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• Semi-Structured Interview | Definition, Guide & Examples

Semi-Structured Interview | Definition, Guide & Examples

Published on 4 May 2022 by Tegan George . Revised on 30 August 2022.

A semi-structured interview is a data collection method that relies on asking questions within a predetermined thematic framework. However, the questions are not set in order or in phrasing.

In research, semi-structured interviews are often qualitative in nature. They are generally used as an exploratory tool in marketing, social science, survey methodology, and other research fields.

They are also common in field research with many interviewers, giving everyone the same theoretical framework, but allowing them to investigate different facets of the research question .

• Structured interviews : The questions are predetermined in both topic and order.
• Unstructured interviews : None of the questions are predetermined.
• Focus group interviews : The questions are presented to a group instead of one individual.

Table of contents

What is a semi-structured interview, when to use a semi-structured interview, advantages of semi-structured interviews, disadvantages of semi-structured interviews, semi-structured interview questions, how to conduct a semi-structured interview, how to analyse a semi-structured interview, presenting your results (with example), frequently asked questions about semi-structured interviews.

Semi-structured interviews are a blend of structured and unstructured types of interviews.

• Unlike in an unstructured interview, the interviewer has an idea of what questions they will ask.
• Unlike in a structured interview, the phrasing and order of the questions is not set.

Semi-structured interviews are often open-ended, allowing for flexibility. Asking set questions in a set order allows for easy comparison between respondents, but it can be limiting. Having less structure can help you see patterns, while still allowing for comparisons between respondents.

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Semi-structured interviews are best used when:

• You have prior interview experience. Spontaneous questions are deceptively challenging, and it’s easy to accidentally ask a leading question or make a participant uneasy.
• Your research question is exploratory in nature. Participant answers can guide future research questions and help you develop a more robust knowledge base for future research.

Just like in structured interviews, it is critical that you remain organised and develop a system for keeping track of participant responses. However, since the questions are less set than in a structured interview, the data collection and analysis become a bit more complex.

Differences between different types of interviews

Make sure to choose the type of interview that suits your research best. This table shows the most important differences between the four types.

Semi-structured interviews come with many advantages.

Best of both worlds

No distractions, detail and richness.

However, semi-structured interviews also have their downsides.

Low validity

High risk of bias, difficult to develop good semi-structured interview questions.

Since they are often open-ended in style, it can be challenging to write semi-structured interview questions that get you the information you’re looking for without biasing your responses. Here are a few tips:

• Define what areas or topics you will be focusing on prior to the interview. This will help you write a framework of questions that zero in on the information you seek.
• Write yourself a guide to refer to during the interview, so you stay focused. It can help to start with the simpler questions first, moving into the more complex ones after you have established a comfortable rapport.
• Be as clear and concise as possible, avoiding jargon and compound sentences.
• How often per week do you go to the gym? a) 1 time; b) 2 times; c) 3 times; d) 4 or more times
• If yes: What feelings does going to the gym bring out in you?
• If no: What do you prefer to do instead?
• If yes: How did this membership affect your job performance? Did you stay longer in the role than you would have if there were no membership?

Once you’ve determined that a semi-structured interview is the right fit for your research topic , you can proceed with the following steps.

Step 1: Set your goals and objectives

You can use guiding questions as you conceptualise your research question, such as:

• What are you trying to learn or achieve from a semi-structured interview?
• Why are you choosing a semi-structured interview as opposed to a different type of interview, or another research method?

If you want to proceed with a semi-structured interview, you can start designing your questions.

Step 2: Design your questions

Try to stay simple and concise, and phrase your questions clearly. If your topic is sensitive or could cause an emotional response, be mindful of your word choices.

One of the most challenging parts of a semi-structured interview is knowing when to ask follow-up or spontaneous related questions. For this reason, having a guide to refer back to is critical. Hypothesising what other questions could arise from your participants’ answers may also be helpful.

Step 3: Assemble your participants

There are a few sampling methods you can use to recruit your interview participants, such as:

• Voluntary response sampling : For example, sending an email to a campus mailing list and sourcing participants from responses
• Stratified sampling of a particular characteristic trait of interest to your research, such as age, race, ethnicity, or gender identity

Step 4: Decide on your medium

It’s important to determine ahead of time how you will be conducting your interview. You should decide whether you’ll be conducting it live or with a pen-and-paper format. If conducted in real time, you also need to decide whether in person, over the phone, or via videoconferencing is the best option for you.

Note that each of these methods has its own advantages and disadvantages:

• Pen-and-paper may be easier for you to organise and analyse, but you will receive more prepared answers, which may affect the reliability of your data.
• In-person interviews can lead to nervousness or interviewer effects, where the respondent feels pressured to respond in a manner they believe will please you or incentivise you to like them.

Step 5: Conduct your interviews

As you conduct your interviews, keep environmental conditions as constant as you can to avoid research bias . Pay attention to your body language (e.g., nodding, raising eyebrows), and moderate your tone of voice.

Relatedly, one of the biggest challenges with semi-structured interviews is ensuring that your questions remain unbiased. This can be especially challenging with any spontaneous questions or unscripted follow-ups that you ask your participants.

After you’re finished conducting your interviews, it’s time to analyse your results. First, assign each of your participants a number or pseudonym for organisational purposes.

The next step in your analysis is to transcribe the audio or video recordings. You can then conduct a content or thematic analysis to determine your categories, looking for patterns of responses that stand out to you and test your hypotheses .

Transcribing interviews

Before you get started with transcription, decide whether to conduct verbatim transcription or intelligent verbatim transcription.

• If pauses, laughter, or filler words like ‘umm’ or ‘like’ affect your analysis and research conclusions, conduct verbatim transcription and include them.
• If not, you can conduct intelligent verbatim transcription, which excludes fillers, fixes any grammatical issues, and is usually easier to analyse.

Transcribing presents a great opportunity for you to cleanse your data . Here, you can identify and address any inconsistencies or questions that come up as you listen.

Your supervisor might ask you to add the transcriptions to the appendix of your paper.

Coding semi-structured interviews

Next, it’s time to conduct your thematic or content analysis . This often involves ‘coding’ words, patterns, or recurring responses, separating them into labels or categories for more robust analysis.

Due to the open-ended nature of many semi-structured interviews, you will most likely be conducting thematic analysis, rather than content analysis.

• You closely examine your data to identify common topics, ideas, or patterns. This can help you draw preliminary conclusions about your participants’ views, knowledge or experiences.
• After you have been through your responses a few times, you can collect the data into groups identified by their ‘code’. These codes give you a condensed overview of the main points and patterns identified by your data.
• Next, it’s time to organise these codes into themes. Themes are generally broader than codes, and you’ll often combine a few codes under one theme. After identifying your themes, make sure that these themes appropriately represent patterns in responses.

Analysing semi-structured interviews

Once you’re confident in your themes, you can take either an inductive or a deductive approach.

• An inductive approach is more open-ended, allowing your data to determine your themes.
• A deductive approach is the opposite. It involves investigating whether your data confirm preconceived themes or ideas.

After your data analysis, the next step is to report your findings in a research paper .

• Your methodology section describes how you collected the data (in this case, describing your semi-structured interview process) and explains how you justify or conceptualise your analysis.
• Your discussion and results sections usually address each of your coded categories.
• You can then conclude with the main takeaways and avenues for further research.

Example of interview methodology for a research paper

Let’s say you are interested in vegan students on your campus. You have noticed that the number of vegan students seems to have increased since your first year, and you are curious what caused this shift.

You identify a few potential options based on literature:

• Perceptions about personal health or the perceived ‘healthiness’ of a vegan diet
• Concerns about animal welfare and the meat industry
• Increased climate awareness, especially in regards to animal products
• Availability of more vegan options, making the lifestyle change easier

Anecdotally, you hypothesise that students are more aware of the impact of animal products on the ongoing climate crisis, and this has influenced many to go vegan. However, you cannot rule out the possibility of the other options, such as the new vegan bar in the dining hall.

Since your topic is exploratory in nature and you have a lot of experience conducting interviews in your work-study role as a research assistant, you decide to conduct semi-structured interviews.

You have a friend who is a member of a campus club for vegans and vegetarians, so you send a message to the club to ask for volunteers. You also spend some time at the campus dining hall, approaching students at the vegan bar asking if they’d like to participate.

Here are some questions you could ask:

• Do you find vegan options on campus to be: excellent; good; fair; average; poor?
• How long have you been a vegan?
• Follow-up questions can probe the strength of this decision (i.e., was it overwhelmingly one reason, or more of a mix?).

Depending on your participants’ answers to these questions, ask follow-ups as needed for clarification, further information, or elaboration.

• Do you think consuming animal products contributes to climate change? → The phrasing implies that you, the interviewer, do think so. This could bias your respondents, incentivising them to answer affirmatively as well.
• What do you think is the biggest effect of animal product consumption? → This phrasing ensures the participant is giving their own opinion, and may even yield some surprising responses that enrich your analysis.

After conducting your interviews and transcribing your data, you can then conduct thematic analysis, coding responses into different categories. Since you began your research with several theories about campus veganism that you found equally compelling, you would use the inductive approach.

Once you’ve identified themes and patterns from your data, you can draw inferences and conclusions. Your results section usually addresses each theme or pattern you found, describing each in turn, as well as how often you came across them in your analysis. Feel free to include lots of (properly anonymised) examples from the data as evidence, too.

A semi-structured interview is a blend of structured and unstructured types of interviews. Semi-structured interviews are best used when:

• You have prior interview experience. Spontaneous questions are deceptively challenging, and it’s easy to accidentally ask a leading question or make a participant uncomfortable.

The four most common types of interviews are:

• Semi-structured interviews : A few questions are predetermined, but other questions aren’t planned.

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.

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6 Semi-structured interviewing

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This chapter presents a guide to conducting effective semi-structured interviews. It discusses the nature of semi-structured interviews and why they should be used, as well as preparation, the logistics of conducting the interview, and reflexivity.

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Semi-structured Interviews

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• First Online: 01 January 2020
• pp 4825–4830
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• Danielle Magaldi 3 &
• Matthew Berler 4  

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Open-ended interview ; Qualitative interview ; Systematic exploratory interview ; Thematic interview

The semi-structured interview is an exploratory interview used most often in the social sciences for qualitative research purposes or to gather clinical data. While it generally follows a guide or protocol that is devised prior to the interview and is focused on a core topic to provide a general structure, the semi-structured interview also allows for discovery, with space to follow topical trajectories as the conversation unfolds.

Introduction

Qualitative interviews exist on a continuum, ranging from free-ranging, exploratory discussions to highly structured interviews. On one end is unstructured interviewing, deployed by approaches such as ethnography, grounded theory, and phenomenology. This style of interview involves a changing protocol that evolves based on participants’ responses and will differ from one participant to the next. On the other end of the continuum...

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Magaldi, D., Berler, M. (2020). Semi-structured Interviews. In: Zeigler-Hill, V., Shackelford, T.K. (eds) Encyclopedia of Personality and Individual Differences. Springer, Cham. https://doi.org/10.1007/978-3-319-24612-3_857

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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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Introduction.

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

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

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

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

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

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

Overview of qualitative research

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

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

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

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

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

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

Types of interview

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

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

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

Conducting an interview

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

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

Greeting and explaining the project/interview

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

Asymmetry between the researcher and participant talking

Expressing interest and cultural ignorance

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

Creating hypothetical situations

Asking friendly questions

Knowing when to leave.

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

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

Box 1: Example of a topic guide

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

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

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

Why did you start cleaning their teeth at that point?

How often do you brush their teeth?

What do you use to brush their teeth and why?

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

Do you find anything difficult?

What makes cleaning their teeth easier for you?

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

Has it become easier or harder?

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

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

What do they enjoy about having their teeth cleaned?

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

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

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

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

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

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

Focus groups

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

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

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

Focus group considerations

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

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

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

Focus group management

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

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

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

Discussions within the group are confidential to the group

Only one person can speak at a time

All participants should have sufficient opportunity to contribute

There should be no unnecessary interruptions while someone is speaking

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

Challenging contrary opinions is appropriate, but ridiculing is not.

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

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

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

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

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

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

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Published : 05 October 2018

Issue Date : 12 October 2018

DOI : https://doi.org/10.1038/sj.bdj.2018.815

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• Volume 7, Issue 2
• Semistructured interviewing in primary care research: a balance of relationship and rigour
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• http://orcid.org/0000-0002-2660-3358 Melissa DeJonckheere 1 and
• Lisa M Vaughn 2 , 3
• 1 Department of Family Medicine , University of Michigan , Ann Arbor , Michigan , USA
• 2 Department of Pediatrics , University of Cincinnati College of Medicine , Cincinnati , Ohio , USA
• 3 Division of Emergency Medicine , Cincinnati Children's Hospital Medical Center , Cincinnati , Ohio , USA
• Correspondence to Dr Melissa DeJonckheere; mdejonck{at}med.umich.edu

Semistructured in-depth interviews are commonly used in qualitative research and are the most frequent qualitative data source in health services research. This method typically consists of a dialogue between researcher and participant, guided by a flexible interview protocol and supplemented by follow-up questions, probes and comments. The method allows the researcher to collect open-ended data, to explore participant thoughts, feelings and beliefs about a particular topic and to delve deeply into personal and sometimes sensitive issues. The purpose of this article was to identify and describe the essential skills to designing and conducting semistructured interviews in family medicine and primary care research settings. We reviewed the literature on semistructured interviewing to identify key skills and components for using this method in family medicine and primary care research settings. Overall, semistructured interviewing requires both a relational focus and practice in the skills of facilitation. Skills include: (1) determining the purpose and scope of the study; (2) identifying participants; (3) considering ethical issues; (4) planning logistical aspects; (5) developing the interview guide; (6) establishing trust and rapport; (7) conducting the interview; (8) memoing and reflection; (9) analysing the data; (10) demonstrating the trustworthiness of the research; and (11) presenting findings in a paper or report. Semistructured interviews provide an effective and feasible research method for family physicians to conduct in primary care research settings. Researchers using semistructured interviews for data collection should take on a relational focus and consider the skills of interviewing to ensure quality. Semistructured interviewing can be a powerful tool for family physicians, primary care providers and other health services researchers to use to understand the thoughts, beliefs and experiences of individuals. Despite the utility, semistructured interviews can be intimidating and challenging for researchers not familiar with qualitative approaches. In order to elucidate this method, we provide practical guidance for researchers, including novice researchers and those with few resources, to use semistructured interviewing as a data collection strategy. We provide recommendations for the essential steps to follow in order to best implement semistructured interviews in family medicine and primary care research settings.

• qualitative research

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https://doi.org/10.1136/fmch-2018-000057

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Introduction

Semistructured interviews can be used by family medicine researchers in clinical settings or academic settings even with few resources. In contrast to large-scale epidemiological studies, or even surveys, a family medicine researcher can conduct a highly meaningful project with interviews with as few as 8–12 participants. For example, Chang and her colleagues, all family physicians, conducted semistructured interviews with 10 providers to understand their perspectives on weight gain in pregnant patients. 1 The interviewers asked questions about providers’ overall perceptions on weight gain, their clinical approach to weight gain during pregnancy and challenges when managing weight gain among pregnant patients. Additional examples conducted by or with family physicians or in primary care settings are summarised in table 1 . 1–6

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Examples of research articles using semistructured interviews in primary care research

From our perspective as seasoned qualitative researchers, conducting effective semistructured interviews requires: (1) a relational focus, including active engagement and curiosity, and (2) practice in the skills of interviewing. First, a relational focus emphasises the unique relationship between interviewer and interviewee. To obtain quality data, interviews should not be conducted with a transactional question-answer approach but rather should be unfolding, iterative interactions between the interviewer and interviewee. Second, interview skills can be learnt. Some of us will naturally be more comfortable and skilful at conducting interviews but all aspects of interviews are learnable and through practice and feedback will improve. Throughout this article, we highlight strategies to balance relationship and rigour when conducting semistructured interviews in primary care and the healthcare setting.

Qualitative research interviews are ‘attempts to understand the world from the subjects’ point of view, to unfold the meaning of peoples’ experiences, to uncover their lived world prior to scientific explanations’ (p 1). 7 Qualitative research interviews unfold as an interviewer asks questions of the interviewee in order to gather subjective information about a particular topic or experience. Though the definitions and purposes of qualitative research interviews vary slightly in the literature, there is common emphasis on the experiences of interviewees and the ways in which the interviewee perceives the world (see table 2 for summary of definitions from seminal texts).

Definitions of qualitative interviews

The most common type of interview used in qualitative research and the healthcare context is semistructured interview. 8 Figure 1 highlights the key features of this data collection method, which is guided by a list of topics or questions with follow-up questions, probes and comments. Typically, the sequencing and wording of the questions are modified by the interviewer to best fit the interviewee and interview context. Semistructured interviews can be conducted in multiple ways (ie, face to face, telephone, text/email, individual, group, brief, in-depth), each of which have advantages and disadvantages. We will focus on the most common form of semistructured interviews within qualitative research—individual, face-to-face, in-depth interviews.

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Key characteristics of semistructured interviews.

Purpose of semistructured interviews

The overall purpose of using semistructured interviews for data collection is to gather information from key informants who have personal experiences, attitudes, perceptions and beliefs related to the topic of interest. Researchers can use semistructured interviews to collect new, exploratory data related to a research topic, triangulate other data sources or validate findings through member checking (respondent feedback about research results). 9 If using a mixed methods approach, semistructured interviews can also be used in a qualitative phase to explore new concepts to generate hypotheses or explain results from a quantitative phase that tests hypotheses. Semistructured interviews are an effective method for data collection when the researcher wants: (1) to collect qualitative, open-ended data; (2) to explore participant thoughts, feelings and beliefs about a particular topic; and (3) to delve deeply into personal and sometimes sensitive issues.

Designing and conducting semistructured interviews

In the following section, we provide recommendations for the steps required to carefully design and conduct semistructured interviews with emphasis on applications in family medicine and primary care research (see table 3 ).

Steps to designing and conducting semistructured interviews

Steps for designing and conducting semistructured interviews

Step 1: determining the purpose and scope of the study.

The purpose of the study is the primary objective of your project and may be based on an anecdotal experience, a review of the literature or previous research finding. The purpose is developed in response to an identified gap or problem that needs to be addressed.

Research questions are the driving force of a study because they are associated with every other aspect of the design. They should be succinct and clearly indicate that you are using a qualitative approach. Qualitative research questions typically start with ‘What’, ‘How’ or ‘Why’ and focus on the exploration of a single concept based on participant perspectives. 10

Step 2: identifying participants

After deciding on the purpose of the study and research question(s), the next step is to determine who will provide the best information to answer the research question. Good interviewees are those who are available, willing to be interviewed and have lived experiences and knowledge about the topic of interest. 11 12 Working with gatekeepers or informants to get access to potential participants can be extremely helpful as they are trusted sources that control access to the target sample.

Sampling strategies are influenced by the research question and the purpose of the study. Unlike quantitative studies, statistical representativeness is not the goal of qualitative research. There is no calculation of statistical power and the goal is not a large sample size. Instead, qualitative approaches seek an in-depth and detailed understanding and typically use purposeful sampling. See the study of Hatch for a summary of various types of purposeful sampling that can be used for interview studies. 12

‘How many participants are needed?’ The most common answer is, ‘it depends’—it depends on the purpose of the study, what kind of study is planned and what questions the study is trying to answer. 12–14 One common standard in qualitative sample sizes is reaching thematic saturation, which refers to the point at which no new thematic information is gathered from participants. Malterud and colleagues discuss the concept of information power , or a qualitative equivalent to statistical power, to determine how many interviews should be collected in a study. They suggest that the size of a sample should depend on the aim, homogeneity of the sample, theory, interview quality and analytic strategy. 14

Step 3: considering ethical issues

An ethical attitude should be present from the very beginning of the research project even before you decide who to interview. 15 This ethical attitude should incorporate respect, sensitivity and tact towards participants throughout the research process. Because semistructured interviewing often requires the participant to reveal sensitive and personal information directly to the interviewer, it is important to consider the power imbalance between the researcher and the participant. In healthcare settings, the interviewer or researcher may be a part of the patient’s healthcare team or have contact with the healthcare team. The researchers should ensure the interviewee that their participation and answers will not influence the care they receive or their relationship with their providers. Other issues to consider include: reducing the risk of harm; protecting the interviewee’s information; adequately informing interviewees about the study purpose and format; and reducing the risk of exploitation. 10

Step 4: planning logistical aspects

Careful planning particularly around the technical aspects of interviews can be the difference between a great interview and a not so great interview. During the preparation phase, the researcher will need to plan and make decisions about the best ways to contact potential interviewees, obtain informed consent, arrange interview times and locations convenient for both participant and researcher, and test recording equipment. Although many experienced researchers have found themselves conducting interviews in less than ideal locations, the interview location should avoid (or at least minimise) interruptions and be appropriate for the interview (quiet, private and able to get a clear recording). 16 For some research projects, the participants’ homes may make sense as the best interview location. 16

Initial contacts can be made through telephone or email and followed up with more details so the individual can make an informed decision about whether they wish to be interviewed. Potential participants should know what to expect in terms of length of time, purpose of the study, why they have been selected and who will be there. In addition, participants should be informed that they can refuse to answer questions or can withdraw from the study at any time, including during the interview itself.

Audio recording the interview is recommended so that the interviewer can concentrate on the interview and build rapport rather than being distracted with extensive note taking 16 (see table 4 for audio-recording tips). Participants should be informed that audio recording is used for data collection and that they can refuse to be audio recorded should they prefer.

Suggestions for successful audio recording of interviews

Most researchers will want to have interviews transcribed verbatim from the audio recording. This allows you to refer to the exact words of participants during the analysis. Although it is possible to conduct analyses from the audio recordings themselves or from notes, it is not ideal. However, transcription can be extremely time consuming and, if not done yourself, can be costly.

In the planning phase of research, you will want to consider whether qualitative research software (eg, NVivo, ATLAS.ti, MAXQDA, Dedoose, and so on) will be used to assist with organising, managing and analysis. While these tools are helpful in the management of qualitative data, it is important to consider your research budget, the cost of the software and the learning curve associated with using a new system.

Step 5: developing the interview guide

Semistructured interviews include a short list of ‘guiding’ questions that are supplemented by follow-up and probing questions that are dependent on the interviewee’s responses. 8 17 All questions should be open ended, neutral, clear and avoid leading language. In addition, questions should use familiar language and avoid jargon.

Most interviews will start with an easy, context-setting question before moving to more difficult or in-depth questions. 17 Table 5 gives details of the types of guiding questions including ‘grand tour’ questions, 18 core questions and planned and unplanned follow-up questions.

Questions and prompts in semistructured interviewing

To illustrate, online supplementary appendix A presents a sample interview guide from our study of weight gain during pregnancy among young women. We start with the prompt, ‘Tell me about how your pregnancy has been so far’ to initiate conversation about their thoughts and feelings during pregnancy. The subsequent questions will elicit responses to help answer our research question about young women’s perspectives related to weight gain during pregnancy.

Supplemental material

After developing the guiding questions, it is important to pilot test the interview. Having a good sense of the guide helps you to pace the interview (and not run out of time), use a conversational tone and make necessary adjustments to the questions.

Like all qualitative research, interviewing is iterative in nature—data collection and analysis occur simultaneously, which may result in changes to the guiding questions as the study progresses. Questions that are not effective may be replaced with other questions and additional probes can be added to explore new topics that are introduced by participants in previous interviews. 10

Step 6: establishing trust and rapport

Interviews are a special form of relationship, where the interviewer and interviewee converse about important and often personal topics. The interviewer must build rapport quickly by listening attentively and respectfully to the information shared by the interviewee. 19 As the interview progresses, the interviewer must continue to demonstrate respect, encourage the interviewee to share their perspectives and acknowledge the sensitive nature of the conversation. 20

To establish rapport, it is important to be authentic and open to the interviewee’s point of view. It is possible that the participants you recruit for your study will have preconceived notions about research, which may include mistrust. As a result, it is important to describe why you are conducting the research and how their participation is meaningful. In an interview relationship, the interviewee is the expert and should be treated as such—you are relying on the interviewee to enhance your understanding and add to your research. Small behaviours that can enhance rapport include: dressing professionally but not overly formal; avoiding jargon or slang; and using a normal conversational tone. Because interviewees will be discussing their experience, having some awareness of contextual or cultural factors that may influence their perspectives may be helpful as background knowledge.

Step 7: conducting the interview

Location and set-up.

The interview should have already been scheduled at a convenient time and location for the interviewee. The location should be private, ideally with a closed door, rather than a public place. It is helpful if there is a room where you can speak privately without interruption, and where it is quiet enough to hear and audio record the interview. Within the interview space, Josselson 15 suggests an arrangement with a comfortable distance between the interviewer and interviewee with a low table in between for the recorder and any materials (consent forms, questionnaires, water, and so on).

Beginning the interview

Many interviewers start with chatting to break the ice and attempt to establish commonalities, rapport and trust. Most interviews will need to begin with a brief explanation of the research study, consent/assent procedures, rationale for talking to that particular interviewee and description of the interview format and agenda. 11 It can also be helpful if the interviewer shares a little about who they are and why they are interested in the topic. The recording equipment should have already been tested thoroughly but interviewers may want to double-check that the audio equipment is working and remind participants about the reason for recording.

Interviewer stance

During the interview, the interviewer should adopt a friendly and non-judgemental attitude. You will want to maintain a warm and conversational tone, rather than a rote, question-answer approach. It is important to recognise the potential power differential as a researcher. Conveying a sense of being in the interview together and that you as the interviewer are a person just like the interviewee can help ease any discomfort. 15

Active listening

During a face-to-face interview, there is an opportunity to observe social and non-verbal cues of the interviewee. These cues may come in the form of voice, body language, gestures and intonation, and can supplement the interviewee’s verbal response and can give clues to the interviewer about the process of the interview. 21 Listening is the key to successful interviewing. 22 Listening should be ‘attentive, empathic, nonjudgmental, listening in order to invite, and engender talk’ 15 15 (p 66). Silence, nods, smiles and utterances can also encourage further elaboration from the interviewee.

Continuing the interview

As the interview progresses, the interviewer can repeat the words used by the interviewee, use planned and unplanned follow-up questions that invite further clarification, exploration or elaboration. As DiCicco-Bloom and Crabtree 10 explain: ‘Throughout the interview, the goal of the interviewer is to encourage the interviewee to share as much information as possible, unselfconsciously and in his or her own words’ (p 317). Some interviewees are more forthcoming and will offer many details of their experiences without much probing required. Others will require prompting and follow-up to elicit sufficient detail.

As a result, follow-up questions are equally important to the core questions in a semistructured interview. Prompts encourage people to continue talking and they can elicit more details needed to understand the topic. Examples of verbal probes are repeating the participant’s words, summarising the main idea or expressing interest with verbal agreement. 8 11 See table 6 for probing techniques and example probes we have used in our own interviewing.

Probing techniques for semistructured interviews (modified from Bernard 30 )

Step 8: memoing and reflection

After an interview, it is essential for the interviewer to begin to reflect on both the process and the content of the interview. During the actual interview, it can be difficult to take notes or begin reflecting. Even if you think you will remember a particular moment, you likely will not be able to recall each moment with sufficient detail. Therefore, interviewers should always record memos —notes about what you are learning from the data. 23 24 There are different approaches to recording memos: you can reflect on several specific ideas, or create a running list of thoughts. Memos are also useful for improving the quality of subsequent interviews.

Step 9: analysing the data

The data analysis strategy should also be developed during planning stages because analysis occurs concurrently with data collection. 25 The researcher will take notes, modify the data collection procedures and write reflective memos throughout the data collection process. This begins the process of data analysis.

The data analysis strategy used in your study will depend on your research question and qualitative design—see the study of Creswell for an overview of major qualitative approaches. 26 The general process for analysing and interpreting most interviews involves reviewing the data (in the form of transcripts, audio recordings or detailed notes), applying descriptive codes to the data and condensing and categorising codes to look for patterns. 24 27 These patterns can exist within a single interview or across multiple interviews depending on the research question and design. Qualitative computer software programs can be used to help organise and manage interview data.

Step 10: demonstrating the trustworthiness of the research

Similar to validity and reliability, qualitative research can be assessed on trustworthiness. 9 28 There are several criteria used to establish trustworthiness: credibility (whether the findings accurately and fairly represent the data), transferability (whether the findings can be applied to other settings and contexts), confirmability (whether the findings are biased by the researcher) and dependability (whether the findings are consistent and sustainable over time).

Step 11: presenting findings in a paper or report

When presenting the results of interview analysis, researchers will often report themes or narratives that describe the broad range of experiences evidenced in the data. This involves providing an in-depth description of participant perspectives and being sure to include multiple perspectives. 12 In interview research, the participant words are your data. Presenting findings in a report requires the integration of quotes into a more traditional written format.

Conclusions

Though semistructured interviews are often an effective way to collect open-ended data, there are some disadvantages as well. One common problem with interviewing is that not all interviewees make great participants. 12 29 Some individuals are hard to engage in conversation or may be reluctant to share about sensitive or personal topics. Difficulty interviewing some participants can affect experienced and novice interviewers. Some common problems include not doing a good job of probing or asking for follow-up questions, failure to actively listen, not having a well-developed interview guide with open-ended questions and asking questions in an insensitive way. Outside of pitfalls during the actual interview, other problems with semistructured interviewing may be underestimating the resources required to recruit participants, interview, transcribe and analyse the data.

Despite their limitations, semistructured interviews can be a productive way to collect open-ended data from participants. In our research, we have interviewed children and adolescents about their stress experiences and coping behaviours, young women about their thoughts and behaviours during pregnancy, practitioners about the care they provide to patients and countless other key informants about health-related topics. Because the intent is to understand participant experiences, the possible research topics are endless.

Due to the close relationships family physicians have with their patients, the unique settings in which they work, and in their advocacy, semistructured interviews are an attractive approach for family medicine researchers, even if working in a setting with limited research resources. When seeking to balance both the relational focus of interviewing and the necessary rigour of research, we recommend: prioritising listening over talking; using clear language and avoiding jargon; and deeply engaging in the interview process by actively listening, expressing empathy, demonstrating openness to the participant’s worldview and thanking the participant for helping you to understand their experience.

Further Reading

Edwards R, & Holland J. (2013). What is qualitative interviewing?: A&C Black.

Josselson R. Interviewing for qualitative inquiry: A relational approach. Guilford Press, 2013.

Kvale S. InterViews: An Introduction to Qualitative Research Interviewing. SAGE, London, 1996.

Pope C, & Mays N. (Eds). (2006). Qualitative research in health care.

• Gold KJ , et al
• Croxson CH ,
• Ashdown HF ,
• DeJonckheere M ,
• Robinson CH ,
• Evans L , et al
• Griffiths F ,
• Boardman F , et al
• Takemura Y ,
• Nishiue T , et al
• Schoenborn NL ,
• Pollack CE , et al
• Pietilä A-M ,
• Johnson M , et al
• Lincoln YS ,
• DiCicco-Bloom B ,
• Crabtree BF
• Malterud K ,
• Siersma VD ,
• Guassora AD
• Josselson R
• Edwards R ,
• Spradley JP
• Opdenakker R
• Anderson K ,
• Huberman AM
• Huberman AM ,
• Creswell JW
• Damschroder L

Contributors Both authors contributed equally to this work.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; internally peer reviewed.

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• What is a semi-structured interview?

Last updated

5 February 2023

Reviewed by

Cathy Heath

When designed correctly, user interviews go much deeper than surface-level survey responses. They can provide new information about how people interact with your products and services, and shed light on the underlying reasons behind these habits.

Semi-structured user interviews are widely considered one of the most effective tools for doing this kind of qualitative research , depending on your specific goals. As the name suggests, the semi-structured format allows for a more natural, conversational flow, while still being organized enough to collect plenty of actionable data .

Analyze semi-structured interviews

Bring all your semi-structured interviews into one place to analyze and understand

A semi-structured interview is a qualitative research method used to gain an in-depth understanding of the respondent's feelings and beliefs on specific topics. As the interviewer prepares the questions ahead of time, they can adjust the order, skip any that are redundant, or create new ones. Additionally, the interviewer should be prepared to ask follow-up questions and probe for more detail.

Semi-structured interviews typically last between 30 and 60 minutes and are usually conducted either in person or via a video call. Ideally, the interviewer can observe the participant's verbal and non-verbal cues in real-time, allowing them to adjust their approach accordingly. The interviewer aims for a conversational flow that helps the participant talk openly while still focusing on the primary topics being researched.

Once the interview is over, the researcher analyzes the data in detail to draw meaningful results. This involves sorting the data into categories and looking for patterns and trends. This semi-structured interview approach provides an ideal framework for obtaining open-ended data and insights.

• When to use a semi-structured interview?

Semi-structured interviews are considered the "best of both worlds" as they tap into the strengths of structured and unstructured methods. Researchers can gather reliable data while also getting unexpected insights from in-depth user feedback.

Semi-structured interviews can be useful during any stage of the UX product-development process, including exploratory research to better understand a new market or service. Further down the line, this approach is ideal for refining existing designs and discovering areas for improvement. Semi-structured interviews can even be the first step when planning future research projects using another method of data collection.

• Advantages of semi-structured interviews

Flexibility

This style of interview is meant to be adapted according to the answers and reactions of the respondent, which gives a lot of flexibility. Semi-structured interviews encourage two-way communication, allowing themes and ideas to emerge organically.

Respondent comfort

The semi-structured format feels more natural and casual for participants than a formal interview. This can help to build rapport and more meaningful dialogue.

Semi-structured interviews are excellent for user experience research because they provide rich, qualitative data about how people really experience your products and services.

Open-ended questions allow the respondent to provide nuanced answers, with the potential for more valuable insights than other forms of data collection, like structured interviews , surveys , or questionnaires.

• Disadvantages of semi-structured interviews

Can be unpredictable

Less structure brings less control, especially if the respondent goes off tangent or doesn't provide useful information. If the conversation derails, it can take a lot of effort to bring the focus back to the relevant topics.

Lack of standardization

Every semi-structured interview is unique, including potentially different questions, so the responses collected are very subjective. This can make it difficult to draw meaningful conclusions from the data unless your team invests the time in a comprehensive analysis.

Compared to other research methods, unstructured interviews are not as consistent or "ready to use."

• Best practices when preparing for a semi-structured interview

While semi-structured interviews provide a lot of flexibility, they still require thoughtful planning. Maximizing the potential of this research method will depend on having clear goals that help you narrow the focus of the interviews and keep each session on track.

After taking the time to specify these parameters, create an interview guide to serve as a framework for each conversation. This involves crafting a range of questions that can explore the necessary themes and steer the conversation in the right direction. Everything in your interview guide is optional (that's the beauty of being "semi" structured), but it's still an essential tool to help the conversation flow and collect useful data.

Best practices to consider while designing your interview questions include:

Prioritize open-ended questions

Promote a more interactive, meaningful dialogue by avoiding questions that can be answered with a simple yes or no, otherwise known as close-ended questions.

Stick with "what," "when," "who," "where," "why," and "how" questions, which allow the participant to go beyond the superficial to express their ideas and opinions. This approach also helps avoid jargon and needless complexity in your questions.

Open-ended questions help the interviewer uncover richer, qualitative details, which they can build on to get even more valuable insights.

Plan some follow-up questions

When preparing questions for the interview guide, consider the responses you're likely to get and pair them up with some effective, relevant follow-up questions. Factual questions should be followed by ones that ask an opinion.

Planning potential follow-up questions will help you to get the most out of a semi-structured interview. They allow you to delve deeper into the participant's responses or hone in on the most important themes of your research focus.

Follow-up questions are also invaluable when the interviewer feels stuck and needs a meaningful prompt to continue the conversation.

Avoid leading questions

Leading questions are framed toward a predetermined answer. This makes them likely to result in data that is biased, inaccurate, or otherwise unreliable.

For example, asking "Why do you think our services are a good solution?" or "How satisfied have you been with our services?" will leave the interviewee feeling pressured to agree with some baseline assumptions.

Interviewers must take the time to evaluate their questions and make a conscious effort to remove any potential bias that could get in the way of authentic feedback.

Asking neutral questions is key to encouraging honest responses in a semi-structured interview. For example, "What do you consider to be the advantages of using our services?" or simply "What has been your experience with using our services?"

Neutral questions are effective in capturing a broader range of opinions than closed questions, which is ultimately one of the biggest benefits of using semi-structured interviews for research.

Use the critical incident method

The critical incident method is an approach to interviewing that focuses on the past behavior of respondents, as opposed to hypothetical scenarios. One of the challenges of all interview research methods is that people are not great at accurately recalling past experiences, or answering future-facing, abstract questions.

The critical incident method helps avoid these limitations by asking participants to recall extreme situations or 'critical incidents' which stand out in their memory as either particularly positive or negative. Extreme situations are more vivid so they can be recalled more accurately, potentially providing more meaningful insights into the interviewee’s experience with your products or services.

• Best practices while conducting semi-structured interviews

Encouraging interaction is the key to collecting more specific data than is typically possible during a formal interview. Facilitating an effective semi-structured interview is a balancing act between asking prepared questions and creating the space for organic conversation. Here are some guidelines for striking the right tone.

Beginning the interview

Make participants feel comfortable by introducing yourself and your role at the organization and displaying appropriate body language.

Outline the purpose of the interview to give them an idea of what to expect. For example, explain that you want to learn more about how people use your product or service.

It's also important to thank them for their time in advance and emphasize there are no right or wrong answers.

Practice active listening

Build trust and rapport throughout the interview with active listening techniques, focusing on being present and demonstrating that you're paying attention by responding thoughtfully. Engage with the participant by making eye contact, nodding, and giving verbal cues like "Okay, I see," "I understand," and "M-hm."

Avoid the temptation to rush to fill any silences while they're in the middle of responding, even if it feels awkward. Give them time to finish their train of thought before interrupting with feedback or another prompt. Embracing these silences is essential for active listening because it's a sign of a productive interview with meaningful, candid responses.

Practicing these techniques will ensure the respondent feels heard and respected, which is critical for gathering high-quality information.

Ask clarifying questions in real time

In a semi-structured interview, the researcher should always be on the lookout for opportunities to probe into the participant's thoughts and opinions.

Along with preparing follow-up questions, get in the habit of asking clarifying questions whenever possible. Clarifying questions are especially important for user interviews because people often provide vague responses when discussing how they interact with products and services.

Being asked to go deeper will encourage them to give more detail and show them you’re taking their opinions seriously and are genuinely interested in understanding their experiences.

Some clarifying questions that can be asked in real-time include:

"That's interesting. Could you give me some examples of X?"

"What do you mean when you say "X"?"

"Why is that?"

"It sounds like you're saying [rephrase their response], is that correct?"

Minimize note-taking

In a wide-ranging conversation, it's easy to miss out on potentially valuable insights by not staying focused on the user. This is why semi-structured interviews are generally recorded (audio or video), and it's common to have a second researcher present to take notes.

The person conducting the interview should avoid taking notes because it's a distraction from:

Keeping track of the conversation

Engaging with the user

Asking thought-provoking questions

Watching you take notes can also have the unintended effect of making the participant feel pressured to give shallower, shorter responses—the opposite of what you want.

Concluding the interview

Semi-structured interviews don't come with a set number of questions, so it can be tricky to bring them to an end. Give the participant a sense of closure by asking whether they have anything to add before wrapping up, or if they want to ask you any questions, and then give sincere thanks for providing honest feedback.

Don't stop abruptly once all the relevant topics have been discussed or you're nearing the end of the time that was set aside. Make them feel appreciated!

• Analyzing the data from semi-structured interviews

In some ways, the real work of semi-structured interviews begins after all the conversations are over, and it's time to analyze the data you've collected. This process will focus on sorting and coding each interview to identify patterns, often using a mix of qualitative and quantitative methods.

Some of the strategies for making sense of semi-structured interviews include:

Thematic analysis : focuses on the content of the interviews and identifying common themes

Discourse analysis : looks at how people express feelings about themes such as those involving politics, culture, and power

Qualitative data mapping: a visual way to map out the correlations between different elements of the data

Narrative analysis : uses stories and language to unlock perspectives on an issue

Grounded theory : can be applied when there is no existing theory that could explain a new phenomenon

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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.

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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.

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• Open access
• Published: 29 April 2024

The experiences and needs of older adults receiving voluntary services in Chinese nursing home organizations: a qualitative study

• Qin Shen 1 &
• Junxian Wu 1  

BMC Health Services Research volume  24 , Article number:  547 ( 2024 ) Cite this article

72 Accesses

Metrics details

Older adults living in nursing home organizations are eager to get voluntary help, however, their past experiences with voluntary services are not satisfactory enough. To better carry out voluntary services and improve the effectiveness of services, it is necessary to have a deeper understanding of the experiences and needs of older adults for voluntary services.

The purposive sampling method was used to select 14 older adults from two nursing home organizations in Hangzhou and conduct semi-structured interviews, Collaizzi’s seven-step method was used to analyze the data.

Older adults in nursing home organizations have both beneficial experiences and unpleasant service experiences in the process of receiving voluntary services; Beneficial experiences include solving problems meeting needs and feeling warmth and care, while unpleasant service experiences include the formality that makes it difficult to benefit truly, lack of organization, regularity, sustainability, and the mismatch between service provision and actual demands. The needs for voluntary services mainly focuses on emotional comfort, Cultural and recreational, and knowledge acquisition.

Older adults in nursing home organizations have varied voluntary experiences, and their voluntary service needs are diversified. Voluntary service needs of older adults should be accurately assessed, and voluntary service activities should be focused upon.

Peer Review reports

Introduction

As a result of advancements in medical technology and improved sanitation conditions, the average life expectancy of Chinese people has increased significantly from 60 years in 1970 to 77.3 years in 2023. However, this has led to a growing number of older adults in China. According to the seventh population census conducted by the National Bureau of Statistics of China, there are now 260 million people over the age of 60 living in the country [ 1 ], The aging population in China is growing, and population balance is becoming a core challenge for the country in the long term. The increasing aging population has posed significant challenges and burdens to the state and society [ 2 ], China’s aging population challenges the current security system, requiring significant efforts from the state and society for improvement [ 3 ].

There are three main modes of old-age care in China: family old-age care, community old-age care, and institutionalized old-age care. Family old-age care is the most traditional form of old-age care in China, due to the reduction in family size and the formation of the “4-2-1” family model - which consists of four older adults, one couple, and one child - the traditional family model is no longer able to meet the growing demand for older adults care [ 4 ]; China’s community old-age care is still in the exploratory stage, facing challenges such as slow construction, insufficient staff, and lack of professional knowledge. As a result, it cannot provide meticulous care services for older adults [ 5 ]. Against this background, institutionalized older adult care has gradually become popular, it refers to older adults in social service organizations such as senior citizen apartments, welfare homes, and homes for older adults to spend their later life [ 6 ]. The challenges of population aging and the inadequacies of family and community support for older adults have resulted in a growing number of older adults opting to reside in nursing home organizations. This has undoubtedly placed additional burdens and challenges on these nursing home organizations. Due to multiple challenges such as late start, low quality, and lack of professional and technical talents, China’s nursing home organizations are still a long way from meeting the comprehensive needs of older adults in terms of health management, skilled nursing care, rehabilitation training, cultural and recreational services, psychological counseling, and social interaction [ 7 ]. To tackle the issue of an aging population in China and ensure that older adults have a high quality of life when choosing nursing home organizations, it is necessary to enhance the quality of older adult care services by engaging social forces, such as volunteer teams [ 8 ]. Voluntary services refer to the voluntary, unpaid public service offered by individuals, organizations, and voluntary service organizations to society or other organizations. The forms of voluntary services are diverse and can be either formal, planned, and long-term, or informal, spontaneous, and intermittent [ 9 ]. At present, volunteer groups in China’s nursing home organizations are mostly informal and consist of university students, healthcare workers, art workers, social workers, and others. These groups are invited by nursing home organizations or come to these institutions on their initiative to provide services for older adults. These services include a wide range of activities such as haircutting, cultural performances, spiritual comfort, hobby learning (e.g., paper-cutting, flower arranging), organizing festive activities (e.g., making rice dumplings on-site at Dragon Boat Festival, making mooncakes at Mid-Autumn Festival, etc.).

Voluntary services are a crucial aspect of long-term care and greatly complement the resources provided by the government,these nursing home organizations welcome volunteers who perform various non-medical activities associated with the daily lives of older adults [ 10 , 11 , 12 ]. Volunteers offer additional assistance and companionship to residents, provide support to employees such as nurses, nutritionists, and physical therapists, and potentially improve the overall quality of care, in China, these services have become increasingly popular and play a crucial role [ 13 , 14 ]. However, some problems have emerged in voluntary services, The voluntary services provided by volunteer organizations for older adults have certain functional defects and efficiency dilemmas, such as an unsound volunteer management system, high mobility of volunteers, and lack of a corresponding volunteer training system, which leads to the inability to provide high-quality services [ 13 ]. The above problems have undermined the effectiveness of voluntary services and affected the regular operation of nursing home organizations [ 15 ].

For effective services for older adults, it’s critical to understand the needs and experiences of older adults in nursing home organizations, there have been limited studies on how older adults feel about receiving voluntary services and if such services are suitable for their actual needs. One qualitative study documented the experiences of older adults who were helped by volunteers, but it was mainly focused on the volunteers themselves [ 16 ]. Another study looked into the benefits and experiences of receiving voluntary services, but it specifically focused on older adults who were confined to their homes [ 17 ]. There is no research available that sheds light on the emotions and requirements of older adults who receive voluntary services in nursing home organizations. To bridge this gap, we conducted interviews with older adults who have been accepted for voluntary services in two nursing home organizations in Hangzhou. The objective of this study is to gain a deeper understanding of the actual needs and experiences of older adults and use this information to guide promoting the effective growth of voluntary services and establishing a voluntary service system that is suitable for older adults in nursing home organizations.

This study adopts a qualitative descriptive approach to examine the experiences and expectations of older adults in nursing home organizations when receiving voluntary services. This study aims to gain a comprehensive understanding of the actual experiences and needs of older adults residing in nursing home organizations regarding receiving voluntary services and explore the types of voluntary services that are most suitable for the needs of older adults. To ensure accuracy and transparency, the authors followed the Consolidated Standards for Reporting Qualitative Research (COREQ) guidelines when reporting their findings [ 18 ].

Participants

During June-August 2023, the authors used purposive sampling to sample older adults residing in two nursing home organizations in Hangzhou, the inclusion criteria for the interview subjects were as follows:

they had to have resided in the nursing home organizations for more than a year;

they had to have received voluntary services;

they had to be conscious and able to express themselves effectively;

they had to have given informed consent and voluntarily agreed to participate in the study.

The number of people participating in the study was decided based on information saturation, this means the interviews were conducted until no new topics emerged and responses were repeated, the data from the twelfth interview indicated that saturation had been reached as confirmed by the other two interviews. This research principle was based on previous qualitative research studies [ 19 ]. A total of 14 older adults, coded N1-N14, were included in this study. All older adults who participated in the study agreed to the interview process, and none withdrew during the study. Detailed information can be found in Table  1 .

Interview outline

We developed an interview outline after thoroughly reviewing the literature sources and consulting with the research group [ 20 , 21 ]. We selected two older adults living in nursing home organizations to conduct pre-interviews, we adjusted the interview outline based on the feedback we received from the pre-interviews.

The interview will cover the following topics:

Please describe the voluntary services you have received in detail. How do you feel about receiving these services?

Are you satisfied with the voluntary service you have received? What aspects of the service make you satisfied?

What are your dissatisfactions with the voluntary service? Why do you feel that way?

What are your expectations and needs for the voluntary service’s content, form, and volunteers?

Is there anything else you would like to add to the discussion?

Data collection

A semi-structured interview method was utilized to gather data for this study. The main researcher, (a master’s degree nursing student) has been trained in qualitative research methods and has mastered the semi-structured interview techniques required to conduct interviews independently. Additionally, the researcher has participated in various volunteer activities in nursing organizations and has established a trustworthy relationship with the interviewees. Before conducting the interviews, the main researcher explained the study’s purpose and methodology to the interviewees and, after acquiring their consent, scheduled an appointment in advance. Face-to-face interviews were conducted with the respondents in a quiet, private, comfortable conference room. During the interview, the researcher recorded the entire process with the respondent’s consent without interrupting the respondent unnecessarily. The researcher confirmed the key concerns and the content that the respondent could not express clearly by repeating, asking follow-up questions, and asking rhetorical questions. The researcher also promptly recorded the respondent’s non-verbal information, such as movements, expressions, and tone of voice. Each interview lasted 30–45 min, and after conducting 14 interviews, no new information was obtained, indicating data saturation and ending the interview process. At the end of the interview, each interviewee was given a small token of appreciation.

Data analysis

The audio recordings of the interviews were transcribed into text within 24 h of completion, non-verbal information was noted in the transcript at relevant places. The transcribed information was then entered into the NVIVO 11.0 software (QST International, Cambridge, MA, USA) for data extraction, coding, and integration. Two researchers independently analyzed and coded the data, and the results were compared to identify common themes. Any discrepancies were resolved after the research team had discussed them to ensure that the data was complete and the analysis was accurate. Colaizzi’s seven-step analysis method was used to refine the themes from the interviews, which involved the following steps [ 22 ]:

Carefully read all the transcriptions of the interviews.

Analyze the significant statements made by the interviewees.

Code the recurring and meaningful ideas discussed in the interviews.

Gather the coded ideas and form the theme clusters.

Define and describe the themes from the coded ideas.

Identify similar ideas and sublimate the theme concepts.

Return the results to the interviewees for verification, and revision, and add the results based on the feedback from the interviewees. For detailed coding results, please see Table  2 .

After the data analysis was summarized, two main themes were identified: Experiences and Needs for volunteerism.

Theme 1: experiences

Beneficial experiences, solving problems and meeting needs.

Many older adults currently reside in nursing home organizations that are situated far away from their children and friends, they often face difficulties in getting help promptly when they encounter problems, which can affect their daily lives. For instance, in today’s rapidly developing society, many older adults own smartphones but lack the necessary knowledge to use them effectively. This, in turn, reduces their social participation and increases their sense of isolation. However, voluntary services have been instrumental in assisting them in overcoming these hurdles and leading a more fulfilling life.

N11: “When the volunteers come to teach me how to use computers, I ask them something that I don’t understand, and the teacher will explain it to me immediately.” N1: “I don’t know how to buy things online. Volunteers taught me little by little, and after a few teaching sessions, I learned how to do it so I don’t have to bother the caregiver every time. I can also do online shopping by myself, and I feel that life is much more convenient.”

Some respondents stated that volunteers could fulfill their needs. Professional volunteers also taught older adults Chinese medicine and health care and assisted with self-care.

N12: “I’m interested in Chinese medicine health care knowledge, and when students from the University of Traditional Chinese Medicine come over, and I ask them What are the functions of different acupoints, they tell me how to press them to make them work.”

Feel warmth and care

Many older adults live in nursing home organizations, away from their familiar environment and social network. This isolation can generate a sense of loneliness, making them more eager for emotional support. Volunteers provide services to add joy to the lives of older adults so that they feel cared for. Interviewees have mentioned that being taken care of on their initiative makes them feel warm and touched, increasing their overall sense of well-being.

N10: “I am delighted when I participate in volunteering, I feel that I have a group life again, I am pleased, I feel that someone cares about us.” N8: “Volunteers come to serve us, feel that people still care about us older adults, and now the country also cares about us, and society also cares about us, I am thrilled.”

Some respondents said that having someone to talk to and greet them would make them feel happy and that they were willing to communicate with young people and accept their new ideas.

N2: “As soon as I see you young people, I am happy, I feel the atmosphere of youth, my mood is different, I feel less lonely.”

Unpleasant service experiences

A formality that makes it difficult to benefit truly.

According to the interviewees, there are certain formalized phenomena in the domain of volunteering. Some volunteers engage in volunteering activities to obtain a certificate, such certificates can help them get extra points at work. Some volunteers participated in volunteering based on the mentality of the herd under the organizational arrangements of their schools or enterprises. These volunteers lack initiative, violate the principle of voluntarism, and cannot provide services that genuinely benefit older adults due to their single-mindedness and formalism during the service process. As a result, older adults have a poorer sense of experience.

N7: “Some volunteers are asked to serve by their companies, and they have to finish the job; some just go through a process.” N13: “Many volunteers come over to perform a show, then take photos and leave; the service time is very short, just like completing a task.” N5: “Some volunteers are very perfunctory; they come for a while and leave quickly.”

Lack of organization, regularity, sustainability

Many volunteers offer their services without compensation, while they have their formal jobs, which makes it difficult for them to provide services consistently. Additionally, volunteers may be more mobile, which can result in a lack of continuity in the services that are provided and the target groups that are served. However, older adults living in nursing home organizations often have monotonous and lonely lives, and occasional voluntary services may not be enough to meet their needs. As a result, some older adults may feel dissatisfied with the irregular and unsustainable nature of voluntary services.

N12: “Volunteers come on an ad hoc basis; they are not regular. Recently, a school teacher came to teach us how to sing, but unfortunately, they had to leave due to commitments and have not been able to come back.’’ N5: “Volunteers can’t come regularly; they come once in a while or not regularly and don’t have a plan.” N7: “Volunteers come to the nursing home occasionally, so they don’t want to bother them.”

The mismatch between service provision and actual demand

The voluntary services provided to older adults in nursing institutions were not able to match their real needs as the volunteers had no prior knowledge of their needs and did not make any advance preparations.

N4: “Last time, a volunteer came and asked me if I needed help with cleaning. However, I declined their kind offer because caregivers in the nursing home clean rooms every day, and the volunteers could not address the specific things I needed help with.”

The needs of older adults for volunteering can vary significantly based on their experiential backgrounds, and physiological and psychological conditions. Therefore, providing the same services to all older adults can lead to negative feelings towards volunteering among them.

N10: “Some volunteers come just to dance and sing, it feels very noisy. I don’t want to participate, I want the volunteers to talk to me peacefully and quietly.” N14: “I am not very good with my legs, so it is difficult for me to participate in activities organized by the volunteers downstairs. I would like to find activities I can participate in in my room, such as playing games or doing crafts.”

Theme 2 needs for volunteerism

Needs for emotional comfort.

Many older adults live in semi-closed institutions where they lack long-term support from their families and struggle to find someone to talk to. During the epidemic, nursing home organizations prohibited visitors to prevent the spread of the virus, leaving many seniors alone and cut off from the outside world. As a result, many older adults experience feelings of loneliness and depression. To help combat these negative emotions, volunteers can provide companionship and support, which can effectively reduce feelings of loneliness and promote emotional well-being.

N1: “I hope someone will come and chat with us; many older adults have no way to contact the outside world, so they have psychological barriers, they need psychological counseling, they need someone to come and chat with them to relieve their loneliness.” N10: “It’s better to have volunteers to come over to the service, to come and chat with me, to visit me.” N12: “I would like volunteers to communicate with us, tell us what is happening outside, tell us something new.”

Cultural and recreational needs

As people age, their social interactions tend to decrease, and they gradually tend to withdraw from daily life. This results in older adults having more free time after their retirement. Nursing home organizations can provide basic living care and medical assistance for older adults, which relieves them of the burden of cooking, cleaning, and shopping. This also means they have more free time than those who live at home or in the community. Many older adults wish to participate in cultural and recreational activities, such as singing, dancing, sports, and watching performances, to add excitement to their lives. They hope that volunteers can organize such activities to help them reduce their loneliness and spend their time in a meaningful way.

N14: “It’s good for volunteers to come and teach us how to dance, sing, and sing opera, and time passes a little faster when we all get together and learn.” N2: “It is popular for volunteers to bring cultural performances to our nursing home, we love to see young people performing programs, singing some classic old songs or Peking Opera, it is very popular.” N9: “We would like to play tai chi, it is a very suitable sport for us as it strengthens the body and the movements are softer, it would be nice if a teacher could teach us.”

Knowledge acquisition needs

According to Maslow’s Hierarchy of Needs Theory, individuals will naturally shift their focus toward higher-level pursuits once their basic and low-level needs are met. In the case of older adults residing in nursing home organizations, their basic material needs are taken care of, and as a result, their need for knowledge and learning becomes increasingly important. Many older adults require assistance in learning how to use electronic equipment, which can help facilitate their communication with the outside world and reduce feelings of isolation.

N1: “It’s become very convenient to buy things online, but I don’t know how to operate it myself and would like someone to teach me.” N2: “My daughter bought me an expensive Apple phone, but I am unfamiliar with how to use it. It would be great if someone could systematically instruct me on how to use the smartphone.” N8: “I don’t know how to use my smartphone, I don’t understand many functions, so I would benefit from having a teacher to guide me.”

As individuals age, their bodily and cognitive functions may deteriorate, adversely affecting their quality of life. Basic healthcare knowledge can be critical for older adults to maintain good health. Many older adults have a strong desire to learn about nutritional diets, rational exercise, and traditional Chinese medicine physiotherapy as a means of improving their health.

N9: “Volunteers can come and talk to us about medicine and how to predict dementia.” N13: “I have high blood pressure and cholesterol. I need advice on what to eat and what to avoid.”

To prevent any disagreements regarding the distribution of their assets among their heirs after they pass away, older adults seek the help of volunteers to assist them in drafting a will that is by national policies and regulations and has legal validity.

N12: “Volunteers can help us learn how to write a will effectively and can avoid unnecessary trouble and conflicts in the future.”

The current situation of voluntary experiences of older adults in nursing home organizations

Analysis of beneficial experiences.

The study’s findings indicate that individuals residing in nursing home organizations who are of advanced age have mixed experiences when it comes to receiving voluntary services. Most respondents conveyed the warmth and care emanating from the volunteers and the society towards older adults. Furthermore, they shared that volunteering offered them a means to engage in activities actively, create connections with fellow older adults, and foster mutual support and camaraderie. This social participation has the potential to enhance the mental well-being of older adults, thereby decreasing feelings of loneliness and depression [ 17 ]. Voluntary activities like smartphone training can help older adults acquire the necessary needed skills and adapt better to modern technology and life. Competent skills are crucial for older adults, particularly in today’s fast-developing technological society, where electronic devices such as smartphones are becoming increasingly popular. However, many older adults need more skills to operate these devices and thus cannot fully utilize them. Through training, older adults can learn how to use smartphones, including sending text messages, browsing the web, using social media, downloading applications, and more. Learning these skills not only improves the quality of life of older adults but also helps them stay connected with family and friends, thereby reducing loneliness.

Improved skills can assist older adults in accessing and utilizing health information, including online medical advice and health apps. This information can aid in managing their health status, preventing and managing chronic illnesses, and ultimately improving their quality of life. Volunteering is crucial in nursing home organizations. It provides numerous benefits to older adults, including enhancing their mental health and quality of life and receiving the necessary support and care by participating in voluntary activities [ 23 ].

Analysis of unpleasant experiences

During the interviews, some older adults shared negative experiences regarding the content, form, and frequency of voluntary services. They pointed out that volunteers did not understand their needs in advance, focusing too much on material assistance and neglecting their psychological and intellectual needs. Additionally, the service process is often too process-oriented and formalized, with less interaction with older adults, resulting in voluntary services failing to meet their expectations.

Research suggests that negative experiences of receiving voluntary services may impact older adults’ willingness to seek help and the effectiveness of voluntary services. Therefore, when providing voluntary services to older adults, it is essential to take the initiative to understand their experiences and continuously optimize the voluntary program. This approach is crucial to improving the quality of voluntary services [ 24 ].

The current situation of the demands for voluntary services by older adults

The study results show that nursing home organizations can provide comprehensive life care services to older adults, meaning they do not require many voluntary services for life care. However, this does not imply that older adults’ needs are met. Their need for emotional support, cultural recreation, and knowledge-seeking and learning is highly concentrated.

When older adults leave their familiar family environment to move into care institutions, they may experience feelings of loneliness and boredom due to the lack of regular interaction with their children, family members, and friends. This sense of isolation can harm their mental health, and they may seek more opportunities to communicate and interact with younger individuals to gain emotional comfort [ 25 ].

As people age, cultural entertainment and knowledge learning become essential for spiritual growth. After their basic living needs are taken care of, older adults desire more fulfilling recreational activities, such as calligraphy, painting, and singing, these activities enrich the spiritual life of older adults and benefit their physical and mental health [ 26 ].

In today’s rapidly developing society, the widespread use of smartphones and the popularity of online shopping have led to a digital divide among older adults. This phenomenon has, to some extent, hindered their social participation and increased their sense of isolation. Consequently, there is a growing demand for voluntary services that assist with smartphone use and can help them enjoy a convenient and fulfilling digital life.

The need for voluntary services for older adults has changed over time. While they still require help with their daily living, they also need emotional support, cultural engagement, and opportunities to learn new things. We should focus on meeting these needs to ensure our voluntary services are beneficial. By doing so, we can help older adults live fulfilling, healthy, and happy lives in their later years [ 27 ].

Suggestions and strategies for optimizing volunteerism

Accurately assessing older adults’ voluntary service needs.

The study results reveal that some older adults have negative experiences with voluntary services that fail to meet their actual needs, leading to unsatisfactory service outcomes. This highlights the need to accurately identify the real service needs of older adults to improve the quality and effectiveness of voluntary services.

To achieve our goal, we need to take a series of steps. Firstly, we must create appropriate tools for evaluating the needs of older adults for voluntary services. We should also clarify the assessment methods and strategies for assessing these needs, before launching voluntary services, relevant organizations and volunteers must understand older adults’ service experience and needs through qualitative and quantitative assessment methods [ 28 ].

To improve the quality and effectiveness of voluntary services for older adults, we can utilize big data technology to carry out precise reforms. This involves building a unified information platform for voluntary services that enables a quick match between the needs of older adults and the specialties of volunteers through the co-construction, sharing, and everyday use of resource information [ 29 ]. By doing so, we can provide multi-level, multi-category, and personalized voluntary services that cater to the actual needs of older adults, thus achieving the purpose of “precise service.”

In conclusion, we must prioritize the actual needs of older adults and provide them with more personalized and intimate voluntary services by continuously improving the assessment tools and information platforms with the orientation of precise services, the use of big data technology will play a key role in helping us realize the goal of efficient and accurate services.

Improving the quality management system of voluntary services

Volunteering quality refers to the quality of services volunteers provide, as perceived by the direct recipients. Research has shown that low-quality voluntary services fail to achieve their intended goals, moreover, negative experiences of receiving voluntary services may discourage older adults from seeking help in the future. The study highlights a significant gap between older adults’ experience of volunteering quality and their expectations, therefore, it is necessary to strengthen the management of volunteering quality to ensure that expectations are met.

To enhance the quality of volunteering, we need to implement measures. Firstly, we must optimize the recruitment and selection system for volunteers, this entails formulating recruitment plans and selection requirements that align with the voluntary services needs of older adults. We aim to create a stable and committed volunteer team skilled in services knowledge and job skills and willing to participate in voluntary services for an extended period [ 30 ].

To enhance the level and quality of service, it is important to provide regular and standardized training to volunteers. Volunteers should receive professional information support services, such as training on volunteer spirit, etiquette, communication skills, and the physiological and psychological characteristics of older adults. The main forms of training include information consultation, professional knowledge, technology lectures, sharing of previous volunteer experiences, summarizing stage-by-stage voluntary services, and experiential services. Volunteers should be provided with face-to-face or online interaction to help them improve their ability to assist older adults. The training for volunteering encompasses theoretical knowledge about volunteering, including its characteristics and principles, the rights and interests of service users, and respect for them. It also includes basic knowledge of social work, such as interpersonal communication methods and skills, as well as knowledge of health care for older adults. The latter includes the introduction of general knowledge about daily life care for older adults, such as diet, hygiene, and exercise, and the evaluation of the training’s effectiveness. Both voluntary service organizations and nursing home organizations should participate in the training process, only volunteers who have completed the training and assessment can engage in service activities [ 31 ]. It is essential to improve the evaluation mechanism of voluntary service quality. This can be done by creating a scientific evaluation index system involving older adults in evaluating their satisfaction with the voluntary service program and conducting a comprehensive analysis of the evaluation results. This analysis can help to optimize and improve the service program, additionally, tracking and evaluating the effectiveness of optimization measures to continuously enhance service quality is crucial [ 32 ].

Improving the quality of voluntary services is a comprehensive project that enhances various aspects, such as volunteer recruitment, training, and service quality evaluation. This systematic approach can help serve the nursing home organizations better and improve their overall quality of life.

Strengths and limitations

The paper’s strength lies in its focus on the experience of older adults in nursing institutions when receiving voluntary services and their need for such services. This study’s understanding of the real feelings and needs of older adults is beneficial for various organizations in society to provide better services in a targeted manner. However, the study’s limitation is that it mainly focuses on the more developed areas of Hangzhou, which affects the sample’s representativeness and makes it challenging to reflect the general situation of older adults in nursing home organizations. Additionally, the author’s subjective viewpoints may affect the analysis of the material during the data analysis process. Finally, the sample size of this study is relatively small, and there may be individual differences in personality, physical condition, and economic situation, among others. Therefore, expanding the sample size and the region’s scope to carry out more in-depth research is necessary.

This research explored the experiences and requirements of older adults who receive voluntary services in Chinese care homes. The study categorized their experiences into two groups: beneficial experiences and unpleasant service experiences, the needs of older adults who receive voluntary services include emotional comfort, cultural and recreational, and knowledge acquisition. It is crucial to have a timely and comprehensive understanding of the experiences and needs of older adults to create a targeted voluntary service model, standardized management, and training of volunteers in nursing home organizations.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. The datasets are not publicly available due to confidentiality and ethical restrictions.

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Acknowledgements

We want to express our heartfelt appreciation to the 14 older adults who participated in the interview and shared their experiences. We are also grateful to the administrators of nursing home organizations in Hangzhou, Zhejiang Province, for granting us access and allowing us to conduct the interviews at their facility. Their cooperation was invaluable in gaining insights into the needs of older adults.

This study did not receive any form of financial support.

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Li, L., Shen, Q. & Wu, J. The experiences and needs of older adults receiving voluntary services in Chinese nursing home organizations: a qualitative study. BMC Health Serv Res 24 , 547 (2024). https://doi.org/10.1186/s12913-024-11045-5

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Delivering clinical tutorials to medical students using the Microsoft HoloLens 2: A mixed-methods evaluation

• Murray Connolly 1 ,
• Gabriella Iohom 1 ,
• Niall O’Brien 2 ,
• James Volz 2 ,
• Aogán O’Muircheartaigh 3 ,
• Paschalitsa Serchan 3 ,
• Agatha Biculescu 3 ,
• Kedar Govind Gadre 3 ,
• Corina Soare 1 ,
• Laura Griseto 3 &
• George Shorten 1  

BMC Medical Education volume  24 , Article number:  498 ( 2024 ) Cite this article

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Mixed reality offers potential educational advantages in the delivery of clinical teaching. Holographic artefacts can be rendered within a shared learning environment using devices such as the Microsoft HoloLens 2. In addition to facilitating remote access to clinical events, mixed reality may provide a means of sharing mental models, including the vertical and horizontal integration of curricular elements at the bedside. This study aimed to evaluate the feasibility of delivering clinical tutorials using the Microsoft HoloLens 2 and the learning efficacy achieved.

Following receipt of institutional ethical approval, tutorials on preoperative anaesthetic history taking and upper airway examination were facilitated by a tutor who wore the HoloLens device. The tutor interacted face to face with a patient and two-way audio-visual interaction was facilitated using the HoloLens 2 and Microsoft Teams with groups of students who were located in a separate tutorial room. Holographic functions were employed by the tutor. The tutor completed the System Usability Scale, the tutor, technical facilitator, patients, and students provided quantitative and qualitative feedback, and three students participated in semi-structured feedback interviews. Students completed pre- and post-tutorial, and end-of-year examinations on the tutorial topics.

Twelve patients and 78 students participated across 12 separate tutorials. Five students did not complete the examinations and were excluded from efficacy calculations. Student feedback contained 90 positive comments, including the technology’s ability to broadcast the tutor’s point-of-vision, and 62 negative comments, where students noted issues with the audio-visual quality, and concerns that the tutorial was not as beneficial as traditional in-person clinical tutorials. The technology and tutorial structure were viewed favourably by the tutor, facilitator and patients. Significant improvement was observed between students’ pre- and post-tutorial MCQ scores (mean 59.2% Vs 84.7%, p  < 0.001).

Conclusions

This study demonstrates the feasibility of using the HoloLens 2 to facilitate remote bedside tutorials which incorporate holographic learning artefacts. Students’ examination performance supports substantial learning of the tutorial topics. The tutorial structure was agreeable to students, patients and tutor. Our results support the feasibility of offering effective clinical teaching and learning opportunities using the HoloLens 2. However, the technical limitations and costs of the device are significant, and further research is required to assess the effectiveness of this tutorial format against in-person tutorials before wider roll out of this technology can be recommended as a result of this study

Peer Review reports

Introduction

Clinical tutorials which include encounters with real patients are recognised as integral elements in medical education [ 1 , 2 , 3 ]. Sir William Osler famously stated that “medicine is learned by the bedside and not in the classroom.” [ 4 ] However, many medical schools are facing challenges in delivering clinical education to students in an environment where there are increasing numbers of students, a limited number of patients and tutors, and increased scrutiny regarding the costs and environmental impacts of travel [ 5 , 6 , 7 , 8 ]. The COVID-19 pandemic also had a significant impact on in-person medical education in many countries, where students’ access to patients was severely curtailed [ 9 , 10 ]..

The argument that medical education requires interactive tutorials on actual patients is supported by various educational theories. Bandura’s Social Learning Theory and Social Cognitive Theory propose that students learn via attention, retention, reproduction and motivation [ 11 , 12 ]. This supports the need for direct observation and modelling of relevant clinical role-models participating in doctor-patient interactions [ 13 , 14 ]..

The Constructivist theory is based on the premise that the act of learning is based on a process which connects new knowledge to pre-existing knowledge [ 15 , 16 ]. Vertical Integration in medical education involves the integration of aspects of the curriculum across time, namely the integration of basic sciences and clinical sciences [ 17 , 18 , 19 ]..

Providing medical education within these frameworks, prioritising student exposure to direct interactions with clinicians and patients, and vertical integration of curriculum material, in situations where physical access to patients may be limited by numbers, logistics or infection control concerns poses a significant challenge to medical schools around the world. Utilising technology to facilitate the delivery of clinical education remotely may present a solution to these issues.

The broadcast of bedside tutorials to a remote location can be delivered using a “third-person” perspective, via a fixed or mobile broadcasting device, or using a first-person perspective, via a device mounted on the tutor. Devices which provide a first-person perspective are typically head-mounted-display devices (HMDs). The capabilities of these devices range widely, from basic two-way communication with a remote location, to devices with Augmented Reality (AR) and Mixed Reality (MR) functions which allow the integration of holographic artefacts into tutorials.

Augmented reality (AR) is a virtual environment that allows the user to view both their physical environment and virtual elements in real-time. Mixed Reality (MR) is an extension of AR which allows the real and holographic elements to interact [ 20 , 21 ]..

The use of AR and MR are expanding in many industries including healthcare, education, engineering, and manufacturing [ 22 , 23 , 24 ]. MR investigated in a variety of settings pertaining to medical education. Many early studies focused on teaching relevant anatomy, and more recently studies have evaluated the use of MR in procedural training, and its use in streaming of clinical ward-rounds to medical students [ 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ]..

Head-mounted-display devices which offer MR experiences are growing in number and capability [ 34 ].The Microsoft HoloLens2 is one such device which enables the creation of an immersive Mixed Reality environment and can superimpose holographic images onto the user’s surroundings.

The HoloLens 2 has a number of specific capabilities which can be utilised in the virtual delivery of in-person clinical tutorials.The device can facilitate educationally effective, three-way communication between students, tutors and patients, as well as facilitating the incorporation of mixed reality elements into tutorials. The MR capabilities may provide a means of sharing holographic artefacts such as images and diagrams, which can allow the vertical and horizontal integration of curricular elements at the bedside.Utilisation of the MR capabilities of the device may improve student experiences and learning, in particular through instructional scaffolding (e.g rendering cell, organ or system pathways proximate to a patient) [ 35 ] Given the device’s connectivity capabilities, students can be in a separate geographical location to the patient and tutor. This has the potential to decrease student travel requirements and enables the delivery of tutorials to students in multiple different locations simultaneously [ 36 ]. The tutorial can also be delivered to a greater number of students than would be practical in a traditional bedside clinical tutorial environment. This can decrease the burden on both tutors and patients in comparison to multiple smaller group sessions. Finally, infection control risks are reduced as only the tutor enters patients’ environments.

Study goals

There is little published research to date which robustly evaluates the use of the HoloLens in replicating bedside tutorials while also incorporating mixed reality elements into the tutorials. The aims of this study are to evaluate the use of the Microsoft HoloLens 2 device to deliver a tutorial on preoperative anaesthetic history and upper airway examination to medical students in a remote location, while incorporating MR holograms in the tutorial delivery. Specific objectives include evaluating the feasibility of delivering tutorials with the HoloLens device, assessing the learning efficacy of these tutorials, and assessing student, tutor, facilitator, and patient perspectives of the tutorials.

This study was approved by the Clinical Research Ethic Committee of the Cork Teaching Hospitals, and the University College Cork Research and Postgraduate Affairs Committee. All participants including students, patients, tutor and technical facilitator provided written informed consent prior to inclusion in the study.

Study population

University College Cork medical students from two cohorts, third year Graduate-Entry and fourth year Direct-Entry medical students attending a tertiary referral teaching hospital for a clinical attachment with the Department of Anaesthesia and Intensive Care Medicine were invited to participate in the study. Both groups are in their second-last year of medical training, and thus have completed modules and examinations in basic medical sciences and clinical practice in the preceding years, with a maximum of 1 week experience in the field of anaesthesia [ 37 , 38 , 39 ]. Patients attending Cork University Hospital for scheduled surgery were selected and approached for consent by tutors according to clinical relevance. All participants were 18 years or over and were deemed capable of providing consent. Each student provided information on their age, gender and previous third-level qualifications.

Tutorial Sturcture

A one-hour tutorial focusing on completing a preoperative history and focused assessment of the upper airway was developed by MC (adjunct clinical lecturer), GI (Senior Clinical Lecturer) and GS (Professor) in line with the University curriculum’s learning objectives. (Fig. 1 ) Tutorials were delivered on a weekly basis to groups of third year Graduate Entry and fourth year Direct Entry medical students across the 2021–2022 academic year.

Preoperative Anaesthetic History and Focused Preoperative Assessment of the upper airway tutorial structure

All tutorials were delivered by one tutor (MC) and assisted by a technical facilitator (NOB), both males aged in their thirties, who enabled the connection between the site of the clinical encounter and nearby tutorial room. The tutor had no prior experience with the HoloLens 2 device or other AR HMDs prior to participation in this study; the facilitator had significant experience in its use. The tutor was given a period of familiarisation with the device which included using the Microsoft “HoloLens Tips” app, which provides a structured tutorial on the various hand gestures used to control the device, as well as a number of practice calls in order to test the network and audiovisual equipment in the tutorial room [ 40 ]. This familiarisation period totalled approximately 3 hours.

During the tutorial, the tutor (MC) interacted with a patient (face to face) in the pre-or postoperative units and remotely with a small group of [ 6 , 7 , 8 , 9 , 10 ] students in a nearby tutorial room. The remote interaction occurred via Hololens 2 worn by the tutor, institutional Wi-Fi (Eduroam), and Microsoft Teams.He demonstrated and explained the techniques of preoperative history taking and preoperative upper airway assessment.

Throughout the patient assessment the tutor interacted both with the patient and with the students as if conducting an in-person tutorial, providing additional information, asking the students pertinent questions, and expanding on the findings of the patient’s history and physical examination. Students communicated with the patient by asking questions via the tutor.

Resources employed

Resources necessary to provide the tutorials via the HoloLens included capital costs of the HoloLens device (€3500) and microphone (€88) as well as annual licence costs of €275 per user ( n  = 4). Human resources employed in developing the tutorials and trialling equipment included approximately 20 hours of training, remote assistance (Microsoft) and collaboration between the tutor (MC), Professor (GS) and facilitator (NOB), as well as 5 hours input from the Senior Clinical Lecturer (GI).

Internet connectivity

An internet connection of at least 1.5mpbs of bandwidth is recommended by Microsoft for best audio, visual and content sharing experience [ 41 ]. Secure, password protected wireless internet access via the University institutional network (Eduroam) was utilised by both tutor and students.

In most tutorials, broadcasts were hosted by an MSI running the Windows 10 operating system, audio was amplified using a Bose SoundLink Mini portable speaker and video was screened via a HDMI cable to a 36″ monitor. In one tutorial students accessed the tutorial via their personal smartphones or laptops. In order to bypass the noise cancellation technology within the HoloLens an external microphone (Saramonic SmartMic+UC L/weight Smartphone Mic USB-C) and 3.5 mm earphone were used.

Dynamics 365 Remote Assist application was used, in-tandem with Microsoft Teams, to host each video call. This connection allowed the students to see the tutors field of vision and hear both the tutor and patient. Hand gestures including the “hand-ray”, “air-tap”, “air-tap and hold” and “start-gesture” were used to control the HMD and manipulate the holographic artefacts. Relevant holographic artefacts were superimposed during the tutorial. This included the insertion of diagramatic representaions of the Mallampati scoring system and Thyromental Distance during the airway assessment portion of the tutorial [Fig. 2 (a) and (b)]. The holographic pointer and “drawing” functions were used by the tutor to highlight relevant upper airway structures and emphasise information on the holographic diagrams [Fig. 2 (c) and (d)].

a Assessment of Mallampati Score. b Assessment of Thyromental Distance. c Identification of thyroid cartilage using holographic pointer. d Illustration of holographic “drawing” function

Assessment of tutor perceptions

Immediately after completion of the first tutorial, the tutor completed a System Usability Scale assessment and on completion of the last tutorial, the tutor and facilitator summarised their perceptions of using the HMD.

Assessment of student perceptions

Immediately after completion of the tutorial, students completed a modified Evaluation of Technology-Enhanced Learning Materials: Learner Perceptions (ETELM-LP) questionnaire in order to assess their perceptions of the tutorial, which incorporated a seven-point Likert Scale and open questions [ 42 ]. Cronbach’s Alpha was calculated after exclusion of question 1 and reverse scoring of questions 13 and 15.

Three students also took part in semi-stuctured interviews via Microsoft Teams. Researchers undertook this study from an interpretive approach [ 43 ]. The interviews were conducted by JV, and followed a template of questions and corresponding probes from which the interviewer expanded as appropriate [Additional file 1 ]. The template served as a foundation from which the interviewer expanded as appropriate. The interviews were recorded and transcribed. Analysis of the interview transcripts and questionnare responses was performed using Dedoose Qualitative Research Software Version 4.3.Qualitative data from interviews and feedback questionnaires were coded thematically in alignment with Clarke and Braun’s suggestions for qualitative analysis [ 44 ]. Following the initial thematic coding, researchers conducted a content analysis to strengthen the interpretation of results. Illustrative quotes were chosen based on the representativeness of the theme or subtheme and the clarity of their intrinsic interpretation. In alignment with current literature, the quotes selected were determined to be illustrative of the point, reflective of patterns observed, and relatively succinct [ 45 ]..

Assessment of patient perceptions

On completion of the tutorials, patients were also asked to complete a mixed quantitative and qualitative questionnaire in order to assess their perceptions of the tutorial.

Assessment of learning efficacy

We carried out a prospective non-comparative study of tutorial efficacy. Students completed a pre-tutorial Multiple Choice Question (MCQ) examination to assess baseline knowledge [Additional file 2 ], and a post-tutorial MCQ two to 3 days later [Additional file 3 ]. Students then completed an end-of-year assessment two to 5 months later consisting of a data interpretation exam and an Objective Structured Clinical Examination (OSCE) which focused on preoperative history taking and preoperative assessment of the upper airway respectively [Additional files 4 and 5 ]. These examinations were written by an investigator and the University Senior Clinical Lecturer in line with University standards. Examination results were converted to percentages and the data interpretation and OSCE results were combined to give a total End-of-Year result.

The Chi-Squared test was used to compare direct-entry and graduate-entry student demographics. Welch’s two-sample t-Test assuming unequal variances was used to compare student group ages. The Shapiro Wilk and Kolmogorov-Smirnov Tests were used to assess to normality of distribution of student assessment scores for data sets less than 50 and greater than 50 respectively. The Mann-Whitney U Test was performed to compare group performance in assessments and overall student performance between the pre- and post-tutorial examinations, and between the post-tutorial and End-of-Year scores. Cohen’s d was calculated for the pre and post-tutorial MCQ scores to assess effect size.

Twelve tutorials were completed involving 12 separate patients and 78 students. Four students did not complete the post-tutorial MCQ and one did not complete the End-of-Year assessments due to illness related absences. These students were excluded from efficacy calculations. Baseline characteristics of the student participants are summarised in Table 1 . As expected the graduate-entry students was a significantly older cohort (graduate-entry median age 26 vs direct-entry mean of 22). Mean age of patient participants was 43.25, with an SD of 16.48, and a range of 18–64.

Feasibility

We found that it was feasible to use the HoloLens2 to facilitate weekly bedside tutorials on live patients in a busy, tertiary referral teaching hospital. No tutorials were cancelled or postponed due to technology-related issues. Of note, in order to improve the audio quality of the patient’s voice, it was neccessary to add the USB microphone, which is not routinely supplied with the HoloLens 2. The tutorials were also dependent on secure Wi-Fi access for both tutor and students, the presence of a tutorial facilitator to control the equipment at the student end, and access to a quiet space to examine the patient.

Tutor feedback

The sole tutor (MC) completed the System Usability Scale score, which was 72.5 (a score > 68 is deemed above average). The tutor (MC) stated that the HoloLens 2 was found to be comfortable to wear, the visor was unobtrusive and did not interfere with interaction with the patient or impede visualisation of clinical signs. The interaction with the device via hand gestures was relatively smooth and intuitive after the intial familiarisation period and the MR functions including the insertion of holographic diagrams, pointing, drawing and highlighting were useful. The holographic artefacts were visible throughout the tutorials at a “brightness” setting of seven out of 10.

Occasionally when talking to the students via the HMD, it was not clear to the patient if the tutor was talking to the patient or to the students. Utilising a structured pattern of speech such as “I am now talking to the students” was found to be useful to overcome this issue.

Facilitator feedback

The technical facilitator (NOB) found that the set-up of the live broadcast to the students was akin to that of a video presentation and that the learning curve for hosting the tutorials was short as the Dynamic 365 Remote Assist application was quite similar to general videoconferencing software. He noted that patient proximity to the tutor was essential to ensure adequate audio quality and referenced an example where a supine patient was farther from the device than normal and that patient responses had to be repeated by the tutor. Backgound noise was noted as a “minor issue and transient in nature”, and the technical facilitator accepted that a certain amount of background noise was unavoidable in an active hospital ward.

Student feedback

Quantitative student feedback via the modified ETELM-LP questionnaire is summarised in Fig. 3 . Results are presented as (mean, SD) and refer to a seven-point Likert scale. Students had little experience in MR prior to the tutorial (1.7, 1.29). They found the audio and visual quality was clear and that the MR elements of the tutorial were useful. Most agreed the tutorial approximated a live patient encounter (5.69, 1.26), was more beneficial than a PowerPoint-based tutorial, and were neutral when asked if it was as beneficial as a live clinical encounter (5, 1.69). They did not agree that the tutorial structure required inappropriately high technology skill levels on the part of the students, nor that the MR elements served as a distraction. Most agreed that they would like MR to be incorporated into further tutorials (6.05, 1). Cronbach’s Alpha, excluding question 1 was calculated as 0.86, displaying good internal consistency.

Student Modified ETELM-LP Scores. 7 point Likert scale with 7 as strongly agree and 1 as strongly disagree. Presented as Mean +/− 1 Standard Deviation

Student qualitative feedback results

Analysis of written and verbal feedback from 78 students identified 90 specific positive excerpts and 62 negatives (Table 2 ). Positive feedback included the technology’s ability to broadcast the tutor’s point-of-vision, the inclusion of holographic artefacts, and the remote nature of the tutorial. Negative feedback included issues with the audio-visual stream quality, the fact that students were not able to individually carry out the practical examination, and 11 students expressed concerns that the tutorial was not as useful as traditional in-person bedside clinical tutorials.

Three students participated in semi-structured interviews. The limited sense of “presence” and interaction with the patient were identified as limitations to the format by all three interviewees. With respect to the physical examination one student explained he would have preferred to “experience it yourself, and have a look and feel and touch”. Specific mention was made of the value of combining broadcast (patient) and rendered (schematics) images, “The adding of the images … right next to the patient was really, really helpful”. This may indicate the potential to employ this format to support vertical and horizontal integration of curricular elements. All three interviewed students reported either a six or seven (on a verbal scale of 1–7) when asked to recommend this technology for inclusion in the medical curriculum.

Patient feedback

Quantitative feedback data from patient questionnaires is summarised in Fig. 4 . Most patients had little experience with MR in the past (mean, SD: 1.75, 1.48) apart from one patient who scored 6. All agreed that the communication with the tutor was clear, that they felt safe, that the experience was enjoyable and that they would participate in a similar session in the future. Six of seven expressed that it was preferable to both small (5 or less) and large group in-person tutorials. Most patients did not agree that the HoloLens served as a distraction or made them uncomfortable.

Patient Feedback Questionnaire Results. 7 point Likert scale with 7 as strongly agree and 1 as strongly disagree. Presented as Mean +/− 1 Standard Deviation

Five patients gave qualitative feedback. Positive comments included that “it is good to see that you are moving on with new technology”, “it was well explained beforehand so I was very comfortable” and “it was fantastic to teach students when they can’t be at the bedside. Very unobtrusive”. One patient commented that “sometimes not sure if he [the tutor] was talking to me or the students” and another commented that “it would be lovely to see who I was talking to [the student group]”.

Learning efficacy

Student examination scores are sumarised in Table 3 and Fig. 5 . Student assessment scores were not normally distrubuted. A statistically significant improvement was observed between overall students’ pre and post tutorial MCQ scores (mean 59.2% Vs 84.7%, p  < 0.001). Cohen’s d was 0.612, indicating a medium effect size. There was a statistically significant difference in student performance between the post tutorial MCQ and the composite End-of-Year scores (84.7% Vs 82.2%, p  < 0.05). There were no statistically significant differences found between the graduate-entry and direct-entry students for any individual examination.

Boxplot of overall student assessment scores

Mixed Reality headsets offer several novel capabilities which can facilitate remote education and vertical and horizontal integration of curriculum elements, particularly when aligned with appropriate educational theories such as Constructivism and Social Cognitive Theory. A large number of studies have focused on applying the technology in surgical and anatomical subject fields [ 46 ]. However, there are significant gaps in the evidence base, particularly studies specific to anaesthesiology, clinical exam, and addressing the provision of interactive tutorials to remote locations. Our study has demonstrated that it is feasible and effective to use the Microsoft HoloLens 2, incorporating its Mixed Reality functions to provide a live bedside tutorial on anaesthetic preoperative assessment to students situated in a remote location. Feedback from students, patients and the tutor were generally positive. Quantitative feedback from students regarding the audio-visual quality was mainly positive, however technical issues were noted, and preference for in-person tutorials was expressed by a minority of students.

Mill et al. previously examined the feasibility of the HoloLens 2 in broadcasting medical ward rounds [ 26 ]. While papers such as that by Mill et al. demonstrated the feasibility of utilizing the HoloLens 2 HMD to stream educational ward-rounds, they did not utilize the MR functions of the HMD, nor assess the learning efficacy of the device [ 26 ]. This study incorporates both quantitative and qualitative feedback from multiple sources, namely students, patients, the tutor, and tutorial facilitator. We believe this demonstrates a robust examination of the perceptions of the relevant stakeholders involved in the provision of clinical tutorials to medical students. Our findings that the tutorials were feasible, agreeable to both patients and students, and that students had occasional audio-visual difficulties are consistent with those of Mill et al. Our study additionally demonstrates that incorporation of holographic artefacts is both feasible and regarded by the tutor and students as useful, and that the tutorials provide effective knowledge acquisition.

Our tutorial format aimed to reproduce some of the educationally relevant components of an in-person tutorial. Other suggested structures advocate streaming video of the physician as opposed to the physician’s point-of-view [ 47 ]. The HoloLens 2 device allows the students to view the tutor’s field of vision which we argue is superior, and student feedback reflected this. This viewpoint allows students to appreciate in real time the clinical signs demonstrated during the clinical examination and correlate these with the holographic diagrammatic examples used. The MR environment provides an ideal setting to facilitate vertical integration in real time by displaying holographic artefacts of anatomical, physiological and pathological information, as well as patient specific data such as radiological imaging or lab results while interacting with a patient. Furthermore, delivering tutorials remotely reduces infection-control concerns and allows delivery to greater numbers of students in multiple locations.

Preserving patient confidentiality is essential in medical practice and education. In our study, both the HMD and devices at the student end were connected to secure institutional Wi-Fi and accessed via University accounts. Also, access to the audio-visual stream was controlled by the technical facilitator, and the students were located in a supervised tutorial room. It would be essential to control both access to the tutorial and the environment to which it is broadcast to maintain confidentiality.

Limitations

Our study design has a number of limitations. It is non-comparative, and thus we are unable to draw conclusions regarding the relative learning experience or efficacy associated with tutorials delivered via the HoloLens device and the more traditional in-person bedside tutorials. Additionally, the different assessment methods between the MCQs and end of year examinations make direct measurement of knowledge retention difficult. The number of patients involved in the study was relatively small, and thus interpretation of both quantitative and qualitative data must be viewed in this context, and the generalisability of the data is low. The feedback from the tutor and tutorial facilitator must be viewed in the context that they were study investigators.

There are a number of limitations specific to research involving the HoloLens. Common limitations in studying the learning effects of the HoloLens in tested roles include the absence of validated measures and comprehensive evaluation instruments. Unlike other technologies, there are no benchmarks, datasets, or standard standardized protocols to specifically evaluate augmented reality systems, experiences, and methodologies [ 48 , 49 , 50 ]. Although the viewpoint offered to the students by the HoloLens allows the students to appreciate what the tutor is demonstrating, one drawback to this is that the focus of attention is primarily controlled by the tutor, and thus it is difficult for the tutorial to challenge the students to select the relevant areas to attend to. Depending on the tutorial topic and structure, an ideal virtual format may provide three perspectives: the tutors view, a third person view of the clinical encounter, and where applicable, an instrument’s view.

Regarding the generalisability of our study to other tutorial topics, the appreciation of clinical signs which would require palpation or auscultation would be beyond the current capabilities of the HoloLens 2 and therefore, careful tutorial design and topic selection is necessary.

Our results demonstrate the feasibility of facilitating remote bedside tutorials on preoperative anaesthetic assessment using the HoloLens 2. The tutorial structure was found to be agreeable to students, patients, and tutors. Provision of tutorials in the format described in this study may be an option for situations where students’ access to live bedside tutorials are limited. However, further research is required to characterise the role, potential and limitations of incorporating Mixed Reality into clinical medical education in a broader context. Poor audio-visual quality and lack of hands-on practice were found to be the most frequent issues identified in our study and may be significant limitations to the use of this technology in wider medical education. There are significant costs involved in developing the infrastructure and expertise necessary to provide tutorials in this format. Prior to this technology being adopted by educational institutions, we recommend the completion studies to compare the learning efficacy of MR facilitated remote tutorials and traditional in-person bedside tutorials.

Availability of data and materials

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

Abbreviations

• Augmented Reality

Evaluation of Technology-Enhanced Learning Materials: Learner Perceptions

Head-Mounted Display

Interquartile Range

Multiple Choice Question

• Mixed Reality

Objective Structured Clinical Examination

Standard Deviation

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Acknowledgements

The authors would like to acknowledge the assistance from members of the UCC College of Medicine and Health, including Dr. Colm O’Tuathaigh, Dr. Gabriella Rizzo, Dr. Pat Henn and Professor Paula O’Leary, as well as Ms. Michelle Donovan in the UCC Centre for Digital Education.

This study received funding and research support through the UCC Learning Analytics LITE programme, which is funded through the Strategic Alignment of Teaching and Learning Enhancement fund. The UCC Learning Analytics LITE programme provided logistical and research support in study design and funds were used to hire assistance in data interpretation.

This study also received funding from the UCC College of Medicine and Health which was utilised to purchase the HoloLens 2 Device and associated licences.

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Contributions

MC lead the design of the study, carried out the tutorials, analysed both quantitative and qualitative data and was the primary author of the manuscript. GI contributed to the design of the study, the student examinations contributed to writing the manuscript. NOB contributed to the technical and logistical design of the study and acted as technical facilitator for the tutorials and contributed to manuscript composition. JV designed, completed and analysed the semi-structured student interviews and contributed to manuscript composition. AOM, PS, AB, LG and supervised and analysed student examination data. KGG analysed student demographic data and student examination data. CS contributed to initial evaluation of the HoloLens device and tutorial design. GS played a central role in study design and completion and was a major contributor in manuscript composition.

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Correspondence to Murray Connolly .

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Ethics approval and consent to participate.

This study was approved by the Clinical Research Ethic Committee of the Cork Teaching Hospitals, and the University College Cork Research and Postgraduate Affairs Committee. All methods were carried out in accordance with guidelines and regulations as set out by the ethics and research committees. All participants provided informed consent to participate in the study.

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All participants including students, patients, tutor and technical facilitator provided written informed consent prior to inclusion in the study. Participants who’s identifiable images are included provided informed consent for publication of identifiable information/ images in an open access journal.

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Healthy eating among people on opioid agonist therapy: a qualitative study of patients’ experiences and perspectives

• Einar Furulund 1 , 2 , 3 ,
• Karl Trygve Druckrey-Fiskaaen 2 , 3 ,
• Siv-Elin Leirvåg Carlsen 2 , 3 ,
• Tesfaye Madebo 2 , 4 , 5 ,
• Lars T. Fadnes 2 , 3 &
• Torgeir Gilje Lid 1  

BMC Nutrition volume  10 , Article number:  70 ( 2024 ) Cite this article

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People with substance use disorders often have unhealthy diets, high in sweets and processed foods but low in nutritious items like fruits and vegetables, increasing noncommunicable disease risks. This study investigates healthy eating perceptions and barriers among individuals with opioid use disorder undergoing opioid agonist therapy. Interviews with 14 participants at opioid agonist therapy clinics in Western Norway, using a semi-structured guide and systematic text condensation for analysis, reveal that most participants view their diet as inadequate and express a desire to improve for better health. Barriers to healthy eating included oral health problems, smoking habits, and limited social relations, while economic factors were less of a concern for the participants. Participants did find healthy eating easier when they were in social settings. This study underscores the importance of understanding and addressing these barriers and facilitators to foster healthier eating patterns in this population, potentially enhancing overall health and well-being.

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Introduction

Substance use disorder (SUD), particularly opioid use disorder (OUD), is complex and extends beyond the risk of overdose, suicide, and infection. Noncommunicable diseases, such as chronic lung diseases, cancer, and cardiovascular diseases, all contribute to increased morbidity and mortality [ 1 , 2 ]. Nutrition is an important but often overlooked aspect of SUD recovery [ 3 ]. Individuals, particularly those with OUD, often report unhealthy eating habits consisting of a high consumption of sweets, sugar-sweetened and processed foods and a low consumption of fruits and vegetables [ 4 , 5 , 6 , 7 , 8 ]. Comorbidities might arise or worsen because of an unhealthy eating behavior [ 9 , 10 ]. Furthermore, substance use can severely impact an individuals’ nutritional habits and diet, as substances are often favored over food [ 11 ]. According to recent Norwegian research [ 12 , 13 ], approximately half of the patients receiving opioid agonist therapy (OAT) are deficient in vitamin D and folic acid.

Despite the established link between dietary habits and health outcomes in the general population, few studies have focused on nutritional interventions for populations with SUD and OUD [ 14 ]. A diet containing a higher intake of fruits and vegetables may reduce morbidity in high-risk populations by improving cardiovascular and mental health, as well as biomarkers of cellular stress defense [ 15 , 16 , 17 , 18 ]. However, it is unclear to what extent interventions aimed at other high-risk groups could be applied directly to OAT patients. This research gap highlights the need for improved understanding of dietary behaviors and attitudes to healthy eating among individuals in OAT.

Materials and methods

This study aims to provide insights into the dietary habits and views of healthy eating among individuals with opioid use disorders receiving opioid agonist therapy. In addition, we intend to lay the framework for the development of dietary interventions that could improve health outcomes and quality of life for individuals receiving OAT by identifying barriers and facilitators.

ATLAS4LAR project aims to improve the health and well-being of individuals with opioid use disorder undergoing OAT [ 19 ]. The project enrols OAT patients from Stavanger and Bergen, two cities in Western Norway, into a cohort and a health registry. This article was based on participants in this cohort. A semi-structured interview guide on dietary habits and perceptions of and barriers to healthy eating was developed as a collaboration between the study group, research nurses, clinicians, and user representatives. The interview guide covers topics of physical activity, smoking cessation [ 20 ] and healthy eating; this article focuses on healthy eating. A COREQ checklist [ 21 ] was applied and is included in the supplementary file.

Study sample and setting

Interviews were conducted with 14 patients at OAT clinics in Stavanger and Bergen, the two largest cities in Western Norway. All patients who completed an annual health assessment and willing to complete an interview about lifestyle were eligible to participate in the study. There were no specific exclusion criteria. Most patients receive follow-up on a weekly basis from multidisciplinary teams, including monitoring of OAT medication intake such as buprenorphine and methadone. For more information regarding the included outpatient clinics, see Fadnes et al. (2019) [ 22 ]. The research nurses collaborated with OAT clinicians to recruit a purposive sample from four different clinics in Bergen and Stavanger. Our goal was to recruit participants from various OAT clinics and ages and genders; the study sample characteristics are outlined in Table  1 .

Data collection

Among the 14 participants, thirteen completed the full interview guide, with one participant leaving the interview after twelve minutes with an incomplete interview. All the 14 participants consented to the interviews being audio recorded. All interviews were conducted during the ongoing COVID-19 pandemic in January and February 2021. Necessary precautions were taken to minimise the risk of transmitting viruses during the interview. This included symptom checklists for COVID-19, maintaining distance, and occasionally wearing facemasks. Three research nurses with training in qualitative interviewing contacted patients by phone or when they had an appointment at the clinic and conducted the interviews. They were instructed to move between topics and questions based on interview dynamics. The final interview guide included three nutrition-related issues: (1) reflections on their daily diets, (2) opportunities to prioritise healthy eating in their daily lives, and (3) reflections on the need to change their diets. See the supplementary file for the interview guide. A total of forty to sixty minutes were spent on each interview.

Data analysis

Due to COVID-19 and geographical distances between researchers, we conducted our meetings through Microsoft Teams for video conferencing and used NVivo 20 for the data analysis A pseudonym reflecting the gender of the participants was assigned to each recording, and it was transcribed verbatim by the study’s authors (EF, SELC, and KTDF). The analysis followed the four steps of systematic text condensation [ 23 , 24 ]. At first, the authors spent extensive time reading the transcripts to better understand what was being said. This thorough reading led to identifying preliminary themes, their presentation, and a collaborative discussion in a workshop. As a result of this discussion, some central themes were agreed upon for further analysis. Afterwards, a second reading was conducted to identify meaningful units, which were then categorized under the earlier themes. The lead author led the data analysis in close collaboration with SELC, KTDF, and TGL. TM and LTF also contributed significantly, ensuring a collective analysis effort. This collaborative approach facilitated the generation of condensed versions that captured the essence of the categorized themes. Ongoing discussions on terminology and limitations among all co-authors ensured clarity and coherence throughout the process. In the end, these condensed insights formed the basis of an overall narrative that addressed the aim of the study.

14 participants were interviewed, 11 male and three females, and all receiving OAT (Table  1 ). All participants had relatively stable housing conditions, and six lived alone. Five had injected drugs within the past six months before the interview. Thirteen reported smoking at least three times a week. The median debut age for tobacco, alcohol and cannabis was 13 to 14 years, while for stimulants it was 23 years and for opioids 25 years.

In this analysis, the researches extracted three themes and several subthemes reflecting the complex interactions between personal health, social environment, and dietary practices. For instance, the theme “Dietary Patterns and Health Practices” explored varied dietary habits among participants, from structured meals incorporating traditional Norwegian foods to periods of unhealthy eating dominated by fast foods and convenience items. Sub-themes include the impact of drug use on dietary habits and the role of smoking in influencing taste and appetite. The theme “Barriers and facilitators to healthy eating” discussed factors influencing patients’ ability to maintain a healthy diet, including economic constraints, access to cooking facilities, and treatment facilities’, and physical and social environment. Sub-themes highlighted the role of oral health in dietary choices and the potential of nutritional interventions within OAT clinics. The last theme, “Social and psychological dimensions of eating”, addressed the social context, focusing on how living arrangements and social interactions influence dietary choices. This theme also delves into the stigma associated with substance use and its impact on participants’ nutritional choices and self-perception.

Participants differed greatly in their eating patterns. Most participants acknowledged the importance of increasing fruit and vegetable consumption and expressed a wish to eat healthier. Some perceived their diet as well-balanced, which included multiple meals of traditional Norwegian foods. Others reported having unstable dietary habits, expressed as having healthy periods of eating nutritious foods, and less healthy periods with mainly intake of unhealthy foods such as fast foods. Additionally, some said they almost did not eat for long periods. Some participants felt they needed more knowledge to implement a nutritious diet into their daily lives.

Economy and access to a kitchen were not important barriers to healthy eating

Although most participants said they could afford healthy food and maintain a healthy diet, some highlighted that they could not afford high-priced food like fresh fish or meat several times a week. Nevertheless, it was possible to cook nutritious food despite having little money. Some participants also mentioned vitamin supplements as a means of enhancing their nutrition.

“Yes, I want to eat healthier food. Much of what is healthy is not that expensive. Buy some tomatoes, cucumber, lemon, and salad. Then, we look for where there is an offer, and we go to each store and pick what is on offer”. - Thomas.

For many participants, the kitchen was a space of both opportunity and challenge. While some engaged in regular meal preparations, others found themselves limited to heating pre-processed foods. Living in treatment facilities posed challenges due to their strict schedules and predetermined diets. Some participants had experienced being responsible for prepare food for the institution and other patients. These routines could be quite demanding, and they could become tired of cooking. An interesting introduction to smoothies was noted in some substance use treatment facilities, for making smoothies accessible where the institutions did buy the fruits and vegetables and stood with available equipment. This was without any cost to the patients. The participants expressed appreciation for the smoothies, citing their taste and feeling healthy as key reasons for the positive reception. After discharge from these institutions, none of the participants regularly continued to make or purchase smoothies.

“If you live in an institution or in those places where you are not completely in charge and do not have your own apartment, then it is probably more difficult to inspire yourself to cook and eat healthy …” - Thomas.

Struggling with stigma related to substance use

Several participants knew of food distribution centres that provided free food. Some said it was a helpful initiative to distribute free food to people in need. In contrast, others experienced barriers such as the stigma of being seen at these centres, or the risk of meeting people under the influence of drugs.

“And I do not like going to those Salvation Army [having a food provision service] centres, because I meet so many weird people [trying to sell drugs] … It can be tough to say no [offers for drugs] to those people sometimes”. - Erik.

Some participants mentioned the drug-related stigma linked to low weight. Some participants did not view their weight as crucial to their overall well-being. However, a few participants reported that their family members focused on the participant’s weight and associated this with their life situation, specifically their substance use.

“… about the kilos. It is not something like that, I think I’m very thin or something like that, but I hear from family members that I have now lost weight. Then, I know that they associate it with illicit drugs and that things are not going well. That probably affects me more than just those kilos”. - Kristian.

Some participants stated that they struggled to gain weight, even though they wanted a better appetite to increase their body weight. Some also made choices accordingly, such as eating a high-fat diet. Despite this, weight gain remained a constant struggle. While some participants had specific goals to increase their body weight by five to ten kilograms, they faced challenges in achieving this in a healthy manner. Despite their intention to gain weight, the participants expressed concerns about excessive sugar intake and its impact on their overall health. The struggle to balance weight gain with a nutritious diet and a lack of self-confidence in the kitchen made it difficult for them to adhere to balanced and healthy eating.

“To gain more weight, I try to eat fat-rich foods. Yes, it is the usual routine with breakfast, lunch and dinner, and there are also snacks in between, and of course, then I eat supper”. - Peter.

Oral health status and smoking impact negatively on healthy eating

Poor oral health was a major barrier that greatly impacted the participants’ diet. Missing several teeth, poorly adapted dentures and pain in their mouth restricted many from eating many of the fruits and vegetables. Some described hard fruits and vegetables such as apples and carrots as impossible for them to eat. Participants with poorly adapted dentures expressed difficulties in eating and needing to clean their dentures after eating, which were perceived as embarrassing and stigmatising in social settings.

“Meat, yes, and then it gets stuck. So, I always have to take [the denture] out after I finish eating. Then, I need to go to rinse my mouth. It was not how I imagined it when I got it [denture]…. The only thing I have been able to chew is bananas and oranges, because they are soft”. - Jacob.

Several participants reported that smoking negatively impacted their taste, reduced their appetite of food, and affected their daily food consumption. Smokers who reduced or stopped smoking, experienced an increase in appetite and a positive impact on the taste of food.

“When I stopped smoking, my taste returned to normal, and my appetite improved since smoking “killed” some of my taste for food”. - Thomas.

The social context is important for all aspects of eating

Most participants expressed that food has a social function, particularly among those who live alone. Participants who had cohabitants also said their diet would have been negatively affected if they had lived alone. Establishing or maintaining healthy eating habits were challenging to many who regularly were eating alone. Some participants did not see the value of making an entire meal just for themselves. Furthermore, when participants were alone, purchasing unhealthy foods such as doughnuts and fast food was easier.

“I see I have such a good diet only because I live with someone. It is better to be two people eating together rather than alone… yes, it has a lot to say. Many complain and say exactly that [to me]; ‘you are lucky to be two people’ [eating together]”. - Jacob.

Some participants found that creating a shopping list simplified the grocery shopping process. Although many lacked the discipline to organize a shopping list and preferred not to shop alone, they found it more manageable to shop with family or friends. Alone, participants said to buy unhealthy food, high in fat, and sugar. In contrast, shopping with others often led to healthier choices. However, for a few participants, the challenge was not in purchasing nutritious food but in the actual cooking and preparation of meals.

“I go to the store every other day to buy food. Instead of thinking ahead that tomorrow I will have this for dinner, and then I will have that for dinner the next day”, I make a list like that in my head. However, I do this [buys the food], and the food ends up in the freezer, and then it stays there”. - Oliver.

Preferences relevant to nutritional interventions in the clinic

We specifically asked participants about their preferences for establishing nutritional interventions in their OAT clinic. Most participants wanted to consume more fruits and vegetables, recognising their health benefits and appealing taste. They thought the OAT clinics should promote a healthy diet more actively, e.g., with posters in the waiting room. These posters could include basic information about different foods and about the consequences of not eating healthy. Other suggestions were more extensive, with a clinic-initiated patient-oriented educational cooking programme, focusing on easy recipes of affordable and tasty food.

The study offers fresh insights into the viewpoints and choices of patients regarding healthy eating within the context of OAT. Numerous participants highlighted challenges such as oral health concerns, smoking habits, and reduced social interactions that hinder their ability to adhere to a healthy diet. Interestingly, economic constraints were cited by only a minority of participants as barriers. Additionally, some individuals expressed that they found it easier to sustain a healthy diet when they had social support and stressed the importance of having a structured grocery shopping list.

It is essential to acknowledge that several factors play a role in dietary choices among the OAT population [ 25 ]. Our research has shown a notable shift in the average age of individuals in our sample compared to previous studies. This demographic transformation toward an older population is associated with an increased susceptibility to chronic diseases and a higher risk of malnutrition [ 26 ]. Specifically, the average age of patients undergoing Opioid Agonist Therapy (OAT) now stands at 47, with a median age of 49 within our dataset. A decade ago, the typical age for this OAT patient group was 42, marking a significant increase of five years over the past decade. Notably, the proportion of OAT patients aged 60 and above has tripled in 2021 when compared to data from 2015 [ 27 ]. Furthermore, within our sample, we have observed significant variations in dietary habits and meal frequency among this demographic. Nevertheless, in the context of an ageing population, the importance of adopting healthy eating habits becomes even more pronounced to reduce the risk of chronic diseases, including cardiovascular and metabolic disorders.

In Norway, people with SUD have a high level of social support offered by the government in terms of financial help, free or subsidised health care services, and mostly stable living conditions [ 28 ]. Previous studies have found that people with long-term SUD experience economic challenges and unstable living conditions, making it difficult to achieve adequate nutrition [ 4 , 29 ]. Our participants, however, did not see the economy as a primary obstacle to healthy eating. Despite some financial limitations, such as the need to prioritise and adhere to a budget, they were generally able to afford several healthy foods as components for their diets. Interestingly, some participants who lived together with others said they were always looking for reasonable offers on food at the store, almost like a sport. This may support that they do not necessarily have a stable and strong economy but have strategies to manage economic limitations. However, even with a stable living situation and kitchen access, they still found attaining a healthy diet to be difficult.

Poor oral health significantly hinders the ability to maintain a nutritious diet primarily due to missing teeth, oral pain, or dentures. Many participants expressed how their oral health directly influenced their diet. These physical constraints and the potential for social discomfort provide insights into the infrequent consumption of fruits and vegetables, even when individuals are aware of their nutritional benefits. This aligns with findings on older adults [ 30 ], with many reporting poor oral health due to lacking and damaged teeth. As a result, they have fewer choices for food, such as fruits, vegetables, and fibre, increasing their risk of unhealthy food choices [ 30 ]. However, not all the participants in our study described difficulties eating healthy food. Interestingly, some were introduced to smoothies at treatment facilities and found them appealing. After being discharged, however, they did not continue to make or purchase smoothies.

A large study found an inverse relationship emerged between cigarette smoking and eating healthy food. Specifically, as individuals increase their daily smoking, their intake of healthy foods, such as fruits and vegetables, declined. This is in line with our findings, where participants shared that smoking adversely affected their ability to taste the food [ 8 ]. This effect may be attributed to nicotine’s widely recognized capacity to suppress appetite, potentially prompting individuals to turn to smoking as a substitute behavior for eating [ 31 ].

The absence of individuals to share meals with and feelings of loneliness posed a significant obstacle to the participants’ attempts to sustain a nutritious diet. Many conversations centred around the challenges of grocery shopping and meal preparation for solitary individuals. These observations align with previous research, which has shown that people living alone typically consume fewer fruits, vegetables, and fish compared to those who have meal companions [ 32 ]. Although our data do not allow direct comparisons, the narratives from our participants are consistent with these findings. In contrast, those living with others credited their dietary stability to their shared living arrangements. They believed that having someone to share meals with added an extra layer of meaning and purpose to meals.

Many participants were interested in adopting healthier eating habits, a positive and noteworthy finding considering their substance use history. This shift towards healthier diets may indicate an awareness of the correlation between health and nutrition even after prolonged substance use. These individuals recognized the potential for an improved diet to enhance their health. Some associated a healthy diet with weight gain as a sign that their drug problem is under control. Those who wanted to increase their weight said they needed to pay attention to their diet, which could be exhausting. A number of epidemiological studies have investigated the relationship between drug use and body weight, and most of the evidence demonstrates an inverse correlation [ 33 ]. A regular diet can have therapeutic benefits, including improving health, self-esteem and social relationships [ 25 ].

During the interview, participants were asked for intervention preferences relevant to their dietary and nutritional needs. Interestingly, not all participants came up with specific suggestions for this topic, yet some proposed the idea of making information available in the waiting rooms or initiating cooking courses. As an alternative, some participants suggested that smoothies would be beneficial to consume more fruit and vegetables without damaging their teeth. The potential of smoothies as effective dietary interventions has been explored in different populations, including adolescents in schools and older adults [ 34 , 35 ].

The current study has several strengths and limitations. The qualitative design provides an in-depth understanding of participants’ experiences, and of barriers and facilitators to healthy eating. However, one limitation regarding its design is that nutritional status was not measured in our study. The participants described their nutritional status through their eating habits, detailing their behaviour and experiences associated with eating patterns. Research nurses assisted with providing insights into how to perform the interview and the interview guide on how to phrase the questions in an understandable way. User representatives offered valuable insight to ensure the relevance and highlighted cultural and societal factors. Even though research nurses are separate from the clinical care, bias may still occur. Some patients may be more inclined to present themselves rather than express their feelings or give feedback. Through collaboration in frequent digital meetings and using a theoretical framework, we were able to test ideas and interpretations, and thus reduce the influence of investigator bias [ 36 ]. It is likely that social desirability influenced the interview process and results. When data were collected, the study participants were receiving treatment from OAT outpatient clinics where they were interviewed, which may have made them more susceptible to social desirability bias during interviews [ 37 ]. The interview guide was designed to minimise such bias, as well as the choice of interviewer being a research nurse and not their contact person/clinician. The participants could steer the order of the topics in the discussion, which probably enabled them to speak more freely from their perspectives.

Together with earlier work, this study emphasises the importance of understanding patients’ perspectives and needs regarding nutrition [ 25 , 38 ]. According to patients, diet and nutrition are important and bidirectionally interlinked with their substance use. Healthcare providers should address the diet and nutrition of patients to facilitate recovery. However, strategies to improve oral health among OAT patients, and motivational and educational strategies to improve cooking skills, are necessary prerequisites in addition to the more specific interventions, to improve patients’ recovery and their overall health.

The OAT platform facilitates communication between healthcare professionals and hard-to-reach patients. To prioritize nutrition, five key topics have been proposed: incorporating discussions about food and nutrition history into clinical consultations, conducting anthropometric measurements including regular weight monitoring, utilizing biochemical data to identify dietary limitations, evaluating potential health implications of individuals’ nutritional profiles, and tailoring approaches based on clients’ personal histories and perspectives [ 39 ]. The results indicate that a combination of individual, social, and environmental factors influenced participants’ dietary habits and eating patterns.

Conclusions

In conclusion, our findings shed light on several critical aspects of a healthy diet among patients in OAT. Oral health issues, smoking habits, and limited social interaction emerged as significant impediments to upholding a nutritious diet. Healthcare professionals should proactively tackle these obstacles, while future research should prioritize devising effective strategies to overcome these barriers and improve the dietary patterns, nutritional well-being, and overall health of individuals undergoing OAT.

Data availability

Because of data protection regulations, the raw interview data for this study are not publicly available.

Abbreviations

Substance use disorder

Opioid use disorder

opioid agonist therapy

Consolidated criteria for reporting qualitative research

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Acknowledgements

In addition to the participants, we would like to thank the dedicated clinical staff for their enthusiasm during the planning stages of the study. Rannveig Elisabeth Nesse deserves recognition for her assistance with the transcription of the interviews. We also acknowledge the ATLAS4LAR Study Group: In Bergen: Vibeke Bråthen Buljovcic, Jan Tore Daltveit, Trude Fondenes, Per Gundersen, Beate Haga Trettenes, Mette Hegland Nordbotn, Maria Olsvold, Marianne Cook Pierron, Christine Sundal, Jørn Henrik Vold. In Stavanger: Maren Borsheim Bergsaker, Eivin Dahl, Tone Lise Eielsen, Torhild Fiskå, Marianne Larssen, Eirik Holder, Ewa Joanna Wilk, Mari Thoresen Soot.

This study is funded by the Western Norway Regional Health Authority («Strategiske forskningsmidler» through the ATLAS4LAR project - August 3, 2020 to December 31, 2029). Open access funding was provided by the University of Bergen. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Einar Furulund & Torgeir Gilje Lid

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All authors (EF, KTDF, SELC, TM, LTF and TGL) were involved in the study’s design, analysis of the data and contributed to the manuscript. EF wrote the first draft and led the writing process. All authors read and approved the final manuscript.

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Furulund, E., Druckrey-Fiskaaen, K.T., Carlsen, SE.L. et al. Healthy eating among people on opioid agonist therapy: a qualitative study of patients’ experiences and perspectives. BMC Nutr 10 , 70 (2024). https://doi.org/10.1186/s40795-024-00880-8

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Barriers, facilitators and needs to deprescribe benzodiazepines and other sedatives in older adults: a mixed methods study of primary care provider perspectives

• Orlando Hürlimann 1 ,
• Daphne Alers 1 ,
• Noël Hauri 1 ,
• Pascal Leist 1 ,
• Claudio Schneider 1 ,
• Lucy Bolt 1 , 2 ,
• Nicolas Rodondi 1 , 2 &
• Carole E. Aubert   ORCID: orcid.org/0000-0001-8325-8784 1 , 2  

BMC Geriatrics volume  24 , Article number:  396 ( 2024 ) Cite this article

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Benzodiazepines and other sedative hypnotic drugs (BSHs) are frequently prescribed for sleep problems, but cause substantial adverse effects, particularly in older adults. Improving knowledge on barriers, facilitators and needs of primary care providers (PCPs) to BSH deprescribing could help reduce BSH use and thus negative effects.

We conducted a mixed methods study (February-May 2023) including a survey, semi-structured interviews and focus groups with PCPs in Switzerland. We assessed barriers, facilitators and needs of PCPs to BSH deprescribing. Quantitative data were analyzed descriptively, qualitative data deductively and inductively using the Theoretical Domain Framework (TDF). Quantitative and qualitative data were integrated using meta-interferences.

The survey was completed by 126 PCPs (53% female) and 16 PCPs participated to a focus group or individual interview. The main barriers to BSH deprescribing included patient and PCP lack of knowledge on BSH effects and side effects, lack of PCP education on treatment of sleep problems and BSH deprescribing, patient lack of motivation, PCP lack of time, limited access to cognitive behavioral therapy for insomnia and absence of public dialogue on BSHs. Facilitators included informing on side effects to motivate patients to discontinue BSHs and start of deprescribing during a hospitalization. Main PCP needs were practical recommendations for pharmacological and non-pharmacological treatment of sleep problems and deprescribing schemes. Patient brochures were wished by 69% of PCPs. PCPs suggested the brochures to contain explanations about risks and benefits of BSHs, sleep hygiene and sleep physiology, alternative treatments, discontinuation process and tapering schemes.

The barriers and facilitators as well as PCP needs and opinions on patient material we identified can be used to develop PCP training and material on BSH deprescribing, which could help reduce the inappropriate use of BSHs for sleep problems.

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Benzodiazepines and other sedative hypnotic drugs (BSHs) are frequently prescribed for sleep problems, although guidelines recommend cognitive behavioral therapy for insomnia (CBT-I) as first-line therapy and to avoid BSHs in older people [ 1 , 2 ]. BSH use has been reported to be as high as 15–30% in older adults with 87% taking BSHs for sleep problems [ 3 , 4 , 5 ]. Nevertheless, their effects on sleep are only modest and short-lasting [ 6 , 7 ]. Furthermore, BSHs cause relevant side effects, including falls, fractures and cognitive impairment as well as dependence [ 8 , 9 ]. This leads to high healthcare and social costs [ 10 ]. Moreover, this also highlights a need for deprescribing.

Deprescribing is defined as “the process of withdrawal of an inappropriate medication, supervised by a health care professional with the goal of managing polypharmacy and improving outcomes” [ 11 ]. Barriers and facilitators to BSH deprescribing from the perspective of patients, physicians and nurses have been studied previously and the application of the Theoretical Domains Framework (TDF) allowed identification of different behavioral determinants to BSH deprescribing in the ambulatory setting [ 12 , 13 , 14 ]. Moreover, different interventions to deprescribe BSHs have been investigated and shown variable success [ 15 ]. This variability might be due to a lack of consideration of barriers and facilitators, among other at a local level. While some barriers and facilitators are universal, others might indeed be more specific to the context.

To our knowledge, barriers and facilitators to deprescribe BSHs in older adults have not been studied in Switzerland. Furthermore, primary care providers (PCPs) needs and opinions on what could support them and their patients have not been evaluated.

The aim of our study was thus to identify local barriers and facilitators to deprescribe BSHs and further assess PCPs perspectives on what could support them and their patients in deprescribing BSHs.

Study design and setting

We conducted a mixed methods parallel study including a survey, semi-structured interviews and focus groups (FGs) with PCPs in Switzerland. The survey included both quantitative and qualitative questions, while interviews and FGs collected qualitative data. A mix of interviews and FGs was chosen for practical organizational reason (easier to plan individual interviews than FGs with PCPs). Focus groups are used in qualitative research and allow to explore thoughts and concepts of participants during a group discussion led by a researcher. The FGs and interviews took place in March 2023, and the survey was open from February to May 2023.

The study protocol was waived from approval by the local ethical committee (“Kantonale Ethikkommission Bern”), because it did not fall under the Swiss Human Research Law (request number 2022–01423). Participation was voluntary, and participants provided consent for interview/FG recording. They were informed that their name would appear nowhere.

This article follows the STROBE checklist for reporting [ 16 ].

Study population and sample size

For the survey, PCPs working in an ambulatory practice in any part of Switzerland and caring for an adult population (i.e., not pediatrician) were eligible. For the interviews and FGs, recruitment was limited to the French- and German-speaking parts of the country, which represent 85% of the population of Switzerland. PCPs were contacted by e-mail, as well as through advertisements in medical journals and newsletters usually read by PCPs in Switzerland.

Using Survey System calculator ( www.surveysystem.com/sscalc.htm ), we calculated that 120 PCPs would provide a margin of error of 9% with a 95% confidence interval. For the qualitative part, we estimated that we would achieve data saturation with 10 interviews/FGs. We planned about half of them with native French speakers, and the other half with native German speakers. Except for language, other elements for variation of sample (e.g., gender, level of experience) were not specially considered.

Data collection and study procedures

The survey was conducted online using surveymonkey.com (SurveyMonkey Inc., San Mateo, California, USA) and was available in German and in French. It included open- and close-ended questions on demographic variables and professional experience, as well as on barriers, facilitators and needs to deprescribe BSHs in older adults taking BSHs for sleep problems (Additional File 2). At the end of the survey, PCPs had the possibility to disclose their contact information to be rewarded an amount of CHF20 (about $20) for participation. They were informed that their data would be treated confidentially. However, they could also leave their answers anonymous. This process was introduced to reduce the risk of selecting only PCPs who agreed to disclose their contact information.

The interviews and FGs were conducted virtually and based on a guide available in Additional File 3. The guide was developed by the authors based on the research goals. It included an explanation of the general conditions of interviews/FG conduction and an introduction of the topic, followed by six questions concerning perceived barriers, facilitators and needs to deprescribe BSHs in older adults taking them for sleep problems. Interviews and FGs were led by two researchers (DA and CEA). The choice of conducting FGs or interviews was led by PCP availability in term of dates and time. Additional researchers (OH, PL) assisted and took field notes. A duration of 20 min for the interviews and 45 min for the FGs was planned. PCPs were compensated CHF30 (about $30) for participation. Interviews and FGs were recorded and transcribed verbatim.

The survey was divided in four parts: 1) nine questions on demographic parameters including age, gender, practice setting, work status (independent vs. employed), professional experience and daily work routine (having ever discontinued BSHs, routinely considering BSH discontinuation, knowing where to refer patients for treatment of sleep problems and for CBT-I); 2) three questions on the need for material for patients; 3) three questions about the needs of a PCP; and 4) three open questions for adding additional information.

Data analysis

Quantitative analysis: Survey quantitative data and population characteristics (age, gender, practice setting, work status (independent vs. employed), professional experience and daily work routine (having ever discontinued BSHs, routinely considering BSH discontinuation, knowing where to refer patients for treatment of sleep problems and for CBT-I)) were analyzed using descriptive statistics and presented as numbers with percentages.

Qualitative analysis: Qualitative data were analyzed using a mixed deductive and inductive approach based on the TDF version 1, which is frequently used for deprescribing/de-implementation research [ 13 , 14 , 17 , 18 , 19 ], to identify barriers and facilitators to BSH deprescribing. The TDF version 1 includes the following domains: knowledge; skills; social/professional role and identity; beliefs about capabilities; beliefs about consequences; motivation and goals; memory, attention and decision processes; environmental context and resources; social influences; emotion; behavioral regulation; nature of behaviors. Coding was conducted by PL and NH and iteratively discussed with the senior author, who made final adaptations.

Integration of quantitative and qualitative data: Quantitative and qualitative results were integrated using joint displays to draw meta-inferences. Meta-inferences are conclusions that we can draw of the integration of both qualitative and quantitative data. We used them to describe the mixed data results as convergent, divergent, or expanding.

When quotes were reported in the article, they were translated to English by the first author, while the last author checked the translation. Both authors are fluent in German, French and English.

Quantitative data were analyzed with Stata version Stata/MP 16.0 (StataCorp LP, College Station, Texas) and qualitative data using MAXQDA 2022 software (VERBI Software, Berlin, Germany).

We use the following abbreviations to report qualitative statements: PCP = primary care provider; FG = focus group; I = Interview; S = Survey; F = French; G = German.

Study population

The survey was completed by 126 PCPs, including 51 (40.5%) French-speaking and 75 (59.5%) German-speaking participants; 16 of them had been approached by e-mail, the rest answered following the advertisements and newsletters. Eleven additional PCPs completed the baseline characteristic form but did not answer any additional survey question and were thus not kept for analysis. Baseline characteristics are presented in Table  1 . Of the 126 PCPs, nine participated to an FG (all of them German-speaking) and seven (six French-speaking, one German-speaking) to an individual interview. Fourteen did not provide contact information. The average duration was 26 min for the interviews and 41 min for the FGs.

PCP work routine concerning BSH deprescribing

One hundred and sixteen (92.1%) PCPs had ever discontinued BSHs in older adults with sleep problems and 86 (68.3%) routinely considered doing it. Eighty-six (68.3%) PCPs reported that they knew where to refer their patients for the treatment of sleep problems and 58 (46.0%) knew where to refer patients for CBT-I.

Barriers and facilitators to BSH deprescribing

In this section, we present the results of the qualitative analysis for which there was no quantitative counterpart, based on the TDF. The TDF domains and constructs that were found during the coding process are displayed in Additional File 1: Appendix Table 3. Below are the domains presented with some examples of the qualitative analysis.

This section reports knowledge of PCPs and patients influencing BSH deprescribing, which was identified as a barrier. Regarding patient knowledge, unrealistic sleep expectations of patients were experienced as a major issue [PCP16, I7, G]: “… the main problem, it seems to me, is that patients simply need to be able to sleep when it gets dark and nothing is going on, to sleep the whole night if possible, and only wake up again when the day begins.” Furthermore, PCPs mentioned that their patients lacked knowledge about BSH risks [PCP7, FG1, G]: “Well, so what I find difficult is, hmm, that patients are not aware that these are problematic drugs. (…) Because, hmm, apparently this was either not communicated when they were prescribed or, which is also quite possible, it [the information] was put aside afterwards.” Regarding knowledge of PCPs, some PCPs expressed a lack of knowledge about side effects of BSHs [PCP15, FG3, G]: “And what is the evidence regarding the, hmm, harmfulness of these, hmm, Z-substances?”.

Lack of skills was identified as a barrier. PCPs mentioned they had not received enough training on the treatment of sleep problems and BSH deprescribing [PCP13, FG2, G]: “So it's such a huge problem. I think it would need some kind of course during medical school. And during residency, hmm, definitely too, or simply that it becomes more important. (…) So I think it has far too little importance. Already during the whole training.”

Motivation and goals

Both barriers and facilitators were classified in this construct. A main barrier encountered by PCPs was patient lack of motivation [PCP2, I2, F]: “And then when we come to it [discussing BSH deprescribing], well, they don't want to talk about it too much. They avoid the subject and then say, ‘Oh no, but we'll do it next time.’” PCPs didn’t consider BSH deprescribing as a priority [PCP12, FG2, G]: “Of course, it [BSH deprescribing] is also time-consuming. So, in the primary care practice, apparently there are on average over four problems per consultation and, hmm, then you have to think about how to use the time. And if there are three much more important problems, then, hmm, you just look at those.” Regarding facilitators, some physicians reported using side effects to motivate their patients to discontinue or not to start BSHs [PCP5, I5, F]: “So, I often talk to them about cognitive impairment and the risk of fall. I think these are really important problems for older adults.” Beside these side effects, patient fear of dependence was mentioned as a facilitator to discontinue or not to start BSHs [PCP4, I4, F]: “The fear of dependence too, I think that's also something that, that can be a lever.”

Environmental context and resources

Environmental context and resources were identified as barriers. Regarding external factors, PCPs experienced lack of time as a barrier to deprescribe BSHs [PCP8, FG1, G]: “Hmm, what I miss is simply the setting and the peace and quiet to discuss it [BSH deprescribing] with the patient, because that also takes a lot of time, so the quarter of an hour I have in the agenda is often not enough.” When coming to the prescription of CBT-I, the limited availability and access to it were mentioned as barriers, making prioritization needed [PCP7, FG1, G]: “But of course, there are too few therapy places, so they are very quickly booked. And, I have to say, I would almost be a bit reluctant to take up such a place for a simple sleep disorder, because there are really many patients with much bigger problems who need it [cognitive behavioral therapy] more urgently.”

Social influences

Lack of public dialogue about BSHs was identified as a barrier, while PCP thought it could facilitate BSH deprescribing [PCP8, FG1, G]: “And I also think a social dialogue, that these are addictive substances, would be very helpful, because then, hmm, maybe they [the health authorities] would give me more time to deal with it [BSH deprescribing] in peace, to get away from these addictive substances.”

Several barriers were related to emotions. PCPs said patient fear of not being able to sleep was a barrier to deprescribe BSHs [PCP3, I3, F]: “The first argument, very often, is, ‘No, no, but you can't take away my [BSH] (…) Since I have it, I can sleep. I don't want to disturb that balance. And it's so important for me to sleep, as I've gone through periods with so much insomnia.’” PCPs reported frustration following repeated failed attempts to deprescribe BSHs to be a barrier to try again [PCP17, S, G]: “My attempts often or almost always fail. (…) So I don't have the courage to try again.”

Behavioral regulation

Several issues related to behavioral regulation were identified as barriers, while other were rather facilitators. PCPs mentioned that costs could impact patient behavior related to BSH deprescribing [PCP18, S, F]: “Difficulties in getting patients to come back for follow-up consultations. High deductibles, fear of costs.” On the other hand, it was perceived positively that in Switzerland CBT-I is now covered by universal health insurance [PCP5, I5, F]: “So, since, since the, hmm, psychotherapy by psychologists started to be covered by health insurance last year, I've really been trying to guide patients by saying, ‘Well, now you can have twice fifteen sessions with a psychologist. It's covered by insurance.’” PCPs experienced patient social situation and interests as a barrier to deprescribe BSHs and implement sleep hygiene measures [PCP14, FG3, G]: “Hmm, but then we end up slipping into complex social difficulties because the problem is, especially in winter: ‘What do you do until eleven in the evening and what do you do at six in the morning?’”.

Nature of the behaviors

Starting deprescribing at hospital was identified as a facilitator [PCP1, I1, F]: “If, if they [the physicians at hospital] can remove [BSHs], and, in parentheses, prove that in hospital they [the patients] sleep without, hmm, they can, in parentheses, more easily keep building on that momentum.” Nevertheless, PCPs made the experience that tapering was often not continued by patients after hospital discharge, which could be addressed by improving continuity of follow-up [PCP5, I5, F]: “… sometimes, when they [the patients] come out of geriatrics, they come out of a unit where there was a lot of motivated people who managed to, supposedly, wean them off benzos. But when the patients come out, well, they run to the pharmacy to get them [the benzodiazepines]. So, hmm, would it also be necessary for a psychologist to be directly involved in the discharge process? To say, “Ah, we're going to support you now that you're going home, to prevent a relapse.” Could it be?”.

PCP opinions on patient material

In this section, we present the mixed methods results about PCP opinions on what could support them and their patients to discontinue BSHs. Meta-interferences are presented in Tables 2 and 3 and complete quantitative survey results in Additional File 1 : Appendix Tables 1 and 2.

Preferences

PCPs were asked whether they preferred standardized materials, i.e., where the information and tapering schemes are similar for all patients, or customizable materials, where the information and tapering schemes can be individualized to each patient. Eighty-eight (69.8%) PCPs preferred customizable and 36 (28.6%) standardized materials for patients, while 2 (1.6%) PCPs had no preference.

Eighty-seven (69.1%) PCPs mentioned they would find brochures for patients useful and that giving a brochure to the patients to read at home could facilitate deprescribing [PCP2, I2, F]: “I mean, if there was something we could give our patients so that, in fact, we could already talk about it at the consultation. So that they can read their brochure or not. But it also tells us if the patient is a bit motivated. And then, afterwards, we can discuss it. It would probably save us time.” Sixty-three (50.0%) PCPs wished documents for relatives, 62 (49.2%) materials for patients with cognitive impairment, and 62 (49.2%) flyers. Figures, apps or websites were thought as less useful.

A clear preference was found for explanations about risks and benefits of BSHs, wished by 112 (88.9%) PCPs [PCP2, I2, F]: “I think what would be important is the, the, that, it's the undesirable effects. So that we, so that they [the patients] understand why we have to change, obviously.” A majority of PCPs also considered recommendations for sleep hygiene, explanations about alternative treatments and about the discontinuation process, as well as tapering schemes, as potentially helpful. Additionally, PCPs wished explanations about sleep physiology for their patients [PCP5, I5, F]: “So, I think one of the main elements is to talk about sleep cycles and explain that these micro-awakenings are natural and difficult to avoid. I think there really needs to be this aspect of ‘What is normal sleep?’, and then, ‘What can we expect from sleep?’, and then, ‘What can't we expect too much of, let's say, with age?’”. A table comparing the effectiveness of the different treatments or testimonials were wished by few PCPs, 50 (39.7%) and 46 (36.5%), respectively.

Concerning useful resources for PCPs, 79 (62.7%) preferred online training, followed by online documents, information on a website and exchange with colleagues. In-person training, printed documents and apps for smartphone were wished by less PCPs. Regarding training in general, PCPs mentioned that sleep problems were just one relevant topic among lots of others [PCP12, FG2, G]: “I don't know if we all really need to do so much training now on how to reduce it [BSH use] exactly. But, hmm, maybe a few basics. (…) But we have to, it's so varied, we have to be fit in so many topics and so I wouldn't want to spend half a day just talking about sleep problems, hmm, or.”

Practical recommendations for pharmacological and non-pharmacological treatment of sleep problems in older people with current BSH consumption were wished by 111 (88.1%) PCPs and deprescribing schemes by 86 (68.3%) [PCP 11, FG2, G]: “So, I think I would find it very helpful to get instructions on exactly how to proceed. Because I don't have much experience in this area.” Concerning CBT-I, 72 (57.1%) PCPs wished its implementation into primary care practice. Seventy-seven (61.1%) said they would be willing to receive information about CBT-I and 74 (58.7%) to complete CBT-I training if it was offered. A minority of PCPs (46, 36.5%) wished recommendations for follow-up and information about motivational interviewing (33, 26.2%). PCPs said, a list of therapists offering CBT-I for sleep problems for older adults using BSHs would be helpful [PCP5, I5, F]: “Well, maybe a list of psychologists who, who willingly take on this type of patients.”

In this mixed-methods study, we assessed barriers and facilitators as well as needs of PCPs to BSH deprescribing. The identified TDF constructs mostly confirmed existing literature [ 12 , 13 ]. Main barriers to deprescribing included patient and PCP lack of knowledge on BSH effects and side effects, PCP lack of education on BSH deprescribing and treatment of sleep problems, patient lack of motivation, PCP lack of time, limited access to CBT-I, and absence of public dialogue on BSHs. Facilitators included informing patients about BSH side effects and deprescribing start during hospitalization. The main PCP needs were practical recommendations for pharmacological and non-pharmacological treatment of sleep problems and deprescribing schemes. For their patients, they wished brochures containing explanations about risks and benefits of BSHs, sleep hygiene and sleep physiology, alternative treatments, discontinuation process and tapering schemes.

Initiating deprescribing of inappropriate BSHs during hospitalization was mentioned as a potential facilitator. This confirms existing literature, showing hospitalization to be an opportunity to review medication and initiate deprescribing [ 20 , 21 ]. However, ensuring continuity could be difficult and PCPs mentioned their patients often resumed BSH use after discharge, using the medication they still had at home, the prescription they had before hospitalization, or asking PCPs for a new prescription. Previous research identified concerns about lack of post-discharge follow-up and disagreement between hospitalists and PCPs [ 18 , 20 ]. This could be improved by enhancing communication around discharge between hospital internists and PCPs, for example by phone contact or electronic communication, and implementing structured care coordination [ 22 ]. It is particularly important that hospital internists communicate to PCPs the shared decision made with the patients regarding deprescribing during hospitalization. Further, PCPs suggested promoting public dialogue on BSHs to support deprescribing. However, public campaigns seem only moderately effective to reduce BSH consumption [ 23 ].

Not all PCPs knew where to refer patients for the treatment of sleep problems and CBT-I. Further, lack of CBT-I therapists and CBT-I costs were mentioned as barriers. Limited access to psychotherapy and often insufficient insurance coverage is a widespread problem globally [ 24 , 25 ]. Absence of psychotherapy reimbursement was previously described as a barrier to deprescribe BSHs [ 26 ]. Providing CBT-I therapists contact details to PCPs, PCP training in CBT-I and self-help CBT-I could help address this issue [ 27 , 28 ].

Regarding PCP opinions on patient materials, they preferred brochures over online material, to avoid limiting access. Research has shown that patient information leaflets could decrease the number of repeat visits to PCPs and therefore save time but should in no way substitute oral information [ 29 ]. Also, the timing of information is relevant [ 29 ]. Providing information prior to the consultation could be beneficial and give patients time to consider the benefits [ 12 , 30 ]. Using patient brochures to support BSH deprescribing was shown to be effective in the EMPOWER trial which tested a pharmacist-led intervention [ 31 ]. Generalizability of this trial is however limited because the implementation in pharmacies might not work in healthcare systems, where pharmacists do not conduct medication review or follow patients on a regular basis, especially if physician drug dispensing is allowed, like in Switzerland. Therefore, multilevel interventions including patient information brochures accounting for country-specific differences should be developed.

PCPs requested online training covering practical recommendations for pharmacological and non-pharmacological treatment of sleep problems in older people currently using BSH. This is consistent with the reported lack of education on sleep problems and BSH deprescribing during medical school, residency and continuing education. Previous research showed that the term “deprescribing” was unfamiliar to medical students and that physician education on BSH deprescribing and insomnia treatment should be reinforced [ 26 , 32 , 33 ]. Online modality of continuous medical education was found to provide flexibility of access in terms of time and geographic location [ 34 ]. Furthermore, PCPs wished to complete CBT-I training to implement it in their practice. These findings underline the importance of integrating training on CBT-I and treatment of sleep problems at medical school and in post-graduate training.

Strengths and limitations

This study has several strengths. First, the mixed methods design with deductive and inductive approach allowed a more comprehensive understanding. Second, the inclusion of PCPs of different practice types (single/group practice) and regions (rural/city, French-/German-speaking) increases result generalizability.

We must acknowledge some limitations. First, as PCPs who participated to the study are potentially more intrigued to deprescribe BSHs, their opinions might not reflect those of all PCPs. Second, the study was conducted in a single country. Nevertheless, assessing local factors is required for successful implementation. Third, we did not power our study to conduct additional analyses according to baseline characteristics such as age, work status or years of experience. Therefore, except for language, other elements of variation of sample were not considered. Finally, the conduction of both FGs and interviews can be both a limitation and a strength. On the one hand, while FGs might have allowed new thoughts to emerge by discussing with colleagues, participants might also have been hesitant to express divergent opinions in front of colleagues. On the other hand, interviews allowed a more intimate setting to express opinions but the lack of exchanges and stimulation by colleagues might have limited PCP reflections.

The identification of barriers and facilitators to BSH deprescribing and particularly of PCP needs to support BSH deprescribing can help develop appropriate materials to reduce the use of BSHs and their adverse effects, as well as training for medical students and board-certified physicians.

Availability of data and materials

Data are available by the corresponding author upon reasonable request.

Abbreviations

Benzodiazepine and other sedative hypnotic drug

Cognitive behavioral therapy for insomnia

Focus group

Healthcare professional (specialized physician and/or non-physician therapist)

Primary care provider

Theoretical Domains Framework

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Acknowledgements

We would like to thank the primary care providers for their participation.

This project was funded by the “Kollegium für Hausarztmedizin”. CEA was funded by the Swiss National Science Foundation (Ambizione Grant PZ00P3_201672). This work is part of the project “BE-SAFE: Implementing a patient-centred and evidence-based intervention to reduce BEnzodiazepine and sedative-hypnotic use to improve patient SAFEty and quality of care” supported by the European Union's Horizon Europe research and innovation programme under the grant agreement No 101057123, and by the Swiss State Secretariat for Education, Research and Innovation (SERI) (contract No 22.00116). Views and opinions expressed are however those of the author(s) only and do not necessarily reflect those of the European Union, the SERI, the “Kollegium für Hausarztmedizin” or the Swiss National Science Foundation. Neither the European Union nor the SERI, nor the “Kollegium für Hausarztmedizin”, nor the Swiss National Science Foundation can be held responsible for them.

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Orlando Hürlimann, Daphne Alers, Noël Hauri, Pascal Leist, Claudio Schneider, Lucy Bolt, Nicolas Rodondi & Carole E. Aubert

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CEA and NR conceived the project. OH, DA, PL, NH and CEA conducted the project. PL, NH, OH and CEA analyzed the data. All authors contributed to data interpretation. OH wrote the first draft of the manuscript. CEA closely supervised manuscript writing. All authors critically revised the manuscript and have approved its final version for publication.

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Supplementary Information

12877_2024_5027_moesm1_esm.pdf.

Supplementary Material 1: Appendix Table 1. Survey results – Patient material. Appendix Table 2. Survey results Needs of PCPs. Appendix Table 3. TDF domains and constructs used for coding

Supplementary Material 2. Survey for PCPs

Supplementary material 3. interview guide for the focus groups and interviews with pcps, rights and permissions.

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Hürlimann, O., Alers, D., Hauri, N. et al. Barriers, facilitators and needs to deprescribe benzodiazepines and other sedatives in older adults: a mixed methods study of primary care provider perspectives. BMC Geriatr 24 , 396 (2024). https://doi.org/10.1186/s12877-024-05027-9

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Received : 11 January 2024

Accepted : 29 April 2024

Published : 04 May 2024

DOI : https://doi.org/10.1186/s12877-024-05027-9

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Kigali Institute of Education (KIE) was issued with copyright registration Certificate No. Rw-C10000866 by the Office of the Registrar General in accordance to the Rwandan IPR Law No. 31/2009. 

N.B .: KIE is now a College of Education, constituent of the University of Rwanda in accordance to the Rwandan Law No. 71/2013 of 10/09/2013 establishing the University of Rwanda (UR), and the College of Education as shown on  its website: http://www.ce.ur.ac.rw/

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Teaching the genocide against the tutsi and its implications for peace education, jean leonard buhigiro.

With the inception of a competence-based curriculum in 2015, genocide and peace education were introduced in the Rwandan education system as crosscutting issues to promote harmonious lives. This paper reports the empirical research conducted with twelve Rwandan secondary school history teachers in four provinces plus the City of Kigali to examine how the dichotomy of teaching death, namely the Genocide against the Tutsi, contributes to peace education. This ‘narrative phenomenology’ employed a qualitative approach based on semi-structured interviews, self-interviews, and photo-elicitation to collect the data. The study findings reveal that contents and teaching methods used to teach the Genocide, instead of dividing Rwandans, implicitly and explicitly contribute to peace education. Most teachers also use indoctrination and adopt a self-care attitude for building a better Rwanda. This strategy can inhibit critical thinking skills which is essential for promoting a peaceful society. Thus, the paper calls for a synergy between partners to continuously support teachers to take on skills to teach sensitive histories for a better Rwan

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