methods of recruitment in qualitative research

How to Recruit Participants for Qualitative Research (2022 Edition)

We explain best practices for recruiting participants for qualitative research that will help you save time and money.

Qualitative research, when executed correctly, explores and uncovers the emotional and cognitive motivations behind your target audience’s actions, behaviors, and opinions relative to your research objectives and goals. 

So, the success of a qualitative research project depends on engaging the “right” participants—highly qualified, fitting the profile, enthusiastic and articulate. But research participant recruitment can be a resource “suck”, devouring time and money that could be used for the actual research, analysis and report writing. Let’s explore how to recruit the best, most qualified participants while saving both time and money.

6 Steps to Recruiting Quality Participants

From defining the objectives of your project to clarifying the factors and qualities of the participants you’ll need to meet those objectives, to creating the questions for the initial screening survey and follow up conversational screener that will identify qualified participants to setting a motivating incentive, the steps to a successful qualitative research project can be a lot. Let’s break it all down. 

1. Hold a Stakeholder Meeting to Define Research Objectives

Before you begin the process to recruit participants for qualitative research , you need to define precisely what you're trying to achieve with the research. This information will be useful when crafting your screener questions, securing participants that fit the profile and even setting the incentive amount. 

If you collaborate with other teams on a research project, the critical first step is to hold a stakeholders’ meeting to determine research objectives and ensure all stakeholders agree on those objectives.

Asking the questions that concisely define the purpose of your research project will also provide the parameters for exactly who the study should focus on. This will become your participant profile.

5 Sample Questions for a Stakeholder’s Meeting

• What’s the objective of this project e.g., what do you want to learn?
• What audience has the demographics, background, education, experience, skill, information you need to meet those objectives?
• What do you already know in relation to the objectives?
• How will your organization use the results of the research/What will your organization do with the learnings?
• What are your concerns, if any, regarding this project? How will those concerns be met and managed?

Once you have the answers to these questions, you can move on to the next step. 

2. Develop and Fine Tune Screener Survey Questions 

Your screener survey allows you to cull potential participants quickly. This means the most important criteria for qualification/disqualification need to be at the beginning of the survey—both your non-negotiables (immediate disqualifiers) and your negotiables (subject-to-approval and/or less rigid disqualifiers). 

In most cases, non-negotiables are concrete questions related to demographics, such as a candidate’s business, location, age, gender, ethnicity and past research participation. However, screening questions can also be identifying behaviors and/or opinions. For example, if you're looking for marketing professionals that use a specific type of software, use of this software and even use of this software over a specified amount of time might be a must to qualify.

Leading questions with transparent choices for response should be avoided. This can be achieved by offering some options in multiple-choice response lists that will mis-direct unqualified potential participants. 

3. Assess For Articulateness and Enthusiasm in the Conversational Screen

When conducting a qualitative study, you are exploring the motivations behind behaviors and opinions . For example, if you're testing a website, you’re learning about participants’ journeys through the site and striving to understand what exactly drove their navigation choices. 

Participants that are articulate and outgoing enough to examine and explain the logical process and emotional triggers that caused them to choose one path over the other are a must. 

Finding these participants is one of the greatest challenges of a successful recruitment. Asking “Articulation Questions” that require time, thought and putting feelings into words, will help identify these participants. 

Sample Articulation Questions 

• Think about the last book you read. Describe it and how it made you feel. 
• What is your thought process when you go shopping for groceries? How does that differ for different types of foods?
• Describe the next vacation you want to take and why you want to go there. 

Note that Articulation Questions in no way relate to the research topic. They are questions anyone can answer and will determine whether a candidate is more likely to answer with thought, in detail and openly sharing emotions versus only responding with the bare minimum.

4. Consider Using Advanced Screening 

Speak directly with candidates : At  Respondent , we provide the ability to conduct unique and advanced screening. One feature allows you to speak directly with candidates. Speaking directly with candidates will help determine if a candidate can elaborate in their answers and offer the detail needed.

Avoid imposters : Because of the incentives offered for research participation, there are people who attempt to participate in any and all research projects whether they qualify or not. Some will create fake email accounts and lie in their screener responses to qualify. Having one of these imposters slip through and take the place of a qualified participant can skew research results. Respondent pre-vets candidates through their social media accounts and the requirement of having a valid business email. This guards against any posers slipping through. 

Participant Ratings : Another Respondent safeguard encourages researchers to rate participants. After a study, a survey is sent out to rate the effectiveness of each of your participants as:  

• Poor (did not meet expectations) 
• Good (met expectations) 
• Great (exceeded expectations)

For Respondent researchers, participant rating is a unique and an important element in the recruiting process. 

5. The Importance of Over-Recruiting

No matter how diligent you are in your recruiting, there will likely be no-shows. So, it's a good idea to always over-recruit. 

For focus groups it’s common practice to recruit two additional participants per group e.g., recruit 10 to seat 8 per group. If 9 or even 10 show up, it’s up to the moderator and client if all participants will be included in the focus group or not. Keep in mind that all participants who show up, whether they are asked to participate or not must be paid their incentive. 

For I-D-Is (one-on-one interviews), recruit several back-up participants that can be contacted and scheduled to replace any no-shows. Again, it’s up to the moderator and client if all who have been recruited will be interviewed or not. 

Respondent makes no-show and replacement management easy. If you have an I-D-I participant that doesn't show up, mark them as "no-show." Respondent will immediately contact you, asking if you want us to identify a replacement from your previously vetted participant pool. The replacement participant will be scheduled as a make up for your no-show. Respondent will not charge for the recruiting of no-shows.

6. Offer Fair & Quick Compensation 

Determining what type and the amount of the incentive for participants can be a challenge.  The amount needs to be motivating for participants to first agree to participate and then to actually show-up. The amount offered must also fit within the research budget. This can be a balancing act. 

Typically, the longer a participant is needed, the larger your incentive needs to be. Additionally, the location of the study must be considered. Higher compensation will be necessary for an in-person study versus a remote one. 

Individuals in certain professions and at higher income levels will not be as motivated by an incentive. Larger incentives must be offered to these participants for both a timely and successful recruit and to encourage their attendance.

Respondent handles the payment of participant incentives which can be a hassle and time-consuming. Simply indicate that a participant has shown up and participated and Respondent takes care of payment. 

Recruiting Made Quick and Easy with Respondent

Following the steps to have a successful recruit which leads to a successful project traditionally has been difficult, time consuming and costly. Respondent offers solutions that streamlines and accelerates the process while providing the highest quality participants you can be confident in and all this at reasonable costs. Give Respondent a try.

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Improving trial recruitment processes: how qualitative methodologies can be used to address the top 10 research priorities identified within the PRioRiTy study

Marita hennessy.

1 Qualitative Research in Trials Centre (QUESTS), School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland

2 Health Behaviour Change Research Group, School of Psychology, National University of Ireland Galway, Galway, Ireland

Andrew Hunter

3 School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland

Patricia Healy

4 Health Research Board—Trials Methodology Research Network, Galway, Ireland

Sandra Galvin

Catherine houghton, associated data.

Not applicable.

How can we improve recruitment to trials? In their recently published paper, Healy et al. outline the top 10 prioritised questions for trial recruitment research identified by the PRioRiTy study. The challenge now is for researchers to answer these questions; but how best can these be answered? In this commentary, we illustrate how qualitative research can be utilised to generate in-depth insight into trial recruitment issues, either as a stand-alone methodology, or through a mixed-methods approach. Consideration is given to how different forms of qualitative research can be used to address these priorities and to help researchers set out an agenda to optimise its value.

In their recently published paper, Healy et al. outline the top 10 prioritised questions for trial recruitment research identified by the Prioritising Recruitment in Randomised Trials (PRioRiTy) study (Table  1 ) [ 1 ]. The challenge now is for researchers to answer these questions. We believe that there are significant opportunities for qualitative methodologies to contribute to better understanding of trial recruitment issues and that the true value of such methodologies has not been fully recognised, or realised, to date. By working together, all key stakeholders—including trialists, researchers, clinicians, practitioners, commissioners, managers, policy makers, and members of the public—can find answers to the various recruitment issues by embedding qualitative designs in trials, or vice versa (i.e. embedding trials within qualitative designs) [ 2 ]. To this end, this paper will present a number of examples where qualitative research has been used to improve the conduct of trials, and specifically recruitment.

The “top 10” research questions prioritised in the Prioritising Recruitment in Randomised Trials (PRioRiTy) study

What is the value of qualitative methods in trial recruitment research?

Qualitative research can address questions in trial recruitment that are not easily addressed by quantitative methods, by providing in-depth information on the experiences of participants and recruiters. It can also help contribute to trial design, including the development of effective recruitment strategies. Qualitative research methods have been used to address various aspects of randomised trials; these include developing and understanding the acceptability of the intervention being trialled, the trial design, process and conduct (including recruitment and retention), explaining trial outcomes, and providing contextual understanding of the target condition for the trial [ 3 ]. Increasingly, more focus is being placed on the pre-trial stage [ 3 ]. Qualitative research can potentially improve the efficiency of trials by identifying problems with recruitment. This enables the trialists to address those problems and increase or optimise recruitment [ 3 ]. Common qualitative research methods include interviews, focus groups, and observations. Other methods include analysis of trial documents, and audio recordings of trial recruitment interactions. While the integration of qualitative methods within randomised trials is recognised as important, in practice, fully embedded/integrated designs are rarely realised and methodological concerns persist [ 3 – 5 ]. It is imperative that researchers in primary qualitative research fully report and justify their methodological approach to ensure the rigor of their methods and maintain the credibility of qualitative research in trials. A range of potential weaknesses have been identified, including lack of clarity regarding methods, sample and data collection, limited explanation of context, poor description of data analysis, and failure to account for the impact, if any, of the qualitative researcher [ 6 , 7 ] There is also a need for those undertaking qualitative evidence synthesis to address the confidence in their findings using GRADE CERQual [ 8 ]. In addition, there are reporting guidelines on the EQUATOR network ( https://www.equator-network.org/ ) specifically aimed at qualitative research and evidence synthesis.

How can questions be answered by qualitative methods?

We will now outline how different qualitative methodologies can be used to address the top 10 priorities. We have grouped the approaches into three categories: 1) interviews and focus groups; 2) observation, audio recording and documentary analysis; and (3) qualitative evidence synthesis. Each of the methods can also be used within mixed-methods approaches; however, we will not specifically address such approaches within this commentary. In mixed-methods research, the researcher collects and analyses both qualitative and quantitative data rigorously, integrates the two forms of data and their results, organizes these procedures into specific research designs, and frames these procedures within theory and philosophy ([ 9 ]: page 5).

Interviews and focus groups

The use of individual interviews or focus groups within randomised trials facilitates understanding from the viewpoint of those experiencing phenomena (in this instance, recruitment to trials), and can be conducted with patient participants, recruiters, health professionals, or others. Individual interviews provide the opportunity for in-depth discussion of individuals’ personal insights and lived experiences, particularly when the topic is potentially sensitive [ 10 , 11 ]. Alternatively, the strengths of focus groups lie in group dynamics and the interactive nature of the unfolding discussions. Focus groups allow discussion in a more relaxed atmosphere to explore shared experiences and develop understanding from their interaction [ 12 ].

Donovan et al. provide a detailed example of how interviews can provide a rich understanding of the complexities and hidden challenges underlying recruitment to randomised trials from the perspectives of recruiters [ 13 ]. Similarly, Oakley et al. provide an example of the use of focus groups to support process evaluation within a trial [ 14 ]. They argue that the science of a randomised trial is enhanced by ongoing high-quality evaluation which considers the context in which the intervention is delivered, helping to explain outcomes. Analysis of focus group data provides insight into acceptability and delivery of interventions from the perspective of participants [ 5 ]; interviews can also facilitate such insights. O’Cathain et al. identify the increasing use of focus groups and individual interviews within trials, suggesting that incorporating these methods at feasibility and pilot stages of trials can enhance the leaning about trials for trialists and researchers, and contribute to the overall trial endeavour [ 5 ].

Dormandy et al. conducted interviews with general practitioners to seek their views on effective ways of recruiting and retaining practices to clinical trials [ 15 ]. This study found that interviews with general practitioners allowed identification of key strategies for communication, data collection, and payment to support retention and recruitment.

Donovan et al. synthesised findings from interviews with recruiters in a number of trials, providing improved understanding of the complexity and fragile nature of recruitment practices [ 13 ]. Interviews elicited detailed information from recruiters regarding their tendency to undermine recruitment practices, specifically randomisation for clinical and equipoise reasons [ 13 ]. Importantly, these findings were elicited in individual interviews, with responses being fed into efforts to improve recruitment practices. In an earlier study, Donovan et al. conducted in-depth interviews with men in the Prostate testing for cancer and Treatment (ProtecT) study to establish interpretation of study information by participants [ 2 ]. Subsequent changes to the content and delivery of study information within this trial, incorporating findings from these interviews amongst other data, increased recruitment rates from 40% to 70% [ 2 ]. The examples presented show that interviews and focus groups would be appropriate qualitative methods for most of the PRioRiTy questions, conscious of the group versus individual dynamic for some sensitive questions. Individual interviews would be more suitable for question nine (‘What are the best approaches to optimise the informed consent process when recruiting participants to randomised trials?’), however, where the process of informed consent would perhaps be better discussed individually.

Observation, audio recording, and documentary analysis

While the strengths of interviews and focus groups are to capture perspectives and experiences, there can sometimes be conflict between what people say happens and what actually happens. There are times when qualitative methods that capture interactions and events would be more suitable for answering questions about trial processes. These methods can include observations, audio recordings, and documentary analysis of trial processes. For example, Healy et al. conducted a mixed-methods process evaluation of the OptiBIRTH trial (a pan-European cluster randomised controlled trial (RCT)) [ 16 ]. An ethnographic study conducted by Maguire was embedded within this study to explore the implementation of the intervention in practice [ 17 ]. Qualitative observations and interviews uncovered the impact of the intervention on culture and rituals within the practice setting.

An example of the use of audio recording was presented by Donovan and colleagues [ 2 ]. Analysis of audiotape recordings of recruitment appointments in the ProtecT study revealed how the language used when presenting trial information could impact on recruitment [ 2 ]. This innovative qualitative approach became the cornerstone of QuinteT Recruitment Intervention (QRI) developed by Donovan and colleagues [ 18 ]. The QRI involves understanding the process of recruitment in real time and then developing an action plan to address the identified difficulties in collaboration with the RCT Chief Investigator, Trial Management Group, and Clinical Trials Unit [ 18 ].

Documentary analysis examines anything written or produced about a context and how it has evolved [ 19 ]. This can include formal and informal sources which may contain clues as to how a phenomenon has evolved [ 19 ]. This is an important method to understand what is happening and the context from which the phenomenon has grown. Documentary sources, unlike interviews, are not the result of a somewhat artificial process of interaction and, therefore, the process by which they are produced cannot be ignored [ 20 ]. Content analysis of trial documents was conducted in the Selective bladder Preservation Against Radical Excision (SPARE) feasibility study (along with analysis of interview data and audio recordings of recruitment appointments) to explore reasons for low recruitment and to attempt to improve recruitment rates [ 21 ]. Trial documents examined included the SPARE trial Patient Information Sheet and trial protocol. Findings contributed to revisions to trial processes that were acceptable to trialists and recruiters.

In recruitment research, these qualitative methods, alone or in combination (as utilized for example in the QRI), could be used to answer the “what is happening?” component of the PRioRiTy questions. For instance, using observation or audio recording, the best approaches for including under-represented or vulnerable populations (question seven) could be explored. Similarly, informed consent processes (question nine: ‘What are the best approaches to optimise the informed consent process when recruiting participants to randomised trials?’) could be examined using observations, audio recording, or documentary analysis. Researchers could also use observational techniques to explore the role of technology in recruitment processes outlined in question ten. In the context of the PRioRiTy questions, documents would be important for augmenting evidence from interviews and observations [ 22 ], to develop a better understanding about recruitment processes and outcomes.

Qualitative evidence synthesis

In addition to emphasising the importance of primary qualitative studies in trial research, there is now recognition of the contribution to be made by qualitative evidence synthesis (QES). QES is a valuable way of synthesising primary qualitative research to capture experiences, perceptions, and factors that impact on certain components of the trial process. QES is rigorous and provides meaningful conclusions that can inform policy and practice [ 23 , 24 ].

As outlined in the PRioRiTy paper, a number of qualitative syntheses have already been conducted that address questions six and nine [ 25 – 28 ]. It should be noted that all of the questions identified in the PRioRiTy paper were deemed “unanswered” if there was no up-to-date systematic review (< 3 years old). Houghton et al. have also published a Cochrane Protocol exploring the factors that impact on recruitment to trials [ 29 ]. This ongoing qualitative review will be integrated with the findings of a Cochrane review [ 30 ] that aimed to identify interventions designed to improve recruitment to RCTs, which in turn will inform PRioRiTy questions two and six. QES has great potential for guiding further recommendations for most of the PRioRiTy questions.

Conclusions: where do we go from here?

The PRioRiTy study identified and prioritised important unanswered questions on how to improve the process of recruiting people to randomised trials. Further research is now required to address those prioritised questions. We propose that qualitative research approaches have a crucial role in providing answers to the questions posed. Similar to the examples provided, qualitative research could be conducted as a stand-alone study embedded as a study within a trial (SWAT), or as part of mixed-methods research. Failure to integrate findings and variations in quality are ongoing issues [ 31 ]. Trialists and qualitative researchers need to collaborate and work together to ensure qualitative work is done appropriately, ethically, and rigorously.

As described above, there is ample opportunity for qualitative methodologies to address the top ten priorities identified for trial recruitment research. Organisations such as QUESTS, the HRB-TMRN, Trial Forge, and QuinteT can bridge links between trialists and researchers to better inform trial recruitment.

Some key considerations for moving this agenda forward are:

• Qualitative research needs to be integral, and not considered an optional add-on.
• There needs to be a common language supporting communication between trialists and researchers.
• Qualitative methodologies should be embedded at the design phase (including costings) and fully reported on completion. This includes pre-trial, pilot, and feasibility stages of the trial [ 3 , 4 ].
• The potential positive impact of qualitative research in trial recruitment and other trial methodology research needs to be rigorously researched, articulated, and disseminated.

Qualitative research can help provide the necessary evidence to guide researchers on how to improve the process of how people are recruited to randomised trials; an issue which persists as a challenge to trialists.

Acknowledgements

Marita Hennessy is a PhD Scholar funded by the Health Research Board under SPHeRE/2013/1.

Availability of data and materials

Abbreviations.

Authors’ contributions

MH conceived the commentary. MH, AH, and CH wrote the initial draft. All authors (MH, AH, PH, SG, and CH) provided significant intellectual contribution towards reviewing and editing. All authors reviewed and approved the final manuscript.

Authors’ information

PH and SG are on behalf of the PRioRiTy study team, listed at https://priorityresearch.ie/ .

Ethics approval and consent to participate

Consent for publication, competing interests.

The authors declare that they have no competing interests.

Publisher’s Note

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

Contributor Information

Marita Hennessy, Email: [email protected] .

Andrew Hunter, Email: [email protected] .

Patricia Healy, Email: [email protected] .

Sandra Galvin, Email: [email protected] .

Catherine Houghton, Email: [email protected] .

Examining the world through qualitative inquiry

Recruiting participants for a qualitative research study

How do qualitative researchers locate potential participants for a study? What approaches might be used to recruit people? Clearly the easiest way to recruit people is to ask people you already know to participate in your study. This is potentially fraught with difficulty, however, since this is known as “convenience sampling”, which is typically perceived to be the weakest form of sampling. Of course there are exceptions to this. For example, if a researcher is doing an autoethnographic study, this would involve talking to people within the researcher’s friendship, family and professional circles (Chang, 2008). Yet, qualitative researchers use a variety of strategies to recruit people. Let’s look at some of these.

Recruiting via personal and professional connections

When researchers are “insiders” to the group that they are examining, then a first place to begin is to start with people who are known. This might mean seeking recommendations for potential participant from known others, and even asking for “expert recommendations”. It might be worthwhile to set up preliminary meetings with people who have a good deal of expertise in a field to ask for recommendations. For example, in my very first qualitative study which examined how music teachers dealt with inaccurate singers, I began by getting in touch with music advisors, and asking them for recommendations for exemplary teachers. I was able to interview music advisors as well as the teachers who they recommended to me. I also arranged visits to these schools for observations. In the same study, I was also able to talk to recognized experts in the field of music education. I was very fortunate at the time to be working with an adviser who was organizing an international conference. She acted as a gate-keeper, in that she introduced me to many of these experts whom I was able to interview during the conference.

Gatekeepers – people who have administrative positions, or in-depth information about a particular setting — can be incredibly helpful, if not crucial, to gain access to a particular community of setting. Sometimes, although people who serve as “formal gatekeepers” to a particular setting may provide access for a research study, those who serve as “informal gatekeepers” may withhold access (Wanat, 2008). Rugkåsa and Canvin (2011) discuss issues that they found to have impacted gatekeepers’ attitudes towards allowing researchers access to a particular community (in their study, they were working with Black and minority ethnic communities in the UK). These included (non)payment of participants and reciprocal arrangements with local community groups. These researchers recommend that researchers use flexible recruitment strategies that attend to the local contexts in which research is being conducted. Let’s look further at the kinds of recruitment strategies used by researchers.

Recruiting via fliers, newspaper advertisements, emails and letters

As anyone who has spent time on a university campus will know, researchers frequently recruit participants via fliers and advertisements. Sometimes, but not always, payment for participation is included as an incentive. Another frequently used approach is to send email or letter requests to people thought to meet sampling criteria. Here, a researcher might purchase a mailing list, and locate people via the information provided with the mailing list, and send letters or emails. Similarly, recruitment notices can be sent via established listservs. It is useful to get in touch with the list-owner first, however, to check if these sorts of notice might be allowed on a listserv.

Recruiting through face-to-face interactions

Sometimes researchers uses face-to-face interactions as a primary method,  recruiting  in neighborhoods through knocking on doors (Freeman, 2000), standing on street corners (McCormack et al., 2013), or visiting boarding houses and airline terminals (Thomas, Bloor, & Frankland, 2007). Here, participants are not known to them, but are recruited on the spot. Putting oneself forward in these kinds of ways as a researcher may entail feelings of “relief, despair, embarrassment, hilarity and even hysteria” (Thomas et al., 2007, p. 435). What they refer to here is the emotional labor entailed in seeking people to participate in studies, yet experiencing repeated refusals.

Yet sometimes, even though researchers might use multiple recruitment methods, efforts appear to be futile. There are few, if any, volunteers. What is happening here?

Difficulties in recruitment for research studies

Researchers have written about some of the problems entailed in recruiting participants for research on sensitive topics (Butera, 2006; Culley, Hudson, & Rapport, 2007), private topics (McCormack, Adams, & Anderson, 2013),and  stigmatized or illegal activities such as prostitution or drug-dealing (Dietze, 2002; Roth, 2012). Further, because of historical abuses perpetrated by researchers, some populations are rightly suspicious of becoming involved in research studies (Reverby, 2009; Skloot, 2010). To address some of these concerns, researchers have worked in participatory ways with community groups (Anthony, Lee, Barry, & Kappesser, 2010), and include members of the populations in which they are engaging with as co-researchers (Shelton & Rianon, 2004). They have also worked with bicultural recruiters (Rugkåsa & Canvin, 2011). Developing relationships with communities will likely take extended time in order to build relationships that will lead to successful recruitment of participants through information sharing and face-to-face interactions (Sixsmith, Boneham, & Goldring, 2003).

Although it is not possible to project a path to recruitment of participants that will always prove successful, researchers have been generous in sharing their recruitment challenges and the strategies that they have used. If you run into challenges with recruiting participants, take a look at what others have done. With more time, and through using a variety of recruitment methods, you will likely be successful. All the best with these efforts.

Kathy Roulston

NB: This post draws on information included in (Roulston & Martinez, 2015). For more information on sampling and selection, see LeCompte and Preissle (1993).

Anthony, J. S., Lee, R. C., Barry, D. G., & Kappesser, M. (2010). Recruiting and Keeping African American Women in an Ethnographic Study of Pregnancy: The Community-Based Partnership Model. Field Methods, 22 (2), 125-132. doi:10.1177/1525822×09358645

Butera, K. J. (2006). Manhunt The Challenge of Enticing Men to Participate in a Study on Friendship. Qualitative Inquiry, 12 (6), 1262-1282.

Chang, H. (2008). Autoethnography as method . Walnut Creek, CA: Left Coast Press.

Culley, L., Hudson, N., & Rapport, F. (2007). Using Focus Groups With Minority Ethnic Communities: Researching Infertility in British South Asian Communities. Qualitative Health Research, 17 (1), 102-112. doi:10.1177/1049732306296506

Dietze, P. (2002). Using ambulance attendances to recruit people who have experienced non-fatal heroin overdose. Drug and Alcohol Dependence, 67 (1), 99.

Freeman, M. (2000). Knocking on Doors: On Constructing Culture. Qualitative Inquiry, 6 (3), 359.

LeCompte, M. D., & Preissle, J. (1993). Ethnography and qualitative design in educational research (2nd ed.). San Diego: Academic Press.

McCormack, M., Adams, A., & Anderson, E. (2013). Taking to the streets: the benefits of spontaneous methodological innovation in participant recruitment. Qualitative Research, 13 (2), 228-241.

Reverby, S. (2009). Examining Tuskegee : the infamous syphilis study and its legacy . University of North Carolina Press: Chapel Hill.

Roth, A. M. (2012). A methodological approach to improve the sexual health of vulnerable female Populations: incentivized peer-recruitment and field-based STD testing. Journal of health care for the poor and underserved, 23 (1), 367.

Roulston, K., & Martinez, B. (2015). Recruitment and sampling in consumer research. In P. Hackett (Ed.), Consumer ethnography: Qualitative and cultural approaches to consumer research . New York & London Routledge.

Rugkåsa, J., & Canvin, K. (2011). Researching Mental Health in Minority Ethnic Communities: Reflections on Recruitment. Qualitative Health Research, 21 (1), 132-143. doi:10.1177/1049732310379115

Shelton, A. J., & Rianon, N. J. (2004). Recruiting Participants from a Community of Bangladeshi Immigrants for a Study of Spousal Abuse: An Appropriate Cultural Approach. Qualitative Health Research, 14 (3), 369-380. doi:10.1177/1049732303261957

Sixsmith, J., Boneham, M., & Goldring, J. E. (2003). Accessing the Community: Gaining Insider Perspectives From the Outside. Qualitative Health Research, 13 (4), 578-589. doi:10.1177/1049732302250759

Skloot, R. (2010). The immortal life of Henrietta Lacks . New York: Crown Publishers.

Thomas, M., Bloor, M., & Frankland, J. (2007). The process of sample recruitment: an ethnostatistical perspective. Qualitative Research, 7 (4), 429-446.

Wanat, C. L. (2008). Getting Past the Gatekeepers: Differences Between Access and Cooperation in Public School Research. Field Methods, 20 (2), 191-208. doi:10.1177/1525822×07313811

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Kathy Roulston is a professor in the Qualitative Research program in the Department of Lifelong Education, Administration and Policy at the University of Georgia, Athens, GA, USA. She teaches qualitative research methods, and has written on qualitative interviewing. https://orcid.org/0000-0002-9429-2694 Kathryn J. Roulston on ResearchGate My books include: Interviewing: A guide to theory and practice, see: https://us.sagepub.com/en-us/nam/interviewing/book272521 Interactional studies of qualitative interviews. See: https://benjamins.com/catalog/z.220 View all posts by qualpage

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Very useful

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• DOI: 10.1177/16094069221119576
• Corpus ID: 251637620

Successful Recruitment to Qualitative Research: A Critical Reflection

• Kelly A. Negrin , S. Slaughter , +1 author Joanne Olson
• Published in International Journal of… 1 January 2022

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Recruitment in qualitative public health research: lessons learned during dissertation sample recruitment, 'to be honest, i haven't even thought about it' - recruitment in small-scale, qualitative research in primary care., strategies to successfully recruit and engage clinical nurses as participants in qualitative clinical research, pharmacist and patient perspectives on recruitment strategies for randomized controlled trials: a qualitative analysis, participant recruitment for qualitative research: a site-based approach to community research in complex societies, participant recruitment to fiction, a primary dental care trial – survey of facilitators and barriers, overcoming barriers to the recruitment of nurses as participants in health care research, ethical challenges in accessing participants at a research site., related papers.

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Chapter 29: Recruitment and sampling

Tess Tsindos

Learning outcomes

Upon completion of this chapter, you should be able to:

• Describe the main types of sampling.
• Describe recruitment approaches.
• Understand how to conduct recruitment and sampling.
• Identify the strengths and limitations of recruitment and sampling.

What is sampling?

Sampling is defined as selecting a suitable group of people (population) for a study. 1 Inviting people to the study who have the information to address the research question is a key consideration in sampling. Sampling is guided by the research question and will also influence data collection.

In qualitative research, different forms of non-random sampling, also known as non-probability sampling (not everyone has the chance of being selected), are utilised. 1 Using non-random sampling means the likelihood of a potential research participant being selected is not known in advance. This form is limited in generalisability; however, it aligns with qualitative research principles of sampling for meaning rather than frequency. Qualitative researchers tend to say that qualitative research is not generalisable, but is representative. 1  While qualitative studies often include non-random sampling, simple random sampling can be conducted when it is important to select a random set of participants from a large population, in which everyone has the same chance of being selected. This could be done by randomly selecting names from a telephone list or voter registration roll.

There are many ways to select a sample (sampling techniques). Among these are:

Snowball sampling ,   whereby study participants recruit or refer people they know to the study. This method is commonly used when potential participants can be hard to find through other means but potential participants are likely known to each other. For example, drug users or patients with rare diseases are likely to know others like themselves. This method may pose challenges for privacy because people may not want to share their contacts. 2

Convenience sampling ,   in which study participants are those most available to participate in the study. Participants may be those who are easily accessible to the researchers – such as a practitioner who is a member of a professional organisation and uses that organisation to recruit participants or patients at a hospital where the researcher works. This method can introduce bias because participants are drawn from within the researcher’s own networks or spheres of influence. 2

Purposive sampling ,   also known as purposeful sampling or selective sampling, involves the selection of participants on the basis of their ability to provide in-depth and detailed information about the phenomenon under investigation. For example, a study on the experience of working in a public hospital as a frontline emergency nurse during the COVID-19 pandemic requires participants to be nurses, working in an emergency department, having worked during the pandemic and at a public hospital. A general practitioner, for example, could not provide in-depth information on the phenomenon being investigated. This method may present challenges in locating potential participants because it can be difficult to find participants who are able to provide in-depth information about the phenomenon being studied. 2

Quota sampling   is sometimes referred to as purposive sampling with more structure. Categories that are important to the study and for which there is likely to be some variation are identified and then subgroups are identified on the basis of each category. The researcher decides how many people to include from each subgroup and collects data from that number of participants in each subgroup. This method requires the investigator to have prior information about the sample. For example, in a study researching students and their experience of attending university, many subgroups need to be considered; for example, those living on or off campus, the course of study, faculty or discipline, age, gender identity, ethnicity and more. This method can present a challenge to fill quotas for each category identified. 2

Snowball, convenience purposive and quota sampling are the most commonly used techniques for sampling in qualitative research. Other, less commonly used techniques include stratified sampling, theoretical sampling, extreme case sampling, typical case sampling, systemic sampling and intensity sampling. The technique used will depend on the research aim and questions.

Sample size in qualitative research

There are no clear guidelines for sample sizing in qualitative research. While researchers often propose a sample size, in general it is not decided on prior to data collection, but rather when data saturation occurs. Data saturation is a controversial concept because it is usually considered the point at which no new data is identified in interviews or focus groups. Some qualitative researchers, such as Braun and Clarke 4 hold that data saturation can never be fully achieved because each participant will have something new to add to the data. For other researchers, data saturation is an acceptable concept, and is often given as 8–17 participants. 1, 3 While 15 might be a proposed sample size for a study involving interviews, when the researcher has completed 10 interviews they may feel they have reached saturation as far as new themes or ideas are concerned. It is important to remember that sample size is not used to generalise and validate findings 5 , but rather to ensure in-depth understandings of the phenomenon under investigation.

Criteria for sampling

Another consideration in sampling is determining the inclusion and exclusion criteria for the study. This is a standard practice in qualitative research and is used to define who will and will not be able to participate in the study. 6 For example, inclusion criteria might include gender identity, age and health diagnosis. People who do not meet the inclusion criteria would not be eligible to participate in the study. Exclusion criteria are more than simply the opposite of inclusion criteria; they cover specific factors such as not being able to provide informed consent, using a specific type of medication, having a certain diagnosis and more. 6 Inclusion and exclusion criteria are broad, and should not be so narrow that they limit the characteristics of participants who can be recruited to the study.

Well-developed inclusion and exclusion criteria and well-considered sampling methods will assist researchers with the next step, recruitment to the study.

W hat is recruitment ?

Broadly speaking, recruitment to a research study involves presenting potential participants with detailed information about the research to help them decide on whether to participate in the study. The information presented during recruitment contributes to the consent process. Researchers who initiate participant recruitment should have a basic knowledge about the research and be part of the study team.

Before any research is to commence, the study must have ethical approval from a human research ethics committee. For academic researchers, this is the university’s human research ethics committee. For researchers outside the academic setting, it is the organisation that has been identified as the review agency. For example, research conducted within a hospital setting is reviewed by the hospital’s research ethics committee or panel. Research ethics committees review applications against the benchmarks set out in the National Statement on Ethical Conduct in Human Research .

As part of their data collection activities, researchers need to consider how they will invite research participants (recruitment) and the process of consent (see Chapter 30).

Recruitment methods need to take account of whether participant contact information is available and if there is permission to use it for the purpose of the research. Having email, phone or in-person (e.g. at a clinic) information will enable the researchers to correspond directly with potential participants, to invite them to participate in the research. Most researchers do not have the contact information of potential participants or are not able to contact them for the purpose of the research. In this instance, more passive methods of recruitment are needed and need to take into account settings frequented by potential participants, in-person or online. Passive methods of recruitment include advertising on social media, posting flyers on clinic noticeboards to advertise the research, asking clinics, sporting clubs, social clubs, schools, professional organisations, patient groups and other agencies to distrubute printed newsletters or to send emails on behalf of the researcher. The author has been involved in many studies in which contact details were not available. In a hospital study examining staff perceptions of how well a program was implemented, the hospital sent out invitations to potential participants (hospital staff) on behalf of the researcher. Staff who wished to participate were able to contact the investigators independently. In other instances where no contact details were available, the author advertised for participants with the assistance of peak bodies and community networks.

Recruiting participants through social media is increasingly common, but researchers need to be mindful about privacy and public availability of information. For example, potential participants may believe their comments in response to a recruitment advertisement on a social media platform are private, when in fact the information they share is available or visible to all users on that platform, or to the public.

Problems that may be encountered during recruitment include (but are not limited to) participants who are not fluent in English, participants who are hard to find and participants who do not trust research. Researchers need to consider these challenges in their recruitment activities and adjust them as necessary. Adjustments may include providing documents translated into the preferred language(s) of potential participants, recruiting research staff who speak the language, being mindful of the gender identity of research staff (e.g. women participants from some cultural backgrounds may prefer to deal with women researchers) and ensuring the research purpose is clearly communicated.

Incentives for research participants

Sometimes recruitment can be enhanced by providing an incentive for participants. This approach must be approved by the human research ethics committee before being offered to participants. Examples of reasonable incentives include providing reimbursement for parking at a hospital, offering a gift/shopping card or a coffee voucher for a nearby café, in recognition of time spent participating in the study. Incentives should not be excessive and therefore potentially coercive. The National Health and Medical Research Council (NHMRC) provides guidance on incentives in research.

Examples of s ampling and recruitment methods are presented in T able 29 .1. Notice how often multiple recruitment methods are used.

Table 29.1: Examples of sampling and recruitment

Strengths and challenges

Each sampling and recruitment method has strengths and challenges. The one chosen depends on the study’s research question(s) and aim(s). Choosing the appropriate methods will bring rigour to the research, while choosing inappropriate methods will reduce rigour and affect the research results. Consider a study in which women’s experience of episiotomy is being sought. 7 It may be possible to recruit many women based on how relatively easy the birth was, or only a few women based on how willing the women are to talk about the use of forceps during delivery. Or consider a descriptive qualitative study in which up to 40 participants are recruited to provide slightly more generalisable results about an experience with a health service. 8 Each sampling and recruitment method is valid, depending on what is being researched.

Sampling refers to the selection of a suitable group of people from a broader population, to participate in a study. Selecting the people suitable for the research study is important because that will affect the study’s findings. There are many ways to sample, and these depend on the research being undertaken as well as the availability of participants. Recruitment refers to providing potential participants with information about the research and gaining their agreement to participate. There are many recruitment methods, and the one(s) chosen depend on the research being undertaken as well as participant agreement to become involved. Issues of privacy, confidentiality and consent need to be fully considered when sampling and recruiting participants to a research study.

• Lopez V, Whitehead D. Sampling data and data collection in qualitative research . In Schneider Z, Whitehead D, LoBiondo-Wood G, Haber J. Nursing & Midwifery Research: Methods and Appraisal for Evidence-Based Practice (4th ed). Elsevier Mosby; 2013:123-140.
• DeCarlo M, Cummings C, Agnelli K. Graduate R esearch M ethods in S ocial W ork : A P roject-based A pproach ; 2020.   Accessed September 26, 2023. https://viva.pressbooks.pub/mswresearch/
• Hennink M & Kaiser B. Sample sizes for saturation in qualitative research: a systematic review of empirical tests . Soc Sci Med . 2022;292:114523. doi.org/10.1016/j.socscimed.2021.114523
• Braun V & Clarke V. To saturate or not to saturate? Questioning data saturation as a useful concept for thematic analysis and sample-size rationales. Qual Res Sport, Exerc Health . 2019;13(2):1-16. doi:10.1080/2159676X.2019.1704846
• Vasileiou K, Barnett J, Thorpe S et al Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a 15-year period. BMC Med Res Methodol  2018;18:148. doi:10.1186/s12874-018-0594-7
• ICORD, Vancouver Coastal Health Research Institute. Inclusion & exclusion criteria explained. Accessed May 28 th 2023. https://icord.org/research/studycriteria/
• He S, Jiang H, Qian X et al Women’s experience of episiotomy: a qualitative study from China BMJ Open  2020;10:e033354. doi:10.1136/bmjopen-2019-033354
• Williams M, Jordan A, Scott J et al Service users’ experiences of contacting NHS patient medicines helpline services: a qualitative study. BMJ Open  2020;10:e036326. doi:10.1136/bmjopen-2019-036326
• Gabriel P, Kaczorowski J, Berry N. Recruitment of refugees for health research: a qualitative study to add refugees’ perspectives . Int J Environ Res Public Health . 2017;14:125. Doi:10.3390/ijerph14020125
• Jola C, Sundström M, McLeod J. Benefits of dance for Parkinson’s: the music, the moves, and the company. PLoS ONE . 2022;17(11): e0265921. doi:10.1371/journal.pone.02659214
• Gauche C, de Beer L & Lizelle Brink L. Managing employee well-being: a qualitative study exploring job and personal resources of at-risk employees. SA Journal of Human Resource Management/SA Tydskrif vir Menslikehulpbronbestuur . 2017;15:a957. doi:10.4102/sajhrm. v15i0.957
• Hoernke K, Djellouli N, Andrews L et al Frontline healthcare workers’ experiences with personal protective equipment during the COVID-19 pandemic in the UK: a rapid qualitative appraisal. BMJ Open .   2021;11:e046199. doi: 10.1136/bmjopen-2020-046199

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

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Key Principles for Successful Qualitative Recruitment Fieldwork

Introduction:

Qualitative recruitment fieldwork is a pivotal element in research, enabling the collection of rich, in-depth data that goes beyond mere statistics. Successful execution of this process requires a combination of strategic planning, interpersonal skills, and a deep understanding of the research objectives. In this blog post, we will delve into the key principles that contribute to the triumph of qualitative recruitment fieldwork.

Clearly Define Research Objectives:

Before embarking on any fieldwork, it is imperative to have a crystal-clear understanding of the research objectives. This involves defining the scope of the study, identifying the target demographic, and outlining the specific information required. A well-defined research objective lays the foundation for successful recruitment by guiding the selection criteria for participants.

Develop a Comprehensive Recruitment Strategy:

Crafting a robust recruitment strategy is essential for identifying and engaging suitable participants. This involves choosing appropriate recruitment channels, such as social media platforms, community centers, or specialized forums. Diversifying recruitment sources ensures a representative sample, enriching the qualitative data collected.

Establish Trust and Rapport:

Building trust with potential participants is fundamental to the success of qualitative recruitment fieldwork. Researchers must be transparent about the purpose of the study, the expected time commitment, and the benefits of participation. Establishing rapport creates a comfortable environment for participants to share their experiences openly, contributing to the depth and quality of the data.

Screen Participants Effectively:

The screening process is a critical step in ensuring that recruited participants align with the research objectives. Researchers should employ thorough screening techniques to identify individuals who possess the relevant experiences, perspectives, and insights sought for the study. A well-defined screening process helps in selecting a diverse yet targeted sample.

Utilize Varied Recruitment Methods:

Employing a mix of recruitment methods enhances the chances of reaching a diverse pool of participants. From online surveys and social media outreach to in-person recruitment events, diversifying the approach allows researchers to tap into different demographics and capture a more comprehensive range of perspectives.

Maintain Flexibility:

Fieldwork is inherently dynamic, and unexpected challenges may arise. Successful qualitative researchers are adaptable and can pivot their strategies when needed. This includes being open to adjusting recruitment criteria, revising timelines, or exploring alternative sources to overcome unforeseen obstacles.

Ensure Ethical Considerations:

Maintaining ethical standards is non-negotiable in qualitative research. Researchers must obtain informed consent from participants, prioritize confidentiality, and adhere to ethical guidelines. A commitment to ethical practices not only upholds the integrity of the research but also fosters trust between researchers and participants.

Conclusion:

In the realm of qualitative recruitment fieldwork , success hinges on a combination of strategic planning, effective communication, and ethical conduct. By embracing these key principles, researchers can navigate the complexities of participant recruitment, ultimately enriching their studies with diverse and insightful perspectives. In the ever-evolving landscape of qualitative research, mastering these principles will pave the way for meaningful, impactful studies.

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Recruitment methods for qualitative research: best practices.

Home » Recruitment Methods for Qualitative Research: Best Practices

Optimal Qualitative Recruitment methods provide a pathway to uncovering profound insights during qualitative research. As researchers seek to understand complex human behaviors and motivations, effective recruitment becomes paramount. The right participants can significantly influence the quality of the data gathered, leading to richer, more nuanced findings.

In qualitative research, optimal qualitative recruitment is not merely about filling seats; it involves carefully selecting individuals who genuinely reflect the target demographic. This careful consideration helps in addressing specific research questions, which ultimately leads to more reliable and actionable insights. Understanding how to implement these methods effectively can pave the way for more meaningful participant interactions and enhanced research outcomes.

Understanding the Basics of Optimal Qualitative Recruitment

Optimal Qualitative Recruitment involves understanding the essential principles to gather rich and meaningful insights. The recruitment process should focus on finding participants whose experiences align closely with the research objectives. By accurately defining the target demographic, researchers can ensure that they engage individuals who will provide the most relevant information.

To achieve effective qualitative recruitment, consider these foundational strategies: First, clearly articulate the research goals, as this clarity will guide the participant selection criteria. Next, utilize diverse recruitment channels, such as social media, community forums, and professional networks, to reach a broader audience. Lastly, prioritize building trust with potential participants, emphasizing confidentiality and the value of their insights. By adhering to these practices, researchers can enhance the quality of their findings and contribute significantly to their field.

What is Optimal Qualitative Recruitment?

Optimal qualitative recruitment involves a systematic approach to selecting participants who can provide rich, relevant insights for research. This process begins with identifying the target audience and understanding their characteristics. Effective recruitment ensures that the participants represent a diverse range of perspectives, enhancing the quality of the data collected.

Key elements of optimal qualitative recruitment include clarity in goals, selecting appropriate sampling techniques, and maintaining transparency throughout the process. A well-defined goal helps guide which participants to invite, whether for focus groups, interviews, or other qualitative methods. Utilizing purposive or convenience sampling can significantly impact the richness of insights gathered. Finally, clear communication with potential participants about the research objectives fosters trust and encourages participation, leading to more meaningful engagement.

Importance of Effective Recruitment in Qualitative Research

Effective recruitment in qualitative research is crucial for gathering in-depth insights that truly reflect participants' perspectives. Optimal qualitative recruitment ensures that the selected participants not only represent the target demographic but also share relevant experiences that inform the study's objectives. When researchers invest time in identifying and recruiting the right individuals, the quality of insights gained is often significantly enhanced.

Moreover, the recruitment process should be tailored to foster trust and open communication. This approach encourages participants to share their authentic thoughts and feelings, leading to richer data. Key elements that contribute to effective recruitment include a clear understanding of the target population, ethical considerations, and appropriate outreach strategies. By focusing on these aspects, researchers can create a more meaningful dialogue during interviews or focus groups, ultimately driving the success of qualitative studies.

Key Strategies for Optimal Qualitative Recruitment

Achieving optimal qualitative recruitment requires strategic planning and execution. First, it's crucial to clearly define your research objectives. Understand what specific insights you seek to gather from participants, as this aids in identifying the right individuals. Next, developing a robust recruitment plan is essential. Consider the characteristics of your target demographic and how best to reach them, using varied platforms like social media, community groups, or specialized forums.

Identifying and building rapport with potential participants is also vital. Personal outreach can foster trust, making individuals more likely to share their experiences honestly. Ensuring inclusivity in the recruitment process helps bring diverse perspectives, enriching your research outcomes. Lastly, maintaining transparency about expectations and compensations engenders a positive participant experience, enhancing response rates and ensuring the reliability of the insights gathered. By implementing these strategies, researchers can enhance their qualitative recruitment efforts significantly.

Leveraging Social Media for Recruitment

Social media offers a powerful avenue for optimal qualitative recruitment, allowing researchers to connect with diverse candidate pools. Platforms like Facebook, LinkedIn, and Twitter enable direct interaction with potential participants, facilitating faster outreach and engagement. This helps in understanding the interests and demographics of potential respondents, making recruitment more tailored and efficient.

To harness social media for recruitment successfully, consider these strategies. First, clearly define your target demographic, so you can focus your outreach efforts on platforms they frequent. Next, create engaging content that highlights the research's purpose, inviting participants to contribute. Lastly, rely on organic sharing methods and paid advertising as needed to maximize your reach. By adopting these methods, you can streamline your recruitment process, enhance participant diversity, and ultimately gather richer insights for your qualitative research.

Building Partnerships with Community Organizations

Building meaningful partnerships with community organizations is essential for optimal qualitative recruitment. Engaging these groups can provide access to diverse populations, enhancing the richness of qualitative research. Understanding the community’s needs and goals can establish rapport, making collaboration more effective.

To build successful partnerships, begin by identifying organizations that share similar values or focus areas. Outreach should be sincere, highlighting the mutual benefits of collaboration. Establishing open lines of communication fosters trust and encourages ongoing dialogue. This can lead to co-designing recruitment strategies and research methodologies that resonate with community members, thus enhancing participation and data quality. Additionally, fostering these relationships can maintain your research’s sustainability and relevance in the community, ensuring ongoing support and insights.

Recognizing the importance of community involvement is crucial for successful qualitative recruitment outcomes. A shared vision encourages participants to engage authentically, resulting in more insightful and meaningful research findings.

Conclusion on Optimal Qualitative Recruitment Best Practices

Optimal Qualitative Recruitment requires a thoughtful approach to ensure success in gathering meaningful insights. This involves understanding participants' experiences and motivations, which can be achieved by conducting interviews and focusing on specific pain points and desires that emerge during conversations. Effective recruitment strategies should emphasize depth over breadth, allowing researchers to explore the nuances of participants’ perspectives.

Moreover, refining recruitment methods can lead to more relevant and engaged participants, thereby enhancing the quality of data collected. By prioritizing the participants' voices and experiences, researchers can cultivate a richer understanding of the subject matter, yielding actionable insights. Continuous evaluation of recruitment practices will support better outcomes in qualitative research, ultimately leading to a more thorough exploration of underlying themes and trends.

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Recruitment for qualitative research

You’ll find a lot of information and debate about sampling issues in qualitative research: discussions over ‘random’ or ‘purposeful’ sampling, the merits and pitfalls of ubiquitous ‘snowball’ sampling, and unending questions about sample size and saturation

Daniel Turner

You’ll find a lot of information and debate about sampling issues in qualitative research: discussions over ‘random’ or ‘purposeful’ sampling, the merits and pitfalls of ubiquitous ‘snowball’ sampling, and unending questions about sample size and saturation. I’m actually going to address most of these in the next blog post, but wanted to paradoxically start by looking at recruitment. What’s the difference, and why think about recruitment strategies before sampling?

Well, I’d argue that the two have to be considered together, but recruitment tends to be a bit of an afterthought and is so rarely detailed in journal articles ( Arcury and Quandt 1999 ) I feel it merits its own post. In fact, there is a great ONS document about sampling , but it only has one sentence on advice for respondent recruitment: “The method of respondent recruitment and its effectiveness is also an important part of the sampling strategy”. Indeed!

When we talk about recruitment, we are considering the way we actually go out and ask people to take part in a research study. The sample frame is how we choose what groups of people and how many to approach, but there are huge practical problems in implementing our chosen sampling method that can be dealt with by writing a comprehensive recruitment strategy.

This might sound a bit dull, but it’s actually kind of fun – and the creation of such a strategy for your qualitative research project is a really good thought exercise, helping you plan and later acknowledge shortcomings in what actually happened. Essentially, think of this process as how you will market and advertise your research project to potential participants.

Sometimes there is a shifting dynamic between sampling and recruitment. Say we are doing random sampling from numbers in a phone book, a classic ‘random’ technique. The sampling process is the selection of x number of phone numbers to call. The recruitment is the actually calling and asking someone to take part in the research. Now, obviously not everyone is going to answer the phone, or want to answer any questions. So you then have a list of recruited people, which you might actually want to sample from again to make a representative sample. If you found out everyone that answered the phone was retired and over 60, but you wanted a wider age profile, you will need to refactor from your recruited sample.

But let’s think about this again. Why could it be that everyone who consented to take part in our study was retired? Well, we used numbers from the phone book, and called during the day. What effect might this have? Numbers in the phone book tend to be people who have been resident in one place for a long time, many students and young people just have mobiles, and if we call during the day, we will not get answers from most people who work. This illustrates the importance of carefully considering the recruitment strategy: although we chose a good random sampling technique, our strategy of making phone calls during the day has already scuppered our plans.

How about another example: recruitment through a poster advertising the study. Many qualitative studies aren’t looking for very large number of respondents, but are targeting a very specific sample. In this example, maybe it’s people who have visited their doctor in the last 6 months. Sounds like a poster in the waiting room of the local GP surgery would work well. What are the obvious limitations here?

First of all, people who see the poster will probably have visited the GP (since they are in that location), however, it actually only would recruit people who are currently receiving treatment. People who had been in the previous 6 months but didn’t need to go back again, or had such a horrible experience they never returned, will not see our poster and don’t have a chance to be recruited. Both of these will skew the sample of respondents in different ways.

In some ways this is inevitable. Whichever sampling technique and recruitment strategy we adopt, some people will not hear about the study or want to take part. However, it is important to be conscious of not just who is being sampled, but who is left out, and the likely effect this has on our sample and consequently our findings. For example our approach here probably means we oversample people who have chronic conditions requiring frequent treatment, and undersample people who hate their doctor. It’s not necessarily a disaster, but just like making a reflexivity statement about our own biases, we must be forthright about the sampling limitations and consider them when analysing and writing conclusions.

For these reasons, it’s often desirable to have multiple and complementary recruitment strategies, so that one makes up for deficiencies in the other. So a poster in the waiting room is great, but maybe we can get a list of everyone registered at the surgery, so we can also contact people not currently seeking treatment. This would be wonderful, but in the real world, we might hit problems with the surgery not being interested in the study, not able to release that information for confidentiality reasons, and the huge extra time such a process would require.

That’s why I see a recruitment strategy as a practical battle plan that tries to consider the limitations and realities of engaging with the real world. You can also start considering seemingly small things that can have a huge impact on successful recruitment:

• The design of the poster • The wording of invitation letters • The time of day you make contact (not just by phone, but don’t e-mail first thing on a Monday morning!) • Any incentives, and how appropriate they are • Data protection issues • Winning the support of ‘gatekeepers’ who control access to your sample • Timescales • Cost (especially if you are printing hundreds of letters of flyers) • Time and effort required to find each respondent • And many more…

For a more detailed discussion, there’s a great article by Newington and Metcalfe (2014) specifically on influencing factors for recruitment in qualitative research.

Finally, I want to reiterate the importance of trying to record who has not been recruited and why. If you are directly contacting a few dozen respondents by phone or e-mail, this is easy to keep track of: you know exactly who has declined or not responded, likely reasons why and probably some demographic details.

However, think about the poster example. Here, we will be lucky if 1% of people that come through the surgery contact us to take part in the study. Think through these classic marketing stages: they have to see the poster, think it’s relevant to them, want to engage, and then reach out to contact you. There will be huge losses at each of those stages, and you don’t know who these people are or why they didn’t take part. This makes it very difficult in this kind of study to know the bias of your final sample: we can guess (busy people, those who aren’t interested in research) but we don’t know for sure.

Response rates vary greatly by method: by post 25% is really good, direct contact much higher, posters and flyers below 10%. However, you can improve these rates with careful planning, by considering carefully who will engage and why, and making it a good prospect to take part: describe the aims of the research, compensate time, and explain the proposed benefits. But you also need to take an ethical approach, don’t coerce, and make promises you can’t keep. Check out the recruitment guidelines drawn up by the Association for Qualitative Research.

My personal experience tells me that most people who engage with qualitative research are lovely! They want to help if they can, and love an opportunity to talk about themselves and have their voice heard. Just be aware of what kinds of people end up being your respondents, and make sure you acknowledge the possibility of hidden voices from people who don’t engage for their own reasons.

Once you get to your analysis, don't forget to try Quirkos for free , and see how our easy-to-use software can make a real qualitative difference to your research project! To keep up to date with new blog articles on this, and other qualitative research topics, follow our Twitter feed: twitter.com/quirkossoftware .

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Methodology

• What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

Published on June 19, 2020 by Pritha Bhandari . Revised on June 22, 2023.

Qualitative research involves collecting and analyzing non-numerical data (e.g., text, video, or audio) to understand concepts, opinions, or experiences. It can be used to gather in-depth insights into a problem or generate new ideas for research.

Qualitative research is the opposite of quantitative research , which involves collecting and analyzing numerical data for statistical analysis.

Qualitative research is commonly used in the humanities and social sciences, in subjects such as anthropology, sociology, education, health sciences, history, etc.

• How does social media shape body image in teenagers?
• How do children and adults interpret healthy eating in the UK?
• What factors influence employee retention in a large organization?
• How is anxiety experienced around the world?
• How can teachers integrate social issues into science curriculums?

Table of contents

Approaches to qualitative research, qualitative research methods, qualitative data analysis, advantages of qualitative research, disadvantages of qualitative research, other interesting articles, frequently asked questions about qualitative research.

Qualitative research is used to understand how people experience the world. While there are many approaches to qualitative research, they tend to be flexible and focus on retaining rich meaning when interpreting data.

Common approaches include grounded theory, ethnography , action research , phenomenological research, and narrative research. They share some similarities, but emphasize different aims and perspectives.

Note that qualitative research is at risk for certain research biases including the Hawthorne effect , observer bias , recall bias , and social desirability bias . While not always totally avoidable, awareness of potential biases as you collect and analyze your data can prevent them from impacting your work too much.

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Each of the research approaches involve using one or more data collection methods . These are some of the most common qualitative methods:

• Observations: recording what you have seen, heard, or encountered in detailed field notes.
• Interviews:  personally asking people questions in one-on-one conversations.
• Focus groups: asking questions and generating discussion among a group of people.
• Surveys : distributing questionnaires with open-ended questions.
• Secondary research: collecting existing data in the form of texts, images, audio or video recordings, etc.
• You take field notes with observations and reflect on your own experiences of the company culture.
• You distribute open-ended surveys to employees across all the company’s offices by email to find out if the culture varies across locations.
• You conduct in-depth interviews with employees in your office to learn about their experiences and perspectives in greater detail.

Qualitative researchers often consider themselves “instruments” in research because all observations, interpretations and analyses are filtered through their own personal lens.

For this reason, when writing up your methodology for qualitative research, it’s important to reflect on your approach and to thoroughly explain the choices you made in collecting and analyzing the data.

Qualitative data can take the form of texts, photos, videos and audio. For example, you might be working with interview transcripts, survey responses, fieldnotes, or recordings from natural settings.

Most types of qualitative data analysis share the same five steps:

• Prepare and organize your data. This may mean transcribing interviews or typing up fieldnotes.
• Review and explore your data. Examine the data for patterns or repeated ideas that emerge.
• Develop a data coding system. Based on your initial ideas, establish a set of codes that you can apply to categorize your data.
• Assign codes to the data. For example, in qualitative survey analysis, this may mean going through each participant’s responses and tagging them with codes in a spreadsheet. As you go through your data, you can create new codes to add to your system if necessary.
• Identify recurring themes. Link codes together into cohesive, overarching themes.

There are several specific approaches to analyzing qualitative data. Although these methods share similar processes, they emphasize different concepts.

Qualitative research often tries to preserve the voice and perspective of participants and can be adjusted as new research questions arise. Qualitative research is good for:

• Flexibility

The data collection and analysis process can be adapted as new ideas or patterns emerge. They are not rigidly decided beforehand.

• Natural settings

Data collection occurs in real-world contexts or in naturalistic ways.

• Meaningful insights

Detailed descriptions of people’s experiences, feelings and perceptions can be used in designing, testing or improving systems or products.

• Generation of new ideas

Open-ended responses mean that researchers can uncover novel problems or opportunities that they wouldn’t have thought of otherwise.

Prevent plagiarism. Run a free check.

Researchers must consider practical and theoretical limitations in analyzing and interpreting their data. Qualitative research suffers from:

• Unreliability

The real-world setting often makes qualitative research unreliable because of uncontrolled factors that affect the data.

• Subjectivity

Due to the researcher’s primary role in analyzing and interpreting data, qualitative research cannot be replicated . The researcher decides what is important and what is irrelevant in data analysis, so interpretations of the same data can vary greatly.

• Limited generalizability

Small samples are often used to gather detailed data about specific contexts. Despite rigorous analysis procedures, it is difficult to draw generalizable conclusions because the data may be biased and unrepresentative of the wider population .

• Labor-intensive

Although software can be used to manage and record large amounts of text, data analysis often has to be checked or performed manually.

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

• Chi square goodness of fit test
• Degrees of freedom
• Null hypothesis
• Discourse analysis
• Control groups
• Mixed methods research
• Non-probability sampling
• Quantitative research
• Inclusion and exclusion criteria

Research bias

• Rosenthal effect
• Implicit bias
• Cognitive bias
• Selection bias
• Negativity bias
• Status quo bias

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

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

There are five common approaches to qualitative research :

• Grounded theory involves collecting data in order to develop new theories.
• Ethnography involves immersing yourself in a group or organization to understand its culture.
• Narrative research involves interpreting stories to understand how people make sense of their experiences and perceptions.
• Phenomenological research involves investigating phenomena through people’s lived experiences.
• Action research links theory and practice in several cycles to drive innovative changes.

Data collection is the systematic process by which observations or measurements are gathered in research. It is used in many different contexts by academics, governments, businesses, and other organizations.

There are various approaches to qualitative data analysis , but they all share five steps in common:

• Prepare and organize your data.
• Review and explore your data.
• Develop a data coding system.
• Assign codes to the data.
• Identify recurring themes.

The specifics of each step depend on the focus of the analysis. Some common approaches include textual analysis , thematic analysis , and discourse analysis .

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• Study Protocol
• Open access
• Published: 08 August 2024

Study protocol: a mixed-methods study of the implementation of doula care to address racial health equity in six state Medicaid programs

• Marian Jarlenski 1 , 2 ,
• Susan Kennedy 3 ,
• Annaliese Johnson 3 ,
• Caroline Hale 3 ,
• Zoe D’Angelo 3 ,
• Aza Nedhari 4 ,
• Gerria Coffee 5 , 6 ,
• Molly Chappell-McPhail 7 ,
• Kiddada Green 8 ,
• Dara D. Méndez 9 , 10 ,
• Leigh G. Goetschius 11 ,
• Sarah Gareau 12 ,
• Kristin Ashford 13 ,
• Andrew J. Barnes 14 ,
• Katherine A. Ahrens 15 ,
• Kara Zivin 16 ,
• Elizabeth Mosley 2 ,
• Lu Tang 17 &

Writing Committee for Medicaid Outcomes Distributed Research Network

Health Research Policy and Systems volume  22 , Article number:  98 ( 2024 ) Cite this article

90 Accesses

Metrics details

Racial inequities in severe maternal morbidity (SMM) and mortality constitute a public health crisis in the United States. Doula care, defined as care from birth workers who provide culturally appropriate, non-clinical support during pregnancy and postpartum, has been proposed as an intervention to help disrupt obstetric racism as a driver of adverse pregnancy outcomes in Black and other birthing persons of colour. Many state Medicaid programs are implementing doula programs to address the continued increase in SMM and mortality. Medicaid programs are poised to play a major role in addressing the needs of these populations with the goal of closing the racial gaps in SMM and mortality. This study will investigate the most effective ways that Medicaid programs can implement doula care to improve racial health equity.

We describe the protocol for a mixed-methods study to understand how variation in implementation of doula programs in Medicaid may affect racial equity in pregnancy and postpartum health. Primary study outcomes include SMM, person-reported measures of respectful obstetric care, and receipt of evidence-based care for chronic conditions that are the primary causes of postpartum mortality (cardiovascular, mental health, and substance use conditions). Our research team includes doulas, university-based investigators, and Medicaid participants from six sites (Kentucky, Maryland, Michigan, Pennsylvania, South Carolina and Virginia) in the Medicaid Outcomes Distributed Research Network (MODRN). Study data will include policy analysis of doula program implementation, longitudinal data from a cohort of doulas, cross-sectional data from Medicaid beneficiaries, and Medicaid healthcare administrative data. Qualitative analysis will examine doula and beneficiary experiences with healthcare systems and Medicaid policies. Quantitative analyses (stratified by race groups) will use matching techniques to estimate the impact of using doula care on postpartum health outcomes, and will use time-series analyses to estimate the average treatment effect of doula programs on population postpartum health outcomes.

Findings will facilitate learning opportunities among Medicaid programs, doulas and Medicaid beneficiaries. Ultimately, we seek to understand the implementation and integration of doula care programs into Medicaid and how these processes may affect racial health equity.

Study registration The study is registered with the Open Science Foundation ( https://doi.org/10.17605/OSF.IO/NXZUF ).

Peer Review reports

Racial inequities in severe maternal morbidity (SMM) and mortality continue to increase and constitute a national public health crisis [ 1 , 2 , 3 ]. Maternal mortality in the United States far exceeds that of comparable high-resource nations [ 4 ], and Black persons have approximately a threefold higher rate of pregnancy-related mortality compared to white persons. Rates of severe maternal morbidity (SMM), which encompasses life-threatening conditions during pregnancy and postpartum, have increased by nearly 200% in the past 20 years, [ 2 , 3 , 5 , 6 ] and significant racial inequities exist in SMM [ 1 , 7 , 8 , 9 ].

Medicaid programs pay for 42% of all pregnancy care in the United States, including 68% of pregnancy care among Black persons [ 10 ]. Social and structural factors drive racial inequities in SMM and mortality, including the policies and decisions that drive medical racism [ 11 , 12 , 13 ]. Therefore, Medicaid programs have great potential to implement structural interventions to advance racial equity in healthcare and health outcomes during pregnancy and postpartum [ 14 , 15 , 16 ]. Currently, state Medicaid programs take various approaches to implement doula care in terms of the generosity of the doula benefit and the centring of racial health equity as part of the doula policy [ 17 , 18 ]. Doulas who provide care in the pregnancy and postpartum periods can identify as community-based doulas or full-spectrum (i.e. provide care throughout all pregnancy-related services). A doula is a trained birth worker who provides non-clinical and culturally relevant supports to a person through a health-related experience such as pregnancy and childbirth [ 19 ]. This can include emotional, physical and informational support and companionship during pregnancy, delivery and postpartum. Past research has shown that doula services can improve healthcare experiences and health by serving as an advocate on how healthcare systems can best serve birthing persons in a way that works for them [ 20 , 21 ]. Doula care may disrupt the multiple forms of racism that people experience during pregnancy and postpartum, not only in the healthcare setting [ 17 ]. Their work is critical in ensuring evidence-based practice that typically centres white populations is coupled with equitable practices.

Research suggests that doula care programs improve delivery outcomes and birth experiences. A recent Cochrane systematic review of 26 trials in 17 countries found that doula support led to a 25% reduced risk of Caesarean-section delivery, and a 30% reduced risk of individuals reporting negative feelings about their birth experience [ 22 ]. Studies from the Minnesota, California and Florida Medicaid programs estimated a 41–53% reduced risk of Caesarean section among birthing persons who received doula services, relative to those who did not [ 23 , 24 ]. Caesarean section may serve as an important proxy for adverse outcomes because it contributes, via the risk of severe obstetric complications [ 25 ], to 37% of cases of SMM [ 26 ]. Further, an evaluation of a New York City program to connect Black and other persons of colour with doula services found that access to doula care significantly reduced the risk of preterm birth – from 12.4% to 6.3% [ 27 ]. Prior work suggests that Medicaid’s adoption of doula care programs could help improve pregnancy and postpartum health outcomes, particularly if Black, Indigenous and persons of colour (BlPOC) communities can access doula programs [ 28 , 29 , 30 ].

This project will support doula research for equitable advances in Medicaid pregnancy health (Project DREAM). Project DREAM will add to knowledge about the role of Medicaid doula benefits in addressing racial equity in pregnancy and postpartum outcomes by assessing variation in the implementation of doula programs in six diverse states and investigating the extent to which doula care programs improve SMM and other outcomes for BIPOC birthing populations.

Study design

We will conduct a non-randomized mixed-methods intervention evaluation study to support doula research for equitable advances in Medicaid pregnancy health (Project DREAM) by assessing the implementation and effectiveness of Medicaid doula care programs on racial equity in postpartum healthcare quality and health outcomes in six US states. The study aims to compare differences in beneficiary experiences, postpartum treatment for chronic conditions (cardiovascular and mental health and substance use disorders) and risk of SMM postpartum among Medicaid beneficiaries who receive doula services, relative to beneficiaries who receive standard care. We focus on Black and BIPOC populations and we will also assess differences in outcomes by race group. Our project draws on the infrastructure of the Medicaid Outcome Distributed Research Network (MODRN), which provides a process to develop consensus-based study designs across sites and to conduct standardized data collection and analyses [ 31 ].

WCG IRB approved this study, effective 6 November 2023. We registered the study with the Open Science Foundation ( https://doi.org/ https://doi.org/10.17605/OSF.IO/NXZUF ).

Conceptual framework

We propose to study how Medicaid implementation of doula programs (including variation in how or whether Medicaid benefits are centring BIPOC populations) affects postpartum health. As part of this project, we recognize the range of expertise that is needed to address these research objectives. As such, our study includes community-based doula and university-based research partners. To additionally inform and contextualize research findings, our study’s advisory board includes Medicaid participants, doula organization partners, Medicaid clinical leaders and researchers.

Our analytical conceptual model draws on the integrated-Promoting Action on Research Implementation in Health Services (iPARIHS) Implementation Science Framework [ 32 ]. The iPARIHS framework conceptualizes the successful implementation of an intervention as the dynamic interaction of multiple actors within a system affected by their broader context and culture. Four key constructs measure the translation of knowledge to practice [ 33 , 34 ]. Innovation (i.e. adapting doula care interventions across different states), contributors (i.e. doulas, Medicaid administrators, beneficiaries), context (i.e. culture and baseline practices within a healthcare system or Medicaid program) and facilitation (i.e. the process by which doula care is implemented in practice) (See Fig.  1 ).

Conceptual framework for the study of doula care to advance racial equity in postpartum health. We hypothesize that upstream factors related to program implementation will affect experiences of care. These intermediate healthcare outcomes will subsequently impact our primary outcome of severe maternal morbidity

We will assess contributors’ perspectives (doulas, beneficiaries) regarding access to doula care and healthcare experiences during the postpartum period. We will examine the context in terms of state-level barriers and facilitators to doula care and person-reported experiences of discrimination and medical racism. Findings will facilitate cross-state learning opportunities among Medicaid programs, doulas and Medicaid beneficiaries about best practices in how to implement doula programs in a sustainable way. Ultimately, we seek to understand the implementation and integration of doula care programs into Medicaid and how these processes may affect racial equity in healthcare quality and outcomes.

Settings and participants

We selected six state Medicaid programs in various stages of implementing doula care programs (Table  1 ). Within each state, we will collect data from doulas andMedicaid beneficiaries, and we will use administrative healthcare data from the Medicaid programs. Figure  2 provides an overview of the study timing, recruitment and retention of subjects and analysis of healthcare data.

Logic model of recruitment and retention of study subjects and analysis of Medicaid healthcare data. Doulas and Medicaid beneficiaries will be recruited into the study. Medicaid administrative healthcare data will be used to study the outcome of severe maternal morbidity

Doula organization research partners will assist with recruiting at least 10 doulas within each of the 6 states ( N  = 60) to participate in qualitative focus groups and surveys to understand the experiences of doulas with Medicaid participation. Specific implementation domains covered in the interviews will include: adequacy of reimbursement, facilitators and barriers to participating in Medicaid managed care organization networks, integration with hospitals or healthcare systems, experiences working with Medicaid beneficiaries and perceptions of how doula services may affect BIPOC persons, specifically by disrupting obstetric racism. Baseline focus groups will occur in year 1, with follow-up in years 3 and 5 of the project to track changes over time. To advance diversity and inclusion in our study, we will purposively sample doulas from rural and urban areas, including BIPOC doulas and those who serve populations who primarily speak languages other than English. The goal of our focus groups among doulas is not to provide a representative sample, but to provide in-depth information on doulas’ experiences. The rigour of qualitative research is judged on the basis of transferability, not generalizability – that is, the extent to which our qualitative results transfer to or fit other similar communities and contexts.The focus group facilitators have expertise working cross-culturally to create communication models to ensure that participants can share meaningful insights that are communicated into research findings. The sample will be purposively designed with theoretical diversity to ensure the results are transferable to other doulas serving Medicaid community members.

Medicaid study participants

We will recruit at least 50 Medicaid beneficiaries per state in each of years 2 and 4 (300 in each year for a total of 600 participants) who have had a delivery and received doula care in the 6 months prior to participating in surveys and focus groups. Medicaid participants will complete brief surveys including demographic questionnaires, instruments to measure medical autonomy and everyday discrimination scales. Focus groups will facilitate group discussion of their births and postpartum periods, the experiences of doula care, and perceptions about how doula services may have affected their experiences in medical care. We will collect cross-sectional data from two different samples of Medicaid beneficiaries in years 2 and 4 of the project. Consistent with our study’s goals of understanding how doula benefits may address obstetric racism, we will purposively sample Medicaid beneficiaries from a range of geographic areas and will oversample BIPOC Medicaid beneficiaries.

Administrative healthcare data

SMM occurs in an estimated 1–2% of delivery hospitalizations and requires a large population to detect clinically meaningful changes due to interventions. We will collect information on person-level clinical outcomes from Medicaid administrative healthcare data and will not recruit individuals for the healthcare-related component of this study. The Medicaid healthcare data will include an estimated 237 700 Black persons across all six states with a delivery, and an estimated 577 300 persons of other races with a delivery, between 2022 and 2025 inclusive. From this comprehensive dataset, we will study the subset of those who use doula services (anticipated N  = 15 000 BIPOC and N  = 25 000 not BIPOC) compared with a propensity-matched cohort of those who do not use doula services (anticipated N  = 40 000). Each participating site has converted its Medicaid healthcare data files to a MODRN Common Data Model so the data have a consistent structure, list of variables and variable formats across states, including comparable variables on Medicaid eligibility categories. This facilitates efficient analyses and comparable results using state-specific data. The MODRN common data model includes a census of inpatient, outpatient, professional and pharmaceutical services billed to the Medicaid program for all enrolled individuals. A distributed research network (DRN) includes multiple organizations using a common data model to support centralized development of analytic plans with local execution of analyses [ 35 , 36 , 37 , 38 , 39 , 40 ].

Study outcomes

Table 2 includes details about primary and secondary outcomes measurement and related statistical power considerations.

Our primary outcomes include SMM, person-reported measures of respectful obstetric care and evidence-based postpartum care for chronic conditions. SMM will be defined on the basis of a modified version of the Centers for Disease Control and Prevention (CDC) algorithm, which includes 21 indicators of life-threatening adverse events or medical interventions related to such events [ 26 ]. We will measure non-fatal SMM (with and without blood transfusion) in inpatient records at delivery, from delivery through 42 days and through 365 days postpartum, including intensive care unit (ICU) admission in the definition of SMM. We will measure SMM with and without evidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, as this disorder contributed to SMM and mortality during the study period [ 49 ]. We will assess wellbeing related to person-reported experiences in maternity care settings, using the validated Mothers Autonomy in Decision-Making scale [ 41 ] and Mothers On Respect index [ 42 ], which include items related to equitable, respectful care. These scales have been shown to be reliable and have been validated via community-engaged research processes. Importantly, both scales demonstrate the ability to measure person-driven priorities in the context of obstetric care. Third, we will assess healthcare utilization (outpatient visits and medication use) related to the management of chronic conditions during 7–365 days after delivery. Specifically, we will focus on the management of hypertension, mental health conditions and substance use disorders as these conditions represent primary causes of postpartum pregnancy-associated mortality [ 50 , 51 ].

Secondary outcomes include participant experiences of discrimination or medical racism and all-cause mortality. We will use the Everyday Discrimination Scale [ 52 ], which has been validated and in use for 20 years to date [ 53 , 54 ], to assess Medicaid beneficiaries’ experiences of racial or socioeconomic discrimination. The scale assesses the perception of and frequency of interpersonal discrimination. To investigate more qualitatively, we will also assess experiences of racism in the medical system via conducting qualitative focus groups with Medicaid beneficiaries. Finally, the number of maternal deaths per 100 000 births from delivery through 365 days postpartum, stratified by race and whether the decedent used doula services, will be assessed. We will not apply statistical analyses to this outcome, given the anticipated low number of cases of mortality.

Implementation data

To track implementation of specific elements of doula programs, we will collect documents that reflect implementation of Medicaid doula programs from state Medicaid agencies, other state regulatory bodies, Medicaid managed care plans, healthcare systems and doula and other healthcare provider organizations. At the end of each project year, we will prepare a report to share with partners for input and for them to check the accuracy of our implementation information. The final implementation matrix will quantify certain implementation domains (e.g. reimbursement amount is a quantitative variable), and it will also include qualitative data (e.g. anecdotes from partners pertaining to successful strategies to centre BIPOC populations).

Qualitative analyses

For our focus group data, we will transcribe interview audio recordings verbatim and transcripts spot-checked against the audio recordings for accuracy. Then, we will delete audio files to protect participants’ confidentiality. We will analyse and report qualitative data using the Consolidated criteria for Reporting Qualitative Research (COREQ) Framework [ 55 ]. To analyse data, we will use template analysis, which combines features of deductive content analysis and inductive grounded theory, thereby allowing us to obtain specific information on participant perspectives while also capturing any new or unanticipated themes [ 56 ]. Two coders will separately code the first three interview transcripts, meet to compare codes, discuss inconsistencies in coding approaches and then alter or add codes. They will repeat this process for the next three items. After this, the coders will meet with the full study team to discuss the coding scheme and a coding rulebook that provides definitions, rules and examples for each code. We will repeat this iterative process until we fully develop the coding scheme. The coders will independently code all transcripts and resolve any coding discrepancies via discussion. Once coding is complete, synthesis of content will begin by organizing codes under broader domains (meta-codes) as well as sub-codes. Reported results will include descriptive statistics of the characteristics of participants, such as demographics. The primary analysis will be to convey qualitative data, including the use of illustrative quotes.

Quantitative analyses

First, we will evaluate the extent to which doula care facilitates equity in the quality of postpartum care, postpartum treatment for chronic conditions (cardiovascular and mental health and substance use disorders) and experiences of postpartum care. We will generate propensity scores to match Medicaid beneficiaries who used doula services to those who did not [ 57 ]. We anticipate a sample of 15 000 BIPOC beneficiaries and 25 000 non-BIPOC beneficiaries who used doula services, and a matched cohort of 40 000 beneficiaries of all races who did not use doula services. Propensity score matching should allow us to achieve balance on the observed covariates (and unobserved covariates that are correlated with those observed) between beneficiaries who do and do not access doula services, ensuring comparable groups [ 58 , 59 , 60 ]. We will conduct analyses of baseline data to assess whether the matching technique achieves balance, and we can adjust to alternative techniques (e.g. weighting approaches) if needed. State-specific generalized regression models (we will base the choice of model on the distribution of the outcome) will incorporate matched data and will examine differences in outcomes between BIPOC beneficiaries who do and do not use doula services, and between BIPOC and white beneficiaries who use doula services. Because this matched analysis cannot rule out potential unmeasured confounding in cases where confounders are not associated with observable characteristics in administrative data, we will conduct sensitivity analyses for unmeasured confounding in meta-analyses [ 61 ].

Second, we will estimate the effects of state Medicaid doula care programs on racial equity in SMM. To estimate the effects of the Medicaid doula care programs, we will use a quasi-experimental approach that takes advantage of the variation in the timing of states’ adoption of doula programs, as well as variation in factors that facilitate doula access, such as reimbursement rates. We will use a comparative interrupted time series (ITS) analysis with the interventions of interest implemented at different times [ 62 ]. We will include Medicaid beneficiaries of all races who have a delivery in the six states of interest (anticipated N  = 815 000 all beneficiaries; anticipated N  = 237 700 BIPOC beneficiaries). On the basis of our implementation matrix, we will construct time-varying exposure measures of implementation of doula programs in Medicaid, including reimbursement rates, integration of doulas into healthcare systems and Medicaid beneficiaries’ levels of access to doulas. Using this measure, we will compare trends in outcomes in states with different implementation of doula programs over multiple time points to identify changes in outcomes over time. We will use log linear or Poisson regression models to test for significant effects of doula program implementation on changes in the SMM rate within each race/ethnic group, with number of births (population at risk) as an offset variable to account for the differences in the denominator of SMM rate across state and year [ 63 ]. We will extend the models to include an interaction term between the doula program implementation strength and the proportion of BIPOC Medicaid beneficiaries. The models will use autoregressive error to account for non-independence of repeated measures. We will use the quasi likelihood information criteria to assess goodness-of-fit of our regression models [ 64 ].

Limitations

This research has limitations. First, we cannot randomly assign participants to receive doula care, and thus rely on an observational study design. Although random assignment to treatment has historically represented the gold standard for understanding causal effects, we will use rigorous longitudinal analyses for understanding the causal impacts of interventions in the real world [ 65 ]. Second, our study includes six states, whereas other state Medicaid programs outside of our study have also implemented doula programs. Results from our study, therefore, may not generalize to other states with different implementation strategies. Third, for the evaluation of SMM, which requires large population-level data, we rely on administrative healthcare data that were not designed for research but for Medicaid programmatic and payment purposes. To minimize potential measurement bias from these types of administrative data, our team will use validated measures to the greatest extent possible and will consider multiple sensitivity analyses for the measurement of SMM. Finally, our evaluation of doula services should be interpreted in the context of state development of the Medicaid benefit, with some states having more experience implementing doula care than other states.

This research will contribute evidence on how Medicaid doula care programs can improve racial equity in SMM among Medicaid populations by disrupting medical racism and facilitating evidence-based care and improved care experiences. Specifically, this research project will: (1) provide ongoing information on the landscape of how implementation of doula programs evolves in six state Medicaid programs; (2) elucidate the experiences of doulas and Medicaid beneficiaries in these states; (3) highlight perspectives of the experiences of BIPOC Medicaid beneficiaries; and (4) generate quantitative estimates from Medicaid healthcare data on doula programs’ effects on health equity.

A vast body of research describes the persistent inequities within the healthcare system’s delivery of quality obstetric care to Black persons and other persons of colour relative to white persons. Medicaid enrollees have reported difficulty in accessing obstetric care, difficulty in receiving requested help with their health and experience racial and socioeconomic biases in care [ 66 ]. Many Medicaid programs have implemented doula care programs to stem SMM and mortality trends that disproportionately affect Black and other persons of colour. However, due to the federalist structure, which offers states flexibility in Medicaid program operations, there are significant variations in state doula care models (e.g, centring of racial equity, access to care, reimbursement rates) with limited evidence on which model components and implementation approaches bare the greatest impact [ 17 , 67 , 68 ].

Therefore, by making three primary innovations in the field, our mixed methods research will address doula care program decisions and birthing persons’ decision-making on healthcare system navigation. Project DREAM represents one of the first multi-state studies of doula care interventions and racial equity in Medicaid populations, addressing the limitations in prior evidence largely restricted to white and middle-class populations. Second, it aims to capture community and lived-experience perspectives through community-engaged research by including both doula organizations, which have explicit goals of Black racial equity, and Medicaid enrollees who have used doula care as our research partners. Third, it incorporates the research infrastructure of MODRN, a well-established collaboration between university researchers and state Medicaid agencies, to facilitate the analysis of Medicaid healthcare data to identify postpartum treatment for chronic conditions commonly associated with SMM and mortality [ 31 ].

Findings from our research will directly inform best practices to implement doula care programs in Medicaid in ways that will ensure that such care is accessible and relevant to the populations who can benefit most. Multiple stakeholders can use these as well as whether these programs are poised to specially promote racial equity. These findings to build a supportive system for high-quality postpartum care, including Medicaid administrators actively engaged in initiatives aimed to address pregnancy health outcomes [ 10 ], doula birth providers who want to understand the best way to participate in Medicaid to serve BIPOC communities and pregnant persons who seek the best quality of care and a positive and supportive postpartum experience.

Availability data and materials

When study data collection is complete, de-identified data from focus groups and interviews will be available from the authors upon reasonable request. The Medicaid administrative healthcare data for the study will be used under data use agreements with individual state Medicaid agencies are therefore are not publicly available.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

Black, Indigenous and persons of colour

Medicaid Outcomes Distributed Research Network

Severe maternal morbidity

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Acknowledgements

We gratefully acknowledge research assistance from Sabnum Pudasainy, MS. This work was made possible by the establishment of the MODRN. The authors appreciate the contributions of the MODRN Founding Members, the Academy Health State University Partnership Learning Network, and the Medicaid Medical Directors Network.

This research is funded by the Patient-Centered Outcomes Research Institute under award #MMM-2022C2-28218. The funder had no role in the study design, data collection, data analysis, data interpretation, writing of this report or decision to publish it.

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Marian Jarlenski & Elizabeth Mosley

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Study conception and/or design: Jarlenski, Kennedy, Ahrens, Zivin, Clark, Barnes, Tang, Goetschius, Ashford and Gareau; acquisition, analysis and interpretation of data: Tang, Jarlenski, Mosley, Mendez and Kennedy; drafting or significantly revision of the manuscript: all authors; approval of the manuscript submission: all authors; and agreement to be personally responsibility for author’s own contributions: All authors.

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Jarlenski, M., Kennedy, S., Johnson, A. et al. Study protocol: a mixed-methods study of the implementation of doula care to address racial health equity in six state Medicaid programs. Health Res Policy Sys 22 , 98 (2024). https://doi.org/10.1186/s12961-024-01185-9

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Healthcare staff experiences on the impact of COVID-19 on emergency departments: a qualitative study

• Ahmet Butun   ORCID: orcid.org/0000-0002-6856-9389 1  

BMC Health Services Research volume  24 , Article number:  921 ( 2024 ) Cite this article

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The COVID-19 pandemic has had a major impact on the access and delivery of healthcare services, posing unprecedented challenges to healthcare staff worldwide. Frontline healthcare staff faced unique stressors and challenges that impact their well-being and patient care. This qualitative study aimed to explore the experiences and perspectives of frontline ED healthcare staff on emergency care services during the COVID-19 pandemic, providing valuable insights into the challenges, adaptations, and lessons learned in delivering emergency care.

This study utilized a qualitative approach. In-depth semi-structured interviews were conducted with 30 ED healthcare staff from three different hospitals located in Turkey between 15/03/2022 and 30/04/2022. Convenience sampling was used to recruit participants. The duration of the interviews ranged from 28 to 37 min. Data saturation was reached as no new information was gathered. The data were analyzed using the thematic analysis method. NVivo software was used to manage the data analysis process. Member check was carried out to ensure that the generated themes conformed to the participants’ views.

15 sub-themes under three themes emerged: (1) the impact of COVID-19 on emergency care services, including sub-themes of “introducing a COVID-19 unit in the ED”, “changes in the routine functioning of EDs”, “changes in the number of ED visits”, “quality of care”, “resources”, and “increased workload”; (2) the psychological effects of COVID-19 on ED healthcare staff, including sub-themes of “staying away from family”, “fear”, “society’s perspective on healthcare professionals”, “morale-staff burnout”, “psychological and emotional effects”, and “unable to receive sufficient support”; and (3) the difficulties faced by ED healthcare staff, including sub-themes of “difficult working conditions”, “community-based effects difficulties”, and “COVID-19 is an unknown situation”.

Staff burnout threatens the quality of patient care and staff retention, and therefore this should be addressed by ED directors and leaders. This study could inform appropriate stakeholders regarding lessons learned from COVID-19 to better manage future pandemics. Learning from such lived experiences and developing appropriate interventions to minimize the difficulties faced during COVID-19 would allow better management of future pandemics. This study calls for a reform to address the challenges faced by healthcare staff, improve the overall response to public health crises, and enhance the resilience of healthcare systems for future crises.

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The COVID-19 pandemic has had a major impact on the access and delivery of healthcare services, posing unprecedented challenges to healthcare staff worldwide. The COVID-19 pandemic caused a high mortality rate and disruption to healthcare and social care around the world [ 1 , 2 ]. The pandemic has required the reconfiguration of health services to ensure the maintenance of essential health services [ 3 ]. The COVID-19 pandemic also caused delays in seeking care due to the fear of infection [ 4 ]. Delaying care may increase morbidity and mortality in non-COVID-19 patients [ 2 , 5 ]. The first COVID-19 case was identified on 11 March 2020 in Turkey. Around 35 million people were tested, around 2.9 million patients were diagnosed with COVID-19, around 30.000 patients were died within 1 year of starting of the pandemic, between 11 March 2020 and 11 March 2021 [ 6 ].

Emergency Departments (EDs) healthcare staff face an enormous mental burden and physical exertion when caring for patients potentially infected with COVID-19. Frontline healthcare staff face unique stressors and challenges that impact their well-being and patient care [ 7 , 8 ]. ED healthcare staff were deeply impacted by COVID-19, and they are at a high risk of burnout due to COVID-19 [ 9 , 10 ]. However, the COVID-19 pandemic has underscored the need for qualitative research to understand the experiences and perceptions of healthcare staff, as well as the use of healthcare services during this unprecedented health emergency [ 11 , 12 , 13 ]. Therefore, exploring the experiences of ED healthcare staff throughout the COVID-19 pandemic will provide a comprehensive understanding of their unique experiences and challenges.

In addition, studies showed that EDs in low-income and middle-income countries are likely to be impacted more significantly by the effects of the COVID-19 pandemic than those in high-income countries [ 9 , 14 , 15 ]. Thus, studying how the COVID-19 pandemic affects emergency care services in the context of a middle-income country (Turkey) is needed. This study focused on the impact of the COVID-19 pandemic on the general working conditions of the emergency care system, including ED services, ED healthcare staff, and ED patients in addition to its impact on general healthcare system. This qualitative study aims to explore the experiences and perspectives of frontline ED healthcare staff on emergency care services during the COVID-19 pandemic, providing valuable insights into the challenges, adaptations, and lessons learned in delivering emergency care.

Study design

This study utilized a qualitative exploratory descriptive approach as this allows to explore, describe, and a deep understanding of ED healthcare staff experiences during the COVID-19 pandemic.

Participants and settings

Participants were ED healthcare staff including ED nurses ( n  = 20), ED physicians ( n  = 8), and ED consultants ( n  = 2) from 3 different hospitals located in Turkey, namely, Mardin Training and Research Hospital ( n  = 21), Midyat Public Hospital ( n  = 6), and Kiziltepe Public Hospital ( n  = 3). Six healthcare staff refused to participate in this study. Mardin Training and Research Hospital is a public and tertiary hospital with a 700-bed capacity and around 150 ED healthcare staff. Midyat Public Hospital and Kiziltepe Public Hospital are public hospitals with 150-bed and 300-bed capacity, respectively. Convenience sampling was used to recruit participants. ED healthcare staff working in three hospitals were invited to participate in an interview. Those who accept to participate were included in the study. Participants characteristics were provided in Table  1 .

Procedure for the interviews

The interview guide (provided in Table  2 ) was developed by the researcher (A.B.) and piloted with 4 healthcare staff before commencing data collection. In-depth semi-structured interviews were conducted by researcher (A.B.), who had experience in conducting interviews and qualitative research, with 30 ED healthcare staff between 15/03/2022 and 30/04/2022. A quiet and comfortable private room at each hospital was arranged for the interviews. All interviews were audio-recorded and conducted in Turkish. The duration of the interviews ranged from 28 to 37 min. Data saturation was reached as no new information was gathered.

Ethical considerations

Ethical approval was obtained from the Mardin Artuklu University Non-Interventional Clinical Research Ethics Committee (Date: 08/03/2022, REF: E-76272411-900-47908). The participants were informed about the aim of the study, and verbal consent was obtained from all participants.

Data analysis and rigor

The data were analyzed using thematic analyses. A six-step thematic analysis developed by Braun and Clarke [ 16 ] was followed: (1) familiarizing with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the report. NVivo software was used to manage the data analysis process. The researcher (A.B.) generates the themes and sub-themes by following a six-step thematic analysis. The developed sub-themes and themes were reviewed and checked by a second qualitative researcher (Y.Y.) using NVivo software, and consensus was reached by discussion. In addition, member check was carried out to ensure that the generated themes conformed to the participants’ views of the topic and the process, and therefore minimized researcher bias. Following the data analysis process, the researcher (A.B.) contacted five participants by email to compare how the themes generated from the analysis related to their experience (member check). They reported a high level of congruence (around 95%) between the themes descriptions and their views, thus adding credibility to the results. All of these processes add to the rigor of the results and increase their credibility and trustworthiness.

The thematic analysis was concluded with 15 sub-themes under three themes. The three themes were the impact of COVID-19 on emergency care services, the psychological effects of COVID-19 on ED healthcare staff, and the difficulties faced by ED healthcare staff.

Impact of COVID-19 on emergency care services

This theme describes how COVID-19 changed the routine functioning of EDs, how ED visits were affected, how protective measures were taken, and how it affected the quality of care, resources used, and workload. Six sub-themes emerged: “introducing a COVID-19 unit in the ED”, “changes in the routine functioning of EDs”, “changes in the number of ED visits”, “quality of care”, “resources”, and “increased workload”.

Introducing a COVID-19 unit in the ED

A separate unit was introduced beside the ED to care for those with COVID-19 or suspected of COVID-19. Extra precautions against COVID-19 were taken in these units. Introducing these services might prevent contamination between those with and without COVID-19. In addition, the COVID-19 process delayed treatment in the ED. ED staff had to take precautions for all patients, which increased the time allocated for each patient and subsequently delayed treatment.

“The COVID-19 unit was introduced in the ED. Those with suspected COVID-19 were referred to the COVID-19 unit for examination. COVID-19 tests were also conducted here.” (Participant 16). “The ED has been divided into two units , the adult ED and the COVID-19 unit. The staff working in the COVID-19 unit paid attention to the use of masks , gowns , and visors , social distance , and cleaning rules while providing care to the patients.” (Participant 19). “The COVID-19 unit was introduced. In the past , we used to quickly perform the procedures of the incoming patients without masks and gloves , but because of the pandemic , we started to perform the procedures of the patients by taking precautions. Because we did not know whether the incoming patients had COVID-19 or not , we took the same precautions for each patient.” (Participant 5).

Changes in the routine functioning of EDs

The COVID-19 pandemic has changed the routine functioning of ED services. ED healthcare staff started to perceive all ED patients as suspected COVID-19 patients. Also, the ED healthcare staff had to take more precautions while examining the patients. They had to use protective equipment such as gloves, masks, aprons, and visors. In addition, healthcare staff also had to pay attention to social distancing and hygiene rules while providing care. All these extra precautions lead to fatigue and working under difficult working conditions, which could lead to high levels of stress and burnout. Working under such circumstances overwhelmed the ED healthcare staff during the COVID-19 pandemic.

“We approached each patient as if they had COVID-19 , without knowing whether the patients had COVID-19 or not. Also , it was very difficult to change the protective equipment each time.” (Participant 16). “We started working with protective equipment. We were working more distantly with the patients. We have started to pay more attention to hygiene rules. The workload of the ED has increased enormously.” (Participant 22).

The ED healthcare staff explained that they had difficulties dealing with COVID-19 as this was a new pandemic and it was an unknown process. ED healthcare staff start to use protective equipment and explain the importance of paying attention to prevention and precautionary methods to patients. In addition, ED healthcare staff had difficulties dealing with COVID-19 because of its high contagiousness.

“Since it was the first time , we had experienced such a process , we had a lot of difficulties managing the process. The disease was new , and people were unconscious. Patients began to be treated more distantly and more carefully. We started to use protective equipment and made a lot of effort to explain the methods of protection and precaution to the patients. The contagiousness of the disease made our job even more difficult.” (Participant 25). “We started using protective equipment to protect ourselves. Disinfectants were used. We pay attention to social distancing while examining patients. We changed the gloves frequently. I washed my hands often. Hand washing is essential. The risk of infection was very high. I started to use protective equipment regularly.” (Participant 6).

Changes in the number of ED visits

ED healthcare staff stated that the number of ED visits by those whose condition was non-urgent decreased. The decrease in the number of ED visits could be a result of fear of acquiring COVID-19 infection and a desire to reduce the pressure on the ED. However, ED healthcare staff reported that patients started to visit the EDs again after a few months from the start of the pandemic. Such decrease in the number of non-urgent ED visits was temporary only at peak incidences of COVID-19.

“At the beginning of the pandemic , non-urgent ED visits decreased. Patients did not come to the ED because of fear of COVID-19. However , they come to the ED now , it has become normal for the people , they do not care about COVID-19.” (Participant 10). “In the early days of COVID-19 , when there were restrictions , the number of patients with non-urgent conditions was quite low. When the restrictions were abolished , it started to increase again. The number of patients with non-urgent conditions increases when COVID-19 cases decrease , and the number of those with non-urgent conditions decreases when COVID-19 cases increase.” (Participant 5).

Quality of care

ED healthcare staff stated that the COVID-19 pandemic decreased the quality of care in the ED because of the limited time allocated for each patient. This is an important issue for patient safety. ED healthcare staff stated that they had limited time for patient examination and this could affect the quality of care provided to patients.

“There has been a decrease in the quality of treatment and care provided to patients. There has not been enough time for patients to be examined.” (Participant 11).

ED healthcare staff stated that they experienced a lack of resources and sometimes unavailability of resources during COVID-19. ED healthcare staff stated that they sometimes had to work without protective equipment while dealing with patients with COVID-19. Working without protective equipment increases the risk of COVID-19 transmission. In addition, some medications were out of stock, and they had to use other available medications while caring for patients.

“Protective equipment such as masks and gloves have decreased over time. Equipment began to be distributed in limited quantities per staff member. There were times when we had to work without protective equipment due to a lack of resources. This increased the risk of transmission of the disease.” (Participant 12).

Increased workload

The participants stated that the workload of the ED increased during COVID-19. Increased workload decreases staff performance and efficiency. In addition, some of the staff were infected with COVID-19 and therefore unable to work during that time. This caused an increased workload for those who are not yet infected. Healthcare staff reported that they experienced irregular working hours due to an unpredicted number of staff to work, and this led to an irregular and limited social life. ED healthcare staff had to deal with COVID-19 with a limited number of staff. ED healthcare staff could not get enough rest, which caused staff burnout.

“When we were infected with COVID-19 , we were away from the hospital and from our work for a week. Therefore , there was a lack of staff and an increase in the workload. The staff had to work a 24-hour shift because employees with COVID-19 could not come to work. We had to work overtime. In the past , we worked according to a certain plan; however , there was an irregular working plan during the COVID-19 process. The high contagiousness of COVID-19 caused disruptions.” (Participant 1). “Our working conditions have become very difficult. Our workload has increased considerably.” (Participant 10). “The workload of the ED has increased with the pandemic. We could not get enough rest. There were limited number of staff. Our working life is always busy , stressful , and exhausting. I had a harder time with the disease. My work routine has changed. There was an unnecessary workload , but there was not enough healthcare staff.” (Participant 26).

Psychological effects of COVID-19 on ED healthcare staff

This theme explains how the COVID-19 pandemic affects ED healthcare staff, including their social life, fears, psychological and emotional effects, and how they were supported during COVID-19. Six sub-themes emerged: “Staying away from family”, “fear”, “society’s perspective on healthcare professionals”, “morale-staff burnout”, “psychological and emotional effects” and “unable to receive enough support”.

Staying away from family

Almost all participants reported that they had experienced difficult times because they had to stay away from their families to reduce the risk of infection and keep them safe. Staying away from their families affects ED healthcare staff psychologically and increases their anxiety and stress levels.

“During the COVID-19 pandemic , most of the staff did not go home; they stayed away from their families because of the risk of infection. Some people stayed in hotels and other types of accommodation” (Participant 10). “The time we spend with our families has decreased. The high contagiousness of the disease and our fear of infecting our loved ones increased our anxiety and stress levels. We had to be very careful not to get the disease and infect our loved ones.” (Participant 11). “Being away from my family made me psychologically depressed.” (Participant 16).

The participants stated that they experienced fear regarding COVID-19. Such fear was regarding their own health and the potential consequences of contracting COVID-19, hospitalization and transmitting the virus to others, including colleagues, patients, and family members. Participants stated that the pandemic affected their mental well-being. Many healthcare staff faced considerable stress and anxiety during COVID-19.

“At the beginning of the pandemic , we were all psychologically feared. I was worried and afraid of how the disease would progress , how I would pass it if I infected , whether I would be hospitalized , and whether it would infect others if it infected me.” (Participant 16). “Psychologically , we were in a constant state of fear.” (Participant 24). “It affected me badly. I am a person who loves to live. I was afraid of dying. The pandemic process was very difficult and worn me out.” (Participant 26). “When there are deaths or negative situations among our colleagues , we are inevitably affected emotionally. We were affected emotionally. Also , I was afraid of infecting my family or any other person” (Participant 1).

Society’s perspective on healthcare professionals

Almost all healthcare staff stated that they were excluded from the members of the society because of being a healthcare staff. Being healthcare staff during the pandemic times means that they have a higher risk of transmission of the disease, and therefore, they were not welcomed in society. Healthcare staff felt excluded by members of society during the pandemic. Such exclusion by society affects the mental health and morale of healthcare staff.

“Society ran away from us during the pandemic.” (Participant 10). “In this process , everyone treated us as if we had COVID-19 because we were healthcare professionals. I felt so excluded.” (Participant 11). “Because I was a healthcare staff member , even my neighbours were not close to me , and they did not even want to use the same lift.” (Participant 13). “Society has become afraid of us.” (Participant 14).

Morale-staff burnout

Some ED healthcare staff members were psychologically affected. ED healthcare staff struggled with COVID-19 and experienced sleeplessness, stress, and exhaustion. Participants reported a high level of burnout related to COVID-19. It was found that COVID-19 caused an increased workload in the ED, which led to staff being exhausted, getting stressed, working without getting enough sleep, and experiencing burnout.

“In addition to the serious battle we fought physically , we were also fighting a great battle spiritually. We had many friends whose psychology was disturbed by this disease. As a result , we were constantly tensed and stressed. We experienced burnout in the process.” (Participant 25). “Due to the increasing number of cases , our workload in the ED has increased a lot. This made it very difficult for us; we were sleepless for days.” (Participant 27). “I cried for nights because of the difficulty of this process. It was an exhausting process. Understanding and tolerance are always expected from us , but we are never shown these things. We are human too , so we get burnout , angry , and tired.” (Participant 30). “Healthcare staff who contracted COVID-19 had to start work after a few days without being tested again.” (Participant 24). “This process has demoralized all of us. Our staff and friends have been infected with COVID-19. Some of the healthcare staff members died. We have also experienced such incidents. We are very saddened by these events.” (Participant 4).

Psychological and emotional effects

Participants expressed that the pandemic had a significant negative impact across multiple domains of life, including family, social, and work life. Participants reported that their social life was negatively affected. They experienced feelings of isolation or disconnection from friends, extended family, or social networks. Such social isolation and working under difficult circumstances overstressed ED healthcare staff and, affected them psychologically and emotionally. ED healthcare staff stated that such conditions increased their stress levels.

“Our family life , social life , and working life have been affected in a very negative way.” (Participant 25). “It was a very difficult process , and we were affected psychologically.” (Participant 28). “It wore me out psychologically. My social life was affected too much. I could not see my loved ones outside.” (Participant 8). “We had difficult days psychologically and physically” (Participant 12). “The pandemic has affected us negatively. We lost a chief physician who was a former colleague of mine. I was affected by this loss. When we thought about the risk of our family , relatives , and those with chronic diseases getting COVID-19 , we were burned out more.” (Participant 13).

Unable to receive sufficient support

Some ED healthcare staff reported that they did not receive sufficient support during the COVID-19 pandemic. Their motivation decreased due to unable to receive the required support. They experienced violence and were affected financially and spiritually. In addition, they experienced social isolation and a lack of social life. Accumulation of all these negative conditions affects ED healthcare staff psychologically and leads them to feel alone. The ED healthcare staff described that the absence of support and motivation contributed to their ability to cope with the challenges they faced.

“This process was difficult. There was no source of motivation. During this period , I was separated from my family and friends. I had difficulties both financially and spiritually. Cases of verbal and physical violence have increased. Health policies must be changed.” (Participant 30).

Difficulties faced by the ED healthcare staff

This theme describes the difficulties faced by ED healthcare staff during the COVID-19 pandemic. Three sub-themes emerged “difficult working conditions”, “community-based effect difficulties”, and “COVID-19 was an unknown situation”.

Difficult working conditions

ED healthcare staff worked under difficult working conditions during COVID-19. They had to work by using protective equipment all the time while working. In addition, ED staff stated that the risk of infection for them was high, and this caused them to be stressed, stay away from their families, and be isolated from society.

“We had a lot of trouble. We had to work with heavy protective equipment. The risk of infection was very high. As the number of cases increased , patient circulation increased , which affected us negatively.” (Participant 1). “We tried to be more careful while working. Healthcare staff are faced with difficulties due to a lack of protective equipment. We put in more effort. We sweated while working with protective equipment. There have also been times when we have put our health at risk.” (Participant 12). “It was very difficult to work with protective equipment; standing with them all day long left us drenched in sweat. It was a very difficult process , and it affected us psychologically.” (Participant 28).

Community-based effect difficulties

The ED healthcare staff stated that they faced significant difficulties due to non-compliance with safety standards by members of the community. ED healthcare staff reported members of the community did not adhere to recommended safety measures such as wearing masks, maintaining social distance, and practising proper hygiene. This non-compliance could cause serious risks for both healthcare staff and other patients because it increases the likelihood of virus transmission within healthcare settings.

“We had serious problems because the patients did not comply with the rules of masking , social distance , and hygiene.” (Participant 10). “When patients are referred to the COVID-19 unit , they do not go there to avoid testing. We started missing real emergency cases. Patients with high blood pressure , heart failure , and diabetes started to burden the emergency department because they did not use their medications or because their controls were delayed.” (Participant 10).

COVID-19 is an unknown situation

The participants stated that the COVID-19 pandemic was an unknown situation and, therefore, they did not know how to respond to this pandemic, including the symptoms of the disease, how to approach patients, what precautions should be taken, and how to treat or alleviate the disease.

“At the beginning of the pandemic , we did not know exactly what to do because the disease was new. Information was limited. Therefore , the emergency department could not be managed.” (Participant 2). “Since we were caught unprepared at the beginning of the pandemic , we had difficulties about what to do , how to take actions , how to make the patient use the protective equipment , and how to protect ourselves.” (Participant 18). “Because we had no information about the disease , we had difficulties in controlling the process , and we did not know how to approach the patients.” (Participant 22). “Since we have experienced such a process for the first time , we have had many difficulties in managing the process. The disease was new , and people were unconscious. All patients were approached with suspicion of COVID-19. Patients began to be treated more distantly and more carefully.” (Participant 25). “We did not know what the disease was like at the beginning of the pandemic and how we should approach patients. Therefore , the care and treatment provided to patients was inadequate.” (Participant 28).

This study found that COVID-19 negatively affects emergency care services in Turkey, including changes in the functioning of EDs and ED visits, decreased quality of care, increased use of resources, and workload. In line with the existing literature [ 2 , 17 , 18 , 19 , 20 ], this study revealed that the number of ED visits decreased at the beginning of the pandemic. The existing literature showed that the number of ED visits decreased by 65% [ 20 ], by 50% [ 21 ], and by 37% [ 22 ] during the first lockdown. Such a reduction in the number of ED visits could be a result of restrictions and the fear of being infected with COVID-19. The existing literature showed that patients were concerned about visiting the ED during the COVID-19 pandemic [ 23 ]. However, ED visits enormously increased after abolishing the restrictions as patients adapted their health-seeking behaviors throughout the pandemic.

The results of this study highlighted that ED healthcare staff experienced many difficulties during the COVID-19 pandemic, such as staying away from their family, fear, negative society perspective on healthcare staff, morale and staff burnout, psychological and emotional effects, and inability to receive enough support. This study found that ED healthcare staff had to stay away from their families during the COVID-19 pandemic because of the risk of infection to their families, which concurred with the existing literature [ 24 , 25 ]. This affects ED healthcare staff psychologically and increases their anxiety and stress levels. In addition, this study found that ED healthcare staff experienced distress and a high level of burnout during the COVID-19 pandemic, which concurs with some of the existing studies [ 8 , 26 , 27 , 28 , 29 , 30 ]. In line with some studies [ 26 , 31 , 32 ], this study found that experiencing burnout could be negatively associated with patient satisfaction, quality of care, staff morale and retention, and therefore a loss of workforce for the future.

In line with the results of this study, ED healthcare staff faced challenges such as increased workload and resource constraints during the COVID-19 pandemic [ 10 , 33 , 34 , 35 ]. ED healthcare staff face mental burdens and physical exertion when caring for patients in the ED during the COVID-19 pandemic. ED healthcare staff provide care under difficult circumstances with limited resources. In line with these results, some studies suggested that stress factors in relation to providing health care for patients with COVID-19 should be addressed [ 7 , 36 ].

Strengths and limitations

One of the strengths of this study is to include a large sample of ED healthcare staff working in three different hospitals with in-depth semi-structured interviewing resulting in a rich and detailed source of qualitative data for analysis. One of the limitations of this study could be the generalizability of the results due to the nature of qualitative research, which does not attempt to generalize the results to other populations. In addition, this study was conducted around 1 year later than the starting point of time of COVID-19. Therefore, participants may not recall all their experiences during COVID-19. The results may be transferrable to policymakers, ED directors, or other key stakeholders across Turkey and other countries with similar contexts.

Conclusion and recommendations

This study could provide a better understanding of how ED services and ED staff were affected by the COVID-19 pandemic, including decreased quality of care in the ED, increased workload, resource strains, psychological effects on ED staff, and related difficulties. Learning from such lived experiences and developing appropriate interventions to minimize the difficulties faced during COVID-19 would allow better management of future pandemics.

Staff burnout threatens the quality of patient care and staff retention, and therefore this should be addressed by ED directors and leaders. Supporting staff in dealing with difficulties such as psychological problems, fears, burnout and providing a safe working environment could contribute to staff well-being, a better workforce for the future, and staff retention. This study calls for a reform to address the challenges faced by healthcare staff, improve the overall response to public health crises such as the COVID-19 pandemic, and enhance the resilience of healthcare systems despite future crises. This study could inform appropriate stakeholders regarding lessons learned from COVID-19 to better manage future pandemics. Learning from such lived experiences and developing appropriate interventions to minimize the difficulties faced during COVID-19 would allow better management of future pandemics.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

The author would like to thank Dr Yesim Yesil for her contribution to this study. The author would also like to acknowledge the participants and the hospital management teams for their help with participant recruitment.

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

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A.B.: Conceptualization, Resources, Data curation, Software, Visualization, Methodology, Project administration, Formal analysis, Writing – original draft, Writing – review & editing.

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Ethical approval was obtained from Mardin Artuklu University Non-Interventional Clinical Research Ethics Committee (Date: 08/03/2022, REF: E-76272411-900-47908). The participants were informed about the aim of the study, and verbal consent was obtained from all participants.

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Butun, A. Healthcare staff experiences on the impact of COVID-19 on emergency departments: a qualitative study. BMC Health Serv Res 24 , 921 (2024). https://doi.org/10.1186/s12913-024-11362-9

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DOI : https://doi.org/10.1186/s12913-024-11362-9

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