qualitative research dissertation interviews

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Tips for a qualitative dissertation

Veronika Williams

17 October 2017

Tips for students

This blog is part of a series for Evidence-Based Health Care MSc students undertaking their dissertations.

Undertaking an MSc dissertation in Evidence-Based Health Care (EBHC) may be your first hands-on experience of doing qualitative research. I chatted to Dr. Veronika Williams, an experienced qualitative researcher, and tutor on the EBHC programme, to find out her top tips for producing a high-quality qualitative EBHC thesis.

1) Make the switch from a quantitative to a qualitative mindset

It’s not just about replacing numbers with words. Doing qualitative research requires you to adopt a different way of seeing and interpreting the world around you. Veronika asks her students to reflect on positivist and interpretivist approaches: If you come from a scientific or medical background, positivism is often the unacknowledged status quo. Be open to considering there are alternative ways to generate and understand knowledge.

2) Reflect on your role

Quantitative research strives to produce “clean” data unbiased by the context in which it was generated.  With qualitative methods, this is neither possible nor desirable.  Students should reflect on how their background and personal views shape the way they collect and analyse their data. This will not only add to the transparency of your work but will also help you interpret your findings.

3)  Don’t forget the theory

Qualitative researchers use theories as a lens through which they understand the world around them. Veronika suggests that students consider the theoretical underpinning to their own research at the earliest stages. You can read an article about why theories are useful in qualitative research  here.

4) Think about depth rather than breadth

Qualitative research is all about developing a deep and insightful understanding of the phenomenon/ concept you are studying. Be realistic about what you can achieve given the time constraints of an MSc.  Veronika suggests that collecting and analysing a smaller dataset well is preferable to producing a superficial, rushed analysis of a larger dataset.

5) Blur the boundaries between data collection, analysis and writing up

Veronika strongly recommends keeping a research diary or using memos to jot down your ideas as your research progresses. Not only do these add to your audit trail, these entries will help contribute to your first draft and the process of moving towards theoretical thinking. Qualitative researchers move back and forward between their dataset and manuscript as their ideas develop. This enriches their understanding and allows emerging theories to be explored.

6) Move beyond the descriptive

When analysing interviews, for example, it can be tempting to think that having coded your transcripts you are nearly there. This is not the case!  You need to move beyond the descriptive codes to conceptual themes and theoretical thinking in order to produce a high-quality thesis.  Veronika warns against falling into the pitfall of thinking writing up is, “Two interviews said this whilst three interviewees said that”.

7) It’s not just about the average experience

When analysing your data, consider the outliers or negative cases, for example, those that found the intervention unacceptable.  Although in the minority, these respondents will often provide more meaningful insight into the phenomenon or concept you are trying to study.

8) Bounce ideas

Veronika recommends sharing your emerging ideas and findings with someone else, maybe with a different background or perspective. This isn’t about getting to the “right answer” rather it offers you the chance to refine your thinking.  Be sure, though, to fully acknowledge their contribution in your thesis.

9) Be selective

In can be a challenge to meet the dissertation word limit.  It won’t be possible to present all the themes generated by your dataset so focus! Use quotes from across your dataset that best encapsulate the themes you are presenting.  Display additional data in the appendix.  For example, Veronika suggests illustrating how you moved from your coding framework to your themes.

10) Don’t panic!

There will be a stage during analysis and write up when it seems undoable.  Unlike quantitative researchers who begin analysis with a clear plan, qualitative research is more of a journey. Everything will fall into place by the end.  Be sure, though, to allow yourself enough time to make sense of the rich data qualitative research generates.

Related course:

Qualitative research methods.

Short Course

How To Write The Results/Findings Chapter

For qualitative studies (dissertations & theses).

By: Jenna Crossley (PhD). Expert Reviewed By: Dr. Eunice Rautenbach | August 2021

So, you’ve collected and analysed your qualitative data, and it’s time to write up your results chapter. But where do you start? In this post, we’ll guide you through the qualitative results chapter (also called the findings chapter), step by step. 

Overview: Qualitative Results Chapter

• What (exactly) the qualitative results chapter is
• What to include in your results chapter
• How to write up your results chapter
• A few tips and tricks to help you along the way
• Free results chapter template

What exactly is the results chapter?

The results chapter in a dissertation or thesis (or any formal academic research piece) is where you objectively and neutrally present the findings of your qualitative analysis (or analyses if you used multiple qualitative analysis methods ). This chapter can sometimes be combined with the discussion chapter (where you interpret the data and discuss its meaning), depending on your university’s preference.  We’ll treat the two chapters as separate, as that’s the most common approach.

In contrast to a quantitative results chapter that presents numbers and statistics, a qualitative results chapter presents data primarily in the form of words . But this doesn’t mean that a qualitative study can’t have quantitative elements – you could, for example, present the number of times a theme or topic pops up in your data, depending on the analysis method(s) you adopt.

Adding a quantitative element to your study can add some rigour, which strengthens your results by providing more evidence for your claims. This is particularly common when using qualitative content analysis. Keep in mind though that qualitative research aims to achieve depth, richness and identify nuances , so don’t get tunnel vision by focusing on the numbers. They’re just cream on top in a qualitative analysis.

So, to recap, the results chapter is where you objectively present the findings of your analysis, without interpreting them (you’ll save that for the discussion chapter). With that out the way, let’s take a look at what you should include in your results chapter.

What should you include in the results chapter?

As we’ve mentioned, your qualitative results chapter should purely present and describe your results , not interpret them in relation to the existing literature or your research questions . Any speculations or discussion about the implications of your findings should be reserved for your discussion chapter.

In your results chapter, you’ll want to talk about your analysis findings and whether or not they support your hypotheses (if you have any). Naturally, the exact contents of your results chapter will depend on which qualitative analysis method (or methods) you use. For example, if you were to use thematic analysis, you’d detail the themes identified in your analysis, using extracts from the transcripts or text to support your claims.

While you do need to present your analysis findings in some detail, you should avoid dumping large amounts of raw data in this chapter. Instead, focus on presenting the key findings and using a handful of select quotes or text extracts to support each finding . The reams of data and analysis can be relegated to your appendices.

While it’s tempting to include every last detail you found in your qualitative analysis, it is important to make sure that you report only that which is relevant to your research aims, objectives and research questions .  Always keep these three components, as well as your hypotheses (if you have any) front of mind when writing the chapter and use them as a filter to decide what’s relevant and what’s not.

Need a helping hand?

How do I write the results chapter?

Now that we’ve covered the basics, it’s time to look at how to structure your chapter. Broadly speaking, the results chapter needs to contain three core components – the introduction, the body and the concluding summary. Let’s take a look at each of these.

Section 1: Introduction

The first step is to craft a brief introduction to the chapter. This intro is vital as it provides some context for your findings. In your introduction, you should begin by reiterating your problem statement and research questions and highlight the purpose of your research . Make sure that you spell this out for the reader so that the rest of your chapter is well contextualised.

The next step is to briefly outline the structure of your results chapter. In other words, explain what’s included in the chapter and what the reader can expect. In the results chapter, you want to tell a story that is coherent, flows logically, and is easy to follow , so make sure that you plan your structure out well and convey that structure (at a high level), so that your reader is well oriented.

The introduction section shouldn’t be lengthy. Two or three short paragraphs should be more than adequate. It is merely an introduction and overview, not a summary of the chapter.

Pro Tip – To help you structure your chapter, it can be useful to set up an initial draft with (sub)section headings so that you’re able to easily (re)arrange parts of your chapter. This will also help your reader to follow your results and give your chapter some coherence.  Be sure to use level-based heading styles (e.g. Heading 1, 2, 3 styles) to help the reader differentiate between levels visually. You can find these options in Word (example below).

Section 2: Body

Before we get started on what to include in the body of your chapter, it’s vital to remember that a results section should be completely objective and descriptive, not interpretive . So, be careful not to use words such as, “suggests” or “implies”, as these usually accompany some form of interpretation – that’s reserved for your discussion chapter.

The structure of your body section is very important , so make sure that you plan it out well. When planning out your qualitative results chapter, create sections and subsections so that you can maintain the flow of the story you’re trying to tell. Be sure to systematically and consistently describe each portion of results. Try to adopt a standardised structure for each portion so that you achieve a high level of consistency throughout the chapter.

For qualitative studies, results chapters tend to be structured according to themes , which makes it easier for readers to follow. However, keep in mind that not all results chapters have to be structured in this manner. For example, if you’re conducting a longitudinal study, you may want to structure your chapter chronologically. Similarly, you might structure this chapter based on your theoretical framework . The exact structure of your chapter will depend on the nature of your study , especially your research questions.

As you work through the body of your chapter, make sure that you use quotes to substantiate every one of your claims . You can present these quotes in italics to differentiate them from your own words. A general rule of thumb is to use at least two pieces of evidence per claim, and these should be linked directly to your data. Also, remember that you need to include all relevant results , not just the ones that support your assumptions or initial leanings.

In addition to including quotes, you can also link your claims to the data by using appendices , which you should reference throughout your text. When you reference, make sure that you include both the name/number of the appendix , as well as the line(s) from which you drew your data.

As referencing styles can vary greatly, be sure to look up the appendix referencing conventions of your university’s prescribed style (e.g. APA , Harvard, etc) and keep this consistent throughout your chapter.

Section 3: Concluding summary

The concluding summary is very important because it summarises your key findings and lays the foundation for the discussion chapter . Keep in mind that some readers may skip directly to this section (from the introduction section), so make sure that it can be read and understood well in isolation.

In this section, you need to remind the reader of the key findings. That is, the results that directly relate to your research questions and that you will build upon in your discussion chapter. Remember, your reader has digested a lot of information in this chapter, so you need to use this section to remind them of the most important takeaways.

Importantly, the concluding summary should not present any new information and should only describe what you’ve already presented in your chapter. Keep it concise – you’re not summarising the whole chapter, just the essentials.

Tips for writing an A-grade results chapter

Now that you’ve got a clear picture of what the qualitative results chapter is all about, here are some quick tips and reminders to help you craft a high-quality chapter:

• Your results chapter should be written in the past tense . You’ve done the work already, so you want to tell the reader what you found , not what you are currently finding .
• Make sure that you review your work multiple times and check that every claim is adequately backed up by evidence . Aim for at least two examples per claim, and make use of an appendix to reference these.
• When writing up your results, make sure that you stick to only what is relevant . Don’t waste time on data that are not relevant to your research objectives and research questions.
• Use headings and subheadings to create an intuitive, easy to follow piece of writing. Make use of Microsoft Word’s “heading styles” and be sure to use them consistently.
• When referring to numerical data, tables and figures can provide a useful visual aid. When using these, make sure that they can be read and understood independent of your body text (i.e. that they can stand-alone). To this end, use clear, concise labels for each of your tables or figures and make use of colours to code indicate differences or hierarchy.
• Similarly, when you’re writing up your chapter, it can be useful to highlight topics and themes in different colours . This can help you to differentiate between your data if you get a bit overwhelmed and will also help you to ensure that your results flow logically and coherently.

If you have any questions, leave a comment below and we’ll do our best to help. If you’d like 1-on-1 help with your results chapter (or any chapter of your dissertation or thesis), check out our private dissertation coaching service here or book a free initial consultation to discuss how we can help you.

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21 Comments

This was extremely helpful. Thanks a lot guys

Hi, thanks for the great research support platform created by the gradcoach team!

I wanted to ask- While “suggests” or “implies” are interpretive terms, what terms could we use for the results chapter? Could you share some examples of descriptive terms?

I think that instead of saying, ‘The data suggested, or The data implied,’ you can say, ‘The Data showed or revealed, or illustrated or outlined’…If interview data, you may say Jane Doe illuminated or elaborated, or Jane Doe described… or Jane Doe expressed or stated.

I found this article very useful. Thank you very much for the outstanding work you are doing.

What if i have 3 different interviewees answering the same interview questions? Should i then present the results in form of the table with the division on the 3 perspectives or rather give a results in form of the text and highlight who said what?

I think this tabular representation of results is a great idea. I am doing it too along with the text. Thanks

That was helpful was struggling to separate the discussion from the findings

this was very useful, Thank you.

Very helpful, I am confident to write my results chapter now.

It is so helpful! It is a good job. Thank you very much!

Very useful, well explained. Many thanks.

Hello, I appreciate the way you provided a supportive comments about qualitative results presenting tips

I loved this! It explains everything needed, and it has helped me better organize my thoughts. What words should I not use while writing my results section, other than subjective ones.

Thanks a lot, it is really helpful

Thank you so much dear, i really appropriate your nice explanations about this.

Thank you so much for this! I was wondering if anyone could help with how to prproperly integrate quotations (Excerpts) from interviews in the finding chapter in a qualitative research. Please GradCoach, address this issue and provide examples.

what if I’m not doing any interviews myself and all the information is coming from case studies that have already done the research.

Very helpful thank you.

This was very helpful as I was wondering how to structure this part of my dissertation, to include the quotes… Thanks for this explanation

This is very helpful, thanks! I am required to write up my results chapters with the discussion in each of them – any tips and tricks for this strategy?

For qualitative studies, can the findings be structured according to the Research questions? Thank you.

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• Harvard Library
• Research Guides
• Faculty of Arts & Sciences Libraries

Library Support for Qualitative Research

• Interview Research

General Handbooks and Overviews

Qualitative research communities.

• Types of Interviews
• Recruiting & Engaging Participants
• Interview Questions
• Conducting Interviews
• Transcription
• Data Analysis
• Managing Interview Data
• Finding Interview Data
• Past Workshops on Interview Research
• Methodological Resources
• Remote & Virtual Fieldwork
• Data Management & Repositories
• Campus Access
• Interviews as a Method for Qualitative Research (video) This short video summarizes why interviews can serve as useful data in qualitative research.  
• InterViews by Steinar Kvale  Interviewing is an essential tool in qualitative research and this introduction to interviewing outlines both the theoretical underpinnings and the practical aspects of the process. After examining the role of the interview in the research process, Steinar Kvale considers some of the key philosophical issues relating to interviewing: the interview as conversation, hermeneutics, phenomenology, concerns about ethics as well as validity, and postmodernism. Having established this framework, the author then analyzes the seven stages of the interview process - from designing a study to writing it up.  
• Practical Evaluation by Michael Quinn Patton  Surveys different interviewing strategies, from, a) informal/conversational, to b) interview guide approach, to c) standardized and open-ended, to d) closed/quantitative. Also discusses strategies for wording questions that are open-ended, clear, sensitive, and neutral, while supporting the speaker. Provides suggestions for probing and maintaining control of the interview process, as well as suggestions for recording and transcription.  
• The SAGE Handbook of Interview Research by Amir B. Marvasti (Editor); James A. Holstein (Editor); Jaber F. Gubrium (Editor); Karyn D. McKinney (Editor)  The new edition of this landmark volume emphasizes the dynamic, interactional, and reflexive dimensions of the research interview. Contributors highlight the myriad dimensions of complexity that are emerging as researchers increasingly frame the interview as a communicative opportunity as much as a data-gathering format. The book begins with the history and conceptual transformations of the interview, which is followed by chapters that discuss the main components of interview practice. Taken together, the contributions to The SAGE Handbook of Interview Research: The Complexity of the Craft encourage readers simultaneously to learn the frameworks and technologies of interviewing and to reflect on the epistemological foundations of the interview craft.
• International Congress of Qualitative Inquiry They host an annual confrerence at the University of Illinois at Urbana-Champaign, which aims to facilitate the development of qualitative research methods across a wide variety of academic disciplines, among other initiatives.
• METHODSPACE An online home of the research methods community, where practicing researchers share how to make research easier.
• Social Research Association, UK The SRA is the membership organisation for social researchers in the UK and beyond. It supports researchers via training, guidance, publications, research ethics, events, branches, and careers.
• Social Science Research Council The SSRC administers fellowships and research grants that support the innovation and evaluation of new policy solutions. They convene researchers and stakeholders to share evidence-based policy solutions and incubate new research agendas, produce online knowledge platforms and technical reports that catalog research-based policy solutions, and support mentoring programs that broaden problem-solving research opportunities.
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• Next: Types of Interviews >>

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Methodology

• What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

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

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

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

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

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

Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

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

• Flexibility

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

• Natural settings

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

• Meaningful insights

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

• Generation of new ideas

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

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

• Unreliability

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

• Subjectivity

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

• Limited generalizability

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

• Labor-intensive

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

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

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

Research bias

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

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

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

There are five common approaches to qualitative research :

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

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

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

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

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

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How to Conduct Interviews in Qualitative Research: Interview Guidelines for Qualitative Research

Rev › Blog › Market Research › How to Conduct Interviews in Qualitative Research: Interview Guidelines for Qualitative Research

Qualitative research interviews are depth interviews. They elicit detailed feedback from your leads and customers. Unstructured interviews reveal why people react in a certain way or make certain decisions. According to The Hartford , qualitative research provides an anecdotal look into your business. That provides an important form of data.

Why Your Business Should Use a Qualitative Interview Process

Qualitative research helps business owners:

• Identify customer needs
• Clarify marketing messages
• Generate ideas for improvements of a product
• Decide to extend a line or brand
• Gain perspective on how a product fits into a customer’s lifestyle

How Is Conducting Qualitative Research & Quantitative Research Different?

Quantitative research concerns measurable quantities and numbers. It involves close-ended questions. Answer possibilities include yes or no, true or false, or various set choices. Qualitative research is descriptive and concerned with understanding behavior. It invites people to tell their stories in their own words.

Examples of Qualitative Research

Qualitative research helps researchers understand the social reality of individuals, groups and cultures. Qualitative research for businesses involves understanding consumer behavior. It can involve ethnographic techniques, including participant observation and field research. It also includes phenomenology, understanding life experiences using written or recorded narratives. Qualitative research also includes in-depth interviews.

What Is a Qualitative Interview?

A qualitative interview is a more personal form of research compared to questionnaires. The interviewer can probe or ask follow-up research questions of the interview participant. In some cases, subjects may start to interview the interviewer. This fosters deep discussion of the interview topic.

Why Are Interview Techniques in Qualitative Research Effective?

Qualitative research interviews help you explain, understand and explore opinions, behavior and experiences. Qualitative research can provide insights into a phenomenon. Qualitative research discoveries can be further researched and analyzed to influence business decisions.

How Are Interviews in Qualitative Research Formatted?

Qualitative research interviews may take place one-on-one or in focus groups. Learn how to run a successful focus group . Interviews span around 30 to 90 minutes. The interview can take place in person, over the phone or through video chat. The interviewer collects information about opinions, behavior, attitudes, feelings, preferences and knowledge.

How to Conduct Interviews in Qualitative Research

1. determine your goal., 2. target people to interview., 3. design interview questions., 4. prep the interview., 5. conduct the interview., 6. transcribe and analyze the interview., 7. optimize and evolve your interview guide., the first step in qualitative research: determine your goal.

Determine what you want to study:

• A current or potential product, service or brand positioning
• Strengths and weaknesses in products
• Purchasing decisions
• Reactions to advertising or marketing campaigns
• Usability of a website or other interactive services
• Perceptions about the company, brand or product
• Reactions to packaging and design

How Can You Decide a Goal for a Qualitative Interview?

Have your business team ask the following questions: 

• What information do you want to get?
• Why do you want to pursue in-depth information about this research topic?
• Why is a qualitative interview process the best solution for this research?
• How will you use qualitative data to improve your business? 

How to Determine the Right Interview Participants

When looking for people to talk to for a qualitative interview, consider your goal. If you want to expand a product line, interview existing customers about their needs. If you’re researching marketing, ask new customers how they found your business. Match interview subjects with the goal of the interview.

How to Design Interview Questions for Qualitative Research

When you’re creating an interview guide, it’s a good idea to: 

• Plan structured interviews with open ended questions.
• Avoid leading questions.
• Create interview questions that are clear and easy to understand.
• Make research questions focused but flexible.
• Design questions that align with data collection and data analysis goals.

Tips for Preparing a Qualitative Research Interview

Preparation improves interview effectiveness. Tips to prepare include:

• Create an interview guide. The guide should include questions, question intent and answer-based paths to take.
• Choose a setting where the subject feels comfortable.
• Build rapport with interview participants.
• Have a reliable way to record the interview.
• Rehearse the interview first.

Environmental Concerns for Qualitative Interviews

The setting of a qualitative interview also affects the quality of the interview. Consider the needs of the subject. For example, if you’re interviewing a teenager, a formal boardroom may not be the best setting. Some cultures may not value direct eye contact. An interview that’s non-face-to-face may be better.

How to Make Qualitative Interview Subjects Comfortable

For long interviews, offer water and breaks to participants. Be polite and respectful when interacting with interview subjects. Let interview participants know the purpose of the research. Explain exactly how you’ll use their answers. Address terms of confidentiality if necessary. Thank participants after the interview and let them know what to expect next.

What Are Interview Techniques in Qualitative Research?

Qualitative research techniques include:

• Start interviews with “get-to-know-you” questions to put the interview participant at ease.
• Pay attention.
• Use active listening techniques.
• Watch for body language cues.
• Pivot questions as needed.
• Acknowledge emotions.
• Avoid interrogation.
• Ending interviews, ask subjects if they have anything to add.

What Is Active Listening in Interviews in Qualitative Research?

Active listening techniques include: 

• Make eye contact.
• Lean in and use body language to show you’re listening.
• Don’t get distracted by devices.
• Use verbal affirmation.
• Paraphrase answers for reflection.
• Reference earlier answers.
• Avoid interrupting.
• Embrace pauses.
• Ask for clarification.
• Pay attention in the moment.

Tips for Transcribing a Qualitative Interview

It’s best to transcribe and analyze a qualitative research interview right away. This helps you optimize future interviews. Transcribe the interview word for word. Note non-verbal interactions in your transcription. Interactions like pauses and laughter can provide deeper insights into responses.

How to Analyze a Qualitative Interview

Analyze your qualitative research data early. That way, you can identify emerging themes to shape future interviews. Consider adding these to each interview report:

• The goal of the interview
• Details about the interview participant
• Questions asked, summarized responses and key findings
• Recommendations

Relate the analysis to the goal of the qualitative research interview.

Optimize the Interview Guide for Qualitative Research

Each interview can help you improve the efficiency and effectiveness of future ones. Adjust your interview guide based on insights from each previous interview. Keep all versions of your transcriptions and interview guides with notes on them. You can reference these for future qualitative research.

Get Reliable Transcription Services for Qualitative Research Interviews

As mentioned, you should transcribe qualitative research interviews as soon as possible. There are several reasons for this.

• You can gain insights that help you shape your interview guide. You might identify questions to add or questions to clarify.
• Your interview participants may not be appropriate for this type of qualitative research. Finding more targeted interview subjects may be better.
• Answers may evolve the qualitative research goal and/or data analysis.

At Rev, we understand the need for fast transcription for accurate market research. We provide a turnaround time of as few as 12 hours, no matter how big your project is. We guarantee 99%+ accuracy. Learn about Rev’s market research transcription . We can help make your qualitative research project a success.

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• Published: 05 October 2018

Interviews and focus groups in qualitative research: an update for the digital age

• P. Gill 1 &
• J. Baillie 2  

British Dental Journal volume  225 ,  pages 668–672 ( 2018 ) Cite this article

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Highlights that qualitative research is used increasingly in dentistry. Interviews and focus groups remain the most common qualitative methods of data collection.

Suggests the advent of digital technologies has transformed how qualitative research can now be undertaken.

Suggests interviews and focus groups can offer significant, meaningful insight into participants' experiences, beliefs and perspectives, which can help to inform developments in dental practice.

Qualitative research is used increasingly in dentistry, due to its potential to provide meaningful, in-depth insights into participants' experiences, perspectives, beliefs and behaviours. These insights can subsequently help to inform developments in dental practice and further related research. The most common methods of data collection used in qualitative research are interviews and focus groups. While these are primarily conducted face-to-face, the ongoing evolution of digital technologies, such as video chat and online forums, has further transformed these methods of data collection. This paper therefore discusses interviews and focus groups in detail, outlines how they can be used in practice, how digital technologies can further inform the data collection process, and what these methods can offer dentistry.

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Interviews in the social sciences

Professionalism in dentistry: deconstructing common terminology

A review of technical and quality assessment considerations of audio-visual and web-conferencing focus groups in qualitative health research, introduction.

Traditionally, research in dentistry has primarily been quantitative in nature. 1 However, in recent years, there has been a growing interest in qualitative research within the profession, due to its potential to further inform developments in practice, policy, education and training. Consequently, in 2008, the British Dental Journal (BDJ) published a four paper qualitative research series, 2 , 3 , 4 , 5 to help increase awareness and understanding of this particular methodological approach.

Since the papers were originally published, two scoping reviews have demonstrated the ongoing proliferation in the use of qualitative research within the field of oral healthcare. 1 , 6 To date, the original four paper series continue to be well cited and two of the main papers remain widely accessed among the BDJ readership. 2 , 3 The potential value of well-conducted qualitative research to evidence-based practice is now also widely recognised by service providers, policy makers, funding bodies and those who commission, support and use healthcare research.

Besides increasing standalone use, qualitative methods are now also routinely incorporated into larger mixed method study designs, such as clinical trials, as they can offer additional, meaningful insights into complex problems that simply could not be provided by quantitative methods alone. Qualitative methods can also be used to further facilitate in-depth understanding of important aspects of clinical trial processes, such as recruitment. For example, Ellis et al . investigated why edentulous older patients, dissatisfied with conventional dentures, decline implant treatment, despite its established efficacy, and frequently refuse to participate in related randomised clinical trials, even when financial constraints are removed. 7 Through the use of focus groups in Canada and the UK, the authors found that fears of pain and potential complications, along with perceived embarrassment, exacerbated by age, are common reasons why older patients typically refuse dental implants. 7

The last decade has also seen further developments in qualitative research, due to the ongoing evolution of digital technologies. These developments have transformed how researchers can access and share information, communicate and collaborate, recruit and engage participants, collect and analyse data and disseminate and translate research findings. 8 Where appropriate, such technologies are therefore capable of extending and enhancing how qualitative research is undertaken. 9 For example, it is now possible to collect qualitative data via instant messaging, email or online/video chat, using appropriate online platforms.

These innovative approaches to research are therefore cost-effective, convenient, reduce geographical constraints and are often useful for accessing 'hard to reach' participants (for example, those who are immobile or socially isolated). 8 , 9 However, digital technologies are still relatively new and constantly evolving and therefore present a variety of pragmatic and methodological challenges. Furthermore, given their very nature, their use in many qualitative studies and/or with certain participant groups may be inappropriate and should therefore always be carefully considered. While it is beyond the scope of this paper to provide a detailed explication regarding the use of digital technologies in qualitative research, insight is provided into how such technologies can be used to facilitate the data collection process in interviews and focus groups.

In light of such developments, it is perhaps therefore timely to update the main paper 3 of the original BDJ series. As with the previous publications, this paper has been purposely written in an accessible style, to enhance readability, particularly for those who are new to qualitative research. While the focus remains on the most common qualitative methods of data collection – interviews and focus groups – appropriate revisions have been made to provide a novel perspective, and should therefore be helpful to those who would like to know more about qualitative research. This paper specifically focuses on undertaking qualitative research with adult participants only.

Overview of qualitative research

Qualitative research is an approach that focuses on people and their experiences, behaviours and opinions. 10 , 11 The qualitative researcher seeks to answer questions of 'how' and 'why', providing detailed insight and understanding, 11 which quantitative methods cannot reach. 12 Within qualitative research, there are distinct methodologies influencing how the researcher approaches the research question, data collection and data analysis. 13 For example, phenomenological studies focus on the lived experience of individuals, explored through their description of the phenomenon. Ethnographic studies explore the culture of a group and typically involve the use of multiple methods to uncover the issues. 14

While methodology is the 'thinking tool', the methods are the 'doing tools'; 13 the ways in which data are collected and analysed. There are multiple qualitative data collection methods, including interviews, focus groups, observations, documentary analysis, participant diaries, photography and videography. Two of the most commonly used qualitative methods are interviews and focus groups, which are explored in this article. The data generated through these methods can be analysed in one of many ways, according to the methodological approach chosen. A common approach is thematic data analysis, involving the identification of themes and subthemes across the data set. Further information on approaches to qualitative data analysis has been discussed elsewhere. 1

Qualitative research is an evolving and adaptable approach, used by different disciplines for different purposes. Traditionally, qualitative data, specifically interviews, focus groups and observations, have been collected face-to-face with participants. In more recent years, digital technologies have contributed to the ongoing evolution of qualitative research. Digital technologies offer researchers different ways of recruiting participants and collecting data, and offer participants opportunities to be involved in research that is not necessarily face-to-face.

Research interviews are a fundamental qualitative research method 15 and are utilised across methodological approaches. Interviews enable the researcher to learn in depth about the perspectives, experiences, beliefs and motivations of the participant. 3 , 16 Examples include, exploring patients' perspectives of fear/anxiety triggers in dental treatment, 17 patients' experiences of oral health and diabetes, 18 and dental students' motivations for their choice of career. 19

Interviews may be structured, semi-structured or unstructured, 3 according to the purpose of the study, with less structured interviews facilitating a more in depth and flexible interviewing approach. 20 Structured interviews are similar to verbal questionnaires and are used if the researcher requires clarification on a topic; however they produce less in-depth data about a participant's experience. 3 Unstructured interviews may be used when little is known about a topic and involves the researcher asking an opening question; 3 the participant then leads the discussion. 20 Semi-structured interviews are commonly used in healthcare research, enabling the researcher to ask predetermined questions, 20 while ensuring the participant discusses issues they feel are important.

Interviews can be undertaken face-to-face or using digital methods when the researcher and participant are in different locations. Audio-recording the interview, with the consent of the participant, is essential for all interviews regardless of the medium as it enables accurate transcription; the process of turning the audio file into a word-for-word transcript. This transcript is the data, which the researcher then analyses according to the chosen approach.

Types of interview

Qualitative studies often utilise one-to-one, face-to-face interviews with research participants. This involves arranging a mutually convenient time and place to meet the participant, signing a consent form and audio-recording the interview. However, digital technologies have expanded the potential for interviews in research, enabling individuals to participate in qualitative research regardless of location.

Telephone interviews can be a useful alternative to face-to-face interviews and are commonly used in qualitative research. They enable participants from different geographical areas to participate and may be less onerous for participants than meeting a researcher in person. 15 A qualitative study explored patients' perspectives of dental implants and utilised telephone interviews due to the quality of the data that could be yielded. 21 The researcher needs to consider how they will audio record the interview, which can be facilitated by purchasing a recorder that connects directly to the telephone. One potential disadvantage of telephone interviews is the inability of the interviewer and researcher to see each other. This is resolved using software for audio and video calls online – such as Skype – to conduct interviews with participants in qualitative studies. Advantages of this approach include being able to see the participant if video calls are used, enabling observation of non-verbal communication, and the software can be free to use. However, participants are required to have a device and internet connection, as well as being computer literate, potentially limiting who can participate in the study. One qualitative study explored the role of dental hygienists in reducing oral health disparities in Canada. 22 The researcher conducted interviews using Skype, which enabled dental hygienists from across Canada to be interviewed within the research budget, accommodating the participants' schedules. 22

A less commonly used approach to qualitative interviews is the use of social virtual worlds. A qualitative study accessed a social virtual world – Second Life – to explore the health literacy skills of individuals who use social virtual worlds to access health information. 23 The researcher created an avatar and interview room, and undertook interviews with participants using voice and text methods. 23 This approach to recruitment and data collection enables individuals from diverse geographical locations to participate, while remaining anonymous if they wish. Furthermore, for interviews conducted using text methods, transcription of the interview is not required as the researcher can save the written conversation with the participant, with the participant's consent. However, the researcher and participant need to be familiar with how the social virtual world works to engage in an interview this way.

Conducting an interview

Ensuring informed consent before any interview is a fundamental aspect of the research process. Participants in research must be afforded autonomy and respect; consent should be informed and voluntary. 24 Individuals should have the opportunity to read an information sheet about the study, ask questions, understand how their data will be stored and used, and know that they are free to withdraw at any point without reprisal. The qualitative researcher should take written consent before undertaking the interview. In a face-to-face interview, this is straightforward: the researcher and participant both sign copies of the consent form, keeping one each. However, this approach is less straightforward when the researcher and participant do not meet in person. A recent protocol paper outlined an approach for taking consent for telephone interviews, which involved: audio recording the participant agreeing to each point on the consent form; the researcher signing the consent form and keeping a copy; and posting a copy to the participant. 25 This process could be replicated in other interview studies using digital methods.

There are advantages and disadvantages of using face-to-face and digital methods for research interviews. Ultimately, for both approaches, the quality of the interview is determined by the researcher. 16 Appropriate training and preparation are thus required. Healthcare professionals can use their interpersonal communication skills when undertaking a research interview, particularly questioning, listening and conversing. 3 However, the purpose of an interview is to gain information about the study topic, 26 rather than offering help and advice. 3 The researcher therefore needs to listen attentively to participants, enabling them to describe their experience without interruption. 3 The use of active listening skills also help to facilitate the interview. 14 Spradley outlined elements and strategies for research interviews, 27 which are a useful guide for qualitative researchers:

Greeting and explaining the project/interview

Asking descriptive (broad), structural (explore response to descriptive) and contrast (difference between) questions

Asymmetry between the researcher and participant talking

Expressing interest and cultural ignorance

Repeating, restating and incorporating the participant's words when asking questions

Creating hypothetical situations

Asking friendly questions

Knowing when to leave.

For semi-structured interviews, a topic guide (also called an interview schedule) is used to guide the content of the interview – an example of a topic guide is outlined in Box 1 . The topic guide, usually based on the research questions, existing literature and, for healthcare professionals, their clinical experience, is developed by the research team. The topic guide should include open ended questions that elicit in-depth information, and offer participants the opportunity to talk about issues important to them. This is vital in qualitative research where the researcher is interested in exploring the experiences and perspectives of participants. It can be useful for qualitative researchers to pilot the topic guide with the first participants, 10 to ensure the questions are relevant and understandable, and amending the questions if required.

Regardless of the medium of interview, the researcher must consider the setting of the interview. For face-to-face interviews, this could be in the participant's home, in an office or another mutually convenient location. A quiet location is preferable to promote confidentiality, enable the researcher and participant to concentrate on the conversation, and to facilitate accurate audio-recording of the interview. For interviews using digital methods the same principles apply: a quiet, private space where the researcher and participant feel comfortable and confident to participate in an interview.

Box 1: Example of a topic guide

Study focus: Parents' experiences of brushing their child's (aged 0–5) teeth

1. Can you tell me about your experience of cleaning your child's teeth?

How old was your child when you started cleaning their teeth?

Why did you start cleaning their teeth at that point?

How often do you brush their teeth?

What do you use to brush their teeth and why?

2. Could you explain how you find cleaning your child's teeth?

Do you find anything difficult?

What makes cleaning their teeth easier for you?

3. How has your experience of cleaning your child's teeth changed over time?

Has it become easier or harder?

Have you changed how often and how you clean their teeth? If so, why?

4. Could you describe how your child finds having their teeth cleaned?

What do they enjoy about having their teeth cleaned?

Is there anything they find upsetting about having their teeth cleaned?

5. Where do you look for information/advice about cleaning your child's teeth?

What did your health visitor tell you about cleaning your child's teeth? (If anything)

What has the dentist told you about caring for your child's teeth? (If visited)

Have any family members given you advice about how to clean your child's teeth? If so, what did they tell you? Did you follow their advice?

6. Is there anything else you would like to discuss about this?

Focus groups

A focus group is a moderated group discussion on a pre-defined topic, for research purposes. 28 , 29 While not aligned to a particular qualitative methodology (for example, grounded theory or phenomenology) as such, focus groups are used increasingly in healthcare research, as they are useful for exploring collective perspectives, attitudes, behaviours and experiences. Consequently, they can yield rich, in-depth data and illuminate agreement and inconsistencies 28 within and, where appropriate, between groups. Examples include public perceptions of dental implants and subsequent impact on help-seeking and decision making, 30 and general dental practitioners' views on patient safety in dentistry. 31

Focus groups can be used alone or in conjunction with other methods, such as interviews or observations, and can therefore help to confirm, extend or enrich understanding and provide alternative insights. 28 The social interaction between participants often results in lively discussion and can therefore facilitate the collection of rich, meaningful data. However, they are complex to organise and manage, due to the number of participants, and may also be inappropriate for exploring particularly sensitive issues that many participants may feel uncomfortable about discussing in a group environment.

Focus groups are primarily undertaken face-to-face but can now also be undertaken online, using appropriate technologies such as email, bulletin boards, online research communities, chat rooms, discussion forums, social media and video conferencing. 32 Using such technologies, data collection can also be synchronous (for example, online discussions in 'real time') or, unlike traditional face-to-face focus groups, asynchronous (for example, online/email discussions in 'non-real time'). While many of the fundamental principles of focus group research are the same, regardless of how they are conducted, a number of subtle nuances are associated with the online medium. 32 Some of which are discussed further in the following sections.

Focus group considerations

Some key considerations associated with face-to-face focus groups are: how many participants are required; should participants within each group know each other (or not) and how many focus groups are needed within a single study? These issues are much debated and there is no definitive answer. However, the number of focus groups required will largely depend on the topic area, the depth and breadth of data needed, the desired level of participation required 29 and the necessity (or not) for data saturation.

The optimum group size is around six to eight participants (excluding researchers) but can work effectively with between three and 14 participants. 3 If the group is too small, it may limit discussion, but if it is too large, it may become disorganised and difficult to manage. It is, however, prudent to over-recruit for a focus group by approximately two to three participants, to allow for potential non-attenders. For many researchers, particularly novice researchers, group size may also be informed by pragmatic considerations, such as the type of study, resources available and moderator experience. 28 Similar size and mix considerations exist for online focus groups. Typically, synchronous online focus groups will have around three to eight participants but, as the discussion does not happen simultaneously, asynchronous groups may have as many as 10–30 participants. 33

The topic area and potential group interaction should guide group composition considerations. Pre-existing groups, where participants know each other (for example, work colleagues) may be easier to recruit, have shared experiences and may enjoy a familiarity, which facilitates discussion and/or the ability to challenge each other courteously. 3 However, if there is a potential power imbalance within the group or if existing group norms and hierarchies may adversely affect the ability of participants to speak freely, then 'stranger groups' (that is, where participants do not already know each other) may be more appropriate. 34 , 35

Focus group management

Face-to-face focus groups should normally be conducted by two researchers; a moderator and an observer. 28 The moderator facilitates group discussion, while the observer typically monitors group dynamics, behaviours, non-verbal cues, seating arrangements and speaking order, which is essential for transcription and analysis. The same principles of informed consent, as discussed in the interview section, also apply to focus groups, regardless of medium. However, the consent process for online discussions will probably be managed somewhat differently. For example, while an appropriate participant information leaflet (and consent form) would still be required, the process is likely to be managed electronically (for example, via email) and would need to specifically address issues relating to technology (for example, anonymity and use, storage and access to online data). 32

The venue in which a face to face focus group is conducted should be of a suitable size, private, quiet, free from distractions and in a collectively convenient location. It should also be conducted at a time appropriate for participants, 28 as this is likely to promote attendance. As with interviews, the same ethical considerations apply (as discussed earlier). However, online focus groups may present additional ethical challenges associated with issues such as informed consent, appropriate access and secure data storage. Further guidance can be found elsewhere. 8 , 32

Before the focus group commences, the researchers should establish rapport with participants, as this will help to put them at ease and result in a more meaningful discussion. Consequently, researchers should introduce themselves, provide further clarity about the study and how the process will work in practice and outline the 'ground rules'. Ground rules are designed to assist, not hinder, group discussion and typically include: 3 , 28 , 29

Discussions within the group are confidential to the group

Only one person can speak at a time

All participants should have sufficient opportunity to contribute

There should be no unnecessary interruptions while someone is speaking

Everyone can be expected to be listened to and their views respected

Challenging contrary opinions is appropriate, but ridiculing is not.

Moderating a focus group requires considered management and good interpersonal skills to help guide the discussion and, where appropriate, keep it sufficiently focused. Avoid, therefore, participating, leading, expressing personal opinions or correcting participants' knowledge 3 , 28 as this may bias the process. A relaxed, interested demeanour will also help participants to feel comfortable and promote candid discourse. Moderators should also prevent the discussion being dominated by any one person, ensure differences of opinions are discussed fairly and, if required, encourage reticent participants to contribute. 3 Asking open questions, reflecting on significant issues, inviting further debate, probing responses accordingly, and seeking further clarification, as and where appropriate, will help to obtain sufficient depth and insight into the topic area.

Moderating online focus groups requires comparable skills, particularly if the discussion is synchronous, as the discussion may be dominated by those who can type proficiently. 36 It is therefore important that sufficient time and respect is accorded to those who may not be able to type as quickly. Asynchronous discussions are usually less problematic in this respect, as interactions are less instant. However, moderating an asynchronous discussion presents additional challenges, particularly if participants are geographically dispersed, as they may be online at different times. Consequently, the moderator will not always be present and the discussion may therefore need to occur over several days, which can be difficult to manage and facilitate and invariably requires considerable flexibility. 32 It is also worth recognising that establishing rapport with participants via online medium is often more challenging than via face-to-face and may therefore require additional time, skills, effort and consideration.

As with research interviews, focus groups should be guided by an appropriate interview schedule, as discussed earlier in the paper. For example, the schedule will usually be informed by the review of the literature and study aims, and will merely provide a topic guide to help inform subsequent discussions. To provide a verbatim account of the discussion, focus groups must be recorded, using an audio-recorder with a good quality multi-directional microphone. While videotaping is possible, some participants may find it obtrusive, 3 which may adversely affect group dynamics. The use (or not) of a video recorder, should therefore be carefully considered.

At the end of the focus group, a few minutes should be spent rounding up and reflecting on the discussion. 28 Depending on the topic area, it is possible that some participants may have revealed deeply personal issues and may therefore require further help and support, such as a constructive debrief or possibly even referral on to a relevant third party. It is also possible that some participants may feel that the discussion did not adequately reflect their views and, consequently, may no longer wish to be associated with the study. 28 Such occurrences are likely to be uncommon, but should they arise, it is important to further discuss any concerns and, if appropriate, offer them the opportunity to withdraw (including any data relating to them) from the study. Immediately after the discussion, researchers should compile notes regarding thoughts and ideas about the focus group, which can assist with data analysis and, if appropriate, any further data collection.

Qualitative research is increasingly being utilised within dental research to explore the experiences, perspectives, motivations and beliefs of participants. The contributions of qualitative research to evidence-based practice are increasingly being recognised, both as standalone research and as part of larger mixed-method studies, including clinical trials. Interviews and focus groups remain commonly used data collection methods in qualitative research, and with the advent of digital technologies, their utilisation continues to evolve. However, digital methods of qualitative data collection present additional methodological, ethical and practical considerations, but also potentially offer considerable flexibility to participants and researchers. Consequently, regardless of format, qualitative methods have significant potential to inform important areas of dental practice, policy and further related research.

Gussy M, Dickson-Swift V, Adams J . A scoping review of qualitative research in peer-reviewed dental publications. Int J Dent Hygiene 2013; 11 : 174–179.

Article   Google Scholar  

Burnard P, Gill P, Stewart K, Treasure E, Chadwick B . Analysing and presenting qualitative data. Br Dent J 2008; 204 : 429–432.

Gill P, Stewart K, Treasure E, Chadwick B . Methods of data collection in qualitative research: interviews and focus groups. Br Dent J 2008; 204 : 291–295.

Gill P, Stewart K, Treasure E, Chadwick B . Conducting qualitative interviews with school children in dental research. Br Dent J 2008; 204 : 371–374.

Stewart K, Gill P, Chadwick B, Treasure E . Qualitative research in dentistry. Br Dent J 2008; 204 : 235–239.

Masood M, Thaliath E, Bower E, Newton J . An appraisal of the quality of published qualitative dental research. Community Dent Oral Epidemiol 2011; 39 : 193–203.

Ellis J, Levine A, Bedos C et al. Refusal of implant supported mandibular overdentures by elderly patients. Gerodontology 2011; 28 : 62–68.

Macfarlane S, Bucknall T . Digital Technologies in Research. In Gerrish K, Lathlean J (editors) The Research Process in Nursing . 7th edition. pp. 71–86. Oxford: Wiley Blackwell; 2015.

Google Scholar  

Lee R, Fielding N, Blank G . Online Research Methods in the Social Sciences: An Editorial Introduction. In Fielding N, Lee R, Blank G (editors) The Sage Handbook of Online Research Methods . pp. 3–16. London: Sage Publications; 2016.

Creswell J . Qualitative inquiry and research design: Choosing among five designs . Thousand Oaks, CA: Sage, 1998.

Guest G, Namey E, Mitchell M . Qualitative research: Defining and designing In Guest G, Namey E, Mitchell M (editors) Collecting Qualitative Data: A Field Manual For Applied Research . pp. 1–40. London: Sage Publications, 2013.

Chapter   Google Scholar  

Pope C, Mays N . Qualitative research: Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. BMJ 1995; 311 : 42–45.

Giddings L, Grant B . A Trojan Horse for positivism? A critique of mixed methods research. Adv Nurs Sci 2007; 30 : 52–60.

Hammersley M, Atkinson P . Ethnography: Principles in Practice . London: Routledge, 1995.

Oltmann S . Qualitative interviews: A methodological discussion of the interviewer and respondent contexts Forum Qualitative Sozialforschung/Forum: Qualitative Social Research. 2016; 17 : Art. 15.

Patton M . Qualitative Research and Evaluation Methods . Thousand Oaks, CA: Sage, 2002.

Wang M, Vinall-Collier K, Csikar J, Douglas G . A qualitative study of patients' views of techniques to reduce dental anxiety. J Dent 2017; 66 : 45–51.

Lindenmeyer A, Bowyer V, Roscoe J, Dale J, Sutcliffe P . Oral health awareness and care preferences in patients with diabetes: a qualitative study. Fam Pract 2013; 30 : 113–118.

Gallagher J, Clarke W, Wilson N . Understanding the motivation: a qualitative study of dental students' choice of professional career. Eur J Dent Educ 2008; 12 : 89–98.

Tod A . Interviewing. In Gerrish K, Lacey A (editors) The Research Process in Nursing . Oxford: Blackwell Publishing, 2006.

Grey E, Harcourt D, O'Sullivan D, Buchanan H, Kipatrick N . A qualitative study of patients' motivations and expectations for dental implants. Br Dent J 2013; 214 : 10.1038/sj.bdj.2012.1178.

Farmer J, Peressini S, Lawrence H . Exploring the role of the dental hygienist in reducing oral health disparities in Canada: A qualitative study. Int J Dent Hygiene 2017; 10.1111/idh.12276.

McElhinney E, Cheater F, Kidd L . Undertaking qualitative health research in social virtual worlds. J Adv Nurs 2013; 70 : 1267–1275.

Health Research Authority. UK Policy Framework for Health and Social Care Research. Available at https://www.hra.nhs.uk/planning-and-improving-research/policies-standards-legislation/uk-policy-framework-health-social-care-research/ (accessed September 2017).

Baillie J, Gill P, Courtenay P . Knowledge, understanding and experiences of peritonitis among patients, and their families, undertaking peritoneal dialysis: A mixed methods study protocol. J Adv Nurs 2017; 10.1111/jan.13400.

Kvale S . Interviews . Thousand Oaks (CA): Sage, 1996.

Spradley J . The Ethnographic Interview . New York: Holt, Rinehart and Winston, 1979.

Goodman C, Evans C . Focus Groups. In Gerrish K, Lathlean J (editors) The Research Process in Nursing . pp. 401–412. Oxford: Wiley Blackwell, 2015.

Shaha M, Wenzell J, Hill E . Planning and conducting focus group research with nurses. Nurse Res 2011; 18 : 77–87.

Wang G, Gao X, Edward C . Public perception of dental implants: a qualitative study. J Dent 2015; 43 : 798–805.

Bailey E . Contemporary views of dental practitioners' on patient safety. Br Dent J 2015; 219 : 535–540.

Abrams K, Gaiser T . Online Focus Groups. In Field N, Lee R, Blank G (editors) The Sage Handbook of Online Research Methods . pp. 435–450. London: Sage Publications, 2016.

Poynter R . The Handbook of Online and Social Media Research . West Sussex: John Wiley & Sons, 2010.

Kevern J, Webb C . Focus groups as a tool for critical social research in nurse education. Nurse Educ Today 2001; 21 : 323–333.

Kitzinger J, Barbour R . Introduction: The Challenge and Promise of Focus Groups. In Barbour R S K J (editor) Developing Focus Group Research . pp. 1–20. London: Sage Publications, 1999.

Krueger R, Casey M . Focus Groups: A Practical Guide for Applied Research. 4th ed. Thousand Oaks, California: SAGE; 2009.

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Gill, P., Baillie, J. Interviews and focus groups in qualitative research: an update for the digital age. Br Dent J 225 , 668–672 (2018). https://doi.org/10.1038/sj.bdj.2018.815

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DOI : https://doi.org/10.1038/sj.bdj.2018.815

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Energy companies are drilling for natural gas using highly controversial methods of extraction known as hydraulic fracturing. In the Marcellus Shale, one of the most active drilling formations in the country, grassroots environmental advocacy groups, nonprofit service providers, and academic researchers have partnered to establish surface water monitoring programs to assess potential changes in water quality that might result from shale gas extraction. This dissertation research project examined the activities of these networks and their use of advanced technologies such as sensors, databases, and GIS tools for collecting, managing, and interpreting environmental data. The project used mixed research methods including: A) qualitative interviews with key informants in monitoring groups, advocacy organizations, research institutions, and regulatory agencies; B) participant observation of training sessions, monitoring events, strategic planning meetings, and data management workshops; and C) comparative case studies of four monitoring organization networks and two data management projects. The study showed that environmental monitoring tools can empower communities when they are deployed as part of projects in which concerned citizens and scientists collaborate as equal partners. Such partnerships enable the public to advocate for more nuanced uses of data, to create meaningful narratives with water quality data, and to critique status-quo environmental governance. Findings from the study were made available to the public through a series of peer reviewed journal articles as well as in a completed doctoral dissertation.

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• Volume 33, Issue 9
• Patient safety in remote primary care encounters: multimethod qualitative study combining Safety I and Safety II analysis
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• Rebecca Payne 1 ,
• Aileen Clarke 1 ,
• Nadia Swann 1 ,
• Jackie van Dael 1 ,
• Natassia Brenman 1 ,
• Rebecca Rosen 2 ,
• Adam Mackridge 3 ,
• Lucy Moore 1 ,
• Asli Kalin 1 ,
• Emma Ladds 1 ,
• Nina Hemmings 2 ,
• Sarah Rybczynska-Bunt 4 ,
• Stuart Faulkner 1 ,
• Isabel Hanson 1 ,
• Sophie Spitters 5 ,
• http://orcid.org/0000-0002-7758-8493 Sietse Wieringa 1 , 6 ,
• Francesca H Dakin 1 ,
• Sara E Shaw 1 ,
• Joseph Wherton 1 ,
• Richard Byng 4 ,
• Laiba Husain 1 ,
• http://orcid.org/0000-0003-2369-8088 Trisha Greenhalgh 1
• 1 Nuffield Department of Primary Care Health Sciences , University of Oxford , Oxford , UK
• 2 Nuffield Trust , London , UK
• 3 Betsi Cadwaladr University Health Board , Bangor , UK
• 4 Peninsula Schools of Medicine and Dentistry , University of Plymouth , Plymouth , UK
• 5 Wolfson Institute of Population Health , Queen Mary University of London , London , UK
• 6 Sustainable Health Unit , University of Oslo , Oslo , Norway
• Correspondence to Professor Trisha Greenhalgh; trish.greenhalgh{at}phc.ox.ac.uk

Background Triage and clinical consultations increasingly occur remotely. We aimed to learn why safety incidents occur in remote encounters and how to prevent them.

Setting and sample UK primary care. 95 safety incidents (complaints, settled indemnity claims and reports) involving remote interactions. Separately, 12 general practices followed 2021–2023.

Methods Multimethod qualitative study. We explored causes of real safety incidents retrospectively (‘Safety I’ analysis). In a prospective longitudinal study, we used interviews and ethnographic observation to produce individual, organisational and system-level explanations for why safety and near-miss incidents (rarely) occurred and why they did not occur more often (‘Safety II’ analysis). Data were analysed thematically. An interpretive synthesis of why safety incidents occur, and why they do not occur more often, was refined following member checking with safety experts and lived experience experts.

Results Safety incidents were characterised by inappropriate modality, poor rapport building, inadequate information gathering, limited clinical assessment, inappropriate pathway (eg, wrong algorithm) and inadequate attention to social circumstances. These resulted in missed, inaccurate or delayed diagnoses, underestimation of severity or urgency, delayed referral, incorrect or delayed treatment, poor safety netting and inadequate follow-up. Patients with complex pre-existing conditions, cardiac or abdominal emergencies, vague or generalised symptoms, safeguarding issues, failure to respond to previous treatment or difficulty communicating seemed especially vulnerable. General practices were facing resource constraints, understaffing and high demand. Triage and care pathways were complex, hard to navigate and involved multiple staff. In this context, patient safety often depended on individual staff taking initiative, speaking up or personalising solutions.

Conclusion While safety incidents are extremely rare in remote primary care, deaths and serious harms have resulted. We offer suggestions for patient, staff and system-level mitigations.

• Primary care
• Diagnostic errors
• Safety culture
• Qualitative research
• Prehospital care

Data availability statement

Data are available upon reasonable request. Details of real safety incidents are not available for patient confidentiality reasons. Requests for data on other aspects of the study from other researchers will be considered.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:  https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/bmjqs-2023-016674

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Safety incidents are extremely rare in primary care but they do happen. Concerns have been raised about the safety of remote triage and remote consultations.

WHAT THIS STUDY ADDS

Rare safety incidents (involving death or serious harm) in remote encounters can be traced back to various clinical, communicative, technical and logistical causes. Telephone and video encounters in general practice are occurring in a high-risk (extremely busy and sometimes understaffed) context in which remote workflows may not be optimised. Front-line staff use creativity and judgement to help make care safer.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

As remote modalities become mainstreamed in primary care, staff should be trained in the upstream causes of safety incidents and how they can be mitigated. The subtle and creative ways in which front-line staff already contribute to safety culture should be recognised and supported.

Introduction

In early 2020, remote triage and remote consultations (together, ‘remote encounters’), in which the patient is in a different physical location from the clinician or support staff member, were rapidly expanded as a safety measure in many countries because they eliminated the risk of transmitting COVID-19. 1–4 But by mid-2021, remote encounters had begun to be depicted as potentially unsafe because they had come to be associated with stories of patient harm, including avoidable deaths and missed cancers. 5–8

Providing triage and clinical care remotely is sometimes depicted as a partial solution to the system pressures facing primary healthcare in many countries, 9–11 including rising levels of need or demand, the ongoing impact of the COVID-19 pandemic and workforce challenges (especially short-term or longer-term understaffing). In this context, remote encounters may be an important component of a mixed-modality health service when used appropriately alongside in-person contacts. 12 13 But this begs the question of what ‘appropriate’ and ‘safe’ use of remote modalities in a primary care context is. Safety incidents (defined as ‘any unintended or unexpected incident which could have, or did, lead to harm for one or more patients receiving healthcare 14 ’) are extremely rare in primary healthcare consultations generally, 15 16 in-hours general practice telephone triage 17 and out-of-hours primary care. 18 But the recent widespread expansion of remote triage and remote consulting in primary care means that a wider range of patients and conditions are managed remotely, making it imperative to re-examine where the risks lie.

Theoretical approaches to safety in healthcare fall broadly into two traditions. 19 ‘Safety I’ studies focus on what went wrong. Incident reports are analysed to identify ‘root causes’ and ‘safety gaps’, and recommendations are made to reduce the chance that further similar incidents will happen in the future. 20 Such studies, undertaken in isolation, tend to lead to a tightening of rules, procedures and protocols. ‘Safety II’ studies focus on why, most of the time, things do not go wrong. Ethnography and other qualitative methods are employed to study how humans respond creatively to unique and unforeseen situations, thereby preventing safety incidents most of the time. 19 Such studies tend to show that actions which achieve safety are highly context specific, may entail judiciously breaking the rules and require human qualities such as courage, initiative and adaptability. 21 Few previous studies have combined both approaches.

In this study, we aimed to use Safety I methods to learn why safety incidents occur (although rarely) in remote primary care encounters and also apply Safety II methods to examine the kinds of creative actions taken by front-line staff that contribute to a safety culture and thereby prevent such incidents.

Study design and origins

Multimethod qualitative study across UK, including incident analysis, longitudinal ethnography and national stakeholder interviews.

The idea for this safety study began during a longitudinal ethnographic study of 12 general practices across England, Scotland and Wales as they introduced (and, in some cases, subsequently withdrew) various remote and digital modalities. Practices were selected for maximum diversity in geographical location, population served and digital maturity and followed from mid-2021 to end 2023 using staff and patient interviews and in-person ethnographic visits. The study protocol, 22 baseline findings 23 and a training needs analysis 24 have been published. To provide context for our ethnography, we interviewed a sample of national stakeholders in remote and digital primary care, including out-of-hours providers running telephone-led services, and held four online multistakeholder workshops, one of which was on the theme of safety, for policymakers, clinicians, patients and other parties. Early data from this detailed qualitative work revealed staff and patient concerns about the safety of remote encounters but no actual examples of harm.

To explore the safety theme further, we decided to take a dual approach. First, following Safety I methodology for the study of rare harms, 20 we set out to identify and analyse a sample of safety incidents involving remote encounters. These were sourced from arm’s-length bodies (NHS England, NHS Resolution, Healthcare Safety Investigation Branch) and providers of healthcare at scale (health boards, integrated care systems and telephone advice services), since our own small sample had not identified any of these rare occurrences. Second, we extended our longitudinal ethnographic design to more explicitly incorporate Safety II methodology, 19 allowing us to examine safety culture and safety practices in our 12 participating general practices, especially the adaptive work done by staff to avert potential safety incidents.

Data sources and management

Table 1 summarises the data sources.

• View inline

Summary of data sources

The Safety I dataset (rows 2-5) consisted of 95 specific incident reports, including complaints submitted to the main arm’s-length NHS body in England, NHS England, between 2020 and 2023 (n=69), closed indemnity claims that had been submitted to a national indemnity body, NHS Resolution, between 2015 and 2023 (n=16), reports from an urgent care telephone service in Wales (NHS 111 Wales) between 2020 and 2023 (n=6) and a report on an investigation of telephone advice during the COVID-19 crisis between 2020 and 2022 7 (n=4). These 95 incidents were organised using Microsoft Excel spreadsheets.

The Safety II dataset (rows 6-10) consisted of extracts from fieldnotes, workshop transcripts and interviews collected over 2 years, stored and coded on NVivo qualitative software. These were identified by searching for text words and codes (e.g. ‘risk’, ‘safety’, ‘incident’) and by asking researchers-in-residence, who were closely familiar with practices, to highlight safety incidents involving harm and examples of safety-conscious work practices. This dataset included over 100 formal interviews and numerous on-the-job interviews with practice staff, plus interviews with a sample of 10 GP (general practitioner) trainers and 10 GP trainees (penultimate row of table 1 ) and with six clinical safety experts identified through purposive sampling from government, arm’s-length bodies and health boards (bottom row of table 1 ).

Data analysis

We analysed incident reports, interview data and ethnographic fieldnotes using thematic analysis as described by Braun and Clarke. 25 These authors define a theme as an important, broad pattern in a set of qualitative data, which can (where necessary) be further refined using coding.

Themes in the incident dataset were identified by five steps. First, two researchers (both medically qualified) read each source repeatedly to gain familiarity. Second, those researchers worked independently using Braun and Clarke’s criterion (‘whether it captures something important in relation to the overall research question’—p 82 25 ) to identify themes. Third, they discussed their initial interpretations with each other and resolved differences through discussion. Fourth, they extracted evidence from the data sources to illustrate and refine each theme. Finally, they presented their list of themes along with illustrative examples to the wider team. Cases used to illustrate themes were systematically fictionalised by changing age, randomly allocating gender and altering clinical details. 26 For example, an acute appendicitis could be changed to acute diverticulitis if the issue was a missed acute abdomen.

These safety themes were then used to sensitise us to seek relevant (confirming and disconfirming) material from our ethnographic and interview datasets. For example, the theme ‘poor communication’ (and subthemes such as ‘failure to seek further clarification’ within this) promoted us to look for examples in our stakeholder interviews of poor communication offered as a cause of safety incidents and examples in our ethnographic notes of good communication (including someone seeking clarification). We used these wider data to add nuance to the initial list of themes.

As a final sense-checking step, the draft findings from this study were shown to each of the six safety experts in our sample and refined in the light of their comments (in some cases, for example, they considered the case to have been overfictionalised, thereby losing key clinical messages; they also gave additional examples to illustrate some of the themes we had identified, which underlined the importance of those themes).

Overview of dataset

The dataset ( table 1 ) consisted of 95 incident reports (see fictionalised examples in box 1 ), plus approximately 400 pages of extracts from interviews, ethnographic fieldnotes and workshop discussions, including situated safety practices (see examples in box 2 ), plus strategic insights relating to policy, organisation and planning of services. Notably, almost all incidents related to telephone calls.

Examples of safety incidents involving death or serious harm in remote encounters

All these cases have been systematically fictionalised as explained in the text.

Case 1 (death)

A woman in her 70s experiencing sudden breathlessness called her GP (general practitioner) surgery. The receptionist answered the phone and informed her that she would place her on the doctor’s list for an emergency call-back. The receptionist was distracted by a patient in the waiting room and did not do so. The patient deteriorated and died at home that afternoon.—NHS Resolution case, pre-2020

Case 2 (death)

An elderly woman contacted her GP after a telephone contact with the out-of-hours service, where constipation had been diagnosed. The GP prescribed laxatives without seeing the patient. The patient self-presented to the emergency department (ED) the following day in obstruction secondary to an incarcerated hernia and died in the operating theatre.—NHS Resolution case, pre-2020

Case 3 (risk to vulnerable patients)

A daughter complained that her elderly father was unable to access his GP surgery as he could not navigate the online triage system. When he phoned the surgery directly, he was directed back to the online system and told to get a relative to complete the form for him.—Complaint to NHS England, 2021

Case 4 (harm)

A woman in her first pregnancy at 28 weeks’ gestation experiencing urinary incontinence called NHS 111. She was taken down by a ‘urinary problems’ algorithm. Both the call handler and the subsequent clinician failed to recognise that she had experienced premature rupture of membranes. She later presented to the maternity department in active labour, and the opportunity to give early steroids to the premature infant was missed.—NHS Resolution case, pre-2020

Case 5 (death)

A doctor called about a 16-year-old girl with lethargy, shaking, fever and poor oral intake who had been unwell for 5 days. The doctor spoke to her older sister and advised that the child had likely glandular fever and should rest. When the parents arrived home, they called an ambulance but the child died of sepsis in the ED.—NHS Resolution case, pre-2020

Case 6 (death)

A 40-year-old woman, 6 weeks after caesarean section, contacted her GP due to shortness of breath, increased heart rate and dry cough. She was advised to get a COVID test and to dial 111 if she developed a productive cough, fever or pain. The following day she collapsed and died at home. The postmortem revealed a large pulmonary embolus. On reviewing the case, her GP surgery felt that had she been seen face to face, her oxygen saturations would have been measured and may have led to suspicion of the diagnosis.—NHS Resolution case, 2020

Case 7 (death)

A son complained that his father with diabetes and chronic kidney disease did not receive any in-person appointments over a period of 1 year. His father went on to die following a leg amputation arising from a complication of his diabetes.—Complaint to NHS England, 2021

Case 8 (death)

A 73-year-old diabetic woman with throat pain and fatigue called the surgery. She was diagnosed with a viral illness and given self-care advice. Over the next few days, she developed worsening breathlessness and was advised to do a COVID test and was given a pulse oximeter. She was found dead at home 4 days later. Postmortem found a blocked coronary artery and a large amount of pulmonary oedema. The cause of death was myocardial infarction and heart failure.—NHS Resolution case, pre-2020

Case 9 (harm)

A patient with a history of successfully treated cervical cancer developed vaginal bleeding. A diagnosis of fibroids was made and the patient received routine care by telephone over the next few months until a scan revealed a local recurrence of the original cancer.—Complaint to NHS England, 2020

Case 10 (death)

A 65-year-old female smoker with chronic cough and breathlessness presented to her GP. She was diagnosed with chronic obstructive pulmonary disease (COPD) and monitored via telephone. She did not respond to inhalers or antibiotics but continued to receive telephone monitoring without further investigation. Her symptoms continued to worsen and she called an ambulance. In the ED, she was diagnosed with heart failure and died soon after.—Complaint to NHS England, 2021

Case 11 (harm)

A 30-year-old woman presented with intermittent episodes of severe dysuria over a period of 2 years. She was given repeated courses of antibiotics but no urine was sent for culture and she was not examined. After 4 months of symptoms, she saw a private GP and was diagnosed with genital herpes.—Complaint to NHS England, 2021

Case 12 (harm)

There were repeated telephone consultations about a baby whose parents were concerned that the child was having a funny colour when feeding or crying. The 6-week check was done by telephone and at no stage was the child seen in person. Photos were sent in, but the child’s dark skin colour meant that cyanosis was not easily apparent to the reviewing clinician. The child was subsequently admitted by emergency ambulance where a significant congenital cardiac abnormality was found.—Complaint to NHS England, 2020 1

Case 13 (harm)

A 35-year-old woman in her third trimester of pregnancy had a telephone appointment with her GP about a breast lump. She was informed that this was likely due to antenatal breast changes and was not offered an in-person appointment. She attended after delivery and was referred to a breast clinic where a cancer was diagnosed.—Complaint to NHS England, 2020

Case 14 (harm)

A 63-year-old woman with a variety of physical symptoms including diarrhoea, hip girdle pain, palpitations, light-headedness and insomnia called her surgery on multiple occasions. She was told her symptoms were likely due to anxiety, but was diagnosed with stage 4 ovarian cancer and died soon after.—Complaint to NHS England, 2021

Case 15 (death)

A man with COPD with worsening shortness of breath called his GP surgery. The staff asked him if it was an emergency, and when the patient said no, scheduled him for 2 weeks later. The patient died before the appointment.—Complaint to NHS England, 2021

Examples of safety practices

Case 16 (safety incident averted by switching to video call for a sick child)

‘I’ve remembered one father that called up. Really didn’t seem to be too concerned. And was very much under-playing it and then when I did a video call, you know this child… had intercostal recession… looked really, really poorly. And it was quite scary actually that, you know, you’d had the conversation and if you’d just listened to what Dad was saying, actually, you probably wouldn’t be concerned.’—GP (general practitioner) interview 2022

Case 17 (‘red flag’ spotted by support staff member)

A receptionist was processing routine ‘administrative’ encounters sent in by patients using AccuRx (text messaging software). She became concerned about a sick note renewal request from a patient with a mental health condition. The free text included a reference to feeling suicidal, so the receptionist moved the request to the ‘red’ (urgent call-back) list. In interviews with staff, it became apparent that there had recently been heated discussion in the practice about whether support staff were adding ‘too many’ patients to the red list. After discussing cases, the doctors concluded that it should be them, not the support staff, who should absorb the risk in uncertain cases. The receptionist said that they had been told: ‘if in doubt, put it down as urgent and then the duty doctor can make a decision.’—Ethnographic fieldnotes from general practice 2023

Case 18 (‘check-in’ phone call added on busy day)

A duty doctor was working through a very busy Monday morning ‘urgent’ list. One patient had acute abdominal pain, which would normally have triggered an in-person appointment, but there were no slots and hard decisions were being made. This patient had had the pain already for a week, so the doctor judged that the general rule of in-person examination could probably be over-ridden. But instead of simply allocating to a call-back, the doctor asked a support staff member to phone the patient, ask ‘are you OK to wait until tomorrow?’ and offer basic safety-netting advice.—Ethnographic fieldnotes from general practice 2023

Case 19 (receptionist advocating on behalf of ‘angry’ walk-in patient)

A young Afghan man with limited English walked into a GP surgery on a very busy day, ignoring the prevailing policy of ‘total triage’ (make contact by phone or online in the first instance). He indicated that he wanted a same-day in-person appointment for a problem he perceived as urgent. A heated exchange occurred with the first receptionist, and the patient accused her of ‘racism’. A second receptionist of non-white ethnicity herself noted the man’s distress and suspected that there may indeed be an urgent problem. She asked the first receptionist to leave the scene, saying she wanted to ‘have a chat’ with the patient (‘the colour of my skin probably calmed him down more than anything’). Through talking to the patient and looking through his record, she ascertained that he had an acute infection that likely needed prompt attention. She tried to ‘bend the rules’ and persuade the duty doctor to see the patient, conveying the clinical information but deliberately omitting the altercation. But the first receptionist complained to the doctor (‘he called us racists’) and the doctor decided that the patient would not therefore be offered a same-day appointment. The second receptionist challenged the doctor (‘that’s not a reason to block him from getting care’). At this point, the patient cried and the second receptionist also became upset (‘this must be serious, you know’). On this occasion, despite her advocacy the patient was not given an immediate appointment.—Ethnographic fieldnotes from general practice 2022

Case 20 (long-term condition nurse visits ‘unengaged’ patients at home)

An advanced nurse practitioner talks of two older patients, each with a long-term condition, who are ‘unengaged’ and lacking a telephone. In this practice, all long-term condition reviews are routinely done by phone. She reflects that some people ‘choose not to have avenues of communication’ (ie, are deliberately not contactable), and that there may be reasons for this (‘maybe health anxiety or just old’). She has, on occasion, ‘turned up’ unannounced at the patient’s home and asked to come in and do the review, including bloods and other tests. She reflects that while most patients engage well with the service, ‘half my job is these patients who don’t engage very well.’—Ethnographic fieldnotes from digitally advanced general practice 2022

Case 21 (doctor over-riding patient’s request for telephone prescribing)

A GP trainee described a case of a 53-year-old first-generation immigrant from Pakistan, a known smoker with hypertension and diabetes. He had booked a telephone call for vomiting and sinus pain. There was no interpreter available but the man spoke some English. He said he had awoken in the night with pain in his sinuses and vomiting. All he wanted was painkillers for his sinuses. The story did not quite make sense, and the man ‘sounded unwell’. The GP told him he needed to come in and be examined. The patient initially resisted but was persuaded to come in. When the GP went to call him in, the man was visibly unwell and lying down in the waiting room. When seen in person, he admitted to shoulder pain. The GP sent him to accident and emergency (A&E) where a myocardial infarction was diagnosed.—Trainee interview 2023

Below, we describe the main themes that were evident in the safety incidents: a challenging organisational and system context, poor communication compounded by remote modalities, limited clinical information, patient and carer burden and inadequate training. Many safety incidents illustrated multiple themes—for example, poor communication and failures of clinical assessment or judgement and patient complexity and system pressures. In the detailed findings below, we illustrate why safety incidents occasionally occur and why they are usually avoided.

The context for remote consultations: system and operational challenges

Introduction of remote triage and expansion of remote consultations in UK primary care occurred at a time of unprecedented system stress (an understaffed and chronically under-resourced primary care sector, attempting to cope with a pandemic). 23 Many organisations had insufficient telephone lines or call handlers, so patients struggled to access services (eg, half of all calls to the emergency COVID-19 telephone service in March 2020 were never answered 7 ). Most remote consultations were by telephone. 27

Our safety incident dataset included examples of technically complex access routes which patients found difficult or impossible to navigate (case 3 in box 1 ) and which required non-clinical staff to make clinical or clinically related judgements (cases 4 and 15). Our ethnographic dataset contained examples of inflexible application of triage rules (eg, no face-to-face consultation unless the patient had already had a telephone call), though in other practices these rules could be over-ridden by staff using their judgement or asking colleagues. Some practices had a high rate of failed telephone call-backs (patient unobtainable).

High demand, staff shortages and high turnover of clinical and support staff made the context for remote encounters inherently risky. Several incidents were linked to a busy staff member becoming distracted (case 1). Telephone consultations, which tend to be shorter, were sometimes used in the hope of improving efficiency. Some safety incidents suggested perfunctory and transactional telephone consultations, with flawed decisions made on the basis of incomplete information (eg, case 2).

Many practices had shifted—at least to some extent—from a demand-driven system (in which every request for an appointment was met) to a capacity-driven one (in which, if a set capacity was exceeded, patients were advised to seek care elsewhere), though the latter was often used flexibly rather than rigidly with an expectation that some patients would be ‘squeezed in’. In some practices, capacity limits had been introduced to respond to escalation of demand linked to overuse of triage templates (eg, to inquire about minor symptoms).

As a result of task redistribution and new staff roles, a single episode of care for one problem often involved multiple encounters or tasks distributed among clinical and non-clinical staff (often in different locations and sometimes also across in-hours and out-of-hours providers). Capacity constraints in onward services placed pressure on primary care to manage risk in the community, leading in some cases to failure to escalate care appropriately (case 6).

Some safety incidents were linked to organisational routines that had not adapted sufficiently to remote—for example, a prescription might be issued but (for various reasons) it could not be transmitted electronically to the pharmacy. Certain urgent referrals were delayed if the consultation occurred remotely (a referral for suspected colon cancer, for example, would not be accepted without a faecal immunochemical test).

Training, supervising and inducting staff was more difficult when many were working remotely. If teams saw each other less frequently, relationship-building encounters and ‘corridor’ conversations were reduced, with knock-on impacts for individual and team learning and patient care. Those supervising trainees or allied professionals reported loss of non-verbal cues (eg, more difficult to assess how confident or distressed the trainee was).

Clinical and support staff regularly used initiative and situated judgement to compensate for an overall lack of system resilience ( box 1 ). Many practices had introduced additional safety measures such as lists of patients who, while not obviously urgent, needed timely review by a clinician. Case 17 illustrates how a rule of thumb ‘if in doubt, put it down as urgent’ was introduced and then applied to avert a potentially serious mental health outcome. Case 18 illustrates how, in the context of insufficient in-person slots to accommodate all high-risk cases, a unique safety-netting measure was customised for a patient.

Poor communication is compounded by remote modalities

Because sense data (eg, sight, touch, smell) are missing, 28 remote consultations rely heavily on the history. Many safety incidents were characterised by insufficient or inaccurate information for various reasons. Sometimes (cases 2, 5, 6, 8, 9, 10 and 11), the telephone consultation was too short to do justice to the problem; the clinician asked few or no questions to build rapport, obtain a full history, probe the patient’s answers for additional detail, confirm or exclude associated symptoms and inquire about comorbidities and medication. Video provided some visual cues but these were often limited to head and shoulders, and photographs were sometimes of poor quality.

Cases 2, 4, 5 and 9 illustrate the dangers of relying on information provided by a third party (another staff member or a relative). A key omission (eg, in case 5) was failing to ask why the patient was unable to come to the phone or answer questions directly.

Some remote triage conversations were conducted using an inappropriate algorithm. In case 4, for example, the call handler accepted a pregnant patient’s assumption that leaking fluid was urine when the problem was actually ruptured membranes. The wrong pathway was selected; vital questions remained unasked; and a skewed history was passed to (and accepted by) the clinician. In case 8, the patient’s complaint of ‘throat’ pain was taken literally and led to ‘viral illness’ advice, overlooking a myocardial infarction.

The cases in box 2 illustrate how staff compensated for communication challenges. In case 16, a GP plays a hunch that a father’s account of his child’s asthma may be inaccurate and converts a phone encounter to video, revealing the child’s respiratory distress. In case 19 (an in-person encounter but relevant because the altercation occurs partly because remote triage is the default modality), one receptionist correctly surmises that the patient’s angry demeanour may indicate urgency and uses her initiative and interpersonal skills to obtain additional clinical information. In case 20, a long-term condition nurse develops a labour-intensive workaround to overcome her elderly patients’ ‘lack of engagement’. More generally, we observed numerous examples of staff using both formal tools (eg, see ‘red list’ in case 17) and informal measures (eg, corridor chats) to pass on what they believed to be crucial information.

Remote consulting can provide limited clinical information

Cases 2 and 4–14 all describe serious conditions including congenital cyanotic heart disease, pulmonary oedema, sepsis, cancer and diabetic foot which would likely have been readily diagnosed with an in-person examination. While patients often uploaded still images of skin lesions, these were not always of sufficient quality to make a confident diagnosis.

Several safety incidents involved clinicians assuming that a diagnosis made on a remote consultation was definitive rather than provisional. Especially when subsequent consultations were remote, such errors could become ingrained, leading to diagnostic overshadowing and missed or delayed diagnosis (cases 2, 8, 9, 10, 11 and 13). Patients with pre-existing conditions (especially if multiple or progressive), the very young and the elderly were particularly difficult to assess by telephone (cases 1, 2, 8, 10, 12 and 16). Clinical conditions difficult to assess remotely included possible cardiac pain (case 8), acute abdomen (case 2), breathing difficulties (cases 1, 6 and 10), vague and generalised symptoms (cases 5 and 14) and symptoms which progressed despite treatment (cases 9, 10 and 11). All these categories came up repeatedly in interviews and workshops as clinically risky.

Subtle aspects of the consultation which may have contributed to safety incidents in a telephone consultation included the inability to fully appraise the patient’s overall health and well-being (including indicators relevant to mental health such as affect, eye contact, personal hygiene and evidence of self-harm), general demeanour, level of agitation and concern, and clues such as walking speed and gait (cases 2, 5, 6, 7, 8, 10, 12 and 14). Our interviews included stories of missed cases of new-onset frailty and dementia in elderly patients assessed by telephone.

In most practices we studied, most long-term condition management was undertaken by telephone. This may be appropriate (and indeed welcome) when the patient is well and confident and a physical examination is not needed. But diabetes reviews, for example, require foot examination. Case 7 describes the deterioration and death of a patient with diabetes whose routine check-ups had been entirely by telephone. We also heard stories of delayed diagnosis of new diabetes in children when an initial telephone assessment failed to pick up lethargy, weight loss and smell of ketones, and point-of-care tests of blood or urine were not possible.

Nurses observed that remote consultations limit opportunities for demonstrating or checking the patient’s technique in using a device for monitoring or treating their condition such as an inhaler, oximeter or blood pressure machine.

Safety netting was inadequate in many remote safety incidents, even when provided by a clinician (cases 2, 5, 6, 8, 10, 12 and 13) but especially when conveyed by a non-clinician (case 15). Expert interviewees identified that making life-changing diagnoses remotely and starting patients on long-term medication without an in-person appointment was also risky.

Our ethnographic data showed that various measures were used to compensate for limited clinical information, including converting a phone consultation to video (case 16), asking the patient if they felt they could wait until an in-person slot was available (case 18), visiting the patient at home (case 20) and enacting a ‘if the history doesn’t make sense, bring the patient in for an in-person assessment’ rule of thumb (case 21). Out-of-hours providers added examples of rules of thumb that their services had developed over years of providing remote services, including ‘see a child face-to-face if the parent rings back’, ‘be cautious about third-party histories’, ‘visit a palliative care patient before starting a syringe driver’ and ‘do not assess abdominal pain remotely’.

Remote modalities place additional burdens on patients and carers

Given the greater importance of the history in remote consultations, patients who lacked the ability to communicate and respond in line with clinicians’ expectations were at a significant disadvantage. Several safety incidents were linked to patients’ limited fluency in the language and culture of the clinician or to specific vulnerabilities such as learning disability, cognitive impairment, hearing impairment or neurodiversity. Those with complex medical histories and comorbidities, and those with inadequate technical set-up and skills (case 3), faced additional challenges.

In many practices, in-person appointments were strictly limited according to more or less rigid triage criteria. Some patients were unable to answer the question ‘is this an emergency?’ correctly, leading to their condition being deprioritised (case 15). Some had learnt to ‘game’ the triage system (eg, online templates 29 ) by adapting their story to obtain the in-person appointment they felt they needed. This could create distrust and lead to inaccurate information on the patient record.

Our ethnographic dataset contained many examples of clinical and support staff using initiative to compensate for vulnerable patients’ inability or unwillingness to take on the additional burden of remote modalities (cases 19 and 20 in Box 2 30 31 ).

Training for remote encounters is often inadequate

Safety incidents highlighted various training needs for support staff members (eg, customer care skills, risks of making clinical judgements) and clinicians (eg, limitations of different modalities, risks of diagnostic overshadowing). Whereas out-of-hours providers gave thorough training to novice GPs (covering such things as attentiveness, rapport building, history taking, probing, attending to contextual cues and safety netting) in telephone consultations, 32–34 many in-hours clinicians had never been formally taught to consult by telephone. Case 17 illustrates how on-the-job training based on acknowledgement of contextual pressures and judicious use of rules of thumb may be very effective in averting safety incidents.

Statement of principal findings

An important overall finding from this study is that examples of deaths or serious harms associated with remote encounters in primary care were extremely rare, amounting to fewer than 100 despite an extensive search going back several years.

Analysis of these 95 safety incidents, drawn from multiple complementary sources, along with rich qualitative data from ethnography, interviews and workshops has clarified where the key risks lie in remote primary care. Remote triage and consultations expanded rapidly in the context of the COVID-19 crisis; they were occurring in the context of resource constraints, understaffing and high demand. Triage and care pathways were complex, multilayered and hard to navigate; some involved distributed work among multiple clinical and non-clinical staff. In some cases, multiple remote encounters preceded (and delayed) a needed in-person assessment.

In this high-risk context, safety incidents involving death or serious harm were rare, but those that occurred were characterised by a combination of inappropriate choice of modality, poor rapport building, inadequate information gathering, limited clinical assessment, inappropriate clinical pathway (eg, wrong algorithm) and failure to take account of social circumstances. These led to missed, inaccurate or delayed diagnoses, underestimation of severity or urgency, delayed referral, incorrect or delayed treatment, poor safety netting and inadequate follow-up. Patients with complex or multiple pre-existing conditions, cardiac or abdominal emergencies, vague or generalised symptoms, safeguarding issues and failure to respond to previous treatment, and those who (for any reason) had difficulty communicating, seemed particularly at risk.

Strengths and limitations of the study

The main strength of this study was that it combined the largest Safety I study undertaken to date of safety incidents in remote primary care (using datasets which have not previously been tapped for research), with a large, UK-wide ethnographic Safety II analysis of general practice as well as stakeholder interviews and workshops. Limitations of the safety incident sample (see final column in table 1 ) include that it was skewed towards very rare cases of death and serious harm, with relatively few opportunities for learning that did not result in serious harm. Most sources were retrospective and may have suffered from biases in documentation and recall. We also failed to obtain examples of safeguarding incidents (which would likely turn up in social care audits). While all cases involved a remote modality (or a patient who would not or could not use one), it is impossible to definitively attribute the harm to that modality.

Comparison with existing literature

This study has affirmed previous findings that processes, workflows and training in in-hours general practice have not adapted adequately to the booking, delivery and follow-up of remote consultations. 24 35 36 Safety issues can arise, for example, from how the remote consultation interfaces with other key practice routines (eg, for making urgent referrals for possible cancer). The sheer complexity and fragmentation of much remote and digital work underscores the findings from a systematic review of the importance of relational coordination (defined as ‘a mutually reinforcing process of communicating and relating for the purpose of task integration ’ (p 3) 37 ) and psychological safety (defined as ‘people’s perceptions of the consequences of taking interpersonal risks in a particular context such as a workplace ’ (p 23) 38 ) in building organisational resilience and assuring safety.

The additional workload and complexity associated with running remote appointments alongside in-person ones is cognitively demanding for staff and requires additional skills for which not all are adequately trained. 24 39 40 We have written separately about the loss of traditional continuity of care as primary care services become digitised, 41–43 and about the unmet training needs of both clinical and support staff for managing remote and digital encounters. 24

Our findings also resonate with research showing that remote modalities can interfere with communicative tasks such as rapport building, establishing a therapeutic relationship and identifying non-verbal cues such as tearfulness 35 36 44 ; that remote consultations tend to be shorter and feature less discussion, information gathering and safety netting 45–48 ; and that clinical assessment in remote encounters may be challenging, 27 49 50 especially when physical examination is needed. 35 36 51 These factors may rarely contribute to incorrect or delayed diagnoses, underestimation of the seriousness or urgency of a case, and failure to identify a deteriorating trajectory. 35 36 52–54

Even when systems seem adequate, patients may struggle to navigate them. 23 30 31 This finding aligns with an important recent review of cognitive load theory in the context of remote and digital health services: because such services are more cognitively demanding for patients, they may widen inequities of access. 55 Some patients lack navigating and negotiating skills, access to key technologies 13 36 or confidence in using them. 30 35 The remote encounter may require the patient to have a sophisticated understanding of access and cross-referral pathways, interpret their own symptoms (including making judgements about severity and urgency), obtain and use self-monitoring technologies (such as a blood pressure machine or oximeter) and convey these data in medically meaningful ways (eg, by completing algorithmic triage forms or via a telephone conversation). 30 56 Furthermore, the remote environment may afford fewer opportunities for holistically evaluating, supporting or safeguarding the vulnerable patient, leading to widening inequities. 13 35 57 Previous work has also shown that patients with pre-existing illness, complex comorbidities or high-risk states, 58 59 language non-concordance, 13 35 inability to describe their symptoms (eg, due to autism 60 ), extremes of age 61 and those with low health or system literacy 30 are more difficult to assess remotely.

Lessons for safer care

Many of the contributory factors to safety incidents in remote encounters have been suggested previously, 35 36 and align broadly with factors that explain safety incidents more generally. 53 62 63 This new study has systematically traced how upstream factors may, very rarely, combine to contribute to avoidable human tragedies—and also how primary care teams develop local safety practices and cultures to help avoid them. Our study provides some important messages for practices and policymakers.

First, remote encounters in general practice are mostly occurring in a system designed for in-person encounters, so processes and workflows may work less well.

Second, because the remote encounter depends more on history taking and dialogue, verbal communication is even more mission critical. Working remotely under system pressures and optimising verbal communication should both be priorities for staff training.

Third, the remote environment may increase existing inequities as patients’ various vulnerabilities (eg, extremes of age, poverty, language and literacy barriers, comorbidities) make remote communication and assessment more difficult. Our study has revealed impressive efforts from staff to overcome these inequities on an individual basis; some of these workarounds may become normalised and increase efficiency, but others are labour intensive and not scalable.

A final message from this study is that clinical assessment provides less information when a physical examination (and even a basic visual overview) is not possible. Hence, the remote consultation has a higher degree of inherent uncertainty. Even when processes have been optimised (eg, using high-quality triage to allocate modality), but especially when they have not, diagnoses and assessments of severity or urgency should be treated as more provisional and revisited accordingly. We have given examples in the Results section of how local adaptation and rule breaking bring flexibility into the system and may become normalised over time, leading to the creation of locally understood ‘rules of thumb’ which increase safety.

Overall, these findings underscore the need to share learning and develop guidance about the drivers of risk, how these play out in different kinds of remote encounters and how to develop and strengthen Safety II approaches to mitigate those risks. Table 2 shows proposed mitigations at staff, process and system levels, as well as a preliminary list of suggestions for patients, which could be refined with patient input using codesign methods. 64

Reducing safety incidents in remote primary care

Unanswered questions and future research

This study has helped explain where the key risks lie in remote primary care encounters, which in our dataset were almost all by telephone. It has revealed examples of how front-line staff create and maintain a safety culture, thereby helping to prevent such incidents. We suggest four key avenues for further research. First, additional ethnographic studies in general practice might extend these findings and focus on specific subquestions (eg, how practices identify, capture and learn from near-miss incidents). Second, ethnographic studies of out-of-hours services, which are mostly telephone by default, may reveal additional elements of safety culture from which in-hours general practice could learn. Third, the rise in asynchronous e-consultations (in which patients complete an online template and receive a response by email) raises questions about the safety of this new modality which could be explored in mixed-methods studies including quantitative analysis of what kinds of conditions these consultations cover and qualitative analysis of the content and dynamics of the interaction. Finally, our findings suggest that the safety of new clinically related ‘assistant’ roles in general practice should be urgently evaluated, especially when such staff are undertaking remote assessment or remote triage.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

Ethical approval was granted by the East Midlands—Leicester South Research Ethics Committee and UK Health Research Authority (September 2021, 21/EM/0170 and subsequent amendments). Access to the NHS Resolution dataset was obtained by secondment of the RP via honorary employment contract, where she worked with staff to de-identify and fictionalise relevant cases. The Remote by Default 2 study (referenced in main text) was co-designed by patients and lay people; it includes a diverse patient panel. Oversight was provided by an independent external advisory group with a lay chair and patient representation. A person with lived experience of a healthcare safety incident (NS) is a co-author on this paper and provided input to data analysis and writing up, especially the recommendations for patients in table 2 .

Acknowledgments

We thank the participating organisations for cooperating with this study and giving permission to use fictionalised safety incidents. We thank the participants in the ethnographic study (patients, practice staff, policymakers, other informants) who gave generously of their time and members of the study advisory group.

• Sarbadhikari SN ,
• Jacob AG , et al
• Hall Dykgraaf S ,
• Desborough J ,
• de Toca L , et al
• Koonin LM ,
• Tsang CA , et al
• England NHS
• Papoutsi C ,
• Greenhalgh T
• ↵ Healthcare safety investigation branch: NHS 111’s response to callers with COVID-19-related symptoms during the pandemic . 2022 . Available : https://www.hsib.org.uk/investigations-and-reports/response-of-nhs-111-to-the-covid-19-pandemic/nhs-111s-response-to-callers-with-covid-19-related-symptoms-during-the-pandemic [Accessed 25 Jun 2023 ].
• Royal College of General Practitioners
• NHS Confederation
• Gupta PP , et al
• Panagioti M ,
• Keers RN , et al
• Panesar SS ,
• deSilva D ,
• Carson-Stevens A , et al
• Campbell JL ,
• Britten N ,
• Green C , et al
• Huibers L , et al
• Hollnagel E ,
• Braithwaite J
• Institute of Medicine (US)
• Jerak-Zuiderent S
• Greenhalgh T ,
• Alvarez Nishio A , et al
• Hemmings N , et al
• Hughes G , et al
• Salisbury C , et al
• Berens E-M ,
• Nowak P , et al
• Macdonald S ,
• Browne S , et al
• Edwards PJ ,
• Bennett-Britton I ,
• Ridd MJ , et al
• Warren C , et al
• Challiner J , et al
• Wieringa S ,
• Greenhalgh T , et al
• Rushforth A , et al
• Edmondson AC ,
• Eddison N ,
• Healy A , et al
• Paparini S , et al
• Byng R , et al
• Moore L , et al
• McKinstry B ,
• Hammersley V ,
• Burton C , et al
• Gafaranga J ,
• McKinstry B
• Seuren LM ,
• Wherton J , et al
• Donaghy E ,
• Parker R , et al
• Sharma SC ,
• Thakker A , et al
• Johnsen TM ,
• Norberg BL ,
• Kristiansen E , et al
• Wherton J ,
• Ferwerda R ,
• Tijssen R , et al
• NHS Resolution
• Marincowitz C ,
• Bath P , et al
• Antonio MG ,
• Williamson A ,
• Kameswaran V , et al
• Oudshoorn N
• Winters D ,
• Newman T , et al
• Huibers L ,
• Renaud V , et al
• ↵ Remote consultations . n.d. Available : https://www.gmc-uk.org/ethical-guidance/ethical-hub/remote-consultations
• Doherty M ,
• Neilson S ,
• O’Sullivan J , et al
• Carson-Stevens A ,
• Hibbert P ,
• Williams H , et al
• Edwards A ,
• Powell C , et al
• Morris RL ,
• Fraser SW ,

X @dakinfrancesca, @trishgreenhalgh

Contributors RP led the Safety I analysis with support from AC. The Safety II analysis was part of a wider ethnographic study led by TG and SS, on which all other authors undertook fieldwork and contributed data. TG and RP wrote the paper, with all other authors contributing refinements. All authors checked and approved the final manuscript. RP is guarantor.

Funding Funding was from NIHR HS&DR (grant number 132807) (Remote by Default 2 study) and NIHR School for Primary Care Research (grant number 594) (ModCons study), plus an NIHR In-Practice Fellowship for RP.

Competing interests RP was National Professional Advisor, Care Quality Commission 2017–2022, where her role included investigation of safety issues.

Provenance and peer review Not commissioned; externally peer reviewed.

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• Editorial Examining telehealth through the Institute of Medicine quality domains: unanswered questions and research agenda Timothy C Guetterman Lorraine R Buis BMJ Quality & Safety 2024; 33 552-555 Published Online First: 09 May 2024. doi: 10.1136/bmjqs-2023-016872

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• Open access
• Published: 19 August 2024

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

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

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

Metrics details

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

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

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

Conclusions

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

Peer Review reports

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

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

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

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

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

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

Study design

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

Sampling and recruitment

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

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

Data analysis

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

Ethical approval

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

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

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

• Saudi Arabia

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

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

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

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

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

Relevant existing policies

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

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

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

Implementation of physical activity policies

(a) physical activity programs.

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

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

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

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

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

(B) Private sector

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

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

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

Data/monitoring

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

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

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

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

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

Future opportunities

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

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

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

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

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

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

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

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

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

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

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

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

Strengths and limitations

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

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

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

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

Availability of data and materials

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

Abbreviations

Coronavirus disease 2019

Gulf Cooperation Council

Health in all policies

Limited liability company

Ministry of Education

Ministry of Health

Ministry of Sport

Non-communicable disease

Non-governmental organization

• Physical activity

Physical education

United Arab Emirates

United States

World Health Organization

Physical Activity Guidelines Advisory Committee. 2018 physical activity guidelines advisory committee scientific report. Washington DC: US Department of Health and Human Services; 2018.

Google Scholar  

World Health Organization. WHO guidelines on physical activity and sedentary behaviour. Geneva: World Health Organization; 2020.

Dishman RK, Heath G, Schmidt MD, Lee I-M. Physical activity epidemiology. Champaign: Human Kinetics; 2022.

Strain T, Flaxman S, Guthold R, Semenova E, Cowan M, Riley LM, Bull FC, Stevens GA. National, regional, and global trends in insufficient physical activity among adults from 2000 to 2022: a pooled analysis of 507 population-based surveys with 5·7 million participants. Lancet Glob Health. 2024;12(8):e1232–43.

Article   PubMed   PubMed Central   CAS   Google Scholar  

Guthold R, Stevens GA, Riley LM, Bull FC. Global trends in insufficient physical activity among adolescents: a pooled analysis of 298 population-based surveys with 1·6 million participants. Lancet Child Adolesc Health. 2020;4(1):23–35.

Article   PubMed   PubMed Central   Google Scholar  

Sallis JF, Owen N, Fisher E. Ecological models of health behavior. In: Glanz K, Rimer BK, Viswanath K, editors. Health behavior: theory, research, and practice. 5th ed. Hoboken: John Wiley and Sons; 2015.

Calvert HG, Turner L, Leider J, Piekarz-Porter E, Chriqui JF. Comprehensive policies to support comprehensive practices: physical activity in elementary schools. J Phys Act Health. 2020;17(3):313–22.

Article   PubMed   Google Scholar  

Klepac Pogrmilovic B, Ramirez Varela A, Pratt M, Milton K, Bauman A, Biddle SJ, Pedisic Z. National physical activity and sedentary behaviour policies in 76 countries: availability, comprehensiveness, implementation, and effectiveness. Int J Behav Nutr Phys Act. 2020;17(1):1–13.

Article   Google Scholar  

Gelius P, Messing S, Goodwin L, Schow D, Abu-Omar K. What are effective policies for promoting physical activity? A systematic review of reviews. Prev Med Rep. 2020;18:101095.

Sallis J, Bauman A, Pratt M. Environmental and policy interventions to promote physical activity. Am J Prev Med. 1998;15(4):379–97.

Article   PubMed   CAS   Google Scholar  

Schmid TL, Pratt M, Witmer L. A framework for physical activity policy research. J Phys Act Health. 2006;3(s1):S20–9.

Bull F, Milton K, Kahlmeier S, Arlotti A, Juričan AB, Belander O, Martin B, Martin-Diener E, Marques A, Mota J. Turning the tide: national policy approaches to increasing physical activity in seven European countries. Br J Sports Med. 2015;49(11):749–56.

Volf K, Kelly L, García Bengoechea E, Casey B, Gobis A, Lakerveld J, Zukowska J, Gelius P, Messing S, Forberger S. Policy Evaluation Network (PEN): protocol for systematic literature reviews examining the evidence for impact of policies on physical activity across seven different policy domains. HRB Open Res. 2022;3:62.

Volf K, Kelly L, García Bengoechea E, Casey B, Gelius P, Messing S, Forberger S, Lakerveld J, Den Braver NR, Zukowska J. Evidence of the impact of sport policies on physical activity and sport participation: a systematic mixed studies review. Int J Sport Pol Polit. 2022;14(4):697–712.

Abarca-Gómez L, Abdeen ZA, Hamid ZA, Abu-Rmeileh NM, Acosta-Cazares B, Acuin C, Adams RJ, Aekplakorn W, Afsana K, Aguilar-Salinas CA. Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. Lancet. 2017;390(10113):2627–42.

World Health Organization. Global status report on physical activity. Geneva: World Health Organization; 2022.

Al-Hazzaa HM. Physical inactivity in Saudi Arabia revisited: a systematic review of inactivity prevalence and perceived barriers to active living. Int J Health Sci. 2018;12(6):50.

Al Siyabi H, Mabry RM, Al Siyabi A, Al Subhi M, Milton K. The development of a national policy framework for physical activity in Oman. J Phys Act Health. 2021;18(12):1471–2.

World Health Organization. Promoting physical activity in the Eastern Mediterranean Region through a life-course approach. Geneva: World Health Organization; 2014.

Klepac Pogrmilovic B, O’Sullivan G, Milton K, Biddle SJ, Bauman A, Bull F, Kahlmeier S, Pratt M, Pedisic Z. A global systematic scoping review of studies analysing indicators, development, and content of national-level physical activity and sedentary behaviour policies. Int J Behav Nutr Phys Act. 2018;15(1):1–17.

Albujulaya N, Stevinson C, Piggin J. Physical activity policy in Saudi Arabia: analysis of progress and challenges. Int J Sport Pol Polit. 2023. https://doi.org/10.1080/19406940.2023.2228812 .

Al-Hazzaa HM, AlMarzooqi MA. Descriptive analysis of physical activity initiatives for health promotion in Saudi Arabia. Front Public Health. 2018;6:329.

Al-Hazzaa HM. Physical activity research in the Gulf Cooperation Council Countries: progress made but work still to do. J Phys Act Health. 2022;19(11):769–70.

Al Siyabi H, Mabry RM, Al Siyabi A, Milton K. A critique of national physical activity policy in Oman using 3 established policy frameworks. J Phys Act Health. 2021;18(12):1473–8.

Denzin NK, Lincoln YS. The Sage handbook of qualitative research. 5th ed. Los Angeles: Sage; 2018.

The World Bank: Data for Saudi Arabia and Oman. https://data.worldbank.org/?locations=SA-OM . Accessed 5 Jan 2024.

Saunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, Burroughs H, Jinks C. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52(4):1893–907.

Bellew B, Bauman A, Bull FC, Schoeppe S. The rise and fall of Australian physical activity policy 1996–2006: a national review framed in an international context. Aust N Z Health Policy. 2008. https://doi.org/10.1186/1743-8462-5-18 .

Klepac Pogrmilovic B, O’Sullivan G, Milton K, Biddle SJH, Bauman A, Bellew W, Cavill N, Kahlmeier S, Kelly MP, Mutrie N, et al. The development of the Comprehensive Analysis of Policy on Physical Activity (CAPPA) framework. Int J Behav Nutr Phys Act. 2019;16(1):60.

Omani Ministry of Health: The national policy for prevention and control of NCDs. https://extranet.who.int/nutrition/gina/sites/default/filesstore/OMN_2016_%20%D8%A7%D9%84%D8%AE%D8%B7%D8%A9%20%D8%A7%D9%84%D9%88%D8%B7%D9%86%D9%8A%D8%A9%20%D9%84%D9%84%D9%88%D9%82%D8%A7%D9%8A%D8%A9%20%D9%85%D9%86%20%D8%A7%D9%84%D8%A7%D9%85%D8%B1%D8%A7%D8%B6%20%D8%A7%D9%84%D9%85%D8%B2%D9%85%D9%86%D8%A9%20%D8%BA%D9%8A%D8%B1%20%D8%A7%D9%84%D9%85%D8%B9%D8%AF%D9%8A%D8%A9%20%D9%88%D9%85%D9%83%D8%A7%D9%81%D8%AD%D8%AA%D9%87%D8%A7_1.pdf . Accessed 12 Dec 2023.

Saudi Vision 2030: Quality of life program. https://www.vision2030.gov.sa/v2030/vrps/qol/ . Accessed 25 Dec 2023.

Kingdom of Saudi Arabia: National transformation program. https://vision2030.gov.sa/sites/default/files/NTP_En.pdf . Accessed 2 Jan 2024.

University Sports Federation: University sports federation strategy. https://m.susfweb.com/publication/f-a4f22d74-b999-465c-9cd0-2a89895555a8.pdf . Accessed 17 Nov 2023.

Ministry of Health 2015: The National Diet and Physical Activity Strategy (DPAS) 2015–2025. https://extranet.who.int/nutrition/gina/sites/default/filesstore/SAU_2015_%D8%A7%D9%84%D8%A7%D8%B3%D8%AA%D8%B1%D8%A7%D8%AA%D9%8A%D8%AC%D9%8A%D8%A9%20%D8%A7%D9%84%D9%88%D8%B7%D9%86%D9%8A%D8%A9%20%D9%84%D9%84%D8%BA%D8%B0%D8%A7%D8%A1%20%D8%A7%D9%84%D8%B5%D8%AD%D9%8A%20%D8%A9%D8%A7%D9%84%D9%86%D8%B4%D8%A7%D8%B7%20%D8%A7%D9%84%D8%A8%D8%AF%D9%86%D9%8A.pdf . Accessed 23 Dec 2023.

Saudi Ministry of Health: Physical activity guidelines for health practitioners. https://www.moh.gov.sa/Ministry/About/Health%20Policies/037.pdf . Accessed 2 Nov 2023.

Public Health Authority: 24-hour movement guidance Saudi Arabia. https://covid19.cdc.gov.sa/wp-content/uploads/2021/10/24-hrs-ar.pdf . Accessed 4 Jan 2024.

Saudi Sports for All Federation: Annual report. https://sportsforall.com.sa/wp-content/uploads/2021/03/SFA-Annual-Report-2020-EN-V2-4.pdf . Accessed 24 Oct 2023.

Oman Vision 2040: Vision Document. https://www.oman2040.om/assets/books/oman2040-en/index.html#p=51 . Accessed 10 Sept 2023.

Omani Ministry of Education: The physical education standards document. https://ict.moe.gov.om/omcust/PDF/Sport1_9_Oman.pdf . Accessed 26 Dec 2023.

Oman Olympic Committee: Regulations. https://ooc.om/wp-content/uploads/2021/08/RulesAndRegulationsArabic.pdf . Accessed 7 Jan 2024.

Saudi Ministry of Health: Exploratory examination for students. https://www.my.gov.sa/downloads/manuals/87d1f31c-1c7a-41a2-8a89-650a718a4a9d.pdf . Accessed 2 Dec 2023.

Saudi Health Promotion Centre 2021: HPC. https://saudihpc.com/ . Accessed 21 Sept 2023.

Chowdhury S, Mok D, Leenen L. Transformation of health care and the new model of care in Saudi Arabia: Kingdom’s Vision 2030. J Med Life. 2021;14(3):347–54.

Alqahtani BA, Alenazi AM, Alhowimel AS, Elnaggar RK. The descriptive pattern of physical activity in Saudi Arabia: analysis of national survey data. Int Health. 2021;13(3):232–9.

Omani Ministry of Health: National nutrition strategy. https://extranet.who.int/nutrition/gina/sites/default/filesstore/OMN%202014%20National%20Nutrition%20Startegy.pdf . Accessed 8 Jan 2024.

Quality of Life Program 2020: Vision 2030. https://planipolis.iiep.unesco.org/sites/default/files/ressources/saudi_arabia_quality_of_life.pdf . Accessed 27 Nov 2023.

Evenson KR, Alhusseini N, Moore CC, Hamza MM, Al-Qunaibet A, Rakic S, Alsukait RF, Herbst CH, AlAhmed R, Al-Hazzaa HM. Scoping review of population-based physical activity and sedentary behavior in Saudi Arabia. J Phys Act Health. 2023;20(6):471–86.

Allender S, Gleeson E, Crammond B, Sacks G, Lawrence M, Peeters A, Loff B, Swinburn B. Policy change to create supportive environments for physical activity and healthy eating: which options are the most realistic for local government? Health Promot Int. 2012;27(2):261–74.

World Health Organization: Country cooperation strategy at glance. https://apps.who.int/iris/bitstream/handle/10665/136842/ccsbrief_sau_en.pdf?sequence=1 . Accessed 18 Oct 2023.

World Health Organization. Health-promoting schools initiative in Oman: a WHO case study in intersectoral action. Cairo: Regional Office for the Eastern Mediterranean; 2013.

Government of Saudi Arabia: Vision 2030. https://www.vision2030.gov.sa/media/rc0b5oy1/saudi_vision203.pdf . Accessed 9 Jan 2024.

World Health Organization: Global action plan on physical activity 2018–2030. https://apps.who.int/iris/bitstream/handle/10665/272722/9789241514187-eng.pdf . Accessed 11 Nov 2023.

Aunger JA, Millar R, Greenhalgh J, Mannion R, Rafferty A-M, McLeod H. Why do some inter-organisational collaborations in healthcare work when others do not? A realist review. Syst Rev. 2021;10(1):82.

Evenson KR, Satinsky SB, Valko C, Gustat J, Healy I, Litt JS, Hooker SP, Reed HL, Tompkins NOH. In-depth interviews with state public health practitioners on the United States National Physical Activity Plan. Int J Behav Nutr Phys Act. 2013;10(1):1–9.

Al-Otaibi HH. Measuring stages of change, perceived barriers and self efficacy for physical activity in Saudi Arabia. Asian Pac J Cancer Prev. 2013;14(2):1009–16.

Abdel-Salam D, Abdel-Khalek E. Pattern and barriers of physical activity among medical students of Al-Jouf University, Saudi Arabia. J High Inst Public Health. 2016;46(2):41–8.

Alahmed Z, Lobelo F. Physical activity promotion in Saudi Arabia: a critical role for clinicians and the health care system. J Epidemiol Global Health. 2018;7:S7–15.

International Society for Physical Activity and Health (ISPAH): ISPAH’s eight investments that work for physical activity. www.ISPAH.org/Resources . Accessed 2 Oct 2023.

Alhumaid MM, Khoo S, Bastos T. The effect of an adapted physical activity intervention program on pre-service physical education teachers’ self-efficacy towards inclusion in Saudi Arabia. Sustainability. 2021;13(6):3459.

Alghannam AF, Malkin JD, Al-Hazzaa HM, AlAhmed R, Evenson KR, Rakic S, Alsukait R, Herbst CH, Alqahtani SA, Finkelstein EA. Public policies to increase physical activity and reduce sedentary behavior: a narrative synthesis of “reviews of reviews.” Glob Health Action. 2023;16(1):2194715.

Lincoln YS, Guba EG. But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. New Dir Eval. 1986;1986(30):73–84.

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Acknowledgements

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

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

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

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Correspondence to Klaus Gebel .

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

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Received : 17 January 2024

Accepted : 20 July 2024

Published : 19 August 2024

DOI : https://doi.org/10.1186/s12961-024-01192-w

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