between variables, like, for example, the connection between poverty and racial hate, it is qualitative research that can illuminate why this connection exists by going directly to the source—the people themselves.

Qualitative research is designed to reveal the meaning that informs the action or outcomes that are typically measured by quantitative research. So qualitative researchers investigate meanings, interpretations, symbols, and the processes and relations of social life.

What this type of research produces is descriptive data that the researcher must then interpret using rigorous and systematic methods of transcribing, coding, and analysis of trends and themes.

Because its focus is everyday life and people's experiences, qualitative research lends itself well to creating new theories using the inductive method , which can then be tested with further research.

Qualitative researchers use their own eyes, ears, and intelligence to collect in-depth perceptions and descriptions of targeted populations, places, and events.

Their findings are collected through a variety of methods, and often a researcher will use at least two or several of the following while conducting a qualitative study:

• Direct observation : With direct observation, a researcher studies people as they go about their daily lives without participating or interfering. This type of research is often unknown to those under study, and as such, must be conducted in public settings where people do not have a reasonable expectation of privacy. For example, a researcher might observe the ways in which strangers interact in public as they gather to watch a street performer.
• Open-ended surveys : While many surveys are designed to generate quantitative data, many are also designed with open-ended questions that allow for the generation and analysis of qualitative data. For example, a survey might be used to investigate not just which political candidates voters chose, but why they chose them, in their own words.
• Focus group : In a focus group, a researcher engages a small group of participants in a conversation designed to generate data relevant to the research question. Focus groups can contain anywhere from 5 to 15 participants. Social scientists often use them in studies that examine an event or trend that occurs within a specific community. They are common in market research, too.
• In-depth interviews : Researchers conduct in-depth interviews by speaking with participants in a one-on-one setting. Sometimes a researcher approaches the interview with a predetermined list of questions or topics for discussion but allows the conversation to evolve based on how the participant responds. Other times, the researcher has identified certain topics of interest but does not have a formal guide for the conversation, but allows the participant to guide it.
• Oral history : The oral history method is used to create a historical account of an event, group, or community, and typically involves a series of in-depth interviews conducted with one or multiple participants over an extended period.
• Participant observation : This method is similar to observation, however with this one, the researcher also participates in the action or events to not only observe others but to gain the first-hand experience in the setting.
• Ethnographic observation : Ethnographic observation is the most intensive and in-depth observational method. Originating in anthropology, with this method, a researcher fully immerses themselves into the research setting and lives among the participants as one of them for anywhere from months to years. By doing this, the researcher attempts to experience day-to-day existence from the viewpoints of those studied to develop in-depth and long-term accounts of the community, events, or trends under observation.
• Content analysis : This method is used by sociologists to analyze social life by interpreting words and images from documents, film, art, music, and other cultural products and media. The researchers look at how the words and images are used, and the context in which they are used to draw inferences about the underlying culture. Content analysis of digital material, especially that generated by social media users, has become a popular technique within the social sciences.

While much of the data generated by qualitative research is coded and analyzed using just the researcher's eyes and brain, the use of computer software to do these processes is increasingly popular within the social sciences.

Such software analysis works well when the data is too large for humans to handle, though the lack of a human interpreter is a common criticism of the use of computer software.

Pros and Cons

Qualitative research has both benefits and drawbacks.

On the plus side, it creates an in-depth understanding of the attitudes, behaviors, interactions, events, and social processes that comprise everyday life. In doing so, it helps social scientists understand how everyday life is influenced by society-wide things like social structure , social order , and all kinds of social forces.

This set of methods also has the benefit of being flexible and easily adaptable to changes in the research environment and can be conducted with minimal cost in many cases.

Among the downsides of qualitative research is that its scope is fairly limited so its findings are not always widely able to be generalized.

Researchers also have to use caution with these methods to ensure that they do not influence the data in ways that significantly change it and that they do not bring undue personal bias to their interpretation of the findings.

Fortunately, qualitative researchers receive rigorous training designed to eliminate or reduce these types of research bias.

• How to Conduct a Sociology Research Interview
• What Is Participant Observation Research?
• Immersion Definition: Cultural, Language, and Virtual
• Definition and Overview of Grounded Theory
• The Differences Between Indexes and Scales
• Pros and Cons of Secondary Data Analysis
• Social Surveys: Questionnaires, Interviews, and Telephone Polls
• The Different Types of Sampling Designs in Sociology
• Principal Components and Factor Analysis
• Sociology Explains Why Some People Cheat on Their Spouses
• Deductive Versus Inductive Reasoning
• Data Sources For Sociological Research
• How to Construct an Index for Research
• A Review of Software Tools for Quantitative Data Analysis
• Constructing a Deductive Theory
• Scales Used in Social Science Research

Identifying Qualitative and Quantitative Research Characteristics

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What is Qualitative in Qualitative Research

Patrik aspers.

1 Department of Sociology, Uppsala University, Uppsala, Sweden

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

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

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

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

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

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

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

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

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

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

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

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

Towards a Definition of Qualitative Research

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Analysis – What is Qualitative Research?

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

Qualitative and Quantitative

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

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

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

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

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

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

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

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

Qualitative Research

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

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

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

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

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

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

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

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

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

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

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

Grounded Theory

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

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

Defining Qualitative Research

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

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

Distinctions

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

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

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

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

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

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

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

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

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

Improved Understanding

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

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

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

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

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

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

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

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

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

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

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

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

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

Acknowledgements

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

Biographies

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

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

Publisher’s Note

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Contributor Information

Patrik Aspers, Email: [email protected] .

Ugo Corte, Email: [email protected] .

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• Open access
• Published: 28 August 2024

A qualitative study identifying implementation strategies using the i-PARIHS framework to increase access to pre-exposure prophylaxis at federally qualified health centers in Mississippi

• Trisha Arnold   ORCID: orcid.org/0000-0003-3556-5717 1 , 2 ,
• Laura Whiteley 2 ,
• Kayla K. Giorlando 1 ,
• Andrew P. Barnett 1 , 2 ,
• Ariana M. Albanese 2 ,
• Avery Leigland 1 ,
• Courtney Sims-Gomillia 3 ,
• A. Rani Elwy 2 , 5 ,
• Precious Patrick Edet 3 ,
• Demetra M. Lewis 4 ,
• James B. Brock 4 &
• Larry K. Brown 1 , 2  

Implementation Science Communications volume  5 , Article number:  92 ( 2024 ) Cite this article

Metrics details

Mississippi (MS) experiences disproportionally high rates of new HIV infections and limited availability of pre-exposure prophylaxis (PrEP). Federally Qualified Health Centers (FQHCs) are poised to increase access to PrEP. However, little is known about the implementation strategies needed to successfully integrate PrEP services into FQHCs in MS.

The study had two objectives: identify barriers and facilitators to PrEP use and to develop tailored implementation strategies for FQHCs.

Semi-structured interviews were conducted with 19 staff and 17 PrEP-eligible patients in MS FQHCs between April 2021 and March 2022. The interview was guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework which covered PrEP facilitators and barriers. Interviews were coded according to the i-PARIHS domains of context, innovation, and recipients, followed by thematic analysis of these codes. Identified implementation strategies were presented to 9 FQHC staff for feedback.

Data suggested that PrEP use at FQHCs is influenced by patient and clinic staff knowledge with higher levels of knowledge reflecting more PrEP use. Perceived side effects are the most significant barrier to PrEP use for patients, but participants also identified several other barriers including low HIV risk perception and untrained providers. Despite these barriers, patients also expressed a strong motivation to protect themselves, their partners, and their communities from HIV. Implementation strategies included education and provider training which were perceived as acceptable and appropriate.

Conclusions

Though patients are motivated to increase protection against HIV, multiple barriers threaten uptake of PrEP within FQHCs in MS. Educating patients and providers, as well as training providers, are promising implementation strategies to overcome these barriers.

Peer Review reports

Contributions to the literature

We propose utilizing Federally Qualified Health Centers (FQHCs) to increase pre-exposure prophylaxis (PrEP) use among people living in Mississippi.

Little is currently known about how to distribute PrEP at FQHCs.

We comprehensively describe the barriers and facilitators to implementing PrEP at FQHCs.

Utilizing effective implementation strategies of PrEP, such as education and provider training at FQHCs, may increase PrEP use and decrease new HIV infections.

Introduction

The HIV outbreak in Mississippi (MS) is among the most critical in the United States (U.S.). It is distinguished by significant inequalities, a considerable prevalence of HIV in remote areas, and low levels of HIV medical care participation and virologic suppression [ 1 ]. MS has consistently ranked among the states with the highest HIV rates in the U.S. This includes being the 6th highest in new HIV diagnoses [ 2 ] and 2nd highest in HIV diagnoses among men who have sex with men (MSM) compared to other states [ 2 , 3 , 4 ]. Throughout MS, the HIV epidemic disproportionately affects racial and ethnic minority groups, particularly among Black individuals. A spatial epidemiology and statistical modeling study completed in MS identified HIV hot spots in the MS Delta region, Southern MS, and in greater Jackson, including surrounding rural counties [ 5 ]. Black race and urban location were positively associated with HIV clusters. This disparity is often driven by the complex interplay of social, economic, and structural factors, including poverty, limited access to healthcare, and stigma [ 5 ].

Pre-exposure prophylaxis (PrEP) has gained significant recognition due to its safety and effectiveness in preventing HIV transmission when taken as prescribed [ 6 , 7 , 8 , 9 ]. However, despite the progression in PrEP and its accessibility, its uptake has been slow among individuals at high risk of contracting HIV, particularly in Southern states such as MS [ 10 , 11 , 12 , 13 , 14 ]. According to the CDC [ 5 ], “4,530 Mississippians at high risk for HIV could potentially benefit from PrEP, but only 927 were prescribed PrEP.” Several barriers hinder PrEP use in MS including limited access to healthcare, cost, stigma, and medical mistrust [ 15 , 16 , 17 ].

Federally qualified health centers (FQHCs) are primary healthcare organizations that are community-based and patient-directed, serve geographically and demographically diverse patients with limited access to medical care, and provide care regardless of a patient’s ability to pay [ 18 ]. FQHCs in these areas exhibit reluctance in prescribing or counseling patients regarding PrEP, primarily because they lack the required training and expertise [ 19 , 20 , 21 ]. Physicians in academic medical centers are more likely to prescribe PrEP compared to those in community settings [ 22 ]. Furthermore, providers at FQHCs may exhibit less familiarity with conducting HIV risk assessments, express concerns regarding potential side effects of PrEP, and have mixed feelings about prescribing it [ 23 , 24 ]. Task shifting might also be needed as some FQHCs may lack sufficient physician support to manage all aspects of PrEP care. Tailored strategies and approaches are necessary for FQHCs to effectively navigate the many challenges that threaten their patients’ access to and utilization of PrEP.

The main objectives of this study were to identify the barriers and facilitators to PrEP use and to develop tailored implementation strategies for FQHCs providing PrEP. To service these objectives, this study had three specific aims. Aim 1 involved conducting a qualitative formative evaluation guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework- with FQHC staff and PrEP-eligible patients across three FQHCs in MS [ 25 ]. Interviews covered each of the three i-PARIHS domains: context, innovation, and recipients. These interviews sought to identify barriers and facilitators to implementing PrEP. Aim 2 involved using interview data to select and tailor implementation strategies from the Expert Recommendations for Implementing Change (ERIC) project [ 26 ] (e.g., provider training) and methods (e.g., telemedicine, PrEP navigators) for the FQHCs. Aim 3 was to member-check the selected implementation strategies and further refine these if necessary. Data from all three aims are presented below. The standards for reporting qualitative research (SRQR) checklist was used to improve the transparency of reporting this qualitative study [ 27 ].

Formative evaluation interviews

Interviews were conducted with 19 staff and 17 PrEP-eligible patients from three FQHCs in Jackson, Canton, and Clarksdale, Mississippi. Staff were eligible to participate if they were English-speaking and employed by their organization for at least a year. Eligibility criteria for patients included: 1) English speaking, 2) aged 18 years or older, 3) a present or prior patient at the FQHC, 4) HIV negative, and 5) currently taking PrEP or reported any one of the following factors that may indicate an increased risk for HIV: in the past year, having unprotected sex with more than one person with unknown (or positive) HIV status, testing positive for a sexually transmitted infection (STI) (syphilis, gonorrhea, or chlamydia), or using injection drugs.

Data collection

The institutional review boards of the affiliated hospitals approved this study prior to data collection. An employee at each FQHC acted as a study contact and assisted with recruitment. The contacts advertised the study through word-of-mouth to coworkers and relayed the contact information of those interested to research staff. Patients were informed about the study from FQHC employees and flyers while visiting the FQHC for HIV testing. Those interested filled out consent-to-contact forms, which were securely and electronically sent to research staff. Potential participants were then contacted by a research assistant, screened for eligibility, electronically consented via DocuSign (a HIPAA-compliant signature capturing program), then scheduled for an interview. Interviews occurred remotely over Zoom, a HIPAA-compliant, video conferencing platform. Interviews were conducted until data saturation was reached. In addition to the interview, all participants were asked to complete a short demographics survey via REDCap, a HIPAA-compliant, online, data collection tool. Each participant received a $100 gift card for their time.

The i-PARIHS framework guided interview content and was used to create a semi-structured interview guide [ 28 ]. Within the i-PARIHS framework’s elements, the interview guide content included facilitators and barriers to PrEP use at the FQHC: 1) the innovation, (PrEP), such as its degree of fit with existing practices and values at FQHCs; 2) the recipients (individuals presenting to FQHCs), such as their PrEP awareness, barriers to receiving PrEP such as motivation, resources, support, and personal PrEP experiences; and 3) the context of the setting (FQHCs), such as clinic staff PrEP awareness, barriers providing PrEP services, and recommendations regarding PrEP care. Interviews specifically asked about the use of telemedicine, various methods for expanding PrEP knowledge for both patients and providers (e.g., social media, advertisements, community events/seminars), and location of services (e.g., mobile clinics, gyms, annual health checkups, health fairs). Staff and patients were asked the same interview questions. Data were reviewed and analyzed iteratively throughout data collection, and interview guides were adapted as needed.

Data analysis

Interviews were all audio-recorded, then transcribed by an outside, HIPAA-certified transcription company. Transcriptions were reviewed for accuracy by the research staff who conducted the interviews.

Seven members of the research team (TA, LW, KKG, AB, CSG, AL, LKB) independently coded the transcripts using an a priori coding schedule that was developed using the i-PARIHS and previous studies [ 15 , 16 , 17 ]. All research team members were trained in qualitative methods prior to beginning the coding process. The coding scheme covered: patient PrEP awareness, clinic staff PrEP awareness, barriers to receiving PrEP services, barriers to providing PrEP services, and motivation to take PrEP. Each coder read each line of text and identified if any of the codes from the a priori coding framework were potentially at play in each piece of text. Double coding was permitted when applicable. New codes were created and defined when a piece of text from transcripts represented a new important idea. Codes were categorized according to alignment with i-PARIHS constructs. To ensure intercoder reliability, the first 50% of the interviews were coded by two researchers. Team meetings were regularly held to discuss coding discrepancies (to reach a consensus). Coded data were organized using NVivo software (Version 12). Data were deductively analyzed using reflexive thematic analysis, a six-step process for analyzing and reporting qualitative data, to determine themes relevant to selecting appropriate implementation strategies to increase PrEP use at FQHCs in MS [ 29 ]. The resulting thematic categories were used to select ERIC implementation strategies [ 26 ]. Elements for each strategy were then operationalized and the mechanism of change for each strategy was hypothesized [ 30 , 31 ]. Mechanisms define how an implementation strategy will have an effect [ 30 , 31 ]. We used the identified determinants to hypothesize the mechanism of change for each strategy.

Member checking focus groups

Member checking is when the data or results are presented back to the participants, who provide feedback [ 32 ] to check for accuracy [ 33 ] and improve the validity of the data [ 34 ]. This process helps reduce the possibility of misrepresentation of the data [ 35 ]. Member checking was completed with clinic staff rather than patients because the focus was on identifying strategies to implement PrEP in the FQHCs.

Two focus groups were conducted with nine staff from the three FQHCs in MS. Eligibility criteria were the same as above. A combination of previously interviewed staff and non-interviewed staff were recruited. Staff members were a mix of medical (e.g., nurses, patient navigators, social workers) and non-medical (e.g., administrative assistant, branding officer) personnel. Focus group one had six participants and focus group two had three participants. The goal was for focus group participants to comprise half of staff members who had previously been interviewed and half of non-interviewed staff.

Participants were recruited and compensated via the same methods as above. All participants electronically consented via DocuSign, and then were scheduled for a focus group. Focus groups occurred remotely over Zoom. Focus groups were conducted until data saturation was reached and no new information surfaced. The goal of the focus groups was to member-check results from the interviews and assess the feasibility and acceptability of selected implementation strategies. PowerPoint slides with the results and implementation strategies written in lay terms were shared with the participants, which is a suggested technique to use in member checking [ 33 ]. Participants were asked to provide feedback on each slide.

Focus groups were all audio-recorded, then transcribed. Transcriptions were reviewed for accuracy by the research staff who completed focus groups. Findings from the focus groups were synthesized using rapid qualitative analyses [ 36 , 37 ]. Facilitators (TA, PPE) both took notes during the focus groups of the primary findings. Notes were then compared during team meetings and results were finalized. Results obtained from previous findings of the interviews and i-PARIHS framework were presented. To ensure the reliability of results, an additional team member (KKG) read the transcripts to verify the primary findings and selected supportive quotes for each theme. Team meetings were regularly held to discuss the results.

Thirty-six semi-structured interviews in HIV hot spots were completed between April 2021 and March 2022. Among the 19 FQHC staff, most staff members had several years of experience working with those at risk for HIV. Staff members were a mix of medical (e.g., doctors, nurses, CNAs, social workers) and non-medical (e.g., receptionists, case managers) personnel. Table 1 provides the demographic characteristics for the 19 FQHC clinic staff and 17 FQHC patients.

Table 2 provides a detailed description of the findings within each category: PrEP knowledge, PrEP barriers, and PrEP motivation. Themes are described in detail, with representative quotes, below. Implementation determinants are specific factors that influence implementation outcomes and can be barriers or facilitators. Table 3 highlights which implementation determinants can increase ( +) or decrease (-) the implementation of PrEP at FQHCs in MS. Each determinant, mapped to its corresponding i-PARIHS construct, is discussed in more detail below. There were no significant differences in responses across the three FQHCs.

PrEP knowledge

Patient prep awareness (i-parihs: recipients).

Most patients had heard of PrEP and were somewhat familiar with the medication. One patient described her knowledge of PrEP as follows, “I know that PrEP is I guess a program that helps people who are high-risk with sexual behaviors and that doesn't have HIV, but they're at high-risk.”- Patient, Age 32, Female, Not on PrEP. However, many lacked knowledge of who may benefit from PrEP, where to receive a prescription, the different medications used for PrEP, and the efficacy of PrEP. Below is a comment made by a patient listing what she would need to know to consider taking PrEP. “I would need to know the price. I would need to know the side effects. I need to know the percentage, like, is it 100 or 90 percent effective.”— Patient, Age Unknown, Female, Not on PrEP. Patients reported learning about PrEP via television and social media commercials, medical providers, and their social networks. One patient reported learning about PrEP from her cousin. “The only person I heard it [PrEP] from was my cousin, and she talks about it all the time, givin’ us advice and lettin’ us know that it’s a good thing.”— Patient, Age Unknown, Female, Not on PrEP.

Clinic Staff PrEP Awareness (i-PARIHS: Context)

Training in who may benefit from PrEP and how to prescribe PrEP varied among clinic staff at different FQHCs. Not all clinics offered formal PrEP education for employees; however, most knew that PrEP is a tool used for HIV prevention. Staff reported learning about PrEP via different speakers and meetings. A clinic staff member reported learning about PrEP during quarterly meetings. “Well, sometimes when we have different staff meetings, we have them quarterly, and we discuss PrEP. Throughout those meetings, they tell us a little bit of information about it, so that's how I know about PrEP.” – Staff, Dental Assistant, Female. Some FQHC staff members reported having very little knowledge of PrEP. One staff member shared that she knew only the “bare minimum” about PrEP, stating,

“I probably know the bare minimum about PrEP. I know a little about it [PrEP] as far as if taken the correct way, it can prevent you from gettin’ HIV. I know it [PrEP] doesn’t prevent against STDs but I know it’s a prevention method for HIV and just a healthier lifestyle.” –Staff, Accountant, Female

A few of the organizations had PrEP navigators to which providers refer patients. These providers were well informed on who to screen for PrEP eligibility and the process for helping the patient obtain a PrEP prescription. One clinic staff member highlighted how providers must be willing to be trained in the process of prescribing PrEP and make time for patients who may benefit. Specifically, she said,

“I have been trained [for PrEP/HIV care]. It just depends on if that’s something that you’re willing to do, they can train on what labs and stuff to order ’cause it’s a whole lot of labs. But usually, I try to do it. At least for everybody that’s high-risk.” – Staff, OB/GYN Nurse Practitioner, Female

Another clinic staff member reported learning about PrEP while observing another staff member being training in PrEP procedures.

“Well, they kinda explained to me what it [PrEP] is, but I was in training with the actual PrEP person, so it was kinda more so for his training. I know what PrEP is. I know the medications and I know he does a patient assistance program. If my patients have partners who are not HIV positive and wanna continue to be HIV negative, I can refer 'em.” – Staff, Administrative Assistant, Female

PrEP barriers

Barriers receiving prep services (i-parihs: recipients, innovation).

Several barriers to receiving PrEP services were identified in both patient and clinic staff interviews. There was a strong concern for the side effects of PrEP. One patient heard that PrEP could cause weight gain and nightmares, “I’m afraid of gaining weight. I’ve heard that actual HIV medication, a lotta people have nightmares or bad dreams.” - Patient, Age 30, Female, Not on PrEP. Another patient was concerned about perceived general side effects that many medications have. “Probably just the [potential] side effects. You know, most of the pills have allergic reactions and side effects, dizziness, seizures, you know.” - Patient, Age 30, Female, Not on PrEP.

The burden of remembering to take a daily pill was also mentioned as a barrier to PrEP use. One female patient explained how PrEP is something she is interested in taking; however, she would be unable to take a daily medication.

“I’m in school now and not used to takin’ a medication every day. I was takin’ a birth control pill, but now take a shot. That was one of the main reasons that I didn’t start PrEP cause they did tell me I could get it that day. So like I wanna be in the mind state to where I’m able to mentally, in my head, take a pill every day. PrEP is somethin’ that I wanna do.” - Patient, Age Unknown, Female, Not on PrEP

Stigma and confidentiality were also barriers to PrEP use at FQHCs. One staff member highlighted how in small communities it is difficult to go to a clinic where employees know you personally. Saying,

“If somebody knows you’re going to talk to this specific person, they know what you’re goin’ back there for, and that could cause you to be a little hesitant in coming. So there’s always gonna be a little hesitancy or mistrust, especially in a small community. Everybody knows everybody. The people that you’re gonna see goes to church with you.” – Staff, Accountant, Female

Some patients had a low perceived risk of HIV and felt PrEP may be an unnecessary addition to their routine. One patient shared that if she perceived she was at risk for HIV, then she would be more interested in taking PrEP, “If it ever came up to the point where I would need it [PrEP], then yes, I would want to know more about it [PrEP].”— Patient, Age Unknown, Female, Not on PrEP.

Some participants expressed difficulty initiating or staying on PrEP because of associated costs, transportation and/or scheduling barriers. A staff member explained how transportation may be available in the city but not available in more rural areas,

“I guess it all depends on the person and where they are. In a city it might take a while, but at least they have the transportation compared to someone that lives in a rural area where transportation might be an issue.” - Staff, Director of Nurses, Female

Childcare during appointments was also mentioned as a barrier, “It looks like here a lot of people don't have transportation or reliable transportation and another thing I don't have anybody to watch my kids right now. —Staff, Patient Navigator, Female.

Barriers Providing PrEP Services (i-PARIHS: Context)

Barriers to providing PrEP services were also identified. Many providers are still not trained in PrEP procedures nor feel comfortable discussing or prescribing PrEP to their patients. One patient shared an experience of going to a provider who was PrEP-uninformed and assumed his medication was to treat HIV,

“Once I told her about it [PrEP], she [clinic provider] literally right in front of me, Googled it [PrEP], and then she was Googlin’ the medication, Descovy. I went to get a lab work, and she came back and was like, “Is this for treatment?” I was like, “Why would you automatically think it’s for treatment?” I literally told her and the nurse, “I would never come here if I lived here.” - Patient, Age 50, Male, Taking PrEP

Also, it was reported that there is not enough variety in the kind of providers who offer PrEP (e.g., OB/GYN, primary care). Many providers such as OB/GYNs could serve as a great way to reach individuals who may benefit from PrEP; however, patients reported a lack of PrEP being discussed in annual visits. “My previous ones (OB/GYN), they’ve talked about birth control and every other method and they asked me if I wanted to get tested for HIV and any STIs, but the conversation never came up about PrEP.” -Patient, Age Unknown, Female, Not on PrEP.

PrEP motivation

Motivation to take prep (i-parihs: recipients).

Participants mentioned several motivators that enhanced patient willingness to use PrEP. Many patients reported being motivated to use PrEP to protect themselves and their partners from HIV. Additionally, participants reported wanting to take PrEP to help their community. One patient reported being motivated by both his sexuality and the rates of HIV in his area, saying, “I mean, I'm bisexual. So, you know, anyway I can protect myself. You know, it's just bein' that the HIV number has risen. You know, that's scary. So just being, in, an area with higher incidents of cases.”— Patient, Age Unknown, Male, Not on PrEP . Some participants reported that experiencing an HIV scare also motivated them to consider using PrEP. One patient acknowledged his behaviors that put him at risk and indicated that this increased his willingness to take PrEP, “I was havin' a problem with, you know, uh, bein' promiscuous. You know? So it [PrEP] was, uh, something that I would think, would help me, if I wasn't gonna change the way I was, uh, actin' sexually.”— Patient, Age Unknown, Male, Taking PrEP .

Table 3 outlines the implementation strategies identified from themes from the interview and focus group data. Below we recognize the barriers and determinants to PrEP uptake for patients attending FQHCs in MS by each i-PARIHS construct (innovation, recipient, context) [ 28 ]. Based on the data, we mapped the determinants to specific strategies from the ERIC project [ 26 ] and hypothesized the mechanism of change for each strategy [ 30 , 31 ].

Two focus groups were conducted with nine staff from threeFQHCs in MS. There were six participants in the 1st focus group and three in the 2nd. Staff members were a mix of medical (e.g., nurses, patient navigators, social workers) and non-medical (e.g., administrative assistant, branding officer) personnel. Table 4 provides the demographic characteristics for the FQHC focus group participants.

Staff participating in the focus groups generally agreed that the strategies identified via the interviews were appropriate and acceptable. Focus group content helped to further clarify some of the selected strategies. Below we highlight findings by each strategy domain.

PrEP information dissemination

Participants specified that awareness of HIV is lower, and stigma related to PrEP is higher in rural areas. One participant specifically said,

“There is some awareness but needs to be more awareness, especially to rural areas here in Mississippi. If you live in the major metropolitan areas there is a lot of information but when we start looking at the rural communities, there is not a lot.” – Staff, Branding Officer, Male

Participants strongly agreed that many patients don’t realize they may benefit from PrEP and that more inclusive advertisements are needed. A nurse specifically stated,

“ When we have new clients that come in that we are trying to inform them about PrEP and I have asked them if they may have seen the commercial, especially the younger population. They will say exactly what you said, that “Oh, I thought that was for homosexuals or whatever,” and I am saying “No, it is for anyone that is at risk.” – Staff, Nurse, Female

Further, staff agreed that younger populations should be included in PrEP efforts to alleviate stigma. Participants added that including PrEP information with other prevention methods (i.e., birth control, vaccines) is a good place to include parents and adolescents:

“Just trying to educate them about Hepatitis and things of that nature, Herpes. I think we should also, as they are approaching 15, the same way we educate them about their cycle coming on and what to expect, it’s almost like we need to start incorporating this (PrEP education), even with different forms of birth control methods with our young ladies.” – Staff, Nurse, Female

Participants agreed that PrEP testimonials would be helpful, specifically from people who started PrEP, stopped, and then were diagnosed with HIV. Participants indicated that this may improve PrEP uptake and persistence. One nurse stated:

“I have seen where a patient has been on PrEP a time or two and at some point, early in the year or later part of the year, and we have seen where they’ve missed those appointments and were not consistent with their medication regimen. And we have seen those who’ve tested positive for HIV. So, if there is a way we could get one of those patients who will be willing to share their testimony, I think they can really be impactful because it’s showing that taking up preventive measures was good and then kind of being inconsistent, this is what the outcome is, unfortunately.” – Staff, Nurse, Female

Increase variety and number of PrEP providers

Participants agreed that a “PrEP champion” (someone to promote PrEP and answer PrEP related questions) would be helpful, especially for providers who need more education about PrEP to feel comfortable prescribing. A patient navigator said,

“I definitely think that a provider PrEP champion is needed in every clinic or organization that is offering PrEP. And it goes back to what we were saying about the providers not being knowledgeable on it [PrEP]. If you have a PrEP champion that already knows this information, it is gonna benefit everybody, patients, patient advocates, the provider, everyone all around. Everyone needs a champion." – Staff, Patient Navigator, Female

Staff noted that they have walk-in appointments for PrEP available; however, they often have too many walk-in appointments to see everyone. They noted that having more resources and providers may alleviate this barrier for some patients:

“We still have challenges with people walking in versus scheduling an appointment, but we do have same day appointments. It is just hard sometimes because the volume that we have at our clinic and the number of patients that we have that walk in on a daily basis.” – Staff, Social Worker, Female

Enhance PrEP provider alliance and trust

Participants agreed that educational meetings would be beneficial and highlighted that meetings should happen regularly and emphasized a preference for in-person meetings. This is emphasized by the statement below,

“They should be in-person with handouts. You have to kind of meet people where they are as far as learning. Giving the knowledge, obtaining the knowledge, and using it, and so you have to find a place. I definitely think that yearly in-person training to update guidelines, medication doses, different things like that." – Staff, Patient Navigator, Female

Staff also suggested hosting one very large collaborative event to bring together all organizations that offer PrEP and HIV testing to meet and discuss additional efforts:

“What I would like to see happen here in the state of Mississippi, because we are so high on the list for new HIV infections, I would like to see a big collaborative event. As far as PrEP goes, those that are not on PrEP, one big collaborative event with different community health centers. You do testing, we do PrEP, and the referral get split. Everyone coming together for one main purpose.” – Staff, Patient Navigator, Female

Increase access to PrEP

Participants highlighted that most of the clinics they worked for already offer a variety of service sites (pharmacy, mobile clinic) but that more clinics should offer these alternative options for patients to receive PrEP. One patient navigator outlined the services they offer,

“We have a mobile unit. We do not have a home health travel nurse. We do telephone visits. We offer primary care, OB/GYN. We have our own pharmacy. We also have samples in our pharmacy available to patients that can’t get their medicine on the same day cos we like to implement same day PrEP. It has worked for us. More people should utilize those services.” – Staff, Patient Navigator, Female

Other staff suggested utilizing minute clinics and pharmacies at grocery stores. Highlighting, that offering PrEP at these locations may increase PrEP uptake.

There has been great scientific expansion of HIV prevention research and priorities must now pivot to addressing how to best implement effective interventions like PrEP [ 38 ]. PrEP remains underutilized among individuals who may benefit, particularly in Southern states such as MS [ 10 , 11 , 12 , 13 , 14 ]. Implementation science could help ameliorate this by identifying barriers and facilitators to PrEP rollout and uptake. We selected and defined several strategies from the ERIC project [ 26 ] to increase PrEP use utilizing FQHCs. Our results, as shown in Table  3 , highlight the four domains of strategies selected: 1) PrEP Information Dissemination, 2) Increase Variety and Number of PrEP Providers, 3) Enhance PrEP Provider Alliance and Trust, and 4) Increase Access to PrEP.

Firstly, individuals cannot utilize PrEP if they are not aware of its presence and utility. In Mississippi, advertising PrEP services is integral to implementation efforts given the existing stigma and lack of health literacy in this region [ 39 ]. Potential avenues for expanding PrEP awareness are integrating it into educational curriculums, adolescents’ routine preventative healthcare, and health fairs. This study compliments prior research that people should be offered sexual health and PrEP education at a younger age to increase awareness of risk, foster change in social norms and enhance willingness to seek out prevention services [ 40 , 41 ]. To meet the resulting growing need for PrEP educators, healthcare professionals should receive up-to-date PrEP information and training, so that they can confidently relay information to their patients. Similar to existing research, increasing provider education could accelerate PrEP expansion [ 42 , 43 , 44 ]. Training programs aimed at increasing provider PrEP knowledge may increase PrEP prescriptions provided [ 43 ] by addressing one of the most frequently listed barriers to PrEP prescription among providers [ 45 , 46 ].

Many patients prefer to receive PrEP at the healthcare locations they already attend and report a barrier to PrEP being limited healthcare settings that offer PrEP [ 39 , 47 , 48 , 49 ]. The aforementioned PrEP training could increase the number of healthcare workers willing to provide PrEP services. It is also imperative that providers in a diverse range of healthcare settings (e.g., primary care, OB/GYN, pediatricians and adolescent medicine providers) join the list of those offering PrEP to reduce stigma and enhance patient comfort.

These results mirrored other studies in the South that have shown that using relatable healthcare providers and trusted members of the community may serve to facilitate PrEP uptake [ 41 , 50 , 51 ]. If patients have a larger number of PrEP providers to choose from, they can select one that best fits their needs (e.g., location, in-network) and preferences (e.g., familiarity, cultural similarities). Enhanced comfort facilitates a strong patient-provider alliance and can lead to more open/honest communication regarding HIV risk behavior.

The lack of conveniently located PrEP providers is consistently reported as a structural barrier in the South [ 44 , 52 ]. This creates an increase in the demand on patients to attend regular follow-up appointments. The three strategies above all play a vital role in increasing access to PrEP. If more individuals are trained to provide PrEP care, there will be more PrEP providers, and patients can choose the best option for them. A sizeable influx of new PrEP providers could help staff new care facilities and service options in the community (e.g., mobile health units, home care, community-based clinics, telemedicine). Offering PrEP via telemedicine and mobile clinics to patients has been largely supported in the literature [ 44 , 53 , 54 ]. Intra- and inter-organizational collaborations could similarly increase PrEP access by sharing information and resources to ensure patients get timely, reliable care.

Our results largely supported previous findings by two systematic reviews on the barriers to PrEP uptake and implementation strategies to overcome it [ 39 , 47 ]. Sullivan et.al.’s review focused on the Southern U.S. [ 38 ], while Bonacci et. al. explored steps to improve PrEP equity for Black and Hispanic/Latino communities [ 47 ]. Both agreed that barriers to PrEP access are complex. Thus, cooperation from policymakers and the expansion of state Medicaid or targeted Medicaid waivers is vital to make PrEP attainable for those living in the coverage gap. Further, many FQHCs receive Ryan White funding for HIV care and treatment, contracting flexibility in the utility of these other sources of support may aid in eliminating the cost of PrEP as a barrier. They also stressed the need for educating community members and healthcare personnel about PrEP, increasing and diversifying PrEP service sites, normalizing PrEP campaigns and screening to alleviate stigma, and streamlining clinical procedures to facilitate the option for same-day PrEP. However, they also noted that these strategies are easier said than done. This further highlights the need for prioritizing research efforts towards implementation studies for effectiveness and practicality of overcoming the complex and systemic needs around HIV prevention/treatment.

The present study was able to build on past findings by providing a more holistic view of the barriers to PrEP use and possible strategies to address them through querying PrEP-eligible patients, medical providers, and non-medical staff. By interviewing a diverse range of stakeholders, it was possible to identify unmet patient needs, current PrEP care procedures and infrastructure, and attitudes and needed resources among those who could potentially be trained to provide PrEP in the future.

Limitations

Our results are limited to participants and clinic staff who were willing to engage in a research interview to discuss PrEP and FQHCs. Results are only generalizable to Mississippi and may be less relevant for other geographic areas. However, this is a strength given these strategies are meant to be tailored specifically to FQHCs in MS. Due to COVID-19 restrictions, interviews were conducted via Zoom. This allowed us to reach participants unable to come in physically for an interview and may have increased their comfort responding to questions [ 55 ]. However, some participants may have been less comfortable discussing via Zoom, which may have limited their willingness to respond.

This study highlighted the need for implementing PrEP strategies to combat HIV in Mississippi. PrEP knowledge, barriers, and motivation were identified as key factors influencing PrEP utilization, and four domains of strategies were identified for improving PrEP accessibility and uptake. Future research should further refine and assess the feasibility and acceptability of selected and defined implementation strategies and test strategies.

Availability of data and materials

De-identified data from this study are not available in a public archive due to sensitive nature of the data. De-identified data from this study will be made available (as allowable according to institutional IRB standards) by emailing the corresponding author.

Abbreviations

Mississippi

Pre-Exposure Prophylaxis

Federally Qualified Health Centers

Integrated-Promoting Action on Research Implementation in Health Services

Expert Recommendations for Implementing Change

Men Who Have Sex With Men

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Acknowledgements

Authors would like to acknowledge and thank Sarah Bailey for reviewing the manuscript and assisting for formatting.

This study was funded by the National Institute of Health (R34MH115744) and was facilitated by the Providence/Boston Center for AIDS Research (P30AI042853). Additionally, work by Dr. Trisha Arnold was supported by the National Institute of Mental Health Grant (K23MH124539-01A1) and work by Dr. Andrew Barnett was supported by the National Institute of Mental Health Grant (T32MH078788). Dr. Elwy is supported by a Department of Veterans Affairs Research Career Scientist Award (RCS 23–018).

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Trisha Arnold, Kayla K. Giorlando, Andrew P. Barnett, Avery Leigland & Larry K. Brown

Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA

Trisha Arnold, Laura Whiteley, Andrew P. Barnett, Ariana M. Albanese, A. Rani Elwy & Larry K. Brown

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Courtney Sims-Gomillia & Precious Patrick Edet

Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA

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Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA

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TA and ARE led the conceptualization of this paper. TA, LW, LKB, DML, and JBB completed the literature search and study design. TA, LW, LKB, KKG, PPE, AB, AL, and CSG assisted with analyzing and interpreting the data. TA, ARE, and AMA finalized the results and implementation concepts of the study. All authors read and approved the final manuscript.

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Arnold, T., Whiteley, L., Giorlando, K.K. et al. A qualitative study identifying implementation strategies using the i-PARIHS framework to increase access to pre-exposure prophylaxis at federally qualified health centers in Mississippi. Implement Sci Commun 5 , 92 (2024). https://doi.org/10.1186/s43058-024-00632-6

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DOI : https://doi.org/10.1186/s43058-024-00632-6

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Towards Defining STEM Professional Identity: A Qualitative Survey Study

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• Jennifer N. Tripp   ORCID: orcid.org/0000-0001-9925-6927 1 &
• Xiufeng Liu   ORCID: orcid.org/0000-0003-2264-9882 1  

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One of the main goals of STEM (science, technology, engineering, mathematics, and medicine) education is the development of STEM identity, yet what STEM identity is remains elusive. This study examines how STEM professionals define themselves via open-ended responses to an online qualitative survey. Through inductive and deductive coding informed by sociocultural, professional, and STEM identity perspectives, supplemented by text mining, valid responses from 103 participants were qualitatively analyzed. Several main findings emerged: (1) STEM professionals primarily defined themselves by their STEM work-related duties; (2) they emphasized STEM competence through their educational background and expertise; (3) recognition by others was influenced by perceived performance and competence; and (4) STEM professionals aspired to advance and be at the forefront of STEM fields through continuously learning and making positive societal impacts. In addition to rethinking STEM education, supports, and public messaging about STEM and STEM professionals through an equity lens, implications include the development of STEM identity instruments that can be used to evaluate the effectiveness and inclusiveness of STEM education and educational contexts, programs, and reforms.

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

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JT led data analysis and manuscript writing. XL was responsible for the study’s conception, survey design, and data collection and contributed to data analysis and manuscript preparation discussions. Both authors read and approved the final manuscript.

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Appendix 1. Identity of STEM professionals survey questions

Q1 This study aims to identify the characteristics of STEM professionals. STEM refers to Science, Technology, Engineering, Mathematics and Medicine, and the STEM profession is defined to consist of computer and mathematical, architecture and engineering, and life and physical science occupations, as well as managerial and postsecondary teaching occupations related to these functional areas and sales occupations requiring scientific or technical knowledge at the postsecondary level.

Based on this definition, are you a STEM professional?

Q2 What is your STEM profession—please describe:

Q3 How do you define yourself as a STEM professional?

Q4 What is your perception of how others may define you as a STEM professional?

Q5 What do you aspire to be as a STEM professional?

Q6 How do you describe your past education and work experiences as a STEM professional?

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Tripp, J.N., Liu, X. Towards Defining STEM Professional Identity: A Qualitative Survey Study. Journal for STEM Educ Res (2024). https://doi.org/10.1007/s41979-024-00131-2

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Accepted : 18 August 2024

Published : 26 August 2024

DOI : https://doi.org/10.1007/s41979-024-00131-2

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