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Qualitative research for education : an introduction to theory and methods

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• 1.Foundations of Qualitative Research in Education: An Introduction. Characteristics of Qualitative Research. Traditions of Qualitative Research. Theoretical Underpinnings. Ten Common Questions about Qualitative Research. Ethics. What Is to Come. 2.Research Design. Choosing a Study. Case Studies. Multi-Site Studies. Additional Issues Related to Design. Concluding Remarks. 3.Fieldwork. Gaining Access. First Days in the Field. The Participant/Observer Continuum. Doing Fieldwork in Another Culture. Researcher Characteristics and Special Problems with Rapport. Be Discreet. Research in Politically Charged and Conflict-Ridden Settings. Feelings. How Long Should an Observation Session Be? Interviewing. Visual Recording and Fieldwork. Triangulation. Leaving the Field. 4.Qualitative Data. Some Friendly Advice. Fieldnotes. The Process of Writing Fieldnotes. Transcripts from Taped Interviews. Documents Photography. Official Statistics and Other Quantitative Data. Concluding Remarks. 5.Data Analysis. Analysis in the Field. Analysis after Data Collection. The Mechanics of Working with Data. Concluding Remarks.
• 6. Writing It Up. Writing Choices. More Writing Tips. Criteria for Evaluating Writing. Texts. A Final Point about Getting Started. 7.Applied Qualitative Research for Education. Evaluation and Policy Research. Action Research. Practitioner Uses of Qualitative Research. Appendix. Examples of Observational Questions for Educational Settings. References. Index.
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Qualitative Research in Education

• Liz Atkins - University of Huddersfield, UK
• Susan Wallace - Nottingham Trent University, UK
• Description

This accessible and practical book is a perfect quick guide for graduate researchers in education. Looking at the interdependence of teaching and research, the authors show that a critical and analytical exploration of policies and practices is a necessary part of what we mean by being a 'professional' in education.

Drawing on the authors' substantial experience of teaching research skills at graduate level, as well as on their own experiences as active researchers, the book will guide you through:

• Discourse analysis
• Visual methods
• Textual research
• Data collection and analysis

This co-authored book is structured around a range of methods applicable to educational research and appropriate for use by practitioners at all stages of their professional development. It takes recognizable, 'real life' scenarios as its starting point for each discussion of method, so that readers are able to start from the known and familiar. As well as exploring theoretical aspects of research method, each chapter provides practical tasks and points for discussion and reflection. These approaches, taken together, are designed to build confidence and encourage reader engagement and enjoyment.

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

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'This book successfully revives Lawrence Stenhouse's seminal work on the 'teacher-researcher' by showing the interconnectedness of teaching and research and stressing the key role of the practitioner-researcher. Its chapters provide comprehensive guidance for researchers at all levels on conducting small scale research in an ethical and reflexive way' -Professor Jerry Wellington, Sheffield

This is a useful book for providing students with useful information to conduct a qualitative study.

Comprehensive text, thorough and clearly laid out. Very useful for supporting PGCE/ SD trainees new to research as well as supporting those who have carried out research before.

This is an excellent text which I will recommend to any of my students undertaking qualitative research. The language is open and clear. Liz Atkins really understands the needs of M level education practitioners.

A great companion for anyone conducting qualitative research in Education. Can recommend this book.

This book covers key methodological issues and qualitative research designs in the educational field. Each chapter includes examples that are particularly useful to understand ‘how’ to carry out research. The activities in each chapter are a good complement to reinforce knowledge and understanding of key concepts. This book is an ideal introduction for master and undergraduate students in Education who are doing or planning to do a small-scale qualitative research. I recommend this book to my second year students and use it as an essential reading at the master level. The examples are brilliant and this is the main reason why I chose to include this book in my teaching.

A rather analytical and easy-to- read book.

Each chapter of the book opens with a useful and clear summary. The additional reflective activities and vignettes offer opportunities for critical thinking and help readers to engage with the material.

This is a genuine title that can help students grasp the skills required for qualitative research. Students not only from Education stream but from other social sciences can benefit from it. I recommend it also for students with Applied Linguistics background at an early stage of research.

Not relevant for Education Leadership and Management field. There are more appropriate books available.

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Educational Research Basics by Del Siegle

Qualitative research.

Although researchers in anthropology and sociology have used the approach known as qualitative research  for a century, the term was not used in the social sciences until the late 1960s. The term qualitative research is used as an umbrella term to refer to several research strategies. Five common types of qualitative research are grounded theory , ethnographic , narrative research , case studies , and phenomenology.

It is unfair to judge qualitative research by a quantitative research paradigm, just as it is unfair to judge quantitative research from the qualitative research paradigm .

“Qualitative researchers seek to make sense of personal stories and the ways in which they intersect” (Glesne & Peshkin, 1992). As one qualitative researcher noted, “I knew that I was not at home in the world of numbers long before I realized that I was at home in the world of words.”

The data collected in qualitative research has been termed “soft”, “that is, rich in description of people, places, and conversations, and not easily handled by statistical procedures.” Researchers do not approach their research with specific questions to answer or hypotheses to test. They are concerned with understanding behavior from the subject’s own frame of reference. Qualitative researcher believe that “multiple ways of interpreting experiences are available to each of us through interacting with others, and that it is the meaning of our experiences that constitutes reality. Reality, consequently,  is ‘socially constructed'” (Bogdan & Biklen, 1992).

Data is usually collected through sustained contact with people in the settings where they normally spend their time. Participant observations and in-depth interviewing are the two most common ways to collect data. “The researcher enters the world of the people he or she plans to study, gets to know, be known, and trusted by them, and systematically keeps a detailed written record of what is heard and observed. This material is supplemented by other data such as [artifacts], school memos and records, newspaper articles, and photographs” (Bogdan & Biklen, 1992).

Rather than test theories, qualitative researchers often inductively analyze their data and develop theories through a process that Strauss called ” developing grounded theory “. They use purposive sampling to select the people they study. Subjects are selected because of who they are and what they know, rather than by chance.

Some key terms:

Access to a group is often made possible by a gate keeper . The gate keeper is the person who helps you gain access to the people you wish to study. In a school setting it might be a principal.

Most qualitative studies involve at least one key informant . The key informant knows the inside scoop and can point you to other people who have valuable information. The “key informant” is not necessarily the same as the gate keeper. A custodian might be a good key informant to understanding faculty interactions. The process of one subject recommending that you talk with another subject is called “ snowballing .”

Qualitative researchers use rich-thick description when they write their research reports. Unlike quantitative research where the researcher wished to generalize his or her findings beyond the sample from whom the data was drawn, qualitative researcher provide rich-thick descriptions for their readers and let their readers determine if the situation described in the qualitative study applies to the reader’s situation. Qualitative researchers do not use the terms validity and reliability. Instead they are concerned about the trustworthiness of their research.

Qualitative researchers often begin their interviews with grand tour questions . Grand tour questions are open ended questions that allow the interviewee to set the direction of the interview. The interviewer then follows the leads that the interviewee provides. The interviewer can always return to his or her preplanned interview questions after the leads have been followed.

Qualitative researchers continue to collect data until they reach a point of data saturation . Data saturation occurs when the researcher is no longer hearing or seeing new information. Unlike quantitative researchers who wait until the end of the study to analyze their data, qualitative researcher analyze their data throughout their study.

Note:   It is beyond the scope of this course to provide an extensive overview of qualitative research. Our purpose is to make you aware of this research option, and hopefully help you develop an appreciation of it. Qualitative research has become a popular research procedure in education.

Del Siegle, PhD [email protected] www.delsiegle.info

Qualitative Research Methods for Science Education

• First Online: 23 November 2011
• pp 1451–1469

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• Frederick Erickson 4  

Part of the book series: Springer International Handbooks of Education ((SIHE,volume 24))

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In this chapter, I describe how high quality research can be done in science education. I include four main sections in which I explain the purposes of qualitative research, data collection, data analysis, and preparation of reports. I emphasize the salience to qualitative research of specifying researchable questions that inevitably change as the research is conducted. I address issues of credibility, ethical conduct, uses of quantitative information, and the necessity to fully understand contradictions.

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Erickson, F. (2012). Qualitative Research Methods for Science Education. In: Fraser, B., Tobin, K., McRobbie, C. (eds) Second International Handbook of Science Education. Springer International Handbooks of Education, vol 24. Springer, Dordrecht. https://doi.org/10.1007/978-1-4020-9041-7_93

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Published : 23 November 2011

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Qualitative Research for Education: An Introduction to Theories and Methods, Fifth Edition 5th Edition

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This concise, applied, and very clearly written introduction to qualitative research methods can be used effectively in a semester, or year-long course. The purpose of this introductory-level text is to provide the reader with a background for understanding the uses of qualitative research in education to examine its theoretical and historical underpinnings, and to provide the “how-to's” of doing qualitative research. This new edition places qualitative research within current debates about research methods and alternative ways of knowing. While the authors approach the subject from a sociological perspective, they also take care to reflect the many changes in conceptualization of qualitative research brought by post-structural and feminist thought.

• ISBN-10 0205482937
• ISBN-13 978-0205482931
• Edition 5th
• Publisher Pearson
• Publication date July 25, 2006
• Language English
• Dimensions 9.3 x 7.21 x 0.86 inches
• Print length 304 pages
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This concise, applied, and very clearly written introduction to qualitative research methods can be used effectively in a semester, or year-long course.

This introductory-level text provides the reader with a background for understanding the uses of qualitative research in education (and other professions) examining its theoretical and historical underpinnings, and providing the “how-to's” of doing qualitative research. This new edition places qualitative research within current debates about research methods and alternative ways of knowing. While the authors approach the subject from a sociological perspective, they also take care to reflect the many changes in conceptualization of qualitative research brought by post-structural and feminist thought.

New to This Edition:

· Rewritten Chapter 5, “Data Analysis,” places more emphasis on the interpretive aspect of research and research writing.

· Expanded coverage of action or practitioner research (Chapter 7) highlights a topic that is of immediate use.

· Added emphasis on technology and qualitative analysis software in qualitative research helps students to use and incorporate technology efficiently. Links to useful research websites have also been integrated throughout.

· Expanded coverage of such topics as formal research designs, work with different cultures, critical race theory, and the debate over quantitative vs. qualitative research.

· New end-of-chapter summaries, questions, and field assignments have been added to make this text easy to use with students.

Product details

• Publisher ‏ : ‎ Pearson; 5th edition (July 25, 2006)
• Language ‏ : ‎ English
• Hardcover ‏ : ‎ 304 pages
• ISBN-10 ‏ : ‎ 0205482937
• ISBN-13 ‏ : ‎ 978-0205482931
• Item Weight ‏ : ‎ 1.26 pounds
• Dimensions ‏ : ‎ 9.3 x 7.21 x 0.86 inches
• #445 in Education Research (Books)
• #21,419 in Unknown
• #29,829 in Social Sciences (Books)

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Qualitative research essentials for medical education

Sayra m cristancho.

1 Department of Surgery and Faculty of Education, Schulich School of Medicine and Dentistry, Western University, Canada

2 Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, Canada

Mark Goldszmidt

3 Department of Medicine, Schulich School of Medicine and Dentistry, Western University, Canada

Lorelei Lingard

Christopher watling.

4 Postgraduate Medical Education, Schulich School of Medicine and Dentistry, Western University, Canada

This paper offers a selective overview of the increasingly popular paradigm of qualitative research. We consider the nature of qualitative research questions, describe common methodologies, discuss data collection and analysis methods, highlight recent innovations and outline principles of rigour. Examples are provided from our own and other authors’ published qualitative medical education research. Our aim is to provide both an introduction to some qualitative essentials for readers who are new to this research paradigm and a resource for more experienced readers, such as those who are currently engaged in a qualitative research project and would like a better sense of where their work sits within the broader paradigm.

INTRODUCTION

Are you a medical education researcher engaged in qualitative research and wondering if you are on the right track? Are you contemplating a qualitative research project and not sure how to get started? Are you reading qualitative manuscripts and making guesses about their quality? This paper offers a selective overview of the increasingly popular domain of qualitative research. We consider the nature of qualitative research questions, describe common methodologies, discuss data collection and analysis methods, highlight recent innovations, and outline principles of rigour. The aim of this paper is to educate newcomers through introductory explanations while stimulating more experienced researchers through attention to current innovations and emerging debates.

WHAT IS QUALITATIVE RESEARCH?

Qualitative research is naturalistic; the natural setting – not the laboratory – is the source of data. Researchers go where the action is; to collect data, they may talk with individuals or groups, observe their behaviour and their setting, or examine their artefacts.( 1 ) As defined by leading qualitative researchers Denzin and Lincoln, qualitative research studies social and human phenomena in their natural settings, attempting to make sense of or interpret these phenomena in terms of the meanings participants bring to them.( 2 )

Because qualitative research situates itself firmly in the world it studies, it cannot aim for generalisability. Its aim is to understand, rather than erase, the influence of context, culture and perspective. Good qualitative research produces descriptions, theory or conceptual understanding that may be usefully transferred to other contexts, but users of qualitative research must always carefully consider how the principles unearthed might unfold in their own distinct settings.

WHAT QUESTIONS ARE APPROPRIATE FOR QUALITATIVE RESEARCH?

Meaningful education research begins with compelling questions. Research methods translate curiosity into action, facilitating exploration of those questions. Methods must be chosen wisely; some questions lend themselves to certain methodological approaches and not to others.

In recent years, qualitative research methods have become increasingly prominent in medical education. The reason is simple: some of the most pressing questions in the field require qualitative approaches for meaningful answers to be found.

Qualitative research examines how things unfold in real world settings. While quantitative research approaches that dominate the basic and clinical sciences focus on testing hypotheses, qualitative research explores processes, phenomena and settings ( Box 1 ). For example, the question “Does the introduction of a mandatory rural clerkship increase the rate of graduates choosing to practise in rural areas? ” demands a quantitative approach. The question embeds a hypothesis – that a mandatory rural clerkship will increase the rate of graduates choosing to practise in rural areas – and so the research method must test whether or not that hypothesis is true. But the question “ How do graduating doctors make choices about their practice location? ” demands a qualitative approach. The question does not embed a hypothesis; rather, it explores a process of decision-making.

Qualitative research questions:

Many issues in medical education could be examined from either a quantitative or qualitative approach; one approach is not inherently superior. The questions that drive the research as well as the products that derive from it are, however, fundamentally different. Consider two approaches to studying the issue of online learning. A quantitative researcher might ask, “ What is the effect of an online learning module on medical students’ end-of-semester OSCE [objective structured clinical examination] scores? ”, while a qualitative researcher might ask “ How do medical students make choices about using online learning resources? ” Although the underlying issue is the same – the phenomenon of online learning in medical school – the studies launched by these questions and the products of those studies will look very different.

WHAT ARE QUALITATIVE METHODOLOGIES AND WHY ARE THEY IMPORTANT?

Executing rigorous qualitative research requires an understanding of methodology – the principles and procedures that define how the research is approached. Far from being monolithic, the world of qualitative research encompasses a range of methodologies, each with distinctive approaches to inquiry and characteristic products. Methodologies are informed by the researcher’s epistemology – that is, their theory of knowledge. Epistemology shapes how researchers approach the researcher’s role, the participant-researcher relationship, forms of data, analytical procedures, measures of research quality, and representation of results in analysis and writing.( 3 )

In medical education, published qualitative work includes methodologies such as grounded theory, phenomenology, ethnography, case study, discourse analysis, participatory action research and narrative inquiry, although the list is growing as the field embraces researchers with diverse disciplinary backgrounds. This paper neither seeks to exhaustively catalogue all qualitative methodologies nor comprehensively describe any of them. Rather, we present a subset, with the aim of familiarising readers with its fundamental goals. In this article, we briefly introduce four common methodologies used in medical education research ( Box 2 ). Using one topic, professionalism, we illustrate how each methodology might be applied and how its particular features would yield different insights into that topic.

Common qualitative methodologies in medical education:

Grounded theory

Arguably the most frequently used methodology in medical education research today, grounded theory seeks to understand social processes. Core features of grounded theory include iteration, in which data collection and analysis take place concurrently with each informing the other, and a reliance on theoretical sampling to explore patterns as they emerge.( 4 ) While many different schools of grounded theory exist, they share the aim of generating theory that is grounded in empirical data.( 5 ) Theory, in this type of research, can be thought of as a conceptual understanding of the process under study, ideally affording a useful explanatory power. For example, if one were interested in the development of professionalism among senior medical students during clerkship, one might design a grounded theory study around the following question: “ What aspects of clerkship support or challenge professional behaviour among senior medical students? ” The resulting product would be a conceptual rendering of how senior medical students navigate thorny professionalism issues, which might in turn be useful to curriculum planners.

Phenomenology

This methodology begins with a phenomenon of interest and seeks to understand the subjective lived experience of that phenomenon.( 6 ) Core features of phenomenology include a focus on the individual experience (typically pursued through in-depth interviewing and/or examinations of personal narratives), inductive analysis and a particular attention to reflexivity.( 7 ) Phenomenological researchers typically enumerate their own ideas and preconceptions about the phenomenon under study and consider how these perceptions might influence their interpretation of data.( 8 ) A phenomenological study around professionalism in senior medical students, for example, might involve interviewing several students who have experienced a professionalism lapse about that experience. The resulting product might be an enhanced understanding of the emotional, social and professional implications of this phenomenon from the student’s perspective, which might in turn inform wellness or resilience strategies.

Ethnography

Ethnography aims to understand people in their contexts, exploring the influence of culture, social organisation and shared values on how people behave – their routines and rituals. Core features of ethnography include reliance on direct observation as a data source, and the use of sustained immersive engagement in the setting of interest in order to understand social dynamics from within.( 9 , 10 ) An ethnographic approach to studying how professional attitudes develop in senior medical students might gather data through observations of ward rounds, team meetings and clinical teaching sessions over a period of time. The resulting product – called an ethnography – would describe how professional values are socialised in junior learners in clinical settings, which could assist educators in understanding how the clinical experiences they programme for their learners are influencing their professional development.

Case study research seeks an in-depth understanding of an individual case (or series of cases) that is illustrative of a problem of interest. Like clinical case studies, the goal is not generalisation but a thorough exploration of one case, in hopes that the fruits of that exploration may prove useful to others facing similar problems. Core features of case study research include: thoughtful bounding or defining of the scope of the case at the outset; collection of data from multiple sources, ranging from interviews with key players to written material in policy documents and websites; and careful attention to both the phenomenon of interest and its particular context.( 11 ) A specific professionalism challenge involving medical students could provide fodder for a productive case study. For example, if a medical school had to discipline several students for inappropriately sharing personal patient information on social media, a case study might be undertaken. The ‘case’ would be the incident of social media misuse at a single medical school, and the data gathered might include interviews with students and school officials, examination of relevant policy documents, examination of news media coverage of the event, and so on. The product of this research might trigger similar institutions to carefully consider how they might approach – or prevent – a similar problem.

As these four examples illustrate, methodology is the backbone of qualitative research. Methodology shapes the way the research question is asked, defines the characteristics of an appropriate sample, and governs the way the data collection and analysis procedures are organised. The researcher’s role is also distinctive in each methodology; for instance, in constructivist grounded theory, the researcher actively constructs the theory,( 12 ) while in phenomenology, the researcher attempts to manage his or her ‘pre-understandings’ through either bracketing them off or being reflexive about them.( 13 ) Interested readers may wish to consult the reference list for recently published examples of research using grounded theory,( 14 ) phenomenology,( 15 ) ethnography( 16 ) and case study approaches( 17 ) in order to appreciate how researchers deploy these methodologies to tackle compelling questions in contemporary medical education.

WHAT ARE SOME COMMON METHODS OF QUALITATIVE DATA COLLECTION?

The most common methods of qualitative data collection are interview – talking to participants about their experiences relevant to the research question, and observation – watching participants while they are having those experiences. Depending on the research questions explored, a research design might combine interviews and observations.

Interview-based methods

Interviews are typically used for situations where a guided conversation with relevant participants can help provide insight into their lived experiences and how they view and interpret the world around them. Interviews are also particularly useful for exploring past events that cannot be replicated or phenomena where direct observation is impossible or unfeasible.

Participants may be interviewed individually or in groups. Focus group interviews are used when the researcher’s topic of interest is best explored through a guided, interactive discussion among the participants themselves. Therefore, when focus groups are used, the sample is conceptualised at the level of the group – three focus groups of five people constitutes a sample of three interactive discussions, not 15 individual participants. Because they centre on the group discussion and dynamic, focus groups are less well-suited for topics that are sensitive, highly personal or perceived to be culturally inappropriate to discuss publicly.( 18 )

Unlike quantitative interviews, where a set of structured, closed-ended (e.g. yes/no) questions are asked in the same order with the same wording every time, qualitative interviews typically involve a semi-structured design where a list of open-ended questions serves to guide, but not constrain, the interview. Therefore, at the interviewer’s discretion, the questions and their sequence may vary from interview to interview. This judgement is made based on both the interviewer’s understanding of the phenomenon under exploration and the emerging dynamic between the interviewer and participant.

The primary goal of a qualitative interview is to get the participants to think carefully about their experience and relate it to the interviewer with rich detail. Getting good data from interviewing relies on using creative strategies to avoid the common trap of getting politically correct answers – often called ‘cover stories’– or answers that are superficial rather than deep and reflective.( 19 ) A common design error occurs when researchers are overly explicit in their questioning, such as asking “ What are the top five criteria you use to assess student professionalism? ” A better approach involves questions that ask participants to describe what they do in practice, with follow-up probes that extend beyond the specific experience described. For example, starting with “ Tell me about a recent experience where you assessed a student’s professionalism ” allows the participant to relay an experience, to which the interviewer can respond with probes such as “ What was tricky about that? ” or “ How typical is that experience? ”

Another common strategy for prompting participants to engage in rich reflection on their experience and perceptions is to use vignettes as discussion prompts. Vignettes are often artificial scenarios presented to participants to read or watch on video, about which they are then asked probing questions.( 20 ) However, vignettes can also be used to recreate an authentic situation for the participant to engage with.( 21 ) For instance, in one interview study, we presented participants with a vignette in the form of the research assistant reading aloud a standard patient admission presentation that the interviewees would typically hear from their students on morning ward rounds. We then asked the participants to interact with the interviewer as though he or she was a student who had presented this case on morning rounds. Recreating this interaction in the context of the interview served as a stepping stone to questions such as “ Why did you ask the student ‘x’? ” and “ How would your approach have differed with a different student presenter, e.g. a stronger or weaker one? ”

Direct observation

Observation-based research can involve a wide spectrum of activities, ranging from brief observations of specific tasks (e.g. handover, preoperative team briefings) to prolonged field observations such as those seen in ethnography. When used effectively, direct observation can provide the researcher with powerful insight into the routines of a group.

Getting good data from observational research relies on several key components. First, it is essential to define the scope of the project upfront: limited budgets, the massive amount of detail to be attended to, and the ability of any individual or group of observers to attend to these make this essential. Good observational research therefore relies on collaboration between knowledgeable insiders and those with both methodological and theoretical expertise. Sampling demands particular attention; an initial purposive sampling approach is often followed by more targeted, theoretical sampling that is guided by the developing analysis. Observational research also typically involves a mix of data sources, including observational field notes, field interviews and document analysis. Audio and video may be helpful when the studied phenomena is particularly complex or nuances of interaction may be missed without the ability to review data, or when precision of verbal and nonverbal interactions is necessary to answer the research question.( 22 )

Field notes are often the dominant data source used for subsequent analysis in observational research. As such, they must be created with great diligence. Usually researchers will jot down brief notes during an observation and afterwards elaborate in as much detail as they can recall. Field notes have an important reflective component. In addition to the factual descriptions, researchers include comments about their feelings, reactions, hunches, speculations and working theories or interpretations. The content of field notes, therefore, usually includes: descriptions of the setting, people and activities; direct quotations or paraphrasing of what people said; and the observer’s reflections.( 23 ) Field notes are time-consuming when done well – even a single hour of observation can lead to several hours of reflective documentation.

An important aspect to consider when designing observation-based research is the ‘observer effect’, also known as the Hawthorne effect, more recently reframed as ‘participant reactivity’ by health professions education researchers Paradis and Sutkin.( 24 ) The Hawthorne effect is conventionally defined as “ when observed participants act differently from how they would act if the observer were not present ”.( 25 ) Researchers have implemented a number of strategies to mitigate this effect, including prolonged embedding of the observer, efforts to ‘fit in’ through dress or comportment, and careful recording of explicit instances of the effect.( 24 ) However, Paradis and Sutkin found that instances of the Hawthorne effect, as conventionally defined, have never been described in qualitative research manuscripts in the health professions education field, perhaps because, as they speculate, healthcare workers and trainees are accustomed to being observed. Based on this, they argued that researchers should worry less about mitigating the Hawthorne effect and instead invest in interpersonal relationships at their study site to mitigate the effects of altered behaviour and draw on theory to make sense of participants’ altered behaviour.( 23 ) Combining interviewing and observation is also common in qualitative research ( Box 3 ).

Combining interviews and observations:

WHAT ARE THE COMMON METHODS OF QUALITATIVE DATA ANALYSIS?

Qualitative data almost invariably takes the form of text; an interview is turned into a transcript and an observation is rendered into a field note. Analysing these qualitative texts is about uncovering meaning, developing understanding and discovering insights relevant to the research question. Analysis is not separated from data collection in qualitative research, and begins with the first interview, the first observation or the first reading of a document. In fact, the iterative nature of data collection and analysis is a hallmark of qualitative research, because it allows the researcher’s emerging insights about the study phenomena to inform subsequent rounds of data collection ( Box 4 ).

The iterative process of analysis:

Data that has been analysed while being collected is both parsimonious and illuminating. However, this process can extend indefinitely. There will always be another person to interview or another observation to record. Deciding when to stop depends on both practical and theoretical concerns. Practical concerns include deadlines and funding. More importantly, the decision should be guided by the theoretical concern of sufficiency.( 26 ) Sufficiency occurs when new data does not produce new insights into the phenomenon, in other words, when you keep hearing and seeing the same things you have heard and seen before.

Qualitative data analysis is primarily inductive and comparative. The overall process of data analysis begins by identifying segments in the data that are responsive to the research question. The next step is to compare one segment with the next, looking for recurring patterns in the data set. During this step, the focus is on sorting the raw data into categories that progressively build a coherent description or explanation of the phenomenon under study. This process of identifying pieces of data and grouping them into categories is called coding.( 14 ) Once a tentative scheme of categories is derived, it is applied to new data to see whether those categories continue to exist or not, or whether new categories arise – this step determines whether sufficiency has been reached. The final step in the analysis is to think about how categories interrelate. At this point, the analysis moves to interpreting the meaning of these categories and their interrelations.( 12 )

The process for data analysis laid out in this section is a basic inductive and comparative analysis strategy that is suitable for analysing data for most interpretive qualitative research methodologies, including the four featured in this paper – phenomenology, grounded theory, ethnography and case study – as well as others such as narrative analysis and action research. While each methodology attends to specific procedures, they all share the use of this basic inductive/comparative strategy. Overall, analysis should be guided by methodology, but different analytical procedures can be creatively combined across methodologies, as long as this combining is explicit and intentional.( 27 )

WHAT ARE SOME CURRENT INNOVATIONS IN QUALITATIVE RESEARCH?

Understanding the complex factors that influence clinical practice and medical education is not an easy research task. Many important issues may be difficult for the insider to articulate during interviews and impossible for the outsider to ‘see’ during observation. Innovations to address these challenges include guided walks,( 28 ) photovoice( 29 ) and point-of-view filming.( 30 ) Our own research has drawn intensively on the innovation termed ‘rich pictures’ to explore the features and implications of complexity in medical education.( 31 ) In one study, we asked medical students to draw pictures of clinical cases that they found complex: an exciting case and a frustrating one.( 32 ) Participants were given 30–60 minutes on their own to reflect on the situation and draw their pictures. This was followed by an in-depth interview using the pictures as triggers to explore the phenomenon under study – in this case, students’ experiences of and responses to complexity during their training.

Such innovations hold great promise for qualitative research in medical education. For instance, rich pictures can reveal emotional and organisational dimensions of complex clinical experiences, which are less likely to be emphasised in participants’ traditional interview responses.( 33 ) Methodological innovations, however, bring new challenges: they can be time-intensive for participants and researchers; they require new analytical procedures to be developed; and they necessitate efforts to educate audiences about the rigour and credibility of unfamiliar approaches.

WHAT ARE THE PRINCIPLES OF RIGOUR IN QUALITATIVE RESEARCH?

Like quantitative research, qualitative research has principles of rigour that are used to judge the quality of the work.( 34 ) Here, we discuss principles that appear in most criteria for rigour in the field: reflexivity, adequacy, authenticity, trustworthiness and resonance ( Box 5 ).

Principles of rigour in qualitative research:

The main data collection tool in qualitative research is the researcher. We talk to participants, observe their practices and interpret their documents. Consequently, a critical feature of rigour in qualitative data collection is researcher reflexivity: the ability to consider our own orientations towards the studied phenomenon, acknowledge our assumptions and articulate regularly our impressions of the data.( 35 ) Only this way can we assure others that our subjectivity has been thoughtfully considered and afford them the ability to judge its influence on the work for themselves. Qualitative research does not seek to remove this subjectivity; it treats research perspective as unavoidable and enriching, not as a form of bias to purge.

Every qualitative dataset is an approximation of a complex phenomenon – no study can capture all dimensions and nuances of situated social experiences, such as medical students’ negotiations of professional dilemmas in the clinical workplace. Therefore, two other important criteria of rigour relate to the adequacy and authenticity of the sampled experiences. Did the research focus on the appropriate participants and/or situations? Was the size and scope of the sample adequate to represent the scope of the phenomenon?( 36 ) Was the data collected an authentic reflection of the phenomenon in question? Qualitative researchers should thoughtfully combine different perspectives, methods and data sources (a process called ‘triangulation’) to intensify the richness of their representation.( 37 ) We should endeavour to draw on data in our written reports such that we provide what sociologist Geertz has termed a sufficiently ‘thick’ description( 38 ) for readers to judge the authenticity of our portrayal of the studied phenomenon.

Qualitative analysis embraces subjectivity: what the researcher ‘sees’ in the data is a product both of what participants told or showed us and of what we were oriented to make of those stories and situations. To some degree, a rhetorician will always see rhetoric and a systems engineer will always see systems. To fulfil the rigour criteria of trustworthiness, qualitative analysis should also be systematic and held to a principle of trustworthiness, which dictates that we should clearly describe: (a) what was done by whom during the inductive, comparative analytical process; (b) how the perspectives of multiple coders were negotiated; (c) how and when theoretical lenses were brought to bear in the iterative process of data collection and analysis; and (d) how discrepant instances in the data – those that fell outside the dominant thematic patterns – were handled.

Finally, the ultimate measure of quality in qualitative research is the resonance of the final product to those who live the social experience under study.( 4 ) As qualitative researchers presenting our work at conferences, we know we have met this bar if our audiences laugh, nod or scowl at the right moments, and if their response at the end is “ You nailed it. That’s my world. But you’ve given me a new way to look at it ”. The situatedness of qualitative research means that its transferability to other contexts is always a matter of the listener/reader’s judgement, based on their consideration of the similarities and differences between the research context and their own. Thus, there is a necessity for qualitative research to sufficiently describe its context, so that consumers of the work have the necessary information to gauge transferability. Ultimately, though, transferability remains an open question, requiring further inquiry to explore the explanatory power of one study’s insights in a new setting.

WHAT ELSE IS THERE TO KNOW?

This overview of qualitative research in medical education is not exhaustive. We have been purposefully selective, discussing in depth some common methodologies and methods, and leaving aside others. We have also passed over important issues such as qualitative research ethics, sampling and writing. There is much, much more for readers to know! Our selectivity notwithstanding, we hope that this paper will provide an accessible introduction to some qualitative essentials for readers who are new to this research domain, and that it may serve as a useful resource for more experienced readers, particularly those who are doing a qualitative research project and would like a better sense of where their work sits within the broader field of qualitative approaches.

• Open access
• Published: 18 April 2024

Attitudes and perceptions towards developing a health educational video to enhance optimal uptake of malaria preventive therapy among pregnant women in Uganda: a qualitative study involving pregnant women, health workers, and Ministry of health officials

• Rita Nakalega 1 ,
• Ruth Nabisere-Arinaitwe 2 ,
• Nelson Mukiza 3 ,
• Cynthia Ndikuno Kuteesa 3 ,
• Denis Mawanda 2 ,
• Paul Natureeba 1 ,
• Ronnie Kasirye 1 ,
• Clemensia Nakabiito 1 ,
• Jane Nabakooza 4 ,
• Emmie Mulumba 1 ,
• Josephine Nabukeera 1 ,
• Joseph Ggita 1 ,
• Abel Kakuru 5 ,
• Lynn Atuyambe 6 ,
• Philippa Musoke 1 ,
• Mary Glenn Fowler 7 &
• Zubair Lukyamuzi 1  

BMC Health Services Research volume  24 , Article number:  484 ( 2024 ) Cite this article

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Malaria in pregnancy remains a major global public health problem. Intermittent prophylaxis treatment of malaria in pregnancy with Sulphadoxine-pyrimethamine and co-trimoxazole is efficacious for prevention of malaria in pregnancy HIV negative and positive women, respectively. However, uptake of the recommended doses of therapies has remained suboptimal in Uganda, majorly due to inadequate knowledge among pregnant women. Therefore, this study aimed to explore attitudes and perceptions towards developing an educational video for malaria preventive therapy.

We conducted an exploratory study with qualitative methods among pregnant women attending antenatal care at Kisenyi Health Center IV (KHCIV), health workers from KHCIV, and officials from the Ministry of Health. The study was conducted at KHCIV from October 2022 to March 2023. Focus group discussions (FGD) were conducted among purposively selected pregnant women and key informant interviews (KII) among health workers and Ministry of Health officials. Data were analyzed using inductive and deductive thematic methods in atlas ti.8.

A total of five FGDs comprising of 7–10 pregnant women were conducted; and KIIs were conducted among four mid-wives, two obstetricians, and two Ministry of Health officials. Generally, all respondents mentioned a need for interventions to improve malaria preventive knowledge among pregnant women; were positive about developing an educative video for malaria preventive therapy in pregnancy; and suggested a short, concise, and edutaining video focusing both the benefits of taking and risks of not taking malaria preventive therapy. They proposed that women may be encouraged to view the video as soon as they conceive and throughout the pregnancy. It also was suggested that the video may be viewed on television sets in maternal and reproductive health clinics and homes, and on smart phones.

Pregnant women, health workers, and Ministry of Health officials were positive about the development of a short edutaining video on malaria preventive therapy that focuses on both benefits of taking and risks of not taking the malaria preventive therapy in pregnancy. This information guided the video development and therefore, in the development of health educative videos, client and stakeholder inputs may always be solicited.

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Introduction

Malaria in pregnancy remains a major public health concern worldwide; more than 50 million pregnant women live in malaria-endemic areas with 88% in sub-Saharan Africa (SSA) [ 1 , 2 ]. Malaria in pregnancy is associated with undesirable fetal and maternal outcomes including miscarriage, low birth weight, stillbirth, maternal morbidity, and mortality; moreover, malaria is the leading cause of preventable fetal and maternal deaths [ 3 , 4 , 5 ]. These undesirable fetal and maternal outcomes are worsened by coinfection with other diseases particularly HIV [ 6 , 7 , 8 ]; and Uganda remains one of the most affected countries by both HIV and malaria [ 9 , 10 , 11 , 12 ]. The country is malaria endemic with the prevalence malaria in pregnancy ranging from 8.9 to 51.1% [ 13 , 14 , 15 ], and HIV prevalence of 8% among women of reproductive age [ 16 ].

Intermittent prophylaxis treatment of malaria in pregnancy with Sulphadoxine-pyrimethamine (IPTp-SP) and co-trimoxazole (CTx) is efficacious for prevention of malaria in pregnancy in pregnant women without HIV and those with HIV, respectively [ 17 , 18 ]. These medications have shown to reduce malaria parasitemia in pregnancy by approximately 80% [ 18 , 19 ]. In HIV negative women, IPTp-SP is initiated after the 1st trimester and taken on a monthly basis throughout the pregnancy [ 20 , 21 ] whereas, CTx is taken on a daily basis throughout the pregnancy for women living with HIV [ 11 , 22 ]. Although antenatal care (ANC) attendance in Uganda had increased to 95%, uptake of the recommended doses of IPTp-SP and CTx had remained suboptimal especially in the urban areas [ 3 , 23 ]. In the country’s capital, Kampala, optimal uptake of IPTp-SP was as low as 39% in 2018 [ 3 ].

Multi-sectoral factors contribute to sub-optimal uptake of malaria preventive therapy in pregnancy. However, lack of education, ignorance, and inadequate awareness about malaria preventive therapy among pregnant women and health workers remain the major factors [ 3 , 24 , 25 , 26 , 27 ]. This is partly due to persistent low ratio of health workers to patients in Low Resource Settings (LRS) [ 28 ]; resulting in inadequate sensitization and education of women on malaria preventive therapy during ANC visits. Hence, a critical need for interventions to improve knowledge and uptake of malaria preventive therapy during pregnancy.

Brief video-based educational interventions are promising approaches in improving health related knowledge among the target populations [ 29 ]. These videos are highly cost-effective [ 29 , 30 ], have a strong track record in improving knowledge, and fostering behavior change in various health related fields including HIV [ 29 , 31 , 32 , 33 ]. However, the responses and reactions to these interventions among stakeholders in malaria prevention during pregnancy remain unknown.

In this study, we recorded client and stakeholder opinions, attitudes, and perceptions, to the development of an educational video to improve knowledge and uptake of malaria preventive therapy in pregnancy.

Study design and setting

This was a sub-study of a larger two phased sequential cross-sectional study that used a client- centered and stakeholder consultative approach to develop an educational video on malaria preventive therapy in pregnancy. The primary study had two phases; the first phase aimed to solicit inputs from clients and stakeholders in the development of an educative video for improving knowledge of malaria preventive therapy among pregnant women; and the second phase aimed to assess the feasibility and acceptability of the developed video. Therefore, the current study describes the first phase of the primary study. This phenomenological qualitative study was conducted at Kisenyi Health Center IV (KHCIV) from October 2022 to March 2023. KHCIV is a public health facility in Kampala Central division, administered by Kampala Capital City Authority (KCCA). In Uganda, a HCIV provides general health services plus minor surgeries [ 34 , 35 ]. The facility has a catchment area of ≈ 2,000,000 people from Kampala and suburbs, and serves over 200 persons per day [ 36 ]. It offers free HIV/TB Care services, ANC services, and other services. Daily, the facility had ANC attendance of about 100 women and conducted about 20 births.

Study population

The study population included pregnant women at any gestation age attending ANC at KHCIV during the study period and key informants. The key informants were obstetricians and midwives from maternal and child health department at KHCIV, and Ministry of Health (MoH) officials from the malaria control department.

Study outcomes

The study outcomes were opinions, attitudes, and perceptions of the study participants about the development of an educative video on malaria preventive therapy in pregnancy.

Sample size and sampling procedures

Fifty pregnant women attending ANC at KHCIV were purposively selected and enrolled in the study. Women were stratified by age and HIV status to undergo focus group discussions (FGD). A total of five FGDs each comprising of 7–10 women were conducted among HIV negative women aged < 18years, 18-24years, and 25-49years; and women living with HIV aged 18-24years, and 25-49years. Due to the limited number of women living with HIV aged < 18 years during the study period, we were unable to get enough women for a FGD for this age group. We, therefore, instead conducted an in-depth interview (IDI) with a teenager living with HIV. We also conducted key informant interviews (KII) among obstetricians, midwives, and Ministry of Health (MoH) officials. Focus group discussions, IDI, and KIIs were conducted until when saturation was reached [ 37 ] in each group.

Data collection procedures

Pregnant women attending ANC at KHCIV were purposively selected and informed about the study, and those who were interested were consented to participate. Women were selected from the ANC clinic daily and scheduled for FGDs. Demographics and clinical information were obtained from all participants using a questionnaire before participating in the FGDs. The FGDs were based on open discussion, and each lasted typically for about two hours in duration. Using an FGD guide (Appendix 1), the discussions were conducted by a trained social scientist (facilitator) in a calm place where conversations could not be overhead. Similarly, the IDI for a teenager living with HIV and KIIs for key informants were conducted in a calm place where conversations could not overhead. The interviews lasted between 15 and 30 min and were conducted face to face using an IDI or KII guide. The FGDs, IDI, and KIIs were conducted in respondents’ preferred language which were Luganda or English. All the interviews were audiotaped and transcribed by a professional. The study documents such as structured questionnaire, FGD/IDI guides, and consents were translated from English to Luganda, the local language used. These were then back translated to English; and we then compared the new translation with the original text and reconciled any meaningful differences between the two to ensure that the translations were accurate.

Data management

Audio recordings were transcribed verbatim directly into English by the study team within one week of collection. Quality checks were performed for each transcript, with corrections and revisions made to identified errors.

Data analysis

Using Stata version 17 (StataCorp, College Station, TX, USA), descriptive continuous variables, such as age, were summarized using mean and standard deviation (SD) while categorical variables were summarized using frequencies and proportions.

Qualitative data analysis

Using an inductive and deductive content analytic approach, recorded data were transcribed and analyzed by the study team supervised by a qualitative research expert, using Atlas t.8 software. The initial review was done during debriefing process to give a baseline understanding of the data and constant comparison process continued to identify new information until there was no redundancy in the themes and this was part of the steps during inductive approach.The Consolidated Criteria for Reporting Qualitative Studies checklist was used to report study findings [ 38 ]. During the inductive analysis, open coding was carried out to identify specific portions of text corresponding to information required for the video development. Provisional labels were defined and illustrated to become codes, which were assembled into a codebook. Data was coded by two coders (social scientist and corresponding author). After development of the initial codebook, the codebook was reviewed for consistency of text segmentation and code application with continued inter-coder agreement. The coders reached a consensus and grouped identified codes into grouped sub-category, category and then into subthemes and themes. Coded themes from all data were compared to obtain generalized themes after removing inconsistent codes. The choice of thematic headings was guided by both the core concepts emerging from the data [ 39 ] and by theoretical concepts of the health belief model (HBM) [ 40 ]. During the second phase of analysis, specific topics were designated as core categories; axial coding and constant comparison to explore the relationships between the discussion of sensitive data and contextual situation [ 41 ]. Findings and interpretations of the data were discussed until there was group consensus on the dominant themes and meanings contained in the data.

Ethical approval

Approval to conduct this study was obtained from the Makerere University School of Medicine Research Ethics Committee (Mak-SOMREC-2021-279) and Uganda National Council for Science and Technology (NS384ES). Administrative clearance was obtained from the Director of Health Services at KCCA and from KHCIV administration. Written informed consent was obtained from all participants; confidentiality and anonymity were strictly observed. Informed consent for illiterate participants was obtained in the presence of an impartial witness (guardian or other literate person not part of study team). The procedure of obtaining informed consent from illiterate participants was approved by the Makerere University School of Medicine Research Ethics Committee IRB. All methods were performed in accordance with the relevant guidelines and regulations of good clinical practice and human subject protection of ICH-6.

A total of 50 women were enrolled for FGDs and IDI. Eight key informants were also enrolled for key informant interviews. These included two obstetricians, four mid-wives, and two Ministry of Health officials. The mean age of the enrolled women was 23 years (SD ± 6 years); the majority, 26 (53.1%) had completed primary level of education and the median gestation age was 24 weeks with interquartile range (IQR) of 20–32 weeks. The majority 36 (73.5%) were currently living with their partners and most 41 (83.7%) were receiving financial support from their partner. The majority 27(55.1%) used 1–2 h to travel to the ANC facility (KHCIV) and most 26 (53.1%) had had more than two ANC visits, and the average number of ANC visits was 3 as shown in Table  1 .

To thematically categorize opinions, perceptions, and attitudes of respondents, we used the HBM [ 40 ] and Gain/Loss messaging Framework [ 42 ]. The HBM postulates that cues to action and presence of an enabling environment are among the vital constructs in the uptake of a particular behavior [ 40 ]. The Gain/Loss framework describes the packaging of a message focusing on the positive benefits of doing something or the risk of not doing something [ 42 ] as shown in Table  2 .

Four broad themes emerged from the data to describe the use of video-based intervention to educate women about malaria preventive therapy in pregnancy. These themes were: needed actions and strategies to improve knowledge of malaria preventive therapy in pregnancy; positive attitudes towards the use of the video-based intervention to educate women on malaria preventive therapy in pregnancy; Packaging and Framing of the message of malaria preventive therapy in the video; and delivery of the message of malaria preventive therapy in the video.

Strategies and actions needed to improve knowledge of malaria preventive therapy in pregnancy

Respondents acknowledged the need for strategies to improve knowledge about malaria preventive therapy in pregnancy; and they mentioned various strategies to improve knowledge and uptake of IPTp-SP and co-trimoxazole during pregnancy. The mentioned strategies included engagement of male sexual partners or treatment supporters and providing regular health education talks.

Regarding male partner and treatment supporter involvement, r espondents mentioned that the involvement males and treatment supporters could help to enhance women’s understanding of the purpose and benefits of taking malaria preventive therapy. The male partners and treatment supporters can educate further the women and can remind them to swallow the medicines in case the women forget.

“We always counsel women to bring their partners or come with a treatment supporter. This helps because if a woman has not understood the message or information given, the treatment supporter or partner can understand and explain or remind her.“ , midwife III.

For continuous educational talks, respondents mentioned that efforts should be made to provide comprehensive and repeated health education talks during ANC to minimize malaria preventive therapy knowledge deficits among women. Respondents suggested various strategies including education and sensitization of women during ANC visits and the use of communication materials (IEC), village health team (VHT) system, and media-based education such as televisions, radios, and social media.

“Like I told you earlier, providing women with information regarding the use of malaria preventive therapy including how to minimize the associated side effects will improve uptake. Women can be organized in small groups during ANC in addition to one-on-one sessions. We should also ensure that the information given reaches the sexual partners and treatment supporters” , Obstetrician II. “Women need to be adequately educated on why they should take these drugs to improve uptake and adherence”. FGD lady aged _15–17 yrs.

Demonstrations and illustrations were also encouraged during education talks.

“Yes, because with the flip chart, you can easily illustrate the importance of taking malaria preventive therapy. You can also have brochures which can show various actions on different pages. For example, you can show a happy woman taking IPTp-SP or co-trimoxazole on the first page, and on next page you show a healthy born baby” , midwife. III. “…like there various apps on phones, they can also develop for us a malaria prevention app to teach women about malaria. I can have that App on my phone and can learn the schedule for taking malaria preventive therapy”. FGD woman 25-49yrs.

Positive attitudes to developing and designing an educative video for malaria preventive therapy

All respondents agreed that an educative video was one of the best interventions that can improve knowledge and uptake of malaria preventive therapy in pregnancy. This is because videos can be easily understood and always attract and capture women’s attention.

“The video can be good and more receptive in educating women because many women don’t know why should take these drugs. We not only need to have health workers acting in the video but also pregnant women. We can have women giving success stories”. Obstetrician I. “ By viewing, we are entertained but also being educated. Yah, I think it is a good innovation”. MoH official I . “It’s a good innovation because, you know how people, especially those in reproductive age want to watch videos. MoH official II.

Packaging and Framing of the message of malaria preventive therapy in the video

Respondents mentioned how to package and provide (message) information in the video.

Packaging information in the video

Regarding packaging, respondents suggested various ways of packaging the information in the video. They mentioned that the video should be short and concise, focused, engaging or edutaining, and be acted by real human beings.

Short, concise, and focused video

Respondents mentioned that for the video to be effective and efficient, it should be short, concise, and focused. This is because some people don’t concentrate for long.

“The video should have well packaged key information. You know people’s concentration, especially for adults, is very short. So, the video should be short. For example , not be more than 5 minutes “. Obstetrician II.

Other respondents were worried about having a very short video which could result in insufficient information given.

“If the video is very fast and short, people may miss out on some information. So, I suggest the video to be about 10 minutes long”. FGD lady aged_15-17yrs. “It depends on how the information is given in the video. It needs actors who talk fast in about three to four minutes. Because, if it lasts longer, one can walk away before the video ends”. FGD lady aged_15-17yrs.

Engaging or edutaining video

Respondents emphasized that the video should be able engage women. This can be achieved by making the video edutaining.

“ …. but I suggest the developed video to be edutaining. Because people are good at watching videos if the videos are entertaining. So, it should not be a boring video”. MoH official I.

Use of real human beings to act in the video

Respondents suggested that the video should be designed in the form of a play to attract attention and concentration.

“A play would work better, but for talking, some of our speeches bore. It needs something that can attract attention. People can be very attentive to watch a play” Midwife. II.

Despite mixed feelings associated with the use of real human beings or animations like cartoons in the video, most of the respondents preferred real human beings because it could provide an impression of reality and seriousness. Moreover, respondents preferred having an individual acting other than providing a narrative story.

“I think having someone act is the best because it attracts someone’s attention to watch how the story goes. But narrating at times may be boring. Some people don’t take cartoons seriously, they think cartoons or animations are for children. But if it is a human talking and identifying themselves, people usually take it seriously “. Obstetrician I. “…a video should use a person who can explain to the women and understand. That person can explain the benefits of swallowing the medicine for malaria prevention, and the consequences of not swallowing the medicines. And that person should be serious to show what happens if you swallow or not swallow the medicine”. FGD lady 18-24yrs.

Messaging or providing information in the video

When asked about the key messages that can be included or provided in the video, respondents mentioned that the information should include the benefits of taking and risks of not taking malaria preventive therapy in pregnancy, and instructions of taking the therapy.

Including information on the benefits of taking and the risks of not taking malaria preventive therapy in pregnancy

Respondents mentioned that the video should have information emphasizing the purpose and benefits of malaria preventive therapy in pregnancy, and the risks of not taking the therapy.

“The video should show the real importance of taking these medicines because we always communicate the risks of not taking the medicine and forget to emphasize the purpose and benefits”. midwife I.

However, respondents mentioned that the purpose and benefits should be more emphasized than risks of not taking the therapy. This is because over emphasizing the potential risks of not taking IPTp-SP or co-trimoxazole can cause fear in women and deter them from following instructions. Additionally, over focusing on the potential risks of not taking malaria preventive therapy can sometimes be interpreted as coercion or forcing women to take the drugs. Therefore, the video should be directed towards motivating women to take the drugs.

“….and include information that motivates or encourages them to take the drugs. For example, giving them assurance about protection of both the woman and the unborn baby, and being healthier for both the woman and the unborn baby”, Obstetrician II. However, some respondents recommended that adequate information on the potential risks of not taking the drugs should be included as well. “We can also include adverse effects of malaria in pregnancy such as severe anemia, miscarriage, fetal death, and low birth weight” , midwife IV. “Let us also include problems like getting miscarriages, babies dying in womb, and mother herself dying. If a woman hears such problems, she can say; let me go and get drugs so that I don’t get problems”. FGD_18–24 years.

Including information on the instructions of taking malaria preventive therapy

Respondents mentioned that the instructions and schedules of taking these medicines should be included in the video.

“The video should include the drugs to use, how to use them, and their benefits, and then the effects of not taking the drugs”. FGD woman aged _25-49years.

Delivery of the message of malaria preventive therapy in the video

Respondents proposed practices that can be used in delivering the developed video to the target population. They mentioned the appropriate stage when pregnant women should start watching the video, the appropriate time of watching the video, channels of watching the video, and places where to watch the video from.

The stage at which a pregnant woman can start watching the video

Many of the respondents recommended watching such educational videos right from preconception or early pregnancy and through the entire pregnancy period.

“These women should be educated about malaria preventive therapy right before they become pregnant (preconception). And the information should be given to them continuously on a regular basis throughout pregnancy” , midwife III . “As early as we get in touch with the pregnant woman, we should provide them with malaria prevention messages. Even if someone has not reached the time of starting IPTp-SP, they can be looking forward to that time. And remember for co-trimoxazole, it should be started as soon as one becomes pregnant”. Obstetrician I.

The appropriate time, channels, and places of watching the video

Respondents also suggested various channels through which the video should be delivered. Respondents mentioned watching the video on television screens during antenatal care clinics or at home and watching the video on phones (smart phones). However, respondents emphasized that the video should be aired out at all points where pregnant women are found especially the ANC and reproductive health clinics.

“Using media like the televisions, this is the information someone can watch for example before the news or favorable programs, for example, women like soaps. You know that we have a bigger audience before the news, before the soaps and on peak of some programs”. Obstetrician II.

There were no noticeable differences regarding preferences to watch the video between women living with HIV and those without.

“I prefer watching the video on television screen at home because when I come to the health facility, I can be busy looking for health workers to work on me. I may not concentrate to watch the video. But when I am at home, I can even rewind the video several times so that I get to understand the message”. FGD lady aged_18–24 years. …. “You realize that someone can sit somewhere pick up their phone and watch the videos that they have on their phones. And if there is a TV, for example in the clinic or at home, people will watch it. MoH official II.

In this study, we aimed to obtain client and stakeholder opinions, attitudes, and perceptions to develop and design an educative video to improve knowledge and uptake of malaria preventive therapy in pregnancy. This study revealed that strategies and actions are needed to improve knowledge of malaria preventive therapy among pregnant women such as engaging of male sexual partners or treatment supporters and providing effective regular health education talks; pregnant women and key stakeholders were positive towards developing and designing a video-based intervention to educate women on malaria preventive therapy in pregnancy; a need for proper packaging and framing of the message of malaria preventive therapy in the video such as having a video that is short, edutaining, and focused on both benefits of taking and risks of not taking the malaria preventive therapy in pregnancy; and a need for effective means of delivering the video to pregnant women such as use of television sets to display the video at the clinic or at home, use of smart phones and social media, and ensuring that pregnant women access or watch the video as soon as possible after conception. The implications of these findings are as below.

Strategies and actions are needed to improve knowledge of malaria preventive therapy among pregnant women

The current study suggests a need for engaging male sexual partners and treatment supporters when educating women about malaria preventive therapy. This is because these can support the women in understanding the purpose and the benefits of the therapy. The male partner and treatment supporter can also remind the women to take their medicine and, hence increasing adherence. Previous studies have also proposed this strategy [ 43 , 44 ]. It’s reported that male partner involvement in ANC services is associated with better utilization of maternal health service, decreased delays in making the decision to seek medical attention, improves material, emotion, and physical support, and increased likelihood of adherence to medical care advice [ 45 , 46 ]. Therefore, more efforts are needed to involve male partners or treatment supporters in maternal and child health services.

Provision of effective regular health education talks. The study revealed that there is a need for more education talks and these talks should be effective. Many women don’t understand the purpose and the benefits of taking malaria preventive therapy, and don’t understand the associated risks of not taking the therapy. Other women may forget what they learnt previously, and policies and guidelines change overtime. Therefore, there is a need to have regular education talks concerning malaria preventive therapy during pregnancy. The importance of regular education talks to pregnant women has been reported previously [ 47 , 48 ]. However, there is a need to ensure that these talks are effective for all categories of pregnant women. In LRS like Uganda, education talks may be ineffective due to low ratio of health workers to patients [ 28 ]. This study revealed that the low health worker to patient ratio results in inadequate sensitization and education of pregnant women on malaria preventive therapy during ANC visits; and therefore, more scalable, and cost-effective interventions may be needed.

Positive reactions towards developing and designing a video-based intervention to educate women on malaria preventive therapy in pregnancy

This study revealed that pregnant women and key stakeholders were positive about the video based educational strategy in increasing knowledge and uptake of malaria preventive therapy in pregnancy. The strategy was seen as an innovation in the field of maternal and child health services. This finding was consistent with a study done in Ghana which showed that video job-aids were welcomed and effectively supported the delivery of seasonal malaria chemoprevention [ 49 ]. In this Ghanaian study, the conveyed videos enhanced learning and information retention. The videos also reinforced messages due to the fact that they could be viewed at any time and repeatedly [ 49 ]. Kim et al. also reported that brief video-based educational interventions are promising approaches in improving health related knowledge among the target population [ 29 ].

Proper packaging and framing of the message of malaria preventive therapy in the video

The current study emphasized a short, concise, and focused educative video. The study in Ghana also utilized short videos, which were found to be easily distributed on social media and thus reached many people in a short period of time [ 49 ]. Therefore, the current study showed that a short video of about 5 min maybe appropriate to improve knowledge and uptake of malaria preventive therapy in pregnancy.

Regarding the contents of the video, the current study showed that the video should emphasize the purpose and benefits of malaria preventive therapy in pregnancy and be edutaining. This was similar to the study conducted in Guinea which showed that positive messaging of the video content is a consensus of good practice and successful video-based education as reflected in the WHO and national guidelines on malaria prevention [ 50 , 51 ]. However, the current study also revealed that the risks of not taking malaria preventive therapy should equally be emphasized. It was mentioned that pregnant should also be informed about the adverse effect of malaria in pregnancy including miscarriage, low birth weight babies, and maternal or fetal death. A study among diabetic patients showed that patients who received negatively framed message showed significantly more favorable attitudes and perceived control toward diabetes self-care than those who viewed the positively framed message [ 52 ]. Therefore, the video may have both the information about the benefits of taking malaria preventive therapy and information about the risks of not taking the therapy.

The study revealed that the video should consistently and address concerns relevant to malaria etiology and prevention measures. This was similar to the recommendations from the Ugandan national health survey [ 53 ]. Relatedly, studies have also shown that highlighting and identifying the correct health messages in a consistent and repetitive manner boosts audience knowledge and malaria intervention uptake [ 49 , 54 ].

Delivering the video-based information to pregnant women

The study revealed that all women of reproductive age should be a target for this video-based education. This was consistent with previous reports and World Health Organization recommendations [ 55 , 56 ]. However, the findings of the current study emphasized women to receive this video-based education as soon as they become pregnant and throughout pregnancy. This was because malaria preventive medication like cotrimoxazole needs to be taken as soon as one becomes pregnant and throughout the pregnancy. Additionally, all women should know what they are supposed to do such as taking IPTp-SP even if they are not yet in 2nd trimester. This strategy has been previously recommended [ 57 , 58 ]. Therefore, women may be provided with the video-based education for malaria prevention as soon as they conceive.

The study revealed that the video-based education may be provided on television sets in maternal and childcare clinics as well as sexual and reproductive health clinics. A previous study showed that planning health messaging and delivery systematically offers the chance to fulfill people’s actual informational demands in addition to creating effective communication tactics [ 59 ]. It was also revealed that the video can also be viewed at home on a television set or anywhere on smart phone. A systematic review showed that short video education messages can be repeatedly watched from anywhere [ 49 ]. Therefore, the educative video for malaria preventive therapy in pregnancy may be designed to be viewed on television sets at clinics and home and on smart phones.

Strengths and limitations

Our study strengths include using iterative client centered processes to tailor and develop a video to improve knowledge on malaria prevention therapy among pregnant women. The study obtained data through a participatory process from pregnant women and key stakeholders in maternal and child health which ensured triangulation and complementation of information from the respondents. The study included HIV negative and HIV-positive women as well as women of different age groups, which enabled us to obtain varied responses and representation from various categories of pregnant women. Our study was conducted in an urban setting therefore, the findings are limited to the urban population and may not be generalized to rural communities.

Conclusions

In conclusion, pregnant women, health care workers, and ministry of health officials were enthusiastic and positive about developing and designing an educative video for malaria preventive therapy during pregnancy. However, they suggested a short edutaining video with properly packaged and framed information focused on both benefits of taking and risks of not taking the malaria preventive therapy in pregnancy. They also suggested delivering the video to pregnant women as soon as they conceive through television sets at maternal and reproductive health clinics and through smart phones. Data from this study was used to develop and design and educative video for malaria preventive therapy in pregnancy.

Data availability

The dataset used and analyzed during this study is available from the corresponding author on reasonable request.

Abbreviations

Acquired immunodeficiency syndrome

Focus Group Discussion

Human Immunodeficiency Virus

In-Depth Interviews

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Acknowledgements

The authors would like to thank the staff at Kisenyi Health Center IV for supporting study recruitment and data collection procedures. We thank study participants for their invaluable time and information. Finally, we thank Kampala Capital City Authority for granting us administrative permission to undertake the study.

This study was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (grants 1R03HD106185-01A1). This content is entirely the responsibility of the authors and does not necessarily represent the official views of the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

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Nakalega, R., Nabisere-Arinaitwe, R., Mukiza, N. et al. Attitudes and perceptions towards developing a health educational video to enhance optimal uptake of malaria preventive therapy among pregnant women in Uganda: a qualitative study involving pregnant women, health workers, and Ministry of health officials. BMC Health Serv Res 24 , 484 (2024). https://doi.org/10.1186/s12913-024-10944-x

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