how to conduct qualitative research in social science

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How to Conduct Qualitative Research in Social Science (How to Research Guides)

• ISBN-10 1800376189
• ISBN-13 978-1800376182
• Publisher Edward Elgar Publishing
• Publication date January 10, 2023
• Language English
• Print length 246 pages
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• Publisher ‏ : ‎ Edward Elgar Publishing (January 10, 2023)
• Language ‏ : ‎ English
• Hardcover ‏ : ‎ 246 pages
• ISBN-10 ‏ : ‎ 1800376189
• ISBN-13 ‏ : ‎ 978-1800376182
• Item Weight ‏ : ‎ 1.12 pounds
• #4,711 in Social Sciences Methodology
• #8,556 in Social Sciences Research
• #176,018 in Social Sciences (Books)

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Pranee liamputtong.

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• Can J Hosp Pharm
• v.67(6); Nov-Dec 2014

Qualitative Research: Getting Started

Introduction.

As scientifically trained clinicians, pharmacists may be more familiar and comfortable with the concept of quantitative rather than qualitative research. Quantitative research can be defined as “the means for testing objective theories by examining the relationship among variables which in turn can be measured so that numbered data can be analyzed using statistical procedures”. 1 Pharmacists may have used such methods to carry out audits or surveys within their own practice settings; if so, they may have had a sense of “something missing” from their data. What is missing from quantitative research methods is the voice of the participant. In a quantitative study, large amounts of data can be collected about the number of people who hold certain attitudes toward their health and health care, but what qualitative study tells us is why people have thoughts and feelings that might affect the way they respond to that care and how it is given (in this way, qualitative and quantitative data are frequently complementary). Possibly the most important point about qualitative research is that its practitioners do not seek to generalize their findings to a wider population. Rather, they attempt to find examples of behaviour, to clarify the thoughts and feelings of study participants, and to interpret participants’ experiences of the phenomena of interest, in order to find explanations for human behaviour in a given context.

WHAT IS QUALITATIVE RESEARCH?

Much of the work of clinicians (including pharmacists) takes place within a social, clinical, or interpersonal context where statistical procedures and numeric data may be insufficient to capture how patients and health care professionals feel about patients’ care. Qualitative research involves asking participants about their experiences of things that happen in their lives. It enables researchers to obtain insights into what it feels like to be another person and to understand the world as another experiences it.

Qualitative research was historically employed in fields such as sociology, history, and anthropology. 2 Miles and Huberman 2 said that qualitative data “are a source of well-grounded, rich descriptions and explanations of processes in identifiable local contexts. With qualitative data one can preserve chronological flow, see precisely which events lead to which consequences, and derive fruitful explanations.” Qualitative methods are concerned with how human behaviour can be explained, within the framework of the social structures in which that behaviour takes place. 3 So, in the context of health care, and hospital pharmacy in particular, researchers can, for example, explore how patients feel about their care, about their medicines, or indeed about “being a patient”.

THE IMPORTANCE OF METHODOLOGY

Smith 4 has described methodology as the “explanation of the approach, methods and procedures with some justification for their selection.” It is essential that researchers have robust theories that underpin the way they conduct their research—this is called “methodology”. It is also important for researchers to have a thorough understanding of various methodologies, to ensure alignment between their own positionality (i.e., bias or stance), research questions, and objectives. Clinicians may express reservations about the value or impact of qualitative research, given their perceptions that it is inherently subjective or biased, that it does not seek to be reproducible across different contexts, and that it does not produce generalizable findings. Other clinicians may express nervousness or hesitation about using qualitative methods, claiming that their previous “scientific” training and experience have not prepared them for the ambiguity and interpretative nature of qualitative data analysis. In both cases, these clinicians are depriving themselves of opportunities to understand complex or ambiguous situations, phenomena, or processes in a different way.

Qualitative researchers generally begin their work by recognizing that the position (or world view) of the researcher exerts an enormous influence on the entire research enterprise. Whether explicitly understood and acknowledged or not, this world view shapes the way in which research questions are raised and framed, methods selected, data collected and analyzed, and results reported. 5 A broad range of different methods and methodologies are available within the qualitative tradition, and no single review paper can adequately capture the depth and nuance of these diverse options. Here, given space constraints, we highlight certain options for illustrative purposes only, emphasizing that they are only a sample of what may be available to you as a prospective qualitative researcher. We encourage you to continue your own study of this area to identify methods and methodologies suitable to your questions and needs, beyond those highlighted here.

The following are some of the methodologies commonly used in qualitative research:

• Ethnography generally involves researchers directly observing participants in their natural environments over time. A key feature of ethnography is the fact that natural settings, unadapted for the researchers’ interests, are used. In ethnography, the natural setting or environment is as important as the participants, and such methods have the advantage of explicitly acknowledging that, in the real world, environmental constraints and context influence behaviours and outcomes. 6 An example of ethnographic research in pharmacy might involve observations to determine how pharmacists integrate into family health teams. Such a study would also include collection of documents about participants’ lives from the participants themselves and field notes from the researcher. 7
• Grounded theory, first described by Glaser and Strauss in 1967, 8 is a framework for qualitative research that suggests that theory must derive from data, unlike other forms of research, which suggest that data should be used to test theory. Grounded theory may be particularly valuable when little or nothing is known or understood about a problem, situation, or context, and any attempt to start with a hypothesis or theory would be conjecture at best. 9 An example of the use of grounded theory in hospital pharmacy might be to determine potential roles for pharmacists in a new or underserviced clinical area. As with other qualitative methodologies, grounded theory provides researchers with a process that can be followed to facilitate the conduct of such research. As an example, Thurston and others 10 used constructivist grounded theory to explore the availability of arthritis care among indigenous people of Canada and were able to identify a number of influences on health care for this population.
• Phenomenology attempts to understand problems, ideas, and situations from the perspective of common understanding and experience rather than differences. 10 Phenomenology is about understanding how human beings experience their world. It gives researchers a powerful tool with which to understand subjective experience. In other words, 2 people may have the same diagnosis, with the same treatment prescribed, but the ways in which they experience that diagnosis and treatment will be different, even though they may have some experiences in common. Phenomenology helps researchers to explore those experiences, thoughts, and feelings and helps to elicit the meaning underlying how people behave. As an example, Hancock and others 11 used a phenomenological approach to explore health care professionals’ views of the diagnosis and management of heart failure since publication of an earlier study in 2003. Their findings revealed that barriers to effective treatment for heart failure had not changed in 10 years and provided a new understanding of why this was the case.

ROLE OF THE RESEARCHER

For any researcher, the starting point for research must be articulation of his or her research world view. This core feature of qualitative work is increasingly seen in quantitative research too: the explicit acknowledgement of one’s position, biases, and assumptions, so that readers can better understand the particular researcher. Reflexivity describes the processes whereby the act of engaging in research actually affects the process being studied, calling into question the notion of “detached objectivity”. Here, the researcher’s own subjectivity is as critical to the research process and output as any other variable. Applications of reflexivity may include participant-observer research, where the researcher is actually one of the participants in the process or situation being researched and must then examine it from these divergent perspectives. 12 Some researchers believe that objectivity is a myth and that attempts at impartiality will fail because human beings who happen to be researchers cannot isolate their own backgrounds and interests from the conduct of a study. 5 Rather than aspire to an unachievable goal of “objectivity”, it is better to simply be honest and transparent about one’s own subjectivities, allowing readers to draw their own conclusions about the interpretations that are presented through the research itself. For new (and experienced) qualitative researchers, an important first step is to step back and articulate your own underlying biases and assumptions. The following questions can help to begin this reflection process:

• Why am I interested in this topic? To answer this question, try to identify what is driving your enthusiasm, energy, and interest in researching this subject.
• What do I really think the answer is? Asking this question helps to identify any biases you may have through honest reflection on what you expect to find. You can then “bracket” those assumptions to enable the participants’ voices to be heard.
• What am I getting out of this? In many cases, pressures to publish or “do” research make research nothing more than an employment requirement. How does this affect your interest in the question or its outcomes, or the depth to which you are willing to go to find information?
• What do others in my professional community think of this work—and of me? As a researcher, you will not be operating in a vacuum; you will be part of a complex social and interpersonal world. These external influences will shape your views and expectations of yourself and your work. Acknowledging this influence and its potential effects on personal behaviour will facilitate greater self-scrutiny throughout the research process.

FROM FRAMEWORKS TO METHODS

Qualitative research methodology is not a single method, but instead offers a variety of different choices to researchers, according to specific parameters of topic, research question, participants, and settings. The method is the way you carry out your research within the paradigm of quantitative or qualitative research.

Qualitative research is concerned with participants’ own experiences of a life event, and the aim is to interpret what participants have said in order to explain why they have said it. Thus, methods should be chosen that enable participants to express themselves openly and without constraint. The framework selected by the researcher to conduct the research may direct the project toward specific methods. From among the numerous methods used by qualitative researchers, we outline below the three most frequently encountered.

DATA COLLECTION

Patton 12 has described an interview as “open-ended questions and probes yielding in-depth responses about people’s experiences, perceptions, opinions, feelings, and knowledge. Data consists of verbatim quotations and sufficient content/context to be interpretable”. Researchers may use a structured or unstructured interview approach. Structured interviews rely upon a predetermined list of questions framed algorithmically to guide the interviewer. This approach resists improvisation and following up on hunches, but has the advantage of facilitating consistency between participants. In contrast, unstructured or semistructured interviews may begin with some defined questions, but the interviewer has considerable latitude to adapt questions to the specific direction of responses, in an effort to allow for more intuitive and natural conversations between researchers and participants. Generally, you should continue to interview additional participants until you have saturated your field of interest, i.e., until you are not hearing anything new. The number of participants is therefore dependent on the richness of the data, though Miles and Huberman 2 suggested that more than 15 cases can make analysis complicated and “unwieldy”.

Focus Groups

Patton 12 has described the focus group as a primary means of collecting qualitative data. In essence, focus groups are unstructured interviews with multiple participants, which allow participants and a facilitator to interact freely with one another and to build on ideas and conversation. This method allows for the collection of group-generated data, which can be a challenging experience.

Observations

Patton 12 described observation as a useful tool in both quantitative and qualitative research: “[it involves] descriptions of activities, behaviours, actions, conversations, interpersonal interactions, organization or community processes or any other aspect of observable human experience”. Observation is critical in both interviews and focus groups, as nonalignment between verbal and nonverbal data frequently can be the result of sarcasm, irony, or other conversational techniques that may be confusing or open to interpretation. Observation can also be used as a stand-alone tool for exploring participants’ experiences, whether or not the researcher is a participant in the process.

Selecting the most appropriate and practical method is an important decision and must be taken carefully. Those unfamiliar with qualitative research may assume that “anyone” can interview, observe, or facilitate a focus group; however, it is important to recognize that the quality of data collected through qualitative methods is a direct reflection of the skills and competencies of the researcher. 13 The hardest thing to do during an interview is to sit back and listen to participants. They should be doing most of the talking—it is their perception of their own life-world that the researcher is trying to understand. Sophisticated interpersonal skills are required, in particular the ability to accurately interpret and respond to the nuanced behaviour of participants in various settings. More information about the collection of qualitative data may be found in the “Further Reading” section of this paper.

It is essential that data gathered during interviews, focus groups, and observation sessions are stored in a retrievable format. The most accurate way to do this is by audio-recording (with the participants’ permission). Video-recording may be a useful tool for focus groups, because the body language of group members and how they interact can be missed with audio-recording alone. Recordings should be transcribed verbatim and checked for accuracy against the audio- or video-recording, and all personally identifiable information should be removed from the transcript. You are then ready to start your analysis.

DATA ANALYSIS

Regardless of the research method used, the researcher must try to analyze or make sense of the participants’ narratives. This analysis can be done by coding sections of text, by writing down your thoughts in the margins of transcripts, or by making separate notes about the data collection. Coding is the process by which raw data (e.g., transcripts from interviews and focus groups or field notes from observations) are gradually converted into usable data through the identification of themes, concepts, or ideas that have some connection with each other. It may be that certain words or phrases are used by different participants, and these can be drawn together to allow the researcher an opportunity to focus findings in a more meaningful manner. The researcher will then give the words, phrases, or pieces of text meaningful names that exemplify what the participants are saying. This process is referred to as “theming”. Generating themes in an orderly fashion out of the chaos of transcripts or field notes can be a daunting task, particularly since it may involve many pages of raw data. Fortunately, sophisticated software programs such as NVivo (QSR International Pty Ltd) now exist to support researchers in converting data into themes; familiarization with such software supports is of considerable benefit to researchers and is strongly recommended. Manual coding is possible with small and straightforward data sets, but the management of qualitative data is a complexity unto itself, one that is best addressed through technological and software support.

There is both an art and a science to coding, and the second checking of themes from data is well advised (where feasible) to enhance the face validity of the work and to demonstrate reliability. Further reliability-enhancing mechanisms include “member checking”, where participants are given an opportunity to actually learn about and respond to the researchers’ preliminary analysis and coding of data. Careful documentation of various iterations of “coding trees” is important. These structures allow readers to understand how and why raw data were converted into a theme and what rules the researcher is using to govern inclusion or exclusion of specific data within or from a theme. Coding trees may be produced iteratively: after each interview, the researcher may immediately code and categorize data into themes to facilitate subsequent interviews and allow for probing with subsequent participants as necessary. At the end of the theming process, you will be in a position to tell the participants’ stories illustrated by quotations from your transcripts. For more information on different ways to manage qualitative data, see the “Further Reading” section at the end of this paper.

ETHICAL ISSUES

In most circumstances, qualitative research involves human beings or the things that human beings produce (documents, notes, etc.). As a result, it is essential that such research be undertaken in a manner that places the safety, security, and needs of participants at the forefront. Although interviews, focus groups, and questionnaires may seem innocuous and “less dangerous” than taking blood samples, it is important to recognize that the way participants are represented in research can be significantly damaging. Try to put yourself in the shoes of the potential participants when designing your research and ask yourself these questions:

• Are the requests you are making of potential participants reasonable?
• Are you putting them at unnecessary risk or inconvenience?
• Have you identified and addressed the specific needs of particular groups?

Where possible, attempting anonymization of data is strongly recommended, bearing in mind that true anonymization may be difficult, as participants can sometimes be recognized from their stories. Balancing the responsibility to report findings accurately and honestly with the potential harm to the participants involved can be challenging. Advice on the ethical considerations of research is generally available from research ethics boards and should be actively sought in these challenging situations.

GETTING STARTED

Pharmacists may be hesitant to embark on research involving qualitative methods because of a perceived lack of skills or confidence. Overcoming this barrier is the most important first step, as pharmacists can benefit from inclusion of qualitative methods in their research repertoire. Partnering with others who are more experienced and who can provide mentorship can be a valuable strategy. Reading reports of research studies that have utilized qualitative methods can provide insights and ideas for personal use; such papers are routinely included in traditional databases accessed by pharmacists. Engaging in dialogue with members of a research ethics board who have qualitative expertise can also provide useful assistance, as well as saving time during the ethics review process itself. The references at the end of this paper may provide some additional support to allow you to begin incorporating qualitative methods into your research.

CONCLUSIONS

Qualitative research offers unique opportunities for understanding complex, nuanced situations where interpersonal ambiguity and multiple interpretations exist. Qualitative research may not provide definitive answers to such complex questions, but it can yield a better understanding and a springboard for further focused work. There are multiple frameworks, methods, and considerations involved in shaping effective qualitative research. In most cases, these begin with self-reflection and articulation of positionality by the researcher. For some, qualitative research may appear commonsensical and easy; for others, it may appear daunting, given its high reliance on direct participant– researcher interactions. For yet others, qualitative research may appear subjective, unscientific, and consequently unreliable. All these perspectives reflect a lack of understanding of how effective qualitative research actually occurs. When undertaken in a rigorous manner, qualitative research provides unique opportunities for expanding our understanding of the social and clinical world that we inhabit.

Further Reading

• Breakwell GM, Hammond S, Fife-Schaw C, editors. Research methods in psychology. Thousand Oaks (CA): Sage Publications Ltd; 1995. [ Google Scholar ]
• Strauss A, Corbin J. Basics of qualitative research. Thousand Oaks (CA): Sage Publications Ltd; 1998. [ Google Scholar ]
• Willig C. Introducing qualitative research in psychology. Buckingham (UK): Open University Press; 2001. [ Google Scholar ]
• Guest G, Namey EE, Mitchel ML. Collecting qualitative data: a field manual for applied research. Thousand Oaks (CA): Sage Publications Ltd; 2013. [ Google Scholar ]
• Ogden R. Bias. In: Given LM, editor. The Sage encyclopedia of qualitative research methods. Thousand Oaks (CA): Sage Publications Inc; 2008. pp. 61–2. [ Google Scholar ]

This article is the seventh in the CJHP Research Primer Series, an initiative of the CJHP Editorial Board and the CSHP Research Committee. The planned 2-year series is intended to appeal to relatively inexperienced researchers, with the goal of building research capacity among practising pharmacists. The articles, presenting simple but rigorous guidance to encourage and support novice researchers, are being solicited from authors with appropriate expertise.

Previous article in this series:

Bond CM. The research jigsaw: how to get started. Can J Hosp Pharm . 2014;67(1):28–30.

Tully MP. Research: articulating questions, generating hypotheses, and choosing study designs. Can J Hosp Pharm . 2014;67(1):31–4.

Loewen P. Ethical issues in pharmacy practice research: an introductory guide. Can J Hosp Pharm. 2014;67(2):133–7.

Tsuyuki RT. Designing pharmacy practice research trials. Can J Hosp Pharm . 2014;67(3):226–9.

Bresee LC. An introduction to developing surveys for pharmacy practice research. Can J Hosp Pharm . 2014;67(4):286–91.

Gamble JM. An introduction to the fundamentals of cohort and case–control studies. Can J Hosp Pharm . 2014;67(5):366–72.

Competing interests: None declared.

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How to Conduct Qualitative Research in Social Science

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What is social science?

Qualitative research.

Social scientists often want to understand how individuals think, feel or behave in particular situations, or in relations with others that develop over time. They use in-depth interviews, participant observation and other qualitative methods to gather data. Researchers might watch a school playground to observe and record bullying behaviours, or ask young people about exactly what they understood by being bullied, and how they thought it affected them.

Qualitative methods are scientific, but are focused more on the meaning of different aspects of people’s lives, and on their accounts of how they understand their own and others’ behaviour and beliefs.

Case studies (where researchers examine a small number of specific examples) and narratives (where researchers study respondents’ stories in depth) are just two examples of methods used in qualitative research.

Case studies can help researchers to explore life in different families, cultures and communities. However, in order to examine how far we can generalise the specific cases for wider society, some form of quantitative methods are often needed.

Qualitative methodologies

Some of the most common qualitative research methodologies are described here. These methodologies are widely-used in ESRC-funded research.

Semi-structured interviews

In semi-structured interviews the researcher has a small core of questions or areas they wish to explore, but will then take the questions in different directions, depending on the answers they receive. Flexibility is important with this type of interview. This method is used when seeking richly descriptive information, for example what makes a good teacher.

Unstructured interviews

Unstructured interviews are open-ended and informal. The researcher is seeking a detailed picture and tries to bring no preconceptions. This type of interview is often used in narrative research. Generally the researcher asks one question and then leaves the interviewee to talk or ‘tell their story’.

Observation

Observation relies heavily on the skills of the researcher to understand and interpret what they are seeing in an unbiased way. It might be used, for example, in education research to see how much time young people spend ‘on task’ and what they do when distracted. In this method, the researcher observes what is happening and makes field notes either at the time or soon afterwards.

Open questionnaire survey

Unlike questionnaires in quantitative research, which offer a limited range of choices, open surveys seek opinion and description in response to open-ended questions. They may be used to gather information and ideas from more people than one-to-one interviewing would allow.

Keeping logs and diaries

Researchers and participants can keep logs or diaries as a way to collect details about daily life. Participants are asked to keep detailed records of some aspect of their life, such as social activities or exercise, so the researcher later can analyse this material. Researchers also keep diaries during the period of data collection on aspects of the research, such as the context in which interviews or observation takes place. This is then used alongside other data to help them to broaden their understanding of the research findings.

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Exploring Thematic Analysis in Qualitative Research

2024, Book Chapter in: Data Collection and Analysis in Scientific Qualitative Research

Thematic analysis has evolved as a prominent qualitative data analysis method, rooted in the rich history of social sciences and, in particular, psychology. It stands as a cornerstone in qualitative inquiry, offering researchers a systematic approach to identifying and interpreting patterns, or themes, within qualitative data. This chapter seeks to provide a comprehensive overview of thematic analysis within the context of qualitative research, addressing its theoretical foundations, methodolog-ical considerations, and practical applications. It explores approaches to thematic analysis, including induction, deduction, and abduction, highlighting their distinctive characteristics and applications to qualitative data analysis. It also outlines key steps involved in conducting thematic analysis. Overall, this chapter aims to equip researchers, practitioners, and students with the knowledge and skills necessary to conduct rigorous and insightful thematic analyses of qualitative data.

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This chapter’s goal is to examine the student engagement and the creation of student knowledge of undergraduate students using a 3D Virtual Learning Environment. After creating a 3D didactic constructivist virtual environment, student conversations were recorded for engagement dimensions using Hara, Bonk, and Angeli (2000) framework and Nonaka and Takeuchi (1995) knowledge creation theory. Findings revealed that five forms of student engagement amplified the learning process and that a complete knowledge spiral occurred emphasizing the four modes of knowledge conversion. Although limited in time and scope, results further suggest that a highly engaged community of learners was created.

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• Published: 28 August 2024

A qualitative study identifying implementation strategies using the i-PARIHS framework to increase access to pre-exposure prophylaxis at federally qualified health centers in Mississippi

• Trisha Arnold   ORCID: orcid.org/0000-0003-3556-5717 1 , 2 ,
• Laura Whiteley 2 ,
• Kayla K. Giorlando 1 ,
• Andrew P. Barnett 1 , 2 ,
• Ariana M. Albanese 2 ,
• Avery Leigland 1 ,
• Courtney Sims-Gomillia 3 ,
• A. Rani Elwy 2 , 5 ,
• Precious Patrick Edet 3 ,
• Demetra M. Lewis 4 ,
• James B. Brock 4 &
• Larry K. Brown 1 , 2  

Implementation Science Communications volume  5 , Article number:  92 ( 2024 ) Cite this article

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Mississippi (MS) experiences disproportionally high rates of new HIV infections and limited availability of pre-exposure prophylaxis (PrEP). Federally Qualified Health Centers (FQHCs) are poised to increase access to PrEP. However, little is known about the implementation strategies needed to successfully integrate PrEP services into FQHCs in MS.

The study had two objectives: identify barriers and facilitators to PrEP use and to develop tailored implementation strategies for FQHCs.

Semi-structured interviews were conducted with 19 staff and 17 PrEP-eligible patients in MS FQHCs between April 2021 and March 2022. The interview was guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework which covered PrEP facilitators and barriers. Interviews were coded according to the i-PARIHS domains of context, innovation, and recipients, followed by thematic analysis of these codes. Identified implementation strategies were presented to 9 FQHC staff for feedback.

Data suggested that PrEP use at FQHCs is influenced by patient and clinic staff knowledge with higher levels of knowledge reflecting more PrEP use. Perceived side effects are the most significant barrier to PrEP use for patients, but participants also identified several other barriers including low HIV risk perception and untrained providers. Despite these barriers, patients also expressed a strong motivation to protect themselves, their partners, and their communities from HIV. Implementation strategies included education and provider training which were perceived as acceptable and appropriate.

Conclusions

Though patients are motivated to increase protection against HIV, multiple barriers threaten uptake of PrEP within FQHCs in MS. Educating patients and providers, as well as training providers, are promising implementation strategies to overcome these barriers.

Peer Review reports

Contributions to the literature

We propose utilizing Federally Qualified Health Centers (FQHCs) to increase pre-exposure prophylaxis (PrEP) use among people living in Mississippi.

Little is currently known about how to distribute PrEP at FQHCs.

We comprehensively describe the barriers and facilitators to implementing PrEP at FQHCs.

Utilizing effective implementation strategies of PrEP, such as education and provider training at FQHCs, may increase PrEP use and decrease new HIV infections.

Introduction

The HIV outbreak in Mississippi (MS) is among the most critical in the United States (U.S.). It is distinguished by significant inequalities, a considerable prevalence of HIV in remote areas, and low levels of HIV medical care participation and virologic suppression [ 1 ]. MS has consistently ranked among the states with the highest HIV rates in the U.S. This includes being the 6th highest in new HIV diagnoses [ 2 ] and 2nd highest in HIV diagnoses among men who have sex with men (MSM) compared to other states [ 2 , 3 , 4 ]. Throughout MS, the HIV epidemic disproportionately affects racial and ethnic minority groups, particularly among Black individuals. A spatial epidemiology and statistical modeling study completed in MS identified HIV hot spots in the MS Delta region, Southern MS, and in greater Jackson, including surrounding rural counties [ 5 ]. Black race and urban location were positively associated with HIV clusters. This disparity is often driven by the complex interplay of social, economic, and structural factors, including poverty, limited access to healthcare, and stigma [ 5 ].

Pre-exposure prophylaxis (PrEP) has gained significant recognition due to its safety and effectiveness in preventing HIV transmission when taken as prescribed [ 6 , 7 , 8 , 9 ]. However, despite the progression in PrEP and its accessibility, its uptake has been slow among individuals at high risk of contracting HIV, particularly in Southern states such as MS [ 10 , 11 , 12 , 13 , 14 ]. According to the CDC [ 5 ], “4,530 Mississippians at high risk for HIV could potentially benefit from PrEP, but only 927 were prescribed PrEP.” Several barriers hinder PrEP use in MS including limited access to healthcare, cost, stigma, and medical mistrust [ 15 , 16 , 17 ].

Federally qualified health centers (FQHCs) are primary healthcare organizations that are community-based and patient-directed, serve geographically and demographically diverse patients with limited access to medical care, and provide care regardless of a patient’s ability to pay [ 18 ]. FQHCs in these areas exhibit reluctance in prescribing or counseling patients regarding PrEP, primarily because they lack the required training and expertise [ 19 , 20 , 21 ]. Physicians in academic medical centers are more likely to prescribe PrEP compared to those in community settings [ 22 ]. Furthermore, providers at FQHCs may exhibit less familiarity with conducting HIV risk assessments, express concerns regarding potential side effects of PrEP, and have mixed feelings about prescribing it [ 23 , 24 ]. Task shifting might also be needed as some FQHCs may lack sufficient physician support to manage all aspects of PrEP care. Tailored strategies and approaches are necessary for FQHCs to effectively navigate the many challenges that threaten their patients’ access to and utilization of PrEP.

The main objectives of this study were to identify the barriers and facilitators to PrEP use and to develop tailored implementation strategies for FQHCs providing PrEP. To service these objectives, this study had three specific aims. Aim 1 involved conducting a qualitative formative evaluation guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework- with FQHC staff and PrEP-eligible patients across three FQHCs in MS [ 25 ]. Interviews covered each of the three i-PARIHS domains: context, innovation, and recipients. These interviews sought to identify barriers and facilitators to implementing PrEP. Aim 2 involved using interview data to select and tailor implementation strategies from the Expert Recommendations for Implementing Change (ERIC) project [ 26 ] (e.g., provider training) and methods (e.g., telemedicine, PrEP navigators) for the FQHCs. Aim 3 was to member-check the selected implementation strategies and further refine these if necessary. Data from all three aims are presented below. The standards for reporting qualitative research (SRQR) checklist was used to improve the transparency of reporting this qualitative study [ 27 ].

Formative evaluation interviews

Interviews were conducted with 19 staff and 17 PrEP-eligible patients from three FQHCs in Jackson, Canton, and Clarksdale, Mississippi. Staff were eligible to participate if they were English-speaking and employed by their organization for at least a year. Eligibility criteria for patients included: 1) English speaking, 2) aged 18 years or older, 3) a present or prior patient at the FQHC, 4) HIV negative, and 5) currently taking PrEP or reported any one of the following factors that may indicate an increased risk for HIV: in the past year, having unprotected sex with more than one person with unknown (or positive) HIV status, testing positive for a sexually transmitted infection (STI) (syphilis, gonorrhea, or chlamydia), or using injection drugs.

Data collection

The institutional review boards of the affiliated hospitals approved this study prior to data collection. An employee at each FQHC acted as a study contact and assisted with recruitment. The contacts advertised the study through word-of-mouth to coworkers and relayed the contact information of those interested to research staff. Patients were informed about the study from FQHC employees and flyers while visiting the FQHC for HIV testing. Those interested filled out consent-to-contact forms, which were securely and electronically sent to research staff. Potential participants were then contacted by a research assistant, screened for eligibility, electronically consented via DocuSign (a HIPAA-compliant signature capturing program), then scheduled for an interview. Interviews occurred remotely over Zoom, a HIPAA-compliant, video conferencing platform. Interviews were conducted until data saturation was reached. In addition to the interview, all participants were asked to complete a short demographics survey via REDCap, a HIPAA-compliant, online, data collection tool. Each participant received a $100 gift card for their time.

The i-PARIHS framework guided interview content and was used to create a semi-structured interview guide [ 28 ]. Within the i-PARIHS framework’s elements, the interview guide content included facilitators and barriers to PrEP use at the FQHC: 1) the innovation, (PrEP), such as its degree of fit with existing practices and values at FQHCs; 2) the recipients (individuals presenting to FQHCs), such as their PrEP awareness, barriers to receiving PrEP such as motivation, resources, support, and personal PrEP experiences; and 3) the context of the setting (FQHCs), such as clinic staff PrEP awareness, barriers providing PrEP services, and recommendations regarding PrEP care. Interviews specifically asked about the use of telemedicine, various methods for expanding PrEP knowledge for both patients and providers (e.g., social media, advertisements, community events/seminars), and location of services (e.g., mobile clinics, gyms, annual health checkups, health fairs). Staff and patients were asked the same interview questions. Data were reviewed and analyzed iteratively throughout data collection, and interview guides were adapted as needed.

Data analysis

Interviews were all audio-recorded, then transcribed by an outside, HIPAA-certified transcription company. Transcriptions were reviewed for accuracy by the research staff who conducted the interviews.

Seven members of the research team (TA, LW, KKG, AB, CSG, AL, LKB) independently coded the transcripts using an a priori coding schedule that was developed using the i-PARIHS and previous studies [ 15 , 16 , 17 ]. All research team members were trained in qualitative methods prior to beginning the coding process. The coding scheme covered: patient PrEP awareness, clinic staff PrEP awareness, barriers to receiving PrEP services, barriers to providing PrEP services, and motivation to take PrEP. Each coder read each line of text and identified if any of the codes from the a priori coding framework were potentially at play in each piece of text. Double coding was permitted when applicable. New codes were created and defined when a piece of text from transcripts represented a new important idea. Codes were categorized according to alignment with i-PARIHS constructs. To ensure intercoder reliability, the first 50% of the interviews were coded by two researchers. Team meetings were regularly held to discuss coding discrepancies (to reach a consensus). Coded data were organized using NVivo software (Version 12). Data were deductively analyzed using reflexive thematic analysis, a six-step process for analyzing and reporting qualitative data, to determine themes relevant to selecting appropriate implementation strategies to increase PrEP use at FQHCs in MS [ 29 ]. The resulting thematic categories were used to select ERIC implementation strategies [ 26 ]. Elements for each strategy were then operationalized and the mechanism of change for each strategy was hypothesized [ 30 , 31 ]. Mechanisms define how an implementation strategy will have an effect [ 30 , 31 ]. We used the identified determinants to hypothesize the mechanism of change for each strategy.

Member checking focus groups

Member checking is when the data or results are presented back to the participants, who provide feedback [ 32 ] to check for accuracy [ 33 ] and improve the validity of the data [ 34 ]. This process helps reduce the possibility of misrepresentation of the data [ 35 ]. Member checking was completed with clinic staff rather than patients because the focus was on identifying strategies to implement PrEP in the FQHCs.

Two focus groups were conducted with nine staff from the three FQHCs in MS. Eligibility criteria were the same as above. A combination of previously interviewed staff and non-interviewed staff were recruited. Staff members were a mix of medical (e.g., nurses, patient navigators, social workers) and non-medical (e.g., administrative assistant, branding officer) personnel. Focus group one had six participants and focus group two had three participants. The goal was for focus group participants to comprise half of staff members who had previously been interviewed and half of non-interviewed staff.

Participants were recruited and compensated via the same methods as above. All participants electronically consented via DocuSign, and then were scheduled for a focus group. Focus groups occurred remotely over Zoom. Focus groups were conducted until data saturation was reached and no new information surfaced. The goal of the focus groups was to member-check results from the interviews and assess the feasibility and acceptability of selected implementation strategies. PowerPoint slides with the results and implementation strategies written in lay terms were shared with the participants, which is a suggested technique to use in member checking [ 33 ]. Participants were asked to provide feedback on each slide.

Focus groups were all audio-recorded, then transcribed. Transcriptions were reviewed for accuracy by the research staff who completed focus groups. Findings from the focus groups were synthesized using rapid qualitative analyses [ 36 , 37 ]. Facilitators (TA, PPE) both took notes during the focus groups of the primary findings. Notes were then compared during team meetings and results were finalized. Results obtained from previous findings of the interviews and i-PARIHS framework were presented. To ensure the reliability of results, an additional team member (KKG) read the transcripts to verify the primary findings and selected supportive quotes for each theme. Team meetings were regularly held to discuss the results.

Thirty-six semi-structured interviews in HIV hot spots were completed between April 2021 and March 2022. Among the 19 FQHC staff, most staff members had several years of experience working with those at risk for HIV. Staff members were a mix of medical (e.g., doctors, nurses, CNAs, social workers) and non-medical (e.g., receptionists, case managers) personnel. Table 1 provides the demographic characteristics for the 19 FQHC clinic staff and 17 FQHC patients.

Table 2 provides a detailed description of the findings within each category: PrEP knowledge, PrEP barriers, and PrEP motivation. Themes are described in detail, with representative quotes, below. Implementation determinants are specific factors that influence implementation outcomes and can be barriers or facilitators. Table 3 highlights which implementation determinants can increase ( +) or decrease (-) the implementation of PrEP at FQHCs in MS. Each determinant, mapped to its corresponding i-PARIHS construct, is discussed in more detail below. There were no significant differences in responses across the three FQHCs.

PrEP knowledge

Patient prep awareness (i-parihs: recipients).

Most patients had heard of PrEP and were somewhat familiar with the medication. One patient described her knowledge of PrEP as follows, “I know that PrEP is I guess a program that helps people who are high-risk with sexual behaviors and that doesn't have HIV, but they're at high-risk.”- Patient, Age 32, Female, Not on PrEP. However, many lacked knowledge of who may benefit from PrEP, where to receive a prescription, the different medications used for PrEP, and the efficacy of PrEP. Below is a comment made by a patient listing what she would need to know to consider taking PrEP. “I would need to know the price. I would need to know the side effects. I need to know the percentage, like, is it 100 or 90 percent effective.”— Patient, Age Unknown, Female, Not on PrEP. Patients reported learning about PrEP via television and social media commercials, medical providers, and their social networks. One patient reported learning about PrEP from her cousin. “The only person I heard it [PrEP] from was my cousin, and she talks about it all the time, givin’ us advice and lettin’ us know that it’s a good thing.”— Patient, Age Unknown, Female, Not on PrEP.

Clinic Staff PrEP Awareness (i-PARIHS: Context)

Training in who may benefit from PrEP and how to prescribe PrEP varied among clinic staff at different FQHCs. Not all clinics offered formal PrEP education for employees; however, most knew that PrEP is a tool used for HIV prevention. Staff reported learning about PrEP via different speakers and meetings. A clinic staff member reported learning about PrEP during quarterly meetings. “Well, sometimes when we have different staff meetings, we have them quarterly, and we discuss PrEP. Throughout those meetings, they tell us a little bit of information about it, so that's how I know about PrEP.” – Staff, Dental Assistant, Female. Some FQHC staff members reported having very little knowledge of PrEP. One staff member shared that she knew only the “bare minimum” about PrEP, stating,

“I probably know the bare minimum about PrEP. I know a little about it [PrEP] as far as if taken the correct way, it can prevent you from gettin’ HIV. I know it [PrEP] doesn’t prevent against STDs but I know it’s a prevention method for HIV and just a healthier lifestyle.” –Staff, Accountant, Female

A few of the organizations had PrEP navigators to which providers refer patients. These providers were well informed on who to screen for PrEP eligibility and the process for helping the patient obtain a PrEP prescription. One clinic staff member highlighted how providers must be willing to be trained in the process of prescribing PrEP and make time for patients who may benefit. Specifically, she said,

“I have been trained [for PrEP/HIV care]. It just depends on if that’s something that you’re willing to do, they can train on what labs and stuff to order ’cause it’s a whole lot of labs. But usually, I try to do it. At least for everybody that’s high-risk.” – Staff, OB/GYN Nurse Practitioner, Female

Another clinic staff member reported learning about PrEP while observing another staff member being training in PrEP procedures.

“Well, they kinda explained to me what it [PrEP] is, but I was in training with the actual PrEP person, so it was kinda more so for his training. I know what PrEP is. I know the medications and I know he does a patient assistance program. If my patients have partners who are not HIV positive and wanna continue to be HIV negative, I can refer 'em.” – Staff, Administrative Assistant, Female

PrEP barriers

Barriers receiving prep services (i-parihs: recipients, innovation).

Several barriers to receiving PrEP services were identified in both patient and clinic staff interviews. There was a strong concern for the side effects of PrEP. One patient heard that PrEP could cause weight gain and nightmares, “I’m afraid of gaining weight. I’ve heard that actual HIV medication, a lotta people have nightmares or bad dreams.” - Patient, Age 30, Female, Not on PrEP. Another patient was concerned about perceived general side effects that many medications have. “Probably just the [potential] side effects. You know, most of the pills have allergic reactions and side effects, dizziness, seizures, you know.” - Patient, Age 30, Female, Not on PrEP.

The burden of remembering to take a daily pill was also mentioned as a barrier to PrEP use. One female patient explained how PrEP is something she is interested in taking; however, she would be unable to take a daily medication.

“I’m in school now and not used to takin’ a medication every day. I was takin’ a birth control pill, but now take a shot. That was one of the main reasons that I didn’t start PrEP cause they did tell me I could get it that day. So like I wanna be in the mind state to where I’m able to mentally, in my head, take a pill every day. PrEP is somethin’ that I wanna do.” - Patient, Age Unknown, Female, Not on PrEP

Stigma and confidentiality were also barriers to PrEP use at FQHCs. One staff member highlighted how in small communities it is difficult to go to a clinic where employees know you personally. Saying,

“If somebody knows you’re going to talk to this specific person, they know what you’re goin’ back there for, and that could cause you to be a little hesitant in coming. So there’s always gonna be a little hesitancy or mistrust, especially in a small community. Everybody knows everybody. The people that you’re gonna see goes to church with you.” – Staff, Accountant, Female

Some patients had a low perceived risk of HIV and felt PrEP may be an unnecessary addition to their routine. One patient shared that if she perceived she was at risk for HIV, then she would be more interested in taking PrEP, “If it ever came up to the point where I would need it [PrEP], then yes, I would want to know more about it [PrEP].”— Patient, Age Unknown, Female, Not on PrEP.

Some participants expressed difficulty initiating or staying on PrEP because of associated costs, transportation and/or scheduling barriers. A staff member explained how transportation may be available in the city but not available in more rural areas,

“I guess it all depends on the person and where they are. In a city it might take a while, but at least they have the transportation compared to someone that lives in a rural area where transportation might be an issue.” - Staff, Director of Nurses, Female

Childcare during appointments was also mentioned as a barrier, “It looks like here a lot of people don't have transportation or reliable transportation and another thing I don't have anybody to watch my kids right now. —Staff, Patient Navigator, Female.

Barriers Providing PrEP Services (i-PARIHS: Context)

Barriers to providing PrEP services were also identified. Many providers are still not trained in PrEP procedures nor feel comfortable discussing or prescribing PrEP to their patients. One patient shared an experience of going to a provider who was PrEP-uninformed and assumed his medication was to treat HIV,

“Once I told her about it [PrEP], she [clinic provider] literally right in front of me, Googled it [PrEP], and then she was Googlin’ the medication, Descovy. I went to get a lab work, and she came back and was like, “Is this for treatment?” I was like, “Why would you automatically think it’s for treatment?” I literally told her and the nurse, “I would never come here if I lived here.” - Patient, Age 50, Male, Taking PrEP

Also, it was reported that there is not enough variety in the kind of providers who offer PrEP (e.g., OB/GYN, primary care). Many providers such as OB/GYNs could serve as a great way to reach individuals who may benefit from PrEP; however, patients reported a lack of PrEP being discussed in annual visits. “My previous ones (OB/GYN), they’ve talked about birth control and every other method and they asked me if I wanted to get tested for HIV and any STIs, but the conversation never came up about PrEP.” -Patient, Age Unknown, Female, Not on PrEP.

PrEP motivation

Motivation to take prep (i-parihs: recipients).

Participants mentioned several motivators that enhanced patient willingness to use PrEP. Many patients reported being motivated to use PrEP to protect themselves and their partners from HIV. Additionally, participants reported wanting to take PrEP to help their community. One patient reported being motivated by both his sexuality and the rates of HIV in his area, saying, “I mean, I'm bisexual. So, you know, anyway I can protect myself. You know, it's just bein' that the HIV number has risen. You know, that's scary. So just being, in, an area with higher incidents of cases.”— Patient, Age Unknown, Male, Not on PrEP . Some participants reported that experiencing an HIV scare also motivated them to consider using PrEP. One patient acknowledged his behaviors that put him at risk and indicated that this increased his willingness to take PrEP, “I was havin' a problem with, you know, uh, bein' promiscuous. You know? So it [PrEP] was, uh, something that I would think, would help me, if I wasn't gonna change the way I was, uh, actin' sexually.”— Patient, Age Unknown, Male, Taking PrEP .

Table 3 outlines the implementation strategies identified from themes from the interview and focus group data. Below we recognize the barriers and determinants to PrEP uptake for patients attending FQHCs in MS by each i-PARIHS construct (innovation, recipient, context) [ 28 ]. Based on the data, we mapped the determinants to specific strategies from the ERIC project [ 26 ] and hypothesized the mechanism of change for each strategy [ 30 , 31 ].

Two focus groups were conducted with nine staff from threeFQHCs in MS. There were six participants in the 1st focus group and three in the 2nd. Staff members were a mix of medical (e.g., nurses, patient navigators, social workers) and non-medical (e.g., administrative assistant, branding officer) personnel. Table 4 provides the demographic characteristics for the FQHC focus group participants.

Staff participating in the focus groups generally agreed that the strategies identified via the interviews were appropriate and acceptable. Focus group content helped to further clarify some of the selected strategies. Below we highlight findings by each strategy domain.

PrEP information dissemination

Participants specified that awareness of HIV is lower, and stigma related to PrEP is higher in rural areas. One participant specifically said,

“There is some awareness but needs to be more awareness, especially to rural areas here in Mississippi. If you live in the major metropolitan areas there is a lot of information but when we start looking at the rural communities, there is not a lot.” – Staff, Branding Officer, Male

Participants strongly agreed that many patients don’t realize they may benefit from PrEP and that more inclusive advertisements are needed. A nurse specifically stated,

“ When we have new clients that come in that we are trying to inform them about PrEP and I have asked them if they may have seen the commercial, especially the younger population. They will say exactly what you said, that “Oh, I thought that was for homosexuals or whatever,” and I am saying “No, it is for anyone that is at risk.” – Staff, Nurse, Female

Further, staff agreed that younger populations should be included in PrEP efforts to alleviate stigma. Participants added that including PrEP information with other prevention methods (i.e., birth control, vaccines) is a good place to include parents and adolescents:

“Just trying to educate them about Hepatitis and things of that nature, Herpes. I think we should also, as they are approaching 15, the same way we educate them about their cycle coming on and what to expect, it’s almost like we need to start incorporating this (PrEP education), even with different forms of birth control methods with our young ladies.” – Staff, Nurse, Female

Participants agreed that PrEP testimonials would be helpful, specifically from people who started PrEP, stopped, and then were diagnosed with HIV. Participants indicated that this may improve PrEP uptake and persistence. One nurse stated:

“I have seen where a patient has been on PrEP a time or two and at some point, early in the year or later part of the year, and we have seen where they’ve missed those appointments and were not consistent with their medication regimen. And we have seen those who’ve tested positive for HIV. So, if there is a way we could get one of those patients who will be willing to share their testimony, I think they can really be impactful because it’s showing that taking up preventive measures was good and then kind of being inconsistent, this is what the outcome is, unfortunately.” – Staff, Nurse, Female

Increase variety and number of PrEP providers

Participants agreed that a “PrEP champion” (someone to promote PrEP and answer PrEP related questions) would be helpful, especially for providers who need more education about PrEP to feel comfortable prescribing. A patient navigator said,

“I definitely think that a provider PrEP champion is needed in every clinic or organization that is offering PrEP. And it goes back to what we were saying about the providers not being knowledgeable on it [PrEP]. If you have a PrEP champion that already knows this information, it is gonna benefit everybody, patients, patient advocates, the provider, everyone all around. Everyone needs a champion." – Staff, Patient Navigator, Female

Staff noted that they have walk-in appointments for PrEP available; however, they often have too many walk-in appointments to see everyone. They noted that having more resources and providers may alleviate this barrier for some patients:

“We still have challenges with people walking in versus scheduling an appointment, but we do have same day appointments. It is just hard sometimes because the volume that we have at our clinic and the number of patients that we have that walk in on a daily basis.” – Staff, Social Worker, Female

Enhance PrEP provider alliance and trust

Participants agreed that educational meetings would be beneficial and highlighted that meetings should happen regularly and emphasized a preference for in-person meetings. This is emphasized by the statement below,

“They should be in-person with handouts. You have to kind of meet people where they are as far as learning. Giving the knowledge, obtaining the knowledge, and using it, and so you have to find a place. I definitely think that yearly in-person training to update guidelines, medication doses, different things like that." – Staff, Patient Navigator, Female

Staff also suggested hosting one very large collaborative event to bring together all organizations that offer PrEP and HIV testing to meet and discuss additional efforts:

“What I would like to see happen here in the state of Mississippi, because we are so high on the list for new HIV infections, I would like to see a big collaborative event. As far as PrEP goes, those that are not on PrEP, one big collaborative event with different community health centers. You do testing, we do PrEP, and the referral get split. Everyone coming together for one main purpose.” – Staff, Patient Navigator, Female

Increase access to PrEP

Participants highlighted that most of the clinics they worked for already offer a variety of service sites (pharmacy, mobile clinic) but that more clinics should offer these alternative options for patients to receive PrEP. One patient navigator outlined the services they offer,

“We have a mobile unit. We do not have a home health travel nurse. We do telephone visits. We offer primary care, OB/GYN. We have our own pharmacy. We also have samples in our pharmacy available to patients that can’t get their medicine on the same day cos we like to implement same day PrEP. It has worked for us. More people should utilize those services.” – Staff, Patient Navigator, Female

Other staff suggested utilizing minute clinics and pharmacies at grocery stores. Highlighting, that offering PrEP at these locations may increase PrEP uptake.

There has been great scientific expansion of HIV prevention research and priorities must now pivot to addressing how to best implement effective interventions like PrEP [ 38 ]. PrEP remains underutilized among individuals who may benefit, particularly in Southern states such as MS [ 10 , 11 , 12 , 13 , 14 ]. Implementation science could help ameliorate this by identifying barriers and facilitators to PrEP rollout and uptake. We selected and defined several strategies from the ERIC project [ 26 ] to increase PrEP use utilizing FQHCs. Our results, as shown in Table  3 , highlight the four domains of strategies selected: 1) PrEP Information Dissemination, 2) Increase Variety and Number of PrEP Providers, 3) Enhance PrEP Provider Alliance and Trust, and 4) Increase Access to PrEP.

Firstly, individuals cannot utilize PrEP if they are not aware of its presence and utility. In Mississippi, advertising PrEP services is integral to implementation efforts given the existing stigma and lack of health literacy in this region [ 39 ]. Potential avenues for expanding PrEP awareness are integrating it into educational curriculums, adolescents’ routine preventative healthcare, and health fairs. This study compliments prior research that people should be offered sexual health and PrEP education at a younger age to increase awareness of risk, foster change in social norms and enhance willingness to seek out prevention services [ 40 , 41 ]. To meet the resulting growing need for PrEP educators, healthcare professionals should receive up-to-date PrEP information and training, so that they can confidently relay information to their patients. Similar to existing research, increasing provider education could accelerate PrEP expansion [ 42 , 43 , 44 ]. Training programs aimed at increasing provider PrEP knowledge may increase PrEP prescriptions provided [ 43 ] by addressing one of the most frequently listed barriers to PrEP prescription among providers [ 45 , 46 ].

Many patients prefer to receive PrEP at the healthcare locations they already attend and report a barrier to PrEP being limited healthcare settings that offer PrEP [ 39 , 47 , 48 , 49 ]. The aforementioned PrEP training could increase the number of healthcare workers willing to provide PrEP services. It is also imperative that providers in a diverse range of healthcare settings (e.g., primary care, OB/GYN, pediatricians and adolescent medicine providers) join the list of those offering PrEP to reduce stigma and enhance patient comfort.

These results mirrored other studies in the South that have shown that using relatable healthcare providers and trusted members of the community may serve to facilitate PrEP uptake [ 41 , 50 , 51 ]. If patients have a larger number of PrEP providers to choose from, they can select one that best fits their needs (e.g., location, in-network) and preferences (e.g., familiarity, cultural similarities). Enhanced comfort facilitates a strong patient-provider alliance and can lead to more open/honest communication regarding HIV risk behavior.

The lack of conveniently located PrEP providers is consistently reported as a structural barrier in the South [ 44 , 52 ]. This creates an increase in the demand on patients to attend regular follow-up appointments. The three strategies above all play a vital role in increasing access to PrEP. If more individuals are trained to provide PrEP care, there will be more PrEP providers, and patients can choose the best option for them. A sizeable influx of new PrEP providers could help staff new care facilities and service options in the community (e.g., mobile health units, home care, community-based clinics, telemedicine). Offering PrEP via telemedicine and mobile clinics to patients has been largely supported in the literature [ 44 , 53 , 54 ]. Intra- and inter-organizational collaborations could similarly increase PrEP access by sharing information and resources to ensure patients get timely, reliable care.

Our results largely supported previous findings by two systematic reviews on the barriers to PrEP uptake and implementation strategies to overcome it [ 39 , 47 ]. Sullivan et.al.’s review focused on the Southern U.S. [ 38 ], while Bonacci et. al. explored steps to improve PrEP equity for Black and Hispanic/Latino communities [ 47 ]. Both agreed that barriers to PrEP access are complex. Thus, cooperation from policymakers and the expansion of state Medicaid or targeted Medicaid waivers is vital to make PrEP attainable for those living in the coverage gap. Further, many FQHCs receive Ryan White funding for HIV care and treatment, contracting flexibility in the utility of these other sources of support may aid in eliminating the cost of PrEP as a barrier. They also stressed the need for educating community members and healthcare personnel about PrEP, increasing and diversifying PrEP service sites, normalizing PrEP campaigns and screening to alleviate stigma, and streamlining clinical procedures to facilitate the option for same-day PrEP. However, they also noted that these strategies are easier said than done. This further highlights the need for prioritizing research efforts towards implementation studies for effectiveness and practicality of overcoming the complex and systemic needs around HIV prevention/treatment.

The present study was able to build on past findings by providing a more holistic view of the barriers to PrEP use and possible strategies to address them through querying PrEP-eligible patients, medical providers, and non-medical staff. By interviewing a diverse range of stakeholders, it was possible to identify unmet patient needs, current PrEP care procedures and infrastructure, and attitudes and needed resources among those who could potentially be trained to provide PrEP in the future.

Limitations

Our results are limited to participants and clinic staff who were willing to engage in a research interview to discuss PrEP and FQHCs. Results are only generalizable to Mississippi and may be less relevant for other geographic areas. However, this is a strength given these strategies are meant to be tailored specifically to FQHCs in MS. Due to COVID-19 restrictions, interviews were conducted via Zoom. This allowed us to reach participants unable to come in physically for an interview and may have increased their comfort responding to questions [ 55 ]. However, some participants may have been less comfortable discussing via Zoom, which may have limited their willingness to respond.

This study highlighted the need for implementing PrEP strategies to combat HIV in Mississippi. PrEP knowledge, barriers, and motivation were identified as key factors influencing PrEP utilization, and four domains of strategies were identified for improving PrEP accessibility and uptake. Future research should further refine and assess the feasibility and acceptability of selected and defined implementation strategies and test strategies.

Availability of data and materials

De-identified data from this study are not available in a public archive due to sensitive nature of the data. De-identified data from this study will be made available (as allowable according to institutional IRB standards) by emailing the corresponding author.

Abbreviations

Mississippi

Pre-Exposure Prophylaxis

Federally Qualified Health Centers

Integrated-Promoting Action on Research Implementation in Health Services

Expert Recommendations for Implementing Change

Men Who Have Sex With Men

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Acknowledgements

Authors would like to acknowledge and thank Sarah Bailey for reviewing the manuscript and assisting for formatting.

This study was funded by the National Institute of Health (R34MH115744) and was facilitated by the Providence/Boston Center for AIDS Research (P30AI042853). Additionally, work by Dr. Trisha Arnold was supported by the National Institute of Mental Health Grant (K23MH124539-01A1) and work by Dr. Andrew Barnett was supported by the National Institute of Mental Health Grant (T32MH078788). Dr. Elwy is supported by a Department of Veterans Affairs Research Career Scientist Award (RCS 23–018).

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TA and ARE led the conceptualization of this paper. TA, LW, LKB, DML, and JBB completed the literature search and study design. TA, LW, LKB, KKG, PPE, AB, AL, and CSG assisted with analyzing and interpreting the data. TA, ARE, and AMA finalized the results and implementation concepts of the study. All authors read and approved the final manuscript.

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Arnold, T., Whiteley, L., Giorlando, K.K. et al. A qualitative study identifying implementation strategies using the i-PARIHS framework to increase access to pre-exposure prophylaxis at federally qualified health centers in Mississippi. Implement Sci Commun 5 , 92 (2024). https://doi.org/10.1186/s43058-024-00632-6

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• Published: 29 August 2024

StreetTalk: exploring energy insecurity in New York City using a novel street intercept interview and social media dissemination method

• Nadav L. Sprague   ORCID: orcid.org/0000-0002-9698-9962 1 ,
• Isabel B. Fan 2 ,
• Michelle Dandeneau 3 ,
• Jorge Fabian Hernandez Perez 2 ,
• Jordyn Birmingham 4 ,
• Daritza De Los Santos 5 ,
• Milan I. Riddick 3 ,
• Gabriella Y. Meltzer 3 ,
• Eva L. Siegel 3 &
• Diana Hernández 3  

Humanities and Social Sciences Communications volume  11 , Article number:  1109 ( 2024 ) Cite this article

Metrics details

• Cultural and media studies
• Environmental studies
• Health humanities
• Science, technology and society

This study introduces StreetTalk, an original qualitative research methodology inspired by social media influencers, to investigate perceptions and experiences of energy insecurity among New York City (NYC) residents. Briefly, energy insecurity is defined as difficulty meeting household energy needs due to affordability, housing quality, outages and coping strategies. This present study employs dynamic short-form interviews with 34 participants from all five NYC boroughs of diverse economic, and racial/ethnic backgrounds. Thematic analysis of video-recorded interviews revealed six major energy insecurity-related categories: (1) conservation and trade-offs, (2) physical inefficiencies, (3) thermal agency, (4) response to the bill, (5) disappointment and distrust in energy-related authorities, and (6) desire for and barriers to clean energy adoption. These themes provide insight into NYC residents’ experiences with energy insecurity and are consistent with prior research. Beyond new scholarly insights, this study introduces StreetTalk, an innovative qualitative research methodology emphasizing rapid data collection and dissemination through social media platforms, including TikTok, Instagram, Facebook, and YouTube (@hotandcold_nyc). Taking advantage of modern technology and modes of communication, the research team was able to effectively break down barriers to academic research consumption as the videos achieved substantial engagement, with almost 200,000 views and impressions within the first year of launching this novel street-based data collection and social media dissemination campaign.

Introduction

Social media has revolutionized all aspects of society. Social media has altered social dynamics, communication patterns, and human relationships, allowing for connection and cultural exchange across geopolitical boundaries (Turkle, 2011 ). Additionally, social media has created a platform for individuals to express their opinions, experiences, and thoughts in a way that has never been seen before (Marwick and Boyd, 2014 ). However, social media has also been linked to negative changes in human behavior, such as reduced in-person interactions, increased feelings of loneliness, reduced physical activity, and reduced attention span (Aboujaoude, 2010 ; Goodyear et al. 2019 ; Kross et al. 2013 ). Unfortunately, social media platforms are also outlets for the spread of both misinformation and propaganda (Guess and Lyons, 2020 ). That said, social media has also reshaped the landscape of scientific research. For example, social media has facilitated unprecedented opportunities for collaboration, knowledge dissemination, and public engagement with research. Social media platforms, such as X (previously named Twitter) and LinkedIn, have become virtual meeting places for researchers across fields, allowing for both interdisciplinary and international collaborations and discussions that would not have occurred otherwise (Zimba and Gasparyan, 2021 ). These platforms also allow for increased visibility and accessibility of scientific findings to a wider audience (Haustein et al. 2016 ).

Social media has also been utilized as a valuable tool within the research process. Studies have utilized social media to recruit cost-effectively study participants (Russomanno et al. 2019 ) and for data analysis purposes (Dong and Lian, 2021 ; Ekenga et al. 2018 ). Despite social media changing the way individuals interact, the speed at which individuals can attain information, and demonstrating its utility in the research process, academic research has yet to embrace the full potential of a social media-based approach to advance and modernize qualitative research methods.

StreetTalk: an innovative qualitative method designed for social media

To date, qualitative research methods still focus primarily on long form, in-depth interviews with a small sample size of research participants (Morse, 2015 ; Silverman, 2020 ). Classic long-form in-depth interviews are vital for providing depth of understanding, exploration of various themes, understanding of interrelated themes, and to develop localized understanding for implementation science (Nevedal et al. 2021 ). However, these traditional qualitative methods also have numerous shortcomings, including time burden to participants, condensing participants’ stories to themes, and long lag time of dissemination (Nevedal et al. 2021 ; Queirós et al. 2017 ). As such, we developed the StreetTalk qualitative method, a short-form social media-style interview method, to address some of the mentioned shortcomings in traditional qualitative methods.

The StreetTalk method is heavily inspired by social media influencers who have garnered millions of views by engaging people on the street and immediately asking them questions on a specific topic, such as how a participant met their partner or how much a participant earns or pays in rent. The person provides a spontaneous and dynamic response. Then, the video content is edited and posted to social media platforms, allowing for widespread dissemination of the recorded interactions.

The StreetTalk method addresses the current state of large lag times between research inception to its public dissemination. Delays occur due to the complexity of the research process, lengthy (albeit essential) peer-review process, and journal production and formatting (Bornmann, 2011 ; Siler et al. 2015 ). Further, once published, journal articles are often not easily accessible to the public due to academic jargon and journal paywalls (Van Noorden, 2013 ). Moreover, due to human subjects research protections regarding confidentiality and since interview interactions are mostly captured in audio form, participants’ accounts are often reduced to anonymized quotes. This leaves little opportunity for anyone other than the interviewers to visualize the participants and the context in which the data was collected. We therefore developed the SteetTalk qualitative research method to collect data on a timely topics in a public format, share participant accounts using their likeness (with permission), and disseminate insights quickly via platforms with greater reach. This approach aims to advance modalities of generating relevant, people-based, in-field information while cultivating new audiences for the consumption of research findings and scientific concepts.

Using StreetTalk to explore energy insecurity in New York City

Energy insecurity has been described as a hidden hardship, although this phenomenon impacts almost a third of households in the United States (Hernández, 2023 ). As living expenses, climate change, housing concerns are commonly discussed topics, the focus of the StreetTalk method centered on questions surrounding energy and energy insecurity. Briefly, energy insecurity is a multidimensional concept encompassing the challenges related to energy access, affordability, and quality, which result in the inability to meet basic household energy needs (Hernández, 2016 ; Hernández and Siegel, 2019 ). While research on household-level energy insecurity (and related topics such as energy poverty and fuel poverty) has been ongoing for decades internationally (Boateng et al. 2020 ; Bouzarovski, 2014 ; Healy and Clinch, 2002 ; Reddy and Nathan, 2013 ; Sovacool, 2013 ), there is a dearth of studies and public discourse related to energy insecurity in the United States (Yoon and Hernandez, 2021 ). This has resulted in a significant gap in understanding the unique challenges and dynamics of energy access and affordability and how this permeates everyday life (Siksnelyte-Butkiene et al. 2021 ; Yoon and Hernández, 2021 ).

A handful of scholars have begun to address the issue of energy insecurity within the United States, shedding light on its complexities and implications for American society (Hernández, 2016 ; Bednar and Reames, 2020 ; Chen et al. 2022 ; Cong et al. 2022 ; Friedman, 2022 ; Siegel et al. 2024 ; Wang et al. 2021 ). A recent study concluded that the amount of academic literature on energy and energy insecurity-related issues in the United States is limited when compared to the amount of coverage by media outlets and journalists (Yoon and Hernández, 2021 ). By choosing this subject matter, we not only aimed to align qualitative research methods with the current media landscape, but also to contribute to the growing evidence base on energy insecurity in the United States.

Energy is a basic need and a prerequisite for good health (Rehfuess, 2006 ). Nevertheless, the cost of residential energy (used for heating, cooling, lighting, refrigeration, and cooking) has consistently increased and therefore accounts for a larger and growing percentage of household expenses (Hernández, 2023 ; Power, 2012 ). Moreover, increasing temperature extremes and the integration of technology has resulted in greater dependencies on energy to carry out daily functions. As such, the burden of increasing energy costs and demands has increased susceptibility among individuals and households to become energy insecure.

Energy insecurity is pervasive globally; however, focusing on the experience of energy insecurity in New York City (NYC) offered the opportunity to gain valuable insights into the localized experience and the particularities of place and population dynamics. NYC’s dense population, large multiunit buildings, and distinct housing dynamics present unique challenges in terms of energy access, affordability, and control (Siegel et al. 2024 ). In NYC, there is a range of control over heating and cooling of residential units, with many residents lacking the ability to manage indoor temperatures, as they are regulated by building management. Additionally, many NYC apartments lack central cooling systems, forcing residents to purchase window air conditioning units, which increases energy expenses. The aged housing stock and vast social inequalities uniquely contribute to the risk of energy insecurity among NYC residents.

A recent study on energy insecurity in NYC revealed a citywide prevalence of 28 percent (Siegel et al. 2024 ), with similar prevalence’s to the national and hyperlocal levels reported in other studies (Cook et al. 2008 ; Debs et al. 2021 ; Hernández and Siegel, 2019 ; 2024 ). Siegel et al. also found that energy insecurity was associated with health vulnerabilities, including mental health conditions, respiratory issues, cardiovascular diseases and use of electronic medical device use, particularly among disadvantaged populations (Siegel et al. 2024 ). Black and Latine residents, low-income households, renters, households with children, long-term neighborhood residents, households with poor building conditions, and foreign-born individuals have also been identified as communities with heightened vulnerabilities to energy insecurity (Hernández and Laird, 2022 ; Hernández and Siegel, 2019 ; Siegel et al. 2024 ). While qualitative research has examined energy insecurity among low-income households in targeted locations including in the Bronx, New York (Hernández and Phillips, 2015 ), New Haven, Connecticut (Mashke et al. 2022 ), the southeast region (Kelley and Bryan, 2023 ) and in various parts of the country (Hernández and Laird, Forthcoming ), no prior study has investigated the issue of energy insecurity in the public domain across a spectrum of demographic characteristics and shared the insights in public-facing, non-academic outlets in video format. Therefore, we developed StreetTalk to address a methodological gap in conducting qualitative research, to fill substantive gaps in the energy insecurity literature and demonstrate new potentials in research dissemination.

In this article, we introduce StreetTalk, a novel ground-truthing street intercept interview method and social media dissemination strategy. Inspired by the approach of numerous social media influencers, we have developed a formalized research methodology for probing passersby in public places on a specific topic. These short-form interviews allow researchers to get a pulse on the public opinion surrounding a given topic. Further, the StreetTalk interview video recordings can easily be edited to be published on social media platforms, thus providing easily digestible and accessible information to the public. In this paper, through the novel StreetTalk research method, we examine public perceptions among NYC residents on issues related to energy insecurity. Below we describe our methodological procedures and the results of our thematic analysis.

The motivation behind the present project was to humanize and publicize the issue of energy insecurity and develop new methods by which to collect and disseminate interview-based data that highlight the lived experiences of this highly prevalent phenomenon.

Research team

This research was conducted by a racially, ethnically, and socioeconomically diverse team of students and trainees from multiple disciplines spanning epidemiology, environmental science, anthropology, sociology, statistics, global/public health, Africana studies, economics, health policy, and medicine. The principal investigator, (Hernández, 2024 ), a Latina sociologist and public health researcher who is also a NYC-native from the South Bronx, has conducted foundational research related to energy insecurity in the United States for over a decade using both qualitative and quantitative methods (Hernández, 2024 ). All authors have lived in NYC and experienced some form of energy insecurity in their lives. Each team member was interviewed by a peer using the interview protocol for both training purposes and to further relate to participants and the issue at hand. Data collection and analyses were completed by all authors of the study. The principal investigator designed the study, supervised the project, and provided guidance and constructive feedback throughout every stage of the research process.

Human subjects

This study was approved by the Institutional Review Board at the Columbia University’s Irving Medical Center [IRB AAAU3071]. The study team supplemented the standard informed consent process with a media release form, employing university-approved language and modifying existing forms to fit this study. Participants were given a $10 gift certificate as compensation for their participation in the study.

StreetTalk data collection

The team identified locations within the five boroughs of NYC that were both representative of the city’s diverse populations and locations that would be recognizable when the videos are posted to social media (such as Yankee Stadium, 125th street, Prospect Park, and the Staten Island Ferry). The selected neighborhoods included Washington Heights, Harlem, Upper East Side, and Hamilton Heights in the borough of Manhattan; Fordham Heights and Morrisania in the Bronx; Prospect Heights and Red Hook in Brooklyn; St. George in Staten Island; and Jackson Heights and Flushing in Queens.

During April 2023, team members went into the field in groups of two to three to recruit and interview individuals to participate in this study. Team members approached potential participants on sidewalks, bus stops, parks, and other public outdoor locations to ask if they would be interested in participating in the study. Upon an individual’s demonstration of interest in the study, potential participants were screened into the study if they currently lived in one of the five NYC boroughs and have experienced at least one of several indicators of energy insecurity (Siegel et al. 2024 ). Team members then reviewed and explained the consent and media release forms with the potential participant, while also highlighting the social media nature of the project. Individuals who agreed to participate then signed both the consent and media release forms. Participants were allowed to opt out of the study at any timepoint or redact statements made during the interview. After receiving signed consent and media releases, participants were audio and/or video recorded according to their preference. Interviews were conducted in English and Spanish by fluent speakers from the research team based on participant preference. Interviews ranged from 10–15 min on average. The questions and associated probes used in the StreetTalk interviews are presented in Table 1 .

StreetTalk thematic analysis

After all recordings were transcribed, we used the interpretivism paradigm (Goldkuhl, 2012 ) to conducted a qualitative thematic analysis that aimed to understand and characterize individuals’ experiences with energy insecurity through the codebook approach (Braun and Clarke, 2023 ). We followed Braun and Clarke’s six phases to thematic analysis. Briefly, the six phases consist of the research team (1) becoming familiar with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing potential themes, (5) defining and naming themes, and (6) producing a report (Clarke et al. 2015 ).

Six trained team members conducted the initial thematic analysis. The review team conducted the first three phases of thematic analysis on eight randomly selected interview recordings. Then, the group of reviewers met to discuss and calibrate their coding methodology. After the initial meeting, phases 1 to 3 were conducted on every interview recording by a minimum of two reviewers for consistency and validity. Once phases 1 through 3 were complete, reviewers of the same interviews met individually to review their codes and potential themes and reach a consensus. Then, all six reviewers met to discuss, evaluate, select, and name themes (phases 4 and 5) across the data set. These themes were presented to the entire research team and then finalized.

StreetTalk social media dissemination

A team led by co-author I.B.F met twice a week to oversee the social media dissemination aspect of this project. The social media dissemination team oversaw the production and all dissemination efforts utilizing the @hotandcold_nyc handle on TikTok, Instagram, Facebook, and YouTube. The team produced video shorts from the StreetTalk interviews that highlighted the themes discovered in the analysis. Team members drafted captions to accompany the video shorts on the social media platforms. Based on a social media calendar developed by the team, video shorts were posted across the various platforms. The team tracked post engagement and analytics, adapting the video production style and content to maximize engagement.

From April 10th to 28th 2023, a total of 31 ground-truthing StreetTalk interviews were recorded, with 34 participants interviewed (some videos had multiple participants). An additional 3 interviews were conducted, but not recorded and therefore excluded from the analysis. Of the 31 StreetTalk interviews, 5 were recorded in Brooklyn, 15 in Manhattan, 4 in the Bronx, 5 in Queens, and 2 in Staten Island. Five of the 31 interviews were conducted in Spanish, with the others being conducted in English. While information on age, race, ethnicity, gender and income were not collected, the video recordings feature a diverse group of individuals across various sociodemographic domains.

Participants shared a wide range of experiences related to energy insecurity based on the interview questions. Subsequent data analysis helped us identify the emergence of a clear set of themes. Table 2 presents the finalized list of themes and subthemes from the qualitative analysis. The six thematic categories were: (1) conservation and trade-offs, (2) housing deficiencies and inefficiencies, (3) thermal agency, (4) response to the bill, (5) disappointment and distrust in energy-related authorities, and (6) desire for and barriers to clean energy adoption.

Conservation and trade-offs

Participants employed different strategies to balance thermal comfort and financial security. For instance, some chose to limit their energy usage to save money. As one Staten Island participant warned, “ Don’t mess with the AC unless you really feel hot .” Another participant in Brooklyn stated that “ you have to limit yourself ” when referring to using air conditioning units to avoid excessive expenses. In fact, one Manhattan participant refrained from using air conditioning with one exception, “ not unless I have company .”

Other participants found alternative ways to reduce energy bills and remain thermally comfortable by “ spend[ing] a lot of time out of our apartment .” For other individuals, thermal comfort took precedence over financial security. When a Manhattan resident’s landlord refused to turn on the heat in their apartment building, an additional financial burden fell on the participants to furnish their own heat. The participant shared that they purchased “ space heaters when cold in house as the landlord is unresponsive ” thus further compounding the economic hardship and risks of this alternative heating strategy.

Participants further described the dilemmas over choosing between affordable energy bills and maintaining comfortable temperatures in their homes. One Manhattan participant, who initially prioritized thermal comfort, shared their struggle to then manage the resultant high costs had to switch gears on their approach when he faced crisis. The participant said, “I couldn’t keep up with the bills. So, they [the energy company] stopped everything.” To avoid another disconnection due to unpaid bills, this participant decided to then limit their use of heating and cooling, causing them to face uncomfortable and potentially dangerous indoor temperatures in their apartment in the winter and summer.

These quotes collectively highlight the conscious decisions many New Yorkers make when deciding between being thermally comfortable and living within their financial means. The struggle to find the right balance was evident in the accounts of trade-offs and forgoing comfort, underscoring the significance of addressing the issue of energy insecurity for residents’ comfort and well-being from an economic perspective.

Personal responsibility to conserve and save

The personal responsibility to conserve and save subtheme refers to participants’ recognition of their personal responsibility in managing energy usage and their deliberate efforts to minimize costs. Individuals were conscious of the need to be diligent in their energy consumption to reduce the impact on their bills and sometimes blamed themselves for unexpected spikes. One participant emphasized the need to “be careful with your light bill,” while another revealed how they proactively “switch all the lights off. No lights on. No TV on when we leave the room” to reduce electricity expenses. This heightened awareness of the relationship between energy usage and billing led participants to take measures to be more mindful of their consumption habits and vigilantly conserve energy (Simes et al. 2023 ).

Housing deficiencies and inefficiencies

Physical deficiencies and inefficiencies was characterized by energy related challenges associated with features inside and outside of their homes, including outdated appliances, poor insulation, and lack of temperature control. Many participants discussed the subpar performance of their appliances, as one Manhattan participant noted, “The stuff that we use are probably not the best, probably not energy efficient” Some noted that they were unable to afford more energy efficient appliances or, as renters, unable to upgrade them on their own accord.

Some of the concern had to do with the aged housing stock of the building or the fact that the infrastructure was outdated. Participants also linked living on higher floors to having more uncomfortably hot apartments, as one participant described, “ I’m on the 6 th floor and… it seems to get extremely hot in there .” Often summertime and the use of air conditioning units exposed these fault lines in residential buildings. For instance, one participant from the Bronx was unable to support the basic use of an air conditioner. They shared that: “During summertime it is extremely hot. When I provide myself with an air conditioner it ‘outshortaged’ the rest of the house.” The electrical capacity was not enough to accomodate the air conditioning unit and when this happened the participant had to reset the circuit breaker and unplug other devices to free up capacity to run the air conditioner. Participants also shared that their air conditioning units did not have sufficient capacity to properly cool their apartments. Still others noted that the size, type and functionality of building windows restricted their ability to properly run air conditioning window units despite that being among their only cooling option besides a fan.

During the winter months, examples of physical energy inefficiencies included the inability to control heat in the apartment, poor insulation, and nonworking heaters. When primary heating systems were not functional, residents resorted to buying their own space heaters and, in some instances, using their stovetops or ovens to heat up their apartments. As one participant in the Bronx shared, “ I’ve struggled for many years, I was in a shelter with my kids and plenty of times we did not have water or gas and were forced to use electric stoves, which took hours to heat our home .” Additionally, participants were aware of the importance of insulation in their homes, as one observed: “ We have an old house and there’s lots of leaks. The first thing we had to do is get new windows, but still insulation is a big help because we … put some insulating materials in the ceiling and now the kitchen that was our coldest room has become our warmest.” Physical deficiencies and energy inefficiencies posed a significant challenge to participants and contributed to uncomfortable temperatures and higher energy costs.

Thermal agency

Thermal agency refers to respondents’ ability to control the temperature in their homes. Residents’ ability to control heating or cooling in their apartment varied drastically from total control to complete lack of control. One Manhattan resident explained that they were able to partially control their home’s heating “through the radiator.” They continued, “I can turn [it] on and off but in terms of the energy coming through I can’t control that.” Two additional sub-themes emerged from New Yorkers’ wide variation in thermal agency: (1) satisfaction based on ability to control indoor temperature and (2) unresponsive landlords.

Satisfaction based on ability to control indoor temperature

Residents’ satisfaction with their apartment temperature was strongly correlated with their ability to control it. Many New Yorkers complained about not being able to control their apartments’ heating during winter. One respondent in Brooklyn stated of the indoor temperature: “It’s controlled by my landlord, so I don’t have much autonomy with it… In the winter it gets pretty hot.” This New Yorker was frustrated that their apartment became uncomfortably hot in the wintertime and expressed frustration over the inability to reduce the amount of heat entering their apartment. Respondents wished that they could control the timing of their heat as well. One participant spoke of a desire to “put the heat on faster when it’s about to be winter.” New York City heating laws are seasonally driven and cover all of winter and some of fall and spring. There are also guidelines for the minimum temperature set points and mechanisms to enforce inadequate heating complaints ( Heat and Hot Water ). There is no equivalent mandate for maximum temperatures. Therefore, New Yorkers, especially those that reside in apartment buildings where the property owner has central control of the heating system, have little say about when the heat comes on or off and how hot it gets. The same is true for hot water. The aspect of control was often a sore point for participants, many of whom would prefer more agency in determining the indoor temperature conditions year-round. Residents who were able to control their apartments’ temperature appeared to be more satisfied. For example, one participant stated, “I have central AC. I think it’s just fine!” Technologies such heat pumps indeed have thermal agency benefits; however, the control also comes with a shift in responsibility for covering the costs such that the tenants would assume the costs of heating and cooling, which could also be burdensome.

Unresponsive landlords

The second sub-theme, unresponsive landlords, revealed the frustration and concern expressed by participants regarding their interactions with landlords surrounding temperature control. Many respondents shared experiences of unresponsive landlords who failed to address heating issues during the cold winter months, leaving them feeling helpless in creating comfortable living conditions. For example, one participant in Queens shared that, “wintertime [is] very cold, [I] complain about fixing heat, and they never do.” Multiple participants shared similar stories and despite the participants taking steps to improve the heating situation by filing a complaint, their landlord remained unresponsive, and the issue persisted. Many participants feel powerless regarding their ability to control home temperatures in the face of an unresponsive landlord. As one participant in Brooklyn shared: “Our neighbors —we call each other. We can’t do anything. We complain. They (the landlords) will just say, ‘I’m listening,’ but won’t do anything. Not responding, but you have to pay the rent anyways.” This participant highlights the vexing power imbalance between tenants and landlords; landlords can repeatedly fail in their responsibility to maintain safe temperatures and perform repairs, while tenants are still expected to pay rent or face consequences. Other participants attempted to act further on these heating issues and circumvent their landlord. As one respondent in Staten Island said that to finally get their heating fixed they, “had to call 311 (a hotline for non-emergency city services) at one time.” The subtheme of unresponsive landlords underscores the need for clearer communication and accountability from landlords to ensure more reliable energy services, particularly for renters who have little control, access, or knowledge about building energy systems.

Response to bill

The response to bill theme was characterized by respondents’ reactions to receiving energy bills. Participants often expressed a wide range of negative reactions (i.e., surprise, anger, disappointment, stress, etc.) to either high energy bills or unexpected spikes in energy bills. A common sentiment among participants was that their bills were, “more expensive than I want it to be” (Brooklyn) and were disappointed by the high costs: “[we] spend a lot, like, for electricity and stuff” (Queens). Others discussed how their energy bill had increased recently, as noted by one participant, “It’s gone up significantly over the last year. My bill went from like 90 a month to almost like 200 something a month.” The way in which individuals responded to energy bills generally fell into one of three subthemes: (1) emotional response, (2) personal responsibility to conserve and save, and (3) perceptions of inappropriate or inconsistent pricing with energy use.

Emotional response

Participants shared a wide range of negative emotions towards increasing energy bills, such as “getting a little peeved,” “feeling upset,” “not happy with the price,” “feel [ing] horrible,” and stating that, “it is stressful.” One participant even likened paying the utility bills to “a disaster.” A Manhattan respondent explained that such negative emotional responses to the bill are linked to the financial strain of paying, sharing: “I think a lot of New Yorkers are living paycheck to paycheck. I think a lot of New Yorkers especially… are struggling financially. I’m one of them, and so I think it’s hard when you see that bill that you weren’t necessarily expecting.” The unexpectedly high bills place strains on many New Yorkers and add additional, unanticipated stress in a high cost city. Moreover, many New Yorkers also knew the consequences of not paying utility bills- being shutoff- and therefore stress not only about the financial difficulty of paying but about the deleterious consequences of missing a payment. As one participant remarked, “ It worries me. I got to pay for the month and if not, they will cut your lights.” The emotional response subtheme highlights the significant negative impact that increasing energy bills has on participants’ well-being, evoking feelings of stress, anxiety, and discontent.

Perception of inappropriate and inconsistent pricing with energy use

The perception of inappropriate and inconsistent pricing with energy use is characterized by participants expressing their dissatisfaction and confusion over erratic and unpredictable energy pricing. Respondents shared instances where energy bills unexpectedly spiked, leaving them unable to comprehend and justify the substantial increases. Many participants voiced frustration with the lack of consistency in billing, as they expected bills to remain stable or decrease due to efforts to reduce energy use. One participant shared their frustrations with the inconsistent pricing by stating, “It’s getting more expensive, and the bill isn’t always the same. And I’m expecting it’s always the same. We’re not using the TV, and we use a small light during the night.” These comments revealed a sense of skepticism towards utility providers, with participants questioning the justification for the steep costs, especially considering the service provided.

Many participants expressed their dissatisfaction with pricing, deeming it excessive for the services rendered by corporate utilities, namely Con Edison and National Grid. One Manhattan participant thought their bill seemed unreasonably high and insisted that they wanted further justification, “I would like to know where all the money we pay to it [ConEd] is going to.” Along the same lines, another Manhattan participant shared, “I was gone for two months. It didn’t really show on my bill. I unplugged just about everything except for the Wi-Fi, and I should have had a lower bill at least a month after or something. I wrote them [ConEd] a letter just months ago, and I have not heard anything. I just wanted to know why that is. Am I just paying for it to come into the house? And I hardly use anything?” The perception of impropriety and inconsistency in pricing reflects participants’ sense that energy costs were not always commensurate with their actual usage, leading to a lack of confidence in the billing process, and a feeling of frustration and powerlessness in not being able to do much to reduce costs despite vigilant conservation efforts.

Disappointment and distrust in energy-related processes and oversight

Many residents that were interviewed on the streets of NYC expressed a strong desire for increased transparency, easily accessible and responsive support, effective communication and greater assistance from utility companies and the government. Participants felt unsupported by utility companies and government agencies. One Brooklyn participant explained the lack of support they received from the government when they called the city’s housing department for help with energy issues that their landlord was neglecting. This participant argued for greater enforcement: “The housing department needs to have more people checking [the energy conditions of apartment buildings]… When you call, they say that they will contact the landlord. And even if they do, and they put it on, the heat, it’s just for short 45   min and then that’s it.” This participant expressed disappointment in NYC governments lack of enforcing their own heating requirements. The participants followed the appropriate protocols and still did not receive the proper heating that their landlord is required to provide. The participant wished that the housing department took a more active role in addressing tenants’ complaints and ensuring landlord compliance.

Many participants expressed interest in the government and energy providers offering greater access and resources related to energy assistance programs, especially for low-income residents. One Brooklyn participant shared their call for help for the most vulnerable, “I just keep asking the government for help [and] support, especially for the lowest income families.” Another Manhattan participant hoped for more affordable rates across the board, “I would ask ConEd to make the bill lower for everyone.” Participants felt that energy bills were too high, and there was a need for better assistance programs from the utility companies or the government. However, participants also demonstrated a lack of knowledge regarding existing energy assistance programs. One Bronx participant shared that the lack of visibility precluded their participation in energy assistance programs, “I don’t really [know] any of kind of those things. I don’t see any programs.” This common sentiment among participants highlighted the need for more accessible information and enrollment in existing energy affordability programs.

Desire for and barriers to renewable energy adoption

Participants were hopeful and interested in renewable energy resources as alternatives to fossil fuels and unknown energy sources. One Brooklyn participant highlighted their disappointment in current energy sources, sharing: “I know it’s not coming from sustainable sources, so that kinda bums me out.” They wanted renewable energy options, particularly solar power, as expressed by a Manhattan participant, “I would like to get solar!” However, in NYC there are many barriers to accessing renewable energy, such as living in multiple unit housing or financing the installation of solar panels. Climate change concerns served as a motivator for clean energy adoption. Anxieties about the role of energy in exacerbating climate change was a critical inspiration for upgrading energy sources to renewables. One Brooklyn participant urged: “ Change the source of the energy itself. It’s really bad for public health and obviously climate change.” There was a palpable longing for clean energy among participants due to their desires to prevent and mitigate further deleterious effects of climate change. Still, there were also many perceived barriers to renewable energy uptake.

Financial constraints and practical challenges including the limitations associated with renting stood as impediments to acquiring renewable energy, despite recognition of the associated benefits. Participants voiced frustration over the inaccessibility of solar energy programs. One Bronx participant hoped to benefit from the potential financial savings of renewable energy stating, “ If the city of New York will allow us to have solar panels, maybe life will be a little bit easier. You know, the majority of [us] are paying light and gas and living from paycheck to paycheck .” This comment also expressed a desire for the government to take steps to make renewable energy more accessible.

A participant in Queens expressed their wish for apartment buildings to integrate solar energy solutions, while acknowledging the challenges of a slow return on investment and high upfront costs: “I wish I had more control over sources of energy but with solar panels it does not pay quickly; it is about 30 years to get money back.” Additionally, a Staten Island participant living in a single-family home shared concerns over renewable energy not being reliable by stating, “I’ve always thought about, like, getting solar but I’ve heard it’s just unreliable. It’s expensive to put in and then after that it doesn’t hold enough, or it doesn’t provide enough energy.” With more assurances on the reliability of solar to meet the household’s energy demand, this participant would opt to invest in solar energy, but the substantial doubts were a hurdle.

Participants discussed the economic disparity between renewable and non-renewable energy options from utility companies, with one Manhattan participant noting the higher costs of opting for energy sourced from clean energy: “ConEd has this thing where you can sign up for renewable energy, right? But it’s a lot more expensive than it [is] for regular energy.”

In New York City, participants shared that the ability to use sustainable energy is only attainable at high costs and therefore individuals who are struggling financially are unable to take on the associated financial burdens of switching to renewable energy sources despite strong interest. This highlights the need for more practical, accessible, and economically feasible options for New Yorkers, many of whom are otherwise ready to make the switch to clean energy.

Within the first year of launching the @hotandcold_nyc social media channels, they have amassed nearly 200,000 views and impressions. Figures 1 – 4 are sample screenshots of social media pages and engagement analytics from YouTube, Instagram, TikTok, and Facebook, respectively. The engagement of videos differed by social media platform. To date, YouTube is our most successful platform, with over 88,795 views. Instagram is our second most successful platform with 41,730 views, closely followed by TikTok with over 47,285 views, and then Facebook with over 1,225 views as of July 28, 2024. There are also several thousand likes and comments across the platforms.

Sample screenshots of Hot & Cold NYC’s YouTube channel and engagement analytics.

Sample screenshots of Hot & Cold NYC’s Instagram page and engagement analytics.

Sample screenshots of Hot & Cold NYC’s TikTok videos and engagement analytics.

Sample screenshots of Hot & Cold NYC’s Facebook page and engagement analytics.

This study utilized a novel, ground-truthing, StreetTalk qualitative research methodology to understand public perceptions among NYC residents on issues of energy insecurity. The qualitative analysis revealed six major themes: (1) conservation and trade-offs, (2) housing deficiencies and inefficiencies, (3) thermal agency, (4) response to the bill, (5) disappointment and distrust in energy-related processes and oversight, and (6) desire for and barriers to renewable energy adoption. These themes summarize how energy insecurity impacts the lives of NYC residents and are congruent with prior quantitative and qualitative findings (Siegel et al. 2024 ; Hernández et al. 2016 ). Our results demonstrated the commonality of trade-offs, energy limiting behavior, and vigilant conservation (Cong et al. 2023 ; Hernández, 2016 ; Simes et al. 2023 ). Siegel et al. ( 2024 ) found that 39 percent of NYC residents report reducing energy to save on their bills, which was the most common energy insecurity indicator reported in a represented survey. Rather than being wasteful, participants tended to be extremely mindful of their energy consumption and did as much as possible to restrict use, primarily to manage costs. Yet, participants also found the physical inefficiencies and capacity limitations encumbered use of appliances and the ability to achieve comfort, which is consistent with prior research on housing quality as a core component of the energy insecurity experience (Bednar et al. 2017 ; Goldstein et al. 2022 ; Hernández, 2016 ).

In addition to confirming and further substantiating prior findings related to the energy insecurity phenomenon, the StreetTalk interviews also offered novel insights. Findings related to thermal agency, emotional responses to bills, perceptions of procedural injustices and oversight gaps, and interest in clean energy adoption among everyday people who are not affiliated with programs or larger movements extend the literature in important ways. While the concept of thermal agency is underexplored in the current literature on energy insecurity and related topics, there is well-established evidence base in the field of occupational health that indicates that thermal agency in the workplace increases productivity, workers’ health, and workers’ wellbeing (Cheong et al. 2003 ; Seppanen et al. 2004 ; Seppanen et al. 2006 ). Future studies should explore thermal agency further as a manifestation of household energy insecurity to understand, for instance, how decisions about heat provision by others activate coping strategies, such as using stoves, ovens, or space heaters, to compensate for the lack of control over thermal conditions. This could also be an outcome of interest in studies on the impacts of heating/cooling upgrades such as the installation of heat pumps which offer more thermal control, albeit often assuming additional costs in tandem.

Participants described themselves as feeling “impotent” vis-à-vis landlords, utility providers, governmental agencies, inflation and the rising cost of living. Having limited domain over their energy realities played a vital role in influencing indoor temperatures, home energy inefficiencies, utility rates, access to relief resources, mechanisms of enforcement and ability to keep up with expenses. Appreciating these nuanced power dynamics across domains and how some groups are rendered more powerless than others is another area worthy of further exploration. Moreover, our findings point to the emotionality of this experience including participants’ reactions to their bills which were often marked by frustration and a sense of hopelessness and resignation. While there was awareness and interest in renewable energy technologies and energy assistance programs, many participants described barriers that reduced the likelihood of uptake. These findings add to existing literature, but they also point to addressable issues that can alleviate the burdens of energy insecurity via greater supports.

The study’s findings shed light on respondents’ experiences of unexpected bill spikes and perceived lack of transparency in pricing, reflecting broader concerns within the energy sector. Previous research has explored the complexities of pricing transparency, energy literacy, and tariff structures, offering valuable insights into these challenges (Brounen et al. 2013 ; Numminen et al. 2022 ; Trotta et al. 2017 ). Studies focusing on pricing transparency have highlighted the importance of clear and accessible information for empowering consumers and promoting trust in energy providers (Kowalska-Pyzalska, 2018 ; Lavrijssen, 2017 ). Additionally, research on energy literacy has emphasized the need for educational initiatives to enhance consumers’ understanding of energy-related concepts and mitigate misconceptions (Abrahamse et al. 2005 ; Iweka et al. 2019 ). Energy literacy interventions and educational initiatives are essential, especially since we observed that some participants made statements that were based on incomplete or wrong information and misconceptions. For example, in NYC, rooftop solar panels do not typically affect the reliability of a home’s energy capabilities, unless that home has been fully islanded from the electricity grid, a practice that is not commonly utilized. Another example of misconceptions among NYC StreetTalk participants was the outdated belief that there is a 30-year payback period for solar installations. However, according to a systematic review published almost a decade ago, the payback time for rooftop solar ranges from one to four years, and given advancements since then, it is reasonable to assume that payback period is even shorter now particularly when factoring in incentives at the local, state and federal levels (Bhandari et al. 2015 ). Identifying and understanding these misconceptions is essential for advancing public education initiatives and policy decisions aimed at promoting accurate understanding of energy issues including the adoption of renewable energy technologies.

In this article, we introduce StreetTalk, a novel qualitative research method and ground-truthing process inspired by social media that allows for rapid data collection and timely, accessible dissemination of findings. Based on the numerous social media influencers who have conducted informal streetside interviews, we have developed a formalized research methodology for probing members of the public on a specific topic. In our case, we did so on a topic that affects almost everyone— household energy—and explored dimensions of this issue that affect people across the social and economic spectrum. These short form interviews allowed our research team to quickly gain a pulse of the public opinion on this given topic. Furthermore, the StreetTalk interview video recordings were easily edited for publication to social media platforms, thus providing easily digestible information to the public with a quick turnaround time between data collection and dissemination. In addition to a traditional research team (principal investigator, interviewers, data analyzers, etc.), the StreetTalk methodology requires training in the development of a social media campaign as well as content creation to populate and manage the social media component for broad-based dissemination. Doing this type of research also requires harmonizing efforts between human subjects and communications protections with informed consent and media release forms both being necessary to comply with legal and ethical protocols.

The StreetTalk method has potential to create a paradigm shift in how research is conducted and disseminated. The street intercept approach provides a mechanism to engage a broad swath of participants identified in public places, including those for whom energy insecurity is not an immediate threat or concern, offering a unique perspective often missing from similar energy insecurity research. We were able to obtain multiple perspectives from people across various racial/ethnic and socioeconomic strata. Other street intercept recruitment and survey methodologies have been employed to target hard-to-reach populations and explore subversive topics in prior studies (Graham et al. 2014 ; Miller et al. 1997 ; Ompad et al. 2008 ; Rotheram-Borus et al. 2001 ), however, these approaches have not been previously used for academic research on emergent environmental issues. Therefore, the StreetTalk street intercept interviewing methods is innovative and promising in its potential to reach varied participant pools and larger, more diverse audiences. As such, the StreetTalk qualitative research method allows for rapid data collection and timely dissemination—having the potential to alter scientific research accessibility and communication to the public, while maintaining rigorous standards in data analysis and reporting of findings.

Unlike traditional qualitative interview methods, the StreetTalk method was developed for community embedded data collection and timely and engaging dissemination of data via social media. After following established protocols for deciphering core themes of the interviews, the research team conducted multiple meetings to also decide on a strategy and approach to creating short-form videos appropriate for social media sites. The videos most often featured compilations of answers to interview questions or responses that clustered around themes that arose during the thematic analysis process. Within one month of completing the interview recordings, our team began sharing videos on social media platforms including TikTok, Instagram, Facebook, and YouTube under the handle @hotandcold_nyc. Our research team continued sharing new videos every week and engaged with similar accounts to enhance exposure. The team also continuously studied and experimented with various social media styles to identify ways to hone video production and editing to increase engagement and viewership.

While the need to communicate science to the public is widely agreed upon, in practice, scientific findings are often siloed within industry and research institutions (Brownell et al. 2013 ). Most scientific findings are only published and disseminated in peer-reviewed academic journal articles. In addition to many journals having a paywall to access these articles, journal articles are often crowded by academic jargon that is difficult for the general public to understand (Bullock et al. 2019 ; Day et al. 2020 ). As such, both financial and educational barriers prevent the general public from accessing scientific information that resonates with their lived experience. Furthermore, academic research is often criticized for its lag time from data collection to research publication to public understanding and ultimately to policy change (Morris et al. 2011 ). As such, the StreetTalk qualitative research methodology was developed to both address these barriers to scientific knowledge access and to reduce the scientific lag time. Dissemination through social media is significantly faster than traditional academic means, as evident through our videos reaching hundreds of thousands of viewers in only a few months. And not only does StreetTalk allow for near immediate dissemination of findings, but it also allows for these findings to be shared on social media where the majority of the general public already receives information (Liedke and Wang, 2022 ).

Often overlooked within the public discourse, energy insecurity remains America’s hidden hardship (Hernández et al. 2022 ; Yoon and Hernandez, 2021 ). Normalizing conversations about this critical issue is essential to enhancing public understanding and engagement. By utilizing social media platforms, StreetTalk aims to bridge the gap between academic research and public discourse, making scientific findings more accessible and relatable to the public. The speed and reach of social media dissemination allow for near-immediate access to information that resonates with people’s lived experiences, breaking down both financial and educational barriers to scientific knowledge. Our social media channels have already reached almost 200,000 views and likes within a ten-month timeframe, a significant achievement in expanding the reach of academic research beyond traditional academic outlets. The active engagement we have received, including likes and comments discussing energy insecurity issues, highlights the importance of social media in fostering meaningful dialogue and community involvement. Moving forward, the research team plans on conducting further thematic analysis of user engagement. The analysis will examine factors that may have impacted more views and greater engagement to develop best practices in this approach. This follow-up study will also consider how to best refine this strategy, as well as evaluate whether this method is more effective in stimulating public discourse on the topic compared to traditional methods. For example, through a thematic analysis of comments, we can assess whether the engagement on social media platforms effectively humanizes the issue of energy insecurity by examining the depth and nature of discussions surrounding personal experiences, emotional responses, and connections made by users. By delving into the nuances of user interactions, we aim to determine the extent to which the study succeeds in humanizing the issue and fostering empathy and understanding among the public. The information gained from this current and the follow-up analyses will drive future research projects, while at the same time existing as a low-effort way for NYC community members to take ownership over and relate to energy insecurity research.

Strengths and limitations

This study has several strengths. As discussed earlier, this novel research methodology allows for rapid data collection and dissemination of findings. Additionally, the research methodology allows for distribution of information that is easily accessible to the public and not siloed within academia. Lastly, while this initial study had a small sample size, the methodology allows for a relatively large sample for qualitative interviews, due in part to its public and short-form format, thus providing a good pulse on the public perception of a specific topic. That said, there are also limitations to this study. StreetTalk interviews are intentionally focused and brief, and therefore responses may not have the depth and exploratory goals of understanding the particularities of their experiences as traditional qualitative research methods. As such, this research methodology is best used as a ground-truthing activity to begin exploring public perceptions and be a jumping off point for more traditional longform interviews, if warranted. The results from a study using StreetTalk can then be used to develop further qualitative approaches that can build on the initial findings in greater focus and depth. This study methodology is prone to selection bias based of who was available to stop and willing to speak to interviewers on camera. This street-based methodology may result in bias toward respondents who are comfortable appearing on social media and excludes individuals who are homebound due to medical or other conditions. This can be mitigated by reassuring participants that their appearance in social media is not required to participate and that techniques can be used to protect their identity such as filming in ways that does not capture their face or using audio only; we employed these tactics as instructed by participants. These participants’ responses can still be included in the analysis and included in social media content using various creative techniques such as audio alongside captions. Additionally, this study was conducted in the context of NYC and therefore the results may not be generalizable to other locations, though the methods are highly adaptable and can easily be used in other settings.

Based on the themes identified in the StreetTalk interviews, next steps include conducting more in-depth, home-based interviews in NYC that explore the themes discussed in this paper. Additional next steps include conducting these interviews in other cities and about other topics. For instance, the StreetTalk method can be applied as a ground truthing technique for unforeseen catastrophic events, such as extreme weather events, pandemics, and sociopolitical instability, all of which require rapid data collection and dissemination of findings (Adams et al. 2024 ).

This study employed an original StreetTalk qualitative research methodology designed to gain insights into perceptions of energy insecurity among NYC residents. Through a thematic analysis, we identified six major themes that shed light on how energy insecurity impacts the lives of local residents. Our findings reinforced prior research (Siegel et al., 2024 ; Hernández et al. 2016 ) by highlighting the prevalence of trade-offs, energy conservation, and the influence of external factors such as landlords, utility providers, and government policies.

The strength of the StreetTalk approach lies in its ability to engage a diverse range of residents, making it a valuable tool for exploring public opinion on various issues. Moreover, this methodology facilitates rapid data collection and dissemination, bridging the gap between scientific research and the general public. Our use of social media platforms to share findings has garnered significant public attention, demonstrating the potential for breaking down barriers to scientific knowledge and processes.

In practice, scientific research often remains locked within academic institutions, with lengthy delays in publication and limited accessibility. StreetTalk addresses these challenges by providing a means for connecting with the public and more swiftly disseminating study-related content to wider audiences on platforms they already frequent for information and engagement. The StreetTalk methodology represents a transformative approach to reducing the lag time between data collection, research publication, public understanding, and policy change.

Data availability

The data underlying this article are available from the corresponding author upon reasonable request.

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Acknowledgements

We wish to acknowledge the Alfred P. Sloan Foundation and the JPB Foundation for funding this project and NIEHST32ES007322-23 for supporting trainees. We also extend our gratitude to the study participants for their essential role in thisresearch.

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Conceptualization: NLS, IBF, MIR, ELS, DH. Methodology: NLS, IBF, MIR, ELS, DH. Software: NLS, IBF, MD, DH. Formal analysis: NLS, IBF, MD, JFHP, JB, DDLS, DH. Data Curation: NLS, IBF, MD, JFHP, JB, DDLS, DH. Writing-Original Draft: NLS. Writing-Reviewing & Editing: NLS, IBF, MD, JFH, JB, DDLS, MIR, GYM, ELS, DH. Visualization: NLS, JB. Supervision: GYM, ELS, DH. Project administration: IBF, MD, JB, DH Funding acquisition: DH

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Sprague, N.L., Fan, I.B., Dandeneau, M. et al. StreetTalk: exploring energy insecurity in New York City using a novel street intercept interview and social media dissemination method. Humanit Soc Sci Commun 11 , 1109 (2024). https://doi.org/10.1057/s41599-024-03477-5

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Leveraging implementation science theories to develop and expand the use of a penicillin allergy de-labeling intervention

• Esra Alagoz 1 ,
• Megan Saucke 1 ,
• Prakash Balasubramanian 2 ,
• Tyler Liebenstein 2 &
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Penicillin allergy is the most frequently reported drug allergy, yet most patients can tolerate the drug if challenged. Despite this discrepancy, large scale penicillin allergy de-labeling interventions have not been widely implemented in many health care systems. The application of a multi-method implementation science approach can provide key tools to study this evidence to practice gap and provide insight to successfully operationalize penicillin allergy evaluation in real-world clinical settings.

We followed a four-step process that leverages qualitative analysis to design evidence-based, actionable strategies to develop an intervention. First, we specified the clinician-perceived barriers to penicillin allergy de-labeling (intervention targets). We then mapped intervention targets onto Theoretical Domains Framework (domains and constructs) and found the root causes of behavior. Next, we linked root causes of behavior with intervention functions (BCW). In the final step, we synthesized participants’ suggestions for process improvement with implementation strategies aligning with the intervention functions.

Evidence-based strategies such as focused education and training in penicillin allergy evaluation can address knowledge and confidence barriers reported by frontline clinicians. Other key strategies involve developing a system of champions, improving communications systems, and restructuring the healthcare team. Implementation mapping can provide a powerful multi-method framework to study, design, and customize intervention strategies. Conclusion: Empowering clinicians beyond allergy specialists to conduct penicillin allergy assessments requires designing new workflows and systems and providing additional knowledge to those clinicians.

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Introduction

The detrimental impact of the penicillin allergy label on patient care, health care utilization, and antimicrobial prescribing practices has been well described [ 1 , 2 , 3 ]. Despite its prevalence, studies have shown that up to 90% of patients with the label of penicillin allergy can tolerate a penicillin antibiotic if challenged [ 4 ]. Interventions that offer systemic evaluation of patients with a penicillin allergy diagnosis have been developed to address this evidence to practice gap of care [ 5 ]. These tools typically include the following: (1) identifying penicillin allergic patients (2) using risk factors such as time and symptoms of past reactions to risk stratify patients regarding the future risk of a reaction to penicillin (3) offering an oral challenge to penicillin, preceded by skin testing when appropriate. Several studies have reported effective algorithms, scoring systems, and challenge protocols that can be implemented at point of demand, including use of telehealth and/or e-consult mechanisms [ 6 , 7 , 8 , 9 ]. Although these innovations exist, further work is needed to address the barriers and contextual factors that may affect key implementation outcomes such as scalability, sustainability, feasibility, and efficacy of large-scale interventions. In addition, variations in clinical settings and patient populations will impact how penicillin allergy evaluations are conducted. To further close the evidence to practice gap, implementation science theories can be applied to study both the clinical efficacy of the intervention and key implementation outcomes related to reach, sustainability, feasibility, and fidelity of a penicillin allergy de-labeling intervention.

Developing theory-based interventions that support healthcare professionals in modifying their clinical practices according to evidence-based recommendations is an important strategy in implementation science. Although the need for evidence-based interventions is well recognized, only a few studies employ social and behavioral theories when developing or implementing interventions [ 10 , 11 , 12 ]. Building on our prior work for which we interviewed inpatient and outpatient clinicians and described the key barriers to the implementation of our penicillin allergy evaluation initiative and Clinical Decision Support Tool (CDST) [ 13 ] (See supplementary files for the interview questions), we have leveraged a multi-methods approach to determine best practices to improve implementation of penicillin allergy de-labeling. This evidence-based process called implementation mapping (IM) translates our qualitative, contextual data to specific strategies to design an effective intervention, specifically for penicillin allergy de-labeling.

Most studies that build on theories to develop behavioral change interventions employ a step-by-step approach during the design process. For example, French et al. [ 10 ] utilized a 4-step approach to develop a cohesive behavioral intervention, Hrisos et al. [ 11 ] employed a 6-step process to design two theory-based interventions, and Foy and colleagues [ 12 ] described a 10-step iterative process to develop their intervention. We developed our IM process with the following steps: first, specify the target behavior; second, select an appropriate theoretical framework; and third, map the target behaviors onto behavior change techniques and fourth, choose the appropriate methods of delivery of techniques (Fig.  1 ).

Four step process for implementation mapping. This describes the process for mapping qualitative data (identified barriers) to design evidence-based actionable strategies to improve the application of penicillin allergy evaluation in real world settings. TDF: Theoretical Domains Framework; COM-B: Capability, Opportunity, Motivation- Behavior; BCW: Behaviour Change Wheel; ERIC: Expert Recommendations for Implementing Change

Our goal was to design a multi-modal intervention that targets clinicians’ behavior and incorporates de-labeling practices into their clinical workflows. Our process (Fig.  1 ) can be outlined by the four steps below:

Step 1. Specify the clinician-perceived barriers to penicillin de-labeling (intervention targets)

In an earlier stage of our research, we conducted individual and group interviews with 20 clinicians from multidisciplinary inpatient and outpatient healthcare teams within a single site veteran’s hospital. Our goal was to explore workflows and contextual factors influencing identification and evaluation of patients with penicillin allergy. A more detailed description of the qualitative methodology has previously been published [ 10 ]. We coded the data using thematic analysis [ 14 ] to identify the major barriers to a risk-based penicillin de-labeling protocol in inpatient and outpatient settings.

Step 2. Map intervention targets onto TDF theory (domains and constructs) and find the root causes of behavior (COM-B)

We then mapped these intervention targets onto domains and constructs within the Theoretical Domains Framework (TDF) [ 15 ] to organize the major barriers to implementing the de-labeling protocol (Table  1 ). This second step elucidated the hospital context and culture, interdependent nature of workflows, and the individual clinicians’ perceptions and behaviors that hinder their engagement with de-labeling and further identified targets for change. These findings highlighted the need to employ a systemic approach that addresses each of the domains influencing clinician behaviors regarding penicillin allergy de-labeling. Each barrier to target behavior categorized under a TDF domain was then mapped onto the sources of the behavior in the Behaviour Change Wheel (BCW) [ 16 ]. Theory of BCW posits that behaviors are a function of three underlying factors: Capability (C) relates to individuals’ psychological and physical capacity to perform behaviors, including having necessary knowledge and skills. Opportunity (O) is linked to external factors that enable or prompt behaviors such as environmental and cultural context. Motivation (M) is connected to internal processes such as habits, impulses, emotions, and logical reasoning that shape decision-making and behavior. Two types of motivation are described in BCW. Reflective motivation relates to the high cognitive processes, such as beliefs, values and goals and can be addressed by increasing knowledge. On the other hand, automatic motivation involves processes that are linked to emotional responses, habits, impulses and inhibitions which could be addressed through habit formation.

Step 3. Link root causes of behavior (COM-B) with intervention functions (BCW)

Once we assigned a root cause (COM) to each barrier, we looked at the intervention functions associated with each factor (Table  1 ). Behavior change theory defines intervention functions as broad categories of planned activities one can do to change a behavior. Each intervention function could influence one or more of the underlying factors. For example, behaviors relating to capability can be intervened on through education, training, and enablement, while behaviors shaped by opportunity can be intervened on through environmental restructuring, enablement, and restriction. In this paper we’ve only reported intervention functions reflected in our interview data. For the full list and definitions, please see Michie et al. [ 16 ].

Step 4. Specify ERIC implementation strategies aligning with the intervention functions

Next, we returned to the interview data we previously gathered from multidisciplinary inpatient and outpatient healthcare teams. We synthesized the data coded for ‘process improvement.’ This coded data included participants’ suggestions to improve the process of implementing penicillin de-labeling into the workflow. As the next step, we mapped these findings onto relevant intervention functions in the BCW and used interviewees’ suggestions as a starting point to ensure that our intervention responds to the needs of key stakeholders (see Figs.  2 and 3 ).

Participant quotes organized by intervention functions (education, training , persuasion , restriction) . CDST: Clinical Decision Support Tool, EMR: Electronic Medical Record, Pcn: Penicillin, Abx: Antibiotics

Participant quotes organized by intervention functions (environmental restructuring, enablement). CDST: Clinical Decision Support Tool, EMR: Electronic Medical Record, Pcn: Penicillin, Abx: Antibiotics

Separately, we brainstormed interventions related to each intervention function and cross-referenced them with our qualitative findings. At this point, we also referred to ERIC Implementation strategies [ 17 ] consisting of a compilation of 73 implementation strategies verified by the experts in the field of implementation science. This process enabled us to develop intervention ideas informed by stakeholder input, behavioral change theories, and evidence-based implementation strategies (Table  2 ).

Ethical considerations

UW-Madison Institutional Review Board approved the study and granted minimal risk status. Participants were provided with written information about the study, told participation was voluntary, and given the opportunity to ask questions. Identifying information was removed from transcripts to ensure confidentiality. All participants provided written consent for participation.

Our results demonstrated a number of intervention targets that could be addressed by six intervention functions: education, training, persuasion, restriction, environmental restructuring, and enablement. The participant quotes mapped on to each intervention function can be found in Figs.  2 and 3 .

All participants talked about the need to disseminate information and increase knowledge for any clinical team members that would be involved in the evaluation process. This education should include information about the spectrum of allergic reactions and how the risk level of evaluation is not any higher than other routine patient care procedures. For the specifics of how to evaluate patients with penicillin allergy, participants discussed the need for a demonstration about the existence of the clinical decision support tool (CDST) and where it can be accessed. Participants also thought it was important for education to include information about the different roles in the evaluation process and who has been trained on what, so that each person is aware of who else is on board with the de-labeling protocols and what their roles are.

Perspectives varied in terms of the format they thought the education could be conveyed. Ideas included information dissemination via email, periodic presentations at meetings so people can ask questions, and videos for clinicians and trainees to watch on their own time.

Participants noted that education to increase knowledge was not enough and that training on how to evaluate patients was necessary to build essential skills and bolster clinicians’ comfort and confidence. Participants also felt it was best to train permanent staff in the de-labeling process, so that they could then champion and train future residents and fellows on the proper protocols.

Most participants emphasized the importance of training for addressing allergic reactions during penicillin allergy challenges. Several mentioned that clinicians may fear patient reactions and thus be hesitant to initiate evaluation. This training could help reduce hesitancy and provide reassurance so that clinicians feel confident and equipped to address any issues that may arise during evaluation.

Persuasion is achieved by using communication to induce positive or negative feelings or stimulate action. Participants discussed a few communication tactics that might help increase clinician motivation for carrying out evaluations of patients’ penicillin allergies. First, they felt that communicating about the data around benefits of de-labeling might increase positive feelings about evaluation. Information about why de-labeling is important and data on the long-term benefits of de-labeling as opposed to prescribing alternative antibiotics could be included as part of the education strategy discussed above.

Participants also stated how reinforcing that the Allergy specialty service endorses the content of the CDST would give frontline clinicians more confidence in following these algorithms and clinical protocols for managing patients with a penicillin allergy.

Restriction

Restriction aims to increase the target behavior by creating rules that reduce the opportunity to engage in competing behaviors. For our project, we identified two competing behaviors that clinicians could engage in. One of them is overlooking the opportunities to challenge a patient and remove the allergy label from their health records. The second is prescribing an alternative medicine to treat the infection, which is often perceived as more efficient. In order to restrict these behaviors, leadership should communicate clearly that that de-labeling patients is a priority in the clinic. This could come in the form of top-down directive, or could include additional weight such as creating an official initiative for quality improvement or a local antimicrobial stewardship (AMS) policy mandating de-labeling as a metric to be monitored.

Environmental restructuring

Another important intervention function included in BCW, environmental restructuring, proposes reshaping the physical or social context in order to achieve a behavior. This function places more emphasis on the external factors that influence behavior change and less on personal agency, which is addressed by the intervention functions including education, training, and persuasion. Our results demonstrated four main areas that could be targeted by environmental restructuring: clarifying roles and responsibilities, rethinking communication systems, addressing staffing demands, and changing the physical environment.

One key area was refining and clarifying the roles and responsibilities of individuals in teams pertaining to penicillin de-labeling. Many participants discussed having a role of a champion who will ‘own’ the process and act as a point person, including developing workflows for tasks, overseeing each team to ensure the completion of challenges, and correctly updating the patient EHR in the system. Having this centralized owner reduces practice variability and “generally works a lot better than asking each individual team or provider to have that on their radar” (PCP 4). The second role recommended by clinicians was a coordinator who will initiate the process by identifying patients who can be evaluated. This person could identify priority patients, such as patients who need penicillin before a surgery or have a higher risk for readmission (e.g. recurrent infections).

Participants also pointed out that restructuring communication systems would enable clearer distribution of responsibilities during the de-labeling process and improve relational connections among interdisciplinary team members. Although increased use of messaging platforms during the pandemic enabled teams to maintain workflows, reliance on virtual and often asynchronous communications also created silos, delays, and misunderstandings about level of importance of particular tasks. Resuming multi-disciplinary rounds and increasing opportunities for in-person huddles were proposed as strategies to address these communication gaps and offer forums for discussing questions about allergy challenge protocols to improve uptake of de-labeling. Rather than discontinuing virtual communications, clinicians suggested protocols to ensure recipients would follow through on recommendations when in-person communication is not possible. Participants also suggested including notes in the EHR system along with a consult order for the next team to facilitate a smoother transition from inpatient to outpatient care or primary care to specialty care. Having alerts to check on patients with a penicillin allergy listed in their EHR but recently prescribed an antibiotic was also proposed.

Hiring additional staff and distributing staff differently was suggested to counteract the competing priorities and lack of bandwidth that were a constant struggle for clinicians in both inpatient and outpatient settings. Staffing shortages exacerbated during the pandemic added to this challenge. Multiple clinicians discussed how help with administrative tasks would enable them to dedicate more time to patient-facing responsibilities. While practices vary among hospitals, some proposed hiring administrative staff to round with teams and handle paperwork to remedy time constraints. Pharmacists also noted that having additional staff to cover weekend shifts would help reach patients who were admitted over the weekend. This would also enable identifying patients with penicillin allergy within 12–24 h after admission, which would help avoid possible delays with hospital discharge due to de-labeling processes. As their bandwidth expands, providers would also have more time to build trust and educate patients who were less willing to agree to getting tested.

Finally, participants suggested that restructuring the physical space so that observation rooms were on the same floor as the clinical team would facilitate nurses and pharmacists to administer the drug challenges. Patients would continue to be monitored by nursing during the process, similar to blood transfusion administration, a protocol which is well established within most hospital systems. This restructuring would allow physicians to continue their normal workflow but allow them to be more easily accessible to nursing if a reaction to the drug challenge occurred.

For our study, we defined enablement as forms of assistance that help clinicians incorporate de-labeling into their everyday workflows. Participants brought up a number of ideas that would enable and enhance uptake of de-labeling. Streamlining and simplifying the EHR system to facilitate easy incorporation of tasks into workflows was proposed as a critical modification, including standardizing de-labeling order sets across the inpatient and outpatient settings and adding reminders. Outpatient pharmacists indicated willingness to take on more de-labeling tasks if they were provided with scripts and/or a one-page information sheet that they could refer to when talking to patients.

The high degree of mislabeling of penicillin allergy coupled with the prevalence of patients with reported penicillin allergy has created a need to de-label a large number of patients. Past literature have described clinical decision rules and protocols for conducting direct oral challenges in low risk penicillin allergy [ 18 , 19 , 20 , 21 , 22 ]. In addition, there is increasing awareness of the need to further study how to best apply validated protocols with a lens on sustainability and scalability [ 23 , 24 , 25 , 26 , 27 ]. Using an implementation science approach can enhance processes to best design and scale interventions to expand access to penicillin allergy evaluation through guideline-based protocols.

Our prior study demonstrated that better role clarification, opportunities to develop necessary skills, and dedicated resources are needed to overcome barriers to implementing de-labeling interventions. Our current study describes a process to strategically leverage these findings to develop evidence-based interventions to overcome these barriers. The steps we follow to this end are twofold: (1) we apply the process of IM to a clinical gap in allergy care (2) we identify theory-driven, actionable strategies to improve penicillin allergy evaluation processes. IM has been shown to be effective in changing chronic disease management and screening in other conditions [ 28 ]. We will utilize this process to develop a multi-level multi-modal intervention (Fig.  4 ). Using this approach will translate Allergy and Immunology evidence-based practices into clinical applications and close the clinical gaps of care in drug allergy and other allergic diseases.

Components of a multi-level multi-modal intervention to increase penicillin allergy de-labeling. AMS: Anti-microbial stewardship; PCN: Penicillin; FTE: Full-time equivalent

Current penicillin allergy evaluation recommendations have advocated for point of service de-labeling of patients, particularly if they are low risk, as it allows efficient tailoring of antimicrobial prescribing [ 29 ]. Point of service de-labeling empowers teams to address mislabeled allergies at the patient encounter rather than referring them to outpatient care. Providing clinicians with necessary training and resources such as toolkits and guidelines that they could refer to if needed is an important first step in improving implementation and will need to be followed by models and processes that address modifying environments and human behavior to improve application of currently available toolkits [ 30 ]. Our study discussed a process method of IM to determine actionable steps to apply and study best practices on how to apply and tailor these tools for local needs. These tools, along with a comprehensive understanding of the system-levels barriers that influence point of demand decision making, will facilitate reach and scalability of penicillin allergy de-labeling interventions. We specifically describe the need to address intervention functions in the areas of environmental restructuring and enablement.

Our results have shown that to implement point of service penicillin allergy de-labeling practices, a multilayered approach is needed that incorporates education to address knowledge barriers, training to develop skills to identify low-risk patients and treat possible allergic reactions, and clarification on how roles are distributed. Additionally, developing a system of champions, improving communication systems, and restructuring the environment around the healthcare team are demonstrated as critical components of an effective behavior change intervention. Our results demonstrate similarities with previous literature. Fahim et al. [ 31 ] utilized a similar process to select interventions to improve the multidisciplinary cancer conferences decision making processes. Similarly, Gallant et al. [ 32 ] presented that a multi-levelled intervention was needed to overcome barriers to vaccine uptake.

Our study is unique in that it describes a scientific process of IM to demonstrate how a multi-method study approach can establish a process and a package of implementation strategies to drive behavior and system change. By targeting the psychological underpinnings of current behavioral and environmental barriers to penicillin de-labeling, we developed a transparent process that demonstrates which intervention components are more likely to yield uptake and sustainment. Limitations of our study involve single site data collection and the impact of pandemic-level staffing and pressures for our inpatient clinicians. We also will need to study the applications of our designed interventions in a repetitive process improvement approach to describe efficacy, scalability and sustainability of our implementation package. Future work can be directed on a mixed methods approach focused on efficacy and implementation outcomes of our proposed implementation strategies. Additionally, prior literature in antimicrobial stewardship have indicated that establishing a metric, linked to strategic institutional outcomes and prescribing practices may bolster antimicrobial stewardship institutional initiatives [ 33 , 34 , 35 ]. Similarly, the development of data reporting tools or dashboards related to numbers of patients de-labeled from penicillin allergy and its relevance to antibiotic prescribing practices may be important future areas of research.

Conclusion and future directions

Given the direct impact penicillin allergy has on antimicrobial stewardship and patient safety, there is a need to support multilevel and multidisciplinary approaches to safely assess penicillin allergies. Key to the success of these interventions is a careful study of process and contextual factors influencing penicillin allergy evaluation and de-labeling. Successful programs and penicillin allergy toolkits have been launched to increase knowledge dissemination and provide procedural tools to promote penicillin allergy evaluation. However, the results of our study show that a comprehensive study of barriers and contextual factors can identify system-level issues that may impede the reach and sustainable use of current state interventions. The IM approach provides a framework to further develop implementation packages to study how to best apply evidence-based penicillin allergy interventions to allow scalability, sustainability and improve efficacy of our interventions.

Data availability

The datasets analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Antimicrobial Stewardship

Behavior Change Wheel

Clinical Decision Support Tool

Continuing Medical Education

Capability, Opportunity, and Motivation- Behavior

Electronic Health Record

Expert Recommendations for Implementing Change

Face to Face

Full time Equivalent

Implementation Mapping

not applicable

Primary Care Provider

Theoretical Domains Framework

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Acknowledgements

We would like to thank Dr. Eric Yanke for the support in developing the Clinical Decision Support Tool. We are also grateful to Dr. Nasia Safdar for her feedback on the design of this study.

This project is funded by the VHA Health Services Research and Development Pilot Funding. The study sponsor was not involved in the design of the study; collection of data; management, analysis, or interpretation of data; writing of the manuscript; or the decision to publish.

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EA, MS, SK, PB, TL conceptualized the paper. EA, MS. developed the methodology. EA, MS, SK. analyzed the data. EA, MS, SJ drafted, and edited the manuscript. All authors.

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Alagoz, E., Saucke, M., Balasubramanian, P. et al. Leveraging implementation science theories to develop and expand the use of a penicillin allergy de-labeling intervention. BMC Health Serv Res 24 , 987 (2024). https://doi.org/10.1186/s12913-024-11364-7

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