qualitative research content analysis pdf

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• Afr J Emerg Med
• v.7(3); 2017 Sep

A hands-on guide to doing content analysis

Christen erlingsson.

a Department of Health and Caring Sciences, Linnaeus University, Kalmar 391 82, Sweden

Petra Brysiewicz

b School of Nursing & Public Health, University of KwaZulu-Natal, Durban 4041, South Africa

Associated Data

There is a growing recognition for the important role played by qualitative research and its usefulness in many fields, including the emergency care context in Africa. Novice qualitative researchers are often daunted by the prospect of qualitative data analysis and thus may experience much difficulty in the data analysis process. Our objective with this manuscript is to provide a practical hands-on example of qualitative content analysis to aid novice qualitative researchers in their task.

African relevance

• • Qualitative research is useful to deepen the understanding of the human experience.
• • Novice qualitative researchers may benefit from this hands-on guide to content analysis.
• • Practical tips and data analysis templates are provided to assist in the analysis process.

Introduction

There is a growing recognition for the important role played by qualitative research and its usefulness in many fields, including emergency care research. An increasing number of health researchers are currently opting to use various qualitative research approaches in exploring and describing complex phenomena, providing textual accounts of individuals’ “life worlds”, and giving voice to vulnerable populations our patients so often represent. Many articles and books are available that describe qualitative research methods and provide overviews of content analysis procedures [1] , [2] , [3] , [4] , [5] , [6] , [7] , [8] , [9] , [10] . Some articles include step-by-step directions intended to clarify content analysis methodology. What we have found in our teaching experience is that these directions are indeed very useful. However, qualitative researchers, especially novice researchers, often struggle to understand what is happening on and between steps, i.e., how the steps are taken.

As research supervisors of postgraduate health professionals, we often meet students who present brilliant ideas for qualitative studies that have potential to fill current gaps in the literature. Typically, the suggested studies aim to explore human experience. Research questions exploring human experience are expediently studied through analysing textual data e.g., collected in individual interviews, focus groups, documents, or documented participant observation. When reflecting on the proposed study aim together with the student, we often suggest content analysis methodology as the best fit for the study and the student, especially the novice researcher. The interview data are collected and the content analysis adventure begins. Students soon realise that data based on human experiences are complex, multifaceted and often carry meaning on multiple levels.

For many novice researchers, analysing qualitative data is found to be unexpectedly challenging and time-consuming. As they soon discover, there is no step-wise analysis process that can be applied to the data like a pattern cutter at a textile factory. They may become extremely annoyed and frustrated during the hands-on enterprise of qualitative content analysis.

The novice researcher may lament, “I’ve read all the methodology but don’t really know how to start and exactly what to do with my data!” They grapple with qualitative research terms and concepts, for example; differences between meaning units, codes, categories and themes, and regarding increasing levels of abstraction from raw data to categories or themes. The content analysis adventure may now seem to be a chaotic undertaking. But, life is messy, complex and utterly fascinating. Experiencing chaos during analysis is normal. Good advice for the qualitative researcher is to be open to the complexity in the data and utilise one’s flow of creativity.

Inspired primarily by descriptions of “conventional content analysis” in Hsieh and Shannon [3] , “inductive content analysis” in Elo and Kyngäs [5] and “qualitative content analysis of an interview text” in Graneheim and Lundman [1] , we have written this paper to help the novice qualitative researcher navigate the uncertainty in-between the steps of qualitative content analysis. We will provide advice and practical tips, as well as data analysis templates, to attempt to ease frustration and hopefully, inspire readers to discover how this exciting methodology contributes to developing a deeper understanding of human experience and our professional contexts.

Overview of qualitative content analysis

Synopsis of content analysis.

A common starting point for qualitative content analysis is often transcribed interview texts. The objective in qualitative content analysis is to systematically transform a large amount of text into a highly organised and concise summary of key results. Analysis of the raw data from verbatim transcribed interviews to form categories or themes is a process of further abstraction of data at each step of the analysis; from the manifest and literal content to latent meanings ( Fig. 1 and Table 1 ).

Example of analysis leading to higher levels of abstraction; from manifest to latent content.

Glossary of terms as used in this hands-on guide to doing content analysis. *

The initial step is to read and re-read the interviews to get a sense of the whole, i.e., to gain a general understanding of what your participants are talking about. At this point you may already start to get ideas of what the main points or ideas are that your participants are expressing. Then one needs to start dividing up the text into smaller parts, namely, into meaning units. One then condenses these meaning units further. While doing this, you need to ensure that the core meaning is still retained. The next step is to label condensed meaning units by formulating codes and then grouping these codes into categories. Depending on the study’s aim and quality of the collected data, one may choose categories as the highest level of abstraction for reporting results or you can go further and create themes [1] , [2] , [3] , [5] , [8] .

Content analysis as a reflective process

You must mould the clay of the data , tapping into your intuition while maintaining a reflective understanding of how your own previous knowledge is influencing your analysis, i.e., your pre-understanding. In qualitative methodology, it is imperative to vigilantly maintain an awareness of one’s pre-understanding so that this does not influence analysis and/or results. This is the difficult balancing task of keeping a firm grip on one’s assumptions, opinions, and personal beliefs, and not letting them unconsciously steer your analysis process while simultaneously, and knowingly, utilising one’s pre-understanding to facilitate a deeper understanding of the data.

Content analysis, as in all qualitative analysis, is a reflective process. There is no “step 1, 2, 3, done!” linear progression in the analysis. This means that identifying and condensing meaning units, coding, and categorising are not one-time events. It is a continuous process of coding and categorising then returning to the raw data to reflect on your initial analysis. Are you still satisfied with the length of meaning units? Do the condensed meaning units and codes still “fit” with each other? Do the codes still fit into this particular category? Typically, a fair amount of adjusting is needed after the first analysis endeavour. For example: a meaning unit might need to be split into two meaning units in order to capture an additional core meaning; a code modified to more closely match the core meaning of the condensed meaning unit; or a category name tweaked to most accurately describe the included codes. In other words, analysis is a flexible reflective process of working and re-working your data that reveals connections and relationships. Once condensed meaning units are coded it is easier to get a bigger picture and see patterns in your codes and organise codes in categories.

Content analysis exercise

The synopsis above is representative of analysis descriptions in many content analysis articles. Although correct, such method descriptions still do not provide much support for the novice researcher during the actual analysis process. Aspiring to provide guidance and direction to support the novice, a practical example of doing the actual work of content analysis is provided in the following sections. This practical example is based on a transcribed interview excerpt that was part of a study that aimed to explore patients’ experiences of being admitted into the emergency centre ( Fig. 2 ).

Excerpt from interview text exploring “Patient’s experience of being admitted into the emergency centre”

This content analysis exercise provides instructions, tips, and advice to support the content analysis novice in a) familiarising oneself with the data and the hermeneutic spiral, b) dividing up the text into meaning units and subsequently condensing these meaning units, c) formulating codes, and d) developing categories and themes.

Familiarising oneself with the data and the hermeneutic spiral

An important initial phase in the data analysis process is to read and re-read the transcribed interview while keeping your aim in focus. Write down your initial impressions. Embrace your intuition. What is the text talking about? What stands out? How did you react while reading the text? What message did the text leave you with? In this analysis phase, you are gaining a sense of the text as a whole.

You may ask why this is important. During analysis, you will be breaking down the whole text into smaller parts. Returning to your notes with your initial impressions will help you see if your “parts” analysis is matching up with your first impressions of the “whole” text. Are your initial impressions visible in your analysis of the parts? Perhaps you need to go back and check for different perspectives. This is what is referred to as the hermeneutic spiral or hermeneutic circle. It is the process of comparing the parts to the whole to determine whether impressions of the whole verify the analysis of the parts in all phases of analysis. Each part should reflect the whole and the whole should be reflected in each part. This concept will become clearer as you start working with your data.

Dividing up the text into meaning units and condensing meaning units

You have now read the interview a number of times. Keeping your research aim and question clearly in focus, divide up the text into meaning units. Located meaning units are then condensed further while keeping the central meaning intact ( Table 2 ). The condensation should be a shortened version of the same text that still conveys the essential message of the meaning unit. Sometimes the meaning unit is already so compact that no further condensation is required. Some content analysis sources warn researchers against short meaning units, claiming that this can lead to fragmentation [1] . However, our personal experience as research supervisors has shown us that a greater problem for the novice is basing analysis on meaning units that are too large and include many meanings which are then lost in the condensation process.

Suggestion for how the exemplar interview text can be divided into meaning units and condensed meaning units ( condensations are in parentheses ).

Formulating codes

The next step is to develop codes that are descriptive labels for the condensed meaning units ( Table 3 ). Codes concisely describe the condensed meaning unit and are tools to help researchers reflect on the data in new ways. Codes make it easier to identify connections between meaning units. At this stage of analysis you are still keeping very close to your data with very limited interpretation of content. You may adjust, re-do, re-think, and re-code until you get to the point where you are satisfied that your choices are reasonable. Just as in the initial phase of getting to know your data as a whole, it is also good to write notes during coding on your impressions and reactions to the text.

Suggestions for coding of condensed meaning units.

Developing categories and themes

The next step is to sort codes into categories that answer the questions who , what , when or where? One does this by comparing codes and appraising them to determine which codes seem to belong together, thereby forming a category. In other words, a category consists of codes that appear to deal with the same issue, i.e., manifest content visible in the data with limited interpretation on the part of the researcher. Category names are most often short and factual sounding.

In data that is rich with latent meaning, analysis can be carried on to create themes. In our practical example, we have continued the process of abstracting data to a higher level, from category to theme level, and developed three themes as well as an overarching theme ( Table 4 ). Themes express underlying meaning, i.e., latent content, and are formed by grouping two or more categories together. Themes are answering questions such as why , how , in what way or by what means? Therefore, theme names include verbs, adverbs and adjectives and are very descriptive or even poetic.

Suggestion for organisation of coded meaning units into categories and themes.

Some reflections and helpful tips

Understand your pre-understandings.

While conducting qualitative research, it is paramount that the researcher maintains a vigilance of non-bias during analysis. In other words, did you remain aware of your pre-understandings, i.e., your own personal assumptions, professional background, and previous experiences and knowledge? For example, did you zero in on particular aspects of the interview on account of your profession (as an emergency doctor, emergency nurse, pre-hospital professional, etc.)? Did you assume the patient’s gender? Did your assumptions affect your analysis? How about aspects of culpability; did you assume that this patient was at fault or that this patient was a victim in the crash? Did this affect how you analysed the text?

Staying aware of one’s pre-understandings is exactly as difficult as it sounds. But, it is possible and it is requisite. Focus on putting yourself and your pre-understandings in a holding pattern while you approach your data with an openness and expectation of finding new perspectives. That is the key: expect the new and be prepared to be surprised. If something in your data feels unusual, is different from what you know, atypical, or even odd – don’t by-pass it as “wrong”. Your reactions and intuitive responses are letting you know that here is something to pay extra attention to, besides the more comfortable condensing and coding of more easily recognisable meaning units.

Use your intuition

Intuition is a great asset in qualitative analysis and not to be dismissed as “unscientific”. Intuition results from tacit knowledge. Just as tacit knowledge is a hallmark of great clinicians [11] , [12] ; it is also an invaluable tool in analysis work [13] . Literally, take note of your gut reactions and intuitive guidance and remember to write these down! These notes often form a framework of possible avenues for further analysis and are especially helpful as you lift the analysis to higher levels of abstraction; from meaning units to condensed meaning units, to codes, to categories and then to the highest level of abstraction in content analysis, themes.

Aspects of coding and categorising hard to place data

All too often, the novice gets overwhelmed by interview material that deals with the general subject matter of the interview, but doesn’t seem to answer the research question. Don’t be too quick to consider such text as off topic or dross [6] . There is often data that, although not seeming to match the study aim precisely, is still important for illuminating the problem area. This can be seen in our practical example about exploring patients’ experiences of being admitted into the emergency centre. Initially the participant is describing the accident itself. While not directly answering the research question, the description is important for understanding the context of the experience of being admitted into the emergency centre. It is very common that participants will “begin at the beginning” and prologue their narratives in order to create a context that sets the scene. This type of contextual data is vital for gaining a deepened understanding of participants’ experiences.

In our practical example, the participant begins by describing the crash and the rescue, i.e., experiences leading up to and prior to admission to the emergency centre. That is why we have chosen in our analysis to code the condensed meaning unit “Ambulance staff looked worried about all the blood” as “In the ambulance” and place it in the category “Reliving the rescue”. We did not choose to include this meaning unit in the categories specifically about admission to the emergency centre itself. Do you agree with our coding choice? Would you have chosen differently?

Another common problem for the novice is deciding how to code condensed meaning units when the unit can be labelled in several different ways. At this point researchers usually groan and wish they had thought to ask one of those classic follow-up questions like “Can you tell me a little bit more about that?” We have examples of two such coding conundrums in the exemplar, as can be seen in Table 3 (codes we conferred on) and Table 4 (codes we reached consensus on). Do you agree with our choices or would you have chosen different codes? Our best advice is to go back to your impressions of the whole and lean into your intuition when choosing codes that are most reasonable and best fit your data.

A typical problem area during categorisation, especially for the novice researcher, is overlap between content in more than one initial category, i.e., codes included in one category also seem to be a fit for another category. Overlap between initial categories is very likely an indication that the jump from code to category was too big, a problem not uncommon when the data is voluminous and/or very complex. In such cases, it can be helpful to first sort codes into narrower categories, so-called subcategories. Subcategories can then be reviewed for possibilities of further aggregation into categories. In the case of a problematic coding, it is advantageous to return to the meaning unit and check if the meaning unit itself fits the category or if you need to reconsider your preliminary coding.

It is not uncommon to be faced by thorny problems such as these during coding and categorisation. Here we would like to reiterate how valuable it is to have fellow researchers with whom you can discuss and reflect together with, in order to reach consensus on the best way forward in your data analysis. It is really advantageous to compare your analysis with meaning units, condensations, coding and categorisations done by another researcher on the same text. Have you identified the same meaning units? Do you agree on coding? See similar patterns in the data? Concur on categories? Sometimes referred to as “researcher triangulation,” this is actually a key element in qualitative analysis and an important component when striving to ensure trustworthiness in your study [14] . Qualitative research is about seeking out variations and not controlling variables, as in quantitative research. Collaborating with others during analysis lets you tap into multiple perspectives and often makes it easier to see variations in the data, thereby enhancing the quality of your results as well as contributing to the rigor of your study. It is important to note that it is not necessary to force consensus in the findings but one can embrace these variations in interpretation and use that to capture the richness in the data.

Yet there are times when neither openness, pre-understanding, intuition, nor researcher triangulation does the job; for example, when analysing an interview and one is simply confused on how to code certain meaning units. At such times, there are a variety of options. A good starting place is to re-read all the interviews through the lens of this specific issue and actively search for other similar types of meaning units you might have missed. Another way to handle this is to conduct further interviews with specific queries that hopefully shed light on the issue. A third option is to have a follow-up interview with the same person and ask them to explain.

Additional tips

It is important to remember that in a typical project there are several interviews to analyse. Codes found in a single interview serve as a starting point as you then work through the remaining interviews coding all material. Form your categories and themes when all project interviews have been coded.

When submitting an article with your study results, it is a good idea to create a table or figure providing a few key examples of how you progressed from the raw data of meaning units, to condensed meaning units, coding, categorisation, and, if included, themes. Providing such a table or figure supports the rigor of your study [1] and is an element greatly appreciated by reviewers and research consumers.

During the analysis process, it can be advantageous to write down your research aim and questions on a sheet of paper that you keep nearby as you work. Frequently referring to your aim can help you keep focused and on track during analysis. Many find it helpful to colour code their transcriptions and write notes in the margins.

Having access to qualitative analysis software can be greatly helpful in organising and retrieving analysed data. Just remember, a computer does not analyse the data. As Jennings [15] has stated, “… it is ‘peopleware,’ not software, that analyses.” A major drawback is that qualitative analysis software can be prohibitively expensive. One way forward is to use table templates such as we have used in this article. (Three analysis templates, Templates A, B, and C, are provided as supplementary online material ). Additionally, the “find” function in word processing programmes such as Microsoft Word (Redmond, WA USA) facilitates locating key words, e.g., in transcribed interviews, meaning units, and codes.

Lessons learnt/key points

From our experience with content analysis we have learnt a number of important lessons that may be useful for the novice researcher. They are:

• • A method description is a guideline supporting analysis and trustworthiness. Don’t get caught up too rigidly following steps. Reflexivity and flexibility are just as important. Remember that a method description is a tool helping you in the process of making sense of your data by reducing a large amount of text to distil key results.
• • It is important to maintain a vigilant awareness of one’s own pre-understandings in order to avoid bias during analysis and in results.
• • Use and trust your own intuition during the analysis process.
• • If possible, discuss and reflect together with other researchers who have analysed the same data. Be open and receptive to new perspectives.
• • Understand that it is going to take time. Even if you are quite experienced, each set of data is different and all require time to analyse. Don’t expect to have all the data analysis done over a weekend. It may take weeks. You need time to think, reflect and then review your analysis.
• • Keep reminding yourself how excited you have felt about this area of research and how interesting it is. Embrace it with enthusiasm!
• • Let it be chaotic – have faith that some sense will start to surface. Don’t be afraid and think you will never get to the end – you will… eventually!

Peer review under responsibility of African Federation for Emergency Medicine.

Appendix A Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.afjem.2017.08.001 .

Appendix A. Supplementary data

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19 Content Analysis

Lindsay Prior, School of Sociology, Social Policy, and Social Work, Queen's University

• Published: 02 September 2020
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In this chapter, the focus is on ways in which content analysis can be used to investigate and describe interview and textual data. The chapter opens with a contextualization of the method and then proceeds to an examination of the role of content analysis in relation to both quantitative and qualitative modes of social research. Following the introductory sections, four kinds of data are subjected to content analysis. These include data derived from a sample of qualitative interviews ( N = 54), textual data derived from a sample of health policy documents ( N = 6), data derived from a single interview relating to a “case” of traumatic brain injury, and data gathered from fifty-four abstracts of academic papers on the topic of “well-being.” Using a distinctive and somewhat novel style of content analysis that calls on the notion of semantic networks, the chapter shows how the method can be used either independently or in conjunction with other forms of inquiry (including various styles of discourse analysis) to analyze data and also how it can be used to verify and underpin claims that arise from analysis. The chapter ends with an overview of the different ways in which the study of “content”—especially the study of document content—can be positioned in social scientific research projects.

What Is Content Analysis?

In his 1952 text on the subject of content analysis, Bernard Berelson traced the origins of the method to communication research and then listed what he called six distinguishing features of the approach. As one might expect, the six defining features reflect the concerns of social science as taught in the 1950s, an age in which the calls for an “objective,” “systematic,” and “quantitative” approach to the study of communication data were first heard. The reference to the field of “communication” was nothing less than a reflection of a substantive social scientific interest over the previous decades in what was called public opinion and specifically attempts to understand why and how a potential source of critical, rational judgment on political leaders (i.e., the views of the public) could be turned into something to be manipulated by dictators and demagogues. In such a context, it is perhaps not so surprising that in one of the more popular research methods texts of the decade, the terms content analysis and communication analysis are used interchangeably (see Goode & Hatt, 1952 , p. 325).

Academic fashions and interests naturally change with available technology, and these days we are more likely to focus on the individualization of communications through Twitter and the like, rather than of mass newspaper readership or mass radio audiences, yet the prevailing discourse on content analysis has remained much the same as it was in Berleson’s day. Thus, Neuendorf ( 2002 ), for example, continued to define content analysis as “the systematic, objective, quantitative analysis of message characteristics” (p. 1). Clearly, the centrality of communication as a basis for understanding and using content analysis continues to hold, but in this chapter I will try to show that, rather than locate the use of content analysis in disembodied “messages” and distantiated “media,” we would do better to focus on the fact that communication is a building block of social life itself and not merely a system of messages that are transmitted—in whatever form—from sender to receiver. To put that statement in another guise, we must note that communicative action (to use the phraseology of Habermas, 1987 ) rests at the very base of the lifeworld, and one very important way of coming to grips with that world is to study the content of what people say and write in the course of their everyday lives.

My aim is to demonstrate various ways in which content analysis (henceforth CTA) can be used and developed to analyze social scientific data as derived from interviews and documents. It is not my intention to cover the history of CTA or to venture into forms of literary analysis or to demonstrate each and every technique that has ever been deployed by content analysts. (Many of the standard textbooks deal with those kinds of issues much more fully than is possible here. See, for example, Babbie, 2013 ; Berelson, 1952 ; Bryman, 2008 , Krippendorf, 2004 ; Neuendorf, 2002 ; and Weber, 1990 ). Instead, I seek to recontextualize the use of the method in a framework of network thinking and to link the use of CTA to specific problems of data analysis. As will become evident, my exposition of the method is grounded in real-world problems. Those problems are drawn from my own research projects and tend to reflect my academic interests—which are almost entirely related to the analysis of the ways in which people talk and write about aspects of health, illness, and disease. However, lest the reader be deterred from going any further, I should emphasize that the substantive issues that I elect to examine are secondary if not tertiary to my main objective—which is to demonstrate how CTA can be integrated into a range of research designs and add depth and rigor to the analysis of interview and inscription data. To that end, in the next section I aim to clear our path to analysis by dealing with some issues that touch on the general position of CTA in the research armory, especially its location in the schism that has developed between quantitative and qualitative modes of inquiry.

The Methodological Context of Content Analysis

Content analysis is usually associated with the study of inscription contained in published reports, newspapers, adverts, books, web pages, journals, and other forms of documentation. Hence, nearly all of Berelson’s ( 1952 ) illustrations and references to the method relate to the analysis of written records of some kind, and where speech is mentioned, it is almost always in the form of broadcast and published political speeches (such as State of the Union addresses). This association of content analysis with text and documentation is further underlined in modern textbook discussions of the method. Thus, Bryman ( 2008 ), for example, defined CTA as “an approach to the analysis of documents and texts , that seek to quantify content in terms of pre-determined categories” (2008, p. 274, emphasis in original), while Babbie ( 2013 ) stated that CTA is “the study of recorded human communications” (2013, p. 295), and Weber referred to it as a method to make “valid inferences from text” (1990, p. 9). It is clear then that CTA is viewed as a text-based method of analysis, though extensions of the method to other forms of inscriptional material are also referred to in some discussions. Thus, Neuendorf ( 2002 ), for example, rightly referred to analyses of film and television images as legitimate fields for the deployment of CTA and by implication analyses of still—as well as moving—images such as photographs and billboard adverts. Oddly, in the traditional or standard paradigm of CTA, the method is solely used to capture the “message” of a text or speech; it is not used for the analysis of a recipient’s response to or understanding of the message (which is normally accessed via interview data and analyzed in other and often less rigorous ways; see, e.g., Merton, 1968 ). So, in this chapter I suggest that we can take things at least one small step further by using CTA to analyze speech (especially interview data) as well as text.

Standard textbook discussions of CTA usually refer to it as a “nonreactive” or “unobtrusive” method of investigation (see, e.g., Babbie, 2013 , p. 294), and a large part of the reason for that designation is because of its focus on already existing text (i.e., text gathered without intrusion into a research setting). More important, however (and to underline the obvious), CTA is primarily a method of analysis rather than of data collection. Its use, therefore, must be integrated into wider frames of research design that embrace systematic forms of data collection as well as forms of data analysis. Thus, routine strategies for sampling data are often required in designs that call on CTA as a method of analysis. These latter can be built around random sampling methods or even techniques of “theoretical sampling” (Glaser & Strauss, 1967 ) so as to identify a suitable range of materials for CTA. Content analysis can also be linked to styles of ethnographic inquiry and to the use of various purposive or nonrandom sampling techniques. For an example, see Altheide ( 1987 ).

The use of CTA in a research design does not preclude the use of other forms of analysis in the same study, because it is a technique that can be deployed in parallel with other methods or with other methods sequentially. For example, and as I will demonstrate in the following sections, one might use CTA as a preliminary analytical strategy to get a grip on the available data before moving into specific forms of discourse analysis. In this respect, it can be as well to think of using CTA in, say, the frame of a priority/sequence model of research design as described by Morgan ( 1998 ).

As I shall explain, there is a sense in which CTA rests at the base of all forms of qualitative data analysis, yet the paradox is that the analysis of content is usually considered a quantitative (numerically based) method. In terms of the qualitative/quantitative divide, however, it is probably best to think of CTA as a hybrid method, and some writers have in the past argued that it is necessarily so (Kracauer, 1952 ). That was probably easier to do in an age when many recognized the strictly drawn boundaries between qualitative and quantitative styles of research to be inappropriate. Thus, in their widely used text Methods in Social Research , Goode and Hatt ( 1952 ), for example, asserted that “modern research must reject as a false dichotomy the separation between ‘qualitative’ and ‘quantitative’ studies, or between the ‘statistical’ and the ‘non-statistical’ approach” (p. 313). This position was advanced on the grounds that all good research must meet adequate standards of validity and reliability, whatever its style, and the message is well worth preserving. However, there is a more fundamental reason why it is nonsensical to draw a division between the qualitative and the quantitative. It is simply this: All acts of social observation depend on the deployment of qualitative categories—whether gender, class, race, or even age; there is no descriptive category in use in the social sciences that connects to a world of “natural kinds.” In short, all categories are made, and therefore when we seek to count “things” in the world, we are dependent on the existence of socially constructed divisions. How the categories take the shape that they do—how definitions are arrived at, how inclusion and exclusion criteria are decided on, and how taxonomic principles are deployed—constitute interesting research questions in themselves. From our starting point, however, we need only note that “sorting things out” (to use a phrase from Bowker & Star, 1999 ) and acts of “counting”—whether it be of chromosomes or people (Martin & Lynch, 2009 )—are activities that connect to the social world of organized interaction rather than to unsullied observation of the external world.

Some writers deny the strict division between the qualitative and quantitative on grounds of empirical practice rather than of ontological reasoning. For example, Bryman ( 2008 ) argued that qualitative researchers also call on quantitative thinking, but tend to use somewhat vague, imprecise terms rather than numbers and percentages—referring to frequencies via the use of phrases such as “more than” and “less than.” Kracauer ( 1952 ) advanced various arguments against the view that CTA was strictly a quantitative method, suggesting that very often we wished to assess content as being negative or positive with respect to some political, social, or economic thesis and that such evaluations could never be merely statistical. He further argued that we often wished to study “underlying” messages or latent content of documentation and that, in consequence, we needed to interpret content as well as count items of content. Morgan ( 1993 ) argued that, given the emphasis that is placed on “coding” in almost all forms of qualitative data analysis, the deployment of counting techniques is essential and we ought therefore to think in terms of what he calls qualitative as well as quantitative content analysis. Naturally, some of these positions create more problems than they seemingly solve (as is the case with considerations of “latent content”), but given the 21st-century predilection for mixed methods research (Creswell, 2007 ), it is clear that CTA has a role to play in integrating quantitative and qualitative modes of analysis in a systematic rather than merely ad hoc and piecemeal fashion. In the sections that follow, I will provide some examples of the ways in which “qualitative” analysis can be combined with systematic modes of counting. First, however, we must focus on what is analyzed in CTA.

Units of Analysis

So, what is the unit of analysis in CTA? A brief answer is that analysis can be focused on words, sentences, grammatical structures, tenses, clauses, ratios (of, say, nouns to verbs), or even “themes.” Berelson ( 1952 ) gave examples of all of the above and also recommended a form of thematic analysis (cf., Braun & Clarke, 2006 ) as a viable option. Other possibilities include counting column length (of speeches and newspaper articles), amounts of (advertising) space, or frequency of images. For our purposes, however, it might be useful to consider a specific (and somewhat traditional) example. Here it is. It is an extract from what has turned out to be one of the most important political speeches of the current century.

Iraq continues to flaunt its hostility toward America and to support terror. The Iraqi regime has plotted to develop anthrax and nerve gas and nuclear weapons for over a decade. This is a regime that has already used poison gas to murder thousands of its own citizens, leaving the bodies of mothers huddled over their dead children. This is a regime that agreed to international inspections then kicked out the inspectors. This is a regime that has something to hide from the civilized world. States like these, and their terrorist allies, constitute an axis of evil, arming to threaten the peace of the world. By seeking weapons of mass destruction, these regimes pose a grave and growing danger. They could provide these arms to terrorists, giving them the means to match their hatred. They could attack our allies or attempt to blackmail the United States. In any of these cases, the price of indifference would be catastrophic. (George W. Bush, State of the Union address, January 29, 2002)

A number of possibilities arise for analyzing the content of a speech such as the one above. Clearly, words and sentences must play a part in any such analysis, but in addition to words, there are structural features of the speech that could also figure. For example, the extract takes the form of a simple narrative—pointing to a past, a present, and an ominous future (catastrophe)—and could therefore be analyzed as such. There are, in addition, several interesting oppositions in the speech (such as those between “regimes” and the “civilized” world), as well as a set of interconnected present participles such as “plotting,” “hiding,” “arming,” and “threatening” that are associated both with Iraq and with other states that “constitute an axis of evil.” Evidently, simple word counts would fail to capture the intricacies of a speech of this kind. Indeed, our example serves another purpose—to highlight the difficulty that often arises in dissociating CTA from discourse analysis (of which narrative analysis and the analysis of rhetoric and trope are subspecies). So how might we deal with these problems?

One approach that can be adopted is to focus on what is referenced in text and speech, that is, to concentrate on the characters or elements that are recruited into the text and to examine the ways in which they are connected or co-associated. I shall provide some examples of this form of analysis shortly. Let us merely note for the time being that in the previous example we have a speech in which various “characters”—including weapons in general, specific weapons (such as nerve gas), threats, plots, hatred, evil, and mass destruction—play a role. Be aware that we need not be concerned with the veracity of what is being said—whether it is true or false—but simply with what is in the speech and how what is in there is associated. (We may leave the task of assessing truth and falsity to the jurists). Be equally aware that it is a text that is before us and not an insight into the ex-president’s mind, or his thinking, or his beliefs, or any other subjective property that he may have possessed.

In the introductory paragraph, I made brief reference to some ideas of the German philosopher Jürgen Habermas ( 1987 ). It is not my intention here to expand on the detailed twists and turns of his claims with respect to the role of language in the “lifeworld” at this point. However, I do intend to borrow what I regard as some particularly useful ideas from his work. The first is his claim—influenced by a strong line of 20th-century philosophical thinking—that language and culture are constitutive of the lifeworld (Habermas, 1987 , p. 125), and in that sense we might say that things (including individuals and societies) are made in language. That is a simple justification for focusing on what people say rather than what they “think” or “believe” or “feel” or “mean” (all of which have been suggested at one time or another as points of focus for social inquiry and especially qualitative forms of inquiry). Second, Habermas argued that speakers and therefore hearers (and, one might add, writers and therefore readers), in what he calls their speech acts, necessarily adopt a pragmatic relation to one of three worlds: entities in the objective world, things in the social world, and elements of a subjective world. In practice, Habermas ( 1987 , p. 120) suggested all three worlds are implicated in any speech act, but that there will be a predominant orientation to one of them. To rephrase this in a crude form, when speakers engage in communication, they refer to things and facts and observations relating to external nature, to aspects of interpersonal relations, and to aspects of private inner subjective worlds (thoughts, feelings, beliefs, etc.). One of the problems with locating CTA in “communication research” has been that the communications referred to are but a special and limited form of action (often what Habermas called strategic acts). In other words, television, newspaper, video, and Internet communications are just particular forms (with particular features) of action in general. Again, we might note in passing that the adoption of the Habermassian perspective on speech acts implies that much of qualitative analysis in particular has tended to focus only on one dimension of communicative action—the subjective and private. In this respect, I would argue that it is much better to look at speeches such as George W Bush’s 2002 State of the Union address as an “account” and to examine what has been recruited into the account, and how what has been recruited is connected or co-associated, rather than use the data to form insights into his (or his adviser’s) thoughts, feelings, and beliefs.

In the sections that follow, and with an emphasis on the ideas that I have just expounded, I intend to demonstrate how CTA can be deployed to advantage in almost all forms of inquiry that call on either interview (or speech-based) data or textual data. In my first example, I will show how CTA can be used to analyze a group of interviews. In the second example, I will show how it can be used to analyze a group of policy documents. In the third, I shall focus on a single interview (a “case”), and in the fourth and final example, I will show how CTA can be used to track the biography of a concept. In each instance, I shall briefly introduce the context of the “problem” on which the research was based, outline the methods of data collection, discuss how the data were analyzed and presented, and underline the ways in which CTA has sharpened the analytical strategy.

Analyzing a Sample of Interviews: Looking at Concepts and Their Co-associations in a Semantic Network

My first example of using CTA is based on a research study that was initially undertaken in the early 2000s. It was a project aimed at understanding why older people might reject the offer to be immunized against influenza (at no cost to them). The ultimate objective was to improve rates of immunization in the study area. The first phase of the research was based on interviews with 54 older people in South Wales. The sample included people who had never been immunized, some who had refused immunization, and some who had accepted immunization. Within each category, respondents were randomly selected from primary care physician patient lists, and the data were initially analyzed “thematically” and published accordingly (Evans, Prout, Prior, Tapper-Jones, & Butler, 2007 ). A few years later, however, I returned to the same data set to look at a different question—how (older) lay people talked about colds and flu, especially how they distinguished between the two illnesses and how they understood the causes of the two illnesses (see Prior, Evans, & Prout, 2011 ). Fortunately, in the original interview schedule, we had asked people about how they saw the “differences between cold and flu” and what caused flu, so it was possible to reanalyze the data with such questions in mind. In that frame, the example that follows demonstrates not only how CTA might be used on interview data, but also how it might be used to undertake a secondary analysis of a preexisting data set (Bryman, 2008 ).

As with all talk about illness, talk about colds and flu is routinely set within a mesh of concerns—about causes, symptoms, and consequences. Such talk comprises the base elements of what has at times been referred to as the “explanatory model” of an illness (Kleinman, Eisenberg, & Good, 1978 ). In what follows, I shall focus almost entirely on issues of causation as understood from the viewpoint of older people; the analysis is based on the answers that respondents made in response to the question, “How do you think people catch flu?”

Semistructured interviews of the kind undertaken for a study such as this are widely used and are often characterized as akin to “a conversation with a purpose” (Kahn & Cannell, 1957 , p. 97). One of the problems of analyzing the consequent data is that, although the interviewer holds to a planned schedule, the respondents often reflect in a somewhat unstructured way about the topic of investigation, so it is not always easy to unravel the web of talk about, say, “causes” that occurs in the interview data. In this example, causal agents of flu, inhibiting agents, and means of transmission were often conflated by the respondents. Nevertheless, in their talk people did answer the questions that were posed, and in the study referred to here, that talk made reference to things such as “bugs” (and “germs”) as well as viruses, but the most commonly referred to causes were “the air” and the “atmosphere.” The interview data also pointed toward means of transmission as “cause”—so coughs and sneezes and mixing in crowds figured in the causal mix. Most interesting, perhaps, was the fact that lay people made a nascent distinction between facilitating factors (such as bugs and viruses) and inhibiting factors (such as being resistant, immune, or healthy), so that in the presence of the latter, the former are seen to have very little effect. Here are some shorter examples of typical question–response pairs from the original interview data.

(R:32): “How do you catch it [the flu]? Well, I take it its through ingesting and inhaling bugs from the atmosphere. Not from sort of contact or touching things. Sort of airborne bugs. Is that right?” (R:3): “I suppose it’s [the cause of flu] in the air. I think I get more diseases going to the surgery than if I stayed home. Sometimes the waiting room is packed and you’ve got little kids coughing and spluttering and people sneezing, and air conditioning I think is a killer by and large I think air conditioning in lots of these offices.” (R:46): “I think you catch flu from other people. You know in enclosed environments in air conditioning which in my opinion is the biggest cause of transferring diseases is air conditioning. Worse thing that was ever invented that was. I think so, you know. It happens on aircraft exactly the same you know.”

Alternatively, it was clear that for some people being cold, wet, or damp could also serve as a direct cause of flu; thus: Interviewer: “OK, good. How do you think you catch the flu?”

(R:39): “Ah. The 65 dollar question. Well, I would catch it if I was out in the rain and I got soaked through. Then I would get the flu. I mean my neighbour up here was soaked through and he got pneumonia and he died. He was younger than me: well, 70. And he stayed in his wet clothes and that’s fatal. Got pneumonia and died, but like I said, if I get wet, especially if I get my head wet, then I can get a nasty head cold and it could develop into flu later.”

As I suggested earlier, despite the presence of bugs and germs, viruses, the air, and wetness or dampness, “catching” the flu is not a matter of simple exposure to causative agents. Thus, some people hypothesized that within each person there is a measure of immunity or resistance or healthiness that comes into play and that is capable of counteracting the effects of external agents. For example, being “hardened” to germs and harsh weather can prevent a person getting colds and flu. Being “healthy” can itself negate the effects of any causative agents, and healthiness is often linked to aspects of “good” nutrition and diet and not smoking cigarettes. These mitigating and inhibiting factors can either mollify the effects of infection or prevent a person “catching” the flu entirely. Thus, (R:45) argued that it was almost impossible for him to catch flu or cold “cos I got all this resistance.” Interestingly, respondents often used possessive pronouns in their discussion of immunity and resistance (“my immunity” and “my resistance”)—and tended to view them as personal assets (or capital) that might be compromised by mixing with crowds.

By implication, having a weak immune system can heighten the risk of contracting colds and flu and might therefore spur one to take preventive measures, such as accepting a flu shot. Some people believe that the flu shot can cause the flu and other illnesses. An example of what might be called lay “epidemiology” (Davison, Davey-Smith, & Frankel, 1991 ) is evident in the following extract.

(R:4): “Well, now it’s coincidental you know that [my brother] died after the jab, but another friend of mine, about 8 years ago, the same happened to her. She had the jab and about six months later, she died, so I know they’re both coincidental, but to me there’s a pattern.”

Normally, results from studies such as this are presented in exactly the same way as has just been set out. Thus, the researcher highlights given themes that are said to have emerged from the data and then provides appropriate extracts from the interviews to illustrate and substantiate the relevant themes. However, one reasonable question that any critic might ask about the selected data extracts concerns the extent to which they are “representative” of the material in the data set as a whole. Maybe, for example, the author has been unduly selective in his or her use of both themes and quotations. Perhaps, as a consequence, the author has ignored or left out talk that does not fit the arguments or extracts that might be considered dull and uninteresting compared to more exotic material. And these kinds of issues and problems are certainly common to the reporting of almost all forms of qualitative research. However, the adoption of CTA techniques can help to mollify such problems. This is so because, by using CTA, we can indicate the extent to which we have used all or just some of the data, and we can provide a view of the content of the entire sample of interviews rather than just the content and flavor of merely one or two interviews. In this light, we must consider Figure 19.1 , which is based on counting the number of references in the 54 interviews to the various “causes” of the flu, though references to the flu shot (i.e., inoculation) as a cause of flu have been ignored for the purpose of this discussion. The node sizes reflect the relative importance of each cause as determined by the concept count (frequency of occurrence). The links between nodes reflect the degree to which causes are co-associated in interview talk and are calculated according to a co-occurrence index (see, e.g., SPSS, 2007 , p. 183).

What causes flu? A lay perspective. Factors listed as causes of colds and flu in 54 interviews. Node size is proportional to number of references “as causes.” Line thickness is proportional to co-occurrence of any two “causes” in the set of interviews.

Given this representation, we can immediately assess the relative importance of the different causes as referred to in the interview data. Thus, we can see that such things as (poor) “hygiene” and “foreigners” were mentioned as a potential cause of flu—but mention of hygiene and foreigners was nowhere near as important as references to “the air” or to “crowds” or to “coughs and sneezes.” In addition, we can also determine the strength of the connections that interviewees made between one cause and another. Thus, there are relatively strong links between “resistance” and “coughs and sneezes,” for example.

In fact, Figure 19.1 divides causes into the “external” and the “internal,” or the facilitating and the impeding (lighter and darker nodes). Among the former I have placed such things as crowds, coughs, sneezes, and the air, while among the latter I have included “resistance,” “immunity,” and “health.” That division is a product of my conceptualizing and interpreting the data, but whichever way we organize the findings, it is evident that talk about the causes of flu belongs in a web or mesh of concerns that would be difficult to represent using individual interview extracts alone. Indeed, it would be impossible to demonstrate how the semantics of causation belong to a culture (rather than to individuals) in any other way. In addition, I would argue that the counting involved in the construction of the diagram functions as a kind of check on researcher interpretations and provides a source of visual support for claims that an author might make about, say, the relative importance of “damp” and “air” as perceived causes of disease. Finally, the use of CTA techniques allied with aspects of conceptualization and interpretation has enabled us to approach the interview data as a set and to consider the respondents as belonging to a community, rather than regarding them merely as isolated and disconnected individuals, each with their own views. It has also enabled us to squeeze some new findings out of old data, and I would argue that it has done so with advantage. There are other advantages to using CTA to explore data sets, which I will highlight in the next section.

Analyzing a Sample of Documents: Using Content Analysis to Verify Claims

Policy analysis is a difficult business. To begin, it is never entirely clear where (social, health, economic, environmental) policy actually is. Is it in documents (as published by governments, think tanks, and research centers), in action (what people actually do), or in speech (what people say)? Perhaps it rests in a mixture of all three realms. Yet, wherever it may be, it is always possible, at the very least, to identify a range of policy texts and to focus on the conceptual or semantic webs in terms of which government officials and other agents (such as politicians) talk about the relevant policy issues. Furthermore, insofar as policy is recorded—in speeches, pamphlets, and reports—we may begin to speak of specific policies as having a history or a pedigree that unfolds through time (think, e.g., of U.S. or U.K. health policies during the Clinton years or the Obama years). And, insofar as we consider “policy” as having a biography or a history, we can also think of studying policy narratives.

Though firmly based in the world of literary theory, narrative method has been widely used for both the collection and the analysis of data concerning ways in which individuals come to perceive and understand various states of health, ill health, and disability (Frank, 1995 ; Hydén, 1997 ). Narrative techniques have also been adapted for use in clinical contexts and allied to concepts of healing (Charon, 2006 ). In both social scientific and clinical work, however, the focus is invariably on individuals and on how individuals “tell” stories of health and illness. Yet narratives can also belong to collectives—such as political parties and ethnic and religious groups—just as much as to individuals, and in the latter case there is a need to collect and analyze data that are dispersed across a much wider range of materials than can be obtained from the personal interview. In this context, Roe ( 1994 ) demonstrated how narrative method can be applied to an analysis of national budgets, animal rights, and environmental policies.

An extension of the concept of narrative to policy discourse is undoubtedly useful (Newman & Vidler, 2006 ), but how might such narratives be analyzed? What strategies can be used to unravel the form and content of a narrative, especially in circumstances where the narrative might be contained in multiple (policy) documents, authored by numerous individuals, and published across a span of time rather than in a single, unified text such as a novel? Roe ( 1994 ), unfortunately, was not in any way specific about analytical procedures, apart from offering the useful rule to “never stray too far from the data” (p. xii). So, in this example, I will outline a strategy for tackling such complexities. In essence, it is a strategy that combines techniques of linguistically (rule) based CTA with a theoretical and conceptual frame that enables us to unravel and identify the core features of a policy narrative. My substantive focus is on documents concerning health service delivery policies published from 2000 to 2009 in the constituent countries of the United Kingdom (that is, England, Scotland, Wales, and Northern Ireland—all of which have different political administrations).

Narratives can be described and analyzed in various ways, but for our purposes we can say that they have three key features: they point to a chronology, they have a plot, and they contain “characters.”

All narratives have beginnings; they also have middles and endings, and these three stages are often seen as comprising the fundamental structure of narrative text. Indeed, in his masterly analysis of time and narrative, Ricoeur ( 1984 ) argued that it is in the unfolding chronological structure of a narrative that one finds its explanatory (and not merely descriptive) force. By implication, one of the simplest strategies for the examination of policy narratives is to locate and then divide a narrative into its three constituent parts—beginning, middle, and end.

Unfortunately, while it can sometimes be relatively easy to locate or choose a beginning to a narrative, it can be much more difficult to locate an end point. Thus, in any illness narrative, a narrator might be quite capable of locating the start of an illness process (in an infection, accident, or other event) but unable to see how events will be resolved in an ongoing and constantly unfolding life. As a consequence, both narrators and researchers usually find themselves in the midst of an emergent present—a present without a known and determinate end (see, e.g., Frank, 1995 ). Similar considerations arise in the study of policy narratives where chronology is perhaps best approached in terms of (past) beginnings, (present) middles, and projected futures.

According to Ricoeur ( 1984 ), our basic ideas about narrative are best derived from the work and thought of Aristotle, who in his Poetics sought to establish “first principles” of composition. For Ricoeur, as for Aristotle, plot ties things together. It “brings together factors as heterogeneous as agents, goals, means, interactions, circumstances, unexpected results” (p. 65) into the narrative frame. For Aristotle, it is the ultimate untying or unraveling of the plot that releases the dramatic energy of the narrative.

Characters are most commonly thought of as individuals, but they can be considered in much broader terms. Thus, the French semiotician A. J. Greimas ( 1970 ), for example, suggested that, rather than think of characters as people, it would be better to think in terms of what he called actants and of the functions that such actants fulfill within a story. In this sense, geography, climate, and capitalism can be considered characters every bit as much as aggressive wolves and Little Red Riding Hood. Further, he argued that the same character (actant) can be considered to fulfill many functions, and the same function may be performed by many characters. Whatever else, the deployment of the term actant certainly helps us to think in terms of narratives as functioning and creative structures. It also serves to widen our understanding of the ways in which concepts, ideas, and institutions, as well “things” in the material world, can influence the direction of unfolding events every bit as much as conscious human subjects. Thus, for example, the “American people,” “the nation,” “the Constitution,” “the West,” “tradition,” and “Washington” can all serve as characters in a policy story.

As I have already suggested, narratives can unfold across many media and in numerous arenas—speech and action, as well as text. Here, however, my focus is solely on official documents—all of which are U.K. government policy statements, as listed in Table 19.1 . The question is, How might CTA help us unravel the narrative frame?

It might be argued that a simple reading of any document should familiarize the researcher with elements of all three policy narrative components (plot, chronology, and character). However, in most policy research, we are rarely concerned with a single and unified text, as is the case with a novel; rather, we have multiple documents written at distinctly different times by multiple (usually anonymous) authors that notionally can range over a wide variety of issues and themes. In the full study, some 19 separate publications were analyzed across England, Wales, Scotland, and Northern Ireland.

Naturally, listing word frequencies—still less identifying co-occurrences and semantic webs in large data sets (covering hundreds of thousands of words and footnotes)—cannot be done manually, but rather requires the deployment of complex algorithms and text-mining procedures. To this end, I analyzed the 19 documents using “Text Mining for Clementine” (SPSS, 2007 ).

Text-mining procedures begin by providing an initial list of concepts based on the lexicon of the text but that can be weighted according to word frequency and that take account of elementary word associations. For example, learning disability, mental health, and performance management indicate three concepts, not six words. Using such procedures on the aforementioned documents gives the researcher an initial grip on the most important concepts in the document set of each country. Note that this is much more than a straightforward concordance analysis of the text and is more akin to what Ryan and Bernard ( 2000 ) referred to as semantic analysis and Carley ( 1993 ) has referred to as concept and mapping analysis.

So, the first task was to identify and then extract the core concepts, thus identifying what might be called “key” characters or actants in each of the policy narratives. For example, in the Scottish documents, such actants included “Scotland” and the “Scottish people,” as well as “health” and the “National Health Service (NHS),” among others, while in the Welsh documents it was “the people of Wales” and “Wales” that figured largely—thus emphasizing how national identity can play every bit as important a role in a health policy narrative as concepts such as “health,” “hospitals,” and “well-being.”

Having identified key concepts, it was then possible to track concept clusters in which particular actants or characters are embedded. Such cluster analysis is dependent on the use of co-occurrence rules and the analysis of synonyms, whereby it is possible to get a grip on the strength of the relationships between the concepts, as well as the frequency with which the concepts appear in the collected texts. In Figure 19.2 , I provide an example of a concept cluster. The diagram indicates the nature of the conceptual and semantic web in which various actants are discussed. The diagrams further indicate strong (solid line) and weaker (dashed line) connections between the various elements in any specific mix, and the numbers indicate frequency counts for the individual concepts. Using Clementine , the researcher is unable to specify in advance which clusters will emerge from the data. One cannot, for example, choose to have an NHS cluster. In that respect, these diagrams not only provide an array in terms of which concepts are located, but also serve as a check on and to some extent validation of the interpretations of the researcher. None of this tells us what the various narratives contained within the documents might be, however. They merely point to key characters and relationships both within and between the different narratives. So, having indicated the techniques used to identify the essential parts of the four policy narratives, it is now time to sketch out their substantive form.

Concept cluster for “care” in six English policy documents, 2000–2007. Line thickness is proportional to the strength co-occurrence coefficient. Node size reflects relative frequency of concept, and (numbers) refer to the frequency of concept. Solid lines indicate relationships between terms within the same cluster, and dashed lines indicate relationships between terms in different clusters.

It may be useful to note that Aristotle recommended brevity in matters of narrative—deftly summarizing the whole of the Odyssey in just seven lines. In what follows, I attempt—albeit somewhat weakly—to emulate that example by summarizing a key narrative of English health services policy in just four paragraphs. Note how the narrative unfolds in relation to the dates of publication. In the English case (though not so much in the other U.K. countries), it is a narrative that is concerned to introduce market forces into what is and has been a state-managed health service. Market forces are justified in terms of improving opportunities for the consumer (i.e., the patients in the service), and the pivot of the newly envisaged system is something called “patient choice” or “choice.” This is how the story unfolds as told through the policy documents between 2000 and 2008 (see Table 19.1 ). The citations in the following paragraphs are to the Department of Health publications (by year) listed in Table 19.1 .

The advent of the NHS in 1948 was a “seminal event” (2000, p. 8), but under successive Conservative administrations, the NHS was seriously underfunded (2006, p. 3). The (New Labour) government will invest (2000) or already has (2003, p. 4) invested extensively in infrastructure and staff, and the NHS is now on a “journey of major improvement” (2004, p. 2). But “more money is only a starting point” (2000, p. 2), and the journey is far from finished. Continuation requires some fundamental changes of “culture” (2003, p. 6). In particular, the NHS remains unresponsive to patient need, and “all too often, the individual needs and wishes are secondary to the convenience of the services that are available. This ‘one size fits all’ approach is neither responsive, equitable nor person-centred” (2003, p. 17). In short, the NHS is a 1940s system operating in a 21st-century world (2000, p. 26). Change is therefore needed across the “whole system” (2005, p. 3) of care and treatment.

Above all, we must recognize that we “live in a consumer age” (2000, p. 26). People’s expectations have changed dramatically (2006, p. 129), and people want more choice, more independence, and more control (2003, p. 12) over their affairs. Patients are no longer, and should not be considered, “passive recipients” of care (2003, p. 62), but wish to be and should be (2006, p. 81) actively “involved” in their treatments (2003, p. 38; 2005, p. 18)—indeed, engaged in a partnership (2003, p. 22) of respect with their clinicians. Furthermore, most people want a personalized service “tailor made to their individual needs” (2000, p. 17; 2003, p. 15; 2004, p. 1; 2006, p. 83)—“a service which feels personal to each and every individual within a framework of equity and good use of public money” (2003, p. 6).

To advance the necessary changes, “patient choice” must be and “will be strengthened” (2000, p. 89). “Choice” must be made to “happen” (2003), and it must be “real” (2003, p. 3; 2004, p. 5; 2005, p. 20; 2006, p. 4). Indeed, it must be “underpinned” (2003, p. 7) and “widened and deepened” (2003, p. 6) throughout the entire system of care.

If “we” expand and underpin patient choice in appropriate ways and engage patients in their treatment systems, then levels of patient satisfaction will increase (2003, p. 39), and their choices will lead to a more “efficient” (2003, p. 5; 2004, p. 2; 2006, p. 16) and effective (2003, p. 62; 2005, p. 8) use of resources. Above all, the promotion of choice will help to drive up “standards” of care and treatment (2000, p. 4; 2003, p. 12; 2004, p. 3; 2005, p. 7; 2006, p. 3). Furthermore, the expansion of choice will serve to negate the effects of the “inverse care law,” whereby those who need services most tend to get catered to the least (2000, p. 107; 2003, p. 5; 2006, p. 63), and it will thereby help in moderating the extent of health inequalities in the society in which we live. “The overall aim of all our reforms,” therefore, “is to turn the NHS from a top down monolith into a responsive service that gives the patient the best possible experience. We need to develop an NHS that is both fair to all of us, and personal to each of us” (2003, p. 5).

We can see how most—though not all—of the elements of this story are represented in Figure 19.2. In particular, we can see strong (co-occurrence) links between care and choice and how partnership, performance, control, and improvement have a prominent profile. There are some elements of the web that have a strong profile (in terms of node size and links), but to which we have not referred; access, information, primary care, and waiting times are four. As anyone well versed in English healthcare policy would know, these elements have important roles to play in the wider, consumer-driven narrative. However, by rendering the excluded as well as included elements of that wider narrative visible, the concept web provides a degree of verification on the content of the policy story as told herein and on the scope of its “coverage.”

In following through on this example, we have moved from CTA to a form of discourse analysis (in this instance, narrative analysis). That shift underlines aspects of both the versatility of CTA and some of its weaknesses—versatility in the sense that CTA can be readily combined with other methods of analysis and in the way in which the results of the CTA help us to check and verify the claims of the researcher. The weakness of the diagram compared to the narrative is that CTA on its own is a somewhat one-dimensional and static form of analysis, and while it is possible to introduce time and chronology into the diagrams, the diagrams themselves remain lifeless in the absence of some form of discursive overview. (For a fuller analysis of these data, see Prior, Hughes, & Peckham, 2012 ).

Analyzing a Single Interview: The Role of Content Analysis in a Case Study

So far, I have focused on using CTA on a sample of interviews and a sample of documents. In the first instance, I recommended CTA for its capacity to tell us something about what is seemingly central to interviewees and for demonstrating how what is said is linked (in terms of a concept network). In the second instance, I reaffirmed the virtues of co-occurrence and network relations, but this time in the context of a form of discourse analysis. I also suggested that CTA can serve an important role in the process of verification of a narrative and its academic interpretation. In this section, however, I am going to link the use of CTA to another style of research—case study—to show how CTA might be used to analyze a single “case.”

Case study is a term used in multiple and often ambiguous ways. However, Gerring ( 2004 ) defined it as “an intensive study of a single unit for the purpose of understanding a larger class of (similar) units” (p. 342). As Gerring pointed out, case study does not necessarily imply a focus on N = 1, although that is indeed the most logical number for case study research (Ragin & Becker, 1992 ). Naturally, an N of 1 can be immensely informative, and whether we like it or not, we often have only one N to study (think, e.g., of the 1986 Challenger shuttle disaster or of the 9/11 attack on the World Trade Center). In the clinical sciences, case studies are widely used to represent the “typical” features of a wider class of phenomena and often used to define a kind or syndrome (as in the field of clinical genetics). Indeed, at the risk of mouthing a tautology, one can say that the distinctive feature of case study is its focus on a case in all of its complexity—rather than on individual variables and their interrelationships, which tends to be a point of focus for large N research.

There was a time when case study was central to the science of psychology. Breuer and Freud’s (2001) famous studies of “hysteria” (originally published in 1895) provide an early and outstanding example of the genre in this respect, but as with many of the other styles of social science research, the influence of case studies waned with the rise of much more powerful investigative techniques—including experimental methods—driven by the deployment of new statistical technologies. Ideographic studies consequently gave way to the current fashion for statistically driven forms of analysis that focus on causes and cross-sectional associations between variables rather than ideographic complexity.

In the example that follows, we will look at the consequences of a traumatic brain injury (TBI) on just one individual. The analysis is based on an interview with a person suffering from such an injury, and it was one of 32 interviews carried out with people who had experienced a TBI. The objective of the original research was to develop an outcome measure for TBI that was sensitive to the sufferer’s (rather than the health professional’s) point of view. In our original study (see Morris et al., 2005 ), interviews were also undertaken with 27 carers of the injured with the intention of comparing their perceptions of TBI to those of the people for whom they cared. A sample survey was also undertaken to elicit views about TBI from a much wider population of patients than was studied via interview.

In the introduction, I referred to Habermas and the concept of the lifeworld. Lifeworld ( Lebenswelt ) is a concept that first arose from 20th-century German philosophy. It constituted a specific focus for the work of Alfred Schutz (see, e.g., Schutz & Luckman, 1974 ). Schutz ( 1974 ) described the lifeworld as “that province of reality which the wide-awake and normal adult simply takes-for-granted in an attitude of common sense” (p. 3). Indeed, it was the routine and taken-for-granted quality of such a world that fascinated Schutz. As applied to the worlds of those with head injuries, the concept has particular resonance because head injuries often result in that taken-for-granted quality being disrupted and fragmented, ending in what Russian neuropsychologist A. R. Luria ( 1975 ) once described as “shattered” worlds. As well as providing another excellent example of a case study, Luria’s work is also pertinent because he sometimes argued for a “romantic science” of brain injury—that is, a science that sought to grasp the worldview of the injured patient by paying attention to an unfolding and detailed personal “story” of the individual with the head injury as well as to the neurological changes and deficits associated with the injury itself. In what follows, I shall attempt to demonstrate how CTA might be used to underpin such an approach.

In the original research, we began analysis by a straightforward reading of the interview transcripts. Unfortunately, a simple reading of a text or an interview can, strangely, mislead the reader into thinking that some issues or themes are more important than is warranted by the contents of the text. How that comes about is not always clear, but it probably has something to do with a desire to develop “findings” and our natural capacity to overlook the familiar in favor of the unusual. For that reason alone, it is always useful to subject any text to some kind of concordance analysis—that is, generating a simple frequency list of words used in an interview or text. Given the current state of technology, one might even speak these days of using text-mining procedures such as the aforementioned Clementine to undertake such a task. By using Clementine , and as we have seen, it is also possible to measure the strength of co-occurrence links between elements (i.e., words and concepts) in the entire data set (in this example, 32 interviews), though for a single interview these aims can just as easily be achieved using much simpler, low-tech strategies.

By putting all 32 interviews into the database, several common themes emerged. For example, it was clear that “time” entered into the semantic web in a prominent manner, and it was clearly linked to such things as “change,” “injury,” “the body,” and what can only be called the “I was.” Indeed, time runs through the 32 stories in many guises, and the centrality of time is a reflection of storytelling and narrative recounting in general—chronology, as we have noted, being a defining feature of all storytelling (Ricoeur, 1984 ). Thus, sufferers both recounted the events surrounding their injury and provided accounts as to how the injuries affected their current life and future hopes. As to time present, much of the patient story circled around activities of daily living—walking, working, talking, looking, feeling, remembering, and so forth.

Understandably, the word and the concept of “injury” featured largely in the interviews, though it was a word most commonly associated with discussions of physical consequences of injury. There were many references in that respect to injured arms, legs, hands, and eyes. There were also references to “mind”—though with far less frequency than with references to the body and to body parts. Perhaps none of this is surprising. However, one of the most frequent concepts in the semantic mix was the “I was” (716 references). The statement “I was,” or “I used to” was, in turn, strongly connected to terms such as “the accident” and “change.” Interestingly, the “I was” overwhelmingly eclipsed the “I am” in the interview data (the latter with just 63 references). This focus on the “I was” appears in many guises. For example, it is often associated with the use of the passive voice: “I was struck by a car,” “I was put on the toilet,” “I was shipped from there then, transferred to [Cityville],” “I got told that I would never be able …,” “I was sat in a room,” and so forth. In short, the “I was” is often associated with things, people, and events acting on the injured person. More important, however, the appearance of the “I was” is often used to preface statements signifying a state of loss or change in the person’s course of life—that is, as an indicator for talk about the patient’s shattered world. For example, Patient 7122 stated,

The main (effect) at the moment is I’m not actually with my children, I can’t really be their mum at the moment. I was a caring Mum, but I can’t sort of do the things that I want to be able to do like take them to school. I can’t really do a lot on my own. Like crossing the roads.

Another patient stated,

Everything is completely changed. The way I was … I can’t really do anything at the moment. I mean my German, my English, everything’s gone. Job possibilities is out the window. Everything is just out of the window … I just think about it all the time actually every day you know. You know it has destroyed me anyway, but if I really think about what has happened I would just destroy myself.

Each of these quotations, in its own way, serves to emphasize how life has changed and how the patient’s world has changed. In that respect, we can say that one of the major outcomes arising from TBI may be substantial “biographical disruption” (Bury, 1982 ), whereupon key features of an individual’s life course are radically altered forever. Indeed, as Becker ( 1997 , p. 37) argued in relation to a wide array of life events, “When their health is suddenly disrupted, people are thrown into chaos. Illness challenges one’s knowledge of one’s body. It defies orderliness. People experience the time before their illness and its aftermath as two separate entities.” Indeed, this notion of a cusp in personal biography is particularly well illustrated by Luria’s patient Zasetsky; the latter often refers to being a “newborn creature” (Luria, 1975 , pp. 24, 88), a shadow of a former self (p. 25), and as having his past “wiped out” (p. 116).

However, none of this tells us about how these factors come together in the life and experience of one individual. When we focus on an entire set of interviews, we necessarily lose the rich detail of personal experience and tend instead to rely on a conceptual rather than a graphic description of effects and consequences (to focus on, say, “memory loss,” rather than loss of memory about family life). The contents of Figure 19.3 attempt to correct that vision. Figure 19.3 records all the things that a particular respondent (Patient 7011) used to do and liked doing. It records all the things that he says he can no longer do (at 1 year after injury), and it records all the consequences that he suffered from his head injury at the time of the interview. Thus, we see references to epilepsy (his “fits”), paranoia (the patient spoke of his suspicions concerning other people, people scheming behind his back, and his inability to trust others), deafness, depression, and so forth. Note that, although I have inserted a future tense into the web (“I will”), such a statement never appeared in the transcript. I have set it there for emphasis and to show how, for this person, the future fails to connect to any of the other features of his world except in a negative way. Thus, he states at one point that he cannot think of the future because it makes him feel depressed (see Figure 19.3 ). The line thickness of the arcs reflects the emphasis that the subject placed on the relevant “outcomes” in relation to the “I was” and the “now” during the interview. Thus, we see that factors affecting his concentration and balance loom large, but that he is also concerned about his being dependent on others, his epileptic fits, and his being unable to work and drive a vehicle. The schism in his life between what he used to do, what he cannot now do, and his current state of being is nicely represented in the CTA diagram.

The shattered world of Patient 7011. Thickness of lines (arcs) is proportional to the frequency of reference to the “outcome” by the patient during the interview.

What have we gained from executing this kind of analysis? For a start, we have moved away from a focus on variables, frequencies, and causal connections (e.g., a focus on the proportion of people with TBI who suffer from memory problems or memory problems and speech problems) and refocused on how the multiple consequences of a TBI link together in one person. In short, instead of developing a narrative of acting variables, we have emphasized a narrative of an acting individual (Abbott, 1992 , p. 62). Second, it has enabled us to see how the consequences of a TBI connect to an actual lifeworld (and not simply an injured body). So the patient is not viewed just as having a series of discrete problems such as balancing, or staying awake, which is the usual way of assessing outcomes, but as someone struggling to come to terms with an objective world of changed things, people, and activities (missing work is not, for example, routinely considered an outcome of head injury). Third, by focusing on what the patient was saying, we gain insight into something that is simply not visible by concentrating on single outcomes or symptoms alone—namely, the void that rests at the center of the interview, what I have called the “I was.” Fourth, we have contributed to understanding a type, because the case that we have read about is not simply a case of “John” or “Jane” but a case of TBI, and in that respect it can add to many other accounts of what it is like to experience head injury—including one of the most well documented of all TBI cases, that of Zatetsky. Finally, we have opened up the possibility of developing and comparing cognitive maps (Carley, 1993 ) for different individuals and thereby gained insight into how alternative cognitive frames of the world arise and operate.

Tracing the Biography of a Concept

In the previous sections, I emphasized the virtues of CTA for its capacity to link into a data set in its entirety—and how the use of CTA can counter any tendency of a researcher to be selective and partial in the presentation and interpretation of information contained in interviews and documents. However, that does not mean that we always must take an entire document or interview as the data source. Indeed, it is possible to select (on rational and explicit grounds) sections of documentation and to conduct the CTA on the chosen portions. In the example that follows, I do just that. The sections that I chose to concentrate on are titles and abstracts of academic papers—rather than the full texts. The research on which the following is based is concerned with a biography of a concept and is being conducted in conjunction with a Ph.D. student of mine, Joanne Wilson. Joanne thinks of this component of the study more in terms of a “scoping study” than of a biographical study, and that, too, is a useful framework for structuring the context in which CTA can be used. Scoping studies (Arksey & O’Malley, 2005 ) are increasingly used in health-related research to “map the field” and to get a sense of the range of work that has been conducted on a given topic. Such studies can also be used to refine research questions and research designs. In our investigation, the scoping study was centered on the concept of well-being. Since 2010, well-being has emerged as an important research target for governments and corporations as well as for academics, yet it is far from clear to what the term refers. Given the ambiguity of meaning, it is clear that a scoping review, rather than either a systematic review or a narrative review of available literature, would be best suited to our goals.

The origins of the concept of well-being can be traced at least as far back as the 4th century bc , when philosophers produced normative explanations of the good life (e.g., eudaimonia, hedonia, and harmony). However, contemporary interest in the concept seemed to have been regenerated by the concerns of economists and, most recently, psychologists. These days, governments are equally concerned with measuring well-being to inform policy and conduct surveys of well-being to assess that state of the nation (see, e.g., Office for National Statistics, 2012 )—but what are they assessing?

We adopted a two-step process to address the research question, “What is the meaning of ‘well-being’ in the context of public policy?” First, we explored the existing thesauri of eight databases to establish those higher order headings (if any) under which articles with relevance to well-being might be cataloged. Thus, we searched the following databases: Cumulative Index of Nursing and Allied Health Literature, EconLit, Health Management Information Consortium, Medline, Philosopher’s Index, PsycINFO, Sociological Abstracts, and Worldwide Political Science Abstracts. Each of these databases adopts keyword-controlled vocabularies. In other words, they use inbuilt statistical procedures to link core terms to a set lexis of phrases that depict the concepts contained in the database. Table 19.2 shows each database and its associated taxonomy. The contents of Table 19.2 point toward a linguistic infrastructure in terms of which academic discourse is conducted, and our task was to extract from this infrastructure the semantic web wherein the concept of well-being is situated. We limited the thesaurus terms to well-being and its variants (i.e., wellbeing or well being). If the term was returned, it was then exploded to identify any associated terms.

To develop the conceptual map, we conducted a free-text search for well-being and its variants within the context of public policy across the same databases. We orchestrated these searches across five time frames: January 1990 to December 1994, January 1995 to December 1999, January 2000 to December 2004, January 2005 to December 2009, and January 2010 to October 2011. Naturally, different disciplines use different words to refer to well-being, each of which may wax and wane in usage over time. The searches thus sought to quantitatively capture any changes in the use and subsequent prevalence of well-being and any referenced terms (i.e., to trace a biography).

It is important to note that we did not intend to provide an exhaustive, systematic search of all the relevant literature. Rather, we wanted to establish the prevalence of well-being and any referenced (i.e., allied) terms within the context of public policy. This has the advantage of ensuring that any identified words are grounded in the literature (i.e., they represent words actually used by researchers to talk and write about well-being in policy settings). The searches were limited to abstracts to increase the specificity, albeit at some expense to sensitivity, with which we could identify relevant articles.

We also employed inclusion/exclusion criteria to facilitate the process by which we selected articles, thereby minimizing any potential bias arising from our subjective interpretations. We included independent, stand-alone investigations relevant to the study’s objectives (i.e., concerned with well-being in the context of public policy), which focused on well-being as a central outcome or process and which made explicit reference to “well-being” and “public policy” in either the title or the abstract. We excluded articles that were irrelevant to the study’s objectives, those that used noun adjuncts to focus on the well-being of specific populations (i.e., children, elderly, women) and contexts (e.g., retirement village), and those that focused on deprivation or poverty unless poverty indices were used to understand well-being as opposed to social exclusion. We also excluded book reviews and abstracts describing a compendium of studies.

Using these criteria, Joanne Wilson conducted the review and recorded the results on a template developed specifically for the project, organized chronologically across each database and timeframe. Results were scrutinized by two other colleagues to ensure the validity of the search strategy and the findings. Any concerns regarding the eligibility of studies for inclusion were discussed among the research team. I then analyzed the co-occurrence of the key terms in the database. The resultant conceptual map is shown in Figure 19.4.

The position of a concept in a network—a study of “well-being.” Node size is proportional to the frequency of terms in 54 selected abstracts. Line thickness is proportional to the co-occurrence of two terms in any phrase of three words (e.g., subjective well-being, economics of well-being, well-being and development).

The diagram can be interpreted as a visualization of a conceptual space. So, when academics write about well-being in the context of public policy, they tend to connect the discussion to the other terms in the matrix. “Happiness,” “health,” “economic,” and “subjective,” for example, are relatively dominant terms in the matrix. The node size of these words suggests that references to such entities is only slightly less than references to well-being itself. However, when we come to analyze how well-being is talked about in detail, we see specific connections come to the fore. Thus, the data imply that talk of “subjective well-being” far outweighs discussion of “social well-being” or “economic well-being.” Happiness tends to act as an independent node (there is only one occurrence of happiness and well-being), probably suggesting that “happiness” is acting as a synonym for well-being. Quality of life is poorly represented in the abstracts, and its connection to most of the other concepts in the space is very weak—confirming, perhaps, that quality of life is unrelated to contemporary discussions of well-being and happiness. The existence of “measures” points to a distinct concern to assess and to quantify expressions of happiness, well-being, economic growth, and gross domestic product. More important and underlying this detail, there are grounds for suggesting that there are in fact a number of tensions in the literature on well-being.

On the one hand, the results point toward an understanding of well-being as a property of individuals—as something that they feel or experience. Such a discourse is reflected through the use of words like happiness, subjective , and individual . This individualistic and subjective frame has grown in influence over the past decade in particular, and one of the problems with it is that it tends toward a somewhat content-free conceptualization of well-being. To feel a sense of well-being, one merely states that one is in a state of well-being; to be happy, one merely proclaims that one is happy (cf., Office for National Statistics, 2012 ). It is reminiscent of the conditions portrayed in Aldous Huxley’s Brave New World , wherein the rulers of a closely managed society gave their priority to maintaining order and ensuring the happiness of the greatest number—in the absence of attention to justice or freedom of thought or any sense of duty and obligation to others, many of whom were systematically bred in “the hatchery” as slaves.

On the other hand, there is some intimation in our web that the notion of well-being cannot be captured entirely by reference to individuals alone and that there are other dimensions to the concept—that well-being is the outcome or product of, say, access to reasonable incomes, to safe environments, to “development,” and to health and welfare. It is a vision hinted at by the inclusion of those very terms in the network. These different concepts necessarily give rise to important differences concerning how well-being is identified and measured and therefore what policies are most likely to advance well-being. In the first kind of conceptualization, we might improve well-being merely by dispensing what Huxley referred to as “soma” (a superdrug that ensured feelings of happiness and elation); in the other case, however, we would need to invest in economic, human, and social capital as the infrastructure for well-being. In any event and even at this nascent level, we can see how CTA can begin to tease out conceptual complexities and theoretical positions in what is otherwise routine textual data.

Putting the Content of Documents in Their Place

I suggested in my introduction that CTA was a method of analysis—not a method of data collection or a form of research design. As such, it does not necessarily inveigle us into any specific forms of either design or data collection, though designs and methods that rely on quantification are dominant. In this closing section, however, I want to raise the issue as to how we should position a study of content in our research strategies as a whole. We must keep in mind that documents and records always exist in a context and that while what is “in” the document may be considered central, a good research plan can often encompass a variety of ways of looking at how content links to context. Hence, in what follows, I intend to outline how an analysis of content might be combined with other ways of looking at a record or text and even how the analysis of content might be positioned as secondary to an examination of a document or record. The discussion calls on a much broader analysis, as presented in Prior ( 2011 ).

I have already stated that basic forms of CTA can serve as an important point of departure for many types of data analysis—for example, as discourse analysis. Naturally, whenever “discourse” is invoked, there is at least some recognition of the notion that words might play a part in structuring the world rather than merely reporting on it or describing it (as is the case with the 2002 State of the Nation address that was quoted in the section “Units of Analysis”). Thus, for example, there is a considerable tradition within social studies of science and technology for examining the place of scientific rhetoric in structuring notions of “nature” and the position of human beings (especially as scientists) within nature (see, e.g., work by Bazerman, 1988 ; Gilbert & Mulkay, 1984 ; and Kay, 2000 ). Nevertheless, little, if any, of that scholarship situates documents as anything other than inert objects, either constructed by or waiting patiently to be activated by scientists.

However, in the tradition of the ethnomethodologists (Heritage, 1991 ) and some adherents of discourse analysis, it is also possible to argue that documents might be more fruitfully approached as a “topic” (Zimmerman & Pollner, 1971 ) rather than a “resource” (to be scanned for content), in which case the focus would be on the ways in which any given document came to assume its present content and structure. In the field of documentation, these latter approaches are akin to what Foucault ( 1970 ) might have called an “archaeology of documentation” and are well represented in studies of such things as how crime, suicide, and other statistics and associated official reports and policy documents are routinely generated. That, too, is a legitimate point of research focus, and it can often be worth examining the genesis of, say, suicide statistics or statistics about the prevalence of mental disorder in a community as well as using such statistics as a basis for statistical modeling.

Unfortunately, the distinction between topic and resource is not always easy to maintain—especially in the hurly-burly of doing empirical research (see, e.g., Prior, 2003 ). Putting an emphasis on “topic,” however, can open a further dimension of research that concerns the ways in which documents function in the everyday world. And, as I have already hinted, when we focus on function, it becomes apparent that documents serve not merely as containers of content but also very often as active agents in episodes of interaction and schemes of social organization. In this vein, one can begin to think of an ethnography of documentation. Therein, the key research questions revolve around the ways in which documents are used and integrated into specific kinds of organizational settings, as well as with how documents are exchanged and how they circulate within such settings. Clearly, documents carry content—words, images, plans, ideas, patterns, and so forth—but the manner in which such material is called on and manipulated, and the way in which it functions, cannot be determined (though it may be constrained) by an analysis of content. Thus, Harper’s ( 1998 ) study of the use of economic reports inside the International Monetary Fund provides various examples of how “reports” can function to both differentiate and cohere work groups. In the same way. Henderson ( 1995 ) illustrated how engineering sketches and drawings can serve as what she calls conscription devices on the workshop floor.

Documents constitute a form of what Latour ( 1986 ) would refer to as “immutable mobiles,” and with an eye on the mobility of documents, it is worth noting an emerging interest in histories of knowledge that seek to examine how the same documents have been received and absorbed quite differently by different cultural networks (see, e.g., Burke, 2000 ). A parallel concern has arisen with regard to the newly emergent “geographies of knowledge” (see, e.g., Livingstone, 2005 ). In the history of science, there has also been an expressed interest in the biography of scientific objects (Latour, 1987 , p. 262) or of “epistemic things” (Rheinberger, 2000 )—tracing the history of objects independent of the “inventors” and “discoverers” to which such objects are conventionally attached. It is an approach that could be easily extended to the study of documents and is partly reflected in the earlier discussion concerning the meaning of the concept of well-being. Note how in all these cases a key consideration is how words and documents as “things” circulate and translate from one culture to another; issues of content are secondary.

Studying how documents are used and how they circulate can constitute an important area of research in its own right. Yet even those who focus on document use can be overly anthropocentric and subsequently overemphasize the potency of human action in relation to written text. In that light, it is interesting to consider ways in which we might reverse that emphasis and instead to study the potency of text and the manner in which documents can influence organizational activities as well as reflect them. Thus, Dorothy Winsor ( 1999 ), for example, examined the ways in which work orders drafted by engineers not only shape and fashion the practices and activities of engineering technicians but also construct “two different worlds” on the workshop floor.

In light of this, I will suggest a typology (Table 19.3 ) of the ways in which documents have come to be and can be considered in social research.

While accepting that no form of categorical classification can capture the inherent fluidity of the world, its actors, and its objects, Table 19.3 aims to offer some understanding of the various ways in which documents have been dealt with by social researchers. Thus, approaches that fit into Cell 1 have been dominant in the history of social science generally. Therein, documents (especially as text) have been analyzed and coded for what they contain in the way of descriptions, reports, images, representations, and accounts. In short, they have been scoured for evidence. Data analysis strategies concentrate almost entirely on what is in the “text” (via various forms of CTA). This emphasis on content is carried over into Cell 2–type approaches, with the key differences being that analysis is concerned with how document content comes into being. The attention here is usually on the conceptual architecture and sociotechnical procedures by means of which written reports, descriptions, statistical data, and so forth are generated. Various kinds of discourse analysis have been used to unravel the conceptual issues, while a focus on sociotechnical and rule-based procedures by means of which clinical, police, social work, and other forms of records and reports are constructed has been well represented in the work of ethnomethodologists (see Prior, 2011 ). In contrast, and in Cell 3, the research focus is on the ways in which documents are called on as a resource by various and different kinds of “user.” Here, concerns with document content or how a document has come into being are marginal, and the analysis concentrates on the relationship between specific documents and their use or recruitment by identifiable human actors for purposeful ends. I have pointed to some studies of the latter kind in earlier paragraphs (e.g., Henderson, 1995 ). Finally, the approaches that fit into Cell 4 also position content as secondary. The emphasis here is on how documents as “things” function in schemes of social activity and with how such things can drive, rather than be driven by, human actors. In short, the spotlight is on the vita activa of documentation, and I have provided numerous example of documents as actors in other publications (see Prior, 2003 , 2008 , 2011 ).

Content analysis was a method originally developed to analyze mass media “messages” in an age of radio and newspaper print, well before the digital age. Unfortunately, CTA struggles to break free of its origins and continues to be associated with the quantitative analysis of “communication.” Yet, as I have argued, there is no rational reason why its use must be restricted to such a narrow field, because it can be used to analyze printed text and interview data (as well as other forms of inscription) in various settings. What it cannot overcome is the fact that it is a method of analysis and not a method of data collection. However, as I have shown, it is an analytical strategy that can be integrated into a variety of research designs and approaches—cross-sectional and longitudinal survey designs, ethnography and other forms of qualitative design, and secondary analysis of preexisting data sets. Even as a method of analysis, it is flexible and can be used either independent of other methods or in conjunction with them. As we have seen, it is easily merged with various forms of discourse analysis and can be used as an exploratory method or as a means of verification. Above all, perhaps, it crosses the divide between “quantitative” and “qualitative” modes of inquiry in social research and offers a new dimension to the meaning of mixed methods research. I recommend it.

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• Published: 26 April 2024

Barriers and facilitators to the implementation of prehabilitation for elderly frail patients prior to elective surgery: a qualitative study with healthcare professionals

• Tamina Isabel Fuchs 1 ,
• Carina Pfab 1 , 2 ,
• Jörn Kiselev 3 , 4 ,
• Stefan J Schaller 3 , 5 ,
• Claudia Spies 3 &
• Tanja Rombey 6  

BMC Health Services Research volume  24 , Article number:  536 ( 2024 ) Cite this article

Metrics details

Prehabilitation aims to enhance functional capacity before surgery, minimise complications and achieve a better postoperative outcome. This can be particularly useful for older, frail patients to better tolerate surgery. The aim of this study was to identify what barriers and facilitators healthcare professionals in Germany experienced in the implementation and delivery of the multimodal prehabilitation programme “PRAEP-GO” for (pre-)frail adults aged 70 years and older to inform the implementation of prehabilitation into standard care.

A nested descriptive qualitative study was conducted using semi-structured face-to-face interviews with healthcare professionals involved in the PRAEP-GO trial from the Berlin and Brandenburg region in Germany. Transcripts were analysed using Kuckartz’ qualitative content analysis. Results were interpreted and synthesised using the Consolidated Framework for Implementation Research, a theoretical framework to allow their application to a more general context.

A total of 14 interviews were conducted. Seven therapists (physio-, ergo-, sports therapy), five physicians and two employees from other professions with mainly administrative and organisational tasks in the project. All identified barriers and facilitating factors could be assigned to the themes of organisation, prehabilitation, cooperation and communication between healthcare professionals and with patients. Much optimisation potential was found regarding organisational aspects, e.g. addressing perceived staff shortages and optimising the patient pathway. Furthermore, it became apparent that communication and cooperation between professionals but also with patients need to be improved. More evidence regarding prehabilitation should be provided to convince professionals more. Prehabilitation should be multimodal and individualised, including the programme duration. Officially introducing prehabilitation into standard care would facilitate its delivery.

These findings underscore the fact that successful implementation of prehabilitation programmes, such as PRAEP-GO, requires sufficient organisational infrastructure, human resources, access to knowledge, an adaptable and individualised programme design as well as good communication among professionals and with patients. The transferability of the findings is limited by the absence of nutritionists and resulting overrepresentation of other therapists in the sample. To further convince professionals and patients of the concept of prehabilitation, more research is needed to build a solid evidence base that will ensure greater awareness and, thus, more motivation and cooperation among professionals and patients.

Trial registration

Open Science Framework (osf.io/ksfgj).

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Introduction

Due to the increasing life expectancy and ageing of society, the number of physically impaired patients with multiple comorbidities is rising and with it the proportion of older patients undergoing surgery [ 1 ]. In Germany, one-third of inpatient surgeries in 2020 were performed on people aged 70 and older. Of all age groups, most surgeries were performed in patients aged 75–80 years, with over 1,5 million surgeries [ 2 ].

A surgery generally represents a stress factor for patients that is associated with temporary deconditioning. Tolerance to surgery may be impaired, particularly in older patients, through age-related psychophysiological changes and comorbidities, increasing the risk of complications and negative health consequences for this patient group [ 3 ]. Especially frail older patients are more vulnerable for perioperative complications [ 4 ], postoperative complications, prolonged hospital stays, disability, and death [ 5 ]. Frailty can be described as a biological syndrome in which reserves and resistance to stressors decline, leading to a cumulative deterioration of multiple physiological systems [ 6 , 7 , 8 , 9 , 10 , 11 ]. It is an age-related condition of high vulnerability for adverse health outcomes like falls, disability, and delirium, in older adults [ 12 , 13 , 14 , 15 ].

Prehabilitation aims to help patients return to the highest possible level of function as quickly as possible after surgery [ 3 ]. It is a process of improving an individual’s functional capacity to withstand the stressors of inactivity [ 16 ], e.g. following surgery. Prehabilitation involves targeted preventive interventions like exercise training or nutrition therapy to improve health and health-related functions before an operation [ 3 , 17 ], thereby speeding up recovery [ 18 , 19 ], and reducing the length of stay in hospital [ 20 ] as well as postoperative complications [ 21 ]. In multimodal prehabilitation programmes, different interventions are combined [ 18 ], making it a complex and multidisciplinary intervention.

For successful implementation of a complex intervention such as multimodal prehabilitation, it is essential to find out which factors promote or hinder different components of the intervention. Apart from the participating patients, the view of the healthcare professionals involved in the prehabilitation process is particularly important because they are both experts for their workplace as well as prehabilitation itself. Furthermore, in multimodal prehabilitation, different professional groups across different areas must work together as a team that is characterised by the mix of different skills of its team members and potential skill-mix change [ 22 , 23 ].

Previous studies identified several barriers to the implementation of prehabilitation from the perspective of healthcare professionals, such as a lack of human resources, lack of time to take an active role in prehabilitation as a physician, unclear financing, lack of communication between healthcare providers [ 24 ], the time for prehabilitation before surgery being too short [ 24 , 25 ] or that exercise information were not well read or understood by patients [ 25 ]. However, these studies also found facilitators, including when there was an opportunity for healthcare professionals to talk about a healthy lifestyle with their patients [ 24 ], when prehabilitation had already been incorporated into standard care [ 24 , 25 ], and when programmes allowed the exercises to be adjusted to the patient’s physical abilities and personal preferences and integrated in patient’s daily living [ 25 ].

The aim of this qualitative study was to identify, through qualitative expert interviews, what barriers and facilitators, specifically to the implementation and delivery of prehabilitation for frail elderly patients, healthcare professionals experienced in the context of the PRAEP-GO trial to inform the implementation of prehabilitation into standard care.

The PRAEP-GO multicentre randomised trial (NCT04418271, registered on 5 June 2020) currently investigates the (cost-)effectiveness of a multimodal prehabilitation programme for elderly (pre-)frail patients prior to elective surgery in Germany [ 26 ]. The trial enrolled approximately 1,400 patients across different regions over 3 years, and follow-up will end in August 2024 [ 27 ]. The overall goal was to inform the nationwide implementation of the PRAEP-GO prehabilitation programme into standard care in Germany.

This was a nested descriptive qualitative study using semi-structured face-to-face interviews with health professionals involved in the ongoing multicentre randomised PRAEP-GO trial that investigates the (cost-)effectiveness of a multimodal prehabilitation programme for frail or pre-frail older people prior to elective surgery [ 26 ].

In the PRAEP-GO trial, patients were identified at participating hospitals during their initial consultation for an upcoming elective surgery with an expected duration of anaesthesia ≥ 60 min and without restriction on the treatment area. Interested patients over the age of 70 were screened for frailty using criteria by Fried et al. 2001 [ 12 ], and included in the trial if pre-frail or frail. When assigned to the intervention group, a three-week prehabilitation programme took place prior to surgery. Prehabilitation was planned individually for each patient during a shared decision-making (SDM) conference involving different healthcare professionals as well as the patient or their relatives. The trial was funded by the Innovation Fund of Germany’s Federal Joint Committee [ 28 ], meaning that the prehabilitation programme might be recommended for nationwide implementation should it prove to be (cost)effective [ 29 ].

The qualitative study presented here was performed in accordance with the Declaration of Helsinki and was approved by the ethics committee of the Charité – Universitätsmedizin Berlin (EA1/266/20, version 1.4) as well as the staff council. A protocol was prospectively registered on May 18, 2022 on the Open Science Framework (OSF) (osf.io/ksfgj). Reporting was guided by the Consolidated criteria for Reporting Qualitative research (COREQ) checklist [ 30 ] (appendix  A ).

Study population

Inclusion criteria for interview participants were healthcare professionals of any age and gender who were involved in the PRAEP-GO trial and represented a mix of professions such as therapists, physicians and staff who mainly take on organisational tasks in the project, such as coordinating patients. Professionals who only carried out study-related tasks, such as outcome assessment, were excluded because we aimed to collect information about the prehabilitation process only. In that regard, purely study-related aspects, such as tests or documentation, were not of interest, as they will be omitted if prehabilitation is introduced into standard care. The interviewees were selected in the form of a convenience sample. For feasibility reasons, only healthcare professionals from the Berlin/Brandenburg region, where the trial lead is based, were included. There was no financial compensation for the interview participants.

Potential interview partners were reached via e-mail invitation. The mail addresses were obtained with the help of the official websites of the respective institutions. Members of the PRAEP-GO administration team supported the contacting process by passing on official e-mail distribution lists or contact information and disseminating information about the study. A total of 29 invitations for interviews were sent to reach all participating institutions of the PRAEP-GO project in Berlin/Brandenburg region to recruit professionals for the interviews. Interview partners were transparently informed about the study and data protection regulations, and their informed consent was obtained before the interview.

Data collection

Data collection was conducted in the form of one-on-one interviews by one researcher, a female postgraduate student of Public Health with an undergraduate degree in Medical Management, student assistant at the Institute of General Medicine at Charité – Universitätsmedizin Berlin, with experience in qualitative research. Interviews were held in person from November 2022 to January 2023. The interviewer had no contact or relationships with participants prior to recruitment. Participants were informed that the researcher was a public health student and that the study took place within the context of a Master’s thesis. Interviewees received the interview guide prior to their participation. The locations where the interviews took place depended on the person to be interviewed and their daily work routine. The interviews were held at the participant’s workplace in the hospital or therapy centre setting without the presence of third parties.

The interviews were conducted following a semi-structured interview guide (available in English and German from the OSF project) [ 31 ]. It was designed following the four-step principle of collecting, reviewing, sorting, and subsuming interview guiding questions by Helfferich 2011 to maintain the basic principle of openness and yet provide the necessary structuring for the research interest [ 32 ]. To develop the interview guide, barriers and facilitators of prehabilitation programs from the perspective of healthcare professionals from previous studies were summarised. The interview guide covered the following aspects: organisation, cooperation and communication, time and prehabilitation implementation [ 24 , 25 , 33 ]. Trial-related matters that would not apply to implementation into routine care, e.g., randomisation or study documentation, were not of interest for the present study and thus not part of the interview guide because the focus lied on the prehabilitation program itself.

A pilot test of the interview guide took place with a healthcare professional involved in the PRAEP-GO trial before the first interview was conducted. Content from the (test-)interview was not included in the analysis. Interviews were expected to last from twenty minutes to a maximum of one hour. The number of interviews depended on content saturation with an expected maximum of 15 interviews. Content saturation was considered to be achieved when no new information emerged from the interviews anymore. Before recording, demographic, and occupational information was obtained to allow characterising the sample. Upon completion of each interview, the researcher prepared a postscript.

Each interview was recorded using a non-web-enabled recorder (Tschisen V90, Tschisen, China). None of the interviews were repeated. The audio recordings were transcribed by the same researcher using MAXQDA version 2022.4.0 [ 34 ]. The basis for this were the transcription rules according to Dresing and Pehl (2015) [ 35 ]. Transcripts were not sent back to any interviewee for checking or correction. Once transcribed, the audio recordings were permanently deleted. The anonymised transcripts were stored on an encrypted data folder at the research institute, to which only the conducting researcher had access.

Data analysis

The analysis was divided into barriers and facilitators. All factors that make prehabilitation more difficult, have made it more difficult, and will make it more difficult regarding introduction into standard care were summarised in the main category “barriers”. All factors that facilitated prehabilitation or will facilitate prehabilitation regarding introduction into standard care, were summarised in the main category “facilitators”.

To categorise the interview content the software MAXQDA version 2022.4.0 was used [ 34 ]. Following transcription, the interviews were analysed using the 7-step model of content structuring content analysis according to Kuckartz (2018) (Fig.  1 ) [ 36 ].

Flow model of a content structuring content analysis; own figure according to Kuckartz (2018) [ 36 ]

The analysis approach by Kuckartz (2018) allows for both a deductive and an inductive creation of the category system. In this study, deductive categories were first created based on the results of background literature searches. The questions of the interview guide were then used as a basis to create the deductive main categories regarding barriers and facilitators (step 2): communication, time, prehabilitation and organisation. Based on these categories, the transcripts were analysed and roughly coded (step 3) and the corresponding text passages were assigned to an appropriate deductive main category using the software MAXQDA 2022 (step 4) [ 34 ]. Next, inductive subcategories based on frequently mentioned themes were added to further differentiate the deductively created main categories during the intensified text work (step 5). Finally, all transcripts were coded using the final category system (step 6) which were then synthesised and visualised (step 7). To adapt the category system to the material, the deductive main category “time” was removed, since all statements about temporal aspects could be divided into the remaining main categories.

The text passages were initially assigned by one researcher, who also conducted the interviews. Kuckartz (2018) recommends conservative coding according to Hopf and Schmidt (1993) to ensure the quality of the coding process [ 36 , 37 ]. Thus, a second researcher (female, Master of Public Health student with expertise in qualitative research, qualified occupational therapist) coded the interviews independently using the pre-existing category system and a coding guide to improve the reliability of the codes (available in English and German from the OSF project) [ 31 ]. Subsequently, the coding of both researchers was compared and discussed until consensus was found. For the purpose of this publication, all participant quotations were translated verbatim into English language using DeepL software [ 38 ]. Where necessary, the grammar of supporting quotations was adapted for better comprehensibility.

Synthesis of results

Synthesis of the final categories was guided by the updated Consolidated Framework for Implementation Research (CFIR) [ 39 ], which is a commonly used theoretical framework based on 19 published implementation science theories [ 40 ]. The updated CFIR consists of the following five main domains: (I) Innovation, (II) Outer setting, (III) Inner setting, (IV) Individuals, and (V) Implementation process [ 39 ]. These areas interact in multiple and complex ways to influence the effectiveness of an intervention’s implementation. Subordinate to the five main areas are an additional 39 underlying constructs and subconstructs, of which those most relevant to the particular setting of the PRAEP-GO trial were chosen to synthesise the final categories, and help organise and explain all outcomes of the implementation process.

A total of 14 individuals volunteered to participate in the interviews, while the remaining 15 invitations were declined or remained unanswered. Interview requests were declined due to lack of staff and time. The demographic and occupational data of the interviewees are listed in Table  1 . Interviews took between ten and 41 min (median 19 min).

A total of 215 sequences were coded under barriers. Most of the barriers experienced by health professionals related to the theme “organisation”. This subcategory included a total of 114 codes and was again subdivided into nine further subthemes or subcategories relating to organisational aspects of the prehabilitation process. The most frequently mentioned barrier was related to perceived staff shortages. One physician said on this topic:

“That was a structural problem – at the time, there was not enough staff in orthopaedics and trauma surgery (…) for additional projects…” (B8) .

One of the therapists mentioned:

“(…) we weren’t well staffed on the ward, we always had staff shortages and that was critical for planning…’’ (B2) .

Another organisational barrier was the perceived short-term planning of prehabilitation, which makes it difficult to integrate patients into the day-to-day business of prehabilitation facilities, as well as training deficits among healthcare professionals with regard to prehabilitation. Trial-related issues, such as testing, randomisation or documentation, were also frequently mentioned by the participants as a barrier, as they require additional work for healthcare staff. In addition, scheduling uncertainties in the operating room (OR) schedule and the resulting rescheduling of OR appointments were found to hamper the implementation of prehabilitation, especially for healthcare professionals from surgery. One physician commented:

“Add to that the increased trauma surgery volume as other hospitals increasingly pull out of emergency care. This is really blowing up our elective operating rooms and patients are having to be moved like dominoes. That makes the patient unhappy, that blows up the PRAEP-GO protocol, and that’s one of the biggest hurdles we’ve had to overcome recently with this project here.” (B3) .

The scope and effort associated with SDM conferences were also criticised, and one physician explained:

“What really hampered it were the [SDM conferences] that are scheduled for an hour and a half and then at times when our surgery day is simply going on…” (B3) .

The discrepancy between the current patient pathway, where patients often do not see anaesthesia at the time of initial planning of their surgery, and the ideal patient pathway, linking prehabilitation to interdisciplinary teamwork approaches within perioperative medicine, was mentioned several times as a complicating factor, e.g., by one of the physicians:

“The concept was that the patients would be sent directly from the admission centre to anaesthesia for screening and inclusion and that didn’t work in practice. The surgeons see these patients first, make an indication and send the patients home again and anaesthetists must chase after the patients…” (B11) .

The daily travel times for frail patients were perceived as too long and the lack of prehabilitation centres was also mentioned as a barrier.

Another subcategory with 64 sequences of “barriers” refers to the communication and cooperation of all persons involved in prehabilitation. Most frequently mentioned here was insufficient cooperation between professional groups, facilities, and medical specialties. Among other things, resistance to the concept of prehabilitation and conflicts between colleagues were reported within this subcategory. One of the physicians described this as follows:

“There was some resistance and rejection at first because my colleagues couldn’t estimate how much work it [prehabilitation] would mean for them.” (B11) .

Additionally, insufficient cooperation of some patients and communication deficits between patients and health professionals were mentioned as an aggravating factor.

Further barriers can be summarised within the subcategory “prehabilitation” with 37 sequences. The most frequent statement within this subcategory was that the predefined therapy plans were too rigid, resulting in patients being under or over challenged and sometimes having to idle time between therapy sessions, as described in the following quote:

“Because some [patients] are actually fitter, they could do much more, so they do more then. They go for a walk for ages, which is not documented as a therapy session.” (B7) .

Additionally, the time span for prehabilitation was criticised as either too long overall or too short for physiological adaptation processes. Finally, it was stated that the health status and the age of the patients made prehabilitation more difficult in some cases.

In Table  2 , all identified barriers are listed by professional group.

• Facilitators

All factors that facilitated prehabilitation or will facilitate prehabilitation regarding introduction into regular care, were summarised in the main category “facilitators”. A total of 176 sequences were coded for this purpose. The facilitating factors are also divided into the three main themes or subcategories of communication & cooperation, prehabilitation, and organisation.

A total of 77 sequences referred to the subcategory “organisation”. The most frequently mentioned facilitating factor was the need for optimising the patient pathway, including the simplification and standardisation of the prehabilitation process. One physician said in this regard:

“I believe that the overall process should be simplified, both in terms of preparing people and asking who is a candidate for prehabilitation, as well as the measures that are taken.” (B10) .

Health professionals stated that by introducing prehabilitation, many complicating factors of prehabilitation, such as rigid therapy plans to ensure comparability of data, would automatically be eliminated, making prehabilitation easier. One of the physicians argued:

“I think if this is incorporated into standard care, then patients are treated more pragmatically and not so according to a standard, according to a protocol. I believe that if a patient has the motivation to stay longer, to do self-exercises, then no one will forbid this patient to do so.” (B11) .

Another frequently mentioned facilitating factor regarding the organisation of prehabilitation was more personnel resources. The SDM conferences were also identified to play an important role in prehabilitation, as they facilitate communication, information sharing, and goal setting among health professionals and with patients. Participants called for more time to plan prehabilitation and involve prehabilitation facilities and suggested the increased use of smart IT solutions and technology within the prehabilitation process to facilitate certain procedures. There was also a call for a clearer documentation within the prehabilitation process.

With a total of 60 coded sequences in the subcategory “prehabilitation” most of the statements here referred to a more individualised therapy design. One of the therapists suggested in this regard:

“It would probably make more sense if you had a little more time or if you could get away from this rigid regulation of breaks, for example in strength training (…)” (B5) .

The choice of outpatient, inpatient, day-care or home visit prehabilitation was identified a facilitating factor. Some statements referred to the fact that a longer prehabilitation period and thus fewer therapy units per week would have a beneficial effect on the prehabilitation and physiological adaptation process. The form of multimodal prehabilitation was also addressed as crucial. One physician praised the concept as follows:

“… The fact that this prehabilitation [programme] is multimodal is really undisputed. We have a very, very wide range and I am glad and proud that we can offer this here and I think the patients are also very taken with the possibility of really being checked through and getting support, which is also worthwhile.” (B11) .

Well-trained therapists and a full hour of therapy time for each patient would ensure that prehabilitation measures can be carried out optimally and quality standards can be better maintained.

Prehabilitation would be further facilitated by stronger evidence, so that the concept becomes more established and known, both by health professionals and patients. A physician commented:

“If the evidence [base] improves and we can show how the patients benefit from it [prehabilitation] and the concept is better or more accepted in people’s minds (…), I believe that they [the patients] will participate. Because now we must convince people of the concept [of prehabilitation] who didn’t even know about it before and already have an idea of how rehabilitation [after the surgery] works. But if they already know that there are also prehabilitation programmes, (…) then they [the patients] might come to us with [an idea of] the concept and then their willingness to participate will be certainly greater…” (B8) .

A total of 39 codes were assigned to the subcategory “communication and cooperation”. Here, close cooperation between different professional groups and institutions was most frequently mentioned as a facilitating factor. One of the physicians shared this view:

“I think it’s conducive and important to really have all the teams on board. That was relatively clear in our case, that if you then work together with senior physicians who are also on board, it works well.” (B8) .

Effective and efficient communication among each other was also found to have a facilitating effect on prehabilitation. There was a desire for fixed contact persons and a fixed team that is responsible for the implementation of prehabilitation.

In Table  3 , all identified facilitators are listed by professional group.

The areas most relevant for implementation of the PRAEP-GO intervention were summarised by placing the results of the present work within three of the five domains of the updated CFIR framework (Innovation, Inner Setting, and Individuals; Fig.  2 ) [ 39 ].The full results can be found in appendix  B .

Synthesis of results using the updated CFIR framework; own figure

At the innovation level, the focus should be on the evidence base, adaptability, and prehabilitation programme design. We identified a need for good communication and high-quality information exchange within the inner setting and across its boundaries, as well as access to knowledge and information for innovation deliverers.

At the level of the inner setting, meaning hospitals or prehabilitation facilities in which the PRAEP-GO intervention takes place, necessary infrastructure must be in place to support the functional performance of the inner setting and enable the implementation of the innovation. This includes physical infrastructure, such as the presence of sufficient prehabilitation centres, information technology infrastructure to support electronic documentation, data storage and management, and the work infrastructure. The work infrastructure refers to the organisation of tasks and responsibilities, but also to the availability of sufficient human resources. Relational connections are another prerequisite for the successful implementation of prehabilitation in the internal setting. This refers to high-quality formal and informal relationships, networks, and teams, also beyond the boundaries of the inner setting, such as good cooperation among professionals or with patients.

At the CFIR level of the individual’s domain, the focus is on the roles and characteristics of the individuals involved in prehabilitation. In this domain, the PRAEP-GO intervention has to meet the needs of the patients and the motivation or commitment of the individuals is a decisive factor.

A total of 14 interviews were conducted with seven therapists, five physicians, and two employees from other professional groups. All identified barriers and facilitating factors could be assigned to the themes of organisation, prehabilitation, cooperation and communication between healthcare professionals and with patients. Almost all the barriers and facilitating factors mentioned were addressed by several or even all professional groups and are therefore relevant for them. The consensus among different professional groups, for example about barriers, underscores their priority and relevance across professions. However, there were some aspects that reflect the specific need of the occupational group. For example, facilitating factors like “proof of evidence” were only addressed by physicians and “manual for therapists” only by therapists.

Most of the space within the interviews, both for barriers and facilitating factors, was taken up by statements about purely organisational aspects of prehabilitation. It can be concluded that organisational structures for the implementation of innovative programmes, such as the PRAEP-GO intervention, are the basis for the smooth running of such projects. Adaptations in the patient pathway are therefore a prerequisite [ 41 ], and should incorporate prehabilitation into the existing interdisciplinary teamwork approaches within perioperative medicine. In 2022, van der Zanden et al. also noted that organisational aspects, such as sufficient human resources, especially for good coordination of the program, must be in place as a prerequisite for the successful implementation of a prehabilitation program, so that physicians and therapists have sufficient capacity for the actual prehabilitation [ 24 ]. This underlines the need for an optimal allocation of resources and a reduction of excessive bureaucracy to free up capacities in the work force and reduce perceived staff shortages. According to Arora et al. (2018) the contextual readiness of organisations in terms of leadership support, flexibility of existing surgical practice culture, data processing capabilities, and generally having sufficient resources for successful implementation of prehabilitation programmes is critical to their success [ 42 ].

Regarding prehabilitation and its implementation, an individually designed and multimodal prehabilitation is essential. According to Beck et al. (2021), recommendations that are too general are an obstacle to patient adherence if they are perceived as irrelevant or unimportant [ 43 ]. In addition, the training programmes must correspond to the individual needs and abilities of the patients [ 24 , 25 ], e.g. the number of sessions per week that are tolerable for the individual patient. From the interviews of the present work, an individual therapy design does not only concern the needs of the patients, but therapists also wish for a more individual therapy design to be able to optimally prepare their patients for their operation with their own methods. In addition, a more flexible therapy design – in comparison to the rigid demands of a standardised intervention within a clinical trial – can avoid over- and under-challenging of patients as well as idle time within and between therapy sessions.

Another aspect that concerns the implementation of prehabilitation relates to its time span. If the patient has an indication that allows the period before surgery to be extended, prehabilitation could also be extended so that physiological adaptation processes can occur more intensively and sustainably until surgery. Extending the prehabilitation period if possible is also recommended by Beck et al. in their study from 2018 on prehabilitation in cancer care [ 43 ]. Evidence, or the perception of evidence by participating health professionals, is also the key factor for successful team engagement [ 42 ]. Adequately demonstrating the effectiveness of prehabilitation could also make it easier to acquire financial support and create a greater willingness to implement prehabilitation among health professionals and within your facilities [ 44 ].

A lack of commitment on the part of health professionals also affects their cooperation and communication with each other and with patients. For example, if the treating surgeons do not fully agree with the concept of prehabilitation, this can lead to misunderstandings, misaligned goals within the treatment team, and lack of patient engagement, according to Ng et al. (2022) [ 45 ]. For the implementation of complex interventions such as PRAEP-GO, it is important that different professional groups across different areas work together as a team. Especially for patient safety the performance of the team is crucial [ 46 ]. Skill mix can only take place with good inter- and intra-professional cooperation of the team members [ 47 ].

Physicians in particular have an important leadership role and influence on the motivation of their patients [ 48 ]. This is critical for the diffusion, dissemination, and implementation of prehabilitation at the micro (clinical integration) and meso (professional and organisational integration) levels, as well as at the macro level (system integration) [ 41 , 49 ]. The prerequisite for cooperation both between health professionals and between patients is sufficient and goal-oriented communication. In the study by van der Zanden et al. (2022), communication deficits, which are usually accompanied by information deficits, also represent a barrier in the context of prehabilitation [ 24 ].

Limitations

Despite following rigorous methodology including the prospective registration of this interview study, some limitations at the study level apply that need to be considered when interpretating the results. First, a saturation of content could not fully be achieved as the recruitment of interview partners had to be discontinued after the 14th interview due to limited resources for the interviews. For the same reason, the recruitment of interview participants took place exclusively in the Berlin and Brandenburg area, although the project also takes place in study centres in other parts of Germany whose perspective could not be captured. Another limitation is that the professional group of therapists predominates in the sample and may have influenced the focus of the barriers and facilitators mentioned. The professional group of nutritionists was also approached during the recruitment process but did not participate, so their perspective could not be represented.

Furthermore, dependability might have been affected by the fact that the interviews and developing the category system was performed by one researcher. Although the interviews were coded independently and the coding was discussed in a team, the researcher who created the coding system and conducted and transcribed the interviews might have had more influence on the final coding than the other coder. In addition, the theoretical framework used was selected after the interviews had been conducted and coded. Lastly, the generalisability of the findings to other populations and contexts should be viewed cautiously.

Conclusions

The aim of the study was to identify barriers and facilitators to the implementation of a prehabilitation programme for frail people aged 70 years and older in Germany from the perspective of the health professionals involved. The findings were synthesised using the theoretical CFIR framework, which highlighted the implications of the study for the areas of the innovation, internal setting, and individuals. Identified barriers were communication deficits and insufficient cooperation between healthcare professionals and with patients. Age, health status of the patients, pain and overly rigid treatment plans were also barriers, as well as lack of staff, the patient pathway not being adapted to incorporate prehabilitation, the scope and effort of SDM conferences, lack of prehabilitation centres, short-term planning, transport of patients, postponement of surgery, training deficits and time-consuming study matters, such as testing and documentation. Facilitators for a successful implementation of prehabilitation programmes, such as the PRAEP-GO programme, are sufficient organisational infrastructure, human resources, and access to knowledge and information for innovation providers. The development of an adaptable and individualised treatment design that must meet patients’ individual needs and abilities is critical. Good cooperation, communication, and quality information exchange among professionals and with patients are also critical. To further convince professionals and patients of the concept of prehabilitation, more research needs to be conducted on this topic to build a solid evidence base. This will ensure greater awareness and thus more motivation and cooperation among professionals and patients.

Data availability

Due to the data protection regulations of the study, no raw data (i.e. transcripts) can be made available. However, a complete coding guide including quotations from the interviews is available from the OSF project (doi: 10.17605/OSF.IO/Q59P8).

Abbreviations

Consolidated Framework for Implementation Research

Consolidated criteria for Reporting Qualitative research

Software package for qualitative data analysis

Prehabilitation of elderly frail or pre-frail patients prior to elective surgery ─ a randomised controlled multicenter study

Shared decision-making conference

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Acknowledgements

We would like to thank all participants who took part in the study.

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Tamina Isabel Fuchs & Carina Pfab

Federal Institute for Occupational Safety and Health (BAuA), Nöldnerstraße 40-42, 10317, Berlin, Germany

Carina Pfab

Department for Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany

Jörn Kiselev, Stefan J Schaller & Claudia Spies

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Jörn Kiselev

Department of Anesthesiology and Intensive Care Medicine, Klinikum rechts der Isar, School of Medicine and Health, Technical University of Munich, Ismaninger Str.22, 81675, München, Germany

Stefan J Schaller

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Tanja Rombey

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TIF: conceptualization, methodology, formal analysis, investigation, writing – original draft, visualization. CP: formal analysis, validation, writing – review & editing. JK: conceptualization, methodology, writing – review & editing. SJS: conceptualization, writing – review & editing, supervision. CS: conceptualization, writing – review & editing, supervision. TR: conceptualization, methodology, writing – review & editing, project administration, supervision. All authors read and approved the final manuscript.

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The qualitative study presented here was performed in accordance with the Declaration of Helsinki and was approved by the ethics committee of the Charité – Universitätsmedizin Berlin (EA1/266/20, version 1.4) as well as the staff council. Interview partners were transparently informed about the study and data protection regulations, and their informed consent was obtained before the interview.

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TIF performed the research as part of her master’s thesis and declares no financial conflict of interest. CP declares no financial conflict of interest. JK, SJS, CS and TR are involved in an ongoing randomised clinical trial on prehabilitation in the frail elderly (PRAEP-GO; ClinicalTrials.gov identifier NCT04418271) funded by the Innovationsfonds des Gemeinsamen Bundesausschusses. JK declares no financial conflict of interest. SJS received grants and non-financial support from Reactive Robotics GmbH (Munich, Germany), ASP GmbH (Attendorn, Germany), STIMIT AG (Biel, Switzerland), ESICM (Geneva, Switzerland), grants, personal fees and non-financial support from Fresenius Kabi Deutschland GmbH (Bad Homburg, Germany), grants from the Innovationsfond of The Federal Joint Committee (G-BA), personal fees from Springer Verlag GmbH (Vienna, Austria) for educational purposes and Advanz Pharma GmbH (Bielefeld, Germany), non-financial support from national and international societies (and their congress organisers) in the field of anesthesiology and intensive care medicine, outside the submitted work. SJS holds stocks in small amounts from Alphabeth Inc., Bayer AG and Siemens AG; these holdings have not affected any decisions regarding his research or this study. CS reports grants from Innovationsfonds des Gemeinsamen Bundesausschusses, Bundesministerium für Bildung und Forschung, Bundesministerium für Gesundheit/Robert Koch-Institut, Deutsche Forschungsgemeinschaft, Deutsches Zentrum für Luft- und Raumfahrt e. V., Einstein Stiftung Berlin, Inneruniversitäre Forschungsförderung, European Society of Anaesthesiology and Intensive Care, Baxter Deutschland GmbH, Cytosorbents Europe GmbH, Edwards Lifesciences Germany GmbH, Fresenius Medical Care, Grünenthal GmbH, Masimo Europe Ltd., Pfizer Pharma GmbH, Dr. F. Köhler Chemie GmbH, Sintetica GmbH, Stifterverband für die deutsche Wissenschaft e.V./Phillips, Stiftung Charité, AGUETTANT Deutschland GmbH, AbbVie Deutschland GmbH & Co. KG, Amomed Pharma GmbH, InTouch Health, Copra System GmbH, Correvio GmbH, Max-Planck-Gesellschaft zur Förderung der Wissenschaften e.V., Deutsche Gesellschaft für Anästhesiologie & Intensivmedizin, Stifterverband für die deutsche Wissenschaft e.V./Metronic, Philips Electronics Nederland BV, Drägerwerk AG & Co. KGaA; personal fees from Georg Thieme Verlag, all outside the submitted work. TR received honorary fees for commissioned research by the Statutory Health Insurance Medical Review Board outside the submitted work.

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Fuchs, T.I., Pfab, C., Kiselev, J. et al. Barriers and facilitators to the implementation of prehabilitation for elderly frail patients prior to elective surgery: a qualitative study with healthcare professionals. BMC Health Serv Res 24 , 536 (2024). https://doi.org/10.1186/s12913-024-10993-2

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• Volume 14, Issue 4
• ‘God protects us from death through faith and science’: a qualitative study on the role of faith leaders in combating the COVID-19 pandemic and in building COVID-19 vaccine trust in Addis Ababa, Ethiopia
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• http://orcid.org/0000-0001-5882-5767 Kalkidan Yibeltal 1 ,
• http://orcid.org/0000-0003-1529-987X Firehiwot Workneh 2 ,
• Hanna Melesse 2 ,
• Habtamu Wolde 3 ,
• Workagegnhu Tarekegn Kidane 4 ,
• Yemane Berhane 2 ,
• http://orcid.org/0000-0002-5270-1170 Sibylle Herzig van Wees 5
• 1 Department of Reproductive Health and Population , Addis Continental Institute of Public Health , Addis Ababa , Ethiopia
• 2 Department of Epidemiology and Biostatistics , Addis Continental Institute of Public Health , Addis Ababa , Ethiopia
• 3 Independent Consultant , Addis Ababa , Ethiopia
• 4 Department of Nutrition and Behavioral Sciences , Addis Continental Institute of Public Health , Addis Ababa , Ethiopia
• 5 Department of Global Public Health , Karolinska Institutet , Stockholm , Sweden
• Correspondence to Dr Sibylle Herzig van Wees; sibylle.hvw{at}ki.se

Objective This study explored faith leaders’ perspectives on the COVID-19 vaccine and their role in building COVID-19 vaccine trust in Addis Ababa, Ethiopia.

Design A qualitative study with in-depth interviews and thematic analysis was conducted.

Participants Twenty-one faith leaders from the seven religious groups represented in the Inter-Religious Council of Ethiopia participated in the study.

Setting The study was conducted in Addis Ababa, Ethiopia.

Results The thematic analysis revealed three themes. First, faith leaders were aware of the risks of the COVID-19 pandemic, although most ascribed a spiritual meaning to the advent of the pandemic. The pandemic seriously affected the faith communities, inflicting financial losses. Second, faith leaders were essential allies during the pandemic by effectively collaborating with government and health professionals in COVID-19 prevention activities and public health interventions using spiritual reasoning. They were actively informing the community about the importance of the COVID-19 vaccine, where many faith leaders were publicly vaccinated to build trust in the vaccine and act as role models. Third, despite this, they faced multiple questions from the congregation about the vaccine, including rumours.

Conclusions This research showed that faith leaders played crucial roles in encouraging vaccine use but were limited in their persuasion power because of intense rumours and misinformation. Empowering faith leaders with the latest vaccine evidence needs to be prioritised in the future.

• Public health
• QUALITATIVE RESEARCH

Data availability statement

Data are available upon reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2023-071566

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STRENGTHS AND LIMITATIONS OF THIS STUDY

Prolonged engagement with data was ensured as the co-authors conducted the interviews.

Working with multiple coders aided in minimising the subjective bias of any researchers.

Interviews were conducted among faith leaders included in the structured inter-religious council; the study did not interview those outside of this structure to capture their perception and role.

Equitable access to safe and effective vaccines is critical to control the spread of infectious pandemics such as COVID-19 and minimise the devastating adverse health outcomes. 1 Achieving herd immunity using effective vaccines is essential to avert pandemic-related morbidity and mortality. 2 3 Promoting the uptake of COVID-19 vaccines requires people’s willingness to get vaccinated and ensuring proper communication of information through trusted sources to aid vaccine acceptance. 4 5

Ethiopia started the COVID-19 vaccination campaign in March 2021 with the Astra Zeneca vaccine, manufactured by the Serum Institute of India and supplied by the COVID-19 Vaccines Global Access initiative. 6 The Ministry of Health launched a national ceremony to initiate the COVID-19 vaccine rollout in the presence of different stakeholders, including religious representatives. Initially, healthcare providers and older people with comorbidities were prioritised and given two doses of AstraZeneca vaccines. 6 7 In the later stage, the Johnson & Johnson vaccine, Sinopharm, and Pfizer vaccines were included in the campaign as they became available. 7 8

Vaccines need to be effectively used by the target population to bring about the intended effect of controlling the pandemic. However, despite the availability of vaccines and vaccination services, vaccine hesitancy—refusal or delay to accept a vaccine, has become a significant concern. 9 10 WHO considers vaccine hesitancy as one of the top 10 Global Health threats. 11 Concerns about vaccine safety, efficacy and side effects have driven vaccine hesitancy related to COVID-19 worldwide. 12 13 Moreover, the slow rollout and politicisation of vaccines in Africa have fuelled rumours, doubts and conspiracy theories about these vaccines. 14 15 Lack of trust in the government and the private sector, reading misinformation on social media and the history of vaccination programmes in a country have been further reasons for vaccine hesitancy among healthcare workers and the population in Africa. 13 14 16 17 Studies have shown high COVID-19 vaccine hesitancy among the Ethiopian population and some factors mentioned to explain the hesitancy were having social media as a primary information source, fear of side effects of the vaccine and thinking of it as a biological weapon and having doubts about the vaccine. 15 18–20

Global surveys show that religious factors are the third most commonly reported reason for vaccine hesitancy globally. 21 Religious views can affect how people react to vaccinations, causing reactions like vaccine hesitancy despite medically sound and scientifically proven information/evidence. 22 In the context of the COVID-19 pandemic, concerns have been raised that religious communities may serve as the basis for misinformation and unfounded theories that undermine the use of COVID-19 vaccines. 23 Thus, the importance of the role of faith leaders in addressing vaccine hesitancy has received increasing attention in global health research. 24

Ethiopia is a religious country where more than 97% of the population is religious, and faith leaders hold significant societal positions. 25 It has been well documented that faith leaders are embedded in society with high-influencing positions and often have considerable leverage with state and non-state actors due to the size of their constituencies. 26–29 Therefore, engagement with faith leaders is critical as they are known to be gatekeepers to local communities, with considerable influence on their communities’ beliefs and behaviours. Thus, this study aimed to explore faith leaders’ perspectives on the COVID-19 vaccine and the role faith leaders can play in building COVID-19 vaccine trust.

Study setting

This study was conducted in Addis Ababa, the capital city of Ethiopia. Orthodox Christianity, Islam and Protestantism are the main religions in Ethiopia. 25 The Inter-Religious Council of Ethiopia (IRCE) was established in 2010 to promote inter-religious harmony in Ethiopia. 30 IRCE is represented at federal, regional and district levels. The IRCE head office is located in Addis Ababa. This council comprises seven religious groups, each with a representative in the head office.

Study design and aim

A qualitative study design using in-depth interviews (IDI) was used to explore faith leaders’ perceptions of the COVID-19 vaccine and the role faith leaders can play in building COVID-19 vaccine trust.

Study population

The participants of this study are faith leaders selected from the seven religious groups represented in the IRCE, which comprises Ethiopian Orthodox Tewahido Church, Islam, seventh Day Adventist, Evangelical Churches Fellowship of Ethiopia, Ethiopian Kale Heywet Church, Ethiopian Evangelical Church Mekane Eyesus, and Ethiopian Catholic Church.

Study sample and sampling procedure

Purposive sampling was used to identify appropriate study participants. The purpose of reaching out to the inter-religious council was with the notion that all the country’s major religions were represented, and interviewing these participants would provide us with a comprehensive understanding of the country’s context. We identified the seven religious entities constituting the IRCE through the inter-religious council. From these seven religions, individuals were selected in consultation with the head office representatives of each religion. We selected three study respondents from each religious entity: two faith leaders at the head offices and one from the religious institutions (Churches and Mosques), culminating in 21 participants. The later interviews in the study did not generate new information, so we assumed reaching data saturation. The data collection was conducted over a period of 2 months.

Data collection procedures

IDIs were used for data collection. The interview guide was developed based on our background research. Themes included faith leaders’ awareness of the COVID-19 and its risks, rumours and uncertainty around the COVID-19 vaccine, and the role of faith leaders in controlling the pandemic. The research team developed the interview guide in English and translated it into Amharic (the official language). Two research assistants with extensive experience in qualitative data collection were recruited to collect the data. The research assistants were trained for 2 days on the interview guides, the purpose of the study and research ethics. Verbal consent was obtained before the interview. All interviews were audio recorded, and additional notes were taken during the IDI. The IDIs were conducted in a private and quiet place, mainly in an area preferred by the participants, usually their offices. The interviews took 40–90 min and were conducted on dates and times convenient to the participants. COVID-19 prevention methods such as keeping physical distance, using hand sanitisers and wearing masks were strictly implemented during the data gathering.

Data analysis

The research assistants transcribed all interviews verbatim and then translated from Amharic to English. Transcripts and translations were checked for accuracy and consistency by two independent persons in the research group who did not conduct the interviews. Field notes taken during the IDIs were integrated into the transcriptions. KY, FW and SHvW conducted a thematic qualitative analysis following Braun and Clarke’s method. 31 All data were coded double blinded. After one round of coding, the coding team met to develop a codebook and kept all audit trail records, such as data reduction notes. The codebooks included definitions and example responses. A further round of coding, using the codebook, was completed. The coding process was continued until the data were exhausted. Two further meetings were held to compare categories. Three more meetings, both in person and virtually, were made to create the themes initially by the coding team and then by the full team. Careful coding and multiple meetings ensured consistency and validity of the data analysis process. Working with multiple coders aided in minimising the subjective bias of researchers. The thematic analysis was done using Atlas.ti software V.7.5.16.

Patient and public involvement

Patients or the public were not involved.

Ethical considerations

Participation in this study was entirely voluntary, and informed consent was obtained from all participants. The study procedures, benefits, anticipated risks or discomforts of participating and right to withdraw were explained. Principles of anonymity and confidentiality were applied to protect the participants’ identities by assigning codes to them. The audio recordings were destroyed after the completion and verification of the transcription and translations. The study was conducted following national ethical standards and the declaration of Helsinki. 32

The thematic analysis revealed three themes and 15 categories, table 1 . A category was created when many codes or data extracts described that specific finding. We only use one data extract to describe the category when presenting the data in this section.

• View inline

Themes and defined categories based on thematic analysis

Faith leaders were aware of the risks of COVID-19, and they and their congregations were seriously affected by the pandemic

Although most faith leaders in this study ascribed a spiritual meaning to the advent of the COVID-19 pandemic, all faith leaders interviewed were aware of the risk and severity of the COVID-19 pandemic. They were well informed and described in great detail the severe effects it had on their religious practice and the members of their spiritual community. In the words of a faith leader: There is nothing it did not touch; it has affected our social life, economy, religious relations, our office, our work… We have lost so many people. (IDI-12)

Faith leaders described the implications of solitude under challenging times, particularly during times of mourning and grief. Participants expressed profound sadness that they were unable to console individuals and support them during times of grief: We could not even comfort the families of the deceased after the funeral. We consider spiritual support as a psychosocial treatment, but we failed to offer that too. (IDI-4)

Moreover, faith leaders described a spiritual crisis in their institutions whereby relationships between faith leaders and those attending religious institutions had been harmed. This is mainly due to not allowing people to participate in religious services, which led to conflicts in several religious institutions. Faith leaders described a change in spiritual practice and organisation, which has remained in practice:

It [COVID-19] even created another culture; older people and people with some medical conditions became too scared to come to our congregation even after we were allowed to gather again. In our religion, Christianity, the New Testament encourages and teaches togetherness to grow in holiness. So, it affected that core value. (IDI-6)

Faith leaders further described the financial implications for their institutions. Due to the loss of participants in religious services, income diminished substantially. Businesses surrounding religious institutions were further negatively affected. This led to significant staff cuts at religious institutions. Moreover, it led to the closure of social activities and programmes used to serve the needs of the poorest: With the limited money we got, we were only able to pay salaries 2for Church ministers; there was nothing left to give to those who are in need. (IDI-4)

Despite these challenges, faith leaders described innovative approaches to countering challenges. This includes the use of social media to reach the community:

We tried to solve this and reach our members through technology by calling them over the phone and using the Zoom application. Fortunately, we launched a Television programme a month or two before the pandemic called Hope Channel, and we used that to preach and praise the Lord… (IDI-14)

Active fundraising in the community, including collecting donations from individuals and businesses in the area, was further organised to make up for the financial loss:

When everyone was told to stay home, it was hard for our community because they had no money or food to eat, especially during fasting. So, we have tried our best to provide them food for the fasting period. We did that here in Addis Ababa and in some other areas, too. For that, we have collected over 30 million birr from investors and distributed it to others. (IDI-16)

Faith leaders are important allies during a pandemic

The second theme summarises faith leaders and their institutions’ work during the pandemic. To begin with, most faith leaders collaborated closely with the Ministry of Health and health professionals to inform their congregations about the disease and preventive measures. The collaboration between the government and religious institutions appears to have been effective, and faith-leaders trusted the information and directives of the Ministry of Health:

In our Church, I invited different medical doctors to convey health messages about getting vaccinated and safety measures practices recommended by the Health Ministry and the government. Based on these messages, I encourage people to practice what they have heard. (IDI-20)

In turn, faith leaders consider themselves highly trusted within their communities and congregations. They are consulted in times of hardship and on important family matters.

Religious leaders have many roles not only in controlling pandemics but also in other national affairs. This is because many people trust religious leaders; they obey them. Their word is associated with God, and what they say will get higher acceptance. Instead of a soldier speaking with a weapon, a priest holding a cross is more heard and accepted. This is a well-known fact in our country (IDI-2).

They were also consulted about questions regarding the COVID-19 pandemic, mainly rumours about the origin of the pandemic and vaccines. There are numerous examples of how faith leaders describe following directives, implementing recommended interventions (hand washing, mask use, social distancing) and actively informing the community about the importance of the COVID-19 vaccine.

Questions are forwarded to me; we often convey a message when we finish teaching in the Church. That people should follow the instructions. In general, we tell them God loves us as we obey, wash our hands, we should respect each other, and the vaccine is also important you should take it. What we do here is critical; we are spiritual doctors. (IDI-3)

Faith leaders saw themselves as key in implementing measures to address the pandemic and proactively raising awareness to help implement directives.

We intensively created awareness, stressing that the vaccine is one of the major remedies for this disease. We assigned responsible persons and Imams who can transmit these messages during the five prayer times in every Mosque. Regarding awareness creation, we successfully changed people’s understanding from wrong to right direction. (IDI-16)

Faith leaders described how they used religious scriptures to promote guidelines to reduce disease transmission. This was particularly important when the community challenged them regarding these measures.

The Bible supports all the recommended preventive safety measures for COVID-19. So, if parishioners come with such concerns, I will teach them this according to the Bible and guide them in the right direction (IDI-2)

Several faith leaders, regardless of the denomination, described examples of how they used spiritual reasoning to address concerns: …the Bible says that Luke, the Evangelist, was one of the writers of the Bible who had medical knowledge. Therefore, the doctrine of the Church does not contradict such wisdom (IDI-11). Almost all faith leaders in this study described a strong trust in science and use religious reasoning to support this. In the words of a faith leader : God protects us from death through faith and science (IDI-21)

Faith leaders are faced with rumours and uncertainty around the COVID-19 vaccine

A significant challenge described by faith leaders was the rumours about the COVID-19 vaccine they encountered. This section summarises faith leaders’ different engagements with these rumours. Despite the strong commitment of faith leaders to implement preventative measures, they faced challenges in addressing rumours about vaccines. Most, but not all, faith leaders in this study trust the COVID-19 vaccine. They described their trust in science and the government and used religious reasoning to support their trust. Many faith leaders were publicly vaccinated to build trust in the vaccine: I and other faith-leaders of different religions in Addis Ababa got vaccinated in public; we did that to be role models to our parishioners. (IDI-13)

Participants described numerous and consistent rumours encountered in the community. The COVID-19 vaccine was considered dangerous because it was sent from abroad and was, therefore, not trusted: Now Ethiopia is in disagreement with America as we all know, what if they send this vaccine to destroy us and attack us?” (IDI-14). There were rumours that the COVID-19 vaccine represented 666—the mark of the beast.

There is a religious teaching about 666 (According to most manuscripts of the New Testament and in English translations of the Bible , the number of the beast is six hundred sixty-six. (Book of Revelation 13:15–18, Wikipedia)). I guess you have heard about that in every Church. So, they say this vaccine is used to insert satanic 666 into our bodies. So, they say Satan makes the vaccine, so this is satanic teaching. They say participating in this is like partnering with Satan. (IDI-13)

Moreover, a repeated concern that faith leaders faced, and some addressed themselves, was the effect of the COVID-19 vaccine on fertility. Faith leaders described how rumours affected their own beliefs, and they described challenges in addressing these questions:

…it is rumored that getting vaccinated [against COVID-19] can cause infertility. They also say that developed countries fabricate this disease to minimize the population of highly populated countries like African countries. There were so many questions. It was tough to answer such questions. (IDI-16)

Few faith leaders actively countered the rumours, but those who did use spiritual reasoning to do so. For example:

When they say it will make you infertile, I will say, are you a prophet? Have you been given the gift of prophesying? So this shows an awareness problem due to a lack of awareness; that’s how I see it. (IDI-3)

However, several faith leaders described that they got uncertain about the vaccine as a result of the rumours: It’s best to try to understand what they want to say. I don’t have evidence it might be what they said or it may not. So the main thing is believing. (IDI-21)

Moreover, some described that they could not address those concerns. They were more comfortable preaching about all other public health prevention measures than the vaccine.

One of our [faith leaders'] tasks is to educate the community on preventing these outbreaks as health professionals recommended. Teaching about the disease/ pandemic is comfortable, but I cannot say anything about specific vaccines (IDI-11)

This qualitative study explored faith leaders’ perspectives towards the COVID-19 vaccine and their role in combating the pandemic and in building COVID-19 vaccine trust in Addis Ababa. The findings of our study showed that most faith leaders included in this study were aware of the risks associated with COVID-19. Due to the advent of the COVID-19 pandemic, faith leaders and their congregations have faced solitude in challenging times. Additionally, religious institutions have encountered significant financial and spiritual crises. Our study also revealed that faith leaders were actively engaged in pandemic measures and held strong beliefs in the medical sciences, including vaccines. However, faith leaders struggled to address COVID-19 vaccine rumours in their communities despite the high trust in vaccines and medical science.

This study indicated that faith leaders were well informed about the risks of COVID-19. This could be due to reasonable access to sources regarding the COVID-19 pandemic due to their networks, mass media and social media exposure. Our findings showed that due to the COVID-19 pandemic, vulnerable groups, faith leaders and their congregations have faced solitude during challenging times and significant financial and spiritual crises. This finding aligns with a qualitative study conducted in Ghana, which showed that the COVID-19 pandemic caused economic challenges to the congregants, a decline in spiritual life and a loss of fellowship and community. 33 In another qualitative study conducted on United Methodist pastors in one of the two Annual Conferences in North Carolina, Pastors reported that COVID-19 fundamentally unsettled the routine works of the ministry. 34

This study also identified innovative approaches faith leaders use to tackle the challenges. This includes using social media to reach the community and fundraising to compensate for the financial loss. A qualitative study on Ghanaian Christian Leaders also showed that as a response to the ban, most participants in their research explicitly reported that they moved at least some activities online, which included conventional activities, such as posting prayer topics and live streaming of services for audiences who wished to view them synchronously. 35 Similarly, religious authorities in Uganda played a critical role in delivering public health messages on COVID-19 risk communication using the web.

According to a recent systematic review that assessed religious communities’ role during the COVID-19 pandemic, religion has acted as an essential platform for inter-sectoral collaboration with science and government to combat COVID-19. 36 National, regional and local faith leaders have high levels of influence and community-organising capabilities. Faith leaders are effective messengers endorsing vaccination compared with other potential messengers. 28 They can help frame approaches that make them more likely to be accepted in their communities. Governments should build trust with faith leaders and integrate them into planning, decision-making and implementation at every level of their COVID-19 response. 37 The findings in this study also showed that there was a strong collaboration between the government and religious institutions, which appeared to have been effective, and faith leaders trusted the information and directives of the Ministry of Health. This might be due to the closeness of the religious institutions to each other and the government through a well-founded and organised inter-religious council that collaborates with the government on different national agendas. 30 Besides, all faith leaders interviewed for this study consider themselves highly trusted within their communities and congregations. They were consulted about questions regarding the COVID-19 pandemic, mainly rumours about the origin of the pandemic and vaccines. Due to that, most of the study participants saw themselves as critical actors in implementing the safety measures and in proactively raising awareness to help implement directives to address the pandemic. Since faith leaders are often highly influential community leaders who are 'listened to by the community members, they often underutilise the potential for catalysing change'. 24 In line with this finding, a qualitative case study conducted in Indonesia showed that the faith leaders supported the health directives designed to reduce high transmission risk. 38 All the scholars and faith leaders stated that funerals, according to the health protocols issued by the authorities, should be conducted considering potential disease transmission. Some Islamic organisations have developed their guidelines for COVID-19 by modifying the religious values of certain institutions to prevent the spread of infectious diseases. 38

This study revealed that regardless of the denomination, almost all faith leaders who participated in this study said they trust in science and use religious scriptures and spiritual reasoning to promote guidelines to reduce the transmission of COVID-19. A study has also shown that many faith leaders see the vaccine as a message of hope. Pope Francis also indicated everyone’s moral obligation to be vaccinated. 39 Our study participants added that many faith leaders were publicly vaccinated to build trust in the vaccine. This was particularly important when the community challenged them regarding these measures. In agreement with that, findings of a qualitative study conducted in Leeds, United Kingdom, also revealed that faith leaders could play a vital role in the health behaviour of their congregants. 27 Faith leaders can influence health behaviour not only on the individual but also on a sociocultural and environmental level. They exert such influence through several mediators, including as scriptural power, social influencer and serving as role models. 27 Our results showed most of the faith leaders faced numerous and consistent rumours in the community. They were affected by the rumours they heard about the COVID-19 vaccine and faced challenges in addressing such questions.

The African Center for Strategic Studies reported that the preponderance of COVID-19 vaccine myths is causing many Africans to forego vaccinations when new, more transmissible coronavirus variants spread across the continent. 40 The report indicated several myths, including live viruses are injected to cause death after vaccination; the vaccine causes infertility by altering the DNA to reduce Africa’s population, and other serious side effects that are worse than contracting the virus, and some claim that vaccines are a cover to implant traceable microchips. 40 Such myths and similar rumours may lead to COVID-19 vaccine hesitancy in the general community. In line with these findings, a population-based online survey conducted in Ethiopia showed that only 31.4% of participants were willing to receive the COVID-19 vaccine. 19 One of the strategies to counter vaccine hesitancy is to follow a multisectoral approach that involves the collaboration between various stakeholders, such as government, private companies, religious groups and other agencies, to leverage the knowledge, expertise and resources, thereby enabling the creation of longstanding public trust of vaccines. 27 39 Given the importance of faith leaders and their trust in science, equipping faith leaders with the knowledge and skills to address rumours appears indispensable.

Limitations of the study can lay in the fact that we only interviewed faith leaders included in the structured inter-religious council and did not directly interview those outside of this structure to capture their perceptions and roles. Although the findings cannot be generalised, inferential generalisations can be drawn, and results may be relevant for other similar settings.

Faith leaders have played an essential role in mitigating the COVID-19 pandemic in Ethiopia. Faith leaders have followed and implemented government directives and promoted the vaccine, further amplifying their important alliance in public health. However, they have been challenged with different rumours about the vaccine, which they struggled to address as they were not equipped to do so. Thus, empowering faith leaders to address rumours about new vaccines could have significant public health implications for ongoing and future pandemics. Future studies need to consider involving faith leaders at all levels and to utilise quantitative methods. In addition, intervention studies addressing issues of hesitancy are necessary.

Ethics statements

Patient consent for publication.

Consent obtained directly from patient(s).

Ethics approval

This study involves human participants and was approved by Institutional Review Board (IRB) of Addis Continental Institute of Public Health (ACIPH/IRB/010/2021). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

We would like to acknowledge the Inter-Religious Council of Ethiopia for their collaboration for the study.

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X @Frehiwot_W

Contributors YB, SHvW, FW and KY designed the study. HM and HW conducted the interviews, transcriptions and translations. KY, FW, HM, WT and SHvW were involved in the coding and conducted the analysis. All authors collaborated on the writing of the manuscript, and the final draft was written by KY and FW. YB is the guarantor of this study. All authors have read and approved the final manuscript.

Funding The Addis Continental Institute of Public Health, Ethiopia, funded the study. SHvW is the recipient of a Postdoc grant awardee by FORTE (2021-01299) in Sweden.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer-reviewed.

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A bibliometric and content analysis of research trends on GIS-based landslide susceptibility from 2001 to 2020

• Review Article
• Published: 24 October 2022
• Volume 29 , pages 86954–86993, ( 2022 )

Cite this article

• Junpeng Huang   ORCID: orcid.org/0000-0003-4785-7506 1 ,
• Xiyong Wu 2   nAff1 ,
• Sixiang Ling   ORCID: orcid.org/0000-0001-9697-1212 1 , 2 ,
• Xiaoning Li 3 ,
• Yuxin Wu 1 ,
• Lei Peng 1 &
• Zhiyi He 1  

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To assess the status of hotspots and research trends on geographic information system (GIS)–based landslide susceptibility (LS), we analysed 1142 articles from the Thomas Reuters Web of Science Core Collection database published during 2001–2020 by combining bibliometric and content analysis. The paper number, authors, institutions, corporations, publication sources, citations, and keywords are noted as sub/categories for the bibliometric analysis. Thematic LS data, including the study site, landslide inventory, conditioning factors, mapping unit, susceptibility models, and mode fit/prediction performance evaluation, are presented in the content analysis. Then, we reveal the advantages and limitations of the common approaches used in thematic LS data and summarise the development trends. The results indicate that the distribution of articles shows clear clusters of authors, institutions, and countries with high academic activity. The application of remote sensing technology for interpreting landslides provides a more convenient and efficient landslide inventory. In the landslide inventory, most of the sample strategies representing the landslides are point and polygon, and the most frequently used sample subdividing strategy is random sampling. The scale effects, lack of geographic consistency, and no standard are key problems in landslide conditioning factors. Feature selection is used to choose the factors that can improve the model’s accuracy. With advances in computing technology and artificial intelligence, LS models are changing from simple qualitative and statistical models to complex machine learning and hybrid models. Finally, five future research opportunities are revealed. This study will help investigators clarify the status of LS research and provide guidance for future research.

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Acknowledgements

The authors thank editor-in-chief Dr. Philippe Garrigues, editorial assistants Fanny Creusot and Giulia Marinaccio, and three reviewers for their critical comments and valuable suggestions.

This work was supported by the National Natural Science Foundation of China (No. 41907228), Chengdu Science and Technology Program (2022-YF05-00340-SN), Sichuan Science and Technology Program, China (No. 2020YFS0297), and the Fundamental Research Funds for the Central Universities (No. 2682020CX11).

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Faculty of Geosciences and Environmental Engineering, Southwest Jiaotong University, 611756, Chengdu, China

Junpeng Huang, Sixiang Ling, Yuxin Wu, Lei Peng & Zhiyi He

Ministry of Education, Key Laboratory of High-Speed Railway Engineering, Southwest Jiaotong University, Chengdu, 610031, China

Xiyong Wu & Sixiang Ling

School of Emergency Management, Xihua University, Chengdu, 610039, China

Xiaoning Li

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All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Junpeng Huang, Yuxin Wu, Lei Peng, and Zhiyi He. The first draft of the manuscript was written by Junpeng Huang and reviewed by Sixiang Ling and Xiaoning Li. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Huang, J., Wu, X., Ling, S. et al. A bibliometric and content analysis of research trends on GIS-based landslide susceptibility from 2001 to 2020. Environ Sci Pollut Res 29 , 86954–86993 (2022). https://doi.org/10.1007/s11356-022-23732-z

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Received : 28 January 2022

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Published : 24 October 2022

Issue Date : December 2022

DOI : https://doi.org/10.1007/s11356-022-23732-z

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