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Analyzing Qualitative Data

• Edition: Second
• By: Graham R Gibbs
• Publisher: SAGE Publications Ltd
• Series: Qualitative Research Kit
• Publication year: 2018
• Online pub date: February 08, 2021
• Discipline: Sociology
• Methods: Coding , Documentary research , Transcription
• DOI: https:// doi. org/10.4135/9781526441867
• Keywords: accounting , discourse , hierarchy , parenting , persons , software , transcripts Show all Show less
• Print ISBN: 9781473915817
• Online ISBN: 9781529771183
• Buy the book icon link

Subject index

This book tackles the challenges of how to make sense of qualitative data. It offers students and researchers a hands-on guide to the practicalities of coding, comparing data, and using computer-assisted qualitative data analysis. Lastly, Gibbs shows you how to bring it all together, so you can see the steps of qualitative analysis, understand the central place of coding, ensure analytic quality and write effectively to present your results.

Front Matter

• Acknowledgements
• List of Illustrations
• Editorial Introduction Uwe Flick
• About this book and its second edition
• Chapter 1 | The nature of qualitative analysis
• Chapter 2 | Data preparation
• Chapter 3 | Writing
• Chapter 4 | Thematic coding and categorizing
• Chapter 5 | Analyzing biographical, narrative and discursive elements
• Chapter 6 | Comparative analysis
• Chapter 7 | Analytic quality and ethics
• Chapter 8 | Getting started with computer-assisted qualitative data analysis
• Chapter 9 | Searching and other analytic activities using software
• Chapter 10 | Putting it all together

Back Matter

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Qualitative Research: Analyzing Life Second Edition

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• ISBN-10 1544372884
• ISBN-13 978-1544372884
• Edition Second
• Publisher SAGE Publications, Inc
• Publication date February 2, 2021
• Language English
• Dimensions 7.38 x 0.82 x 9.13 inches
• Print length 362 pages
• See all details

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Editorial Reviews

About the author.

Johnny Saldaña is Professor Emeritus from Arizona State University’s (ASU) School of Film, Dance, and Theatre in the Herberger Institute for Design and the Arts, where he taught from 1981 to 2014. He received his BFA in Drama and English Education in 1976, and MFA in Drama Education in 1979 from the University of Texas at Austin.

Saldaña is the author of Longitudinal Qualitative Research: Analyzing Change through Time (AltaMira Press, 2003); Fundamentals of Qualitative Research (Oxford University Press, 2011); Ethnotheatre: Research from Page to Stage (Left Coast Press, 2011); Thinking Qualitatively: Methods of Mind (Sage Publications, 2015); a commissioned title for Routledge’s World Library of Educationalists Series, Writing Qualitatively: The Selected Works of Johnny Saldaña (Routledge, 2018); co-author with the late Matthew B. Miles and A. Michael Huberman for Qualitative Data Analysis: A Methods Sourcebook (4th ed., Sage Publications, 2020); co-author with Matt Omasta for Qualitative Research: Analyzing Life (Sage Publications, 2018); and the editor of Ethnodrama: An Anthology of Reality Theatre (AltaMira Press, 2005). Previous editions of The Coding Manual for Qualitative Researchers have been translated into Korean, Turkish, and Chinese-Simplified.

Saldaña’s methods works have been cited and referenced in more than 16,000 research studies conducted in over 130 countries in disciplines such as K-12 and higher education, medicine and health care, technology and social media, business and economics, government and social services, the fine arts, the social sciences, human development, and communication. He has published a wide range of research articles in journals such as Research in Drama Education , The Qualitative Report , Multicultural Perspectives , Youth Theatre Journal , Journal of Curriculum and Pedagogy , Teaching Theatre , Research Studies in Music Education , Cultural Studies ? Critical Methodologies , the International Journal of Qualitative Methods , the International Review of Qualitative Research , and Qualitative Inquiry , and has contributed several chapters to research methods handbooks. His most popular journal article, “Blue-Collar Qualitative Research: A Rant” ( Qualitative Inquiry , 2014), has been downloaded by over 3,000 readers, according to ResearchGate.

Saldaña’s research in qualitative inquiry, data analysis, and performance ethnography has received awards from the American Alliance for Theatre & Education, the National Communication Association-Ethnography Division, the American Educational Research Association’s Qualitative Research Special Interest Group, New York University’s Program in Educational Theatre, the Children’s Theatre Foundation of America, and the ASU Herberger Institute for Design and the Arts.

Matt Omasta is Associate Professor and Theatre Education Program Director at Utah State University. He received his BA from Ithaca College, his MA from Emerson College, and his PhD from Arizona State University. He is the author of Play, Performance, and Identity: How Institutions Structure Ludic Spaces (Routledge), Playwriting and Young Audiences (Intellect), and numerous articles in journals including Research in Drama Education: The Journal of Applied Theatre and Performance , Youth Theatre Journal , Theatre for Young Audiences Today , Theatre Topics , and the International Journal of Education and the Arts among others. Omasta′s work has been recognized by honors including the Founders′ Award from the Educational Theatre Association, the Lin Wright Special Recognition Award and the Research Award from the American Alliance for Theatre & Education, and the Arts and Learning Special Interest Group (A & L SIG) Dissertation Award from the American Educational Research Association (AERA).

Product details

• Publisher ‏ : ‎ SAGE Publications, Inc; Second edition (February 2, 2021)
• Language ‏ : ‎ English
• Paperback ‏ : ‎ 362 pages
• ISBN-10 ‏ : ‎ 1544372884
• ISBN-13 ‏ : ‎ 978-1544372884
• Item Weight ‏ : ‎ 1.41 pounds
• Dimensions ‏ : ‎ 7.38 x 0.82 x 9.13 inches
• #159 in Scientific Research
• #176 in Social Sciences Methodology
• #258 in Education Research (Books)

About the authors

Johnny saldaña.

Johnny Saldaña is Professor Emeritus of Theatre in the Herberger Institute of Design and the Arts' School of Film, Dance, and Theatre at Arizona State University (ASU) where he taught from 1981 to 2014. He has been involved in the field of theatre education as a teacher educator, drama specialist, director, and researcher. His works have been cited in over 21,000 research studies conducted in over 135 countries.

Mr. Saldaña is the author of "Drama of Color: Improvisation with Multiethnic Folklore" (Heinemann, 1995), a teacher's resource text and recipient of the 1996 Distinguished Book Award from the American Alliance for Theatre & Education (AATE); "Longitudinal Qualitative Research: Analyzing Change Through Time" (AltaMira Press, 2003), a research methods book and recipient of the 2004 Outstanding Book Award from the National Communication Association's Ethnography Division; "Ethnodrama: An Anthology of Reality Theatre" (AltaMira Press, 2005), an edited collection of ethnographic-based plays; "The Coding Manual for Qualitative Researchers" (Sage Publications, fourth edition 2021), a handbook on qualitative data analysis; "Ethnotheatre: Research from Page to Stage" (Left Coast Press, 2011), winner of the American Educational Research Association's Qualitative Research SIG's Outstanding Book Award; "Fundamentals of Qualitative Research" (Oxford University Press, 2011), an introductory textbook on the subject; as co-author, the fourth edition of the late Matthew B. Miles and A. Michael Huberman's "Qualitative Data Analysis: A Methods Sourcebook" (Sage Publications, 2020); as co-author with Matt Omasta, a new introductory textbook, "Qualitative Research: Analyzing Life" (Sage Publications, second edition, 2022); and a volume for the World Library of Educationalists' series, "Writing Qualitatively: The Selected Works of Johnny Saldaña" (Routledge, 2018).

Saldaña has published articles in such journals as Youth Theatre Journal, Stage of the Art, Teaching Theatre, Research in Drama Education, Research Studies in Music Education, Multicultural Perspectives, Journal of Curriculum and Pedagogy, and Qualitative Inquiry. He has also published chapters on research methods for such titles as "Arts-Based Research in Education," "Handbook of the Arts in Qualitative Research," "Handbook of Longitudinal Research," and entries for "The Sage Encyclopedia of Qualitative Research Methods."

Saldaña's research methods in longitudinal inquiry, ethnotheatre, coding, and qualitative data analysis have been applied and cited by researchers internationally in disciplines such as K-12 and higher education, business, social sciences, technology, government, social services, communication, human development, interpersonal relationships, sport, health care, and medicine.

Mr. Saldaña's workshops and keynote addresses reflect a broad range of interests including drama in the classroom, drama with multicultural materials, ethnotheatre, theatre for social change, and qualitative research methods. Saldaña has presented for such organizations as: the Arizona Artist/Teacher Institute, the New Orleans Public Schools, the Louisiana Institute for Education in the Arts, the Southeast Institute for Education in Theatre, the Tennessee Arts Academy, Northwestern University, Western Michigan University, New York University, the University of Hartford, the University of Amsterdam, the University of Alberta, the University of Victoria, the University of Leeds, Mary Immaculate College / University of Limerick; and at national conferences of: AATE, the Educational Theatre Association, Pedagogy and Theatre of the Oppressed, the International Drama in Education Research Institute, the American Educational Research Association, the National Association for Multicultural Education, Narrative Inquiry in Music Education, the International Institute for Qualitative Methodology, the European Qualitative Research Conference in Health and Social Care, and the International Congress of Qualitative Inquiry.

Saldaña is a recipient of the 1989 Creative Drama Award from AATE, the 1996, 2001, and 2010 Research Awards from AATE, the 2015 Campton Bell Lifetime Achievement Award, New York University's Swortzell Innovator Award in 2017, the Burlington Resources Foundation Faculty Achievement Award in 1991, the ASU College of the Arts Distinguished Teacher of the Year Award in 1995 and 2008, and the ASU College of the Arts Research Award in 2005. In 2000, 2008, and 2009 he was recognized as a finalist by the ASU Parents Association for Professor of the Year.

Mr. Saldaña received his BFA in Drama and English Education in 1976, and MFA in Drama in 1979 from the University of Texas at Austin. Saldaña has taught at UT-Austin and Washington State University in Pullman. He was born in Austin, Texas, and currently resides in Phoenix. Professional memberships include: the International Association of Qualitative Inquiry, the American Alliance for Theatre & Education, and the American Educational Research Association.

Matt Omasta

Author Website: www.mattomasta.com

Matt Omasta is Associate Dean of the Caine College of the Arts and Professor of Theatre Arts at Utah State University (USU), where he has taught since 2010. His work focuses on theatre and drama in applied, community-engaged, and educational contexts; theatre for young audiences; and audience / spectator studies. He is particularly interested in exploring how performance impacts human experience. His publications, which have been cited over 700 times, include:

• Play, Performance, and Identity (Routledge, 2015) with Drew Chappell

• Playwriting and Young Audiences (Intellect, 2017) with Nicole B. Adkins

• Qualitative Research: Analyzing Life (2nd edition, SAGE, 2021) with Johnny Saldaña

• Impacting Theatre Audiences: Methods for Studying Change (Routledge, 2022) with Dani Snyder-Young

Dr. Omasta was the inaugural recipient of the Johnny Saldaña Outstanding Professor of Theatre Education award from the American Alliance for Theatre and Education (AATE). Other honors include AATE’s Lin Wright Special Recognition Award and the Founders Award from the Educational Theatre Association. At USU, he has received the university-wide Eldon J. Gardner Teacher of the Year award as well as the Scholar / Creative Artist of the Year, Faculty Mentor of the Year, and Undergraduate Research Mentor of the Year awards from the Caine College of the Arts.

An active leader in theatre arts and education, Dr. Omasta has served three terms on the AATE Board of Directors, as an officer of two arts-focused special interest groups of the American Educational Research Association, and on the American Society for Theatre Research’s Executive Committee.

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Qualitative study.

Steven Tenny ; Janelle M. Brannan ; Grace D. Brannan .

Affiliations

Last Update: September 18, 2022 .

• Introduction

Qualitative research is a type of research that explores and provides deeper insights into real-world problems. [1] Instead of collecting numerical data points or intervene or introduce treatments just like in quantitative research, qualitative research helps generate hypotheses as well as further investigate and understand quantitative data. Qualitative research gathers participants' experiences, perceptions, and behavior. It answers the hows and whys instead of how many or how much. It could be structured as a stand-alone study, purely relying on qualitative data or it could be part of mixed-methods research that combines qualitative and quantitative data. This review introduces the readers to some basic concepts, definitions, terminology, and application of qualitative research.

Qualitative research at its core, ask open-ended questions whose answers are not easily put into numbers such as ‘how’ and ‘why’. [2] Due to the open-ended nature of the research questions at hand, qualitative research design is often not linear in the same way quantitative design is. [2] One of the strengths of qualitative research is its ability to explain processes and patterns of human behavior that can be difficult to quantify. [3] Phenomena such as experiences, attitudes, and behaviors can be difficult to accurately capture quantitatively, whereas a qualitative approach allows participants themselves to explain how, why, or what they were thinking, feeling, and experiencing at a certain time or during an event of interest. Quantifying qualitative data certainly is possible, but at its core, qualitative data is looking for themes and patterns that can be difficult to quantify and it is important to ensure that the context and narrative of qualitative work are not lost by trying to quantify something that is not meant to be quantified.

However, while qualitative research is sometimes placed in opposition to quantitative research, where they are necessarily opposites and therefore ‘compete’ against each other and the philosophical paradigms associated with each, qualitative and quantitative work are not necessarily opposites nor are they incompatible. [4] While qualitative and quantitative approaches are different, they are not necessarily opposites, and they are certainly not mutually exclusive. For instance, qualitative research can help expand and deepen understanding of data or results obtained from quantitative analysis. For example, say a quantitative analysis has determined that there is a correlation between length of stay and level of patient satisfaction, but why does this correlation exist? This dual-focus scenario shows one way in which qualitative and quantitative research could be integrated together.

Examples of Qualitative Research Approaches

Ethnography

Ethnography as a research design has its origins in social and cultural anthropology, and involves the researcher being directly immersed in the participant’s environment. [2] Through this immersion, the ethnographer can use a variety of data collection techniques with the aim of being able to produce a comprehensive account of the social phenomena that occurred during the research period. [2] That is to say, the researcher’s aim with ethnography is to immerse themselves into the research population and come out of it with accounts of actions, behaviors, events, etc. through the eyes of someone involved in the population. Direct involvement of the researcher with the target population is one benefit of ethnographic research because it can then be possible to find data that is otherwise very difficult to extract and record.

Grounded Theory

Grounded Theory is the “generation of a theoretical model through the experience of observing a study population and developing a comparative analysis of their speech and behavior.” [5] As opposed to quantitative research which is deductive and tests or verifies an existing theory, grounded theory research is inductive and therefore lends itself to research that is aiming to study social interactions or experiences. [3] [2] In essence, Grounded Theory’s goal is to explain for example how and why an event occurs or how and why people might behave a certain way. Through observing the population, a researcher using the Grounded Theory approach can then develop a theory to explain the phenomena of interest.

Phenomenology

Phenomenology is defined as the “study of the meaning of phenomena or the study of the particular”. [5] At first glance, it might seem that Grounded Theory and Phenomenology are quite similar, but upon careful examination, the differences can be seen. At its core, phenomenology looks to investigate experiences from the perspective of the individual. [2] Phenomenology is essentially looking into the ‘lived experiences’ of the participants and aims to examine how and why participants behaved a certain way, from their perspective . Herein lies one of the main differences between Grounded Theory and Phenomenology. Grounded Theory aims to develop a theory for social phenomena through an examination of various data sources whereas Phenomenology focuses on describing and explaining an event or phenomena from the perspective of those who have experienced it.

Narrative Research

One of qualitative research’s strengths lies in its ability to tell a story, often from the perspective of those directly involved in it. Reporting on qualitative research involves including details and descriptions of the setting involved and quotes from participants. This detail is called ‘thick’ or ‘rich’ description and is a strength of qualitative research. Narrative research is rife with the possibilities of ‘thick’ description as this approach weaves together a sequence of events, usually from just one or two individuals, in the hopes of creating a cohesive story, or narrative. [2] While it might seem like a waste of time to focus on such a specific, individual level, understanding one or two people’s narratives for an event or phenomenon can help to inform researchers about the influences that helped shape that narrative. The tension or conflict of differing narratives can be “opportunities for innovation”. [2]

Research Paradigm

Research paradigms are the assumptions, norms, and standards that underpin different approaches to research. Essentially, research paradigms are the ‘worldview’ that inform research. [4] It is valuable for researchers, both qualitative and quantitative, to understand what paradigm they are working within because understanding the theoretical basis of research paradigms allows researchers to understand the strengths and weaknesses of the approach being used and adjust accordingly. Different paradigms have different ontology and epistemologies . Ontology is defined as the "assumptions about the nature of reality” whereas epistemology is defined as the “assumptions about the nature of knowledge” that inform the work researchers do. [2] It is important to understand the ontological and epistemological foundations of the research paradigm researchers are working within to allow for a full understanding of the approach being used and the assumptions that underpin the approach as a whole. Further, it is crucial that researchers understand their own ontological and epistemological assumptions about the world in general because their assumptions about the world will necessarily impact how they interact with research. A discussion of the research paradigm is not complete without describing positivist, postpositivist, and constructivist philosophies.

Positivist vs Postpositivist

To further understand qualitative research, we need to discuss positivist and postpositivist frameworks. Positivism is a philosophy that the scientific method can and should be applied to social as well as natural sciences. [4] Essentially, positivist thinking insists that the social sciences should use natural science methods in its research which stems from positivist ontology that there is an objective reality that exists that is fully independent of our perception of the world as individuals. Quantitative research is rooted in positivist philosophy, which can be seen in the value it places on concepts such as causality, generalizability, and replicability.

Conversely, postpositivists argue that social reality can never be one hundred percent explained but it could be approximated. [4] Indeed, qualitative researchers have been insisting that there are “fundamental limits to the extent to which the methods and procedures of the natural sciences could be applied to the social world” and therefore postpositivist philosophy is often associated with qualitative research. [4] An example of positivist versus postpositivist values in research might be that positivist philosophies value hypothesis-testing, whereas postpositivist philosophies value the ability to formulate a substantive theory.

Constructivist

Constructivism is a subcategory of postpositivism. Most researchers invested in postpositivist research are constructivist as well, meaning they think there is no objective external reality that exists but rather that reality is constructed. Constructivism is a theoretical lens that emphasizes the dynamic nature of our world. “Constructivism contends that individuals’ views are directly influenced by their experiences, and it is these individual experiences and views that shape their perspective of reality”. [6] Essentially, Constructivist thought focuses on how ‘reality’ is not a fixed certainty and experiences, interactions, and backgrounds give people a unique view of the world. Constructivism contends, unlike in positivist views, that there is not necessarily an ‘objective’ reality we all experience. This is the ‘relativist’ ontological view that reality and the world we live in are dynamic and socially constructed. Therefore, qualitative scientific knowledge can be inductive as well as deductive.” [4]

So why is it important to understand the differences in assumptions that different philosophies and approaches to research have? Fundamentally, the assumptions underpinning the research tools a researcher selects provide an overall base for the assumptions the rest of the research will have and can even change the role of the researcher themselves. [2] For example, is the researcher an ‘objective’ observer such as in positivist quantitative work? Or is the researcher an active participant in the research itself, as in postpositivist qualitative work? Understanding the philosophical base of the research undertaken allows researchers to fully understand the implications of their work and their role within the research, as well as reflect on their own positionality and bias as it pertains to the research they are conducting.

Data Sampling 

The better the sample represents the intended study population, the more likely the researcher is to encompass the varying factors at play. The following are examples of participant sampling and selection: [7]

• Purposive sampling- selection based on the researcher’s rationale in terms of being the most informative.
• Criterion sampling-selection based on pre-identified factors.
• Convenience sampling- selection based on availability.
• Snowball sampling- the selection is by referral from other participants or people who know potential participants.
• Extreme case sampling- targeted selection of rare cases.
• Typical case sampling-selection based on regular or average participants. 

Data Collection and Analysis

Qualitative research uses several techniques including interviews, focus groups, and observation. [1] [2] [3] Interviews may be unstructured, with open-ended questions on a topic and the interviewer adapts to the responses. Structured interviews have a predetermined number of questions that every participant is asked. It is usually one on one and is appropriate for sensitive topics or topics needing an in-depth exploration. Focus groups are often held with 8-12 target participants and are used when group dynamics and collective views on a topic are desired. Researchers can be a participant-observer to share the experiences of the subject or a non-participant or detached observer.

While quantitative research design prescribes a controlled environment for data collection, qualitative data collection may be in a central location or in the environment of the participants, depending on the study goals and design. Qualitative research could amount to a large amount of data. Data is transcribed which may then be coded manually or with the use of Computer Assisted Qualitative Data Analysis Software or CAQDAS such as ATLAS.ti or NVivo. [8] [9] [10]

After the coding process, qualitative research results could be in various formats. It could be a synthesis and interpretation presented with excerpts from the data. [11] Results also could be in the form of themes and theory or model development.

Dissemination

To standardize and facilitate the dissemination of qualitative research outcomes, the healthcare team can use two reporting standards. The Consolidated Criteria for Reporting Qualitative Research or COREQ is a 32-item checklist for interviews and focus groups. [12] The Standards for Reporting Qualitative Research (SRQR) is a checklist covering a wider range of qualitative research. [13]

Examples of Application

Many times a research question will start with qualitative research. The qualitative research will help generate the research hypothesis which can be tested with quantitative methods. After the data is collected and analyzed with quantitative methods, a set of qualitative methods can be used to dive deeper into the data for a better understanding of what the numbers truly mean and their implications. The qualitative methods can then help clarify the quantitative data and also help refine the hypothesis for future research. Furthermore, with qualitative research researchers can explore subjects that are poorly studied with quantitative methods. These include opinions, individual's actions, and social science research.

A good qualitative study design starts with a goal or objective. This should be clearly defined or stated. The target population needs to be specified. A method for obtaining information from the study population must be carefully detailed to ensure there are no omissions of part of the target population. A proper collection method should be selected which will help obtain the desired information without overly limiting the collected data because many times, the information sought is not well compartmentalized or obtained. Finally, the design should ensure adequate methods for analyzing the data. An example may help better clarify some of the various aspects of qualitative research.

A researcher wants to decrease the number of teenagers who smoke in their community. The researcher could begin by asking current teen smokers why they started smoking through structured or unstructured interviews (qualitative research). The researcher can also get together a group of current teenage smokers and conduct a focus group to help brainstorm factors that may have prevented them from starting to smoke (qualitative research).

In this example, the researcher has used qualitative research methods (interviews and focus groups) to generate a list of ideas of both why teens start to smoke as well as factors that may have prevented them from starting to smoke. Next, the researcher compiles this data. The research found that, hypothetically, peer pressure, health issues, cost, being considered “cool,” and rebellious behavior all might increase or decrease the likelihood of teens starting to smoke.

The researcher creates a survey asking teen participants to rank how important each of the above factors is in either starting smoking (for current smokers) or not smoking (for current non-smokers). This survey provides specific numbers (ranked importance of each factor) and is thus a quantitative research tool.

The researcher can use the results of the survey to focus efforts on the one or two highest-ranked factors. Let us say the researcher found that health was the major factor that keeps teens from starting to smoke, and peer pressure was the major factor that contributed to teens to start smoking. The researcher can go back to qualitative research methods to dive deeper into each of these for more information. The researcher wants to focus on how to keep teens from starting to smoke, so they focus on the peer pressure aspect.

The researcher can conduct interviews and/or focus groups (qualitative research) about what types and forms of peer pressure are commonly encountered, where the peer pressure comes from, and where smoking first starts. The researcher hypothetically finds that peer pressure often occurs after school at the local teen hangouts, mostly the local park. The researcher also hypothetically finds that peer pressure comes from older, current smokers who provide the cigarettes.

The researcher could further explore this observation made at the local teen hangouts (qualitative research) and take notes regarding who is smoking, who is not, and what observable factors are at play for peer pressure of smoking. The researcher finds a local park where many local teenagers hang out and see that a shady, overgrown area of the park is where the smokers tend to hang out. The researcher notes the smoking teenagers buy their cigarettes from a local convenience store adjacent to the park where the clerk does not check identification before selling cigarettes. These observations fall under qualitative research.

If the researcher returns to the park and counts how many individuals smoke in each region of the park, this numerical data would be quantitative research. Based on the researcher's efforts thus far, they conclude that local teen smoking and teenagers who start to smoke may decrease if there are fewer overgrown areas of the park and the local convenience store does not sell cigarettes to underage individuals.

The researcher could try to have the parks department reassess the shady areas to make them less conducive to the smokers or identify how to limit the sales of cigarettes to underage individuals by the convenience store. The researcher would then cycle back to qualitative methods of asking at-risk population their perceptions of the changes, what factors are still at play, as well as quantitative research that includes teen smoking rates in the community, the incidence of new teen smokers, among others. [14] [15]

Qualitative research functions as a standalone research design or in combination with quantitative research to enhance our understanding of the world. Qualitative research uses techniques including structured and unstructured interviews, focus groups, and participant observation to not only help generate hypotheses which can be more rigorously tested with quantitative research but also to help researchers delve deeper into the quantitative research numbers, understand what they mean, and understand what the implications are.  Qualitative research provides researchers with a way to understand what is going on, especially when things are not easily categorized. [16]

• Issues of Concern

As discussed in the sections above, quantitative and qualitative work differ in many different ways, including the criteria for evaluating them. There are four well-established criteria for evaluating quantitative data: internal validity, external validity, reliability, and objectivity. The correlating concepts in qualitative research are credibility, transferability, dependability, and confirmability. [4] [11] The corresponding quantitative and qualitative concepts can be seen below, with the quantitative concept is on the left, and the qualitative concept is on the right:

• Internal validity--- Credibility
• External validity---Transferability
• Reliability---Dependability
• Objectivity---Confirmability

In conducting qualitative research, ensuring these concepts are satisfied and well thought out can mitigate potential issues from arising. For example, just as a researcher will ensure that their quantitative study is internally valid so should qualitative researchers ensure that their work has credibility.  

Indicators such as triangulation and peer examination can help evaluate the credibility of qualitative work.

• Triangulation: Triangulation involves using multiple methods of data collection to increase the likelihood of getting a reliable and accurate result. In our above magic example, the result would be more reliable by also interviewing the magician, back-stage hand, and the person who "vanished." In qualitative research, triangulation can include using telephone surveys, in-person surveys, focus groups, and interviews as well as surveying an adequate cross-section of the target demographic.
• Peer examination: Results can be reviewed by a peer to ensure the data is consistent with the findings.

‘Thick’ or ‘rich’ description can be used to evaluate the transferability of qualitative research whereas using an indicator such as an audit trail might help with evaluating the dependability and confirmability.

• Thick or rich description is a detailed and thorough description of details, the setting, and quotes from participants in the research. [5] Thick descriptions will include a detailed explanation of how the study was carried out. Thick descriptions are detailed enough to allow readers to draw conclusions and interpret the data themselves, which can help with transferability and replicability.
• Audit trail: An audit trail provides a documented set of steps of how the participants were selected and the data was collected. The original records of information should also be kept (e.g., surveys, notes, recordings).

One issue of concern that qualitative researchers should take into consideration is observation bias. Here are a few examples:

• Hawthorne effect: The Hawthorne effect is the change in participant behavior when they know they are being observed. If a researcher was wanting to identify factors that contribute to employee theft and tells the employees they are going to watch them to see what factors affect employee theft, one would suspect employee behavior would change when they know they are being watched.
• Observer-expectancy effect: Some participants change their behavior or responses to satisfy the researcher's desired effect. This happens in an unconscious manner for the participant so it is important to eliminate or limit transmitting the researcher's views.
• Artificial scenario effect: Some qualitative research occurs in artificial scenarios and/or with preset goals. In such situations, the information may not be accurate because of the artificial nature of the scenario. The preset goals may limit the qualitative information obtained.
• Clinical Significance

Qualitative research by itself or combined with quantitative research helps healthcare providers understand patients and the impact and challenges of the care they deliver. Qualitative research provides an opportunity to generate and refine hypotheses and delve deeper into the data generated by quantitative research. Qualitative research does not exist as an island apart from quantitative research, but as an integral part of research methods to be used for the understanding of the world around us. [17]

• Enhancing Healthcare Team Outcomes

Qualitative research is important for all members of the health care team as all are affected by qualitative research. Qualitative research may help develop a theory or a model for health research that can be further explored by quantitative research.  Much of the qualitative research data acquisition is completed by numerous team members including social works, scientists, nurses, etc.  Within each area of the medical field, there is copious ongoing qualitative research including physician-patient interactions, nursing-patient interactions, patient-environment interactions, health care team function, patient information delivery, etc. 

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Disclosure: Steven Tenny declares no relevant financial relationships with ineligible companies.

Disclosure: Janelle Brannan declares no relevant financial relationships with ineligible companies.

Disclosure: Grace Brannan declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

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Choosing and accessing COVID-19 treatment options: a qualitative study with patients, caregivers, and health care providers in Lebanon

• Reem Hoteit   ORCID: orcid.org/0000-0001-8139-9321 1 ,
• Aya Hassoun 2 ,
• Elie Bou Sanayeh 3 ,
• Marie Christelle Saade 3 ,
• Gladys Honein-AbouHaidar 4 &
• Elie A. Akl   ORCID: orcid.org/0000-0002-3444-8618 3 , 5  

Health Research Policy and Systems volume  22 , Article number:  38 ( 2024 ) Cite this article

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The coronavirus disease 2019 (COVID-19) pandemic has strained healthcare systems globally, particularly in terms of access to medicines. Lebanon has been greatly affected by the pandemic, having faced concomitant financial and economic crises. The objective of the study was to understand the experiences of patients with COVID-19 in Lebanon, as well as those of their families, and healthcare providers, with regards to their treatment decisions and accessibility to COVID-19 medicines.

For this qualitative study, we conducted 28 semi-structured interviews. We used purposive sampling to recruit participants with a diverse range of perspectives. The data collection phase spanned from August to November 2021 and was conducted virtually. After transcribing and translating the interviews, we employed thematic analysis to identify recurring themes and patterns.

In total, 28 individuals participated in this study. Participants highlighted challenges owing to the COVID-19 pandemic and economic crisis. Accessing COVID-19 medicines posed major hurdles for physicians and patients, given limited availability, global shortages, local circumstances, community hoarding and stockpiling by pharmacies. Providers based treatment decisions on research, local and international practice guidelines, experiences and expert feedback. Patients sought information from social media, community members and physicians, as well as through word of mouth. Accessing medicines involved navigating the healthcare system, the black market, charities, personal networks and political parties and sourcing from abroad. The medicines were either free, subsidized or at inflated costs.

Conclusions

This study highlights the diversity and complexity of factors influencing decision-making and accessing medicines during the COVID-19 pandemic in Lebanon. Future research should explore strategies for ensuring medicine access during crises, drawing insights from comparative studies across different countries.

Peer Review reports

Introduction

The emergence of the coronavirus disease 2019 (COVID-19) instigated a global health crisis, presenting formidable challenges to healthcare systems and economies across the world [ 1 , 2 ]. Since its first appearance in December 2019 in China, severe acute respiratory coronavirus 2 (SARS-CoV-2) has infected around 700 million individuals, resulting in a staggering death toll exceeding 6.9 million by November 2023 [ 3 , 4 ]. Owing to COVID-19-related lockdowns and the heightened demand for essential medications, drug shortages have become a significant global problem [ 5 , 6 ].

Prior to the pandemic, healthcare systems in low- and middle-income countries (LMICs) suffered from limited financial resources, healthcare workforce shortages and unavailability of medications [ 7 , 8 , 9 ]. The pandemic further strained these already fragile health systems [ 2 ]. For example, the strong demand for medications to treat COVID-19 patients, including analgesics, sedatives, antibiotics, hydroxychloroquine and remdesivir, considerably affected medication accessibility and inadvertently encouraged black market activity [ 10 , 11 , 12 , 13 ]. Escalating medication prices rendered these crucial medications unaffordable for many patients, particularly in LMICs [ 13 , 14 , 15 ].

The economic and financial crises in Lebanon, coupled with the Beirut Port’s destruction, severely impacted the entire healthcare sector, affecting hospitals, healthcare providers and the pharmaceutical and medical supply industry [ 16 ]. The COVID-19 pandemic worsened this situation, posing two major challenges: the selection of appropriate therapies and ensuring access to these treatments [ 17 , 18 ]. This shortage of prescription drugs in Lebanon peaked during the COVID-19 pandemic [ 19 ].

Factors influencing decisions regarding COVID-19 treatment can be complicated and multidimensional. They encompass an individual patient’s medical history, comorbidities and risk factors, as well as the availability and efficacy of various therapeutic options [ 20 ]. Therapeutic management in the early stages of the pandemic was challenging owing to uncertainty and continuously evolving evidence [ 21 ]. Clinicians attempted to manage COVID-19 using a variety of treatments that targeted numerous possible mechanisms, such as antiviral, anti-inflammatory and immunomodulatory drugs [ 22 ]. There was also misinformation in various media outlets about the benefits of some medications for either preventing or treating COVID-19 [ 23 ]. This resulted in an increase in risky self-medication with several over-the-counter medications [ 2 , 24 ].

The objective of the study is to understand the experiences of patients with COVID-19 in Lebanon, as well as those of their families, and healthcare providers, with regards to their treatment decisions and accessibility to COVID-19 medicines.

Study design

This study adopted a descriptive qualitative research design using semi-structured individual interviews (refer to Appendix 1 for the interview guide). The qualitative approach utilized is rooted in naturalistic inquiry and offers a wide array of theoretical or philosophical orientations, sampling techniques and data-gathering strategies [ 25 ].

Participants

We recruited participants from different regions in Lebanon. Eligible participants belonged to one of the following groups:

physicians and nurses directly involved in caring for patients diagnosed with COVID-19

hospital and community pharmacists involved in dispensing medications for patients diagnosed with COVID-19

patients previously diagnosed with COVID-19

family members or caregivers of patients previously diagnosed with COVID-19.

We excluded patients who were psychologically unable to participate or provide coherent and clear descriptions of their experiences.

Sampling and recruitment

We used purposeful sampling by approaching individuals belonging to the groups of interest. We also used snowballing sampling by asking participants to refer us to other eligible individuals. Additionally, physicians and pharmacists assisted in the recruitment of potential former patients and caregivers. The Institutional Review Board (IRB) at the American University of Beirut (AUB) approved the study. All participants provided oral consent prior to participation. The interviewers took all precautions to guarantee participants’ anonymity and confidentiality. Participants were informed that their participation was entirely voluntary and that they could opt-out at any time.

Data collection

Following an explanation of the study’s objectives, we interviewed participants virtually in either English or Arabic, depending on their preferences. We audio-recorded interviews following participants’ consent. We conducted a total of 28 interviews, and we ceased to collect data when thematic saturation was reached, that is, no new themes emerged from the data analysis [ 26 ].

Two team members (AH and EBS) conducted the interviews between August and November of 2021. The individuals received thorough training on conducting interviews, focusing on techniques to remain neutral and nonjudgemental and to sustain the interviewees’ engagement in the subject matter. To enhance the quality of data collection, we held regular debriefing meetings following the initial interviews. These meetings provided an opportunity for reflection on the data collection process and identification of areas of improvement.

Data analysis

The interviewers transcribed the audio-recorded interviews, and translated them into English when applicable. Another team member (RH) verified transcript accuracy by checking them against the audio recordings. We employed Quirkos, a qualitative analysis software, for coding and organizing the data. We applied Braun and Clarke’s six-step thematic analysis approach [ 27 ]. In phase 1, GHA and RH read a few transcripts independently to familiarize themselves with the information and established a preliminary framework for data coding. In phase 2, they independently annotated the transcripts line by line. They assigned labels to each idea (coding), leaving room for new codes as they emerged. In phase 3, GHA, EAA and RH reviewed the coded transcripts and identified emerging themes, along with quotes that illustrated each theme. In phase 4, GHA, EAA and RH reviewed and refined the list of emerging themes, and created a thematic map. In phase 5, they outlined the final thematic framework. Finally, in phase 6, we developed a complete narrative of the findings and selected interviewee quotes for each theme and sub-theme.

Increasing rigour

All interviewers received training in interviewing skills, maintaining consistency and rigour [ 28 ]. We also made sure that interviewers had no prior relationship with participants, fostering objectivity and minimizing bias [ 28 ]. We interviewed participants in their preferred language as a way to ensure their understanding of the questions and their ability to easily express their thoughts [ 28 , 29 ]. To ensure transferability, we employed triangulation by compiling viewpoints of various population groups [ 29 ]. We halted data collection upon reaching saturation [ 30 ], ensuring comprehensive data coverage and depth. We verified transcript accuracy by checking them against the audio recordings [ 31 ]. Three members of our research team (GHA, EAA and RH) actively participated in the analysis and the generation of codes, themes and subthemes. In reporting this study, we adhered to the highest standards by following the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [ 32 ].

Demographics

We recruited 28 participants: 3 community pharmacists, 4 hospital pharmacists, 8 physicians, 1 nurse, 3 patients and 9 caregivers. The interviews lasted about 40 min on average.

Emerging themes

The following themes emerged in relation to the experiences of participants with regards to treatment decisions and accessibility to COVID-19 medicines: country crises, access challenges, cost challenges, drivers for providers’ decision-making, drivers for patients and caregivers’ decision-making and accessing medicines (Fig.  1 ).

Factors influencing decision-making and accessing medicines during the COVID-19 pandemic in Lebanon

When the majority of participants expressed the same opinions, we used the term “most participants”; otherwise, we used the terms “many” or “few” as appropriate. When citing quotes from participants, we used the following acronyms: physicians (Phys), nurses (Nurse), community pharmacists (C-Pharm), hospital pharmacists (H-Pharm), patients (Pt) and caregivers (Cg).

Country crises

Most participants discussed current events in the country, including the COVID-19 pandemic, the economic crisis and the financial crisis. “Because of the current situation in Lebanon, we’re seeing things we never thought we would” (H-Pharm 02). “COVID-19 came around in March 2020, and Lebanon had already started its economic crisis” (H-Pharm 04).

Participants noted their experiences with the financial crisis and the closure of banks. “I woke up in the morning at 6:45 am, wore my clothes and went down to the bank but found it closed […], I went down to [..], same thing, it closed as I was on my way so I said, ‘where should I get them the money now?; they asked for money for the tests” (Cg 08).

One caregiver also mentioned that the economic crisis had forced them to work multiple jobs. “I work two jobs but now if you work in Lebanon the salaries are not enough” (Cg 08).

In addition to this, participants complained about how the country’s financial situation impacted access to medicines. “The purchasing power of the patients had already decreased. And like all countries when it comes to medication and the healthcare system, which was already collapsing in Lebanon, it’s common that in the end, the patient has to self-fund their treatment. And patients in low economical standing will have no access to treatment” (H-Pharm 04).

Access challenges

The crisis impacted the supply of COVID-19 medications. First, there were drug shortages directly related to the COVID-19 medicines, similar to the global crisis “… we saw that everyone is facing this, worldwide… Then we went into shortages, we didn’t have anymore because the consumption had increased” (H-Pharm 02). “Even the Colchicine, we heard about it, and we went around and looked for it and it was very hard for us to find it easily” (Cg 02).

“For example, remdesivir they used for my mother-in-law we got six injections, and the first day we tried to get it we called the pharmacies they told us they don’t have it. In the hospital, there was no remdesivir because it was getting brought based on an order from the company and it needed a prescription from the doctor to obtain” (Cg 01).

Second, the challenging circumstances in Lebanon had an additional impact on the accessibility of medicines. “The effect of the medications is unrelated to COVID-19. I mean, the availability of the medications. Now, even after COVID-19 has decreased, we have shortages in medications that are unrelated to COVID-19, it has to do with the economic situation. So, it’s not COVID-19 that made the crisis in medications, not at all” (Phys 08). “It was hard to provide medications because of the terrible situation of Lebanon” (Nurse 01).

Many pharmacists discussed community hoarding. “People were running to the pharmacies to secure one of these medications even if they did not need it at the time, just for the sake of keeping it at home just in case, which led to a huge shortage of supply” (C-Pharm 02).

However, patients were concerned about pharmacies stockpiling medications. “Exactly, because of the economic crisis selling the drug was not beneficial for the pharmacies so they started keeping it for emergency cases and selling it at the black market rate. After all the demand was very high” (Cg 07).

Few physicians mentioned lack of availability of medicines specifically in the hospitals, particularly for the new medications. “They had to get the medications outside of the hospital…the shortage was due to the fact that basically, this is a new medication, and it hasn’t been brought to Lebanon yet.” (Phys 08).

A few pharmacists stated that they always had a backup plan. “To be honest we never had really bad shortages, we never fully ran out, we always had a plan B. When there was no more dexamethasone for IV, we prepared other corticoids, even if it wasn’t mentioned in any studies or guidelines. We used to prepare them and keep them as backups in case they were ever needed” (H-Pharm 04).

Cost challenges

Both providers and patients noted unaffordable costs as another factor affecting access to medications, considering the devaluation of the currency. “The single pill got to about 50 USD, it was very expensive. So, it was really expensive for most people. Its actual price was 5000 Lira” [H-Pharm 04; note that at the time 5000 Lira was worth less than 5 US dollars (USD)]. “Even tablets like vitamins are available but they are very expensive, not everyone can afford them” (Cg 04).

Patients complained about price manipulation. “The prices were definitely manipulated because when I would buy a medication I would find more than one price tag… The lozenges for her throat used to cost 19 000 Lira and now it costs 45 000 Lira. They put more than one label on the box of medication, there are about three price tags on it” (Cg 06).

Additionally, it was mentioned that the pricing of medications was changed to the US currency. “Yes, most of the time they were fresh dollar” (Phys 08).

Drivers of decision-making for providers

During the COVID-19 pandemic, several factors influenced decisions by providers, patients and caregivers about which medicines to use or not use.

Owing to the rapid development of evidence, providers were compelled to rely on research to prescribe certain medications. “There was a committee that used to review the data available and to review all the evidence at the time and make the decisions.” (Phys 04). “… the COVID-19 protocol changed every couple of days. Every once in a while, a new study would appear, a new update, and it would change again” (H-Pharm 01).

Providers also relied on clinical practice guidelines developed either locally or internationally, for example, by the WHO. “The medications we were prescribing were based on WHO” (Phys 03). Although they relied on those guidelines, some providers expressed hesitations about them. “Yes, we were following the guidelines of treatment of COVID-19, we would tell this is the medication that needs to be taken because this is what the guidelines say. We are not sure of the guidelines, but this is what is needed now” (Phys 09).

Additionally, the providers’ prior experience or trial and error played a role in the decision-making process. “At first, personally, I did not have much experience with this disease but later on and after I acquired some experience, I was finally able to give my own opinion on the matter” (C-Pharm 01).

Reliance on local peers with different specialities played a significant role in decision-making. “Because we had several specialities – cardiovascular, internal medicine, and others – everyone did their research and every week we would meet and explain to each other… Everyone gave their inputs and propositions, in their own specialities, about which drugs might be good, and which drugs were used in which cases” (H-Pharm 04).

International expertise was also sought during the pandemic. “We also had video conferences with hospitals and ICUs in France and the United States, because we had physicians that went and studied in those countries and still had contacts, we did one video conference with France, and one with the US to ask about their protocols. And there were discussions about what’s best. And when Actemra was first being used by the ones we talked to somewhere in Houston, we weren’t using it yet in our hospital. After the video conference, they found that their patients are showing good results, so it was added to our protocol..” (H-Pharm 04).

It is of note that the country’s situation and drug availability influenced the decision-making process. As expressed by many doctors: “We were following the new guidelines, taking into consideration the situation of the country and the availability of the drugs and imaging” (Phys 02).

Drivers of decision-making for patients and caregivers

Patients and caregivers relied on social media to decide on drug purchases. “Yes. Honestly, they saw me crying and I had posted on Instagram that if anyone please could help with their experience because there were no studies at that time” (Cg 03). “At first people used to wait for what the media says and then come running to the pharmacies to buy these medications, it happened first with vitamin C then 2 weeks later with vitamin D then it was the zinc 25 mg and then zinc 50 mg turns” (C-Pharm 01). “Even the colchicine, we heard about it on social media, and we went around and looked for it and it was very hard for us to find easily” (Cg 02).

Patients and caregivers were also influenced by people in their communities, some of whom had experience with COVID-19. “Other people around us who also had corona, everyone that got corona would say take this and do this” (Pt 02). “My dad caught it in the beginning, so I started asking people to see what we could do. One of my friends told me that there was a person who took this medicine, and they told me to try it, so I decided to do that” (Cg 03).

Patients reported different attitudes about consulting with their doctors. “We heard about remdesivir and asked the doctor, he told us he can’t advise us to take it or not, if we would like to try it based on other patients and not on medical research then go ahead” (Cg 07). Some made decisions on their own on the basis of word of mouth. “My friend called me and told to me not listen to the doctors and to take zithromax. I bought it and took one pill” (Pt 08).

Accessing medicines

We have identified two subthemes under the theme of “accessing medicines”: information about how to get the medicines and the sources of medicines.

Information about how to get the medicines

Typically, patients obtained information about how to get the medicines from healthcare providers, including nurses, physicians and pharmacists. “Yes sure!… [local charities] used to give those medications (remdesivir, Actemra, etc.) for free. And there were some other providers. We used to indicate the providers to the families of the patients” (Nurse 01).

Patients also inquired about the source of medicines from recovered COVID-19 patients: “From other people around us who also had corona” (Pt 02).

Sources of medicines

Patients and their caregivers obtained the medicines either through the healthcare system or from outside the healthcare systems, including the black market, nongovernmental organizations (NGOs), personal networks, political parties and outside of the country.

• Healthcare system

When patients were admitted, few reported that COVID-19 medicines were available in the hospital. “They were all found in the hospital” (Cg 05). However, for several patients, their family members had to seek medicines from community pharmacies. “We got them from the pharmacy” (Cg 01).

Medicines were obtained at no cost thanks to a subsidy by the Lebanese government. “So, it was for free if it was from the Ministry” (Cg 02). However, some other medicines were purchased on an unsubsidized basis and at high cost. “A few pills were for 1 300 000 Lebanese Lira in the pharmacy” (Cg 02).

• Black market

Owing to the limited supply and urgent need for COVID-19 medications, the black market flourished. “There were two more weeks, and the Ministry was supposed to secure it, but we needed it urgently, so they gave us the number of someone who sells it in the black market and he got it for us” (Pt 03).

The black market was viewed as a double-edged sword because it allowed access but at an inflated cost. “They gave us five remdesivir and one Actemra for US$ 1200” (Cg 07). “The remdesivir is like. So, he made us pay US$ 700 for one,.. So, US$ 4200 for six pills” (Pt 03).

Because of the country’s financial crisis, inflated black market prices presented a major challenge for patients. “… it was a challenge for us to financially secure the medicine. And of course, him asking for US$ 4200 cash was not something easy for someone to get and pay, but if it is the only solution of course we would do it” (Pt 03).

Charities supported patients in accessing their medicines either for free or through financial support. “Suppose I were to get COVID-19 now, my name would go down at the municipality and they get you vitamin C and vitamin D – a charity organization, not from the government” (Cg 08). “I paid 1 million and the rest was on the charity organization” (Cg 08); “For ivermectin there were a lot of organizations trying to supply it, it’s a very cheap drug… that costs US$ 4. There were also a lot of organizations trying to supply remdesivir, ‘Hariri’ (a local charity) was trying to help with it since hospitals did not have it, people were going to her villa to get it, it costs I think about US$ 4000” (Phys 02).

Personal network

Caregivers of patients with COVID-19 used their personal networks, including family and friends: “Also, from a person who knows a pharmacist he’s friends with, they got them for us” (Cg 02). “We had to get the baricitinib from someone we know, who got it for us from the Ministry” (Cg 02).

Political parties

Political parties also supplied medicines to their supporters. “There were parties that were obtaining them, like [name of political parties]. Those were for free as a donation from [name of political party]” (Pt 02).

From outside of the country

Typically, family or friends helped by purchasing medicines while travelling. “At the time, an Iraqi who is friends with my relative got it and he paid US$ 400” (Pt 08).

Out-of-country purchases were driven by either lack of local supply or inflated costs. “The ivermectin was still not in Lebanon, so we got it elsewhere, from a woman who lives in Africa, she got it for us and sent it. And we started with cortisone, this is from day 1” (Cg 02). “My cousin sent it from Sweden, she sent zinc and vitamin C because vitamin C here now costs 60 000 Lira, before it cost 14 000 Lira and now it costs 60 000” (Cg 06).

This study aimed to to understand the experiences of patients with COVID-19 in Lebanon, as well as those of their families, physicians, nurses and pharmacists, with regards to their treatment decisions and accessibility to COVID-19 medicines.

The participants highlighted the country’s difficulties, especially the severe impact of COVID-19 pandemic and the economic crisis. Access to COVID-19 medicines and their costs were major challenges according to the three groups interviewed. Limited access related to global shortage of medicines, the local challenging circumstances, community hoarding (according to pharmacists) and stockpiling by pharmacies (according to patients). For providers, the decision-making process for COVID-19 treatments was shaped by research evidence, local and international practice guidelines, previous experiences and feedback from both local and international experts. Patients and their caregivers relied on social media, community members, physicians and word of mouth. Information on how to get the medicines was obtained from either healthcare providers or patients who recovered from COVID-19. Accessing medicines involved navigating through the healthcare system (hospitals and pharmacies), as well as outside that system, including the black market, charities, personal networks, political parties and outside of the country. Across these different sources, the medicines were either free, subsidized or at inflated costs.

Comparison to similar studies

A major finding in our study was the accessibility of patients and healthcare providers to needed medicines. This is corroborated by other studies conducted in Lebanon [ 33 , 34 ] and low-and middle-income countries [ 35 ]. The global impact of lockdowns on medicine manufacturing, supply and distribution contributed to shortages during the high-demand period of the COVID-19 pandemic [ 36 , 37 ]. Furthermore, Lebanon has faced severe economic and financial crises starting in 2019, which severely hindered the capacity to import vital healthcare equipment and medicines [ 38 , 39 ]. Indeed, the World Bank characterized the crisis as “among the world’s worst since the 1850s” [ 40 ]. The lack of government reimbursement further hindered hospitals in procuring necessary medications and medical supplies [ 41 ]. Consequently, individuals affected by COVID-19 in Lebanon resorted to unregulated sources, including the black market, often resulting in inflated prices and the risk of expired or counterfeit drugs [ 13 , 14 , 15 , 42 ].

Moreover, in line with our findings, other studies found that healthcare providers followed both international and national guidelines when deciding on potential treatments for COVID-19 patients [ 43 , 44 ]. However, in the absence of effective medications, discussion on various social media platforms encouraged self-medication and the use of herbal medicines [ 45 , 46 ]. In addition, a recent study conducted in Jordan assessing the usage of medications and natural products amidst the second wave of COVID-19 revealed that individuals primarily sought guidance from family and friends, with social media platforms serving as significant sources of advice concerning the use of these medications [ 47 ]. The same study showed that pharmacists notably played a significant role in guiding individuals on choosing these treatments compared with other healthcare providers [ 47 ].This highlights the impact of social media on treatment choices and emphasizes the need for disseminating accurate and evidence-based information.

Strengths and limitations

To our knowledge, this is the first study in Lebanon to comprehensively explore the interplay between country crises and medication accessibility during the COVID-19 pandemic, offering valuable insights into the unique challenges faced by the country. We explored in-depth the lived experiences of our participants, ensuring the representation of the perspectives of healthcare providers, patients and caregivers. Also, we used a rigorous qualitative methodology (please refer to the “Increasing rigour” section).

There are several limitations to consider. Firstly, the study focuses primarily on Lebanon, which may limit the findings’ generalizability to other countries with distinct settings and healthcare systems. Moreover, there is a possibility of recall bias among participants, as their recollections of events and experiences concerning medication accessibility during the crisis might be influenced by subjective interpretations or memory lapses. Additionally, the sampling technique employed might introduce selection bias, as participants were recruited through purposive sampling. Furthermore, it is important to note that this study is based on a specific snapshot in time during the COVID-19 pandemic. Consequently, its findings may not fully encapsulate the dynamic and evolving nature of the crisis or account for potential shifts in medication accessibility and decision-making processes over time.

This study sheds light on the wide range of factors influencing treatment decisions during the COVID-19 pandemic in Lebanon. It also unveils how patients and their families had to access medications either through the formal healthcare systems or through black markets and other channels. Plans are needed to address medicine availability, affordability and equitable distribution during similar future crises. There is an urgent need for collaborative efforts involving stakeholders, policy-makers and key systems such as Meditrack and AMAN within the Ministry of Public Health [ 48 , 49 ]. These initiatives are intended to establish resilient and sustainable drug supply chains and to ensure timely and equitable access to medications for all individuals, particularly in times of crisis. Furthermore, improving collaboration among healthcare providers, expediting medication access and creating patient support programs can alleviate the difficulties that people seeking treatment confront. For example, streamlining communication between hospitals, pharmacies and primary care doctors could speed up the prescription and dispensing processes.

Future research should focus on effective strategies to ensure medicine access during crises. Comparative research across different countries can provide valuable insights into successful tactics that can be tailored across different countries.

What is already known on this topic

global healthcare systems have been strained owing to the COVID-19 pandemic, leading to challenges in medicine access; and

Lebanon’s healthcare system has been significantly impacted by the pandemic and financial crises, affecting the availability of medicines.

What this study adds

it uncovers key factors influencing both healthcare providers and patients in their treatment decisions, providing a comprehensive perspective; and

it describes varied sources for medicines, including informal networks and the black market.

How this study might affect research, practice or policy

the findings emphasize the necessity for strategies that ensure continuous medicine access, particularly during times of crises and economic instability.

Availability of data and materials

The datasets analysed during the current study available from the corresponding author on reasonable request.

Abbreviations

American University of Beirut

Consolidated Criteria for Reporting Qualitative Research

Coronavirus disease 2019

Community pharmacists

Hospital pharmacists

Institutional review board

Low- and middle-income countries

Lebanese Ministry of Public Health

Nongovernmental organizations

Severe acute respiratory syndrome coronavirus 2

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Hoteit, R., Hassoun, A., Bou Sanayeh, E. et al. Choosing and accessing COVID-19 treatment options: a qualitative study with patients, caregivers, and health care providers in Lebanon. Health Res Policy Sys 22 , 38 (2024). https://doi.org/10.1186/s12961-024-01131-9

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Rainstorms impacts on water, sediment, and trace elements loads in an urbanized catchment within Moscow city: case study of summer 2020 and 2021

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In 2020 and 2021, the city of Moscow, Russia, has experienced two historical rainfall events that had caused major flooding of small rivers. Based on long-term observation datasets from the surrounding weather stations, regional mesoscale COSMO-CLM climate model results, and a detailed hydrological and water quality monitoring data, we performed a pioneer assessment of climate change and urbanization impact on flooding hazard and water quality of the urban Setun River as a case study. Statistically significant rise of some moderate ETCCDI climate change indices (R20mm and R95pTOT) was revealed for the 1966–2020 period, while no significant trends were observed for more extreme indices. The combined impact of climate change and increased urbanization is highly non-linear and results in as much as a fourfold increase in frequency of extreme floods and shift of water regime features which lead to formation of specific seasonal flow patterns. The rainstorm flood wave response time, involving infiltrated and hillslope-routed fraction of rainfall, is accounted as 6 to 11 h, which is more than twice as rapid as compared to the non-urbanized nearby catchments. Based on temporal trends before and after rainfall flood peak, four groups of dissolved chemicals were identified: soluble elements whose concentrations decrease with an increase in water discharge; mostly insoluble and well-sorted elements whose concentrations increase with discharge (Mn, Cs, Cd, Al); elements negatively related to water discharge during flood events (Li, B, Cr, As, Br and Sr); and a wide range of dissolved elements (Cu, Zn, Mo, Sn, Pb, Ba, La, Cs, U) which concentrations remain stable during rainfall floods. Our study identifies that lack of research focused on the combined impacts of climate change and urbanization on flooding and water quality in the Moscow urban area is a key problem in water management advances.

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Field studies were supported by Russian Science Foundation project 19–77-30004. The analytical experiments were done under Ministry of Science and Higher Education of Russian Federation project 075–15-2021–574. COSMO-CLM model setup is a part of RFBR project 21–55-53039. The methodology of this study is developed under the Interdisciplinary Scientific and Educational School of Lomonosov Moscow State University «Future Planet and Global Environmental Change» and Kazan Federal University Strategic Academic Leadership Program (“PRIORITY-2030”). The research is carried out using the equipment of the shared research facilities of HPC computing resources at Lomonosov Moscow State University. Streamflow patterns analysis was carried out under Governmental Order to Water Problems Institute, Russian Academy of Sciences, subject no. FMWZ-2022–0003, project 3.7.

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Sergey Chalov, Vladimir Platonov, Oxana Erina, Vsevolod Moreido, Mikhail Samokhin, Dmitriy Sokolov, Maria Tereshina, Yulia Yarinich & Nikolay Kasimov

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Conceptualization, original draft preparation—Sergey Chalov; numerical experiments conducting and evaluation, precipitation data analysis, writing—Vladimir Platonov; the rainfall-runoff patterns analysis—Vsevolod Moreido; methodology, validation, writing—Oxana Erina, Dmitriy Sokolov, Maria Tereshina, Mikhail Samokhin; precipitation data preparation and visualization—Yulia Yarinich; review, editing—Nikolay Kasimov. All authors have read and agreed to the published version of the manuscript.

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Chalov, S., Platonov, V., Erina, O. et al. Rainstorms impacts on water, sediment, and trace elements loads in an urbanized catchment within Moscow city: case study of summer 2020 and 2021. Theor Appl Climatol 151 , 871–889 (2023). https://doi.org/10.1007/s00704-022-04298-9

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