semi structured interviews in healthcare research

Semistructured interviewing in primary care research: a balance of relationship and rigour

Affiliations.

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.
PMID: 32148704
PMCID: PMC6910737
DOI: 10.1136/fmch-2018-000057

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.

Keywords: qualitative research.

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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.

You have full access to this article via your institution.

Interviews in the social sciences

Eleanor Knott, Aliya Hamid Rao, … Chana Teeger

semi structured interviews in healthcare research

Professionalism in dentistry: deconstructing common terminology

Andrew Trathen, Sasha Scambler & Jennifer E. Gallagher

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

Hiba Bawadi, Sara Elshami, … Banan Mukhalalati

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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Semi-structured Interviews

Danielle Magaldi 3 &
Matthew Berler 4
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First Online: 01 January 2020

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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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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

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.

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Semi-structured, narrative, and in-depth interviewing, focus groups, action research, participant observation

In contrast to survey questionnaires, qualitative interviewing aims to delve deep beneath the surface of superficial responses to obtain true meanings that individuals assign to events, and the complexity of their attitudes, behaviours and experiences. Qualitative interviews may take different formats depending on the nature of the research question and the population studied.

Semi-structured interviews

Semi-structured interviews are characterised by topic guides containing major questions that are used in the same way in every interview, although the sequence of the questions might vary as well as the level of probing for information by the interviewer. Semi-structured interviewing is suitable when the researcher already has some grasp of what is happening within the sample in relation to the research topic. However, the researcher should ensure there is no danger of loss of meaning as a consequence of imposing a standard way of asking questions (6). This could be achieved by conducting pilot interviews (these use broad topic guides with few direct questions) prior to data collection.

Even in a semi-structured interview, the questions posed during the interview should be as open-ended as possible, in order to avoid yes/no or rehearsed answers. Further, the questioning techniques should encourage respondents to communicate their underlying attitudes, beliefs and values that are so central to this method. This can be limited where the interviewee has a lack of awareness/information or is not used to putting feelings into words. Interviewees might feel exposed by questions (in particular where attitudes are probed in sensitive topics such as political attitudes, sexual orientation, borderline or illegal behaviour). On the other hand, interviewees might feel that they need to present themselves in a specific way in order to fit in with their perception of the researcher's requirements, or wish to bring in their own agenda of life-topics that do not fit easily with the aim of the interview. For these reasons, it is important to build a rapport with the interviewee before starting the interview so that both sides can feel more at ease. Different ways of posing questions and using probing and prompting help to elicit more information or steer the interview.

Narrative interviews

Unstructured interviewing allows the respondent to tell their own stories in their own words, with prompting by the interviewer. The objective of the unstructured interview has been summarised as, 'to elicit rich, detailed materials that can be used in qualitative analysis. Its objective is to find out what kind of things are happening rather than to determine the frequency of predetermined kinds of things that the researcher already believes can happen' (7). In an unstructured interview, the researcher simply has a list of topics that they want the respondent to talk about. But the way the questions are phrased and which order they come will vary from one interview to the next as the interview process is determined by the responses (stories) of the interviewees.

In-depth interviews

In in-depth interviews the aim is to obtain a more detailed, rich understanding of the topic of interest. They usually comprise an ethnographic approach and complement participant observation or action research methods.

In in-depth interviews the participant’s experience, behaviour, feelings, and/or attitudes may be probed deeply to identify underlying concepts that the researcher analyses to generate a theory surrounding the research topic. In-depth interviews are more structured than narrative interviews as the topic discussed will be directed by the researcher and they rarely involve stories or life histories. However in-depth interviews do allow the participant to communicate much more freely and to provide more detailed descriptions when compared to semi-structured interviews.

Sometimes interviewers do not reveal all the exact details of the research hypothesis when conducting in-depth interviews, as this may influence or “lead” the qualitative material obtained. Rather, the general area of interest is explained to the participant as part of recruitment and consent (see later in the chapter) and the interviewer directs the interview according to the responses.

Focus groups

Focus groups are a form of group interview with the aim of capturing the interaction between the participants based on topics that are supplied by the researcher(8). The main purpose of focus group research is to evoke a level of respondents' attitudes, feelings, beliefs, experiences and reactions otherwise not available when using methods, such as observation or interviewing. These attitudes, feelings and beliefs may be partially independent of a group or its social setting, but are more likely to be revealed via the social gathering and the interaction created in a focus group. Focus groups are particularly useful when there are power differences between the participants and decision-makers or professionals, when the everyday use of language and culture of particular groups is of interest, and when one wants to explore the degree of consensus on a given topic (9). For these reasons, it is important to make sure that the participants have a specific experience/opinion about the topic to be discussed, and that a specific interview guide is used.

Despite all the potential of focus groups, this method has its limitations. However, these limitations are dependent on the study design and can be reduced by diligent planning. Four of the main limitations are:

(a) The researcher has less control over the data produced

(b) The researcher has little control over the interaction other than generally keeping participants focused on the topic

(c) The researcher can have difficulties in recruiting and assembling the focus group (e.g. finding a date and time for seven busy health care professionals, or resistance from people who are less articulate or confident)

(d) The researcher cannot assure full confidentiality and anonymity as information is shared in the group.

The practical organisation of focus groups requires the following:

Planning the recruitment process
Negotiating the date and time of the focus group
Choosing a venue (a neutral place is usually of advantage; where participants live/work too far apart the focus group can also be conducted via a telephone conference line)
Ensuring adequate recording facilities
Organising a co-moderator (e.g. to take notes and monitor recording equipment), deciding how many people should be in the focus group (usually six to ten)
Informing participants about the potential length of the focus group (usually one to two hours).
Being clear about the role of the moderator. This will require the researcher to provide clear explanations of the purpose to the group, ask questions and facilitate interaction between group members (e.g. allowing quieter participants to speak).

Action research

This is a collaborative and cyclical (between practical action and research) approach to research, in which both practitioners (e.g. clinicians, nurses, public health specialists, etc.) and researchers (although they can potentially be one and the same) look for a solution to a practice-related problem or to bring about change in a particular setting. Action research methodologies aim to integrate action and reflection, so that the knowledge developed in the research process is directly relevant to the issues being studied. Action research has a long history, going back to social scientists' attempts to help solve practical problems in wartime situations in both Europe and America. Over the past ten years there has been a resurgence of interest, and many developments in both theory and practice. The newer approaches to action research place emphasis on a full integration of action and reflection and on increased collaboration between all those involved in the inquiry project. They include, among other approaches, "co-operative inquiry", "participatory action research", and "action science" or "action inquiry".

Participant observation

When undertaking observational fieldwork the researcher is also known as the 'ethnographer' as he/she attempts to discover the practices and meanings that the members of the group under study take for granted (10). By observing a group of people, the researcher sets out to identify the meanings people develop about their existence (11). In participant observation, the researcher adopts the perspective of those studied. For example, a study might be interested in the rules of the waiting room in a GP practice. The researcher in his/her observing role would adopt the perspective of a patient waiting to be called in to see the doctor. He/she would observe the interaction of the people present, e.g. the receptionist, other patients, cleaning staff, an occasional appearance of a nurse. However, this does not mean simply adopting a passive watching role; the researcher might also interact with those that he/she is observing.

Observation can involve a combination of methods, including e.g. unstructured conversations/interviews, notes on observations, recordings (audio and video) and illustrative material (floor maps, information material). Nevertheless, like all data collection methods, observation does have its limitations. These include observer bias (the influence the observer's presence might have on the situation he/she is watching), and the difficulty of replicating the data.

There are a number of points that a researcher needs to be cognisant of before embarking on observational fieldwork, a selection is listed here:

Selecting the field setting
Gaining access
Deciding whether participant observation will be concealed (e.g. gaining employment to field setting without informing anyone there about the observation) or open (i.e. being open about the observing role)
Recording the action - field notes
Validation of the observations

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v.9(8); 2019

Semistructured interviews regarding patients’ perceptions of Choosing Wisely and shared decision-making: an Australian study

Jacqueline allen.

1 School of Nursing and Midwifery, Monash University, Clayton, Victoria, Australia

Richard King

2 Monash Health, Clayton, Victoria, Australia

Stacy K Goergen

3 Imaging, Monash University, Clayton, Victoria, Australia

4 Radiology, Monash Health, Clayton, Victoria, Australia

Angela Melder

5 Centre for Clinical Effectiveness, Monash Health, Clayton, Victoria, Australia

Naama Neeman

6 Children's Cancer Foundation, Hudson Institute of Medical Research, Clayton, Victoria, Australia

Annemarie Hadley

Alison m hutchinson.

7 School of Nursing and Midwifery; Centre for Quality and Patient Safety Monash Health Partnership, Monash Health, Deakin University, Geelong, Victoria, Australia

Associated Data

bmjopen-2019-031831supp001.pdf

bmjopen-2019-031831supp002.pdf

bmjopen-2019-031831supp003.pdf

This study aimed to examine how patients perceive shared decision-making regarding CT scan referral and use of the five Choosing Wisely questions with their general practitioner (GP).

This is a qualitative exploratory study using semistructured interviews.

This study was conducted in a large metropolitan public healthcare organisation in urban Australia.

Participants

Following purposive sampling, 20 patients and 2 carers participated. Patient participants aged 18 years or older were eligible if they were attending the healthcare organisation for a CT scan and referred by their GP. Carers/family were eligible to participate when they were in the role of an unpaid carer and were aged 18 years or older. Participants were required to speak English sufficiently to provide informed consent. Participants with cognitive impairment were excluded.

Eighteen interviews were conducted with the patient only. Two interviews were conducted with the patient and the patient’s carer. Fourteen participants were female. Five themes resulted from the thematic analysis: (1) needing to know, (2) questioning doctors is not necessary, (3) discussing scans is not required, (4) uncertainty about questioning and (5) valuing the Choosing Wisely questions. Participants reported that they presented to their GP with a health problem that they needed to understand and address. Participants accepted their GPs decision to prescribe a CT scan to identify the nature of their problem. They reported ambivalence about engaging in shared decision-making with their doctor, although many participants reported valuing the Choosing Wisely questions.

Conclusions

Shared decision-making is an important principle underpinning Choosing Wisely. Practice implementation requires understanding patients’ motivations to engage in shared decision-making with a focus on attitudes, beliefs, knowledge and emotions. Systems-level support and education for healthcare practitioners in effective communication is important. However, this needs to emphasise communication with patients who have varying degrees of motivation to engage in shared decision-making and Choosing Wisely.

Strengths and limitations of this study

The qualitative methods enabled a detailed examination of patients’ attitudes and beliefs.
Factors supporting the implementation of shared decision-making in Choosing Wisely were identified.
Participants were referred for and attended a CT scan and nothing is known about use of the five Choosing Wisely questions among patients who were not referred for a CT scan.

Introduction

Choosing Wisely is a de-implementation initiative aiming to reduce low value healthcare. Two main principles underpin Choosing Wisely: (1) the responsible stewardship of healthcare resources and (2) the inclusion of patients in healthcare decisions. 1 Numerous studies have been conducted to assess the implementation of Choosing Wisely in relation to responsible stewardship. 2–5 There is mixed research in relation to shared decision-making. Previous studies have identified that decision support tools facilitate shared decision-making. 6 7 Other research has found that patients overestimate the benefits of medical interventions and underestimate the associated harms. 8 However, few studies have been conducted about shared decision-making from the patient perspective in a de-implementation context such as Choosing Wisely.

Choosing Wisely

Initiated in 2012 by the American Board of Internal Medicine Foundation, the US-based Consumer Reports and nine US-based medical specialty societies, the Choosing Wisely campaign aims to avoid healthcare services, including tests and treatments, associated with evidence of low efficacy and/or potential risk of harm to patients. 1 4 Over 20 countries, including Canada, Italy, the UK and Australia, have joined the Choosing Wisely initiative. Choosing Wisely emphasises the responsibilities of medical professionals to justly distribute and manage healthcare resources. 1 9 Additionally, Choosing Wisely emphasises shared decision-making between healthcare practitioners and patients. 9

To date, studies investigating the effectiveness of Choosing Wisely implementation have addressed responsible stewardship in terms of the development of lists of tests and treatments to avoid, 10 11 impact studies, 12 13 education interventions 14 and physician attitudes. 15 16 Previous studies have identified a range of patient attitudes regarding Choosing Wisely. A Canadian study identified that patients endorsed Choosing Wisely values and de-implementing low value care. 17 In an Australian evaluation, 61% of consumer participants indicated that they agreed with the Choosing Wisely campaign and the patient’s role in reducing care of low value. 18 However, 61% of participants expected that their medical practitioner should order all medical tests if they were unwell. 18

Shared decision-making

Shared decision-making refers to the involvement of patients in making decisions about their health and healthcare with clinicians. 6 19 The Choosing Wisely movement promotes shared decision-making between patients and healthcare professionals in relation to de-implementation of low value care. 1 4 Shared decision-making is promoted through the five Choosing Wisely questions (listed in box 1 ) recommended for patients to use in discussions with their healthcare practitioner. 18

Five Choosing Wisely questions

Do I really need this test or procedure?
What are the risks?
Are there simpler, safer options?
What happens if I don’t do anything?
What are the costs? 28

Previous research about shared decision-making has largely focused on developing and testing decision support tools. 19 In their systematic review, Stacey et al 6 found good effectiveness of decision support tools on promoting patients’ knowledge, communication between patients and practitioners, and patient satisfaction. Another systematic review found that medical practitioners endorse the use of decision support tools. 20 Decision support tools have also been found to challenge practice because of lack of clinician time, lack of care continuity, lack of patient knowledge and power imbalance between patients and clinicians. 7 21 The decision support tools investigated in these systematic reviews were based on high quality research evidence and addressed a range of focused health conditions. 6 7 19 20

Despite the substantial quantity of research in relation to decision support tools, 6 limited research is available about shared decision-making and Choosing Wisely from the patient’s perspective. Additionally, previous studies about shared decision-making have emphasised specified health problems. 19 We explored patients’ perspectives about shared decision-making in relation to CT scans and any medical condition with their general practitioner (GP) with regard to using the five Choosing Wisely questions. We selected CT scans for inclusion because reductions in CT scans for nominated conditions are one important target area of Choosing Wisely due to the risk of exposure to unnecessary radiation. 1 9

Research question

How do patients perceive shared decision-making about CT scan referral and use of the five Choosing Wisely questions with their GP?

Methodology

The research design was qualitative exploratory using interviews. The Standards for Reporting Qualitative Research (SRQR) guidelines were used to report the study methodology. 22

Patient involvement in research

Patients were not involved in the development of the research question, study design, recruitment or conduct of the study. However, the research was designed to elicit patients’ perceptions.

Conceptual framework

The Theoretical Domains Framework (TDF) formed the conceptual framework underpinning this study. The TDF was selected because it was developed and validated from a synthesis of the 33 theories of behaviour change best suited to implementation research and practice. 23–25 We adopted the most recently published version of the TDF, which comprises 14 domains. The domains focus on individual motivation for behaviour and change including knowledge, beliefs, memory and decision processes, social and environmental influences, and emotion. 25

The setting comprised a large metropolitan public healthcare network in south-eastern Australia. Following referral by their GP, patients attended the health network for an outpatient CT scan. The public healthcare network provides acute, subacute and outpatient services, including medical imaging, to a culturally and socioeconomically diverse community. Selection of this setting was expected to maximise variation and opportunities for information about patients from different cultural and socioeconomic backgrounds.

Purposive sampling using maximum variation for educational background and for socioeconomic status was used to select, for a semistructured interview, up to 20 patients plus or minus carers/family. All patients were aged 18 years or older. Participants were attending the healthcare organisation for a CT scan having been referred by their GP. Where carers/family accompanied the patient, and with the patient’s permission, the carer/family member was invited to participate in the interview. Carers/family were eligible to participate when they were in the role of an unpaid carer, as nominated by the patient. Participants were required to be at least 18 years of age and speak English sufficiently to provide informed consent. Where participants had a diagnosis of dementia or cognitive impairment recorded on the GP referral, they were not approached to participate.

Data collection tools and guidelines

Data collection tools and guidelines comprised a demographic questionnaire and a semistructured interview guide. These tools and guidelines were developed using the TDF and an earlier unpublished literature review as guides. The demographic questionnaire included questions about the participant’s age, gender, country of birth, presenting health problem, educational background and employment. Interview guidelines comprised questions regarding the participant’s perceptions of shared decision-making with their GP in relation to their CT scan and their perceptions of the five Choosing Wisely patient questions. The interview guide for the study is presented in online supplementary file 1 .

Supplementary data

Procedure and data collection.

Reception staff in the imaging department at the participating healthcare organisation identified participants who met the selection criteria. With the participant’s permission, the researcher (JA) used the Participant Information and Consent Form (PICF) to introduce the study including the overall goal of improved understanding of patients’ perceptions about shared decision-making in order to support patients’ conversations with their doctors. Patients who agreed to participate were invited to nominate their informal carer to participate as well. Following an explanation of the study guided by the PICF, written consent from patients and carers was obtained. All participants were provided with a copy of the PICF. The researcher then invited the patient, and if applicable their carer, to complete the demographic questionnaire to establish their eligibility to participate in the study. The researcher invited eligible patients and, if acceptable, their carer to participate in a face-to-face semistructured interview in a private office at the imaging department after their scan, or to participate, at a later date, in a telephone interview of no more than 45-min duration. With permission, the semistructured interview was audio-recorded for transcription. Interviews were conducted by the first author, a registered nurse with professional education in interviewing, at psychology Master’s degree and nursing PhD level, and experience in interviewing patients and carers in both community health and research contexts. A professional transcriber transcribed the data.

Data analysis

Demographic data were entered into Statistical Package for the Social Sciences V.21. Categorical information was analysed using frequencies. The inductive analysis technique of thematic analysis was used to analyse interview data and to make decisions about data saturation. 26 27 Data saturation occurs when similar codes and categories are identified across interviews with subsequent interviews identifying no new codes and categories. 26 27 As the number of participants required to achieve data saturation varies by research project, the research team decided to conduct an additional six interviews to confirm data saturation.

Guided by the research aim and TDF, thematic analysis involved the comparing and contrasting of codes and categories within and between interviews to identify themes and subthemes. 26 27 The first author conducted the data analysis. The last author cross-coded interview transcripts. The first and last authors discussed codes, categories and themes to test the interpretation of the data and support a coherent interpretation of the interviews. All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics approvals

In accordance with the Australian National Health and Medical Research Council guidelines, the Ethics Committees at the healthcare organisation and Deakin University provided ethics approvals. Patients and carers were voluntary participants in the study. Following an explanation of the study, guided by the PICF, participants provided verbal and written consent. All data were de-identified. Project identifier numbers were allocated to all qualitative information.

Twenty-two people agreed to participate. Eighteen interviews were conducted with the patient only. At two patients’ requests, interviews were conducted with both the patient and the patient’s carer who had accompanied them to the medical imaging department. Similar codes and categories were identified during analysis of the first 14 interviews. An additional six interviews were conducted with no new codes and categories emerging. Therefore, data saturation was considered to be achieved after 20 interviews. Most interviews (17) were conducted face-to-face at the healthcare organisation after the participant’s scan. Three interviews were conducted by telephone 1 week after their scan.

Six participants were aged less than 50 years, nine participants were aged 50–69 years and seven participants were aged 70–89 years. Fourteen participants were female and 16 spoke English at home. Participants experienced a range of health conditions including gastrointestinal problems, respiratory conditions, cardiovascular conditions, neuropathy and back pain. Other demographic information is presented in online supplementary file 2 .

Five themes resulted from the thematic analysis:

Needing to know.
Questioning doctors is not necessary.
Discussing scans is not required.
Uncertainty about questioning.
Valuing the Choosing Wisely questions.

Needing to know

All participants noted that they required a CT scan because they needed to know what was wrong with them. All participants commented that their need to know what was wrong with them was the main reason for booking an appointment with their GP. According to one carer:

I don’t think there was too much to decide. She [patient] complained about the pain and the doctor wanted to do this [CT scan] to see what’s going on there. She just wants to feel a bit better. She would probably have any procedure. (P2)

The scan was important to most participants in order to plan and prepare for treatment to resolve their health problem. Three participants noted that the scan was important for their peace of mind so that they could prepare for pain in the future and rule ‘sinister’ things out. Two participants considered that the scan was important to help remove their pain. One participant wanted to be sure that their infection was gone. Another participant wanted to be properly diagnosed to stop people doubting that he had back problems. One patient commented:

…peace of mind is the right thing, but I think it’s [the CT scan] just to know what’s going on so I can prepare myself. (P7)

Questioning doctors is not necessary

Participants explained their perspectives about communicating with their doctor in the theme ‘Questioning doctors is not necessary’. Many participants commented on their belief that their doctors made the right decision by requesting a CT scan for the quickest assessment of their illness. According to these participants, they did not have a discussion with their doctor or ask questions, as this was not perceived to be necessary.

Our doctor, she’s a doctor who doesn’t want you to have unnecessary tests. We know that about her because she said that. So that when she recommends a test we tend to just think, yeah. (P6)

According to several participants, their doctor explained radiation and reassured them about the risk, therefore there was no need to ask questions. According to other participants, because they had a relationship with their doctor, there was no need for discussion:

I’ve been seeing her [the GP] for a while, I haven’t had many CTs or x-rays done but I vaguely remember years ago her explaining radiation and not to be too stressed about it. This time “No” because we’ve got an established relationship so she doesn’t really need to rehash. (P3)

Several participants commented that they trusted their doctor and their doctor’s knowledge, and complied with their doctor’s suggestions and decisions because they wished to feel better. Additionally, since they trusted their doctor’s judgement and knowledge, they considered that asking questions about the decision to have a CT scan was not important or necessary. One patient commented:

All through life you have to have x-rays. In the long run, it might cause some of your cancers. I don’t know. But I don’t think it would change me. You see people have got to keep believing in their GP. If you lose the trust. … I wouldn’t even go to a GP. That defeats the purpose. (P20)

Most participants considered that people of older generations and also from some traditional family backgrounds and cultures might feel that it was disrespectful to ask their doctor any questions. Several participants commented that when a patient is in pain or very unwell they would not be well enough to ask questions.

Two participants noted that they needed to be their own advocate with their doctor and ensure that they were listened to. According to one participant, being her own advocate was important, as doctors could not know everything and could assume that patients wanted a quick answer to their problems:

I think you’ve got to be your own advocate. … You have to stand up and speak for yourself, and listen. … Because sometimes they [the doctors] don’t know better. (P4)

Discussing scans is not required

In the third theme ‘Discussing scans is not required’, participants explained their perspectives about deciding to have a CT scan. Most participants commented that they did not want more discussion with their doctor, because they knew what the scan was for, understood their CT scan and experienced no anxiety. Thirteen participants noted that as they had undergone at least one CT scan in the past, they were familiar with CT scans and understood what to expect. Nine participants reported that they were satisfied with the explanation about the purpose of the CT scan they received from their doctor.

I understand most of what is going on a lot of the time anyway, so I don’t really need to ask a lot of questions. I do ask when I need to but this wasn’t a case that I needed to. (P13)

Two participants did not want to ask any questions because they perceived this would make them anxious. One participant did not ask questions because she did not want to know details about her diagnosis. Four participants commented that they asked questions of their doctor during the consultation to clarify the need for the scan.

According to most participants, discussion about the pros and cons of their scan was not desirable because they had already received adequate information from their GP about CT scans at previous consultations and they had acquired a good understanding of the risks and benefits. Two participants noted that their doctor explained the pros and cons of their scan to them, and nine participants commented that this was not explained to them. Three participants reported their belief that they needed to have the scan done and therefore did not consider that questions about the pros and cons of the scan were necessary. One participant reflected that he should have asked about the pros and cons of his scan; however, he understood that his scan was a straightforward CT scan.

Most participants reported that as far as they were aware there were no major disadvantages of having a CT scan and the most important thing was to find out what was wrong with their health. Several participants considered that CT scans were safe. Other participants noted some disadvantages of CT scans. Four participants noted that people should not be exposed to CT scans too often due to radiation although this risk was considered minimal. Several participants reported that their doctor had informed them of this risk. According to one patient:

Why would there be a disadvantage [of the CT scan]? … I’ve had three CT scans in 12 months, so I don’t find that over excessive. (P1)

Uncertainty about questioning

In the theme ‘Uncertainty about questioning’, many participants expressed uncertainty and hesitation about the usefulness of the five Choosing Wisely questions for themselves and for others in decision-making with their doctors. Eighteen participants commented that they had not seen the five Choosing Wisely questions before. Some participants reported their belief that patients should use the questions yet many patients do not ask their doctors questions. Several participants noted that the doctor would need to explain the five Choosing Wisely questions to patients in order for the questions to be used. Many participants commented that they did not need to ask their doctors the five Choosing Wisely questions due to the quality trusting relationship that they had with their doctor and their assumption that the doctor knew best. According to these participants, people without a trusting relationship with their doctor would need to ask questions. Other participants considered that patients would only be able to ask questions of their doctor if they had a trusting relationship where their doctor would accept a patient asking questions.

I think if you have a good relationship or have trust with your doctor, your GP, I guess you just would assume that she is going to decide the right thing for you. (P5) It depends on the relationship that they have with their doctor. I think that if you don’t really know your doctor and you don’t trust your doctor then it [the five Choosing Wisely questions] potentially can help. (P7) I think some people would [ask the five Choosing Wisely questions] and some people wouldn’t. Some people are very switched on and want to know things and other people still have that, well the doctor knows best. I’ll do what you tell me. (P10)

Three participants were undecided about whether the five Choosing Wisely questions would assist a patient to weigh benefits against risks. One participant noted that he had everything explained to him and he would not need to question his doctor. However, where patients did not have a relationship with their doctor, they may need to use the Choosing Wisely questions to weight up benefits against risks for themselves. One participant considered that patients would agree with the doctor and not use the questions. One participant reflected that patients might be too afraid of the answers from their doctor, in relation to risks, if they were to ask the five Choosing Wisely questions. Some people would prefer not to know and would not use the questions. According to one patient:

It’s a scary thing to ask questions you really sometimes don’t want to hear what they’ve [the doctor] got to say. (P9)

Six participants commented that they would not use the five Choosing Wisely questions, as they needed their scan in order to recover their health. Several other participants commented that they would never opt to do nothing and therefore they would not ask their doctor the Choosing Wisely question ‘What happens if I don’t do anything?’ According to two participants, doctors may not want patients to ask them questions. Further, it was perceived that some patients may not want to ask their doctors questions since they may feel that questioning the doctor is too confrontational. One patient noted:

Do I really need this test or procedure? I think it’s almost questioning the doctor. I think there is potential for some doctors to have their nose out of joint. (P7)

Valuing the Choosing Wisely questions

All participants were invited to discuss the value of the questions. However, only 14 participants commented. These participants expressed a range of views about the value of the questions. Several participants considered the questions were valuable because they guided patients to reflect on decisions with their doctor and to take greater responsibility for their healthcare decisions. One carer participant reported their belief that some people did have unnecessary tests and procedures and that there may be associated risks that were not considered. According to this carer, some people thought that an X-ray test was just like taking a photograph with no risks and therefore the Choosing Wisely questions could be valuable in prompting patients to consider risks with their doctors. Another participant further explained that during a consultation with a doctor, patients were more concerned with what they thought that they needed. According to this participant, the questions would prompt a patient to consider additional priorities such as are there safer or cheaper options. Two participants reported that the questions would be valuable because they would increase the information available to patients, which would be reassuring for patients in making decisions with their doctors. Another two participants noted that the questions would be valuable as a memory prompt for patients. According to one patient:

I think it [the five Choosing Wisely questions] might jolt a person’s memory. It might engage the patient on a different level. You know outside their paradigm of thinking. So it’s a bit like a safety map. (P18)

Some participants commented that the five Choosing Wisely questions were valuable because availability of the questions would give patients permission to ask questions of their doctors. According to one participant, some people believed that they were not permitted to ask their doctors questions and needed to know that asking doctors questions was acceptable. Several participants noted that the questions would need to be brought to patients’ attention by doctors to signal to patients that it was acceptable to ask questions.

I think … some patients need to have that so that they’re given permission in their minds to ask those questions. (P6) Some people just do what they’re told. But if there was a set of questions then they would know to ask wouldn’t they? (P21)

Additionally, participants commented on a range of facilitators and barriers to using the five Choosing Wisely questions. These are listed in online supplementary file 3 . Several participants reported that they did not find the Choosing Wisely question regarding costs was valuable as they considered that it was not applicable to the publicly funded Australian health setting. Two participants asked if the Choosing Wisely question pertaining to costs reflected monetary costs or human costs.

Findings indicate that participants presented to their GP with a health problem that they needed to understand and address. Participants accepted their GPs decision to prescribe a CT scan to identify the nature of the problem. Participants reported ambivalence about using the five Choosing Wisely questions with their doctor; although, many participants reported valuing these questions. Few past studies have examined using the five Choosing Wisely questions from the patient perspective. 17 18 Findings from the current study contribute knowledge about patients’ use of questions in healthcare contexts of de-implementation of low value care.

Previous research about shared decision-making has found decision support tools with clearly articulated decision choices are effective. 6 19 20 Asking questions, such as use of the five Choosing Wisely questions, is one part of shared decision-making. 1 9 However, in the current study, findings indicate that all participants perceived that they required a solution to their health problem in the form of an investigatory intervention. Although many participants understood the value of Choosing Wisely in terms of healthcare stewardship, when the decision was about their own health directly, they expected their doctor to order all medical tests. Most participants expected that their GP would make this decision and that the tests would be beneficial. These findings are aligned with previous research that patients overestimate the benefits and underestimate the harms of medical interventions. 8 18 Implementation of the five Choosing Wisely questions into practice is complicated by patients’ beliefs, attitudes, knowledge and emotions. 25 Although the Choosing Wisely literature emphasises the need to change patients’ expectations, 4 18 few studies have examined implementation facilitators and barriers from patients’ perspectives. The current study highlights the role of patients’ motivation in using the five Choosing Wisely questions and de-implementation of low value care.

Our findings also indicate a lack of consumer and patient awareness of the five questions. This is reflective of the emphasis to date of the Choosing Wisely campaign on disinvestment by health practitioners and healthcare organisations in low value care, without similar efforts being made to educate patients and consumers about how to engage in shared decision-making by using the five questions.

Some participants commented on the value of the five Choosing Wisely questions as a signal that patients were permitted to ask questions of their doctor. The availability and application of communication tools such as the five Choosing Wisely questions may assist patients in addressing their lack of knowledge and the power imbalance between patients and clinicians. Although this may improve shared decision-making in de-implementation of low value care, support for GPs to engage and educate patients about using the five Choosing Wisely questions is needed. This may require a focus on giving patients permission to ask their doctors questions about the benefits of a watch and wait approach.

Further research

The five Choosing Wisely questions are a communication rather than a decision support tool. Research about decision support tools inclusive of communication guides and de-implementation in primary care contexts is warranted with focus on understanding patient motivation and also on empowering patients to ask questions and engage in shared decision-making. Research with larger representative samples to ascertain patients’ perspectives would add knowledge at population levels. Further research is required in regard to the implementation of the five Choosing Wisely questions in defined populations with potentially different motivation for shared decision-making such as people living with chronic illness engaged in self-management.

Study strengths and limitations

Findings from the current study may have application to similar contexts of care elsewhere. The study included a small sample using semistructured interviews. This enabled a detailed descriptive exploration of participant’s attitudes, beliefs and knowledge, and identification of factors and processes facilitating and constraining patients’ use of the Choosing Wisely questions. The participants in the current study were all referred for and attended a CT scan and nothing is known about use of the five Choosing Wisely questions among patients who were not referred for a CT scan. Many participants had experienced a previous CT scan and this may have limited their perceived need to question their doctor. The timing of the interview after the CT scan may have predisposed participants to assume that the test was beneficial. Additionally, three interviews were conducted 1 week after their scan and this may have affected recall bias.

Conclusions and implications for practice

Shared decision-making is a principle underpinning Choosing Wisely. This ideal may not be matched in practice where patients seek a solution from an authoritative expert clinician such as a medical practitioner. Patients may require education that they are permitted to ask questions of their medical practitioner. Patients’ motivation to engage in shared decision-making requires clinicians’ understanding of patients’ attitudes, beliefs, knowledge and emotions. Systems support and education for healthcare practitioners in effective communication is essential. However, this needs to emphasise communication with patients with varying motivation to engage in shared decision-making. Skilful application with patients of available communication tools, such as the five Choosing Wisely questions, and paid clinician time to undertake this important healthcare practice are imperative to future success in implementation of Choosing Wisely.

Supplementary Material

Acknowledgments.

We are thankful for the support of all patients and carers who generously participated in the study. We acknowledge the support and time of staff at the medical imaging department at Casey Hospital including Nick Ardley, the reception staff and the nursing staff. We acknowledge the support by Monash Health and the Deakin University School of Nursing and Midwifery.

Contributors: JA and AH designed and conceptualised the study with RK, SKG, AM, NN and AMH. JA recruited participants and collected data. JA and AH analysed data. JA and AH drafted the manuscript with support from RK, SKG, AM, NN and AMH.

Funding: This work was supported by funding from Monash Health, Clayton Victoria, Australia.

Competing interests: None declared.

Patient consent for publication: Not required.

Ethics approval: In accordance with the Australian National Health and Medical Research Council guidelines, the Ethics Committees at the healthcare organisation and Deakin University provided ethics approvals. Patients and carers were voluntary participants in the study. Following an explanation of the study, guided by the Participant Information and Consent Form, participants provided verbal and written consent. All data were de-identified. Project identifier numbers were allocated to all qualitative information.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement: All data relevant to the study are included in the article or uploaded as supplementary information.

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Introduction

Purpose of semistructured interviews

Designing and conducting semistructured interviews

Steps for designing and conducting semistructured interviews

Step 2: identifying participants

Step 3: considering ethical issues

Step 4: planning logistical aspects

Step 5: developing the interview guide

Supplemental material

Step 6: establishing trust and rapport

Step 7: conducting the interview

Beginning the interview

Interviewer stance

Active listening

Continuing the interview

Step 8: memoing and reflection

Step 9: analysing the data

Step 10: demonstrating the trustworthiness of the research

Step 11: presenting findings in a paper or report

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Semi-structured, narrative, and in-depth interviewing, focus groups, action research, participant observation

Semi-structured interviews

Narrative interviews

In-depth interviews

Focus groups

Action research

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Semistructured interviews regarding patients’ perceptions of Choosing Wisely and shared decision-making: an Australian study

Richard King

Stacy K Goergen

Angela Melder

Naama Neeman

Annemarie Hadley

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Participants

Conclusions

Strengths and limitations of this study

Introduction