qualitative research theoretical framework

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Chapter 4: Theoretical frameworks for qualitative research

Tess Tsindos

Learning outcomes

Upon completion of this chapter, you should be able to:

• Describe qualitative frameworks.
• Explain why frameworks are used in qualitative research.
• Identify various frameworks used in qualitative research.

What is a Framework?

A framework is a set of broad concepts or principles used to guide research.  As described by Varpio and colleagues 1 , a framework is a logically developed and connected set of concepts and premises – developed from one or more theories – that a researcher uses as a scaffold for their study. The researcher must define any concepts and theories that will provide the grounding for the research and link them through logical connections, and must relate these concepts to the study that is being carried out. In using a particular theory to guide their study, the researcher needs to ensure that the theoretical framework is reflected in the work in which they are engaged.

It is important to acknowledge that the terms ‘theories’ ( see Chapter 3 ), ‘frameworks’ and ‘paradigms’ are sometimes used interchangeably. However, there are differences between these concepts. To complicate matters further, theoretical frameworks and conceptual frameworks are also used. In addition, quantitative and qualitative researchers usually start from different standpoints in terms of theories and frameworks.

A diagram by Varpio and colleagues demonstrates the similarities and differences between theories and frameworks, and how they influence research approaches. 1(p991) The diagram displays the objectivist or deductive approach to research on the left-hand side. Note how the conceptual framework is first finalised before any research is commenced, and it involves the articulation of hypotheses that are to be tested using the data collected. This is often referred to as a top-down approach and/or a general (theory or framework) to a specific (data) approach.

The diagram displays the subjectivist or inductive approach to research on the right-hand side. Note how data is collected first, and through data analysis, a tentative framework is proposed. The framework is then firmed up as new insights are gained from the data analysis. This is referred to as a specific (data) to general (theory and framework) approach .

Why d o w e u se f rameworks?

A framework helps guide the questions used to elicit your data collection. A framework is not prescriptive, but it needs to be suitable for the research question(s), setting and participants. Therefore, the researcher might use different frameworks to guide different research studies.

A framework informs the study’s recruitment and sampling, and informs, guides or structures how data is collected and analysed. For example, a framework concerned with health systems will assist the researcher to analyse the data in a certain way, while a framework concerned with psychological development will have very different ways of approaching the analysis of data. This is due to the differences underpinning the concepts and premises concerned with investigating health systems, compared to the study of psychological development. The framework adopted also guides emerging interpretations of the data and helps in comparing and contrasting data across participants, cases and studies.

Some examples of foundational frameworks used to guide qualitative research in health services and public health:

• The Behaviour Change Wheel 2
• Consolidated Framework for Implementation Research (CFIR) 3
• Theoretical framework of acceptability 4
• Normalization Process Theory 5
• Candidacy Framework 6
• Aboriginal social determinants of health 7(p8)
• Social determinants of health 8
• Social model of health 9,10
• Systems theory 11
• Biopsychosocial model 12
• Discipline-specific models
• Disease-specific frameworks

E xamples of f rameworks

In Table 4.1, citations of published papers are included to demonstrate how the particular framework helps to ‘frame’ the research question and the interpretation of results.

Table 4.1. Frameworks and references

As discussed in Chapter 3, qualitative research is not an absolute science. While not all research may need a framework or theory (particularly descriptive studies, outlined in Chapter 5), the use of a framework or theory can help to position the research questions, research processes and conclusions and implications within the relevant research paradigm. Theories and frameworks also help to bring to focus areas of the research problem that may not have been considered.

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Qualitative Research – a practical guide for health and social care researchers and practitioners Copyright © 2023 by Tess Tsindos is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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What Is A Theoretical Framework? A Practical Answer

• Published: 30 November 2015
• Volume 26 , pages 593–597, ( 2015 )

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• Norman G. Lederman 1 &
• Judith S. Lederman 1  

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Other than the poor or non-existent validity and/or reliability of data collection measures, the lack of a theoretical framework is the most frequently cited reason for our editorial decision not to publish a manuscript in the Journal of Science Teacher Education . A poor or missing theoretical framework is similarly a critical problem for manuscripts submitted to other journals for which Norman or Judith have either served as Editor or been on the Editorial Board. Often the problem is that an author fails to justify his/her research effort with a theoretical framework. However, there is another level to the problem. Many individuals have a rather narrow conception of what constitutes a theoretical framework or that it is somehow distinct from a conceptual framework. The distinction on lack thereof is a story for another day. The following story may remind you of an experience you or one of your classmates have had.

Doctoral students live in fear of hearing these now famous words from their thesis advisor: “This sounds like a promising study, but what is your theoretical framework?” These words instantly send the harried doctoral student to the library (giving away our ages) in search of a theory to support the proposed research and to satisfy his/her advisor. The search is often unsuccessful because of the student’s misconception of what constitutes a “theoretical framework.” The framework may actually be a theory, but not necessarily. This is especially true for theory driven research (typically quantitative) that is attempting to test the validity of existing theory. However, this narrow definition of a theoretical framework is commonly not aligned with qualitative research paradigms that are attempting to develop theory, for example, grounded theory, or research falling into the categories of description and interpretation research (Peshkin, 1993 ). Additionally, a large proportion of doctoral theses do not fit the narrow definition described. The argument here is not that various research paradigms have no overarching philosophies or theories about knowing. Clearly quantitative research paradigms are couched in a realist perspective and qualitative research paradigms are couched in an idealist perspective (Bogdan & Biklen, 1982 ). The discussion here is focused on theoretical frameworks at a much more specific and localized perspective with respect to the justification and conceptualization of a single research investigation. So, what is a theoretical framework?

It is, perhaps, easier to understand the nature and function of a theoretical framework if it is viewed as the answer to two basic questions:

What is the problem or question?

Why is your approach to solving the problem or answering the question feasible?

Indeed, the answers to these questions are the substance and culmination of Chapters I and II of the proposal and completed dissertation, or the initial sections preceding the Methods section of a research article. The answers to these questions can come from only one source, a thorough review of the literature (i.e., a review that includes both the theoretical and empirical literature as well as apparent gaps in the literature). Perhaps, a hypothetical situation can best illustrate the development and role of the theoretical framework in the formalization of a dissertation topic or research investigation. Let us continue with the doctoral student example, keeping in mind that a parallel situation also presents itself to any researcher planning research that he/she intends to publish.

As an interested reader of educational literature, a doctoral student becomes intrigued by the importance of questioning in the secondary classroom. The student immediately begins a manual and computer search of the literature on questioning in the classroom. The student notices that the research findings on the effectiveness of questioning strategies are rather equivocal. In particular, much of the research focuses on the cognitive levels of the questions asked by the teacher and how these questions influence student achievement. It appears that the research findings exhibit no clear pattern. That is, in some studies, frequent questioning at higher cognitive levels has led to more achievement than frequent questioning at the lower cognitive levels. However, an equal number of investigations have shown no differences between the achievement of students who are exposed to questions at distinctly different cognitive levels, but rather the simple frequency of questions.

The doctoral student becomes intrigued by these equivocal findings and begins to speculate about some possible explanations. In a blinding flash of insight, the student remembers hearing somewhere that an eccentric Frenchman named Piaget said something about students being categorized into levels of cognitive development. Could it be that a student’s cognitive level has something to do with how much and what he/she learns? The student heads back to the library and methodically searches through the literature on cognitive development and its relationship to achievement.

At this point, the doctoral student has become quite familiar with two distinct lines of educational research. The research on the effectiveness of questioning has established that there is a problem. That is, does the cognitive level of questioning have any effect on student achievement? In effect, this answers the first question identified previously with respect to identification of a theoretical framework. The research on the cognitive development of students has provided an intriguing perspective. That is, could it be possible that students of different cognitive levels are affected differently by questions at different cognitive levels? If so, an answer to the problem concerning the effectiveness questioning may be at hand. This latter question, in effect, has addressed the second question previously posed about the identification of a theoretical framework. At this point, the student has narrowed his/her interests as a result of reviewing the literature. Note that the doctoral student is now ready to write down a specific research question and that this is only possible after having conducted a thorough review of the literature.

The student writes down the following research hypotheses:

Both high and low cognitive level pupils will benefit from both high and low cognitive levels of questions as opposed to no questions at all.

Pupils categorized at high cognitive levels will benefit more from high cognitive level questions than from low level questions.

Pupils categorized at lower cognitive levels will benefit more from low cognitive level questions than from high level questions.

These research questions still need to be transformed into testable statistical hypotheses, but they are ready to be presented to the dissertation advisor. The advisor looks at the questions and says: “This looks like a promising study, but what is your theoretical framework?” There is no need, however for a sprint to the library. The doctoral student has a theoretical framework. The literature on questioning has established that there is a problem and the literature on cognitive development has provided the rationale for performing the specific investigation that is being proposed. ALL IS WELL!

If some of the initial research completed by Norman concerning what classroom variables contributed to students’ understandings of nature of science (Lederman, 1986a , 1986b ; Lederman & Druger, 1985 ) had to align with the overly restricted definition of a theoretical framework, which necessitates the presence of theory, it never would have been published. In these initial studies, various classroom variables were identified that were related to students’ improved understandings of nature of science. The studies were descriptive and correlational and were not driven by any theory about how students learn nature of science. Indeed, the design of the studies was derived from the fact that there were no existing theories, general or specific, to explain how students might learn nature of science more effectively. Similarly, the seminal study of effective teaching, the Beginning Teacher Evaluation Study (Tikunoff, Berliner, & Rist, 1975 ), was an ethnographic study that was not guided by the findings of previous research on effective teaching. Rather, their inductive study simply compared 40 teachers “known” to be effective and ineffective of mathematics and reading to derive differences in classroom practice. Their study had no theoretical framework if one were to use the restrictive conception that a theory needed to provide a guiding framework for the investigation. There are plenty of other examples that have guided lines of research that could be provided, but there is no need to beat a dead horse by detailing more examples. The simple, but important, point is that research following qualitative research paradigms or traditions (Jacob, 1987 ; Smith, 1987 ) are particularly vulnerable to how ‘theoretical framework’ is defined. Indeed, it could be argued that the necessity of a theory is a remnant from the times in which qualitative research was not as well accepted as it is today. In general, any research design that is inductive in nature and attempts to develop theory would be at a loss. We certainly would not want to eliminate multiple traditions of research from the Journal of Science Teacher Education .

Harry Wolcott’s discussion about validity in qualitative research (Wolcott, 1990 ) is quite explicit about the lack of theory or necessity of theory in driving qualitative ethnography. Interestingly, he even rejects the idea of validity as being a necessary criterion in qualitative research. Additionally, Bogdan and Biklen ( 1982 ) emphasize the importance of qualitative researchers “bracketing” (i.e., masking or trying to forget) their a priori theories so that it does not influence the collection of data or any meanings assigned to data during an investigation. Similar discussions about how qualitative research differs from quantitative research with respect to the necessity of theory guiding the research have been advanced by many others (e.g., Becker, 1970 ; Bogdan & Biklen, 1982 ; Erickson, 1986 ; Krathwohl, 2009 ; Rist, 1977 ; among others). Perhaps, Peshkin ( 1993 , p. 23) put it best when he expressed his concern that “Research that is not theory driven, hypothesis testing, or generalization producing may be dismissed as deficient or worse.” Again, the key point is that qualitative research is as valuable and can contribute as much to our knowledge of teaching and learning as quantitative research.

There is little doubt that qualitative researchers often invoke theory when analyzing the data they have collected or try to place their findings within the context of the existing literature. And, as stated at the beginning of this editorial, different research paradigms have large overarching theories about how one comes to know about the world. However, this is not the same thing has using a theory as a framework for the design of an investigation from the stating of research questions to developing a design to answer the research questions.

It is quite possible that you may be thinking that this editorial about the meaning of a theoretical framework is too theoretical. Trust us in believing that there is a very practical reason for us addressing this issue. At the beginning of the editorial we talked about the lack of a theoretical framework being the second most common reason for manuscripts being rejected for publication in the Journal of Science Teacher Education . Additionally, we mentioned that this is a common reason for manuscripts being rejected by other prominent journals in science education, and education in general. Consequently, it is of critical importance that we, as a community, are clear about the meaning of a theoretical framework and its use. It is especially important that our authors, reviewers, associate editors, and we as Editors of the journal are clear on this matter. Let us not fail to mention that most of us are advising Ph.D. students in the conceptualization of their dissertations. This issue is not new. In 1992, the editorial board of the Journal of Research in Science Teaching was considering the claim, by some, that qualitative research was not being evaluated fairly for publication relative to quantitative research. In their analysis of the relative success of publication for quantitative and qualitative research, Wandersee and Demastes ( 1992 , p. 1005) noted that reviewers often noted, “The manuscript had a weak theoretical basis” when reviewing qualitative research.

Theoretical frameworks are critically important to all of our work, quantitative, qualitative, or mixed methods. All research articles should have a valid theoretical framework to justify the importance and significance of the work. However, we should not live in fear, as the doctoral student, of not having a theoretical framework, when we actually have such, because an Editor, reviewer, or Major Professor is using any unduly restrictive and outdated meaning for what constitutes a theoretical framework.

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Lederman, N.G., Lederman, J.S. What Is A Theoretical Framework? A Practical Answer. J Sci Teacher Educ 26 , 593–597 (2015). https://doi.org/10.1007/s10972-015-9443-2

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Theoretical Frameworks in Qualitative Research

• Vincent A. Anfara, Jr. - University of Tennessee, Knoxville, USA
• Norma T. Mertz - University of Tennessee, Knoxville, USA
• Description

The Second Edition of Theoretical Frameworks in Qualitative Research brings together some of today’s leading qualitative researchers to discuss the frameworks behind their published qualitative studies. They share how they found and chose a theoretical framework, from what discipline the framework was drawn, what the framework posits, and how it influenced their study. Both novice and experienced qualitative researchers are able to learn first-hand from various contributors as they reflect on the process and decisions involved in completing their study. The book also provides background for beginning researchers about the nature of theoretical frameworks and their importance in qualitative research; about differences in perspective about the role of theoretical frameworks; and about how to find and use a theoretical framework.

Committee decision because of the depth of the qualitative information.

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Home » Theoretical Framework – Types, Examples and Writing Guide

Theoretical Framework – Types, Examples and Writing Guide

Table of Contents

Theoretical Framework

Definition:

Theoretical framework refers to a set of concepts, theories, ideas , and assumptions that serve as a foundation for understanding a particular phenomenon or problem. It provides a conceptual framework that helps researchers to design and conduct their research, as well as to analyze and interpret their findings.

In research, a theoretical framework explains the relationship between various variables, identifies gaps in existing knowledge, and guides the development of research questions, hypotheses, and methodologies. It also helps to contextualize the research within a broader theoretical perspective, and can be used to guide the interpretation of results and the formulation of recommendations.

Types of Theoretical Framework

Types of Types of Theoretical Framework are as follows:

Conceptual Framework

This type of framework defines the key concepts and relationships between them. It helps to provide a theoretical foundation for a study or research project .

Deductive Framework

This type of framework starts with a general theory or hypothesis and then uses data to test and refine it. It is often used in quantitative research .

Inductive Framework

This type of framework starts with data and then develops a theory or hypothesis based on the patterns and themes that emerge from the data. It is often used in qualitative research .

Empirical Framework

This type of framework focuses on the collection and analysis of empirical data, such as surveys or experiments. It is often used in scientific research .

Normative Framework

This type of framework defines a set of norms or values that guide behavior or decision-making. It is often used in ethics and social sciences.

Explanatory Framework

This type of framework seeks to explain the underlying mechanisms or causes of a particular phenomenon or behavior. It is often used in psychology and social sciences.

Components of Theoretical Framework

The components of a theoretical framework include:

• Concepts : The basic building blocks of a theoretical framework. Concepts are abstract ideas or generalizations that represent objects, events, or phenomena.
• Variables : These are measurable and observable aspects of a concept. In a research context, variables can be manipulated or measured to test hypotheses.
• Assumptions : These are beliefs or statements that are taken for granted and are not tested in a study. They provide a starting point for developing hypotheses.
• Propositions : These are statements that explain the relationships between concepts and variables in a theoretical framework.
• Hypotheses : These are testable predictions that are derived from the theoretical framework. Hypotheses are used to guide data collection and analysis.
• Constructs : These are abstract concepts that cannot be directly measured but are inferred from observable variables. Constructs provide a way to understand complex phenomena.
• Models : These are simplified representations of reality that are used to explain, predict, or control a phenomenon.

How to Write Theoretical Framework

A theoretical framework is an essential part of any research study or paper, as it helps to provide a theoretical basis for the research and guide the analysis and interpretation of the data. Here are some steps to help you write a theoretical framework:

• Identify the key concepts and variables : Start by identifying the main concepts and variables that your research is exploring. These could include things like motivation, behavior, attitudes, or any other relevant concepts.
• Review relevant literature: Conduct a thorough review of the existing literature in your field to identify key theories and ideas that relate to your research. This will help you to understand the existing knowledge and theories that are relevant to your research and provide a basis for your theoretical framework.
• Develop a conceptual framework : Based on your literature review, develop a conceptual framework that outlines the key concepts and their relationships. This framework should provide a clear and concise overview of the theoretical perspective that underpins your research.
• Identify hypotheses and research questions: Based on your conceptual framework, identify the hypotheses and research questions that you want to test or explore in your research.
• Test your theoretical framework: Once you have developed your theoretical framework, test it by applying it to your research data. This will help you to identify any gaps or weaknesses in your framework and refine it as necessary.
• Write up your theoretical framework: Finally, write up your theoretical framework in a clear and concise manner, using appropriate terminology and referencing the relevant literature to support your arguments.

Theoretical Framework Examples

Here are some examples of theoretical frameworks:

• Social Learning Theory : This framework, developed by Albert Bandura, suggests that people learn from their environment, including the behaviors of others, and that behavior is influenced by both external and internal factors.
• Maslow’s Hierarchy of Needs : Abraham Maslow proposed that human needs are arranged in a hierarchy, with basic physiological needs at the bottom, followed by safety, love and belonging, esteem, and self-actualization at the top. This framework has been used in various fields, including psychology and education.
• Ecological Systems Theory : This framework, developed by Urie Bronfenbrenner, suggests that a person’s development is influenced by the interaction between the individual and the various environments in which they live, such as family, school, and community.
• Feminist Theory: This framework examines how gender and power intersect to influence social, cultural, and political issues. It emphasizes the importance of understanding and challenging systems of oppression.
• Cognitive Behavioral Theory: This framework suggests that our thoughts, beliefs, and attitudes influence our behavior, and that changing our thought patterns can lead to changes in behavior and emotional responses.
• Attachment Theory: This framework examines the ways in which early relationships with caregivers shape our later relationships and attachment styles.
• Critical Race Theory : This framework examines how race intersects with other forms of social stratification and oppression to perpetuate inequality and discrimination.

When to Have A Theoretical Framework

Following are some situations When to Have A Theoretical Framework:

• A theoretical framework should be developed when conducting research in any discipline, as it provides a foundation for understanding the research problem and guiding the research process.
• A theoretical framework is essential when conducting research on complex phenomena, as it helps to organize and structure the research questions, hypotheses, and findings.
• A theoretical framework should be developed when the research problem requires a deeper understanding of the underlying concepts and principles that govern the phenomenon being studied.
• A theoretical framework is particularly important when conducting research in social sciences, as it helps to explain the relationships between variables and provides a framework for testing hypotheses.
• A theoretical framework should be developed when conducting research in applied fields, such as engineering or medicine, as it helps to provide a theoretical basis for the development of new technologies or treatments.
• A theoretical framework should be developed when conducting research that seeks to address a specific gap in knowledge, as it helps to define the problem and identify potential solutions.
• A theoretical framework is also important when conducting research that involves the analysis of existing theories or concepts, as it helps to provide a framework for comparing and contrasting different theories and concepts.
• A theoretical framework should be developed when conducting research that seeks to make predictions or develop generalizations about a particular phenomenon, as it helps to provide a basis for evaluating the accuracy of these predictions or generalizations.
• Finally, a theoretical framework should be developed when conducting research that seeks to make a contribution to the field, as it helps to situate the research within the broader context of the discipline and identify its significance.

Purpose of Theoretical Framework

The purposes of a theoretical framework include:

• Providing a conceptual framework for the study: A theoretical framework helps researchers to define and clarify the concepts and variables of interest in their research. It enables researchers to develop a clear and concise definition of the problem, which in turn helps to guide the research process.
• Guiding the research design: A theoretical framework can guide the selection of research methods, data collection techniques, and data analysis procedures. By outlining the key concepts and assumptions underlying the research questions, the theoretical framework can help researchers to identify the most appropriate research design for their study.
• Supporting the interpretation of research findings: A theoretical framework provides a framework for interpreting the research findings by helping researchers to make connections between their findings and existing theory. It enables researchers to identify the implications of their findings for theory development and to assess the generalizability of their findings.
• Enhancing the credibility of the research: A well-developed theoretical framework can enhance the credibility of the research by providing a strong theoretical foundation for the study. It demonstrates that the research is based on a solid understanding of the relevant theory and that the research questions are grounded in a clear conceptual framework.
• Facilitating communication and collaboration: A theoretical framework provides a common language and conceptual framework for researchers, enabling them to communicate and collaborate more effectively. It helps to ensure that everyone involved in the research is working towards the same goals and is using the same concepts and definitions.

Characteristics of Theoretical Framework

Some of the characteristics of a theoretical framework include:

• Conceptual clarity: The concepts used in the theoretical framework should be clearly defined and understood by all stakeholders.
• Logical coherence : The framework should be internally consistent, with each concept and assumption logically connected to the others.
• Empirical relevance: The framework should be based on empirical evidence and research findings.
• Parsimony : The framework should be as simple as possible, without sacrificing its ability to explain the phenomenon in question.
• Flexibility : The framework should be adaptable to new findings and insights.
• Testability : The framework should be testable through research, with clear hypotheses that can be falsified or supported by data.
• Applicability : The framework should be useful for practical applications, such as designing interventions or policies.

Advantages of Theoretical Framework

Here are some of the advantages of having a theoretical framework:

• Provides a clear direction : A theoretical framework helps researchers to identify the key concepts and variables they need to study and the relationships between them. This provides a clear direction for the research and helps researchers to focus their efforts and resources.
• Increases the validity of the research: A theoretical framework helps to ensure that the research is based on sound theoretical principles and concepts. This increases the validity of the research by ensuring that it is grounded in established knowledge and is not based on arbitrary assumptions.
• Enables comparisons between studies : A theoretical framework provides a common language and set of concepts that researchers can use to compare and contrast their findings. This helps to build a cumulative body of knowledge and allows researchers to identify patterns and trends across different studies.
• Helps to generate hypotheses: A theoretical framework provides a basis for generating hypotheses about the relationships between different concepts and variables. This can help to guide the research process and identify areas that require further investigation.
• Facilitates communication: A theoretical framework provides a common language and set of concepts that researchers can use to communicate their findings to other researchers and to the wider community. This makes it easier for others to understand the research and its implications.

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Use of theoretical and conceptual frameworks in qualitative research, helen elise green director of student education, university of leeds, uk.

Aim To debate the definition and use of theoretical and conceptual frameworks in qualitative research.

Background There is a paucity of literature to help the novice researcher to understand what theoretical and conceptual frameworks are and how they should be used. This paper acknowledges the interchangeable usage of these terms and researchers’ confusion about the differences between the two. It discusses how researchers have used theoretical and conceptual frameworks and the notion of conceptual models. Detail is given about how one researcher incorporated a conceptual framework throughout a research project, the purpose for doing so and how this led to a resultant conceptual model.

Review methods Concepts from Abbott ( 1988 ) and Witz ( 1992 ) were used to provide a framework for research involving two case study sites. The framework was used to determine research questions and give direction to interviews and discussions to focus the research.

Discussion Some research methods do not overtly use a theoretical framework or conceptual framework in their design, but this is implicit and underpins the method design, for example in grounded theory. Other qualitative methods use one or the other to frame the design of a research project or to explain the outcomes. An example is given of how a conceptual framework was used throughout a research project.

Conclusion Theoretical and conceptual frameworks are terms that are regularly used in research but rarely explained. Textbooks should discuss what they are and how they can be used, so novice researchers understand how they can help with research design.

Implications for practice/research Theoretical and conceptual frameworks need to be more clearly understood by researchers and correct terminology used to ensure clarity for novice researchers.

Nurse Researcher . 21, 6, 34-38. doi: 10.7748/nr.21.6.34.e1252

This article has been subject to double blind peer review

None declared

Received: 22 May 2013

Accepted: 28 August 2013

Theoretical framework - conceptual framework - case study - conceptual model - qualitative research - research design - case study research.

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Use of theoretical and conceptual frameworks in qualitative research

Affiliation.

• 1 University of Leeds, UK.
• PMID: 25059086
• DOI: 10.7748/nr.21.6.34.e1252

Aim: To debate the definition and use of theoretical and conceptual frameworks in qualitative research.

Background: There is a paucity of literature to help the novice researcher to understand what theoretical and conceptual frameworks are and how they should be used. This paper acknowledges the interchangeable usage of these terms and researchers' confusion about the differences between the two. It discusses how researchers have used theoretical and conceptual frameworks and the notion of conceptual models. Detail is given about how one researcher incorporated a conceptual framework throughout a research project, the purpose for doing so and how this led to a resultant conceptual model.

Review methods: Concepts from Abbott (1988) and Witz ( 1992 ) were used to provide a framework for research involving two case study sites. The framework was used to determine research questions and give direction to interviews and discussions to focus the research.

Discussion: Some research methods do not overtly use a theoretical framework or conceptual framework in their design, but this is implicit and underpins the method design, for example in grounded theory. Other qualitative methods use one or the other to frame the design of a research project or to explain the outcomes. An example is given of how a conceptual framework was used throughout a research project.

Conclusion: Theoretical and conceptual frameworks are terms that are regularly used in research but rarely explained. Textbooks should discuss what they are and how they can be used, so novice researchers understand how they can help with research design.

Implications for practice/research: Theoretical and conceptual frameworks need to be more clearly understood by researchers and correct terminology used to ensure clarity for novice researchers.

Keywords: Theoretical framework; case study; case study research.; conceptual framework; conceptual model; qualitative research; research design.

• Nursing Research / organization & administration*
• Qualitative Research*
• Research Design

Examples of Theoretical Framework in Qualitative Research

Theoretical framework, also known as a theoretical standpoint, is the foundation of a qualitative study. It guides researchers to analyze data and helps them interpret results. The theoretical framework is a leading idea in a qualitative paper, and it helps shape the research plan.

What is a Theory?

It is a set of ideas that explain the relationship among variables in a cause-effect relationship. It guides researchers to make inferences about results or answer a research question.

How Does a Theoretical Framework in a Qualitative Study?

In general, the theoretical framework presents assumptions about relationships among concepts in theory. It is then applied to the study to explain certain phenomena.

A theoretical framework in qualitative studies is usually based on an existing theory or theories. A proposed theoretical framework should be relevant to the study’s goals and objectives.

Theoretical frameworks can be presented in different ways, including visual models or diagrams used to illustrate relationships among concepts.

A theoretical framework is flexible. It can change as the study progresses, depending on the data collected. Researchers then check if their assumptions are correct, refine the framework based on results, or refine it as they go along the way.

A theoretical framework addresses three key questions:

• What do we think or feel about the phenomenon being studied?
• Do we seek to explain, describe, interpret, critique, support, or read?
• What might be the consequences of doing such work?

A theoretical framework is a type of theory that links the data and the subject of study.

Some examples of theoretical frameworks in qualitative research are:

Grounded Theory Approach

This type of inquiry uses emergent theories during data collection and focuses more on discovery rather than explanation.

For example, a researcher might start by asking: “What is the experience of early motherhood like in a particular culture?”

In this case, the grounded theory approach would guide you to collect interviews from mothers and then analyze data inductively to construct theories that emerge from the collected data.

The grounded theory does not try to explain results. It only focuses on describing the phenomenon in question.

Key assumptions of this approach are:

• The theory is created during the research process
• Theory development is continuous
• Theoretical sensitivity is the basis upon which a framework is built
• The theory can explain something that would otherwise be unknown

Participatory Action Research

This inquiry focuses on people too, who are actively involved in research. The participants also have a say in directing the inquiry to address their needs.

The main assumptions in this approach are:

• Knowledge is developed through collaboration
• Collaboration requires community involvement
• The concept of power is acknowledged
• There’s no predetermined outcome
• Knowledge is both theoretical and practical

An example of participatory action research for a non-profit organization is to involve community members in the review of policies that affect them.

Critical Theory Approach

This framework helps researchers consider power relations within a society and emphasizes how access, voice, and representation are central to a study.

For example, the researcher might ask: “How have the effects of colonization changed the role of women in this culture?”

Here, the critical theory would inform your theoretical framework. This theory helps you explore power dynamics and their relationship to the subject of your study.

The critical theory framework will help you pay attention to the following:

• The intersection of various forms of oppression and power relations in a society
• Examining the influence of other structures such as capitalism, colonialism, and patriarchy
• The relationship between structural forces and individual behavior
• Studying the role of knowledge and how it is produced
• How dominant discourses silence people
• The significance of social action

Driving Force Approach

This framework helps you explore the motives behind people’s actions and decisions. It aims to explain why something happens.

For example, the researcher might pose the question: “Why do African-American girls experience emergency room care differently than their Caucasian peers?”

The driving force’s approach would guide you to explore the motives behind people’s actions, which helps you answer this research question.

This approach taps into the following:

• The motivation that drives people to behave in a certain way
• Assumptions about human nature and the importance of individual action
• Use of case studies that are drawn from small samples
• Comparing different situations to see which factors have the greatest influence on decisions or actions

Semiotic Approach

This type of inquiry uses symbols and signs to help you understand how people construct meanings. It focuses on the processes through which meaning is influenced by social context.

For instance, the research question could be: “How does this culture define success?”

The semiotic approach helps you explore how symbols are used to construct meaning and how meaning is influenced by cultural context.

Researchers use this framework to determine:

• The use of signs and symbols
• Interpretative repertoires – the language people use to describe their experiences
• Discourses – the socially shared set of values, assumptions, and expectations at play in your study
• Conceptual metaphors – comparisons that people make with ideas or objects
• Cultural models – the shared understandings that link people to a particular cultural group

Phenomenological Approach

It focuses on subjective experiences, feelings, and thoughts. The goal is to understand the meaning people make of their lived experiences.

For example, the researcher might ask: “What is it like to go blind?”

This inquiry would utilize a phenomenological approach to guide your research process.

This framework seeks to examine:

• The unique experiences of the individual/group you are studying
• The influence of social and cultural factors on people’s beliefs, feelings, and behaviors
• The meaning people make of their experiences
• How people describe their own experiences

Transcendental Approach Framework

It is used to explore the “true” or universal aspects of human nature that exist independent of social context. It is a form of philosophical inquiry.

In the example above, the researcher might ask: “Is going blind psychologically devastating?”

This type of framework would help you explore the “fundamental,” universal aspects of human nature. The researcher focuses on broad, conceptual questions about human nature.

Feminist Approach

This framework helps researchers consider how women are portrayed and treated within society.

An example of a research problem would be: “How does this society define a ‘real man’?”

In this case, the feminist approach would guide you to explore how women are portrayed and treated within society.

Symbolic Interactionism Framework

According to this framework, the meaning of a situation for an individual is influenced by social interaction.

For example, consider the following research question: “What is a ‘high status’ job in this culture?”

The symbolic interactionist approach would guide you to explore how individuals define and negotiate their status within a culture, which helps you answer this research question.

Functionalism Framework

This approach focuses on how institutions, objects, and behaviors are interconnected within a culture.

For example, the researcher could pose the question: “How does this society keep its history alive?”

The functionalist framework would guide this research question. It helps you explore how institutions, objects, and behaviors are interconnected for this culture.

Postmodern Approach

In this framework, knowledge is fluid, and there are no absolute truths. It challenges traditional concepts of hierarchy, power, and knowledge.

For example, you might pose the question: “How do cultural norms construct gender in this society?”

The postmodern approach would guide you to explore how knowledge is fluid, and there are no absolute truths.

This approach is fluid, so the researcher is free to explore any topic they are interested in. It does not adhere to a specific set of guidelines. Instead, the researcher is free to explore any topic they are interested in.

The researcher is free to pose broad, open-ended questions that focus on the unique characteristics of their study.

Marxist Framework

This framework looks at how class, race, and gender influence the way people live.

For example, a research question could be: “What is the meaning of ‘success in this culture for a female business executive?”

In this case, the Marxist framework would help you explore how class, race, and gender influence the way people live. This framework would help you consider the unique experiences of a female business executive.

Considering the impact of race, class, and gender on people’s lives within this society would guide your research process.

Constructionist Framework

This approach helps you analyze language and meaning-making systems. It focuses on the process through which social structures are created and maintained.

For instance, if your research study is about the youth’s understanding of their rights, you might ask: “What is considered ‘childhood’ in this culture?”

The constructionist framework would guide you to explore how social structures are created and maintained. This understanding will help you answer the research question.

When using the constructionist framework, your research study is more of a process than a result. The constructionist approach focuses on the process through which social structures are created and maintained. It helps the researcher consider language and meaning-making systems.

Emergent Design

The emergent design focuses on collaborative research. It is used when the researcher wants to bring multiple perspectives into their study and has little control over the research process.

An example of a question you could ask is: “What makes a marriage successful?”

In this case, in an emergent design, you would be collaborating with multiple people or participants to answer this question.

Emergent design framework makes it easier for you to invite participants to share their insights and opinions during your study. This approach will help you involve more people in your research process. It also enables you to gain a deeper understanding of a specific topic.

Individualist Approach

It works by identifying, understanding, and describing the behavior of individuals within a society.

For example, you might develop a research question such as: “How do people in this culture experience illness daily?”

The individualist approach would help you explore the behavior of individuals within the society.

This framework is best used when the researcher needs a deep understanding of an individual’s experience. It is helpful for exploratory research where you are noticing patterns within people’s behavior.

Radical Framework/Subversive Methods

The radical approach is focused on social change and liberation. The research method uses a major research question to engage in a political project.

For example, you might ask: “How does this culture perpetuate inequality?”

In the radical framework/subversive methods, you would engage in a political project to answer the research question.

The main difference between the radical approach and other frameworks is that you must form a major research question for this approach.

Using the radical framework also helps the researcher ensure that people have a voice in their studies.

Critical Race Approach

This approach helps understand and challenge racism through the lens of law. In this framework, you analyze how laws and other societal structures impact people from different backgrounds.

You might ask: “What are the barriers to education for people of color?”

In this case, the critical race approach will help you explore how laws and other societal structures impact people of different backgrounds.

If you are interested in the intersection of law and social justice, this approach may be for you. It helps you understand how the law works and enables you to develop a productive way to challenge racism.

Categories of Theoretical Frameworks

• Theoretical orientation: it provides the conceptual basis for your study. It guides you through answering what’s important and why while also helping you determine which data are relevant.
• Philosophical perspective: this helps researchers address ethical considerations during their studies. For example, political or social justice orientations are helpful in that they help researchers consider the effects of their research on society at large.
• The ontological perspective focuses on what is real and how it might be depicted in a study. Does it address questions like, ‘What kinds of things exist? What is our role as researchers?
• Theoretical paradigm: this provides the structure for directing your research. It highlights how you determine what is relevant and influences how you need to do your work.

The Importance of Theoretical Frameworks in Qualitative Research

• A theoretical framework is critical because it guides you through answering research questions and synthesizing your data.
• It influences how you determine what is relevant and how you locate, select, analyze, and interpret your data.
• It also helps to determine the worth of your study, and it helps to give a structure for guiding your research.
• A theoretical framework also provides a lens that helps you interpret your findings.
• It helps you assess the validity and credibility of your data. An example is: studying a phenomenon that impacted people from different cultures. You might look at the various theoretical orientations to help you interpret your findings.
• Theoretical frameworks are analogous to maps that help researchers trace out the terrain of their research. Without a map, you would not know where to go and thus, misguide your research. Likewise, theoretical frameworks help researchers stay on track throughout the research process.
• A good theoretical framework guides you to ask the right questions. For example, knowing which theoretical perspective is most appropriate for your research will help you choose the right research questions and thus, make your inquiry more focused.

Theoretical Framework Vs. Conceptual Framework.

It’s important to note that theoretical frameworks and conceptual frameworks are not synonymous. Below are the main differences between the two:

How to Develop a Strong Theoretical Framework for Your Study

When reaching the theoretical framework section of your proposal, you might feel a sense of panic. It’s common to feel overwhelmed by the theoretical frameworks that are available to you. The following are the steps you can take to develop a theoretical framework for your study:

• Identify what you already know. It’s helpful to reflect on the knowledge that you already possess about your topic. Existing knowledge can provide the basis for developing a coherent theoretical framework.
• Choose the theoretical perspective that will provide the best framework for your study. It’s important to consider which theoretical perspective is best suited for your research topic. For example, if you were interested in conducting a critical ethnography, you would use the critical theory perspective.
• Develop your framework by synthesizing different theoretical perspectives. When developing your framework, make sure to draw from multiple theoretical perspectives and integrate their unique contributions.
• Make sure your framework is relevant to your research topic . For example, if you were studying prison reform, a humanistic perspective might not be appropriate. Instead, symbolic Interactionism would be more relevant.
• Use a theoretical perspective that you feel comfortable with and facilitates understanding of the field you are studying.
• Address how your theoretical framework will help guide your research within that methodology.

Sometimes a research question is theoretical. Other times it can be a practical one. To use a theoretical framework means to engage in the way of thinking about the topic under study. It is a way to develop a meaningful question about something which can help you better understand it.

Theoretical frameworks are a set of assumptions based on a theoretical perspective. At its best, a theoretical framework guides you through answering your research questions. Choosing an appropriate framework for your study will help you ask the right questions and make more informed decisions.

A theoretical framework will help you explore your research topic from different angles. It must be relevant to your research topic. The theoretical framework you choose must be able to stand up to scrutiny, so it’s best to use well-known and established frameworks.

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• Open access
• Published: 18 September 2013

Using the framework method for the analysis of qualitative data in multi-disciplinary health research

• Nicola K Gale 1 ,
• Gemma Heath 2 ,
• Elaine Cameron 3 ,
• Sabina Rashid 4 &
• Sabi Redwood 2  

BMC Medical Research Methodology volume  13 , Article number:  117 ( 2013 ) Cite this article

518k Accesses

4724 Citations

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Metrics details

The Framework Method is becoming an increasingly popular approach to the management and analysis of qualitative data in health research. However, there is confusion about its potential application and limitations.

The article discusses when it is appropriate to adopt the Framework Method and explains the procedure for using it in multi-disciplinary health research teams, or those that involve clinicians, patients and lay people. The stages of the method are illustrated using examples from a published study.

Used effectively, with the leadership of an experienced qualitative researcher, the Framework Method is a systematic and flexible approach to analysing qualitative data and is appropriate for use in research teams even where not all members have previous experience of conducting qualitative research.

The Framework Method for the management and analysis of qualitative data has been used since the 1980s [ 1 ]. The method originated in large-scale social policy research but is becoming an increasingly popular approach in medical and health research; however, there is some confusion about its potential application and limitations. In this article we discuss when it is appropriate to use the Framework Method and how it compares to other qualitative analysis methods. In particular, we explore how it can be used in multi-disciplinary health research teams. Multi-disciplinary and mixed methods studies are becoming increasingly commonplace in applied health research. As well as disciplines familiar with qualitative research, such as nursing, psychology and sociology, teams often include epidemiologists, health economists, management scientists and others. Furthermore, applied health research often has clinical representation and, increasingly, patient and public involvement [ 2 ]. We argue that while leadership is undoubtedly required from an experienced qualitative methodologist, non-specialists from the wider team can and should be involved in the analysis process. We then present a step-by-step guide to the application of the Framework Method, illustrated using a worked example (See Additional File 1 ) from a published study [ 3 ] to illustrate the main stages of the process. Technical terms are included in the glossary (below). Finally, we discuss the strengths and limitations of the approach.

Glossary of key terms used in the Framework Method

Analytical framework: A set of codes organised into categories that have been jointly developed by researchers involved in analysis that can be used to manage and organise the data. The framework creates a new structure for the data (rather than the full original accounts given by participants) that is helpful to summarize/reduce the data in a way that can support answering the research questions.

Analytic memo: A written investigation of a particular concept, theme or problem, reflecting on emerging issues in the data that captures the analytic process (see Additional file 1 , Section 7).

Categories: During the analysis process, codes are grouped into clusters around similar and interrelated ideas or concepts. Categories and codes are usually arranged in a tree diagram structure in the analytical framework. While categories are closely and explicitly linked to the raw data, developing categories is a way to start the process of abstraction of the data (i.e. towards the general rather than the specific or anecdotal).

Charting: Entering summarized data into the Framework Method matrix (see Additional File 1 , Section 6).

Code: A descriptive or conceptual label that is assigned to excerpts of raw data in a process called ‘coding’ (see Additional File 1 , Section 3).

Data: Qualitative data usually needs to be in textual form before analysis. These texts can either be elicited texts (written specifically for the research, such as food diaries), or extant texts (pre-existing texts, such as meeting minutes, policy documents or weblogs), or can be produced by transcribing interview or focus group data, or creating ‘field’ notes while conducting participant-observation or observing objects or social situations.

Indexing: The systematic application of codes from the agreed analytical framework to the whole dataset (see Additional File 1 , Section 5).

Matrix: A spreadsheet contains numerous cells into which summarized data are entered by codes (columns) and cases (rows) (see Additional File 1 , Section 6).

Themes: Interpretive concepts or propositions that describe or explain aspects of the data, which are the final output of the analysis of the whole dataset. Themes are articulated and developed by interrogating data categories through comparison between and within cases. Usually a number of categories would fall under each theme or sub-theme [ 3 ].

Transcript: A written verbatim (word-for-word) account of a verbal interaction, such as an interview or conversation.

The Framework Method sits within a broad family of analysis methods often termed thematic analysis or qualitative content analysis. These approaches identify commonalities and differences in qualitative data, before focusing on relationships between different parts of the data, thereby seeking to draw descriptive and/or explanatory conclusions clustered around themes. The Framework Method was developed by researchers, Jane Ritchie and Liz Spencer, from the Qualitative Research Unit at the National Centre for Social Research in the United Kingdom in the late 1980s for use in large-scale policy research [ 1 ]. It is now used widely in other areas, including health research [ 3 – 12 ]. Its defining feature is the matrix output: rows (cases), columns (codes) and ‘cells’ of summarised data, providing a structure into which the researcher can systematically reduce the data, in order to analyse it by case and by code [ 1 ]. Most often a ‘case’ is an individual interviewee, but this can be adapted to other units of analysis, such as predefined groups or organisations. While in-depth analyses of key themes can take place across the whole data set, the views of each research participant remain connected to other aspects of their account within the matrix so that the context of the individual’s views is not lost. Comparing and contrasting data is vital to qualitative analysis and the ability to compare with ease data across cases as well as within individual cases is built into the structure and process of the Framework Method.

The Framework Method provides clear steps to follow and produces highly structured outputs of summarised data. It is therefore useful where multiple researchers are working on a project, particularly in multi-disciplinary research teams were not all members have experience of qualitative data analysis, and for managing large data sets where obtaining a holistic, descriptive overview of the entire data set is desirable. However, caution is recommended before selecting the method as it is not a suitable tool for analysing all types of qualitative data or for answering all qualitative research questions, nor is it an ‘easy’ version of qualitative research for quantitative researchers. Importantly, the Framework Method cannot accommodate highly heterogeneous data, i.e. data must cover similar topics or key issues so that it is possible to categorize it. Individual interviewees may, of course, have very different views or experiences in relation to each topic, which can then be compared and contrasted. The Framework Method is most commonly used for the thematic analysis of semi-structured interview transcripts, which is what we focus on in this article, although it could, in principle, be adapted for other types of textual data [ 13 ], including documents, such as meeting minutes or diaries [ 12 ], or field notes from observations [ 10 ].

For quantitative researchers working with qualitative colleagues or when exploring qualitative research for the first time, the nature of the Framework Method is seductive because its methodical processes and ‘spreadsheet’ approach seem more closely aligned to the quantitative paradigm [ 14 ]. Although the Framework Method is a highly systematic method of categorizing and organizing what may seem like unwieldy qualitative data, it is not a panacea for problematic issues commonly associated with qualitative data analysis such as how to make analytic choices and make interpretive strategies visible and auditable. Qualitative research skills are required to appropriately interpret the matrix, and facilitate the generation of descriptions, categories, explanations and typologies. Moreover, reflexivity, rigour and quality are issues that are requisite in the Framework Method just as they are in other qualitative methods. It is therefore essential that studies using the Framework Method for analysis are overseen by an experienced qualitative researcher, though this does not preclude those new to qualitative research from contributing to the analysis as part of a wider research team.

There are a number of approaches to qualitative data analysis, including those that pay close attention to language and how it is being used in social interaction such as discourse analysis [ 15 ] and ethnomethodology [ 16 ]; those that are concerned with experience, meaning and language such as phenomenology [ 17 , 18 ] and narrative methods [ 19 ]; and those that seek to develop theory derived from data through a set of procedures and interconnected stages such as Grounded Theory [ 20 , 21 ]. Many of these approaches are associated with specific disciplines and are underpinned by philosophical ideas which shape the process of analysis [ 22 ]. The Framework Method, however, is not aligned with a particular epistemological, philosophical, or theoretical approach. Rather it is a flexible tool that can be adapted for use with many qualitative approaches that aim to generate themes.

The development of themes is a common feature of qualitative data analysis, involving the systematic search for patterns to generate full descriptions capable of shedding light on the phenomenon under investigation. In particular, many qualitative approaches use the ‘constant comparative method’ , developed as part of Grounded Theory, which involves making systematic comparisons across cases to refine each theme [ 21 , 23 ]. Unlike Grounded Theory, the Framework Method is not necessarily concerned with generating social theory, but can greatly facilitate constant comparative techniques through the review of data across the matrix.

Perhaps because the Framework Method is so obviously systematic, it has often, as other commentators have noted, been conflated with a deductive approach to qualitative analysis [ 13 , 14 ]. However, the tool itself has no allegiance to either inductive or deductive thematic analysis; where the research sits along this inductive-deductive continuum depends on the research question. A question such as, ‘Can patients give an accurate biomedical account of the onset of their cardiovascular disease?’ is essentially a yes/no question (although it may be nuanced by the extent of their account or by appropriate use of terminology) and so requires a deductive approach to both data collection and analysis (e.g. structured or semi-structured interviews and directed qualitative content analysis [ 24 ]). Similarly, a deductive approach may be taken if basing analysis on a pre-existing theory, such as behaviour change theories, for example in the case of a research question such as ‘How does the Theory of Planned Behaviour help explain GP prescribing?’ [ 11 ]. However, a research question such as, ‘How do people construct accounts of the onset of their cardiovascular disease?’ would require a more inductive approach that allows for the unexpected, and permits more socially-located responses [ 25 ] from interviewees that may include matters of cultural beliefs, habits of food preparation, concepts of ‘fate’, or links to other important events in their lives, such as grief, which cannot be predicted by the researcher in advance (e.g. an interviewee-led open ended interview and grounded theory [ 20 ]). In all these cases, it may be appropriate to use the Framework Method to manage the data. The difference would become apparent in how themes are selected: in the deductive approach, themes and codes are pre-selected based on previous literature, previous theories or the specifics of the research question; whereas in the inductive approach, themes are generated from the data though open (unrestricted) coding, followed by refinement of themes. In many cases, a combined approach is appropriate when the project has some specific issues to explore, but also aims to leave space to discover other unexpected aspects of the participants’ experience or the way they assign meaning to phenomena. In sum, the Framework Method can be adapted for use with deductive, inductive, or combined types of qualitative analysis. However, there are some research questions where analysing data by case and theme is not appropriate and so the Framework Method should be avoided. For instance, depending on the research question, life history data might be better analysed using narrative analysis [ 19 ]; recorded consultations between patients and their healthcare practitioners using conversation analysis [ 26 ]; and documentary data, such as resources for pregnant women, using discourse analysis [ 27 ].

It is not within the scope of this paper to consider study design or data collection in any depth, but before moving on to describe the Framework Method analysis process, it is worth taking a step back to consider briefly what needs to happen before analysis begins. The selection of analysis method should have been considered at the proposal stage of the research and should fit with the research questions and overall aims of the study. Many qualitative studies, particularly ones using inductive analysis, are emergent in nature; this can be a challenge and the researchers can only provide an “imaginative rehearsal” of what is to come [ 28 ]. In mixed methods studies, the role of the qualitative component within the wider goals of the project must also be considered. In the data collection stage, resources must be allocated for properly trained researchers to conduct the qualitative interviewing because it is a highly skilled activity. In some cases, a research team may decide that they would like to use lay people, patients or peers to do the interviews [ 29 – 32 ] and in this case they must be properly trained and mentored which requires time and resources. At this early stage it is also useful to consider whether the team will use Computer Assisted Qualitative Data Analysis Software (CAQDAS), which can assist with data management and analysis.

As any form of qualitative or quantitative analysis is not a purely technical process, but influenced by the characteristics of the researchers and their disciplinary paradigms, critical reflection throughout the research process is paramount, including in the design of the study, the construction or collection of data, and the analysis. All members of the team should keep a research diary, where they record reflexive notes, impressions of the data and thoughts about analysis throughout the process. Experienced qualitative researchers become more skilled at sifting through data and analysing it in a rigorous and reflexive way. They cannot be too attached to certainty, but must remain flexible and adaptive throughout the research in order to generate rich and nuanced findings that embrace and explain the complexity of real social life and can be applied to complex social issues. It is important to remember when using the Framework Method that, unlike quantitative research where data collection and data analysis are strictly sequential and mutually exclusive stages of the research process, in qualitative analysis there is, to a greater or lesser extent depending on the project, ongoing interplay between data collection, analysis, and theory development. For example, new ideas or insights from participants may suggest potentially fruitful lines of enquiry, or close analysis might reveal subtle inconsistencies in an account which require further exploration.

Procedure for analysis

Stage 1: transcription.

A good quality audio recording and, ideally, a verbatim (word for word) transcription of the interview is needed. For Framework Method analysis, it is not necessarily important to include the conventions of dialogue transcriptions which can be difficult to read (e.g. pauses or two people talking simultaneously), because the content is what is of primary interest. Transcripts should have large margins and adequate line spacing for later coding and making notes. The process of transcription is a good opportunity to become immersed in the data and is to be strongly encouraged for new researchers. However, in some projects, the decision may be made that it is a better use of resources to outsource this task to a professional transcriber.

Stage 2: Familiarisation with the interview

Becoming familiar with the whole interview using the audio recording and/or transcript and any contextual or reflective notes that were recorded by the interviewer is a vital stage in interpretation. It can also be helpful to re-listen to all or parts of the audio recording. In multi-disciplinary or large research projects, those involved in analysing the data may be different from those who conducted or transcribed the interviews, which makes this stage particularly important. One margin can be used to record any analytical notes, thoughts or impressions.

Stage 3: Coding

After familiarization, the researcher carefully reads the transcript line by line, applying a paraphrase or label (a ‘code’) that describes what they have interpreted in the passage as important. In more inductive studies, at this stage ‘open coding’ takes place, i.e. coding anything that might be relevant from as many different perspectives as possible. Codes could refer to substantive things (e.g. particular behaviours, incidents or structures), values (e.g. those that inform or underpin certain statements, such as a belief in evidence-based medicine or in patient choice), emotions (e.g. sorrow, frustration, love) and more impressionistic/methodological elements (e.g. interviewee found something difficult to explain, interviewee became emotional, interviewer felt uncomfortable) [ 33 ]. In purely deductive studies, the codes may have been pre-defined (e.g. by an existing theory, or specific areas of interest to the project) so this stage may not be strictly necessary and you could just move straight onto indexing, although it is generally helpful even if you are taking a broadly deductive approach to do some open coding on at least a few of the transcripts to ensure important aspects of the data are not missed. Coding aims to classify all of the data so that it can be compared systematically with other parts of the data set. At least two researchers (or at least one from each discipline or speciality in a multi-disciplinary research team) should independently code the first few transcripts, if feasible. Patients, public involvement representatives or clinicians can also be productively involved at this stage, because they can offer alternative viewpoints thus ensuring that one particular perspective does not dominate. It is vital in inductive coding to look out for the unexpected and not to just code in a literal, descriptive way so the involvement of people from different perspectives can aid greatly in this. As well as getting a holistic impression of what was said, coding line-by-line can often alert the researcher to consider that which may ordinarily remain invisible because it is not clearly expressed or does not ‘fit’ with the rest of the account. In this way the developing analysis is challenged; to reconcile and explain anomalies in the data can make the analysis stronger. Coding can also be done digitally using CAQDAS, which is a useful way to keep track automatically of new codes. However, some researchers prefer to do the early stages of coding with a paper and pen, and only start to use CAQDAS once they reach Stage 5 (see below).

Stage 4: Developing a working analytical framework

After coding the first few transcripts, all researchers involved should meet to compare the labels they have applied and agree on a set of codes to apply to all subsequent transcripts. Codes can be grouped together into categories (using a tree diagram if helpful), which are then clearly defined. This forms a working analytical framework. It is likely that several iterations of the analytical framework will be required before no additional codes emerge. It is always worth having an ‘other’ code under each category to avoid ignoring data that does not fit; the analytical framework is never ‘final’ until the last transcript has been coded.

Stage 5: Applying the analytical framework

The working analytical framework is then applied by indexing subsequent transcripts using the existing categories and codes. Each code is usually assigned a number or abbreviation for easy identification (and so the full names of the codes do not have to be written out each time) and written directly onto the transcripts. Computer Assisted Qualitative Data Analysis Software (CAQDAS) is particularly useful at this stage because it can speed up the process and ensures that, at later stages, data is easily retrievable. It is worth noting that unlike software for statistical analyses, which actually carries out the calculations with the correct instruction, putting the data into a qualitative analysis software package does not analyse the data; it is simply an effective way of storing and organising the data so that they are accessible for the analysis process.

Stage 6: Charting data into the framework matrix

Qualitative data are voluminous (an hour of interview can generate 15–30 pages of text) and being able to manage and summarize (reduce) data is a vital aspect of the analysis process. A spreadsheet is used to generate a matrix and the data are ‘charted’ into the matrix. Charting involves summarizing the data by category from each transcript. Good charting requires an ability to strike a balance between reducing the data on the one hand and retaining the original meanings and ‘feel’ of the interviewees’ words on the other. The chart should include references to interesting or illustrative quotations. These can be tagged automatically if you are using CAQDAS to manage your data (N-Vivo version 9 onwards has the capability to generate framework matrices), or otherwise a capital ‘Q’, an (anonymized) transcript number, page and line reference will suffice. It is helpful in multi-disciplinary teams to compare and contrast styles of summarizing in the early stages of the analysis process to ensure consistency within the team. Any abbreviations used should be agreed by the team. Once members of the team are familiar with the analytical framework and well practised at coding and charting, on average, it will take about half a day per hour-long transcript to reach this stage. In the early stages, it takes much longer.

Stage 7: Interpreting the data

It is useful throughout the research to have a separate note book or computer file to note down impressions, ideas and early interpretations of the data. It may be worth breaking off at any stage to explore an interesting idea, concept or potential theme by writing an analytic memo [ 20 , 21 ] to then discuss with other members of the research team, including lay and clinical members. Gradually, characteristics of and differences between the data are identified, perhaps generating typologies, interrogating theoretical concepts (either prior concepts or ones emerging from the data) or mapping connections between categories to explore relationships and/or causality. If the data are rich enough, the findings generated through this process can go beyond description of particular cases to explanation of, for example, reasons for the emergence of a phenomena, predicting how an organisation or other social actor is likely to instigate or respond to a situation, or identifying areas that are not functioning well within an organisation or system. It is worth noting that this stage often takes longer than anticipated and that any project plan should ensure that sufficient time is allocated to meetings and individual researcher time to conduct interpretation and writing up of findings (see Additional file 1 , Section 7).

The Framework Method has been developed and used successfully in research for over 25 years, and has recently become a popular analysis method in qualitative health research. The issue of how to assess quality in qualitative research has been highly debated [ 20 , 34 – 40 ], but ensuring rigour and transparency in analysis is a vital component. There are, of course, many ways to do this but in the Framework Method the following are helpful:

Summarizing the data during charting, as well as being a practical way to reduce the data, means that all members of a multi-disciplinary team, including lay, clinical and (quantitative) academic members can engage with the data and offer their perspectives during the analysis process without necessarily needing to read all the transcripts or be involved in the more technical parts of analysis.

Charting also ensures that researchers pay close attention to describing the data using each participant’s own subjective frames and expressions in the first instance, before moving onto interpretation.

The summarized data is kept within the wider context of each case, thereby encouraging thick description that pays attention to complex layers of meaning and understanding [ 38 ].

The matrix structure is visually straightforward and can facilitate recognition of patterns in the data by any member of the research team, including through drawing attention to contradictory data, deviant cases or empty cells.

The systematic procedure (described in this article) makes it easy to follow, even for multi-disciplinary teams and/or with large data sets.

It is flexible enough that non-interview data (such as field notes taken during the interview or reflexive considerations) can be included in the matrix.

It is not aligned with a particular epistemological viewpoint or theoretical approach and therefore can be adapted for use in inductive or deductive analysis or a combination of the two (e.g. using pre-existing theoretical constructs deductively, then revising the theory with inductive aspects; or using an inductive approach to identify themes in the data, before returning to the literature and using theories deductively to help further explain certain themes).

It is easy to identify relevant data extracts to illustrate themes and to check whether there is sufficient evidence for a proposed theme.

Finally, there is a clear audit trail from original raw data to final themes, including the illustrative quotes.

There are also a number of potential pitfalls to this approach:

The systematic approach and matrix format, as we noted in the background, is intuitively appealing to those trained quantitatively but the ‘spreadsheet’ look perhaps further increases the temptation for those without an in-depth understanding of qualitative research to attempt to quantify qualitative data (e.g. “13 out of 20 participants said X). This kind of statement is clearly meaningless because the sampling in qualitative research is not designed to be representative of a wider population, but purposive to capture diversity around a phenomenon [ 41 ].

Like all qualitative analysis methods, the Framework Method is time consuming and resource-intensive. When involving multiple stakeholders and disciplines in the analysis and interpretation of the data, as is good practice in applied health research, the time needed is extended. This time needs to be factored into the project proposal at the pre-funding stage.

There is a high training component to successfully using the method in a new multi-disciplinary team. Depending on their role in the analysis, members of the research team may have to learn how to code, index, and chart data, to think reflexively about how their identities and experience affect the analysis process, and/or they may have to learn about the methods of generalisation (i.e. analytic generalisation and transferability, rather than statistical generalisation [ 41 ]) to help to interpret legitimately the meaning and significance of the data.

While the Framework Method is amenable to the participation of non-experts in data analysis, it is critical to the successful use of the method that an experienced qualitative researcher leads the project (even if the overall lead for a large mixed methods study is a different person). The qualitative lead would ideally be joined by other researchers with at least some prior training in or experience of qualitative analysis. The responsibilities of the lead qualitative researcher are: to contribute to study design, project timelines and resource planning; to mentor junior qualitative researchers; to train clinical, lay and other (non-qualitative) academics to contribute as appropriate to the analysis process; to facilitate analysis meetings in a way that encourages critical and reflexive engagement with the data and other team members; and finally to lead the write-up of the study.

We have argued that Framework Method studies can be conducted by multi-disciplinary research teams that include, for example, healthcare professionals, psychologists, sociologists, economists, and lay people/service users. The inclusion of so many different perspectives means that decision-making in the analysis process can be very time consuming and resource-intensive. It may require extensive, reflexive and critical dialogue about how the ideas expressed by interviewees and identified in the transcript are related to pre-existing concepts and theories from each discipline, and to the real ‘problems’ in the health system that the project is addressing. This kind of team effort is, however, an excellent forum for driving forward interdisciplinary collaboration, as well as clinical and lay involvement in research, to ensure that ‘the whole is greater than the sum of the parts’, by enhancing the credibility and relevance of the findings.

The Framework Method is appropriate for thematic analysis of textual data, particularly interview transcripts, where it is important to be able to compare and contrast data by themes across many cases, while also situating each perspective in context by retaining the connection to other aspects of each individual’s account. Experienced qualitative researchers should lead and facilitate all aspects of the analysis, although the Framework Method’s systematic approach makes it suitable for involving all members of a multi-disciplinary team. An open, critical and reflexive approach from all team members is essential for rigorous qualitative analysis.

Acceptance of the complexity of real life health systems and the existence of multiple perspectives on health issues is necessary to produce high quality qualitative research. If done well, qualitative studies can shed explanatory and predictive light on important phenomena, relate constructively to quantitative parts of a larger study, and contribute to the improvement of health services and development of health policy. The Framework Method, when selected and implemented appropriately, can be a suitable tool for achieving these aims through producing credible and relevant findings.

The Framework Method is an excellent tool for supporting thematic (qualitative content) analysis because it provides a systematic model for managing and mapping the data.

The Framework Method is most suitable for analysis of interview data, where it is desirable to generate themes by making comparisons within and between cases.

The management of large data sets is facilitated by the Framework Method as its matrix form provides an intuitively structured overview of summarised data.

The clear, step-by-step process of the Framework Method makes it is suitable for interdisciplinary and collaborative projects.

The use of the method should be led and facilitated by an experienced qualitative researcher.

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All authors were funded by the National Institute for Health Research (NIHR) through the Collaborations for Leadership in Applied Health Research and Care for Birmingham and Black Country (CLAHRC-BBC) programme. The views in this publication expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

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Nicola K Gale

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Gemma Heath & Sabi Redwood

School of Life and Health Sciences, Aston University, Aston Triangle, Birmingham, B4 7ET, UK

Elaine Cameron

East and North Hertfordshire NHS Trust, Lister hospital, Coreys Mill Lane, Stevenage, SG1 4AB, UK

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All authors were involved in the development of the concept of the article and drafting the article. NG wrote the first draft of the article, GH and EC prepared the text and figures related to the illustrative example, SRa did the literature search to identify if there were any similar articles currently available and contributed to drafting of the article, and SRe contributed to drafting of the article and the illustrative example. All authors read and approved the final manuscript.

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Gale, N.K., Heath, G., Cameron, E. et al. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol 13 , 117 (2013). https://doi.org/10.1186/1471-2288-13-117

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31 Theoretical Framework Examples

A theoretical framework is a theory that can be applied to interpret and understand data in your research study.

A useful working definition comes from Connaway and Radford (2021):

“…a theoretical framework utilizes theory/theories and their constituent elements as the presumed ‘working model’ that drives the investigation and analysis of a social phenomenon.” (Connaway & Radford, 2021)

There are a range of theories that each look at the world through different lenses. Each will shape how we look at and interpret our data.

For example:

• Feminists look at the world through the lens of power and oppression of women. 
• Functionalists look at the world and see how the concepts and ideas in our societies have a role in maintaining social order. 
• Behaviorists look at the world and see how incentives – rewards and punishments – shape human behavior .
• Postmodernists look at the world and see how language and discourse shape belief systems .

When selecting a theoretical framework, we’re making a conscious decision about our approach and focus. For example, ‘feminism’ and ‘ critical theory ’ are theoretical frameworks that will focus on how power functions in society. This might be useful in a sociological or cultural studies analysis. But they won’t be so useful in a study of classroom learning, which might best be served by ‘behaviorism’ or ‘constructivism’ as your theoretical frames.

Theoretical Framework Examples

1. constructivism.

Scholarly Fields: Psychology, Education

Constructivism is a theory in educational psychology about how people think and learn.

It states that people construct their own understanding and knowledge of the world through experiencing things and reflecting on those experiences.

When new information challenges past beliefs, cognitive dissonance occurs, which is overcome through processes of assimilation and accommodation until we develop a new understanding of what we observe, which is ideally a closer approximation of the truth.

It challenges the previously dominant concept in psychology, behaviorism , that states we learn best through rewards, punishments, and forming associations between concepts.

Example of Constructivism in the Classroom

A researcher examines how students learn about the concept of gravity in a physics classroom. The study would observe the process as the students first encounter basic information, then explore related concepts through hands-on experiments and classroom discussions. The focus of the study would be on how students construct their understanding utilizing prior knowledge and evolving their understanding through experience and reflection.

2. Behaviorism

Behaviorism is a learning theory in behavioral psychology that holds that behaviors are learned through association, trial and error.

This theory takes a principled stance that learning needs to be measurable . Inner cognitive states are not taken into account because thoughts are, to behaviorists, not possible to be measured. Therefore, the theory suggests that behavior must be studied in a systematic and observable manner with no consideration of internal mental states.

A famous behaviorist study is Pavlov’s study of how his dog learned to salivate when he heard a bell ringing, because the dog associated the bell with food. This is now known as a Pavlovian response .

Similarly, B.F. Skinner found that rewarding and punishing rats can lead them into learning how to navigate mazes at faster and faster speeds, demonstrating the observable effects of rewards and punishments in learning.

If you were to use Behaviorism as your theoretical framework, it would likely inform both your research question – where you may want to focus on a situation where you will measure changes in behaviors through rewards and punishments – as well as your research methods, where you’ll likely employ a quantitative research method that measures changes in behaviors, such as application of pre-tests and post-tests in an educational environment.

Example of a Study Using a Behaviorist Theoretical Framework

In a study using a behaviorist framework, a psychologist might investigate the effects of positive reinforcement on the classroom behavior of elementary school children. The experiment could involve implementing a rewards system for a selected behavior, such as raising a hand before speaking, and observing any changes in the frequency of this behavior. The behaviorist theoretical framework would guide the researcher’s expectation that the reinforcement (reward) would increase the occurrence of the desired behavior.

3. Psychoanalytic Theory

Scholarly Fields: Psychology, Social Work

Psychoanalytic and psychodynamic theories , originally proposed by Sigmund Freud, posit that human behavior is the result of the interactions among three component parts of the mind: the id, ego, and superego .

This theory might be used by a psychology student in their research project where they test patients’ behaviors, comparing them to Freud’s (or, for that matter, Carl Jung’s) theoretical ideas about stages of development, interaction between id, ego, and superego, or the power of the subconscious to affect thoughts and behavior.

This theoretical frame is rarely used today, although it acts as a foundation to subsequent theories that are held in higher esteem, such as psychosocial theory, explained next.

Example of a Study Using a Psychoanalytic Theoretical Framework

A researcher using a psychoanalytic framework might study the influence of early childhood experiences on adult relationship patterns. Through in-depth interviews, the study would examine participants’ recollections of their early relationships with their parents and the unconscious conflicts and defenses that may have arisen from these experiences. The study would then look for patterns in the participants’ current relationships that might reflect these early experiences and defense mechanisms.

4. Psychosocial Theory

Psychosocial theory builds upon (and, in some ways, rejects) Freud’s psychoanalytic theory. This theory maintains that subconscious thoughts affect behavior, but focuses on how early social interactions affect outcomes later in life.

Erik Erikson, a central figure in the history of psychosocial theory, theorized that humans go through roughly set-in-stone stages of life, where in each stage, we must overcome challenges like industry vs inferiority (where we need to learn to embrace an industrious and creative personality or else risk having an inferiority complex later in life).

Psychosocial theory can be applied in the study of how people develop psychological complexes in their lives and helps them overcome them by exploring the origins of these complexes.

Example of a Study Using a Psychosocial Theoretical Framework

A study based on a psychosocial framework could explore individual patients’ core challenges and relate them to Erikson’s psychosocial states. The psychosocial theory would guide the interpretation of the results, suggesting that past events, such as being berated by parents, can lead to increased psychological stress.

5. Feminist Theory

Scholarly Fields: Sociology, Cultural Studies, and more

Feminism is a social and political framework that analyzes the status of women and men in society with the purpose of using that knowledge to promote women’s rights and interests.

Generally, a person applying a feminist framework would have at the core of their research question an interest in how women are positioned in society in relation to men, and how their lives and personal agency is shaped and structured by a manufactured gender hirearchy.

Of course, within Feminism, there are a range of conflicting views and perspectives. The intersectional feminists are highly concerned with how black, working-class, and other marginalized women face compounding disadvantages; whereas other feminists might focus exclusively on gender in the workforce, or even how women’s rights intersect with, and are possibly impacted by, trans* rights.

Example of a Study Using a Feminist Theoretical Framework

A researcher could use a feminist theoretical framework to investigate gender bias in workplace promotions within a large corporation. The study might involve collecting and analyzing qualitative data and quantitative data on promotion rates, gender ratios in upper management, and employee experiences related to promotion opportunities. From a feminist perspective, the study would aim to identify any potential systemic inequalities and their impact on women’s career trajectories.

7. Conflict Theory

Scholarly Fields: Sociology, Cultural Studies

Conflict theory is a framework derived from Marxism’s teachings about the operation of power through economic and cultural apparatuses in a society.

It generally works to highlight the role of coercion and power, particularly as it relates to social class and possession of economic capital .

Generally, this approach will involve an examination of the ways the economy, policy documents, media, and so forth, distribute power in a capitalist context . Other conflict theorists might examine non-capitalist contexts, such as workers’ cooperatives with the intention of exploring possibilities for economic and cultural life in a post-capitalist society.

Example of a Study Using a Conflict Theory Framework

A sociologist might utilize conflict theory to study wealth and income disparities within a specific urban community. This study might involve the analysis of economic data, alongside a consideration of social and political structures in the community. The conflict theory would guide an understanding of how wealth and power disparities contribute to social tensions and conflict.

8. Functionalism

Scholarly Fields: Sociology (see the separate concept: Functionalism in Psychology )

Functionalism , based on the works of Durkheim. Merton and their contemporaries, is an approach to sociology that assumes each aspect of society is interdependent and contributes to society’s functioning as a whole.

Functionalism often leans on the analogy of the human body to describe society. Just as the human body has organs which each have a purpose (i.e. a function), each social institution also serves a function to support the whole.

So, a functionalist theoretical framework aims to examine social institutions and social structures (e.g. economic conditions, family relationships, religious practices, media outlets, etc.) to explore how they do or do not fulfill their purposes.

Building on Merton’s work in functionalism, many functionalist studies in sociology also explore how institutions have both manifest functions (intended purposes and consequences) and latent functions (unintended purposes and functions).

Key social institutions explored in functionalism in sociology include: the education system, hospitals, workplaces, factories, religion, and families.

Example of a Study Using a Functionalist Theoretical Framework

A  key question in functionalism is: “What is the role of this institution in upholding society, the status quo, and social hierarchies?” Following this approach, an educational researcher using a functionalist framework might study the role of schools in preparing students for various roles in society. They might collect data on curriculum, teaching methods, student performance, and post-graduation outcomes. Using a functionalist lens, the researcher would be interested in how each aspect of the education system contributes to the socialization process and preparation of individuals for adulthood and societal roles.

9. Symbolic Interactionism

Scholarly Fields: Sociology (see: symbolic interactionism in sociology )

The symbolic interaction theory states that the meaning we ascribe to objects, processes, ideas, concepts, and systems are subjective. They are constructed through language, words, and communication, and differ from context to context and culture to culture.

Symbolic interactionism is very common in qualitative research in the social sciences, especially work that involves interviews as a research method.

Symbolic interaction is a theoretical frame that challenges that of functionalism by focusing on microsociology rather than macrosociology .

Whereas functionalists are generally concerned with how social structures, institutions, and concepts have meaning on a social level , symbolic interactionists are concerned with how people make their own meanings of things in their surroundings.

For example, symbolic interactionism argues that people derive their understanding of their world through social interactions and personal experiences and interpretations.

Example of a Study Using a Symbolic Interactionist Framework

A researcher applying symbolic interactionist theory might investigate how medical patients and doctors negotiate understandings of illness during medical consultations. The study would likely involve observations and perhaps recordings of consultations, focusing on the language and symbols used by both parties. A symbolic interactionist approach would highlight how shared meanings and interpretations are built in these interactions, impacting the patient-doctor relationship and treatment decisions.

10. Postmodernism

Scholarly Fields: Sociology, Cultural Studies, Media Studies

Postmodern theory critiques social narratives, beliefs, and definitions, arguing that they’re historically, culturally and socially situated.

A key concept in postmodernism is discourse , which refers to how knowledge is constructed through language. The ways people talk about something constructs normative ideas about it (i.e. ideas, like gender, a socially constructed).

Postmodernists are therefore skeptical of truth-claims made about anything. Their research aims to demonstrate how truth-claims, such as “men are natural-born leaders” emerge through language and social narratives that normalize such as belief.

Postmodernism’s role, therefore. Is to highlight the relativity of truths and social narratives propagated by media and culture.

Example of a Study Using a Postmodern Theoretical Framework

A researcher using a postmodernist framework might conduct a study analyzing the portrayal of reality in contemporary television news. They might examine the selection and presentation of stories, the use of imagery and language, and the underlying assumptions about truth and objectivity. From a postmodernist perspective, the study would not be looking for an objective reality represented in the news but would explore how the news constructs multiple, subjective realities.

List of Additional Theoretical Frameworks

In communication studies.

• Uses and Gratifications Theory
• Agenda-Setting Theory
• Spiral of Silence Theory
• Cultivation Theory
• Muted Group Theory

In Psychology

• Cognitive Development Theory
• Evolutionary psychology
• Socio-cultural Theory

In Sociology

• Social Action Theory
• Poststructuralism
• Labeling Theory
• Strain Theory
• Differential Opportunity Theory
• Differential Association Theory
• Postcolonialism

In Economics

• Keynesian Economics
• Neoclassical Economics
• Marxist Economics
• Behavioral Economics

Choosing a theoretical framework is an early step in developing your research study. Once it is selected, it will go on to inform your research methodology and methods of data collection and analysis. Furthermore, in your analysis chapters of your dissertation, you will be regularly leaning upon the ideas and concepts within your chosen theoretical framework to shed light on your observations. Academic research that uses theoretical frameworks is all about using theory to interpret the world and shed new light on phenomena. With theory, we can develop a cohesive understanding of our subjects and construct detailed, well-thought-out arguments throughout our work.

Anfara Jr, V. A., & Mertz, N. T. (Eds.). (2014). Theoretical frameworks in qualitative research . Sage publications.

Borsboom, D., van der Maas, H. L., Dalege, J., Kievit, R. A., & Haig, B. D. (2021). Theory construction methodology: A practical framework for building theories in psychology.  Perspectives on Psychological Science ,  16 (4), 756-766.

Connaway, L. S., & Radford, M. L. (2016). Research methods in library and information science . Los Angeles: ABC-CLIO.

Given, L. M. (Ed.). (2008). The Sage encyclopedia of qualitative research methods . Sage publications.

Gelso, C. J. (2006). Applying theories to research.  The psychology research handbook: A guide for graduate students and research assistants ,  455 .

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• Open access
• Published: 06 May 2024

Drivers of district-level differences in outpatient antibiotic prescribing in Germany: a qualitative study with prescribers

• Benjamin Schüz 1 ,
• Oliver Scholle 2 ,
• Ulrike Haug 2 , 3 ,
• Roland Tillmann 4 &
• Christopher Jones 1 , 5  

BMC Health Services Research volume  24 , Article number:  589 ( 2024 ) Cite this article

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Previous studies have identified substantial regional variations in outpatient antibiotic prescribing in Germany, both in the paediatric and adult population. This indicates inappropriate antibiotic prescribing in some regions, which should be avoided to reduce antimicrobial resistance and potential side effects. The reasons for regional variations in outpatient antibiotic prescribing are not yet completely understood; socioeconomic and health care density differences between regions do not fully explain such differences. Here, we apply a behavioural perspective by adapting the Theoretical Domains Framework (TDF) to examine regional factors deemed relevant for outpatient antibiotic prescriptions by paediatricians and general practitioners.

Qualitative study with guideline-based telephone interviews of 40 prescribers (paediatricians and general practitioners) in outpatient settings from regions with high and low rates of antibiotic prescriptions, stratified by urbanity. TDF domains formed the basis of an interview guide to assess region-level resources and barriers to rational antibiotic prescription behaviour. Interviews lasted 30–61 min (M = 45 min). Thematic analysis was used to identify thematic clusters, and relationships between themes were explored through proximity estimation.

Both paediatricians and general practitioners in low-prescribing regions reported supporting contextual factors (in particular good collegial networks, good collaboration with laboratories) and social factors (collegial support and low patient demand for antibiotics) as important resources. In high-prescribing regions, poor coordination between in-patient and ambulatory health services, lack of region-level information on antimicrobial resistance, few professional development opportunities, and regional variations in patient expectations were identified as barriers to rational prescribing behaviour.

Conclusions

Interventions targeting professional development, better collaboration structures with laboratories and clearer and user-friendly guidelines could potentially support rational antibiotic prescribing behaviour. In addition, better networking and social support among physicians could support lower prescription rates.

Peer Review reports

Antimicrobial resistance is a major threat to global health systems [ 1 ]. Despite improvements in international surveillance programs [ 2 ], for example in the WHO European region in 2019 alone, around 541,000 deaths were associated with and 133,000 deaths were directly attributable to antimicrobial resistance [ 3 ]. One of the key drivers of antimicrobial resistance in humans is previous exposure to antibiotics [ 4 ]. To reduce the development of antimicrobial resistance, improving rational antibiotic prescription practices (i.e. avoiding unnecessary prescriptions) is crucial [ 5 , 6 ]. Most antibiotic prescriptions in outpatient settings in Europe are for respiratory and urinary tract infections [ 7 , 8 ]. In Germany, the setting of this study, most outpatient prescriptions for antibiotics are issued by general practitioners and paediatricians [ 8 , 9 ].

Germany consistently ranks among the European countries with the lowest community consumption of antibiotics, for example, in the 2021 surveillance report of the European Centre for Disease Prevention and Control [ 10 ], Germany has the 3rd lowest community consumption of antibiotics for systemic use. Still, there is considerable regional variation in outpatient prescription rates across regions in Germany [ 11 ]. International research suggests that such regional differences in outpatient prescriptions cannot be fully explained by regional differences in infectious disease prevalence [ 12 ]. Instead, socioeconomic, demographic and cultural differences have been highlighted as additional key determinants [ 13 ].

A recent small-area analysis based on health insurance claims data [ 11 ], breaking down differences between the 401 administrative districts in Germany, found up to 4-fold differences in outpatient prescription rates for children (between 188 and 710 age- and sex-standardized outpatient prescriptions per 1000 persons/year), and more than 2-fold differences in adults (between 300 and 693 prescriptions per 1000 persons/year). These substantial regional variations in prescription rates continue to raise concern about the appropriateness of antibiotic prescribing practices in Germany [ 8 ].

At the same time, reasons for the observed regional differences in outpatient antibiotic prescription rates are not fully understood. On the one hand, urban-rural differences in prescription patterns might be due to differences in health care access and socioeconomic differences in populations such as age or deprivation status [ 14 ]. Proximity to animal breeding or fattening farms has also been associated with variations in antibiotic prescriptions [ 15 ]. Further regional differences exist in the quality and accessibility of out-of-hours emergency primary care settings, which have both been associated with an increase in antibiotic prescriptions [ 16 ].

On the other hand, non-clinical factors such as demographic and socioeconomic differences [ 13 ], or differences in patient demand and prescription practices have been suggested to underlie regional variations [ 17 ], and the influence of patient demand on inappropriate antibiotic prescriptions is well documented [ 18 , 19 ]. Supporting small-area differences, calls have been made to take into account small-area regional factors in devising targeted interventions to support rational prescription practices [ 20 ].

Together, this suggests that a better understanding of the reasons underlying regional variations in outpatient antibiotic prescriptions is vital, especially for the development and implementation of better interventions to avoid inappropriate antibiotic prescriptions. The present study is based on a mixed methods research project commissioned by the German Federal Ministry of Health (SARA; “Studie zur Analyse der Regionalen Unterschiede bei der Antibiotika-Verordnung” [Study to analyse regional variations in antibiotic prescriptions]). Previous publications from this research project include the abovementioned small-area analysis of health insurance claims data [ 11 ] and a conference presentation containing some of the present data [ 21 ]. The current study focuses on the qualitative part of the project and reports results from interviews with prescribers in outpatient settings.

To this end, it builds on the patterns of regional differences identified in the previous quantitative study [ 11 ] to better understand the drivers of these regional differences in prescription behaviour based on perceptions of prescribers (general practitioners and paediatricians) in districts differing by outpatient antibiotic prescription rates.

In order to do so, an established framework of determinants of health care professional behaviours, the Theoretical Domains Framework (TDF; [ 22 , 23 ]) was used to guide qualitative interviews with prescribers.

The TDF is a psychological model developed for healthcare and behaviour change research and is based on comprehensive reviews of behavioural theories [ 22 , 24 ]. It comprises 14 key individual, social and contextual domains influencing human behaviour: knowledge, skills, social/professional role/identity, beliefs about capabilities, optimism, beliefs about consequences, reinforcement, intentions, goals, memory/attention/decision processes, environmental context/resources, social influences, emotion, and behavioural regulation. Both main effects of and interactions between domains are possible.

The TDF has been instrumental in examining individual determinants of antibiotic prescribing behaviour [ 25 , 26 , 27 , 28 ], and most studies show the domain of environmental context and resources to be influential for antibiotic prescriptions. However, which contextual aspects are particularly relevant is poorly understood to date.

The degree to which contextual resources and barriers as well as their interactions are specific to small-area districts and regions is vital to understand the observed variations in prescription rates and improve future intervention efforts. This study will therefore apply the TDF to understand differences in contextual determinants of antibiotic prescriptions and map these onto established small-area differences in paediatricians and general practitioners in Germany.

Participants and procedure

To identify region-level determinants of differences in outpatient antibiotic prescribing, semi-structured interviews were conducted with general practitioners and paediatricians working in outpatient settings. The protocol for this study was approved by the University of Bremen Ethics committee (AZ 2021-03).

Data collection materials

An interview guide (supplementary file 1 ) based on the Theoretical Domains Framework (TDF) [ 22 , 23 ] and previous studies using the TDF in antibiotic prescription contexts [ 25 , 28 ] was designed with input from a paediatrician (RT) and pharmacoepidemiologists (UH, OS) and was pilot-tested with GP representatives known to the researchers. The interview guide started with informing participants about the status of their district as high-or low-prescribing and subsequently asked an open question on prescribers’ ideas on reasons for this. Following this, we asked prescribers for their perceptions on regional levels of TDF domains relevant for prescribing antibiotics [ 25 , 28 ]; (i) knowledge, (ii) social support, (iii) environmental context and resources (and perceived differences to other districts), (iv) social and professional role, (v) social influences (patients), (vi) goals, (vii) beliefs about capabilities (patient expectation management), (viii) beliefs about consequences, (ix) optimism, (x) intentions, (xi) memory and attention processes.

Recruitment

We employed purposive sampling and stratified potential participants based on our previous quantitative analysis of regional differences in medical claims data of outpatient antimicrobial prescriptions in Germany [ 11 ]. Here, differences in prescriptions were compared between administrative districts (“Landkreise” or “kreisfreie Städte”; Nomenclature of Territorial Units for Statistics NUTS level-3 subdivision [ 29 ]).

In order to compare and contrast health care providers’ perspectives on regional differences, we selected, separately for paediatricians and GPs, 5 districts each that were within the 5% highest antibiotic prescription rates per 1,000 insured persons, and 5 districts that were within the 5% lowest antibiotic prescription rates. Within each district group, we further selected rural and urban districts (classification based on official regional statistics in Germany; [ 30 ]) to account for potential differences in settlement structure.

Contact information for paediatrician and GP practices in the respective districts were obtained through the regional representations of the respective medical councils, and were contacted through email and phone calls. Snowball recruitment was used during which participants recommended further colleagues within the respective districts, and a total of 1,444 contact attempts were made. Participants received €75 (approximately US$80) for their participation.

Prescribers who had expressed interest in the study were emailed a participant information sheet and were asked to suggest a date and time for a phone interview. Semi-structured telephone interviews were subsequently conducted by experienced female and male qualitative researchers (CJ, BS, PK), audio recorded and were transcribed verbatim. Interviews lasted a mean of 45 min (range 30–61 min) and started with an introduction, brief overview of the study goals, and verbal informed consent was obtained prior to interview commencement. The interviewed prescribers had no personal or professional connection to the researchers before the interviews.

Data analysis

Starting with the TDF domains in the interview guide, data analysis utilized an deductive approach and was based on thematic analysis [ 31 ]. Two researchers (CJ, BS) independently coded the material using MaxQDA data management software. Initial codes were reviewed between the two researchers, and saturation was achieved with both the paediatrician and GP interviews. All codes were mapped onto at least one of the TDF domains. Relationships between codes were examined looking at code overlaps in coded segments and analysing the relative proximity of coded segments in the transcribed text. The more frequently two codes appear in the same segment or in relative proximity, the more substantial overlaps between the codes are assumed. The relative positions of codes in this two-dimensional space were operationalized using multidimensional scaling implemented in MaxQDA. Here, a solution is estimated which replicates the distance between elements in the two-dimensional space between codes as well as possible relationships. Assigning of a code to a cluster of codes is estimated using the Unweighted Average Linkage method [ 32 ]. Disagreements were resolved through discussion between the researchers.

Results of the thematic analyses are presented separately for GPs and paediatricians.

Participants

A total of 40 interviews (17 paediatricians; 10 from high-prescription and 7 from low-prescription districts, 23 GPs; 10 from high-prescription and 13 from low-prescription districts) were conducted. Participants had between 1 and 35 years of experience in their current positions (mean 13.4 years, SD 9.9 years). Interviews lasted an average of 44.8 min (SD 7.1 min, range 30–61 min).

Paediatricians

TDF domains on region levels mentioned as influencing paediatricians’ prescribing behaviour (Fig.  1 ) included context and resources (86 mentions), social influences (56 mentions), knowledge (36 mentions), skills (22 mentions), social/professional role (15 mentions), beliefs about consequences (15 mentions), beliefs about capabilities (9 mentions), goals (9 mentions), behavioural regulation (6 mentions), optimism (3 mentions) and emotions (2 mentions).

TDF domains mentioned as barriers (red) or resources (blue) by paediatricians

Context and resources

Regional context and resources can affect prescribing behaviour through multiple, direct and indirect pathways, according to the participating paediatricians. The distinction between contextual (i.e., factors specific to the region) and composition effects (i.e., factors resulting from the composition of the population within a region; [ 33 ]) is particularly relevant.

Paediatricians mainly mentioned contextual factors, e.g., air pollution as a risk factor:

This area here is a former working-class area, air quality is poor, and this means we have more respiratory illnesses which are the most frequent reasons for antimicrobial prescriptions.

(A, paediatrician, urban area, high prescription rate)

Similar direct contextual effects are evident in the density of paediatricians:

…This means service provision for children in an emergency is limited, and they are rather seen by GPs. And the GPs are fantastic, […], but they don’t have our special training and might be a bit more anxious if they see a child with a high fever….

(B, paediatrician, rural area, high prescription rate)

This low density then results in overload of the paediatricians, which in turn can increase antimicrobial prescriptions:

I mean on a Monday in February I have seen about 200 children, or thereabouts. And then I can’t start discussing for ages, this just doesn’t work.

(C, paediatrician, rural area, high prescription rates)

Suboptimal transition from in-patient to out-patient care were also seen to increase antimicrobial prescriptions in districts with higher prescription rates:

…in the hospitals, they prescribe broad-spectrum antibiotics. And I have to say, after we have sat down together a year ago and have talked about outpatient antibiotic therapies, we had agreed on not prescribing some particular antibiotics. And now I see that these exact antibiotics are still being used in the hospital.

(D, paediatrician, rural area, high prescription rates)

Contextual effects however also can constitute resources for lower prescription rates, for example in high-quality laboratories and quick turnaround times:

This means we can get samples to them three or four times a day and are not dependent on pickups once a day like in the practices out there. This really is a resource I think .

(E, paediatrician, rural area, low prescription rates)

Social influences

Social influences have been mentioned frequently, both as social influences through patients and through other health care providers. In particular where patient characteristics are being discussed, such influences could also be classified as compositional context resources (see above). However, as most of the quotes illustrate, these compositional factors also contain social influences.

Social influences as factors affecting high prescription rates are mainly located on patient level, illustrated in the following quote referring to patients with Middle-Eastern migration history:

This is a totally different culture, also affecting ideas about illnesses. Their ideas are totally different, and antibiotics are seen as miracle drugs – they are over the moon if they can get an antibiotic.

(F, paediatrician, urban area, high prescription rates)

However, the demand by patients is also being attributed to context effects such as dominating agricultural influences:

I think that there are lots of expectations for antibiotics by patients. For example, I do have a mother who generally insists on getting an antibiotic for her child, and I wouldn’t prescribe it. And I tell you how she says it: ‘I also give this to my pigs, so it can’t be bad for my kids’. So I think that antibiotic practices in the farms around here, I think that this means they (antibiotics) are applied liberally and happily, and the parents have experience and want them for their kids as well.

At the same time, social influences are seen as malleable influences, in particular in combination with skills and knowledge which can then contribute to improvements in prescription practice:

It has become much better, yes. They (patients) now understand it, they have gotten used to it. And now we have, when the doctor says, you don’t need an antimicrobial, then more than half of them don’t go and see another doctor immediately and say ‘I need an antibiotic’.

(G, paediatrician, urban area, low prescription rates)

Knowledge included both information on current recommendations for antimicrobial prescribing, information on local resistance prevalence, information on local and personal prescription rates, and training content relevant to prescribing antimicrobials.

Participants from low-prescription districts mentioned knowledge on current recommendations as a resource and linked this knowledge to lower prescription rates within their districts:

We feel quite well informed. And everyone builds on that through individual research, further training and talking to colleagues. And I think, else we wouldn’t see these numbers.

(H, paediatrician, rural area, low prescription rates)

In contrast, paediatricians from high-prescription areas mentioned increased effort in obtaining relevant information:

[…] There is no information in the district, you always have to look after this yourself.

(I, paediatrician, rural area, high prescription rates).

In districts that had employed a paediatrician-initiated education programme (AnTiB; [ 34 ]), this programme was mentioned as an explicit resource:

We used to have this little informal guideline here in (city), which is also lying around in out-of-hours paediatric services and which every paediatrician here is likely to have in their practice. It is very useful and if you are doing emergency shifts, you pull it out of the drawer, look at the dosage and then prescribe.

(J, paediatrician, urban area, low prescription rate).

In contrast, the lack of specific knowledge in paediatric emergency services is seen as a barrier to effective prescribing:

We live in one of the areas with the most children in Germany, and, you can’t make this stuff up, we don’t have a paediatric out-of-hours service. This means out-of-hours is staffed by colleagues, e.g., urologists who have no clue, who start googling first – and then quickly prescribe an antibiotic.

Skills as mentioned by the paediatricians include both discipline-specific and generic skills such as language skills or interpersonal skills.

Lack of specific treatment skills are mentioned as barriers to lower prescription rates by paediatricians in high-prescribing districts:

Perhaps the experience that as a urologist, you might not have that much experience with these really high fever temperatures in toddlers under two years.

(K, paediatrician, rural area, high prescription rate).

Similarly, a lack of language skills both on the side of the prescribers and patients is being seen as a barrier, both to non-prescribing and to instructing parents to monitor their children’s health:

… there is such a large language barrier which prevents you from explaining what the parents have to look out for, what are the signs of deteriorations, when do they need to come back, well, that this is a problem overall.

(L, paediatrician, urban area, high prescription rate)

Social and professional role

Social and professional role are mainly seen as a resource for low prescription rates. The main effects are seen to be indirect, via social norms and better professional networks. In some areas, this professional role is a relevant part of paediatricians’ identity which is used to be a role model to other paediatricians.

I think there are these lighthouse or role model practices here, the bigger ones. And they do this on purpose, to set standards and blaze a trail, and the younger colleagues or others then orient themselves on them.

(M, paediatrician, urban area, low prescription rates)

In addition, the social influence through networks is being seen as strengthened through social and professional roles and identity:

So we do have quite a number of colleagues who are really well connected. They always participate in our quality groups, participate very reliably, and have good contact amongst themselves.

Beliefs about consequences

Beliefs about consequences tend to be related to contextual and environmental resources or barriers as well as regional outcomes. A particularly strong motive seems to be using antibiotics to prevent potential risks.

Paediatricians from districts with high prescription rates discuss avoiding consequences in particular with regards to patient overload:

My personal record in winter was 209 children a day. […] I have briefly checked them and then prescribed an antibiotic, because even if most of it is viral, you have children with whooping cough and I tend to be generous, because the hospitals are full of pneumonia.

Paediatricians from districts with low prescription rates on the other hand discuss low beliefs about negative consequences such as patients changing doctors due to low competition pressure:

So we don’t really have a competitive mindset here, because changes from one paediatrician to the other are really, really rare.

Interestingly, beliefs about consequences in terms of developing resistant microbes differ between paediatricians from low- and high-prescribing districts. Whereas those from high-prescribing districts argue that the responsibility for resistances is mainly located in the agricultural sector:

I think that resistant microbes develop if the farms in the area use lots of antibiotics […] So the kids who have MRSA here, they are all from farms. So they didn’t get MRSA because we gave them antibiotics but because the farms at home use lots of antibiotics.

(C, paediatrician, rural area, high prescription rates),

Those from low-prescription districts tend to attribute resistance development to health care professional behaviour:

The less antibiotics one prescribes, and if this happens everywhere, then we can expect, that the development of resistances will be less bad than elsewhere.

Beliefs about competences

Beliefs about competences mainly revolved around perceptions of competence to influence local resistance developments and largely mirror those exemplified in the beliefs about consequences section.

Both paediatricians from low- and high-prescribing districts explicitly mentioned goals to prescribe less antimicrobials, and mention that these goals are also shared by colleagues in the respective districts. Differences exist in the context within goals are mentioned – paediatricians from low-prescription districts mention the goal of lower prescriptions as part of a combinations of goals (e.g., optimal therapy or limiting resistance development), paediatricians from high-prescription districts concentrate on potentially more relevant goals than lower prescription rates:

…I think I can speak for most of my colleagues here, one tries to prescribe as little as possible. But if they really all read the reports, do they change their prescription behaviour, I doubt that. There are quite some other problems here that need solving as well.

Behavioural regulation

Behavioural regulation had only six mentions, but these were mainly together with contextual factors in districts with high prescription prevalence to highlight that contextual factors can pose barriers which also affect the low likelihood to change through impeding behavioural regulation:

And I think that these are basically deeply rooted, historic, ritualized prescription patterns, which then manifest regionally such that it is really difficult to change this.

General Practitioners (GPs)

TDF domains on district level that affected GP prescribing behaviour (Fig.  2 ) included context and resources (159 mentions), social influence (60 mentions), knowledge (41 mentions), beliefs about consequences (29 mentions), social/professional role (16 mentions), skills (16 mentions), goals (6 mentions), and behavioural regulation (4 mentions).

TDF domains mentioned as barriers (red) or resources (blue) by GPs

Similar to the paediatric participants, GPs reported on a range of regional contextual factors that influenced prescribing behaviour. These can also be differentiated along contextual and compositional factors [ 33 ].

A combination of contextual (main industry in the region) and compositional (migrant workers in the main industry) is a good example for these influences:

With the (migrant) workers in the meat industry, we do have a lot of people who might have potentially problems in dental hygiene, infections due to cuts for example. This happens a lot, and then increases the prescription of (antimicrobials).

(N, GP, rural area, high prescription rates).

GPs also report on regional differences in the influence of pharmaceutical representatives in their practices. For example, a GP from a low-prescription rural district mentioned that their local quality circles “will not invite pharmaceutical representatives if possible”.

Social influence

Social influences differ between districts, according to GP participants, and similar to paediatricians, these influences come through colleagues and patients.

One example for a local social influence could be long established GPs who influence local quality circles:

…as a young and newly arrived doctor, I quit going to the quality circles because the old guard was so present and influenced communication, work and thinking about practices. However, we do have now a new generation of GPs and things change.

(O, GP, rural area, low prescription rates)

Patient-level influences are also perceived to differ between districts, with some of the differences in expectations to be prescribed antibiotics being attributed to cultural factors:

There is a group of patients who are really eager to get antibiotics and who are incredibly demanding. Germans from the former Soviet Republics, and we do have many of them in this district. For them, it (not being prescribed antibiotics) is not a real therapy, even if it is viral….

(P, GP, rural area, high prescription rates)

Similar to cultural factors, the age distribution in a district is perceived to affect prescription, with more older adults in a district being associated with higher antibiotic demand.

Similar to this influence on higher prescriptions, specific regional social influences are also perceived as being influential for low prescription rates:

I mean, (city) is a very special city. It’s an administrative centre, a big university city, so I think there are a lot of people with a relatively high educational attainment, relatively little industry and I guess it’s also related to the fact that people have a bit of a different attitude. .

(Q, GP, urban area, low prescription rates)

Similar to the results in paediatricians, knowledge about current recommendations, information on local resistance, and training content relevant to prescribing antimicrobials were seen as relevant resources. One particular additional factor was that in one of the participating districts, the local university was seen as influential for particularly rational prescribing behaviour:

I think that this is due to the fact that here in (city) there are many doctors who have studied in (city). And I remember from my studies that antibiotic prescriptions were an important topic, and that in microbiology et cetera we were always being reminded that one does not just prescribe antibiotics but needs to justify this really well.

(R, GP, rural area, low prescription rates)

At the same time, similar to the paediatricians, a lack of knowledge in out-of-hours services is seen as a relevant factor for high prescription rates:

But there are many colleagues working in the out-of-hours primary care and doing GP tasks who have for example an anesthesia background, or something else from the hospital, they don’t know it any better.

(N, GP, rural area, high prescription rates)

These knowledge factors interact with resources and barriers on context level.

Similar to paediatricians, beliefs about consequences include beliefs about having to avoid liabilities, which are often mentioned in combination with structural and contextual factors:

And if something does go wrong, and that’s always a problem in outpatient settings, you are the one who screwed it up. That’s what all the colleagues are afraid of. So the fear of making a mistake and not prescribing the antibiotic is always bigger than the fear of damaging something with the antibiotic.

(S, GP, rural area, high prescription rates)

Losing patients to other practices in situations with strong competition was a strong belief about consequences in districts with high prescriptions:

You can say, No I am not going to prescribe this, but then you lose the patient, they are just going somewhere else.

(T, GP, urban area, high prescription rates).

At the same time, a lack of such perceived consequences has been perceived as a resource for lower prescriptions:

…at least we don’t have to bow to patient demands too much. It is very different here compared to (city) where I was before, in the inner city, where there was a lot of competition due to too many GPs. You are much more likely to give in to irrational demands then.

(U, GP, rural area, low prescription rates)

Social / professional role

Specific regional ideas on the professional roles are perceived to influence prescription behaviour, in particular in combination with specific aspects of rurality that could affect the composition of the local GP structure:

I just see what kind of colleagues – to say it cautiously – are coming to this region, who take over old practices or establish new ones. They are not necessarily the most committed doctors.

(V, GP, rural area, high prescription rates)

In districts with low prescription rates, skills were mainly being mentioned with regards to interpersonal skills regarding expectation management with patients, which were perceived to be higher in the respective districts:

…in fact, skills training in multiple areas. General communication skills, difficult patients, bad prognosis, diagnosis, or making the patients understand why a particular therapy is indicated – these are all key skills and have always been emphasized during our studies.

Similar to paediatricians, GPs from both low- and high-prescription districts mention the goal of low prescription rates, and assume that their colleagues in the district have similar goals. GPs in low-prescription districts mention this goal as part of multiple goals (ideal therapy, avoid resistance) in low-prescription districts, GPs in high-prescription districts mention this goal as having lower priority compared to competing demands.

Similar to the paediatricians, a lack of behavioural regulation in combination with contextual measures such as relatively old GPs in the district was seen as a risk factor for higher prescriptions:

Prescription behaviour by older colleagues plays a role I think. You can see this when you look at the age structure of the GPs here. They tend to prescribe antibiotics quickly whenever there are respiratory infections.

(W, GP, rural area, high prescription rates)

This study examined prescribers’ perceptions of region-specific drivers of outpatient antibiotic prescriptions. We conducted 40 interviews in districts stratified by antibiotic prescription rates, and mapped these perceptions on dimensions of the Theoretical Domains Framework [ 22 , 23 ]. A total of 11 domains were identified, and these served as, partially interacting, barriers against and resources for low antibiotic prescription rates. Most barriers and facilitators were similar between paediatricians and GPs. However, while GPs mentioned the age and workforce structure in districts as additional barrier, paediatricians emphasized a lack of skills and knowledge of GP colleagues treating young children as a barrier in districts with only few paediatricians.

We could link differences in the perception of TDF domains and their interactions to differences in prescribing behaviour in the districts to identify overarching barriers and resources for appropriate prescription practices.

Overarching barriers to low prescription rates

Both paediatric and GPs mentioned a lack of knowledge on district-level resistance developments as particular barrier to rational prescribing. This knowledge factor overlaps with a lack of contextual and environmental resources which could provide this information such as routine information flows between laboratories and health care providers.

Similarly, a lack of collaboration and coordination of knowledge in out-of-hours services was perceived to be associated with higher prescription rates – partly also due to a perception to avoid liabilities if prescribing antibiotics.

Lower health care provider density as contextual factor has been associated with higher prescription rates in previous international studies [ 35 , 36 ]. In the present study, lower prescriber density has only indirectly been associated with higher prescription rates – in the cases where lower density correlates with suboptimal emergency services prescription guidelines [ 16 ].

Participants also associated specific regional industries in rural districts (pig farming and meat factories) with higher patient demands due to either antibiotic practices in farming [ 15 ] or an increased demand for antibiotics by migrant workers and due to cuts in meat factories.

Social influences included culture-specific expectations about the effectiveness of antibiotics leading to higher patient demand for antibiotics, which together with time pressure from high patient load increased pressure on prescribers during consultations. This finding replicates findings from other European studies on antibiotic prescribing behaviour [ 18 , 19 ].

Overarching resources for low prescription rates

Overarching resources for low prescription rates that were mentioned by both paediatricians and GPs included environmental context and resources . Here in particular existing local networks supporting quality control were perceived as supportive of appropriate prescribing, both through the provision of information, best-practice examples and social norms. This replicates an earlier study suggesting that well-functioning local or regional primary care networks in Germany are associated with more appropriate antibiotic prescribing [ 37 ]. In addition, laboratories routinely providing information on local resistance data were perceived as resources for rational prescribing, which is in line with previous studies in Germany outlining the lack of local resistance information as a barrier to appropriate prescribing [ 38 ] and, similarly, showing that practitioners perceive information on local resistance as beneficial [ 39 ]. Low local population demand for antibiotics was also perceived as resource, as participants reported this to positively impact their prescription practice.

Implications

Most barriers and resources to rational outpatient prescribing in this study were contextual factors. However, contextual factors such as the local population, the main local branches of industry or (at least in Germany), or the free choice of practitioners to open practices anywhere within a district are not directly modifiable. This means that interventions should in particular target local collaboration structures and the availability of locally adapted guidelines.

If collaborations between local medical councils and laboratories can be improved to routinely provide local antimicrobial resistance data to prescribers, this information can readily be included into the prescription decision-making process [ 39 ]. In particular since both German and international studies [ 40 ] show that there is substantial variation in the degree to which individual practices take local resistance data into consideration, routine approaches are warranted. Germany has implemented a standardized surveillance program for multiresistant microbes such as MSRA [ 2 ], but the degree to which these surveillance findings are broken down locally and are available to practices varies considerably between districts, suggesting policies to standardise practice. If these findings are then included into local prescription guidelines such as the AnTiB guidelines [ 34 ], local prescription practices can be improved.

Routine antibiotic stewardship programmes that support paediatric and general practices could also help facilitating such closer collaborations and in turn build on some of the networking aspects mentioned as resources in the interviews. At the moment, antibiotic stewardship programs for outpatient settings in Germany are supported through national professional and scientific associations and are eligible for training credits, but implementation depends on local initiatives [ 5 ]. National policies to mandate such programmes would help to reduce the current regional disparities in antibiotic prescription practices, and the current antibiotic strategy of the German government DART 2030 [ 41 ] plans to explore compulsory training.

In terms of knowledge resources, participants mentioned that easy-to-use recommendations for emergency practice services are an important resource in particular if there is no paediatric emergency service, and children are seen by non-paediatrician practitioners. In Germany, initiatives such as Antibiotic Therapy in Bielefeld (AnTiB; [ 34 ]) provide such guidelines, but a systems-wide implementation of easy-to-follow guidelines such as e.g., NICE guidelines for upper respiratory tract infections [ 42 ] is currently lacking and would likely improve prescription practices in Germany.

Patient information such as leaflets might lead to increased patient knowledge about the role of antibiotics in managing infections and lower patient demand [ 43 ] without increased reconsultations [ 44 ]. At the same time, the role of involving audiences in the design of such leaflets and ensuring their understandability is crucial [ 45 ].

Strengths and limitations

A particular strength of the study lies in using the TDF to examine district-level differences in prescription behaviour, which allowed us to identify and interpret the impact of the factors mentioned by GPs and paediatricians. This deductive approach allowed mapping key themes on an established framework, which can in turn be used to determine and develop potential intervention applications. Our study complements previous work applying the TDF to understand antibiotic prescribing behaviour [ 25 ] by extending the perspective of the TDF on individual determinants onto characteristics of the district.

At the same time, the perceptions of participants regarding district-level TDF-based characteristics are subjective perceptions and do not necessarily correspond to the actual level of resources and barriers in the districts. Compared to face-to-face interviews, telephone interviews miss out on nonverbal information, but have allowed us to accommodate prescribers’ schedules. Due to the self-report nature of interviews, demand characteristics might affect responses such that participants exaggerate or downplay relevant factors.

Saturation in that no new codes emerged was achieved in all study cells (defined by practitioner group, urban/rural practice site and prescription rates) apart from GPs from high-prescribing urban areas, where only one interview could be realised. It is thus possible that additional interviews could have provided additional barriers and resources.

Substantial district-level differences in outpatient antibiotic prescriptions in paediatric and general practices can be mapped on differences in prescriber perceptions of district-level barriers and resources to rational prescribing. Given the regional variation in underlying reasons for inappropriate prescribing of antibiotics, similar qualitative studies in all districts in Germany with high prescription rates could be a promising approach to design targeted interventions. According to the results of interviews conducted in this study, routine provision of local antibiotic resistance data, better and clearer guidelines for paediatric patients in ambulatory emergency services, patient information and a wider implementation of standardised antibiotic stewardship programs could be promising targets for interventions.

Data availability

The qualitative data collected for this study was de-identified before analysis. Consent was not obtained to use or publish individual-level data from the participants and therefore may not be shared publicly. The de-identified (German) data can be obtained from the corresponding author upon reasonable request.

Change history

09 may 2024.

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Acknowledgements

The support of Paula Kinzel during data assessment is gratefully acknowledged.

Open Access funding enabled and organized by Projekt DEAL.

The SARA project—on which this publication is based—was commissioned by the Federal Ministry of Health (grant number ZMVI1-2519FSB115).

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Benjamin Schüz & Christopher Jones

Department of Clinical Epidemiology, Leibniz Institute of Prevention Research and Epidemiology – BIPS, Bremen, Germany

Oliver Scholle & Ulrike Haug

Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany

Ulrike Haug

Praxis für Kinder- und Jugendmedizin Roland Tillmann, Ärztenetz Bielefeld, Bielefeld, Germany

Roland Tillmann

Medical Faculty Mannheim, Center for Preventive Medicine and Digital Health (CPD), Heidelberg University, Mannheim, Germany

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Contributions

BS conceived of the study, analysed and interpreted data and wrote the first draft of the manuscript. OS contributed to design of the study, interpretation of data. UH contributed to acquisition, concept and design of the study as well as interpretation of data. RT contributed to design and acquisition of the study as well as interpretation of data. CJ contributed to design and concept of the study as well as assessment, analysis and interpretation of the data. All authors critically reviewed the manuscript.

Corresponding author

Correspondence to Benjamin Schüz .

Ethics declarations

Ethics approval and consent to participate.

Ethics approval was obtained through the University of Bremen ethics committee (AZ 2021-03). All methods and procedures were performed in accordance with the relevant guidelines. All participants provided informed consent including before being interviewed for this study.

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Not applicable.

Competing interests

OS and UH are working at an independent, non-profit research institute, the Leibniz Institute for Prevention Research and Epidemiology – BIPS. Unrelated to this study, BIPS occasionally conducts studies financed by the pharmaceutical industry. These are post-authorization safety studies (PASS) requested by health authorities. The design and conduct of these studies as well as the interpretation and publication are not influenced by the pharmaceutical industry. The study presented was not funded by the pharmaceutical industry. The Federal Ministry of Health specified the research question and the main content of the study concept and regularly participated in discussions on the implementation of the study. The authors were independent in the specific design, execution, interpretation, and writing of the study. The Federal Ministry of Health has authorized the publication of the results. BS, RT and CJ declare no conflicts of interest.

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Schüz, B., Scholle, O., Haug, U. et al. Drivers of district-level differences in outpatient antibiotic prescribing in Germany: a qualitative study with prescribers. BMC Health Serv Res 24 , 589 (2024). https://doi.org/10.1186/s12913-024-11059-z

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Received : 09 November 2023

Accepted : 29 April 2024

Published : 06 May 2024

DOI : https://doi.org/10.1186/s12913-024-11059-z

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Theoretical Frameworks in Qualitative Research

• Vincent A. Anfara, Jr. - University of Tennessee, Knoxville, USA
• Norma T. Mertz - University of Tennessee, Knoxville, USA
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The Second Edition of Theoretical Frameworks in Qualitative Research brings together some of today’s leading qualitative researchers to discuss the frameworks behind their published qualitative studies. They share how they found and chose a theoretical framework, from what discipline the framework was drawn, what the framework posits, and how it influenced their study. Both novice and experienced qualitative researchers are able to learn first-hand from various contributors as they reflect on the process and decisions involved in completing their study. The book also provides background for beginning researchers about the nature of theoretical frameworks and their importance in qualitative research; about differences in perspective about the role of theoretical frameworks; and about how to find and use a theoretical framework.

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Committee decision because of the depth of the qualitative information.

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NEW TO THIS EDITION:

• Abstracts added to the beginning of each contributed chapter highlight what can be learned about the chapter’s theoretical frameworks.
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• A comprehensive examination of the role and influence of theoretical frameworks in qualitative research helps readers plan for their own qualitative research studies.
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