Chapter 4: Theoretical frameworks for qualitative research

Tess Tsindos

Chapter 4: Theoretical frameworks for qualitative research

Tess Tsindos

Learning outcomes

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

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

What is a Framework?

A framework is a set of broad concepts or principles used to guide research. As described by Varpio and colleagues¹, a framework is a logically developed and connected set of concepts and premises – developed from one or more theories – that a researcher uses as a scaffold for their study. The researcher must define any concepts and theories that will provide the grounding for the research and link them through logical connections, and must relate these concepts to the study that is being carried out. In using a particular theory to guide their study, the researcher needs to ensure that the theoretical framework is reflected in the work in which they are engaged.

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

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

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

Why do we use frameworks?

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

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

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

The Behaviour Change Wheel²
Consolidated Framework for Implementation Research (CFIR)³
Theoretical framework of acceptability⁴
Normalization Process Theory⁵
Candidacy Framework⁶
Aboriginal social determinants of health^7(p8)
Social determinants of health⁸
Social model of health^9,10
Systems theory¹¹
Biopsychosocial model¹²
Discipline-specific models
Disease-specific frameworks

Examples of frameworks

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

Table 4.1. Frameworks and references

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Framework	Relevant foundational information	Studies using the frameworks	How the framework is presented
The Behaviour Change Wheel – also known as the COM-B framework Suits research exploring: • Changing behaviours within health contexts to address patient and carer practices • Changing behaviours regarding environmental concerns • Barriers and enablers to behaviour/ practice/ implementation • Intervention planning and implementation • Post-evaluation • Promoting physical activity	The behaviour change wheel: a new method for characterising and designing behaviour change interventions²	A cross-sectional survey assessing the influence of theoretically informed behavioural factors on hand hygiene across seven countries during the COVID-19 pandemic¹³ Understanding public attitudes to death talk and advance care planning in Northern Ireland using health behaviour change theory: a qualitative study¹⁴ Empowerment for behaviour change through social connections: a qualitative exploration of women’s preferences in preconception health promotion in the state of Victoria, Australia¹⁵ Barriers and enablers to the implementation of the 6-PACK falls prevention program: a pre-implementation study in hospitals participating in a cluster randomised controlled trial¹⁶	This study examined how the COM-B model could be used to increase children’s hand-washing and improve disinfecting surfaces in seven countries. Each country had a different result based on capability, opportunity and/or motivation. This study examined the barriers and facilitators to talking about death and dying among the general population in Northern Ireland. The findings were mapped across the COM-B behaviour change model and the theoretical domains framework. This study explored women’s understanding of health and health behaviours and the supports that were important to promote behavioural change in the preconception period. Coding took place and a deductive process identified themes mapped to the COM-B framework. Identified perceived barriers and enablers of the implementation of a falls-prevention program to inform the implementation in a randomised controlled trial. Strategies to optimise the successful implementation of the program were also sought. Results were mapped against the COM-B framework.
Consolidated Framework for Implementation Research (CFIR) Great for: • Evaluation • Intervention and implementation planning	Consolidated Framework for Implementation Research (CFIR)³	The implementation of a smoking cessation and alcohol abstinence intervention for people experiencing homelessness.¹⁷ Protocol for the process evaluation of a counselling intervention designed to educate cancer patients on complementary and integrative health care and promote interprofessional collaboration in this area (the CCC-Integrativ study).¹⁸ Factors influencing implementation of health-promoting interventions at workplaces: Protocol for a scoping review¹⁹ Evaluation of a school-based participatory intervention to improve school environments using the Consolidated Framework for Implementation Research²⁰	Explored participants’ experiences with the program (ceasing smoking) to inform future implementation efforts of combined smoking cessation and alcohol abstinence interventions, guided by the CFIR. Key findings from the interviews are presented in relation to overarching CFIR domains. This mixed-methods study drew upon the CFIR combined with the concept of ‘intervention fidelity’ to evaluate the quality of the interprofessional counselling sessions, to explore the perspective of, directly and indirectly, involved healthcare staff, as well as to analyse the perceptions and experiences of the patients. This is a protocol for a scoping study to identify the topics in need of study and areas for future research on barriers to and facilitators of the implementation of workplace health-promoting interventions. Data analysis was aligned to the CFIR. This study examined the utility of the CFIR in identifying and comparing barriers and facilitators influencing the implementation of participatory research trials, by employing an adaptation of the CFIR to assess the implementation of a multi-component, urban public school-based participatory health intervention. Adapted CFIR constructs guided the largely deductive approach to thematic data analysis.
Theoretical Framework of Acceptability (TFA) Good for: • Pre-implementation, implementation and post-implementation studies • Feasibility studies • Intervention development	Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework⁴	Application of the Theoretical Framework of Acceptability to assess a telephone-facilitated health coaching intervention for the prevention and management of type 2 diabetes²¹ Understanding factors that could influence patient acceptability of the use of the PINCER intervention in primary care: A qualitative exploration using the Theoretical Framework of Acceptability²² Acceptability, reach and implementation of a training to enhance teachers’ skills in physical activity promotion²³ A qualitative study of the acceptability of remote electronic bednet use monitoring in Uganda²⁴	This study aimed to develop and assess the psychometric properties of a measurement scale for acceptance of a telephone-facilitated health coaching intervention, based on the TFA; and to determine the acceptability of the intervention among participants living with diabetes or having a high risk of diabetes in socio-economically disadvantaged areas in Stockholm. A questionnaire using TFA was employed. This paper reported patients’ perceived acceptability of the use of PINCER in primary care and proposes suggestions on how delivery of PINCER-related care could be delivered in a way that is acceptable and not unnecessarily burdensome. This study describes the nationwide implementation of a program targeting physical activity and sedentary behaviour in vocational schools (Lets’s Move It; LMI). Results showed high levels of acceptability and reach of training. This study drew on established models such TFA to assess the acceptability of SmartNet in Ugandan households. Results showed the monitor needs to continue to be optimised to make it more acceptable to users and to accurately reflect standard insecticide-treated nets use to improve understanding of prevention behaviours in malaria-endemic settings.
Normalization Process Theory (NPT) Good for: • Implementation • Evaluation	Normalization Process Theory²⁵	Ready for prime time? Using Normalization Process Theory to evaluate implementation success of personal health records designed for decision making ²⁶ Impact of a health literacy intervention combining general practitioner training and a consumer facing intervention to improve colorectal cancer screening in underserved areas: protocol for a multicentric cluster randomized controlled trial²⁷ Acceptability of a cessation intervention for pregnant smokers: a qualitative study guided by Normalization Process Theory²⁸ “Primary care is primary care”: use of Normalization Process Theory to explore the implementation of primary care services for transgender individuals in Ontario²⁹	This pre-implementation evaluation of an integrated, shared decision-making personal health record system (e-PHR) was underpinned by NPT. The theory provides a framework to analyse cognitive and behavioural mechanisms known to influence implementation success. It was extremely valuable for informing the future implementation of e-PHR, including perceived benefits and barriers. This study assessed the impact of an intervention combining health literacy colorectal cancer-screening (CRC) training for GPs, using a pictorial brochure and video targeting eligible patients, to increase screening and other secondary outcomes, after 1 year, in several underserved geographic areas in France. They propose to evaluate health literacy among underserved populations to address health inequalities and improve CRC screening uptake and other outcomes. This study aimed to ascertain acceptability among pregnant smokers receiving the intervention. Interview schedules were informed by NPT and theoretical domains framework; interviews were analysed thematically, using the framework method and NPT. Findings are grouped according to the four NPT concepts. The study sought to understand how the implementation of primary care services for transgender individuals compares across various models of primary care delivery in Ontario, Canada. Using the NPT framework to guide analysis, key themes emerged about the successful implementation of primary care services for transgender individuals.
Candidacy Framework Good for: • Patient experiences • Evaluation of health services • Evaluation	Is ‘Candidacy’ a Useful Concept for Understanding Journeys through Public Services? A Critical Interpretive Literature Synthesis³⁰	Using the candidacy framework to understand how doctor-patient interactions influence perceived eligibility to seek help for cancer alarm symptoms: a qualitative interview study⁶ Exploring people’s candidacy for mobile health–supported HIV testing and care services in rural KwaZulu-Natal, South Africa: qualitative study³¹ What is the 'problem' that outreach work seeks to address and how might it be tackled? Seeking theory in a primary health prevention programme³² Qualitative study of candidacy and access to secondary mental health services during the COVID-19 pandemic³³	The study used the candidacy framework to explore how the doctor–patient relationship can influence perceived eligibility to visit their GP among people experiencing cancer alarm symptoms. A valuable theoretical framework for understanding the interactional factors of the doctor–patient relationship which influence perceived eligibility to seek help for possible cancer alarm symptoms. The study aimed to understand ways in which a mHealth intervention could be developed to overcome barriers to existing HIV testing and care services and promote HIV self-testing and linkage to prevention and care in a poor, HIV hyperendemic community in rural KwaZulu-Natal, South Africa. Themes were identified from the interview transcripts, manually coded, and thematically analysed informed by the candidacy framework. This study explored the perceived problems of non-engagement that outreach aims to address and specific mechanisms of outreach hypothesised to tackle these. Analysis was thematically guided by the concept of 'candidacy', which theorises the dynamic process through which services and individuals negotiate appropriate service use. This was a theoretically informed examination of experiences of access to secondary mental health services during the first wave of the COVID-19 pandemic in England. Findings affirm the value of the construct of candidacy for explaining access to mental health care, but also enable deepened understanding of the specific features of candidacy.

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

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