practical guide qualitative methods in health and educational research

• Science & Math

Enjoy fast, free delivery, exclusive deals, and award-winning movies & TV shows with Prime Try Prime and start saving today with fast, free delivery

Amazon Prime includes:

Fast, FREE Delivery is available to Prime members. To join, select "Try Amazon Prime and start saving today with Fast, FREE Delivery" below the Add to Cart button.

• Cardmembers earn 5% Back at Amazon.com with a Prime Credit Card.
• Unlimited Free Two-Day Delivery
• Streaming of thousands of movies and TV shows with limited ads on Prime Video.
• A Kindle book to borrow for free each month - with no due dates
• Listen to over 2 million songs and hundreds of playlists
• Unlimited photo storage with anywhere access

Important:  Your credit card will NOT be charged when you start your free trial or if you cancel during the trial period. If you're happy with Amazon Prime, do nothing. At the end of the free trial, your membership will automatically upgrade to a monthly membership.

Return this item for free

Free returns are available for the shipping address you chose. You can return the item for any reason in new and unused condition: no shipping charges

• Go to your orders and start the return
• Select the return method

Download the free Kindle app and start reading Kindle books instantly on your smartphone, tablet, or computer - no Kindle device required .

Read instantly on your browser with Kindle for Web.

Using your mobile phone camera - scan the code below and download the Kindle app.

Image Unavailable

• To view this video download Flash Player

Practical Guide: Qualitative Methods in Health and Educational Research Paperback – September 21, 2021

Purchase options and add-ons.

• Print length 176 pages
• Language English
• Publication date September 21, 2021
• Dimensions 8.5 x 0.44 x 11 inches
• ISBN-10 1685097901
• ISBN-13 978-1685097905
• See all details

Product details

• Publisher ‏ : ‎ Notion Press (September 21, 2021)
• Language ‏ : ‎ English
• Paperback ‏ : ‎ 176 pages
• ISBN-10 ‏ : ‎ 1685097901
• ISBN-13 ‏ : ‎ 978-1685097905
• Item Weight ‏ : ‎ 2.31 pounds
• Dimensions ‏ : ‎ 8.5 x 0.44 x 11 inches
• #3,867 in Scientific Research

Customer reviews

Customer Reviews, including Product Star Ratings help customers to learn more about the product and decide whether it is the right product for them.

To calculate the overall star rating and percentage breakdown by star, we don’t use a simple average. Instead, our system considers things like how recent a review is and if the reviewer bought the item on Amazon. It also analyzed reviews to verify trustworthiness.

• Sort reviews by Top reviews Most recent Top reviews

Top reviews from the United States

Top reviews from other countries.

• Amazon Newsletter
• About Amazon
• Accessibility
• Sustainability
• Press Center
• Investor Relations
• Amazon Devices
• Amazon Science
• Sell on Amazon
• Sell apps on Amazon
• Supply to Amazon
• Protect & Build Your Brand
• Become an Affiliate
• Become a Delivery Driver
• Start a Package Delivery Business
• Advertise Your Products
• Self-Publish with Us
• Become an Amazon Hub Partner
• › See More Ways to Make Money
• Amazon Visa
• Amazon Store Card
• Amazon Secured Card
• Amazon Business Card
• Shop with Points
• Credit Card Marketplace
• Reload Your Balance
• Amazon Currency Converter
• Your Account
• Your Orders
• Shipping Rates & Policies
• Amazon Prime
• Returns & Replacements
• Manage Your Content and Devices
• Recalls and Product Safety Alerts
• Conditions of Use
• Privacy Notice
• Consumer Health Data Privacy Disclosure
• Your Ads Privacy Choices

Qualitative Research – a practical guide for health and social care researchers and practitioners

(0 reviews)

Darshini Ayton, Monash University

Tess Tsindos, Monash University

Danielle Berkovic, Monash University

Copyright Year: 2023

Last Update: 2024

ISBN 13: 9780645755404

Publisher: Monash University

Language: English

Formats Available

Conditions of use.

Table of Contents

• Acknowledgement of Country
• About the authors
• Accessibility statement
• Introduction to research
• Research design
• Data collection
• Data analysis
• Writing qualitative research
• Peer review statement
• Licensing and attribution information
• Version history

Ancillary Material

About the book.

This guide is designed to support health and social care researchers and practitioners to integrate qualitative research into the evidence base of health and social care research. Qualitative research designs are diverse and each design has a different focus that will inform the approach undertaken and the results that are generated. The aim is to move beyond the “what” of qualitative research to the “how”, by (1) outlining key qualitative research designs for health and social care research – descriptive, phenomenology, action research, case study, ethnography, and grounded theory; (2) a decision tool of how to select the appropriate design based on a guiding prompting question, the research question and available resources, time and expertise; (3) an overview of mixed methods research and qualitative research in evaluation studies; (4) a practical guide to data collection and analysis; (5) providing examples of qualitative research to illustrate the scope and opportunities; and (6) tips on communicating qualitative research.

About the Contributors

Associate Professor Darshini Ayton is the Deputy Head of the Health and Social Care Unit at Monash University in Melbourne, Australia. She is a transdisciplinary implementation researcher with a focus on improving health and social care for older Australians and operates at the nexus of implementation science, health and social care policies, public health and consumer engagement. She has led qualitative research studies in hospitals, aged care, not-for-profit organisations and for government and utilises a range of data collection methods.  Associate Professor Ayton established and is the director of the highly successful Qualitative Research Methods for Public Health short course which has been running since 2014.

Dr Tess Tsindos  is a Research Fellow with the Health and Social Care Unit at Monash University in Melbourne, Australia. She is a public health researcher and lecturer with strong qualitative and mixed methods research experience conducting research studies in hospital and community health settings, not-for-profit organisations and for government. Prior to working in academia, Dr Tsindos worked in community care for government and not-for-profit organisations for more than 25 years. Dr Tsindos has a strong evaluation background having conducted numerous evaluations for a range of health and social care organisations. Based on this experience she coordinated the Bachelor of Health Science/Public Health Evaluation unit and the Master of Public Health Evaluation unit and developed the Evaluating Public Health Programs short course in 2022. Dr Tsindos is the Unit Coordinator of the Master of Public Health Qualitative Research Methods Unit which was established in 2022.

Dr Danielle Berkovic  is a Research Fellow in the School of Public Health and Preventive Medicine at Monash University in Melbourne, Australia. She is a public health and consumer-led researcher with strong qualitative and mixed-methods research experience focused on improving health services and clinical guidelines for people with arthritis and other musculoskeletal conditions. She has conducted qualitative research studies in hospitals and community health settings. Dr Berkovic currently provides qualitative input into Australia’s first Living Guideline for the pharmacological management of inflammatory arthritis. Dr Berkovic is passionate about incorporating qualitative research methods into traditionally clinical and quantitative spaces and enjoys teaching clinicians and up-and-coming researchers about the benefits of qualitative research.

Contribute to this Page

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Int J Prev Med

Qualitative Methods in Health Care Research

Vishnu renjith.

School of Nursing and Midwifery, Royal College of Surgeons Ireland - Bahrain (RCSI Bahrain), Al Sayh Muharraq Governorate, Bahrain

Renjulal Yesodharan

1 Department of Mental Health Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Judith A. Noronha

2 Department of OBG Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Elissa Ladd

3 School of Nursing, MGH Institute of Health Professions, Boston, USA

Anice George

4 Department of Child Health Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Healthcare research is a systematic inquiry intended to generate robust evidence about important issues in the fields of medicine and healthcare. Qualitative research has ample possibilities within the arena of healthcare research. This article aims to inform healthcare professionals regarding qualitative research, its significance, and applicability in the field of healthcare. A wide variety of phenomena that cannot be explained using the quantitative approach can be explored and conveyed using a qualitative method. The major types of qualitative research designs are narrative research, phenomenological research, grounded theory research, ethnographic research, historical research, and case study research. The greatest strength of the qualitative research approach lies in the richness and depth of the healthcare exploration and description it makes. In health research, these methods are considered as the most humanistic and person-centered way of discovering and uncovering thoughts and actions of human beings.

Introduction

Healthcare research is a systematic inquiry intended to generate trustworthy evidence about issues in the field of medicine and healthcare. The three principal approaches to health research are the quantitative, the qualitative, and the mixed methods approach. The quantitative research method uses data, which are measures of values and counts and are often described using statistical methods which in turn aids the researcher to draw inferences. Qualitative research incorporates the recording, interpreting, and analyzing of non-numeric data with an attempt to uncover the deeper meanings of human experiences and behaviors. Mixed methods research, the third methodological approach, involves collection and analysis of both qualitative and quantitative information with an objective to solve different but related questions, or at times the same questions.[ 1 , 2 ]

In healthcare, qualitative research is widely used to understand patterns of health behaviors, describe lived experiences, develop behavioral theories, explore healthcare needs, and design interventions.[ 1 , 2 , 3 ] Because of its ample applications in healthcare, there has been a tremendous increase in the number of health research studies undertaken using qualitative methodology.[ 4 , 5 ] This article discusses qualitative research methods, their significance, and applicability in the arena of healthcare.

Qualitative Research

Diverse academic and non-academic disciplines utilize qualitative research as a method of inquiry to understand human behavior and experiences.[ 6 , 7 ] According to Munhall, “Qualitative research involves broadly stated questions about human experiences and realities, studied through sustained contact with the individual in their natural environments and producing rich, descriptive data that will help us to understand those individual's experiences.”[ 8 ]

Significance of Qualitative Research

The qualitative method of inquiry examines the 'how' and 'why' of decision making, rather than the 'when,' 'what,' and 'where.'[ 7 ] Unlike quantitative methods, the objective of qualitative inquiry is to explore, narrate, and explain the phenomena and make sense of the complex reality. Health interventions, explanatory health models, and medical-social theories could be developed as an outcome of qualitative research.[ 9 ] Understanding the richness and complexity of human behavior is the crux of qualitative research.

Differences between Quantitative and Qualitative Research

The quantitative and qualitative forms of inquiry vary based on their underlying objectives. They are in no way opposed to each other; instead, these two methods are like two sides of a coin. The critical differences between quantitative and qualitative research are summarized in Table 1 .[ 1 , 10 , 11 ]

Differences between quantitative and qualitative research

Qualitative Research Questions and Purpose Statements

Qualitative questions are exploratory and are open-ended. A well-formulated study question forms the basis for developing a protocol, guides the selection of design, and data collection methods. Qualitative research questions generally involve two parts, a central question and related subquestions. The central question is directed towards the primary phenomenon under study, whereas the subquestions explore the subareas of focus. It is advised not to have more than five to seven subquestions. A commonly used framework for designing a qualitative research question is the 'PCO framework' wherein, P stands for the population under study, C stands for the context of exploration, and O stands for the outcome/s of interest.[ 12 ] The PCO framework guides researchers in crafting a focused study question.

Example: In the question, “What are the experiences of mothers on parenting children with Thalassemia?”, the population is “mothers of children with Thalassemia,” the context is “parenting children with Thalassemia,” and the outcome of interest is “experiences.”

The purpose statement specifies the broad focus of the study, identifies the approach, and provides direction for the overall goal of the study. The major components of a purpose statement include the central phenomenon under investigation, the study design and the population of interest. Qualitative research does not require a-priori hypothesis.[ 13 , 14 , 15 ]

Example: Borimnejad et al . undertook a qualitative research on the lived experiences of women suffering from vitiligo. The purpose of this study was, “to explore lived experiences of women suffering from vitiligo using a hermeneutic phenomenological approach.” [ 16 ]

Review of the Literature

In quantitative research, the researchers do an extensive review of scientific literature prior to the commencement of the study. However, in qualitative research, only a minimal literature search is conducted at the beginning of the study. This is to ensure that the researcher is not influenced by the existing understanding of the phenomenon under the study. The minimal literature review will help the researchers to avoid the conceptual pollution of the phenomenon being studied. Nonetheless, an extensive review of the literature is conducted after data collection and analysis.[ 15 ]

Reflexivity

Reflexivity refers to critical self-appraisal about one's own biases, values, preferences, and preconceptions about the phenomenon under investigation. Maintaining a reflexive diary/journal is a widely recognized way to foster reflexivity. According to Creswell, “Reflexivity increases the credibility of the study by enhancing more neutral interpretations.”[ 7 ]

Types of Qualitative Research Designs

The qualitative research approach encompasses a wide array of research designs. The words such as types, traditions, designs, strategies of inquiry, varieties, and methods are used interchangeably. The major types of qualitative research designs are narrative research, phenomenological research, grounded theory research, ethnographic research, historical research, and case study research.[ 1 , 7 , 10 ]

Narrative research

Narrative research focuses on exploring the life of an individual and is ideally suited to tell the stories of individual experiences.[ 17 ] The purpose of narrative research is to utilize 'story telling' as a method in communicating an individual's experience to a larger audience.[ 18 ] The roots of narrative inquiry extend to humanities including anthropology, literature, psychology, education, history, and sociology. Narrative research encompasses the study of individual experiences and learning the significance of those experiences. The data collection procedures include mainly interviews, field notes, letters, photographs, diaries, and documents collected from one or more individuals. Data analysis involves the analysis of the stories or experiences through “re-storying of stories” and developing themes usually in chronological order of events. Rolls and Payne argued that narrative research is a valuable approach in health care research, to gain deeper insight into patient's experiences.[ 19 ]

Example: Karlsson et al . undertook a narrative inquiry to “explore how people with Alzheimer's disease present their life story.” Data were collected from nine participants. They were asked to describe about their life experiences from childhood to adulthood, then to current life and their views about the future life. [ 20 ]

Phenomenological research

Phenomenology is a philosophical tradition developed by German philosopher Edmond Husserl. His student Martin Heidegger did further developments in this methodology. It defines the 'essence' of individual's experiences regarding a certain phenomenon.[ 1 ] The methodology has its origin from philosophy, psychology, and education. The purpose of qualitative research is to understand the people's everyday life experiences and reduce it into the central meaning or the 'essence of the experience'.[ 21 , 22 ] The unit of analysis of phenomenology is the individuals who have had similar experiences of the phenomenon. Interviews with individuals are mainly considered for the data collection, though, documents and observations are also useful. Data analysis includes identification of significant meaning elements, textural description (what was experienced), structural description (how was it experienced), and description of 'essence' of experience.[ 1 , 7 , 21 ] The phenomenological approach is further divided into descriptive and interpretive phenomenology. Descriptive phenomenology focuses on the understanding of the essence of experiences and is best suited in situations that need to describe the lived phenomenon. Hermeneutic phenomenology or Interpretive phenomenology moves beyond the description to uncover the meanings that are not explicitly evident. The researcher tries to interpret the phenomenon, based on their judgment rather than just describing it.[ 7 , 21 , 22 , 23 , 24 ]

Example: A phenomenological study conducted by Cornelio et al . aimed at describing the lived experiences of mothers in parenting children with leukemia. Data from ten mothers were collected using in-depth semi-structured interviews and were analyzed using Husserl's method of phenomenology. Themes such as “pivotal moment in life”, “the experience of being with a seriously ill child”, “having to keep distance with the relatives”, “overcoming the financial and social commitments”, “responding to challenges”, “experience of faith as being key to survival”, “health concerns of the present and future”, and “optimism” were derived. The researchers reported the essence of the study as “chronic illness such as leukemia in children results in a negative impact on the child and on the mother.” [ 25 ]

Grounded Theory Research

Grounded theory has its base in sociology and propagated by two sociologists, Barney Glaser, and Anselm Strauss.[ 26 ] The primary purpose of grounded theory is to discover or generate theory in the context of the social process being studied. The major difference between grounded theory and other approaches lies in its emphasis on theory generation and development. The name grounded theory comes from its ability to induce a theory grounded in the reality of study participants.[ 7 , 27 ] Data collection in grounded theory research involves recording interviews from many individuals until data saturation. Constant comparative analysis, theoretical sampling, theoretical coding, and theoretical saturation are unique features of grounded theory research.[ 26 , 27 , 28 ] Data analysis includes analyzing data through 'open coding,' 'axial coding,' and 'selective coding.'[ 1 , 7 ] Open coding is the first level of abstraction, and it refers to the creation of a broad initial range of categories, axial coding is the procedure of understanding connections between the open codes, whereas selective coding relates to the process of connecting the axial codes to formulate a theory.[ 1 , 7 ] Results of the grounded theory analysis are supplemented with a visual representation of major constructs usually in the form of flow charts or framework diagrams. Quotations from the participants are used in a supportive capacity to substantiate the findings. Strauss and Corbin highlights that “the value of the grounded theory lies not only in its ability to generate a theory but also to ground that theory in the data.”[ 27 ]

Example: Williams et al . conducted a grounded theory research to explore the nature of relationship between the sense of self and the eating disorders. Data were collected form 11 women with a lifetime history of Anorexia Nervosa and were analyzed using the grounded theory methodology. Analysis led to the development of a theoretical framework on the nature of the relationship between the self and Anorexia Nervosa. [ 29 ]

Ethnographic research

Ethnography has its base in anthropology, where the anthropologists used it for understanding the culture-specific knowledge and behaviors. In health sciences research, ethnography focuses on narrating and interpreting the health behaviors of a culture-sharing group. 'Culture-sharing group' in an ethnography represents any 'group of people who share common meanings, customs or experiences.' In health research, it could be a group of physicians working in rural care, a group of medical students, or it could be a group of patients who receive home-based rehabilitation. To understand the cultural patterns, researchers primarily observe the individuals or group of individuals for a prolonged period of time.[ 1 , 7 , 30 ] The scope of ethnography can be broad or narrow depending on the aim. The study of more general cultural groups is termed as macro-ethnography, whereas micro-ethnography focuses on more narrowly defined cultures. Ethnography is usually conducted in a single setting. Ethnographers collect data using a variety of methods such as observation, interviews, audio-video records, and document reviews. A written report includes a detailed description of the culture sharing group with emic and etic perspectives. When the researcher reports the views of the participants it is called emic perspectives and when the researcher reports his or her views about the culture, the term is called etic.[ 7 ]

Example: The aim of the ethnographic study by LeBaron et al . was to explore the barriers to opioid availability and cancer pain management in India. The researchers collected data from fifty-nine participants using in-depth semi-structured interviews, participant observation, and document review. The researchers identified significant barriers by open coding and thematic analysis of the formal interview. [ 31 ]

Historical research

Historical research is the “systematic collection, critical evaluation, and interpretation of historical evidence”.[ 1 ] The purpose of historical research is to gain insights from the past and involves interpreting past events in the light of the present. The data for historical research are usually collected from primary and secondary sources. The primary source mainly includes diaries, first hand information, and writings. The secondary sources are textbooks, newspapers, second or third-hand accounts of historical events and medical/legal documents. The data gathered from these various sources are synthesized and reported as biographical narratives or developmental perspectives in chronological order. The ideas are interpreted in terms of the historical context and significance. The written report describes 'what happened', 'how it happened', 'why it happened', and its significance and implications to current clinical practice.[ 1 , 10 ]

Example: Lubold (2019) analyzed the breastfeeding trends in three countries (Sweden, Ireland, and the United States) using a historical qualitative method. Through analysis of historical data, the researcher found that strong family policies, adherence to international recommendations and adoption of baby-friendly hospital initiative could greatly enhance the breastfeeding rates. [ 32 ]

Case study research

Case study research focuses on the description and in-depth analysis of the case(s) or issues illustrated by the case(s). The design has its origin from psychology, law, and medicine. Case studies are best suited for the understanding of case(s), thus reducing the unit of analysis into studying an event, a program, an activity or an illness. Observations, one to one interviews, artifacts, and documents are used for collecting the data, and the analysis is done through the description of the case. From this, themes and cross-case themes are derived. A written case study report includes a detailed description of one or more cases.[ 7 , 10 ]

Example: Perceptions of poststroke sexuality in a woman of childbearing age was explored using a qualitative case study approach by Beal and Millenbrunch. Semi structured interview was conducted with a 36- year mother of two children with a history of Acute ischemic stroke. The data were analyzed using an inductive approach. The authors concluded that “stroke during childbearing years may affect a woman's perception of herself as a sexual being and her ability to carry out gender roles”. [ 33 ]

Sampling in Qualitative Research

Qualitative researchers widely use non-probability sampling techniques such as purposive sampling, convenience sampling, quota sampling, snowball sampling, homogeneous sampling, maximum variation sampling, extreme (deviant) case sampling, typical case sampling, and intensity sampling. The selection of a sampling technique depends on the nature and needs of the study.[ 34 , 35 , 36 , 37 , 38 , 39 , 40 ] The four widely used sampling techniques are convenience sampling, purposive sampling, snowball sampling, and intensity sampling.

Convenience sampling

It is otherwise called accidental sampling, where the researchers collect data from the subjects who are selected based on accessibility, geographical proximity, ease, speed, and or low cost.[ 34 ] Convenience sampling offers a significant benefit of convenience but often accompanies the issues of sample representation.

Purposive sampling

Purposive or purposeful sampling is a widely used sampling technique.[ 35 ] It involves identifying a population based on already established sampling criteria and then selecting subjects who fulfill that criteria to increase the credibility. However, choosing information-rich cases is the key to determine the power and logic of purposive sampling in a qualitative study.[ 1 ]

Snowball sampling

The method is also known as 'chain referral sampling' or 'network sampling.' The sampling starts by having a few initial participants, and the researcher relies on these early participants to identify additional study participants. It is best adopted when the researcher wishes to study the stigmatized group, or in cases, where findings of participants are likely to be difficult by ordinary means. Respondent ridden sampling is an improvised version of snowball sampling used to find out the participant from a hard-to-find or hard-to-study population.[ 37 , 38 ]

Intensity sampling

The process of identifying information-rich cases that manifest the phenomenon of interest is referred to as intensity sampling. It requires prior information, and considerable judgment about the phenomenon of interest and the researcher should do some preliminary investigations to determine the nature of the variation. Intensity sampling will be done once the researcher identifies the variation across the cases (extreme, average and intense) and picks the intense cases from them.[ 40 ]

Deciding the Sample Size

A-priori sample size calculation is not undertaken in the case of qualitative research. Researchers collect the data from as many participants as possible until they reach the point of data saturation. Data saturation or the point of redundancy is the stage where the researcher no longer sees or hears any new information. Data saturation gives the idea that the researcher has captured all possible information about the phenomenon of interest. Since no further information is being uncovered as redundancy is achieved, at this point the data collection can be stopped. The objective here is to get an overall picture of the chronicle of the phenomenon under the study rather than generalization.[ 1 , 7 , 41 ]

Data Collection in Qualitative Research

The various strategies used for data collection in qualitative research includes in-depth interviews (individual or group), focus group discussions (FGDs), participant observation, narrative life history, document analysis, audio materials, videos or video footage, text analysis, and simple observation. Among all these, the three popular methods are the FGDs, one to one in-depth interviews and the participant observation.

FGDs are useful in eliciting data from a group of individuals. They are normally built around a specific topic and are considered as the best approach to gather data on an entire range of responses to a topic.[ 42 Group size in an FGD ranges from 6 to 12. Depending upon the nature of participants, FGDs could be homogeneous or heterogeneous.[ 1 , 14 ] One to one in-depth interviews are best suited to obtain individuals' life histories, lived experiences, perceptions, and views, particularly while exporting topics of sensitive nature. In-depth interviews can be structured, unstructured, or semi-structured. However, semi-structured interviews are widely used in qualitative research. Participant observations are suitable for gathering data regarding naturally occurring behaviors.[ 1 ]

Data Analysis in Qualitative Research

Various strategies are employed by researchers to analyze data in qualitative research. Data analytic strategies differ according to the type of inquiry. A general content analysis approach is described herewith. Data analysis begins by transcription of the interview data. The researcher carefully reads data and gets a sense of the whole. Once the researcher is familiarized with the data, the researcher strives to identify small meaning units called the 'codes.' The codes are then grouped based on their shared concepts to form the primary categories. Based on the relationship between the primary categories, they are then clustered into secondary categories. The next step involves the identification of themes and interpretation to make meaning out of data. In the results section of the manuscript, the researcher describes the key findings/themes that emerged. The themes can be supported by participants' quotes. The analytical framework used should be explained in sufficient detail, and the analytic framework must be well referenced. The study findings are usually represented in a schematic form for better conceptualization.[ 1 , 7 ] Even though the overall analytical process remains the same across different qualitative designs, each design such as phenomenology, ethnography, and grounded theory has design specific analytical procedures, the details of which are out of the scope of this article.

Computer-Assisted Qualitative Data Analysis Software (CAQDAS)

Until recently, qualitative analysis was done either manually or with the help of a spreadsheet application. Currently, there are various software programs available which aid researchers to manage qualitative data. CAQDAS is basically data management tools and cannot analyze the qualitative data as it lacks the ability to think, reflect, and conceptualize. Nonetheless, CAQDAS helps researchers to manage, shape, and make sense of unstructured information. Open Code, MAXQDA, NVivo, Atlas.ti, and Hyper Research are some of the widely used qualitative data analysis software.[ 14 , 43 ]

Reporting Guidelines

Consolidated Criteria for Reporting Qualitative Research (COREQ) is the widely used reporting guideline for qualitative research. This 32-item checklist assists researchers in reporting all the major aspects related to the study. The three major domains of COREQ are the 'research team and reflexivity', 'study design', and 'analysis and findings'.[ 44 , 45 ]

Critical Appraisal of Qualitative Research

Various scales are available to critical appraisal of qualitative research. The widely used one is the Critical Appraisal Skills Program (CASP) Qualitative Checklist developed by CASP network, UK. This 10-item checklist evaluates the quality of the study under areas such as aims, methodology, research design, ethical considerations, data collection, data analysis, and findings.[ 46 ]

Ethical Issues in Qualitative Research

A qualitative study must be undertaken by grounding it in the principles of bioethics such as beneficence, non-maleficence, autonomy, and justice. Protecting the participants is of utmost importance, and the greatest care has to be taken while collecting data from a vulnerable research population. The researcher must respect individuals, families, and communities and must make sure that the participants are not identifiable by their quotations that the researchers include when publishing the data. Consent for audio/video recordings must be obtained. Approval to be in FGDs must be obtained from the participants. Researchers must ensure the confidentiality and anonymity of the transcripts/audio-video records/photographs/other data collected as a part of the study. The researchers must confirm their role as advocates and proceed in the best interest of all participants.[ 42 , 47 , 48 ]

Rigor in Qualitative Research

The demonstration of rigor or quality in the conduct of the study is essential for every research method. However, the criteria used to evaluate the rigor of quantitative studies are not be appropriate for qualitative methods. Lincoln and Guba (1985) first outlined the criteria for evaluating the qualitative research often referred to as “standards of trustworthiness of qualitative research”.[ 49 ] The four components of the criteria are credibility, transferability, dependability, and confirmability.

Credibility refers to confidence in the 'truth value' of the data and its interpretation. It is used to establish that the findings are true, credible and believable. Credibility is similar to the internal validity in quantitative research.[ 1 , 50 , 51 ] The second criterion to establish the trustworthiness of the qualitative research is transferability, Transferability refers to the degree to which the qualitative results are applicability to other settings, population or contexts. This is analogous to the external validity in quantitative research.[ 1 , 50 , 51 ] Lincoln and Guba recommend authors provide enough details so that the users will be able to evaluate the applicability of data in other contexts.[ 49 ] The criterion of dependability refers to the assumption of repeatability or replicability of the study findings and is similar to that of reliability in quantitative research. The dependability question is 'Whether the study findings be repeated of the study is replicated with the same (similar) cohort of participants, data coders, and context?'[ 1 , 50 , 51 ] Confirmability, the fourth criteria is analogous to the objectivity of the study and refers the degree to which the study findings could be confirmed or corroborated by others. To ensure confirmability the data should directly reflect the participants' experiences and not the bias, motivations, or imaginations of the inquirer.[ 1 , 50 , 51 ] Qualitative researchers should ensure that the study is conducted with enough rigor and should report the measures undertaken to enhance the trustworthiness of the study.

Conclusions

Qualitative research studies are being widely acknowledged and recognized in health care practice. This overview illustrates various qualitative methods and shows how these methods can be used to generate evidence that informs clinical practice. Qualitative research helps to understand the patterns of health behaviors, describe illness experiences, design health interventions, and develop healthcare theories. The ultimate strength of the qualitative research approach lies in the richness of the data and the descriptions and depth of exploration it makes. Hence, qualitative methods are considered as the most humanistic and person-centered way of discovering and uncovering thoughts and actions of human beings.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

• - Google Chrome

Intended for healthcare professionals

• Access provided by Google Indexer
• My email alerts
• BMA member login
• Username * Password * Forgot your log in details? Need to activate BMA Member Log In Log in via OpenAthens Log in via your institution

Search form

• Advanced search
• Search responses
• Search blogs
• Practical thematic...

Practical thematic analysis: a guide for multidisciplinary health services research teams engaging in qualitative analysis

• Related content
• Peer review
• Catherine H Saunders , scientist and assistant professor 1 2 ,
• Ailyn Sierpe , research project coordinator 2 ,
• Christian von Plessen , senior physician 3 ,
• Alice M Kennedy , research project manager 2 4 ,
• Laura C Leviton , senior adviser 5 ,
• Steven L Bernstein , chief research officer 1 ,
• Jenaya Goldwag , resident physician 1 ,
• Joel R King , research assistant 2 ,
• Christine M Marx , patient associate 6 ,
• Jacqueline A Pogue , research project manager 2 ,
• Richard K Saunders , staff physician 1 ,
• Aricca Van Citters , senior research scientist 2 ,
• Renata W Yen , doctoral student 2 ,
• Glyn Elwyn , professor 2 ,
• JoAnna K Leyenaar , associate professor 1 2
• on behalf of the Coproduction Laboratory
• 1 Dartmouth Health, Lebanon, NH, USA
• 2 Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH, USA
• 3 Center for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
• 4 Jönköping Academy for Improvement of Health and Welfare, School of Health and Welfare, Jönköping University, Jönköping, Sweden
• 5 Highland Park, NJ, USA
• 6 Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
• Correspondence to: C H Saunders catherine.hylas.saunders{at}dartmouth.edu
• Accepted 26 April 2023

Qualitative research methods explore and provide deep contextual understanding of real world issues, including people’s beliefs, perspectives, and experiences. Whether through analysis of interviews, focus groups, structured observation, or multimedia data, qualitative methods offer unique insights in applied health services research that other approaches cannot deliver. However, many clinicians and researchers hesitate to use these methods, or might not use them effectively, which can leave relevant areas of inquiry inadequately explored. Thematic analysis is one of the most common and flexible methods to examine qualitative data collected in health services research. This article offers practical thematic analysis as a step-by-step approach to qualitative analysis for health services researchers, with a focus on accessibility for patients, care partners, clinicians, and others new to thematic analysis. Along with detailed instructions covering three steps of reading, coding, and theming, the article includes additional novel and practical guidance on how to draft effective codes, conduct a thematic analysis session, and develop meaningful themes. This approach aims to improve consistency and rigor in thematic analysis, while also making this method more accessible for multidisciplinary research teams.

Through qualitative methods, researchers can provide deep contextual understanding of real world issues, and generate new knowledge to inform hypotheses, theories, research, and clinical care. Approaches to data collection are varied, including interviews, focus groups, structured observation, and analysis of multimedia data, with qualitative research questions aimed at understanding the how and why of human experience. 1 2 Qualitative methods produce unique insights in applied health services research that other approaches cannot deliver. In particular, researchers acknowledge that thematic analysis is a flexible and powerful method of systematically generating robust qualitative research findings by identifying, analysing, and reporting patterns (themes) within data. 3 4 5 6 Although qualitative methods are increasingly valued for answering clinical research questions, many researchers are unsure how to apply them or consider them too time consuming to be useful in responding to practical challenges 7 or pressing situations such as public health emergencies. 8 Consequently, researchers might hesitate to use them, or use them improperly. 9 10 11

Although much has been written about how to perform thematic analysis, practical guidance for non-specialists is sparse. 3 5 6 12 13 In the multidisciplinary field of health services research, qualitative data analysis can confound experienced researchers and novices alike, which can stoke concerns about rigor, particularly for those more familiar with quantitative approaches. 14 Since qualitative methods are an area of specialisation, support from experts is beneficial. However, because non-specialist perspectives can enhance data interpretation and enrich findings, there is a case for making thematic analysis easier, more rapid, and more efficient, 8 particularly for patients, care partners, clinicians, and other stakeholders. A practical guide to thematic analysis might encourage those on the ground to use these methods in their work, unearthing insights that would otherwise remain undiscovered.

Given the need for more accessible qualitative analysis approaches, we present a simple, rigorous, and efficient three step guide for practical thematic analysis. We include new guidance on the mechanics of thematic analysis, including developing codes, constructing meaningful themes, and hosting a thematic analysis session. We also discuss common pitfalls in thematic analysis and how to avoid them.

Summary points

Qualitative methods are increasingly valued in applied health services research, but multidisciplinary research teams often lack accessible step-by-step guidance and might struggle to use these approaches

A newly developed approach, practical thematic analysis, uses three simple steps: reading, coding, and theming

Based on Braun and Clarke’s reflexive thematic analysis, our streamlined yet rigorous approach is designed for multidisciplinary health services research teams, including patients, care partners, and clinicians

This article also provides companion materials including a slide presentation for teaching practical thematic analysis to research teams, a sample thematic analysis session agenda, a theme coproduction template for use during the session, and guidance on using standardised reporting criteria for qualitative research

In their seminal work, Braun and Clarke developed a six phase approach to reflexive thematic analysis. 4 12 We built on their method to develop practical thematic analysis ( box 1 , fig 1 ), which is a simplified and instructive approach that retains the substantive elements of their six phases. Braun and Clarke’s phase 1 (familiarising yourself with the dataset) is represented in our first step of reading. Phase 2 (coding) remains as our second step of coding. Phases 3 (generating initial themes), 4 (developing and reviewing themes), and 5 (refining, defining, and naming themes) are represented in our third step of theming. Phase 6 (writing up) also occurs during this third step of theming, but after a thematic analysis session. 4 12

Key features and applications of practical thematic analysis

Step 1: reading.

All manuscript authors read the data

All manuscript authors write summary memos

Step 2: Coding

Coders perform both data management and early data analysis

Codes are complete thoughts or sentences, not categories

Step 3: Theming

Researchers host a thematic analysis session and share different perspectives

Themes are complete thoughts or sentences, not categories

Applications

For use by practicing clinicians, patients and care partners, students, interdisciplinary teams, and those new to qualitative research

When important insights from healthcare professionals are inaccessible because they do not have qualitative methods training

When time and resources are limited

Steps in practical thematic analysis

• Download figure
• Open in new tab
• Download powerpoint

We present linear steps, but as qualitative research is usually iterative, so too is thematic analysis. 15 Qualitative researchers circle back to earlier work to check whether their interpretations still make sense in the light of additional insights, adapting as necessary. While we focus here on the practical application of thematic analysis in health services research, we recognise our approach exists in the context of the broader literature on thematic analysis and the theoretical underpinnings of qualitative methods as a whole. For a more detailed discussion of these theoretical points, as well as other methods widely used in health services research, we recommend reviewing the sources outlined in supplemental material 1. A strong and nuanced understanding of the context and underlying principles of thematic analysis will allow for higher quality research. 16

Practical thematic analysis is a highly flexible approach that can draw out valuable findings and generate new hypotheses, including in cases with a lack of previous research to build on. The approach can also be used with a variety of data, such as transcripts from interviews or focus groups, patient encounter transcripts, professional publications, observational field notes, and online activity logs. Importantly, successful practical thematic analysis is predicated on having high quality data collected with rigorous methods. We do not describe qualitative research design or data collection here. 11 17

In supplemental material 1, we summarise the foundational methods, concepts, and terminology in qualitative research. Along with our guide below, we include a companion slide presentation for teaching practical thematic analysis to research teams in supplemental material 2. We provide a theme coproduction template for teams to use during thematic analysis sessions in supplemental material 3. Our method aligns with the major qualitative reporting frameworks, including the Consolidated Criteria for Reporting Qualitative Research (COREQ). 18 We indicate the corresponding step in practical thematic analysis for each COREQ item in supplemental material 4.

Familiarisation and memoing

We encourage all manuscript authors to review the full dataset (eg, interview transcripts) to familiarise themselves with it. This task is most critical for those who will later be engaged in the coding and theming steps. Although time consuming, it is the best way to involve team members in the intellectual work of data interpretation, so that they can contribute to the analysis and contextualise the results. If this task is not feasible given time limitations or large quantities of data, the data can be divided across team members. In this case, each piece of data should be read by at least two individuals who ideally represent different professional roles or perspectives.

We recommend that researchers reflect on the data and independently write memos, defined as brief notes on thoughts and questions that arise during reading, and a summary of their impressions of the dataset. 2 19 Memoing is an opportunity to gain insights from varying perspectives, particularly from patients, care partners, clinicians, and others. It also gives researchers the opportunity to begin to scope which elements of and concepts in the dataset are relevant to the research question.

Data saturation

The concept of data saturation ( box 2 ) is a foundation of qualitative research. It is defined as the point in analysis at which new data tend to be redundant of data already collected. 21 Qualitative researchers are expected to report their approach to data saturation. 18 Because thematic analysis is iterative, the team should discuss saturation throughout the entire process, beginning with data collection and continuing through all steps of the analysis. 22 During step 1 (reading), team members might discuss data saturation in the context of summary memos. Conversations about saturation continue during step 2 (coding), with confirmation that saturation has been achieved during step 3 (theming). As a rule of thumb, researchers can often achieve saturation in 9-17 interviews or 4-8 focus groups, but this will vary depending on the specific characteristics of the study. 23

Data saturation in context

Braun and Clarke discourage the use of data saturation to determine sample size (eg, number of interviews), because it assumes that there is an objective truth to be captured in the data (sometimes known as a positivist perspective). 20 Qualitative researchers often try to avoid positivist approaches, arguing that there is no one true way of seeing the world, and will instead aim to gather multiple perspectives. 5 Although this theoretical debate with qualitative methods is important, we recognise that a priori estimates of saturation are often needed, particularly for investigators newer to qualitative research who might want a more pragmatic and applied approach. In addition, saturation based, sample size estimation can be particularly helpful in grant proposals. However, researchers should still follow a priori sample size estimation with a discussion to confirm saturation has been achieved.

Definition of coding

We describe codes as labels for concepts in the data that are directly relevant to the study objective. Historically, the purpose of coding was to distil the large amount of data collected into conceptually similar buckets so that researchers could review it in aggregate and identify key themes. 5 24 We advocate for a more analytical approach than is typical with thematic analysis. With our method, coding is both the foundation for and the beginning of thematic analysis—that is, early data analysis, management, and reduction occur simultaneously rather than as different steps. This approach moves the team more efficiently towards being able to describe themes.

Building the coding team

Coders are the research team members who directly assign codes to the data, reading all material and systematically labelling relevant data with appropriate codes. Ideally, at least two researchers would code every discrete data document, such as one interview transcript. 25 If this task is not possible, individual coders can each code a subset of the data that is carefully selected for key characteristics (sometimes known as purposive selection). 26 When using this approach, we recommend that at least 10% of data be coded by two or more coders to ensure consistency in codebook application. We also recommend coding teams of no more than four to five people, for practical reasons concerning maintaining consistency.

Clinicians, patients, and care partners bring unique perspectives to coding and enrich the analytical process. 27 Therefore, we recommend choosing coders with a mix of relevant experiences so that they can challenge and contextualise each other’s interpretations based on their own perspectives and opinions ( box 3 ). We recommend including both coders who collected the data and those who are naive to it, if possible, given their different perspectives. We also recommend all coders review the summary memos from the reading step so that key concepts identified by those not involved in coding can be integrated into the analytical process. In practice, this review means coding the memos themselves and discussing them during the code development process. This approach ensures that the team considers a diversity of perspectives.

Coding teams in context

The recommendation to use multiple coders is a departure from Braun and Clarke. 28 29 When the views, experiences, and training of each coder (sometimes known as positionality) 30 are carefully considered, having multiple coders can enhance interpretation and enrich findings. When these perspectives are combined in a team setting, researchers can create shared meaning from the data. Along with the practical consideration of distributing the workload, 31 inclusion of these multiple perspectives increases the overall quality of the analysis by mitigating the impact of any one coder’s perspective. 30

Coding tools

Qualitative analysis software facilitates coding and managing large datasets but does not perform the analytical work. The researchers must perform the analysis themselves. Most programs support queries and collaborative coding by multiple users. 32 Important factors to consider when choosing software can include accessibility, cost, interoperability, the look and feel of code reports, and the ease of colour coding and merging codes. Coders can also use low tech solutions, including highlighters, word processors, or spreadsheets.

Drafting effective codes

To draft effective codes, we recommend that the coders review each document line by line. 33 As they progress, they can assign codes to segments of data representing passages of interest. 34 Coders can also assign multiple codes to the same passage. Consensus among coders on what constitutes a minimum or maximum amount of text for assigning a code is helpful. As a general rule, meaningful segments of text for coding are shorter than one paragraph, but longer than a few words. Coders should keep the study objective in mind when determining which data are relevant ( box 4 ).

Code types in context

Similar to Braun and Clarke’s approach, practical thematic analysis does not specify whether codes are based on what is evident from the data (sometimes known as semantic) or whether they are based on what can be inferred at a deeper level from the data (sometimes known as latent). 4 12 35 It also does not specify whether they are derived from the data (sometimes known as inductive) or determined ahead of time (sometimes known as deductive). 11 35 Instead, it should be noted that health services researchers conducting qualitative studies often adopt all these approaches to coding (sometimes known as hybrid analysis). 3

In practical thematic analysis, codes should be more descriptive than general categorical labels that simply group data with shared characteristics. At a minimum, codes should form a complete (or full) thought. An easy way to conceptualise full thought codes is as complete sentences with subjects and verbs ( table 1 ), although full sentence coding is not always necessary. With full thought codes, researchers think about the data more deeply and capture this insight in the codes. This coding facilitates the entire analytical process and is especially valuable when moving from codes to broader themes. Experienced qualitative researchers often intuitively use full thought or sentence codes, but this practice has not been explicitly articulated as a path to higher quality coding elsewhere in the literature. 6

Example transcript with codes used in practical thematic analysis 36

• View inline

Depending on the nature of the data, codes might either fall into flat categories or be arranged hierarchically. Flat categories are most common when the data deal with topics on the same conceptual level. In other words, one topic is not a subset of another topic. By contrast, hierarchical codes are more appropriate for concepts that naturally fall above or below each other. Hierarchical coding can also be a useful form of data management and might be necessary when working with a large or complex dataset. 5 Codes grouped into these categories can also make it easier to naturally transition into generating themes from the initial codes. 5 These decisions between flat versus hierarchical coding are part of the work of the coding team. In both cases, coders should ensure that their code structures are guided by their research questions.

Developing the codebook

A codebook is a shared document that lists code labels and comprehensive descriptions for each code, as well as examples observed within the data. Good code descriptions are precise and specific so that coders can consistently assign the same codes to relevant data or articulate why another coder would do so. Codebook development is iterative and involves input from the entire coding team. However, as those closest to the data, coders must resist undue influence, real or perceived, from other team members with conflicting opinions—it is important to mitigate the risk that more senior researchers, like principal investigators, exert undue influence on the coders’ perspectives.

In practical thematic analysis, coders begin codebook development by independently coding a small portion of the data, such as two to three transcripts or other units of analysis. Coders then individually produce their initial codebooks. This task will require them to reflect on, organise, and clarify codes. The coders then meet to reconcile the draft codebooks, which can often be difficult, as some coders tend to lump several concepts together while others will split them into more specific codes. Discussing disagreements and negotiating consensus are necessary parts of early data analysis. Once the codebook is relatively stable, we recommend soliciting input on the codes from all manuscript authors. Yet, coders must ultimately be empowered to finalise the details so that they are comfortable working with the codebook across a large quantity of data.

Assigning codes to the data

After developing the codebook, coders will use it to assign codes to the remaining data. While the codebook’s overall structure should remain constant, coders might continue to add codes corresponding to any new concepts observed in the data. If new codes are added, coders should review the data they have already coded and determine whether the new codes apply. Qualitative data analysis software can be useful for editing or merging codes.

We recommend that coders periodically compare their code occurrences ( box 5 ), with more frequent check-ins if substantial disagreements occur. In the event of large discrepancies in the codes assigned, coders should revise the codebook to ensure that code descriptions are sufficiently clear and comprehensive to support coding alignment going forward. Because coding is an iterative process, the team can adjust the codebook as needed. 5 28 29

Quantitative coding in context

Researchers should generally avoid reporting code counts in thematic analysis. However, counts can be a useful proxy in maintaining alignment between coders on key concepts. 26 In practice, therefore, researchers should make sure that all coders working on the same piece of data assign the same codes with a similar pattern and that their memoing and overall assessment of the data are aligned. 37 However, the frequency of a code alone is not an indicator of its importance. It is more important that coders agree on the most salient points in the data; reviewing and discussing summary memos can be helpful here. 5

Researchers might disagree on whether or not to calculate and report inter-rater reliability. We note that quantitative tests for agreement, such as kappa statistics or intraclass correlation coefficients, can be distracting and might not provide meaningful results in qualitative analyses. Similarly, Braun and Clarke argue that expecting perfect alignment on coding is inconsistent with the goal of co-constructing meaning. 28 29 Overall consensus on codes’ salience and contributions to themes is the most important factor.

Definition of themes

Themes are meta-constructs that rise above codes and unite the dataset ( box 6 , fig 2 ). They should be clearly evident, repeated throughout the dataset, and relevant to the research questions. 38 While codes are often explicit descriptions of the content in the dataset, themes are usually more conceptual and knit the codes together. 39 Some researchers hypothesise that theme development is loosely described in the literature because qualitative researchers simply intuit themes during the analytical process. 39 In practical thematic analysis, we offer a concrete process that should make developing meaningful themes straightforward.

Themes in context

According to Braun and Clarke, a theme “captures something important about the data in relation to the research question and represents some level of patterned response or meaning within the data set.” 4 Similarly, Braun and Clarke advise against themes as domain summaries. While different approaches can draw out themes from codes, the process begins by identifying patterns. 28 35 Like Braun and Clarke and others, we recommend that researchers consider the salience of certain themes, their prevalence in the dataset, and their keyness (ie, how relevant the themes are to the overarching research questions). 4 12 34

Use of themes in practical thematic analysis

Constructing meaningful themes

After coding all the data, each coder should independently reflect on the team’s summary memos (step 1), the codebook (step 2), and the coded data itself to develop draft themes (step 3). It can be illuminating for coders to review all excerpts associated with each code, so that they derive themes directly from the data. Researchers should remain focused on the research question during this step, so that themes have a clear relation with the overall project aim. Use of qualitative analysis software will make it easy to view each segment of data tagged with each code. Themes might neatly correspond to groups of codes. Or—more likely—they will unite codes and data in unexpected ways. A whiteboard or presentation slides might be helpful to organise, craft, and revise themes. We also provide a template for coproducing themes (supplemental material 3). As with codebook justification, team members will ideally produce individual drafts of the themes that they have identified in the data. They can then discuss these with the group and reach alignment or consensus on the final themes.

The team should ensure that all themes are salient, meaning that they are: supported by the data, relevant to the study objectives, and important. Similar to codes, themes are framed as complete thoughts or sentences, not categories. While codes and themes might appear to be similar to each other, the key distinction is that the themes represent a broader concept. Table 2 shows examples of codes and their corresponding themes from a previously published project that used practical thematic analysis. 36 Identifying three to four key themes that comprise a broader overarching theme is a useful approach. Themes can also have subthemes, if appropriate. 40 41 42 43 44

Example codes with themes in practical thematic analysis 36

Thematic analysis session

After each coder has independently produced draft themes, a carefully selected subset of the manuscript team meets for a thematic analysis session ( table 3 ). The purpose of this session is to discuss and reach alignment or consensus on the final themes. We recommend a session of three to five hours, either in-person or virtually.

Example agenda of thematic analysis session

The composition of the thematic analysis session team is important, as each person’s perspectives will shape the results. This group is usually a small subset of the broader research team, with three to seven individuals. We recommend that primary and senior authors work together to include people with diverse experiences related to the research topic. They should aim for a range of personalities and professional identities, particularly those of clinicians, trainees, patients, and care partners. At a minimum, all coders and primary and senior authors should participate in the thematic analysis session.

The session begins with each coder presenting their draft themes with supporting quotes from the data. 5 Through respectful and collaborative deliberation, the group will develop a shared set of final themes.

One team member facilitates the session. A firm, confident, and consistent facilitation style with good listening skills is critical. For practical reasons, this person is not usually one of the primary coders. Hierarchies in teams cannot be entirely flattened, but acknowledging them and appointing an external facilitator can reduce their impact. The facilitator can ensure that all voices are heard. For example, they might ask for perspectives from patient partners or more junior researchers, and follow up on comments from senior researchers to say, “We have heard your perspective and it is important; we want to make sure all perspectives in the room are equally considered.” Or, “I hear [senior person] is offering [x] idea, I’d like to hear other perspectives in the room.” The role of the facilitator is critical in the thematic analysis session. The facilitator might also privately discuss with more senior researchers, such as principal investigators and senior authors, the importance of being aware of their influence over others and respecting and eliciting the perspectives of more junior researchers, such as patients, care partners, and students.

To our knowledge, this discrete thematic analysis session is a novel contribution of practical thematic analysis. It helps efficiently incorporate diverse perspectives using the session agenda and theme coproduction template (supplemental material 3) and makes the process of constructing themes transparent to the entire research team.

Writing the report

We recommend beginning the results narrative with a summary of all relevant themes emerging from the analysis, followed by a subheading for each theme. Each subsection begins with a brief description of the theme and is illustrated with relevant quotes, which are contextualised and explained. The write-up should not simply be a list, but should contain meaningful analysis and insight from the researchers, including descriptions of how different stakeholders might have experienced a particular situation differently or unexpectedly.

In addition to weaving quotes into the results narrative, quotes can be presented in a table. This strategy is a particularly helpful when submitting to clinical journals with tight word count limitations. Quote tables might also be effective in illustrating areas of agreement and disagreement across stakeholder groups, with columns representing different groups and rows representing each theme or subtheme. Quotes should include an anonymous label for each participant and any relevant characteristics, such as role or gender. The aim is to produce rich descriptions. 5 We recommend against repeating quotations across multiple themes in the report, so as to avoid confusion. The template for coproducing themes (supplemental material 3) allows documentation of quotes supporting each theme, which might also be useful during report writing.

Visual illustrations such as a thematic map or figure of the findings can help communicate themes efficiently. 4 36 42 44 If a figure is not possible, a simple list can suffice. 36 Both must clearly present the main themes with subthemes. Thematic figures can facilitate confirmation that the researchers’ interpretations reflect the study populations’ perspectives (sometimes known as member checking), because authors can invite discussions about the figure and descriptions of findings and supporting quotes. 46 This process can enhance the validity of the results. 46

In supplemental material 4, we provide additional guidance on reporting thematic analysis consistent with COREQ. 18 Commonly used in health services research, COREQ outlines a standardised list of items to be included in qualitative research reports ( box 7 ).

Reporting in context

We note that use of COREQ or any other reporting guidelines does not in itself produce high quality work and should not be used as a substitute for general methodological rigor. Rather, researchers must consider rigor throughout the entire research process. As the issue of how to conceptualise and achieve rigorous qualitative research continues to be debated, 47 48 we encourage researchers to explicitly discuss how they have looked at methodological rigor in their reports. Specifically, we point researchers to Braun and Clarke’s 2021 tool for evaluating thematic analysis manuscripts for publication (“Twenty questions to guide assessment of TA [thematic analysis] research quality”). 16

Avoiding common pitfalls

Awareness of common mistakes can help researchers avoid improper use of qualitative methods. Improper use can, for example, prevent researchers from developing meaningful themes and can risk drawing inappropriate conclusions from the data. Braun and Clarke also warn of poor quality in qualitative research, noting that “coherence and integrity of published research does not always hold.” 16

Weak themes

An important distinction between high and low quality themes is that high quality themes are descriptive and complete thoughts. As such, they often contain subjects and verbs, and can be expressed as full sentences ( table 2 ). Themes that are simply descriptive categories or topics could fail to impart meaningful knowledge beyond categorisation. 16 49 50

Researchers will often move from coding directly to writing up themes, without performing the work of theming or hosting a thematic analysis session. Skipping concerted theming often results in themes that look more like categories than unifying threads across the data.

Unfocused analysis

Because data collection for qualitative research is often semi-structured (eg, interviews, focus groups), not all data will be directly relevant to the research question at hand. To avoid unfocused analysis and a correspondingly unfocused manuscript, we recommend that all team members keep the research objective in front of them at every stage, from reading to coding to theming. During the thematic analysis session, we recommend that the research question be written on a whiteboard so that all team members can refer back to it, and so that the facilitator can ensure that conversations about themes occur in the context of this question. Consistently focusing on the research question can help to ensure that the final report directly answers it, as opposed to the many other interesting insights that might emerge during the qualitative research process. Such insights can be picked up in a secondary analysis if desired.

Inappropriate quantification

Presenting findings quantitatively (eg, “We found 18 instances of participants mentioning safety concerns about the vaccines”) is generally undesirable in practical thematic analysis reporting. 51 Descriptive terms are more appropriate (eg, “participants had substantial concerns about the vaccines,” or “several participants were concerned about this”). This descriptive presentation is critical because qualitative data might not be consistently elicited across participants, meaning that some individuals might share certain information while others do not, simply based on how conversations evolve. Additionally, qualitative research does not aim to draw inferences outside its specific sample. Emphasising numbers in thematic analysis can lead to readers incorrectly generalising the findings. Although peer reviewers unfamiliar with thematic analysis often request this type of quantification, practitioners of practical thematic analysis can confidently defend their decision to avoid it. If quantification is methodologically important, we recommend simultaneously conducting a survey or incorporating standardised interview techniques into the interview guide. 11

Neglecting group dynamics

Researchers should concertedly consider group dynamics in the research team. Particular attention should be paid to power relations and the personality of team members, which can include aspects such as who most often speaks, who defines concepts, and who resolves disagreements that might arise within the group. 52

The perspectives of patient and care partners are particularly important to cultivate. Ideally, patient partners are meaningfully embedded in studies from start to finish, not just for practical thematic analysis. 53 Meaningful engagement can build trust, which makes it easier for patient partners to ask questions, request clarification, and share their perspectives. Professional team members should actively encourage patient partners by emphasising that their expertise is critically important and valued. Noting when a patient partner might be best positioned to offer their perspective can be particularly powerful.

Insufficient time allocation

Researchers must allocate enough time to complete thematic analysis. Working with qualitative data takes time, especially because it is often not a linear process. As the strength of thematic analysis lies in its ability to make use of the rich details and complexities of the data, we recommend careful planning for the time required to read and code each document.

Estimating the necessary time can be challenging. For step 1 (reading), researchers can roughly calculate the time required based on the time needed to read and reflect on one piece of data. For step 2 (coding), the total amount of time needed can be extrapolated from the time needed to code one document during codebook development. We also recommend three to five hours for the thematic analysis session itself, although coders will need to independently develop their draft themes beforehand. Although the time required for practical thematic analysis is variable, teams should be able to estimate their own required effort with these guidelines.

Practical thematic analysis builds on the foundational work of Braun and Clarke. 4 16 We have reframed their six phase process into three condensed steps of reading, coding, and theming. While we have maintained important elements of Braun and Clarke’s reflexive thematic analysis, we believe that practical thematic analysis is conceptually simpler and easier to teach to less experienced researchers and non-researcher stakeholders. For teams with different levels of familiarity with qualitative methods, this approach presents a clear roadmap to the reading, coding, and theming of qualitative data. Our practical thematic analysis approach promotes efficient learning by doing—experiential learning. 12 29 Practical thematic analysis avoids the risk of relying on complex descriptions of methods and theory and places more emphasis on obtaining meaningful insights from those close to real world clinical environments. Although practical thematic analysis can be used to perform intensive theory based analyses, it lends itself more readily to accelerated, pragmatic approaches.

Strengths and limitations

Our approach is designed to smooth the qualitative analysis process and yield high quality themes. Yet, researchers should note that poorly performed analyses will still produce low quality results. Practical thematic analysis is a qualitative analytical approach; it does not look at study design, data collection, or other important elements of qualitative research. It also might not be the right choice for every qualitative research project. We recommend it for applied health services research questions, where diverse perspectives and simplicity might be valuable.

We also urge researchers to improve internal validity through triangulation methods, such as member checking (supplemental material 1). 46 Member checking could include soliciting input on high level themes, theme definitions, and quotations from participants. This approach might increase rigor.

Implications

We hope that by providing clear and simple instructions for practical thematic analysis, a broader range of researchers will be more inclined to use these methods. Increased transparency and familiarity with qualitative approaches can enhance researchers’ ability to both interpret qualitative studies and offer up new findings themselves. In addition, it can have usefulness in training and reporting. A major strength of this approach is to facilitate meaningful inclusion of patient and care partner perspectives, because their lived experiences can be particularly valuable in data interpretation and the resulting findings. 11 30 As clinicians are especially pressed for time, they might also appreciate a practical set of instructions that can be immediately used to leverage their insights and access to patients and clinical settings, and increase the impact of qualitative research through timely results. 8

Practical thematic analysis is a simplified approach to performing thematic analysis in health services research, a field where the experiences of patients, care partners, and clinicians are of inherent interest. We hope that it will be accessible to those individuals new to qualitative methods, including patients, care partners, clinicians, and other health services researchers. We intend to empower multidisciplinary research teams to explore unanswered questions and make new, important, and rigorous contributions to our understanding of important clinical and health systems research.

Acknowledgments

All members of the Coproduction Laboratory provided input that shaped this manuscript during laboratory meetings. We acknowledge advice from Elizabeth Carpenter-Song, an expert in qualitative methods.

Coproduction Laboratory group contributors: Stephanie C Acquilano ( http://orcid.org/0000-0002-1215-5531 ), Julie Doherty ( http://orcid.org/0000-0002-5279-6536 ), Rachel C Forcino ( http://orcid.org/0000-0001-9938-4830 ), Tina Foster ( http://orcid.org/0000-0001-6239-4031 ), Megan Holthoff, Christopher R Jacobs ( http://orcid.org/0000-0001-5324-8657 ), Lisa C Johnson ( http://orcid.org/0000-0001-7448-4931 ), Elaine T Kiriakopoulos, Kathryn Kirkland ( http://orcid.org/0000-0002-9851-926X ), Meredith A MacMartin ( http://orcid.org/0000-0002-6614-6091 ), Emily A Morgan, Eugene Nelson, Elizabeth O’Donnell, Brant Oliver ( http://orcid.org/0000-0002-7399-622X ), Danielle Schubbe ( http://orcid.org/0000-0002-9858-1805 ), Gabrielle Stevens ( http://orcid.org/0000-0001-9001-178X ), Rachael P Thomeer ( http://orcid.org/0000-0002-5974-3840 ).

Contributors: Practical thematic analysis, an approach designed for multidisciplinary health services teams new to qualitative research, was based on CHS’s experiences teaching thematic analysis to clinical teams and students. We have drawn heavily from qualitative methods literature. CHS is the guarantor of the article. CHS, AS, CvP, AMK, JRK, and JAP contributed to drafting the manuscript. AS, JG, CMM, JAP, and RWY provided feedback on their experiences using practical thematic analysis. CvP, LCL, SLB, AVC, GE, and JKL advised on qualitative methods in health services research, given extensive experience. All authors meaningfully edited the manuscript content, including AVC and RKS. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

Funding: This manuscript did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Competing interests: All authors have completed the ICMJE uniform disclosure form at https://www.icmje.org/disclosure-of-interest/ and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

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

• Ziebland S ,
• ↵ A Hybrid Approach to Thematic Analysis in Qualitative Research: Using a Practical Example. 2018. https://methods.sagepub.com/case/hybrid-approach-thematic-analysis-qualitative-research-a-practical-example .
• Maguire M ,
• Vindrola-Padros C ,
• Vindrola-Padros B
• ↵ Vindrola-Padros C. Rapid Ethnographies: A Practical Guide . Cambridge University Press 2021. https://play.google.com/store/books/details?id=n80HEAAAQBAJ
• Schroter S ,
• Merino JG ,
• Barbeau A ,
• ↵ Padgett DK. Qualitative and Mixed Methods in Public Health . SAGE Publications 2011. https://play.google.com/store/books/details?id=LcYgAQAAQBAJ
• Scharp KM ,
• Korstjens I
• Barnett-Page E ,
• ↵ Guest G, Namey EE, Mitchell ML. Collecting Qualitative Data: A Field Manual for Applied Research . SAGE 2013. https://play.google.com/store/books/details?id=-3rmWYKtloC
• Sainsbury P ,
• Emerson RM ,
• Saunders B ,
• Kingstone T ,
• Hennink MM ,
• Kaiser BN ,
• Hennink M ,
• O’Connor C ,
• ↵ Yen RW, Schubbe D, Walling L, et al. Patient engagement in the What Matters Most trial: experiences and future implications for research. Poster presented at International Shared Decision Making conference, Quebec City, Canada. July 2019.
• ↵ Got questions about Thematic Analysis? We have prepared some answers to common ones. https://www.thematicanalysis.net/faqs/ (accessed 9 Nov 2022).
• ↵ Braun V, Clarke V. Thematic Analysis. SAGE Publications. 2022. https://uk.sagepub.com/en-gb/eur/thematic-analysis/book248481 .
• Kalpokas N ,
• Radivojevic I
• Campbell KA ,
• Durepos P ,
• ↵ Understanding Thematic Analysis. https://www.thematicanalysis.net/understanding-ta/ .
• Saunders CH ,
• Stevens G ,
• CONFIDENT Study Long-Term Care Partners
• MacQueen K ,
• Vaismoradi M ,
• Turunen H ,
• Schott SL ,
• Berkowitz J ,
• Carpenter-Song EA ,
• Goldwag JL ,
• Durand MA ,
• Goldwag J ,
• Saunders C ,
• Mishra MK ,
• Rodriguez HP ,
• Shortell SM ,
• Verdinelli S ,
• Scagnoli NI
• Campbell C ,
• Sparkes AC ,
• McGannon KR
• Sandelowski M ,
• Connelly LM ,
• O’Malley AJ ,

• Technical Support
• Find My Rep

You are here

The SAGE Handbook of Qualitative Methods in Health Research

• Ivy Bourgeault - University of Ottawa, Canada
• Robert Dingwall - Dingwall Enterprises Ltd.
• Ray de Vries - University of Michigan, USA
• Description

The Sage Handbook of Qualitative Methods in Health Research is a comprehensive and authoritative source on qualitative research methods.

The Handbook compiles accessible yet vigorous academic contributions by respected academics from the fast-growing field of qualitative methods in health research and consists of:

• A series of case studies in the ways in which qualitative methods have contributed to the development of thinking in fields relevant to policy and practice in health care.
• A section examining the main theoretical sources drawn on by qualitative researchers.
• A section on specific techniques for the collection of data.
• A section exploring issues relevant to the strategic place of qualitative research in health care environments.

The Sage Handbook of Qualitative Methods in Health Research is an invaluable source of reference for all students, researchers, and practitioners with a background in the health professions or health sciences.

See what’s new to this edition by selecting the Features tab on this page. Should you need additional information or have questions regarding the HEOA information provided for this title, including what is new to this edition, please email [email protected] . Please include your name, contact information, and the name of the title for which you would like more information. For information on the HEOA, please go to http://ed.gov/policy/highered/leg/hea08/index.html .

For assistance with your order: Please email us at [email protected] or connect with your SAGE representative.

SAGE 2455 Teller Road Thousand Oaks, CA 91320 www.sagepub.com

"The demand for high-quality, evidence-based health care represents a paradigm shift in health research, which this handbook explores. Essays focus on a wide range of topics within qualitative research investigation, including the philosophy of science, chaos theory, bioethics, reliability and validity issues, levels of research, and mixed methods approaches. With this volume, the editors--all internationally recognized experts in the social sciences--offer a valuable educational tool for instructors at either the undergraduate or the graduate level."

Excellent resource for students undertaking a higher degree using qualitative research methods.

A comprehensive text suitable for PhD students.

This is one of the most comprehensive handbook's on qualitative research. Highly recommended.

I have found this text most useful for my PhD study and do recommend it to other students. Thank you.

The students considered the book very useful and friendly . Was regarded as the best in qualitative methods in health

brilliant - comprehensive and clear. An excellent library resource.

Very good introductory level chapters as a reference for students learning about qualitative research for the 1st time

A practical books that guides the reader through qualatitive research methods.

Preview this book

Sample materials & chapters.

Chapter 1: There's More to Dying than Death: Qualitative Research on the End-of-

Select a Purchasing Option

Related products.

This title is also available on SAGE Knowledge , the ultimate social sciences online library. If your library doesn’t have access, ask your librarian to start a trial .

This title is also available on SAGE Research Methods , the ultimate digital methods library. If your library doesn’t have access, ask your librarian to start a trial .

Items related to Practical Guide: Qualitative Methods in Health and...

Practical guide: qualitative methods in health and educational research - softcover, amol dongre ; pradeep deshmukh.

This specific ISBN edition is currently not available.

• About this edition
• Publisher Notion Press
• Publication date 2021
• ISBN 10  1685097901
• ISBN 13  9781685097905
• Binding Paperback
• Number of pages 176

(No Available Copies)

• Advanced Search
• AbeBooks Home

If you know the book but cannot find it on AbeBooks, we can automatically search for it on your behalf as new inventory is added. If it is added to AbeBooks by one of our member booksellers, we will notify you!

Top Search Results from the AbeBooks Marketplace

Want to create or adapt books like this? Learn more about how Pressbooks supports open publishing practices.

Book Title: Qualitative Research – a practical guide for health and social care researchers and practitioners

Authors: Darshini Ayton; Tess Tsindos; and Danielle Berkovic

Download this book

• Digital PDF
• Pressbooks XML
• WordPress XML
• OpenDocument
• Common Cartridge (Web Links)

Book Description: This guide is designed to support health and social care researchers and practitioners to conduct qualitative research. (Published 2023)

Book Information

Book description.

This guide is designed to support health and social care researchers and practitioners to integrate qualitative research into the evidence base of health and social care research. Qualitative research designs are diverse and each design has a different focus that will inform the approach undertaken and the results that are generated. The aim is to move beyond the “what” of qualitative research to the “how”, by (1) outlining key qualitative research designs for health and social care research – descriptive, phenomenology, action research, case study, ethnography, and grounded theory; (2) a decision tool of how to select the appropriate design based on a guiding prompting question, the research question and available resources, time and expertise; (3) an overview of mixed methods research and qualitative research in evaluation studies; (4) a practical guide to data collection and analysis; (5) providing examples of qualitative research to illustrate the scope and opportunities; and (6) tips on communicating qualitative research.

Cover design by Les Thomas

Qualitative Research – a practical guide for health and social care researchers and practitioners Copyright © 2023 by Darshini Ayton; Tess Tsindos; Danielle Berkovic is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

Research methods: general

Darshni Ayton, Tess Tsindos, and Danielle Berkovic assert their right to be known as the authors of this work.

This book was published via the Council of Australian University Librarians Open Educational Resources Collective in 2023. The online version is available at https://oercollective.caul.edu.au/qualitative-research/

Disclaimer:    Note that corporate logos (and the logos of any other company represented) and branding are specifically excluded from the Creative Commons Attribution NonCommercial Licence 4.0 of this work, and may not be reproduced under any circumstances without the express written permission of the copyright holders.

A practical guide for conducting qualitative research in medical education: Part 3-Using software for qualitative analysis

Affiliations.

• 1 Department of Emergency Medicine University of California, Davis Health System Sacramento California USA.
• 2 Department of Emergency Medicine University of California, Los Angeles, David Geffen School of Medicine at UCLA Los Angeles California USA.
• 3 Department of Emergency Medicine Harbor-UCLA Medical Center Torrance California USA.
• 4 Department of Emergency Medicine Ronald Reagan UCLA Medical Center Los Angeles California USA.
• PMID: 34589659
• PMCID: PMC8457694
• DOI: 10.1002/aet2.10644

The process of performing qualitative analysis can be a daunting task. Technology can be employed to ease the burden of the work; however, the researcher may not fully appreciate how and when computer software can assist in conducting qualitative analysis. In this, the third installment of our "how-to" series on qualitative research methods, we describe basic concepts and approaches to using both simple word processing programs and specific qualitative research software programs to assist in coding and analysis. We hope that the concepts put forth in this paper will help qualitative researchers become more familiar with available technological approaches and that they will, in turn, enhance the efficiency of the research process as well as the depth, clarity and richness of research findings.

Keywords: education research; qualitative analysis; qualitative research methods; software.

© 2021 by the Society for Academic Emergency Medicine.

• Download PDF
• CME & MOC
• Share X Facebook Email LinkedIn
• Permissions

Practical Guide to Education Program Evaluation Research

• 1 Department of Surgery, Medical College of Wisconsin, Milwaukee
• 2 Department of Emergency Medicine, University of Colorado, Aurora
• 3 Statistical Editor, JAMA Surgery
• 4 Department of Surgery, VA Boston Healthcare System, Boston University, Harvard Medical School, Boston, Massachusetts
• Editorial Improving the Integrity of Surgical Education Scholarship Amalia Cochran, MD, MA; Dimitrios Stefanidis, MD, PhD; Melina R. Kibbe, MD JAMA Surgery
• Guide to Statistics and Methods Practical Guide to Ethics in Surgical Education Research Michael M. Awad, MD, PhD, MHPE; Amy H. Kaji, MD, PhD; Timothy M. Pawlik, MD, PhD, MTS, MPH, MBA JAMA Surgery
• Guide to Statistics and Methods Practical Guide to Curricular Development Research Kevin Y. Pei, MD, MHS; Todd A. Schwartz, DrPH; Marja A. Boermeester, MD, PhD JAMA Surgery
• Guide to Statistics and Methods Practical Guide to Survey Research in Surgical Education Adnan A. Alseidi, MD, EdM; Jason S. Haukoos, MD, MSc; Christian de Virgilio, MD JAMA Surgery
• Guide to Statistics and Methods Practical Guide to Common Flaws With Surgical Education Research Dimitrios Stefanidis, MD, PhD; Laura Torbeck, PhD; Amy H. Kaji, MD, PhD JAMA Surgery
• Guide to Statistics and Methods Practical Guide to Machine Learning and Artificial Intelligence in Surgical Education Research Daniel A. Hashimoto, MD; Julian Varas, MD; Todd A. Schwartz, DrPH JAMA Surgery
• Guide to Statistics and Methods Practical Guide to Surgical Simulation Research Aimee K. Gardner, PhD; Amy H. Kaji, MD, PhD; Marja Boermeester, MD, PhD JAMA Surgery
• Guide to Statistics and Methods Practical Guide to Qualitative Research in Surgical Education Gurjit Sandhu, PhD; Amy H. Kaji, MD, PhD; Amalia Cochran, MD, MA JAMA Surgery
• Guide to Statistics and Methods Practical Guide to Assessment Tool Development for Surgical Education Research Mohsen M. Shabahang, MD, PhD; Todd A. Schwartz, DrPH; Liane S. Feldman, MD JAMA Surgery
• Guide to Statistics and Methods Practical Guide to Experimental and Quasi-Experimental Research in Surgical Education Roy Phitayakorn, MD, MHPE; Todd A. Schwartz, DrPH; Gerard M. Doherty, MD JAMA Surgery
• Guide to Statistics and Methods Practical Guide to Pragmatic Clinical Trials in Surgical Education Research Karl Y. Bilimoria, MD, MS; Jason S. Haukoos, MD, MSc; Gerard M. Doherty, MD JAMA Surgery

Program evaluation is the systematic assessment of a program’s implementation. In medical education, evaluation includes the synthesis and analysis of educational programs, which in turn provides evidence for educational best practices. In medical education, as in other fields, the quality of the synthesis is dependent on the rigor by which evaluations are performed. Individual program evaluation is best achieved when similar programs apply the same scientific rigor and methodology to assess outcomes, thus allowing for direct comparisons. The pedagogy of a given program, particularly in medical education, can be driven by nonscientific forces (ie, political, faddism, or ideology) rather than evidence. 1 This often impedes more rapid progress of educational methods to achieve an educational goal compared with a more evidence-based practice. 2

• Editorial Improving the Integrity of Surgical Education Scholarship JAMA Surgery

Read More About

de Moya M , Haukoos JS , Itani KMF. Practical Guide to Education Program Evaluation Research. JAMA Surg. Published online January 03, 2024. doi:10.1001/jamasurg.2023.6702

Manage citations:

© 2024

Artificial Intelligence Resource Center

Surgery in JAMA : Read the Latest

Browse and subscribe to JAMA Network podcasts!

Others Also Liked

Select your interests.

Customize your JAMA Network experience by selecting one or more topics from the list below.

• Academic Medicine
• Acid Base, Electrolytes, Fluids
• Allergy and Clinical Immunology
• American Indian or Alaska Natives
• Anesthesiology
• Anticoagulation
• Art and Images in Psychiatry
• Artificial Intelligence
• Assisted Reproduction
• Bleeding and Transfusion
• Caring for the Critically Ill Patient
• Challenges in Clinical Electrocardiography
• Climate and Health
• Climate Change
• Clinical Challenge
• Clinical Decision Support
• Clinical Implications of Basic Neuroscience
• Clinical Pharmacy and Pharmacology
• Complementary and Alternative Medicine
• Consensus Statements
• Coronavirus (COVID-19)
• Critical Care Medicine
• Cultural Competency
• Dental Medicine
• Dermatology
• Diabetes and Endocrinology
• Diagnostic Test Interpretation
• Drug Development
• Electronic Health Records
• Emergency Medicine
• End of Life, Hospice, Palliative Care
• Environmental Health
• Equity, Diversity, and Inclusion
• Facial Plastic Surgery
• Gastroenterology and Hepatology
• Genetics and Genomics
• Genomics and Precision Health
• Global Health
• Guide to Statistics and Methods
• Hair Disorders
• Health Care Delivery Models
• Health Care Economics, Insurance, Payment
• Health Care Quality
• Health Care Reform
• Health Care Safety
• Health Care Workforce
• Health Disparities
• Health Inequities
• Health Policy
• Health Systems Science
• History of Medicine
• Hypertension
• Images in Neurology
• Implementation Science
• Infectious Diseases
• Innovations in Health Care Delivery
• JAMA Infographic
• Law and Medicine
• Leading Change
• Less is More
• LGBTQIA Medicine
• Lifestyle Behaviors
• Medical Coding
• Medical Devices and Equipment
• Medical Education
• Medical Education and Training
• Medical Journals and Publishing
• Mobile Health and Telemedicine
• Narrative Medicine
• Neuroscience and Psychiatry
• Notable Notes
• Nutrition, Obesity, Exercise
• Obstetrics and Gynecology
• Occupational Health
• Ophthalmology
• Orthopedics
• Otolaryngology
• Pain Medicine
• Palliative Care
• Pathology and Laboratory Medicine
• Patient Care
• Patient Information
• Performance Improvement
• Performance Measures
• Perioperative Care and Consultation
• Pharmacoeconomics
• Pharmacoepidemiology
• Pharmacogenetics
• Pharmacy and Clinical Pharmacology
• Physical Medicine and Rehabilitation
• Physical Therapy
• Physician Leadership
• Population Health
• Primary Care
• Professional Well-being
• Professionalism
• Psychiatry and Behavioral Health
• Public Health
• Pulmonary Medicine
• Regulatory Agencies
• Reproductive Health
• Research, Methods, Statistics
• Resuscitation
• Rheumatology
• Risk Management
• Scientific Discovery and the Future of Medicine
• Shared Decision Making and Communication
• Sleep Medicine
• Sports Medicine
• Stem Cell Transplantation
• Substance Use and Addiction Medicine
• Surgical Innovation
• Surgical Pearls
• Teachable Moment
• Technology and Finance
• The Art of JAMA
• The Arts and Medicine
• The Rational Clinical Examination
• Tobacco and e-Cigarettes
• Translational Medicine
• Trauma and Injury
• Treatment Adherence
• Ultrasonography
• Users' Guide to the Medical Literature
• Vaccination
• Venous Thromboembolism
• Veterans Health
• Women's Health
• Workflow and Process
• Wound Care, Infection, Healing
• Register for email alerts with links to free full-text articles
• Access PDFs of free articles
• Manage your interests
• Save searches and receive search alerts

• Open access
• Published: 14 May 2024

Health systems challenges, mitigation strategies and adaptations to maintain essential health services during the COVID-19 pandemic: learnings from the six geopolitical regions in Nigeria

• Segun Bello 1 ,
• Rachel Neill 2 ,
• Ayodele S Jegede 1 ,
• Eniola A. Bamgboye 1 ,
• Mobolaji M. Salawu 1 ,
• Rotimi Felix Afolabi 1 ,
• Charles Nzelu 3 ,
• Ngozi Azodo 3 ,
• Anthony Adoghe 3 ,
• Munirat Ogunlayi 2 ,
• Saudatu Umma Yaradua 2 ,
• William Wang 4 ,
• Anne Liu 4 &
• Olufunmilayo I. Fawole 1  

BMC Health Services Research volume  24 , Article number:  625 ( 2024 ) Cite this article

171 Accesses

1 Altmetric

Metrics details

The COVID-19 pandemic control strategies disrupted the smooth delivery of essential health services (EHS) globally. Limited evidence exists on the health systems lens approach to analyzing the challenges encountered in maintaining EHS during the COVID-19 pandemic. This study aimed to identify the health system challenges encountered and document the mitigation strategies and adaptations made across geopolitical zones (GPZs) in Nigeria.

The national qualitative survey of key actors across the six GPZs in Nigeria involved ten states and the Federal Capital Territory (FCT) which were selected based on resilience, COVID-19 burden and security considerations. A pre-tested key informant guide was used to collect data on service utilization, changes in service utilization, reasons for changes in primary health centres’ (PHCs) service volumes, challenges experienced by health facilities in maintaining EHS, mitigation strategies implemented and adaptations to service delivery. Emerging sub-themes were categorized under the appropriate pillars of the health system.

A total of 22 respondents were interviewed. The challenges experienced in maintaining EHS cut across the pillars of the health systems including: Human resources shortage, shortages in the supply of personal protective equipments, fear of contracting COVID-19 among health workers misconception, ignorance, socio-cultural issues, lockdown/transportation and lack of equipment/waiting area (. The mitigation strategies included improved political will to fund health service projects, leading to improved accessibility, affordability, and supply of consumables. The health workforce was motivated by employing, redeploying, training, and incentivizing. Service delivery was reorganized by rescheduling appointments and prioritizing some EHS such as maternal and childcare. Sustainable systems adaptations included IPC and telehealth infrastructure, training and capacity building, virtual meetings and community groups set up for sensitization and engagement.

The mitigation strategies and adaptations implemented were important contributors to EHS recovery especially in the high resilience LGAs and have implications for future epidemic preparedness plans.

Peer Review reports

The COVID-19 pandemic remains the biggest global health systems shock of the 21st century leading to about 6.8 million deaths as of 26th February, 2023 [ 1 ]. The interventions implemented to control the pandemic have had far-reaching consequences, ranging from disruptions to socio-economic activities, to decline in health services provision and utilization. According to the World Health Organization (WHO), countries henceforth need to make trade-offs between the scale of direct response to health threats and the actions geared towards maintaining essential health service delivery, to mitigate the risk of system collapse [ 2 ].

Disruptions are defined as “unforeseen events that interfere with the provision of healthcare goods and services” [ 3 ]. During the COVID-19 pandemic, disruptions in health service delivery and decline in essential health services utilization was documented across all health systems including high, medium and low-income countries [ 4 ]. These disruptions were attributed to aspects of the COVID-19 pandemic response including lockdowns and reorganization of health service delivery with a shift in focus to COVID-19 control [ 2 ]. For example, in Europe, screening for cancers decreased by as much as 65 − 95% during the early phase of the pandemic [ 5 ]. In Africa, several health programmes including the malaria elimination programme, HIV/tuberculosis control, diabetes, and hypertension services were deprioritized during the pandemic [ 6 , 7 ]. Heavy declines were also reported for maternal, child health and immunization programmes [ 8 , 9 ]. effectively threatening the gains achieved in health programme outcomes over decades of investment [ 10 ]. These health programmes reported decline in service output as well as set- backs in performance indicators as similarly demonstrated during the West Africa Ebola outbreak pandemic. Analysis of the 2014–2015 Ebola outbreak suggested that the number of deaths caused by measles, malaria, HIV/AIDS and tuberculosis attributable to health systems failure during the Ebola outbreak exceeded deaths from Ebola [ 11 , 12 , 13 , 14 ].

The WHO health systems framework describes the core building blocks or pillars of the health systems which contribute to the resilience of a health system [ 15 ]. The performance of the health system in handling health crisis depends on its baseline capacity predating the crisis, as well as the magnitude of the crisis [ 2 ]. Kruk et al. defined health systems resilience as ‘the capacity of health actors, institutions, and populations to prepare for and effectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learned during the crisis, reorganize if conditions require it.’ [ 16 ] Thus, apart from maintaining the core functions of a health system, resilience includes the health system’s ability to transform, evolve and enhance its performance in improving the health of the population [ 17 ].

A well-prepared health system should have the capacity to maintain essential health services delivery to reduce morbidity and mortality from sources other than the cause of the health systems shock, throughout the duration of an emergency. Both demand and supply factors have been documented as challenges mitigating against the maintenance and utilization of essential services across health systems during the COVID-19 pandemic. The pandemic increased the workload for health systems, resulting in pressure and inadequate health workforce all over the world [ 5 ]. However, LMICs have been particularly affected from operating more vulnerable health systems with challenges that predated the COVID-19 pandemic. To compound the challenges of human resource shortages, about 50% of health facilities across Africa reported COVID-19 infection among staff, shortages in personal protective equipment (PPE), underfunding, reduced supply of medications and poor information systems [ 6 , 18 ]. Most African countries are dependent on importation of essential medicines and products. These countries were affected by the disruptions in the global supply chain because drugs were not readily available or were expensive because of the high demand relative to supply [ 19 ]. Patients expressed difficulties in accessing medicines due to the high cost [ 20 ].

Geographic variability in the level of disruptions and restorations to EHS were reported within countries [ 21 ]. The COVID-19 high burden states/areas were likely to have experienced a higher level of restrictions and enforcements of protocols which could affect the levels of disruptions and the time taken for restorations. Furthermore, recovery may be slow, temporary, or partial depending on sub-national health systems resilience. Reported innovative adaptations to halt or reverse decline in EHS delivery included home delivery, use of phones, improved triaging, shift to remote consultations, and expansion of the scope of work of community health workers and task shifting [ 21 , 22 ]. Limited evidence exists on the health systems lens approach to analyzing the challenges encountered in maintaining EHS delivery during the COVID-19 pandemic, particularly at the sub-national levels. Therefore, this study aimed to identify the health system challenges encountered during the COVID-19 pandemic and document the mitigation strategies and adaptations made across the geopolitical zones (GPZs) in Nigeria. The learnings will guide policymakers, decision makers and health administrators on how to improve health systems in Nigeria to ensure that they are resilient and prepared to respond to public health emergencies. Learnings from Nigeria especially on the mitigation and adaptation strategies may be transferrable to similar decentralized health systems.

Study setting

The study was qualitative in design involving interviews of key persons at state ministries of health (SMoH) and State Primary Health Care Development Agencies (SPHCDA) across the six geopolitical zones of Nigeria. Following the Alma Ata declaration in 1978, the primary health care (PHC) system became the fulcrum of health systems development in Nigeria. Not much progress was made in PHC however, until 1985 when the then Minister of Health adopted 52 Local Government Areas (LGAs) to build models based on the Alma Ata declaration [ 23 ]. Thereafter, the model was expanded to include all LGAs and the responsibility for overseeing the working of the PHC including immunization, antenatal care services was devolved to the LGAs [ 23 ]. PHC in Nigeria focuses on preventive services including immunization, antenatal care services, as well as the provision of basic health care services at the grass root level [ 23 ].

The Primary Health Care Under One Roof policy was introduced in 2010 and approved in 2011 [ 24 ]. It aims to strengthen the national health system by integrating all PHC services under one authority. By implications, all resources for PHC implementation are to be repositioned from all agencies, departments and ministries to the new State PHC development agencies or boards [ 24 ]. This initiative produced some improvements in health outcomes [ 25 ].

Like many other African countries, Nigeria has consistently failed to implement the 2001 Abuja declaration at which African heads of state pledged to allocate 15% of the annual national budget to health [ 26 , 27 ]. Currently, the PHC system has deteriorated with most of the 30,000 PHC facilities across the country lacking the capacity to provide essential healthcare services thereby, transferring enormous pressure to the higher levels of healthcare [ 28 ]. The challenges PHC facilities experienced before COVID-19 included poor staffing, inadequate equipment, poor distribution of health workers, poor quality of healthcare services, poor condition of infrastructure, and lack of essential drug supply.

Study design and approach

The study was part of a large national qualitative survey on resilience of the health system which aimed at identifying the key challenges to maintaining essential health services during the pandemic, from the perspective of subnational actors. This current report focused on the regional level data, but the other aspect of the study focused on comparative LGA-level data on how some LGAs overcame challenges and sustained essential health services, while comparable, neighbouring LGAs experienced ongoing disruptions [ 29 ].

Study site and participants’ selection

The study enrolled subnational actors at the state level, across the six geopolitical zones of Nigeria. These participants were engaged in the COVID-19 response and were at decision-making levels such as directors, assistant directors and heads of programmes.

Selection of study sites was guided by multiple criteria namely High Resilience (HR) LGAs; COVID 19 disease burden and regional hotspots such as LGAs with the highest cumulative cases and those with international airport or land borders; security considerations, by avoiding LGAs with considerable security challenges such as LGAs with insurgents and banditry. The procedure for identifying high resilience LGAs has been described in detail elsewhere [ 29 ]. In brief, the general outpatient (GOPD) and Ante-natal care (ANC) health services data from the National Health Management Information System (NHMIS) (January 2019 – December 2021) was analyzed using the interrupted time series. The analysis identified HR LGAs. HR LGAs were defined as LGAs which experienced a recovery in service volumes within three months of decline precipitated by the COVID-19 pandemic. LGAs were then stratified and ranked within each geopolitical zones and, in combination with COVID-19 burden and security considerations, 12 h LGAs were finally selected from 10 states and the Federal Capital Territory (FCT) across the six geopolitical zones: South-West [ 3 ], South-South [ 2 ], South-East [ 2 ], North-West [ 1 ], North-Central [ 2 ], North-East [ 1 ].

Participants for the parent study were selected purposively across state, LGA, health facilities, and community levels. However, this report is limited to the analysis of response from state-level participants across the GPZs where two participants each were selected per state.

Data collection

A key informant guide was developed following extensive review of literature on health systems resilience and essential health service maintenance (see Supplementary File). The guide was pretested among similar personnel in Nasarawa state before data collection. The interview guide was sectioned according to: profile of the study participants; services used during COVID-19; data monitoring and use; self-regulation; adaptive-short term; integrated capacities or planning; relevance to maternal neonatal and child health (MNCH); and adaptive-long term. The data presented in this report focuses on the following sections of the tool: services used during the COVID-19 pandemic and self-regulation which contained information on participants’ assessment of changes in service utilization during the COVID-19 pandemic; reasons for the changes in Primary Health Centres (PHCs) attendance, challenges experienced by facilities to maintain routine services during the pandemic, specific countermeasures that the state governments took to overcome the challenges and activities done by the state governments to encourage clients to continue to utilize the PHCs.

The Federal Ministry of Health (FMoH) led the project and played an oversight role in data collection with supervisors leading research teams to the states. The interview teams paid advocacy visits to explain the purpose of the research and obtain the support of stakeholders in the ministries of health. The interview team comprised of a supervisor, a moderator and a note taker per state. All data collectors and supervisors were trained for the purpose of this research. All participants gave informed consent before they were interviewed face-to-face and audio-recorded in their offices. A data collection pause was implemented after the first few interviews during which the interviews conducted were transcribed, reviewed and feedback were communicated to the field teams. The interview took an average of 73 min. Data was collected between June through July, 2022.

Data management

The recorded interview audios were transcribed verbatim in the original language of the interview. Transcripts were complemented with notes taken during the interviews. The transcripts, audio files and notes were labelled with unique identifiers that enabled data linkage across files. A data security protocol was implemented to safeguard against data breach. A Dropbox folder, which was only accessible to designated research team members, was created for the safe storage of the audio files, transcripts and summary notes.

Coding was done using Atlas.ti. One coder was involved in the coding the data while multiple coders coded subsets of the data for agreement. The entire research team interrogated the data and review the coding. Emerging sub-themes were categorized under the appropriate pillars of health system including (i) service delivery, (ii) health workforce, (iii) health information systems, (iv)medicines and supplies, (v) financing, (vi) leadership/governance [ 15 ].

Respondent socio-demographic characteristics

A total of 22 state-level participants were interviewed from 10 states and the Federal Capital Territory (FCT). Respondents’ age ranged from 40 to 60 years. The majority 18(82%) were male while the median total duration of employment was 23.5 years. The respondents held leadership positions in SMoH and SPHCDA, with many being Deputy/Acting Directors 6 (27%) and Directors 5 (23%) and commissioners for health 2 (9%) (Table  1 ). Most 20 (91%) had been in their current position for at least 2 years.

Health services delivery volumes at the PHC during the COVID-19 pandemic

All participants acknowledged reduction in patients’ attendance at the PHCs while some also mentioned interruption in health services delivery. The decrease in facility utilization was more pronounced during the early stage of the pandemic particularly from March 2020 through June/July, 2020. Notably, there was a drastic reduction in the antenatal clinic attendance by pregnant women and the under-5 children outpatient visits across all regions of the country.

The movement restriction during lockdowns and the fear of contracting COVID-19 were the two most prominent reasons stated for reduction in health facility patients’ attendance. Where facilities were still in operation, fear of contracting the virus among patient and health workers was common in all regions.

On the supply side, some health workers did not go to work, while some facilities were instructed to close completely. The lockdown reduced the number of health workers who were able to commute to work especially those who did not have personal means of transportation. Some state governments (such as Lagos) tried to ameliorate this by providing ambulances that took frontline workers to work. Health workers were also given stickers to identify them as essential workers so that the law enforcement agents would allow them to move through the lockdown. Like the patients, the health workers were also scared of contracting COVID-19 infection and they encouraged patients that could be managed at home to stay away from the health centers. They also referred patients very readily to the next level of health care with minimal investigations. The decline in services were attributed majorly to the COVID-19 pandemic.

On the demand side, patients were unable to travel to health facilities because of lockdown restrictions. Participants also emphasized on the economic challenges and bank closures which reduced people’s ability to purchase goods and services including healthcare. Community members exhibited fears from the belief that COVID-19 was domiciled in the health facilities. People were further afraid of being isolated in the event that they were diagnosed with COVID-19.

Differential impact of COVID-19 on LGAs

There was consensus between the participants from the different regions that urban areas had a higher burden of COVID-19 infection including disease incidence and case fatality. Consequently, there were more COVID-19 response activities in urban areas.

Participants in all regions believed that health service provision had returned to normal by June, 2022 especially for some suspended activities in the pandemic. Such activities included the integrated supportive supervision of health facilities which was believed to have returned to pre-COVID-19 levels. The isolation centers were no longer in existence and ad-hoc workers were no longer in employment. However, some COVID-19 prevention strategies such as the social mobilization, advocacy and risk communication were still on-going at the time of data collection.

Challenges faced in maintaining essential health services

Key challenges were identified by participants. Human resources shortage was the most commonly mentioned challenge from 4 GPZs, 6 states (Lagos, FCT, Imo, Kano, Abia, Ogun) of the country. Other commonly mentioned challenges included: Shortages in the supply of Personal Protective Equipments (PPEs) 4 GPZs, 5 states (Imo, Lagos, Ogun, FCT, Gombe); fear of contracting COVID-19 among health workers 4 GPZs, 4 states (Imo, Ogun, FCT, Rivers); misconception, ignorance, socio-cultural issues 2 GPZs, 2 states (Rivers, Imo); lockdown/transportation 2 GPZs, 2 states (Abia, Lagos); and lack of equipment/waiting area 2 GPZs, 2 states (FCT, Oyo). Less commonly mentioned challenges included: training gap, inadequate referral, diversion of other facility budget lines to PPEs purchase, and insecurity. The challenges considered to pre-date COVID-19 included: human resources shortage, shortages in equipment and PPEs, poor infrastructure and inadequate funding.

The challenges faced in maintaining essential health services in different health systems pillars are highlighted below with sample quotes from individual respondents (Table  2 ):

Leadership and governance

The respondent from the North Central (NC) zone explained that most of the resources allocated to various other activities in health facilities were redirected to meet the needs of COVID-19 response especially the provision of PPEs (Table  2 ):

…. the challenge of diversion… of resources [budget for other facility needs]… for PPEs.

From the Southwest (SW) zone, a respondent stated that insufficient funding had always been a challenge in carrying activities such as providing electricity in the PHCs. The challenge pre-dated COVID-19 pandemic.

“Insufficient funding has always been on ground. It is not really related to COVID-19. It has always been a case in most of the PHCs getting stipend to run the PHC like lightings, generators, pumping of water.” ( SW , )

Service delivery

The majority of the PHCs lacked infrastructure that could aid organization of services to provide physical distancing for the patients. A participant in the SW was quoted:

…majority of the health facilities do not have waiting area….

The health facilities experienced difficulty in transporting COVID-19 patients referred to isolation center for care. This was expressed by a participant in the NC zone:

“…referral, when somebody is positive having to evacuate from the hospital to the treatment center was a challenge” ( NC ) .

In the South-south (SS) and Southeast (SE) zone, the participants expressed concerns about patients’ misconceptions about COVID-19. Many patients did not believe that COVID-19 exist and as a result, were unwilling to adhere to facility COVID 19 prevention protocols. These misconceptions were reinforced by socio-cultural norms and reliance on dictates of religious leaders.

“.Misconceptions about the disease… with thoughts that there was no COVID-19 in the first place” ( SS ) .

“…the person [patient], and/or.relatives are not willing to adhere to the protocols, …what do you do?.socio-cultural issues,…where some people will say my pastor said…” ( SE ) .

Human resources

Inadequate human resource which predated the COVID-19 pandemic was expressed by both northern and southern zone respondents across six states. However, this challenge was amplified by the pandemic. There was limited number of personnel with the requisite skills to perform tasks related to the response. The task shifting strategy implemented to share task and thereby, reduce the number of health workers in facilities at any one time, also reduced the human resource capacity in the PHCs.

“The major challenge is… inadequate man power which has existed before COVID-19….” ( SW ) .

“Then during the pandemic too some health care workers absconded….health workers who had the requisite capacity were quite few” ( SE ) .

“….there was some sort of shifting done to reduce the number of health workers working at the same time…” ( NC ) .

Respondents in SW and SE also described the challenges that health workers encountered in getting to the health facility during the early period of the pandemic due to the lockdown. This was said to compound the human resource shortages.

“They [workers] find it a bit difficult to get to their work place some of them have to use their workplace as home …” ( SW ) .

“It included even the health service providers. They were locked down. They could not even access the facilities” ( SE) .

The human resources shortages in the facilities was confirmed to have been a long-standing problem that existed before the pandemic across all regions of the country which was now amplified by the pandemic.

“It [staff shortfalls] was on ground before …” ( SW ) .

“Yes, I said it that staff shortfall has been a long-term issue. The work is becoming voluminous everyday” ( SW ) .

“Of course, we have human resources gaps, before and even during the pandemic” ( NC ) .

“Well, I will say the issue of the human resource for health, it has been a long-lasting challenge even before the pandemic. So, it was now heightened by the pandemic…” ( SE ) .

Health workers’ attitude to work was stated as being a challenge to utilization of PHCs by clients. Due to the fear of contracting COVID-19, health workers were not committed to work.

“We had challenges with attitude to work you understand? Some people were more reluctant” ( SS ) .

“…health workers had a ground to be afraid because there were gaps [in] science” ( SE) .

“…even health workers were scared and they were not so committed to work because there was risk [of infection]” ( NC) .

Medicines and supplies

Respondents across most of the regions reported shortages in medical consumables such as PPEs, face masks and sanitizers especially at the beginning of the pandemic. One respondent decried challenges with the supply chain because of restricted access to PPEs even though some facilities had supplies locked up in the store.

“… it was so bad that some doctors will even use their money to buy sanitizers and face masks so as to protect themselves” (SW) .

“…dearth in supply of PPEs….but that was at the initial period. Before COVID − 19, there were no local manufacturers” (SE) .

“…when we started there was really a challenge in the facilities because even face masks were running out. Sanitizers were running out because of the increased use.” (NE) .

“…challenges about the supply chain in terms of internal access to the PPE. We put the PPE in the store and health workers in the emergency unit were not having access” (NC) .

“Rapid test for SARS-CoV-2 was not available at the beginning [of the pandemic]” as expressed by a respondent from the FCT (NC) .

The dearth in supply of consumables was confirmed to be a challenge that existed before the COVID-19 pandemic. However, the increase in the cost of some consumables such as PPE, gloves and face masks was a challenge that came with the COVID-19 pandemic.

“Dearth in supply of PPEs was actually a challenge that was in existence beforehand” ( SW) .

Mitigation strategies to health systems challenges during COVID-19 pandemic

Several interventions were implemented by state governments to address the challenges of maintaining essential health services (Table  3 ). State governments focused on the provision of consumables; recruitment, redeployment and provision of training for health workers; expansion of the infrastructural capacity; provision of vaccines, stipends, security and subsidizing health services costs. These interventions were in all regions of the country.

Political will improved during the COVID-19 pandemic, state governments were positively disposed to improving health services delivery.

“Government was ready to approve all the ongoing projects, all the ongoing services, basic medical services were being provided, they also were fighting stigma within the facilities” (NC) .

“They [government] made some services affordable, available and accessible and within the reach of the community member. They were taking services even to the community outside the facilities, services like outreach services, information dissemination and empowerment. ” (NC) .

Key interventions implemented across the regions were cascaded from state level to the LGA and facility levels down to the community. Across all regions, training and capacity building were stepped down to LGAs, facility heads and community. These activities were facilitated through LGA officers and community stakeholders.

“Health worker training was also done for health workers at the primary care centres and the secondary facilities at each of the area council. So, all the activities, all the IPC was also done.” ( NC ) .

“At the state, we have a state officer, we have the Local Government officers, we also have the health facility officers. These trainings were cascaded down from the State to the Local Government and to the health facilities to ensure that the various layers of response are well equipped in terms of capacity.” ( SE ) .

“We train and monitor. We also conduct supportive supervision from the state level down to the local government levels then to the ward and facility level; we do that routinely. We check their knowledge gap and also do on the spot training for whichever gap that we are able to identify.” ( SE ) .

“…there were trainings that we received, training upon training which usually comes from the national to the State and then we step it down to the local government and then from the local government to the wards within local governments and the facilities.” ( SW ) .

“We work with the medical officers of health in the twenty-three LGAs and the heads of facility to redistribute our staffs.” ( SS ) .

Coordination across levels of the health systems also ensured timely distribution of health facility materials:

“The moment the supply comes into the state with immediate effect they write to the MOHs (Medical office of health) in the local government stating we have some materials for you, because we do not wait until the MOHs come to collect the materials, so we send a letter to them via email communicating the delivery time. E.g. we are bringing it tomorrow morning or we are bringing it this evening be available to receive it. The moment it gets to the MOHs, the MOHs step it down to all the facilities and PHCs with immediate effect.” ( SW ) .

“The state primary health board makes funds and logistics available at the local government level” ( SW ) .

“The intervention trickles down to the facility level. The State made sure that the issue of man power, issue of adequacy of jobs you know and consumables at the health facility are addressed at the highest decision level” ( SW ) .

The COVID-19 response was supported by donor partners such as in the provision of PPEs. The government also mobilized funds from the private sector which was made available to the hospitals and PHCs.

“The state government provided PPEs, because there were also donations to them, many private sectors also donated and… they made it available for the public hospitals” ( SE) .

Regarding service delivery during the pandemic, interventions implemented included reorganizing service delivery for more facilities to render more services.

“We had to reorganize our system to ensure that more facilities in some strategic locations were rendering more services, had more people to render services, you understand, 24/7. We actually had to do that” ( SS) .

The government also built COVID-19 isolation and treatment centers to relieve the pressure on the hospitals and ensure COVID-19 patients had good care.

“They [state government] provided treatment centers for those who required admission,” ( NC) .

“Government-built isolation centers all across the 20 local government in Ogun state that is the jurisdiction.” ( SW ) .

In the Northwest (NW) zone, the government organized the Emergency Maternal and Child (EMC) services where they provided ambulances to pick up pregnant woman that required emergency surgery. Provision of ambulances was not limited to the NW region as other regions also mentioned government support by providing ambulances.

“For example, during COVID-19 pandemic people there had emergency cesarean sections especially pregnant women. There is an ambulance that picks them and there is also another one that is called EMC services, it is a special service provided by the State government for Maternal and newborn child free up to this moment” (NW) .

Intervention strategies in facilities also included prioritization of facilities in terms of services and staffing needs, rescheduling of patients’ appointment that were not emergency cases.

Clients were also redirected from facilities that were shutdown to nearby facilities that could provide treatment services. Services prioritized included patient monitoring/treatment, immunization services and provision of ambulance for transportation.

“Well, the patient monitoring evaluation and treatment were prioritized because we do not want to come down with a lot of mortality. So adequate equipment [and] consumables were provided by the State and the manpower involved were adequately remunerated and then the State paid a lot of money for them to maintain this service” ( SE ) .

“The services like maternal and child care…. those services are key. We want to make sure that mothers, pregnant mothers access care on time, the children too… Those that need to be immunized and all of that.” ( SW ) .

“The maternal, new born and child health services were prioritized and also the health workers themselves were prioritized because they are the frontliners” ( SE ) .

“…anybody that falls sick and gets to the hospital will receive care but we pay attention on pregnant women and little babies more because their own case is peculiar” ( SW ) .

“The mother too who attended antenatal clinic and even the test that will be run everything was done for free and was sponsored bby the PHC Board to the extent that they printed cards and gave it to them for free that they were not supposed to pay. The registration, everything was made free at that time. This is just to act as reliefs at that time for those who access health at the health facilities” ( SW ) .

To address the shortfall in human resources, the SW region employed health worker cadres such as doctors and nurses in batches per time, as the budget could accommodate. In some other regions such as the SE, health workers were redeployed to work at facilities which were near where they lived to improve delivery. Ad hoc staff were also engaged to work for a few months.

Workshops were organized by the state governments to train and inform the health workers on IPC and to improve their skills. This helped to alleviate their fears on contracting the virus so as to alleviate their apprehension.

Health workers including adhoc staff were motivated by increasing the hazard allowance, which led to the increment in their monthly salary.

“They [government] gave some allowances to adhoc workers for a few months. So those adhoc workers helped….The state government also provided ambulances, one ambulance to one local government. They gave ambulances and drivers…also provided security…” ( SE ) .

“Health care workers were also provided with the relief materials to also help them continue in their work” ( SE ) .

“Increasing the health workers hazard allowance is something that the government did….” ( SW ) .

“Yes, the government provided allowances to encourage those who were at the frontline to ensure that they [health workers] at least had something reasonable to hold on to while offering their services and apart from that government was coordinating the activities of the various fronts including that of security.” ( SE ) .

“Giving reliefs, packages, and giving us bonus that was all.” ( SW ) .

“Those that took part in surveillance were given certain stipends, those that did case management were given certain stipends, those that took part IPC, risk communication, point of entry was given certain stipends.” ( SS ) .

“Governor continued, was even giving transport stipends to surveillance officers, laboratory personnel, just to encourage them to do the work and so, these things were going on as a kind of stimulant, a kind of motivation to assist in getting the job done. So as at that period those things were not lacking for us, so that is what I can say about that .” ( SS ) .

“The support is the trainings that were done, stipends were paid adequately as at when due and the health workers were happy with that, as they carried out their duties” ( SE ) .

“The hazard allowance was increased, I think to about 15% or thereabout, so all those incentives were there for health workers to actually motivate them to do more, so the State government did that.” ( SW ) .

“Palliatives, all the health workers were given palliatives.” ( SW ) .

“All the health workers were given adequate and reasonable support; number one, in the FCT, they were well paid. Those that were directly involved [in COVID-19 control] were well paid by the honorable minister of the FCT, secondly, they were all provided at any given point in time with PPEs, they were also well trained to monitor patient, and even the family of those who died were given some support, I think some were promised land, I don’t know if they have given them. They were given high level of support.” ( NC ) .

Other support granted by the State to motivate health workers included training, recruitment to support existing staff, provision of security, relief packages and ambulances.

“I know I have talked about redistribution of workers, of course ad-hoc workers for those very few months, then some of the PPEs and some of the security, I think that’s the only thing I can say.” ( SE ) .

“To be sincere we have to appreciate the state government, at that time they even gave us accommodations, food and everything during the first pandemic. They support us with training of case management for us to take care of patients as well as series of other training. We all attended online training on oxygen therapy and it was even paid for” ( NW ) .

“At one point, it was difficult for health workers to move from one point to the other, so government aided the movement of health workers by providing certain things to identify them, also providing ambulances, movement support to enable them move from their homes. They also provided accommodation for health workers at the isolation center.” ( SE ) .

“And also, they bring in special teams to also support the teams on ground.” ( SE ) .

“Well, we did some form of reorganization and that did include the personnel. So, we had to increase the number of personnel in our focal facilities which increase the services” ( SS ) .

“Yes training has always been in existence so they do refresher training but during the COVID it become more intensified because of the session or season we are.” ( SW ) .

Information systems

Respondents mentioned that government engaged in communication/sensitization programmes to improve service utilization using different media including the traditional and social media. The targets of the communication programmes were the community members including religious and ethnic groups. Communities, markets, churches and mosques were some of the places where the health promotion campaigns took place (Table  3 ).

Adaptations of the health systems during COVID-19

Sustainable adaptations.

Table  4 shows the emerging themes on sustainable adaptations done by the health systems. Respondents considered the infection, prevention and control (IPC) infrastructure (taps for running water), the telehealth call center, the IPC protocols and the service reorganization, as sustainable. A respondent mentioned that each health facility had an IPC focal person and also IPC teams which the health system can continually optimize.

Respondents considered that the training programs and capacity building efforts (especially the ‘network electronic platform’), implemented during the pandemic were sustainable. They opined that IPC training should be mainstreamed because the topic was broad and had impact on prevention of other infectious disease areas apart from COVID-19.

Respondents also mentioned that the volunteer groups formed during the pandemic for community sensitization and community engagement, were retained and would be used for other intervention programmes. Health teams have also retained the virtual mode of conducting team meetings.

Unsustainable adaptations

Respondents considered some adaptations in financing, service delivery and supplies, as unsustainable (Table  5 ). The funds that the government mobilized in form of incentives to health workers, stipends for campaigns team members and payment for other ad hoc staff such as town criers, were no longer being provided. The free testing and healthcare for COVID-19 patients which governments implemented was not sustained. The health workers who were redeployed have returned to their pre-pandemic assignments. In addition, all the services rendered to patients at the COVID-19 treatment centers including treatment, accommodation, consumables, were free and therefore, considered unsustainable. This also included the free consumables supplied to the health workers.

Summary of findings

The qualitative study selected senior persons in decision-making positions. Respondents acknowledged a reduction in patients’ attendance at the PHCs and interruption in service delivery. This prominently affected antenatal care attendance by pregnant women and the care for the under-5 children across all regions in the country. There was consensus among the regions that the urban communities had a higher burden of COVID-19 infection making the activities around COVID-19 control more intense in these communities. Unfortunately, this negatively impacted the provision of care in health facilities in these communities, leading to a negative impact on provision of EHS.

The challenges experienced in maintaining essential health services cut across the pillars of the health systems. Resources were reallocated to COVID-19 control activities from other budgetary lines due to insufficient funds to implement control activities. The infrastructure of most of the PHCs could not accommodate changes in service reorganization which was needed to enable physical distancing. It was also challenging to transport referred COVID-19 patients to isolation centers. Patients had misconceptions on the cause and transmission of COVID-19 and were unwilling to adhere to facility protocols. There was severe shortage of human resources which predated and was accentuated by COVID-19 control interventions such as lockdowns, staff redeployment and task shifting. Health workers were reluctant to discharge their duties because of fear of contracting the infection. There was inadequate consumables for use albeit sometimes due to deficient supply chain management.

Several mitigation strategies were implemented to address the challenges encountered. Political will towards improvement of health service projects was increased during the COVID-19 pandemic. This was reflected in government efforts to make health services available, accessible and affordable. Efforts were also made to provide consumables, recruit both permanent and ad-hoc staff, motivate existing health workforce, and redeploy/train health workers. The health infrastructure capacity was also expanded across regions, to free up spaces for provision of EHS by building/renovating COVID-19 isolation and treatment centers. Service delivery was also reorganized by rescheduling appointment for non-emergency to a later date and prioritizing essential services such as immunization, maternal and child care. Health promotion campaigns to groups and communities, were conducted to improve service patronage. Sustainable systems adaptations included IPC and telehealth infrastructure, IPC protocols, IPC teams and focal persons, training and capacity building, virtual meetings and community groups set up for sensitization and engagement. Unsustainable adaptations included funding, free healthcare and consumables, redistribution of staff, and the maintenance of COVID-19 treatment centers.

Results in the context of the literature

The COVID-19 pandemic disrupted EHS in almost all countries of the world and the disruption continued for over two years in more than 90% of countries surveyed by the WHO [ 30 ]. Particularly affected were the maternal and childcare services as corroborated in both quantitative and mixed methods design studies [ 31 , 32 , 33 ]. Our study corroborated findings from surveys among health workers and community members in Burkina Faso, Ethiopia and Nigeria, confirmed partial-to-total interruptions in health services delivery and utilization especially maternal and child health services [ 34 ] due to lockdowns, fear of infection/stigmatization, misconceptions/misinformation about the disease, stockout of drugs, and lack of transportation due to lockdowns [ 35 , 36 ]. As noted in this study, the disruption affected most services to the extent that some PHCs with low capacity were closed down. Studies indicated that disruptions appeared to affect disproportionately maternal and child care including immunization [ 30 ]. As noted in the WHO survey and as corroborated by our study, the major barriers to health service recovery were health systems challenges which predated the COVID-19 pandemic. Very prominent pre-existing health systems deficiencies identified by our study were in the human resources, service delivery and the finance pillars.

The adaptations to service delivery implemented in healthcare facilities were similar across regions in Nigeria and notably, were designed to reduce patient inflow. Non-emergency cases were discouraged from accessing clinics and follow-up appointments were rescheduled because the facilities lacked the capacity to implement the recommended physical distancing between patients. In Ghana [ 37 ] similar adaptations were made to routine healthcare service delivery which also aimed at reducing patient flow to the health facilities. In this study, only clients with extremely important conditions were encouraged to visit the health facilities, appointments were reduced, non-essential medical and surgical procedures were less prioritized.

Although, facility closures occurred in most settings around the world during lockdowns because there was no health manpower to provide services [ 3 ], the telemedicine infrastructure which existed before the pandemic in some settings, were deployed to bridge the gap in consultation demands [ 3 , 38 ]. Nigeria developed a telehealth call center which was mainly for COVID-19 case finding but provides opportunities for general health consultations use.

Also, some health professionals were reassigned to COVID-19 control programmes which ultimately affected services such as home visits, immunization and other community health services [ 37 ]. A study conducted in Lagos, Nigeria highlighted the willingness of community health workers to function as care providers during the pandemic but were challenged by heavy workload and lack of transportation [ 39 ]. These recommendations informed some of the decisions to improve health workforce care packages including financial incentives and employment of additional staff [ 39 ].

Limited evidence exist in the literature on the challenges encountered in maintaining EHS in health systems. In Bangladesh, similar challenges were reported as we found in our study. The demand pull challenges in Bangladesh included fear of COVID-19 infection, difficulty with commuting during lockdown and reduction in health seeking behavior emanating from closure of health facilities without providing alternatives [ 40 ]. Also, as found in our study, health resources were redirected to COVID-19 leaving other important health programmes deprived. Likewise, there were staff shortages which predated COVID-19: Acting in synergy with panic among health workers, more health facilities and programmes were further abandoned as similarly documented in our study.

The literature was richer in terms of mitigation and adaptation strategies implemented to maintain EHS during the COVID-19 pandemic. Kabwama et al., used the same health systems pillar thematic framework to analyze the interventions implemented in maintaining EHS in Uganda [ 41 ]. Prominent in the Uganda analysis was the private sector engagement for public-private partnership in fund mobilization as reported in our Nigeria analysis. Unique adaptation in service provisions in Uganda involved leveraging patient networks to deliver medicine which was not found in our analysis. The Ugandan study appeared to focus more on general interventions that were not specifically directed at challenges in maintaining EHS contrary to what our study did. The mitigation strategies implemented in Bangladesh closely mirrored what our study found such as provision of consumables under the medicines and supply pillar, fund mobilization under the leadership/governance and finances pillars among others [ 40 ].

Perhaps, the most robust survey on service adaptations involved 129 countries and was conducted by the WHO [ 30 ]. It was clear that in all countries, services were shifted off the health facilities and moved to home-based or to tele-infrastructure. Low and middle income countries like Nigeria may benefit from such easily adaptable strategies because creating separate facilities for COVID-19 and EHS delayed implementation as a result of the considerable financial investment required. Policy makers involved in emergency and epidemic preparedness plans may incorporate proactive plans to achieve rapid implementation of similar strategies. Other prominent cross-cutting mitigation strategies reported across countries in the WHO survey included healthcare financing, health workforce training and capacity building, procuring of essential medicines and consumables, risk communications and community engagement.

Implication of findings and lessons learned

The WHO recommends that advanced planning and long-term investments in health systems is important for epidemic preparedness and in safeguarding the continued provision of EHS during a health crisis [ 42 ]. Findings derived from this study are imperative for a robust epidemic preparedness plan. Strategies to maintain supply and demand for EHS should be incorporated as essential elements of epidemic preparedness plans. Response to health crisis require a more holistic and proactive approach at planning. The challenges facing the Nigerian health system are long-term which will require considerable and consistent efforts to resolve. Thus, learnings on mitigation strategies and adaptations during the COVID-19 pandemic would be applicable for future public health emergencies as well as routine health services delivery. The sustainable adaptations can potentially serve as a foundation for a gradual, planned, and intentional investments in the core functions of the Nigerian health system in order to improve its resilience and preparedness. For example, maintaining a pool of potential ad hoc volunteers consisting of retired health workers and community volunteers who can be mobilized at short notice. Also, the partnership built during the COVID-19 pandemic between the government of Nigeria and the private sector could be strengthened and optimized for epidemic preparedness and EHS delivery. The government at all levels received funds and donations from the private sector which was channelled to COVID-19 control and health care service delivery.

Our study also highlights the importance of adequate and timely public health messaging. Misconceptions and misinformation were rife during the COVID-19 pandemic in Nigeria [ 23 ]. Also noted [ 23 ], most of the information provided were technical and focused on prevention of COVID-19, with only minimal messaging on the provision/utilization of EHS. Thus, on the social media, misconceptions festered and was a major cause of demand-pull decline in EHS utilization by communities. Both patients in need of treatment and those who were on follow-up appointments, largely stayed away from the health facilities due to fear of contracting COVID-19. Health facilities were stigmatized, and health providers discriminated against for fear of contracting the virus. Another driver of decline in demand was the fear of testing positive and being isolated [ 43 ]. Although, adaptations to EHS later reduced the need for physical contact with the health facilities, a large proportion of potential clients stayed away from the formal health system. The learnings derived from adaptations during the pandemic could provide opportunities for a transformative evolution of the primary health care system in Nigeria. Before the pandemic, across the country, only about 20% of the PHCs were assessed as functional [ 28 ], resulting in consultation overload of the secondary and tertiary facilities. The participants considered the telehealth call center to be a sustainable innovation. The Nigerian health system could benefit from upgrading and expanding telemedicine infrastructure to shift some of the PHC overload to this platform. This will enhance an elastic, epidemic prepared EHS delivery system.

As confirmed in this study, poor funding was a systemic challenge that predated COVID-19 pandemic. EHS delivery suffered major set-backs partly because the meagre financial resources available for healthcare delivery were diverted to COVID-19 control. The budget for the State PHC Board in a state in North Central zone of Nigeria was reduced by 11.5% in order to secure funds for COVID-19 control activities [ 44 ]. The government was able to raise some funds mainly from the private sector most of which was deployed towards public health measures for COVID-19 control with little investment to strengthen the health system [ 45 ]. Public-private partnership could be strengthened to form an extra-budgetary sovereign wealth fund which will be used for emergency health purpose only and which can be mobilized at short notice. The state governments demonstrated commitment to long-term public health investments and reforms during, and in the immediate post-pandemic period [ 46 ]. A sustained commitment will improve the overall performance of primary healthcare in Nigeria in the near future.

Strengths and limitations of the study

The strength of this study is that participants were actors at the sub-national (state) -level. They were senior personnel who were decision makers in COVID-19 control and provision of EHS. They had good knowledge of activities that transpired in the states during the COVID-19 pandemic. Also, we sampled participants from all geopolitical zones of Nigeria in the interviews, which ensured representativeness. We translated and back-translated tools across zones to ensure accuracy.

The tool was designed using the conceptual framework developed by Kruk et al. [ 16 ], which was not initially based on the health systems pillars. It is possible that data on some health systems pillars exist which were not captured during the interviews. Conceptual framework used in the Kruk’s framework are not strictly health systems pillars or building blocks. Our study recruited mainly senior personnel in the ministries which might skew observations without the views of the junior personnel. Readers should interpret the findings with the view that potential richer health systems context may exist.

This study showed that there were significant challenges in maintaining essential health services delivery and utilization during the COVID-19 pandemic in Nigeria. The maternal and child care services were particularly affected. The core health systems challenges which prevented the maintenance of EHS delivery were mainly in the human resources, service delivery and the financing pillars. The mitigation strategies and adaptations implemented were important contributors to EHS recovery especially in the high resilience LGAs and have implications for future epidemic preparedness plans.

Data availability

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

Acknowledgements

The authors appreciate all participants who invested their time in responding to the interviews, colleagues at the FMoH who guided the smooth execution of this work and Hanovia Limited colleagues for the implementation of the qualitative data collection and transcription. Mohammad Tawab Hashemi provided additional support from the Global Financing Facility for Women, Children, and Adolescents.

Funding for this study was provided by Gates Ventures and the Global Financing Facility for Women, Children, and Adolescents. The funders of this study were involved in the study design, data collection, interpretation, and reporting. The views, opinions, and content of this publication are those of the authors and do not necessarily reflect the views, opinions, or policies of the funders.

Author information

Authors and affiliations.

University of Ibadan, Ibadan, Nigeria

Segun Bello, Ayodele S Jegede, Eniola A. Bamgboye, Mobolaji M. Salawu, Rotimi Felix Afolabi & Olufunmilayo I. Fawole

The Global Financing Facility for Women, Children, and Adolescents, 1818 H ST NW, Washington, DC, 204333, USA

Rachel Neill, Munirat Ogunlayi & Saudatu Umma Yaradua

Nigeria Federal Ministry of Health, Federal Secretariat Complex, Phase III, Shehu Shagari Way, Central Business District, Abuja, Nigeria

Charles Nzelu, Ngozi Azodo & Anthony Adoghe

Gate Ventures, Seattle, Washington, USA

William Wang & Anne Liu

You can also search for this author in PubMed   Google Scholar

Contributions

SB, RN, ASJ, EAB, MMS, RFA, CN, NA, AA, MO, SUY, WW, AL, & OIF were involved in the conceptualization and/or design of this study. RN, SB, ASJ, NA, CN, AA, MO, SUY, & OIF were involved in data collection and analysis. SB and OIF developed the first draft of the manuscript. SB, RN, ASJ, EAB, MMS, RFA, CN, NA, AA, MO, SUY, WW, AL, & OIF reviewed and revised the manuscript. All coauthors have approved the manuscript for publication.

Corresponding author

Correspondence to Segun Bello .

Ethics declarations

Ethics approval and consent to participate.

The study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from the participants. Ethical clearance was obtained from National Health Research Ethics Committee NHREC/01/01/2007.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Bello, S., Neill, R., Jegede, A.S. et al. Health systems challenges, mitigation strategies and adaptations to maintain essential health services during the COVID-19 pandemic: learnings from the six geopolitical regions in Nigeria. BMC Health Serv Res 24 , 625 (2024). https://doi.org/10.1186/s12913-024-11072-2

Download citation

Received : 09 September 2023

Accepted : 03 May 2024

Published : 14 May 2024

DOI : https://doi.org/10.1186/s12913-024-11072-2

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Health systems resilience
• Essential health services

BMC Health Services Research

ISSN: 1472-6963

• General enquiries: [email protected]

A .gov website belongs to an official government organization in the United States.

A lock ( ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

• Test for Fentanyl
• if You Think Someone is Overdosing
• Stop Overdose
• Naloxone FAQs
• Stigma Reduction

About Stop Overdose

• Through preliminary research and strategic workshops, CDC identified four areas of focus to address the evolving drug overdose crisis.
• Stop Overdose resources speak to the reality of drug use, provide practical ways to prevent overdoses, educate about the risks of illegal drug use, and show ways to get help.

Drugs take nearly 300 lives every day. 1 To address the increasing number of overdose deaths related to both prescription opioids and illegal drugs, we created a website to educate people who use drugs about the dangers of illegally manufactured fentanyl, the risks and consequences of mixing drugs, the lifesaving power of naloxone, and the importance of reducing stigma around recovery and treatment options. Together, we can stop drug overdoses and save lives.

What you can do

• Get the facts on fentanyl
• Learn about lifesaving naloxone
• Understand the risks of polysubstance use
• Reduce stigma around recovery and treatment

Explore and download Stop Overdose and other educational materials on CDC's Overdose Resource Exchange .

• Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Mortality 2018-2021 on CDC WONDER Online Database, released in 2023. Data are from the Multiple Cause of Death Files, 2018-2021, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/mcd-icd10-expanded.html on Mar 5, 2024

Every day, drugs claim hundreds of lives. The Stop Overdose website educates drug users on fentanyl, naloxone, polysubstance use, and dealing with stigma.