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• Types of Interviews in Research | Guide & Examples

Types of Interviews in Research | Guide & Examples

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

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

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

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

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

Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Here are some examples.

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

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

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

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

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

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

Research bias

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

The four most common types of interviews are:

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

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

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

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

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

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

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

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

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

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The Interview Method In Psychology

Saul McLeod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

Learn about our Editorial Process

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

On This Page:

Interviews involve a conversation with a purpose, but have some distinct features compared to ordinary conversation, such as being scheduled in advance, having an asymmetry in outcome goals between interviewer and interviewee, and often following a question-answer format.

Interviews are different from questionnaires as they involve social interaction. Unlike questionnaire methods, researchers need training in interviewing (which costs money).

How Do Interviews Work?

Researchers can ask different types of questions, generating different types of data . For example, closed questions provide people with a fixed set of responses, whereas open questions allow people to express what they think in their own words.

The researcher will often record interviews, and the data will be written up as a transcript (a written account of interview questions and answers) which can be analyzed later.

It should be noted that interviews may not be the best method for researching sensitive topics (e.g., truancy in schools, discrimination, etc.) as people may feel more comfortable completing a questionnaire in private.

There are different types of interviews, with a key distinction being the extent of structure. Semi-structured is most common in psychology research. Unstructured interviews have a free-flowing style, while structured interviews involve preset questions asked in a particular order.

Structured Interview

A structured interview is a quantitative research method where the interviewer a set of prepared closed-ended questions in the form of an interview schedule, which he/she reads out exactly as worded.

Interviews schedules have a standardized format, meaning the same questions are asked to each interviewee in the same order (see Fig. 1).

   Figure 1. An example of an interview schedule

The interviewer will not deviate from the interview schedule (except to clarify the meaning of the question) or probe beyond the answers received.  Replies are recorded on a questionnaire, and the order and wording of questions, and sometimes the range of alternative answers, is preset by the researcher.

A structured interview is also known as a formal interview (like a job interview).

• Structured interviews are easy to replicate as a fixed set of closed questions are used, which are easy to quantify – this means it is easy to test for reliability .
• Structured interviews are fairly quick to conduct which means that many interviews can take place within a short amount of time. This means a large sample can be obtained, resulting in the findings being representative and having the ability to be generalized to a large population.

Limitations

• Structured interviews are not flexible. This means new questions cannot be asked impromptu (i.e., during the interview), as an interview schedule must be followed.
• The answers from structured interviews lack detail as only closed questions are asked, which generates quantitative data . This means a researcher won’t know why a person behaves a certain way.

Unstructured Interview

Unstructured interviews do not use any set questions, instead, the interviewer asks open-ended questions based on a specific research topic, and will try to let the interview flow like a natural conversation. The interviewer modifies his or her questions to suit the candidate’s specific experiences.

Unstructured interviews are sometimes referred to as ‘discovery interviews’ and are more like a ‘guided conservation’ than a strictly structured interview. They are sometimes called informal interviews.

Unstructured interviews are most useful in qualitative research to analyze attitudes and values. Though they rarely provide a valid basis for generalization, their main advantage is that they enable the researcher to probe social actors’ subjective points of view.

Interviewer Self-Disclosure

Interviewer self-disclosure involves the interviewer revealing personal information or opinions during the research interview. This may increase rapport but risks changing dynamics away from a focus on facilitating the interviewee’s account.

In unstructured interviews, the informal conversational style may deliberately include elements of interviewer self-disclosure, mirroring ordinary conversation dynamics.

Interviewer self-disclosure risks changing the dynamics away from facilitation of interviewee accounts. It should not be ruled out entirely but requires skillful handling informed by reflection.

• An informal interviewing style with some interviewer self-disclosure may increase rapport and participant openness. However, it also increases the chance of the participant converging opinions with the interviewer.
• Complete interviewer neutrality is unlikely. However, excessive informality and self-disclosure risk the interview becoming more of an ordinary conversation and producing consensus accounts.
• Overly personal disclosures could also be seen as irrelevant and intrusive by participants. They may invite increased intimacy on uncomfortable topics.
• The safest approach seems to be to avoid interviewer self-disclosures in most cases. Where an informal style is used, disclosures require careful judgment and substantial interviewing experience.
• If asked for personal opinions during an interview, the interviewer could highlight the defined roles and defer that discussion until after the interview.
• Unstructured interviews are more flexible as questions can be adapted and changed depending on the respondents’ answers. The interview can deviate from the interview schedule.
• Unstructured interviews generate qualitative data through the use of open questions. This allows the respondent to talk in some depth, choosing their own words. This helps the researcher develop a real sense of a person’s understanding of a situation.
• They also have increased validity because it gives the interviewer the opportunity to probe for a deeper understanding, ask for clarification & allow the interviewee to steer the direction of the interview, etc. Interviewers have the chance to clarify any questions of participants during the interview.
• It can be time-consuming to conduct an unstructured interview and analyze the qualitative data (using methods such as thematic analysis).
• Employing and training interviewers is expensive and not as cheap as collecting data via questionnaires . For example, certain skills may be needed by the interviewer. These include the ability to establish rapport and knowing when to probe.
• Interviews inevitably co-construct data through researchers’ agenda-setting and question-framing. Techniques like open questions provide only limited remedies.

Focus Group Interview

Focus group interview is a qualitative approach where a group of respondents are interviewed together, used to gain an in‐depth understanding of social issues.

This type of interview is often referred to as a focus group because the job of the interviewer ( or moderator ) is to bring the group to focus on the issue at hand. Initially, the goal was to reach a consensus among the group, but with the development of techniques for analyzing group qualitative data, there is less emphasis on consensus building.

The method aims to obtain data from a purposely selected group of individuals rather than from a statistically representative sample of a broader population.

The role of the interview moderator is to make sure the group interacts with each other and do not drift off-topic. Ideally, the moderator will be similar to the participants in terms of appearance, have adequate knowledge of the topic being discussed, and exercise mild unobtrusive control over dominant talkers and shy participants.

A researcher must be highly skilled to conduct a focus group interview. For example, the moderator may need certain skills, including the ability to establish rapport and know when to probe.

• Group interviews generate qualitative narrative data through the use of open questions. This allows the respondents to talk in some depth, choosing their own words. This helps the researcher develop a real sense of a person’s understanding of a situation. Qualitative data also includes observational data, such as body language and facial expressions.
• Group responses are helpful when you want to elicit perspectives on a collective experience, encourage diversity of thought, reduce researcher bias, and gather a wider range of contextualized views.
• They also have increased validity because some participants may feel more comfortable being with others as they are used to talking in groups in real life (i.e., it’s more natural).
• When participants have common experiences, focus groups allow them to build on each other’s comments to provide richer contextual data representing a wider range of views than individual interviews.
• Focus groups are a type of group interview method used in market research and consumer psychology that are cost – effective for gathering the views of consumers .
• The researcher must ensure that they keep all the interviewees” details confidential and respect their privacy. This is difficult when using a group interview. For example, the researcher cannot guarantee that the other people in the group will keep information private.
• Group interviews are less reliable as they use open questions and may deviate from the interview schedule, making them difficult to repeat.
• It is important to note that there are some potential pitfalls of focus groups, such as conformity, social desirability, and oppositional behavior, that can reduce the usefulness of the data collected.

For example, group interviews may sometimes lack validity as participants may lie to impress the other group members. They may conform to peer pressure and give false answers.

To avoid these pitfalls, the interviewer needs to have a good understanding of how people function in groups as well as how to lead the group in a productive discussion.

Semi-Structured Interview

Semi-structured interviews lie between structured and unstructured interviews. The interviewer prepares a set of same questions to be answered by all interviewees. Additional questions might be asked during the interview to clarify or expand certain issues.

In semi-structured interviews, the interviewer has more freedom to digress and probe beyond the answers. The interview guide contains a list of questions and topics that need to be covered during the conversation, usually in a particular order.

Semi-structured interviews are most useful to address the ‘what’, ‘how’, and ‘why’ research questions. Both qualitative and quantitative analyses can be performed on data collected during semi-structured interviews.

• Semi-structured interviews allow respondents to answer more on their terms in an informal setting yet provide uniform information making them ideal for qualitative analysis.
• The flexible nature of semi-structured interviews allows ideas to be introduced and explored during the interview based on the respondents’ answers.
• Semi-structured interviews can provide reliable and comparable qualitative data. Allows the interviewer to probe answers, where the interviewee is asked to clarify or expand on the answers provided.
• The data generated remain fundamentally shaped by the interview context itself. Analysis rarely acknowledges this endemic co-construction.
• They are more time-consuming (to conduct, transcribe, and analyze) than structured interviews.
• The quality of findings is more dependent on the individual skills of the interviewer than in structured interviews. Skill is required to probe effectively while avoiding biasing responses.

The Interviewer Effect

Face-to-face interviews raise methodological problems. These stem from the fact that interviewers are themselves role players, and their perceived status may influence the replies of the respondents.

Because an interview is a social interaction, the interviewer’s appearance or behavior may influence the respondent’s answers. This is a problem as it can bias the results of the study and make them invalid.

For example, the gender, ethnicity, body language, age, and social status of the interview can all create an interviewer effect. If there is a perceived status disparity between the interviewer and the interviewee, the results of interviews have to be interpreted with care. This is pertinent for sensitive topics such as health.

For example, if a researcher was investigating sexism amongst males, would a female interview be preferable to a male? It is possible that if a female interviewer was used, male participants might lie (i.e., pretend they are not sexist) to impress the interviewer, thus creating an interviewer effect.

Flooding interviews with researcher’s agenda

The interactional nature of interviews means the researcher fundamentally shapes the discourse, rather than just neutrally collecting it. This shapes what is talked about and how participants can respond.

• The interviewer’s assumptions, interests, and categories don’t just shape the specific interview questions asked. They also shape the framing, task instructions, recruitment, and ongoing responses/prompts.
• This flooding of the interview interaction with the researcher’s agenda makes it very difficult to separate out what comes from the participant vs. what is aligned with the interviewer’s concerns.
• So the participant’s talk ends up being fundamentally shaped by the interviewer rather than being a more natural reflection of the participant’s own orientations or practices.
• This effect is hard to avoid because interviews inherently involve the researcher setting an agenda. But it does mean the talk extracted may say more about the interview process than the reality it is supposed to reflect.

Interview Design

First, you must choose whether to use a structured or non-structured interview.

Characteristics of Interviewers

Next, you must consider who will be the interviewer, and this will depend on what type of person is being interviewed. There are several variables to consider:

• Gender and age : This can greatly affect respondents’ answers, particularly on personal issues.
• Personal characteristics : Some people are easier to get on with than others. Also, the interviewer’s accent and appearance (e.g., clothing) can affect the rapport between the interviewer and interviewee.
• Language : The interviewer’s language should be appropriate to the vocabulary of the group of people being studied. For example, the researcher must change the questions’ language to match the respondents’ social background” age / educational level / social class/ethnicity, etc.
• Ethnicity : People may have difficulty interviewing people from different ethnic groups.
• Interviewer expertise should match research sensitivity – inexperienced students should avoid interviewing highly vulnerable groups.

Interview Location

The location of a research interview can influence the way in which the interviewer and interviewee relate and may exaggerate a power dynamic in one direction or another. It is usual to offer interviewees a choice of location as part of facilitating their comfort and encouraging participation.

However, the safety of the interviewer is an overriding consideration and, as mentioned, a minimal requirement should be that a responsible person knows where the interviewer has gone and when they are due back.

Remote Interviews

The COVID-19 pandemic necessitated remote interviewing for research continuity. However online interview platforms provide increased flexibility even under normal conditions.

They enable access to participant groups across geographical distances without travel costs or arrangements. Online interviews can be efficiently scheduled to align with researcher and interviewee availability.

There are practical considerations in setting up remote interviews. Interviewees require access to internet and an online platform such as Zoom, Microsoft Teams or Skype through which to connect.

Certain modifications help build initial rapport in the remote format. Allowing time at the start of the interview for casual conversation while testing audio/video quality helps participants settle in. Minor delays can disrupt turn-taking flow, so alerting participants to speak slightly slower than usual minimizes accidental interruptions.

Keeping remote interviews under an hour avoids fatigue for stare at a screen. Seeking advanced ethical clearance for verbal consent at the interview start saves participant time. Adapting to the remote context shows care for interviewees and aids rich discussion.

However, it remains important to critically reflect on how removing in-person dynamics may shape the co-created data. Perhaps some nuances of trust and disclosure differ over video.

Vulnerable Groups

The interviewer must ensure that they take special care when interviewing vulnerable groups, such as children. For example, children have a limited attention span, so lengthy interviews should be avoided.

Developing an Interview Schedule

An interview schedule is a list of pre-planned, structured questions that have been prepared, to serve as a guide for interviewers, researchers and investigators in collecting information or data about a specific topic or issue.

• List the key themes or topics that must be covered to address your research questions. This will form the basic content.
• Organize the content logically, such as chronologically following the interviewee’s experiences. Place more sensitive topics later in the interview.
• Develop the list of content into actual questions and prompts. Carefully word each question – keep them open-ended, non-leading, and focused on examples.
• Add prompts to remind you to cover areas of interest.
• Pilot test the interview schedule to check it generates useful data and revise as needed.
• Be prepared to refine the schedule throughout data collection as you learn which questions work better.
• Practice skills like asking follow-up questions to get depth and detail. Stay flexible to depart from the schedule when needed.
• Keep questions brief and clear. Avoid multi-part questions that risk confusing interviewees.
• Listen actively during interviews to determine which pre-planned questions can be skipped based on information the participant has already provided.

The key is balancing preparation with the flexibility to adapt questions based on each interview interaction. With practice, you’ll gain skills to conduct productive interviews that obtain rich qualitative data.

The Power of Silence

Strategic use of silence is a key technique to generate interviewee-led data, but it requires judgment about appropriate timing and duration to maintain mutual understanding.

• Unlike ordinary conversation, the interviewer aims to facilitate the interviewee’s contribution without interrupting. This often means resisting the urge to speak at the end of the interviewee’s turn construction units (TCUs).
• Leaving a silence after a TCU encourages the interviewee to provide more material without being led by the interviewer. However, this simple technique requires confidence, as silence can feel socially awkward.
• Allowing longer silences (e.g. 24 seconds) later in interviews can work well, but early on even short silences may disrupt rapport if they cause misalignment between speakers.
• Silence also allows interviewees time to think before answering. Rushing to re-ask or amend questions can limit responses.
• Blunt backchannels like “mm hm” also avoid interrupting flow. Interruptions, especially to finish an interviewee’s turn, are problematic as they make the ownership of perspectives unclear.
• If interviewers incorrectly complete turns, an upside is it can produce extended interviewee narratives correcting the record. However, silence would have been better to let interviewees shape their own accounts.

Recording & Transcription

Design choices.

Design choices around recording and engaging closely with transcripts influence analytic insights, as well as practical feasibility. Weighing up relevant tradeoffs is key.

• Audio recording is standard, but video better captures contextual details, which is useful for some topics/analysis approaches. Participants may find video invasive for sensitive research.
• Digital formats enable the sharing of anonymized clips. Additional microphones reduce audio issues.
• Doing all transcription is time-consuming. Outsourcing can save researcher effort but needs confidentiality assurances. Always carefully check outsourced transcripts.
• Online platform auto-captioning can facilitate rapid analysis, but accuracy limitations mean full transcripts remain ideal. Software cleans up caption file formatting.
• Verbatim transcripts best capture nuanced meaning, but the level of detail needed depends on the analysis approach. Referring back to recordings is still advisable during analysis.
• Transcripts versus recordings highlight different interaction elements. Transcripts make overt disagreements clearer through the wording itself. Recordings better convey tone affiliativeness.

Transcribing Interviews & Focus Groups

Here are the steps for transcribing interviews:

• Play back audio/video files to develop an overall understanding of the interview
• Format the transcription document:
• Add line numbers
• Separate interviewer questions and interviewee responses
• Use formatting like bold, italics, etc. to highlight key passages
• Provide sentence-level clarity in the interviewee’s responses while preserving their authentic voice and word choices
• Break longer passages into smaller paragraphs to help with coding
• If translating the interview to another language, use qualified translators and back-translate where possible
• Select a notation system to indicate pauses, emphasis, laughter, interruptions, etc., and adapt it as needed for your data
• Insert screenshots, photos, or documents discussed in the interview at the relevant point in the transcript
• Read through multiple times, revising formatting and notations
• Double-check the accuracy of transcription against audio/videos
• De-identify transcript by removing identifying participant details

The goal is to produce a formatted written record of the verbal interview exchange that captures the meaning and highlights important passages ready for the coding process. Careful transcription is the vital first step in analysis.

Coding Transcripts

The goal of transcription and coding is to systematically transform interview responses into a set of codes and themes that capture key concepts, experiences and beliefs expressed by participants. Taking care with transcription and coding procedures enhances the validity of qualitative analysis .

• Read through the transcript multiple times to become immersed in the details
• Identify manifest/obvious codes and latent/underlying meaning codes
• Highlight insightful participant quotes that capture key concepts (in vivo codes)
• Create a codebook to organize and define codes with examples
• Use an iterative cycle of inductive (data-driven) coding and deductive (theory-driven) coding
• Refine codebook with clear definitions and examples as you code more transcripts
• Collaborate with other coders to establish the reliability of codes

Ethical Issues

Informed consent.

The participant information sheet must give potential interviewees a good idea of what is involved if taking part in the research.

This will include the general topics covered in the interview, where the interview might take place, how long it is expected to last, how it will be recorded, the ways in which participants’ anonymity will be managed, and incentives offered.

It might be considered good practice to consider true informed consent in interview research to require two distinguishable stages:

• Consent to undertake and record the interview and
• Consent to use the material in research after the interview has been conducted and the content known, or even after the interviewee has seen a copy of the transcript and has had a chance to remove sections, if desired.

Power and Vulnerability

• Early feminist views that sensitivity could equalize power differences are likely naive. The interviewer and interviewee inhabit different knowledge spheres and social categories, indicating structural disparities.
• Power fluctuates within interviews. Researchers rely on participation, yet interviewees control openness and can undermine data collection. Assumptions should be avoided.
• Interviews on sensitive topics may feel like quasi-counseling. Interviewers must refrain from dual roles, instead supplying support service details to all participants.
• Interviewees recruited for trauma experiences may reveal more than anticipated. While generating analytic insights, this risks leaving them feeling exposed.
• Ultimately, power balances resist reconciliation. But reflexively analyzing operations of power serves to qualify rather than nullify situtated qualitative accounts.

Some groups, like those with mental health issues, extreme views, or criminal backgrounds, risk being discredited – treated skeptically by researchers.

This creates tensions with qualitative approaches, often having an empathetic ethos seeking to center subjective perspectives. Analysis should balance openness to offered accounts with critically examining stakes and motivations behind them.

Potter, J., & Hepburn, A. (2005). Qualitative interviews in psychology: Problems and possibilities.  Qualitative research in Psychology ,  2 (4), 281-307.

Houtkoop-Steenstra, H. (2000). Interaction and the standardized survey interview: The living questionnaire . Cambridge University Press

Madill, A. (2011). Interaction in the semi-structured interview: A comparative analysis of the use of and response to indirect complaints. Qualitative Research in Psychology, 8 (4), 333–353.

Maryudi, A., & Fisher, M. (2020). The power in the interview: A practical guide for identifying the critical role of actor interests in environment research. Forest and Society, 4 (1), 142–150

O’Key, V., Hugh-Jones, S., & Madill, A. (2009). Recruiting and engaging with people in deprived locales: Interviewing families about their eating patterns. Social Psychological Review, 11 (20), 30–35.

Puchta, C., & Potter, J. (2004). Focus group practice . Sage.

Schaeffer, N. C. (1991). Conversation with a purpose— Or conversation? Interaction in the standardized interview. In P. P. Biemer, R. M. Groves, L. E. Lyberg, & N. A. Mathiowetz (Eds.), Measurement errors in surveys (pp. 367–391). Wiley.

Silverman, D. (1973). Interview talk: Bringing off a research instrument. Sociology, 7 (1), 31–48.

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Chapter 10: Qualitative Data Collection & Analysis Methods

10.7 Strengths and Weaknesses of Qualitative Interviews

As the preceding sections have suggested, qualitative interviews are an excellent way to gather detailed information. Whatever topic is of interest to the researcher can be explored in much more depth by employing this method than with almost any other method. Not only are participants given the opportunity to elaborate in a way that is not possible with other methods, such as survey research, but, in addition, they are able share information with researchers in their own words and from their own perspectives, rather than attempting to fit those perspectives into the perhaps limited response options provided by the researcher. Because qualitative interviews are designed to elicit detailed information, they are especially useful when a researcher’s aim is to study social processes, or the “how” of various phenomena. Yet another, and sometimes overlooked, benefit of qualitative interviews that occurs in person is that researchers can make observations beyond those that a respondent is orally reporting. A respondent’s body language, and even her or his choice of time and location for the interview, might provide a researcher with useful data.

As with quantitative survey research, qualitative interviews rely on respondents’ ability to accurately and honestly recall whatever details about their lives, circumstances, thoughts, opinions, or behaviors are being examined. Qualitative interviewing is also time-intensive and can be quite expensive. Creating an interview guide, identifying a sample, and conducting interviews are just the beginning of the process. Transcribing interviews is labor-intensive, even before coding begins. It is also not uncommon to offer respondents some monetary incentive or thank-you for participating, because you are asking for more of the participants’ time than if you had mailed them a questionnaire containing closed-ended questions. Conducting qualitative interviews is not only labor intensive but also emotionally taxing. Researchers embarking on a qualitative interview project with a subject that is sensitive in nature should keep in mind their own abilities to listen to stories that may be difficult to hear.

Research Methods for the Social Sciences: An Introduction Copyright © 2020 by Valerie Sheppard is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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Qualitative interviewing is a foundational method in qualitative research and is widely used in health research and the social sciences. Both qualitative semi-structured and in-depth unstructured interviews use verbal communication, mostly in face-to-face interactions, to collect data about the attitudes, beliefs, and experiences of participants. Interviews are an accessible, often affordable, and effective method to understand the socially situated world of research participants. The approach is typically informed by an interpretive framework where the data collected is not viewed as evidence of the truth or reality of a situation or experience but rather a context-bound subjective insight from the participants. The researcher needs to be open to new insights and to privilege the participant’s experience in data collection. The data from qualitative interviews is not generalizable, but its exploratory nature permits the collection of rich data which can answer questions about which little is already known. This chapter introduces the reader to qualitative interviewing, the range of traditions within which interviewing is utilized as a method, and highlights the advantages and some of the challenges and misconceptions in its application. The chapter also provides practical guidance on planning and conducting interview studies. Three case examples are presented to highlight the benefits and risks in the use of interviewing with different participants, providing situated insights as well as advice about how to go about learning to interview if you are a novice.

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Interviewing in Qualitative Research

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Nathan, S., Newman, C., Lancaster, K. (2019). Qualitative Interviewing. In: Liamputtong, P. (eds) Handbook of Research Methods in Health Social Sciences. Springer, Singapore. https://doi.org/10.1007/978-981-10-5251-4_77

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• Published: 05 October 2018

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

• P. Gill 1 &
• J. Baillie 2  

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

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

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

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

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

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Interviews in the social sciences

Professionalism in dentistry: deconstructing common terminology

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

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

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

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

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

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

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

Overview of qualitative research

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

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

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

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

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

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

Types of interview

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

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

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

Conducting an interview

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

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

Greeting and explaining the project/interview

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

Asymmetry between the researcher and participant talking

Expressing interest and cultural ignorance

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

Creating hypothetical situations

Asking friendly questions

Knowing when to leave.

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

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

Box 1: Example of a topic guide

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

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

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

Why did you start cleaning their teeth at that point?

How often do you brush their teeth?

What do you use to brush their teeth and why?

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

Do you find anything difficult?

What makes cleaning their teeth easier for you?

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

Has it become easier or harder?

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

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

What do they enjoy about having their teeth cleaned?

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

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

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

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

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

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

Focus groups

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

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

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

Focus group considerations

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

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

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

Focus group management

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

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

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

Discussions within the group are confidential to the group

Only one person can speak at a time

All participants should have sufficient opportunity to contribute

There should be no unnecessary interruptions while someone is speaking

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

Challenging contrary opinions is appropriate, but ridiculing is not.

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

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

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

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

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

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Interviews in Social Research: Advantages and Disadvantages

Table of Contents

Last Updated on September 11, 2023 by Karl Thompson

An interview involves an interviewer asking questions verbally to a respondent. Interviews involve a more direct interaction between the researcher and the respondent than questionnaires. Interviews can either be conducted face to face, via phone, video link or social media.

This post has primarily been written for students studying the Research Methods aspect of A-level sociology, but it should also be useful for students studying methods for psychology, business studies and maybe other subjects too!

Types of interview

Structured or formal interviews are those in which the interviewer asks the interviewee the same questions in the same way to different respondents. This will typically involve reading out questions from a pre-written and pre-coded structured questionnaire, which forms the interview schedule. The most familiar form of this is with market research, where you may have been stopped on the street with a researcher ticking boxes based on your responses.

Unstructured or Informal interviews (also called discovery interviews) are more like a guided conversation. Here the interviewer has a list of topics they want the respondent to talk about, but the interviewer has complete freedom to vary the specific questions from respondent to respondent, so they can follow whatever lines of enquiry they think are most appropriated, depending on the responses given by each respondent.

Semi-Structured interviews are those in which respondents have a list of questions, but they are free to ask further, differentiated questions based on the responses given. This allows more flexibility that the structured interview yet more structure than the informal interview.

Group interviews – Interviews can be conducted either one to one (individual interviews) or in a a group, in which the interviewer interviews two or more respondents at a time. Group discussions among respondents may lead to deeper insight than just interviewing people along, as respondents ‘encourage’ each other.

Focus groups are a type of group interview in which respondents are asked to discuss certain topics.

Interviews: key terms

The Interview Schedule – A list of questions or topic areas the interviewer wishes to ask or cover in the course of the interview. The more structured the interview, the more rigid the interiew schedule will be. Before conducting an interview it is usual for the reseracher to know something about the topic area and the respondents themselves, and so they will have at least some idea of the questions they are likely to ask: even if they are doing ‘unstructred interviews’ an interviewer will have some kind of interview schedule, even if it is just a list of broad topic areas to discuss, or an opening question.

The problem of Leading Questions – In Unstructured Interviews, the interviewer should aim to avoid asking leading questions.

The Strengths and Limitations of Unstructured Interviews 

The strengths of unstructured interviews

The key strength of unstructured interviews is good validity , but for this to happen questioning should be as open ended as possible to gain genuine, spontaneous information rather than ‘rehearsed responses’ and questioning needs to be sufficient enough to elicit in-depth answers rather than glib, easy answers.

Rapport and empathy – unstructured interviews encourage a good rapport between interviewee and interviewer. Because of their informal nature, like guided conversations, unstructured interviews are more likely to make respondents feel at ease than with the more formal setting of a structured questionnaire or experiment. This should encourage openness, trust and empathy.

They are good for finding out why respondents do not do certain things . For example postal surveys asking why people do not claim benefits have very low response rates, but informal interviews are perfect for researching people who may have low literacy skills.

The Limitations of unstructured interviews

The main theoretical disadvantage is the lack of reliability – unstructured Interviews lack reliability because each interview is unique – a variety of different questions are asked and phrased in a variety of different ways to different respondents.

We also need to keep in mind that interviews can only tap into what people SAY about their values, beliefs and actions, we don’t actually get to see these in action, like we would do with observational studies such as Participant Observation. This has been a particular problem with self-report studies of criminal behaviour. These have been tested using polygraphs, and follow up studies of school and criminal records and responses found to be lacking in validity, so much so that victim-surveys have become the standard method for measuring crime rather than self-report studies.

Sudman and Bradburn (1974) conducted a review of literature and found that responses varied depending on the relative demographics of the interviewer and respondent. For example white interviewers received more socially acceptable responses from black respondents than they did from white respondents. Similar findings have been found with different ethnicities, age, social class and religion.

Practical disadvantages – unstructured Interviews may take a relatively long time to conduct. Some interviews can take hours. They also need to be taped and transcribed, and in the analysis phase there may be a lot of information that is not directly relevant to one’s research topic that needs to be sifted through.

There are few ethical problems , assuming that informed consent is gained and confidentially ensured. Although having said this, the fact that the researcher is getting more in-depth data, more of an insight into who the person really is, does offer the potential for the information to do more harm to the respondent if it got into the wrong hands (but this in turn depends on the topics discussed and the exact content of the interviews.

Sociological perspectives on interviews

Fo r Interactionists , interviews are based on mutual participant observation. The context of the interview is intrinsic to understanding responses and no distinction between research interviews and other social interaction is recognised. Data are valid when mutual understanding between interviewer and respondent is agreed.

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interviews in research advantages and disadvantages

Interviews are a widely used research method that allows researchers to gather valuable information directly from participants. This article explores the advantages and disadvantages of conducting interviews in research, providing insights into the strengths and weaknesses of this approach.

Advantages of Interviews in Research

1. rich and in-depth data:.

Interviews provide researchers with the opportunity to delve deep into a topic and obtain detailed information from participants. Through open-ended questions, researchers can explore various aspects and gain a comprehensive understanding of the subject matter.

2. Flexibility:

Interviews offer flexibility in terms of location, timing, and format. Researchers can choose to conduct interviews face-to-face, over the phone, or even through video conferencing. This flexibility allows for convenience and increases the likelihood of participation.

3. Probing and Clarification:

Unlike other research methods, interviews allow for immediate clarification and probing. Researchers can ask follow-up questions, seek elaboration, or request examples during the interview, ensuring a clearer understanding of the participant’s responses.

4. Personal Connection:

Interviews foster a personal connection between the researcher and the participant. This connection often leads to a greater level of trust, resulting in participants sharing more detailed and honest responses. It also provides an opportunity to observe non-verbal cues, gestures, and emotions that may contribute to the research findings.

5. Adaptability:

Researchers can adapt their interviews based on the participant’s background, knowledge, or cultural context. This adaptability allows for a tailored approach that enhances the quality and relevance of the data obtained.

Disadvantages of Interviews in Research

1. potential for bias:.

Interviews may introduce bias as the researcher’s personal presence and interaction can influence the participant’s responses. Researchers must remain impartial and minimize any potential bias or leading questions.

2. Time-consuming:

Conducting interviews can be time-consuming as it requires scheduling, preparation, execution, and transcription of the recorded data. Researchers must allocate ample time and resources to ensure thorough data collection and analysis.

3. Difficulty in Generalizing Findings:

While interviews provide rich and detailed data, it can be challenging to generalize the findings to a larger population. The sample size is often limited, making it difficult to draw broad conclusions from interview-based research.

4. Interviewer Influence:

The presence and behavior of the interviewer may impact the participant’s responses. Participants might alter their answers based on their perception of the researcher’s expectations, potentially leading to skewed or inaccurate data.

5. Resource-Intensive:

Conducting interviews requires significant resources, including time, manpower, and financial investment. Expenses may include travel costs, transcription services, and compensation for participants, making interviews a more resource-intensive research method.

Benefits of Knowing the Interviews in Research Advantages and Disadvantages

Understanding the advantages and disadvantages of interviews in research can significantly benefit researchers in several ways:

• Improved Research Design: Knowledge of the strengths and limitations of interviews helps researchers design studies that leverage the advantages while mitigating potential drawbacks.
• Informed Decision-Making: Researchers can make informed choices about when to use interviews as a research method and when to employ other techniques better suited to their objectives.
• Data Quality Enhancement: Awareness of the disadvantages allows researchers to implement strategies to minimize bias and increase the reliability and validity of the data collected through interviews.
• Ethical Considerations: Understanding the advantages and disadvantages helps researchers navigate potential ethical dilemmas during the interview process and ensures the protection of participants’ rights and well-being.

In conclusion, interviews offer valuable advantages in research, including rich and in-depth data, flexibility, probing capabilities, personal connection, and adaptability. However, there are also disadvantages to consider, such as the potential for bias, time consumption, difficulty in generalizing findings, interviewer influence, and resource intensiveness. By understanding these advantages and disadvantages, researchers can make more informed decisions, enhance their research methodologies, and ensure the validity and integrity of their findings.

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Qualitative Interview Pros and Cons

Interviews with members and nonmembers can help tell the story behind your quantitative research data, but only if done right. Find out how to make interviews effective and what pitfalls to avoid.

The proliferation of cheap, high-quality online survey tools has revolutionized our ability to conduct surveys to obtain quick snapshots of what our members are thinking. For all but the most complex projects, it is possible to begin and conclude a well-defined study of a subject of interest with the participation of a representative group of members within a 10-day timeframe. Perhaps more than any other development, this technology has made it possible for us to become "data driven" associations, as was put forth in 7 Measures of Success: What Remarkable Associations Do That Others Don't .

At the same time, we need to balance this easy source of quantitative data with a similar easy source of qualitative data. Why? Survey tools do a great job of providing us with definitive numbers and visuals to help tell our story, to ensure that our colleagues or committees understand and buy into our key findings. Databases also provide much better snapshots in the form of statistical reports and charts to help us document usage and sales baselines and trends. But to obtain greater insight into what actually determines these levels and drives changes, we often need to go deeper and directly engage representative members and customers in two-way dialogue. 

Structure and Method for Member Interviews

There are entire books regarding methodology for qualitative interviews, but as associations we often benefit by simplifying them considerably. Here are some suggestions:

Conduct only telephone interviews (rather than face-to-face), prescheduling from a small random sample of the members or other targeted constituency. This allows them to speak at their convenience, although speaking to them at home or on a cellphone undermines the quality of conversation.

Prepare a discussion guide in advance. Rather than treat this as an agenda or survey form, keep it broad and flexible. After all, an interview is two-way communication. The majority of each interview will probably consist of follow-up questions to probe initial responses more deeply.

Use (or be) good interviewers. Effective interviewers (and facilitators) are friendly and open, and they know how to probe effectively. Through active listening, surface level discussions rapidly give way to deeper motivations, and if the interviewer can demonstrate objectivity and candor, he or she can quickly establish a trusting relationship in the interview. You should welcome digressions, and don't worry if every interview is unique. The end product of aggregating all the interviews will be far more robust as a result.

Guarantee confidentiality. Ensure participants that no individual information or attribution will be released to others in transcripts or written reports.

Allow interviews to run long. Even with the shortest guides and most focused of objectives, we often find that interviews run 30 minutes or more. Members rarely get a chance to speak directly with their association. A member who begins an interview emphasizing their time constraints inevitably is the one who will speak the longest.

Don't do too many interviews. Since time is money, structure the interviews as a discrete project, with a limited number of conversations. For any specific topic, we find most issues converge within 10 to 15 interviews—that is, we begin to hear repeated comments and similar thinking so we are not learning much new information from each new conversation. As with all qualitative research, we are generally not trying to establish or force a consensus; instead we want to hear the widest range of perspectives possible and understand why members feel that way.

Strengths of Interviews

Often we think of focus groups when considering qualitative research. Group dynamics are sometimes important to measure, and focus groups have also migrated online to a certain extent, but there are several reasons why in-depth interviews are superior.

Relative absence of bias. Interviews generally have less observer or participant bias. Even a trained moderator will encounter subtle bias in membership focus groups. In associations people often know each other, which can lead to conscious or subconscious posturing or suppression of some comments. Groups may seem to have homogeneous participants, yet some factor differentiates them once they are in the room. For example, we may find while discussing a service with which two people have had negative experiences that they are overly eager to share. If they speak first, it can undermine the perceptions of those who speak later and have had no experiences, or only positive ones. In interviews, the member is rarely trying to impress the interviewer except by trying to be as articulate and well understood as possible.

Built-in flexibility. Although you lose some rapport and communications through phone contact, it is far more cost-effective, allowing you to efficiently conduct interviews back-to-back and to give members who miss an appointment to call back at their convenience. Too often we are constrained in focus groups by having members gathered at a conference or in their local area, which yields a sampling of only our most motivated “super-users” and cognoscenti, or group dynamics reflecting participants who are very familiar with one another.

An interview is two-way communication. The majority of each interview will probably consist of follow-up questions to probe initial responses more deeply.

"Feed" your survey. Often we design surveys based on our assumptions regarding what matters, drawn from internal management perspectives, questions from the last survey, or good ideas a consultant brought in. However, it is harder to get a candid take on current issues that are of greatest concern to members. Conducting interviews as part of the process of designing the survey helps provide timely, titillating observations, unproven hypotheses, and possible hidden connections between attitudes and behavior that you will want to quantify in the survey work.

Enough talk time for members. A 90-minute focus group allows each participant to speak perhaps eight to 10 minutes. Online surveys generally take between five and 15 minutes. Many members may only have only a few minutes of thought to share, but for subjects that do warrant more in-depth discussion and a clear understanding of their background, a 20- to 30-minute period for one person's feedback is more appropriate. Interviews lose a group dynamic, but they also spare interviewees from spending time listening to others—helpful particularly if your members have type A personalities and tend to equate "listening" with "waiting to speak again." (Yes, we all have many of them in our databases!)

Candor and intimacy. Even if you have never spoken to members regarding their inner feelings, don't worry—they will make it easy for you. Often members are flattered to be asked. They make the time to speak with you and they reward you with candor. Sometimes you may not like what you hear, but the more the interviewer plays the role of objective outsider, the better the process will be. As a market research director, I often introduced myself as "acting as an independent researcher today" and that's often all you need in order to pull yourself out of the equation and to put the focus of conversation where it belongs—on the member or customer you're interviewing.

Low-cost and easy interpretation. Even surveys that are easy to administer online require some statistical knowledge to properly interpret. To conduct and analyze, interviews require a finger to dial, an ear to listen, a telephone, and a keyboard or notepad. Like surveys today, interviews can launch in real time, and it is easy to share top-line reports in a day for time-sensitive projects.

Weaknesses of Interviews

Of course, interviews also have inherent weaknesses. These are a few of their  limitations:

Missing objectivity. There is a potential for observer bias in just about all qualitative research. If the people conducting the interviews are staff or service providers who can't maintain a strong sense of objectivity inside and out, the interviewee will pull their punches and not tell the whole truth, or the interpretation of the end results starts to resemble a process of hearing what you want to hear. Be on the lookout for what can be an almost subliminal bias.

Negative reactions. I often found that associations need to be prepared to accept what they hear. Not all of it is pleasant. The kneejerk reaction to negative feedback often can be outright rejection—a belief that the method just wasn't reliable enough. This may be true, but it is important to balance a sudden keen interest in valid methodology with an urgent need to cover one's backside. We are often politically sensitive and very PC, and when interviewees take advantage of glasnost to say exactly what they feel, it can be jarring. Sometimes you will need to smooth off the rough edges and edit the unadulterated stream of feedback, unless you are a big fan of Impromptu Job Loss or like being perceived as a traitor when you're only the messenger.

Open-endedness. Digressions and lack of standardization across interviews can be a good or a bad thing. When you try to make interviews "sum up" to a consensus or quantify them, you'll be disappointed. To push for consensus is to force interviews to do something they don't do well. It is best to accept this limitation, even to the point of managing your interviewee's expectations upfront. Sometimes an interviewee will refer to our "phone survey" and we gently correct them, since survey implies a rigid format. Interviews often yield digressions into arcane specialties, heretical opinions, conspiracy theories, and wildly inventive suggestions that each represent a unique viewpoint.

Subject to these caveats, qualitative interviews can be a valuable tool to help inform most association problems. Like some people we know, the feedback we receive may be amorphous, messy, and sometimes contradictory. However, regular use of the method can improve member and customer relations and provide a critical additional source of intelligence that we rarely obtain otherwise.

Editor’s Note: This article, originally published in 2009, has been updated.

Kevin Whorton is principal of Whorton Marketing & Research in Silver Spring, Maryland.

Email: [email protected]                       

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Advantages and Disadvantages of Interview in Research

Approaching the Respondent- according to the Interviewer’s Manual, the introductory tasks of the interviewer are: tell the interviewer is and whom he or she represents; telling him about what the study is, in a way to stimulate his interest. The interviewer has also ensured at this stage that his answers are confidential; tell the respondent how he was chosen; use letters and clippings of surveys in order to show the importance of the study to the respondent. The interviewer must be adaptable, friendly, responsive, and should make the interviewer feel at ease to say anything, even if it is irrelevant.

Dealing with Refusal- there can be plenty of reasons for refusing for an interview, for example, a respondent may feel that surveys are a waste of time, or may express anti-government feeling. It is the interviewer’s job to determine the reason for the refusal of the interview and attempt to overcome it.

Conducting the Interview- the questions should be asked as worded for all respondents in order to avoid misinterpretation of the question. Clarification of the question should also be avoided for the same reason. However, the questions can be repeated in case of misunderstanding. The questions should be asked in the same order as mentioned in the questionnaire, as a particular question might not make sense if the questions before they are skipped. The interviewers must be very careful to be neutral before starting the interview so as not to lead the respondent, hence minimizing bias.

listing out the advantages of interview studies, which are noted below:

There are certain disadvantages of interview studies as well which are:.

INTERVIEW AS SOCIAL INTERACTION

The interview subjects to the same rules and regulations of other instances of social interaction. It is believed that conducting interview studies has possibilities for all sorts of bias, inconsistency, and inaccuracies and hence many researchers are critical of the surveys and interviews. T.R. William says that in certain societies there may be patterns of people saying one thing, but doing another. He also believes that the responses should be interpreted in context and two social contexts should not be compared to each other. Derek L. Phillips says that the survey method itself can manipulate the data, and show the results that actually does not exist in the population in real. Social research becomes very difficult due to the variability in human behavior and attitude. Other errors that can be caused in social research include-

Apart from the errors caused by the responder, there are also certain errors made by the interviewers that may include-

Bailey, K. (1994). Interview Studies in Methods of social research. Simonand Schuster, 4th ed. The Free Press, New York NY 10020.Ch8. Pp.173-213.

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Presenting and Evaluating Qualitative Research

The purpose of this paper is to help authors to think about ways to present qualitative research papers in the American Journal of Pharmaceutical Education . It also discusses methods for reviewers to assess the rigour, quality, and usefulness of qualitative research. Examples of different ways to present data from interviews, observations, and focus groups are included. The paper concludes with guidance for publishing qualitative research and a checklist for authors and reviewers.

INTRODUCTION

Policy and practice decisions, including those in education, increasingly are informed by findings from qualitative as well as quantitative research. Qualitative research is useful to policymakers because it often describes the settings in which policies will be implemented. Qualitative research is also useful to both pharmacy practitioners and pharmacy academics who are involved in researching educational issues in both universities and practice and in developing teaching and learning.

Qualitative research involves the collection, analysis, and interpretation of data that are not easily reduced to numbers. These data relate to the social world and the concepts and behaviors of people within it. Qualitative research can be found in all social sciences and in the applied fields that derive from them, for example, research in health services, nursing, and pharmacy. 1 It looks at X in terms of how X varies in different circumstances rather than how big is X or how many Xs are there? 2 Textbooks often subdivide research into qualitative and quantitative approaches, furthering the common assumption that there are fundamental differences between the 2 approaches. With pharmacy educators who have been trained in the natural and clinical sciences, there is often a tendency to embrace quantitative research, perhaps due to familiarity. A growing consensus is emerging that sees both qualitative and quantitative approaches as useful to answering research questions and understanding the world. Increasingly mixed methods research is being carried out where the researcher explicitly combines the quantitative and qualitative aspects of the study. 3 , 4

Like healthcare, education involves complex human interactions that can rarely be studied or explained in simple terms. Complex educational situations demand complex understanding; thus, the scope of educational research can be extended by the use of qualitative methods. Qualitative research can sometimes provide a better understanding of the nature of educational problems and thus add to insights into teaching and learning in a number of contexts. For example, at the University of Nottingham, we conducted in-depth interviews with pharmacists to determine their perceptions of continuing professional development and who had influenced their learning. We also have used a case study approach using observation of practice and in-depth interviews to explore physiotherapists' views of influences on their leaning in practice. We have conducted in-depth interviews with a variety of stakeholders in Malawi, Africa, to explore the issues surrounding pharmacy academic capacity building. A colleague has interviewed and conducted focus groups with students to explore cultural issues as part of a joint Nottingham-Malaysia pharmacy degree program. Another colleague has interviewed pharmacists and patients regarding their expectations before and after clinic appointments and then observed pharmacist-patient communication in clinics and assessed it using the Calgary Cambridge model in order to develop recommendations for communication skills training. 5 We have also performed documentary analysis on curriculum data to compare pharmacist and nurse supplementary prescribing courses in the United Kingdom.

It is important to choose the most appropriate methods for what is being investigated. Qualitative research is not appropriate to answer every research question and researchers need to think carefully about their objectives. Do they wish to study a particular phenomenon in depth (eg, students' perceptions of studying in a different culture)? Or are they more interested in making standardized comparisons and accounting for variance (eg, examining differences in examination grades after changing the way the content of a module is taught). Clearly a quantitative approach would be more appropriate in the last example. As with any research project, a clear research objective has to be identified to know which methods should be applied.

Types of qualitative data include:

• Audio recordings and transcripts from in-depth or semi-structured interviews
• Structured interview questionnaires containing substantial open comments including a substantial number of responses to open comment items.
• Audio recordings and transcripts from focus group sessions.
• Field notes (notes taken by the researcher while in the field [setting] being studied)
• Video recordings (eg, lecture delivery, class assignments, laboratory performance)
• Case study notes
• Documents (reports, meeting minutes, e-mails)
• Diaries, video diaries
• Observation notes
• Press clippings
• Photographs

RIGOUR IN QUALITATIVE RESEARCH

Qualitative research is often criticized as biased, small scale, anecdotal, and/or lacking rigor; however, when it is carried out properly it is unbiased, in depth, valid, reliable, credible and rigorous. In qualitative research, there needs to be a way of assessing the “extent to which claims are supported by convincing evidence.” 1 Although the terms reliability and validity traditionally have been associated with quantitative research, increasingly they are being seen as important concepts in qualitative research as well. Examining the data for reliability and validity assesses both the objectivity and credibility of the research. Validity relates to the honesty and genuineness of the research data, while reliability relates to the reproducibility and stability of the data.

The validity of research findings refers to the extent to which the findings are an accurate representation of the phenomena they are intended to represent. The reliability of a study refers to the reproducibility of the findings. Validity can be substantiated by a number of techniques including triangulation use of contradictory evidence, respondent validation, and constant comparison. Triangulation is using 2 or more methods to study the same phenomenon. Contradictory evidence, often known as deviant cases, must be sought out, examined, and accounted for in the analysis to ensure that researcher bias does not interfere with or alter their perception of the data and any insights offered. Respondent validation, which is allowing participants to read through the data and analyses and provide feedback on the researchers' interpretations of their responses, provides researchers with a method of checking for inconsistencies, challenges the researchers' assumptions, and provides them with an opportunity to re-analyze their data. The use of constant comparison means that one piece of data (for example, an interview) is compared with previous data and not considered on its own, enabling researchers to treat the data as a whole rather than fragmenting it. Constant comparison also enables the researcher to identify emerging/unanticipated themes within the research project.

STRENGTHS AND LIMITATIONS OF QUALITATIVE RESEARCH

Qualitative researchers have been criticized for overusing interviews and focus groups at the expense of other methods such as ethnography, observation, documentary analysis, case studies, and conversational analysis. Qualitative research has numerous strengths when properly conducted.

Strengths of Qualitative Research

• Issues can be examined in detail and in depth.
• Interviews are not restricted to specific questions and can be guided/redirected by the researcher in real time.
• The research framework and direction can be quickly revised as new information emerges.
• The data based on human experience that is obtained is powerful and sometimes more compelling than quantitative data.
• Subtleties and complexities about the research subjects and/or topic are discovered that are often missed by more positivistic enquiries.
• Data usually are collected from a few cases or individuals so findings cannot be generalized to a larger population. Findings can however be transferable to another setting.

Limitations of Qualitative Research

• Research quality is heavily dependent on the individual skills of the researcher and more easily influenced by the researcher's personal biases and idiosyncrasies.
• Rigor is more difficult to maintain, assess, and demonstrate.
• The volume of data makes analysis and interpretation time consuming.
• It is sometimes not as well understood and accepted as quantitative research within the scientific community
• The researcher's presence during data gathering, which is often unavoidable in qualitative research, can affect the subjects' responses.
• Issues of anonymity and confidentiality can present problems when presenting findings
• Findings can be more difficult and time consuming to characterize in a visual way.

PRESENTATION OF QUALITATIVE RESEARCH FINDINGS

The following extracts are examples of how qualitative data might be presented:

Data From an Interview.

The following is an example of how to present and discuss a quote from an interview.

The researcher should select quotes that are poignant and/or most representative of the research findings. Including large portions of an interview in a research paper is not necessary and often tedious for the reader. The setting and speakers should be established in the text at the end of the quote.

The student describes how he had used deep learning in a dispensing module. He was able to draw on learning from a previous module, “I found that while using the e learning programme I was able to apply the knowledge and skills that I had gained in last year's diseases and goals of treatment module.” (interviewee 22, male)

This is an excerpt from an article on curriculum reform that used interviews 5 :

The first question was, “Without the accreditation mandate, how much of this curriculum reform would have been attempted?” According to respondents, accreditation played a significant role in prompting the broad-based curricular change, and their comments revealed a nuanced view. Most indicated that the change would likely have occurred even without the mandate from the accreditation process: “It reflects where the profession wants to be … training a professional who wants to take on more responsibility.” However, they also commented that “if it were not mandated, it could have been a very difficult road.” Or it “would have happened, but much later.” The change would more likely have been incremental, “evolutionary,” or far more limited in its scope. “Accreditation tipped the balance” was the way one person phrased it. “Nobody got serious until the accrediting body said it would no longer accredit programs that did not change.”

Data From Observations

The following example is some data taken from observation of pharmacist patient consultations using the Calgary Cambridge guide. 6 , 7 The data are first presented and a discussion follows:

Pharmacist: We will soon be starting a stop smoking clinic. Patient: Is the interview over now? Pharmacist: No this is part of it. (Laughs) You can't tell me to bog off (sic) yet. (pause) We will be starting a stop smoking service here, Patient: Yes. Pharmacist: with one-to-one and we will be able to help you or try to help you. If you want it. In this example, the pharmacist has picked up from the patient's reaction to the stop smoking clinic that she is not receptive to advice about giving up smoking at this time; in fact she would rather end the consultation. The pharmacist draws on his prior relationship with the patient and makes use of a joke to lighten the tone. He feels his message is important enough to persevere but he presents the information in a succinct and non-pressurised way. His final comment of “If you want it” is important as this makes it clear that he is not putting any pressure on the patient to take up this offer. This extract shows that some patient cues were picked up, and appropriately dealt with, but this was not the case in all examples.

Data From Focus Groups

This excerpt from a study involving 11 focus groups illustrates how findings are presented using representative quotes from focus group participants. 8

Those pharmacists who were initially familiar with CPD endorsed the model for their peers, and suggested it had made a meaningful difference in the way they viewed their own practice. In virtually all focus groups sessions, pharmacists familiar with and supportive of the CPD paradigm had worked in collaborative practice environments such as hospital pharmacy practice. For these pharmacists, the major advantage of CPD was the linking of workplace learning with continuous education. One pharmacist stated, “It's amazing how much I have to learn every day, when I work as a pharmacist. With [the learning portfolio] it helps to show how much learning we all do, every day. It's kind of satisfying to look it over and see how much you accomplish.” Within many of the learning portfolio-sharing sessions, debates emerged regarding the true value of traditional continuing education and its outcome in changing an individual's practice. While participants appreciated the opportunity for social and professional networking inherent in some forms of traditional CE, most eventually conceded that the academic value of most CE programming was limited by the lack of a systematic process for following-up and implementing new learning in the workplace. “Well it's nice to go to these [continuing education] events, but really, I don't know how useful they are. You go, you sit, you listen, but then, well I at least forget.”

The following is an extract from a focus group (conducted by the author) with first-year pharmacy students about community placements. It illustrates how focus groups provide a chance for participants to discuss issues on which they might disagree.

Interviewer: So you are saying that you would prefer health related placements? Student 1: Not exactly so long as I could be developing my communication skill. Student 2: Yes but I still think the more health related the placement is the more I'll gain from it. Student 3: I disagree because other people related skills are useful and you may learn those from taking part in a community project like building a garden. Interviewer: So would you prefer a mixture of health and non health related community placements?

GUIDANCE FOR PUBLISHING QUALITATIVE RESEARCH

Qualitative research is becoming increasingly accepted and published in pharmacy and medical journals. Some journals and publishers have guidelines for presenting qualitative research, for example, the British Medical Journal 9 and Biomedcentral . 10 Medical Education published a useful series of articles on qualitative research. 11 Some of the important issues that should be considered by authors, reviewers and editors when publishing qualitative research are discussed below.

Introduction.

A good introduction provides a brief overview of the manuscript, including the research question and a statement justifying the research question and the reasons for using qualitative research methods. This section also should provide background information, including relevant literature from pharmacy, medicine, and other health professions, as well as literature from the field of education that addresses similar issues. Any specific educational or research terminology used in the manuscript should be defined in the introduction.

The methods section should clearly state and justify why the particular method, for example, face to face semistructured interviews, was chosen. The method should be outlined and illustrated with examples such as the interview questions, focusing exercises, observation criteria, etc. The criteria for selecting the study participants should then be explained and justified. The way in which the participants were recruited and by whom also must be stated. A brief explanation/description should be included of those who were invited to participate but chose not to. It is important to consider “fair dealing,” ie, whether the research design explicitly incorporates a wide range of different perspectives so that the viewpoint of 1 group is never presented as if it represents the sole truth about any situation. The process by which ethical and or research/institutional governance approval was obtained should be described and cited.

The study sample and the research setting should be described. Sampling differs between qualitative and quantitative studies. In quantitative survey studies, it is important to select probability samples so that statistics can be used to provide generalizations to the population from which the sample was drawn. Qualitative research necessitates having a small sample because of the detailed and intensive work required for the study. So sample sizes are not calculated using mathematical rules and probability statistics are not applied. Instead qualitative researchers should describe their sample in terms of characteristics and relevance to the wider population. Purposive sampling is common in qualitative research. Particular individuals are chosen with characteristics relevant to the study who are thought will be most informative. Purposive sampling also may be used to produce maximum variation within a sample. Participants being chosen based for example, on year of study, gender, place of work, etc. Representative samples also may be used, for example, 20 students from each of 6 schools of pharmacy. Convenience samples involve the researcher choosing those who are either most accessible or most willing to take part. This may be fine for exploratory studies; however, this form of sampling may be biased and unrepresentative of the population in question. Theoretical sampling uses insights gained from previous research to inform sample selection for a new study. The method for gaining informed consent from the participants should be described, as well as how anonymity and confidentiality of subjects were guaranteed. The method of recording, eg, audio or video recording, should be noted, along with procedures used for transcribing the data.

Data Analysis.

A description of how the data were analyzed also should be included. Was computer-aided qualitative data analysis software such as NVivo (QSR International, Cambridge, MA) used? Arrival at “data saturation” or the end of data collection should then be described and justified. A good rule when considering how much information to include is that readers should have been given enough information to be able to carry out similar research themselves.

One of the strengths of qualitative research is the recognition that data must always be understood in relation to the context of their production. 1 The analytical approach taken should be described in detail and theoretically justified in light of the research question. If the analysis was repeated by more than 1 researcher to ensure reliability or trustworthiness, this should be stated and methods of resolving any disagreements clearly described. Some researchers ask participants to check the data. If this was done, it should be fully discussed in the paper.

An adequate account of how the findings were produced should be included A description of how the themes and concepts were derived from the data also should be included. Was an inductive or deductive process used? The analysis should not be limited to just those issues that the researcher thinks are important, anticipated themes, but also consider issues that participants raised, ie, emergent themes. Qualitative researchers must be open regarding the data analysis and provide evidence of their thinking, for example, were alternative explanations for the data considered and dismissed, and if so, why were they dismissed? It also is important to present outlying or negative/deviant cases that did not fit with the central interpretation.

The interpretation should usually be grounded in interviewees or respondents' contributions and may be semi-quantified, if this is possible or appropriate, for example, “Half of the respondents said …” “The majority said …” “Three said…” Readers should be presented with data that enable them to “see what the researcher is talking about.” 1 Sufficient data should be presented to allow the reader to clearly see the relationship between the data and the interpretation of the data. Qualitative data conventionally are presented by using illustrative quotes. Quotes are “raw data” and should be compiled and analyzed, not just listed. There should be an explanation of how the quotes were chosen and how they are labeled. For example, have pseudonyms been given to each respondent or are the respondents identified using codes, and if so, how? It is important for the reader to be able to see that a range of participants have contributed to the data and that not all the quotes are drawn from 1 or 2 individuals. There is a tendency for authors to overuse quotes and for papers to be dominated by a series of long quotes with little analysis or discussion. This should be avoided.

Participants do not always state the truth and may say what they think the interviewer wishes to hear. A good qualitative researcher should not only examine what people say but also consider how they structured their responses and how they talked about the subject being discussed, for example, the person's emotions, tone, nonverbal communication, etc. If the research was triangulated with other qualitative or quantitative data, this should be discussed.

Discussion.

The findings should be presented in the context of any similar previous research and or theories. A discussion of the existing literature and how this present research contributes to the area should be included. A consideration must also be made about how transferrable the research would be to other settings. Any particular strengths and limitations of the research also should be discussed. It is common practice to include some discussion within the results section of qualitative research and follow with a concluding discussion.

The author also should reflect on their own influence on the data, including a consideration of how the researcher(s) may have introduced bias to the results. The researcher should critically examine their own influence on the design and development of the research, as well as on data collection and interpretation of the data, eg, were they an experienced teacher who researched teaching methods? If so, they should discuss how this might have influenced their interpretation of the results.

Conclusion.

The conclusion should summarize the main findings from the study and emphasize what the study adds to knowledge in the area being studied. Mays and Pope suggest the researcher ask the following 3 questions to determine whether the conclusions of a qualitative study are valid 12 : How well does this analysis explain why people behave in the way they do? How comprehensible would this explanation be to a thoughtful participant in the setting? How well does the explanation cohere with what we already know?

CHECKLIST FOR QUALITATIVE PAPERS

This paper establishes criteria for judging the quality of qualitative research. It provides guidance for authors and reviewers to prepare and review qualitative research papers for the American Journal of Pharmaceutical Education . A checklist is provided in Appendix 1 to assist both authors and reviewers of qualitative data.

ACKNOWLEDGEMENTS

Thank you to the 3 reviewers whose ideas helped me to shape this paper.

Appendix 1. Checklist for authors and reviewers of qualitative research.

Introduction

• □ Research question is clearly stated.
• □ Research question is justified and related to the existing knowledge base (empirical research, theory, policy).
• □ Any specific research or educational terminology used later in manuscript is defined.
• □ The process by which ethical and or research/institutional governance approval was obtained is described and cited.
• □ Reason for choosing particular research method is stated.
• □ Criteria for selecting study participants are explained and justified.
• □ Recruitment methods are explicitly stated.
• □ Details of who chose not to participate and why are given.
• □ Study sample and research setting used are described.
• □ Method for gaining informed consent from the participants is described.
• □ Maintenance/Preservation of subject anonymity and confidentiality is described.
• □ Method of recording data (eg, audio or video recording) and procedures for transcribing data are described.
• □ Methods are outlined and examples given (eg, interview guide).
• □ Decision to stop data collection is described and justified.
• □ Data analysis and verification are described, including by whom they were performed.
• □ Methods for identifying/extrapolating themes and concepts from the data are discussed.
• □ Sufficient data are presented to allow a reader to assess whether or not the interpretation is supported by the data.
• □ Outlying or negative/deviant cases that do not fit with the central interpretation are presented.
• □ Transferability of research findings to other settings is discussed.
• □ Findings are presented in the context of any similar previous research and social theories.
• □ Discussion often is incorporated into the results in qualitative papers.
• □ A discussion of the existing literature and how this present research contributes to the area is included.
• □ Any particular strengths and limitations of the research are discussed.
• □ Reflection of the influence of the researcher(s) on the data, including a consideration of how the researcher(s) may have introduced bias to the results is included.

Conclusions

• □ The conclusion states the main finings of the study and emphasizes what the study adds to knowledge in the subject area.

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Research Methods Guide: Interview Research

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Tutorial Videos: Interview Method

Interview as a Method for Qualitative Research

Goals of Interview Research

• Preferences
• They help you explain, better understand, and explore research subjects' opinions, behavior, experiences, phenomenon, etc.
• Interview questions are usually open-ended questions so that in-depth information will be collected.

Mode of Data Collection

There are several types of interviews, including:

• Face-to-Face
• Online (e.g. Skype, Googlehangout, etc)

FAQ: Conducting Interview Research

What are the important steps involved in interviews?

• Think about who you will interview
• Think about what kind of information you want to obtain from interviews
• Think about why you want to pursue in-depth information around your research topic
• Introduce yourself and explain the aim of the interview
• Devise your questions so interviewees can help answer your research question
• Have a sequence to your questions / topics by grouping them in themes
• Make sure you can easily move back and forth between questions / topics
• Make sure your questions are clear and easy to understand
• Do not ask leading questions
• Do you want to bring a second interviewer with you?
• Do you want to bring a notetaker?
• Do you want to record interviews? If so, do you have time to transcribe interview recordings?
• Where will you interview people? Where is the setting with the least distraction?
• How long will each interview take?
• Do you need to address terms of confidentiality?

Do I have to choose either a survey or interviewing method?

No.  In fact, many researchers use a mixed method - interviews can be useful as follow-up to certain respondents to surveys, e.g., to further investigate their responses.

Is training an interviewer important?

Yes, since the interviewer can control the quality of the result, training the interviewer becomes crucial.  If more than one interviewers are involved in your study, it is important to have every interviewer understand the interviewing procedure and rehearse the interviewing process before beginning the formal study.

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Strengths and Weaknesses of Qualitative Interviews

As the preceding sections have suggested, qualitative interviews are an excellent way to gather detailed information. Whatever topic is of interest to the researcher employing this method can be explored in much more depth than with almost any other method. Not only are participants given the opportunity to elaborate in a way that is not possible with other methods such as survey research, but they also are able share information with researchers in their own words and from their own perspectives rather than being asked to fit those perspectives into the perhaps limited response options provided by the researcher. And because qualitative interviews are designed to elicit detailed information, they are especially useful when a researcher’s aim is to study social processes, or the “how” of various phenomena. Yet another, and sometimes overlooked, benefit of qualitative interviews that occurs in person is that researchers can make observations beyond those that a respondent is orally reporting. A respondent’s body language, and even her or his choice of time and location for the interview, might provide a researcher with useful data.

Of course, all these benefits do not come without some drawbacks. As with quantitative survey research, qualitative interviews rely on respondents’ ability to accurately and honestly recall whatever details about their lives, circumstances, thoughts, opinions, or behaviors that are being asked about. As Esterberg (2002) puts it, “If you want to know about what people actually do, rather than what they say they do, you should probably use observation [instead of interviews].” 1 Further, as you may have already guessed, qualitative interviewing is time intensive and can be quite expensive. Creating an interview guide, identifying a sample, and conducting interviews are just the beginning. Transcribing interviews is labor intensive—and that’s before coding even begins. It is also not uncommon to offer respondents some monetary incentive or thank-you for participating. Keep in mind that you are asking for more of participants’ time than if you’d simply mailed them a questionnaire containing closed-ended questions. Conducting qualitative interviews is not only labor intensive but also emotionally taxing. When I interviewed young workers about their sexual harassment experiences, I heard stories that were shocking, infuriating, and sad. Seeing and hearing the impact that harassment had had on respondents was difficult. Researchers embarking on a qualitative interview project should keep in mind their own abilities to hear stories that may be difficult to hear.

KEY TAKEAWAYS

• In-depth interviews are semi-structured interviews where the researcher has topics and questions in mind to ask, but questions are open ended and flow according to how the participant responds to each.
• Interview guides can vary in format but should contain some outline of the topics you hope to cover during the course of an interview.
• NVivo and Atlasti are computer programs that qualitative researchers use to help them with organizing, sorting, and analyzing their data.
• Qualitative interviews allow respondents to share information in their own words and are useful for gathering detailed information and understanding social processes.
• Drawbacks of qualitative interviews include reliance on respondents’ accuracy and their intensity in terms of time, expense, and possible emotional strain.
• Based on a research question you have identified through earlier exercises in this text, write a few open-ended questions you could ask were you to conduct in-depth interviews on the topic. Now critique your questions. Are any of them yes/no questions? Are any of them leading?
• Read the open-ended questions you just created, and answer them as though you were an interview participant. Were your questions easy to answer or fairly difficult? How did you feel talking about the topics you asked yourself to discuss? How might respondents feel talking about them?
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The interview method: advantages and limitations | social research.

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After reading this article you will learn about the advantages and disadvantages of the interview method of conducting social research.

Advantages of the Interview Method :

(1) The personal interviews, compared especially to questionnaires usually yield a high percentage of returns.

(2) The interview method can be made to yield an almost perfect sample of the general population because practically everyone can be reached by and can respond to this approach. It will be remembered that the questionnaire approach is severely limited by the fact that only the literate persons can be covered by it.

Again, the observational approach is also subject to limitations because many things or facts cannot be observed on the spot.

(3) The information secured through interviews is likely to be more correct compared to that secured through other techniques. The interviewer who is present on the spot can clear up the seemingly inaccurate or irrelevant answers by explaining the questions to the informant. If the informant deliberately falsifies replies, the interviewer is able to effectively check them and use special devices to verify the replies.

(4) The interviewer can collect supplementary information about the informant’s personal characteristics and environment which is often of great value in interpreting results. Interview is a much more flexible approach, allowing for posing of new questions or check-questions if such a need arises.

Its flexibility makes the interview a superior technique for the exploration of areas where there is little basis for knowing what questions to ask and how to formulate them.

(5) In as much as the interviewer is present on the spot, he can observe the facial expressions and gestures etc., of the informants as also the existing pressures obtaining in the interview-situation. The facility of such observations helps the interviewer to evaluate the meaning of the verbal replies given by informants.

For example, hesitation, particular inhibitive reactions etc., may give rise to certain doubts about the reliability of the responses and the interviewer may then ask indirect questions to verify his doubts.

(6) Scoring and test-devices can be used, the interviewer acting as experimenter. At the same time, visual stimuli to which the informant may react can be presented.

(7) The use of interview method ensures greater number of usable returns compared to other methods. Returned visits to complete items on the schedule or to correct mistakes can usually be made without annoying the informant.

(8) The interviewer can usually control which person or persons will answer the questions. This is not possible in the mailed questionnaire approach. If so desired and warranted group discussions may also be held.

(9) A personal interview may take long enough to allow the informant to become oriented to the topic under investigation. Thus, recall of relevant information is facilitated. The informant can be made to devote more time if, as is the case, the interviewer is present on the spot to elicit and record the information.

The interviewer’s presence is a double headed weapon, the advantageous aspect of it being that face-to-face contact provides enough stimulation to the respondent to probe deeper within himself. As we have suggested, interviewer acts as a catalyst.

(10) The interviewer may catch the informant off his guard and thus secure the most spontaneous reactions than would be the case if mailed questionnaire were used.

(11) The interview method allows for many facilities which aid on the spot adjustments and thus ensure rich response material. For example, the interviewer can carefully sandwich the questions about which the informant is likely to be sensitive.

The interviewer can also change the subject by observing informant’s reactions or give explanations if the interviewee needs them. In other words, a delicate situation can usually be handled more effectively by personal interview method.

(12) The language of the interview can be adapted to the ability or educational level of the person interviewed. Therefore, it is comparatively easy to avoid misinterpretations or misleading questions.

(13) The interview is a more appropriate technique for revealing information about complex, emotionally-laden subjects or for probing the sentiments underlying an expressed opinion.

Major Limitations of the Interview Method :

(1) In terms of cost, energy and time, the interview approach poses a heavy demand. The transportation cost and the time required to cover addresses in a large area as also possibility of non-availability or ‘not at home’, may make the interview method uneconomical and often inoperable.

(2) The efficacy of interviews depends on a thorough training and skill of interviewers as also on a rigorous supervision over them. Failing this, data recorded may be inaccurate and incomplete.

(3) The human equation may distort the returns. If an interviewer has a certain bias, he may unconsciously devise questions so as to secure confirmation of his views.

(4) The presence of the interviewer on the spot may over stimulate the respondent, sometimes even to the extent that he may give imaginary information just to make it interesting. He may tell things about which he may not himself be very sure.

He may also get emotionally involved with the interviewer and give answers that he anticipates would please the interviewer. It is also possible that the interviewer’s presence may inhibit free responses because there is no anonymity. The respondent may hesitate to give correct answers for the fear that it would adversely affect his image. Some fear of this information being used against him may grip him.

(5) In the interview method, the organization required for selecting, training and supervising a field staff is more complex.

(6) It is the usual experience that costs per interview are higher when field investigators are employed. This is especially so when the area to be covered is widely spread out.

(7) The personal interview usually takes more time. Sometimes, the interview lasts for hours on end and the interviewer cannot check the free flow of the respondent’s replies for fear that it may disrupt the ‘rapport.’ Added to this is the time spent for journeys to and fro to the addresses and the possibility of not always being able to meet them.

(8) Effective interview presupposes proper rapport with the respondent and controlling of interview atmosphere in a manner that would facilitate free and frank responses. This is often a very difficult requirement, it needs time, skills and often resources.

Secondly, it is not always possible for the interviewer to judge whether the interview atmosphere is how it should ideally be and whether or not ‘rapport’ has been established.

(9) Interviewing may also introduce systematic errors. For example, if the interviews are conducted at their homes during the day, a majority of informants will be housewives. Now if the information is to be obtained from the male members, most of the field-work will have to be done in the evening or on holidays. If this be the case, only a few hours can be used per week for interviewing.

(10) Many actions human beings carry out are not easily verbalized, but easily observed. Through observation a social process may be followed as it develops. Verbal techniques such as interview may give valuable reports, but post hoc, unless one is dealing with rather unusual respondents capable of acting and being interviewed at the same time.

Some of the prerequisites that ensure successful interviewing. The quality of interviewing depends, firstly on a proper study-design. It should be noted that even the most skilled interviewer will not be able to collect valid and useful data, if the schedule of questions is inadequate or unrelated to the objectives of research.

If a well-designed, standardized schedule can elicit the required information, a staff of ordinary men and women, properly selected, and trained, can serve well enough.

Within the limits of a study-design, there is some room for the art of interviewing to come into play. Interviewing is an art governed by certain scientific principles. The interviewer’s art consists in creating a situation wherein the respondents’ answers will be reliable and valid.

This ideal requires a permissive situation in which the respondent is encouraged to voice his frank opinion without the fear of his attitudes being revealed to others.

The basic requirement of successful interviewing, understandably, is to create a friendly atmosphere; on of trust and confidence that will put the respondent at ease. Through subsequent stages, the interviewer’s art consists in asking questions properly and intelligently, in obtaining a valid and meaningful response and in recording the responses accurately and completely.

Let us consider how the interviewer can create a friendly interview atmosphere. It is the interviewer’s approach that really does the trick. The interviewer should introduce himself briefly and explain clearly the purpose of his study.

Interviewer’s approach should be positive. His aim should be to interview everyone included in the sample. It is possible that a small proportion of respondents will be suspicious or hostile and the large number may require a little encouragement and persuasion.

Many people ar6 flattered to be selected for an interview. The interviewer should answer any legitimate questions and clear any doubt the respondent has. He should also if need be, explain that the respondent should not be afraid of being identified and that interview is not a test and that the interviewer just wants to know how people feel about certain issues and the only way to find out, is to ask them.

The interviewer’s manners should be friendly, courteous, conversational and unbiased. He should represent the golden mean — neither too grim, nor too effusive, neither too talkative nor too timid. The main idea should be to put the respondent at ease so that he will talk freely and fully.

It helps if the interview starts with the casual conversation about weather, pets or children. An informal conversational interview, above all, is dependent upon a thorough mastery by the interviewer over the actual questions in the schedule.

He should be able to ask them conversationally rather than real them stiffly. He should know what questions are coming next so that there will be no awkward disruption of smooth interaction. Fundamentally, the interviewer’s job is that of a reporter.

He should not act as an adviser, custodian of morality, curio-seeker or debator. He should not show surprise or disapproval of a respondent’s answer. He should show an interested disposition toward his respondent’s opinion. On his own, he should never divulge his own. The interviewer must keep the direction of interview in his Own hand, discouraging irrelevant conversation and trying to keep the respondent on the track.

Next, we turn to consider how the interviewer should ask his questions. The interviewer must be alert to the importance of asking each question exactly as it is worded unless the interview is unstructured. Interviewers should remember that even a slight rewording of a question can so change the stimulus as to elicit answers in a different frame of reference.

The interviewer should refrain from giving unwarranted explanation of questions because this also may change the frame of reference, or inject bias into the response. If each interviewer were permitted to vary the questions according to his sweet will, the resulting responses recorded by different interviewers may not be comparable.

If at all the interviewer has to offer any explanation to the respondents, he should offer only those that he has specifically been authorized to do. Should the respondent fail to understand the question, the interviewer may advisedly repeat it slowly and with proper emphasis.

Questions must be asked in the sequence they appear on the schedule. Varying this order will change the respondent’s frame of reference since each question sets up a frame of reference for the following questions. Thus, if the sequences vary from interviewer to interviewer, the responses will not be comparable. The interviewer must make it a point to ask every question, unless directions permit skipping a few.

It may seem that the respondent has given his opinion on a subsequent question in answering an earlier question, but he must nevertheless ask the question in order to be sure.

A question may appear to be naive or inapplicable but the interviewer should never omit asking it. Wherever necessary and appropriate, the interviewer should preface the question with certain conversational phrases to maintain continuity and tempo.

We shall now consider another important requirement of successful interviewing. It is often difficult as interviewers have often experienced, to obtain a specific complete response. This is perhaps the most difficult part of his job. Respondents often qualify or hedge their opinions.

They often answer, ‘do not know’ just to avoid thinking about the question, they misinterpret the question, divert the process of interview by launching off an irrelevant discussion or they give self-contradictory answers. In all these cases the interviewer has to probe deeper.

The test of a good interviewer is that he is alert to incomplete or nonspecific answers. Each interviewer must understand fully the overall objective of each question and what it is precisely trying to measure. A pre-test on the interviewers helps to equip them with such understanding.

The interviewer should be able to ask himself after every reply the respondent gives whether the question is completely answered. If the respondent’s answer is vague or diffuse or incomplete, effective probe questions should be asked.

The interviewer must be careful at every stage, not to suggest a possible reply, that is, the interviewer should riot ask leading questions (i.e., put words into the subject’s mouth). The “don’t know” reply is another problem of the interviewer.

Sometimes, this response may be due to a genuine lack of opinion or knowledge, but at other times it may be a cloak wittingly or unwittingly used by the interviewee to hide many attitudes, fear, reluctance, vague opinions, lack of understanding, etc. The interviewer should distinguish between the different types of’ don’t-know response’ and repeat the questions with suitable assurances.

An important consideration in successful interviewing relates to recording the responses of interviewees. There are two chief means of recording responses during the interview. If the question is a fixed alternative one, the interviewer need only mark or check an appropriate category. But if the question is open-ended, the interviewer is expected to record the response, verbatim.

On pre-coded schedules, errors and omissions in recording the replies are a frequent source of interview-error. In the midst of various tasks that the interviewer is supposed to perform in the course of interviews, viz., trying to pin the respondent down to a specific answer, remembering the sequence of questions, observing facial expressions etc., the interviewer may sometimes neglect to indicate the respondent’s reply to some item, overlook a particular question or check the wrong category, etc.

Even the best interviewer should, therefore, make it a habit to inspect each interview to make sure that it is filled in accurately and completely.

If any information is lacking he should go back and ask the respondent for it. He should correct the errors and omissions in the schedules on the spot. If he has recorded verbatim replies only sketchily, he should correct the weakness right there. It is not at all proper to wait until later in the day or until he returns home at night, since by then he may have forgotten quite a few crucial circumstances of the interview.

The interviewer should understand that the omission or inaccurate reporting of a single answer can make the entire interview worthless since the schedule is designed as an integral whole.

In reporting responses to open-ended or free answer questions, the interviewer should give complete, verbatim reporting. It may often be difficult to fulfill this requirement, but apart from obvious irrelevancies and repetitions, this should be the goal.

It is necessary that the interviewers have some idea of the coding process. This will ensure that they are able to record responses in such a manner that the coders will be able to reconstruct the whole set of responses correctly in a codified form.

The interviewer should ideally quote the respondents exactly. Paraphrasing the replies, summarizing them in one’s own words or “polishing up” any slang or cursing etc., not only might distort the respondent’s meanings and emphases but also miss the tenor of his replies.

Although it is frequently difficult to record responses verbatim without using short­hand, a few simple techniques can greatly increase the interviewer’s speed and honest reproduction.

The interviewer can ask the subject to wait until the interviewer has written the last thought but this may slow down the interview and may have certain adverse effects. In order not to slow up the interview, the interviewer should be prepared to write at the same time as the respondent talks.

This may prevent him from watching the expressions of the respondent but some adjustments have got to be made. The interviewer may also use common abbreviations. He may also use a telegraphic style of recording. In doing so, the interviewer must not make the recording incomprehensible to the coders.

One final point related to successful interviewing is, how to minimize bias introduced by the interviewer. Known as the interviewer-“bias”, it refers to systematic differences from interviewer to interviewer or occasionally systematic errors on the part of the interviewers in the selection of the samples (e.g., in quota sampling where the selection of interviewees is left to the interviewers), in asking questions, eliciting and recording responses.

Much of what we call interviewer-bias, can be more correctly described as interviewer- differences which are inherent in the fact that interviewers are human beings and not machines and thus they do not work identically or infallibly.

The fact that respondents too are human beings with differing perceptions, judgements, etc., simply enhances the differences that would occur if different interviewers were dealing with physical rather than human materials. It is too much to expect, therefore, that the interviewers will return complete, comparable and valid reports.

Even assuming an unbiased selection of respondents, bias in the interview-situation may stem from two sources:

(a) Respondent’s perception of the interviewer.

(b) Interviewer’s perception of the respondent.

‘Perception’ here points to the manner in which the relation between the interviewer and respondent is influenced and modified by their wishes, expectations and personality structure.

There is a sizable experimental evidence to prove that bias may result under certain conditions in spite of anything the interviewer may do to eliminate it. Respondents have been shown to frequently answer differently when interviewed by people from different social strata or ethnic group or nationality group. For example, the working-class respondents are less likely to talk freely to middle-class interviewers.

The magnitude of these effects naturally varies with the way in which the respondents perceive the situation. The biasing effects can often be reduced by altering the respondent’s perception of the situation, e.g., by assuring him that his identity will not be revealed but these effects can seldom be completely eliminated.

The interviewers should dress inconspicuously so that their appearance will not adversely sensitize certain categories of respondents.

The staff in a large-scale research project should be instructed to interview the respondent privately (unless the whole group is to be interviewed) so that his opinions will not be affected by the presence of some third person and to adopt an informal and conversational attitude in an effort to achieve the best possible ‘report.’

It should be noted that not all interview-biasing effects operate through the respondent’s perception by an interviewer. Some respondents may be totally immune to the most crucial biasing’s characteristics of the interviewer. The other dimension, we must consider in this context, is the interviewer’s perception of the respondent.

This is as important a source of bias as the respondent’s perception of the interviewer. No matter how standardized the schedule and how rigidly the interviewer is instructed, he still has much opportunity to exercise freedom of choice during the actual interview.

Thus, it is often his perception of the respondent that determines the manner in which he asks questions, the way in which he probes, his classification of responses to pre-coded questions and his recording of verbatim answers.

The interviewers often have strong expectations from respondents and as such, stereotypes are likely to come into play during the interview. On the basis of their past experience, judgements or prior answers received from other respondents, the interviewers may often quite unconsciously assume that they are inferior to him or that they are hostile, deceptive or ignorant, etc.

Such expectations will affect their performance. For example, a ‘No response’ from an educated well-to-do respondent may be probed into on the assumption that an opinion may be lurking somewhere or the interviewer may think that the respondents do not mean what they say.

Experiments have shown that the interviewers tend to select from long verbatim answers those parts that most closely conform to their expectations, beliefs or opinions and discard the rest.

An important source of bias arises from the interviewer’s perception of the situation. If he sees the results of the study as a possible threat to his interests, he is likely to introduce bias. Such difficulties can be overcome by proper motivation and supervision.

The interviewers being human, such biasing’s factors can never be overcome completely. Of Course, their effects can be reduced by standardizing the interview so that the interviewer has as little free choice as possible. If interviewers are given clear and standard instructions on questioning procedures, on the classification of responses etc., their biases will have lesser chances of operation.

It should not be overlooked, however, that if the interviewer’s freedom is restricted, correspondingly, the opportunities for effective use of his insight are restricted too. The more responsibilities the interviewer is given for questioning and evaluating the respondent’s opinions, the more likely it is that bias will result. This calls for a very careful selection of some middle course.

In so far as bias, in the sense of different interviewers not returning exactly the same responses from equivalent respondents, can never be totally eliminated, the main responsibility of the director of the research project is to select, train and supervise his staff in such a way that any net result of bias will be at a minimum.

He must be aware of the possibilities of bias at various points so that he is in a position to discount their effects in his analysis.

Related Articles:

• Interview Schedule : Meaning, Uses and Limitations
• Interview Techniques for Doing a Research

Techniques , Research , Social Research , The Interview Method

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Interviews can be defined as a qualitative research technique which involves “conducting intensive individual interviews with a small number of respondents to explore their perspectives on a particular idea, program or situation.” [1]

There are three different formats of interviews: structured, semi-structured and unstructured.

Structured interviews consist of a series of pre-determined questions that all interviewees answer in the same order. Data analysis usually tends to be more straightforward because researcher can compare and contrast different answers given to the same questions.

Unstructured interviews are usually the least reliable from research viewpoint, because no questions are prepared prior to the interview and data collection is conducted in an informal manner. Unstructured interviews can be associated with a high level of bias and comparison of answers given by different respondents tends to be difficult due to the differences in formulation of questions.

Semi-structured interviews contain the components of both, structured and unstructured interviews. In semi-structured interviews, interviewer prepares a set of same questions to be answered by all interviewees. At the same time, additional questions might be asked during interviews to clarify and/or further expand certain issues.

Advantages of interviews include possibilities of collecting detailed information about research questions.  Moreover, in in this type of primary data collection researcher has direct control over the flow of process and she has a chance to clarify certain issues during the process if needed. Disadvantages, on the other hand, include longer time requirements and difficulties associated with arranging an appropriate time with perspective sample group members to conduct interviews.

When conducting interviews you should have an open mind and refrain from displaying disagreements in any forms when viewpoints expressed by interviewees contradict your own ideas. Moreover, timing and environment for interviews need to be scheduled effectively. Specifically, interviews need to be conducted in a relaxed environment, free of any forms of pressure for interviewees whatsoever.

Respected scholars warn that “in conducting an interview the interviewer should attempt to create a friendly, non-threatening atmosphere. Much as one does with a cover letter, the interviewer should give a brief, casual introduction to the study; stress the importance of the person’s participation; and assure anonymity, or at least confidentiality, when possible.” [2]

There is a risk of interviewee bias during the primary data collection process and this would seriously compromise the validity of the project findings. Some interviewer bias can be avoided by ensuring that the interviewer does not overreact to responses of the interviewee. Other steps that can be taken to help avoid or reduce interviewer bias include having the interviewer dress inconspicuously and appropriately for the environment and holding the interview in a private setting.  [3]

My e-book, The Ultimate Guide to Writing a Dissertation in Business Studies: a step by step assistance offers practical assistance to complete a dissertation with minimum or no stress. The e-book covers all stages of writing a dissertation starting from the selection to the research area to submitting the completed version of the work within the deadline.John Dudovskiy

[1] Boyce, C. & Neale, P. (2006) “Conducting in-depth Interviews: A Guide for Designing and Conducting In-Depth Interviews”, Pathfinder International Tool Series

[2] Connaway, L.S.& Powell, R.P.(2010) “Basic Research Methods for Librarians” ABC-CLIO

[3] Connaway, L.S.& Powell, R.P.(2010) “Basic Research Methods for Librarians” ABC-CLIO

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Vaccination Coverage among Adults in the United States, National Health Interview Survey, 2022

Limitations.

Adults are at risk of illness, hospitalization, disability, and death from vaccine-preventable diseases (VPDs). The Centers for Disease Control and Prevention (CDC) recommends vaccinations for adults based on age, health conditions, prior vaccinations, and other considerations to prevent morbidity and mortality from VPDs. Updated CDC vaccination recommendations for adults are published annually. Despite the burden and consequences of VPDs and recommendations to get vaccinated, vaccination coverage among U.S. adults remains low for most vaccines. In addition, large disparities in adult vaccination coverage by race and ethnicity and other demographic factors have remained mostly unchanged over the last several years.

To assess vaccination coverage among adults aged ≥19 years, CDC analyzed data from the National Health Interview Survey (NHIS). The NHIS is a continuous, cross-sectional national household survey of the noninstitutionalized U.S. civilian population. Interviews are conducted over the course of the year in a probability sample of households, and data are compiled and released on an annual basis. For this report, adult receipt of influenza, pneumococcal, herpes zoster (including any type of herpes zoster and recombinant zoster vaccine [RZV]), tetanus and diphtheria [Td], tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis [Tdap], human papillomavirus [HPV], and COVID-19 vaccines were assessed using the data collected in 2022. A composite adult vaccination quality measure, which tracks vaccines routinely recommended for all adults (tetanus toxoid-containing and influenza vaccine) or indicated among adults based on age (herpes zoster and pneumococcal vaccines), was assessed using 2022 data. Recent trends in adult vaccination were examined using data from 2017–2022.

Coverage for all vaccines differed by race and ethnicity with generally lower coverage among Black and Hispanic adults compared with White adults*. Coverage for the age-appropriate composite measure (including influenza vaccination) among adults aged ≥19 years was low (22.8%) and ranged from 14.7% among those aged 50–64 years to 26.2% among those aged ≥65 years. Adults without health insurance or a usual place for health care were less likely to be vaccinated than those with insurance and a usual place for health care for all vaccines. Linear trend tests since 2017 indicated that coverage increased for any type of herpes zoster vaccination among adults aged ≥60 years, remained stable for pneumococcal vaccination among adults aged 19–64 years at increased risk of disease, and decreased for pneumococcal vaccination among adults aged ≥65 years. While the overall trend for influenza vaccination (aged ≥19 years and aged ≥19 years with high-risk conditions) reveals increased coverage, coverage was statistically similar for the 2020–21 and 2021–22 seasons. Coverage with ≥2 doses of RZV among adults aged ≥50 years increased from 1.1% in 2018, when RZV was first recommended, to 18.1% in 2022.

A majority of adults had not received age-appropriate vaccinations based on the composite measure. Substantial improvement in adult vaccination uptake is needed to reduce the burden of VPDs nationally. Increasing the proportion of adults who receive recommended age-appropriate vaccines and ensuring equitable access to and uptake of recommended vaccines is a high-priority public health issue.

The NHIS is a continuous, cross-sectional national household survey of the noninstitutionalized U.S. civilian population conducted by the U.S. Census Bureau for CDC’s National Center for Health Statistics ( 1 ). The objectives of the NHIS are to monitor the health of the U.S. population and provide estimates of health indicators, health care use and access, and health-related behaviors ( 2 ). Non-institutionalized adults aged ≥19 years with interviews conducted during August 2021–June 2022 (for influenza vaccination) and January 2022–December 2022 (for pneumococcal, herpes zoster, Td/Tdap, HPV, and COVID-19 vaccination) were included in this analysis. The total sample of persons aged ≥19 years was 27,376 in 2022. The final sample adult core response rate was 47.7% for the 2022 NHIS. Questions about receipt of vaccinations recommended for adults are asked of one randomly selected adult within each family in the household. Vaccination questions included in the 2022 NHIS were as follows:

• for influenza vaccination, respondents were asked if they had received an influenza shot or nasal spray during the preceding 12 months and, if so, in which month and year;
• for pneumococcal vaccination, respondents were asked if they had ever had a pneumonia shot;
• for herpes zoster vaccination, respondents were asked if they had ever received a shingles vaccine and, if yes, if they ever had RZV (Shingrix), number of vaccine doses received, and timing of vaccine receipt;
• for tetanus-containing vaccine, respondents were asked if they had received a tetanus shot in the past 10 years, and, if yes, they were asked if their most recent shot included the pertussis or whooping cough vaccine (Tdap);
• for HPV, respondents were asked if they had ever received the HPV shot or cervical cancer vaccine and, if yes, how old they were when they received their first HPV shot; and,
• for COVID-19 vaccine, respondents were asked if they had ever received at least one dose of a COVID-19 vaccination.

Weighted data were used to produce national vaccination coverage estimates. For non-influenza adult vaccination coverage estimates, the weighted proportion of respondents who reported receiving selected vaccinations was calculated. To better assess season-specific influenza vaccination coverage, the Kaplan-Meier survival analysis procedure was used ( 3 ). Race and ethnicity were categorized into five mutually exclusive groups as follows: White, Black, Hispanic, Asian, and other. In this report, persons were included in White, Black, Asian, or other race categories if they did not report Hispanic ethnicity. Persons who reported Hispanic ethnicity were classified as Hispanic in the analyses regardless of reported race.  Other race was defined as non-Hispanic persons reporting American Indian, Alaska Native, Native Hawaiian, Pacific Islander, or any other race and persons who reported multiple races.

For the adult vaccination composite measure ( 4 ), data from the 2022 NHIS were analyzed to determine estimates of vaccination coverage for select vaccines routinely recommended for all adults aged ≥19 years (tetanus toxoid-containing and influenza vaccine) or indicated based on age (herpes zoster: all adults age ≥50; pneumococcal vaccine: all adults ≥65 years). Respondents had to have received all vaccines appropriate for their age group to be considered up-to-date † .  Estimates for composite measures were calculated with and without influenza vaccination in the past 12 months. Point estimates and 95% confidence intervals (CIs) were calculated using SUDAAN software (Research Triangle Institute, Research Triangle Park, NC, version 11.0.1) to account for the complex sample design. Differences were measured as the simple difference between 2021 and 2022 for pneumococcal, and herpes zoster vaccination coverage, and between 2019 and 2022 for Td/Tdap and HPV vaccination coverage due to the NHIS survey question rotation every 3 years for these two vaccines. T-tests were used for comparisons between data years and for comparisons of each level of each respondent characteristic to a chosen referent level (e.g., for race and ethnicity, White was the reference group). Statistical significance was defined as p<0.05. Coverage estimates are not reported for small sample size (n<30) or large relative standard errors (standard error/estimate >0.3). Only statistically significant comparisons are noted in the text. Logistic regression under the predictive marginal was used to compare vaccination with each vaccine between adults with and without health insurance and with and without a usual place for health care. Trends in adult vaccination were assessed from 2017 through 2022 for influenza, pneumococcal, and herpes zoster vaccinations using weighted linear regression of annual estimates using inverse of estimated variances of the estimates as weights.

Pneumococcal Vaccination

• Coverage among White adults aged 19–64 years at increased risk was higher (24.0%) compared with Hispanic (19.5%) adults.
• Coverage among White adults aged ≥65 years (69.1%) was higher compared with Black (53.5%), Hispanic (41.7%), Asian (50.2%), and other race (54.0%) adults.

TABLE 1. Estimated proportion of adults aged ≥19 years who ever received pneumococcal vaccination by age, increased-risk status and race and ethnicity — National Health Interview Survey, United States, 2022

Herpes Zoster Vaccination

• White adults aged ≥19 years with an indication had higher coverage compared with Black, Hispanic, and other race adults.
• White adults aged ≥50 and ≥60 years had higher coverage compared with Black and Hispanic adults.
• Coverage was 29.5% among adults aged ≥60 years, higher than the estimate for 2021.
• RZV coverage (≥2 doses) was 17.1% among adults aged ≥19 years and 18.1% among adults aged ≥50 years, including 11.9% among adults aged 50–59 years, 19.8% among adults aged 60–64 years, and 22.0% among adults aged ≥65 years, all higher than estimates for 2021.

TABLE 2. Estimated proportion of adults aged ≥50 years or adults aged ≥19 years with weakened immune system who ever received herpes zoster vaccination, by age and race and ethnicity — National Health Interview Survey, United States, 2022

Tetanus Vaccination Coverage (Td and Tdap)

• Overall, White adults had higher coverage compared with Black, Hispanic, and Asian adults.
• Tdap coverage for Black (17.8%), Hispanic (21.2%), and Asian (28.9%) adults aged ≥19 years was lower compared with White (32.6%) adults.

TABLE 3. Estimated proportion of adults aged ≥19 years who in the past 10 years received any tetanus vaccination and Tdap vaccination, by race and ethnicity and overall, by age group — National Health Interview Survey, United States, 2022

Adult Vaccination Composite Measure

• In 2022, 22.8% of adults aged ≥19 years had received all age-appropriate vaccines (including influenza vaccination) included in the composite measure.
• Low coverage with herpes zoster vaccine was the primary driver of lower coverage among adults aged 50–64 years compared with the other age groups.
• Coverage with all age-appropriate vaccines in the composite adult vaccination measure (including influenza vaccination) was lower among Black (12.1%) and Hispanic (17.0%) adults compared with White (26.1%), Asian (26.2%) and other race (24.5%) adults aged ≥19 years.

TABLE 4. Vaccination coverage estimates using an age-appropriate composite adult vaccination quality measure and individual component measures, by age group — National Health Interview Survey, United States, 2022

TABLE 4_1. Vaccination coverage estimates using an age-appropriate composite adult vaccination quality measure and individual component measures, by race and ethnicity — National Health Interview Survey, United States, 2022

HPV Vaccination

• Among females aged 19–26 years, White females had higher coverage compared with Black females.
• In 2022, HPV vaccination coverage (≥1 dose) was 34.8% among males 19–26 years overall, and within age strata 39.8% among males 19–21 years, and 32.1% among males 22–26 years, similar to the estimate for 2019.
• HPV vaccination (≥1 dose) among females aged 19–26 years who had not received HPV vaccination prior to age 19 years was 9.4%, similar to the estimate for 2019. Among males aged 19–26 years who had not received HPV vaccination prior to age 19 years, HPV vaccination coverage was 3.5%, similar to the estimate for 2019.

TABLE 5. Estimated proportion of adults aged 19–26 years who received at least one dose of human papillomavirus (HPV) vaccination, by age group, sex, and race and ethnicity — National Health Interview Survey, United States, 2022

COVID-19 Vaccination

• Overall, White adults had higher coverage compared with Black adults and lower coverage than Asian adults.

TABLE 6. Estimated proportion of adults aged ≥19 years who received at least one dose of COVID-19 vaccination, by age and race and ethnicity — National Health Interview Survey, United States, 2022

Association of Health Insurance Status and Usual Place for Health Care with Adult Vaccination Coverage

• Overall, vaccination coverage was generally lower among adults without health insurance compared with those with health insurance, with prevalence ratios ranging from 0.1 for both pneumococcal (aged ≥65 years) and herpes zoster vaccine to 0.7 for tetanus and COVID-19 vaccine.
• Overall, adults without a usual place for health care were less likely to report having received recommended vaccinations than those who have a usual place for health care, with prevalence ratios ranging from 0.3 for pneumococcal (aged 19–64 years at increased risk) vaccine to 0.8 for tetanus, HPV (females aged 19–26 years), and COVID-19 vaccines.

TABLE 7. Vaccination coverage among adults aged ≥19 years, by age group, increased-risk status, health insurance status, and usual place for health care status — National Health Interview Survey, United States, 2022

Trends in Adult Vaccination Coverage

• Trends in coverage from 2017–2022 with selected vaccines recommended for adults are shown in Figure 1.
• However, coverage was statistically similar between the 2020–21 and 2021–22 seasons for all adults aged ≥19 and adults aged ≥19 years at high risk.
• Coverage with ≥2 doses RZV among adults ≥50 years increased from 1.1% in 2018, the first year of the RZV recommendation, to 18.1% in 2022.
• Decreases in coverage were observed for pneumococcal vaccination among adults aged ≥65 years (annual average percentage point decrease: -1.0%, 95% CI: -1.3, -0.6), but coverage for pneumococcal vaccination among adults aged 19–64 years at increased risk remained stable from 2017 to 2022.

Figure 1. Estimated proportion of adults aged ≥19 years who received selected vaccines, by age group and risk status — National Health Interview Survey, United States, 2017–2022 [XLS – 20 KB]

NHIS data from 2022 indicate that many adults in the United States remained unprotected against VPDs. A majority of adults had not received age-appropriate vaccinations based on the composite measure. Overall vaccination trends indicated that, for the years assessed, influenza and herpes zoster vaccination coverage increased, although influenza vaccination coverage plateaued for the 2020–21 and 2021–22 seasons; and pneumococcal vaccination coverage remained stable among adults aged 19–64 years at increased risk of disease and decreased among adults aged ≥65 years.

Pneumococcal vaccination coverage among adults aged ≥65 years decreased, especially during the COVID-19 pandemic period. A separate analysis of adults in NHIS who reached age 65–70 years and became eligible for pneumococcal conjugate vaccination (PCV) after the start of the COVID-19 pandemic in 2020, as well as similar analysis of data from the Behavioral Risk Factor Surveillance System, showed a pandemic effect on pneumococcal vaccination coverage and suggested a modest decrease in pneumococcal vaccination among older adults, which might be associated with COVID-19-related reductions in persons accessing vaccination services ( 5 , 6 , CDC unpublished data). Pneumococcal vaccination recommendations for older adults also changed around this same time ( 7 ). Importantly, the NHIS does not distinguish between PCV and polysaccharide 23 valent (PPSV23) vaccines and PPSV23 was recommended for all adults aged ≥65 years through 2020; after 2020, providers had several options for pneumococcal vaccination of patients. At all times during the COVID-19 pandemic, some form of the pneumococcal vaccine was recommended for adults ≥65 years ( 7 ).

This report estimated COVID-19 vaccine coverage for one or more doses received any time before the interview date through 2022. Although CDC recommended bivalent COVID-19 vaccination for adults in September 2022 ( 8 ), coverage with bivalent vaccine was not specifically assessed in the 2022 NHIS.

Racial and ethnic differences in vaccination coverage persisted for all vaccines, with generally lower coverage among Black and Hispanic adults compared with White adults. Coverage for the age-appropriate composite measure was low in all age groups and in all race and ethnicity groups.

For all vaccines, adults without health insurance were less likely to be vaccinated than those with health insurance. Differences were most pronounced for pneumococcal and zoster vaccination, where adults with health insurance were 3-10 times more likely to be vaccinated compared to those without health insurance. By contrast, the difference between insured and uninsured adults in coverage with COVID-19 vaccines, which were provided free of charge by the U.S. government, was smaller. Expansion of adult vaccination benefits and elimination of out-of-pocket expenses by the Inflation Reduction Act (IRA) for recommended adult vaccines covered under Medicare and Medicaid may contribute to increasing coverage among insured persons in the coming years; however, vaccine access remains challenging for uninsured persons ( 9 ). Additionally, our results showed that adults without a usual place for health care were less likely to be vaccinated than those with a usual place for health care. Having a usual place for health care and routine physician contact can provide important opportunities for providers to educate their patients about VPDs, as well as strongly recommend and offer vaccination. The Standards for Adult Immunization Practice recommend that providers assess vaccination status at every patient visit, offer needed vaccines or refer patients to other vaccination sites if vaccines are not available ( 10 ), and use evidenced-based interventions such as provider reminder systems and standing orders to improve vaccination coverage ( 11 ).

The estimates in this report are subject to several limitations. First, all data rely on respondent self-report and were not validated with medical records. However, adult self-reported vaccination status has been shown to be ≥70% sensitive in one or more studies for influenza, pneumococcal, and herpes zoster vaccines and ≥70% specific in one or more studies ( 12 – 14 ). Adults might not be able to recall accurately vaccines received as adolescents and as a result, coverage levels for HPV might be substantially underestimated. Additional studies are needed to determine accuracy of recall for vaccinations that adults might have received as children or adolescents. Second, the NHIS response rate was 47.7% in 2022. Nonresponse bias can result if respondents and non-respondents differ in their vaccination behaviors and if survey weighting does not fully correct for this. Finally, the NHIS sample excludes persons in the military and those residing in institutions, which might result in underestimation or overestimation of adult vaccination coverage levels.

Coverage of routinely recommended vaccines among adults remains low. Disparities in vaccination coverage by race and ethnicity, health insurance, and usual place for health care were seen for all vaccines assessed. Ensuring equitable access to and increasing uptake of recommended vaccines is needed to maximally reduce the burden of vaccine preventable diseases.

Authors : Mei-Chuan Hung, MPH, PhD 1,2 ; Anup Srivastav, B.V.Sc.&A.H., MPVM, PhD 1,2 ; Peng-jun Lu, MD, PhD 1 ; Carla L. Black, PhD 1 ; Megan C. Lindley, MPH 1 ; James A. Singleton, PhD 1

1 Immunization Services Division, National Center for Immunization and Respiratory Diseases, CDC 2 Eagle Health Analytics, Inc, Atlanta, GA

• National Center for Health Statistics. Survey description, National Health Interview Survey, 2022. Hyattsville, Maryland. 2022. Available at: https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHIS/2022/srvydesc-508.pdf .
• National Center for Health Statistics. Public-use data file and documentation. Available at: https://www.cdc.gov/nchs/nhis/about_nhis.htm .
• Lu PJ, Santibanez TA, Williams WW, Zhang J, Ding H. et al. Surveillance of influenza vaccination coverage—United States, 2007-08 through 2011-12 influenza seasons. MMWR Surveill Summ. 2013 Oct 25;62(4):1-28.
• Shen AK, Williams WW, O’Halloran AC, et al. Promoting adult immunization using population-based data for a composite measure. Am J Prev Med 2018; 55:517–23.
• CDC. Pneumococcal vaccination among adults 65–70 years of age before and during the COVID-19 pandemic— United States, 2021. Available at https://www.cdc.gov/vaccines/imz-managers/coverage/adultvaxview/pubs-resources/pandemic-impact-on-ppv.html )
• Czeisler MÉ, Marynak K, Clarke KEN, et al. Delay or avoidance of medical care because of COVID-19–related concerns—United States, June 2020. MMWR Morb Mortal Wkly Rep 2020;69(36):1250–1257.
• CDC. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged ≥65 years: updated recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2019;68:1068–1075.
• CDC. Use of updated COVID-19 vaccines 2023–2024 formula for persons aged ≥6 months: Recommendations of the Advisory Committee on Immunization Practices — United States, September 2023. MMWR 2023; 72(42);1140–1146.
• Centers for Medicare & Medicaid Services. Anniversary of the Inflation Reduction Act: Update on CMS implementation. Available at: https://www.cms.gov/newsroom/fact-sheets/anniversary-inflation-reduction-act-update-cms-implementation .
• CDC. Standards for adult immunization practice. Available at: https://www.cdc.gov/vaccines-adults/hcp/imz-standards/index.html .
• Community Preventive Services Task Force. The Guide to Community Preventive Services: what works to promote health? Available at: http://www.thecommunityguide.org/index.html .
• Rolnick SJ, Parker ED, Nordin JD, et al. Self-report compared to electronic medical record across eight adult vaccines: do results vary by demographic factors? Vaccine 2013;31(37):3928–3935.
• Donald RM, Baken L, Nelson A, Nichol KL. Validation of self-report of influenza and pneumococcal vaccination status in elderly outpatients. Am J Prev Med. 1999; 16:173–177.
• Zimmerman RK, Raymund M, Janosky JE, et al. Sensitivity and specificity of patient self-report of influenza and pneumococcal polysaccharide vaccinations among elderly outpatients in diverse patient care strata. Vaccine. 2003; 21:1486–1491.

*In this report, persons identified as White, Black, Asian, or other race are non-Hispanic. Persons identified as Hispanic might be of any race. “Other” includes American Indian/Alaska Native, Native Hawaiian, Pacific Islander, or any other race and persons who identified multiple races. The five racial/ethnic categories are mutually exclusive.

† To be considered up-to-date based on age recommendations, adults aged ≥19–49 years had to have received an influenza vaccine in the past year and a tetanus toxoid-containing vaccine in the past 10 years; adults aged 50–64 years had to have received an influenza vaccine in the past year and a tetanus toxoid-containing vaccine in the past 10 years, plus ever received a herpes zoster vaccine; and adults ≥65 years had to have received an influenza vaccine in the past year and a tetanus toxoid-containing vaccine in the past 10 years, plus ever received a herpes zoster vaccine and a pneumococcal vaccine.

• Open access
• Published: 27 August 2024

Facilitating and limiting factors of cultural norms influencing use of maternal health services in primary health care facilities in Kogi State, Nigeria; a focused ethnographic research on Igala women

• Uchechi Clara Opara 1 ,
• Peace Njideka Iheanacho 2 ,
• Hua Li 1 &
• Pammla Petrucka 1  

BMC Pregnancy and Childbirth volume  24 , Article number:  555 ( 2024 ) Cite this article

Metrics details

Facilitating factors are potential factors that encourage the uptake of maternal health services, while limiting factors are those potential factors that limit women’s access to maternal health services. Though cultural norms or values are significant factors that influence health-seeking behaviour, there is a limited exploration of the facilitating and limiting factors of these cultural norms and values on the use of maternal health services in primary health care facilities.

To understand the facilitating and limiting factors of cultural values and norms that influence the use of maternal health services in primary healthcare facilities.

The study was conducted in two primary healthcare facilities (rural and urban) using a focused ethnographic methodology described by Roper and Shapira. The study comprised 189 hours of observation of nine women from the third trimester to deliveries. Using purposive and snowballing techniques, data was collected through 21 in-depth interviews, two focus group discussions comprising 13 women, and field notes. All data was analyzed using the steps described by Roper and Shapira (Ethnography in nursing research, 2000).

Using the enabler and nurturer constructs of the relationships and the expectations domain of the PEN-3 cultural model, four themes were generated: 1, The attitude of healthcare workers and 2, Factors within primary healthcare facilities, which revealed both facilitating and limiting factors. The remaining themes, 3, The High cost of services, and 4, Contextual issues within communities revealed factors that limit access to facility care.

Several facilitating and limiting factors of cultural norms and values significantly influence women’s health-seeking behaviours and use of primary health facilities. Further studies are needed on approaches to harness these factors in providing holistic care tailored to communities' cultural needs. Additionally, reinvigoration and strengthening of primary health facilities in Nigeria is critical to promoting comprehensive care that could reduce maternal mortality and enhance maternal health outcomes.

Peer Review reports

Access to maternal health services (MHS) during pregnancy, labour and puerperium is a significant global mandate that has informed the development of maternal health strategies globally. Maternal health strategies are crucial as more than 80% of all pregnancy-related maternal mortality is preventable if adequate, timely and evidence-based MHS is made available to women around childbirth [ 1 ]. Consequently, to enhance maternal health outcomes, the Sustainable Development Goals (SDG) were developed, with goal #3:1 focusing on strengthening the health system in reducing maternal mortality, with two indicators aiming to reduce maternal mortality ratio (MMR) and increase skilled birth attendants (SBAs) at birth [ 2 ]. Specifically, SDG# 3:1 aims to reduce the maternal mortality ratio to less than 70 per 100,000 live births by 2030 [ 3 ]. While approximately 83% of women access SBAs at birth globally, in Sub-Saharan Africa (SSA), only 70% of women access SBAs at birth, and these rates could be even lower in some SSA countries such as Nigeria (United Nations International Children’s Emergency Fund [ 4 ].

Nigeria has one of the highest maternal mortality ratios of 1047 per 100,000 live births, with approximately 61% of women having access to SBAs in urban areas and only 26% in rural areas in 2018 [ 5 ], despite maternal health policies such as the Integrated Maternal Newborn and Child Health Strategies (IMNCH) and the Midwives Service Scheme (MSS) developed to enhance access to MHS [ 6 , 7 , 8 ]. However, the World Health Organization emphasized that the current global evidence of MMR status is calculated based on the estimate from the COVID-19 pandemic [ 1 ], which contributed significantly to increased maternal mortality due to limited access to maternal healthcare provision globally as well as in Nigeria [ 1 , 9 , 10 , 11 , 12 ]. Thus, the Nigerian MMR is unclear due to a lack of current national evidence on maternal mortality.

In Nigeria, delays in seeking facility care, reaching a health facility, and receiving expert care were seen as major contributing factors to maternal mortality [ 13 , 14 , 15 ]. Systemic factors, such as lack of access to facility care, lack of awareness of the importance of MHS, limited health infrastructure, and cultural factors, are significant factors that limit women’s access to facility care [ 13 , 16 , 17 ].

Several studies have identified cultural norms and practices associated with the use of traditional medicine, reliance on intergenerational values around pregnancy and birth, patriarchal norms and home deliveries as significant factors that limit access to MHS in Nigeria [ 16 , 17 , 18 , 19 , 20 , 21 ]. These cultural norms and values are intergenerational standards, beliefs, and practices characterized by distinct cultural features in religion, health, illness and language, which could influence people’s health-seeking behaviour [ 18 , 20 , 21 , 22 ]. For example, a cultural group’s interpretations of health and illness could contradict Western medical opinions or interpretations and may not always be shared within Western health facilities [ 23 , 24 ]. Thus, maternal health issues may not easily be diagnosed, which could delay the detection of preventable maternal health issues in Western facilities while favouring traditional and alternative healers, given the cultural interpretation of such health issues [ 23 , 24 , 25 , 26 ]. While some cultural beliefs and practices are beneficial and should be encouraged, others could be harmful and negatively influence women’s use of MHS and maternal health outcomes [ 25 , 27 , 28 ].

Studies also reveal that the safe motherhood initiative developed by the Nigerian government to increase access to facility care and reduce maternal mortality was hindered by several factors, including cultural beliefs and values that limited women’s access to quality MHS, especially in rural areas, resulting in significant maternal mortality [ 13 , 19 , 29 ]. Regardless, there is a limited understanding of the facilitating and limiting factors of these cultural beliefs and practices. Facilitating factors are potential factors that encourage the uptake of MHS, while limiting factors are those potential factors that limit women’s access to MHS.

Limited use of MHS is found to be significant in primary health care facilities (PHC), which are the first tier of the three-tiered health systems in Nigeria. These PHCs are located within five kilometres of residential areas and are considered the first point of call for all Nigerian citizens in rural and urban areas [ 18 , 30 , 31 , 32 ]. The PHCs are designed to provide comprehensive MHS ranging from preventive, curative, and promotive services that are timely and safe, without the barriers of cost, culture, and geographical limitations [ 19 , 30 , 31 ]. A functional PHC facility provides a conducive environment that ensures adequate and comprehensive provision of MHS through the availability of human and material resources in the form of health personnel, medical supplies, and adequate health financing [ 17 , 18 , 32 , 33 ]. A wide range of people, such as stakeholders, policymakers, healthcare providers, leaders, and representatives of health institutions, as well as community and traditional leaders, make decisions that inform the effective functioning of PHC facilities [ 19 , 34 ]. According to [ 35 ], only 20% of the total 30,000 PHCs in Nigeria are functional, limiting access to quality MHS to a vast population of women. Such limitations could account for women’s preference for traditional practices and traditional birth attendants who live within communities and are believed to provide culturally appropriate care to women around childbirth [ 18 , 21 ].

Though studies have emphasized the significance of culture in influencing quality access to maternal health [ 17 , 18 , 19 ], there is a limited understanding of the facilitating or limiting factors of cultural norms and values that influence the use of MHS in PHC facilities. Consequently, based on these imperatives, understanding women’s perspectives and experiences of these facilitating and limiting factors of cultural norms or values that influence women’s use of MHS in PHC is crucial as such could be harnessed to inform culture-centred maternal health strategies and interventions that could enhance women’s use of MHS and achievement of the SDG #3:1 in 2030. To promote an in-depth understanding of these facilitating and limiting factors, the PEN-3 cultural model was used as a framework to organize our findings, which provided a deep exploration of the facilitating and limiting factors of cultural norms and values that influence women’s use of MHS in PHCs. The PEN-3 cultural model is a culturally-focused model that has been used to explore and understand cultural issues related to health and illness in many countries, including Nigeria [ 36 , 37 ], where the study was conducted.

The PEN-3 cultural model

The PEN-3 cultural model is made up of three domains, namely (1) cultural identity (person, extended family, neighbourhood), (2) relationships and expectations (perceptions, enablers, and nurturers) and (3) cultural empowerment (positive, existential, and negative [ 38 , 39 ]. The cultural identity domain is the port of entry for health interventions, which could be at the level of persons (mothers or health care workers), extended family members (grandmothers), or neighbourhoods (communities or villages) [ 40 ]. In the relationships and expectations domain, which forms a part of the assessment phase, people’s perceptions or attitudes concerning health issues, social structures or facilities, such as health services that enhance or limit effective health-seeking practices, and the part played by the family and kin in health-seeking decision related to use of health facilities is explored [ 39 , 40 ]. The cultural empowerment domain forms the second assessment domain, where health issues are explored to understand and highlight those that are positive [ 40 ]. The existential factors or factors without harmful effects are explored before the negative health beliefs and practices are explored and discouraged during the intervention phase [ 39 ]. The enabler and nurturer constructs of the relationships and expectations domain guided this study.

The study aimed to understand the facilitating and limiting factors of cultural values, norms, and practices influencing the use of MHS in PHC facilities among the Igala ethnicity in Kogi state, Nigeria.

The focused ethnographic methodology described by nurse anthropologists Roper and Shapira [ 41 ] guided this study. Focused ethnography focuses on exploration of a distinct phenomenon within a subculture using narrow research questions. One aim of focused ethnography is to explore health beliefs, values, and practices within a specific subculture of a population in which such experiences occur [ 41 ]. Findings from focused ethnographic research could be integrated into nursing practice to enhance health outcomes [ 41 ].

The focused ethnography described by Roper and Shapira [ 41 ] was deemed appropriate for the study because, unlike other qualitative methodologies, the philosophical underpinning of focused ethnography is grounded on culture and on understanding the subculture of a population [ 41 ], which is the focus of this study. In addition, while many qualitative approaches may have some similarities in ontological, epistemological and methodological approaches, the aim, research questions and methods employed in answering such questions differ [ 42 ]. Thus, using Roper and Shapira’s [ 41 ] focused ethnography, which allows for diverse methods in data collection, enhanced a rich exploration of our research question, leading to a deep understanding of the facilitating and limiting factors of cultural norms and values that influence the use of MHS in PHC facilities in Kogi state Nigeria.

Using Roper and Shapira’s [ 41 ] focus ethnographic methodology allowed for engagement in short-term and targeted data-gathering sections with participant observations, individual interviews, field notes, and focused group discussions in the fieldwork, specifically structured to fit the research question. The authors strove for rigour by using diverse data triangulation approaches such as interviews, focused group discussions, participant observations, field notes, reflective memo, and analysis of all documents gathered in the research context. This approach provided us with a thick understanding and interpretation of the facilitating and limiting factors of cultural norms and values influencing the use of MHS in PHCs. This study was reported according to the Standard for Reporting Qualitative Research (SRQR) [ 43 ]. In addition, this study is part of a larger study conducted to understand the cultural beliefs and practices of Igala women influencing their use of MHS in PHC facilities in Kogi state Nigeria.

Positionality

The first and second authors are Nigerian clinical nurse midwives and researchers who have worked among the Igalas in Kogi state, Nigeria, for the past 25 years. Both authors understand the Indigenous Igala language and speak pidgin English (an English-based Indigenous language spoken as a lingua franca in Nigeria). The first author practiced as a clinical nurse midwife in a secondary health care facility among the Igalas in Kogi state for 25 years and has carried out several qualitative studies in Igala land. The second author, who has extensive qualitative research experience, is a professor at a university in Nigeria. The third author is a Canadian professor with years of experience in maternal health research in middle and low-income countries. Finally, the anchor author is a Canadian professor with immense experience in maternal health research in Africa and other low- and middle-income countries and is the overall supervisor of the research. The first author (who collected the data) ensured reflexivity, given her exposure to the ethnic group and her role in data gathering, which could influence the research and data analysis processes.

Reflexivity

The researchers put in place a range of approaches to enhance reflexivity. The first author’s position as an insider allowed her to assume the diffractive way of knowing, which positioned her as an active participant in knowledge creation and not one she distanced from, knowing that knowledge creation is an entangled relationship that is influenced by the researcher’s experience, her senses, and her embodied presence in the research context [ 44 ]. Thus, the first author went back and forth along the continuum of epistemic knowledge to gain a thick description and interpretation of knowledge [ 45 ]. This approach allowed for deep immersion and prolonged observation of the participants and spaces in each context to enhance an in-depth understanding of the phenomenon under study. Consequently, the researchers explored and pulled in significant relevant details that would otherwise be taken for granted. Reflective memos and discussions with the research team on various issues provided opportunities to challenge individual interpretations and mitigate potential bias.

Research setting

The study was conducted in two different PHC facilities in rural and urban areas of two local government areas (LGAs) (Olamaboro and Dekina LGAs) of Kogi State, Nigeria, with populations ranging from 213,900 to 352,300 [ 46 ]. These PHCs are within five kilometres of residential areas, implying that the PHC facilities are available and accessible to most Nigerians [ 32 ]. These two PHCs were chosen because they offer comprehensive services ranging from antenatal, delivery, immunization, treatment of uncomplicated tropical diseases, and provision of antiretroviral medications.

Participants

The study was conducted among Igala women of 18- 45 years of childbearing who were either pregnant and attended the antenatal clinic in a PHC facility in Kogi state or had given birth in a PHC facility in Kogi state within the last 12 months. All other ethnicities were excluded from the study, given that focused ethnographic research focuses on a population's subculture. The research was open to women of all sexual orientations and women who were single, divorced, separated and married. However, all study participants were married and had living partners. The purposive and snowballing techniques were used in different ways to recruit participants. First, through purposive sampling, the first author gained entrance to the antenatal and immunization health talks, with the assistance of the gatekeepers in each facility, where she invited women to participate in the study. Following the health talks, interested women met privately with the researcher, who explained the aim and objective of the study. Women who showed interest in the study were recruited after they obtained oral consent from their husbands to participate in the study. Through the snowballing technique, recruited women also referred other women with similar characteristics who met the inclusion criteria. See Table 1 for the demographic characteristics of women included in the study.

Data collection

Data collection was conducted between August 2023 and November 2023, congruent with ethnographic methodology, to understand people in their natural environment. We used semi-structured one-on-one interviews, participant observations, and focused group discussions in the study.

Participant observations

The first author employed two types of observation, starting with passive observation, which allowed for an in-depth understanding of the context, processes and relationships existing in the population. Later, a selective approach of participant observation, “observer as participant,” was instituted, allowing the researcher to follow up on nine women in the last trimester of pregnancy and four of those women during delivery. Observation flyers were posted in strategic places in each facility, and observation guides ensured boundaries of observation. The selective observation aimed to understand how much culture is integrated into antenatal and post-natal health talk, quality of care provided, approach to communication, support provided for women during pregnancy and delivery, respect of cultural preferences and verbal and non-verbal cues, and eye contact.

The observations ended when the researcher reached saturation, and no new data was generated to answer the research question. Thus, saturation was reached when the researcher repeatedly began to observe the same themes and patterns previously observed. Each observation lasted 4-5 hours but was longer on the days the researcher was observing a woman in labour. The participant observation yielded a total of 189 hours of observation. The observations were recorded in a field note by the first author and were transferred into a Microsoft Word™ document that was transcribed within 12 hours after the study to maintain the accuracy of the event [ 47 ].

Interviews and focused group discussions

Recruitment for participation in one-on-one interviews, focus group discussion and selective participant observation, ran concurrently. With the assistance of the gatekeepers in each facility, the researcher was invited each week to share information about the research and invite women to participate in the study during antenatal and immunization schedules. Though the gatekeepers enhanced ease of entry to each facility, they were unaware of the participants interviewed during the study as there were clearly documented and discussed boundaries on their role in the study, which was duly signed by the two gatekeepers. For example, each gatekeeper did not have access to data, and did not suggest participants to the researcher, or interview participants.

Interested women who were attending the facility for antenatal and immunization clinics and women who were referred by participants usually met with the researcher privately in an office that was specifically assigned to the researcher. The first meeting with each participant focused on the researcher introducing herself and the research. The researcher started by describing the aim, purpose, objectives, potential benefits and harm related to the research, the participant's right to withdraw from the study, and audio recording of conversations with the participant’s permission. Issues of confidentiality and anonymity, as well as how the generated information from participants would be used, were also discussed with each participant. Thus, the researcher assured participants that their names, demographic characteristics and other sensitive information provided were protected and separated from study documents [ 48 , 49 ]. Additionally, participants were informed that their names would be replaced with serial numbers, which will ensure that participants were not identified in the presentation of results and data analysis. Participants were also informed that their raw data would only be accessible to the study researchers.

During the conversation, participants asked diverse questions about the research and their participation, which were duly answered. Prospective participants who showed interest in the research were then informed to consult with their husbands at home, and if their husbands provided oral consent, they could sign the consent form and participate in the study. After obtaining consent from their husbands, women still interested in participating in the study were allowed to sign the consent form. Participants were scheduled for one-on-one interviews, focus group discussions and participant observation based on their availability and interest.

Interviews were conducted with 11 women in rural areas and ten women in urban areas who had recently given birth. Most of the interviews were conducted in a secure hall within both health facilities, ensuring privacy and comfort for the participants. Before commencing each interview, the researcher obtained participants' demographic characteristics using a questionnaire. The interview started with the researcher introducing herself and providing participants with information on the aim and purpose of the research. Oral consent and permission to record the interview were also obtained. Interviews were guided by an interview guide, informed by past literature reviews and themes generated during observations and validated by two authors who have lived among the Igalas for over 25 years. The researcher started the interview by asking preliminary questions such as “how has your day been today? The purpose was to establish rapport with participants and reduce anxiety associated with one-on-one interviews. The researcher continued with open ended semi-structured question, such as “What MHS are provided for you in this facility? Why do you access health services in this facility? How do the services here limit or satisfy your cultural and traditional expectations? How do health workers support and accommodate your cultural needs and preferences during pregnancy and delivery? How does the cost of maternal health services influence your use of facility care? How do cultural issues in this community influence your access to facility care? How do the equipment and amenities provided in this facility influence your use of this facility around pregnancy and childbirth? What roles do the community rulers play in ensuring women access MHS in this facility? What could be the challenges you have accessing MHS in this facility? What could the health workers and government do better to ensure your culture and traditions are respected throughout pregnancy and delivery? The researcher used probes to facilitate clarifications, elaborations, and a deeper explanation of previously provided responses [ 50 ]. Interviews lasted 30-50 minutes and were audio recorded, ensuring a thorough documentation of the discussions.

To enhance triangulation in the study, focus group discussions were held in the rural PHC facility with six women and seven women in the urban area in a mini hall within the PHC facilities. Given that women scheduled for focus group discussions were those accessing the facility for antenatal care and child immunization, the focus group discussions were held after the immunization of babies. The researcher collected each participant's demographic characteristics privately before ushering each participant into the hall for the discussion. The questions in the focus interview guide were a combination of the questions asked in one-on-one interviews and significant themes generated from observations and interviews, such as How does out-of-pocket payment for health services influence where you access care during pregnancy and childbirth? How does the quality of services provided here encourage women’s use of MHS? What role(s) do the elders in the community play in women’s use of facility care? What do you think the government and elders could do better to enhance your use of facility care? Focus group discussions lasted an average of one hour and fifteen minutes.

Interviews and focus group discussions were conducted mainly in English and a few in pidgin English (a simplified language of communication derived from the English language), which was spoken generally by the population and by the first and second authors. A back translation of all interview guides, consent, and recruitment documents was conducted [ 51 ] by the first author and checked by the second author, who both understand and speak English and pidgin English. All interviews and focus group discussions were conducted privately in a mini hall designated for the study, away from the activities of the facilities, with only the participants and the first author, which enhanced confidentiality and participants’ ability to freely and deeply share their experiences with the researcher [ 52 ]. In both interviews and focus group discussions, oral consent was obtained from participants to audio record the interviews and focus group discussion.

Data analysis

Data analysis began with data gathering and continued iteratively until the researcher gained a rich understanding and interpretation of the findings [ 41 , 42 ]. There was a verbatim transcription of participant observations, field notes, reflective memo, and documents made freely available in both facilities, and all interviews and focus group discussions conducted in English. Back translation of a few interviews conducted in pidgin English was done and integrated into the analysis, which enriched the data. Data analysis followed the five steps described by Roper and Shapira [ 41 ], namely, (a) coding for descriptive labels, (b) sorting for patterns, (c) identification of outliers or negative cases, (d) generalizing with constructs and theories, and (e) memoing and reflective remarks. However, though these steps exist, data analysis in this study was not chronological as the researchers kept moving back and forth between the steps until a thick description and interpretation of the phenomenon under study was achieved [ 41 , 42 ]. In the first step of coding for descriptive labels, the authors read the initial transcripts line by line to identify the codes running through each transcript. During this stage, the researchers met regularly to incorporate new themes in observations and early interviews in later interviews to enhance a rich interpretation of the data.

In the second stage of sorting of patterns, the authors began to identify the subthemes running through the codes, and their connections to the main themes identified. In the third stage of identifying outliers or negative cases, the researchers looked out for themes unrelated to the research question. These identified outliers were not discarded but were preserved to identify the relationship such outliers could have on the study. In the fourth stage of generalizing with constructs and theories, we compared our findings with existing literature on the phenomenon under study. The last stage of memoing and reflective remarks ensured our continuous reflexivity, which was enhanced by the reflective notes documented throughout the research process to enhance transparency and limit bias. Data saturation in this study was not instantaneous [ 42 ]. The first author gained insights from initial observations and interviews to expand future interviews and observations throughout the data-gathering process. Data saturation was reached when generated themes were supported with substantial data with no emerging new or contradictory information. See Table 2 for themes, codes, and excerpts of the study findings.

Trustworthiness

The study followed the criteria of credibility, transferability, dependability, and confirmability described by Lincoln and Guba [ 53 ]. We met the credibility criterion by piloting the research instruments with three women with the same characteristics as the participants to ensure the tools were valid and appropriate to the research question. Data from the pilot study were not included in the main data. The first author had a prolonged engagement in the context and deep immersion in the data to promote understanding and interpretation. The authors met continuously to debrief on the generated findings. Member checking was also done by the first author, who collected the data to reduce errors and ensure that data represents the participants' views. To meet the criterion of transferability, purposive and snowballing sampling techniques were employed to ensure participants were selected based on their experience with the phenomena of interest, which enriched the data. We also provided a detailed description of the data-gathering approach and ensured that research team members conducted data coding to meet the criterion of dependability. Several data triangulation approaches were employed to ensure confirmability, such as a detailed audit trail, reflective and field notes, participant observations, and focus group discussions, to enhance the confirmability of research findings and ensure a rich study.

Forty-three pregnant and nursing women of diverse demographic characteristics in education, religion, and location aged 18 to 44 years, with parity ranging from one to six, participated in the study. Using the construct of enablers and nurturers of the relationships and expectations domain of the PEN-3 cultural model, four themes were generated: The attitude of health workers, The high cost of services, Factors within PHC facilities and Contextual issues within communities. The theme, Attitude of healthcare workers and The presence of male skilled attendants, a subtheme in the theme of Factors within PHC, were found to be both positive and negative enablers that either facilitated or limited women's engagement in cultural practices and use of facility care. However, other themes, such as the High cost of facility care, subthemes in the theme of Factors within PHC facilities, such as Limited access to far away PHC facilities, PHC does not operate 24 Hours, Lack of awareness of available MHS, Poor facility infrastructure, Unavailability of modern equipment and subthemes in the theme of Contextual issues within communities such as The influence of intergenerational cultural norms and value, The attitude of elders in communities and Lack of community engagement were found to be negative enablers and nurturers that limit women’s access to facility care and enhanced engagement in harmful cultural practices. See Fig. 1 for themes and subthemes generated using the PEN 3 cultural model.

Results of findings using the relationship and expectations domain of the PEN 3 cultural model

The relationship and expectation domain of the PEN 3 cultural model

Using the relationship and expectation domain, we explored the societal or structural resources, such as the health system, socioeconomic factors, and contextual issues, that facilitate or limit women’s access to MHS in PHC facilities.

Under this construct, we found that themes such as The attitude of health workers and The presence of male skilled attendants, a subtheme generated under Factors within PHC facilities, were significant positive and negative enablers of cultural norms and practices that either limited or facilitated the use of MHS in PHC facilities. However, the theme, High Cost of Services, and subthemes under Factors within PHC facilities such as Limited access to far away PHC facilities, PHC does not operate 24 hours, Lack of awareness of available MHS, Poor facility infrastructure and Unavailability of modern equipment were negative enablers that limited women’s access to PHC facilities and engagement in harmful cultural norms and practices.

The attitude of health workers

We found that the attitude of healthcare workers was both a positive and a negative enabler that facilitated and limited women’s use of MHS in PHC facilities. As a positive enabler, women narrated that the care providers' friendly, kind, accommodating, and respectful attitude were the reasons for the continued use of MHS in PHC facilities. Many narrate that most health workers in the PHC facilities do not shout at them, scold or maltreat them, unlike in other health facilities. Such attitudes also extend to the labour period, where women receive significant support from health workers during labour and delivery, which they believe makes the pain of childbirth bearable.

… the nurses they are very kind and they talk to us in a peaceful manner that will make you to come next time. So, there is no day that you come here for immunization or antenatal care that you will go home with a heavy heart or as in you are hurt and angry. Whenever you come here, you go home… happy. (RA/FGD/05). … the support they give us in the health facility, like this (mentions a PHC facility) that we are going to, …..what makes us to go there always is whenever we are doing labour, their nurse, they will be petting you, they will be holding you, they will be walking around petting you, that makes us to be going there always (RA/IDI/07).

A few women also narrated that they were allowed birth companions, such as their husbands and families, who support and encourage them during delivery. Women narrated that such support was significant as it encouraged bonding between women and their husbands, made the labour pain bearable, and increased the respect their husbands had for them when they watched them go through labour and give birth. However, most of the participants recounted that their husbands and families were not allowed into the labour room to support them emotionally and physically during labour.

They will have to drive him (husband) out and nurses will tell him that a man cannot enter the labor room, that he should wait outside and your wife will be fine. He said he knows, but he just wants one minute to pray with his wife (UA/FGD/05)

Women also recounted that, in most cases, health workers respect their cultural values and beliefs in care, which is important to them and enhances their continual use of such PHC facilities.

You know, even when we come in labour and we bring our “Rubutu” (an Islamic concoction usually believed to promote speedy and safe delivery), we don’t need to hide it like in some other places where they do not allow us to use it, they even help us and allow us to drink it and help rub some on our belly and private part, so why will I not come again when I am in labour” (Urban Area/Observation/01)

Women stress that most health workers from other ethnicities provide appropriate culture-focused care, have learned the Igala language, and communicate with patients in Igala land. However, some health workers are still not conversant with contextual cultural values in most PHC facilities. Women emphasize that such health workers must understand their cultural beliefs, values, and practices and apply these in care provision to establish trust, acceptance, and women's continued use of MHS in PHC facilities.

So, when you are in the midst of people you have to monitor them to know the ways of their life so that you can live the ways of their life, with that you can have unity. Maybe your way of life is different from their way of life, there will be no unity because they will see you as a stranger, you understand? So, they must understand us (RA/IDI/11).

However, as a negative enabler that could limit women's access to MHS, a few women narrated issues of abuse during the second stage of labour, such as slapping, unnecessary restraints, verbal abuse, and denial of a companion at birth. Women recount that, in most cases, many health workers interpret such abuse as a strategy to prevent birth complications in the second stage of labour and assist mothers to focus during delivery.

…during my birth, there was a nurse that beat me and asked me if I wanted to kill my baby or do I want my baby to drink water, that I should balance well and give birth and, so she was beating me, and I was asking in my mind that why is this nurse beating me not knowing that she was helping me. So, when I delivered, she came to me and asked me not to be angry of what she did to me in the labor room that she wanted to help me, I then told her that I wasn’t angry, that I was even happy she helped because if she didn’t, then I wouldn’t have known what will happen to my baby (UA/IDI/02).

High cost of services

The high cost of MHS, which is unaffordable for most women, was found to be a negative enabler that limited women’s use of MHS in most PHC facilities. Moreover, most MHS are paid out of pocket, which is beyond the reach of many families and is responsible for women’s decision to seek cheaper options such as the use of herbal medicine and home deliveries. Many women do not use PHC facilities as they believe that the amount spent in facility care could be transferred to meet other basic pressing needs in the family, especially at this time in Nigeria, when feeding is a significant problem.

They feel health care is going to take more money from them. So, the little money they saved, they want to use it to buy baby things or to eat. Some are not privileged enough to take care of themselves, and so they feel that since I can get herbs that can last me for a week for a hundred naira, why will I go to the hospital that will charge me one thousand naira for ante-natal drugs? That is the main reason they do that here in Igala land (UA/IDI/05). Sometimes you go to hospital…you have to pay…maybe high amount before you give birth. They will ask you to pay a lot of money, and some of them are not buoyant enough. That is why they chose to go for home delivery; sometimes you deliver at home if God helps you to deliver safely, they will say you should pay 5000 thousand naira, they prefer that one to the hospital because of the bill. If I see someone that attends to me at home, the price is less and she is perfect in what she is doing, I will go for that, irrespective of the help I got from the facility (RA/IDI/04).

However, according to some women, some health facilities provide the required MHS and allow women to make initial deposits and complete the payment at their convenience. Women narrate that such provision assists in reducing the burden of paying large sums of money at an instance that many may not have access to. Based on the economic situation in Nigeria, many women emphasize the need for free MHS to increase women’s use of facility care and enhance maternal health outcomes.

The government can also help by making registration for antenatal to be free. And also to reduce the money paid for delivery. That is the major thing to me (UA/FGD/01).

Factors within PHC facilities

Limited access to far away phc facilities.

We also found that access to far-away PHC facilities was a negative enabler that limited the use of PHC and promoted the use of traditional birth attendants. While many PHC facilities are located within five kilometres of residential areas, women narrate that many traditional birth attendants live closer to them and are more accessible than most PHCs facilities. These traditional birth attendants provide culturally focused care and are cheaper to access than PHC facilities. Women stated the need for the government to build closer PHC facilities, providing essential services to women, especially in rural areas where most women have limited access to numerous PHC facilities. Women also stressed the need for the government to build accommodations for health workers in rural areas to enhance ease of access for women when labour starts at odd hours, which could reduce maternal and fetal mortality.

One of the reasons, my sister, that people access traditional birth attendant at times, is not even because of culture, it is because of nearness. The woman next door is a traditional birth attendant, so even if the thing happens in the night and I am feeling pain, I know I can rush to her… The government should provide places that are near… medical facilities for us … to walk across there when you are in labour (RA/IDI/01).

PHCs do not operate 24 hours

The lack of 24-hour services in some PHC facilities was seen as a negative enabler that limited access to facility care. Women narrated that some PHC facilities provide day shifts running for six to eight hours, which discourages women’s use of such facilities during labour. Based on this awareness, many women whose labour onset occurs at night, especially in rural areas, end up delivering with traditional birth attendants or with families who may have limited understanding or experience with conducting deliveries.

Some of our clinics do not operate at night, so when a woman is in labour, her first point of call will be, my neighbour is there…at least she has some knowledge (RA/IDI/01).

Lack of awareness of available MHS in PHC facilities

Lack of awareness of available MHS in PHC facilities was a significant negative enabler that limited access and use of services in many PHC facilities. Women emphasized the need for PHC facilities to raise awareness of the services they provide. Most women are unaware of the scope of services provided in most PHC facilities, which limits their use of such facilities.

I don’t even know that they do delivery in this health centre. I have been coming here for my antenatal and for immunization. It was when the health centre was near the market that I used to hear that people deliver there (RA/Observation/02).

Presence of skilled male attendants

The presence of male skilled attendants during labour was one of the themes generated during the research and was both a positive and a negative enabler. Women provided diverse views related to the presence of a male-skilled birth attendant during pregnancy and labour. For some, the presence of a male-skilled attendant is unacceptable as their culture does not permit another man to see their nakedness. Moreover, many women narrated that the presence of a male skilled attendant would make them shy and limit their ability to communicate freely during childbirth. In addition, women emphasize that male skilled attendants’ knowledge is limited to theoretical knowledge, lacking experiential knowledge when compared to female skilled birth attendants. Thus, women believe that male skilled attendants may not fully understand or adequately handle pregnancy and delivery. Many women narrated that the presence of a male skilled attendant is one of the reasons they would cease to access facility care and seek services with a traditional birth attendant or a facility with female skilled birth attendants.

I will not allow a male nurse to see my nakedness, as that is our culture. I don’t think I will open my body to a male health worker. If I must, I will not go back to that clinic again; rather, I will choose a place where a woman will take care of me (RA/IDI/O2).

However, many Muslim women narrated that while it is Islamically unacceptable for a male-skilled birth attendant to see the nakedness of a married woman, women during pregnancy and delivery are exempted due to their condition. As such, the Islamic religion does not frown at the presence of a male skilled attendant during pregnancy and birth.

while you are pregnant…the religion only permit the male nurses to attend to you if you are in that situation… because you are on a condition, so it permits that, but aside that, if another man should see your nakedness, it is abomination, traditionally and even Islamically (RA/IDI/04).

For many women, irrespective of religion, the gender of a skilled attendant is irrelevant. Women narrate that at the point of delivery, what really matters is having a safe delivery void of complications. Consequently, whoever attends to them is not an issue as long as the male skilled worker is trained, capable, and competent to handle labour and delivery.

My first child, it was a man that checked me …I didn’t know there was a difference between male and female. I thought they were all the same since it is his profession…I just want to be on the safer side… I don’t care if you are a man or a woman (UA/IDI/05).

Poor facility infrastructure

Women identified poor facility infrastructure as a negative enabler that limits access to PHC facilities. Women narrated that while staff in most PHCs facilities aim to provide quality care, several factors limit adequate and quality MHS provision in most PHC facilities. Many women also stressed that most health facilities, especially in rural areas, are run down without appropriate basic infrastructure and equipment to provide antenatal and delivery services.

This health centre does not have running water or light, and sometimes they cannot even test for blood here, so I am always afraid to come and deliver here. If my labour starts at night, where will they get light to see and work? So, I don’t come here (RA/Observation/ 04)

Unavailability of modern equipment

The unavailability of modern equipment in primary health facilities, especially in rural areas, was a negative enabler that limited women’s use of PHC facilities. Women narrated that the fear of losing their lives or their baby’s life hinders their use of the PHC facility in emergencies due to the lack of essential equipment and emergency services in most PHC facilities. In most cases, women are referred to bigger hospitals in the city to have a test or a procedure done for them, which raises questions about how such a facility could provide comprehensive services throughout pregnancy and delivery.

We don’t have very good hospitals here that are well equipped with the necessary supplies that are needed to save lives so that people will not be transferred during pregnancy, labour and during emergency (RA/IDI/06)..

Capacity of providers (knowledge and skills)

The lack of trained nurses and midwives in PHC facilities was another negative enabler limiting most women's facility care use. Most women recount that one of the reasons they do not access MHS in most PHC facilities is that most healthcare providers have limited training to care for women during pregnancy and to conduct deliveries. Many women narrate that while most facility care workers have some training, many health workers are not midwives who have been trained to attend to women during pregnancy and delivery. Thus, they lack the knowledge to understand emergencies and provide adequate care during emergencies. Consequently, due to such limitations, many women are afraid to access MHS in most PHC facilities.

My own reason is that sometimes you might come, you might …meet a quack. I don’t think, anyone will like to leave his or her life to a quack nurse or what ever to attend to. In a situation like that anybody will like to go to where he or she will be safe, sorry, where she will be safe and the baby will be safe (RA/IDI/04)

Contextual issues within communities

We also found that within this construct, several contextual issues within communities, such as The Influence of intergenerational cultural norms and values, The attitude of elders in communities, and the Lack of community engagement, were found to be negative nurturers that facilitate cultural values and practices and limit women’s access to MHS in PHC facilities.

The influence of intergenerational cultural norms and values

Women’s beliefs and values of intergenerational cultural norms and practices are significant negative nuturers that limit access to facility care. Women narrated that such cultural norms are passed on from their forefathers and have guided them during pregnancy and delivery for generations. Such norms, they say, are important to them as they emphasize that even before Western civilization, several protective cultural practices and norms allowed them to experience pregnancy and deliveries without complication. Consequently, women narrated that, although they engage in Western medical practices, they do not intend to discard their inherited traditions, values, and norms that have been a way of life and have sustained and protected them all their lives.

Our tradition is important to us. My mother sat me down when I got pregnant and talked to me on several traditional things I have to respect and obey so that my pregnancy and delivery will be without problem. I know I can go to the hospital and obey all they tell me, but our traditional medicine is also good for me to take because oyibo (Western) medicine does not cure everything. Some women in our place here don’t even go to the hospital; they don’t value it, they visit old men and women in our place here to help them in this condition. There are some things our local medicine can cure that Oyibo medicine cannot cure. So if you decide to follow the oyibo, oyibo way and forget what we do here, you may lose your life and that of your baby (Observation/RA/03).

However, while many women narrated the significance of holding tenaciously to cultural values and practices, for some, such practices were not passed on to them and so are not known to them. Moreover, some believe that some traditional beliefs and practices, such as taking traditional medicines, could lead to complications that could lead to abortions, premature labour, and maternal and fetal death. Some women even narrated that though they may want to take traditional medicine, their initial reaction after taking such herbal concoction put them off trying native medicines. Consequently, based on their experience, they totally depend on medicines provided in PHC facilities.

The attitude of elders in communities

Many women in rural areas recounted the attitudes of elders in local communities who hold tenaciously and enforce traditional beliefs and practices that negatively influence maternal health outcomes. They indicated that these elders make laws on issues related to cultural norms and practices that must be respected in communities, such as traditional laws and values guiding the non-use of modern contraceptives. Women emphasized that such norms predispose women to unintended pregnancies, unsafe abortion, and pregnancy-related maternal mortality. Such norms and values have negative consequences if disobeyed and are believed to result in premature deaths in families. To make matters worse, these traditional norms and values are interwoven in religion as most elders in communities also hold high positions in churches or mosques.

Some of our elders, when any problem like that comes to them, some of them will be dodging …because they don’t want anything that will bring problem to their head. They don’t accept it because they base their decision on tradition, they say tradition is tradition… you cannot use your head to replace church matters because you will overlook your tradition (RA/IDI/03).

Women also stated that, in most cases, health workers are cautioned by leaders in communities to avoid stressing cultural issues that impinge on the use of MHS in PHC facilities, as such, could negatively affect the relationship with community leaders, their jobs, and their ability to operate effectively in such communities. Consequently, most health workers are not able to openly oppose dominant cultural or traditional issues that could impinge on the use of MHS in most communities where the study was conducted.

Lack of community engagement

The lack of community engagement was seen as a negative nurturer that negatively influence maternal health outcomes. Women emphasized the need for community engagement in communities that could bring an end to diverse cultural norms and practices that limit women's access to MHS and create awareness of the significance of MHS. Given the patriarchal setup of most communities in Nigeria, which is also reflected in the community where the study was conducted, women narrated the need for community engagement with community elders, religious leaders, and men who, in Igala ethnicity, are decision-makers. Women emphasize the need for the government and health workers to hold meetings with these elders and with women of childbearing age to emphasize the need for the use of MHS around childbirth to reduce maternal and fetal health complications.

They will call them together now, the government, they will call our community, the elders, the husbands together, before taking the meeting and they will educate them, then advise them, for them to understand what they are talking about (RA/IDI/02).

While most women agreed that community engagement with community elders could end cultural norms and practices that limit the use of MHS, some believe such engagements may have a limited effect on intergenerational cultural norms and values that are detrimental to maternal health. Some women believe that ending such traditional norms could attract the anger of the ‘gods’ or ancestors, which could be detrimental to the whole community.

This study was conducted to provide an in-depth understanding of facilitating and limiting factors of cultural norms and values influencing the use of MHS in PHC facilities among the Igalas in Kogi state, Nigeria. Using the enabler and nurturer constructs of the relationships and expectations domain of the PEN 3 cultural model allowed for a deep understanding of some of the factors that influence the use of MHS in Nigeria. One of the themes generated is the attitude of healthcare workers which, in most instances, showed that health workers were respectful, accommodating, and kind, in facilitating women’s use of facility care. Women further emphasized that accommodation of their traditional practices also encouraged them to access care in PHC facilities. Such respectful maternal care was also reported in a study in Ethiopia, where many of the women reported respectful care and assistance without physical and emotional abuse around childbirth [ 54 ], contrary to several studies that revealed significant abuse around childbirth in Ghana and South Africa [ 55 , 56 ]. The reason for respectful maternal care in this study could be that most health workers are of Igala ethnicity, which enhances understanding of the language, values, and beliefs surrounding childbirth, promoting appropriate culture-centred and respectful care around childbirth.

A few of the women reported disrespectful treatment around childbirth, which is consistent with several studies that showed that the negative attitude of health workers is a significant deterrent to women’s use of MHS, especially in most SSA countries [ 55 , 56 , 57 ]. Abuse, such as slapping, unnecessary restraints, verbal abuse, and denial of a companion at birth, were described by women in the present study and were also revealed in studies conducted in Ghana, Kenya, and South Africa [ 55 , 56 , 57 , 58 ]. However, such actions were not seen as disrespectful by health workers but seen as protective acts [ 59 , 60 ], as narrated in the present study, which is quite disturbing. Studies have also shown that such abuse is a significant determinant of home deliveries, the use of traditional birth attendants, and the avoidance of facility care [ 18 , 58 ] and could potentially contribute to high maternal mortality [ 60 , 61 ]. Though the [ 62 ] established recommendations to promote respective, supportive, and culturally sensitive care provision around childbirth, the effectiveness of such recommendations is limited in Nigeria due to limited policies guiding respectful maternal care, a weak health system, limited communications, and lack of a trusting relationship between care providers and the public [ 63 ]. Consequently, given the complex nature of respectful maternal care, a collaboration of stakeholders, policymakers, health system and care providers are needed to eliminate disrespectful maternal care [ 59 , 63 ].

High cost of MHS was also a theme generated in the study that contributed to the non-use of facility care and home delivery as MHS is paid out of pocket (OOP) in most PHC facilities, which could be unaffordable for most low-income earners, especially in rural areas. Studies reveal that, since the launch of the Nigerian National Health Insurance Scheme (NHIS) in 2005, only 5% of the population has benefited from such insurance, as many states in Nigeria and public servants lack access to the scheme [ 64 , 65 , 66 ]. Thus, approximately 70% of the population's health care is financed through OOP expenditure [ 65 , 67 ]. The NHIS provides comprehensive coverage of antenatal, delivery (vaginal and caesarian section), and post-natal services [ 66 ]; however, there remain hidden costs, such as medications not listed under NHIS, and cost of transportation not covered by the scheme. Studies in Central and Latin American countries and India are consistent with the findings in this study and have revealed that OOP for MHS has been found to decrease the use of facility care and increase maternal mortality, especially in socially marginalized communities [ 68 , 69 ]. Though many women in this study narrated the need for free MHS to enhance women’s access to MHS, many studies emphasize the need to address multiple barriers that limit MHS access to women, including dominant contextual and cultural issues that limit MHS access, even when such services are made freely available [ 6 , 70 ].The study also found issues of accessibility and limitation of human and material resources consistent with most PHC facilities in Nigeria, which was also revealed in several studies [ 19 , 31 , 71 ]. In Nigeria, a standard PHC staffing should consist of a physician, four nurse/midwives, a pharmacy technician, one medical record officer, a laboratory technician, a community health extension worker (CHEW), and six junior CHEWS [ 32 , 72 ]. However, while this list may reflect the standard expectation for a functional PHC, studies reveal a shortage of nurses, midwives and doctors in most PHCs in Nigeria, with most PHC facilities manned by CHEWS, providing care beyond their jurisdiction and capacity even with limited training to manage pregnancy and delivery when compared to nurses and midwives [ 73 , 74 , 75 ]. Consequently, many women are predisposed to maternal health complications or preventable deaths due to the substandard MHS received in most PHC facilities [ 74 ]. Moreover, most PHC facilities are unable to provide comprehensive care due to inadequate infrastructure, limited material and medical resources, geographical barriers and limited funding of the health system in Nigeria [ 19 , 31 , 71 ]. Budgetary allocation to health in Nigeria is about the lowest in most SSA countries, hardly exceeding 7% of the total national budget, which is below the 2001 Abuja declaration of assigning at least 15% of the national budget to health [ 64 , 76 ]. Thus, the meagre funding allocated to curative care leaves the PHC system largely underfunded to undertake a multidisciplinary and comprehensive maternal healthcare provision [ 64 ]. In addition, community engagement, designed to be integrated as part of PHC, is non-existent in most facilities, limiting communities’ participation in healthcare projects and programs to promote sustainable outcomes [ 31 , 34 ]. Such limitations could account for why women prefer accessing traditional birth attendants due to ease of access, provision of culture-appropriate care and provision of cost-effective care when compared to PHC facilities [ 18 , 21 ], as also seen in this present study. Consequently, the reinvigoration and financial strengthening of PHC facilities in Nigeria is critical to meet the rising population's demands through equitable and affordable services and availability of human and material resources, especially in rural areas where PHC facilities are the only available facility within reach.

We also found conflicting views about the presence of male skilled attendants in delivery. While many women narrated that such was against their culture and could limit their access to facility care, others were not bothered about the gender of the skilled attendant as far as such male skilled attendant had sufficient skills to manage obstetric issues and delivery. Our findings align with a study conducted in Kenya [ 77 ], where women were not bothered about the gender of care providers during labour as long as such skilled attendants had the necessary qualifications. Similar to our finding, studies in Ethiopia [ 78 , 79 ] showed that many women were uncomfortable with a male skilled attendant at delivery. Given the conflicting findings, understanding women’s gender preferences in care provision is crucial to enhancing women’s access to MHS.

Similar to other studies in Ethiopia and Tanzania [ 78 , 79 , 80 ], contextual cultural norms passed on from generation to generation, such as the use of herbal concoctions, access to traditional birth attendants, and patriarchal and gender issues, were found to be significant factors influencing women’s use of MHS. However, several studies emphasized the need for community engagement, as was suggested by participants in this study, which could enhance women’s use of MHS and reduce maternal mortality. According to [ 81 ], community engagement enables individuals, groups, or organizations within a social context to participate and make decisions in the planning, designing, managing, and delivering of health interventions. Such engagement could allow stakeholders to understand a community’s priorities and ensure contextually appropriate health strategies tailored to the community’s cultural needs, given that cultural norms and social structures within communities, impact health behaviours and outcomes [ 82 , 83 ]. Community engagement in Mozambique, Pakistan and India has enhanced the engagement of families, partners, communities and families in decision-making to support MHS tailored to the needs of the population, promoting increased understanding of pregnancy and birth complications, increased use of MHS and enhancing maternal health outcomes [ 84 , 85 , 86 ]. The Nigerian government could harness such strategies to ensure appropriate culturally focused MHS, which is adapted to the cultural expectations of the population.

Strength and limitations

A strength of this study is the participation of women with diverse demographic characteristics in education, religion, age, parity, location, and occupation, which promoted a thick description and interpretation of the phenomenon of interest. Additionally, focused ethnographic research offered us diverse methods that enhanced triangulation and the study’s rigor. The PEN-cultural model was also beneficial, as it's use as a framework allowed us to capture significant facilitating and limiting factors of cultural values and norms that influence women’s use of MHS in PHC facilities. However, the study was conducted in PHC facilities alone, necessitating future exploration of women’s perspectives in secondary and tertiary health systems. Thus, further research could be employed to understand the perspectives of women who access secondary and tertiary health facilities in Nigeria.

Policy statements

Though cultural beliefs and practices are significant factors that influence women’s use of MHS, not much is known about significant factors that facilitate or hinder these cultural norms and values regarding women’s use of MHS in PHC facilities. This study has brought to light numerous significant factors that could facilitate or hinder cultural norms and values with regard to the use of MHS in PHC facilities. Findings reveal that the attitude of health workers and culture-appropriate care are facilitating factors that influence women’s use of MHS, though few women reported abuse, which was insignificant to most health workers. Consequently, modules of respectful maternal care and culture-appropriate care could be introduced among health workers in PHC facilities, which is lacking in Nigeria to ensure respect, dignity, and valuing of women’s cultural preference in care provision, which could enhance women’s satisfaction, increased use of maternal health services and promote maternal health outcomes.

Additionally, the OOP payment for MHS is a significant factor that limits the use of services in PHC facilities and increases engagement in harmful traditional practices. Consequently, policies could look towards free MHS by making the NHIS available to individuals in rural areas to reduce maternal mortality. The state of PHC facilities in Nigeria is deplorable, given the lack of human and material resources needed for the provision of timely, adequate MHS due to limited health financing [ 19 , 31 , 71 ]. Consequently, stakeholders, policy makers, and the Nigerian government need to critically explore multiple approaches to ensure comprehensive MHS provision in PHC facilities. Additionally, community engagement is an important strategy that could enhance understanding of contextual and cultural issues, which could be harnessed to promote the provision of MHS that is responsive to communities' cultural needs [ 71 , 72 , 73 ]. Such community engagement, which has been effective in Asian and other African countries [ 87 , 88 , 89 ], could be harnessed to enhance maternal health outcomes in Nigeria.

In this study we have provided a deep understanding of some of the facilitating and limiting factors of cultural values and norms that influence the use of MHS in PHC facilities. The use of the enabler and nurturer constructs of the relationships and expectations domain of the PEN 3 cultural model was significant as a framework for organizing our findings and understanding the facilitating and limiting factors of cultural norms and values. Using the PEN 3 cultural model, we found that the theme, attitude of healthcare workers was both a positive and a negative enabler that either facilitated or limited women’s use of MHS in PHC facilities. We also found that the high cost of MHS was a negative enabler that influenced women’s engagement in harmful cultural practices and nonuse of facility care.

Additionally, a subtheme of the factors within the health system, such as the presence of male skilled attendants, was both a positive and negative enabler that facilitated and limited women’s access to PHC facilities. However, other subthemes in the theme of factors within the health system, such as the lack of nearby PHCs, the lack of appropriate human and material resources, and lack of awareness of services provided in PHC facilities, are significant negative enablers that promote alternative cultural care-seeking behaviours and limited use of MHS in PHC facilities. Finally, contextual cultural issues, such as the influence of intergenerational cultural issues, the attitude of community elders, and the lack of community engagement, were dominant cultural nurturers that deepened cultural norms and limited the use of MHS in PHC facilities. Further studies are needed on approaches to enhance sustainable strategies that limit harmful cultural norms and practices and enhance MHS use. Additionally, the reinvigoration of PHC is critical through increased health financing, attention to material and human resources, and community engagement to promote comprehensive care delivery in communities.

Availability of data and materials

Data are available on the reasonable request from the corresponding author.

Abbreviations

Community Health Extension Worker

Focused Ethnography

Integrated Maternal, Newborn and Child Health Strategies

Maternal Health Services

Maternal Mortality Ratio

Midwives Service Scheme

Nigerian National Health Insurance Scheme

Out-of-Pocket

Primary Health Care

Sustainable Development Goals

Skilled Birth Attendants

Sub-Saharan Africa

United Nations

United Nations Emergency Fund

World Health Organization

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Acknowledgements

We wish to acknowledge all the women who participated in this study and freely shared in-depth perspectives of their experiences. We also appreciate the gatekeepers in the two facilities, who granted us ease of entrance into the study settings.

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UCO and PP conceptualized the study and methodology. UCO, PNI, HL and PP analyzed and interpreted the findings. UCO, PNI, HL and PP were involved in the preparation and critically guided the writing of the manuscript, revision and interpretation of the findings. All authors read and approved the final manuscript.

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The University of Saskatchewan Behavioural Research Ethics Board (ID/4003) and the Ministry of Health, Kogi State, Nigeria (MOH/PRS/465/V.1/60) approved the study. Informed consent was obtained from all study participants after explanation of the aim, purpose, and potential benefit of the study. Women were also informed that they could withdraw from the study, which would not affect the care they received in the facility. Women willingly signed the consent after they accepted to share their experiences and obtained oral consent from their husbands. Verbal consent was obtained from women before the scheduled observations, interviews, and focus group discussions. Participants in focus group discussions were informed not to disclose what was said in the group with others. Consent for observations was obtained from each health facility, with posters placed strategically at different points. Data from observations, interviews, and focus group discussions were anonymized (participants were assigned numerical codes) and stored securely in a password-protected computer separate from participants' personal information, only accessible to the first and last authors. Participants' personal data were processed and stored in accordance with the University of Saskatchewan Behavioural Research Ethics Board.

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Opara, U.C., Iheanacho, P.N., Li, H. et al. Facilitating and limiting factors of cultural norms influencing use of maternal health services in primary health care facilities in Kogi State, Nigeria; a focused ethnographic research on Igala women. BMC Pregnancy Childbirth 24 , 555 (2024). https://doi.org/10.1186/s12884-024-06747-x

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DOI : https://doi.org/10.1186/s12884-024-06747-x

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• Open access
• Published: 28 August 2024

Long-acting injectable antiretroviral treatment: experiences of people with HIV and their healthcare providers in Uganda

• Henry Zakumumpa 1 ,
• Adolf Alinaitwe 2 , 4 ,
• Marjorie Kyomuhendo 3 &
• Brenda Nakazibwe 1 , 5  

BMC Infectious Diseases volume  24 , Article number:  876 ( 2024 ) Cite this article

Metrics details

Introduction

Long-acting injectable antiretroviral treatment (LAI-ART) has emerged as a novel alternative to the burden of daily oral pills. The bi-monthly intramuscular injectable containing cabotegravir and rilpivirine holds the promise of improving adherence to ART. The perspectives of potential users of LAI-ART, the majority of whom reside in Eastern and Southern Africa, are still largely unexplored. We set out to understand the experiences of people with HIV (PWH) who received LAI-ART at Fort Portal Regional Referral Hospital in mid-Western Uganda for at least 12 months.

This qualitative study, conducted between July and August 2023, was nested within a larger study. We conducted four focus groups with 32 (out of 69) PWH who received intramuscular injections of cabotegravir and rilpivirine. In-depth interviews were held with six health workers who delivered LAI-ART to PWH. Data were analyzed by thematic approach broadly modeled on the five domains of the Consolidated Framework for Implementation Research (CFIR).

There was high acceptability of LAI-ART (30 /32 or 94%) participants requested to remain on LAI-ART even after the end of the 12-month trial. Adherence to ART was reportedly improved when compared to daily oral treatment. Participants credited LAI-ART with; superior viral load suppression, redemption from the daily psychological reminder of living with HIV, enhanced privacy in HIV care and treatment, reduced HIV-related stigma associated with taking oral pills and that it absolved them from carrying bulky medication packages. Conversely, nine participants reported pain around the injection site and a transient fever soon after administering the injection as side effects of LAI-ART. Missed appointments for receiving the bi-monthly injection were common. Providers identified health system barriers to the prospective scale-up of LAI-ART which include the perceived high cost of LAI-ART, stringent cold chain requirements, physical space limitations, and workforce skills gaps in LAI-ART delivery as potential drawbacks.

Overall, PWH strongly preferred LAI-ART and expressed a comparatively higher satisfaction with this treatment alternative. Health system barriers to potential scale-up are essential to consider if a broader population of PWH will benefit from this novel HIV treatment option in Uganda and other resource-limited settings.

Trial registration

Trial Registry Number PACTR ID PACTR202104874490818 (registered on 16/04/2021).

Peer Review reports

Long-acting injectable antiretroviral treatment (LAI-ART) has emerged as a novel alternative to the burden of daily oral HIV treatment [ 1 ]. The bi-monthly intramuscular injectable containing cabotegravir and rilpivirine holds the promise of improving adherence to ART and viral load suppression in low-income countries where the 95-95-95 targets have not yet been fully achieved [ 2 ]. This is particularly so among sub-groups of people with HIV (PWH) with adherence constraints. Some of the common barriers to adherence to ART include individualized stigma, forgetfulness, being away from home, depression and alcohol misuse [ 2 ]. Sub-groups with adherence challenges include older adolescents, children/caregivers and sex workers who experience constraints in observing the daily oral pills routine [ 3 ]. LAI-ART is said to reduce HIV-related stigma among those taking daily oral pills such as in discordant couples [ 1 ]. Clinical trials conducted in high-income countries demonstrate that LAI-ART is non-inferior to daily oral ART [ 2 ]. The World Health Organization approved LAI-ART in 2022. In July 2023, ViiV Healthcare, a pharmaceutical company committed to sharing the intellectual property underpinning LAI-ART making generic production a possibility for millions of PWH in low and middle-income countries (LMICs) [ 4 ].

Most of the evidence on therapeutic efficacy and the notion of high acceptability of LAI-ART has emerged out of clinical trials and controlled environments in high-income settings [ 5 , 6 , 7 ].

There is little research around ‘real world’ implementation experiences in high-burden, LMICs such as Uganda [ 5 ]. The perspectives of potential users of LAI-ART, the majority of whom reside in Eastern and Southern Africa are still largely unexplored [ 3 ]. The medication safety of LAI-ART in African populations is largely unknown. Little is known on the operational context and health system capacity for the implementation of LAI-ART in Eastern and Southern Africa, even though over 55% of the global population of people living with HIV reside in this region [ 5 ]. Implementation research on patient experiences of LAI-ART in LMICs can inform decision making by policy makers and funders such as the President’s Emergency Plan for AIDS Relief (PEPFAR).

HIV epidemiological context in Uganda

Uganda has a generalized HIV epidemic with one of the largest populations of PWH in Eastern and Southern Africa, the region with largest HIV burden in the world [ 8 ]. Over 1.4 million Ugandans are accessing ART. Since 2004, ART has been widely available at public facilities country-wide with funding from external donors particularly PEPFAR which accounts for almost two thirds of HIV spending [ 8 ].

Uganda has registered remarkable strides in its national HIV response from a high of almost 30% HIV prevalence at ante natal sites in the 1990s to about 6% in 2023. Viral load suppression rates in some parts of Uganda do not meet UNAIDS 95-95-95 targets [ 8 ]. Viral load suppression rates in Uganda vary widely in some sub-populations and communities. In some studies, conducted in Uganda, viral load suppression rates have been reported to be as low as 8% and at 24% among children, at 48% at military hospitals and at 74% at some sites in Eastern Uganda [ 3 ].

In Uganda, select sub-groups of PWH have sub-optimal rates of adherence to ART and these include adolescents, children and younger men compared to older age groups [ 3 ]. Multi-level interventions are therefore needed in these sub-groups to accelerate progress towards attaining targets for viral load suppression [ 3 ].

To this end, in December 2022, Uganda approved long-acting injectable ART joining Zimbabwe in providing regulatory approval [ 9 ].

Little is known about the experiences and preferences of PWH regarding LAI-ART as an alternative option to oral HIV treatment [ 10 , 11 , 12 ]. A notable exception is a study conducted in Uganda by Kennedy and colleagues [ 13 ], however this study explored the perceptions of potential users of LAI-ART in Uganda.

To the best of our knowledge this is the first study in Uganda to report qualitative findings of PWH in Uganda who actually received LAI-ART for 12 months and their attending clinicians. The objective of this paper is to document the experiences of 32 (out of 69) PWH who received LAI-ART and the health workers who offered this treatment option for at least 12 months in mid-Western Uganda.

Research design

We adopted a qualitative exploratory research design [ 14 , 15 , 16 ], to understand the experiences of PWH under long-acting injectable antiretroviral treatment (LAI-ART) as compared to oral HIV treatment (containing tenofovir, lamivudine, dolutegravir) which they had been on in the past 12 months prior to initiation on LAI-ART. In so doing, we undertook a post-hoc evaluation of the intervention which was rolled out in April 2021 [ 17 , 18 , 19 ]. The first patient enrollment date was on 15th September 2021. Trial participants were started on an oral formulation of LAI-ART for the first four weeks after the enrollment date. We interviewed PWH who received LAI-ART for at least 12 months and their attending HIV clinicians and nurses. PWH had been on the oral standard of care before switching to LAI-ART (containing tenofovir, lamivudine, dolutegravir). The clinical trial in which our study participants engaged was part of an open label, multi-centre clinical trial implemented in Uganda, Kenya and South Africa with funding from Janssen pharmaceuticals [ 17 ]. The clinical trial in Uganda received local ethical approval [ 17 , 18 , 19 ] from the Uganda National Council of Science and Technology (HS1117ES) and the clinical trial is registered with the National Drug Authority of Uganda (CTC0161/2021) [ 20 ]. The underpinning clinical trial is registered with the Pan African Clinical Trials registry (PACTR ID: PACTR202104874490818).

Theoretical orientation

This qualitative study of post-implementation experiences of LAI-ART by PWH and their providers was underpinned by the updated Consolidated Framework for Implementation Research (CFIR) [ 21 ]. The CFIR is a widely used framework that is informed by a robust literature review of facilitators and barriers to implementation of health care interventions from a multi-level lens of ‘five domains’ namely; (i) Innovation domain (ii) outer setting domain (iii) Inner setting domain ii) outer setting, (iv) Individuals domain (v) Implementation process domain. A detailed description of the five CFIR domains and ‘sub-domains’ used in this study is shown in Table  1 .

The CFIR was used as an overarching deductive framework in developing our qualitative interview guides as well as in the analysis and presentation of data shown in Table  2 .

Fort Portal Regional Referral Hospital (FPRRH) is at the highest level of tertiary care in mid-Western Uganda [ 22 ]. The hospital caters to patients from Fort Portal as well as other neighboring districts.

The HIV clinic at FPRRH has over 17,000 active PWH on ART and operates on a five-day-a-week basis, on an outpatient basis. The clinic runs as an autonomous service unit under the hospital [ 23 ] with its own dedicated workforce (HIV clinicians, nurses, counsellors), separate physical space within a large hospital complex, triage systems and a dedicated HIV-specific laboratory.

Fort Portal Regional Referral hospital was one of three sites in Uganda [ 17 , 18 ] implementing a clinical trial of LAI-ART with funding from Janssen pharmaceuticals [ 17 , 18 , 19 ]. FPRRH was selected because it was the first site to enroll participants in the LAI-ART clinical and because it had the longest implementation experience of LAI-ART in Uganda.

Selection of study participants

For this qualitative post-hoc evaluation, we enrolled 32 (out of 69) adult PWH who took part in a clinical trial of LAI-ART for at least 12 months. The detailed inclusion and exclusion criteria for those who participated in the clinical trial underpinning this study are described in the results. In terms of study procedure, we approached the study coordinator of the clinical trial at FPRRH and described our study objective of understanding the experiences of PWH under the novel option of LAI-ART. The study coordinator then informed PWH who participated in the clinical trial of our study objective. PWH who offered to participate in this study on a purely voluntary basis and could offer written informed consent were enrolled in this post-hoc qualitative evaluation.

We enrolled three HIV clinicians (including the site Principal Investigator) and three nurses who implemented the 12-month clinical trial.

Data collection

Focus group discussions.

We explored the experiences of PWH under the novel long-acting injectable alternative as compared to their previous experience on oral HIV treatment. We conducted four gender-disaggregated focus group discussions (FGDs) involving thirty-two participants. Each of the FGDs comprised eight participants. A pre-tested focus group guide informed by the CFIR framework was used entailing 17 open-ended questions. We conducted face-to-face FGDs in a quiet room at the study site. We conducted two focus groups involving females and two FGDs involving male participants. The focus groups were conducted between July and September 2023. The FGDs were audio-recorded with the consent of participants. Each of the two lead investigators was assisted by a research assistant who took notes and operated the recorder. The focus groups were conducted in Rutooro the local language spoken in mid-Western Uganda. On average, each of the focus groups lasted one and a half hours. A sample focus group guide is attached (supplementary file ).

In-depth interviews

In addition, we conducted in-depth interviews (IDIs) with six health workers who offered LAI-ART as part of the clinic trial. These included three HIV clinicians and three nurses. The face-to-face IDIs were conducted at FPRRH in the offices of the health workers. The IDIs were conducted in the English language and were led by the first and last author. The interviews were audio-recorded. The interview guide used in the IDIs is attached (supplementary file ). The objective of the IDIs was to understand the facilitators and barriers to implementation of LAI-ART from a provider perspective of health system context [ 21 ].

Data analysis

We followed the procedures recommended for qualitative data analysis proposed by Miles and Huberman [ 24 ]. Broadly, we followed four steps in analysis although it was a largely iterative process. Our audio files were translated into text transcripts. In the case of our focus groups, the transcripts were translated from Rutooro , a local Ugandan dialect spoken in Mid-Western Uganda, to English by a professional language translator proficient in both languages. Our first step entailed transcript review. The verbatim transcripts were read multiple times for data familiarization by two authors. We applied the framework approach to qualitative data analysis [ 25 ], hence our five deductive thematic categories informed by the CFIR framework guided data analysis (e.g. i) Innovation domain ii) outer setting domain iii) inner setting domain iv) individual’s domain v) implementation process domain). In the second stage, three authors inductively generated codes from multiple readings of the FGD and IDI transcripts. In the third stage, the inductively generated ‘sub-themes’ were then grouped under the five CFIR ‘domains’ or deductive thematic matrices (e.g. i) Innovation domain ii) outer setting domain iii) inner setting domain iv) individual’s domain v) implementation process domain). Hence we utilized a hybrid approach of both inductive and deductive theme development [ 26 ]. The fourth stage involved overall interpretation and synthesis [ 27 ] involving all co-authors. Disagreements in the assignment of themes and sub-themes were resolved by consensus in a team-based process.

Demographic profile of focus group participants

As illustrated in Table  3 below, there was equal representation of male and female participants in the focus groups comprising PWH. Most of the participants were aged 35–44 years (43.75%) followed by those aged 55–64 years (25.00%) and 25–34 years (18.75%) respectively. The least represented age group was those between 45 and 54 (12.50%). Regarding the participants’ marital status, most were married (75.00%) compared to the unmarried (25.00%). Additionally, most participants had attained basic primary education (75.00%) compared to those who achieved secondary education (25.00%). Because the majority of participants had attained a basic primary education, our focus groups were conducted in Rutooro the local language spoken in mid-Western Uganda to enable effective participation of all PWH in the proceedings of our FGDs. Regarding the participants’ duration on ART, the majority had received treatment for 11 to 15 years (56.25%), followed by those on treatment for 6–10 years (31.25%). Hence, most participants had been on ART for multiple years with only a few participants reporting a treatment duration of less than five years (6.52%).

Implementation process domain

Selection of participants for the trial.

Health workers comprising three HIV clinicians and three nurses described the selection criteria for participants in the LAI-ART clinical trial arm of the study. They observed that although the demand from RoC for LAI-ART was overwhelming, those selected to participate in the clinical trial had to meet stringent eligibility criteria. The only virological criteria set for participants in the trial was having achieved a viral suppression which was defined as having less than 200 copies of HIV per milliliter of blood. Secondly, as described by a health worker, the other criteria demanded that one had no active tuberculosis disease before enrollment in the trial:

‘To be enrolled for the injectable , we had a certain criterion we follow to put them on because currently , the first group we considered patients who were suppressed , who were stable , their viral load has been suppressed all through ever since they started ART. So , we wanted to see if the injectable ART can maintain the viral load suppression like the oral alternative’ [IDI, HCP_03].

The third criteria was that patients with liver or hepatitis disease and those using herbs concomitantly with ART were excluded. Likewise, pregnant or breastfeeding females were not eligible to participate in the trial. Tests were done to include only PWH, whose vital organs such as the liver, kidney, and heart had no indication of disease. As one of the health workers observed:

‘We did extensive screening to rule out those patients who have like liver disease , we could do ALT (elevation of alanine aminotransferase) to assess. Also , you know our patients take drugs and take alcohol at times and herbs. So you may find when the liver is already damaged so when you are putting some body on the new product they say it’s the product now not the other social life style , so we had to rule out that’ [IDI, HCP_01].

In the same vein, a PWH corroborated the health worker’s aforementioned submission noting that ‘this is how the injection started. They took us for a test that day , checking the heart , the kidney , the liver , blood pressure , blood sugars so that’s how I started like that and I moved to the injection’ [Male 41, PWH, _08].

Having followed the selection criteria, 69 eligible PWH were enrolled on the LAI-ART clinical trial for 12 months effective 15th September 2021.

Although there was extreme demand for enrollment in the clinical trial by PWH, the health workers observed that some participants initially selected to participate in the trial became ambivalent. This ambivalence was attributed to ‘conspiracy theories’ and misinformation about the new HIV therapies as propagated by peers in the community.

‘Some patients told us that they were scared by false rumors from their peers regarding injectable ARVs. They were told false tales that the injection was harmful and that it was meant to eliminate those with HIV with a lethal injection. Of course this was untrue and we had to counsel those had received this misinformation’ [IDI, HCP_03].

Consequently, during the enrollment of PWH on the clinical trial, health workers routinely informed the participants about the objectives of the clinical trials to wade off misinformation.

Intervention delivery

Prior to the administration of the bi-monthly injection, participants were initially started on an oral formulation of the trial medication, comprising cabotegravir and rilpivirine, for four weeks to ensure that there were no adverse drug reactions and that the medication was well tolerated.

‘We first give them oral medicine of the injectable , so when they take this particular medication entailing Cabotegravir and Rilpivirine , the body gets used and if there is any reaction , we can see easily from the oral treatment and if there’s any reaction we can stop. But if there is no reaction to the oral treatment it’s obvious that on the injection somebody will do well’ [IDI, HCP_02].

Thereafter, two separate injections containing cabotegravir and rilpivirine respectively, were administered intramuscularly on the buttocks, to each participant every two months. A trained health worker administered the injections in a private room at the trial site set up to administer the bi-monthly injections. Describing the injection administration process, a PWH stated thus:

‘When you come from home and you arrive at the hospital , the doctor reviews you while checking in your patient file. The other health worker then goes into the store for the injectable drug and retrieves it from the fridge and places it aside. Now the time comes the doctor gives you the paper to do some investigation may be for urine or blood. So as you come back they tell you to go up were we have a private room which is very special having all the things; like beddings - so that’s where you go and you lie. The injections are always there. The nurse comes with the doctor and they inject you on the buttocks , after they put a plaster (on the injection site) to stop any possible bleeding. And they ask you to either lie for a moment or rest for a while. If you wish you can rest and if you don’t want , you can go away. There is also some water to take , you can either take hot or cold water as you wish. That’s how it is’ . [Female 38, PWH, _06].

Furthermore, the health workers reported that since a number of participants frequently missed their appointments for administering the bi-monthly injections, reminders by phone call were necessary.

In instances where a PWH missed an injection appointment, the standard operating procedure was such that a PWH was immediately started on an oral formulation of LAI-ART for two weeks and then the missed injection was administered two weeks after the oral formulation.

Monitoring of trial participants

Telephone reminders were made to participants to attend their appointment for injection administration a day prior to the event. To ensure treatment adherence, a transport subsidy was provided to participants to enable them travel to the facility. Upon administering the injection, the health workers made a weekly call-in to the participants to ensure that they were not experiencing difficulties associated with the medication such as adverse drug reactions (ADRs).

Other monitoring measures conducted on each of the participants included viral load suppression laboratory tests once every six months, and medication safety tests such as assessing the functioning of the participants’ vital organs such as the liver, kidneys and heart. In this regard, a health worker recounted:

‘We assess them for safety. So , when we do safety tests , we test the liver , the kidney , the blood , we do viral load monitoring , CD4 count. We ensure that the patients are still safe on the product the laboratories are busy providing us with test results. We have to probe and see if they have any (adverse drug) reactions or presenting complaints and any other opportunistic infections so we can treat them’ [IDI, HCP_01].

Innovation domain

Bi-monthly interval of treatment.

Participants indicated that bi-monthly injections were a much more preferable option to oral HIV treatment involving oral daily pill taking. They expressed relief at the reduced burden of HIV treatment that requires a daily routine of swallowing a pill. According to them, they were able to spend more time at work unlike with the previous treatment options that required multiple visits to the health facilities. Likewise, both PWH and health workers mentioned how the bi-monthly treatment was advantageous regarding savings in transport costs and reduction of time spent at the health facilities. For instance, a health worker opined thus:

‘Sometimes they are caught up in jobs that are far away from their providers and they end up not taking the drugs. But now all those are covered with the injection , because when you see now the calendar , somebody has to take three hundred and sixty something (365) tabs in a year but for injection you only take six dozes in a year that is a very great improvement’. [IDI, HCP_04].

Relatedly, a female participant’s views applauding the benefits of LAI-ART treatment were that:

‘What a relief! I have been saved from the daily burden of having to swallow pills. For me , injectable ART is a God-send. The daily burden of having to swallow these tablets has been taken away. I am so relieved. For me , injectables are the way to go’ [Female 37, PWH, _09].

Perceived improved adherence to ART

A recurring narrative among the participants was that LAI-ART improved their adherence to ART when compared to the oral treatment. There was unanimity among several participants indicating that they often forget to take their daily oral pills. However, with LAI-ART, most of the participants reported not having missed their bi-monthly injections since the health workers reminded of their upcoming treatment appointments.

‘I would forget that I have to swallow the medicine by the time I remember four hours have already gone past the time of taking it. And it would stress me. Even when you go to the clinician for review and they do pill counting , the numbers aren’t balancing and the clinician says now you have brought less or , you have brought many , how has it come to this?’ [Female, 37, PWH, FPRH].

Nonetheless, the health workers observed that although they consistently reminded the participants to come for their bi-monthly injections as scheduled, some of them missed their treatment due date and had to be prompted with numerous reminders.

Perceived superior viral load suppression by LAI-ART Innovation

Superior viral load suppression was another element of the LAI-ART innovation. Participants in the clinical trial reported that they had registered better viral load suppression rates while under LAI-ART compared to the time they took daily oral pills. When probed on how they were able to ascertain this improvement viral load suppression, they indicated that viral load monitoring was conducted every six-months during the clinical trial. Consequently, the results of these tests confirmed a viral load suppression. As a female participant put it:

‘I have taken about three viral load tests since I started the injection and it is clear from the numbers after the tests that my viral load is improving compared to when I was on the tablets’ [Female, 32, PWH, FPRH].

On their part, the health workers concurred with the participants that their viral load suppression rates had improved under LAI-ART in comparison with oral treatment. Moreover, they noted that no cases of relapse were reported once a PWH had attained viral load suppression. To elucidate this view, a health worker explained that:

‘The injectable is doing good because with it you are unlikely to suffer a viral load rebound compared to our experience with patients on oral treatment where viral load was undetected for prolonged periods but then viral load becomes high again. That one is not easy to get on with the injectable’. [IDI, HCP_03].

Individuals domain

Perceived reduced hiv-related stigma.

Regarding Individuals domain, PWH indicated that being on LAI-ART reduced the HIV-related stigma associated with taking daily oral pills. Such stigma was reportedly rampant in their own households, the community and workplaces. They observed that the bi-monthly injection enhanced privacy since it was administered by a health worker in a private room within the health facility. As a respondent articulated:

‘But nowadays I can go a whole month without anyone at home seeing me swallowing tablets. So for me that fear stopped because I now feel free. Before I would say ‘oh’ if I visit home , they see me starting look to for water with which to swallow the tablets. And how to pull them (tablets) out of the bag , even getting space to swallow them was a headache and then even when I put the tablet packaging back in the bag it makes noise. But now all that trouble ended even me now I am like other people without HIV’ [Female, 28, PWH, FPRH].

Similar ideas were expressed by the health workers who noted that LAI-ART lessened HIV-related stigma associated with taking oral treatment in the presence of family and work colleagues. For example, a health worker narrated:

‘You find that that if a patient has to swallow his medicine and there is a colleague in the house or even their own child , that day they will miss and if the colleague stays for a week the patient will miss for a week. But the injectable you just take your injection and go home’. [IDI, HCP_02].

The other indication of perceived reduced stigma manifested in the participants’ expression of relief at being freed from the burden of carrying bulky six-monthly oral medication refills packaging from facilities to their homes. The bulky medication often invited curiosity from community members, which was a manifestation of external pressure as stipulated in the outer setting domain. Therefore, according to the participants’, LAI-ART saved them from inadvertent disclosure of their HIV treatment, since the injection was administered discreetly.

Reduced psychological burden of living with HIV

A recurring theme in our focus groups with PWH was the view that being on LAI-ART liberated them from the daily psychological reminder of living with HIV. PWH emotively described how taking oral pills daily reminded them that they lived with HIV infection. As a male participant put it:

‘The injection (LAI-ART) has somehow made be forget that they I have HIV. When I used to take oral tablets , I was reminded every day that I have HIV. You know as you are there enjoying yourself and having fun then you suddenly remember you have to go home and take the medicine. It always interrupted my life’ [Male, 35, PWH, FPRH].

Better satisfaction with HIV treatment

PWH described experiencing a better satisfaction with their HIV treatment under LAI-ART in comparison to the oral standard of care. Several participants mentioned they had developed fatigue with the daily routine of taking oral tablets.

‘For me I feel the injection has worked much better than the other medicines (oral tablets) , the other medicines (oral pills) were also working for me but I feel the injection has superseded them. I had grown tired of taking tablets. Tablets had even taken away my peace’. [Female, 28, PWH, FPRH].

Additionally, the participants perceived LAI-ART to be a more convenient treatment option since it allowed them more time to work due to the reduced health facility visits. Similarly, they reported reduced transport costs associated with less visits to the health facilities for medication refills.

Given the reported benefits of LAI-ART, PWH expressed their interest to remain on the treatment even after the end of the 12-month clinical trial phase.

Indeed, the health workers attested that that all the majority of participants requested to remain on LAI-ART after the end of the clinical trial since they experienced improved quality of life. Accordingly, the health workers confirmed that the manufacturer had granted the participants’ request.

‘They have reported good quality of life because they are adhering well. They aren’t falling sick frequently , they are not getting opportunistic infections because they are taking their injection well and they are doing really well. Actually , the majority requested to remain on the injectable even beyond the trial period of 12 months. Fortunately , the manufacturer agreed to provide the injectable beyond the clinical trial’ [IDI, HCP_06].

Furthermore, PWH called for longer intervals between their appointments for injection administration from the current eight weekly intervals. PWH were unanimous in expressing preference for six-monthly long –acting injectables.

‘For me I am requesting for a longer interval between the injections from the two months to six months. If there is a way of increasing the months of the injection we would very grateful about it because two months , you know for us who are employed we seem like we are escaping from work. If you request for permission to be off-work every two months they complain at work that she is always asking for off-duty permission every two months’ . [Male, 35, PWH, FPRH].

Perceived fewer side effects

During our focus groups with PWH, they frequently compared injectable ART with oral dolutegravir (DTG)-based ART. As such, there was consensus among PWH that they had experienced significantly less side effects over the 12-month LAI-ART trial compared to the time they transitioned to dolutegravir (DTG)-based ART over a similar period [ 28 ]. In the words of a female participant:

‘For me the injection has no harm it has ever done to me for the time I have been on it.

However , when I was taking the oral tablets , they are the ones that would do me bad. Whenever I would take the tablets , they would give me headaches and also weaken me physically but when I moved to the injection , and I have never been put down (physically). I immediately exist the facility after I am injected and right away I head go straight to the garden’. [Female, 28, PWH, FPRH].

Another dominant narrative among the participants was that the side effects, of hyperglycemia, reduced libido and insomnia previously experienced on oral treatment, has ceased upon transition to LAI-ART. For instance, a male PWH described how his uptake of LAI-ART had improved his libido:

‘ When I was on dolutegravir (DTG) oral tablets my mood for sex was very low. However , ever since I started getting this injection , my interest in having sex has improved. I now have frequent sex every week with my partner than I used not to have’ [ Male, 34, PWH, FPRH].

Nonetheless, some participants reported experiencing side effects while on LAI-ART. The most common side effects reported by participants was pain around the injection site which lasted between two and three days after administration of the injection.

‘I feel pain around at the spot on the buttocks where the injection was administered. Where they inject you is the very place you feel the pain. When I bend there is pain , when I walk I feel the pain. Walking after the injection has been administered you feel as if your legs are very heavy to lift. The pain usually lasts about four days ’ [Female, 32, PWH, FPRH].

In light of this, the health workers concurred that LAI-ART has some side effects particularly around the injection site.

‘Patients do get some reactions though not so much. The most common one is pain around the injection site. This is an injection , where the injection goes pain is a given. But what I have seen in the first few months when they have just started injection , those people get that pain at the injection site off like three days on average. But its mild. I have received some complaints from patients that the get some kind of pain but usually after those four days the pain is gone’. [IDI, HCP_02].

PWH perceived the technique of injection administration to be influential on whether they experienced pain at the injection site pain. PWH reported that they experienced less effects of injection site pain if the injection was administered by particular health workers. Interestingly, two health workers appeared to agree with PWH view that injection administration technique determined the presence or absence of pain.

‘For the pain around the injection site , it may be due to the technic of administration rather than the drug itself. So , if you administer the injection properly there will be no problem. The other thing with administering the injection is focusing much on the proximity because we need this drug to go in the muscle. For patients with a body mass index above 30 , those people who are chubby they have advised us to use a 2.5-inch needle so that the drug can reach the muscle. The needles we use are usually 1.5 inches’. [IDI, HCP_01].

The other most frequently cited side effect of LAI-ART by PWH was the onset of a fever after the injection was administered. The pain was reported to disappear within less than a week after administering the injection. As corroborated by one of the participants:

‘When they injected me the first time , I got some coldness like a fever , it took about two days only and it ceased. Then I settled. [Female, 37, PWH, FPRH].

Likewise, a male participant reaffirmed his experience noting that:

‘I only got a little fever after the injection when I returned home. I kind of feel chilly but I spend only two days feeling like and I after which I am well again’. [Male, 28, FPRH]

Indeed, the health workers indicated that they knew before the trial that LAI-ART may have drug-drug interactions with medications for treating active tuberculosis. As such they opted to exclude some potential participants who were on medication for active tuberculosis (TB).

‘We ruled out patients with TB because this drug also interacts with anti-tuberculosis medication. So , patients on anti-tuberculosis medication had to be withdrawn from the injection’. [IDI, HCP_06].

Inner setting

Over the 12- month clinical trial phase, health workers reported that they had gained proficiency and competencies in being able to delivery ART.

‘’ We have learnt how to give injectable ART because we were the first people to give it in the whole of Africa , so that was a good milestone. It’s quite exciting to be part of the trial because we didn’t know the technics of how to deliver it. Now we can comfortably know what to expect’. [IDI, HCP_01].

Even when there was enthusiasm around the skills gained in LAI-ART delivery, several implementation barriers to potential roll-out were identified.

Cold chain requirements

Health workers reported that delivering LAI-ART requires stringent cold chain standards to preserve the efficacy of the medication at set temperatures. It was reported that LAI-ART medication particularly rilpivirine needs to be stored in deep freezers at set cold conditions (–2° to 8 °C). This implies that storage of rilpivirine demands constant electricity supply and a standby generator in event of power black outs which are not uncommon in Uganda.

‘You have to have a deep freezer in which to store the rilpivirine at very cold temperatures which means your monthly bill for electricity will be high. We are fortunate that the funder is covering all these costs but what happens when the funding stops?’ [IDI, HCP_01].

Workforce skills in LAI-ART delivery

The trial personnel interviewed for the study indicated that health workers training was imperative for LAI-ART delivery. The workforce skills trainings needed for LAI-ART delivery were wide ranging and include technique of injection administration, identifying eligible PWH for LAI-ART and laboratory monitoring such as tracking viral load and timely identification of adverse drug reactions.

Perceived high cost of LAI-ART

Because of the novelty of the injectable treatment option, health workers perceived LAI-ART to be an expensive treatment option compared to oral HIV treatment. The costs of LAI-ART which were cited include the cost of the brand drug (cabotegravir and rilviprine) for which there are no generic options yet, the associated consumables such as needles, the procurement of appropriate bio-waste bins, the need for physical space such as private rooms for administering the injections.

‘We have been able to provide LAI-ART due to generous support from the funder. We had funding for needles , freezers , the medication itself (LAI-ART) , we have funds to send reminders to patients , we designated a special room for them for administering the injection. We were able to delivery this treatment option due to substantial funding from our sponsor under a clinical trial arrangement but in our normal operational context I am not sure how it would be to meet all the demand that is out there’ [IDI, HCP_02].

Outer setting

High demand for lai-art.

Health workers recounted experiences of overwhelming demand from participants at the study site during the process of selection of participants to enroll in the LAI-ART clinical trial.

‘That was the trickiest part of the study because everybody who would come , would really wish to be part of it. Some people would fast and pray so that the computer gives them the injection , so that was the trickiest part of it.’ [IDI, HCP_01].

Overall, PWH perceived being on LAI-ART as a privilege they cherished. They used descriptors such as ‘precious’, ‘divine providence’ and ‘treasured’ to describe how they considered themselves fortunate to have been selected to undergo the clinical trial. As a female participant intimated:

‘For me I think it’s the grace of God. You know it’s God that chooses. For me to be selected among the hundreds at this hospital to receive the injectable , it is a blessing from up above’ , . [Female, 28, PWH, FPRH].

Indeed, the health workers attested that that the majority of participants in the clinical trial requested to remain on LAI-ART even after the end of the 12-month trial since they experienced improved quality of life. Accordingly, the health workers confirmed that the manufacturer had granted the participants’ request.

This study was conducted to gain insight into the experiences of 32 individuals (out of a total of 69 participants) from the HIV care cohort which participated in a clinical trial involving long-acting antiretroviral therapy (LAI-ART) for 12 months at Fort Portal Regional Referral Hospital in mid-Western Uganda. There was high acceptability of LAI-ART and participants requested to remain on LAI-ART and were retained on this treatment even after the end of the 12-month trial. PWH perceived their adherence to ART to have improved when compared to their experiences under the oral treatment option. Participants reported that they had registered superior viral load suppression under LAI-ART. PWH credited LAI-ART with liberating them from the daily reminder of living with HIV, it enhanced privacy in HIV care and reduced HIV-related stigma associated with taking oral pills in the presence of family or co-workers as well as in carrying bulky medication refill packages.

On the other hand, pain around the injection site, a transient fever soon after administration of the injection were frequently cited as side effects. Previous studies have identified pain around the injection site as one of the side effects of LAI-ART [ 29 , 30 , 31 ]. A potentially new finding from our study is that PWH perceived the technic employed by the health worker in administering the injection as influential on whether they experienced pain around the injection site. It was reported that the pain is not experienced when the injection is delivered by particular health workers due to a perceived technique used. This warrants further research and may point to the need for training health workers in administering LAI-ART injections. The side effects reported in our study should be understood in the context of the extensive exclusion criteria for participants selected for the clinical trial (such as excluding those without disease in their kidney, liver, heart). It is plausible that with a broader patient population a wider range of side effects may be experienced hence further research is warranted [ 32 ].

Patient preferences

Overall, participants described a better satisfaction with LAI-ART when compared to the oral standard of care. Our focus groups appear to suggest a better quality of life under LAI-ART relative to daily oral pills. The notion that PWH perceive the LAI-ART treatment option results in a better quality of life when compared to oral treatment concurs with findings by Koester and colleagues in the United States [ 12 ].

In this study, PWH indicated a preference for longer intervals between injection appointments beyond the eight weeks under the clinical trial. A number of our participants called for a six-monthly interval between injections. Perhaps this is because in Uganda, less- intensive HIV care models known as ‘differentiated service delivery’ (DSD) models provide for multi-month dispensing of up to six months for stable patients [ 32 ]. This may, in part, reflect wishes by PWH for the novel LAI-ART option to align with DSD ethos of more patient-centred HIV care entailing reduced frequency of engagement with the formal health system [ 33 , 34 ].

Health workers described extreme demand by PWH for the LAI-ART option and the opportunity to participate in the trial which was perceived as a precious opportunity to receive LAI-ART and the benefits that accrue from it such as improved adherence to ART, reduced treatment burden, less HIV-related stigma and relief from having to remember to swallow oral tablets on a daily basis. Our study contributes to the emerging evidence suggesting that LAI-ART improves adherence to ART and reduces HIV-related stigma [ 11 , 12 , 13 ].

Taken together, our study appears to suggest that demand for LAI-ART was high but supply-side bottlenecks may hinder wider access in LMICs in a prospective public health approach [ 35 ]. It is worth noting that participants in the clinical trial requested to remain, and were retained on LAI-ART even after the end of the 12-month trial.

In this study, missed appointments for receiving the bi-monthly injection were reported by PWH and were identified by health workers as an area necessitating interventions such as phone-based reminders. Missed appointments for the injection have been identified in previous studies as requiring attention [ 36 , 37 ]. This is an area worthy of attention in potential scale-up planning and program design given accumulating evidence in this regard [ 12 ].

Health system readiness and implementation climate considerations

The health workers we interviewed indicated a myriad of implementation needs before LAI-ART can be scaled-up ‘in HIV clinic contexts where resources are constrained’ [ 12 ].

Firstly, providers perceived LAI-ART to be of high cost relative to oral treatment due to the resource in-puts required in routine service delivery in terms of the necessary consumables such as disposable needles, cold chain facilities for storing rilviprine, modifying physical spaces within already congested facilities as rooms for administering the injections, retooling health workers in LAI-ART delivery and instituting monitoring systems such as reminders to PWH to attend their injection appointments [ 12 ]. From their perspective, extending this novel treatment to the wider population of PWH may be hindered by operational limitations. The backdrop was that the clinical trial received substantial funding by the sponsor and that the trial was implemented in ‘vertical’ fashion given that it was not fully embedded in the existing HIV treatment delivery systems at the study site. Hence based on their assessment, it may be practical for select sub-groups with sub-optimal adherence to get priority in potential scale up initiatives. Considering the perspectives of the trial personnel in our study around the perceived high cost of LAI-ART, we call for studies examining cost effectiveness in Uganda and other LMICs. Such studies can inform policy decision making by governments and major donors such as PEPFAR. Kityo and colleagues [ 11 ] have enumerated the potential implementation barriers to uptake of LAI-ART in LMICs. Kennedy and colleagues [ 13 ] have alluded to the potential health system constraints in low and middle income countries such as commodity stock-outs. A recent study in the United States by Koester and colleagues alludes to the need for reconfiguring routine HIV service delivery to enable uptake of LAI-ART such as the ‘difficulty integrating long-acting antipsychotics into clinic flow’ [ 12 ].

Providers identified health system barriers to roll-out such as the perceived high cost of LAI-ART, stringent cold chain requirements, physical space limitations, workforce skills gaps in LAI-ART delivery as a potential draw backs. Our findings add to the emerging evidence on health system barriers to LAI-ART roll out in low-income countries [ 4 , 6 , 11 , 13 ] including in high-income countries such as the United states [ 2 , 12 ]. There has been a discourse around pushing for generic versions of LAI-ART [ 38 , 39 ]. However, studies suggest that LAI-ART may not be amenable to generic production due to ‘complex manufacturing platforms’ [ 11 ]. Individual-level barriers such as the likelihood of missing injection appointments and the need for reminders have been identified as potential implementation constraints [ 11 ].

In our in-depth interviews, health workers mentioned that prior to roll out of the clinical trial, that they were aware of potential drug-drug interactions between LAI-ART and some anti-tuberculosis medications and as such several prospective participants were excluded from participating in the trial. This notion presents limitations to the number of PWH who are eligible to access LAI-ART given the intersection between tuberculosis and HIV [ 1 , 40 ].

Our study findings align well with previous qualitative studies which have reported high acceptability of LAI-ART by PWH particularly those from high-income settings [ 41 , 42 , 43 , 44 ]. Mantsios and colleagues [ 41 ] in findings that mirror those of our study found that women in the United States and Spain expressed relief at the daily burden of having to remember to take oral treatment and that LAI-ART is ‘emotionally freeing and empowering’. These studies highlight the potential of LAI-ART in overcoming HIV-related stigma at the individual and community-levels [ 44 ]. In this study, PWH reported that LAI-ART has fewer side effects relative to their prior experience on dolutegravir (DTG)-based oral HIV treatment. Our study findings broadly align with previous ones that suggest that LAI-ART has a favourable adverse effect profile [ 45 , 46 ] which enhances its appeal for rollout and implementation in high-burden countries.

Recommendations

Considering the perceived high costs needed to deliver LAI-ART by providers despite the extreme demand by PWH, cost-effectiveness studies in low-income settings are warranted. In a related recommendation, we call for systematic criteria for selecting sub-populations of PWH to access LAI-ART particularly in high-burden but resource-limited settings such as Uganda. Engaging leading funders of HIV programs in Eastern and Southern Africa such as PEPFAR in supporting pilot LAI-ART scale-up initiatives for priority sub-populations is worthwhile given their influence in setting HIV policy [ 47 , 48 ].

In this study, we found that missed appointments for injections by PWH were not uncommon. Our study underscores the importance of innovations around sending reminders to PWH to report for their injection appointments. There is an emerging implementation science around phone-based reminders for improving adherence to treatment which may have value in LAI-ART roll-outs in settings such as Uganda and beyond [ 49 , 50 ].

In this study we found that the two most frequently mentioned side effects were pain around the injection site and a transient fever soon after the injection was administered. More research is warranted around medication safety in a broader range of PWH in Eastern and Southern Africa considering that in this clinical trial only those without evidence of disease in their vital organs were enrolled [ 51 , 52 ].

Study limitations

Our study had multiple limitations. Our small sample size and the extensive exclusion criteria for participating in the LAI-ART clinical trial limits the extent of generalizability of our study findings to the general population of recipients of HIV care in Uganda. One of the strengths of this study is that it reports actual experiences of recipients of HIV care who received this novel treatment option for at least 12 months unlike many studies reporting the perspectives of potential users.

Overall, PWH indicated a strong preference for LAI-ART and expressed a comparatively higher satisfaction with this treatment option. Health system barriers to potential scale-up are important to consider if a wider population of PWH are to benefit from this novel treatment option in Uganda and other resource-limited settings.

Data availability

The datasets generated during and/or analyzed during the current study are not publicly available due to ethical reasons but are available from the corresponding author on reasonable request.

Abbreviations

Acquired Immune Deficiency Syndrome

Adverse Drug Reactions

Anti-retroviral therapy

Anti-retrovirals

Dolutegravir

Long Acting Injectable Antiretroviral Treatment

Ministry of Health

The Presidents’ Emergency Plan for AIDS Relief

People Living with HIV

sub-Saharan Africa

World Health Organization

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Acknowledgements

We gratefully acknowledge the Joint Clinical Research Centre (JCRC) which led implementation of this clinical trial at Fort Portal Regional Referral Hospital in Mid-Western Uganda.

This paper was written under the auspices of a post-doctoral research grant managed by the Consortium for Advanced Research Training in Africa (CARTA/2020/354.707 A).

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HZ conceptualized the study, collected the data, analyzed the data and produced the initial manuscript draft. AA, MK and BN contributed to data analysis and provided comments on the draft manuscript. All authors approved the final manuscript.

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Zakumumpa, H., Alinaitwe, A., Kyomuhendo, M. et al. Long-acting injectable antiretroviral treatment: experiences of people with HIV and their healthcare providers in Uganda. BMC Infect Dis 24 , 876 (2024). https://doi.org/10.1186/s12879-024-09748-5

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