inductive analysis in qualitative research example

Inductive content analysis: A guide for beginning qualitative researchers

• Danya F Vears Murdoch Children's Research Institute Melbourne Law School, University of Melbourne
• Lynn Gillam Children's Bioethics Centre, The Royal Children's Hospital Melbourne School of Population and Global Health, University of Melbourne

Inductive content analysis (ICA), or qualitative content analysis, is a method of qualitative data analysis well-suited to use in health-related research, particularly in relatively small-scale, non-complex research done by health professionals undertaking research-focused degree courses. For those new to qualitative research, the methodological literature on ICA can be difficult to navigate, as it employs a wide variety of terminology and gives a number of different descriptions of when and how to carry it out.

In this article, we describe in plain language what ICA is, highlight how it differs from deductive content analysis and thematic analysis, and discuss the key aspects to consider when making decisions about employing ICA in qualitative research. Using a study investigating practices and views around genetic testing in children as an example, we provide a clear step-by-step account of analysing text using ICA. 

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Inductive content analysis: A guide for beginning qualitative researchers

• D. Vears , L. Gillam
• Published in Focus on Health Professional… 31 March 2022
• Education, Medicine

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A worked example of Braun and Clarke’s approach to reflexive thematic analysis

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• Published: 26 June 2021
• Volume 56 , pages 1391–1412, ( 2022 )

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Since the publication of their inaugural paper on the topic in 2006, Braun and Clarke’s approach has arguably become one of the most thoroughly delineated methods of conducting thematic analysis (TA). However, confusion persists as to how to implement this specific approach to TA appropriately. The authors themselves have identified that many researchers who purport to adhere to this approach—and who reference their work as such—fail to adhere fully to the principles of ‘reflexive thematic analysis’ (RTA). Over the course of numerous publications, Braun and Clarke have elaborated significantly upon the constitution of RTA and attempted to clarify numerous misconceptions that they have found in the literature. This paper will offer a worked example of Braun and Clarke’s contemporary approach to reflexive thematic analysis with the aim of helping to dispel some of the confusion regarding the position of RTA among the numerous existing typologies of TA. While the data used in the worked example has been garnered from health and wellbeing education research and was examined to ascertain educators’ attitudes regarding such, the example offered of how to implement the RTA would be easily transferable to many other contexts and research topics.

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1 Introduction

Although the lineage of thematic analysis (TA) can be traced back as far as the early twentieth century (Joffe 2012 ), it has up until recently been a relatively poorly demarcated and poorly understood method of qualitative analysis. Much of the credit for the recent enlightenment and subsequent increase in interest in TA can arguably be afforded to Braun and Clarke’s ( 2006 ) inaugural publication on the topic of thematic analysis in the field of psychology. These authors have since published several articles and book chapters, as well as their own book, all of which make considerable contributions to further delineating their approach to TA (see, for example, Braun and Clarke 2012 , 2013 , 2014 , 2019 , 2020 ; Braun et al. 2016 ; Terry et al. 2017 ). However, on numerous occasions Braun and Clarke have identified a tendency for scholars to cite their 2006 article, but fail to fully adhere to their contemporary approach to RTA (see Braun and Clarke 2013 , 2019 , 2020 ). Commendably, they have acknowledged that their 2006 paper left several aspect of their approach incompletely defined and open to interpretation. Indeed, the term ‘reflexive thematic analysis’ only recently came about in response to these misconceptions (Braun and Clarke 2019 ). Much of their subsequent body of literature in this area addresses these issues and attempts to correct some of the misconceptions in the wider literature regarding their approach. Braun and Clarke have repeatedly iterated that researchers who chose to adopt their approach should interrogate their relevant publications beyond their 2006 article and adhere to their contemporary approach (Braun and Clarke 2019 , 2020 ). The purpose of this paper is to contribute to dispelling some of the confusion and misconceptions regarding Braun and Clarke’s approach by providing a worked example of their contemporary approach to reflexive thematic analysis. The worked example will be presented in relation to the author’s own research, which examined the attitudes of post-primary educators’ regarding the promotion of student wellbeing. This paper is intended to be a supplementary resource for any prospective proponents of RTA, but may be of particular interest to scholars conducting attitudinal studies in an educational context. While this paper is aimed at all scholars regardless of research experience, it may be most useful to research students and their supervisors. Ultimately, the provided example of how to implement the six-phase analysis is easily transferable to many contexts and research topics.

2 What is reflexive thematic analysis?

Reflexive thematic analysis is an easily accessible and theoretically flexible interpretative approach to qualitative data analysis that facilitates the identification and analysis of patterns or themes in a given data set (Braun and Clarke 2012 ). RTA sits among a number of varied approaches to conducting thematic analysis. Braun and Clarke have noted that very often, researchers who purport to have adopted RTA have failed to fully delineate their implementation of RTA, of have confused RTA with other approaches to thematic analysis. The over-riding tendency in this regard is for scholars to mislabel their analysis as RTA, or to draw from a number of different approaches to TA, some of which may not be compatible with each other (Braun and Clarke 2012 , 2013 , 2019 ; Terry et al. 2017 ). In an attempt to resolve this confusion, Braun and Clarke have demarcated the position of RTA among the other forms of thematic analysis by differentiating between three principal approaches to TA: (1) coding reliability TA; (2) codebook approaches to TA, and; (3) the reflexive approach to TA (Braun et al. 2019 ).

Coding reliability approaches, such as those espoused by Boyatzis ( 1998 ) and Joffe ( 2012 ), accentuate the measurement of accuracy or reliability when coding data, often involving the use of a structured codebook. The researcher would also seek a degree of consensus among multiple coders, which can be measured using Cohen’s Kappa (Braun and Clarke 2013 ). When adopting a coding reliability approach, themes tend to be developed very early in the analytical process. Themes can be hypothesised based on theory prior to data collection, with evidence to support these hypotheses then gathered from the data in the form of codes. Alternatively, themes can be hypothesised following a degree of familiarisation with the data (Terry et al. 2017 ). Themes are typically understood to constitute ‘domain summaries’, or “summaries of what participants said in relation to a particular topic or data collection question” (Braun et al. 2019 , p. 5), and are likely to be discussed as residing within the data in a positivistic sense.

Codebook approaches, such as framework analysis (Smith and Firth 2011 ) or template analysis (King and Brooks 2017 ), can be understood to be something of a mid-point between coding reliability approaches and the reflexive approach. Like coding reliability approaches, codebook approaches adopt the use of a structured codebook and share the conceptualisation of themes as domain summaries. However, codebook approaches are more akin to the reflexive approach in terms of the prioritisation of a qualitative philosophy with regard to coding. Proponents of codebook approaches would typically forgo positivistic conceptions of coding reliability, instead recognising the interpretive nature of data coding (Braun et al. 2019 ).

The reflexive approach to TA highlights the researcher’s active role in knowledge production (Braun and Clarke 2019 ). Codes are understood to represent the researcher’s interpretations of patterns of meaning across the dataset. Reflexive thematic analysis is considered a reflection of the researcher’s interpretive analysis of the data conducted at the intersection of: (1) the dataset; (2) the theoretical assumptions of the analysis, and; (3) the analytical skills/resources of the researcher (Braun and Clarke 2019 ). It is fully appreciated—even expected—that no two researchers will intersect this tripartite of criteria in the same way. As such, there should be no expectation that codes or themes interpreted by one researcher may be reproduced by another (although, this is of course possible). Prospective proponents of RTA are discouraged from attempting to provide accounts of ‘accurate’ or ‘reliable’ coding, or pursuing consensus among multiple coders or using Cohen’s Kappa values. Rather, RTA is about “the researcher’s reflective and thoughtful engagement with their data and their reflexive and thoughtful engagement with the analytic process” (Braun and Clarke 2019 , p. 594). Multiple coders may, however, be beneficial in a reflexive manner (e.g. to sense-check ideas, or to explore multiple assumptions or interpretations of the data). If analysis does involve more than one researcher, the approach should be collaborative and reflexive, aiming to achieve richer interpretations of meaning, rather than attempting to achieve consensus of meaning. Indeed, in this sense it would be beneficial for proponents of RTA to remain cognisant that qualitative analysis as a whole does not contend to provide a single or ‘correct’ answer (Braun and Clarke 2013 ).

The process of coding (and theme development) is flexible and organic, and very often will evolve throughout the analytical process (Braun et al. 2019 ). Progression through the analysis will tend to facilitate further familiarity with the data, which may in turn result in the interpretation of new patterns of meaning. This is converse to the use of codebooks, which can often predefine themes before coding. Through the reflexive approach, themes are not predefined in order to ‘find’ codes. Rather, themes are produced by organising codes around a relative core commonality, or ‘central organising concept’, that the researcher interprets from the data (Braun and Clarke 2019 ).

In their 2006 paper, Braun and Clarke ( 2006 ) originally conceptualised RTA as a paradigmatically flexible analytical method, suitable for use within a wide range of ontological and epistemological considerations. In recent publications, the authors have moved away from this view, instead defining RTA as a purely qualitative approach. This pushes the use RTA into exclusivity under appropriate qualitative paradigms (e.g. constructionism) (Braun and Clarke 2019 , 2020 ). As opposed to other forms of qualitative analysis such as content analysis (Vaismoradi et al. 2013 ), and even other forms of TA such as Boyatzis’ ( 1998 ) approach, RTA eschews any positivistic notions of data interpretation. Braun and Clarke ( 2019 ) encourage the researcher to embrace reflexivity, subjectivity and creativity as assets in knowledge production, where they argue some scholars, such as Boyatzis ( 1998 ), may otherwise construe these assets as threats.

3 A worked example of reflexive thematic analysis

The data used in the following example is taken from the qualitative phase of a mixed methods study I conducted, which examined mental health in an educational context. This study set out to understand the attitudes and opinions of Irish post-primary educators with regard to the promotion of students’ social and emotional wellbeing, with the intention to feed this information back to key governmental and non-governmental stakeholders such as the National Council for Curriculum and Assessment and the Department of Education. The research questions for this study aimed to examine educators’ general attitudes toward the promotion of student wellbeing and towards a set of ‘wellbeing guidelines’ that had recently been introduced in Irish post-primary schools. I also wanted to identify any potential barriers to wellbeing promotion and to solicit educators’ opinions as to what might constitute apposite remedial measures in this regard.

The qualitative phase of this study, from which the data for this example is garnered, involved eleven semi-structured interviews, which lasted approximately 25–30 min each. Participants consisted of core-curriculum teachers, wellbeing curriculum teachers, pastoral care team-members and senior management members. Participants were questioned on their attitudes regarding the promotion of student wellbeing, the wellbeing curriculum, the wellbeing guidelines and their perceptions of their own wellbeing. When conducting these interviews, I loosely adhered to an interview agenda to ensure each of these four key topics were addressed. However, discussions were typically guided by what I interpreted to be meaningful to the interviewee, and would often weave in and out of these different topics.

The research questions for this study were addressed within a paradigmatic framework of interpretivism and constructivism. A key principle I adopted for this study was to reflect educators’ own accounts of their attitudes, opinions and experiences as faithfully as was possible, while also accounting for the reflexive influence of my own interpretations as the researcher. I felt RTA was highly appropriate in the context of the underlying theoretical and paradigmatic assumptions of my study and would allow me to ensure qualitative data was collected and analysed in a manner that respected and expressed the subjectivity of participants’ accounts of their attitudes, while also acknowledging and embracing the reflexive influence of my interpretations as the researcher.

In the next section, I will outline the theoretical assumptions of the RTA conducted in my original study in more detail. It should be noted that outlining these theoretical assumptions is not a task specific to reflexive thematic analysis. Rather, these assumptions should be addressed prior to implementing any form of thematic analysis (Braun and Clarke 2012 , 2019 , 2020 ; Braun et al. 2016 ). The six-phase process for conducting reflexive thematic analysis will then be appropriately detailed and punctuated with examples from my study.

3.1 Addressing underlying theoretical assumptions

Across several publications, Braun and Clarke ( 2012 , 2014 , 2020 ) have identified a number of theoretical assumptions that should be addressed when conducting RTA, or indeed any form of thematic analysis. These assumptions are conceptualised as a series of continua as follows: essentialist versus constructionist epistemologies; experiential versus critical orientation to data; inductive versus deductive analyses, and; semantic versus latent coding of data. The aim is not just for the researcher to identify where their analysis is situated on each of these continua, but why the analysis is situated as it is and why this conceptualisation is appropriate to answering the research question(s).

3.1.1 Essentialist versus constructionist epistemologies

Ontological and epistemological considerations would usually be determined when a study is first being conceptualised. However, these considerations may become salient again when data analysis becomes the research focus, particularly with regard to mixed methods. The purpose of addressing this continuum is to conceptualise theoretically how the researcher understands their data and the way in which the reader should interpret the findings (Braun and Clarke 2013 , 2014 ). By adhering to essentialism, the researcher adopts a unidirectional understanding of the relationship between language and communicated experience, in that it is assumed that language is a simple reflection of our articulated meanings and experiences (Widdicombe and Wooffiitt 1995 ). The meanings and systems inherent in constructing these meanings are largely uninterrogated, with the interpretive potential of TA largely unutilised (Braun et al. 2016 ).

Conversely, researchers of a constructionist persuasion would tend to adopt a bidirectional understanding of the language/experience relationship, viewing language as implicit in the social production and reproduction of both meaning and experience (Burr 1995 ; Schwandt 1998 ). A constructionist epistemology has particular implications with regard to thematic analysis, namely that in addition to the recurrence of perceptibly important information, meaningfulness is highly influential in the development and interpretation of codes and themes. The criteria for a theme to be considered noteworthy via recurrence is simply that the theme should present repeatedly within the data. However, what is common is not necessarily meaningful or important to the analysis. Braun and Clarke ( 2012 , p. 37) offer this example:

…in researching white-collar workers’ experiences of sociality at work, a researcher might interview people about their work environment and start with questions about their typical workday. If most or all reported that they started work at around 9:00 a.m., this would be a pattern in the data, but it would not necessarily be a meaningful or important one.

Furthermore, there may be varying degrees of conviction in respondents’ expression when addressing different issues that may facilitate in identifying the salience of a prospective theme. Therefore, meaningfulness can be conceptualised, firstly on the part of the researcher, with regard to the necessity to identify themes that are relevant to answering the research questions, and secondly on the part of the respondent, as the expression of varying degrees of importance with regard to the issues being addressed. By adopting a constructionist epistemology, the researcher acknowledges the importance of recurrence, but appreciates meaning and meaningfulness as the central criteria in the coding process.

In keeping with the qualitative philosophy of RTA, epistemological consideration regarding the example data were constructionist. As such, meaning and experience was interpreted to be socially produced and reproduced via an interplay of subjective and inter-subjective construction. Footnote 1

3.1.2 Experiential versus critical orientation

An experiential orientation to understanding data typically prioritises the examination of how a given phenomenon may be experienced by the participant. This involves investigating the meaning ascribed to the phenomenon by the respondent, as well as the meaningfulness of the phenomenon to the respondent. However, although these thoughts, feelings and experiences are subjectively and inter-subjectively (re)produced, the researcher would cede to the meaning and meaningfulness ascribed by the participant (Braun and Clarke 2014 ). Adopting an experiential orientation requires an appreciation that the thoughts, feelings and experiences of participants are a reflection of personal states held internally by the participant. Conversely, a critical orientation appreciates and analyses discourse as if it were constitutive, rather than reflective, of respondents’ personal states (Braun and Clarke 2014 ). As such, a critical perspective seeks to interrogate patterns and themes of meaning with a theoretical understanding that language can create, rather than merely reflect, a given social reality (Terry et al. 2017 ). A critical perspective can examine the mechanisms that inform the construction of systems of meaning, and therefore offer interpretations of meaning further to those explicitly communicated by participants. It is then also possible to examine how the wider social context may facilitate or impugn these systems of meaning (Braun and Clarke 2012 ). In short, the researcher uses this continuum to clarify their intention to reflect the experience of a social reality (experiential orientation) or examine the constitution of a social reality (critical orientation).

In the present example, an experiential orientation to data interpretation was adopted in order to emphasise meaning and meaningfulness as ascribed by participants. Adopting this approach meant that this analysis did not seek to make claims about the social construction of the research topic (which would more so necessitate a critical perspective), but rather acknowledged the socially constructed nature of the research topic when examining the subjective ‘personal states’ of participants. An experiential orientation was most appropriate as the aim of the study was to prioritise educators’ own accounts of their attitudes, opinions. More importantly, the research questions aimed to examine educators’ attitudes regarding their experience of promoting student wellbeing—or the ‘meanings made’—and not, for example, the socio-cultural factors that may underlie the development of these attitudes—or the ‘meaning making’.

3.1.3 Inductive versus deductive analysis

A researcher who adopts a deductive or ‘theory-driven’ approach may wish to produce codes relative to a pre-specified conceptual framework or codebook. In this case, the analysis would tend to be ‘analyst-driven’, predicated on the theoretically informed interpretation of the researcher. Conversely, a researcher who adopts an inductive or ‘data-driven’ approach may wish to produce codes that are solely reflective of the content of the data, free from any pre-conceived theory or conceptual framework. In this case, data are not coded to fit a pre-existing coding frame, but instead ‘open-coded’ in order to best represent meaning as communicated by the participants (Braun and Clarke 2013 ). Data analysed and coded deductively can often provide a less rich description of the overall dataset, instead focusing on providing a detailed analysis of a particular aspect of the dataset interpreted through a particular theoretical lens (Braun and Clarke 2020 ). Deductive analysis has typically been associated with positivistic/essentialist approaches (e.g. Boyatzis 1998 ), while inductive analysis tends to be aligned with constructivist approaches (e.g. Frith and Gleeson 2004 ). That being said, inductive/deductive approaches to analysis are by no means exclusively or intrinsically linked to a particular epistemology.

Coding and analysis rarely fall cleanly into one of these approaches and, more often than not, use a combination of both (Braun and Clarke 2013 , 2019 , 2020 ). It is arguably not possible to conduct an exclusively deductive analysis, as an appreciation for the relationship between different items of information in the data set is necessary in order to identify recurring commonalities with regard to a pre-specified theory or conceptual framework. Equally, it is arguably not possible to conduct an exclusively inductive analysis, as the researcher would require some form of criteria to identify whether or not a piece of information may be conducive to addressing the research question(s), and therefore worth coding. When addressing this issue, Braun and Clarke ( 2012 ) clarify that one approach does tend to predominate over the other, and that the predominance of the deductive or inductive approach can indicate an overall orientation towards prioritising either researcher/theory-based meaning or respondent/data-based meaning, respectively.

A predominantly inductive approach was adopted in this example, meaning data was open-coded and respondent/data-based meanings were emphasised. A degree of deductive analysis was, however, employed to ensure that the open-coding contributed to producing themes that were meaningful to the research questions, and to ensure that the respondent/data-based meanings that were emphasised were relevant to the research questions.

3.1.4 Semantic versus latent coding

Semantic codes are identified through the explicit or surface meanings of the data. The researcher does not examine beyond what a respondent has said or written. The production of semantic codes can be described as a descriptive analysis of the data, aimed solely at presenting the content of the data as communicated by the respondent. Latent coding goes beyond the descriptive level of the data and attempts to identify hidden meanings or underlying assumptions, ideas, or ideologies that may shape or inform the descriptive or semantic content of the data. When coding is latent, the analysis becomes much more interpretive, requiring a more creative and active role on the part of the researcher. Indeed, Braun and Clarke ( 2012 , 2013 , 2020 ) have repeatedly presented the argument that codes and themes do not ‘emerge’ from the data or that they may be residing in the data, waiting to be found. Rather, the researcher plays an active role in interpreting codes and themes, and identifying which are relevant to the research question(s). Analyses that use latent coding can often overlap with aspects of thematic discourse analysis in that the language used by the respondent can be used to interpret deeper levels of meaning and meaningfulness (Braun and Clarke 2006 ).

In this example, both semantic and latent coding were utilised. No attempt was made to prioritise semantic coding over latent coding or vice-versa. Rather, semantic codes were produced when meaningful semantic information was interpreted, and latent codes were produced when meaningful latent information was interpreted. As such, any item of information could be double-coded in accordance with the semantic meaning communicated by the respondent, and the latent meaning interpreted by the researcher (Patton 1990 ). This was reflective of the underlying theoretical assumptions of the analysis, as the constructive and interpretive epistemology and ontology were addressed by affording due consideration to both the meaning constructed and communicated by the participant and my interpretation of this meaning as the researcher.

3.2 The six-phase analytical process

Braun and Clarke ( 2012 , 2013 , 2014 , 2020 ) have proposed a six-phase process, which can facilitate the analysis and help the researcher identify and attend to the important aspects of a thematic analysis. In this sense, Braun and Clarke ( 2012 ) have identified the six-phase process as an approach to doing TA, as well as learning how to do TA. While the six phases are organised in a logical sequential order, the researcher should be cognisant that the analysis is not a linear process of moving forward through the phases. Rather, the analysis is recursive and iterative, requiring the researcher to move back and forth through the phases as necessary (Braun and Clarke 2020 ). TA is a time consuming process that evolves as the researcher navigates the different phases. This can lead to new interpretations of the data, which may in turn require further iterations of earlier phases. As such, it is important to appreciate the six-phase process as a set of guidelines, rather than rules, that should be applied in a flexible manner to fit the data and the research question(s) (Braun and Clarke 2013 , 2020 ).

3.2.1 Phase one: familiarisation with the data

The ‘familiarisation’ phase is prevalent in many forms of qualitative analysis. Familiarisation entails the reading and re-reading of the entire dataset in order to become intimately familiar with the data. This is necessary to be able to identify appropriate information that may be relevant to the research question(s). Manual transcription of data can be a very useful activity for the researcher in this regard, and can greatly facilitate a deep immersion into the data. Data should be transcribed orthographically, noting inflections, breaks, pauses, tones, etc. on the part of both the interviewer and the participant (Braun and Clarke 2013 ). Often times, data may not have been gathered or transcribed by the researcher, in which case, it would be beneficial for the researcher to watch/listen to video or audio recordings to achieve a greater contextual understanding of the data. This phase can be quite time consuming and requires a degree of patience. However, it is important to afford equal consideration across the entire depth and breadth of the dataset, and to avoid the temptation of being selective of what to read, or even ‘skipping over’ this phase completely (Braun and Clarke 2006 ).

At this phase, I set about familiarising myself with the data by firstly listening to each interview recording once before transcribing that particular recording. This first playback of each interview recording required ‘active listening’ and, as such, I did not take any notes at this point. I performed this active-listen in order to develop an understanding of the primary areas addressed in each interview prior to transcription. This also provided me an opportunity, unburdened by tasks such as note taking, to recall gestures and mannerisms that may or may not have been documented in interview notes. I manually transcribed each interview immediately after the active-listen playback. When transcription of all interviews was complete, I read each transcripts numerous times. At this point, I took note of casual observations of initial trends in the data and potentially interesting passages in the transcripts. I also documented my thoughts and feelings regarding both the data and the analytical process (in terms of transparency, it would be beneficial to adhere to this practice throughout the entire analysis). Some preliminary notes made during the early iterations of familiarisation with the data can be seen in Box 1. It will be seen later that some of these notes would go on to inform the interpretation of the finalised thematic framework.

Example of preliminary notes taken during phase one

3.2.2 Phase two: generating initial codes

Codes are the fundamental building blocks of what will later become themes. The process of coding is undertaken to produce succinct, shorthand descriptive or interpretive labels for pieces of information that may be of relevance to the research question(s). It is recommended that the researcher work systematically through the entire dataset, attending to each data item with equal consideration, and identifying aspects of data items that are interesting and may be informative in developing themes. Codes should be brief, but offer sufficient detail to be able to stand alone and inform of the underlying commonality among constituent data items in relation to the subject of the research (Braun and Clarke 2012 ; Braun et al. 2016 ).

A brief excerpt of the preliminary coding process of one participant’s interview transcript is presented in Box 2. The preliminary iteration of coding was conducted using the ‘comments’ function in Microsoft Word (2016). This allowed codes to be noted in the side margin, while also highlighting the area of text assigned to each respective code. This is a relatively straightforward example with no double-codes or overlap in data informing different codes, as new codes begin where previous codes end. The code C5 offers an exemplar of the provision of sufficient detail to explain what I interpreted from the related data item. A poor example of this code would be to say “the wellbeing guidelines are not relatable” or “not relatable for students”. Each of these examples lack context. Understanding codes written in this way would be contingent upon knowledge of the underlying data extract. The code C8 exemplifies this issue. It is unclear if the positivity mentioned relates to the particular participant, their colleagues, or their students. This code was subsequently redefined in later iterations of coding. It can also be seen in this short example that the same code has been produced for both C4 and C9. This code was prevalent throughout the entire dataset and would subsequently be informative in the development of a theme.

Extract of preliminary coding

Any item of data that might be useful in addressing the research question(s) should be coded. Through repeated iterations of coding and further familiarisation, the researcher can identify which codes are conducive to interpreting themes and which can be discarded. I would recommend that the researcher document their progression through iterations of coding to track the evolution of codes and indeed prospective themes. RTA is a recursive process and it is rare that a researcher would follow a linear path through the six phases (Braun and Clarke 2014 ). It is very common for the researcher to follow a particular train of thought when coding, only to encounter an impasse where several different interpretations of the data come to light. It may be necessary to explore each of these prospective options to identify the most appropriate path to follow. Tracking the evolution of codes will not only aid transparency, but will afford the researcher signposts and waypoints to which they may return should a particular approach to coding prove unfruitful. I tracked the evolution of my coding process in a spreadsheet, with data items documented in the first column and iterations of codes in each successive column. I found it useful to highlight which codes were changed in each successive iteration. Table 1 provides an excerpt of a Microsoft Excel (2016) spreadsheet that was established to track iterations of coding and document the overall analytical process. All codes developed during the first iteration of coding were transferred into this spreadsheet along with a label identifying the respective participant. Subsequent iterations of coding were documented in this spreadsheet. The original transcripts were still regularly consulted to assess existing codes and examine for the interpretation of new codes as further familiarity with the data developed. Column one presents a reference number for the data item that was coded, while column two indicates the participant who provided each data item. Column three presents the data item that was coded. Columns four and five indicate the iteration of the coding process to be the third and fourth iteration, respectively. Codes revised between iterations three and four are highlighted.

With regard to data item one, I initially considered that a narrative might develop exploring a potential discrepancy in levels of training received by wellbeing educators and non-wellbeing educators. In early iterations of coding, I adopted a convention of coding training-related information with reference to the wellbeing or non-wellbeing status of the participant. While this discrepancy in levels of training remained evident throughout the dataset, I eventually deemed it unnecessary to pursue interpretation of the data in this way. This coding convention was abandoned at iteration four in favour of the pre-existing generalised code “insufficient training in wellbeing curriculum”. With data item three, I realised that the code was descriptive at a semantic level, but not very informative. Upon re-evaluating this data item, I found the pre-existing code “lack of clarity in assessing student wellbeing” to be much more appropriate and representative of what the participant seemed to be communicating. Finally, I realised that the code for data item five was too specific to this particular data item. No other data item shared this code, which would preclude this code (and data item) from consideration when construction themes. I decided that this item would be subsumed under the pre-existing code “more training is needed for wellbeing promotion”.

The process of generating codes is non-prescriptive regarding how data is segmented and itemised for coding, and how many codes or what type of codes (semantic or latent) are interpreted from an item of data. The same data item can be coded both semantically and latently if deemed necessary. For example, when discussing how able they felt to attend to their students’ wellbeing needs, one participant stated “…if someone’s struggling a bit with their schoolwork and it’s getting them down a bit, it’s common sense that determines what we say to them or how we approach them. And it might help to talk, but I don’t know that it has a lasting effect” [2B]. Here, I understood that the participant was explicitly sharing the way in which they address their students’ wellbeing concerns, but also that the participant was implying that this commonsense approach might not be sufficient. As such, this data item was coded both semantically as “educators rely on common sense when attending to wellbeing issues”, and latently as “common sense inadequate for wellbeing promotion”. Both codes were revised later in the analysis. However, this example illustrates the way in which any data item can be coded in multiple ways and for multiple meanings. There is also no upper or lower limit regarding how many codes should be interpreted. What is important is that, when the dataset is fully coded and codes are collated, sufficient depth exists to examine the patterns within the data and the diversity of the positions held by participants. It is, however, necessary to ensure that codes pertain to more than one data item (Braun and Clarke 2012 ).

3.2.3 Phase three: generating themes

This phase begins when all relevant data items have been coded. The focus shifts from the interpretation of individual data items within the dataset, to the interpretation of aggregated meaning and meaningfulness across the dataset. The coded data is reviewed and analysed as to how different codes may be combined according to shared meanings so that they may form themes or sub-themes. This will often involve collapsing multiple codes that share a similar underlying concept or feature of the data into one single code. Equally, one particular code may turn out to be representative of an over-arching narrative within the data and be promoted as a sub-theme or even a theme (Braun and Clarke 2012 ). It is important to re-emphasise that themes do not reside in the data waiting to be found. Rather, the researcher must actively construe the relationship among the different codes and examine how this relationship may inform the narrative of a given theme. Construing the importance or salience of a theme is not contingent upon the number of codes or data items that inform a particular theme. What is important is that the pattern of codes and data items communicates something meaningful that helps answer the research question(s) (Braun and Clarke 2013 ).

Themes should be distinctive and may even be contradictory to other themes, but should tie together to produce a coherent and lucid picture of the dataset. The researcher must be able and willing to let go of codes or prospective themes that may not fit within the overall analysis. It may be beneficial to construct a miscellaneous theme (or category) to contain all the codes that do not appear to fit in among any prospective themes. This miscellaneous theme may end up becoming a theme in its own right, or may simple be removed from the analysis during a later phase (Braun and Clarke 2012 ). Much the same as with codes, there is no correct amount of themes. However, with too many themes the analysis may become unwieldy and incoherent, whereas too few themes can result in the analysis failing to explore fully the depth and breadth of the data. At the end of this stage, the researcher should be able to produce a thematic map (e.g. a mind map or affinity map) or table that collates codes and data items relative to their respective themes (Braun and Clarke 2012 , 2020 ).

At this point in the analysis, I assembled codes into initial candidate themes. A thematic map of the initial candidate themes can be seen in Fig.  1 . The theme “best practice in wellbeing promotion” was clearly definable, with constituent coded data presenting two concurrent narratives. These narratives were constructed as two separate sub-themes, which emphasised the involvement of the entire school staff and the active pursuit of practical measures in promoting student wellbeing, respectively. The theme “recognising student wellbeing” was similarly clear. Again, I interpreted a dichotomy of narratives. However, in this case, the two narratives seemed to be even more synergetic. The two sub-themes for “best practice…” highlighted two independently informative factors in best practice. Here, the sub-themes are much more closely related, with one sub-theme identifying factors that may inhibit the development of student wellbeing, while the second sub-theme discusses factors that may improve student wellbeing. At this early stage in the analysis, I was considering that this sub-theme structure might also be used to delineate the theme “recognising educator wellbeing”. Finally, the theme “factors influencing wellbeing promotion” collated coded data items that addressed inhibitive factors with regard to wellbeing promotion. These factors were conceptualised as four separate sub-themes reflecting a lack of training, a lack of time, a lack of appropriate value for wellbeing promotion, and a lack of knowledge of supporting wellbeing-related documents. While it was useful to bring all of this information together under one theme, even at this early stage it was evident that this particular theme was very dense and unwieldy, and would likely require further revision.

Initial thematic map indicating four candidate themes

3.2.4 Phase four: reviewing potential themes

This phase requires the researcher to conduct a recursive review of the candidate themes in relation to the coded data items and the entire dataset (Braun and Clarke 2012 , 2020 ). At this phase, it is not uncommon to find that some candidate themes may not function well as meaningful interpretations of the data, or may not provide information that addresses the research question(s). It may also come to light that some of the constituent codes and/or data items that inform these themes may be incongruent and require revision. Braun and Clarke ( 2012 , p. 65) proposed a series of key questions that the researcher should address when reviewing potential themes. They are:

Is this a theme (it could be just a code)?

If it is a theme, what is the quality of this theme (does it tell me something useful about the data set and my research question)?

What are the boundaries of this theme (what does it include and exclude)?

Are there enough (meaningful) data to support this theme (is the theme thin or thick)?

Are the data too diverse and wide ranging (does the theme lack coherence)?

The analysis conducted at this phase involves two levels of review. Level one is a review of the relationships among the data items and codes that inform each theme and sub-theme. If the items/codes form a coherent pattern, it can be assumed that the candidate theme/sub-theme makes a logical argument and may contribute to the overall narrative of the data. At level two, the candidate themes are reviewed in relation to the data set. Themes are assessed as to how well they provide the most apt interpretation of the data in relation to the research question(s). Braun and Clarke have proposed that, when addressing these key questions, it may be useful to observe Patton’s ( 1990 ) ‘dual criteria for judging categories’ (i.e. internal homogeneity and external heterogeneity). The aim of Patton’s dual criteria would be to observe internal homogeneity within themes at the level one review, while observing external heterogeneity among themes at the level two review. Essentially, these two levels of review function to demonstrate that items and codes are appropriate to inform a theme, and that a theme is appropriate to inform the interpretation of the dataset (Braun and Clarke 2006 ). The outcome of this dual-level review is often that some sub-themes or themes may need to be restructured by adding or removing codes, or indeed adding or removing themes/sub-themes. The finalised thematic framework that resulted from the review of the candidate themes can be seen in Fig.  2 .

Finalised thematic map demonstrating five themes

During the level one review, inspection of the prospective sub-theme “sources of negative affect” in relation to the theme “recognising educator wellbeing” resulted in a new interpretation of the constituent coded data items. Participants communicated numerous pre-existing work-related factors that they felt had a negative impact upon their wellbeing. However, it was also evident that participants felt the introduction of the new wellbeing curriculum and the newly mandated task of formally attending to student wellbeing had compounded these pre-existing issues. While pre-existing issues and wellbeing-related issues were both informative of educators’ negative affect, the new interpretation of this data informed the realisation of two concurrent narratives, with wellbeing-related issues being a compounding factor in relation to pre-existing issues. This resulted in the “sources of negative affect” sub-theme being split into two new sub-themes; “work-related negative affect” and “the influence of wellbeing promotion”. The “actions to improve educator wellbeing” sub-theme was folded into these sub-themes, with remedial measures for each issue being discussed in respective sub-themes.

During the level two review, my concerns regarding the theme “factors inhibiting wellbeing promotion” were addressed. With regard to Braun and Clarke’s key questions, it was quite difficult to identify the boundaries of this theme. It was also particularly dense (or too thick) and somewhat incoherent. At this point, I concluded that this theme did not constitute an appropriate representation of the data. Earlier phases of the analysis were reiterated and new interpretations of the data were developed. This candidate theme was subsequently broken down into three separate themes. While the sub-themes of this candidate theme were, to a degree, informative in the development of the new themes, the way in which the constituent data was understood was fundamentally reconceptualised. The new theme, entitled “the influence of time”, moves past merely describing time constraints as an inhibitive factor in wellbeing promotion. A more thorough account of the bi-directional nature of time constraints was realised, which acknowledged that previously existing time constraints affected wellbeing promotion, while wellbeing promotion compounded previously existing time constraints. This added an analysis of the way in which the introduction of wellbeing promotion also produced time constraints in relation to core curricular activities.

The candidate sub-themes “lack of training” and “knowledge of necessary documents” were re-evaluated and considered to be topical rather than thematic aspects of the data. Upon further inspection, I felt that the constituent coded data items of these two sub-themes were informative of a single narrative of participants attending to their students’ wellbeing in an atheoretical manner. As such, these two candidate sub-themes were folded into each other to produce the theme “incompletely theorised agreements”. Finally, the level two review led me to the conclusion that the full potential of the data that informed the candidate sub-theme “lack of value of wellbeing promotion” was not realised. I found that a much richer understanding of this data was possible, which was obscured by the initial, relatively simplistic, descriptive account offered. An important distinction was made, in that participants held differing perceptions of the value attributed to wellbeing promotion by educators and by students. Further, I realised that educators’ perceptions of wellbeing promotion were not necessarily negative and should not be exclusively presented as an inhibitive factor in wellbeing promotion. A new theme, named “the axiology of wellbeing” and informed by the sub-themes “students’ valuation of wellbeing promotion” and “educators’ valuation of wellbeing promotion”, was developed to delineate this multifaceted understanding of participants’ accounts of the value of wellbeing promotion.

It is quite typical at this phase that codes, as well as themes, may be revised or removed to facilitate the most meaningful interpretation of the data. As such, it may be necessary to reiterate some of the activities undertaken during phases two and three of the analysis. It may be necessary to recode some data items, collapse some codes into one, remove some codes, or promote some codes as sub-themes or themes. For example, when re-examining the data items that informed the narrative of the value ascribed to wellbeing promotion, I observed that participants offered very different perceptions of the value ascribed by educators and by students. To pursue this line of analysis, numerous codes were reconceptualised to reflect the two different perspectives. Codes such as “positivity regarding the wellbeing curriculum” were split into the more specified codes “student positivity regarding the wellbeing curriculum” and “educator positivity regarding the wellbeing curriculum”. Amending codes in this way ultimately contributed to the reinterpretation of the data and the development of the finalised thematic map.

As with all other phases, it is very important to track and document all of these changes. With regard to some of the more significant changes (removing a theme, for example), I would recommend making notes on why it might be necessary to take this action. The aim of this phase is to produce a revised thematic map or table that captures the most important elements of the data in relation to the research question(s).

3.2.5 Phase five: defining and naming theme

At this phase, the researcher is tasked with presenting a detailed analysis of the thematic framework. Each individual theme and sub-theme is to be expressed in relation to both the dataset and the research question(s). As per Patton’s ( 1990 ) dual criteria, each theme should provide a coherent and internally consistent account of the data that cannot be told by the other themes. However, all themes should come together to create a lucid narrative that is consistent with the content of the dataset and informative in relation to the research question(s). The names of the themes are also subject to a final revision (if necessary) at this point.

Defining themes requires a deep analysis of the underlying data items. There will likely be many data items underlying each theme. It is at this point that the researcher is required to identify which data items to use as extracts when writing up the results of the analysis. The chosen extracts should provide a vivid and compelling account of the arguments being made by a respective theme. Multiple extracts should be used from the entire pool of data items that inform a theme in order to convey the diversity of expressions of meaning across these data items, and to demonstrate the cohesion of the theme’s constituent data items. Furthermore, each of the reported data extracts should be subject to a deep analysis, going beyond merely reporting what a participant may have said. Each extract should be interpreted in relation to its constitutive theme, as well as the broader context of the research question(s), creating an analytic narrative that informs the reader what is interesting about this extract and why (Braun and Clarke 2012 ).

Data extracts can be presented either illustratively, providing a surface-level description of what participants said, or analytically, interrogating what has been interpreted to be important about what participants said and contextualising this interpretation in relation to the available literature. If the researcher were aiming to produce a more illustrative write-up of the analysis, relating the results to the available literature would tend to be held until the ‘discussion’ section of the report. If the researcher were aiming to produce an analytical write-up, extracts would tend to be contextualised in relation to the literature as and when they are reported in the ‘results’ section (Braun and Clarke 2013 ; Terry et al. 2017 ). While an illustrative write-up of RTA results is completely acceptable, the researcher should remain cognisant that the narrative of the write-up should communicate the complexities of the data, while remaining “embedded in the scholarly field” (Braun and Clarke 2012 , p. 69). RTA is an interpretive approach to analysis and, as such, the overall report should go beyond describing the data, providing theoretically informed arguments as to how the data addresses the research question(s). To this end, a relatively straightforward test can reveal a researcher’s potential proclivity towards one particular reporting convention: If an extract can be removed and the write-up still makes sense, the reporting style is illustrative; if an extract is removed and the write-up no longer makes sense, the reporting style is analytical (Terry et al. 2017 ).

The example in Box 3 contains a brief excerpt from the sub-theme “the whole-school approach”, which demonstrates the way in which a data extract may be reported in an illustrative manner. Here, the narrative discussed the necessity of having an ‘appropriate educator’ deliver the different aspects of the wellbeing curriculum. One participant provided a particularly useful real-world example of the potential negative implications of having ‘the wrong person’ for this job in relation to physical education (one of the aspects of the wellbeing curriculum). This data extract very much informed the narrative and illustrated participants’ arguments regarding the importance of choosing an appropriate educator for the job.

Example of data extract reported illustratively

In Box 4, an example is offered of how a data extract may be reported in an analytical manner. This excerpt is also taken from the sub-theme “the whole-school approach”, and also informs the ‘appropriate educator for the job’ narrative. Here, however, sufficient evidence has already been established to illustrate the perspectives of the participants. The report turns to a deeper analysis of what has been said and how it has been said. Specifically, the way in which participants seemed to construe an ‘appropriate educator’ was examined and related to existing literature. The analytical interpretation of this data extract (and others) proposes interesting implications regarding the way in which participants constructed their schema of an ‘appropriate educator’.

Example of data extract reported analytically

The names of themes are also subject to a final review (if necessary) at this point. Naming themes may seem trivial and might subsequently receive less attention than it actually requires. However, naming themes is a very important task. Theme names are the first indication to the reader of what has been captured from the data. Names should be concise, informative, and memorable. The overriding tendency may be to create names that are descriptors of the theme. Braun and Clarke ( 2013 , 2014 , 2020 ) encourage creativity and advocate the use of catchy names that may more immediately capture the attention of the reader, while also communicating an important aspect of the theme. To this end, they suggest that it may be useful to examine data items for a short extract that could be used to punctuate the theme name.

3.2.6 Phase six: producing the report

The separation between phases five and six can often be blurry. Further, this ‘final’ phase would rarely only occur at the end of the analysis. As opposed to practices typical of quantitative research that would see the researcher conduct and then write up the analysis, the write-up of qualitative research is very much interwoven into the entire process of the analysis (Braun and Clarke 2012 ). Again, as with previous phases, this will likely require a recursive approach to report writing. As codes and themes change and evolve over the course of the analysis, so too can the write-up. Changes should be well documented by this phase and reflected in informal notes and memos, as well as a research journal that should be kept over the entire course of the research. Phase six then, can be seen as the completion and final inspection of the report that the researcher would most likely have begun writing before even undertaking their thematic analysis (e.g. a journal article or thesis/dissertation).

A useful task to address at this point would be to establish the order in which themes are reported. Themes should connect in a logical and meaningful manner, building a cogent narrative of the data. Where relevant, themes should build upon previously reported themes, while remaining internally consistent and capable of communicating their own individual narrative if isolated from other themes (Braun and Clarke 2012 ). I reported the theme “best practice in wellbeing promotion” first, as I felt it established the positivity that seemed to underlie the accounts provided by all of my participants. This theme was also strongly influence by semantic codes, with participants being very capable of describing what they felt would constitute ‘best practice’. I saw this as an easily digestible first theme to ease the reader into the wider analysis. It made sense to report “the axiology of wellbeing promotion” next. This theme introduced the reality that, despite an underlying degree of positivity, participants did indeed have numerous concerns regarding wellbeing promotion, and that participants’ attitudes were generally positive with a significant ‘but’. This theme provided good sign-posting for the next two themes that would be reported, which were “the influence of time” and “incompletely theorised agreements”, respectively. I reported “the influence of time” first, as this theme established how time constraints could negatively affect educator training, contributing to a context in which educators were inadvertently pushed towards adopting incompletely theorised agreements when promoting student wellbeing. The last theme to be reported was “recognising educator wellbeing”. As the purpose of the analysis was to ascertain the attitudes of educators regarding wellbeing promotion, it felt appropriate to offer the closing commentary of the analysis to educators’ accounts of their own wellbeing. This became particularly pertinent when the sub-themes were revised to reflect the influence of pre-existing work-related issues and the subsequent influence of wellbeing promotion.

An issue proponents of RTA may realise when writing up their analysis is the potential for incongruence between traditional conventions for report writing and the appropriate style for reporting RTA—particularly when adopting an analytical approach to reporting on data. The document structure for academic journal articles and Masters or PhD theses typically subscribe to the convention of reporting results of analyses in a ‘results’ section and then synthesising and contextualising the results of analyses in a ‘discussion’ section. Conversely, Braun and Clarke recommend synthesising and contextualising data as and when they are reported in the ‘results’ section (Braun and Clarke 2013 ; Terry et al. 2017 ). This is a significant departure from the traditional reporting convention, which researchers—particularly post-graduate students—may find difficult to reconcile. While Braun and Clarke do not explicitly address this potential issue, it is implicitly evident that they would advocate that researchers prioritise the appropriate reporting style for RTA and not cede to the traditional reporting convention.

4 Conclusion

Although Braun and Clarke are widely published on the topic of reflexive thematic analysis, confusion persists in the wider literature regarding the appropriate implementation of this approach. The aim of this paper has been to contribute to dispelling some of this confusion by provide a worked example of Braun and Clarke’s contemporary approach to reflexive thematic analysis. To this end, this paper provided instruction in how to address the theoretical underpinnings of RTA by operationalising the theoretical assumptions of the example data in relation to the study from which the data was taken. Clear instruction was also provided in how to conduct a reflexive thematic analysis. This was achieved by providing a detailed step-by-step guide to Braun and Clarke’s six-phase process, and by providing numerous examples of the implementation of each phase based on my own research. Braun and Clarke have made (and continue to make) an extremely valuable contribution to the discourse regarding qualitative analysis. I strongly recommended that any prospective proponents of RTA who may read this paper thoroughly examine Braun and Clarke’s full body of literature in this area, and aim to achieve an understanding of RTA’s nuanced position among the numerous different approaches to thematic analysis.

While the reconceptualisation of RTA as falling within the remit of a purely qualitative paradigm precipitates that the research fall on the constructionist end of this continuum, it is nevertheless good practice to explicate this theoretical position.

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Byrne, D. A worked example of Braun and Clarke’s approach to reflexive thematic analysis. Qual Quant 56 , 1391–1412 (2022). https://doi.org/10.1007/s11135-021-01182-y

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Accepted : 06 June 2021

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How to Do Thematic Analysis | Step-by-Step Guide & Examples

Published on September 6, 2019 by Jack Caulfield . Revised on June 22, 2023.

Thematic analysis is a method of analyzing qualitative data . It is usually applied to a set of texts, such as an interview or transcripts . The researcher closely examines the data to identify common themes – topics, ideas and patterns of meaning that come up repeatedly.

There are various approaches to conducting thematic analysis, but the most common form follows a six-step process: familiarization, coding, generating themes, reviewing themes, defining and naming themes, and writing up. Following this process can also help you avoid confirmation bias when formulating your analysis.

This process was originally developed for psychology research by Virginia Braun and Victoria Clarke . However, thematic analysis is a flexible method that can be adapted to many different kinds of research.

Table of contents

When to use thematic analysis, different approaches to thematic analysis, step 1: familiarization, step 2: coding, step 3: generating themes, step 4: reviewing themes, step 5: defining and naming themes, step 6: writing up, other interesting articles.

Thematic analysis is a good approach to research where you’re trying to find out something about people’s views, opinions, knowledge, experiences or values from a set of qualitative data – for example, interview transcripts , social media profiles, or survey responses .

Some types of research questions you might use thematic analysis to answer:

• How do patients perceive doctors in a hospital setting?
• What are young women’s experiences on dating sites?
• What are non-experts’ ideas and opinions about climate change?
• How is gender constructed in high school history teaching?

To answer any of these questions, you would collect data from a group of relevant participants and then analyze it. Thematic analysis allows you a lot of flexibility in interpreting the data, and allows you to approach large data sets more easily by sorting them into broad themes.

However, it also involves the risk of missing nuances in the data. Thematic analysis is often quite subjective and relies on the researcher’s judgement, so you have to reflect carefully on your own choices and interpretations.

Pay close attention to the data to ensure that you’re not picking up on things that are not there – or obscuring things that are.

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Once you’ve decided to use thematic analysis, there are different approaches to consider.

There’s the distinction between inductive and deductive approaches:

• An inductive approach involves allowing the data to determine your themes.
• A deductive approach involves coming to the data with some preconceived themes you expect to find reflected there, based on theory or existing knowledge.

Ask yourself: Does my theoretical framework give me a strong idea of what kind of themes I expect to find in the data (deductive), or am I planning to develop my own framework based on what I find (inductive)?

There’s also the distinction between a semantic and a latent approach:

• A semantic approach involves analyzing the explicit content of the data.
• A latent approach involves reading into the subtext and assumptions underlying the data.

Ask yourself: Am I interested in people’s stated opinions (semantic) or in what their statements reveal about their assumptions and social context (latent)?

After you’ve decided thematic analysis is the right method for analyzing your data, and you’ve thought about the approach you’re going to take, you can follow the six steps developed by Braun and Clarke .

The first step is to get to know our data. It’s important to get a thorough overview of all the data we collected before we start analyzing individual items.

This might involve transcribing audio , reading through the text and taking initial notes, and generally looking through the data to get familiar with it.

Next up, we need to code the data. Coding means highlighting sections of our text – usually phrases or sentences – and coming up with shorthand labels or “codes” to describe their content.

Let’s take a short example text. Say we’re researching perceptions of climate change among conservative voters aged 50 and up, and we have collected data through a series of interviews. An extract from one interview looks like this:

In this extract, we’ve highlighted various phrases in different colors corresponding to different codes. Each code describes the idea or feeling expressed in that part of the text.

At this stage, we want to be thorough: we go through the transcript of every interview and highlight everything that jumps out as relevant or potentially interesting. As well as highlighting all the phrases and sentences that match these codes, we can keep adding new codes as we go through the text.

After we’ve been through the text, we collate together all the data into groups identified by code. These codes allow us to gain a a condensed overview of the main points and common meanings that recur throughout the data.

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Next, we look over the codes we’ve created, identify patterns among them, and start coming up with themes.

Themes are generally broader than codes. Most of the time, you’ll combine several codes into a single theme. In our example, we might start combining codes into themes like this:

At this stage, we might decide that some of our codes are too vague or not relevant enough (for example, because they don’t appear very often in the data), so they can be discarded.

Other codes might become themes in their own right. In our example, we decided that the code “uncertainty” made sense as a theme, with some other codes incorporated into it.

Again, what we decide will vary according to what we’re trying to find out. We want to create potential themes that tell us something helpful about the data for our purposes.

Now we have to make sure that our themes are useful and accurate representations of the data. Here, we return to the data set and compare our themes against it. Are we missing anything? Are these themes really present in the data? What can we change to make our themes work better?

If we encounter problems with our themes, we might split them up, combine them, discard them or create new ones: whatever makes them more useful and accurate.

For example, we might decide upon looking through the data that “changing terminology” fits better under the “uncertainty” theme than under “distrust of experts,” since the data labelled with this code involves confusion, not necessarily distrust.

Now that you have a final list of themes, it’s time to name and define each of them.

Defining themes involves formulating exactly what we mean by each theme and figuring out how it helps us understand the data.

Naming themes involves coming up with a succinct and easily understandable name for each theme.

For example, we might look at “distrust of experts” and determine exactly who we mean by “experts” in this theme. We might decide that a better name for the theme is “distrust of authority” or “conspiracy thinking”.

Finally, we’ll write up our analysis of the data. Like all academic texts, writing up a thematic analysis requires an introduction to establish our research question, aims and approach.

We should also include a methodology section, describing how we collected the data (e.g. through semi-structured interviews or open-ended survey questions ) and explaining how we conducted the thematic analysis itself.

The results or findings section usually addresses each theme in turn. We describe how often the themes come up and what they mean, including examples from the data as evidence. Finally, our conclusion explains the main takeaways and shows how the analysis has answered our research question.

In our example, we might argue that conspiracy thinking about climate change is widespread among older conservative voters, point out the uncertainty with which many voters view the issue, and discuss the role of misinformation in respondents’ perceptions.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

• Normal distribution
• Measures of central tendency
• Chi square tests
• Confidence interval
• Quartiles & Quantiles
• Cluster sampling
• Stratified sampling
• Discourse analysis
• Cohort study
• Peer review
• Ethnography

Research bias

• Implicit bias
• Cognitive bias
• Conformity bias
• Hawthorne effect
• Availability heuristic
• Attrition bias
• Social desirability bias

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Qualitative Research Journal

ISSN : 1443-9883

Article publication date: 31 October 2018

Issue publication date: 15 November 2018

The purpose of this paper is to explain the rationale for choosing the qualitative approach to research human resources practices, namely, recruitment and selection, training and development, performance management, rewards management, employee communication and participation, diversity management and work and life balance using deductive and inductive approaches to analyse data. The paper adopts an emic perspective that favours the study of transfer of human resource management practices from the point of view of employees and host country managers in subsidiaries of western multinational enterprises in Ghana.

Design/methodology/approach

Despite the numerous examples of qualitative methods of data generation, little is known particularly to the novice researcher about how to analyse qualitative data. This paper develops a model to explain in a systematic manner how to methodically analyse qualitative data using both deductive and inductive approaches.

The deductive and inductive approaches provide a comprehensive approach in analysing qualitative data. The process involves immersing oneself in the data reading and digesting in order to make sense of the whole set of data and to understand what is going on.

Originality/value

This paper fills a serious gap in qualitative data analysis which is deemed complex and challenging with limited attention in the methodological literature particularly in a developing country context, Ghana.

• Qualitative
• Emic interviews documents

Azungah, T. (2018), "Qualitative research: deductive and inductive approaches to data analysis", Qualitative Research Journal , Vol. 18 No. 4, pp. 383-400. https://doi.org/10.1108/QRJ-D-18-00035

Emerald Publishing Limited

Copyright © 2018, Emerald Publishing Limited

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• Open access
• Published: 16 September 2024

A qualitative exploration of disseminating research findings among public health researchers in China

• Yiluan Hu 1 ,
• Xuejun Yin 1 , 2 ,
• Yachen Wang 1 ,
• Enying Gong 1 ,
• Xin Xin 3 ,
• Jing Liu 4 ,
• Xia Liu 4 ,
• Ruitai Shao 1 ,
• Juan Zhang 1 , 5 &
• Ross C. Brownson 6 , 7  

BMC Public Health volume  24 , Article number:  2518 ( 2024 ) Cite this article

Metrics details

Research dissemination is essential to accelerate the translating of evidence into practice. Little is known about dissemination among Chinese public health researchers. This study aimed to explore the understanding and practices of disseminating research findings and to identify barriers and facilitators that influence dissemination activities to non-research audiences.

This study deployed an exploratory qualitative design with purposive and snowball sampling. One focus group with 5 participants and 12 in-depth interviews were conducted with participants working in diverse fields from universities ( n  = 10), the National Chinese Center for Disease Control and Prevention ( n  = 4), the Chinese National Cancer Center ( n  = 1), the Chinese National Center for Cardiovascular Disease ( n  = 1), and China office of a global research institute ( n  = 1) from May to December 2021 to reach saturation. Data were initially analyzed using inductive thematic analysis. The designing for dissemination (D4D) logic model was then used to organize themes and subthemes. Two coders independently coded all transcripts and discussed disparities to reach a consensus.

Out of 17 participants, 12 misunderstood the concept of dissemination; 14 had disseminated to non-research audiences: 10 to the public, 10 to practitioners, and 9 to policymakers. We identified multiple barriers to dissemination to non-research audiences across four phases of the D4D logic model, including low priority of dissemination, limited application of D4D strategies, insufficient support from the research organizations, practice settings, and health systems, and overemphasis on academic publications.

Conclusions

There was a lack of understanding and experience of dissemination, indicating a lack of emphasis on active dissemination in China. We provide implications for raising awareness, building capacity, facilitating multidisciplinary collaboration, providing incentives and infrastructure, changing climate and culture, establishing communication and executive networks, and accelerating systematic shifts in impact focus.

Peer Review reports

Introduction

The gap between research and practice is well documented [ 1 , 2 , 3 , 4 ]. Dissemination refers to the active approach of spreading evidence-based interventions to the target audience via predetermined channels using planned strategies [ 3 , 5 ] and is a prerequisite for bridging the gap between research and practice. The concept of dissemination has some overlap with other related concepts including science popularization and knowledge translation. Although both use communication techniques as useful strategies, science popularization is mainly about propagating general knowledge to the public with the aim of improving citizens’ science literacy [ 6 ], whereas dissemination involves wider audiences and aims to maximize the impact of research and promote the uptake of evidence. On the other hand, although sharing a similar goal with dissemination of bridging the research-practice gap, knowledge translation refers to the dynamic and iterative process involving synthesis, dissemination, exchange, and ethically-sound application of knowledge, which considers dissemination a component of translation [ 7 , 8 ].

Despite the importance of dissemination, dissemination is often not a priority for researchers and their organization [ 9 ] and is largely missed. For example, in a study of US public health researchers, 78% reported dissemination as important to their research, while only 27% spent over 10% of their time on dissemination [ 3 ] and 28% rated their dissemination efforts as excellent or good [ 10 ]. In addition, there are inconsistencies in preferred sources of information between researchers and non-researchers. Almost all researchers disseminated their research through academic publications [ 11 , 12 , 13 , 14 ], yet practitioners and policymakers may find them inaccessible, difficult to understand, or time-consuming [ 11 , 15 , 16 , 17 ].

To effectively disseminate the evidence, dissemination and implementation (D&I) science has thrived and designing for dissemination (D4D) has emerged as a promising direction within D&I science. The D4D perspective highlights the responsibility of researchers to actively disseminate and the need to plan from the outset to fit the adopters’ needs, assets, and time frames [ 3 ]. Useful D4D strategies include stakeholder involvement, application of D&I science theories and frameworks, incorporation of marketing, business, communication, systems approaches and professionals, and related disciplines [ 3 , 18 , 19 ]. Despite the availability of D4D, the application remains insufficient. For example, only 17% of US public health researchers used a framework or theory to plan their dissemination activities and only 34% typically involved stakeholders in the research process in 2012; 55% of US and Canadian D&I scientists typically involved stakeholders in the research process in 2018. While there is a growing body of evidence on D4D in some regions of the world, there are limited data on D4D from China.

Evidence from high-income countries has revealed individual-level barriers such as lack of capacity and reluctance to disseminate findings of a single study, and organizational-level barriers such as lack of financial resources, staff time, and academic incentives [ 14 , 20 ]. Yet, little is known about dissemination in China, where the D&I science is still in its infancy. With progresses in China’s health reform, science popularization and knowledge translation has received increasing attention, but dissemination received little attention in the field of public health. In addition, the large population, high disease burden, shortage of healthcare providers, and relatively centralized health system further exacerbate the complexity of dissemination in China [ 16 , 21 ]. A quantitative study conducted by the current team among Chinese public health researchers suggested that only 58.1% had disseminated their research findings, and that main barriers included a lack of financial resources, platforms, and collaboration mechanisms at the organizational level, as well as a lack of time, knowledge, and skills at the individual level [ 22 ].

Hence, there is urgency to explore factors underlying the dissemination in China from the perspective of researchers. We aimed to explore researchers’ understanding of the concept of dissemination and current dissemination activities, further to identify barriers and facilitators that influence dissemination to non-research audiences guided by the D4D logic model.

A qualitative study design was deployed to explore public health researchers’ perspectives on contextual factors affecting the dissemination of research findings in China. The study was reported according to the Consolidated criteria for reporting qualitative research (COREQ) guidelines (see Additional file 1) [ 23 ].

Theoretical framework

With the aim to gain insight into the barriers and facilitators for researchers to design for dissemination, this study adopted the D4D logic model as an analytical framework. The D4D logic model was published by Kwan and colleagues [ 19 ] in 2022 and included four phases: (1) the initial conceptualization phase identifying need and demand, and establishing evidence base of health issues; (2) the design phase using multiple strategies to determine the design of dissemination product as well as the packaging, messaging, and distribution plan; (3) the subsequent dissemination phase based on the push-pull-capacity model and situating the push of research, pull of practice, and capacity of health systems to support dissemination; and (4) the impact phase ensuring adoption, sustainment, and equity benefits [ 19 ].

Participants and sampling

Study participants were public health researchers working in universities, the National Chinese Center for Disease Control and Prevention (briefly as China CDC), the Chinese National Cancer Center, the Chinese National Center for Cardiovascular Disease, or China Offices of global research institutes. Universities are the most important producers of evidence in China, followed by healthcare institutions, research institutions, and companies [ 24 ].Teaching and researching are core activities for university researchers, and academic publication is one of the key tenure and promotion criteria. The China CDC is a governmental and national-level technical institution affiliated with the National Health Commission of China, and shoulders the responsibilities of focusing on the key tasks of national disease prevention and control and of instructing the provincial-, prefecture-, city-, and county-level CDC. Also under the leadership of the National Health Commission of China and shoulder responsibilities of evidence generation and implementation, the Chinese National Cancer Center and the Chinese National Center for Cardiovascular Disease are based in two big specialized hospitals in China. Given that university researchers are the biggest community for evidence generation in China, most of the participants were university researchers.

Purposive and snowball sampling methods were applied to reach less accessible target participants. First, participants were purposively selected on the basis that they had rich experience in public health research and took an active part in academia. Second, interviewees were asked to nominate other researchers who might be willing to provide information for in-depth interviews, particularly those with expertise in dissemination and implementation science. All potential participants were contacted directly by telephone by a senior member (JZ) of the research team to seek their participation. Participants were informed of the study’s purpose, process, confidentiality, and right to withdraw at any time. They were then asked to give informed oral consent to participate in the study and to be audio-recorded prior to the formal interview. In total, 18 researchers received the invitation; one declined due to unavailability during the time of this study.

Data collection

Data were collected from May 2021 to December 2021 through a focus group and in-depth interviews. Given that participants may be unfamiliar with the concept of dissemination and the experience of dissemination may be limited, we initially conducted a focus group of five participants to stimulate discussion. During the discussion, participants were actively involved and contributed a lot to the topic, so we later conducted individual interviews to gather a rich and detailed understanding of the participants’ perspectives. The focus group of five participants and the first two individual in-depth interviews were conducted face-to-face, while later ten individual in-depth interviews were conducted via Tencent Meeting (Chinese online meeting software, similar to Zoom) because of the COVID-19-related physical distancing restrictions. During the interviews, participants were alone in their office or a private space to ensure confidentiality so that they could share freely.

A multidisciplinary team of researchers and students in dissemination and implementation science, behavior science, psychology, and qualitative methods contributed to developing the interview guide. The interview guide was pilot tested and refined prior to the formal interview. As dissemination is a relatively new concept in China, participants entered interviews with a discussion about their understanding of this concept. To ensure participants have consistent understanding of dissemination, the interviewer then clarified the concept as the active approach of spreading evidence-based interventions to the target audience via predetermined channels using planned strategies [ 3 , 5 ]. Then, participants were encouraged to have a deep, detailed discussion on their dissemination experience and barriers and facilitators of dissemination to non-research audiences. Participants’ demographic information, which was pre-collected, was confirmed with participants at the end of the interview. The interview guide can be found in supplementary file 2.

All interviews were conducted in Mandarin Chinese by an interviewer experienced in qualitative research (JZ, professor, Ph.D., female) with a note-taker (YH, master’s student, female). No repeat interviews were conducted. The researchers collected participants’ demographic information, research interests, and research projects online before the formal interview to have a deep understanding of their perspectives. All interviews were audio-recorded and transcribed after obtaining oral consent from the interviewees. Transcripts were not returned to participants for comment or correction. Following qualitative research best practices [ 25 , 26 , 27 ], data collection ended when information saturation occurred and no new information was observed.

Data analysis

Data analysis occurred concurrently with data collection. Verbatim transcripts were coded using the inductive thematic analysis approach in NVivo 11 software. First, a coder (YH) reviewed transcripts to generate initial codes and aggregated them into categories to form early themes and subthemes. The D4D logic model [ 19 ] was then used to organize and map the relationships between themes and subthemes. Then, another coder (YW) independently applied codes to transcripts using the same coding framework. The codebook was constantly checked against the transcripts and was finally determined by comparison until no new information was identified. All coding results were compared and discussed between the two coders to reach a consensus. Unsolved discrepancies were resolved through discussion with a senior researcher (JZ) and at research team meetings. Data analysis was conducted in Chinese. All themes, subthemes, and typical verbatim quotes used to illustrate the main themes, were translated into English. Quotes are identified by participants’ ID to guarantee anonymity. Participants did not provide feedback on the findings.

Information saturation was reached after completing a focus group of 5 participants and 12 in-depth individual interviews with public health researchers in China. The interviews took 41.9 ± 10.9 min on average. Participants aged between 32 and 65 years, with an average of 46.5 ± 8.3 years, were primarily female (70.6%), and had a Ph.D. degree (88.2%). They worked in the universities in the field of health policy, behavioral science, global health, and implementation science ( n  = 10), the China CDC in the field of tobacco control, AIDS/STD control, tuberculosis control, and environmental health ( n  = 4), the Chinese National Cancer Center ( n  = 1), the Chinese National Center for Cardiovascular Disease ( n  = 1), and the China office of a global research institute ( n  = 1).

Theme 1: understanding of the concept of dissemination

Five out of 17 participants had no difficulty understanding the concept of dissemination as the active approach of spreading evidence-based interventions to the target audience via predetermined channels using planned strategies, while 12 participants misunderstood dissemination to some extent. Eight participants did not differentiate dissemination of research findings from science popularization of general knowledge when discussing their dissemination activities.

Dissemination means that I share some knowledge with others… I have always paid close attention to new media , and I have written and post some health science articles in Zhihu (Chinese online question-and-answer social media , similar to Quora) … Some online magazines often invite me and my colleagues to write some science articles , for example , I recently wrote an article to share some psychological and behavioral techniques for smoking cessation (Participant 01).

One participant viewed dissemination as knowledge translation, saying that dissemination referred to the process of translating and applying research, especially interventional research, into practice and policy.

I feel that dissemination in Chinese would be easily understood as science popularization , but it actually highlights the translation to the practice and policy , so translating it as ‘knowledge translation’ in Chinese may be more appropriate (participant 16).

Three participants argued that dissemination was similar to health communication, which refers to the communication and sharing of information.

The government is now promoting the awareness of knowledge translation , but I feel that knowledge translation in Chinese emphasizes the process of translating and applying our research , which is more about health technology , and sometimes there may be some commercial elements in knowledge translation. Dissemination is more similar to health communication (participant 14).

Theme 2: experience of dissemination

Subtheme 2.1: dissemination within academia.

Three participants working in the universities mainly published their research findings in peer-reviewed journals or through academic conferences for different reasons: one expressed a lack of resources in reaching non-research audiences, while two showed a lack of motivation, saying that dissemination to non-research audiences was not their priority.

I mainly published my research on peer-reviewed journals… for ordinary researchers like me , access and resources were limited (participant 07). As a researcher , I am very competent when disseminating within academia. Even if I encounter difficulties , I will face them. But for dissemination to practitioners or policymakers , the main disseminator is not me and should not be me… I am a teacher , and my priorities for the next five to ten years include publishing textbooks , participating in academic activities , working with young students , and conducting research (participant 17).

Subtheme 2.2: dissemination beyond academia

Fourteen participants described their experiences disseminating research findings to non-research audiences: 10 had disseminated to the public, 10 to practitioners, and 9 to policymakers. Participants disseminated to the public through social media and mass media. They cited social media as an accessible channel for every individual researcher. However, they felt their personal influence was limited in reaching a wide population, and they needed more resources to use mass media for dissemination. In addition, researchers were worried about possible misinformation and disinformation when disseminating on social media and mass media.

Our impact as a researcher to disseminate is so weak that our research findings posted on WeChat (Chinese social media , similar to WhatsApp and Snapchat) Moments can only be noticed by a few hundred people at most (participant 02). We are not required to add references , and sometimes the already added ones may even be deleted… and because our target audience is the public , we need to translate academic language into plain language… sometimes I am afraid of making scientific mistakes or causing misinformation (participant 01).

Dissemination to policymakers was considered impactful but with a high threshold. A participant indicated that in such cases, dissemination to practitioners was an alternative strategy to influence practice since it was more accessible. Of nine participants who have ever disseminated to policymakers, three worked in China CDC, and five engaged in health policy research.

My organization (China CDC) is a technical support organization for administrative decisions and policy-making , so a lot of our work is done for dissemination (participant 15). For researchers conducting health policy research like me , it is a must to disseminate to our government (participant 08).

Some participants felt the issuance of standards and guidelines ( n  = 4) and publication of patents ( n  = 5) as their dissemination routes. In contrast, some participants thought standards, guidelines, and patents were dissemination products that needed further disseminated, and the issuance of these products did not mean successful dissemination.

The implementation of patents is limited… now patents are mainly used by my peer researchers. Publishing patents does not mean dissemination , and patents themselves actually need to be further disseminated and implemented (participant 15).

Theme 3: facilitators and barriers of dissemination based on the D4D logic model

Factors influencing dissemination to non-research audiences emerged across four phases of the D4D logic model [ 19 ], and seven subthemes were identified: (1) motivation; (2) design processes; (3) packaging and distribution design; (4) push of research; (5) pull of practice; (6) capacity of health systems; and (7) impact of research. The subthemes are discussed in detail below and in Table  1 .

Subtheme 3.1: motivation

Most participants expressed their willingness to disseminate to non-research audiences out of a sense of social responsibility and social recognition, with the exception of two participants who did not consider dissemination to be their priority. Social climate was mentioned as another facilitator of dissemination.

The ultimate goal of scientific research is to change the public’s cognition and behavior , and the government’s decision-making process. If you do not consider dissemination , your research has no value , and it is hard to get recognition from our peers and the public (participant 12).

Subtheme 3.2: design processes

Subtheme 3.2.1: stakeholder involvement and context analysis.

Some participants indicated difficulties building relationships and reaching consensus with stakeholders (e.g., the public, media, practitioners, and policymakers) because of potential conflicts of interest between stakeholders and researchers. Involving stakeholders from the outset, building contacts based on previous relationships, and matching stakeholders’ needs were recommended by participants as helpful for stakeholder involvement. In addition, involving stakeholders from all sectors of society, not only within the health system but also outside of it (e.g., education system, non-governmental organizations, non-profit organizations, and commercial organizations), was thought to have the potential to make a greater influence.

This was based on previous collaboration between their organization and ours , and we have a long-term collaboration with them , so it was quite natural and easy to involve them… We got in touch with them when the research is being formulated. The sooner you can get in touch with stakeholders and get their support , the better… and if we can connect with people and organizations outside the health system , our dissemination efforts may have a greater impact and be more sustainable (participant 13).

Subtheme 3.2.2: application of D&I methodologies

The application of D&I methodologies was stressed as a facilitator of dissemination. However, some participants indicated that D&I science was still an emerging field in China, the limited understanding of D&I methodologies impeded the dissemination and implementation of research.

Currently , there is limited knowledge of methodologies including research design , theoretical frameworks , and qualitative methods for D&I science in China , which hinders the dissemination and implementation of research (participant 16).

Subtheme 3.2.3: marketing and business approaches

Some participants mentioned that the field of marketing was quite relevant to dissemination design and that marketing and communication approaches were promising for dissemination to non-research audiences, especially to the general public.

Take food marketing in food policy as an example , I feel that Coke’s advertising is so good that I also want to drink it; on the contrary , if you simply tell me not to eat food high in sugar and salt , then I will just not listen , let alone the ordinary consumers (participant 06).

Subtheme 3.2.4: context and situation analysis

Conducting context and situation analysis was cited as the foundation for understanding context and tailoring dissemination efforts.

Health communication always emphasizes needs assessment and audience segmentation , and it is important to understand the audiences’ needs. In many cases , what we were doing did not meet the needs of our audiences , and they did not accept (participant 04).

Subtheme 3.2.5: complexity of social, health, organizational, and political systems

Participants perceived policy resistance and low confidence in disseminating research with negative, politically or economically sensitive findings in complex social, health, organizational, and political systems. In addition, some participants noted that the COVID-19 pandemic increased the uncertainty of research findings and the vulnerability of collaboration networks.

For example , research involving the control of the tobacco industry , which is related to the economy , is very sensitive (participant 06). At first , everything went well , and they were very supportive. But because of the COVID-19 pandemic , the organization changed leadership , so we had to communicate with them again (participant 13).

Subtheme 3.3: packaging and distribution design

Subtheme 3.3.1: capability of packaging.

Participants indicated that integrating and packaging for non-research audiences was difficult and time-consuming and could be irregular and misleading, which calls for special competencies that differ from usual academic training.

It is demanding , requiring a high level of processing , summarizing , writing , and packaging skills. These are huge challenges that our daily training does not teach us (participant 12).

Subtheme 3.3.2: availability of distribution channels and platforms

The availability of channels and platforms was highlighted as an important contextual factor affecting dissemination. Those in the early stages of their careers, who had not yet established academic influence, expressed a lack of access to channels to interact with policymakers who were beyond the reach of individual researchers. Leveraging existing channels, platforms, and programs was recommended to facilitate dissemination to intended audiences.

Especially , we young researchers actually have many ideas and know a lot , but we do not have channels to share (participant 01). It is important to consider taking advantage of existing platforms or programs and hitching a ride whenever possible. Otherwise , dissemination involves a lot of financial and personnel input (participant 13).

Subtheme 3.4: push of research

Subtheme 3.4.1: incentives.

Academic publications were cited as the chief yardstick of performance evaluation, promotion requirements, and grant obligations. Some participants stated that the extent of dissemination to policymakers would also influence performance evaluation but were not given the same importance as academic publications. This was attributed by some participants to the difficulty in quantifiably evaluating dissemination activities. Although the China CDC participants expressed less pressure for academic publication than their university counterparts, they also complained about the academic incentive systems.

Dissemination to policymakers is now considered in performance evaluation , but still not as much as publishing papers on peer-reviewed journals… they may never regard dissemination as the most important criterion (participant 06). Currently , the value of science is still limited to publication and ‘Impact Factor’… Another problem is that it is difficult to define our dissemination efforts. For example , I cannot say how many people are using my APP and how much impact it burst , but I can say how many papers I have published in top journals (participant 11).

Subtheme 3.4.2: infrastructure

Seven participants reported having a dedicated person or team responsible for dissemination-related activities in their organization. These persons or teams served mainly for patent applications, communication, and publicity.

We have a Development Office dedicated for knowledge translation. They would organize seminars on dissemination like how to apply for patents (participant 14). The attitude of the communication platform in our school is very clear , and its purpose is to build prestige for our school. If we have proper research to disseminate , they will help with propaganda (participant 17).

Some participants mentioned that their organization would provide additional support, such as administrative facilitation, to help them disseminate more smoothly.

In addition to providing administrative costs , our university also provides intangible support for the development of D&I science and for the coordination of different departments (participant 16).

Subtheme 3.5: pull of practice

Participants noted a lack of climate or culture to support dissemination mainly because of the lack of priority given to some health issues themselves and the dissemination activities among leaders and practitioners.

The national government is advocating the dissemination and implementation of many innovations , but the local government may find it difficult to understand the value of (disseminating) these innovations and may not be unwilling to provide financial or personnel support (participant 10). We introduced our research and why we wanted to work with them to disseminate it , but they said that was not their focus. Then what was their focus at that time? All they wanted to do was help village doctors to pass a qualification exam and select the ‘most beautiful village doctor’. They were not interested in our dissemination of chronic diseases (participant 17).

Subtheme 3.6: capacity of health systems

Subtheme 3.6.1: communication networks.

The lack of networks between researchers and non-research audiences was cited as a barrier. Some researchers expected the health systems to build mechanisms for bidirectional communication networks between researchers and non-research audiences.

There is no mechanism to collaborate us with non-research audience… some researchers may have such relationships with non-research audiences , but that is out of their personal impact and efforts rather than the mechanisms in the health system (participant 02). There is a gap between researchers and policymakers in the academic system… maybe our organization could help bridge the gap. For example , the organization could build a system to collect our research findings regularly and disseminate to policymakers because universities have this kind of relationship with the government (participant 07).

Subtheme 3.6.2: executive networks

Executive network in the health system was considered necessary for dissemination on a large scale but difficult for ordinary university researchers to have. A participant in the China CDC pointed out that although the top-down CDC system in China, including CDCs at national, provincial, city, and county levels, could facilitate wide dissemination, their dissemination impact was still limited by the lack of human resources for public health.

Our dissemination success has benefited greatly from the solid executive network built before. For example , under the Chinese National Cancer Center , we have Cancer Prevention Offices at the provincial level. They could help us disseminate our research findings , like our evidence and apps. However , most researchers , especially university researchers , do not have such an objective support network (participant 11). The lack of human resources in public health is one of the most common problems in our country. For example , we have 40 staff working on tuberculosis at the China CDC , but only 10 at each provincial CDC , and 2 at each county CDC. In many cases , there are even half a person in counties working on tuberculosis (participant 10).

Subtheme 3.7: impact of research

Participants noted a chasm between overemphasis on academic publications and ignorance of long-term impact in the current academic system. Despite a series of national policies designed to break the undesirable orientation of “academic publications only” issued by the Chinese government, participants were pessimistic about them. They stated that the interpretation and implementation of these policies need to be further reviewed and improved.

Dissemination to non-research audiences is not expected by my organization , which does not care about these activities. However , it is the government that holds the baron , and there is nothing my organization can do about it. (participant 09). At present , national policies are developing and changing fast , but how to interpret and implement these policies needs to be gradually improved… our government is paying more and more attention to dissemination , but when it comes to the implementation level , there are still many shortcomings (participant 14).

This qualitative study explored the understanding and practices of dissemination, and further identified the barriers and facilitators of dissemination, which may be the first of this type in China. We found a lack of understanding of the concept and inadequate practices of dissemination to non-research audiences among Chinese public health researchers. We also identified barriers and facilitators in the conceptualization, design, dissemination, and impact phases of the D4D logic model [ 19 ], suggesting considerable room for improvement in the application of D4D strategies and the development of systematic resources. Our findings begin to provide a roadmap of ideas and actions to improve the active dissemination of research in China.

Dissemination was poorly understood by Chinese public health researchers, who confused it with some related concepts such as communication, science popularization, and knowledge translation, indicating a lag in the development and advocacy of dissemination in China. The lag in development and the lack of understanding of dissemination may hinder the dissemination practice and the uptake of evidence. Hence, dissemination, which highlights taking an active approach, identifying target audience, selecting predetermined channels, and using planned strategies to disseminate, should be deeply rooted in researchers’ mind to facilitate research uptake and understanding.

The public, practitioners, and policymakers were identified as three key non-research audiences for dissemination, yet most only gave a brief description when asked about their dissemination practices. While the internet and media are promising for large-scale dissemination, there is a need to strengthen the capacity of researchers to address misinformation and disinformation [ 28 , 29 ] and to facilitate collaboration between researchers and the media to achieve wide dissemination in China. Dissemination to the public and practitioners is considered as feasible and direct, while dissemination to policymakers as crucial for long-term impact. Indeed, the Chinese government holds accountability for the health of people, and proactively disseminating research findings to policymakers and government officials helps make a a greater public health impact. Nevertheless, the participants faced the dilemma of lacking personal relationships and access to channel to interact with policymakers. Although some academic associations (e.g., the Chinese Preventive Medicine Association) bring together researchers and practitioners in China, their potential to connect researchers and policymakers needs to be further strengthened to lead to dissemination success. Most of the participants with experience of dissemination in policy dissemination were those working in the China CDC or engaged in health policy research: the former stressed the mission of the China CDC to provide technical support for policy-making, and the latter stated that influencing policy was the fundamental goal of health policy research. This also suggests that organizations and researchers with stronger missions and resources to influence policy may have greater opportunities to disseminate to policymakers.

Although few in this study explicitly stated that dissemination to non-research audiences was not their priority, a lack of design capacity and distribution channels among researchers, insufficient support in organizations and the health systems, and an overemphasis on academic publications hindered dissemination to non-research audiences. First, there was a limited application of D4D strategies in the design of dissemination products, packaging and distribution plans. This is consistent with other studies suggesting that the lack of capacity was a common barrier to dissemination practice in low- and middle-income countries [ 30 ]. A good news was that Chinese researchers were actively involved diverse stakeholders at multiple stages of their research, which is consistent with the international trend of increasing emphasis on stakeholder engagement [ 31 , 32 ]. A survey of US and Canadian researchers in 2018 also revealed increases in stakeholder involvement compared to a survey of US researchers in 2012 [ 3 , 33 ]. However, there was a need to build multisectoral partnerships and improve stakeholder involvement’s depth and quality [ 32 ]. In addition, some researchers were aware of the potential for leveraging methods and frameworks from D&I science, marketing and business, communications and visual arts, and systems science to achieve dissemination success, yet the practical application needed to be improved. These disciplines (e.g., D&I science, marketing, systems science, and complexity science) originated from abroad and may not seem familiar to the Chinese public health researchers, it may require a lengthy learning and adaptation process. There are some simple tools and principles for guidance [ 34 ]. Notably, not all research finding should be disseminated to all audiences, the ability of deciding what to disseminate and to whom to disseminate should be strengthened in initial stage. Therefore, it is necessary to build capacity in the D4D principles and skills and to promote teaming across disciplines, as it may be unrealistic for public health researchers to develop all the D4D skills [ 13 ].

In addition to the need to improve researchers’ capacity and partnership across disciplines, there remained substantial room for improvement in the resources and structures that support dissemination. Specifically, there was a lack of incentives and infrastructure in research organizations (the push), a lack of climate and culture in practice or policy settings (the pull), and a lack of dissemination networks in the health system (the capacity). The persistent push–pull disconnect between researchers and practitioners was reported in other study [ 35 , 36 ]. As might have been expected, academic publications were the main criteria for performance evaluation, which may also be true in many other countries [ 10 , 14 , 33 , 37 , 38 , 39 ]. Furthermore, although some participants reported having a dedicated person or team for dissemination-related activities, the responsibilities of these dedicated persons or teams need to be further clarified and their capacity needs to be further enhanced. On the other hand, previous research points out that attention to dissemination tends to focus more on the push side than the pull and capacity sides [ 11 , 19 ]. For example, studies in the US suggested that 53% of researchers reported having a designated individual or team for dissemination [ 3 ] while only 20% of practitioners reported so [ 40 ]. Thus, changing the climate and culture in practice or policy settings to be receptive and prepared for dissemination, providing infrastructure to enhance communication between researchers and non-research audiences, and building executive networks to support wide dissemination are needed as a lack of platforms and collaboration mechanisms is also a common barrier to dissemination [ 30 ].

Problems with the lack of push, pull, and capacity for dissemination may be partly attributed to overemphasizing academic metrics rather than the long-term health and equity impacts. Several government funding agencies in developed countries have adopted policies to support or even require dissemination efforts [ 12 , 19 , 41 , 42 , 43 ]. Yet most funding agencies in China still focus on academic impact, existing fundings for dissemination in China are small in terms of its scale and are competitive to apply for. To address this issue, the Chinese government has adopted a series of national policies to reduce the overemphasis on academic publications and improve the evaluation system [ 44 , 45 , 46 , 47 ]. However, policy interpretation and grassroots implementation need to be further improved to accelerate the system shift to focus on the long-term impact of research. Frameworks such as the Research Excellence Framework (REF) [ 48 ] and the Translational Science Benefits Model (TSBM) [ 49 ] provide an outline and benchmarks by which researchers can measure the impact of scientific discoveries beyond traditional academic metrics.

This study revealed important aspects regarding research dissemination in China from the perspective of researchers with some limitations. First, 17 interview participants may not fully reflect the full spectrum in China although data saturation was reached. Given that dissemination is in its infancy in China, this study plays an initial study and future studies may need to involve more and more diversified participants to reveal dissemination of the whole research system in China. Second, some interviews were conducted online due to the COVID-19 pandemic, which limited the ability to gain information from contextual details and nonverbal expressions during the interviews. Third, the study is a qualitative exploratory study, additional large-scale quantitative studies are needed to triangulate the findings across the broader population. Indeed, the research team has run a large-scale survey to examine the attitudes and practices of Chinese public health researchers towards dissemination.

This study highlights a lack of emphasis on active dissemination in China and identifies multiple barriers to dissemination. There is a need to advance the field to promote understanding and raise awareness of dissemination—with the goal of ultimately more rapidly and equitably moving evidence to practice and policy. There is also a need to build capacity in D4D and to collaborate with experts from multiple disciplines (e.g., marketing, systems science, complexity science) to break down disciplinary silos. The findings also provide implications for promoting training programs, providing incentives and infrastructure for diverse dissemination activities, creating a climate and culture of readiness for dissemination, establishing bidirectional communication networks and efficient executive networks, and accelerating systematic shifts in policy orientation. Otherwise, dissemination is likely to sink to low priority in the already over-stretched system.

Data availability

All the data and materials of this qualitative study are available from the corresponding author on reasonable request.

Abbreviations

designing for dissemination

dissemination and implementation

National Chinese Center for Disease Control and Prevention

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Acknowledgements

We would like to acknowledge the support of all participants.

This work was supported in part by Disciplines Construction Project: Population Medicine (number WH10022022010) and Disciplines construction project: Multimorbidity (number WH10022022034). RCB is supported by the US National Cancer Institute (number P50CA244431), the National Institute of Diabetes and Digestive and Kidney Diseases (numbers P30DK092950, P30DK056341), and the Centers for Disease Control and Prevention (number U48DP006395), and the Foundation for Barnes-Jewish Hospital.

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The George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia

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JZ, RS, and RCB obtained funding. JZ, RS, RCB, and YH were responsible for the conceptualization and design of the study. JZ, RS, YH, XY, EG, and XX developed the interview guide. JZ, YH, JL, and XL collected data. YH and YW analyzed the data. YH wrote the first draft. JZ, RCB, RS, YH, and YW edited the manuscript. All authors approved the final version for submission.

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Hu, Y., Yin, X., Wang, Y. et al. A qualitative exploration of disseminating research findings among public health researchers in China. BMC Public Health 24 , 2518 (2024). https://doi.org/10.1186/s12889-024-19820-z

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A community health-coaching referral program following discharge from treatment for chronic low back pain – a qualitative study of the patient’s perspective

• Katharine Roberts   ORCID: orcid.org/0000-0003-0017-0803 1 ,
• Melissa Baysari   ORCID: orcid.org/0000-0003-1645-9126 1 ,
• Emma Ho   ORCID: orcid.org/0000-0002-2479-0081 1 ,
• Paula Beckenkamp   ORCID: orcid.org/0000-0003-3986-6111 2 ,
• Ye Tian 2 ,
• Matthew Jennings 3 ,
• Anita Amorim 4 ,
• Katherine Maka 5 ,
• Rachael Morton 6 ,
• Dragana Ceprnja 5 ,
• Mark Halliday 7 ,
• Manuela Ferreira   ORCID: orcid.org/0000-0002-3479-0683 8 &
• Paulo Ferreira   ORCID: orcid.org/0000-0002-5861-7770 5  

BMC Health Services Research volume  24 , Article number:  1072 ( 2024 ) Cite this article

Metrics details

Global policy and guidelines for low back pain (LBP) management promote physical activity and self-management yet adherence is poor and a decline in outcomes is common following discharge from treatment. Health coaching is effective at improving exercise adherence, self-efficacy, and social support in individuals with chronic conditions, and may be an acceptable, cost-effective way to support people in the community following discharge from treatment for LBP.

This qualitative study aimed to understand which aspects of a community over-the-phone health-coaching program, were liked and disliked by patients as well as their perceived outcomes of the service after being discharged from LBP treatment.

A purposive sampling approach was used to recruit 12 participants with chronic LBP, from a large randomised controlled trial, who were randomly allocated to receive a health coaching program from the Get Healthy Service ® in Australia. Semi-structured interviews were conducted, and a general inductive thematic analysis approach was taken.

The main themes uncovered regarding the intervention included the positive and negative aspects of the health coaching service and the relationship between the participant and health coach. Specifically, the participants spoke of the importance of the health coach, the value of goal setting, the quality of the advice received, the benefits of feeling supported, the format of the coaching service, and LBP-specific knowledge. They also reported the health coach and the coaching relationship to be the primary factors influencing the program outcomes and the qualities of the coaching relationship they valued most were connection, communication, care, and competence. The sub-themes uncovered regarding the outcomes of the intervention included positive impacts (a greater capacity to cope, increased confidence, increased motivation and increased satisfaction) and negative impacts (receiving no personal benefit).

Clinical implications

In an environment where self-management and self-care are becoming increasingly important, understanding the patient’s experience as part of a coaching program is likely to lead to improved quality of health coaching care, more tailored service delivery and potentially more effective and cost-effective community-based care for individuals with chronic LBP in the community after being discharged from treatment.

Trial Registration

The GBTH trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12620000889954) on 10/9/2020. Ethical approval was prospectively granted by the Western Sydney Local Health District Human Research and Ethics Committee (2020/ETH00115). Written informed consent was obtained from all participants. The relevant sponsor has reviewed the study protocol and consent form.

Peer Review reports

Introduction

Low back pain (LBP) is the leading cause of years lived with disability globally [ 1 ] and is regarded as a long-lasting condition with high rates of recurrence [ 1 ]. LBP is associated with a significant public health burden [ 2 ], with direct and indirect health costs exceeding $9 billion annually in Australia [ 3 ]. The high cost is in part, associated with a small proportion of people who seek ongoing care for their LBP [ 4 ]. It is recommended that LBP should be managed with a multimodal, biopsychosocial approach [ 5 ], encompassing exercise and physical activity prescription [ 6 , 7 ]. However, adherence to advice following treatment for LBP is undeniably poor, with rates reaching as low as 30%, and may be associated with expanding healthcare costs [ 8 ] due to re-presentation to care.

Health coaching has been defined as a behavioural approach designed to support a person to be actively involved in the management of their illness or injury [ 9 ]. It emphasises self-management and empowerment [ 10 ] with a focus on helping the individual take responsibility for achieving and maintaining treatment goals [ 11 , 12 ]. It is based around sound theoretical work, such as the transtheoretical model of change, self-efficacy theory, social cognitive theory and the health-belief model [ 13 ], and is an approach to management that is patient-centred and focussed on wellness and health [ 13 ]. Telephone-based health coaching has been found to decrease medical costs and hospitalisations in patients with chronic health conditions [ 14 ], to improve self-efficacy [ 15 , 16 ] and social support [ 17 ] in individuals with chronic conditions, and to increase activity levels in individuals with chronic disease [ 10 ] and in healthy adults [ 11 ]. It has also been found to be acceptable to patients with LBP [ 18 ] with increased levels of self-reported activity levels, improved recovery expectation [ 10 ] and potentially decreased health care utilisation [ 18 ], thereby assisting self-management for those who suffer with chronic LBP.

Policy and guidelines for LBP management globally are increasingly focussed on self-management and self-care. However, a decline in clinical outcomes is commonly reported by patients with chronic LBP following discharge from treatment [ 19 ] resulting in low levels of self-management, re-presentation to care [ 20 ] and increased health care costs [ 21 ]. Health coaching is designed to provide increased social support and increase motivation through collaboration [ 22 ]. As such, it may be an efficacious, cost-effective strategy to provide community-based support and improve long-term outcomes in individuals following discharge from treatment for chronic LBP.

Community-based health-coaching programs have been shown to be effective in managing conditions such as diabetes [ 23 ] and cardiovascular disease [ 24 ] and yet there is a lack of structured community support programs for people following discharge from treatment for LBP. There is also limited evidence available on the experiences of patients with LBP who are receiving health coaching services. For this reason, this study aimed to understand which aspects of the health coaching service, delivered by the Get Healthy Information and Coaching Service ® (Get Healthy Service ® ) – an Australian community-based health coaching program – patients liked and disliked, as well as their perceived outcomes of the program. Understanding the patient’s perspective may be particularly important for improving discharge care for LBP through enhancing adherence to an established community health-coaching referral program.

Study design

This study used a qualitative descriptive design [ 25 ] and was part of an ongoing randomised controlled trial – the Get Back to Healthy (GBTH) Trial [ 26 ]. The GBTH trial aims to evaluate the effectiveness of referring patients directly to a pre-existing, free, community-based health-coaching program, called the Get Healthy Service ® , at the point of discharge from treatment for chronic non-specific LBP from a public hospital physiotherapy outpatient department or a private general practitioner, physiotherapist, or chiropractor. The service provides participants with up to 10 over-the-phone health coaching sessions, over a 6-month period, which are delivered by university-qualified health coaches. The frequency and total number of health coaching calls received are mutually determined by the participant and their health coach. As part of the trial, health coaches received additional training regarding working with people with chronic LBP. The training involved teachings on how to monitor and support participants to achieve improvements in physical activity levels, and diet or weight goals, if selected by the participant, to assist with managing their LBP as well as best current evidence for managing LBP, common psychological factors in this population, and strategies for addressing these factors.

Recruitment

A purposive sampling approach was used to recruit participants for this qualitative study. On completion of the 12-month GBTH trial period, a member of the research team (KR) was unblinded to the participant’s trial group. Sequential participants who received the health coaching as part of the GBTH trial, were asked in the final phone call whether they were interested in participating in a qualitative sub-study and, if the participant agreed, a subsequent interview was scheduled. All participants provided written consent to participate in the GBTH trial, were reassured that no identifiable information would be collected and were assigned a new study code. This manuscript has been guided by the Standards for Reporting Qualitative Research Checklist [ 27 ] and utilises a constructivist paradigm [ 28 ].

Data collection

One-on-one semi-structured interviews were carried out by KR via Zoom videoconferencing at a time that was convenient for participants. The Zoom interviews were audio-recorded and subsequently transcribed. On two occasions, participants preferred to be interviewed over the phone, and in these instances, the interview was audio-recorded and transcribed using Microsoft Word online. Individual interview transcriptions were immediately reviewed for completeness and de-identified by the first author (KR).

The interview questions were developed by the research team, which included researchers and clinicians with extensive experience in LBP, chronic pain and health services research and were overseen by a highly experienced qualitative researcher (MB). The questions were designed to ascertain background context regarding the participant’s LBP history, their beliefs regarding LBP management, and their confidence to follow their healthcare provider’s advice. Participants were subsequently asked questions regarding the health coaching intervention and the health coach they were assigned. Pilot interviews were run to assess the appropriateness of the questions prior to commencing the participant interviews and the interview questions were adjusted accordingly to ensure questions were open-ended, non-leading and easy to understand. The final questions are available as supplementary digital content . All interviews were conducted between May and September 2023 by the first author (KR), who has over 24 years of clinical experience as a physiotherapist working in the area of LBP and chronic pain and is a PhD student.

Data analysis

A general inductive thematic analysis approach was taken [ 29 ] and a framework was created from the data [ 30 , 31 ], which allowed the themes and codes to be developed and modified in an iterative process as the interviews were reviewed. The coding framework grouped themes into three main components – the background context (characteristics of the recipients and their environments), intervention (characteristics of the coaching service that were liked and disliked), and outcomes. In line with inductive thematic analysis, the evaluation followed a step-wise process [ 29 ].

The raw data files were prepared and then read closely to gain an understanding of the ideas covered in the text.

Themes and sub-themes were then created from phrases or meanings in the text during multiple reviews of the text.

Continued revision and refinement of the themes occurred with collaboration between the researchers with appropriate quotations selected to convey each theme or subtheme [ 29 ] (Table  1 ).

Two researchers (KR and YT) performed the initial analysis of the first three interviews, then met with the experienced qualitative researcher (MB) to compare the themes and codes, discuss inconsistencies, and refine the categorisation. The remaining interviews were coded by KR, under the supervision of MB, and were reviewed by YT, a recent honours physiotherapy graduate and research assistant. Where possible interviews were transcribed, coded and reviewed immediately after the interview was performed to assist in identifying the point of thematic saturation [ 32 ]. Data collection and coding continued until thematic saturation occurred (i.e. no new themes or subthemes were emerging from the interviews), as agreed by the research team. The participant demographic data was obtained from the participants’ baseline surveys as part of the GBTH trial, and analysed using Stata SE 16.1 [ 33 ]. A manifest analysis approach [ 34 ] was utilised with the researchers intending to stay close to the actual words the participants said rather than interpreting the meaning behind the interviews. The data abstraction was performed in a cyclic process with the researchers returning to the interviews multiple times to ensure codes and themes were accurate and trustworthy [ 35 ].

18 study participants who received health coaching as part of the ongoing GBTH trial were invited to take part in an interview and 12 participants agreed. Participants’ baseline characteristics, at entry into the GBTH trial, are shown in Table  2 . Participants were on average 63 years old, 83% were female, and the mean body mass index (BMI) was 26.1 kg/m 2 . The majority of participants (83%) were married or in a relationship, and half were employed to some degree at the time of commencing the trial. The intervention and the outcomes were analysed with two main themes (and ten sub-themes) emerging within the intervention analysis (Fig.  1 ) and four within the outcomes analysis (Fig.  2 ).

Themes and subthemes that emerged from the interviews within the intervention analysis and the outcomes analysis

Subthemes that emerged from the interviews within the outcomes analysis

The context: characteristics of recipients and their environments

Low back pain history.

All participants reported experiencing chronic LBP before starting the GBTH trial, with some describing their symptoms as constant and grumbly pain, and others describing their pain as episodic. All participants explained that their pain was difficult to control and ongoing.

When questioned about their usual LBP management, the majority of participants reported relying on regular appointments with their healthcare provider in combination with either specific exercises that had been recommended or general exercise, such as walking. Some were compliant with exercises and others noted struggling to follow this advice. Half of the participants reported relying on rest when their LBP flared up and were conscious of limiting their activities such as vacuuming, lifting heavy objects, or walking up hills. Several participants were also aware of the benefits of lifestyle changes for managing their LBP.

All participants noted relying on pain medication for exacerbations or flare-ups, for maintenance, or for sleep. They most commonly spoke of using paracetamol and over-the-counter anti-inflammatory medications. Participants said that the use of medications was prescribed by health care providers in some circumstances and was self-prescribed in others.

Participants varied in their confidence to follow the advice they had been given for managing their LBP with some participants believing the advice they received would be easy to follow and others believing following the advice would be difficult. In the former case, participants described themselves as independent, willing to give anything a go, and committed. They reported personal characteristics, such as being conscientious, proactive, and analytical. In the latter case, participants cited external factors as challenges, such as finding time, finding people to exercise with, exercises being boring, and receiving no benefit from following the advice received. Another frequently reported barrier was time, with participants explaining that the amount of time required to complete exercises makes it difficult to stay on track with the advice.

“I get fed up when I am expecting it to get better. I am thinking I am doing all this stuff so it should be getting better , but then it doesn’t.” 011. “At first it was not as easy [to follow the advice I was given] , but then , I did discover that if I didn’t do the stretches then my pain was worse. So , then it became easy.” 004. “Most people I see and doctors I see , always reckon I’m a wonderful patient because….I follow instructions [but] it’s frustrating because I can’t find people to do exercise with me much. They’ve got diabetes , they’ve got arthritis , they’re really overweight or whatever.” 001.

When asked whether they had certain expectations or specific desires for the health coaching prior to commencing their health coaching sessions, the majority of participants reported being open-minded, interested, and willing to give anything a go. Those who reported having specific expectations cited looking forward to having someone to talk to, being pleased to let someone else take control, and hoping to find some motivation to exercise.

“Because I do so much on my own. I just thought it would be good to have someone to talk to , and report to , and get support from.” 001.

The intervention: characteristics of the Get Healthy Service®

The mean number of health coaching sessions received by the participants interviewed was nine, ranging from three to 13. Two-thirds of participants set physical activity goals and one-third set diet or weight goals. The health coaching service reported that 50% of participants graduated from the program, defined as achieving their goals and the mean length of phone calls was 11.5 min (ranging from 6 min to 23 min). Sub-themes were described in a positive light by some participants, and in a negative light by others, depending on their experience of the service, so each theme in Table  3 is described as both a liked and disliked feature.

Participants were asked to discuss which aspects of the health coaching they found to be the most and least valuable. They indicated that the perceived positives and negatives of the program predominantly relied on whether it met their needs. According to the participants, whether the program met their needs depended on their connection and communication with the health coach, the advice provided and the perceived competence of their health coach, whether the health coach listened or cared, and specific intervention characteristics.

The health coach

For the majority of participants, the health coach was viewed as a positive aspect of the intervention. The health coaches were frequently described as encouraging, positive, active in helping, and non-judgemental. One participant noted that the health coach was ‘interested’ in them which they thought was important. Listening was also considered to be an important positive quality of the health coach by the majority of participants, and several reported a sense of friendship or caring.

“I think it was a constant reinforcement that somebody was interested in the progress that one was making. And I’d say overall that was by far the most relevant aspect of a regular follow-up of the telephone conversation for 15–20 minutes.” 009.

The health coach’s willingness to learn was considered to be a positive aspect by almost half of the participants. Participants recounted their health coach as providing relevant and useful information either during health coaching sessions or in the follow-up call if they needed to research the answers. One participant described their health coach as ‘a great little researcher’. Interviewees reported having confidence in the health coach’s information and valued having someone who could bring expertise and a different perspective.

“I think what I liked the most was her expertise…She was able to give me very good websites to go to for excellent , excellent exercises.” 012. “At the next phone call , she’d have the answers to the questions from the last [call].” 005.

The participants who felt the coach was a negative aspect of the health coaching program discussed issues such as discord between themselves and their coach, their coach appearing to be disinterested, businesslike or impatient. One participant described their coach as ‘going through the motions’ and another described theirs as ‘not connecting with me’.

“Occasionally I thought , oh , maybe she’s getting impatient , you know , I don’t know , [there was] just a discord.” 008. “They (health coach) didn’t seem interested or motivated. I felt like it was going through the motions.” 010.

The value of goal setting

A key aspect of health coaching involves setting and working towards specific, achievable health goals. Whilst all participants set goals at the commencement of their program, not all could remember at the time of the interview what their goals had been. Of those who had a clear recollection of their goals, the vast majority reported their goals as being collaborative, flexible, and realistic. However, three participants described their goals as unrealistic. The collaborative and flexible goals were considered to be a positive aspect of the health coaching contributing to increased confidence.

“We set different [goals] as we progressed through. And like for instance , my last call , we spoke about being able to do things on my own and stuff. So that was the goal we set from our last call , and I’ve done that…. And I’m still sort of thinking about some other things I might do.” 001.

The advice received

Almost half of the participants felt the specific advice they received contributed to the sense of support they gained whilst engaging in the health coaching. When the advice conflicted with the participants’ needs, it was seen as unsupportive and unhelpful.

“I knew that I had someone who had access to very good resources…. So , absolutely. It was nice to have access to someone who could give websites that were actually developed by health professionals rather than influencers.” 012. “[The health coaching did not make me feel supported] because that was the nature of the interaction I was having with the health coach. So , I ceased it. I didn’t feel I was personally getting much out of it if anything. Nothing that I couldn’t have got off the Internet anyway.” 010.

A lack of appropriate advice provided by the coach was considered to be a significant problem by almost half of the participants. Participants noted a lack of LBP-specific information, a lack of new or novel information, advice that was not tailored to their needs, and advice that was vague or general in nature. These participants used words such as disappointing, curious, irritating, boring, and inadequate when discussing this lack of appropriate information and advice. The mismatch between the health coach’s qualification and the participant’s goal was also highlighted as a negative aspect with two participants wondering whether they should have chosen a different coach and two participants ceasing the health coaching as they felt the coach was unable to give them any advice they did not already know.

“I would tell her ‘So I have done that in the past and explain to her and she would still say ‘well let’s still try this’. And this can be your goal’ and I am thinking ‘I just told you that I have tried that in the past and it didn’t work’. But that is what she had set for that day so that was what we were going to do.” 011. “And that was why I particularly didn’t like the coaching. Mostly because everything they told me I’ve already read. You know , I’ve already done it and they just irritated with me.” 010.

Feeling supported

Participants reported that having another person there for them, the specific advice they received and the coach’s encouragement as contributing to the sense of support they felt whilst engaging in the health coaching. One participant described their health coach as a ‘Jiminy Cricket on my shoulder’, and another felt the benefit of having a health coach was more about not wanting to let them down. The program being individualised and the health coach understanding their journey were also seen as contributing to the sense of support they felt. In contrast, if the health coach was perceived as pushy and not supportive, their presence was regarded as a barrier.

“Because they asked questions and you know , and by asking , how are you feeling? What are you up to? You know , is there something you want to talk about? You know that sort of person-centred [approach]. I felt like I was at the centre of the universe , and I was very engaged in that sense.” 007 . “I reflected on it at the time and thought , it’s like going to a psychologist who is constantly asking you questions. Well , how do you feel about that? And how does that make you feel? It was just always putting it back on to me. It’s like , well , this is not. It’s not helping me. It’s like she didn’t get that.” 010.

Several participants also felt that having an objective person to support them from outside their personal circle was beneficial.

“And I think the most supportive part about it is that you have to report in , well , okay , did you do that , or what happened when you tried this , or why did it not happen , and what can we do to work around it.” 010. “I’ve always been kind of the leader for my family , and I support them , so to have someone who specialised in what [the health coaches do]… and that’s the area I need to get my back better. It was just wonderful.” 007.

Almost half of the participants reported the encouragement of their health coach as a positive contributor to the sense of support they felt. However, almost half also felt that the program was demotivational and sometimes beyond their capacity which was linked by some participants to a lack of understanding.

“Sometimes [the conversation] went a little bit askew. But it still left me feeling really good and really high and really positive and motivated to you know , keep going. For me [the benefit was] to talk freely. And confidentially with someone.” 007. “I didn’t feel that my coach was particularly interested or understood the health condition that I had or even was offering any advice. I just got the feeling. She was bored. She was just going through the motions.” 010.

Ten of the 12 participants believed that the support of the health coach helped them stay accountable and motivated. Over half of the participants described feeling more responsible and several noted feeling more motivated, in particular, to exercise. One participant noted that knowing they were going to receive a call helped them stay on track with their exercises and goals while another felt that reporting to their health coach gave them direction and incentive. Over half of the participants described experiencing increased motivation. Most of them discussed receiving text messages or email reminders from their health coach after each call, reinforcing their goals and action plan. They felt this kept them on track, reminded them what to do and provided ‘checkpoints’ along the way.

“I think they just , they kept me motivated. Like , you know , sometimes people just get lazy , so you just need something externally , you know , reminding you…. that’s your plan , and then it’s good for your health. You need to do it.” 003.

The Get Healthy Service® coaching format

Six of the 12 participants felt the over-the-phone format was effective, three were unsure, and three felt it was ineffective. Those who were happy with the format reported the flexibility of the scheduling and convenience of the phone call as key reasons. Over half of the participants felt that the over-the-phone format met their needs. One participant commented that it may have been different if they had wanted the health coach to tell them how to do their exercises. A few participants mentioned a safety aspect of the phone call as a positive although they also noted disadvantages of not seeing the person you are talking to. Almost half of the participants reported preferring to be able to see the person they are speaking with but were unsure if it would have changed their health coaching experience. Ten of the 12 participants would consider another format such as teleconferencing or face-to-face as long as it was still convenient, was not a long distance to travel, and met their needs.

“I liked the fact that it was [over the phone] because I’d always do it when I was going for a walk. So , I always did it walking because I really am absurdly busy. And so , it was convenient.” 012. “I think , to a degree , [the anonymity] was a positive. But you know you can pick up on how people are feeling by looking at them.” 008.

Follow-up communications were discussed by almost half of the participants as a positive aspect of the health coaching. They described the text and email follow-ups as regular, great, and worthwhile for increasing their motivation, reminding them of their goals and keeping them on track. For those participants who did not receive follow-up information, this was perceived as a significant negative.

“I prefer to stay on the couch. I often didn’t want to get out , but when I saw the messages [I would think] I should get out and do the exercises.” 003.

Specific knowledge about LBP

The health coaches received basic training around working with people who have chronic LBP as part of the GBTH Trial [ 26 ]. The majority of participants felt their health coach did not address their LBP adequately however, only a few felt this impacted negatively on their experience of the program. Some participants reported specifically discussing their LBP with their coach and building it into their goals and exercises. Others reported their LBP ‘never came up’ and some felt the fact the health coach was a dietician was the reason for their lack of understanding. One participant did not expect the health coach to be an expert on LBP and only one felt the lack of LBP knowledge was a distinct disadvantage.

“The health [coaching] wasn’t focused on disease. It wasn’t focused on the medical model. No , no. It wasn’t on my back. It was more ‘How are you feeling today’ and ‘what have you been up to’ and you know , ‘is there something you want to talk about’.” 007. “There were times I just thought…. She’s not getting this. She’s just not getting this. She’s not understanding it.” 008.

The coaching relationship

The aspects of the coaching relationship that most participants spoke of valuing were communication, care, connection, and competence. All of the participants who viewed the health coaching positively reported the connection with their health coach as central to the sense of support they felt. These participants also believed the health coaching relationship was vital to positive outcomes.

“She was very , very attentive to helping [me]. She listened to me , and she gave me information. She encouraged me…. and she built my confidence” 002.

Over half of the participants reported the connection with their health coach as important, describing decreased loneliness, the ability to talk freely and confidentially and positivity as important contributors. Those who reported a lack of connection described poor communication as the key negative contributor.

“I think , loneliness in that exercise and social sense , has been something I’ve identified [through the health coaching process]” 001. “I just didn’t overly connect with her to be perfectly honest. There was a bit of a disconnect…. And I said [I was] going really well when I probably wasn’t.” 008.

Participants valued the support of someone who cared and reported that the personal connection with their coach contributed to this sense of caring. Several participants described their health coach as being like a call with a friend, someone who called when they said they would, another person who cared, or someone who listened to them. One participant described their coach as ‘businesslike’ and ‘aloof’ which negatively impacted their experience.

“Our calls became , like a friend just checking in , seeing how you’re going.” 004. “Someone like me who does a lot of caring for others. It was nice to think that there were others who were caring about me.” 007.

Five of the participants valued the competence of their health coach. Most described their health coach as being able to provide individualised, person-centred advice that met their needs. Some participants, however, felt their coach was not able to tell them anything new or useful.

“It was really nice to be able to feel confidence in who was guiding , who was leading , who was giving the advice , what was going on , and helping me.” 007 . “Every time she called me she told me something new , but it was all stuff that I already knew” 011.

Outcomes: participants’ perceptions of the impact of the service

Of the 12 participants interviewed, four described their LBP as improving throughout the 6-month health coaching program and the 6-month follow-up period, four described theirs as worsening, two reported no change and two reported their LBP as having resolved. Those who reported their pain as improving or resolved attributed the improvement to their increased participation in exercise, increased awareness of their body and improved control over their pain. Of the four who reported their pain as worsening, two noted they had been improving until they experienced a flare up and one felt their increase in pain was due to cutting back on their medication.

“[My pain is] the same as always. Really. Not much difference. Okay. I couldn’t say that it was significantly different.” 010.

Most participants interviewed described positive outcomes of the health coaching program as an increased capacity to cope, increased motivation, and increased confidence to manage their LBP (Table  4 ). The increased capacity to cope was described as ‘knowing I can stick to my plan’ or ‘the process of accepting something and then moving with it’. Participants used words such as learning curve, acceptance, in control, and resilience to describe their improved capacity to cope.

“So , it was more of a learning journey… and it actually taught me a lot.” 005.

Increased motivation was noted as a core positive outcome of the program with participants suggesting this was achieved through consistent reminders, reporting back to someone regularly, and having someone to work with to set up goals. Participants also reported improved motivation through achieving small goals and focussing on results such as improved pain, decreased weight, and staying on target.

“Yeah , I think the [health coaching] just , kept me motivated……so you just need something externally …. keep reminding you that you need to do something , you know , that’s your plan.” 003. “And it worked. So being very deliberate and trying to be more active and along with losing the weight , it did help. Well , it was sort of truth by results because that pain just went.” 012.

A small number of participants strongly felt they did not feel more supported or motivated while receiving the health coaching program.

“Not really. No. [It did not make me feel supported] And look! I think I was , I thought it was a good idea to do it. And I like to help , if it’s going to help other people but I don’t think it was something that helped me.” 011.

The majority of participants believed the health coaching improved their confidence to manage their LBP. They described learning about themselves, creating solutions to specific problems, increased accountability and decreased pain levels as contributing to this increase in confidence. Participants noted the benefit of having a plan to follow and an increased sense of control and accountability contributing to their increased confidence to manage their LBP. For those participants who noted a decrease in their LBP, they noticed this decrease in pain to not only improve motivation, but to also contribute to their increased confidence.

“Just starting off with the exercise. It was the kick start. I really believe it was… And realising now that physio is finished. And having a health coach. It actually made me feel so proud to be able to say to people ‘No I can’t do that - my health coach has told me I’m not to do that.” 007. “It’s sort of part of my general way of behaving now , so part of that was because it was [increased my confidence] and part of that was because it was long term.” 012.

Participants expressed having increased confidence to make bigger lifestyle changes as a result of the health coaching and three described the health coaching as a learning journey and self-exploration. Two participants spoke specifically about increased confidence through accepting their LBP and moving on.

“Having the health coach there gave [me] the confidence to look wider and go ‘I need to make a bigger change’.” 007. “I think I’m very confident [now]. Yeah , this going to be , you know , part of my life in the future.” 003. “It’s really nice to take this moment to self-reflect. And look back on where I was and where I am now and I think , you know , I’ll just take a deep breath and realize it’s getting better.” 007.

Some participants did not believe the health coaching program increased their confidence in managing their LBP. All four described withdrawing from the health coaching program because the health coach could not teach them anything new or because they thought their health coach was not interested in them.

“I called [the health coaching] a little bit early because it was annoying me. Just the fact that there wasn’t anything. No , there wasn’t anything that I didn’t already know , and I didn’t feel that I got anything out of it to be able to [help] me manage.” 011.

Three of the participants felt the health coaching did not meet their needs and was not individualised.

“But the knowledge [the health coach] had , I already knew that”. 013. “The thing when you’re doing exercises without any ongoing guidance is that you might be cheating. …. but obviously [that requires] lots and lots and lots more resources”. 009.

Patient recommendations

Almost half of the participants provided recommendations on how the health coaching program could be improved. Suggestions included potential improvements relating to the participant, the health coach, and the program itself. Some participants noted that health coaching ‘takes two people’ and participants should be primed to work on changing their behaviours for the program to be more successful. Several participants felt that choosing their health coach would potentially improve rapport and connection as well as ensure the coach had the appropriate qualifications to help them. One participant reported the age of the health coach was an important factor and that older individuals should be matched with older coaches who would understand their life experiences. One participant also believed the program would be better if a single coaching session was provided by a physiotherapist to ensure their LBP was being adequately addressed. This participant described the program as ‘unidimensional’ and strongly recommended a more multidimensional program.

“It takes two to work on change. So the person who’s the recipient needs to be able , and needs to want to change their own physical behaviours…. So , you can get all the good advice in the world…. But [I was] in the right place at the right time.” 012.

One participant reported feeling gratitude for having received the coaching and another reported the program should be compulsory for people with severe pain. Two participants suggested the health coaching should be offered more extensively such as through maternity services and Aboriginal community health and two participants spoke of the financial benefit of connecting the free health coaching to existing physiotherapy services.

This qualitative study explored patients’ experiences of health coaching that was provided as part of an existing community health coaching program following discharge from treatment for LBP. When discussing the intervention, participants described their perceptions of the health coaching service itself and the rapport they had with their health coach. Regarding the health coaching outcome, many participants reported positive impacts such as an increased capacity to cope, increased motivation, and increased confidence to manage their LBP at the end of their program while others felt they received no benefit. Some participants also made recommendations for improving their health coaching experience.

One of the key results that emerged from this study is the pivotal role of the relationship between the health coach and the participant, highlighting the importance of the health coach’s interpersonal skills that build communication, and connection. This relationship is likely to be similar to the working relationship or therapeutic alliance which encompasses warmth, partnership, and support between a client and therapist [ 36 ]. The study participants spoke of the positive and negative aspects of this relationship and its impact on the outcomes of the health coaching program which is in line with previous research which has found a positive therapeutic alliance to be associated with better outcomes in chronic disease care [ 37 ], and LBP [ 36 ]. Importantly, psychologically informed training for health coaches working with chronic conditions [ 38 ] could potentially strengthen the coaching relationship and enhance both the coaching experience and outcomes.

The qualities of the health coach the study participants felt were beneficial were communication, connection, care, and competence. These qualities mirror those that have been reported in previous research regarding the relationship between a patient with LBP and their healthcare provider. Participants spoke of opposing ends of these themes as contributing positively or negatively to their experience. For example, a health coach who communicated well, listened, and empathised was seen as helpful and beneficial, whereas a health coach who was perceived to not listen and was unable to individualise advice was seen as unhelpful and ineffective. This is supported by previous research which has found that LBP patients value healthcare providers who display empathetic and person-centred care that focuses on them as a human being and not just their pain [ 39 ], friendliness, genuine interest, clarity of information and listening [ 40 ] as well as good communication skills, encouragement and personalised care [ 41 ].

One of the primary aims of a health-coaching program such as the Get Healthy Service ® is to provide social support in an effort to improve health behaviours and health outcomes [ 42 , 43 ]. Participants described the advice they received, having another person there, the connection they felt, being valued, and understood and the program being person-centred as contributing to an increased sense of support they felt. For these participants, it is likely the health coaching provided a degree of emotional, informational, companionate and esteem support which are important contributors to an overall sense of support [ 44 ]. For those participants who reported an increased sense of support, this resulted in increased coping, improved motivation, and increased confidence to manage their LBP which is congruent with previous research [ 15 , 16 ].

Another important aspect of LBP care to consider in the health coaching setting is the value LBP patients place on receiving appropriate, individualised information from their therapists [ 45 ]. The participants in this study reported the advice received as being both a positive and a negative aspect of their coaching experience. Several participants spoke about the quality of the information they received as being useful and they appreciated their health coach taking the time to research answers for them. While a few participants found a lack of LBP specific information to be a barrier to participation in the program, several reported this to not be important. It is possible the information received, the research, and the answers provided by the health coach, actually represent the positive aspects of communication such as listening and respect rather than informational support in this context of health coaching which may differ to the context of medical care for LBP.

Whilst the health coach and the coaching relationship were reported to be of primary importance by the participants, some also spoke about factors specific to the health coaching program. Most reported that the over-the-phone format met their needs, and they valued the convenience, regularity, and flexibility of the calls. Several participants reported a willingness to trial another format of health coaching such as via videoconferencing, as long as it was still convenient and met their needs, but none were certain it would change their experience or their outcomes. As telephone coaching has been shown to be an effective and cost-effective method of supporting people to change behaviour and self-manage chronic conditions [ 46 , 47 , 48 ], programs such as the Get Healthy Service ® may provide an important opportunity to continue to support individuals with chronic LBP following discharge from treatment.

A review of 18 articles found nine key skills that are important for health coaches to master, noting communication as a primary competency [ 49 ]. This review also found the ability to deliver patient-centred care and the capacity to demonstrate relevant, evidence-based knowledge, with a willingness to learn, as fundamental to effective health coaching. The findings of our study support this review, with interviewed participants reporting similar key mechanisms through which their health coaching may or may not have helped them.

Considering the Stages of Change Theory [ 50 ] on which health coaching is partially based, participants who volunteered to be involved in the GBTH trial were presumably in the contemplation or preparation stage of behaviour change. Readiness to change was reported by participants to be important in the health coaching process, not only as a willingness to work towards goals but also to take on bigger lifestyle changes that may assist them with managing their LBP. Interestingly, as part of the health coaching, goal setting and problem solving are usually reserved for those individuals who are ready to change [ 51 ] and it is possible that participants who reported their goals as being demotivational or unrealistic were not yet ready to change, reflecting personal dimensions rather than health coach or relationship elements as an issue.

The most common barriers to change are lack of information, lack of support, and previous negative experiences [ 51 ]. The results of this study replicate these barriers with unsatisfied participants reporting their health coach as unable to provide them with new or useful information, not having the right skillset to give them advice or not helping them feel supported. These participants tended to withdraw from the health coaching and therefore attend fewer sessions. With health coaching more likely to be successful with more sessions [ 52 ] it is possible the participants may have been able to overcome these barriers had they attended further sessions with their health coach.

To ensure services such as the Get Healthy Service ® are an effective and viable discharge support option for individuals with LBP, it may be beneficial to consider training the coaches in psychologically informed practices to strengthen the coaching relationship and to consider the recommendations made by participants. One participant recommended a multimodal approach with one coaching session provided by a physiotherapist. This is supported in the literature where strong communication between the health coach and primary care provider is recommended [ 48 , 49 ]. Ensuring a strong connection between the participant and the health coach was also recommended by several participants either through allowing them to choose their health coach or purposefully matching based on age, skillset, or patient goals.

Strengths and limitations

There are some limitations to this study. While 18 participants of the GBTH trial were invited to participate in the interviews only 12 agreed which may introduce some bias as individuals with strong views (both positive and negative) about the service may have been more likely to agree to participate. Further to this, the interviews were performed when the participants completed their 12 months in the GBTH trial. As the health coaching program ran for the first six months of the trial, and participants may have completed or withdrawn from their health coaching program prior to this time point, this may have introduced recall bias. Further, we have not linked the participant experiences with the trial outcomes and are therefore unable to determine whether a positive experience and a strong health coaching relationship led to greater improvements in outcomes related to LBP (e.g., use of health services for LBP, pain intensity, disability). The high education level of the sample could be seen as a lack of diversity in the sample however, this could also be seen as a strength representing a potential increased depth of insight and articulation of experience provided by the participants. Importantly, the majority of participants felt their health coach did not address their LBP adequately but only a few felt this impacted negatively on their experience of the program. This study also has some strengths. In particular, the in-depth data resulting from the semi-structured, open-ended interview questions provides rich information regarding patient’s perceptions of the use of a community health-coaching program to assist LBP discharge support in a real world, care setting. Ensuring trustworthiness in qualitative research is central to the decisions and processes involved in preparing and organising the research, as well as reporting the research [ 32 ]. The data collection method utilised, the piloting and adjusting of the interview questions, the sampling strategy chosen and selecting the sample size based on thematic saturation all contribute to the trustworthiness of the preparation phase [ 32 ] of this research. The credibility (validity) and dependability (reliability) of this research were ensured through the collaboration of the researchers, the purposive sample selection and the choice of suitable meaning units [ 35 ]. The transferability (generalisability) and confirmability (data accuracy) of this research are ensured through the attention to detail and the meticulous presentation of the results [ 32 , 34 , 35 ]. Finally, the extensive clinical experience of the primary researcher could be seen as a limitation as they may have had preconceived ideas and biases when interviewing and reviewing the transcripts. This researcher was careful not to ask leading questions in the interviews and the collaborative process involved when generating themes and sub-themes from the interviews minimises this risk. This study has also been conducted following the EQUATOR Standards for Reporting Qualitative Research Checklist.

Clinical application

A 2021 Lancet editorial on chronic pain called for chronic pain care to be ‘grounded in the community’ supported by well-trained, multidisciplinary healthcare workers [ 53 ]. An ageing population, rising healthcare costs and ongoing negative health behaviours [ 54 ] are cementing the importance of supporting self-management and self-care [ 55 ] leading to an increased need to understand the patient experience and patient perspectives of healthcare services. Health coaching such as that provided by the Get Healthy Service ® may be an important pathway for providing community-based, high-quality, cost-effective discharge care for supporting LBP patients to self-manage their condition. Therefore, understanding the patient’s experiences may lead to greater knowledge, thereby improving the quality of health coaching and long-term outcomes for those with chronic LBP. While this study does not assess the Get Healthy Service ® program structure and the LBP training the health coaches received was specifically for this study, it provides important information regarding patient’s experiences. In particular, their perceptions of the program outcomes as well as what they perceive to be both beneficial and unhelpful aspects of their health coaching experiences. Embracing these participant opinions may lead to improved discharge support services for individuals with chronic LBP in the future.

Examining health coaching after discharge from treatment for chronic LBP from the patient’s viewpoint offers valuable insights that could enhance post-discharge care for numerous individuals coping with LBP. Participants valued the role of the health coach, goal setting, high quality, person-centred advice and the sense of being supported. Participants valued the service if it met their personal needs and while several participants felt the LBP-specific information was inadequate, this did not necessarily impact negatively on their experience of the health coaching. Participants also spoke of the importance of the rapport they felt with their health coach citing communication, connection, care, and competence to be important factors in their relationship. Despite significant variations in the reported progression of their LBP, the participants in this study found both positive and negative outcomes of the health coaching. However, the positive outcomes of a greater capacity to cope as well as increased motivation and increased confidence to manage their LBP are important insights for potentially improving the post-discharge care of people coping with chronic LBP.

Data availability

The data used and/or analysed are available on reasonable request however are not publicly available due to participants’ consent to their data being shared by the University of Sydney.

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Acknowledgements

The authors thank all the patients who participated in the study, and in particular those who shared their experiences regarding their health coaching experience with the research team. The health coaching was provided by the Get Healthy Service ® and the authors would like to acknowledge the support of the Get Healthy Service ® and Sandra Davidson. The Get Back to Healthy trial is funded by the National Health and Medical Research Council (NHMRC)(APP1180474), and Sydney, Western Sydney, and South Western Sydney Local Health Districts in New South Wales, Australia.

KR is funded by a University of Sydney LBP research scholarship. The Get Back to Healthy trial is funded by the National Health and Medical Research Council (NHMRC)( APP1180474 ), and Sydney, Western Sydney, and South Western Sydney Local Health Districts in New South Wales, Australia. External grant bodies (NHMRC and Western Sydney Local Health District) peer-reviewed the trial during the funding process. The NHMRC has no role in the trial design, implementation, data collection and analysis, decision to publish, or preparation of the manuscript. Western Sydney Local Health District clinicians and consumer groups (Allied Health Consumer Committee) were involved in the trial design process; however, funding was granted independent from their involvement in the trial. MLF, PWH (APP1194937), and PHF hold NHMRC Research Fellowships. RLM is supported by an Australian National Health and Medical Research Council (NHMRC) Investigator grant #1194703.

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KR, MB, YT and EH participated in the design of the study. KR, MB, and YT participated in the analysis of the study. KR led the writing of the manuscript. All authors made contributions to the drafted manuscript. All authors read, edited, and approved the final version of the manuscript.

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The GBTH trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12620000889954). Ethical approval was prospectively granted by the Western Sydney Local Health District Human Research and Ethics Committee (2020/ETH00115). Written informed consent was obtained from all participants. The relevant sponsor has reviewed the study protocol and consent form.

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Roberts, K., Baysari, M., Ho, E. et al. A community health-coaching referral program following discharge from treatment for chronic low back pain – a qualitative study of the patient’s perspective. BMC Health Serv Res 24 , 1072 (2024). https://doi.org/10.1186/s12913-024-11509-8

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