qualitative research in public health pdf

DOI: 10.1249/01.mss.0000172593.20181.14
Corpus ID: 72462548

Qualitative Methods in Public Health: A Field Guide for Applied Research

P. Ulin , E. Robinson , Elizabeth E. Tolley
Published 1 November 2004

1,681 Citations

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Qualitative Research Inquiry and Global Public Health

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First Online: 10 September 2023
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qualitative research in public health pdf

Pranee Liamputtong 2 &
Zoe Sanipreeya Rice 3

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Globally, public health issues impact the lives of individuals, families, communities, and nations. This has led public health researchers to conduct research to improve people’s health and well-being. Qualitative research rooted in social science is adopted in global public health where there is a global health problem or issue that needs to be explored. This is particularly when the health problems or issues cannot be easily analyzed using traditional quantitative approaches and when “silenced voices” are not being heard. Qualitative research is an approach researchers use to examine the health and well-being of individuals within the sociocultural contexts of their lives. Fundamentally, qualitative research is interpretive; the meanings and interpretations of the research participants are the essence of qualitative research. Qualitative research is useful for global public health in many ways. It encourages researchers to work with marginalized and vulnerable people and to address these issues within the social justice framework. The methods adopted in qualitative research embrace the lived experiences of people who occupy a variety of social spaces. This chapter discusses the value of qualitative research in global public health. It outlines some recent global public health concerns, the nature and role of qualitative inquiry, and the use of qualitative research in implementation science and evidence-based public health care.

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Qualitative Research in Global Health Research

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Liamputtong, P., Rice, Z.S. (2023). Qualitative Research Inquiry and Global Public Health. In: Liamputtong, P. (eds) Handbook of Social Sciences and Global Public Health. Springer, Cham. https://doi.org/10.1007/978-3-031-25110-8_45

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Published: 13 December 2018

Using qualitative Health Research methods to improve patient and public involvement and engagement in research

Danielle E. Rolfe 1 ,
Vivian R. Ramsden 2 ,
Davina Banner 3 &
Ian D. Graham 1

Research Involvement and Engagement volume 4 , Article number: 49 ( 2018 ) Cite this article

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Patient engagement (or patient and public involvement) in health research is becoming a requirement for many health research funders, yet many researchers have little or no experience in engaging patients as partners as opposed to research subjects. Additionally, many patients have no experience providing input on the research design or acting as a decision-making partner on a research team. Several potential risks exist when patient engagement is done poorly, despite best intentions. Some of these risks are that: (1) patients’ involvement is merely tokenism (patients are involved but their suggestions have little influence on how research is conducted); (2) engaged patients do not represent the diversity of people affected by the research; and, (3) research outcomes lack relevance to patients’ lives and experiences.

Qualitative health research (the collection and systematic analysis of non-quantitative data about peoples’ experiences of health or illness and the healthcare system) offers several approaches that can help to mitigate these risks. Several qualitative health research methods, when done well, can help research teams to: (1) accurately incorporate patients’ perspectives and experiences into the design and conduct of research; (2) engage diverse patient perspectives; and, (3) treat patients as equal and ongoing partners on the research team.

This commentary presents several established qualitative health research methods that are relevant to patient engagement in research. The hope is that this paper will inspire readers to seek more information about qualitative health research, and consider how its established methods may help improve the quality and ethical conduct of patient engagement for health research.

Research funders in several countries have posited a new vision for research that involves patients and the public as co-applicants for the funding, and as collaborative partners in decision-making at various stages and/or throughout the research process. Patient engagement (or patient and public involvement) in health research is presented as a more democratic approach that leads to research that is relevant to the lives of the people affected by its outcomes. What is missing from the recent proliferation of resources and publications detailing the practical aspects of patient engagement is a recognition of how existing research methods can inform patient engagement initiatives. Qualitative health research, for example, has established methods of collecting and analyzing non-quantitative data about individuals’ and communities’ lived experiences with health, illness and/or the healthcare system. Included in the paradigm of qualitative health research is participatory health research, which offers approaches to partnering with individuals and communities to design and conduct research that addresses their needs and priorities.

The purpose of this commentary is to explore how qualitative health research methods can inform and support meaningful engagement with patients as partners. Specifically, this paper addresses issues of: rigour (how can patient engagement in research be done well?); representation (are the right patients being engaged?); and, reflexivity (is engagement being done in ways that are meaningful, ethical and equitable?). Various qualitative research methods are presented to increase the rigour found within patient engagement. Approaches to engage more diverse patient perspectives are presented to improve representation beyond the common practice of engaging only one or two patients. Reflexivity, or the practice of identifying and articulating how research processes and outcomes are constructed by the respective personal and professional experiences of researchers and patients, is presented to support the development of authentic, sustainable, equitable and meaningful engagement of patients as partners in health research.

Conclusions

Researchers will need to engage patients as stakeholders in order to satisfy the overlapping mandate in health policy, care and research for engaging patients as partners in decision-making. This paper presents several suggestions to ground patient engagement approaches in established research designs and methods.

Peer Review reports

Patient engagement (or patient and public involvement) in research involves partnering with ‘patients’ (a term more often used in Canada and the US, that is inclusive of individuals, caregivers, and/or members of the public) to facilitate research related to health or healthcare services. Rather than research subjects or participants, patients are engaged as partners in the research process. This partnership is intended to be meaningful and ongoing, from the outset of planning a research project, and/or at various stages throughout the research process. Engagement can include the involvement of patients in defining a research question, identifying appropriate outcomes and methods, collecting and interpreting data, and developing and delivering a knowledge translation strategy [ 1 ].

The concept of engaging non-researchers throughout the research process is not new to participatory health researchers, or integrated knowledge translation researchers, as the latter involves ongoing collaboration with clinicians, health planners and policy makers throughout the research process in order to generate new knowledge [ 2 , 3 ]. Patients, however, are less frequently included as partners on health research teams, or as knowledge users in integrated knowledge translation research teams compared to clinicians, healthcare managers and policy-makers, as these individuals are perceived as having “the authority to invoke change in the practice or policy setting.” (p.2) [ 2 ] Recent requirements for patient engagement by health research funders [ 4 , 5 , 6 ], ,and mandates by most healthcare planners and organizations to engage patients in healthcare improvement initiatives, suggest that it would be prudent for integrated knowledge translation (and indeed all) health researchers to begin engaging patients as knowledge users in many, if not all, of their research projects.

Training and tools for patient engagement are being developed and implemented in Canada via the Canadian Institutes for Health Research (CIHR) Strategy for Patient Oriented Research (SPOR) initiative, in the US via Patient Centered Outcomes Research Institute (PCORI), and very practical resources are already available from the UK’s more established INVOLVE Advisory Group [ 5 , 6 , 7 ]. What is seldom provided by these ‘get started’ guides, however, are rigorous methods and evidence-based approaches to engaging diverse patient perspectives, and ensuring that their experiences, values and advice are appropriately incorporated into the research process.

The purpose of this commentary is to stimulate readers’ further discussion and inquiry into qualitative health research methods as a means of fostering the more meaningfully engagement of patients as partners for research. Specifically, this paper will address issues of: rigour (how do we know that the interpretation of patients’ perspectives has been done well and is applicable to other patients?); representation (are multiple and diverse patient perspectives being sought?); and, reflexivity (is engagement being done ethically and equitably?). This commentary alone is insufficient to guide researchers and patient partners to use the methods presented as part of their patient engagement efforts. However, with increased understanding of these approaches and perhaps guidance from experienced qualitative health researchers, integrated knowledge translation and health researchers alike may be better prepared to engage patients in a meaningful way in research that has the potential to improve health and healthcare experiences and outcomes.

What can be learned from methods utilized in qualitative health research?

There is wide variation in researchers’ and healthcare providers’ openness to engaging patients [ 8 ]. Often, the patients that are engaged are a select group of individuals known to the research team, sometimes do not reflect the target population of the research, are involved at a consultative rather than a partnership level, and are more likely to be involved in the planning rather than the dissemination of research [ 9 , 10 , 11 ]. As a result, patient engagement can be seen as tokenistic and the antithesis of the intention of most patient engagement initiatives, which is to have patients’ diverse experiences and perspectives help to shape what and how research is done. The principles, values, and practices of qualitative health research (e.g., relativism, social equity, inductive reasoning) have rich epistemological traditions that align with the conceptual and practical spirit of patient engagement. It is beyond the scope of this commentary, however, to describe in detail the qualitative research paradigm, and readers are encouraged to gain greater knowledge of this topic via relevant courses and texts. Nevertheless, several qualitative research considerations and methods can be applied to the practice of patient engagement, and the following sections describe three of these: rigour, representation and reflexivity.

Rigour: Interpreting and incorporating patients’ experiences into the design and conduct of research

When patient engagement strategies go beyond the inclusion of a few patient partners on the research team, for example, by using focus groups, interviews, community forums, or other methods of seeking input from a broad range of patient perspectives, the diversity of patients’ experiences or perspectives may be a challenge to quickly draw conclusions from in order to make decisions about the study design. To make these decisions, members of the research team (which should include patient partners) may discuss what they heard about patients’ perspectives and suggestions, and then unsystematically incorporate these suggestions, or they may take a vote, try to achieve consensus, implement a Delphi technique [ 12 ], or use another approach designed specifically for patient engagement like the James Lind Alliance technique for priority setting [ 13 ]. Although the information gathered from patients is not data (and indeed would require ethical review to be used as such), a number of qualitative research practices designed to increase rigour can be employed to help ensure that the interpretation and incorporation of patients’ experiences and perspectives has been done systematically and could be reproduced [ 14 ]. These practices include member checking , dense description , and constant comparative analysis . To borrow key descriptors of rigour from qualitative research, these techniques improve “credibility” (i.e., accurate representations of patients’ experiences and preferences that are likely to be understood or recognized by other patients in similar situations – known in quantitative research as internal validity), and “transferability” (or the ability to apply what was found among a group of engaged patients to other patients in similar contexts – known in quantitative research as external validity) [ 15 ].

Member checking

Member checking in qualitative research involves “taking ideas back to the research participants for their confirmation” (p. 111) [ 16 ]. The objective of member checking is to ensure that a researcher’s interpretation of the data (whether a single interview with a participant, or after analyzing several interviews with participants) accurately reflects the participants’ intended meaning (in the case of a member check with a single participant about their interview), or their lived experience (in the case of sharing an overall finding about several individuals with one or more participants) [ 16 ]. For research involving patient engagement, member checking can be utilized to follow-up with patients who may have been engaged at one or only a few time points, or on an on-going basis with patient partners. A summary of what was understood and what decisions were made based on patients’ recommendations could be used to initiate this discussion and followed up with questions such as, “have I understood correctly what you intended to communicate to me?” or “do you see yourself or your experience(s) reflected in these findings or suggestions for the design of the study?”

Dense description

As with quantitative research, detailed information about qualitative research methods and study participants is needed to enable other researchers to understand the context and focus of the research and to establish how these findings relate more broadly. This helps researchers to not only potentially repeat the study, but to extend its findings to similar participants in similar contexts. Dense description provides details of the social, demographic and health profile of participants (e.g., gender, education, health conditions, etc.), as well as the setting and context of their experiences (i.e., where they live, what access to healthcare they have). In this way, dense description improves the transferability of study findings to similar individuals in similar situations [ 15 ]. To date, most studies involving patient engagement provide limited details about their engagement processes and who was engaged [ 17 ]. This omission may be done intentionally (e.g., to protect the privacy of engaged patients, particularly those with stigmatizing health conditions), or as a practical constraint such as publication word limits. Nonetheless, reporting of patient engagement using some aspects of dense description of participants (as appropriate), the ways that they were engaged, and recommendations that emanated from engaged patients can also contribute to greater transferability and understanding of how patient engagement influenced the design of a research study.

Constant comparative analysis

Constant comparative analysis is a method commonly used in grounded theory qualitative research [ 18 ]. Put simply, the understanding of a phenomenon or experience that a researcher acquires through engaging with participants is constantly redeveloped and refined based on subsequent participant interactions. This process of adapting to new information in order to make it more relevant is similar to processes used in rapid cycle evaluation during implementation research [ 19 ]. This method can be usefully adapted and applied to research involving ongoing collaboration and partnership with several engaged patient partners, and/or engagement strategies that seek the perspectives of many patients at various points in the research process. For example, if, in addition to having ongoing patient partners, a larger group of patients provides input and advice (e.g., a steering or advisory committee) at different stages in the research process, their input may result in multiple course corrections during the design and conduct of the research processes to incorporate their suggestions. These suggestions may result in refinement of earlier decisions made about study design or conduct, and as such, the research process becomes more iterative rather than linear. In this way, engaged patients and patient partners are able to provide their input and experience to improve each step of the research process from formulating an appropriate research question or objective, determining best approaches to conducting the research and sharing it with those most affected by the outcomes.

Representation: Gathering diverse perspectives to design relevant and appropriate research studies

The intention of engaging patients is to have their lived experience of health care or a health condition contribute to the optimization of a research project design [ 20 ]. Development of a meaningful and sustainable relationship with patient partners requires considerable time, a demonstrated commitment to partnership by both the patient partners and the researcher(s), resources to facilitate patient partners’ engagement, and often, an individual designated to support the development of this relationship [ 17 , 21 ]. This may lead some research teams to sustain this relationship with only one or two patients who are often previously known to the research team [ 17 ]. The limitation of this approach is that the experiences of these one or two individuals may not adequately reflect the diverse perspectives of patients that may be affected by the research or its outcomes. The notion of gaining ‘ the patient perspective’ from a single or only a few individuals has already been problematized [ 22 , 23 ]. To be sure, the engagement of a single patient is better than none at all, but the engagement of a broader and diverse population of patients should be considered to better inform the research design, and to help prevent further perpetuation of health disparities. Key issues to be considered include (1) how engagement can be made accessible to patients from diverse backgrounds, and (2) which engagement strategies (e.g., ranging from a community information forum to full partnership on the research team) are most appropriate to reach the target population [ 24 ].

Making engagement accessible

Expecting patient partner(s) to attend regular research team meetings held during working hours in a boardroom setting in a hospital, research institute or university limits the participation of many individuals. To support the participation and diversity of engaged patients, effort should be made to increase the accessibility and emotional safety of engagement initiatives [ 25 ]. A budget must be allocated for patient partners’ transportation, childcare or caregiving support, remuneration for time or time taken off work and, at the very least, covering expenses related to their engagement. Another consideration that is often made by qualitative health researchers is whether brief counselling support can be provided to patients should the sharing of their experiences result in emotional distress. There are some resources that can help with planning for costs [ 26 ], including an online cost calculator [ 27 ].

Engagement strategies

Patient partners can be coached to consider the needs and experiences of people unlike them, but there are other methods of engagement that can help to gain a more fulsome perspective of what is likely a diverse patient population that is the focus of the research study. In qualitative health research, this is known as purposeful or purposive sampling: finding people who can provide information-rich descriptions of the phenomenon under study [ 28 ]. Engagement may require different approaches (e.g., deliberative group processes, community forums, focus groups, and patient partners on the research team), at different times in the research process to reach different individuals or populations (e.g., marginalized patients, or patients or caregivers experiencing illnesses that inhibit their ability to maintain an ongoing relationship with the research team). Engagement strategies of different forms at different times may be required. For example, ongoing engagement may occur with patient partners who are members of the research team (e.g., co-applicants on a research grant), and intermittent engagement may be sought from other patients through other methods that may be more time-limited or accessible to a diverse population of patients (e.g., a one-time focus group, community forum, or ongoing online discussion) to address issues that may arise during various stages of the research or dissemination processes. The result of this approach is that patients are not only consulted or involved (one-time or low commitment methods), but are also members of the research team and have the ability to help make decisions about the research being undertaken.

Engagement can generate a wealth of information from very diverse perspectives. Each iteration of engagement may yield new information. Knowing when enough information has been gathered to make decisions with the research team (that includes patient partners) about how the research may be designed or conducted can be challenging. One approach from qualitative research that can be adapted for patient engagement initiatives is theoretical saturation [ 29 ], or “the point in analysis when…further data gathering and analysis add little new to the conceptualization, though variations can always be discovered.” (p. 263) [ 18 ]. That is, a one-time engagement strategy (e.g., a discussion with a single patient partner) may be insufficient to acquire the diverse perspectives of the individuals that will be affected by the research or its outcomes. Additional strategies (e.g., focus groups or interviews with several individuals) may be initiated until many patients identify similar issues or recommendations.

Engagement approaches should also consider: how patients are initially engaged (e.g., through known or new networks, posted notices, telephone or in-person recruitment) and whether involvement has been offered widely enough to garner multiple perspectives; how patients’ experiences are shared (e.g., community forums, formal meetings, individual or group discussions) and whether facilitation enables broad participation; and finally, how patients’ participation and experiences are incorporated into the research planning and design, with patients having equal decision-making capacity to other research team members. Several publications and tools are available that can help guide researchers who are new to processes of engaging patients in research [ 24 , 30 , 31 , 32 , 33 , 34 ], but unfortunately few address how to evaluate the effectiveness of engagement [ 35 ].

Reflexivity: Ensuring meaningful and authentic engagement

In qualitative research, reflexivity is an ongoing process of “the researcher’s scrutiny of his or her research experience, decisions, and interpretations in ways that bring the researcher into the process and allow the reader to assess how and to what extent the researcher’s interests, positions, and assumptions influenced inquiry. A reflexive stance informs how the researcher conducts his or her research, relates to the research participants, and represents them in written reports,” (p.188–189) [ 16 ]. The concept of reflexivity can be applied to research involving patient engagement by continually and explicitly considering how decisions about the research study were made. All members of the research team must consider (and perhaps discuss): (1) how patient partners are invited to participate in research planning and decision-making; (2) how their input is received relative to other team members (i.e., do their suggestions garner the same respect as researchers’ or providers’?); and, (3) whether engaged patients or patient partners feel sufficiently safe, able and respected to share their experiences, preferences and recommendations with the research team.

Ideally, reflexivity becomes a practice within the research team and may be operationalized through regular check-ins with patients and researchers about their comfort in sharing their views, and whether they feel that their views have been considered and taken onboard. Power dynamics should also be considered during patient engagement initiatives. For example, reflecting on how community forums, focus groups or interviews are to be facilitated, including a consideration of who is at the table/who is not, who speaks/who does not, whose suggestions are implemented/whose are not? Reflexivity can be practiced through informal discussions, or using methods that may allow more candid responses by engaged patients (e.g., anonymous online survey or feedback forms). At the very least, if these practices were not conducted throughout the research process, the research team (including patient partners) should endeavor to reflect upon team dynamics and consider how these may have contributed to the research design or outcomes. For example, were physicians and researchers seen as experts and patients felt less welcome or able to share their personal experiences? Were patients only engaged by telephone rather than in-person and did this influence their ability to easily engage in decision-making? Reflexive practices may be usefully supplemented by formal evaluation of the process of patient engagement from the perspective of patients and other research team members [ 36 , 37 ], and some tools are available to do this [ 35 ].

A note about language

One way to address the team dynamic between researchers, professional knowledge users (such as clinicians or health policy planners) and patients is to consider the language used to engage with patients in the planning of patient engagement strategies. That is, the term ‘patient engagement’ is a construction of an individual’s identity that exists only within the healthcare setting, and in the context of a patient-provider dynamic. This term does not consider how people make decisions about their health and healthcare within a broader context of their family, community, and culture [ 22 , 38 ]. This may be why research communities in some countries (e.g., the United Kingdom) use the term ‘patient and public involvement’. Additionally, research that involves communities defined by geography, shared experiences, cultural or ethnic identity, as is the case with participatory health research, may refer to ‘community engagement.’ Regardless of the term used, partnerships with patients, the public, or with communities need to be conceived instead as person-to-person interactions between researchers and individuals who are most affected by the research. Discussions with engaged patients should be conducted early on to determine how to best describe their role on the team or during engagement initiatives (e.g., as patient partners, community members, or people with lived experience).

Tokenism is the “difference between…the empty ritual of participation and having the real power needed to affect the outcome,” (p.2) [ 39 ]. Ongoing reflection on the power dynamic between researchers and engaged patients, a central tenet of critical qualitative health research [ 40 , 41 ], can increase the likelihood that engagement involves equitable processes and will result in meaningful engagement experiences by patients rather than tokenism [ 36 , 42 ]. Patient engagement initiatives should strive for “partnership” amongst all team members, and not just reflect a patient-clinician or researcher-subject dynamic [ 43 ]. To develop meaningful, authentic and sustainable relationships with engaged patients, methods used for participatory, action or community-based research (approaches that fall under the paradigm of qualitative inquiry) provide detailed experiential guidance [ 44 ]. For example, a realist review of community-based participatory research projects reported that gaining and maintaining trust with patient or community partners, although time-intensive, is foundational to equitable and sustainable partnerships that benefit communities and individuals [ 45 , 46 ]. Additionally, Chapter Nine of the Canadian Tri-Council Policy Statement on Research involving Humans, which has to date been applied to research involving First Nations, Inuit and, Métis Peoples in Canada [ 47 ], provides useful information and direction that can be applied to working with patient partners on research [ 48 ].

Authentic patient engagement should include their involvement at all stages of the research process [ 49 , 50 ], but this is often not the case [ 10 ]. .Since patient partners are not research subjects or participants, their engagement does not (usually) require ethics approval, and they can be engaged as partners as early as during the submission of grant applications [ 49 ]. This early engagement helps to incorporate patients’ perspectives into the proposed research before the project is wedded to particular objectives, outcomes and methods, and can also serve to allocate needed resources to support patient engagement (including remuneration for patient partners’ time). Training in research for patient partners can also support their meaningful engagement by increasing their ability to fully engage in decision-making with other members of the research team [ 51 , 52 ]. Patient partners may also thrive in co-leading the dissemination of findings to healthcare providers, researchers, patients or communities most affected by the research [ 53 ].

Patient engagement has gained increasing popularity, but many research organizations are still at the early stages of developing approaches and methods, many of which are based on experience rather than evidence. As health researchers and members of the public will increasingly need to partner for research to satisfy the overlapping mandate of patient engagement in health policy, healthcare and research, the qualitative research methods highlighted in this commentary provide some suggestions to foster rigorous, meaningful and sustained engagement initiatives while addressing broader issues of power and representation. By incorporating evidence-based methods of gathering and learning from multiple and diverse patient perspectives, we will hopefully conduct better patient engaged research, live out the democratic ideals of patient engagement, and ultimately contribute to research that is more relevant to the lives of patients; as well as, contribute to the improved delivery of healthcare services. In addition to the references provided in this paper, readers are encouraged to learn more about the meaningful engagement of patients in research from several key texts [ 54 , 55 , 56 ].

Abbreviations

Canadian Institutes for Health Research

Patient Centered Outcomes Research Institute

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Acknowledgements

This paper was drafted in response to a call for concept papers related to integrated knowledge translation issued by the Integrated Knowledge Translation Research Network (CIHR FDN #143237).

This paper was commissioned by the Integrated Knowledge Translation Network (IKTRN). The IKTRN brings together knowledge users and researchers to advance the science and practice of integrated knowledge translation and train the next generation of integrated knowledge translation researchers. Honorariums were provided for completed papers. The IKTRN is funded by a Canadian Institutes of Health Research Foundation Grant (FDN #143247).

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Rolfe, D.E., Ramsden, V.R., Banner, D. et al. Using qualitative Health Research methods to improve patient and public involvement and engagement in research. Res Involv Engagem 4 , 49 (2018). https://doi.org/10.1186/s40900-018-0129-8

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Doing good qualitative research in public health: not as easy as it looks

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In this paper, we discuss qualitative research for public health professionals. Quality matters in qualitative research, but the principles by which it is judged are critically different from those used to judge epidemiology. Compared to quantitative research, good quality qualitative studies serve different aims, answer distinct research questions and have their own logic for sampling, data collection and analysis. There is, however, no need for antagonism between qualitative research and epidemiology; the two are complementary. With theoretical and methodological guidance from experienced qualitative researchers, public health professionals can learn how to make the most of qualitative research for themselves.

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Qualitative Research and its Uses in Health Care

Although relatively uncommon in health care research, qualitative research is now receiving recognition and is increasingly used in health care research with social and cultural dimensions. Unlike quantitative research, which is deductive and tends to analyze phenomena in terms of trends and frequencies, qualitative research seeks to determine the meaning of a phenomenon through description. It aims to develop concepts that aid in the understanding of natural phenomena with emphasis on the meaning, experiences and views of the participants. Differences among qualitative researchers exist on matters of ontology, epistemology, data collection methods and methods of evaluation. The aim of this article is not to act as a practical guide on how to conduct qualitative research, but is an attempt to give an introduction to qualitative research methods and their use in health-related research.

Q ualitative research is defined as an umbrella term covering an array of interpretative techniques which seek to describe, decode, translate and otherwise come to terms with the meaning, not the frequency, of certain more or less naturally occurring phenomena in the social world. 1 , 2

As a method of inquiry, it was first used by sociologists and anthropologists in the early twentieth century, although it existed much earlier than that in its non-structural form. Researchers studied cultures and groups in their own and foreign settings and told stories of their experience long before then. In the 1920s and 1930s, social anthropologists and sociologists implemented a more focused approach compared to the old unsystematic and journalistic style used in those days. Since the 1960s, qualitative research has experienced a steady growth starting with the development of grounded theory and new publications in ethnography. 3 , 4 The number of books, articles and papers related to qualitative research has increased tremendously during the past 20 years and more researchers, including health-related professionals, have moved to a more qualitative paradigm adapting and modifying these approaches to the study needs of their own areas. 4

Since qualitative research does not aim to enumerate, it is sometimes viewed as the exact opposite to quantitative methods and the two methods are frequently presented as antagonists. Quantitative research is based on structure and uses experiments and surveys as methods. In addition, it is deductive in nature and uses statistical sampling methods. In contrast, qualitative research is described as an action research using observation and interview methods. It is inductive in nature and depends on the purposeful selection of participants. Whereas quantitative researchers use reliability as a way of verification, qualitative researchers use validity. Recently, there has been a growing recognition that the quantitative-qualitative debate and distinction is unnecessary and that it would be more fruitful for the relation between the two methods to be complementary and overlapping rather than exclusive. 6 In fact, neither qualitative nor quantitative research is superior to the other; there are weaknesses and strengths in each method. Qualitative and quantitative research methods can indeed be seen as complementary and both are necessary to provide an understanding of a phenomenon.

Several researchers have argued that the research questions and the phenomenon under investigation should determine the methodology to used. 7 , 8 , 9 The crucial question, therefore, is not “what is the best research method?” but “what is the best research method for answering this question most effectively and efficiently?” 10 So, while qualitative and quantitative research may well investigate similar topics, each will address a different type of question. Holman sums up this position: “true understanding in medicine cannot be achieved without adding qualitative methods to the research arsenal”. 11

Traditional quantitative methods, such as randomised controlled trials, are the appropriate means of testing, for example, the effect of an intervention or a treatment, while a qualitative exploration of beliefs and understandings is needed to find out why the results of research are often not implemented in clinical practice. The aim of qualitative research is to develop concepts that can help us understand social phenomena in natural settings, giving emphasis on the meanings, experiences and views of the participants. 10

Qualitative research methods are the most suitable for this approach because of their emphasis on people’s lived experience. They are considered to be well suited for locating the meanings that people place on the events, processes, and structures of their lives and their perceptions, presuppositions and assumptions. 5 In his advice to graduate students, Patton lists a number of conditions that are suitable for a qualitative study. These include: questions about people’s experiences; inquiry into the meanings people make of their experiences; studying a person in the context of her or his social/interpersonal environment and research where it is difficult to develop a standardised instrument due to the lack of knowledge on the phenomenon. 12

ARGUMENTS FOR AND AGAINST QUALITATIVE METHODS

There are major differences of opinions among qualitative researchers on matters of ontology and epistemology as well as the methods to be used and criteria of evaluation. There are also disagreements about the nature, purpose, status and practice of its methods. A large number of authors take a predominantly method-based approach; authors such as Miles and Huberman 5 and Patton 12 put emphasis on data collection techniques. Another approach is to classify qualitative research according to research traditions, i.e. whether phenomenological, grounded theory or ethnography, amongst others. Authors such as Creswel 9 and Denzin and Lincolin 3 prefer this approach, which has the advantage of being based on systematisation of knowledge providing a sense of order and orientation. On the other hand, it has the disadvantage of oversimplification, ignoring the issues of the research question and conceptual frameworks used and the way these issues can shape the research process and the findings. 13 In addition, some researchers have decided to classify qualitative research according to the research question or the method of analysis.

Although the majority of qualitative researchers stress that qualitative research is inductive in nature, in contrast to quantitative research which is deductive, there are qualitative researchers who argue that both can be used for different purposes and at different times, and that qualitative research can be done in a deductive way where prior assumptions are tested on new cases. 14 Retroduction, which is defined as the movement backward and forward between theory and data or the combination of deduction and induction, is said to be a characteristic of qualitative research. 11 The degree of deduction or induction and which one follows the other depends on the research question. 12 .

Guba and Lincoln 15 used the term “emergent design” to describe a qualitative study design that emerges as the study progresses in response to the researcher’s early observations. There are also qualitative studies in health care that base their research questions on the results of prior literature of quantitative studies on the subject. 16 , 17 While the research questions in these studies were relatively precise, the method used was flexible.

Miles and Huberman 5 state that no study conforms exactly to a standard methodology and that the researcher bends the methodology to the peculiarities of the study. According to Creswell, 9 traditions of inquiry used “need not be pure, and one might mix procedures from several”. Mixing approaches and procedures is encouraged by some authors and regarded as a creative approach to qualitative research. 12

Studies using qualitative research in health care have been criticised for the misguided separation of method from theory and of technique from the conceptual underpinnings. 18 However, qualitative health researchers respond by stating that the choice of method and how it is used can perfectly well be matched to what is being studied rather than to the methodological leanings of the researcher. 10 It has been suggested that incorporating qualitative research method experts into health research teams enriches research and ensures that the right methodology is used for answering the right questions. Finally, using qualitative methods in health-related research has resulted in more insight into health professionals’ perceptions of lay participation in care and identification of barriers to changing healthcare practice.

QUALITATIVE RESEARCH APPROACHES

Grounded theory, phenomenology and ethnography are three approaches used in qualitative research. Grounded theory approach is a commonly used qualitative method in the social sciences to inductively generate or discover a theory out of the data. 9 Phenomenology and ethnography are more commonly used qualitative approaches in health care and will be highlighted below.

PHENOMENOLOGY

One of the major strengths of qualitative research is its emphasis upon understanding the phenomenon of interest holistically and in its context. The term phenomenology is popular and widely embraced, but its meaning has become confusing and faint. Different researchers refer to phenomenology differently. It can refer to an inquiry paradigm, an interpretive theory, a philosophy, an analytical perspective, a major qualitative research tradition or a research method framework. 12

In spite of the differences, all of these approaches share the focus of phenomenology, which is exploring how human beings make sense of experience and the meaning they give to these experiences. Phenomenology is being used in the social and human sciences including sociology, education, psychology, nursing and health sciences. 9

Phenomenologists are interested in how people put together the phenomena they experience in such a way as to make sense of the world and develop a worldview. They assume commonality in human experience and focus on meaning-making as the essence of human experience. The essence is the core meaning mutually understood through a phenomenon commonly experienced. 12 The phenomenon under study may be emotions, relationships, a programme, an organisation or a culture. 12 Bracketing is one of the central ideas in phenomenology. It means that the researcher has to set aside all of his prejudgments and his previous experience about the phenomena and approach the field with an open mind, imagination and intuition. Although important, bracketing is often said to be a difficult task. 9

Patton 12 describes the difference between conducting a phenomenological study and using a phenomenological perspective to a study. He argues that, “one can employ a general phenomenological perspective to elucidate the importance of using methods that capture people’s experience of the world without conducting a phenomenological study that focuses on the essence of shared experience”.

ETHNOGRAPHY

In ethnography, the researcher studies the structure and function of a group of people. An example of a structure or configuration is the kinship, while the function refers to patterns of relationships affecting and regulating behaviour. 9 The aim of ethnographic studies is to give a holistic picture of the social group studied, attempting to describe aspects of the cultural and social system of that particular group. These aspects could be the group history, religion, economy, politics or environment.

Data collection methods vary in ethnographic studies with observation and interviews being the most popular methods. Although some authors expressed concern that anthropological methods may be misused or applied superficially by the medical profession, 19 others, however, expressed the need for acknowledging and incorporating ethnographic methods in health care research. 20 Savage 19 explains that today the term ethnography can be applied to any small-scale social research carried out in everyday settings and uses several methods evolving in design and focusing on an individual’s meanings and explanations. In health care, ethnography has been used in topics related to health beliefs and practices, allowing these issues to be viewed in the context in which they occur and therefore helping broaden the understanding of behaviours related to health and illness. 20

In addition, there has been an increase in the amount of cross-cultural research and a change in the form of this research. Recently, more short-term ethnographic and cross-cultural studies have been undertaken, for example, studies sponsored by international development agencies or student exchange projects. 12

QUALITATIVE RESEARCH INSTRUMENTS

Qualitative research instruments used for data collection include interviews, observations, and analysis of documents. Interviews are the most common techniques used to gather research information. There are three types of interviews: structured, semi-structured and unstructured, described in some books as structured, informed and guided, respectively. 13

The semi-structured interview is more commonly used in health care-related qualitative research. Such an interview is characteristically based on a flexible topic guide that provides a loose structure of open-ended questions to explore experiences and attitudes. It has the advantage of great flexibility, enabling the researcher to enter new areas and produce richer data. In addition, it helps the researcher to develop a rapport with the informants. Semi-structured interviews elicit people’s own views and descriptions and have the benefit of uncovering issues or concerns that have not been anticipated by the researcher. 6 They are commonly used when the aim is to gain information on the perspectives, understandings and meanings constructed by people regarding the events and experiences of their lives. However, this type of interviewing is claimed to reduce the researcher’s control over the interview situation and take a longer time to conduct and analyse, in addition to the difficulties of the analysis process. 21

In health care, interviews are the appropriate tool to be used if the research is concerned with interpersonal aspects of care or if the available evidence is limited. 6

Another qualitative research instrument that can be used in health care research is the focus group. Focus group interviews have the advantage of being more time efficient as more people can be interviewed for the same amount of time. They also provide a richer source of data. On the other hand, focus group interviews tend to document the ‘public’ rather than the ‘private’ views of the individuals. In addition some people do not interview well in-group situations. 13

THE USE OF THE INTERVIEW GUIDE

Some qualitative researchers are reluctant to plan a design of their study in advance of the data collection. They argue that the phenomenon studied must first be discovered and they describe their design as emergent. However, increasingly more qualitative researchers appear ready to define a research question and develop an interview guide prior to starting the data collection. 11 Patton defines an interview guide as a series of topics or broad interview questions which the researcher is free to explore and probe with the interviewee. 12 The advantage of an interview guide is that it helps the interviewer pursue the same basic lines of inquiry with each person interviewed and manage the interviews in a more systematic and comprehensive way. The findings of earlier work are increasingly being used as a facilitator for further research. However, concepts drawn from earlier work are supposed to be held lightly and to be subject to reformulation or rejection by the researcher especially as the study goes on and the research progresses. 11 The extent to which such a flexibility of design is important will vary depending on the topic and the aim of the study.

Sampling strategies in qualitative research are largely determined by the purpose of the study. Statistical representativeness is not considered as a prime requirement in qualitative research and is not normally sought. Furthermore, qualitative data collection is more time consuming and expensive, which makes the use of a probability sample impractical. 6 The aim of sampling in qualitative research is to identify specific groups of people who hold characteristics or live in circumstances relevant to the phenomena being studied. In this way, identified informants are expected to enable enriched exploration of attitudes and aspects of behaviour relevant to the research. 10 Two types of samples used in qualitative research, maximum variation and homogenous samples, are explained below.

According to Patton, 12 maximum variation sampling is where the researcher attempts to study a phenomenon by seeking out settings or persons that represent the greatest differences in that phenomenon. A maximum variation sample documents diverse variations and identifies important common patterns by representing diverse cases to develop fully multiple perspectives about the cases. 9 This means that the participants are sampled based on particular predetermined criteria in order to cover a range of constituencies, such as different age, cultural background or class. 6

Similarly, the researcher can select the setting of the data collection on the basis that it is sufficiently similar to other settings in which generalisation is sought. This way the researcher is demonstrating the possibility that the setting studied is representative of the population studied. 2

In homogeneous sampling, the researcher chooses a small homogenous sample with the purpose of describing some particular subgroups in depth. 12

The sample size in qualitative research is not determined by fixed rules, but by factors such as the depth and duration of the interview and what is feasible for a single interviewer. 22 Although it is theoretically possible to carry out qualitative research on large samples, qualitative researchers find themselves obliged by time and resource limits to trade breadth for depth. 11 The sample size for interview studies is usually much smaller than those of a quantitative research, usually not exceeding 50 participants, although this can vary with the research question asked. 6 Patton 12 states, “there are no rules for sample size in qualitative inquiry”. In other words, sample size depends on the aim of the study and what is possible, given the time and resources available.

ANALYSING QUALITATIVE RESEARCH

Although there are plenty of guidelines for analysing qualitative research, applying these guidelines requires judgment and creativity because each qualitative study is unique. 12 A researcher might also be confused by the different terms used by qualitative researchers when describing analysis. Analysis might be described as interpretation, making sense of data, or transforming data. Analysis is sometimes presented to indicate different procedures based on language, theory or what is described as interpretive/descriptive analysis. 11 However, overlap can take place between these different methods and a researcher might decide to use a method of analysis that is based on language, such as symbolic interactionist, while using grounded theory to develop a theory at the same time. Most of the analytical approaches to qualitative research in health care are ‘generic’ and are not labelled within one of the specific traditions of qualitative research. A common approach in most of these studies is general and inductive in nature, but does not comply with the very systematic and rigorous inductive approach of grounded theory. In addition, it has been described that many researchers use a simple two-level analysis scheme followed by a more specific level. This means that the researcher can initiate the analysis based on the conceptual framework used in order to produce more inductive data, and the coding moves from the descriptive to the more interpretative and inferential codes. 5

COMPUTER USE IN QUALITATIVE DATA ANALYSIS

Qualitative research studies typically produce very large amount of data that needs to be managed efficiently. Computer packages can improve the efficiency of data management. 11 Computer programs provide a way of storing and retrieving material. They are therefore useful in locating cases, statements, phrases or even words, thereby replacing the tedious and time-consuming process of “cutting and pasting” and “colour coding”. The use of computer packages, however, is claimed to distance the analyst from the data, 11 and may take the place of a close and careful analysis. Using a computer programme can lead to quantitative analysis instead of qualitative, for example, counting occurrences, giving more weight to more frequent events, and ignoring isolated incidences. 23 In addition, computer programmes are said to fix and label categories during the analysis process and the researcher may be reluctant to change these categories. 9 Furthermore, the researcher is required to learn the computer programme, which may add to the time and effort he or she will need to spend on the research project. The researcher also has to be aware of the limitations of computer programmes. While computer packages can help with the intensive process of analysis and the management of large data sets, they are not a substitute for “immersion” in the data, and thorough knowledge that can enable the researcher to make comparisons, identify patterns and develop interpretations. 6 There are different packages available: Ethnograph, Atlas and NUD.IST are the mostly used. QSR NVivo is a new product developed by the makers of NUD.IST and is user-friendlier, more suitable for individual research projects and more visually attractive than previous packages.

THE ROLE OF THE RESEARCHER IN QUALITATIVE RESEARCH

Patton 12 states that, “the human element in qualitative research is both its strength and weakness”. It is considered a point of strength because it allows human insight and experience to develop new understandings of the world, and a point of weakness because it depends heavily on the researcher’s skills, creativity, training and intellect. Qualitative methods depend on both critical and creative thinking and the balance between the two in conducting the study and interpreting its results. The role of the researcher is approached differently according to the type of research tradition used. A phenomenologist researcher is required to bracket his/her own assumptions when collecting data. On the other hand, in an ethnographic study, the effect of the researcher on the interview and the interaction is seen as inevitable and important in shaping the results of the study.

Although practising clinicians routinely interview patients during their clinical work, interviewing is a well-established technique in sociology and related disciplines. One of the differences between clinical and research-aimed interviews lies in their different purposes. The usual aim of the clinical interview is to fit the patient’s problem into the appropriate medical category for diagnosis and management. On the other hand, the aim of a qualitative research interview is to discover the interviewee’s own meaning and avoid prior assumptions and preset categories. 22 Having said that, there are general skills in clinical interviewing that can be useful, such as listening and observation. A good level of self-awareness is necessary in the researcher in order to reduce possible biases.

Researchers in qualitative research need to consider how they are perceived by interviewees and the effect of features related to the researcher, such as class, race, and sex on the interview. This question is more important if the interviewee knows that the interviewer is a doctor. It has been described that a patient, or someone who is likely to be become one, may give what he or she thinks is a desirable response, thinking that the doctor will be pleased.

RIGOUR IN QUALITATIVE RESEARCH

Health field research is generally quantitative and based on biomedical traditions and experimental methods. In this field, qualitative research is criticized for being subject to researcher bias and for lacking reproducibility and generalisability. 10 Researchers presenting their qualitative work in health-related research are partly responsible for this view. Many qualitative researchers neglect the importance of giving an adequate description of their theoretical concepts and methods used in their research. A systematic research method is also essential when conducting qualitative research. Rigour in qualitative research includes procedures taken at different stages of the research process including during data collection and analysis. Several procedures have been described to increase rigour in qualitative research. For example, triangulation is commonly used as a way of validating of data.

TRIANGULATION

In triangulation, the researcher uses multiple methods, sources, researchers or theories to provide evidence that strengthens his or her study. Triangulation provides different ways of looking at the same phenomenon and adds credibility and confidence in the conclusions drawn from the study. There are two main types of triangulation, triangulation of sources and analyst triangulation. Patton 12 defines triangulation of sources as “checking out the consistency of different data sources within the same method”. When using this type of triangulation, the researcher compares the perspectives of people from different points of view. For example, studies in programme evaluation might compare the views of staff, clients or funding bodies. 12 Studies in health care have used this method of verification to study the accounts of doctors, patients, and managers in order to identify similarities and differences in views. An example is the study of patients’ versus doctors’ agendas in general practice. 23 Both similarities and differences from different sources, when given reasonable explanation, could contribute significantly to the credibility of the findings. Triangulation with multiple analysts can also be used as a method of verification. It is defined as “having two or more persons independently analyse the same qualitative data and compare their findings”. 12

QUALITATIVE RESEARCH IN HEALTH CARE MANAGEMENT

Recently, there has been a greater acceptance of the qualitative approach, even as a stand-alone method, in health care research. Institutions that control funding for medical research have developed ethical guidelines for assessing qualitative studies which indicates formal acceptance of this form of research within an area previously dominated by quantitative methods. 13 More qualitative research articles are published in health-related journals, in addition to a new qualitative research journal (Qualitative Health Research).

Quality of health care is one of the areas where qualitative methods can be used. The concept of quality in health care is multidimensional and multifaceted and some of the questions asked related to the quality of care or services may not be acquiescent to quantitative methods. 6 Qualitative research offers a variety of methods to be used for identifying what is really important to both patients and carers. It can also be used to identify and detect obstacles to change and the reasons why improvement does not occur. 6 It is therefore an essential component of health services research because it enables us to reach areas not amenable to quantitative research, for example, lay and professional health beliefs. In addition, qualitative description can be a prerequisite of quantitative research, particularly in areas that have received little previous investigation.

Qualitative research is widely used to study issues related to doctor-patient interaction especially in general practice. Studies concerning patients’ versus doctors’ agendas in general practice and general practitioners perceptions of effective health care are examples. 23 , 24 Recently there have been more studies concentrating on patients’ own perceptions and views regarding their health and health care services, for example a study on women’s views on the impact of operative delivery in the second stage of labour. 25 Another example is the study on middle-aged person’s experience of living with severe heart failure. 26

Another area where qualitative research is being used in health care is to identify obstacles and barriers to practice change by exploring the reasons behind certain behaviours. A good example of this is the study of patients’ decisions about whether or not to take anti-hypertensive drugs. 27 There are similar studies on issues such as the use of antibiotics in general practice and patient compliance.

In addition to issues related to the patients’ perception, some qualitative studies concentrated on factors fostering the doctor’s motivation and the effect of doctors’ social life and culture, in addition to issues related to the doctor’s own health. Examples are the study by Dumelow et al. 28 on the relation between a career and family life for English hospital consultants. Another example is a study aimed at exploring general practitioners’ perceptions of the effects of their profession and training on their attitudes to illness in themselves and colleagues. 29

Qualitative work can help in identifying cultural and social factors that affect health care positively or negatively. Such information can be helpful in improving service delivery. 6 Studies on patients from ethnic minorities have identified administrative and language barriers that affected health care and shed light on some of the beliefs and behaviours of these patients that might have affected help seeking and compliance. Good examples are the studies by Bush et al. 30 exploring the influences on smoking in Bangladeshi and Pakistani adults in the UK, and the multi-centre cross-cultural postnatal depression study. 31

There has been an increasing interest and use of qualitative research methods in primary health care and general practice articles. Britten 32 states that “the nature of general practice is such that a variety of research methods are needed to explore all its intricacies” He adds that qualitative methods can enrich research in general practice by opening up areas not amenable to quantitative methods, topics such as patient satisfaction, doctor-patient interaction, in addition to identifying and explaining attitudes, beliefs and behaviour. In addition, qualitative research has been used in the assessment of new technology methods used in health care. For example, the studies on the implementation of the National Health System information technology programme in the UK. 11 , 33

Qualitative research methods are receiving an increasing recognition in health care related research. The use of qualitative research in health care enables researchers to answer questions that may not be easily answered by quantitative methods. Moreover, it seeks to understand the phenomenon under study in the context of the culture or the setting in which it has been studied, therefore, aiding in the development of new research instruments, such as questionnaires that are more culturally acceptable. However, because health care related research has, for decades, been based on quantitative methods, the introduction of a new method requires researchers in health care who attempt to use it, to have a thorough understanding of its theoretical basis, methodology and evaluation techniques.

Acknowledgments

I would like to thank Sultan Qaboos University, Oman, for granting me a scholarship to do my PhD at the University of Nottingham, UK. I am also grateful to my PhD supervisor, Dr Margaret Oates, for her guidance and support.

PH717 Module 1B - Descriptive Tools

Descriptive epidemiology & descriptive statistics.

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Quantitative and Qualitative Methods for Public Health

This course focuses on quantitative methods, which are designed to precisely estimate population parameters and measure the association between biologic, social, environmental, and behavioral factors and health conditions in order to define the determinants of health and disease and, ultimately, to understand causal pathways.

However, it is important to acknowledge the importance of qualitative methods which provide a means of understanding public health problems in greater depth by providing contextual information regarding a population's beliefs, opinions, norms, and behaviors. This type of information is difficult to capture using traditional quantitative methods, yet it can be vitally important for understanding the "why" for many health problems and also the "how" in terms of how to achieve improvements in health outcomes.

These two approaches might be thought of as the positivist and the constructivist approaches. In positivist research data are more easily quantified, but they are disconnected from the context in which they occur. For example, people of lower socioeconomic status are more likely to smoke tobacco, but the data collected does not indicate why. However, with a constructivist approach, the exposures that people are subjected to (or choose) are better understood in the context of their personal circumstances and the significance that people attribute to things in their environment.

Qualitative methods provide a means of understanding health problems and potential barriers and solutions in greater detail, and they provide an opportunity to understand the "how" and "why" and to identify overlooked issues and themes.

The table below, from the introductory course on fundamentals of public health, highlights some of the major differences between quantitative and qualitative research.

	Quantitative	Qualitative
General Framework	Test hypotheses; data collection is rigid relying on structured methods, such as questionnaires, surveys, record reviews	Explore phenomena using more flexible methods that categorize responses to semi-structured methods such as in-depth interviews, focus groups, and participant observation
Analytic Objectives	Describe populations and to quantify exposure-outcome associations	Describe and explain variations and relationships
Question Format	Closed-ended	Open-ended
Data Format	Numeric or categorical	Textual (based on audiotapes, videotapes, and field notes)
Flexibility in Study Design	Study design is stable throughout a study. Participant responses do not influence or determine how and which questions researchers ask next.	The study design is more flexible. Participant responses affect how and which questions researchers ask next. Questions can be adjusted according to what is learned

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Open access
Published: 25 August 2024

Navigating sexual minority identity in sport: a qualitative exploration of sexual minority student-athletes in China

Meng Xiang 1 , 2 ,
Kim Geok Soh 2 ,
Yingying Xu 3 ,
Seyedali Ahrari 4 &
Noor Syamilah Zakaria 5

BMC Public Health volume 24 , Article number: 2304 ( 2024 ) Cite this article

Metrics details

Sexual minority student-athletes (SMSAs) face discrimination and identity conflicts in intercollegiate sport, impacting their participation and mental health. This study explores the perceptions of Chinese SMSAs regarding their sexual minority identities, aiming to fill the current gap in research related to non-Western countries.

A qualitative methodology was adopted, utilising the Interpretive Phenomenological Analysis (IPA) approach with self-categorization theory as the theoretical framework. Participants were recruited through purposive and snowball sampling, and data were collected via semi-structured interviews, documents, and field notes. Sixteen former and current Chinese SMSAs participated in this study.

The study reveals four themes: hidden truths, prioritisation of athlete identity, self-stereotyping, and attempt. The results revealed that while SMSAs were common in intercollegiate sport, their identities were often concealed and not openly discussed. The predominant focus on athlete identity in sport overshadowed their sexual minority identities. Additionally, SMSAs developed self-stereotypes that influenced their thoughts and behaviours. The non-heterosexual team atmosphere in women’s teams led to the development of intimate relationships among teammates.

Conclusions

The findings from this study could be incorporated into existing sport policies to ensure the safe participation of SMSAs in Chinese intercollegiate sports. This research offers valuable insights for the development and implementation of inclusive policies. Future research in China could investigate the attitudes of coaches and heterosexual student-athletes toward sexual minority identities to inform targeted interventions.

Peer Review reports

Collegiate sport serves as a conduit for hope, competition, learning, success, and enhanced well-being for students [ 1 , 2 ]. Within this context, situated at the intersection of student-athlete and sexual minority identities [ 3 ], sexual minority student-athletes (SMSAs) experience more challenges than their heterosexual counterparts. Sexual minority constitutes a group of individuals whose sexual and affectual orientation, romantic attraction, or sexual characteristics differ from that of heterosexuals. Sexual minority persons are inclusive of lesbian, gay, bi+, and asexual-identified individuals [ 4 ].

In an effort to enhance the support of SMSAs in sport, Team DC, the association of sexual minorities sport club, awarded seven SMSAs the 2023 Team DC College Scholarship [ 5 ]. Besides the Team DC scholarship, there are the Rambler Scholarship, US Lacrosse SMSAs Inclusion Scholarship, NCAA Women’s Athletics Scholarship and Ryan O’Callaghan Foundation [ 6 , 7 , 8 ]. These scholarships were set up to make sport a more welcoming and safer environment for SMSAs. In particular, the Sexual Minority Scholarship echoes the International Olympic Committee’s framework of equity, inclusion, and non-discrimination, which states that everyone has the right to participate in sport without discrimination and in a manner that respects their health, safety and dignity [ 9 , 10 ].

Despite efforts by educational and sport organisations to foster inclusivity, research shows that the sport environment remains hostile to sexual minority individuals [ 11 , 12 ]. In intercollegiate sport, empirical evidence points to persistent negative attitudes [ 13 , 14 , 15 , 16 , 17 ], which are expressed through marginalisation, exclusion, use of homophobic language, discrimination, and harassment [ 17 , 18 , 19 , 20 ]. SMSAs frequently confront the difficult choice of disclosing their identity, often opting for concealment. Denison et al. found that SMSAs who disclose their identity to their teams may face increased discrimination [ 21 ]. Pariera et al. also observed deep-rooted fears among SMSAs of being marginalised by their teams upon revealing their sexual orientation [ 22 ]. Consequently, the hostile environment led to lower participation rates among sexual minority youth compared to their heterosexual counterparts [ 23 ].

In China, there is a lack of clear public policies related to the sexual minority population [ 24 ]. Despite homosexuality being removed from the Chinese Classification of Mental Disorders-3 in 2001 [ 25 ]. China’s stance towards sexual minority issues remains ambiguous. Many scholars describe this attitude as “no approval, no disapproval, and no promotion” [ 26 , 27 , 28 , 29 ]. Due to the lack of legal protection, sexual minorities frequently encounter discrimination. A Chinese national survey revealed that only 5.1% of sexual minority individuals felt comfortable being open about their gender and sexual identity in China [ 30 ]. This discrimination is particularly severe among Chinese sexual minority youth, who are at higher risk of bullying in school and college [ 31 , 32 ]. These youths face childhood victimisation [ 33 , 34 , 35 ], which heightens their risk of mental and behavioural health issues [ 36 , 37 , 38 ], including non-medical use of prescription drugs [ 39 ], depression [ 40 , 41 ], and suicide [ 42 ].

While sports participation is crucial for the well-being of sexual minority individuals, research on the sports participation of sexual minority youth in China is limited. The literature highlights a significant gap in understanding the status and circumstances of SMSAs in China. Most existing studies focus on Western populations [ 43 , 44 , 45 ], overlooking the unique sociocultural interactions affecting SMSAs in non-Western contexts, making it challenging for China to apply these findings. Furthermore, the lack of reliable research on the interactions between sexual minorities and institutions in Chinese higher education hampers a comprehensive understanding of SMSAs’ situations. This research gap impedes the development of effective interventions to foster inclusivity. Persistent discrimination and inadequate protective policies underscore the urgent need for academic, policy, and practical advancements to support sexual minorities in China [ 46 ]. Therefore, the aim of this study was to explore SMSAs’ perceptions of their sexual minority identity in Chinese sports, providing insights to guide the creation of supportive educational and organisational strategies.

Homonegativity and discrimination in sport

Homonegativity refers to any prejudicial attitude or discriminatory behaviour directed towards an individual because of their homosexual orientation [ 47 ]. Compared to the more common term “homophobia,” [ 48 ] “homonegativity” more accurately describes negative attitudes towards homosexuality [ 49 ] because the fear is not irrational but is learned from parents, peers, teachers, coaches, and the daily interaction environment [ 50 ]. Sport context is an integral part of society, and an extensive body of research has consistently demonstrated the presence of homonegativity in sport [ 12 , 21 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 ].

Homonegativity can manifest in forms such as verbal harassment, physical violence, or discriminatory behaviours. The “Out on the Fields” survey, conducted in 2015, represents the first large-scale international study focusing on homophobia in sports [ 60 ]. Participants were from six countries: Canada, Australia, Ireland, the United States, New Zealand, and the United Kingdom. It revealed extensive discrimination in sport, with a high percentage of gay men and lesbians experiencing verbal slander, bullying, threats, and physical assault. The OUTSPORT project, completed in 2019 and funded by the European Union, is the first comprehensive EU-wide study on homophobia and transphobia in sport. The project collected data from over 5500 sexual minority individuals across all 28 EU member countries [ 61 ]. The results revealed that a significant portion of participants faced adverse experiences in sport contexts related to their sexual orientation and gender identity, including verbal abuse, structural discrimination, physical boundary crossing, and violence. An overwhelming majority of respondents (92.9%) view homophobia and transphobia in sport as current issues. Additionally, 20% of respondents reported avoiding participation in sport due to concerns about their sexual orientation or gender identity, while 16% of active participants experienced at least one related negative incident in the past year. Notably, male student-athletes exhibited higher levels of homophobic attitudes compared to their female counterparts and non-physical education students [ 15 , 16 , 62 ]. Conversely, female athletes reported experiencing less fear of exclusion and a more inclusive team environment [ 22 , 63 , 64 ], highlighting significant gender disparities in homonegativity in sport.

Group and individual identity

The distinct team interaction inherent in sport may enhance or support expressions of homonegativity and discrimination, as Social Identity Theory posits that negative beliefs about certain groups may develop group identity [ 65 , 66 , 67 ]. This phenomenon is particularly noticeable in intercollegiate sport, where a strong emphasis on physical attributes and abilities often results in prejudices against those who deviate from established norms [ 16 ]. Such discrimination and mistreatment of SMSAs frequently stem from their teammates and coaches. Many SMSAs choose to conceal their sexual orientation due to fear of ostracism [ 60 ], with team members often identified as the primary perpetrators of discrimination [ 61 ].

Therefore, navigating sexual identity within intercollegiate sport is challenging for SMSAs, as their minority status becomes a focal point, impacting their overall experience [ 68 , 69 ]. They encounter a unique psychological and emotional burden, striving to reconcile societal norms and expectations with their true selves. This constant negotiation and management of their identity across different contexts further complicates their experiences, frequently leading to difficulties in maintaining authenticity [ 19 ]. Therefore, SMSAs in intercollegiate sport face intricate challenges in balancing their authentic identity with societal norms, significantly impacting their experience and sense of self.

Theoretical framework

Self-categorisation theory (SCT), an extension of Social Identity Theory, provides a valuable perspective for examining the perceptions of SMSAs in China, focusing on intragroup processes and individual navigation of personal and social identities [ 70 , 71 ]. Key principles of SCT, including self-categorisation, salience, depersonalisation, and individuality [ 67 ], are instrumental in understanding how SMSAs navigate their sexual identities within the confines of sport norms. Applying SCT, this study could explore the complex interplay of intragroup relations and identity processes among SMSAs in the Chinese sport context, underscoring how contextual factors distinctly shape their identity.

Purpose of the study

The purpose of this study is to explore SMSAs’ perceptions of their sexual minority identity within the Chinese sports context and understand how this identity influences their participation in sports. By illuminating the specific challenges and issues related to sexual minority identity in Chinese intercollegiate sports, this study provides a deeper understanding of the experiences of sexual minorities in this field.

Research design

This study was conducted with the interpretivist paradigm, which emphasises understanding the subjective experiences and meanings that individuals assign to their world. It posits that reality is not objective but is constructed through individual perceptions and social interactions [ 72 ]. Given the aim of exploring the perceptions of sexual minority identity in sport from SMSAs’ perspectives, a qualitative research approach is appropriate. In line with the purpose of the study, the Interpretative Phenomenological Analysis (IPA) was adopted in this study, an approach aimed at understanding people’s lived experiences and how they make sense of these experiences in the context of their personal and social worlds [ 73 ]. IPA research encompasses phenomenology, hermeneutics, and idiography and emphasises the personal significance of self-reflection among individuals with a shared experience in a specific context [ 74 ]. Additionally, IPA is particularly suitable for research focusing on identity and self-awareness [ 75 ]. The features and focus of IPA are consistent with the purpose of this study. Therefore, IPA was considered a suitable approach to explore the SMSAs’ perceptions of their sexual minority identity within the sport context in China.

Researcher characteristics and reflexivity

During the data collection phase of this study, the first researcher was a Ph.D. candidate and had obtained her Ph.D. by the time of this manuscript’s submission. Her doctoral committee continuously supervised the research. The first researcher’s doctoral committee members are proficient in qualitative research. The first researcher and the second coder have received systematic qualitative training, are skilled in qualitative analysis software (NVivo), and have published empirical studies using the IPA approach. Although none of the research team members were SMSAs, the first researcher and the second coder maintained long-term contact with SMSAs through their involvement in sport teams. The first researcher was a former student-athlete and is currently working as a coach. Given her background, she has had extensive time to interact with and understand SMSAs within student teams.

Participants and procedures

Purposive and snowball sampling methods were employed to recruit a homogeneous sample for this study, as recommended by Smith and Nizza [ 73 ]. Following approval from Universiti Putra Malaysia’s Human Research Review Committee, the researcher initially reached out to SMSAs within her network, subsequently expanding outreach through social media to reach a broader pool of potential participants. The participants were selected based on specific inclusion criteria (Table 1 ), ensuring relevance to the study’s focus. Of the 22 individuals contacted, 16 agreed to participate, while six individuals declined participation due to concerns regarding potential exposure. The sample included a diverse representation of sexual minority subgroups: one asexual man, four bisexual women, three gay men, and eight lesbians. Given the relatively low prevalence of asexual individuals [ 76 , 77 ], we only had one participant from this subgroup. Strict confidentiality measures were enforced, with participants assigned pseudonyms and their college affiliations omitted for anonymity. The demographic details of the participants are outlined in Table 2 .

In phenomenological research, the focus is on rich individual experiences rather than data saturation [ 78 ]. Similarly, IPA research aims to explore participants’ personal and social worlds through detailed, in-depth analysis [ 79 ]. Smith and Nizza [ 73 ] also highlighted that in IPA research, sample size is less crucial because of the emphasis on detailed analysis in small, homogeneous samples. Therefore, the richness of data and the depth of insight into each participant’s experience are more important than the number of participants or reaching data saturation. This study utilised IPA’s in-depth analytical approach with sixteen participants to provide detailed data. This methodological approach allows for a comprehensive exploration of individual experiences, aligning with the study’s objectives.

Data collection

Data for this study were collected through semi-structured interviews (Appendix A), allowing participants to choose the mode, time, and location, including face-to-face or online sessions on Chinese social networks. Each interview’s length is detailed in Table 2 , with an average duration of 63 min. Before each interview, participants signed informed consent forms following a detailed briefing on the study’s purpose and procedures. Given the sensitive nature of the research, the interviews were conducted solely between the researcher and the participant to ensure a safe and comfortable environment, fostering open and honest communication.

The methods of data collection exhibited some qualitative differences. In face-to-face interviews, participants were often cautious and hesitant to share personal experiences. Conversely, online interviews proved more effective, as participants felt more relaxed, leading to quicker rapport and greater openness. This difference likely stems from the reduced perceived risk of exposure in an online setting. Due to the clear objectives of the study and the structured interview guide, there were no differences between the data from current SMSAs and former SMSAs.

Notably, one participant provided data through written essays instead of a semi-structured interview due to concerns about exposure and discomfort. After discussing the matter, the participant agreed to respond to interview questions in written form. The first researcher sent the interview questions to the participant, who then provided written responses. Follow-up questions were asked based on these initial responses, resulting in four sets of essay responses. This approach, which aligns with the conventions of phenomenological research [ 80 ], allowed the participant to express their experiences comfortably. The essay data were analysed alongside the semi-structured interview data, with common themes identified across all responses.

Documents and field notes supplemented the data collection. Documents included photographs, videos, and diaries. With participant consent, these documents were analysed for relevance to the research purpose. Field notes captured contextual information during both face-to-face and online interviews, including keywords and participants’ pauses and intonations, with immediate elaboration post-interview to avoid biases [ 81 , 82 ]. These detailed notes contextualised data analysis [ 74 ] and contributed to the research’s credibility.

Data analysis

The data analysis in this study followed a seven-step process aligned with IPA research guidelines and contemporary IPA terminology. The data analysis procedure is depicted in Fig. 1 . The IPA analysis is iterative and inductive [ 83 ], involving the organisation of data into a structured format for easy tracking through various stages – from initial exploratory notes on transcripts to the development of empirical statements, theme clustering, and final group theme structure. The theoretical framework was incorporated at the final stage of empirical theme development.

To enhance the study’s validity, the first author invited another Ph.D. candidate to participate in the data analysis process. After the interview recordings were translated into transcripts using audio software, the first researcher listened to the recordings repeatedly to correct the transcripts. The second coder reviewed the recordings to ensure the transcriptions were accurate and verbatim. The first author employed NVivo software (released in March 2020) for coding, and the second coder utilised manual coding. All data were analysed in Chinese to maintain linguistic integrity and then translated into English for theme presentation.

Data Analysis Procedure. Adapted from Smith et al. ( 74 )

The procedures of this study adhered to the COREQ Checklist [ 84 ] (Appendix B) and the IPA Quality Evaluation Guide [ 85 ] to ensure rigour. The research met the good quality requirements for IPA studies as outlined by Smith [ 85 ] (Table 3 ). Throughout the research, emphasis was placed on internal validity, external validity, and reliability to maintain the study’s rigour and quality. The methods employed to address these aspects are summarised in Table 4 .

This study explored SMSAs’ perceptions of sexual minority identity within intercollegiate sport in China. From the perspective of SCT, the results uncovered four key themes from SMSA’s team-based interactive experiences. The research themes, along with their corresponding sub-themes and occurrences, are presented in Table 5 .

Hidden truths

The hidden truths refer to facts, scenarios, or knowledge that are not commonly known or readily available. In this study, the existence of SMSAs in intercollegiate sport was undeniable, yet it remained concealed due to the prevailing lack of transparency.

SMSAs are common in sport

This research uncovered the extensive existence of SMSAs in Chinese sport. Almost all participants acknowledged the ubiquity of sexual minorities in sport, with 12 out of the 16 participants specifically highlighting the presence of SMSAs in collegiate sport:

I think everyone is generally aware of sexual minorities; all people are aware of them to a greater or lesser extent. It is generally agreed that the existence of sexual minorities is a common phenomenon in modern society, and even more so in Sport, as anyone involved in sport knows that (Adam).

Participants frequently described the presence of SMSAs in intercollegiate sport, using terms like “widespread”, “common”, “normal”, and “quite many”. Several participants also provided specific details about the number of SMSAs in their respective teams. Jackie remarked, “At that time, half of my teammates were lesbians” (Jackie). Similarly, Zoe noted the significant presence of SMSAs in her team, “I think it (the number of SMSAs) was almost half of the team at that time. But I don’t know about the senior players; almost half of our junior players were SMSAs” (Zoe).

Silent identity

Participants noted the prevalence of SMSAs in sport but also emphasised the difficulty of openly discussing sexual minority identity in this context. They described the sport environment as reserved and lacking open conversations about SMSAs and their experiences.

The reticent nature of sport teams regarding sexual minority identity was evident in their attitudes. William observed, “I feel like most of my teammates just don’t take a stand. They don’t want to make a statement about SMSAs. Nor did they say they supported it or didn’t support it” (William). Similarly, Mia considered sexual minority identity as a personal issue, inappropriate for open discussion.

No one wants to ask or discuss this openly…we live in a very conservative environment all the time, and none of this content is something that teammates should be concerned about, and people would feel offended if you don’t handle it well (Mia).

Some SMSAs viewed avoiding discussions on sexual minorities in sport as respectful to teammates, aiming for a comfortable, stress-free environment. Joy said, “We came here to play, right? I don’t think any of the other players want to feel phased by who you are” (Joy). Mia echoed this sentiment:

…in team training, the game is the game, and I rarely bring other emotions into it…. In the company of most of our teammates, we don’t interact with each other in that way. It’s probably a default rule that respect is distance, I guess (Mia).

Charlotte, involved in volleyball and basketball, recounted a teammate’s public derogation due to her sexual minority identity, an incident not openly addressed by the team. She perceived sexual identity as a “taboo” topic. The narratives revealed a cautious approach among SMSAs towards expressing their sexual minority identity in sport. They felt compelled to carefully manage their sexual orientation, minimising its disclosure. This hesitancy likely stemmed from the existing reticence and limited acceptance of SMSAs in sport, fostering a sense of invisibility and concern over potential negative consequences.

Prioritisation of athlete identity

The theme of prioritisation of athlete identity suggests that for SMSAs, their identity as an athlete may play a more prominent or influential role in shaping their self-conception compared to their sexual minority identity.

Be an athlete

Several participants believed their primary role as student-athletes was to engage in sport, and they valued this aspect of their identity significantly. Joy expressed this sentiment, “I love volleyball very much … I don’t care much about relationships; I just love volleyball, and I think we are all here to do this, and nothing else matters. You don’t need to stress about it (sexual minority identity)” (Joy).

Emma echoed a similar perspective, noting, “I think my teammates are very professional; our program requires a high technical standard, and we spend most of our time training; other than that, things don’t seem that important” (Emma). When queried about the importance of sexual minority identity, she responded, “Yes, at least not concerning sport performance, or maybe it will have a bad effect” (Emma). Additionally, some participants felt that in the context of sport, sexual minority identity might be sidelined. Adam commented:

“We don’t share it (sexual minority identity) unless someone asks. We’re a team first, and then we’re individuals, and for me, I’m important personally, but in the team, we all probably need to sacrifice some of ourselves to make the team more united and stronger” (Adam).

Participants’ views as both student-athletes and sexual minorities highlighted contrasts in the intercollegiate sport environment. Their student-athlete identity was key in shaping self-perception and fostering a sense of community, while their sexual minority identity was often marginalised in aspects of interpersonal relations, team support, and self-identity development.

Sport performance first norms

In team sport, leaders are crucial in creating inclusive spaces for SMSAs and setting behavioural and attitudinal standards, including those towards SMSAs. In this study, some participants believed that coaches’ criteria for acceptance of sexual minority individuals or intra-team romantic relationships were based on athletic performance.

Some coaches firmly believe that team relationships negatively impact team performance and, therefore, strictly prohibit romantic relationships between teammates. Joy recalled,

She couldn’t accept that… she thinks being an athlete like that is ridiculous. It would make a mess; her team would be in a mess. She said you two are dating and that playing will affect your emotions, which means she meant to say there is no way I can treat another girl as a normal teammate… (Joy).

In contrast, some coaches adopt a more tolerant attitude. Jackie’s coach believes that if the team’s overall performance is not affected, issues such as sexual orientation or team relationships can be ignored. Jackie stated, “My coach is male and old, but he should know what’s going on, especially since our captain has dated several teammates and the coach pretends not to know. He would only care if we were winning games” (Jackie).

Whether it instructs prohibition or an indifferent attitude, both narratives reflect that the team’s norms for inclusivity are based on sport performance. These norms also influence how SMSAs assess their own sexual minority identity within the team, as Adam said:

As of now, I have someone in the team that I have a crush on and haven’t dated. Maybe if he and I argued over training or a game, it would affect the performance of the team and the relationship between teammates…. I don’t think I could let that happen (Adam).

The participants’ narratives emphasise how the “Sports Performance First” norms influence the attitudes and behaviours of coaches and SMSAs within the team. These norms not only shape the team culture but also profoundly affect how SMSAs navigate their identities and relationships in the team environment.

However, the excessive focus on sport performance highlights the athletic identity of student-athletes while neglecting their other identities, especially those of sexual minorities. This singular focus leads to the neglect of the personal needs and diverse identities of athletes. Although these measures may seem to ensure the overall performance of the team, they overlook the psychological health and holistic development needs of the individuals.

Self-stereotyping

Self-stereotyping denotes the tendency of SMSAs to describe themselves using stereotypical attributes in the sport context. These descriptions frequently align with stereotypical perceptions prevalent in the external environment. SMSAs tend to be perceived as having specific physical traits or behavioural tendencies.

Specific physical traits

Sophia provided an illustrative example of self-stereotyping through her personal experience. She commented:

In the beginning, I would think that if you are an SMSA, you must fit some characteristics. For example, at that time, I saw some lesbians in my team who had short hair or wore baggy t-shirts; I was a bit frustrated by my long hair and feminine appearance…and I felt that I might not quite fit those criteria. So, then I cut my hair and even wore a wrapping bra to the training ground (Sophia). Sophia’s narrative underscores how the pressure to conform to certain physical traits led her to change her appearance to fit the stereotypical image of an SMSA within the sport context.

Behavioural tendencies

In addition to physical traits, SMSAs also feel compelled to conform to certain behavioural tendencies that are stereotypically associated with SMSAs. Zoe explained, “Because of who I am (T), I felt I should have to perform stronger, so I put up with much training…. I felt I should be there to protect the other players; if I were vulnerable, I would look down on myself” (Zoe). This indicates a sense of obligation among some female SMSAs to embody strength, aligning with the stereotypical image of female SMSAs in sport. Conversely, male SMSAs in men’s teams often faced stereotypes of being fragile, weak, or exhibiting feminine traits. Royal noted that behaviours of some male SMSAs, like engaging in non-sport-related banter, led to gossip and negative perceptions within men’s sport. To avoid these stereotypes, Royal aimed to mimic the mannerisms of heterosexual athletes, as he explained:

I try to avoid being close to the team’s prominent male SMSAs and try to stay out of related conversations; I don’t want to be a standard gay; I want to have the same college life as the rest of the team (heterosexuality) (Royal).

Stereotypes in sport often forced SMSAs into roles incongruent with their authentic identities, significantly impacting their self-expression and identity. The pressure to conform to societal norms in sport settings created internal conflicts for SMSAs, challenging their ability to maintain their true sense of self.

This theme addresses situations where student-athletes engage in intra-team intimacy or mimic being SMSAs in sport. This attempt has two key elements: prolonged contact leading to intimacy and influence from sexual minority teammates.

Prolonged contact leading to intimacy

Participants noted that extensive training and competition schedules in sport fostered close bonds among team members. Lucas shared, “When we were preparing for the tournament, we trained together every morning and evening…the game spanned for almost a month, and after that, we felt as close as family to our teammates” (Lucas). Similarly, Ruby pointed out, “Back then, we were training every afternoon until late at night; it was quite hard (the training was very strenuous) … it lasted for six months” (Ruby). These prolonged interactions sometimes led to the development of more profound attractions among student-athletes.

“I think we had many moments of trust and intimacy together on the field that built up some heartfelt feelings. These feelings made me feel emotions beyond that of a teammate…. Then I realised that gender might not be so important because it’s hard to build that kind of relationship in a typical romance” (Savannah).

Influence from sexual minority teammates

Participants also described how interactions with sexual minority teammates led them to explore their own sexual identities, as illustrated by Ava’s recounting of her initial same-gender relationship experience:

That time we went out to a tournament, and I found that four of my teammates, three of them were lesbians…we didn’t have games at night, so they had been talking to their girlfriends every night on the phone, and I just felt as if that was not too bad. Probably influenced by them, I got a girlfriend at that tournament as well…. Even though we broke up when we returned, I could accept girls (Ava).

Mia described a similar experience:

There were some lesbians in my team, and then it just seemed natural that I got close to one of them…. Well, I was thinking about whether that relationship would affect the team. But then I found out that there were other couples on the team. So, I feel like I wasn’t doing anything wrong (Mia).

The phenomenon highlights the significant role of peer influence in team settings. When individuals are around many teammates in same-gender relationships, it fosters an environment that normalises such relationships. Notably, this influence is not coercive but stems from observing and interacting with teammates who are comfortable with their sexual orientations. This environment helps individuals feel accepted and more confident in exploring their identities and relationships.

This study explored the perceptions of SMSAs regarding their sexual identity within intercollegiate sport in China. Its importance lies in its contribution to understanding the complex realities of SMSAs in China, an area that has lacked depth in the literature. By reaffirming the necessity of examining these athletes’ experiences, this study reveals the intricate conflict between adhering to team norms and expressing personal characteristics within the context of the Chinese social and cultural background.

The results show that SMSAs are a recognised reality in Chinese intercollegiate sport, consistent with findings from Western countries. While precise figures of sexual minorities in sport may vary across countries, it is acknowledged that they are present at all competitive levels, from school and college sport to the professional sphere [ 22 , 86 , 87 , 88 , 89 , 90 , 91 ]. Although no national census on sexual minorities in China or in sports environments exists, related research indicates that many college and university students self-identify as sexual minorities. For instance, an online survey conducted across 26 colleges and universities in 10 Chinese provinces found that over 8% of students identify as sexual minorities [ 36 ]. Additionally, another national survey revealed that nearly a quarter of college students identify as non-heterosexual [ 92 ]. Recognising and addressing the unique challenges faced by sexual minority youth, who make up a notable percentage of the student population, is essential for sport and educational institutions.

Despite the apparent prevalence of SMSAs, the study confirms that their identities often remain hidden in the context of Chinese intercollegiate sport. This can be attributed to two main reasons: First is the concern about discrimination if exposed. Chinese sexual minorities frequently report experiencing abuse or discrimination in families, schools, and workplaces [ 93 ]. Additionally, conversion therapies and discriminatory counselling practices persist in mental health services [ 94 ], creating an environment where discrimination is a significant concern, thereby reducing the likelihood of SMSAs coming out in the sports environment. The second reason is the constraint of traditional Chinese culture. The dominant Confucian culture in China emphasises harmony, internalised homonegativity, and conformity [ 95 , 96 ], often at the expense of individual expression and identity development. This cultural backdrop influences how sexual minorities perceive their own identities [ 97 ] and creates an ideological constraint that leads to social rejection and resistance towards sexual minorities [ 98 ], thereby reducing the visibility of sexual orientation-related topics in the Chinese sport context.

Moreover, SMSAs in China often prioritise their athlete identity over their sexual minority identity, influenced by the attitudes of team leaders. This tendency is reinforced by coaches who primarily focus on the biological sex of athletes and lack training or understanding related to sexual minority issues [ 99 ]. Consequently, the Chinese coaches’ lack of knowledge about sex and sexual orientation exacerbates the silence surrounding sexual minority identities in the Chinese collegiate sport environment and intensifies the identity conflict for SMSAs. Emphasising athletic performance is central in sport but should not overshadow the holistic development of student-athletes. McCavanagh and Cadaret [ 100 ] noted that student-athletes might face challenges in reconciling various aspects of their identity in a heteronormative sport context. The suppression of sexual minority identity can lead to isolation from potential support systems that nurture positive sexual and gender identities. Prioritising athletic success over broader student development in sport departments limits growth opportunities for all students, including SMSAs. Chavez et al. [ 101 ] emphasised that student development requires recognising and valuing diversity, suggesting that a singular focus on athletic prowess can diminish the benefits of diversity among student-athletes. Embracing diversity is not only a personal journey but also one that can enhance the collective experience within sport settings.

In addition, self-stereotyping within SCT involves aligning one’s self-concept with the characteristics of valued social categories [ 102 ]. Latrofa [ 103 ] suggests that members of low-status groups, like SMSAs in sport, may self-stereotype to align more closely with their group, reflecting recognition of lower status and self-perception through peers. This study revealed SMSAs shape their self-identity based on the attitudes prevalent in their sport environment, with influences from peers and coaches being internalised as personal attitudes [ 104 ]. Such self-stereotyping supports maintaining a favourable social identity and adhering to group norms but can reinforce negative stereotypes and prejudices within sport.

Internalising stereotypes may lead SMSAs to develop prejudices against themselves and others, perpetuating discrimination. It can also hinder individual development, impacting self-esteem and confidence. For example, aligning with negative stereotypes could cause SMSAs to doubt their worth and capabilities, affecting emotional well-being and satisfaction. Liu and Song’s [ 105 ] survey of Chinese college students illustrated the direct impact of gender self-stereotypes on life satisfaction, highlighting the significant effects of self-stereotyping on individual well-being.

Furthermore, in the context of traditional and reserved Chinese culture, intercollegiate sport offers a relatively free and open space for sexual minority women. The results of this study suggest that the visibility of sexual minority women in teams and the long time spent together allow these athletes to explore and establish intimate relationships. These results are similar to findings in Spanish studies [ 103 ], which highlighted the protective and liberating role of sports teams in the sexual exploration of female sexual minority athletes. Research by Organista and Kossakowski on Polish female footballers [ 106 ] and Xiong and Guo [ 96 ] on Chinese women’s basketball teams also revealed a climate of non-heteronormativity in women’s sport. These climates provide a sanctuary from heterosexual pressures, allowing sexual minority athletes to engage in sport free from traditional constraints. Such environments help female sexual minority athletes navigate and subvert heteronormative norms by cultivating supportive subcultural networks within their teams.

This study addresses the lack of in-depth research on the experiences of SMSAs in Chinese intercollegiate sport. It fills the gap by exploring the complex realities of SMSAs, focusing on their identity conflicts and the influence of the Chinese social and cultural background. Specifically, this study provides valuable insights that align with SCT [ 71 ]. This study addresses a notable gap in the existing literature regarding sexual minority sport participation, as rarely have these perceptions been explored. Drawing from the lens of SCT, the results of this study revealed several valuable insights into how their sexual minority identity impacts their participation in sport. These findings not only enhance our understanding of how SCT applies to the sport experiences of sexual minority individuals but also contribute to the advancement of SCT in research on sexual minority sport participation. The themes uncovered in this study closely align with central SCT concepts such as identity salience, self-stereotyping, and depersonalisation, illuminating the ways SMSAs comprehend and express their sexual minority identity within the intercollegiate sport context. SCT, with its focus on both intragroup and intergroup relations within the multifaceted construct of the self, offers valuable insights into the complexities of SMSAs’ self-perceptions and the intricacies involved in developing and manifesting their identities in the realm of sport.

Based on the results, more effort needs to be put into understanding sexual minority identities in intercollegiate sport. By examining the perspectives and experiences of SMSAs, we can gain insights into the interactions and influences of sexual minority individuals in the sport context. The interplay between an individual’s self-perception and situational dynamics results in a self-identity that mirrors the collective. In addition, the prevalent pressures and normative prejudices inherent in the sport system significantly influence their self-identity. Therefore, valuing SMSAs’ understanding of their self-identity shows respect for each person’s differences and rights. We hope the findings will be incorporated into existing sport policies to promote inclusivity and ensure safe participation for sexual minority students. To encourage and support the full development of SMSAs, college athletics and related institutions should prioritise understanding and respecting their perceptions of their sexual minority identity. By doing so, institutions can create a more inclusive and supportive environment that acknowledges and addresses the unique challenges faced by SMSAs.

Nevertheless, caution should be exercised when generalizing the findings, especially for subgroups with low representation, such as asexual individuals. While the study provides valuable insights into SMSAs’ perceptions of their sexual minority identity within the Chinese sport context, the limited number of asexual participants means their unique perspectives may not be fully captured. Therefore, these findings may not fully represent all sexual minority subgroups.

Future research could focus on exploring the perceptions and experiences among various sexual minority subgroups within sport participation in China. Additionally, considering the cultural diversity across China’s vast geographic regions, it would be valuable to examine how SMSAs perceive their minority identity in different cultural contexts. Given the scarcity of related studies in China, it is also important to survey other stakeholders in the sport environment, such as coaches and heterosexual student-athletes, to gain a broader understanding of perceptions of sexual minority identities. These insights can inform the development of targeted interventions aimed at ensuring the safe and inclusive participation of SMSAs in intercollegiate sport.

Data availability

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

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Published: 23 August 2024

Using wiki surveys to rapidly test messages promoting COVID-19 vaccination boosters and child vaccination among Philadelphia residents

Brittany A. Zulkiewicz 1 ,
Allison Li 2 ,
Gretel Tassah 2 ,
Minnie Kim 2 ,
Karen Glanz 3 , 4 ,
Antonia Villarruel 4 ,
Jose A. Bauermeister 4 ,
Terri Lipman 4 ,
Stephen Bonett 4 ,
Ufuoma Oyiborhoro 4 &
Andy S. L. Tan 1 , 5

Scientific Reports volume 14 , Article number: 19611 ( 2024 ) Cite this article

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Risk factors

Formative research is an important component of health communication campaign development. Rapid message testing approaches are useful for testing new messaging quickly and efficiently during public health emergencies, such as COVID-19, when guidance and recommendations are rapidly changing. Wiki surveys simultaneously collect quantitative message testing data and qualitative feedback on potential social media campaign messages. Philly CEAL used wiki surveys to test messages about COVID-19 vaccinations for dissemination on social media. A cross-sectional survey of Philadelphia residents (N = 199) was conducted between January and March 2023. Wiki surveys were used to assess the perceived effectiveness of messages promoting the updated COVID-19 booster and child vaccination. In each wiki survey, participants were presented with two messages and asked to select the one that they perceived as most effective. Participants could alternatively select “can’t decide” or submit their own message. A score estimating the probability of selection was calculated for each message. Participant-generated messages were routinely reviewed and incorporated into the message pool. Participants cast a total of 32,281 votes on messages seeded by the research team (n = 20) and participants (n = 43). The highest scoring messages were those that were generated by participants and spoke to getting your child vaccinated to protect them against serious illness and getting the booster to protect your health and that of your community. These messages were incorporated into social media posts disseminated by Philly CEAL’s social media accounts. Wiki surveys are a feasible and efficient method of rapid message testing for social media campaigns.

Using big data to understand the online ecology of COVID-19 vaccination hesitancy

The heterogeneous effects of social support on the adoption of Facebook’s vaccine profile frames feature

Field testing the transferability of behavioural science knowledge on promoting vaccinations

Introduction.

Public health communication is a key strategy used throughout the COVID-19 pandemic to combat misinformation 1 , promote health behaviors 2 , and address inequities 3 . Health communication campaigns are more likely to be successful when formative research is conducted to understand the beliefs and behaviors of the intended audience and to pretest messages for appropriateness and effectiveness 4 . COVID-19 campaigns have used long-established formative research approaches such as observational surveys 5 , 6 , survey experiments 7 , 8 , individual interviews 6 , and focus groups 5 , 9 . While technology can accelerate formative research, many of these established methods can take months to develop research instruments, collect and analyze data, and disseminate final campaign materials.

Because of the formative research timeline and the rapidly changing environment of COVID-19 and other emergent outbreaks 10 , 11 , findings can become outdated before campaigns are activated. Conducting no formative research, however, can lead to ineffective or harmful messaging. Rapid and responsive message testing approaches are most promising to quickly develop effective campaigns, especially in the context of a pandemic such as COVID-19 12 . Multiple rapid message testing studies for COVID-19 utilized digital survey platforms 12 , 13 and text ads 14 . These approaches hold promise for effectively eliciting relevant beliefs and disseminating messaging for clinical and healthcare topics 12 .

Wiki surveys are a rapid message testing approach that allow researchers to conduct quantitative testing similar to A/B testing, a user experience research methodology that consists of randomized experiments that compare the perceived effectiveness of two different messages 12 . A novel feature of wiki surveys is the integration of user-generated messages into the experimental design. In this way, users can rate existing messages and suggest new messages in the same platform through a seamless user experience. Then, future users give ratings for these user-generated messages as well as researcher-generated messages. Wiki surveys investigating message strength in the areas of the legalization of marijuana and sustainability and education policy found that user-generated messages were among the highest-rated 15 , 16 .

We used wiki surveys hosted on the All Our Ideas (allourideas.org) platform in January to March 2023 to rapidly test messages promoting pediatric COVID-19 vaccination and booster vaccinations for dissemination on Philly CEAL’s social media accounts. Philly CEAL, part of the National Institutes of Health’s (NIH) Community Engagement Alliance against COVID-19 Disparities (CEAL) 17 , is a community-wide alliance working to provide the Philadelphia community with resources to reduce COVID-19 disparities in testing, vaccination, and participation in clinical trials and to prevent the spread of misinformation. At the time of the study, CDC recommended the COVID-19 vaccine for all adults and children 6 months and older 18 and the bivalent COVID-19 booster for immunized adults and children over 12 years old 19 . For the wiki surveys, adults who lived or worked in Philadelphia were randomly presented with one of two messages and asked to select the message they thought would be most effective for promoting pediatric or booster COVID-19 vaccinations. Each message received score quantifying the probability that the message would be perceived as more effective than a randomly selected alternative. This paper describes the results of the wiki surveys, how these results were translated into subsequent Philly CEAL’s social media messaging, and how wiki surveys were implemented to conduct rapid message testing.

Participant characteristics

Of the 544 people invited, 199 (36.6%) completed the survey and are included in the analysis. Table 1 summarizes the characteristics of our sample. The mean age was 37.4 years (SD = 11.3). Most participants identified as women (74%) and heterosexual or straight (73%). Most (60%) participants were White; 27% were Black or African American, 13% were Asian, and 3% were American Indian or Alaska Native. Almost 10% identified as Hispanic or Latino ethnicity. Three-quarters of participants had at least a Bachelor’s degree. Nearly all participants were fully vaccinated (94%), and among those fully vaccinated, about half had received two boosters (49%). Table 2 summarizes the vaccination status of the participants’ children. Approximately one-third (37%) of participants had at least one child under the age of 18. Most (62%) reported that all their children were fully vaccinated, and 16% reported not vaccinating any of their children.

Booster messages

Participants voted a total of 13,897 times on 9 seed and 10 participant-generated messages. Table 2 presents the voting results and the message scores for the top 10 booster messages. The three highest performing messages were participant-generated and focused on the health protection provided by the boosters and the importance of community protection (e.g., “Don’t gamble with your health. Stay up to date with your Covid-19 boosters” and “Each reinfection increases chances of serious and long term COVID complications. Get the booster to protect yourself and your community”). Results for all seed and participant-generated messages are available in Appendix 3. Seven of the 8 messages that had less than a 50% chance of being chosen over a randomly selected message were about COVID-19 variants ( e.g., “Many COVID-19 variants are connected to Omicron, which the booster shot helps protect against!”).

Child vaccination messages

Participants cast a total of 18,384 votes on 11 seed and 33 participant-generated messages. Table 3 presents the results for the 10 child vaccination messages with the highest message ratings. Of the nine highest performing messages, 7 were participant-generated and all addressed child vaccine protection from serious illness (e.g., “Vaccination is the best way to protect your child from serious illness against COVID-19” and “Protect your children from serious health complications of COVID-19 by getting them vaccinated”). Message scores and voting results for all seed and participant-generated messages are available in Appendix 4. Messages that focused solely on eligibility for and availability of vaccinations had less than a 50% chance of being chosen over a randomly selected message (e.g., “On November 2, 2021, all Philadelphians 5–11 years became eligible for the vaccine. Thousands of children have since been vaccinated”).

We conducted wiki surveys in January-March 2023 to rapidly generate and test messages to promote COVID-19 boosters and child vaccinations among Philadelphia residents and incorporated highly rated messages into social media posts on Philly CEAL accounts. Notably, participant-generated messages were consistently perceived as more effective than investigator-generated seed messages in our study. This finding is consistent with results of previous wiki surveys 15 , 16 and underscores the importance of obtaining qualitative feedback during rapid message testing. While some participant-generated messages were novel (e.g., “COVID damage can be silent and stealthy”), others reflected arguments from seed messages in participants’ own words. These messages usually outperformed the seed message. For example, the participant-generated message “Vaccination is the best way to protect your child from serious illness against COVID-19” was rated more highly than the seed message “COVID-19 vaccines prevent children in Philadelphia from getting seriously sick if they do get COVID-19.”

Wiki surveys have been previously used to generate ideas for New York City’s sustainability plan 15 and to assess the strength of arguments for marijuana legalization 16 . To our knowledge, this is the first published study to use wiki surveys to rapidly evaluate perceived effectiveness of and generate messages for promoting COVID-19 vaccinations and disseminate highly rated messages through a social media campaign. Examples of the resulting posts on Philly CEAL’s social media accounts are shown in Appendix 5. The study establishes the feasibility and advantages of using wiki surveys for rapid message testing, especially when time and resources for formative research may be limited.

Using wiki surveys for rapid message testing has several advantages compared to other formative research approaches. First, community partners and residents were able to contribute messages and these messages were iteratively incorporated into the messaging testing pool. Second, other message testing surveys have a fixed set of items. Adding new items would increase the length of the survey, prevent comparisons over time, and require time for revisions and publishing of updated versions. Messages can be added to wiki surveys quickly and efficiently, and doing so does not add to participant burden because participants control how many votes they cast. Third, the message score statistically accounts for the fact that some participants would not have been able to vote on messages that were added to the pool after their votes were cast.

There are several important limitations to the wiki survey approach. The seed messages based on contemporaneous Philly CEAL and NIH CEAL social media posts may have constrained the range of arguments and themes that participants thought of when generating additional messages. Only brief messages that are less than 140 characters and include only text can be tested in the All Our Ideas platform’s current version. While this is acceptable for testing messages for social media, the wiki survey approach may not be feasible for other avenues of dissemination. Currently, the wiki survey data cannot be linked to survey platforms by passing embedded variables. We are therefore unable to compare how message ratings differed by participant characteristics or determine how many votes individual participants cast. Although the wiki survey platform reduces the burden of updating the message pool and analyzing data, resources are still required to stagger recruitment so that there is sufficient time for messages to be generated by participants, added to the pool, and voted on by subsequent participants. New messages also needed to be reviewed before being added to the pool for appropriateness and clarity.

In addition to the limitations of wiki surveys generally, our study has several limitations. The community partners and prior survey participants are not representative of all Philadelphia residents nor of our target audiences. Our sample was highly educated, with 44% having a college degree and 31% an advanced degree. More than 94% of our sample were fully vaccinated, so the wiki survey did not yield input from unvaccinated groups. Our messages aimed to reach Philadelphia residents who had not been boosted or had their children vaccinated, but only 11% of our sample had not received a booster, 16.2% of those with children under 18 had not had their children at least partially vaccinated, and all participants contributed to the child vaccination wiki survey even though 63% did not have children under 18. Due to the platform limitations, messages designed to resemble social media posts (i.e., images and captions) based on the wiki survey results could not be tested. Finally, our findings cannot be generalized to other time periods given the changing landscape of COVID-19 outbreaks and vaccine recommendations. As new vaccines become available and COVID-19 variants emerge, messages will need to be re-tested using formative research methods like wiki surveys to ensure that they are appropriate and effective in the current context.

Wiki surveys could be applied to other formative research aims. For example, they could be implemented over extended periods of time to examine shifts in messaging strategies that are perceived as effective and the evolution of preferred messages instead of using multiple cross-sectional surveys. This is important because the type of messages that would be effective at changing behavior may change as the pandemic progresses. For example, those who chose to delay receiving the COVID-19 vaccines during the first few months of vaccine availability may have different beliefs and motivations influencing their health behaviors when compared to individuals who have remained unvaccinated for several years. Wiki surveys could also be used to compare different geographic locations or groups if the same user-generated messages were added to both pools. To address the limitation of the maximum message length that could be tested, new tools on Qualtrics, OpinionX, and other survey platforms could also be used to do A/B testing with images.

Wiki surveys are a feasible and efficient method for rapidly testing and obtaining audience feedback on short messages for social media campaigns. This study demonstrated how Philly CEAL used wiki surveys to develop social media campaign messaging to promote COVID-19 boosters and child vaccinations among Philadelphia residents. Participant-generated messages were perceived as more effective than messages seeded by the research team. These messages were incorporated into social media posts and shared through Philly CEAL’s X (formerly Twitter) and Facebook accounts. Future research should test the comparative effectiveness of higher versus lower ranked messages and participant- versus researcher-generated messages at increasing uptake of COVID-19 boosters and child vaccinations.

Sampling and recruitment

Participants in the present study were primarily recruited from respondents who had completed a previous study conducted by Philly CEAL. The study recruited Philadelphia residents ages 13 and older to complete an online survey through online and community-based outreach between September 2021 and February 2022. Responses were validated using a multi-step fraud detection protocol to enhance data integrity.

For the present study, e-mail invitations were sent between January and March 2023 to a randomly selected subset of verified respondents to the previous survey who had agreed to be recontacted for future studies (N = 493), Philly CEAL community partner organization representatives (N = 27), and VaxUpPhillyFamilies Ambassadors (N = 24) who engaged with local parents and caregivers to promote vaccination for children on social media and at in-person events. To be eligible for the wiki survey study, participants needed to be at least 18 years of age and currently living or working in the city of Philadelphia. We randomly sampled verified respondents of the previous survey and sent follow-ups to previously invited participants until we reached 200 completes. Because participants in previous wiki surveys had cast an average of 55 and 43 votes 16 , we estimated that 200 participants would result in 8600 to 11,000 votes per wiki survey. Of the 544 individuals invited, 264 (48.5%) started the screener, 256 (47.1%) were eligible (seven participants were ineligible because they did not work or live in Philadelphia and one was ineligible because they were under 18), 252 (46.3%) provided informed consent, 200 (36.8%) responded to all Qualtrics survey items, and 199 (36.6%) were verified to have completed the wiki surveys and included in the analysis.

Figure 1 describes the protocol for this cross-sectional study and Appendix 1 includes the full questionnaire. Participants completed the screener and informed consent in Qualtrics, were directed to two wiki surveys hosted on All Our Ideas, and then returned to Qualtrics to complete demographic and COVID-19 vaccination status questions.

Survey workflow.

Email invitations included a unique link to a Qualtrics survey where participants first completed screener questions to assess eligibility (age, ZIP codes where they live and work). Eligible participants then provided informed consent and were randomized (using Qualtrics’ built-in randomizer function) to view either the booster or the child vaccination wiki survey first. For each wiki survey, participants were instructed to click a link that would open the appropriate wiki survey on the All Our Ideas website in a separate window, vote on messages for at least 3 min, and return to Qualtrics to continue the survey. Once the participant clicked the link, a three-minute countdown timer was displayed on the Qualtrics survey. Participants could not continue to the next screen until three minutes elapsed. To ensure that participants visited both wiki surveys, clicks on the wiki survey links were tracked using Qualtrics’ built-in click count variable and a JavaScript function that updated an embedded variable when the link was clicked on each instruction page.

On the All Our Ideas website, participants were presented with two messages randomly selected from a pool of messages and asked to rate the messages by selecting the message that they thought “would most encourage parents to get their child vaccinated against COVID-19” or “would most encourage someone to get the updated COVID-19 booster.” They could also select “can’t decide” or provide their own message (see Appendix 2). The initial pool included 11 messages for child vaccination and 9 messages for boosters based on the text obtained from Philly CEAL’s previous social media posts and contemporaneous social media toolkits from the NIH CEAL 20 . Three study team members (BZ, MK, GT) reviewed participant-submitted messages three times per week for appropriateness and grammar. Participant-submitted messages that were relevant to and not duplicative were added to the message rating pool. Recruitment was staggered so that there was approximately one week between each round of invitations to allow sufficient opportunity for participant-submitted messages to be added and voted on by subsequent participants.

After completing both wiki surveys, participants returned to Qualtrics and completed questions assessing demographic characteristics, COVID-19 vaccination status, and availability of COVID-19 information in respondents’ preferred language(s). Participants received a $10 gift card for completing the survey. The study was reviewed and approved by the University’s Institutional Review Board (protocol no. 848650). The research protocol was performed in accordance with the relevant guidelines and regulations.

Demographics. In addition to providing their age in the screener, participants were asked to indicate their gender identity, sexuality identity, race, ethnicity, education, and whether they worked with a community-based organization that partnered with Philly CEAL.

COVID-19 vaccination status. Participants’ COVID-19 vaccination status was assessed using two items. The first item asked if participants had received the COVID-19 vaccine. Response options included “Yes, I am fully vaccinated (one dose of Johnson and Johnson or two doses of Moderna or Pfizer)”, “I am partially vaccinated (i.e., one dose of Moderna or Pfizer)”, and “No, I am not vaccinated against COVID-19.” Participants who were fully vaccinated were then asked if they had received one, two, three or more, or no boosters. Participants were also asked to indicate the ages of each of their children and whether each of their children under the age of 18 were fully, partially, or not vaccinated against COVID-19, if applicable.

Data analysis

Participant characteristics. Participants who completed the demographic and COVID-19 vaccination status measures at the end of the survey and were verified to have completed both wiki surveys were included in the descriptive analyses of participant characteristics (N = 199). Descriptive statistics for demographic characteristics and COVID-19 vaccination status were generated.

Message score. The All Our Ideas website collects data on every vote cast, including a unique respondent ID, a session ID, the two contending messages, and the resulting vote. All Our Ideas also provides aggregated statistics for each message summarizing the total number of votes; how many times the message won, lost, or resulted in a ‘can’t decide’ vote; and a message score 15 that estimates the probability that the message would be chosen over a randomly selected competing message by a randomly selected participant. Scores range from 0 (the message is always expected to lose) to 100 (the message is always expected to win). The All Our Ideas website generates a message score using a two-step process. In the first step, an opinion matrix is generated that uses Bayesian inference to estimate how much each respondent values each message. Message values are imputed for participants who did not encounter the given message either because they did not encounter the message while casting votes or they could not have seen the message because it was participant-generated or they cast their votes prior to the message being added to the pool. This approach assumes that the votes reflect participants’ relative preferences for messages and that preferences for each item follow a normal distribution across respondents. The opinion matrix is then summarized to generate a message-level score for each item that estimates the probability of a message being chosen over a randomly selected message by a randomly selected participant. Because we cannot link votes to individual participants, all votes from all participants are included in the message score analysis regardless of whether they completed the study.

No financial disclosures were reported by the authors of this paper.

Data availability

Data are not available in a repository. Because we did not specify in the online consent that the data could be used for secondary data analyses, we are not able to make the data public. All message score data are available in the appendices. A restricted dataset including voting data, demographic characteristics, and vaccination status data may be requested from Brittany Zulkiewicz ([email protected]) and should include a plan for its use. Data may be made available to qualified researchers after the main findings are published in a peer-reviewed journal. All data sharing will comply with local, state, and federal laws and regulations and may be subject to appropriate human subjects institutional review board approvals.

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Acknowledgements

Research reported in this publication was supported by the National Institutes of Health/CEAL (grant number 10T2HL161568). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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B.Z.: Conceptualization, Methodology, Formal analysis, Investigation, Data curation, Writing—Original draft, Writing—Review & editing, Visualization, Project administration. A.L.: Writing—Original draft, Writing—Review & editing. G.T.: Investigation, Writing—Review & editing, Project administration. M.K.: Investigation, Writing—Review & editing, Project administration. K.G.: Writing—Review & editing. A.V.: Writing—Review & editing, Funding acquisition. J.B.: Writing—Review & editing, Funding acquisition. T.L.: Writing—Review & editing, Funding acquisition. S.B.: Writing—Review & editing. U.O.: Writing—Review & editing, Project administration. A.T.: Conceptualization, Methodology, Writing—Review & editing, Supervision, Project administration.

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Zulkiewicz, B.A., Li, A., Tassah, G. et al. Using wiki surveys to rapidly test messages promoting COVID-19 vaccination boosters and child vaccination among Philadelphia residents. Sci Rep 14 , 19611 (2024). https://doi.org/10.1038/s41598-024-70554-9

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Published: 19 August 2024

Physical activity policies in Saudi Arabia and Oman: a qualitative study using stakeholder interviews

Ali Ahmed Alzahrani 1 ,
Peter Gelius 2 ,
Adrian E. Bauman 3 &
Klaus Gebel ORCID: orcid.org/0000-0003-0330-7756 1

Health Research Policy and Systems volume 22 , Article number: 111 ( 2024 ) Cite this article

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Countries in the Middle East have some of the lowest rates of physical activity and some of the highest rates of obesity in the world. Policies can influence population levels of physical activity. However, there is a dearth of research on physical activity policies in the Gulf region. This qualitative study analyses cross-sectoral barriers and facilitators for the development, implementation and evaluation of physical activity policies in Saudi Arabia and Oman, two of the largest countries in the region.

Semi-structured interviews were conducted with 19 senior policymakers from the Ministries of Health, Education, and Sport in Saudi Arabia and Oman, and were examined using thematic analysis.

We identified seven themes related to physical activity policies in Saudi Arabia and Oman: leadership; existing policies; physical activity programs related to policies; private sector policies; challenges; data/monitoring; and future opportunities. Both countries have a central document that guides policy-makers in promoting physical activity, and the available policies in both countries are implemented via multiple programs and initiatives to increase physical activity. Compared with Oman, in Saudi Arabia, programs from the non-profit sector, represented by community groups, play a more significant role in promoting physical activity outside the government framework. The private sector has contributed to promoting physical activity in both countries, but interviewees stated that more financial support is required. Policy limitations differ between Saudi Arabia and Oman: intersectoral collaboration in Oman is limited and mainly based on individuals’ own initiative, while the health transformation in Saudi Arabia tends to slow down policy implementation in relevant areas. Physical education in Saudi Arabia and Oman is similar; however, increased support and collaboration between government agencies and the private sector for out-of-school sports academies are needed.

Conclusions

This study addresses key gaps in analysing physical activity policies in Gulf Cooperation Council countries. Our study highlights the importance of increasing financial support, improving collaboration between governmental agencies and between them and the private sector and consolidating efforts to back physical activity policies and dismantle cross-sectoral barriers in Saudi Arabia and Oman. Educational institutions in Saudi Arabia and Oman play a crucial role in promoting physical activity from early childhood to young adults. Our insights assist policy-makers, public health officials and stakeholders in shaping effective physical activity-promoting policies, programs and interventions to prevent non-communicable diseases. Challenges identified in Saudi Arabia and Oman's policies will inform their future development.

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Despite the health benefits of physical activity [ 1 , 2 , 3 ], in most countries, large proportions of the population remain insufficiently active [ 4 , 5 ]. In line with social–ecological models of health [ 6 ], the need for policies to increase population levels of physical activity has been highlighted [ 7 , 8 ]. Physical activity policy is defined as any formal or informal legislative or regulatory action or organized guidance provided by governments and organizations [ 9 , 10 , 11 , 12 ]. Policies can be cross-sectoral and encompass access to various forms of physical activity, including walking and cycling, regulate and promote programs and initiatives, and provide a comprehensive framework for the design, funding and implementation of diverse physical activity interventions [ 9 , 13 , 14 ].

Countries in the Middle East have amongst the lowest levels of physical activity and some of the highest rates of overweight and obesity in the world [ 4 , 15 ]. In Saudi Arabia and Oman, only 29.7% and 25.6% of the adult population, respectively, meet the physical activity recommendations. For the Middle East and North Africa (MENA) region the rate is 38.5% and the global average is 31.3% [ 4 ]. Moreover, in 2020 in Oman, Qatar, Bahrain, Kuwait and the United Arab Emirates, more than 80% of teenagers and 55% of adults (45% of men and 65% of women) were not sufficiently active [ 16 ]. In Saudi Arabia and Oman, dietary patterns are shifting due to increased consumption of processed foods, leading to higher rates of obesity, diabetes and cardiovascular diseases. Traditional diets rich in fruits, vegetables and lean meats are being replaced by fast food and sugary drinks. Moreover, reduced physical activity and increasingly sedentary lifestyles are major determinants of the obesity epidemic [ 17 , 18 ]. Therefore, there is an urgent need in this region for action on physical activity, including policy development, implementation and evaluation.

The 2014 report from the WHO Regional Office for the Eastern Mediterranean on promoting physical activity in the region included a policy mapping exercise on national policy and action on physical activity in all 22 member states [ 19 ]. National physical activity policies were reported for most countries, including all members of the Gulf Cooperation Council (GCC), a political and economic alliance of six Middle Eastern countries [Saudi Arabia, Kuwait, the United Arab Emirates (UAE), Qatar, Bahrain and Oman] that share a similar cultural, social and economic background. According to WHO’s recent Global Status Report on Physical Activity [ 16 ], only 11 of the 22 countries in the Eastern Mediterranean Region had a national physical activity strategy, while all GCC countries had one. The report also identified some partnerships to promote physical activity between various ministries in the Gulf states, particularly across the health, sports and education sectors.

In a systematic scoping review, Klepac Pogrmilovic et al. examined the academic literature on physical activity policy and identified 163 papers, covering 168 countries, including all 6 GCC members [ 20 ]. Few papers on physical activity policy across the Eastern Mediterranean region were identified, thus, the findings for the region were largely based on the 2014 report of the WHO Regional Office [ 20 ]. In another study by Klepac Pogrmilovic and colleagues, a survey on national physical activity policies was completed by representatives of 76 countries. However, this only included three of the 22 countries from the Eastern Mediterranean Region. The authors also emphasized that although national policies and strategies exist in all GCC countries, implementation is lacking. The authors recommended that further research be undertaken into physical activity and sedentary behaviour policy in the region [ 8 ]. It is essential to contextualize these findings with regard to physical activity policies in the Gulf region, including disparities and challenges in their implementation.

Recently, Albujulaya et al. analysed physical activity policy initiatives in Saudi Arabia by conducting semi-structured interviews with three policy-makers from the Ministries of Education and Sports and with six Saudi academics working in this field [ 21 ]. Surprisingly, they did not interview anyone from the Ministry of Health. They concluded that while physical activity amongst Saudis overall has increased, levels among women are still low. While Albujulaya et al. analysed aspects of physical activity policy development, implementation and evaluation in Saudi Arabia, they did not address potential cross-sectoral barriers and facilitators for these processes.

The primary objective of the present study was to analyse cross-sectoral barriers and facilitators for physical activity policy development, implementation and evaluation in GCC countries. The best research paradigm for this study is qualitative research. We chose interpretivist research to describe complex social realities, explore new or under-researched subjects and generate hypotheses for future quantitative research. This approach allows for a detailed examination of phenomena, which is difficult with quantitative methods. Practically, we also lacked a large, easily accessible sample to survey quantitatively. Therefore, interpretivism is particularly effective for understanding stakeholder perspectives on physical activity policies in unique cultural settings, such as those in Saudi Arabia and Oman, providing deep insights into subjective experiences and nuanced views. To achieve this, we interviewed policy-makers from the Ministries of Health, Sport and Education in Saudi Arabia and Oman, the two largest countries in the GCC. We picked these three ministries as previous research highlights that they are chiefly responsible for promoting physical activity and implementing related policies in the Gulf region [ 22 , 23 , 24 ].

Study design

This is a qualitative study using the interpretivist research paradigm [ 25 ], comprising semi-structured interviews with key stakeholders in physical activity policy-making in Saudi Arabia and Oman. We utilized the COREQ checklist to ensure the rigour and transparency of our qualitative methods (Appendix 1).

Sampling and recruitment

We defined stakeholders as those that are directly involved in the development, implementation and evaluation of physical activity policies. We initially sought to conduct interviews with stakeholders in all six GCC countries. We attempted to reach a contact in the Ministry of Health (MoH) in each GCC country by writing to the official email address of the ministries to introduce the study and request the contact details of relevant stakeholders. Despite following up with non-responders, we did not receive any replies from Qatar, Bahrain, Kuwait and the United Arab Emirates. Therefore, we narrowed the scope to Saudi Arabia and Oman, the two largest countries of the six, with 36.4 million and 4.6 million inhabitants, respectively, accounting for 70% of the GCC’s population [ 26 ]. After obtaining contact details of key stakeholders from the ministries, the participants were contacted directly via email or telephone. To recruit additional participants, we used snowball sampling by asking interviewees to provide contact details of other relevant stakeholders in their organization. Because of the documented previous involvement of the sports and education sectors in promoting physical activity in the Gulf States [ 19 ], we also asked participants to identify relevant stakeholders in the Ministries of Sports and Education in Saudi Arabia and Oman. Our study focussed on the Ministries of Sports, Health and Education as they are significantly involved in promoting physical activity within Gulf Cooperation Council countries [ 22 , 23 , 24 ]. Attempts to contact the ministers directly were unsuccessful. However, we managed to reach senior staff in the ministries and in university sports federations which belong to the Ministries of Education. Additionally, we employed different strategies to engage participants from the non-governmental sector in both countries, including networking through professional contacts of the first author, utilizing online platforms such as Twitter and Facebook and forums and capitalizing on established partnerships with both non-governmental organizations (NGOs) and governmental sectors.

Participants were provided with information on the study, and all gave written consent to participate. Additionally, participants were informed at the beginning of the interview that they could withdraw from the study at any time if they chose not to continue participating. An interview guide, based on a review of previous literature [ 22 , 24 ] and collaborative input from the authors, was developed (Appendix 2). In the interviews, we explored stakeholders’ perspectives and opinions regarding existing physical activity policy documents from the Ministries of Health, Education and Sport in their country, as well as facilitators and barriers to physical activity policy development, implementation and evaluation, with field notes made during the interviews. A.A. conducted the interviews via Zoom due to the coronavirus disease 2019 (COVID-19) pandemic between December 2021 and February 2022. Interviews were conducted in Arabic, were audio-recorded with permission obtained from the participants and transcribed verbatim, and lasted between 10 min and 45 min. Repeat interviews were not carried out. The following personal information was collected from each participant: name, organization, position, age, gender and previous work experience. The participants were provided with an opportunity to review the Arabic transcripts for accuracy, and the final transcripts were translated to English. Monitoring of data saturation, an ongoing process based on the notion of informational redundancy [ 27 ], was conducted to ensure that comprehensive insights were obtained. The determination of the number of samples needed to reach data saturation was done separately in each country.

Data analysis

Authors A.A., A.B. and P.G. reviewed the transcripts to familiarize themselves with the content, after which thematic analysis was jointly undertaken by A.A., A.B. and P.G. to code each transcript. Themes were subsequently developed through a partially deductive approach: Main categories in Table 1 were derived from existing frameworks of the policy process, such as the HARDWIRED framework [ 28 ] (covering aspects such as development process, partnerships, resources, communication, evaluation and evidence-base) and CAPPA criteria [ 29 ] (including sectors/institutions involved, implementation, legal status, target groups, goals and targets, timeframe, budget and evaluation/surveillance). Subsequently, sub-categories were added via an inductive process conducted by A.A. during the thematic exploration stage, involving a comprehensive review of all codes within the combined dataset encompassing both Saudi Arabia and Oman. A.A., A.B. and P.G. discussed the coding and the preliminary interpretations to cross-validate the findings. These themes were informed by a comprehensive analysis of the extant literature and relevant findings from previous studies [ 22 , 24 ]. As a medical doctor at King Faisal Medical City in the southern region of Saudi Arabia, the lead author’s professional background informed his approach to data analysis in this qualitative study.

Ethical approval

The study was approved by the Human Research Ethics Committee of the University of Technology Sydney (UTS HREC ref. no. ETH21-6428).

Interviews were conducted with 19 high-level stakeholders in physical activity policy; 12 from Saudi Arabia and 7 from Oman. A total of four of the participants (two from each country) were women. In Saudi Arabia, four participants were from the Ministry of Health (MoH, including one from an NGO that is supervised by the MoH), five were from the Ministry of Education (MoE) and three represented the Ministry of Sport (MoS). In Oman, one participant represented the Ministry of Health, three were from the Ministry of Education and three were from the Ministry of Sport.

We generated six themes regarding physical activity policies in Saudi Arabia and Oman: leadership; existing policy documents; implementation of physical activity policies; challenges; data/monitoring for physical activity policies; and future opportunities. The theme non-profit sector/community groups was generated only for Saudi Arabia. Table 1 provides an overview of the derived main themes and findings.

Saudi Arabia

Participants from the Saudi MoH and MoS stated that the leadership in the legislation, regulation, and evaluation of physical activity policies is divided between the two ministries. They also collaborate with other government agencies, including the MoE and the Ministry of Municipal and Rural Affairs, to increase physical activity opportunities in schools, workplaces and communities. Two participants from the MoE mentioned that the University Affairs Council and the Supreme Economic Council also work in the promotion of physical activity by regulating the implementation of programs in their sectors according to policy documents from the MoH and MoE.

According to the participant from the NGO supervised by the MoH, the non-profit sector is instrumental in promoting physical activity through walking groups. These have been established throughout the country to provide opportunities for people to engage in physical activity and to socialize, and which are co-organized by various stakeholders, including local businesses, schools, healthcare providers and government agencies: “I firmly believe that the non-profit sector plays a pivotal role in advocating for physical activity in Saudi Arabia” (NGO participant).

Participants from the Saudi MoH underlined that Health in All Policies is one of the main objectives in the new health care transformation in the kingdom. Most participants from the three ministries identified a certain level of cooperation between different stakeholders, particularly between the Ministries of Health, Sport and Education.

The Omani MoH leads the policies and programs to promote physical activity. Participant 1 from the MoH said that their non-communicable disease (NCD) and Health Committees are crucial for leading policy-making and promoting physical activity related to the National Policy for Prevention and Control of NCDs document [ 30 ].

Regarding Health in All Policies, all participants from Oman stated that there is cooperation between the different ministries, but that it is limited and based on individual agencies’ own initiatives rather than combined efforts or a policy imprimatur: “Partnerships exist, but they are limited and based on individual initiatives” (participant 2 from the MoS).

Relevant existing policies

Most of the participants from all three ministries in Saudi Arabia referred to the Quality of Life document [ 31 ], an economic and social reform blueprint that is part of the government’s overarching Saudi Vision 2030 development program [ 32 ]. The Quality of Life document includes the most important physical activity policies implemented by the three ministries: “There is no doubt that the 2030 Vision is our basic guidance” (participant 3 from the MoH). “Before 2017 there were no clear policies. Everyone works on vision files, and everyone has to achieve the [Vision 2030] target to increase the quality of life of the Saudi community” (participant 2 from the MoE). The Quality of Life document emphasizes the need to enhance public health and healthcare services, promote healthy behaviours, and provide opportunities for physical activity and sports participation.

Interviewees from the MoE highlighted that the University Sports Federation strategy promotes physical activity and sport in tertiary education [ 33 ]. Some important miscellaneous policy documents were identified by staff of the three ministries, such as the National Strategy for Healthy Food and Physical Activity 2015–2025 [ 34 ], the Physical Activity Guidelines for Health Practitioners [ 35 ], the 24-Hour Movement Guidelines [ 36 ] (all by the MoH) and the annual report of the Sport for All Federation by the MoS [ 37 ].

Almost all participants across all three ministries stated that the government of Oman’s overarching Vision 2040 [ 38 ] is currently the most important policy document. Participants from the MoE reported that the Vision 2040 guides the promotion of student physical activity, with support from related documents such as the student learning calendar, education document, standards document and the school sports curriculum. These policy documents aim to promote physical activity among students by better integrating physical education (PE) classes into the overall curriculum to encourage regular physical activity and healthy habits. According to participant 1 from the MoH, the Education Document is a comprehensive strategy, including PE and promotion of physical activity in schools and universities. The document outlines various initiatives, policies and guidelines to ensure that education includes a focus on physical health and fitness [ 39 ]. Three participants from the three different Omani ministries referred to the National Policy for Prevention and Control of NCDs [ 30 ], published by the MoH, as the central policy document for physical activity promotion in Oman. Three study participants from the MoS suggested that the Omani Sports Strategy [ 40 ] is important for guiding the promotion of physical activity for different segments of society.

Implementation of physical activity policies

(a) physical activity programs.

The MoH and MoE collaborate on a range of health-related issues (obesity, diabetes, mental health and visual acuity) to improve the overall health of school students and to detect problems at an early stage [ 41 ]. This led to the development of the Rashaka initiative, a large-scale multi-component school-based obesity prevention program, which started in 2016 and involved nearly 1000 schools across the country. In 2020, Rashaka was replaced by an annual program composed of screening of students for early signs of chronic diseases and lectures highlighting the significance of physical activity and a healthy diet.

Participants 3 and 4 of the Saudi MoH mentioned the Walk 30 Minutes initiative, which was implemented in 2021 and intends to increase physical activity through mass media and social media, and forms part of the National Strategy for Healthy Food and Physical Activity 2015–2025 of the MoH. An initiative by the University Sports Federation [ 33 ] (related to policies from the MoS), aiming to support sports facilities and clubs for girls and women, was mentioned by three participants from the MoS, and one participant highlighted the MoS’s Talent Support Program to identify and develop talented athletes in different sports.

Participant 3 of the Saudi MoH and participant 5 of the MoE mentioned the Healthy Mall Campaign and the Healthy Campus Project to promote physical activity in air-conditioned malls and universities. These initiatives are related to policies of the National Strategy for Healthy Food and Physical Activity (MoH and MoE). Despite challenges, the study participants considered the Saudi physical activity programs to be effective.

Participants 1 and 2 of the MoE identified programs related to PE policies from the Education Document, which include increasing the number of PE classes per week and organizing tournaments in different sports. According to participants from the three different ministries, a range of physical activity programs took place during the COVID-19 pandemic, including campaigns calling for physical activity at home using apps with exercise videos. These initiatives, as reported by the participants, align with and are supported by the physical activity policy documents from the Ministries of Health, Sport and Education, that is, the National Policy for Prevention and Control of NCDs [ 30 ] and the Oman Sport Strategy [ 40 ].

According to multiple participants, several community-based initiatives were underway in Oman, such as Active Community, Healthy Cities and Healthy Villages and The Green Playgrounds Project. These initiatives had been set up in all Omani cities to make the built environment more activity friendly, for example, by improving neighbourhood walkability, which is also based on the National Policy for Prevention and Control of NCDs [ 30 ].

(B) Private sector

According to most of the participants, the private sector makes important contributions to physical activity promotion in Saudi Arabia by being directly involved in the policy development process. The Tatweer Educational Company, a private holding dedicated to implementing the government's education reform initiative, has developed programs to promote physical activity in schools, aligning with its commitment to a holistic education system. In line with the conceptualization of active travel as physical activity, the Red Sea Company drives the development of Saudi Arabia’s west coast and aims to improve neighbourhood walkability. Participants from the MoE were unanimous in the view that private universities make significant contributions to the promotion of physical activity among staff and students on the basis of financial support from their funders. International and local investors in the education sector are urging private universities to promote physical activity to enhance the universities’ reputation and to be more attractive for prospective students.

According to participant 1 from the Ministry of Health, walking and hiking groups supported by the Health Promotion Center [ 42 ] (a non-profit charitable organization under the umbrella of the Saudi Ministry of Labor and Social Affairs) play an important role in promoting physical activity in Saudi Arabia. This is despite a lack of governmental support, with influencers and celebrities utilizing social media platforms for the promotion of physical activity. This organization has internal policies for the promotion of physical activity through different programs: “The fact is that community groups working to spread this culture of walking have no ceilings, no limits, and no bureaucracy” (participant 1 from the MoH).

In contrast to Saudi Arabia, participants in Oman stated that more support from the private sector is needed to promote physical activity in the country. However, participant 3 from the MoE mentioned an agreement between the MoE and Muscat Pharmacy & Stores limited liability company (LLC) to hold a football tournament for elementary school students. Nevertheless, it is important to highlight that there is a prevailing perception that physical activity cannot be easily monetized. This contributes to the private sector’s limited interest in supporting such initiatives in the Gulf countries, as it is not perceived to yield immediate profits. Overall, the participants from both Saudi Arabia and Oman stated that, unlike in government-supported programs, in the private sector there are no performance indicators to track the progress of physical activity programs.

Data/monitoring

Two participants from the Saudi MoH and MoE mentioned challenges in relation to physical activity monitoring, as each of the three involved ministries independently conducts surveys on physical activity with different methodologies and tools, which may yield conflicting results in monitoring the effects or end-product of physical activity policies. Furthermore, participants from all three ministries confirmed the existence of national surveys for physical activity and emphasized their importance in assessing activity levels. They also shared insights about how they monitor the implementation of physical activity policies and evaluate the effectiveness of various initiatives in their respective sectors: “We follow and evaluate health through periodic national surveys, but each ministry has its own survey with different results. It is not clear how widely these data are utilized in different sectors, such as education, and sports, to inform policies and interventions” (participant 2 from the MoH).

Participants from the MoH and MoS stated that participation rates, policy compliance, budget allocation and health outcomes are being tracked to assess the effectiveness and progress of physical activity policies, with a specific focus on regular reports and data analysis. Furthermore, one participant from the MoE said that there is no monitoring happening for their education-specific policies.

Participant 4 from the MoH suggested that limited policy implementation is likely until the health transformation process is completed by 2030. The health transformation in Saudi Arabia is a recent, prominent project that aims to restructure the health sector to make it more comprehensive, effective and integrated. The transformation is mainly focussed on the prevention of chronic diseases and the promotion of a healthy lifestyle through physical activity and a nutritious diet. On the ground, this transformation entails significant changes in healthcare infrastructure, delivery and accessibility, as well as increased awareness campaigns and the implementation of various programs aimed at improving public health and wellbeing [ 43 ]. To expedite the health transformation in Saudi Arabia, the respondent considered it essential to implement the policies from the Quality of Life document, which is part of the Kingdom’s Vision 2030. This particularly involves promoting physical activity and healthy lifestyles. By fostering these habits, the country could achieve significant improvements in public health and wellbeing. Participant 3 suggested that bureaucracy is a limitation, as new policies and regulations take a long time to implement under different administrations. Moreover, participants from the MoH and MoE declared that a lack of sustainability of physical activity programs and funding were major limitations due to changes in administrations over short periods. Most participants representing the three Saudi ministries stated that a lack of collaboration and cooperation between government departments was a major challenge. For instance, some policies from the MoH need to be implemented by the MoE, such as the screening program of school students [ 41 ]. The hot climate and the desert environment in the Gulf region also present challenges when it comes to implementing physical activity policies.

According to most participants, a lack of funding for the promotion of physical activity was a common challenge in Saudi Arabia because health budgets are mostly allocated to hospitals and curative services rather than to NCD prevention, including physical activity promotion. A lack of facilities (e.g. sports fields, recreation centres, indoor and outdoor courts and multi-use sporting hubs) is a further challenge according to most Saudi respondents. Moreover, negative societal attitudes towards physical activity were highlighted by one participant, citing challenges such as the prevalence of social norms that prioritize sedentary pastimes and leisure activities, thereby reinforcing a culture that tends to discourage physical activity [ 44 ].

According to most participants, insufficient collaboration between different stakeholders, as well as a lack of government funding and support from the private sector, were the most important barriers to physical activity promotion. Like in Saudi Arabia, participants from Oman said that the hot climate and desert environment in the Gulf region, a lack of facilities and/or a lack of access to them and negative attitudes in the population towards physical activity (social norms that prioritize sedentary pastimes and leisure activities) all pose obstacles to physical activity. Some participants from the MoE stated that a lack of support for PE facilities in schools has been a major obstacle to increasing students’ physical activity. Like in Saudi Arabia, respondents from Oman felt that the country should rapidly implement the provisions of the Vision 2040, specifically those related to the prevention of chronic diseases through the promotion of a healthy lifestyle and physical activity. Furthermore, an increase in government funding dedicated to promoting physical activity would be desirable.

Future opportunities

Participant 3 from the Saudi MoH stated that future policies might include investment in technology, such as developing smartphone apps for the promotion of physical activity during pandemics, and these could contribute to future physical activity programs. However, this requires direct support from the government, both financially and technically, by providing technical expertise, developing and implementing technology-based solutions and ensuring privacy and security. Furthermore, participant 1 from the MoS and participant 3 of the MoE claimed that programs, such as out-of- school academies for talented young athletes, could further encourage physical activity and foster athletic talent. Three participants from the MoE pointed out that unifying efforts between different stakeholders would be important. Moreover, more support in terms of funding, infrastructure, a skilled workforce, and research are considered promising opportunities by most participants from the three ministries.

Participants from the three ministries stated that community participation, such as activating schools as centres for physical activity promotion in the community, would be a great opportunity in the future if cooperation between different ministries is enhanced. Three participants from the Omani MoS and MoE said that improvements to facilities and the skills of the workforce (e.g. PE teachers, coaches, gym instructors, etc.) are required to increase activity levels. Despite the existence of the national plan for physical activity promotion in Oman [ 45 ], all participants emphasized that the lack of partnerships between the government and other relevant parties, such as schools, sports clubs and community organizations, is a common and significant obstacle. Furthermore, participant 1 from the MoS and participant 3 from the MoE said that more support for out-of-school sport academies, including improved collaboration between governmental agencies and the private sector, and supporting physical education as a part of the Omani education strategy, would be great opportunities.

Participants from the Ministries of Education of Saudi Arabia and Oman highlighted that physical education is crucial for the future in both countries, fostering healthy habits essential for a productive workforce. Integrating physical education into the curriculum promotes wellness and prevents lifestyle-related diseases, contributing to various sectors [ 39 ]. As both nations progress, emphasizing physical education will enhance individual health and serve as a strategic investment in a robust, dynamic workforce.

This study examined cross-sectoral barriers and facilitators for physical activity policy development, implementation and evaluation in Saudi Arabia and Oman by interviewing high-level stakeholders from their Ministries of Health, Sports and Education. Oman established a national policy framework for physical activity in 2014 [ 18 ] under the umbrella of the Oman Vision 2040 [ 38 ], 3 years before Saudi Arabia introduced its Quality of Life Program [ 46 ] under the umbrella of the Saudi Vision 2030 [ 31 ]. Many programs and initiatives to enhance physical activity in both countries were identified, particularly sports initiatives. However, it is worth noting that these efforts often lack comprehensiveness, encompassing a broad range of activities and demographics, and face challenges in effective implementation – observations that are in line with findings from a survey on national physical activity policies by Klepac Pogrmilovic et al. [ 8 ]. The programs and initiatives are predominantly focussed on urban areas and may neglect rural communities [ 44 , 47 ]. Interest in promoting gender equity in physical activity in Oman was prominent, with several programs for female participants [ 24 ]; there was less focus on gender equity in Saudi Arabia, although a positive development was the introduction of PE classes for female students in primary and secondary education in 2018. Policies for promoting physical activity should also support individuals with special needs, patients and the elderly by implementing community programs targeted at these groups, such as walking groups and fitness classes for older adults, and programs targeting people with chronic conditions. Additionally, it is important to focus on policies and programs that support gender equality in physical activity and health.

Our finding regarding insufficient backing of policy interventions to create environments supportive of physical activity in both countries aligns with a study by Allender et al., who interviewed stakeholders in local government in Victoria, Australia, to analyse physical activity policies and initiatives. Similar to our findings from Saudi Arabia and Oman, they identified a lack of relevance and competing priorities (i.e. promoting healthy eating environments was not considered a priority above food safety) as reasons for the lack of support towards creating supportive environments for physical activity and healthy eating [ 48 ].

Health in All Policies has been embraced in Saudi Arabia by integrating the promotion of physical activity into policy development across various areas such as education, sports and the private sector. However, while this integration is mentioned in the respective documents, challenges in implementation may have arisen due to limited cooperation between sectors. Many partnerships have been established with multiple parties in the Kingdom (MoH, MoS, MoE, and the Ministry of Municipal and Rural Affairs) to further develop physical activity policies in each sector and to remove obstacles to the implementation of physical activity programs. According to a WHO report from 2017, promoting Health in All Policies in Saudi Arabia has been identified as a national priority, monitored by the Ministry of Health [ 49 ]. Intersectoral collaboration in Oman is apparently less developed than in Saudi Arabia, hindering the integration of physical activity policies across sectors. Unlike Saudi Arabia’s comprehensive approach of Health in All Policies, Oman relies more on individual agency initiatives. However, there is potential for improvement in Oman to strengthen intersectoral collaboration and enhance the integration of physical activity policies by establishing a comprehensive policy framework and promoting coordinated efforts among sectors. For instance, the Omani government could create an intersectoral task force or committee dedicated to fostering collaboration.

In Saudi Arabia, the non-profit sector, represented by community groups, plays a significant role in promoting physical activity outside of the government framework, aided by the promotion of physical activity by influencers and celebrities through social media platforms [ 42 ]. By contrast, our study participants did not mention any significant involvement of the non-profit sector in physical activity promotion in Oman, either because these types of organizations do not play a role or because their role is not valued by the government stakeholders who we interviewed. The private sector contributes to promoting physical activity in both countries, with particularly strong partnerships with the governmental sector in Saudi Arabia. This may be because tax benefits exist for companies that encourage and promote physical activity in Saudi Arabia [ 31 ]. There are previous examples of these types of partnerships in Oman, such as a collaboration between the education and private sector aiming to create a healthier environment and lifestyle in schools. These partnerships have been achieved through the provision of financial support and sponsorships, specifically targeting sports equipment, facilities and physical activity programs in schools [ 50 ]. However, insufficient budget allocation in this area was considered a challenge, which is consistent with our study, with most participants from the sultanate expressing the need for greater financial support from the private sector.

Policy limitations differ between both countries, mainly due to the health transformation in Saudi Arabia, specifically with the Kingdom’s Vision 2030 [ 51 ]. The slow pace of transformation in various Saudi public health, infrastructure, urban planning, sports and recreation policies may impact their likelihood of being fully implemented by 2030, potentially falling short of WHO’s target for increased physical activity by that year set in their Global Action Plan on Physical Activity [ 52 ]. One of the objectives of the health sector transformation and the Quality of Life Program is to decrease the proportion of the Saudi population who are not sufficiently physically active below (67%) by 2030 [ 51 ]. The government has taken proactive measures to promote physical activity, investing in initiatives that raise awareness about its importance and the associated health benefits. This includes campaigns, public awareness programs and the establishment of recreational facilities to facilitate physical activity. In Oman, more collaboration between political parties is essential to improve the implementation of physical activity policies. According to participant 1 from the Omani MoH, several meetings were recently held with all parties to create plans to better implement physical activity policies. These meetings have led to increased monitoring and stricter enforcement by the Omani government regarding the implementation of physical activity policies in all relevant ministries. Effective health system policies significantly depend on inter-institutional collaboration. While primary health institutions play a central role, the impact of related entities is equally crucial. Educational bodies, sports organizations and community health centres contribute significantly to decision-making processes. Their closer involvement would ensure a more comprehensive approach to promoting physical activity, enhancing wellness and preventing lifestyle-related diseases [ 53 ].

According to previous studies, insufficient funding for promoting physical activity, and more broadly for NCD prevention, is a challenge in both Saudi Arabia and Oman [ 23 , 24 ]. Similarly, in a US study, state public health practitioners were interviewed about the National Physical Activity Plan, who also identified implementation costs and the complexity of physical activity policies as significant challenges [ 54 ]. Financial incentives and private sector involvement, while valuable, do not ensure adequate funding for all aspects of public health initiatives. The private sector’s contribution is often focussed on areas aligned with their business interests or corporate social responsibility. Nevertheless, in Saudi Arabia, certain private sector companies run national programs, such as the Tatweer Educational Company, a private holding dedicated to implementing the government's education reform initiative [ 55 , 56 ]. Enhancing funding for the implementation of physical activity policies in the Gulf region holds great promise in advancing infrastructure, cultivating a proficient workforce, and fostering research initiatives. On the basis of the Saudi Quality of Life document 2030 [ 46 ], the budget of the Ministries of Health, Sport and Education for promoting physical activity will likely increase until 2030.

The monitoring and evaluation of policy implementation across ministries in both countries is challenging due to the absence of comprehensive and precise data on physical activity prevalence in key sectors such as health, sport and education. Therefore, there is an urgent need to address data quality issues, such as inconsistent measurement methods employed across different sectors, which make it difficult to compare and consolidate data, and the lack of standardized protocols which undermines the accuracy and reliability of prevalence estimates. To efficiently monitor policy implementation, the responsibility could, for instance, be entrusted to the MoH for coordination with all pertinent sectors, while the General Statistics Authority should be designated to collect data on physical activity.

Responsibility for ensuring data quality rests with various stakeholders involved in the data collection, including researchers, survey administrators, data analysts and policy-makers. These stakeholders must work collectively to implement robust data collection methodologies, appropriate sampling techniques, rigorous quality control measures and transparent reporting practices. Monitoring of the impact of policies on population levels of physical activity in Saudi Arabia and Oman has improved, but more work is needed, particularly in the education sector in Oman, which requires evaluation of the progress and impact of policies.

To create and implement comprehensive policies, programs and supporting environments, a variety of sectors must collaborate in both countries. This may include transport, urban planning, media, social work, religious and cultural affairs [ 23 ]. In Saudi Arabia, one of the most effective health-promoting practices is physician-recommended physical activity [ 57 ], which is recognized as one of the eight best investments for physical activity by the International Society for Physical Activity and Health [ 58 ]. Therefore, the primary healthcare system in the Gulf region has a critical role in the promotion of physical activity, and further policy development in this area would be promising [ 57 ]. In addition, physical education policies in schools play an integral part in the Gulf states [ 59 ]. Educational institutions in Saudi Arabia and Oman are crucial in promoting physical activity among various age groups. From childhood through adolescence to young adulthood, schools offer structured physical education programs, health education and gender-inclusive activities. Universities support these efforts by providing sports facilities and activities as well as by conducting research on active lifestyles. Coordinated national policies amplify the effectiveness of these initiatives [ 22 , 39 , 60 ]. Furthermore, active transport and urban design policies have not yet been developed sufficiently to become potential contributors to population levels of physical activity in these countries due to cultural, environmental and climatic differences [ 23 ].

Strengths and limitations

Strengths of this study include a sample of high-level stakeholders who are directly involved in the formulation of physical activity policies from three ministries in Saudi Arabia and Oman, the two largest countries in the GCC. Additionally, we recruited one prominent participant from an NGO that is supervised by the Saudi Ministry of Health. We were not able to reach participants from the non-governmental sector in Oman. The original research plan was targeted at all six member countries of the Gulf Cooperation Council, but we were not able to recruit participants from the other GCC states due to political sensitivities surrounding the subject and a lack of responsiveness from relevant authorities. This may limit the generalizability of our findings beyond these specific contexts. However, we managed to recruit senior participants from the two largest GCC countries, which account for 70% of the GCC population. As in many countries, governmental representatives may have been constrained in what they reported in these interviews. Regarding the limitation of interview responses, some participants spoke about the existence of physical activity policies but did not want to provide further information on how they are being implemented, and this kind of information is not easy to obtain from other sources either. Thus, these gaps constitute a need for future research. To ensure research quality based on Lincoln and Guba’s criteria [ 61 ], we implemented several strategies. For credibility, we used investigator triangulation (involving multiple researchers) and theoretical triangulation (utilizing multiple policy frameworks). We did not use methodological triangulation, as we only conducted interviews, nor data triangulation, relying solely on audio transcripts. To ensure dependability, we kept detailed records of data collection and assessed coding accuracy and reliability among our team. For transferability, we addressed inherent challenges by collecting data from two countries, Saudi Arabia and Oman, enhancing the applicability of our findings to similar contexts. Although achieving confirmability was challenging due to our focus on individual perceptions, we aimed for transparency and objectivity in documenting our procedures and decisions.

This study fills important gaps in the analysis of physical activity policies in the Gulf region. Understanding the unique challenges, barriers and successes in promoting physical activity in the GCC countries is essential for developing relevant policies and strategies in the future. Our study highlights the importance of increasing financial support, improving collaboration between governmental agencies and between them and the private sector, and consolidating efforts to back physical activity policies and dismantle cross-sectoral barriers in Saudi Arabia and Oman. Educational institutions in Saudi Arabia and Oman play a crucial role in promoting physical activity from early childhood to young adults. Schools offer structured physical education, health education and gender-inclusive activities, while universities provide sport facilities and conduct research on active lifestyles. Coordinated national policies enhance the effectiveness of these efforts.

Specifically, we recommend allocating dedicated funds, establishing a centralized task force for coordinated policy implementation, creating incentives for private sector investment, developing a national strategy with measurable targets and conducting comprehensive policy reviews to remove bureaucratic obstacles. These steps will facilitate sustained progress and broader engagement in physical activity initiatives.

Our findings provide valuable insights and evidence for policy-makers, public health officials and other stakeholders in the region to develop targeted policies, programs and interventions that promote physical activity and prevent non-communicable diseases. The identified challenges and limitations of physical activity policies in Saudi Arabia and Oman will guide their future development.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available to maintain participants’ confidentiality. However, they can be obtained from the corresponding author upon reasonable request.

Abbreviations

Coronavirus disease 2019

Gulf Cooperation Council

Health in all policies

Limited liability company

Ministry of Education

Ministry of Health

Ministry of Sport

Non-communicable disease

Non-governmental organization

Physical activity

Physical education

United Arab Emirates

United States

World Health Organization

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Acknowledgements

We would like to express our sincere thanks to the policy-makers in the Kingdom of Saudi Arabia and Oman for their participation in this research.

This project is kindly supported through a PhD scholarship from King Faisal Medical City in Saudi Arabia and PhD funding from the Faculty of Health of the University of Technology Sydney.

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Adrian E. Bauman

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A.A. recruited participants and conducted interviews with policy-makers. A.A., A.B. and P.G. collectively analysed the transcripts. K.G., A.B. and P.G. made significant contributions to the thorough review and editing of the manuscript.

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Alzahrani, A.A., Gelius, P., Bauman, A.E. et al. Physical activity policies in Saudi Arabia and Oman: a qualitative study using stakeholder interviews. Health Res Policy Sys 22 , 111 (2024). https://doi.org/10.1186/s12961-024-01192-w

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Comparing GPT-4 and Human Researchers in Health Care Data Analysis: Qualitative Description Study

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Kevin Danis Li 1, 2 , BS ; Adrian M Fernandez 1 , MD ; Rachel Schwartz 3, 4 , PhD ; Natalie Rios 1 , BS ; Marvin Nathaniel Carlisle 1 , BS ; Gregory M Amend 5 , MD ; Hiren V Patel 1 , MD, PhD ; Benjamin N Breyer 1, 2 , MAS, MD

1 Department of Urology, University of California San Francisco, San Francisco, CA, United States

2 Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, United States

3 Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, United States

4 Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States

5 Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, United States

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Kevin Danis Li , BS
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Home life, work and housing decisions: a qualitative analysis"

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Qualitative Methods in Public Health: A Field Guide for Applied Research

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Using qualitative Health Research methods to improve patient and public involvement and engagement in research

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What can be learned from methods utilized in qualitative health research?

Rigour: Interpreting and incorporating patients’ experiences into the design and conduct of research

Member checking

Dense description

Constant comparative analysis

Representation: Gathering diverse perspectives to design relevant and appropriate research studies

Making engagement accessible

Engagement strategies

Reflexivity: Ensuring meaningful and authentic engagement

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Doing good qualitative research in public health: not as easy as it looks

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Qualitative Research and its Uses in Health Care

ARGUMENTS FOR AND AGAINST QUALITATIVE METHODS

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ETHNOGRAPHY

QUALITATIVE RESEARCH INSTRUMENTS

THE USE OF THE INTERVIEW GUIDE

ANALYSING QUALITATIVE RESEARCH

COMPUTER USE IN QUALITATIVE DATA ANALYSIS

THE ROLE OF THE RESEARCHER IN QUALITATIVE RESEARCH

RIGOUR IN QUALITATIVE RESEARCH

TRIANGULATION

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Acknowledgments

PH717 Module 1B - Descriptive Tools

Quantitative and Qualitative Methods for Public Health

Navigating sexual minority identity in sport: a qualitative exploration of sexual minority student-athletes in China

Conclusions

Homonegativity and discrimination in sport

Group and individual identity

Theoretical framework

Purpose of the study

Research design

Researcher characteristics and reflexivity

Participants and procedures

Data collection

Data analysis

Hidden truths

SMSAs are common in sport

Silent identity

Prioritisation of athlete identity

Be an athlete

Sport performance first norms

Self-stereotyping

Specific physical traits

Behavioural tendencies

Prolonged contact leading to intimacy

Influence from sexual minority teammates