Drivers, Barriers, Maintenance, and Discontinuation of Hookah Smoking Among Women: A Qualitative Study Using Content Analysis

Who is sensitising whom? A participatory interview guide development as an awareness tool within a health care research project

Background and aim:Researchers, in qualitative researches, both influences on and take effect from the research process. One of the mainissues in qualitative research is validity of the researcher as an instrument of data collection. If the researcher doesnot have enough validity in the data collection, the results of the study will also not be cited. The researcher asinstrument provides an opportunity for researchers to enter into the unknown world of individual about thephenomena in question and sometimes faced many challenges in reaching this goal. This study has been reviewingthe opportunities and challenges of researchers as an instrument in the qualitative research.Materials and methods:This was a review study on the methodology of qualitative research. Using keywords including qualitative research,instrument, challenges, and opportunities, articles and available books were investigated in PubMed, Scopus,Science Direct, Proquest, Magiran iSCI iIranDoc, SID, Medlib, IranMedex databases with no time limit. TheQuality of the articles was assessed by using the McMaster Critical Review Form for Qualitative studies.Findings:Studies over 12 books and 18 articles showed that the role of the researcher can be varied in different qualitativeresearch designs such as phenomenology researches, grounded theory, ethnography, and content analysis researches.Also previous experience and skills in the process of observation and interview, having effective communicationand asking the appropriate questions have an important impact on the role of researchers as a key factor inqualitative research.Conclusions:Researchers have the main role, especially in data gathering of different types of qualitative researches. Actuallythey are factors that validate the data. Experience and skills, ability to communicate, asking the right questions arethe most important factors that have an influence on doing qualitative research in an appropriate ways.Key words:Qualitative Research, Instrument, Challenge, OpportunityREFERENCES‐ Abedi H A (2010) [Application of phenomenological research in clinical sciences]. Jounal ofRahbord 19(54) 207-24. (persian) ‐ Alvandi S M and Boudlaei H (2010) [Phenomenology in entrepreneurship studies]. IranianJournal of Management Sciences 5(19) 33-61. (persian) ‐ Bogdan R and Biklen S K (1997). Qualitative research for education, Fourth Edition, New York,Allyn & Bacon, 1997 ] Briggs D (2013) Emotions, ethnography and crack cocaine users. Emotion, Space and Society7(13) 1-12] Brockopp D Y and Hastings-Tolsma M T (2003) Fundamentals of nursing research, ThirdEdition, Massachusetts, Jones & Bartlett Learning.] Burns N Grove S K (2010) Understanding nursing research: Building an evidence-basedpractice, 5th Edition, Philadelphia, Elsevier Health Sciences.] Corbin J and Strauss A (2014). Basics Of Qualitative Research: Techniques And Procedures ForDeveloping Grounded Theory, Fourth Edition, New York, Sage publications.] Delavar A (2009) [Qualitative methodology]. Journal of Rahbord. 19(54) 307-29. (persian)] Dempsey P A and Dempsey A D (2000) Using nursing research: Process, critical evaluation,and utilization. 5th Edition, Philadelphia, Lippincott Williams & Wilkins.] Emami S A, Dehghan Nayeri N, Rahnavard Z et al. (2012) [Qualitative research methodology:phenomenology]. Holistic Nursing and Midwifery 22(68) 56-63. (persian)] Feyz D (2010) [The strategic analysis of the role of qualitative research in the country andstrategies for its development by SWOT model]. Journal of Rahbord 19(54) 169-85. (persian)] Gall M D, Borg W R, Gall J P (1996) Educational research: An introduction. 6th Edition,London, Longman Publishing.] Goetz J P and LeCompte M D (1984) Ethnography and qualitative design in educationalresearch. Second Edition, United States, Academic Press Orlando, FL.] Hallberg L R (2006) The gcore categoryh of grounded theory: Making constant comparisons.International Journal of Qualitative Studies on Health and Well-being 1(3) 141-48.] Iman M T Noshadi M R (2011) [Qualitative content analysis] Journal of Pazhuhesh 3(2) 15-44.(pesian)] Johnson N (2009) The role of self and emotion within qualitative sensitive research: A reflectiveaccount. Enquire 2(2) 191-214] Khanifar H and Zarvandi N (2010) [Qualitative research: A new approach in managementstudies]. Journal of Rahbord 19(54) 243-56. (persian)] Kondracki N L, Wellman N S and Amundson D R (2002) Content analysis: Review of methodsand their applications in nutrition education. Journal of Nutrition Education and Behavior 34(4)224-30] Krauss S E (2005) Research paradigms and meaning making: A primer. The Qualitative Report10(4) 758-70] Krippendorff, K. (2012). Content analysis: An introduction to its methodology, New York, SagePublications] Lombard M, Snyder-Duch J and Bracken C C (2002) Content analysis in mass communication.Human Communication Research 28(4) 587-604] Monadi M (2010) [Qualitative methods and theorization]. Journal of Rahbord 19(54) 107-34(persian)] Nourouzi R A and Bidhendi M (2010) [Human agency in qualitative approach to research].Journal of Rahbord 19(54) 187-206. (persian)] Pope C, Ziebland S and Mays N (2000) Qualitative research in health care: Analysingqualitative data. BMJ: British Medical Journal 320(7227) 114-6‐ Ranjbar H, Haghdoost A A, Salsali M, et al. (2012) [Sampling in qualitative research: A Guidefor beginning]. Journal of Army University of Medical Sciences 10(3) 238-250. (Persian) ‐ Rouhani H (2010) [Qualitative research: Background and approaches]. Journal of Rahbord19(54) 7-29. (persian) ‐ Soleimani M A, Negarandeh, R and Bastani F (2015) [Exploring for self-care Process in patientswith parkinson's disease: A grounded theory study]. Hayat 21(1) 6-22. (persian) ‐ Soleimani M A, Negarandeh R, Bastani F, et al. (2014) Disrupted social connectedness in peoplewith Parkinson's disease. British Journal of Community Nursing 19(3) 136-4. ‐ Speziale H S, Streubert H J and Carpenter D R (2011) Qualitative research in nursing:Advancing the humanistic imperative, Philadelphia, Lippincott Williams & Wilkins. ‐ Steen M and Roberts T (2011) The handbook of midwifery research. 1st Edition, New Jersey,John Wiley & Sons. ‐ Weeks M R and Schensul J J (2014) Ethnographic Research on AIDS Risk Behavior and theMaking of Policy. Speaking the Language of Power: Communication, Collaboration and Advocacy (translating Ethnology Into Action) 50. ‐Yin R K (2013) Case study research: Design and methods, 5th Edition, New York, Sagepublications.

This paper compares the research method of phenomenological psychology to other qualitative research methods such as ethnography, participant observation, grounded theory, dramaturgical interviewing and content analysis. An attempt is made to identify similarities and differences. As a prelude, the major metatheories with which they are associated (phenomenology and symbolic interactionism) and the related differences between natural science and human science are discussed.Interest in qualitative research methodology appears to have gathered momentum over the last decade (e.g., Rist, 1980). One of the recurrent themes in the discussion of qualitative methods has been the question of whether quantitative and qualitative methods are compatible. Opinion has been divided. Gibbs (1979) made a plea for complementarity of subjectivist and objectivist methods in psychology. Mahrer (1988) has advocated discovery oriented research in the field of psychotherapy, while Sperry (1988) has suggested an integration of positivistic and phenomenological thought to form a more naturalistic approach to the study of brain and consciousness.The split between those who support and those who do not support complementarity of quantitative and qualitative methodology has also occurred in the field of educational research. For example, Howe (1985, 1988) and Firestone (1987) have argued for compatibility, while Smith (1983) and Smith and Heshusius (1986) have argued for incompatibility.The early eighties marked the growth of an interest in qualitative methodology which has paralleled the growing disenchantment with traditional logical - empirical research methods. The hegemony of natural science type research methods has been increasingly challenged by descriptive and hermeneutically oriented methods (e.g., Giorgi, 1986; Packer, 1985; Palmer, 1969; Polkinghorne, 1983; Rommetveit, 1987). Contextualism (Rosnow & Georgoudi, 1986), social constructionism (Gergen, 1985) and deconstructionism (Derrida, 1977) have also challenged the objectivity of traditional natural science methodology by emphasizing the socially derived foundationalisms upon which methods are based.There seems little doubt that qualitative methodology has come out of the closet in the field of the human sciences. Although quantitative methodological hegemony continues, the degree of coexistence and complementaritybetween quantitative and qualitative research methods seems to be increasing. Nonetheless, there are those who, while seeing symptoms of the inadequacy of standard quantitative methodological practice, see possible cures and solutions in the same metatheoretical terms (e.g., Aiken, West, Sechrest & Reno, 1990). Sarbin (1976) has noted the difficulty that psychologists trained in logical - empirical traditions have in breaking their reliance on habitual methods.The Transition from Quantitative to Qualitative MethodologyThose researchers who are willing to explore qualitative methods face several difficulties. Usually they have been trained in the quantitative tradition and find the transition to qualitative research methods requires a major shift in world - view. The metatheories underlying such methods often differ from the logical - empirical base of natural science (Jacob, 1987). As will be seen later, some aspects of the qualitative methods associated with symbolic interactionism follow normative natural science practice (e.g., the Iowa school of ethnography) while other qualitative methods use a mixture of natural and human science approaches to research (e.g., the Chicago School of ethnography). Qualitative research methods such as phenomenology and the phenomenological aspects of ethnography, participant observation and grounded theory are based on metatheories that are associated with a human science approach to psychology (see Giorgi, 1970). The emphasis is upon discovery, description and meaning rather than the traditional natural science criteria of prediction, control and measurement. …

This session will engage participants in how to apply multiple qualitative research methods to examine emerging issues in engineering education. The focus will be on using qualitative methods — grounded theory, thematic analysis, and content analysis — across multiple data collection methods (individual interviews, focus groups, key informant interviews, and policy/programmatic artifacts) and across several institutions. Benefits and challenges associated with data collection, synthesis, analysis, and triangulation across multiple research sites will be discussed, as well as the important role of theoretical frameworks in designing engineering education inquiry. It is expected that participants will gain a greater appreciation of qualitative methods that can be used to answer important questions in engineering education.

BackgroundQualitative methods are essential for providing an in-depth understanding of “why” and “how” evidence-based interventions are successfully implemented—a key area of implementation science (IS) research. A systematic synthesis of the applications of qualitative methods is critical for understanding how qualitative methods have been used to date and identifying areas of innovation and optimization. This scoping review explores which qualitative data collection and analytic methods are used in IS research, what and how frameworks and theories are leveraged using qualitative methods, and which implementation issues are explored with qualitative implementation research.MethodWe conducted a systematic scoping review of articles in MEDLINE and Embase using qualitative methods in IS health research. We systematically extracted information including study design, data collection method(s), analytic method(s), implementation outcomes, and other domains.ResultsOur search yielded a final dataset of 867 articles from 76 countries. Qualitative study designs were predominantly single elicitation (67.7%) and longitudinal (20.3%). In-depth interviews were the most common data collection method (84.3%), followed by focus group discussions (FGDs) (34.5%), and nearly 25% used both. Sample sizes were, on average, 40 in-depth interviews (range: 1–1,131) and nine FGDs (range: 1–46). The most common analytic approaches were thematic analysis (45.3%) and content analysis (18.5%) with substantial variation in analytic conceptualization. Nearly one-quarter (23.2%) of articles used one or more TMF to conceptualize the study, and less than half (40.9%) of articles used a TMF to guide both data collection and analysis.ConclusionsWe highlight variation in how qualitative methods were used, as well as detailed examples of data collection and analysis descriptions. By reviewing how qualitative methods have been used in well-described and innovative ways, and identifying important gaps, we highlight opportunities for strengthening their use to optimize IS research.RegistrationThe protocol can be found 10.11124/JBIES-20-00120.

Background and Purpose of the Research The purpose of the research reported in this thesis was to explore the challenges of managing the 2009/A/H1N1 influenza pandemics in primary care in Australia, Israel and England. The influenza pandemic 2009/A/H1N1 was less devastating than originally anticipated; however, its burden on the health systems of many countries was substantial. It affected 214 countries and territories disproportionally afflicting young children and pregnant women. During this influenza pandemic, the main burden of the pandemic response fell on primary care services, and General Practitioners (GPs) were the ones who diagnosed and treated most of the patients. The prominent role of GPs in the 2009/A/H1N1 influenza pandemic presented an excellent opportunity to investigate the implications of pandemic policies for primary care and to tackle the potential problems that these policies may impose on the ability of GPs to participate effectively in the pandemic response. Method The research design consisted of three complementary studies: a systematic review of the literature, a document study, and qualitative semi-structured interviews with GPs. The systematic literature review (Study 1) was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and applied systematic approach to the literature search, study selection and data extraction. The objective of the systematic review was to examine evidence of challenges that primary care physicians encountered responding to past pandemics or large-scale epidemics. The document study (Study 2) involved analysis of the documents published by the health authorities in Australia, Israel and England during the 2009/A/H1N1 influenza pandemic. Information pertinent for the research question was separated from non-pertinent applying qualitative content analysis approach. Subsequent thematic analysis involved more focused reviewing of the retrieved data, which involved coding and category construction. The objective of the document study was to compare the approaches for management of the 2009/A/H1N1 influenza pandemic in primary care in these three countries. Qualitative semi-structured interviews with 65 GPs in Australia, Israel and England (Study 3) were conducted during June-September 2010. Thematic analysis of the qualitative data was applied. The objective was to explore the views of GPs on challenges they encountered managing the 2009/A/H1N1 influenza pandemic in these three countries. Findings The systematic review of the literature (Study 1) revealed that GPs from different countries experienced similar challenges during past epidemic or pandemic responses. These included: difficulties of communication with the health authorities; limited supply of Personal Protective Equipment (PPE) and difficulties with its use; challenges in performing public health responsibilities; limited support from the authorities; lack of appropriate training. However, the review did not allow a full-scale list of possible challenges of the pandemic response in primary care and yielded little systematic information concerning the nature of the identified challenges. The reasons for these were that only 10 studies met the inclusion criteria of the systematic review; the included studies had different objectives and designs; the studies provided little relevant information needed to consider the differences in patterns of the disease spread and GP involvement in the response in different countries. Study 2 and Study 3 of this thesis were designed to address the identified gap and to investigate the challenges of GP involvement in the 2009/A/H1N1 pandemic response in the selected examples of Australia, Israel and England. Study 2, document analysis, provided systematic evidence concerning the different approaches for involvement of GPs in the pandemic response in Australia, Israel and England. It showed that the involvement of GPs in the three countries differed in timing and allocated responsibilities. Study 3 of the thesis, qualitative interviews with GPs in Australia, Israel and England, elicited challenges in providing the pandemic response in primary care from the respective of GPs. The identified challenges were consistent with the findings of the systematic review of the literature. Systematic collection and analysis of the qualitative data from the three countries allowed identification of a full-scale list of challenges in three fields of the pandemic response: treatment of patients, performance of public health responsibilities and communication with the health authorities. Contribution of the Research to Knowledge This thesis adds to the existing knowledge concerning challenges of the pandemic response in primary care by differentiating between two types of challenges: (i) country specific challenges and (ii) cross country challenges intrinsic to the pandemic response in primary care in general. This was done by collating the data from the document study (Study 2) and qualitative interviews with GPs (Study 3). (i) Country specific challenges. These challenges were found to be influenced by the timing and severity of the disease spread, level of GP involvement in the response, support provided to GPs by the health authorities, and organization of primary care services in a country. (ii) Cross country challenges intrinsic to the pandemic response in primary care in general. These same difficulties were evident in each of the three countries and included difficulties in following pandemic guidelines (barriers affecting knowledge, attitudes and behaviour of GPs) and challenges related to the role delineation during the pandemic response that resulted in role ambiguity and role conflict. Conclusion and Recommendations for Future Pandemic Planning The experience of the 2009/A/H1N1 influenza pandemic management highlighted the centrality of primary care in the pandemic response. The findings of this thesis showed that GPs were intensively involved in the pandemic response in the three investigated countries, despite the differences in the responsibilities that were allocated to them. The connection of GPs to the populations they routinely serve and trust that these populations have in GPs, positioned them as the pivotal figures when people were concerned about their health or the possibility of getting sick. This situation is not likely to change in the future. In order to overcome challenges identified in this research, improvements in planning for involvement of GPs in the pandemic response should be introduced. Based on the thesis findings, the following recommendations were made: First, broader involvement of GPs in the process of planning should be targeted. This includes engagement of GPs and public health representatives in pre-pandemic drills, collaborative meetings and knowledge transfer; engagement of GP representatives and health authorities in pandemic policy evaluation; inclusion of GP representatives in decision making and planning committees. Second, improvement in clarity and strategy of the pandemic policies and guidelines communication to GPs should be introduced. This includes the establishment of one body that is responsible for communicating pandemic policy updates to GPs; making policy updates oriented to primary care by engaging GPs in pre-pandemic policy planning committees; engagement with GP professional bodies that develop and distribute guidelines for primary care; and establishment of mechanisms for GP feedback provision during the pandemic response. Third, planning the support to be provided to GPs during the pandemic response is imperative. This should include planning for rapid distribution of PPE and antiviral drugs in primary care; reimbursement for the pandemic vaccine administration; coordination during the mass vaccination campaign in primary care; and detailed guidelines to treat complicated pandemic cases.

Qualitative research methods, in many forms, have been used to deepen understandings in the field of severe disabilities for decades. Using methods such as individual case studies, grounded theory, phenomenology, content analysis, life history, and ethnography, qualitative research has served to explain bounded systems, generate theory, study the lived experiences of individuals, investigate historical and contemporary texts and contexts, share first-person narratives, and investigate cultural and social systems that involve students with severe disabilities. Indicators of quality in qualitative methods and means of establishing credibility have been explicated and are widely applied in the field. To varying degrees, qualitative methods have allowed researchers to represent the voices of students with severe disabilities and engage them actively in the research process, which is important given that a mantra among persons with severe disabilities and their advocates is nothing about us without us. Regardless of the methods, accurately representing the voices of students with severe disabilities and including them as active participants in research is not always easy to accomplish given the nature of their cognitive and communication profiles. Many students with severe disabilities do not communicate symbolically through speech, sign language, or graphic symbols. Others have limited means of communication and are dependent on familiar communication partners to co-construct meaning with them. Some approaches to qualitative research, such as post-critical ethnography, provide a potential path toward representing the voice of a broader range of students with severe disabilities because these methods lead researchers to interrogate assumptions in the field while examining their own positions, perceptions, and beliefs relative to the subject of the investigation. While these methods offer opportunity with respect to their ability to fairly represent and involve students with severe disabilities, they challenge previously accepted indicators of quality and means of establishing credibility in qualitative research. As qualitative research methods are applied in understanding students with severe disabilities in the future, these challenges will have to be addressed.

Guest editorial: What's common with qualitative nursing research these days?

Objectives: Qualitative health research can contribute to knowledge building in public health and medicine, but there is a lack of research-oriented training of qualitative methods at universities with public health programs and in medical schools. The aim of this paper is to describe our experiences in conceptualising, implementing and evaluating an elective on qualitative methods in the Master of Public Health (MPH) programme at the Medical Faculty of the Ludwig-Maximilians-University (LMU) Munich. Methods: A new research-oriented elective (3 Credit Points) was developed and delivered to MPH and medical students in summer 2016. This elective consisted of three blocks that were complemented by two practice sessions. The students worked in small groups. These groups developed a research question and a qualitative study design addressing the thematic focus of vaccinations. Each student conducted two semi-structured interviews with a semi-structured interview grid. Students transcribed the interviews, analysed them according to content analysis and presented the results collaboratively. Results: In that semester, 16 students successfully completed the elective. Groups of two to three students worked on their respective research questions, presented, and reflected on their research results. The participants evaluated the module as very good, particularly with regard to the structure and consistency of the blocks. To facilitate individualised mentoring and guidance, a high student-lecturer ratio is required. Timeframe and workload should pay tribute to the module's credit points. Conclusions: We successfully implemented a research-oriented elective providing a first-hand experience with qualitative health research methods. Students were able to learn about the theory and practical application of qualitative research in the field of medicine and public health.

O objetivo deste estudo foi compreender os riscos e as medidas para garantia da segurança dos pacientes em setores de Radiodiagnóstico. Um estudo exploratório qualitativo, por meio da análise de conteúdo foi realizado com a participação de 12 profissionais de uma instituição de ensino. As entrevistas transcritas foram organizadas no software WebQDA em duas categorias: A categoria ‘Riscos à Segurança ao Paciente em setores de Radiodiagnóstico’ emergiram o uso incorreto ou ausência de equipamentos de proteção individual, manejo inadequado de contraste, entre outros. A categoria ‘Adoção de Medidas de Segurança ao Paciente em setores de Radiodiagnóstico’ a educação para a saúde se mostrou como condição para garantir medidas de Segurança ao Paciente, considerando a educação continuada, treinamento entre outros. A riqueza dos resultados foram possíveis frente ao delineamento com abordagem qualitativa e análise de conteúdo, que possibilitou a compreensão aprofundada dos significados extraídos. Descritores: Segurança do Paciente, Radiodiagnóstico, Qualidade em Saúde, Pesquisa Qualitativa, Análise de Conteúdo. Patient safety in radiodiagnosis: a qualitative study with content analysis Abstract: The aim of this study was to understand the risks and measures to ensure patient safety in radiology departments. A qualitative exploratory study using content analysis was carried out with the participation of 12 professionals from an educational institution. The transcribed interviews were organized in the WebQDA software into two categories: The category 'Risks to Patient Safety in Radiodiagnostic Sectors' emerged as incorrect use or absence of personal protective equipment, inadequate handling of contrast, among others. In the category 'Adoption of Patient Safety Measures in Radiodiagnosis Sectors', health education was shown to be a condition for guaranteeing Patient Safety measures, considering continuing education, training and others. The richness of the results was made possible by the qualitative approach and content analysis, which enabled an in-depth understanding of the meanings extracted. Descriptors: Patient Safety, Radiodiagnostic, Quality in Healthcare, Qualitative Research, Content Analysis. Seguridad del paciente en radiodiagnóstico: un estudio cualitativo con análisis de contenido Resumen: El objetivo de este estudio fue conocer los riesgos y las medidas para garantizar la seguridad del paciente en los departamentos de radiología. Se realizó un estudio cualitativo exploratorio mediante análisis de contenido con la participación de 12 profesionales de una institución educativa. Las entrevistas transcritas fueron organizadas en el software WebQDA en dos categorías: En la categoría 'Riesgos para la Seguridad del Paciente en los Sectores de Radiodiagnóstico' surgieron el uso incorrecto o la ausencia de equipos de protección individual, el manejo inadecuado del contraste, entre otros. En la categoría 'Adopción de Medidas de Seguridad del Paciente en los Sectores de Radiodiagnóstico', la educación sanitaria se mostró como una condición para garantizar las medidas de Seguridad del Paciente, considerando la educación continuada, la formación y otras. La riqueza de los resultados fue posible gracias al abordaje cualitativo y al análisis de contenido, que permitieron una comprensión profunda de los significados extraídos. Descriptores: Seguridad del Paciente, Radiodiagnóstico, Calidad Sanitaria, Investigación Cualitativa, Análisis de Contenido.

Content analysis, initially a quantitative technique for identifying patterns in qualitative data, has evolved into a widely used qualitative method. However, this evolution has resulted in a confusing array of differing qualitative content analysis approaches that lack clear distinction from other methods. To address these issues, this paper introduces reflexive content analysis, a transtheoretical and flexible researcher-oriented method for the description and reduction of manifest qualitative data. RCA is used to identify patterns in the overt surface meanings of qualitative data through the use of a hierarchical structure of quantifiable analytical strata called codes, subcategories, and categories. Each stratum exists on a continuum of abstraction with codes being the closest to the original data and categories being the most abstract. During each stage of the RCA process, reflexivity is regarded as a valuable analytical resource that is crucial for ensuring adequate description of the data. RCA is intended to be used as method for data analysis, not a methodology, and therefore can be integrated with various methodological and epistemological approaches. This paper provides an introductory guide to conducting RCA. It first presents an overview of existing challenges in qualitative content analysis methods, followed by a rationale for the development of RCA. Then, the foundational principles of RCA and key concepts that support this method are discussed. The paper culminates by outlining the process for conducting an inductive RCA within a qualitative framework, using a previous application of this method as a reference point.

Qualitative research methodologies are a group of approaches designed to capture human experience through the use of soft data such as words and images. The approaches are based on the assumption that behavior is the result of attributed meaning. In media psychology, qualitative methodologies are used to research the way people interpret and make sense of their experiences with media and technology. The principles of qualitative research are applied to the study of media content and consumption as well as to technology‐enabled behaviors, such as social connection and media participation. Social technologies highlight the socially embedded and continually adaptive nature of media consumption and production. This complex environment is well served by qualitative methodologies, such as ethnography, phenomenology, grounded theory, and content analysis, that address a range of goals, from individual meaning to the dynamics of social structures. Qualitative methodologies produce descriptive analyses that capture the depth of human experience, add context to a researcher's understanding of mediated experience, and highlight new and emerging voices that can challenge existing theories, models, and assumptions.

<p dir="ltr">Background<br>Clinical practice is an important part of medical education, providing students with an opportunity to put theory into practice and develop clinical skills. Primary health care (PHC) has gained increasing importance for students' development of clinical skills and provides a place where students can prepare for their future profession under supervision. The clinical learning environment in PHC is also a workplace with patients, supervisors, and other professionals, which creates a complex learning environment. In PHC, students meet authentic patients as they come to PHC with they problems when the students participate in everyday clinical work. </p><p dir="ltr"><br></p><p dir="ltr">In order to ensure the quality of the learning environment in PHC and provide an opportunity for both the PHC centre and the university to receive up-to-date feedback, it is important that the students have access to an evaluation instrument. The instrument needs to measure several aspects of the learning environment.</p><p dir="ltr">To ensure quality and the student's opportunity to progress in their journey towards a future profession, it is important to gain an understanding of how the clinical learning in PHC is perceived by students and patients and how it can be evaluated.</p><p dir="ltr">Aims<br>The aim of Study I was to adapt and validate the Clinical Learning Environment and Supervision (CLES) instrument to measure medical students' perceptions of their learning environment in PHC. In Study II, the aim was to explore medical students' perceptions of the clinical learning environment in PHC and how these perceptions vary according to the stage in the education programme. In Study III, the aim was to explore the perceptions of ordinary patients in PHC when participating in encounters with medical students and what they believe they contribute to the students' learning. In Study IV, the aim was to explore medical students' perceptions of learning from patient encounters in a PHC context.</p><p><br></p><p dir="ltr">Methods<br>In Study I, the CLES instrument was adapted to measure medical students' learning environment in PHC. The CLES instrument, which contains 25 items, was sent electronically to 1,256 students in the medical programme over 9 semesters. The study used exploratory factor analysis based on the principal components method, followed by oblique rotation, to confirm the adequate number of factors in the data. Construct validity was assessed by factor analysis. Confirmatory factor analysis was used to confirm the dimensions of the CLES instrument. In Study II, content analysis was used to analyse the students' free text comments, which they wrote in connection with the usual evaluation of their learning environment. In Study II, an adapted CLES instrument was used as an evaluation instrument. Study III was a qualitative study where individual interviews were analysed by inductive content analysis. A total of 13 patients were interviewed immediately after they had met a medical student during their visit to the PHC centre. Study IV was a qualitative study that used individual interviews with a semi-structured interview guide. The data was analysed by inductive content analysis. In total, 21 medical students were interviewed.</p><p dir="ltr"><br></p><p dir="ltr">Results<br>In Study I, a total 394 of students answered the questionnaire. The construct validity showed a clearly indicated four-factor model. The cumulative variance explanation was 0.65. The overall Cronbach's alpha was 0.95. The adapted CLES instrument had high construct validity and reliability and high internal consistency. In Study II, the two main themes were 'The supervisor was the central factor in determining the meaningfulness of the placement at all stages of the education' and 'Basic prerequisites for perceived clinical learning were to having an active role in an authentic clinical context and being trusted to work independently with patients'. The three categories were 'The perceived relationship with the supervisor', 'The perceived journey to become a doctor' and 'The perceived structure and culture'. In Study III, one main theme was found: 'Participating in a dialogue adapted to students' needs without being aware of one's role as a teacher' and four categories: 'Expectations and conditions for participation', 'Contribution to learning', 'Collaboration in learning', and 'Perceived benefit for the patient'. In Study IV, the main theme was 'The individual patient encounters are the key to learning in PHC'. Four categories were found: 'Patient encounters in primary health care are instructive, rewarding, and challenging', 'Encounters with patients in PHC provide opportunities for gradual professional development', 'A committed supervisor plays a significant role in learning', and 'Learning in PHC and learning in hospitals complement one another'.</p><p dir="ltr"><br></p><p dir="ltr">Conclusion<br>The CLES evaluation instrument was adopted for medical students and was subsequently seen as a useful tool for their evaluation of the clinical learning environment in PHC. Students' perceptions and experiences of clinical practice in PHC showed that the supervisor and patient were important for the student's progression. Active participation in clinical work and patient encounters, and the mix of patients in PHC, were seen as important for the development of clinical and communication skills. Patients were not always aware of their role in the student's learning but were able to contribute in many ways. The patients adapted to the students and allowed the students to perform examinations at their own pace. Students felt responsible for the patient and sometimes felt uncertain about whether they had the necessary competence. Committed supervisors provided students with the confidence to act on their own, and the students were aware of their own development.</p><h3>List of scientific papers</h3><p dir="ltr">I. <b>Öhman E,</b> Alinaghizadeh H, Kaila P, Hult H, Nilsson G.H, Salminen H. Adaptation and validation of the instrument Clinical Learning Environment and Supervision for medical students in primary health care. BMC Medical Education. 2016. 16:308. <a href="https://doi.org/10.1186/s12909-016-0809-8">https://doi.org/10.1186/s12909-016-0809-8</a></p><p dir="ltr">II. Salminen H, <b>Öhman E,</b> Stenfors-Hayes T. Medical students' feedback regarding their clinical learning environment in primary healthcare: a qualitative study. BMC Medical Education. 2016. 16:313. <a href="https://doi.org/10.1186/s12909-016-0837-4">https://doi.org/10.1186/s12909-016-0837-4<br></a><br>III. <b>Öhman E,</b> Toth-Pal E, Hult H, Nilsson G.H, Salminen H. How patients in primary health care perceive their contribution to medical students' learning - an interview study. [Manuskript]</p><p dir="ltr"><br></p><p dir="ltr">IV. <b>Öhman E,</b> Toth-Pal E, Hult H, Nilsson G.H, Salminen H. Medical students' perception of learning from patient encounters in primary health care; a qualitative interview study. BMC Medical Education. 2023. 23:935. <a href="https://doi.org/10.1186/s12909-023-04923-9" rel="noreferrer" target="_blank">https://doi.org/10.1186/s12909-023-04923-9</a></p>

<p dir="ltr">Background<br>Clinical practice is an important part of medical education, providing students with an opportunity to put theory into practice and develop clinical skills. Primary health care (PHC) has gained increasing importance for students' development of clinical skills and provides a place where students can prepare for their future profession under supervision. The clinical learning environment in PHC is also a workplace with patients, supervisors, and other professionals, which creates a complex learning environment. In PHC, students meet authentic patients as they come to PHC with they problems when the students participate in everyday clinical work. </p><p dir="ltr"><br></p><p dir="ltr">In order to ensure the quality of the learning environment in PHC and provide an opportunity for both the PHC centre and the university to receive up-to-date feedback, it is important that the students have access to an evaluation instrument. The instrument needs to measure several aspects of the learning environment.</p><p dir="ltr">To ensure quality and the student's opportunity to progress in their journey towards a future profession, it is important to gain an understanding of how the clinical learning in PHC is perceived by students and patients and how it can be evaluated.</p><p dir="ltr">Aims<br>The aim of Study I was to adapt and validate the Clinical Learning Environment and Supervision (CLES) instrument to measure medical students' perceptions of their learning environment in PHC. In Study II, the aim was to explore medical students' perceptions of the clinical learning environment in PHC and how these perceptions vary according to the stage in the education programme. In Study III, the aim was to explore the perceptions of ordinary patients in PHC when participating in encounters with medical students and what they believe they contribute to the students' learning. In Study IV, the aim was to explore medical students' perceptions of learning from patient encounters in a PHC context.</p><p><br></p><p dir="ltr">Methods<br>In Study I, the CLES instrument was adapted to measure medical students' learning environment in PHC. The CLES instrument, which contains 25 items, was sent electronically to 1,256 students in the medical programme over 9 semesters. The study used exploratory factor analysis based on the principal components method, followed by oblique rotation, to confirm the adequate number of factors in the data. Construct validity was assessed by factor analysis. Confirmatory factor analysis was used to confirm the dimensions of the CLES instrument. In Study II, content analysis was used to analyse the students' free text comments, which they wrote in connection with the usual evaluation of their learning environment. In Study II, an adapted CLES instrument was used as an evaluation instrument. Study III was a qualitative study where individual interviews were analysed by inductive content analysis. A total of 13 patients were interviewed immediately after they had met a medical student during their visit to the PHC centre. Study IV was a qualitative study that used individual interviews with a semi-structured interview guide. The data was analysed by inductive content analysis. In total, 21 medical students were interviewed.</p><p dir="ltr"><br></p><p dir="ltr">Results<br>In Study I, a total 394 of students answered the questionnaire. The construct validity showed a clearly indicated four-factor model. The cumulative variance explanation was 0.65. The overall Cronbach's alpha was 0.95. The adapted CLES instrument had high construct validity and reliability and high internal consistency. In Study II, the two main themes were 'The supervisor was the central factor in determining the meaningfulness of the placement at all stages of the education' and 'Basic prerequisites for perceived clinical learning were to having an active role in an authentic clinical context and being trusted to work independently with patients'. The three categories were 'The perceived relationship with the supervisor', 'The perceived journey to become a doctor' and 'The perceived structure and culture'. In Study III, one main theme was found: 'Participating in a dialogue adapted to students' needs without being aware of one's role as a teacher' and four categories: 'Expectations and conditions for participation', 'Contribution to learning', 'Collaboration in learning', and 'Perceived benefit for the patient'. In Study IV, the main theme was 'The individual patient encounters are the key to learning in PHC'. Four categories were found: 'Patient encounters in primary health care are instructive, rewarding, and challenging', 'Encounters with patients in PHC provide opportunities for gradual professional development', 'A committed supervisor plays a significant role in learning', and 'Learning in PHC and learning in hospitals complement one another'.</p><p dir="ltr"><br></p><p dir="ltr">Conclusion<br>The CLES evaluation instrument was adopted for medical students and was subsequently seen as a useful tool for their evaluation of the clinical learning environment in PHC. Students' perceptions and experiences of clinical practice in PHC showed that the supervisor and patient were important for the student's progression. Active participation in clinical work and patient encounters, and the mix of patients in PHC, were seen as important for the development of clinical and communication skills. Patients were not always aware of their role in the student's learning but were able to contribute in many ways. The patients adapted to the students and allowed the students to perform examinations at their own pace. Students felt responsible for the patient and sometimes felt uncertain about whether they had the necessary competence. Committed supervisors provided students with the confidence to act on their own, and the students were aware of their own development.</p><h3>List of scientific papers</h3><p dir="ltr">I. <b>Öhman E,</b> Alinaghizadeh H, Kaila P, Hult H, Nilsson G.H, Salminen H. Adaptation and validation of the instrument Clinical Learning Environment and Supervision for medical students in primary health care. BMC Medical Education. 2016. 16:308. <a href="https://doi.org/10.1186/s12909-016-0809-8">https://doi.org/10.1186/s12909-016-0809-8</a></p><p dir="ltr">II. Salminen H, <b>Öhman E,</b> Stenfors-Hayes T. Medical students' feedback regarding their clinical learning environment in primary healthcare: a qualitative study. BMC Medical Education. 2016. 16:313. <a href="https://doi.org/10.1186/s12909-016-0837-4">https://doi.org/10.1186/s12909-016-0837-4<br></a><br>III. <b>Öhman E,</b> Toth-Pal E, Hult H, Nilsson G.H, Salminen H. How patients in primary health care perceive their contribution to medical students' learning - an interview study. [Manuskript]</p><p dir="ltr"><br></p><p dir="ltr">IV. <b>Öhman E,</b> Toth-Pal E, Hult H, Nilsson G.H, Salminen H. Medical students' perception of learning from patient encounters in primary health care; a qualitative interview study. BMC Medical Education. 2023. 23:935. <a href="https://doi.org/10.1186/s12909-023-04923-9" rel="noreferrer" target="_blank">https://doi.org/10.1186/s12909-023-04923-9</a></p>

<p dir="ltr">Background<br>Clinical practice is an important part of medical education, providing students with an opportunity to put theory into practice and develop clinical skills. Primary health care (PHC) has gained increasing importance for students' development of clinical skills and provides a place where students can prepare for their future profession under supervision. The clinical learning environment in PHC is also a workplace with patients, supervisors, and other professionals, which creates a complex learning environment. In PHC, students meet authentic patients as they come to PHC with they problems when the students participate in everyday clinical work.</p><p dir="ltr">In order to ensure the quality of the learning environment in PHC and provide an opportunity for both the PHC centre and the university to receive up-to-date feedback, it is important that the students have access to an evaluation instrument. The instrument needs to measure several aspects of the learning environment.</p><p dir="ltr">To ensure quality and the student's opportunity to progress in their journey towards a future profession, it is important to gain an understanding of how the clinical learning in PHC is perceived by students and patients and how it can be evaluated.</p><p dir="ltr">Aims<br>The aim of Study I was to adapt and validate the Clinical Learning Environment and Supervision (CLES) instrument to measure medical students' perceptions of their learning environment in PHC. In Study II, the aim was to explore medical students' perceptions of the clinical learning environment in PHC and how these perceptions vary according to the stage in the education programme. In Study III, the aim was to explore the perceptions of ordinary patients in PHC when participating in encounters with medical students and what they believe they contribute to the students' learning. In Study IV, the aim was to explore medical students' perceptions of learning from patient encounters in a PHC context.</p><p dir="ltr"><br></p><p dir="ltr">Methods<br>In Study I, the CLES instrument was adapted to measure medical students' learning environment in PHC. The CLES instrument, which contains 25 items, was sent electronically to 1,256 students in the medical programme over 9 semesters. The study used exploratory factor analysis based on the principal components method, followed by oblique rotation, to confirm the adequate number of factors in the data. Construct validity was assessed by factor analysis. Confirmatory factor analysis was used to confirm the dimensions of the CLES instrument. In Study II, content analysis was used to analyse the students' free text comments, which they wrote in connection with the usual evaluation of their learning environment. In Study II, an adapted CLES instrument was used as an evaluation instrument. Study III was a qualitative study where individual interviews were analysed by inductive content analysis. A total of 13 patients were interviewed immediately after they had met a medical student during their visit to the PHC centre. Study IV was a qualitative study that used individual interviews with a semi-structured interview guide. The data was analysed by inductive content analysis. In total, 21 medical students were interviewed.</p><p dir="ltr">Results</p><p dir="ltr">In Study I, a total 394 of students answered the questionnaire. The construct validity showed a clearly indicated four-factor model. The cumulative variance explanation was 0.65. The overall Cronbach's alpha was 0.95. The adapted CLES instrument had high construct validity and reliability and high internal consistency. In Study II, the two main themes were 'The supervisor was the central factor in determining the meaningfulness of the placement at all stages of the education' and 'Basic prerequisites for perceived clinical learning were to having an active role in an authentic clinical context and being trusted to work independently with patients'. The three categories were 'The perceived relationship with the supervisor', 'The perceived journey to become a doctor' and 'The perceived structure and culture'. In Study III, one main theme was found: 'Participating in a dialogue adapted to students' needs without being aware of one's role as a teacher' and four categories: 'Expectations and conditions for participation', 'Contribution to learning', 'Collaboration in learning', and 'Perceived benefit for the patient'. In Study IV, the main theme was 'The individual patient encounters are the key to learning in PHC'. Four categories were found: 'Patient encounters in primary health care are instructive, rewarding, and challenging', 'Encounters with patients in PHC provide opportunities for gradual professional development', 'A committed supervisor plays a significant role in learning', and 'Learning in PHC and learning in hospitals complement one another'.</p><p dir="ltr">Conclusion<br>The CLES evaluation instrument was adopted for medical students and was subsequently seen as a useful tool for their evaluation of the clinical learning environment in PHC. Students' perceptions and experiences of clinical practice in PHC showed that the supervisor and patient were important for the student's progression. Active participation in clinical work and patient encounters, and the mix of patients in PHC, were seen as important for the development of clinical and communication skills. Patients were not always aware of their role in the student's learning but were able to contribute in many ways. The patients adapted to the students and allowed the students to perform examinations at their own pace. Students felt responsible for the patient and sometimes felt uncertain about whether they had the necessary competence. Committed supervisors provided students with the confidence to act on their own, and the students were aware of their own development.</p><h3>List of scientific papers</h3><p dir="ltr">I. <b>Öhman E,</b> Alinaghizadeh H, Kaila P, Hult H, Nilsson G.H, Salminen H. Adaptation and validation of the instrument Clinical Learning Environment and Supervision for medical students in primary health care. BMC Medical Education. 2016. 16:308. <a href="https://doi.org/10.1186/s12909-016-0809-8">https://doi.org/10.1186/s12909-016-0809-8</a></p><p dir="ltr">II. Salminen H, <b>Öhman E,</b> Stenfors-Hayes T. Medical students' feedback regarding their clinical learning environment in primary healthcare: a qualitative study. BMC Medical Education. 2016. 16:313. <a href="https://doi.org/10.1186/s12909-016-0837-4">https://doi.org/10.1186/s12909-016-0837-4</a></p><p dir="ltr"><br>III. <b>Öhman E,</b> Toth-Pal E, Hult H, Nilsson G.H, Salminen H. How patients in primary health care perceive their contribution to medical students' learning - an interview study. [Manuskript]</p><p dir="ltr"><br></p><p dir="ltr">IV. <b>Öhman E,</b> Toth-Pal E, Hult H, Nilsson G.H, Salminen H. Medical students' perception of learning from patient encounters in primary health care; a qualitative interview study. BMC Medical Education. 2023. 23:935. <a href="https://doi.org/10.1186/s12909-023-04923-9" rel="noreferrer" target="_blank">https://doi.org/10.1186/s12909-023-04923-9</a></p>