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Qualitative thematic analysis based on descriptive phenomenology

Annelie j. sundler.

1 Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden

Elisabeth Lindberg

Christina nilsson, lina palmér.

The aim of this paper was to discuss how to understand and undertake thematic analysis based on descriptive phenomenology. Methodological principles to guide the process of analysis are offered grounded on phenomenological philosophy. This is further discussed in relation to how scientific rigour and validity can be achieved.

This is a discursive article on thematic analysis based on descriptive phenomenology.

This paper takes thematic analysis based on a descriptive phenomenological tradition forward and provides a useful description on how to undertake the analysis. Ontological and epistemological foundations of descriptive phenomenology are outlined. Methodological principles are explained to guide the process of analysis, as well as help to understand validity and rigour. Researchers and students in nursing and midwifery conducting qualitative research need comprehensible and valid methods to analyse the meaning of lived experiences and organize data in meaningful ways.

1. INTRODUCTION

Qualitative research in health care is an increasingly complex research field, particularly when doing phenomenology. In nursing and midwifery, qualitative approaches dealing with the lived experiences of patients, families and professionals are necessary. Today, there are number of diverse research approaches. Still, the clarity regarding approaches for thematic analysis is not yet fully described in the literature and only a few papers describe thematic analysis (Ho, Chiang, & Leung, 2017 ; Vaismoradi, Turunen, & Bondas, 2013 ). It may be difficult to find a single paper that can guide researchers and students in doing thematic analysis in phenomenology.

From our research experiences, it may be complex to read and understand phenomenological approaches. Similarly, the process of analysis can be challenging to comprehend. This makes methodological issues related to the clarity of ontological and epistemological underpinnings and discussions of validity and rigour complex. Norlyk and Harder ( 2010 ) points to difficulties finding a guide for phenomenological research. There is a need for understandable guidelines to take thematic analysis forward. Useful approaches are required to provide researchers and students guidance in the process of thematic analysis. With this paper, we hope to clarify some important methodological stances related to the thematic analysis of meaning from lived experiences that are grounded in descriptive phenomenology and useful to teachers and researchers in nursing and midwifery.

1.1. Background

Phenomenology has been widely used to understand human phenomena in nursing and midwifery practices (Matua, 2015 ). Today, there are several phenomenological approaches available. When using phenomenology, the researcher needs an awareness of basic assumptions to make important methodological decisions. Thus, it is important to understand the underpinnings of the approach used (Dowling & Cooney, 2012 ). Phenomenological underpinnings may, however, be difficult to understand and apply in the research process.

Thematizing meaning has been emphasized as one of a few shared aspects across different qualitative approaches (Holloway & Todres, 2003 ), suggesting that some qualitative research strategies are more generic than others. Although different approaches sometimes overlap, they have different ontological and epistemological foundations. A range of approaches are used to thematize meaning, but some of them would benefit from clarifying ontological and epistemological assumptions. In hermeneutic phenomenological traditions, thematizing meaning can be understood as related to the interpretation of data, illuminating the underlying or unspoken meanings embodied or hidden in lived experiences (Ho et al., 2017 ; van Manen, 2016 ). Another commonly used approach to thematic analysis is the method presented in the psychology literature by Braun and Clarke ( 2006 ). The method is frequently used to find repeated patterns of meaning in the data. However, there is a lack of thematic analysis approaches based on the traditions of descriptive phenomenology.

Researchers must make methodological considerations. In phenomenology, an awareness of the philosophical underpinning of the approach is needed when it is used in depth (Dowling & Cooney, 2012 ; Holloway & Todres, 2003 ). This places demands on methods to be comprehensible and flexible yet consistent and coherent. Questions remain regarding how thematic analysis can be further clarified and used based on descriptive phenomenology.

In this discursive paper, we provide guidance for thematic analysis based on descriptive phenomenology, which, to our knowledge, has not been made explicit in this way previously. This can be used as a guiding framework to analyse lived experiences in nursing and midwifery research. The aim of this paper was to discuss how to understand and undertake thematic analysis based on descriptive phenomenology. Methodological principles to guide the process of analysis are offered grounded on phenomenological philosophy. This is further discussed in relation to how scientific rigour and validity can be achieved.

2. ONTOLOGICAL AND EPISTEMOLOGICAL FOUNDATIONS OF DESCRIPTIVE PHENOMENOLOGY

Phenomenology consists of a complex philosophical tradition in human science, containing different concepts interpreted in various ways. One main theme among phenomenological methods is the diversity between descriptive versus interpretive phenomenology (Norlyk & Harder, 2010 ). Both traditions are commonly used in nursing and midwifery research. Several phenomenological methods have been recognized in the descriptive or interpretative approaches (Dowling, 2007 ; Dowling & Cooney, 2012 ; Norlyk & Harder, 2010 ). The descriptive tradition of phenomenology originated from the writings of Husserl was further developed by Merleau‐Ponty, while the interpretive approach was developed mainly from Heidegger and Gadamer.

The thematic analysis in this paper uses a descriptive approach with focus on lived experience, which refers to our experiences of the world. The philosophy of phenomenology is the study of a phenomenon, for example something as it is experienced (or lived) by a human being that means how things appear in our experiences. Consequently, there is a strong emphasis on lived experiences in phenomenological research (Dowling & Cooney, 2012 ; Norlyk & Harder, 2010 ). In this paper, lived experience is understood from a lifeworld approach originating from the writing of Husserl (Dahlberg, Dahlberg, & Nyström, 2008 ). The lifeworld is crucial and becomes the starting point for understanding lived experiences. Hence, the lifeworld forms the ontological and epistemological foundation for our understanding of lived experiences. In the lifeworld, our experiences must be regarded in the light of the body and the lifeworld of a person (i.e., our subjectivity). Consequently, humans cannot be reduced to a biological or psychological being (Merleau‐Ponty, 2002 /1945). When understanding the meaning of lived experiences, we need to be aware of the lifeworld, our bodily being in the world and how we interact with others.

The understanding of lived experiences is closely linked to the idea of the intentionality of consciousness, or how meaning is experienced. Intentionality encompasses the idea that our consciousness is always directed towards something, which means that when we experience something, the “thing” is experienced as “something” that has meaning for us. For example, a birthing woman's experience of pain or caregiving as it is experienced by a nurse. In a descriptive phenomenological approach, based on the writing of Husserl (Dahlberg et al., 2008 ) such meanings can be described. From this point of view, there are no needs for interpretations of these meanings, although this may be argued differently in interpretive phenomenology. Intentionality is also linked to our natural attitude. In our ordinary life, we take ourselves and our life for granted, which is our natural attitude and how we approach our experiences. We usually take for granted that the world around us is as we perceive it and that others perceive it as we do. We also take for granted that the world exists independently of us. Within our natural attitude, we normally do not constantly analyse our experiences. In phenomenology, an awareness of the natural attitude is important.

3. METHODOLOGICAL PRINCIPLES

In the ontological and epistemological foundations of descriptive phenomenology, some methodological principles can be recognized and how these are managed throughout the research process. Phenomenological studies have been criticized for lacking in clarity on philosophical underpinnings (Dowling & Cooney, 2012 ; Norlyk & Harder, 2010 ). Thus, philosophical stances must be understood and clarified for the reader of a study. Our suggestion is to let the entire research process, from data gathering to data analysis and reporting the findings, be guided by the methodological principles of emphasizing openness , questioning pre‐understanding and adopting a reflective attitude . We will acknowledge that the principles presented here may not be totally distinct from, or do follow, a particular phenomenological research approach. However, the outlined approach has some commonalities with the approaches of, for example, Dahlberg et al. ( 2008 ) and van Manen ( 2016 ).

When researching lived experiences, openness to the lifeworld and the phenomenon focused on must be emphasized (i.e., having curiosity and maintaining an open mind when searching for meaning). The researcher must adopt an open stance with sensitivity to the meaning of the lived experiences currently in focus. Openness involves being observant, attentive and sensitive to the expression of experiences (Dahlberg et al., 2008 ). It also includes questioning the understanding of data (Dahlberg & Dahlberg, 2003 ). Thus, researchers must strive to maintain an attitude that includes the assumption that hitherto the researcher does not know the participants experience and the researcher wants to understand the studied phenomenon in a new light to make invisible aspects of the experience become visible.

When striving for openness, researchers need to question their pre‐understanding , which means identifying and becoming aware of preconceptions that might influence the analysis. Throughout the research process and particularly the analysis, researchers must deal with the natural attitude and previous assumptions, when analysing and understanding the data. Questioning involves attempting to set aside one's experiences and assumptions as much as possible and means maintaining a critical stance and reflecting on the understanding of data and the phenomenon. This is similar to bracketing, a commonly used term in descriptive phenomenology based on Husserl, but it has been criticized (Dowling & Cooney, 2012 ). Some would argue that bracketing means to put aside such assumptions, which may not be possible. Instead, Gadamer ( 2004 ) deals with this in a different way, arguing that such assumptions are part of our understanding. Instead of using bracketing, our intention is to build on questioning as a representative way to describe what something means. Accordingly, researchers need to recognize personal beliefs, theories or other assumptions that can restrict the researcher's openness. Otherwise, the researcher risks describing his or her own pre‐understanding instead of the participants' experiences. Our pre‐understanding, described as “prejudice” in interpretive phenomenology by Gadamer ( 2004 ), is what we already know or think we know about a phenomena. As humans, we always have such a pre‐understanding or prejudice and Gadamer ( 2004 ) posits this is the tradition of our lived context and emphasizes that our tradition has a powerful influence on us. This means that it might be more difficult to see something new in the data than describe something already known by the researcher. Therefore, an open and sensitive stance is needed towards oneself, one's pre‐understanding and the understanding of data. However, one must be reflective and critical towards the data, as well as how to understand meanings from the data. Questioning can help researchers become aware of their pre‐understanding and set aside previous assumptions about the phenomenon (Dahlberg et al., 2008 ).

Questioning one's pre‐understanding is closely linked to having a reflective attitude . With a reflective attitude, the researcher needs to shift from the ordinary natural understanding of everyday life to a more self‐reflective and open stance towards the data (Dahlberg et al., 2008 ). An inquiring approach throughout the research process helps researchers become more aware of one's assumptions and reflect regarding the context of the actual research. For instance, researchers may need to reflect on why some meanings occur, how meanings are described and if meanings are grounded in the data. In striving for an awareness of the natural attitude, a reflective attitude becomes imperative. By having such an awareness, some of the pitfalls related to our natural attitude can be handled in favour of an open and reflective mind.

To summarize, methodological principles have been described in terms of emphasizing openness, questioning pre‐understanding and adopting a reflective attitude, which are three related concepts. To emphasis openness, one needs to reflect on preconceptions and judgements concerning the world and our experiences with a reflective approach to become aware of the natural attitude and process of understanding. Engaging in critical reflection throughout the research process may facilitate an awareness of how the researcher influences the research process. These methodological principles, related to ontological and epistemological foundations of phenomenology, are suggested to guide the research process, particularly the analysis.

4. THEMATIC ANALYSIS OF LIVED EXPERIENCES

The thematic analysis approach described in this paper is inductive. A prerequisite for the analysis is that it includes data on lived experiences, such as interviews or narratives. Themes derived from the analysis are data driven (i.e., grounded in data and the experience of the participants). The analysis begins with a search for meaning and goes on with different meanings being identified and related to each other. The analysis is aimed to try to understand the complexity of meanings in the data rather than measure their frequency. It involves researcher engaging in the data and the analysis. The analysis contains a search for patterns of meanings being further explored and determining how such patterns can be organized into themes. Moreover, the analysis must be guided by openness. Thus, the analysis involves a reflective process designed to illuminate meaning. Although the process of analysis is similar to descriptive phenomenological approaches focusing on the understanding and description of meaning‐oriented themes (Dahlberg et al., 2008 ; van Manen, 2016 ), there are important differences. While the thematic analysis in this paper focuses on how to organize patterns of meaning into themes, some would argue that an essential, general structure of meaning, rather than fragmented themes, is preferred (van Wijngaarden, Meide, & Dahlberg, 2017 ) and that such an essential meaning structure is a strength. We argue that meaning‐oriented themes can contribute to robust qualitative research findings. Still, it is important that the findings move between concrete expressions and descriptive text on meanings of lived experiences.

4.1. The process of analysis

The goal of the thematic analysis is to achieve an understanding of patterns of meanings from data on lived experiences (i.e., informants' descriptions of experiences related to the research question in, e.g., interviews or narratives). The analysis begins with data that needs to be textual and aims to organize meanings found in the data into patterns and, finally, themes. While conducting the analysis, the researcher strives to understand meanings embedded in experiences and describe these meanings textually. Through the analysis, details and aspects of meaning are explored, requiring reading and a reflective writing. Parts of the text need to be understood in terms of the whole and the whole in terms of its parts. However, the researcher also needs to move between being close to and distant from the data. Overall, the process of analysis can be complex and the researcher needs to be flexible. This process is summarized in Figure ​ Figure1 1 and detailed in the description below.

Summary of thematic analysis

To begin the analysis, the researcher needs to achieve familiarity with the data through open‐minded reading. The text must be read several times in its entirety. This is an open‐ended reading that puts the principle of openness into practice with the intention of opening one's mind to the text and its meanings. When reading, the researcher starts to explore experiences expressed in the data, such as determining how these are narrated and how meanings can be understood. The goal is to illuminate novel information rather than confirm what is already known while keeping the study aim in mind.

Thereafter, the parts of the data are further illuminated and the search for meanings and themes deepens. By moving back and forth between the whole and its parts, a sensitive dialogue with the text may be facilitated. While reading, meanings corresponding to the study's aim are marked. Notes and short descriptive words can be used to give meanings a preliminary name. As the analysis progresses, meanings related to each other are compared to identify differences and similarities. Meanings need to be related to each other to get a sense of patterns. Patterns of meanings are further examined. It is important to not make meanings definite too rapidly, slow down the understanding of data and its meanings. This demands the researcher's openness to let meanings emerge.

Lastly, the researcher needs to organize themes into a meaningful wholeness. Methodological principles must remind the researcher to maintain a reflective mind, while meanings are further developed into themes. Meanings are organized into patterns and, finally, themes. While deriving meaning from text, it is helpful to compare meanings and themes derived from the original data. Nothing is taken for granted, and the researcher must be careful and thoughtful during this part of the process. It can be valuable to discuss and reflect on tentative themes emerging from the data. Findings need to be meaningful, and the naming and wording of themes becomes important. The writing up of the themes is aimed to outline meanings inherent in the described experiences. At this point, findings are written and rewritten. Faithful descriptions of meanings usually need more than a single word, and the writing is important.

To conclude, the process of thematic analysis, based in a descriptive phenomenological approach, goes from the original data to the identification of meanings, organizing these into patterns and writing the results of themes related to the study aim and the actual context. When the findings are reported, these are described conversely (i.e., starting with the themes and the descriptive text, illustrated with quotes). Thus, meanings found from participants experiences are described in a meaningful text organized in themes.

4.2. Validity and Rigour

Hereby follows our discussion on scientific quality in terms of validity and rigour in the thematic analysis process. There is no consensus on which concepts should be used regarding validity in qualitative and phenomenological research. The term validity is typically used in relation to quantitative methods; however, qualitative researchers claim that the term is suitable in all paradigms as a generic term implying whether the research conclusions are sound, just and well‐founded (Morse, 2015 ; Whittemore, Chase, & Mandle, 2001 ). Rolfe ( 2006 ) states that scientific rigour can be judged based on how the research is presented for the reader and appraising research lies with both the reader and the writer of the research. Thus, clarity regarding methodological principles used becomes necessary. Porter ( 2007 ) argues that a more realistic approach is needed and that scientific rigour needs to be taken seriously in qualitative research (Porter, 2007 ). It has been stressed that strategies are needed to ensure rigour and validity; such strategies must be built into the research process and not solely evaluated afterwards (Cypress, 2017 ). Therefore, we further discuss scientific rigour and phenomenological validity in relation to reflexivity , credibility and transferability .

Reflexivity is strictly connected to previously described methodological principles of a reflective attitude and questioning one's pre‐understanding. Reflexivity must be maintained during the entire process, and the researcher needs to sustain a reflective attitude. Particularly, reflexivity must involve questioning the understanding of data and themes derived. Qualitative researchers are closely engaged in this process and must reflect on what the data actually state that may be different from the researcher's understanding. This means the researcher should question the findings instead of taking them for granted. Malterud ( 2001 ) claims that multiple researchers might strengthen the study since they can give supplementary views and question each other's statements, while an independent researcher must find other strategies. Another way to maintain reflexivity is comparing the original data with the descriptive text of themes derived. Moreover, findings need to be illustrated with original data to demonstrate how the derived descriptions are grounded in the data rather than in the researcher's understanding. Furthermore, information is needed on the setting so the reader can understand the context of the findings.

Credibility refers to the meaningfulness of the findings and whether these are well presented (Kitto, Chesters, & Grbich, 2008 ). Credibility and reflexivity are not totally distinct but are correlated with each other. Credibility stresses that nothing can be taken for granted and is associated with the methodological principles described above. The researcher needs to emphasize how the analysis and findings are presented for the reader. The analysis needs to be transparent, which means that the researcher should present it as thoroughly as possible to strive for credibility. The reader needs information concerning the methodology used and methodological decisions and considerations made. This includes, for instance, how the thematic analysis was performed, descriptions of how meanings were derived from the data and how themes were identified. Descriptions need to be clear and consistent. However, it must be possible to agree with and understand the logic of the findings and themes. Credibility lies in both the methodology and in the presentation of findings. Thus, in striving for credibility, the procedures and methods need to be presented as thoroughly and transparently as possible. Themes described must be illustrated with quotes to ensure the content and described meanings are consistent.

Transferability refers to the usefulness and relevance of the findings. However, the method used does not guarantee transferability in itself. Transferability is not explicitly related to any of the methodological principles, but it may be a result of them. Transferability is a measure of whether the findings are sound and if the study adds new knowledge to what is already known. The clarity of findings is also important. Thus, findings must be understandable and transferable to other research (i.e., findings need to be recognizable and relevant to a specific or broader context other than the original study). Specifically, the relevance, usefulness and meaningfulness of research findings to other contexts are important components of the study's transferability.

To conclude, reflexivity, credibility and transferability are concepts important to acknowledge and consider throughout the research process to engender validity and rigour. We maintain that meaning‐oriented themes can contribute to robust findings, if reported in a text describing patterns of meanings illustrated with examples of expressions from lived experiences. Questions researchers need to ask themselves in relation to validity when conducting a thematic analysis are presented in Figure ​ Figure2. 2 . Since the method in itself is no guarantee of validity and rigour, discussions related to these areas are needed.

Overview of questions useful to the uphold reflexivity, credibility and transferability of the research process in the thematic analysis of meanings

5. IMPLICATIONS FOR NURSING AND MIDWIFERY

In this paper, a method for thematic analysis based on phenomenology has been outlined. Doing phenomenological research is challenging. Therefore, we hope this paper contributes to the understanding of phenomenological underpinnings and methodological principles of thematic analysis based on descriptive phenomenology. This approach can be useful for teachers and researchers in nursing and midwifery. The thematic analysis presented can offer guidance on how to understand meaning and analyse lived experiences. Methodological stances of descriptive phenomenology are clarified, linking the process of analysis with theoretical underpinnings. Methodological principles are explained to give guidance to the analysis and help understand validity and rigour. Thus, this paper has the potential to provide researchers and students who have an interest in research on lived experiences with a comprehensive and useful method to thematic analysis in phenomenology. Nurses and midwives conducting qualitative research on lived experiences need robust methods to ensure high quality in health care to benefit patients, childbearing women and their families.

6. CONCLUSION

We provide researchers in nursing and midwifery with some clarity regarding thematic analysis grounded in the tradition of descriptive phenomenology. We argue that researchers need to comprehend phenomenological underpinnings and be guided by these in the research process. In thematic analysis, descriptive phenomenology is a useful framework when analysing lived experiences with clarified applicable ontological and epistemological underpinnings. Emphasizing openness, questioning pre‐understanding and adopting a reflective attitude were identified as important methodological principles that can guide researchers throughout the analysis and help uphold scientific rigour and validity. For novice researchers, the present paper may serve as an introduction to phenomenological approaches.

CONFLICT OF INTEREST

No conflict of interest has been declared by the authors.

AUTHOR CONTRIBUTIONS

AS, EL, CN, LP: Made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; involved in drafting the manuscript or revising it critically for important intellectual content; given final approval of the version to be published and each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content; and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Common terms and phrases, about the author  (2021).

Virginia Braun is a Professor in the School of Psychology at The University of Auckland, Aotearoa New Zealand. She is a feminist and critical (health) psychologist and teaches around gender and psychology and critical health psychology at undergraduate and graduate levels. When she gets time for it, her research (sometimes in collaboration with Victoria Clarke) explores the intersecting areas of gender, bodies, sex/sexuality, health, and (now) food. She is on Twitter @ginnybraun, where sometimes her tweets about qualitative research, usually in that case a retweet of an awesome thread by Victoria.

Victoria Clarke is an Associate Professor in Qualitative and Critical Psychology in the Department of Health and Social Sciences at the University of the West of England (UWE), Bristol, where she teaches about qualitative methods, and gender and sexuality, and supervises student research, on a variety of undergraduate and postgraduate programmes. When she′s not busy collaborating with Virginia Braun, she has conducted research in the intersecting areas of gender and sexuality, family and relationships, and appearance and embodiment. She is also active on Twitter – mainly tweeting about thematic analysis and qualitative research @drvicclarke.

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Supporting Sense of Meaningful Life and Human Dignity in Digitally Assisted Physiotherapy Environment – Qualitative Secondary Research with Thematic Analyses and Inductive Synthesis

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• Tuulikki Sjögren   ORCID: orcid.org/0000-0001-6908-4618 15 &
• Hilkka Korpi   ORCID: orcid.org/0000-0001-6590-0542 15 , 16  

Part of the book series: Communications in Computer and Information Science ((CCIS,volume 2083))

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• Nordic Conference on Digital Health and Wireless Solutions​

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The goal of this secondary research was to create a model that aims at increasing the sense of meaningful life and human dignity in physiotherapy by utilizing remote and digital rehabilitation technologies, focusing on people with cerebrovascular accident (CVA) and multiple sclerosis (MS). The results of this qualitative research effort have been obtained using thematic analyses and inductive synthesis. Our primary research, which provides materials for the secondary analysis, is based on qualitative systematic literature reviews and a meta-synthesis of the perceived meaningfulness of physiotherapy. The outcome of the secondary analysis is a research-based model, which combines rehabilitees´ experiences and expectations towards physiotherapy, professionals’ competence needs, and the technological prerequisites for using digital rehabilitation technologies with CVA and MS rehabilitees. Maintenance of human dignity and promotion of the sense of meaningful life, and various issues related to them, were most meaningful for the rehabilitees. The essential prerequisites of meaningful use of re- mote and digital rehabilitation technologies in physiotherapy were enabling identification of the rehabilitees’ own current functioning, needs and goals, supporting their motivation and commitment, choosing relevant and meaningful activities, creating safe and variable environments, and enabling social interaction and relationships. As far as we know, this is the first model which combines neuro- logical rehabilitees’ experiences of physiotherapy with remote and digital technology’s potential. In the future, the usefulness of our novel research-based holistic and biopsychosocial physiotherapy model should be tested in real life situations.

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• Human dignity and sense of meaningfulness
• Digitalization
• Re- mote physiotherapy
• Modelling physiotherapy

1 Introduction

Countries worldwide face challenges linked to population ageing. This demographic trend, coupled with increasing chronic diseases and mental problems poses significant social challenges. Both the active-age and senior citizens’ health and functional ability need to be supported to lessen the growth in health care costs and thus to ensure the economic and social sustainability of societies. Therefore, there is an increasing need for effective physiotherapy measures, firstly using early rehabilitation before individuals experience debilitating problems, and secondly to alleviate the inevitable later symptoms and functional capacity problems [ 1 – 3 ].

The tendency toward digitalization and greater role of remote techniques in rehabilitation requires new approaches on rehabilitation research. Compared to traditional face-to-face rehabilitation remote rehabilitation, relying to a greater extent on digital technologies, increases the significance of rehabilitees’ own commitment and technological skills. This type of change in the rehabilitation paradigm calls for a deeper understanding of those factors which support the rehabilitees’ sense of purpose in their efforts to work towards recovery and thus trigger intrinsic motivation. Consequently, the scope of the current mainstream rehabilitation research should be supplemented with more research on broader biopsychosocial, cultural, environmental, or artistic aspects of the rehabilitation process. Typical rehabilitation studies focus on testing the outcomes and short-term effectiveness of a single rehabilitation technique and some- times just on one group of rehabilitees suffering from a single functionality impairment [ 4 – 6 ].

Even in the most recent policy reports, which cover activities in rehabilitation, the medical aspects have the primary role [ 7 – 9 ]. The organization of health and social services are currently at a watershed moment in Finland. In 2023, the organization of health and social services have been transferred from the responsibility of municipali- ties to 21 wellbeing services counties [ 10 ]. As part of this extensive change, it is im- portant to research and develop the use of digitalization and remote technologies even in physiotherapy, and in such a way that individuals’ sense of human dignity and meaningful life is preserved during the rehabilitation process.

In future we urgently need an open-minded approach to new technologies to ensure human resources, develop more personalized services, maintain sound public finances, alleviate sustainability crisis, and all-in-all respond to the variable challenges posed by ageing societies [ 11 ]. It is important to develop digital solutions which are useful, efficient and sustainable. During the process, rehabilitees’ and rehabilitation staffs’ attitudes and opinions should be taken into consideration [ 12 , 13 ]. For example, our recently published study indicated that, 75% of Finnish physiotherapists reported that they used mainly conventional physiotherapy, and remote physiotherapy is still minimally used as the primary working method at different stages of the physiotherapy process [ 14 ]. According to physiotherapists, remote rehabilitation techniques are least suit- able for neurological rehabilitees [ 15 ], even though they are a group of rehabilitees who are in most need of very intensive therapeutic training as well as guidance, counselling and support in their everyday life [ 5 , 16 – 18 ]. Development of rehabilitation platforms, rehabilitation applications, telemedicine solutions and even digital twin solutions are rapidly increasing [ 19 ]. There is a lack of digital and remote technology solutions which are rehabilitee-centered, holistic and reflect the biopsychosocial model of rehabilitation for use in neurological physiotherapy. For example, the main contents of commercial models for MS rehabilitees are still narrowly focused on medical care [ 19 , 20 ], medical aspects of self-care [ 19 , 21 ], physical activity [ 19 , 22 , 23 ], or self-management [ 19 , 24 ].

Non-compliance with various therapies and treatments in chronic diseases is a worldwide problem of striking magnitude, making this a critical issue in population health both from the perspective of life quality, and health economics as well as of health system effectiveness [ 1 ]. The same problem concerns also home exercise that shows low adherence (as low as 50%), potentially having detrimental effects on clinical outcomes. Some studies highlight that well-designed health technologies provide us with the opportunity to better support both the patient and clinician. Of significance is a data-driven approach that incorporates features designed to increase adherence to exercise, such as coaching, self-monitoring and education, as well as the ability to re- motely monitor adherence rates more objectively [ 25 ]. However, a recently published meta-analysis showed that technology assisted self-rehabilitation (remote coaching, self-monitoring, education, and adherence) did not appear to have a significant effect on the outcomes [ 26 ]. So, as far as we can conclude, commitment and adherence in self-rehabilitation context is still an unresolved problem in remote physiotherapy [ 25 – 28 ].

The goal of this research was to create a rehabilitation model that aims at sustaining the sense of meaningful life and human dignity in physiotherapy, potentially having positive effects on rehabilitees´ commitment and adherence when using remote and digital rehabilitation technologies. The focus was on people with cerebrovascular accident (CVA) or multiple sclerosis (MS).

2 Materials and Methods

CVA and MS rehabilitees are very suitable study populations for the purpose of this study. CVA and MS have an impact on persons’ physical, psychological, social, and cognitive functioning, affecting their daily life activities, participation, and quality of life. In addition to the affected individuals, CVA and MS also place a considerable burden on their families, caregivers, and in overall on the entire society [ 29 , 30 ]. Since 1990, the prevalence of CVA has increased over 70% worldwide in less than 30 years [ 31 ]. Each year, approximately 1.1 million Europeans suffer a stroke, and in 2020 there were an estimated 9.5 million stroke survivors in Europe [ 32 , 33 ]. By 2030, the stroke prevalence is expected to rise by 35% [ 34 ]. An increasing trend can also be seen in people with MS showing a 30% increase from 2013 to 2020 worldwide [ 35 ].

This study is a secondary analysis using thematic analyses and inductive synthesis of detected meanings in the materials [ 36 ], considering both the results of rehabilitee experiences of meaningful physiotherapy and the results of the experiences in using rehabilitation technology. The primary analyses have been produced as part of our previous line of research using two extensive systematic literature reviews (publication dates extending from Jan. 2001 to Nov. 2017), the first one focusing on CVA rehabilitees and the second one on MS rehabilitees.

The reviews included 50 qualitative studies in total (711 rehabilitees) [ 16 , 17 ]. The literature search of qualitative studies was conducted from the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the National Library of Medicine (Ovid MEDLINE), and the Education Resources Information Center (ERIC). In addi- tion, the searches were supplemented with manual and reference searches. According to the qualitative PICoS framework, the inclusion criteria were adult CVA and MS rehabilitees (age ≥ 18 years) (P = population or problem, i.e. patient). Our focus of interest was on rehabilitees’ views, perceptions, and experiences of physiotherapy (I = interest). In the literature search, the content of physiotherapy was not limited, and different methods, practices and operating environments of physiotherapy used in Finnish physiotherapy were accepted (Co = context). All original studies conducted using a qualitative research design (S = study design) were included. Studies published in English, Swedish, German and Finnish were accepted as data.

The original idea of the study was to use the literature reviews to investigate reha- bilitee experiences of meaningful physiotherapy. The analysis of the systematic litera- ture (CVA/MS) review data was conducted in five phases: 1) Classifying and summa- rizing the study results according to the PICoS criteria and main results, 2) narrative synthesis of the results [cf.37], 3) constructing lower and upper themes of meaningful experiences [cf. 38], 4) metasynthesis of qualitative research results by rehabilitee-specific (CVA/MS) groups, and 5) combining both rehabilitee groups [cf.38]. The stages of the analysis were carried out as triangulation by two pairs of researchers [ 16 , 17 ].

The results of our primary research have been published in Korpi et al. 2022 [ 16 ], Sjögren et al. 2022 [ 17 , 18 ]. These results have served as the materials for our secondary analysis, which we have divided into three phases. For the first phase of the analysis, we have focused on the rehabilitee experiences of meaningful physiotherapy and re- classified the findings in such a manner that we can create a coherent synthesis (i.e., phase three) when combined the outcomes with the outcomes of the second phase. For the second phase, the sense of meaningfulness in physiotherapy was examined from the perspective of rehabilitation technologies, including remote technologies. Technology use in rehabilitation was not a specific issue in our primary study, but it frequently had come up as part of the experiences tackled by the rehabilitees. These data were analyzed following a standard thematic content analysis process [cf.38]. For the third phase, we have integrated the main results of the previous secondary analysis phases to create a theoretical model as a synthesis of this study. The model is expected to provide tools for sustaining the sense of meaningful life and human dignity in physiotherapy for CVA and MS rehabilitees, particularly when using digital rehabilitation technologies and techniques of remote physiotherapy.

The key concepts used throughout this study are human dignity and sense of mean- ingful life. Human dignity has generally been identified as a concept or phenomenon intertwined with human rights [ 39 ] or defined in several various ways [ 40 ]. From the perspective of physiotherapy science or rehabilitation we have not tied the concept of human dignity with any single human characteristic (e.g., gender, functional ability) or operational environment (e.g., clinical work). Our perspective is more linked to the general idea that every individual holds a special value that is tied with their humanity. In our research context, human dignity means that during physiotherapy rehabilitation rehabilitates should be treated in such manner that their individual human value and basic human rights, needs and wishes are consistently respected. The sense of meaningful life, in turn, can be associated with, e.g., safety, dependency, flexibility and one’s physical and social world [ 41 ].

The entire process of secondary analysis was carried out using researcher triangulation conducted by the authors. At first, the researchers worked independently by adding the relevant factors of a meaningful physiotherapy process and the use of technology in the same context to the framework originating from the primary analysis (“meaningful experiences of physiotherapy”). Secondly, the researchers formed a consensus over the results by discussing as well as by forming the principal essential prerequisites for meaningful physiotherapy, also focusing on the use of digital and remote technologies.

Our secondary analysis confirmed that the most fundamental generic elements in physiotherapy, based on the interpretation of the rehabilitee feedback (mostly interviews), should be preservation of meaningfulness in life and maintenance of human dignity. These elements were primarily reinforced by treating the rehabilitees as individuals, respecting their independence and freedom of choice, promoting their participation in ordinary life, and ensuring that they could preserve faith and hope for the future (see the middle sections in Fig.  1 ).

Technology assisted personalized physiotherapy model: The Human Dignity Centered Rehabilitation approach

Striving for the above listed goals requires a physiotherapy model, which takes into account the following seven factors related to the content of physiotherapy treatment:1) Improving self-confidence, 2) strengthening psychological and cognitive wellbeing, 3) maintaining the meaningfulness of rehabilitation, 4) using reflective discussions to overcome rehabilitation linked challenges, 5) conducting a fair and professional rehabilitation process, also recognizing the need for a holistic biopsychosocial approach to rehabilitation, 6) enabling improvements in body awareness/image, physical functioning and physical activity as well as accessibility, and 7) enabling empowerment through dynamic interaction with others. Table  1 is a concise presentation of all these factors, which have been derived from the systematic literature review data using the applied qualitative analysis approach.

Keeping in mind the key generic elements of rehabilitation, the process should sup- port the sense of meaningful life and respect rehabilitees’ human dignity, even when conventional physiotherapy is supplemented with remote and digital physiotherapy technologies. Such technologies pose obvious challenges, particularly in terms of pro- fessionals’ competence requirements, but our results show that digital and remote technologies can also open a window for new opportunities, supposing that the technological solutions are innovative and fit for people facing various disabilities (see Table  2 ). Such technologies could enable rehabilitees’ self-management, ensuring their autonomy, flexibility, and progressive ownership of the rehabilitation process. Rehabilitation technologies could also offer opportunities for equal dialogue, easy communication and fast contact with rehabilitation professionals thus empowering an equal, professional, comprehensive, and fair rehabilitation process. The important elements of (digital) technology assisted physiotherapy consist of the following issues: 1) Motivation and commitment support, 2) enablement of social interactions and social relationships, 3) design of safe and variable training environments, 4) flexibility in choosing relevant and meaningful activities for oneself, 5) identification of rehabilitation needs and goals, 6) support for rehabilitees to understand their current functioning status and the appropriate paths to improvement (see the left and right edge in Fig.  1 ).

4 Discussion

The goal of this secondary analysis was to create a practical model for implementation of physiotherapy treatment which support the maintenance and reinforcement of the sense of human dignity and meaningful life among physiotherapy rehabilitees, particularly when using remote and digital techniques in physiotherapy. Based on our primary research [ 16 , 17 ] human dignity and sense of meaningful life appeared to be the most fundamental generic elements in aspired physiotherapy, based on the interpretation of the rehabilitee feedback. This central finding was reinforced by our secondary analysis, which also increased our understanding of the key factors which are considered essential in the content of physiotherapy treatment, both in conventional and remote/digitally supported physiotherapy. The results also gave ideas about the plausible advantages of digital rehabilitation techniques as well as the challenges related to the use of such techniques, the latter being largely linked with current competence requirements of the physiotherapy professionals.

We believe that our rehabilitee-oriented model emphasizing the essential role of in- dependence and freedom of choice, promoting social interactions, participation in the society and in ordinary life, and preservation of faith in the future, all of which help to promote the sense of human dignity and meaningful life, enables stronger adherence to physiotherapy as well as positive effects on biopsychosocial functioning and quality of life among rehabilitees. Rehabilitees´ strong commitment to their rehabilitation process is likely to become even more important in the future, because due to population ageing and cost pressure on public expenditure it is unavoidable that digital services are becoming more significant across all sectors of the society, including medical and rehabilitation services [ 4 , 6 ]. Digitalization of rehabilitation services is likely to increase the role of remote activities in physiotherapy, a central topic in our research effort. This will be a huge paradigm change because, so far, physiotherapy services have mostly been offered as face-to-face treatment [ 14 , 15 ].

From this perspective, our study approach is valuable, because so far scientific re- search has largely reflected the traditional rehabilitation research paradigm of quantitative effectiveness studies [e.g., 4 ]. The expected new physiotherapy and rehabilitation paradigm calls for new approaches to rehabilitation research. To our knowledge, this kind of modelling we have carried out in this paper has not been done before in physiotherapy, at least not among people with CVA and MS rehabilitees.

Our secondary analysis is linked to authors’ previous study efforts, in which the goal has been to evaluate effectiveness of physiotherapy and increase understanding of the meaningfulness of physiotherapy among CVA and MS rehabilitees [see 5 ]. The strength of the study and created physiotherapy model is that it is based on extensive and comprehensive research data (50 studies, 771 rehabilitees) [ 16 , 17 ] and supported by the authors’ long-term experiences in the field of physiotherapy and their intensive researcher triangulation working method extending over all the phases of the research process. During the entire development process (2021–2023) of the model we have also subjected its earlier versions to expert scrutiny at different occasions (conferences, workshops). Expert feedback (researchers, clinicians, teachers) reinforced the view that our research scope focusing on understanding the elements of meaningful physiotherapy, and of even multidisciplinary rehabilitation, in the context of remote and digitally assisted activities is important.

The limitation in our research is that it focuses only on neurological rehabilitees suffering from CVA and MS. Despite the specific disease etiology of CVA and MS, we are quite confident that the generic results of our secondary analysis are generally applicable to physiotherapy. Whatever is causing the limitations in persons’ physical, psychological, social, or cognitive abilities, their fundamental desire is to get treatment that makes them feel that they are valued as individuals and promotes their sense of meaningful life, regardless of the degree of improvement in their condition. However, the role of the more practical elements of physiotherapeutic activities can vary depending on what is causing the need for rehabilitation. Therefore, it would be important to study also other rehabilitee groups, e.g. cardiac, chronic pain or dementia patients. Moreover, the study of various rehabilitee groups is essential considering the use of remote and digitally assisted physiotherapy to learn more about how technology can best be utilized with individuals suffering from various health and functionality related issues. All in all, it is important to test our research-based physiotherapy model and future variations of it in real-life settings evaluating the degree of improved adherence and effectiveness of physiotherapy and improved meaningfulness, compared to the results of conventional physiotherapy [cf. 4 – 6 ]. The scope of future research should also be extended to the different stages of functioning (primary, secondary and tertiary prevention).

The general opinion appears to be that increased availability of technology, particularly digital technology, is the driving force when societies are moving towards more effective and cost-effective availability of services [ 42 ]. However, there are still few studies in rehabilitation that have investigated the cost-effectiveness of technology assisted rehabilitation [cf. 5 , 43 ]. This would be a challenging and complex research topic because one should be able to project simultaneously both short- and longer-term cost effects. For example, enhancing primary (preventive) rehabilitation may increase spending in the short term but making relevant technology accessible and alluring could decrease future costs in secondary or tertiary rehabilitation. Furthermore, as we have pointed out, factors which strengthen rehabilitees’ own commitment to physiotherapy may increase initial costs in physiotherapy but can be of major importance in terms of short- and mid-term effectiveness as well as longer-term impacts. This kind of thinking is crucial in terms of our research approach, and we hope that our research findings will pave the way for developing new modes of rehabilitation services provision. For example, in Finland, people receiving intensive medical rehabilitation has increased from 20000 to almost 40000 individuals in less than 15 years [ 3 ].

Countries worldwide are facing similar challenges, at least to some degree. Effective rehabilitation, particularly when extended to preventive rehabilitation, is expected to lessen the burden on health care costs in the long-run and ensure the maintenance of functional capabilities of the working age population. On top of these practical policy issues, we hope that our research and the human dignity and sense of meaningful life centered physiotherapy contribute to the development of theoretical and even philosophical understanding of physiotherapy.

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Acknowledgements

Thank you to all who were part of the research project Effectiveness of physiotherapy in multiple sclerosis and cerebrovascular disorder patients’ rehabilitation: systematic literature review (In Finnish: Fysioterapian vaikuttavuus vaativassa lääkinnällisessä AVH- ja MS-kuntoutuksessa: järjestelmällinen kirjallisuuskatsaus (2016–22) at the University of Jyväskylä and contributed to this study.

Conflict of Interest Statement.

The Authors declare that there is no conflict of interest.

The authors disclosed receipt of the following financial support for the re- search, authorship, and/or publication of this article: This work was supported by the Social Insurance Institution of Finland (Kela) [Dnro 4212612076].

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The data that support the findings of this study are available from the corresponding author, (TS), upon reasonable request.

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Sjögren, T., Korpi, H. (2024). Supporting Sense of Meaningful Life and Human Dignity in Digitally Assisted Physiotherapy Environment – Qualitative Secondary Research with Thematic Analyses and Inductive Synthesis. In: Särestöniemi, M., et al. Digital Health and Wireless Solutions. NCDHWS 2024. Communications in Computer and Information Science, vol 2083. Springer, Cham. https://doi.org/10.1007/978-3-031-59080-1_27

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