Qualitatively-Driven Mixed-Methods Health Research Protocol: “HIV/STBBIs in a Post-Pandemic World: Challenges and Opportunities for Addressing the Needs of People Living With HIV”

Abstract

This qualitatively-driven, mixed-methods study explores the impacts of the COVID-19 pandemic on people living with human immunodeficiency virus (HIV) testing, treatment, and linkage to care in Manitoba, Canada. Building on the “Landscape of Risk” study, a population-level quantitative analysis examining associations between COVID-19 vaccination and HIV/sexually transmitted and blood borne infection (STBBI) testing, this protocol describes the qualitative phase designed to contextualize those findings. Preliminary data suggests that people living with HIV (PLWHIV) were more likely to receive COVID-19 vaccinations than the general population while also being more likely to acquire the virus. This contrasts with lower vaccination rates among other STBBI-affected cohorts, raising critical questions about health system engagement, trust, and access. Through interviews and focus groups with both PLWHIV and health care service providers, this study aims to validate quantitative results, explore pandemic-era shifts in HIV/STBBI service use, and generate recommendations for improving health equity in future pandemic responses. Guided by constructivist, critical, and poststructuralist paradigms, and informed by ethical, community-based research principles, the study uses a sequential exploratory design to integrate community narratives with administrative health data. Data will be collected in partnership with Nine Circles Community Health Centre and analyzed using thematic analysis. This study’s commitment to rigor, reflexivity, and participant voice ensures relevance to public health policy, while offering insights into resilience, service adaptations, and equity-oriented strategies for vulnerable populations navigating intersecting health risks in a post-pandemic world.

Background

This qualitatively-driven, mixed methods study aims to contextualize quantitative findings from a study titled: “The Landscape of Risk: Examining the correlates of inequitable COVID-19 infection and vaccination rates in Manitoba using population-based laboratory and administrative healthcare data,” (the Landscape of Risk Study) related to Human Immunodeficiency virus and other sexually transmitted bloodborne infection (HIV/STBBI) testing, treatment and linkage to care. Initial data analysis through the Landscape of Risk Study, which used a retrospective cohort design to analyse administrative health data, reveals associations between HIV testing and COVID-19 vaccination which require further elaboration. For example, preliminary analysis suggests people living with HIV (PLWHIV) were no worse off than the general population, when it came to receiving the complete series (2+ doses) of COVID-19 vaccinations during the first two years of availability of the vaccine (Shaw et al., 2025). In fact, PLWHIV were slightly more likely to have been vaccinated, which is beneficial because they were also more likely to acquire COVID-19. This is of particular importance as people in cohorts positive for other STBBIs, such as those with a syphilis and/or a chlamydia/gonorrhea diagnosis during the same period, were shown to have lower vaccination rates by between 10% and 20%.

This potentially represents a “good news” story for public health efforts to address COVID-19 in vulnerable populations (i.e., PLHIV), however more information is needed to determine if those associations are reflective of real-life experiences and why. Moreover, given the time passed since major public health responses to COVID-19 were enacted, there is an opportunity to explore what aspects of HIV/STBBI testing, treatment and linkage to care have changed for better or worse, and what challenges and opportunities exist from the perspectives of PLWHIV as we remain vigilant to new pandemic threats.

Rationale for the Landscape of Risk Study

The speed and scale at which SARS-CoV-2, the virus that causes COVID-19 disease, revealed inequities in society during the first two years of the Pandemic (2020–2022) was unprecedented (Bilal et al., 2021; Blagev et al., 2021; Jemberie et al., 2020; Manitoba, 2021; Mody et al., 2021; Pareek et al., 2020; Sze et al., 2020; Webb Hooper et al., 2020); gradients in the distribution of, and adverse outcomes from COVID-19 fell along socio-economic and structurally-disadvantaged lines (Adhikari et al., 2020; Chin et al., 2020; Hawkins, 2020; Webb Hooper et al., 2020). Manitoba served as a case example with one of the highest cumulative mortality rates in Canada (Government of Canada, 2021), highlighting the complex structural drivers related to morbidity and mortality due to COVID-19. Race-based disparities in Manitoba were substantial, with incidence and hospitalizations over 35 and 4 times as high, respectively, amongst those from Black, Indigenous and People of Colour (BIPOC) communities compared to Caucasians (Manitoba, 2021).

The risk environment and comorbidities associated with certain populations were contemporaneous risk factors for COVID-19 (Jemberie et al., 2020; Ogunbodede et al., 2021; Tao et al., 2021; Wang et al., 2021); with the impact of these factors amplified by disruptions to healthcare due to pandemic control efforts (Landes et al., 2021; Richards et al., 2020; Turk et al., 2020). For example, those with a diagnosed substance use disorder faced over 8 times the odds of acquiring COVID-19, with this population more likely to have existing comorbidities, including chronic kidney disease and diabetes (Wang et al., 2021). This was especially notable in light of recommendations for immunocompromised populations, and those with multiple co-morbidities, to receive additional doses of the COVID-19 vaccine following the first two (NACI, 2021). Control efforts disrupted healthcare access to some of society’s most vulnerable, including people with intellectual disabilities (Landes et al., 2021; Turk et al., 2020), living with cancer (Richards et al., 2020), and at risk of sexually transmitted and bloodborne infections, including HIV (Ogunbodede et al., 2021; Tao et al., 2021). The complexity in understanding risk to COVID-19, and the complications in mounting appropriate responses was illustrated in one finding where those with intellectual disabilities were less likely to be exposed to COVID-19, but case fatality was threefold higher amongst those who were exposed (Landes et al., 2021).

The more transmissible Delta lineage, differing re-opening policies across the country, and the return of unvaccinated children <12 years to school all contributed to substantial uncertainty regarding the amplitude and intensity of future waves in Canada (Public Health Agency of Canada, 2021). Vaccines paved the way for societies to re-open (Kontopantelis et al., 2015); however, disparities inherent to COVID-19 rendered vaccines necessary, but insufficient to ensure that public health “left no one behind,” (Webb Hooper et al., 2020). This was especially true as the structural factors that made COVID-19 a disease of inequity also impacted preventive healthcare use, such as vaccination and testing (Agarwal et al., 2021; Mody et al., 2021; Webb Hooper et al., 2020). Areas with the highest COVID-19 hospitalizations have been shown to have the lowest per-capita tests, with the lowest testing-to-hospitalization ratios associated with poverty and precarious employment (Mody et al., 2021).

Differential vaccine and testing rates made future waves of the pandemic potentially the most heterogeneous. Although disparities were consistently noted, the specific population groups, and the extent of differences between groups may have differed locally. Thus, timely “hyper-local” epidemiological situational awareness was needed to inform public health strategies to contain the virus (Greene et al., 2021; Hegde et al., 2020). Methods that can quickly reveal disparities in disease incidence, vaccine coverage, and breakthrough infections in specific groups can inform the timely mobilization of public health resources to prevent, detect, treat, and manage new outbreaks. At the same time, understanding determinants of infection and vaccine uptake in marginalized groups from previous waves can provide useful clues for prevention and prioritization. Combining these two perspectives serves as a powerful foundation to make evidence-informed policy decisions, as the patterns of this phase of the pandemic began - and continue to - become clear.

Finally, Manitoba is home to unique and routinely collected whole-of-population health and social databases that can be linked together to form longitudinal records of Manitobans (Roos et al., 2005). Importantly, cohorts of specific under-researched populations can be quickly assembled, their healthcare utilization examined (Bernstein et al., 2006; Bolton et al., 2020; Lix et al., 2008; Nickel et al., 2020; Shaw et al., 2016, 2017, 2019), and individual and area-level (“ecological”) factors associated with utilization can be assessed (Adhikari et al., 2020; Chin et al., 2020; Hawkins, 2020). Thus, Manitoba is well-situated for a data-driven approach to understand the epidemiology of COVID-19 and vaccine uptake in under-researched populations as Canada prepares for future waves of the virus.

Rationale for Current Study & Research Objectives

As noted above, preliminary findings from the Landscape of Risk study warrant deeper investigation due to the need to both validate the findings and elucidate insights related to learning from the first two years of COVID-19 to prepare for future pandemics. With preliminary quantitative findings in hand, this protocol speaks specifically to a subsequent qualitative phase of direct data collection that will thus pursue the following research objectives:

1. To validate and contextualize findings from the Landscape of Risk study by engaging community members living with or affected by HIV/STBBIs to ensure the results are relevant, accurate, and reflective of their experiences.

2. To interpret the results collaboratively with service providers who work in HIV/STBBI care to deepen our understanding of the association from their perspectives.

3. To identify how service use and provision has changed since the last COVID-19 wave in order to capture and catalyze any learnings or experiences that can generate actionable insights for public health policies and programs.

4. To develop recommendations for improving service delivery and addressing identified to equitable testing for COVID-19 (and other potential pandemic pathogen) and HIV based on the study’s findings and community input.

Methodology

The study adopts a qualitatively-driven mixed-methods research methodology, specifically employing a sequential exploratory design, which integrates both quantitative (Quan) and qualitative (Qual) approaches (Johnson et al., 2007). This methodology is chosen to leverage the strengths of both quantitative and qualitative research, providing a more comprehensive understanding of the research problem. In the initial phase, quantitative data is collected and analyzed to identify patterns, trends, and relationships among variables. This phase has already been completed. The second phase uses qualitative methods to explore these findings in greater depth. This second phase will involve interviews allowing for a deeper exploration of the context, meanings, and perspectives behind the initial quantitative results. The qualitative phase aims to provide insights into the ‘why’ and ‘how’ behind the trends and relationships identified in the quantitative phase.

The sequential exploratory design of this mixed methods study is particularly beneficial when investigating new or complex phenomena where quantitative data alone might be insufficient to capture the nuances of the topic (see for example Jonsson et al., 2025). By first quantifying the problem and then exploring it qualitatively, the study aims to achieve a more rounded and comprehensive understanding. This approach not only enhances the validity of the findings by cross-verifying them across methods, but also enriches the insights gained, as the qualitative data can provide context and depth to the quantitative results. Ultimately, this mixed methods approach seeks to capitalize on the strengths of both quantitative and qualitative research while mitigating their individual limitations.

Theoretical Framework

This study is qualitatively driven in its design within a mixed methods framework, and as such is guided by constructivist, critical and poststructuralist theoretical influences (Brown & Strega, 2005). Each of these rely on ontological assumptions that see reality as subjective and multiple, and influenced by power regimes, while holding epistemological assumptions that knowledge is generated through resistance and is located in situations and contexts specific to the subject of research (Brown & Strega, 2005). The following excerpt further articulates how this influences mixed methods research:

Qualitative dominant [or qualitatively driven] mixed methods research is the type of mixed research in which one relies on a qualitative, constructivist-poststructuralist-critical view of the research process, while concurrently recognizing that the addition of quantitative data and approaches are likely to benefit most research projects. Quantitative dominant [or quantitatively driven] mixed methods research is the type of mixed research in which one relies on a quantitative, postpositivist view of the research process, while concurrently recognizing that the addition of qualitative data and approaches are likely to benefit most research projects. (Johnson et al., 2007, p. 124)

The choice to ground the study in this such a paradigm emerges from the reality that eligible participants are part of a community that faces a range of additional barriers to accessing health and social care services in society, including based specifically on their HIV-positive status. While the quantitative aspect paints a demographic and statistical picture of the sample, it is ‘situated knowledge’ generated through qualitative research and analysis that will achieve community-driven and informed results for the development of programs and policies. Moreover, the use of qualitative methods invites opportunities to advance critical theoretical perspectives related to both the topic at hand and the role that quantitative research plays in shaping qualitative methods. Situating this phase in a critical paradigm encourages reflexivity on the part of the researchers that aides in accounting for power dynamics, imbalances, and other influences throughout the research process (Dodgson, 2019).

Study Setting

Nine Circles Community Health Centre (NC), a key site for HIV prevention in Manitoba, operates as a community health centre and community-based harm reduction distribution site, and is the community site of the MB HIV program. As such, NC is an ideal site to engage in data collection as it can provide access to both service providers engaged in HIV/STBBI testing, treatment and linkage to care, while also providing access to clients who use their services. As such, all data will be collected through access to NC, either in person or virtually by zoom.

Sampling and Recruitment

This study will recruit both Service Providers who work in HIV/STBBI testing, treatment and linkage to care, as we all as clients who use their services, including those enrolled in the Manitoba HIV Program, and thus are living with HIV. All participants must have been engaged in providing or receiving care between April 1, 2020 and March 31, 2022.

Participant Inclusion Criteria

Inclusion Criteria for Clients:

• Must be 18 years old or older

• Must currently reside or work in Manitoba.

• Is currently – or was between March 1, 2020 and March 31, 2022 - a person living with HIV

• Received at least one dose of a COVID-19 vaccine between March 1, 2020 and March 31

Inclusion Criteria for Service Providers:

• Must be a health care provider that currently provides or has provided sexual health services during COVID-19 between March 1, 2020 and March 31, 2022

Sampling and Sample Size

Purposive sampling will be used to target clients and community members via specific means to ensure that a specific perspective is included in the study. This study aims to recruit a minimum of 15 service providers and 25 clients.

Recruitment

Participants will be recruited from within Nine Circles and other MB HIV Program Sites, including at the Health Sciences Centre, where many HIV-positive clients from rural and Northern communities travel for routine care. A poster will be used to invite both participant groups to enroll in the study.

Data Collection Procedures

Qualitative interviews and focus groups will be used for both clients and service providers – each participant will be given the choice of participating in one or both. A semi-structured interview/focus group guide for each group will be used to facilitate discussions with participants. Focus groups and interviews will be audio and video recorded for transcription purposes. Participants will be offered a copy of their transcript and given the opportunity to add, change, or delete anything they choose to. All data will be collected by one or two members of the research team and analyzed by the same for consistency and continuity.

Study Compensation

All participants will be offered a $50.00 cash honorarium for their time, except in cases where service providers are representing their organization and are presumably being compensated to participate by their employer.

Data Handling and Analysis Procedures

All data will be analyzed using VERBI Software (2024), which is qualitative data analysis software program that can process both quantitative and qualitative data. “Thematic Analysis” (Braun & Clarke, 2021) will be used to facilitate open and axial coding, which will enable us to respond to the research question and achieve the objectives noted above. MAXQDAs “AIAssist” may also be used to process qualitative data within the software, pending ethics approval. According to the manufacturer, AIAssist is a new AI add-on - powered by OpenAI. AI Assist offers the possibility to have text passages summarized automatically. Data chosen by the user is sent to Open AI for processing, which is hosed on AWS [Amazon Web Services] servers in the United States. As noted above, data is anonymized prior to being sent. Data sent is processed and returned to the user, after which point it is immediately deleted (or held for a maximum of 30 days should further processing be required by the user). MAXQDA states: “Your data will be sent anonymously to OpenAI and will not be used for AI training,” (MAXQDA, 2025), which means that there is no risk of research data being comingled into the training of the AI model. It processes the information, returns the results, and then deletes that data either immediately or within 30 days. We will clearly articulate this in all consent forms and will review this with participants who complete qualitative interviews.

We appreciate the controversy surrounding AI and the relative novelty of the technology for lay users, particularly for underserved, marginalized communities. As such, we have confirmed there are no risks for breaches in confidentiality, and using this software will enable us to process large amounts of data faster and at a reduced cost. We are also aware of new developments in the use of Large Language Models (LLMs), such as ChatGPT, to analyze qualitative data, including recent findings that while they perform well at leading to the same thematic results as humans, ChatGPT was less successful at locating “subtle, interpretive themes, and more successful at reproducing concrete, descriptive themes,” (Morgan, 2023, p. 1). With this in mind, we will follow recently published guidance from Goyanes et al. (2025) if and when implementing this feature.

Ethics

Data Access and Storage

This study is confidential, and all participant data and will be anonymized prior to analysis. Data collected will be kept strictly confidential, on secured servers, password-protected computers and/or locked in filing cabinets in secure offices at the University of Manitoba for 7 years following study completion. Anonymized data will then be digitally archived for future analysis. These data will be accessible only to members of the research team. Quantitative survey data will be downloaded upon completion of data collection and deleted from the server. That file will be stored according to the protocols mentioned above. The University of Manitoba Health Research Ethics Board may review records related to the study for quality assurance purposes. A list of study personnel will be stored on password protected computers.

Participant tracking sheets will be developed, including a “Master Linking Log” which will include their name and a unique Participant Identification Number (PID) that is assigned based on their enrollment in the study (for example, PID 001, PID 002, etc.) and a “Participant Demographic Sheet” that will include the PID number and associated demographic information (See Appendix for Log Templates). Only their PID number will enable both sheets to be linked. All sheets will be stored in secure folders on secure servers, and each sheet will be password protected with different passwords. Participant confidentiality is strictly held in trust by the participating investigators, their staff, and the sponsor(s) and their agents. The study protocol, documentation, data, and all other information generated will be held in strict confidence. No information concerning the study, or the data will be released to any unauthorized third party.

Ethical Standard

This study is guided by the TCPS CORE 2.0 research principles (Government of Canada, 2023) and the research integrity standards of the University of Manitoba (University of Manitoba, 2025). All participants will be required to read, understand and acknowledge their understanding by indicating consent on a dual INTERVIEW/FOCUS GROUP informed consent form in English, which will be approved by the Human Research Ethics Board (HREB) at Bannatyne Campus and the University of Manitoba.

Research Ethics Board

The protocol, informed consent form, recruitment materials, and all participant materials will be submitted to the HREB at Bannatyne Campus for review and approval. Any amendment to the protocol will require review and approval by the HREB before the changes are implemented to the study.

Informed Consent Procedures and Documentation

Informed consent is a process that is initiated prior to an individual agreeing to participate in the study and continues throughout the individual’s study participation. Extensive discussion of risks and possible benefits of participation will be provided to the participants prior to their invitation to sign the Informed Consent Form (ICF). Consent forms will be HREB approved, and the potential participant will be asked to read and review the document. The person conducting the interview will explain the research study to the potential participant and answer any questions that may arise.

All potential participants will have the opportunity to receive a verbal explanation in terms suited to their comprehension of the purposes, procedures, and potential risks of the study and of their rights as research participants. Interview participants will have the opportunity to carefully review the written consent form and ask questions prior to signing. The potential participant will sign the informed consent document prior to any procedures being done specifically for the study. 60 min will be scheduled to complete the informed consent process for interviews, and if more time is needed, more time will be allowed. The participants may withdraw consent at any time throughout the course of the study.

A copy of the signed informed consent document will be provided to participants for their records, and a copy of the signed/acknowledged informed consent documents will be stored on the secure servers of the University of Manitoba. Paper copies from interviews will be saved in the office of the Principal Investigator at the University of Manitoba in a locked cabinet located in a locked office for a minimum of 7 years. The consent process, including the name of the individual obtaining consent, will be thoroughly documented in the Master Linking Log and kept separate from the data collected.

Study Records Retention

All Study documents and records will be stored for 7 years in the office of the Landscape of Risk Study Principal Investigator.

Potential Benefits of Research Participation

Participants may appreciate or experience positive reactions, feelings, and motivations as a result from sharing their story and/or contributing to the development of evidence intended to help their community.

Potential Risks of Research Participation and Their Mitigation

There are no physical risks to participating in this study, however participants may experience emotional or psychological stress from sharing or discussing their experiences, particular as they relate to potential challenging life experiences such as living HIV during the COVID-19 pandemic. This study is designed to mitigate these risks in the following ways: First, participants will be involved in informed consent procedures that include a detailed description of the limitations of the study to fully protect their identity. Every effort will be made to conceal their identities through anonymizing practices. These include using masking of direct and indirect identifiers through pseudonyms or codes being used in the transcripts as well as anonymizing all other information that may link the participant to their data. Second, the consent form will also outline the cases in which confidentiality must be broken. These include instances where there are threats of harm to the self, to others, or information arises that indicates a threat of harm to a child or a vulnerable person under the care of legitimate or illegitimate authority figure (for example, a child under the care of their own parent, or of a daycare attendant who is not their parent but is still responsible for their care).

Third, participants of the interviews will receive copies of their recorded responses if they wish and will be provided the opportunity to alter, redact or amend their data up until a time where data is aggregated in the analysis phase. This form of member-checking ensures that their wishes are met while also ensuring accuracy and clarity. They will also be able to withdraw from the study at any point, including during the interviews. Fourth, interview participants will be offered the choice of meeting at Nine Circles Community Health Centre for their interview, or to complete their interview by phone or Zoom. A thorough description of the environment at Nine Circles will be provided prior to choosing to provide as much choice and autonomy in the process. Fifth, some questions may be uncomfortable for participants to answer given the nature of the study being focused on health. This will be discussed in advance and participants will be reminded that they are not required to answer all questions to participate in the study.

Sixth, participants will be offered a resource list of local health agencies and programs in case they are feeling the need to access support. These include mental health crisis lines and local, free, accessible drop-in counselling services. Similarly, should the participant indicate an interest in the interview to receive other resources related to sexual health, for example, these will be provided after the interview is complete. Finally, participants will be invited to opt-in to receive copies of any published materials that result from the study.

Protocol Compliance

In pursuit of an ethically grounded study that reaches success, it is noted that accidental protocol deviations can happen at any time. They must be adequately documented on the relevant forms and reported to the Principal Investigator and Sponsor immediately. Deviations from the protocol which are found to frequently recur are not acceptable, will require immediate action and could potentially be classified as a serious breach.

Study Monitoring & Early Termination

The study will be monitored by both Co-Principal Investigators (Star and Shaw), who will meet biweekly or more to review any challenges or risks that may arise. The study may be terminated early in the event there is harm to a participant or a member of the research team, as well as in cases where ethical breaches to data occur. Any such incidents will be reported to the Bannatyne REB as soon as possible prior to the study continuing.

Rigor

As this is study is qualitatively driven and follows a completed phase of quantitative data collection and analysis, the work ahead will draw from Tracy’s eight criteria for quality in qualitative research (2010). According to Tracy, qualitative research can be evaluated against “eight key markers of quality in qualitative research including (a) worthy topic, (b) rich rigor, (c) sincerity, (d) credibility, (e) resonance, (f) significant contribution, (g) ethics, and (h) meaningful coherence,” (2010, p. 837). At this protocol stage, we are signaling our intent to achieve these markers of quality in the following ways. As noted above, we believe this to be a worthy topic due to the timely nature of gaining deeper perspectives on the effects of public health policy and programming related to pandemic response during a period of relative pandemic stability. We also infer from the quantitative findings that there are opportunities to clarify, specify and develop public health policies and programs that may benefit other marginalized groups, but also society as a whole.

We also commit to applying qualitative methods rooted in richness, sincerity and credibility. The analysis process will be logged and detailed to provide methodological insights, the time spent collecting data, including space within interviews and focus groups to share, will be determined by participants and the flow of recruitment, and we – as a research team – will demonstrate critical thinking and reflexivity through regular and ongoing discussion about study progress. We are particularly curious as to the influence of quantitative data on the study, and the interview process. Our plan is to show the findings to community members and ask them to respond. We anticipate a wide range of reactions, and as we are open to receiving them, we will be both attuned to our own bias and influence as well as truly understanding the perspectives of participants.

As it relates to the presentation of findings, we are also committed to “keeping stories intact” so as not to diffract or diffuse the data into convenient themes. This requires deepening the analysis so that our presentation moves beyond the quantitative results both to honor and respect the research process, but also to avoid the shallowness that can occur in health research thematic analysis (Braun & Clarke, 2023). We note that qualitative research can at times appear to be superficial (Haynes & Loblay, 2024); it is not our intention to graze the surface. Rather, our goal is to share findings that resonate with a broad array of audiences, first of which being those who participate in sharing their experiences. We also intend to publish results in both quantitative and qualitative journals, and present both sets of findings together within the context of qualitatively-drive mixed methods research to make a significant contribution to the field of qualitative health research. As it relates to ethics, there are many factors within research of this kind to consider which have been laid out above. Both PIs (Star and Shaw) are well versed in the area of HIV research and have extensive experience working with communities from equity-deserving groups. All practices and procedures will follow necessary protocols according to the HREB at the University of Manitoba, and were necessary, we will seek additional support should the need arise. Finally, we are committed to meaningful coherence in the presentation of results through linking the findings to literature, stating clearly the outcomes of pursuing our objectives, and situating this knowledge in the appropriate field. We are confident that these efforts will support the goals of this study, but also the uptake of results and overall impact for those living with HIV in Manitoba.

Supplemental Material

Supplemental Material - Qualitatively-Driven Mixed-Methods Health Research Protocol: “HIV/STBBIs in a Post-Pandemic World: Challenges and Opportunities for Addressing the Needs of People Living With HIV”

Supplemental Material for Qualitatively-Driven Mixed-Methods Health Research Protocol: “HIV/STBBIs in a Post-Pandemic World: Challenges and Opportunities for Addressing the Needs of People Living With HIV” by Jared Star, Elizabeth Hamilton, Michael Payne, Jami Neufeld, Kim Bailey, Kim Templeton, Misbah Hassan and Souradet Shaw in International Journal of Qualitative Methods.