two granddaughters when I get the chance!! I enjoy most
music except for Rap! I keep fit by jogging, walking, and bicycling(at least three times a week). I have travelled to many places and RVD the South-West U.S., but I would now like to find that special travel partner to do more travel to warm and interesting countries. I now feel it’s time to meet a nice, kind, honest woman who has some of the same interests as I do; to share the happy times, quiet times and adventures together.
Profile No. | Data Item | Initial Codes |
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2 | I enjoy photography, lapidary & seeking collectables in the form of classic movies & 33 1/3, 45 & 78 RPM recordings from the 1920s, ’30s & ’40s. I am retired & looking forward to travelling to Canada, the USA, the UK & Europe, China. I am unique since I do not judge a book by its cover. I accept people for who they are. I will not demand or request perfection from anyone until I am perfect, so I guess that means everyone is safe. My musical tastes range from Classical, big band era, early jazz, classic ’50s & 60’s rock & roll & country since its inception. | HobbiesFuture plans Travel Unique Values Humour Music |
At this stage, you have to make the themes. These themes should be categorised based on the codes. All the codes which have previously been generated should be turned into themes. Moreover, with the help of the codes, some themes and sub-themes can also be created. This process is usually done with the help of visuals so that a reader can take an in-depth look at first glance itself.
Now you have to take an in-depth look at all the awarded themes again. You have to check whether all the given themes are organised properly or not. It would help if you were careful and focused because you have to note down the symmetry here. If you find that all the themes are not coherent, you can revise them. You can also reshape the data so that there will be symmetry between the themes and dataset here.
For better understanding, a mind-mapping example is given here:
You need to review the themes after coding them. At this stage, you are allowed to play with your themes in a more detailed manner. You have to convert the bigger themes into smaller themes here. If you want to combine some similar themes into a single theme, then you can do it. This step involves two steps for better fragmentation.
You need to observe the coded data separately so that you can have a precise view. If you find that the themes which are given are following the dataset, it’s okay. Otherwise, you may have to rearrange the data again to coherence in the coded data.
Here you have to take into consideration all the corpus data again. It would help if you found how themes are arranged here. It would help if you used the visuals to check out the relationship between them. Suppose all the things are not done accordingly, so you should check out the previous steps for a refined process. Otherwise, you can move to the next step. However, make sure that all the themes are satisfactory and you are not confused.
When all the two steps are completed, you need to make a more précised mind map. An example following the previous cases has been given below:
Now you have to define all the themes which you have given to your data set. You can recheck them carefully if you feel that some of them can fit into one concept, you can keep them, and eliminate the other irrelevant themes. Because it should be precise and clear, there should not be any ambiguity. Now you have to think about the main idea and check out that all the given themes are parallel to your main idea or not. This can change the concept for you.
The given names should be so that it can give any reader a clear idea about your findings. However, it should not oppose your thematic analysis; rather, everything should be organised accurately.
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Also, read about discourse analysis , content analysis and survey conducting . we have provided comprehensive guides.
You need to make the final report of all the findings you have done at this stage. You should include the dataset, findings, and every aspect of your analysis in it.
While making the final report , do not forget to consider your audience. For instance, you are writing for the Newsletter, Journal, Public awareness, etc., your report should be according to your audience. It should be concise and have some logic; it should not be repetitive. You can use the references of other relevant sources as evidence to support your discussion.
What is meant by thematic analysis.
Thematic Analysis is a qualitative research method that involves identifying, analyzing, and interpreting recurring themes or patterns in data. It aims to uncover underlying meanings, ideas, and concepts within the dataset, providing insights into participants’ perspectives and experiences.
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Advantages of a thematic literature review, structuring and writing a thematic literature review.
A thematic literature review serves as a critical tool for synthesizing research findings within a specific subject area. By categorizing existing literature into themes, this method offers a structured approach to identify and analyze patterns and trends across studies. The primary goal is to provide a clear and concise overview that aids scholars and practitioners in understanding the key discussions and developments within a field. Unlike traditional literature reviews , which may adopt a chronological approach or focus on individual studies, a thematic literature review emphasizes the aggregation of findings through key themes and thematic connections. This introduction sets the stage for a detailed examination of what constitutes a thematic literature review, its benefits, and guidance on effectively structuring and writing one.
A thematic literature review methodically organizes and examines a body of literature by identifying, analyzing, and reporting themes found within texts such as journal articles, conference proceedings, dissertations, and other forms of academic writing. While a particular journal article may offer some specific insight, a synthesis of knowledge through a literature review can provide a comprehensive overview of theories across relevant sources in a particular field.
Unlike other review types that might organize literature chronologically or by methodology , a thematic review focuses on recurring themes or patterns across a collection of works. This approach enables researchers to draw together previous research to synthesize findings from different research contexts and methodologies, highlighting the overarching trends and insights within a field.
At its core, a thematic approach to a literature review research project involves several key steps. Initially, it requires the comprehensive collection of relevant literature that aligns with the review's research question or objectives. Following this, the process entails a meticulous analysis of the texts to identify common themes that emerge across the studies. These themes are not pre-defined but are discovered through a careful reading and synthesis of the literature.
The thematic analysis process is iterative, often involving the refinement of themes as the review progresses. It allows for the integration of a broad range of literature, facilitating a multidimensional understanding of the research topic. By organizing literature thematically, the review illuminates how various studies contribute to each theme, providing insights into the depth and breadth of research in the area.
A thematic literature review thus serves as a foundational element in research, offering a nuanced and comprehensive perspective on a topic. It not only aids in identifying gaps in the existing literature but also guides future research directions by underscoring areas that warrant further investigation. Ultimately, a thematic literature review empowers researchers to construct a coherent narrative that weaves together disparate studies into a unified analysis.
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Conducting a literature review thematically provides a comprehensive and nuanced synthesis of research findings, distinguishing it from other types of literature reviews. Its structured approach not only facilitates a deeper understanding of the subject area but also enhances the clarity and relevance of the review. Here are three significant advantages of employing a thematic analysis in literature reviews.
Thematic literature reviews allow for a detailed exploration of the research landscape, presenting themes that capture the essence of the subject area. By identifying and analyzing these themes, reviewers can construct a narrative that reflects the complexity and multifaceted nature of the field.
This process aids in uncovering underlying patterns and relationships, offering a more profound and insightful examination of the literature. As a result, readers gain an enriched understanding of the key concepts, debates, and evolutionary trajectories within the research area.
One of the pivotal benefits of a thematic literature review is its ability to highlight gaps in the existing body of research. By systematically organizing the literature into themes, reviewers can pinpoint areas that are under-explored or warrant further investigation.
Additionally, this method can reveal emerging trends and shifts in research focus, guiding scholars toward promising areas for future study. The thematic structure thus serves as a roadmap, directing researchers toward uncharted territories and new research questions .
A thematic literature review excels in synthesizing findings from diverse studies, enabling a coherent and integrated overview. By concentrating on themes rather than individual studies, the review can draw comparisons and contrasts across different research contexts and methodologies . This comparative analysis enriches the review, offering a panoramic view of the field that acknowledges both consensus and divergence among researchers.
Moreover, the thematic framework supports the integration of findings, presenting a unified and comprehensive portrayal of the research area. Such integration is invaluable for scholars seeking to navigate the extensive body of literature and extract pertinent insights relevant to their own research questions or objectives.
The process of structuring and writing a thematic literature review is pivotal in presenting research in a clear, coherent, and impactful manner. This review type necessitates a methodical approach to not only unearth and categorize key themes but also to articulate them in a manner that is both accessible and informative to the reader. The following sections outline essential stages in the thematic analysis process for literature reviews , offering a structured pathway from initial planning to the final presentation of findings.
The initial phase in a thematic literature review is the identification of themes within the collected body of literature. This involves a detailed examination of texts to discern patterns, concepts, and ideas that recur across the research landscape. Effective identification hinges on a thorough and nuanced reading of the literature, where the reviewer actively engages with the content to extract and note significant thematic elements. Once identified, these themes must be meticulously categorized, often requiring the reviewer to discern between overarching themes and more nuanced sub-themes, ensuring a logical and hierarchical organization of the review content.
After categorizing the themes, the next step involves a deeper analysis and synthesis of the identified themes. This stage is critical for understanding the relationships between themes and for interpreting the broader implications of the thematic findings. Analysis may reveal how themes evolve over time, differ across methodologies or contexts, or converge to highlight predominant trends in the research area. Synthesis involves integrating insights from various studies to construct a comprehensive narrative that encapsulates the thematic essence of the literature, offering new interpretations or revealing gaps in existing research.
The final stage of the thematic literature review is the discussion of the thematic findings in a research paper or presentation. This entails not only a descriptive account of identified themes but also a critical examination of their significance within the research field. Each theme should be discussed in detail, elucidating its relevance, the extent of research support, and its implications for future studies. The review should culminate in a coherent and compelling narrative that not only summarizes the key thematic findings but also situates them within the broader research context, offering valuable insights and directions for future inquiry.
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Darshini Ayton
Upon completion of this chapter, you should be able to:
Thematic analysis is a common method used in the analysis of qualitative data to identify, analyse and interpret meaning through a systematic process of generating codes (see Chapter 20) that leads to the development of themes. 1 Thematic analysis requires the active engagement of the researcher with the data, in a process of sorting, categorising and interpretation. 1 Thematic analysis is exploratory analysis whereby codes are not predetermined and are data-derived, usually from primary sources of data (e,g, interviews and focus groups). This is in contrast to themes generated through directed or summative content analysis, which is considered confirmatory hypothesis-driven analysis, with predetermined codes typically generated from a hypothesis (see Chapter 21). 2 There are many forms of thematic analysis. Hence, it is important to treat thematic analysis as one of many methods of analysis, and to justify the approach on the basis of the research question and pragmatic considerations such as resources, time and audience. The three main forms of thematic analysis used in health and social care research, discussed in this chapter, are:
This involves multiple, inductive analytic techniques designed to identify and examine themes from textual data in a way that is transparent and credible, drawing from a broad range of theoretical and methodological perspectives. It focuses on presenting the stories of participants as accurately and comprehensively as possible. Applied thematic analysis mixes a bit of everything: grounded theory, positivism, interpretivism and phenomenology. 2
Applied thematic analysis borrows what we feel are the more useful techniques from each theoretical and methodological camp and adapts them to an applied research context. 2(p16)
Applied thematic analysis involves five elements:
Code | Definition | When to use | When not to use | Example |
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Attitudes or perceptions: falls | Attitudes about falls from health professionals | When a health professional describes their thoughts about falls. Look for ‘I think’ and ‘I believe’ statements. | When providing definitions about falls | 'I think they [falls] are an unsolved problem.’ |
This method originated in the 1980s in social policy research. Framework analysis is suited to research seeking to answer specific questions about a problem or issue, within a limited time frame and with homogenous data (in topics, concepts and participants); multiple researchers are usually involved in the coding process. 4-6 The process of framework analysis is methodical and suits large data sets, hence is attractive to quantitative researchers and health services researchers. Framework analysis is useful for multidisciplinary teams in which not all members are familiar with qualitative analysis. Framework analysis does not seek to generate theory and is not aligned with any particular epistemological, philosophical or theoretical approach. 5 The output of framework analysis is a matrix with rows (cases), columns (codes) and cells of summarised data that enables researchers to analyse the data case by case and code by code. The case is usually an individual interview, or it can be a defined group or organisation. 5
The process for conducting framework analysis is as follows 5 :
1. Transcription – usually verbatim transcription of the interview.
2. Familiarisation with the interview – reading the transcript and listening to the audio recording (particularly if the researcher doing the analysis did not conduct the interview) can assist in the interpretation of the data. Notes on analytical observations, thoughts and impressions are made in the margins of the transcript during this stage.
3. Coding – completed in a line-by-line method by at least two researchers from different disciplines (or with a patient or public involvement representative), where possible. Coding can be both deductive – (using a theory or specific topics relevant to the project – or inductive, whereby open coding is applied to elements such as behaviours, incidents, values, attitudes, beliefs, emotions and participant reactions. All data is coded.
4. Developing a working analytical framework – codes are collated and organised into categories, to create a structure for summarising or reducing the data.
5. Applying the analytical framework – indexing the remaining transcripts by using the categories and codes of the analytical framework.
6. Charting data into the framework matrix – summarising the data by category and from each transcript into the framework matrix, which is a spreadsheet with numbered cells in which summarised data are entered by codes (columns) and cases (rows). Charting needs to balance the reduction of data to a manageable few lines and retention of the meaning and ‘feel’ of the participant. References to illustrative quotes should be included.
7. Interpreting the data – using the framework matrix and notes taken throughout the analysis process to interpret meaning, in collaboration with team members, including lay and clinical members.
This is the thematic analysis approach developed by Braun and Clarke in 2006 and explained in the highly cited article ‘ Using thematic analysis in psychology ’ . 7 Reflexive thematic analysis recognises the subjectiveness of the analysis process, and that codes and themes are actively generated by the researcher. Hence, themes and codes are influenced by the researcher’s values, skills and experiences. 8 Reflexive thematic analysis ‘exists at the intersection of the researcher, the dataset and the various contexts of interpretation’. 9(line 5-6) In this method, the coding process is less structured and more organic than in applied thematic analysis. Braun and Clarke have been critical of the use of the term ‘emerging themes’, which many researchers use to indicate that the theme was data-driven, as opposed to a deductive approach:
This language suggests that meaning is self evident and somehow ‘within’ the data waiting to be revealed, and that the researcher is a neutral conduit for the revelation of said meaning. In contrast, we conceptualise analysis as a situated and interactive process, reflecting both the data, the positionality of the researcher, and the context of the research itself… it is disingenuous to evoke a process whereby themes simply emerge, instead of being active co-productions on the part of the researcher, the data/participants and context. 10 (p15)
Since 2006, Braun and Clarke have published extensively on reflexive thematic analysis, including a methodological paper comparing reflexive thematic analysis with other approaches to qualitative analysis, 8 and have provided resources on their website to support researchers and students. 9 There are many ways to conduct reflexive thematic analysis, but the six main steps in the method are outlined following. 9 Note that this is not a linear, prescriptive or rule-based process, but rather an approach to guide researchers in systematically and robustly exploring their data.
1. Familiarisation with data – involves reading and re-reading transcripts so that the researcher is immersed in the data. The researcher makes notes on their initial observations, interpretations and insights for both the individual transcripts and across all the transcripts or data sources.
2. Coding – the process of applying succinct labels (codes) to the data in a way that captures the meaning and characteristics of the data relevant to the research question. The entire data set is coded in numerous rounds; however, unlike line-by-line coding in grounded theory (Chapter 27), or data segmentation in applied thematic analysis, not all sections of data need to be coded. 8 After a few rounds of coding, the codes are collated and relevant data is extracted.
3. Generating initial themes – using the collated codes and extracted data, the researcher identifies patterns of meaning (initial or potential themes). The researcher then revisits codes and the data to extract relevant data for the initial themes, to examine the viability of the theme.
4 . Developing and reviewing themes – checking the initial themes against codes and the entire data set to assess whether it captures the ‘story’ of the data and addresses the research question. During this step, the themes are often reworked by combining, splitting or discarding. For reflexive thematic analysis, a theme is defined as a ‘pattern of shared meaning underpinned by a central concept or idea’. 8 (p 39 )
5. Refining, defining and naming themes – developing the scope and boundaries of the theme, creating the story of the theme and applying an informative name for the theme.
6. Writing up – is a key part of the analysis and involves writing the narrative of the themes, embedding the data and providing the contextual basis for the themes in the literature.
As described above, themes are informed by codes, and themes are defined at a conceptually higher level than codes. Themes are broader categorisations that tend to describe or explain the topic or concept. Themes need to extend beyond the code and are typically statements that can stand alone to describe and/or explain the data. Fereday and Muir-Cochrane explain this development from code to theme in Table 22.2. 11
First-order theme | Clustered themes | Second-order themes |
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The relationship between the source and recipient is important for feedback credibility, including frequency of contact, respect and trust The source of the feedback must demonstrate an understanding of the situational context surrounding the feedback message. Feedback should be gathered from a variety of sources.Verbal feedback is preferred to formal assessment, due to timing, and the opportunity to discuss issues. | Familiarity with a person increases the credibility of the feedback message. Feedback requires a situational-context. Verbal feedback is preferred over written feedback. Trust and respect between the source and recipient of feedback enhances the feedback message. Familiarity within relationships is potentially detrimental to the feedback process. | Familiarity When relationships enhance the relevance of feedback |
*Note: This table is from an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
When I [the author] first started publishing qualitative research, many of my themes were at the code level. I then got advice that when the themes are the subheadings of the results section of my paper, they should tell the story of the research. The difference in my theme naming can be seen when comparing a paper from my PhD thesis, 12 which explores the challenges of church-based health promotion, with a more recent paper that I published on antimicrobial stewardship 13 (refer to the theme tables in the publications).
Title
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CC
| CC BY 4.0
| CC BY 4.0
| Public Domain Mark 1.0
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First
| McKenna-Plumley, 2021
| Dickinson, 2020
| Bunzli, 2019
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Aim/research
| What are people’s experiences of loneliness while practising physical distancing due to a global pandemic?
| ‘To explore how medical students in their first clerkship year perceive the relevance of biomedical science knowledge to clinical medicine with the goal of providing insights relevant to curricular reform efforts that impact how the biomedical sciences are taught’
| ‘To investigate the patient-related cognitive factors (beliefs/attitudes toward knee osteoarthritis and its treatment) and health system-related factors (access, referral pathways) known to influence treatment decisions.’ ‘Exploring why patients may feel that nonsurgical interventions are of little value in the treatment of knee osteoarthritis.’
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Data
| Semi-structured interviews by phone or videoconferencing software. Interview topics covered social isolation, social connection, loneliness and coping. (supplementary file 2)
| 55 student essays in response to the prompt: ‘How is biomedical science knowledge relevant to clinical medicine?’ A reflective writing assignment based on the principles of Kolb experiential learning model
| Face-to-face or phone interviews with 27 patients who were on a waiting list for total knee arthroplasty.
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Thematic
| Reflexive thematic analysis
| Applied thematic analysis
| Framework analysis
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Results
| Table of themes and illustrative quotes: 1. Loss of in-person interaction causing loneliness 2. Constrained freedom 3. Challenging emotions 4. Coping with loneliness
| 1. Knowledge-to-practice medicine 2. Lifelong learning 3. Physician-patient relationship 4. Learning perception of self | Identity beliefs – knee osteoarthritis is ‘bone on bone’ Casual belief – ‘osteoarthritis is due to excessive loading through the knee’ Consequence beliefs – fear of falling and damaging the joint Timeline beliefs – osteoarthritis as a downward trajectory, the urgency to do something and arriving at the end of the road. |
Thematic analysis is flexible and can be used to analyse small and large data sets with homogenous and heterogenous samples. Thematic analysis can be applied to any type of data source, from interviews and focus groups to diary entries and online discussion forums. 1 Applied thematic analysis and framework analysis are accessible approaches for non-qualitative researchers or beginner researchers. However, the flexibility and accessibility of thematic analysis can lead to limitations and challenges when thematic analysis is misapplied or done poorly. Thematic analysis can be more descriptive than interpretive if not properly anchored in a theoretical framework. 1 For framework analysis, the spreadsheet matrix output can lead to quantitative researchers inappropriately quantifying the qualitative data. Therefore, training and support from a qualitative researcher with the appropriate expertise can help to ensure that the interpretation of the data is meaningful. 5
Thematic analysis is a family of analysis techniques that are flexible and inductive and involve the generation of codes and themes. There are three main types of thematic analysis: applied thematic analysis, framework analysis and reflexive thematic analysis. These approaches span from structured coding to organic and unstructured coding for theme development. The choice of approach should be guided by the research question, the research design and the available resources and skills of the researcher and team.
Qualitative Research – a practical guide for health and social care researchers and practitioners Copyright © 2023 by Darshini Ayton is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.
Sometimes it’s good to know what ‘doing a good job’ looks like… To help those wanting to understand what describing the reflexive TA process well might look like, we offer some good examples here, from student projects. This may be particularly helpful for students doing research projects, and for people very well-trained in positivism.
As well as the example(s) we provide here, you can find a much more detailed discussion in our book Thematic Analysis: A Practical Guide (SAGE, 2022).
The following sections are by Suzy Anderson, from her UWE Counselling Psychology Professional Doctorate thesis – The Problem with Picking: Permittance, Escape and Shame in Problematic Skin Picking.
An example of a description of the thematic analysis process:
Process of Coding and Developing Themes
Coding and analysis were guided by Braun and Clarke’s (2006, 2013) guidelines for using thematic analysis. Each stage of the coding and theme development process described below was clearly documented ensuring that the evolution of themes was clear and traceable. This helped to ensure research rigour and means that process and dependability may be demonstrable.
I familiarised myself with the data by reading the transcripts several times while making rough notes. As data collection took place over a protracted period of time, coding of transcribed interviews began before the full dataset was available. Transcripts were read line-by-line and initial codes were written in a column alongside the transcripts. These codes were refined and added to as interviews were revisited over time. Throughout this process I was careful to note and re-read areas of relatively sparse coding to ensure they were not neglected. My supervisor also independently coded three of the interviews for purposes of reflexivity, providing an interesting alternative standpoint. I cross-referenced our two perspectives to notice and reflect on our differences of perspective.
Once initial coding was complete, I looked for larger patterns across the dataset and grouped the codes into themes (Braun & Clarke, 2006). I found it helpful to think of the theme titles as spoken in the first person, and imagine participants saying them, to check whether they reflected the dataset and participants’ meanings. I tried not to have my coding and themes steered by ideas, categories and definitions from previous research, to allow a more inductive, data-driven approach, while recognising my role as researcher in co-creation of themes (Braun & Clarke, 2013). However, there were times when the language of previous research appeared a good fit, such as in the discussion of ‘automatic’ and ‘focussed’ picking. Given that the experience of SP is an under-researched area, particularly from a qualitative perspective, and that the aim is for this study to contribute to therapeutic developments, themes were developed with the entire dataset in mind (Braun & Clarke, 2006), such that they would more likely be relevant to someone presenting in therapy for help with SP. There was clear heterogeneity in the interviews, and in cases where I have taken a narrower perspective on an experience (such as when describing an experience only true for some of the participants), I have tried to give a loose indication of prevalence and alternative views.
I created a large ‘directory’ of themes and smaller sub-themes, with the relevant participant quotations filed under each theme or sub-theme heading. This helped me to adjust theme titles, boundaries and position, meant that I could check that themes were faithful to the data at a glance, and was of practical help when writing the analysis.
The process of coding and developing themes was intended to have both descriptive and interpretive elements (using Braun & Clarke’s definitions, 2013). The descriptive element was intended to represent what participants said, while the interpretative element drew on my subjectivity to consider less directly evident patterns, such as those that might be influenced by social context or forces such as shame. This interpretation was of particular value to the current study as participants often struggled to find words for their experience and several reported or implied that they did not understanding the mechanisms of their picking. An interpretative stance meant that I could develop ideas about what they were able to describe and consider the relationships between these experiences, making sense of them alongside previous literature (Braun & Clarke, 2006). Writing was considered an integral part of the analysis (Braun & Clarke, 2013) and it helped me to adjust the boundaries of themes, notice more latent patterns and considered how themes and their content were related.
Given the known heterogeneity of picking I was keen to make sure my analysis did not become skewed towards one type of SP experience to the detriment of another. I actively looked for participant experiences that diverged from those of the developing themes (with similar intentions to a ‘deviant case analysis’; Lincoln & Guba, 1985) so that the final analysis would represent themes in context and with balance. When adding quotations to the prose of my analysis I re-read them in their original context to ensure that my representation of their words appeared to be a credible reflection of what was said.
An example of researcher reflexivity in relation to analysis process
Subjectivity as a Resource
I considered my subjectivity to be a resource when conducting interviews and analysing data (Gough & Madill, 2012). It guided my judgement when interviewing, helping me to respond to participants’ explicit, implicit and more verbally concealed distress. I allowed aspects of my own experience to resonate with those of participants meaning that I could listen to their stories with empathy and a genuine curiosity. During analysis, themes were actively created and categorised, demanding my use of self (DeSantis & Ugarriza, 2000). I sought to interpret the data rather than simply describe it, which necessarily requires acknowledgement of both researcher and participant subjectivity. I strongly feel that we can only make sense of another’s story by relating it to our own phenomenology (Smith & Shinebourne, 2012), and that we re-construct their stories on frameworks formed by our own subjective experience. As such it is useful to be aware of my personal experiences and assumptions.
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3 (2), 77-101.
Braun, V., & Clarke, V. (2013). Successful qualitative research: A practical guide for beginners. Sage.
DeSantis, L., & Ugarriza, D. N. (2000). The concept of theme as used in qualitative nursing research. Western Journal of Nursing Research, 22 (3), 351-372.
Gough, B., & Madill, A. (2012). Subjectivity in psychological research: From problem to prospect. Psychological Methods, 17 (3), 374-384.
Lincoln, Y. S., & Guba, E. G. (1985). Establishing trustworthiness. Naturalistic Inquiry, 289 (331), 289-327.
Smith, J. A., & Shinebourne, P. (2012). Interpretative phenomenological analysis. In H. Cooper, P. M. Camic, D. L. Long, A. T. Panter, D. Rindskopf, & K. J. Sher (Eds.), APA handbook of research methods in psychology, Vol. 2. Research designs: Quantitative, qualitative, neuropsychological, and biological (p. 73–82). American Psychological Association.
The following extract is by Gina Broom, from her University of Auckland Master’s thesis (2020): “Oh my god, this might actually be cheating”: Experiencing attractions or feelings for others in committed relationships .
A detailed description of reflexive TA analytic approach and process
I analysed data through a process of reflexive thematic analysis (reflexive TA), as outlined by Braun, Clarke, Hayfield, and Terry (2019), who describe reflexive TA as a method by which a researcher will “explore and develop an understanding of patterned meaning across the dataset” with the aim of producing “a coherent and compelling interpretation of the data, grounded in the data” (p. 848). I utilized Braun and colleagues’ reflexive approach to TA, as opposed to alternative models of TA, due to my alignment with critical qualitative research. I did not select a c oding reliability TA approach, for example, due to its foundation of (post)positivist assumptions and processes (such as predetermined hypotheses, the aim of discovering ‘accurate’ themes or “domain summaries”, and efforts to ‘remove’ researcher bias while evidencing reliability/replicability), which were not suitable for the critical realist epistemology underpinning this thesis. In contrast, Reflexive TA is a ‘Big Q’ qualitative approach, constructing patterns of meaning as an ‘output’ from the data (rather than as predetermined domain summaries) while valuing “researcher subjectivity as not just valid but a resource” (Braun et al., 2019, p. 848). As the critical realist and feminist approaches of this thesis theorize knowledge as contextual, subjective, and partial, with reflexivity valued as a crucial process, a reflexive TA was the most appropriate method for this analysis.
Braun and colleagues’ (2019) reflexive TA process involves six-phases, including familiarization with the data, generating codes, constructing themes, revising and defining themes, and producing the report of the analysis. I outline my process for each of these below:
Phase 1, familiarization: Much of my initial engagement with the data was done through my transcription of the interviews, as the process provided extended time with each interview, both listening to the audio of the participant, and in the writing of the transcript. Some qualitative researchers describe transcription as an essential process for a researcher to perform themselves, as “transcribing discourse, like photographing reality, is an interpretive practice” (Riessman, 1993, p. 13), and as a result, “analysis begins during transcription” (Bird, 2005, p. 230). Braun and Clarke (2012) suggest certain questions to consider during the process of familiarization: “How does this participant make sense of their experiences? What assumptions do they make in interpreting their experience? What kind of world is revealed through their accounts?” (p. 61). During transcription, I took notes of potential points of interest for the analysis, using these types of questions as a guide. In exploring attractions or feelings for others in committed relationships, these questions (and my notes) often related to the meaning participants applied to their feelings and relationships, particularly in terms of morality and social acceptability, while the ‘world’ of their accounts was conveyed through their discourse of the contemporary relational context.
Phase 2, generating initial codes : Following transcription, I systematically coded each interview, searching for instances of talk that produced snippets of meaning relevant to the topic of attractions or feelings for others. I coded interviews using the ‘comment’ feature in the Microsoft Word document of each transcript, highlighting the relevant text excerpt for each code comment. I used this approach, rather than working ‘on paper’, so that I would later be able to easily export my coded excerpts for use in my theme construction. The coding of thematic analysis can be either an inductive ‘bottom up’ approach, or a deductive or theoretical ‘top down’ approach, or a combination of the two, depending on the extent to which the analysis is driven by the content of the data, and the extent to which theoretical perspectives drive the analysis (Braun & Clarke, 2006, 2013). Coding can also be semantic , where codes capture “explicit meaning, close to participant language”, or latent , where codes “focus on a deeper, more implicit or conceptual level of meaning” (Braun et al., 2019, p. 853). I used an inductive approach due to the need for exploratory research on experiences attractions or feelings for others, as it is a relatively new topic without an existing theoretical foundation. The focus of my coding therefore developed throughout the process of engaging with the data, focusing on segments of participants’ meaning-making in relation to general, personal, or partner-centred experiences of: attractions or feelings for others in the contemporary relational context, implied moral and/or social acceptability (or unacceptability), related affective experiences and responses, and enacted or recommended management of attractions or feelings for others. At the beginning of the process, I mostly noted semantic codes such as ‘feels guilty about attractions or feelings for others’, particularly as my coding was exploratory and inductive, rather than guided by a knowledge of ‘deeper’ contextual meaning. As I progressed, however, I began to notice and code for more latent meanings, such as ‘love = effortless emotional exclusivity’ or ‘monogamy compulsory/unspoken relationship default’. When all interviews had been systematically and thoroughly coded (and when highly similar codes had been condensed into single codes), I had a final list of roughly 200 codes to take into the next phase of analysis.
Phase 3, constructing themes : When developing my initial candidate themes, I utilized the approach described by Braun and colleagues (2019) as “using codes as building blocks”, sorting my codes into topic areas or “clusters of meaning” (p. 855) with bullet-point lists in Microsoft Word. From this grouping of codes, I produced and refined a set of candidate themes through visual mapping and continuous engagement with the data. These candidate themes were grouped into two overarching themes: the first encompassed 2 themes and 6 sub-themes evidencing pervasive ‘traditional’ conceptions of committed relationships (as monogamous by default with an assumption of emotionally exclusivity), and the way attractions or feelings for others were positioned as an unexpected threat within this context; the second encompassed four themes and eight sub-themes exploring modern contradictions (which problematized the quality of the relationship or the ‘maturity’ of those within it, rather than the attractions or feelings), and the way attractions or feelings for others were positioned as ‘only natural’ or even positive agents of change. This process of candidate theme development was still explorative and inductive, as I worked closely with the coded data and had only brief engagement with potentially relevant theoretical literature at this stage. Further engagement with contextually relevant literature, and a deductive integration of it into the analysis, was developed in the next phases.
Phases 4 and 5, revising and defining themes : My process of revising and defining themes started by using a macro (that was developed for this project) to export all of my initial codes and their associated excerpts into a single master sheet in Microsoft Excel, with columns indicating the source interview for each excerpt, as well as relevant participant demographic information (e.g. age, gender, relationship as monogamous or non-monogamous). This master sheet contained 6006 coded excerpts. In two new columns (one for themes and one for sub-themes), I ‘tagged’ excerpts relevant to my candidate analysis by writing the themes and/or sub-themes that they fit into. I was then able to export these excerpts, using the macro designed for this project, sorting the relevant data for each theme and sub-theme into separate tabs. I then reviewed all the excerpts for each individual theme and sub-theme, which allowed me to revise and define my candidate themes into my first full thematic analysis for the writing phase.
The thematic analysis at this stage included 13 themes and seven sub-themes, and these differed from the original candidate themes in a number of ways. In reviewing the collated data, I noted that some sub-themes were nuanced and prominent enough to be promoted to themes; the sub-theme ‘stay or go? (partner or other)’, for example, became the theme ‘you have to choose’. Similarly, I found other themes or sub-themes to be ‘thin’, and either removed them, or integrated them into other parts of the analysis; the sub-theme roughly titled ‘families at stake (marriage, children)’, for example, became a smaller part of the ‘safety in exclusivity’ theme. I also noted that the first overarching theme in the candidate analysis was ‘messy’, and in an effort to improve focus and clarity, I split this first overarching theme into three new ones, each with its own “central organizing concept” (Braun et al., 2019, p. 48): the first evidenced the contemporary relational context as one of default monogamy with an idealization of exclusivity; the second evidenced infidelity as an unforgivable offence, while associating attractions or feelings for others with this threat of infidelity; the third evidenced discourses in which someone must be to blame (either the person with the feelings or their partner). The second half of the candidate analysis became a fourth and final overarching theme, which encompassed a revised list of themes evidencing favourable talk of attractions or feelings for others.
Phase 6, writing the report : In writing my first draft of my analysis, I developed an even deeper sense of which themes and sub-themes were ‘falling into place’, and which did not fit so well with the overall analysis. At this point I was also engaging in a deeper exploration of relevant literature, and writing my chapter on the context of sexuality and relationships, which provided a foundation of theoretical knowledge that I could deductively integrate into my analysis. Through a process of supervisor feedback on my initial draft, engagement with literature, and revision of the data, I developed the analysis into the final thematic structure. My initial research question of ‘how do people make sense of attractions or feelings for others in committed relationships?’ also developed into three final research questions, each of which is explored across the three overarching themes of the final analysis:
Upon revision, both of the first two overarching themes from the second (revised) thematic map (‘the safety of default monogamy’ and ‘the danger of infidelity’) involved themes and sub-themes which situated attractions or feelings for others within the dominant contemporary relational context. I combined relevant parts of these into one overarching theme in the final analysis, which explored the research question: What is the contemporary relational context, and how are attractions or feelings for others made sense of within that context? Two themes and five sub-themes together evidenced attractions or feelings for others as a threat (by association with infidelity) within the mononormative sociocultural context.
The third overarching theme from the second (revised) thematic map (‘there’s gotta be someone to blame’) did not require much revision to fit with the final analysis. I refined information that was too similar or redundant in the original analysis, such as the sub-themes ‘partner is flawed’ and ‘deficit in partner’ which were combined into one sub-theme. I also added a third theme, ‘the relationship was wrong’, from a later part of the original analysis, as this also fit with the central organizing concept of wrongness and accountability. Together, these three themes and two sub-themes formed the second overarching theme of the final analysis, exploring the question: What accountabilities are at stake with attractions or feelings for others in committed relationships? This chapter also explores the affective consequences of these attributed accountabilities, as described by participants and interpreted by myself as researcher.
I revised and developed the final overarching theme most, in contrast to the analysis previously done, as my process of writing, feedback, and revision demonstrated that this section was the least coherent, and the central organizing concept required development. There were various themes and sub-themes across the initial analysis that explored imperatives or choices that were either made or recommended by participants. These parts of the original analysis were combined to produce the third overarching theme of the final analysis, including four (contradictory) themes and four sub-themes exploring the research question: How do people navigate, or recommend navigating, attractions or feelings for others?.
Combined, these three final overarching themes tell a story of (dominant or ‘normative’) initial sense making of attractions or feelings for others, subsequent attributions of accountability, and various (often contradictory and moralized) ways these feelings are navigated. Braun and Clarke (2006) describe thematic analysis as an active production of knowledge by the researcher, as themes aren’t ‘discovered’ or a pre-existing form of knowledge that will ‘emerge’, but rather patterns that a researcher identifies through their perspective of the data. My thematic analysis was influenced by my own social context, experiences, and theoretical positioning. In the context of critical research, ethical considerations are often complex, and researcher reflexivity is a crucial part of the process (Bott, 2010; L. Finlay, 2002; Lafrance & Wigginton, 2019; Mauthner & Doucet, 2003; Price, 1996; Teo, 2019; Weatherall et al., 2002). As the theoretical foundation of this thematic analysis was a combination of critical realism and critical feminist psychology, I engaged in an ongoing consideration of ethics and reflexivity throughout my data collection and analysis, which I discuss in the following section.
Bird, C. M. (2005). How I stopped dreading and learned to love transcription. Qualitative Inquiry , 11 (2), 226–248.
Bott, E. (2010). Favourites and others: Reflexivity and the shaping of subjectivities and data in qualitative research. Qualitative Research , 10 (2), 159–173.
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology , 3 (2), 77–101.
Braun, V., & Clarke, V. (2012). Thematic analysis. In H. Cooper, P. M. Camic, D. L. Long, A. T. Panter, D. Rindskopf, & K. J. Sher (Eds.), APA Handbook of Research Methods in Psychology (Vol. 2: Research Designs: Quantitative, qualitative, neuropsychological, and biological, pp. 57-71). APA books.
Braun, V., & Clarke, V. (2013). Successful qualitative research: A practical guide for beginners . Sage.
Braun, V., Clarke, V., Hayfield, N., & Terry, G. (2019). Thematic analysis. In P. Liamputtong (Ed.), Handbook of Research Methods in Health Social Sciences (pp. 843-860). Springer.
Finlay, L. (2002). “Outing” the researcher: The provenance, process, and practice of reflexivity. Qualitative Health Research , 12 (4), 531–545.
Lafrance, M. N., & Wigginton, B. (2019). Doing critical feminist research: A Feminism & Psychology reader. Feminism & Psychology , 29 (4), 534–552.
Mauthner, N. S., & Doucet, A. (2003). Reflexive accounts and accounts of reflexivity in qualitative data analysis. Sociology , 37 (3), 413–431.
Price, J. (1996). Snakes in the swamp: Ethical issues in qualitative research. In R. Josselson (Ed.), Ethics and Process in the Narrative Study of Lives (pp. 207–215). Sage.
Riessman, C. K. (1993). Narrative analysis . Sage.
Teo, T. (2019). Beyond reflexivity in theoretical psychology: From philosophy to the psychological humanities. In T. Teo (Ed.), Re-envisioning Theoretical Psychology (pp. 273–288). Palgrave Macmillan.
Weatherall, A., Gavey, N., & Potts, A. (2002). So whose words are they anyway? Feminism & Psychology , 12 (4), 531–539.
The following sections are by Lucie Wheeler, from her UWE Counselling Psychology Professional Doctorate thesis – “It’s such a hard and lonely journey”: Women’s experiences of perinatal loss and the subsequent pregnancy .
Data from the qualitative surveys and interviews were analysed using reflexive thematic analysis within a contextualist approach, as this allows the flexibility of combining multiple sources of data (Braun & Clarke, 2006; 2020). Both forms of data provided accounts of perinatal experiences, and therefore were considered as one whole data set throughout analysis, rather than analysed separately. The inclusion of data from different perspectives, by not limiting the type of perinatal loss experienced, and offering multiple ways to engage with the research, allowed a rich understanding of the experiences being studied (Polkinghorne, 2005). However, despite the data providing a rich and complex picture of the participants’ experiences, I acknowledge that any understanding that has developed though this analysis can only ever be partial, and therefore does not aim to completely capture the phenomenon under scrutiny (Tracy, 2010). An inductive approach was taken to analysis, working with the data from the bottom-up (Braun & Clarke, 2013), exploring the perspectives of the participants, whilst also examining the contexts from which the data were produced. Through the analysis I sought to identify patterns across the data in order to tell a story about the journey through loss and the next pregnancy. The six phases of Braun and Clarke’s (2006; 2020) reflexive thematic analysis were used through an iterative process, in the following ways:
Phase 1 – Data familiarisation and writing familiarisation notes:
By conducting every aspect of the data collection myself, from developing the interview schedule and survey questions, to carrying out the face-to-face interviews, and then transcribing them, I was immersed in the data from the outset. Particularly for the interviews, the experience allowed me to engage with participants, build rapport, explore their stories with them, and then listen to each interview multiple times through the transcription process. I therefore felt familiar with the interview data before actively engaging with analysis. I found the process of transcribing the interviews a particularly useful way to engage with the data, as it slowed the interview process down, with a need to take in every word, and therefore led me to notice things that hadn’t been apparent when carrying out the interviews. The surveys, as well as the interview transcripts, were read through several times. I used a reflective journal throughout this process to makes notes about anything that came to mind during data collection and transcription. This included personal reflections, what the data had reminded me of, led me to think about, as well as what I noticed about the participant and the way in which they framed their experiences.
Phase 2 – Systematic data coding:
Coding of the data was done initially for the interviews, and then for the survey responses. I began by going line by line through each transcript, paying equal attention to each part of the data, and applying codes to anything identified as meaningful. The majority of coding was semantic, sticking closely to the participants’ understanding of their own experiences, however, as the process developed, and each transcript was re-visited, some latent coding was applied, that sought to look below the surface level meaning of what participants had said. Again, throughout this process, a reflective journal was used in order to make notes about my own experience of the data, to capture anything I felt may be drawing on my own experience, and to reflect on what I was being drawn to in the data.
Due to the quantity of data (over 70,000 words in the transcripts, and over 23,000 words of survey responses), this was a slow process, and required repeatedly stepping away from the data and coming back to it in a different frame of mind, reviewing data items in a different order, and discussions with peers and supervisors in the process. I noticed that my coding tended to be longer phrases, rather than one-to-two words, as it felt important to maintain some element of context for the codes, particularly as the stories being told had a sense of chronology to them, that seemed related to the way in which experiences were understood. The codes were then collated into a Word document. Writing up the codes in this way separately to the data, it was important to ensure that the codes captured meaning in a way that could be understood in isolation. Therefore, the wording of some of the codes was developed further at this stage. During the coding process I began to notice a number of patterns in the data, so alongside coding, I also developed some rough diagrams of ideas that could later be used in the development of thematic maps.
Phase 3: Generating initial themes from coded and collated data:
The process of generating themes from the data was initially a process of collating the codes from both the interviews and the surveys, and organising them in a way that reflected some of the commonality in what participants had expressed. Despite each of the participants having a unique story to tell, with details specific to their personal context, there was also commonality found in these experiences. Through reflecting on the codes themselves, going back to the data, and using notes and diagrams that had been made throughout the process in my reflective journal, I began to further develop ideas about the patterns that I had developed from the data. Related codes were collated, and developed into potential theme and sub theme ideas. I used thematic maps to develop my thinking, and changed these as my understanding of the data developed. I was conscious that in the development of codes and theme ideas, I wanted to ensure that my analysis was firmly grounded in the data, and therefore, repeatedly returned to the raw data during this process. The use of my reflective notes was also vital at this stage, to ensure that I did not become too fixated on limited ways of seeing the data, but was able to remain open and willing to let initial ideas go.
Phase 4: Developing and reviewing themes:
Theme development was an iterative process of going back and fore between the codes, and the way that patterns had been identified, and the data, collating quotes to illustrate ideas. A number of thematic maps were created that aimed to illustrate the way in which participants made sense of their experiences across the data set, including identifying areas of contradiction and overlap. The use of thematic maps was particularly useful as a visual tool of the way in which different ideas and patterns were connected and related.
Phase 5: Refining, defining and naming themes:
Through the process of developing thematic maps, areas of overlap became evident, which led to further refinement of ideas. There were many possible ways in which the data could be described, and therefore defining and articulating ideas to colleagues and supervisors brought helpful clarity about what could be defined as a theme, where related ideas fitted together into sub themes, and also where separation of ideas was necessary. The theme names were developed once there were clear differences between ideas, and with the use of participants’ quotes where appropriate, in order to keep close links between the themes and the data itself.
Phase 6: Writing the report:
Writing up each theme required further clarity as I sought to articulate ideas, and illustrate these through multiple participant quotes. The process of writing a theme report required further refinement of ideas, and rather than just a final part of the process, still required the iterative process of revisiting earlier phases to ensure that the ideas being presented closely represented the data whilst meeting the research aims. At this stage links were also made to existing literature in order to expand upon patterns identified in the data. Referring to relevant existing literature also helped me to further question my interpretation of the data, and to expand upon my understanding of the participants’ experiences.
Braun, V., & Clarke, V. (2013). Successful qualitative research: A practical guide for beginners . London: SAGE.
Braun, V., & Clarke, V. (2020). One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qualitative Research in Psychology , 1-25. [online first]
Polkinghorne, D. E. (2005). Language and meaning: Data collection in qualitative research. Journal of Counseling Psychology, 52 (2), 137-145.
Tracy, S. J. (2010). Qualitative quality: Eight “big tent” criteria for excellent qualitative research. Qualitative Inquiry, 16 (10), 837.
Intended for healthcare professionals
Qualitative research methods explore and provide deep contextual understanding of real world issues, including people’s beliefs, perspectives, and experiences. Whether through analysis of interviews, focus groups, structured observation, or multimedia data, qualitative methods offer unique insights in applied health services research that other approaches cannot deliver. However, many clinicians and researchers hesitate to use these methods, or might not use them effectively, which can leave relevant areas of inquiry inadequately explored. Thematic analysis is one of the most common and flexible methods to examine qualitative data collected in health services research. This article offers practical thematic analysis as a step-by-step approach to qualitative analysis for health services researchers, with a focus on accessibility for patients, care partners, clinicians, and others new to thematic analysis. Along with detailed instructions covering three steps of reading, coding, and theming, the article includes additional novel and practical guidance on how to draft effective codes, conduct a thematic analysis session, and develop meaningful themes. This approach aims to improve consistency and rigor in thematic analysis, while also making this method more accessible for multidisciplinary research teams.
Through qualitative methods, researchers can provide deep contextual understanding of real world issues, and generate new knowledge to inform hypotheses, theories, research, and clinical care. Approaches to data collection are varied, including interviews, focus groups, structured observation, and analysis of multimedia data, with qualitative research questions aimed at understanding the how and why of human experience. 1 2 Qualitative methods produce unique insights in applied health services research that other approaches cannot deliver. In particular, researchers acknowledge that thematic analysis is a flexible and powerful method of systematically generating robust qualitative research findings by identifying, analysing, and reporting patterns (themes) within data. 3 4 5 6 Although qualitative methods are increasingly valued for answering clinical research questions, many researchers are unsure how to apply them or consider them too time consuming to be useful in responding to practical challenges 7 or pressing situations such as public health emergencies. 8 Consequently, researchers might hesitate to use them, or use them improperly. 9 10 11
Although much has been written about how to perform thematic analysis, practical guidance for non-specialists is sparse. 3 5 6 12 13 In the multidisciplinary field of health services research, qualitative data analysis can confound experienced researchers and novices alike, which can stoke concerns about rigor, particularly for those more familiar with quantitative approaches. 14 Since qualitative methods are an area of specialisation, support from experts is beneficial. However, because non-specialist perspectives can enhance data interpretation and enrich findings, there is a case for making thematic analysis easier, more rapid, and more efficient, 8 particularly for patients, care partners, clinicians, and other stakeholders. A practical guide to thematic analysis might encourage those on the ground to use these methods in their work, unearthing insights that would otherwise remain undiscovered.
Given the need for more accessible qualitative analysis approaches, we present a simple, rigorous, and efficient three step guide for practical thematic analysis. We include new guidance on the mechanics of thematic analysis, including developing codes, constructing meaningful themes, and hosting a thematic analysis session. We also discuss common pitfalls in thematic analysis and how to avoid them.
Qualitative methods are increasingly valued in applied health services research, but multidisciplinary research teams often lack accessible step-by-step guidance and might struggle to use these approaches
A newly developed approach, practical thematic analysis, uses three simple steps: reading, coding, and theming
Based on Braun and Clarke’s reflexive thematic analysis, our streamlined yet rigorous approach is designed for multidisciplinary health services research teams, including patients, care partners, and clinicians
This article also provides companion materials including a slide presentation for teaching practical thematic analysis to research teams, a sample thematic analysis session agenda, a theme coproduction template for use during the session, and guidance on using standardised reporting criteria for qualitative research
In their seminal work, Braun and Clarke developed a six phase approach to reflexive thematic analysis. 4 12 We built on their method to develop practical thematic analysis ( box 1 , fig 1 ), which is a simplified and instructive approach that retains the substantive elements of their six phases. Braun and Clarke’s phase 1 (familiarising yourself with the dataset) is represented in our first step of reading. Phase 2 (coding) remains as our second step of coding. Phases 3 (generating initial themes), 4 (developing and reviewing themes), and 5 (refining, defining, and naming themes) are represented in our third step of theming. Phase 6 (writing up) also occurs during this third step of theming, but after a thematic analysis session. 4 12
Step 1: reading.
All manuscript authors read the data
All manuscript authors write summary memos
Coders perform both data management and early data analysis
Codes are complete thoughts or sentences, not categories
Researchers host a thematic analysis session and share different perspectives
Themes are complete thoughts or sentences, not categories
For use by practicing clinicians, patients and care partners, students, interdisciplinary teams, and those new to qualitative research
When important insights from healthcare professionals are inaccessible because they do not have qualitative methods training
When time and resources are limited
Steps in practical thematic analysis
We present linear steps, but as qualitative research is usually iterative, so too is thematic analysis. 15 Qualitative researchers circle back to earlier work to check whether their interpretations still make sense in the light of additional insights, adapting as necessary. While we focus here on the practical application of thematic analysis in health services research, we recognise our approach exists in the context of the broader literature on thematic analysis and the theoretical underpinnings of qualitative methods as a whole. For a more detailed discussion of these theoretical points, as well as other methods widely used in health services research, we recommend reviewing the sources outlined in supplemental material 1. A strong and nuanced understanding of the context and underlying principles of thematic analysis will allow for higher quality research. 16
Practical thematic analysis is a highly flexible approach that can draw out valuable findings and generate new hypotheses, including in cases with a lack of previous research to build on. The approach can also be used with a variety of data, such as transcripts from interviews or focus groups, patient encounter transcripts, professional publications, observational field notes, and online activity logs. Importantly, successful practical thematic analysis is predicated on having high quality data collected with rigorous methods. We do not describe qualitative research design or data collection here. 11 17
In supplemental material 1, we summarise the foundational methods, concepts, and terminology in qualitative research. Along with our guide below, we include a companion slide presentation for teaching practical thematic analysis to research teams in supplemental material 2. We provide a theme coproduction template for teams to use during thematic analysis sessions in supplemental material 3. Our method aligns with the major qualitative reporting frameworks, including the Consolidated Criteria for Reporting Qualitative Research (COREQ). 18 We indicate the corresponding step in practical thematic analysis for each COREQ item in supplemental material 4.
We encourage all manuscript authors to review the full dataset (eg, interview transcripts) to familiarise themselves with it. This task is most critical for those who will later be engaged in the coding and theming steps. Although time consuming, it is the best way to involve team members in the intellectual work of data interpretation, so that they can contribute to the analysis and contextualise the results. If this task is not feasible given time limitations or large quantities of data, the data can be divided across team members. In this case, each piece of data should be read by at least two individuals who ideally represent different professional roles or perspectives.
We recommend that researchers reflect on the data and independently write memos, defined as brief notes on thoughts and questions that arise during reading, and a summary of their impressions of the dataset. 2 19 Memoing is an opportunity to gain insights from varying perspectives, particularly from patients, care partners, clinicians, and others. It also gives researchers the opportunity to begin to scope which elements of and concepts in the dataset are relevant to the research question.
The concept of data saturation ( box 2 ) is a foundation of qualitative research. It is defined as the point in analysis at which new data tend to be redundant of data already collected. 21 Qualitative researchers are expected to report their approach to data saturation. 18 Because thematic analysis is iterative, the team should discuss saturation throughout the entire process, beginning with data collection and continuing through all steps of the analysis. 22 During step 1 (reading), team members might discuss data saturation in the context of summary memos. Conversations about saturation continue during step 2 (coding), with confirmation that saturation has been achieved during step 3 (theming). As a rule of thumb, researchers can often achieve saturation in 9-17 interviews or 4-8 focus groups, but this will vary depending on the specific characteristics of the study. 23
Braun and Clarke discourage the use of data saturation to determine sample size (eg, number of interviews), because it assumes that there is an objective truth to be captured in the data (sometimes known as a positivist perspective). 20 Qualitative researchers often try to avoid positivist approaches, arguing that there is no one true way of seeing the world, and will instead aim to gather multiple perspectives. 5 Although this theoretical debate with qualitative methods is important, we recognise that a priori estimates of saturation are often needed, particularly for investigators newer to qualitative research who might want a more pragmatic and applied approach. In addition, saturation based, sample size estimation can be particularly helpful in grant proposals. However, researchers should still follow a priori sample size estimation with a discussion to confirm saturation has been achieved.
We describe codes as labels for concepts in the data that are directly relevant to the study objective. Historically, the purpose of coding was to distil the large amount of data collected into conceptually similar buckets so that researchers could review it in aggregate and identify key themes. 5 24 We advocate for a more analytical approach than is typical with thematic analysis. With our method, coding is both the foundation for and the beginning of thematic analysis—that is, early data analysis, management, and reduction occur simultaneously rather than as different steps. This approach moves the team more efficiently towards being able to describe themes.
Coders are the research team members who directly assign codes to the data, reading all material and systematically labelling relevant data with appropriate codes. Ideally, at least two researchers would code every discrete data document, such as one interview transcript. 25 If this task is not possible, individual coders can each code a subset of the data that is carefully selected for key characteristics (sometimes known as purposive selection). 26 When using this approach, we recommend that at least 10% of data be coded by two or more coders to ensure consistency in codebook application. We also recommend coding teams of no more than four to five people, for practical reasons concerning maintaining consistency.
Clinicians, patients, and care partners bring unique perspectives to coding and enrich the analytical process. 27 Therefore, we recommend choosing coders with a mix of relevant experiences so that they can challenge and contextualise each other’s interpretations based on their own perspectives and opinions ( box 3 ). We recommend including both coders who collected the data and those who are naive to it, if possible, given their different perspectives. We also recommend all coders review the summary memos from the reading step so that key concepts identified by those not involved in coding can be integrated into the analytical process. In practice, this review means coding the memos themselves and discussing them during the code development process. This approach ensures that the team considers a diversity of perspectives.
The recommendation to use multiple coders is a departure from Braun and Clarke. 28 29 When the views, experiences, and training of each coder (sometimes known as positionality) 30 are carefully considered, having multiple coders can enhance interpretation and enrich findings. When these perspectives are combined in a team setting, researchers can create shared meaning from the data. Along with the practical consideration of distributing the workload, 31 inclusion of these multiple perspectives increases the overall quality of the analysis by mitigating the impact of any one coder’s perspective. 30
Qualitative analysis software facilitates coding and managing large datasets but does not perform the analytical work. The researchers must perform the analysis themselves. Most programs support queries and collaborative coding by multiple users. 32 Important factors to consider when choosing software can include accessibility, cost, interoperability, the look and feel of code reports, and the ease of colour coding and merging codes. Coders can also use low tech solutions, including highlighters, word processors, or spreadsheets.
To draft effective codes, we recommend that the coders review each document line by line. 33 As they progress, they can assign codes to segments of data representing passages of interest. 34 Coders can also assign multiple codes to the same passage. Consensus among coders on what constitutes a minimum or maximum amount of text for assigning a code is helpful. As a general rule, meaningful segments of text for coding are shorter than one paragraph, but longer than a few words. Coders should keep the study objective in mind when determining which data are relevant ( box 4 ).
Similar to Braun and Clarke’s approach, practical thematic analysis does not specify whether codes are based on what is evident from the data (sometimes known as semantic) or whether they are based on what can be inferred at a deeper level from the data (sometimes known as latent). 4 12 35 It also does not specify whether they are derived from the data (sometimes known as inductive) or determined ahead of time (sometimes known as deductive). 11 35 Instead, it should be noted that health services researchers conducting qualitative studies often adopt all these approaches to coding (sometimes known as hybrid analysis). 3
In practical thematic analysis, codes should be more descriptive than general categorical labels that simply group data with shared characteristics. At a minimum, codes should form a complete (or full) thought. An easy way to conceptualise full thought codes is as complete sentences with subjects and verbs ( table 1 ), although full sentence coding is not always necessary. With full thought codes, researchers think about the data more deeply and capture this insight in the codes. This coding facilitates the entire analytical process and is especially valuable when moving from codes to broader themes. Experienced qualitative researchers often intuitively use full thought or sentence codes, but this practice has not been explicitly articulated as a path to higher quality coding elsewhere in the literature. 6
Example transcript with codes used in practical thematic analysis 36
Depending on the nature of the data, codes might either fall into flat categories or be arranged hierarchically. Flat categories are most common when the data deal with topics on the same conceptual level. In other words, one topic is not a subset of another topic. By contrast, hierarchical codes are more appropriate for concepts that naturally fall above or below each other. Hierarchical coding can also be a useful form of data management and might be necessary when working with a large or complex dataset. 5 Codes grouped into these categories can also make it easier to naturally transition into generating themes from the initial codes. 5 These decisions between flat versus hierarchical coding are part of the work of the coding team. In both cases, coders should ensure that their code structures are guided by their research questions.
A codebook is a shared document that lists code labels and comprehensive descriptions for each code, as well as examples observed within the data. Good code descriptions are precise and specific so that coders can consistently assign the same codes to relevant data or articulate why another coder would do so. Codebook development is iterative and involves input from the entire coding team. However, as those closest to the data, coders must resist undue influence, real or perceived, from other team members with conflicting opinions—it is important to mitigate the risk that more senior researchers, like principal investigators, exert undue influence on the coders’ perspectives.
In practical thematic analysis, coders begin codebook development by independently coding a small portion of the data, such as two to three transcripts or other units of analysis. Coders then individually produce their initial codebooks. This task will require them to reflect on, organise, and clarify codes. The coders then meet to reconcile the draft codebooks, which can often be difficult, as some coders tend to lump several concepts together while others will split them into more specific codes. Discussing disagreements and negotiating consensus are necessary parts of early data analysis. Once the codebook is relatively stable, we recommend soliciting input on the codes from all manuscript authors. Yet, coders must ultimately be empowered to finalise the details so that they are comfortable working with the codebook across a large quantity of data.
After developing the codebook, coders will use it to assign codes to the remaining data. While the codebook’s overall structure should remain constant, coders might continue to add codes corresponding to any new concepts observed in the data. If new codes are added, coders should review the data they have already coded and determine whether the new codes apply. Qualitative data analysis software can be useful for editing or merging codes.
We recommend that coders periodically compare their code occurrences ( box 5 ), with more frequent check-ins if substantial disagreements occur. In the event of large discrepancies in the codes assigned, coders should revise the codebook to ensure that code descriptions are sufficiently clear and comprehensive to support coding alignment going forward. Because coding is an iterative process, the team can adjust the codebook as needed. 5 28 29
Researchers should generally avoid reporting code counts in thematic analysis. However, counts can be a useful proxy in maintaining alignment between coders on key concepts. 26 In practice, therefore, researchers should make sure that all coders working on the same piece of data assign the same codes with a similar pattern and that their memoing and overall assessment of the data are aligned. 37 However, the frequency of a code alone is not an indicator of its importance. It is more important that coders agree on the most salient points in the data; reviewing and discussing summary memos can be helpful here. 5
Researchers might disagree on whether or not to calculate and report inter-rater reliability. We note that quantitative tests for agreement, such as kappa statistics or intraclass correlation coefficients, can be distracting and might not provide meaningful results in qualitative analyses. Similarly, Braun and Clarke argue that expecting perfect alignment on coding is inconsistent with the goal of co-constructing meaning. 28 29 Overall consensus on codes’ salience and contributions to themes is the most important factor.
Themes are meta-constructs that rise above codes and unite the dataset ( box 6 , fig 2 ). They should be clearly evident, repeated throughout the dataset, and relevant to the research questions. 38 While codes are often explicit descriptions of the content in the dataset, themes are usually more conceptual and knit the codes together. 39 Some researchers hypothesise that theme development is loosely described in the literature because qualitative researchers simply intuit themes during the analytical process. 39 In practical thematic analysis, we offer a concrete process that should make developing meaningful themes straightforward.
According to Braun and Clarke, a theme “captures something important about the data in relation to the research question and represents some level of patterned response or meaning within the data set.” 4 Similarly, Braun and Clarke advise against themes as domain summaries. While different approaches can draw out themes from codes, the process begins by identifying patterns. 28 35 Like Braun and Clarke and others, we recommend that researchers consider the salience of certain themes, their prevalence in the dataset, and their keyness (ie, how relevant the themes are to the overarching research questions). 4 12 34
Use of themes in practical thematic analysis
After coding all the data, each coder should independently reflect on the team’s summary memos (step 1), the codebook (step 2), and the coded data itself to develop draft themes (step 3). It can be illuminating for coders to review all excerpts associated with each code, so that they derive themes directly from the data. Researchers should remain focused on the research question during this step, so that themes have a clear relation with the overall project aim. Use of qualitative analysis software will make it easy to view each segment of data tagged with each code. Themes might neatly correspond to groups of codes. Or—more likely—they will unite codes and data in unexpected ways. A whiteboard or presentation slides might be helpful to organise, craft, and revise themes. We also provide a template for coproducing themes (supplemental material 3). As with codebook justification, team members will ideally produce individual drafts of the themes that they have identified in the data. They can then discuss these with the group and reach alignment or consensus on the final themes.
The team should ensure that all themes are salient, meaning that they are: supported by the data, relevant to the study objectives, and important. Similar to codes, themes are framed as complete thoughts or sentences, not categories. While codes and themes might appear to be similar to each other, the key distinction is that the themes represent a broader concept. Table 2 shows examples of codes and their corresponding themes from a previously published project that used practical thematic analysis. 36 Identifying three to four key themes that comprise a broader overarching theme is a useful approach. Themes can also have subthemes, if appropriate. 40 41 42 43 44
Example codes with themes in practical thematic analysis 36
After each coder has independently produced draft themes, a carefully selected subset of the manuscript team meets for a thematic analysis session ( table 3 ). The purpose of this session is to discuss and reach alignment or consensus on the final themes. We recommend a session of three to five hours, either in-person or virtually.
Example agenda of thematic analysis session
The composition of the thematic analysis session team is important, as each person’s perspectives will shape the results. This group is usually a small subset of the broader research team, with three to seven individuals. We recommend that primary and senior authors work together to include people with diverse experiences related to the research topic. They should aim for a range of personalities and professional identities, particularly those of clinicians, trainees, patients, and care partners. At a minimum, all coders and primary and senior authors should participate in the thematic analysis session.
The session begins with each coder presenting their draft themes with supporting quotes from the data. 5 Through respectful and collaborative deliberation, the group will develop a shared set of final themes.
One team member facilitates the session. A firm, confident, and consistent facilitation style with good listening skills is critical. For practical reasons, this person is not usually one of the primary coders. Hierarchies in teams cannot be entirely flattened, but acknowledging them and appointing an external facilitator can reduce their impact. The facilitator can ensure that all voices are heard. For example, they might ask for perspectives from patient partners or more junior researchers, and follow up on comments from senior researchers to say, “We have heard your perspective and it is important; we want to make sure all perspectives in the room are equally considered.” Or, “I hear [senior person] is offering [x] idea, I’d like to hear other perspectives in the room.” The role of the facilitator is critical in the thematic analysis session. The facilitator might also privately discuss with more senior researchers, such as principal investigators and senior authors, the importance of being aware of their influence over others and respecting and eliciting the perspectives of more junior researchers, such as patients, care partners, and students.
To our knowledge, this discrete thematic analysis session is a novel contribution of practical thematic analysis. It helps efficiently incorporate diverse perspectives using the session agenda and theme coproduction template (supplemental material 3) and makes the process of constructing themes transparent to the entire research team.
We recommend beginning the results narrative with a summary of all relevant themes emerging from the analysis, followed by a subheading for each theme. Each subsection begins with a brief description of the theme and is illustrated with relevant quotes, which are contextualised and explained. The write-up should not simply be a list, but should contain meaningful analysis and insight from the researchers, including descriptions of how different stakeholders might have experienced a particular situation differently or unexpectedly.
In addition to weaving quotes into the results narrative, quotes can be presented in a table. This strategy is a particularly helpful when submitting to clinical journals with tight word count limitations. Quote tables might also be effective in illustrating areas of agreement and disagreement across stakeholder groups, with columns representing different groups and rows representing each theme or subtheme. Quotes should include an anonymous label for each participant and any relevant characteristics, such as role or gender. The aim is to produce rich descriptions. 5 We recommend against repeating quotations across multiple themes in the report, so as to avoid confusion. The template for coproducing themes (supplemental material 3) allows documentation of quotes supporting each theme, which might also be useful during report writing.
Visual illustrations such as a thematic map or figure of the findings can help communicate themes efficiently. 4 36 42 44 If a figure is not possible, a simple list can suffice. 36 Both must clearly present the main themes with subthemes. Thematic figures can facilitate confirmation that the researchers’ interpretations reflect the study populations’ perspectives (sometimes known as member checking), because authors can invite discussions about the figure and descriptions of findings and supporting quotes. 46 This process can enhance the validity of the results. 46
In supplemental material 4, we provide additional guidance on reporting thematic analysis consistent with COREQ. 18 Commonly used in health services research, COREQ outlines a standardised list of items to be included in qualitative research reports ( box 7 ).
We note that use of COREQ or any other reporting guidelines does not in itself produce high quality work and should not be used as a substitute for general methodological rigor. Rather, researchers must consider rigor throughout the entire research process. As the issue of how to conceptualise and achieve rigorous qualitative research continues to be debated, 47 48 we encourage researchers to explicitly discuss how they have looked at methodological rigor in their reports. Specifically, we point researchers to Braun and Clarke’s 2021 tool for evaluating thematic analysis manuscripts for publication (“Twenty questions to guide assessment of TA [thematic analysis] research quality”). 16
Awareness of common mistakes can help researchers avoid improper use of qualitative methods. Improper use can, for example, prevent researchers from developing meaningful themes and can risk drawing inappropriate conclusions from the data. Braun and Clarke also warn of poor quality in qualitative research, noting that “coherence and integrity of published research does not always hold.” 16
An important distinction between high and low quality themes is that high quality themes are descriptive and complete thoughts. As such, they often contain subjects and verbs, and can be expressed as full sentences ( table 2 ). Themes that are simply descriptive categories or topics could fail to impart meaningful knowledge beyond categorisation. 16 49 50
Researchers will often move from coding directly to writing up themes, without performing the work of theming or hosting a thematic analysis session. Skipping concerted theming often results in themes that look more like categories than unifying threads across the data.
Because data collection for qualitative research is often semi-structured (eg, interviews, focus groups), not all data will be directly relevant to the research question at hand. To avoid unfocused analysis and a correspondingly unfocused manuscript, we recommend that all team members keep the research objective in front of them at every stage, from reading to coding to theming. During the thematic analysis session, we recommend that the research question be written on a whiteboard so that all team members can refer back to it, and so that the facilitator can ensure that conversations about themes occur in the context of this question. Consistently focusing on the research question can help to ensure that the final report directly answers it, as opposed to the many other interesting insights that might emerge during the qualitative research process. Such insights can be picked up in a secondary analysis if desired.
Presenting findings quantitatively (eg, “We found 18 instances of participants mentioning safety concerns about the vaccines”) is generally undesirable in practical thematic analysis reporting. 51 Descriptive terms are more appropriate (eg, “participants had substantial concerns about the vaccines,” or “several participants were concerned about this”). This descriptive presentation is critical because qualitative data might not be consistently elicited across participants, meaning that some individuals might share certain information while others do not, simply based on how conversations evolve. Additionally, qualitative research does not aim to draw inferences outside its specific sample. Emphasising numbers in thematic analysis can lead to readers incorrectly generalising the findings. Although peer reviewers unfamiliar with thematic analysis often request this type of quantification, practitioners of practical thematic analysis can confidently defend their decision to avoid it. If quantification is methodologically important, we recommend simultaneously conducting a survey or incorporating standardised interview techniques into the interview guide. 11
Researchers should concertedly consider group dynamics in the research team. Particular attention should be paid to power relations and the personality of team members, which can include aspects such as who most often speaks, who defines concepts, and who resolves disagreements that might arise within the group. 52
The perspectives of patient and care partners are particularly important to cultivate. Ideally, patient partners are meaningfully embedded in studies from start to finish, not just for practical thematic analysis. 53 Meaningful engagement can build trust, which makes it easier for patient partners to ask questions, request clarification, and share their perspectives. Professional team members should actively encourage patient partners by emphasising that their expertise is critically important and valued. Noting when a patient partner might be best positioned to offer their perspective can be particularly powerful.
Researchers must allocate enough time to complete thematic analysis. Working with qualitative data takes time, especially because it is often not a linear process. As the strength of thematic analysis lies in its ability to make use of the rich details and complexities of the data, we recommend careful planning for the time required to read and code each document.
Estimating the necessary time can be challenging. For step 1 (reading), researchers can roughly calculate the time required based on the time needed to read and reflect on one piece of data. For step 2 (coding), the total amount of time needed can be extrapolated from the time needed to code one document during codebook development. We also recommend three to five hours for the thematic analysis session itself, although coders will need to independently develop their draft themes beforehand. Although the time required for practical thematic analysis is variable, teams should be able to estimate their own required effort with these guidelines.
Practical thematic analysis builds on the foundational work of Braun and Clarke. 4 16 We have reframed their six phase process into three condensed steps of reading, coding, and theming. While we have maintained important elements of Braun and Clarke’s reflexive thematic analysis, we believe that practical thematic analysis is conceptually simpler and easier to teach to less experienced researchers and non-researcher stakeholders. For teams with different levels of familiarity with qualitative methods, this approach presents a clear roadmap to the reading, coding, and theming of qualitative data. Our practical thematic analysis approach promotes efficient learning by doing—experiential learning. 12 29 Practical thematic analysis avoids the risk of relying on complex descriptions of methods and theory and places more emphasis on obtaining meaningful insights from those close to real world clinical environments. Although practical thematic analysis can be used to perform intensive theory based analyses, it lends itself more readily to accelerated, pragmatic approaches.
Our approach is designed to smooth the qualitative analysis process and yield high quality themes. Yet, researchers should note that poorly performed analyses will still produce low quality results. Practical thematic analysis is a qualitative analytical approach; it does not look at study design, data collection, or other important elements of qualitative research. It also might not be the right choice for every qualitative research project. We recommend it for applied health services research questions, where diverse perspectives and simplicity might be valuable.
We also urge researchers to improve internal validity through triangulation methods, such as member checking (supplemental material 1). 46 Member checking could include soliciting input on high level themes, theme definitions, and quotations from participants. This approach might increase rigor.
We hope that by providing clear and simple instructions for practical thematic analysis, a broader range of researchers will be more inclined to use these methods. Increased transparency and familiarity with qualitative approaches can enhance researchers’ ability to both interpret qualitative studies and offer up new findings themselves. In addition, it can have usefulness in training and reporting. A major strength of this approach is to facilitate meaningful inclusion of patient and care partner perspectives, because their lived experiences can be particularly valuable in data interpretation and the resulting findings. 11 30 As clinicians are especially pressed for time, they might also appreciate a practical set of instructions that can be immediately used to leverage their insights and access to patients and clinical settings, and increase the impact of qualitative research through timely results. 8
Practical thematic analysis is a simplified approach to performing thematic analysis in health services research, a field where the experiences of patients, care partners, and clinicians are of inherent interest. We hope that it will be accessible to those individuals new to qualitative methods, including patients, care partners, clinicians, and other health services researchers. We intend to empower multidisciplinary research teams to explore unanswered questions and make new, important, and rigorous contributions to our understanding of important clinical and health systems research.
All members of the Coproduction Laboratory provided input that shaped this manuscript during laboratory meetings. We acknowledge advice from Elizabeth Carpenter-Song, an expert in qualitative methods.
Coproduction Laboratory group contributors: Stephanie C Acquilano ( http://orcid.org/0000-0002-1215-5531 ), Julie Doherty ( http://orcid.org/0000-0002-5279-6536 ), Rachel C Forcino ( http://orcid.org/0000-0001-9938-4830 ), Tina Foster ( http://orcid.org/0000-0001-6239-4031 ), Megan Holthoff, Christopher R Jacobs ( http://orcid.org/0000-0001-5324-8657 ), Lisa C Johnson ( http://orcid.org/0000-0001-7448-4931 ), Elaine T Kiriakopoulos, Kathryn Kirkland ( http://orcid.org/0000-0002-9851-926X ), Meredith A MacMartin ( http://orcid.org/0000-0002-6614-6091 ), Emily A Morgan, Eugene Nelson, Elizabeth O’Donnell, Brant Oliver ( http://orcid.org/0000-0002-7399-622X ), Danielle Schubbe ( http://orcid.org/0000-0002-9858-1805 ), Gabrielle Stevens ( http://orcid.org/0000-0001-9001-178X ), Rachael P Thomeer ( http://orcid.org/0000-0002-5974-3840 ).
Contributors: Practical thematic analysis, an approach designed for multidisciplinary health services teams new to qualitative research, was based on CHS’s experiences teaching thematic analysis to clinical teams and students. We have drawn heavily from qualitative methods literature. CHS is the guarantor of the article. CHS, AS, CvP, AMK, JRK, and JAP contributed to drafting the manuscript. AS, JG, CMM, JAP, and RWY provided feedback on their experiences using practical thematic analysis. CvP, LCL, SLB, AVC, GE, and JKL advised on qualitative methods in health services research, given extensive experience. All authors meaningfully edited the manuscript content, including AVC and RKS. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.
Funding: This manuscript did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Competing interests: All authors have completed the ICMJE uniform disclosure form at https://www.icmje.org/disclosure-of-interest/ and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Not commissioned; externally peer reviewed.
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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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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.
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.
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.
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).
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
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’.
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.
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.
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 ).
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
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 ).
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
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).
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.
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.
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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Childhood obesity is a major concern in today's society. Research suggests the inclusion of the views and understandings of a target group facilitates strategies that have better efficacy. The objective of this study was to explore the concepts and themes that make up children's understandings of the causes and consequences of obesity. Participants were selected from Reception (4–5 years old) and Year 6 (10–11 years old), and attended a school in an area of Sunderland, in North East England. Participants were separated according to age and gender, resulting in four focus groups, run across two sessions. A thematic analysis (Braun & Clarke, 2006) identified overarching themes evident across all groups, suggesting the key concepts that contribute to children's understandings of obesity are “Knowledge through Education,” “Role Models,” “Fat is Bad,” and “Mixed Messages.” The implications of these findings and considerations of the methodology are discussed in full.
The Health Survey for England 2009 illustrated that 65.9% of men and 56.9% of women have a body mass index (BMI) higher than 25 kg/m 2 , classing them as overweight, obese (>30 kg/m 2 ), or morbidly obese (>40 kg/m 2 ). Obesity is linked to many chronic illnesses, including type II diabetes, heart disease, and some cancers—specifically bowel and others within the digestive system (Renehan, Tyson, Egger, Heller, & Zwahlen, 2008 ). As a result, the direct cost to the National Health Service (NHS) of treating obesity was estimated to be between £991 and £1,124 million, for the 2001/2002 financial year (McCormick & Stone, 2007 ).
Childhood obesity is of particular concern because obese children are far more likely than children of a normal weight to become obese adults (Alexander & Sherman, 1991 ). The Health Survey for England 2009 showed that between 1995 and 2008, the percentage of overweight and obese girls rose from 25.5 to 29.2% and from 24.5 to 31.4% for boys. This is despite the fact that during the same period reported total energy intake in the United Kingdom (UK) fell by around 20% (Statistics on Obesity, Physical Activity and Diet England, 2006 ). These contradictory figures highlight the complexity of factors contributing to obesity, pointing to issues such as levels of physical activity, which have significantly fallen over the past two decades (Prentice & Jebb, 1995 ).
Many other factors influence incidences of obesity. The negative impact of childhood obesity causes the greatest concern and needs to be further understood. Obese children are more likely to become obese adults and experience increased health problems. Knowler, Pettitt, and Saad ( 1991 ), highlighted the links between childhood obesity and a poor immune system, risk of raised blood pressure, and cardiovascular problems. Studies have also identified that overweight and obese children are more likely to suffer psychological problems associated with low self-esteem, bullying, and social exclusion (Breat, Mervielde, & Vandereycken, 1997 ).
On an international scale, obesity can be seen as a problem of the developed world, a result of economic wealth, high food availability, and low levels of manual labour leading to lower levels of physical activity. This is in conjunction with high levels of car ownership and wide ranging public transport systems adding to the problem. In short, at the heart of obesity lies a homeostatic biological system that works constantly to maintain energy balance to keep the body at a constant weight. This system has not yet adapted to the world in which we currently live because the pace of technological progress has surpassed evolution resulting in a more sedentary lifestyle (Department of Innovation Universities and Skills, 2007). One surprising feature of the geographical distribution of obesity is its increased prevalence in economically and socially deprived areas in the western world, including the focus of this current piece of research, the United Kingdom. This phenomenon is very much a recent development, because historically deprived areas tended to see higher levels of under-nutrition. Brunt, Lester, Davies, and Williams ( 2008 ) illustrate how this situation has now reversed. They found between 1995 and 2005 the gap between obesity levels in the most deprived areas compared to the least (the latter typically having the higher levels) was steadily closing, and that by 2005 obesity levels in the most deprived areas had overtaken those in the least deprived areas, a phenomena that persists today.
The Childhood Measurement Programme (Department of Health and Department for Children, Schools and Families, 2008 ) demonstrated Sunderland in the north-east of England has some of the highest levels of overweight and obese children in the United Kingdom. This same publication also points out the strong positive correlation between areas considered as deprived and levels of obesity in children in Reception (4–5 year olds) and Year 6 (10–11 year olds). Areas of Sunderland are considered to be economically and socially deprived meaning the children who live there can be considered high risk. The statistics relating to Sunderland, where this study took place, demonstrate that 27.8% of Reception-aged children are either overweight or obese and for Year 6 pupils this rises to 38.4%.
The Foresight Report (Department of Innovation Universities and Skills, 2007), tackling obesity, points out that current policies are failing because they do not provide the depth and range of interventions needed. This might lead to positive interventions being ineffective if they are undermined by other areas in society such as social factors and the power of media advertising. The government launched its Healthy Schools Initiative in 2005; however, there has been no substantial reduction in obesity levels since 2005 (Department of Health and Department for Children, Schools and Families, 2008). With this in mind it would seem timely to approach the problem from a different perspective. Effective policies to tackle obesity need to consider all parties involved. However, current policies have been formed using a top down approach i.e., from government, health and education professionals, and even celebrity chefs! Even though these groups are likely to have a broad understanding of the problem from its roots to the long-term consequences, there has been a notable failure to take into consideration the understandings of the individuals at highest risk of obesity, the children themselves. There is growing evidence that interventions incorporating the views of the target population have a greater level of success (Hesketh, Water, Green, Salmon, & Williams, 2005). In the United Kingdom there has been a strong movement to ensure the inclusion of children in decision making particularly in relation to issues that directly affect them such as education, social care, and health (Department of Health, 2002 ; Department of Health and Department for Education and Skills, 2004 ). The collection and dissemination of the understandings of children relating to obesity could provide an insight into why so many strategies are failing. This in turn could lead to the development of policies that can be delivered to provide more successful outcomes.
There is a clear shortage of research examining children's understandings’ of obesity, the studies that have attempted to explore this domain have focused on exploring parent and care giver perceptions (Young-Hyman, Herman, Scott, & Schlundt, 1999), and the understandings of health professionals (Chamberlin, Sherman, Jain, Powers, & Whitaker, 2002 ). More recently studies have considered the understandings of care givers, health professionals, and teachers alongside those of the children themselves (Borra, Kelly, Shirreffs, Neville, & Geiger, 2003; Hesketh et al., 2005). Studies that have examined children's understanding have been focused on body image, overweight versus underweight (Hill & Silver, 1995 ), and peer perceptions of overweight and eating behaviour (Bell & Morgan, 2000 ; Oliver & Thelen, 1996 ), but not on the understandings’ of the children themselves with regards to the causes and consequences of obesity.
Focus groups have proved to be a particularly useful method for collecting data from children, they are most effective with groups of three children and in situations where the children know and like each other. Groups must be carefully selected to ensure the children are comfortable with each other. Talking together in small groups is familiar territory for children because it simulates class work. This method allows the researcher to structure the discussion around themes or topics rather than direct questions. This in turn enables the children to take control of the discussion (Mauthner, 1997 ) with the researcher present to keep things on track. Conducting group discussions in single sex groups can also prove to be more successful because boys are often louder and more willing to talk and this can mean they direct the topic of conversation. It has also been noted the use of some sort of structured activity such as drawing, reading, or sorting cards, can help focus discussion in particular with young children. When discussing diet with children, nutritionists and dieticians regularly use replica food items to help visualise the topic under discussion and photos depicting scenes of physical activity have proved effective in qualitative studies (Hesketh et al., 2005 ).
In summary the objective of this research is to investigate the understandings of a high risk group of children (high risk because of their socio-economic status so determined by their locality), of some of the causes and consequences of obesity, and its links to diet and physical activity. The concepts and themes generated by this research should be used to provide an insight that may inform local policies and interventions that need to be developed to provide a broader and deeper range of options to address this multi-faceted issue.
In order to address the gaps in current literature it was decided this research should focus on identifying themes within the participants understanding. This would provide the researcher with scope for further investigation of the subject in question. It was therefore decided that the most appropriate method of analysis would be a thematic analysis. However, there have been criticisms of this approach in the past due to the lack of clear guidelines for researchers employing such methods. This has subsequently contributed to some researchers omitting “how” they actually analysed their results (Attride-Stirling, 2001 ). It was of upmost importance to the authors in this current study to employ a clear, replicable, and transparent methodology.
Braun and Clarke ( 2006 ) outline a series of phases through which researchers must pass in order to produce a thematic analysis. This procedure allows a clear demarcation of thematic analysis, providing researchers with a well-defined explanation of what it is and how it is carried out whilst maintaining the “flexibility” tied to its epistemological position. The authors in this paper take a position that acknowledges our desire to incorporate the individual experiences of the participants and the meanings they attach to them. However, we also wish to consider the impact of the wider social context on these meanings. Braun and Clarke describe such a position as “contextualist,” sitting firmly between essentialism or realism and constuctionism. Not all theorists describe these two poles of epistemological outlook in the same way; Madill et al. ( 2000 ) refers to them as “naive realist” and “radical relativist.” Methodologies that go hand in hand with this mid-ground position are typically phenomenological in nature, but the flexibility of thematic analysis means that it can also be underpinned by an “in-between” epistemological position. Willig ( 2008 , p. 13) summarises this by explaining a position that argues “while experience is always the product of interpretation and, therefore, constructed (and flexible) … it is nevertheless ‘real’ to the person who is having the experience.” We wish to consider the reality of obesity to the participants, through an exploration of their experiences and the meanings they attach to them, whilst incorporating the broader role society plays in contributing to and shaping the participants meaning making and subsequent understandings.
Twelve participants were selected through liaising with the school and class teachers, this was particularly important considering the sensitive nature of the research topic and the fact that the participants taking part in this study were children—a vulnerable group. Measures were taken to prevent any of the participants feeling stigmatised. Therefore, under the guidance of the class teachers, the participants approached to take part in the study were carefully selected to ensure no children who may have been made to feel uncomfortable by the discussion were included, and to make sure that the children selected to be in the same focus groups were comfortable with each other. Six (three boys and three girls) were selected from two school years; Reception, aged between 4 and 5 years and Year 6 aged between 10 and 11. The motivation for selecting these age groups was that government statistics relating to childhood obesity are published for these two age brackets. These age groups are viewed as critical points in measuring children's BMI and in monitoring their changing health status. Through looking at these age groups, it may help us to gain an insight into what understandings children arrive at school with (primarily shaped by their experiences set within a home environment) and those that they have later on in their school life when further social influence (school and peers) may play a role in shaping their understandings. Efforts were made to make the sample representative of ethnicities attending the school so a proportionate number of children of Bangladeshi and Afro-Caribbean heritage took part. Participants were not recruited on account of their BMI or weight status. The parents of the children were provided with a study information letter and, in addition, received a phone call from the school's community liaison officer to ensure that parents fully understood the nature of the study because the researcher was aware that for some parents English was not their first language. The phone calls were made in their mother tongue thus allowing the parents to sign the parental assent form with all their queries being answered. Participants were also asked for their verbal consent on the day prior to the study taking place.
The study had received ethical approval from Northumbria University's School of Psychology and Sports Science Ethics Board prior to commencing. The researcher had also been approved by means of an enhanced criminal records background check clearing her to work with children; this approval was required by both the school and the university.
The focus groups all took place in the same quiet room at the school and were conducted by the principal investigator (referred to herein as the researcher). On arrival, the researcher introduced herself and provided name badges for the participants. The researcher briefly explained to the participants that she was there to talk to them about food and exercise. The researcher also explained to the participants that she wanted them to assume that she knew nothing, they were not being tested, and she was only interested in hearing what they had to say—not whether they were right or wrong. Verbal instructions were provided to the participants and they provided verbal assent prior to the recording commencing. A series of questions were developed by the research team, these were designed to keep the focus group sessions on track whilst exploring issues relevant to the research question. The sessions started initially with a discussion centred on the replica food items laid out on the table. Participants were asked to use the replica food and pick out healthy foods and make what they thought would be a healthy lunch. They were asked to explain why it was healthy and what made it healthy. Participants were then asked about foods they liked and why they liked them. In addition, they were asked about the sorts of things they normally ate at home and in school and things they liked to eat. Once conversation had dwindled concerning the replica food the researcher introduced the laminated picture cards, and the discussion moved to physical activity with the researcher encouraging the participants to explore the relationship between diet and exercise. Questions focussed on what activities they thought were healthy (as the images depicted activities that were both physical and sedentary; that is, one image of somebody running another of somebody playing computer games). The participants were asked about what sorts of activities they liked doing and what made those activities good for them. They were asked what activities they regularly engaged with, the sorts of sports their parents and siblings took part in, and the activities they did as families. The themes of discussion were encouraged around the two elements pertinent to any strategy looking to reduce obesity: healthy eating and physical activity. Furthermore, questions also probed at what the participants thought the benefits were of following a healthy lifestyle and what the consequences were of not following one. They were also asked what advice they would give somebody who wanted to be healthier and how important it was to them to be healthy. The focus group guide was intended to provide a structure but not rigidly dictate the line of questioning. The researcher included prompts and encouraged participants to expand on their initial responses and followed up on notions that the participants raised themselves. The sessions on the first day lasted between 20 and 30 min, ending when the participants input was insufficient to continue. At the end of each session the researcher read out the participant debrief and provided each participant with a parental debrief information sheet to take home.
In order to strengthen the analysis process and gather the most appropriate data, the researchers reviewed the recording made on the first day and reflected on the procedures employed in the focus groups. Similar approaches of reviewing data to informing further data collection are used in methods such as grounded theory and it was felt that doing so would strengthen the current study. The decision was made not to use the props (replica food and cards) used on the first day in the second round of focus groups, as at times they had proved to be a distraction to the participants. As an alternative, Reception children were given colouring pens and paper to focus their attention. Year 6 focus groups were run again allowing for free discussion, following on from issues and understandings they had raised in the initial session. The second round of focus groups, other than the changes already detailed above, followed the same sequence as they had on day one and lasted around 30 min. The recordings were transcribed combining the recordings from both days creating four transcripts, one for each group.
The data collected from all the focus groups was transcribed by the principal investigator, during this process the initial thoughts and ideas were noted down as this is considered an essential stage in analysis (Riessman, 1993 ). The transcribed data was then read and re-read several times and, in addition, the recordings were listened to several times to ensure the accuracy of the transcription. This process of “repeated reading” (Braun & Clarke, 2006 ) and the use of the recordings to listen to the data, results in data immersion and refers to the researcher's closeness with the data. Following on from this initial stage and building on the notes and ideas generated through transcription and data immersion is the coding phase. These codes identified features of the data that the researcher considered pertinent to the research question. Furthermore, as is intrinsic to the method, the whole data set was given equal attention so that full consideration could be given to repeated patterns within the data. The third stage involved searching for themes; these explained larger sections of the data by combining different codes that may have been very similar or may have been considered the same aspect within the data. All initial codes relevant to the research question were incorporated into a theme. Braun and Clarke (2006) also suggest the development of thematic maps to aid the generation of themes. These helped the researchers to visualise and consider the links and relationships between themes. At this point any themes that did not have enough data to support them or were too diverse were discarded. This refinement of the themes took place on two levels, primarily with the coded data ensuring they formed a coherent pattern, secondly once a coherent pattern was formed the themes were considered in relation to the data set as a whole. This ensured the themes accurately reflected what was evident in the data set as a whole (Braun & Clarke, 2006 ). Further coding also took place at this stage to ensure no codes had been missed in the earlier stages. Once a clear idea of the various themes and how they fitted together emerged, analysis moved to phase five. This involves defining and naming the themes, each theme needs to be clearly defined and accompanied by a detailed analysis. Considerations were made not only of the story told within individual themes but how these related to the overall story that was evident within the data. In addition, it was highly important to develop short but punchy names that conveyed an immediate indication of the essence of the theme. The final stage or the report production involved choosing examples of transcript to illustrate elements of the themes. These extracts clearly identified issues within the theme and presented a lucid example of the point being made.
The thematic analysis process that was applied to the transcripts elicited key concepts that were evident in the data. These themes are viewed as essential in determining the understandings of all the participants. These categories have been labelled as “Knowledge through Education,” “Role Models,” “Fat is Bad,” and “Mixed Messages.” There are of course aspects of the participants’ understandings that overlap across these categories. This, however, should be viewed as a good interpretation of understandings and attitudes in general, which are never made up of isolated concepts but are all relative to each other.
This theme is defined by the ability of all the participants to understand the roles of diet and physical activity. This is, in part, likely to be defined by different levels of education that the two age groups represented have, but nothing conclusive can be drawn given the relatively small sample size. The impact of their education on their knowledge will be demonstrated through evidence from the transcript.
All participants in the reception age group expressed the ability to name and identify different food items from the replica food. When they were asked to prepare a healthy lunch from the food items, they were able to point out food that would typically be classified as healthy.
I: No none of it is real! So what have you put in your healthy lunches girls? You tell me what you have got. *: Apple, I've got pasta, egg, cracker, grapes, bun and cheese. Girls reception Open in a separate window
However, despite displaying that they “know” what healthy means there is evidence of confusion, and it would seem the concept of something being “good” for them is interpreted to be things they like to eat. This suggests that they don't yet fully understand the concept of “healthy” food.
I: And why's rice healthy? *: Because it's nice. I: What healthy food do you eat? *: Chips Boys reception Open in a separate window
Their definition of healthy is centred on food they believe will make them grow for which fruit is highlighted as being particularly important. However, they also attribute this property to the food that makes up their personal diets. This understanding might result from being told to eat so they grow up to be big and strong. It is important to consider younger children's understandings are likely to be primarily shaped by their home environment, where the emphasis is often on how much children are eating as opposed to what they are eating.
I: Why is a banana important? *: Because it makes you strong so you can grow you have to have fruit so you can grow. I: Can you tell me then girls, we have found all these things that are good, as an example can you tell me, sausage, why is sausage good? *: Because it makes you feel strong. Girls reception Open in a separate window
This understanding of the reception-aged girls represented in this study of eating so they can grow up to be strong is also evident with the boys in the same age group. However, the reception boys also place great importance on the necessity of exercise to develop strength, this demonstrates another aspect in their knowledge.
I: What about this one here, swimming, who likes swimming? *: Me *: Me *: Me I: And why is swimming good for you? *: Cos it makes you strong. Boys reception Open in a separate window
It is fair to say Year 6 groups relished the opportunity to express their knowledge. They were able to identify and name different food groups and discuss different types of physical activity; what's more they understand the link between the two in relation to obesity. It seems other influences have impacted on the children's understandings’ such as school and extracurricular groups.
*: This is a banana. I: Ok why's a banana healthy? *: Because it's got seeds inside, because it's a fruit. Girls year 6 Open in a separate window
The ability to identify a particular fruit by one of its universal characteristics shows a deeper level of understanding and suggests that a higher degree of learning. In fact it is explicitly stated that this nutritional knowledge has been gained at school.
I: So do you know the different groups of food like carbohydrates, I heard you say protein and dairy before? *: Done it in science. Girls year 6 Open in a separate window
Moreover, it isn't just a nutritional knowledge they have developed through education. They appear well versed in the concept of a balanced diet and also understand the importance of a balanced lifestyle in relation to physical activity. They are able to articulate the notion of a balanced, healthy lifestyle through a consideration of the consequences of over eating and not exercising.
I: So what happens to you if all you do is you do watch TV and play the computer, eat the food that you told me was the bad food, what would happen to you? *: You would have a miserable life. *: Get fat, teeth will fall out. Girls year 6 Open in a separate window
In the case of the Year 6 boys who took part in this study, it is apparent that although a great deal of their knowledge has come through education at school, other avenues have helped them develop different aspects of their understandings. In this case it seems to be through taking part in activities, typically sport outside of school, or and more uniquely to this group through the influence of their fathers.
*: I would say my dad likes fish so I eat fish loads. *: My dad likes chicken, so he gives me chicken cos after school I do sport, like boxing, he gives me a sandwich with loads of different toppings in cos meats a muscle maker and vegetables is like an energy maker, so if you eat those you will get fitter and healthier. Boys year 6 Open in a separate window
It is evident where the ability exists, or is encouraged, to apply knowledge they have in a context relevant to their own lives, the knowledge becomes embedded in their understandings; it is applicable to them and, therefore, moves from being written on the board in school to being important to their own existence. This is exhibited by those participants, in particular the boys who participated, who have an involvement in sport. Having a motivation to understand nutrition and exercise leads to a desire to apply it because they comprehend the potential benefits. This aspect within the initial theme of knowledge through education leads directly on to the next theme of role models. The key difference between these two themes is the first relates to information that is directly and intentionally meant to inform the children about healthy lifestyles in an institutional setting, while the second theme is typified by understandings that are formed through interactions with other people.
The application of knowledge gained through education is often facilitated by role models such as family members who reiterate this information through example. Role models play an important role in the concepts described by all the groups, for example, the older boys reported that their fathers helped encourage healthy behaviours, above and beyond the nutritional knowledge in the previous theme.
*: Like sometimes on an afternoon my dad goes to the gym, then there is these tracks outside, and I practice every day on my 100 meter sprint and I can do it in 12 seconds, and when I started doing it I was 21 second, so I keep practicing. Boys year 6 Open in a separate window
This demonstrates some of the participants’ understandings have developed by examples set for them by significant individuals in their lives. This is evident in the younger children's understandings in a less explicit manner; the example below demonstrates good health behaviours can be established through everyday behaviour exhibited by role models.
I: What about this one, walking to school? … Why is it good for you? *: Because me and my mam walk to school and its good. Girls reception Open in a separate window
There is some evidence that examples set to the girls who took part in this study, at home and by other role models, can encourage behaviours or ideals that are not beneficial to the girls health. Girls appear to look up to older female family members who aspire to be skinny.
*: I like to be skinny, my nana does as well, and she wants to be skinny because she's fat now but I still love her. Girls reception Open in a separate window
They also appear to have developed unrealistic ideas about weight loss and the consequences in terms of treatment. Viewing hospital treatment as a solution to obesity, demonstrates a lack of understanding about the role of lifestyle behaviours in the condition. This may also suggest that these participants don't appreciate the importance of lifestyle behaviours in the onset of obesity.
*: Guess what, I seen this film right the boy was fat right, his legs was right down to the bottom, he had a fat tummy, I was hiding cos I hated him, he was horrible, he will have to go to hospital, he was fat. Girls reception I: So what would you tell somebody if you pretend that I was really, really fat, what would you tell me to do. *: Go to the doctors … hospital, operation. Girls reception Open in a separate window
There was some evidence that the older girls in this study had a more balanced outlook on what sort of body shape was healthiest, because they were aware of the negative health consequences associated with being underweight. It is interesting, however, that they are aware that maintaining a healthy lifestyle may be a challenge and this may result in a barrier to adopting healthier practices.
I: What about the other end of the scale, you know if you've got overweight being fat on this side what about being underweight at this end? *: It's bad cos you're all bony and you can't do anything cos you're not strong enough, you're weak. *: So you need to be in the middle. I: Is it easy to stay in the middle? *: No, because sometimes you can't be bothered to eat well and exercise. Girls year 6 Open in a separate window
Within the theme of role models, there was some evidence of a difference between the genders in terms of available role models. The participating boys often cited football heroes as people whom they looked up to and aspired to be like. This highlights the role of the celebrity in providing a role model for today's children; the evidence from the participants in this study may suggest that typically boys look to footballers and other sporting heroes. It can be argued that such individuals do not always provide a strong moral code; they are seen as following a healthy lifestyle in terms of diet and exercise. It would seem that the female participants in this study often looked up to celebrities who weren't so explicitly seen to be following healthy lifestyles, or a sense of caution was attached to following healthier behaviours.
*: Yeah like Wayne Rooney. I: And why is he fit? *: Cos he's good at footballing. I: Do you think that they have to eat special food? *: Yes I: And what special food do they have to eat? *: Bananas and apples. Boys reception *: Actually you can put weight on running cos muscle weighs more than fat so you can put weight on—like Katie Price she put on 10 pounds cos she started running. Girls year 6 Open in a separate window
Another interesting aspect of the notion of role models’ is that the girls were more concerned with how they appeared in a physical sense; it was particularly striking that the Year 6 boys identified unhealthy behaviour in their female peers attributing this to a desire to be like models.
*: Yes, she wants to be a model so she starves herself, her mam gives her a big packed lunch and she puts most of it in the bin, she's like that skinny then she walks out of the dinner hall. Boys year 6 Open in a separate window
There were many aspects of the transcript that highlighted participants were aware that being underweight was as worrying as being overweight. However, across the board they were far more critical of individuals who were overweight and discussed wide ranging consequences for these individuals, this leads on to the next theme evident in the analysis.
There was a united consensus that being fat was something to avoid, that it was a bad thing, and had typically negative consequences. Elements of this theme have been demonstrated throughout the discussion of the previous two themes; however, this illustrates how their understanding impacts on their attitudes toward obesity.
*: Like all the fat goes through your blood and stuff. *: Like sugar, like all the sugar goes through your blood if you eat too much of it would clog up your arteries and you might die. Boys year 6 I: Like how? What would happen to you? Is something going to happen straight away or is it something that's going to happen to. *: You would get rotten teeth and you would not be as strong as you would be if you ate healthy and stuff. *: You could die. Girls year 6 *: Because fat would be horrible. *: Because it's bad for you, because it looks bad. *: Because people call you big fat. Girls reception Open in a separate window
In addition to the health issues and those relating to physical attractiveness were the issues of bullying and social exclusion, which seemed to play a big role in the children's understandings of what it would be like to be overweight. The stigma attached to being overweight is evident as participants often started giggling when talking about people being overweight.
I: Is it important to eat things that are good for you? *: Laughter I: What do you think happens to you if you eat lots of these biscuits? *: Fat I: And what good would stop you from getting fat, or would help you not be fat? *: Giggling Boys reception Open in a separate window
Inability to have a successful career and even death were understood to be the results of obesity. Participants felt people who were overweight were in some way bad or an embarrassment. There was even a sense of fear toward people who they considered overweight, indicating that they would avoid being seen with somebody who was obese.
I: So … so what do you think about being fat, like if you see somebody in the street who looks like they are not very healthy do you think? *: They can't do much, like most of the things you want to do in life, like swimming, jogging. *: Jobs when you grow older. Girls year 6 *: Like if my parents were proper massive and I went to the town with them I would just say they took me to the town and I don't know them. Boys year 6 Open in a separate window
It is clear that the participants’ understanding is that obesity is a very negative issue. However, there is also evidence that they understand the complexity of the condition and are also aware being underweight maybe as much of a problem. The older children in this study seemed to understand that it is a complex issue and fully grasped the concept of moderation. They often refer to the fact that you can have a small amount of things that maybe classified as unhealthy, as long as you don't eat them all the time or balance them out with exercise.
I: And what sort of things for eating well? *: Like fruit and vegetables. *: Some Sugar. *: If you eat vegetables and fruit and you might get back to underweight. *: And you want to be in the middle. *: You need a bit of fat on you. Girls year 6 Open in a separate window
This category of Fat is Bad highlights an issue that clouds all the children's understandings of issues surrounding obesity and that is of conflicting messages. This notion of mixed messages forms the final theme evident in the data.
The evidence presented here would suggest the information intended to educate and inform children is often met with equal amounts of contradictory or confusing messages and behaviours. The result of this is easily demonstrated by comparing what the children know they should be doing with what they actually talk about doing. For the majority of the participants their knowledge did not always match with their described behaviour, their food preferences often overriding their knowledge. This was perhaps not so surprising; knowledge does not by any means dictate behaviour.
I: Do you have breakfast most mornings? Do you normally have some breakfast, what do you normally have for breakfast? *: Miss I have chocolate cookies. I: What did you have for your tea last night? *: I just had for my supper. I: What did you have last night for your supper? *: Err sandwiches, cake and I: What about what did you have last night for your tea? *: Pizza Girls reception I: You eat two, two pieces of fruit? *: Yes, cos my mam chops it into two halves. Boys reception Open in a separate window
Conflict existed in a number of forms in the understandings expressed by the participants. It is worth reiterating that the younger girls who participated believed treatment for obesity was to go to the hospital and have an operation—something they have picked up from a TV documentary—this conflicts with diet and exercise education they receive at school. Other participants gave more specific and direct examples of receiving contradictory information. This ranged from conflicts in direct health messages to conflicting information and action between school and home. They felt that at times it was difficult to know which information was the right information, not only was it conflicting but it was forever changing.
*: And people say if you make fruit smoothies its healthy for you but it said in the news something about being obese again it said that if you drink a smoothie one a day you'll put on 13 pounds, that's nearly a stone in a year. Boys year 6 I: What about at home? You know if you're taught all this stuff at school what happens when you go home? Do Mum and Dad teach you the same things or is it different? *: Different I: And why is it different? *: I eat more sweets. Girls year 6 Open in a separate window
In addition to this, older children also pointed out they felt that healthy lifestyle information wasn't always delivered in the correct manner, there was a belief that stigmatising people who were overweight was negative. There was an awareness that there is a psychological aspect to overeating, and in some individuals it is this that needs to be addressed. Moreover, there was a feeling again demonstrated solely by the older participants that being overweight/obese could be difficult to rectify and maintaining a healthy weight could be a challenge.
*: So you need to be in the middle. I: Is it easy to stay in the middle? *: No, because sometimes you can't be bothered to eat well and exercise. Girls year 6 I: Do you think it's quite easy to lose weight? *: Yes *: Well for some people. *: If you put your mind to it, it is. I: No go on cos everyone's got different ideas. *: You can't just lose weight quickly. *: Cos my dad when he was young he was obese so he told me, but he's sort of addicted really. *: Addicted to what. *: Addicted he cannot stop but he's trying. *: He cannot stop what. *: Eating when he was young, he like learnt now he's saying to me about being fit cos he tells me about what happened when he was young so I try it. Boys year 6 Open in a separate window
This understanding of the complex nature of the obesity problem, coupled with the confusion and conflict in both the information and behaviours the participants are exposed to, can help explain some of the barriers to individuals adopting a healthier lifestyle.
The results detailed above highlight some important findings as to how children understand obesity in terms of some of its causes and consequences. It was particularly clear that knowledge, often imparted in a school setting, is getting through to the children who participated in this study. However, it appears equally evident that this knowledge in many cases does not transfer to behaviour. Further examination of the results allows us to explore the potential reasons behind the knowledge-behaviour gap.
Role models by their nature provide examples for both the children's beliefs and their behaviour. There are a wide variety of potential role models for children from parents, teachers, peers, and celebrities. What seems particularly important, in terms of being a positive role model with regards to healthy lifestyles, is that children have an opportunity to view the process of being healthy. In this study, this was typified by the examples of the Year 6 boys who participated in sport with their fathers. It appears this close and active relationship allows the knowledge that has been started at school to grow. Allowing children the opportunity to apply their knowledge and see the steps taken by a role model to get or stay fit help translate this knowledge into behaviour. What is interesting, however, is that it seems passive behaviours by role models can have the same impact. It was the case with these participants that the effect of passive knowledge transfer seemed to be more negative, but that is by no means to say that passive behaviours by role models will not also encourage positive lifestyle behaviours in other cases. The most obvious example of this within this data set was the seemingly implicit messages that the girls received about being skinny. There was not an overtly explicit attempt on the behalf of the role models described here to encourage a “skinny” ideal; however, messages seemed to reach the participants that would indicate this is the case. The key difference between these active and passive role models appears to come from whether the role models place focus on the process; taking part in sport (in the example of the older boys) or outcome being skinny (in the example of the girls). Focus on the action of being physically active or enjoying a healthy diet in the case of these participants produces a healthier outlook on maintaining a healthy body weight. When that focus is on the outcome—the weight loss or the weight gain—there seems to be less concern for actually “being healthy” in terms of body weight and lifestyle. This notion about process and outcome is intrinsically linked to the theme of Fat is Bad.
It is interesting to note that whilst the children expressed an understanding of fat as a component of diet and were able to identify high fat foods and their link to obesity, the focus was on fat as an outcome and not so much about it as input. It is a well-documented fact that fat is a requirement of a balanced diet. The participants were able to recite in great detail the consequences of becoming fat but were not so forthright about the processes involved in becoming fat. It can be suggested that by focussing on the process of becoming fat and understanding the need for fat in moderation and being physically active it may help to discourage fat becoming the output. This may also help to draw away the focus from physical appearance that is so closely tied to the stigma attached to being overweight and place it on living a healthy lifestyle and being healthy.
The key finding of this study is that it is evident that children receive contradictory messages when it comes to following a healthy diet and taking part in exercise. The research presented here highlights children's understandings of some of the causes of obesity and the consequences of becoming overweight. However, it is equally evident that this information has reached them on a knowledge level but has not or cannot be fully translated into behaviour. It appears that central to this problem are the multiple discourses that exist around diet and exercise. Whilst government campaigns may impart facts and figures and provide advice on changes that can be made, there are a whole host of other sources to contend with. There is an undoubted role played by the media both in terms of active advertising campaigns for junk food or sedentary games and the passive portrayal of unattainable body shapes and sizes in magazines and by celebrity culture. However, more than this, health messages are competing against a variety of cultural values, social, and personal norms that may well go against messages that encourage certain behaviours. What is more is that ultimately individuals have the power and autonomy to make their own choices about diet and exercise. Stakeholders need to ensure that people are in a position to make an informed decision and not one where their judgement is clouded by an array of contradicting messages. There is also a responsibility to ensure that individuals are able to act on advice given and to provide advice that is relevant and tailored to individual circumstances. It is easy to understand why parents on a low income may struggle to incorporate “5 a day” into their families diets when they perhaps don't have access to a car and the nearest shop selling fresh fruit and vegetables is several miles away. Ensuring people know that frozen fruits and vegetables are just as good and, in some cases better, is a far more useful and usable message.
The objective of this study was to explore children's understandings of obesity in terms of diet and physical activity; the children included were considered high risk because of their socio-economic status. To meet this objective, focus group data was analysed using thematic analysis. This analysis produced key themes pertaining to the understandings of the participants. There is not a wealth of prior research in this domain and it was for this reason thematic analysis was chosen to analyse the data. The method proved to be particularly useful in generating these exploratory data that are discussed here in relation to previous findings.
The theme of knowledge has previously been identified by Hesketh et al. ( 2005 ) in terms of information and awareness that is pertinent to children's perceptions of healthy eating, activity, and preventing obesity. Increasing knowledge relating to diet and physical activity cannot prevent obesity but it can encourage children to make informed choices.
This study, as have others (Hesketh et al., 2005 ; Borra et al., 2003 ; Musaiger, Mater, Alekri, & Mahdi, 1991 ), identified misunderstandings in children's knowledge as barriers to healthful behaviour. It might be useful to address this issue, particularly with younger children who are developing their knowledge. Previous literature has identified young children often consume their recommended daily intake of fruit but fall well short when it comes to vegetables (Dennison, Rockwell, & Baker, 1998 ). Government campaigns encourage people to eat five portions of fruit and vegetables a day ( www.5aday.nhs.co.uk ); however, nutritionists would encourage three portions of vegetables and two of fruit—fruit having high sugar content. There was no evidence in the transcripts that any of the children were aware of or understood this distinction. This needs further investigation; however, education should encourage an understanding of fruit and vegetables as separate entities to help increase the consumption of vegetables (Gibson, Wardle, & Watts, 1998 ).
The evidence in this study suggests children grasp the causes of obesity, overeating, and low levels of physical activity; however, there was a general lack of understanding of the underlying physiological processes. There was a limited understanding of the concept of energy balance or that there might also be medical reasons for the obesity. Bell and Morgan ( 2000 ) demonstrated providing medical explanations for obesity can have a positive effect on children's attitudes to obese individuals. Overweight individuals were generally stigmatised by the participants in this study, so providing better medical information could help to alleviate these negative attitudes. It is fair to say those children who did have more in-depth knowledge of obesity were more sympathetic in their considerations of overweight individuals acknowledging the difficulty in making lifestyle changes.
The influence of parents concerning diet and exercise behaviours is well documented (Prout, 1996 ). Hesketh et al. (2005), Borra et al. (2003), and Young-Hyman et al. ( 2000 ) consider parental influence to be a determining factor in children's attitudes and understandings of obesity. It is clear this influence can be as detrimental as it can be beneficial. Previous research (Borra et al., 2003 ) argues interventions need to be developed that consider the role of the parent. Children cannot be expected to apply the information they receive at school to themselves if it is not reiterated at home. Nutritional education and physical education have not formed a core or extensive part of school curriculums in the United Kingdom in previous years, and there is now a generation of young parents who do not have the skills to attractively present appropriate foods (Tuttle & Truswell, 2002 ) or who regularly take part in sport themselves. The impact of this on their children's behaviour is that they don't always have examples of healthy behaviour to model their own on.
Of particular importance was the finding that children feel that they often receive mixed and contradicting messages. This is of great relevance when considering the development of policies and strategies that can be more effective. More over this backs up the findings of Dorey and McCool ( 2009 ) who conclude that nutritional messages evident in health promotion and advertising were often perceived by child audiences to be ambiguous. The authors warn that these contradictory messages could potentially serve to weaken the trustworthiness viewers have in health promotion initiatives. This really points to a key area in which health professionals can target efforts to tackle obesity. Clarity and consistency in healthy messages and recommendations are central to helping people take on board and act on the information they receive. Contradiction allows room for people to question the advice given and when effort is required to make a change in behaviour that change is less likely to be made if there is reason to doubt the accuracy of information. Furthermore, coherent messages need to consider person specific factors that may inhibit behaviour change; when individuals are encouraged to behave in a certain way but the constraints of day-to-day life lead to another, the results are confusion and hostility to the initial message (Owens & Driffill, 2008 ).
The main methodological issue arising was participants from Reception struggled to engage fully in conversation, and the sessions followed a structure more a kin to an interview (i.e., question and answer). It was difficult to encourage responses that were longer than a few words; often one word responses were given. There is the potential to gain some very useful information from children in this age group; however, it can be a long and time-consuming process to elicit enough information to make the analysis process worthwhile. The length of the sessions also must be kept relatively short because attention spans are not long lasting; this was a finding similar to that of Miller ( 2000 ). The replica food items selected to help provide structure to the focus groups were useful and did provide a catalyst for discussion; however, for very young children (i.e., those in Reception) they resemble toys too closely, this then leads to them becoming more of a distraction, hindering the discussion. The use of the picture cards and pens and paper as suggested by Backett and Alexander ( 1991 ) provided a more a suitable means of structuring focus groups for young children.
There were at times issues with certain members of the groups making themselves heard more than others, thus the researcher had to encourage those happier to sit back and let others take the lead (Kirk, 2007 ). However, through a little encouragement all participants appeared comfortable talking with each other and participated equally, a result of the careful selection process. It also appeared to be beneficial speaking to boys and girls separately, with the boys often more excitable in their discussion style in comparison to the girls. It also facilitated the identification of some important issues, for example, the Year 6 boys identified eating behaviours present in the Year 6 girls that the girls themselves did not discuss.
The Foresight Report (Department of Innovation Universities and Skills, 2007 ), in tackling obesity, points out that current policies are failing because they do not provide the depth and range of interventions needed. This present study has determined that central to children's understandings of the causes and consequences of obesity are the concepts of knowledge, the opportunity to apply this knowledge to their own lives, and the existence of role models to set an example. There exist certain myths and misconceptions that need to be addressed and children need to believe they can trust the health messages they receive because they are aware some messages are misleading or forever changing.
The key to this issue seems to be children learn by example, they can have all the knowledge in the world provided to them through an institution such as a school but this information needs to be supported by life at home. This provides evidence that campaigns need to target parents to tackle childhood obesity; this is an issue that policy makers are already aware of ( National Institute for Health and Clinical Excellence, 2006 ). However, this means health messages delivered to the general public need to be clearer and avoid ambiguity. There needs to be careful considerations of the context in which health messages are received, taking into account the understandings of the target population (Hesketh et al., 2005).
There were some issues raised in the focus group that were beyond the scope of this particular study. There was a representation of different ethnic minorities in the groups, and slight differences in the understandings of these different groups were identified. Further research should investigate the understandings of different minority groups to see if ethnicity influences or results in divergent concepts. Future study also needs to look at strategies that enable children to apply healthy lifestyle information to their own lives.
Children spend, on average, a quarter of their waking lives in schools; therefore, schools can be seen as an effective environment and source to help encourage healthy lifestyles. However, that leaves three quarters of a child's time in which they are out of the control of the school environment. Strategies must be developed to unite the teaching at school with practices in the home. This supports the conclusions of Hughes, Sherman, and Whitaker ( 2010 ) who write that strategies need to be framed in a manner that makes low income mothers feel more supported in addressing issues their children may have with their weight. Ensuring that approaches to encourage healthy lives take on a holistic format will also help to provide consistent and realistic role models. There needs to be a concerted effort from within society to develop role models who have a healthy relationship with food and exercise. These seem to already exist for young boys in the form of sporting heroes but seem in short supply for young girls who already consider that being healthy is the ideal but then look to surgery as a form of weight loss. Lieberman, Gauvin, Bukowski, and White ( 2001 ) highlight the importance of role models and peer influence in the onset of disordered eating in young girls and this needs to be seriously taken into account when sending out messages that being overweight is bad, girls need to be aware that being underweight also has severe health consequences.
In conclusion, the time children spend eating and taking part in physical activity out of school is likely to be the biggest challenge to preventing the continuing obesity problems in the United Kingdom, and this is where current strategies appear to be failing. Children understand obesity and its contributing factors in terms set out to them by those people they consider role models. It is only by helping these role models to provide consistent and reliable information by setting suitable active examples and by being aware of the impact of their passive actions that we can begin to address the problem of obesity.
The authors would like to thank Sunderland Children's Centres and Back on the Map for their support in facilitating this research.
The author have not received any funding or benefits from industry or elsewhere to conduct this study
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Different approaches to thematic analysis. 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 ...
The Systematic Thematic Analysis Process Model also includes an exceptional step of conceptualization through interpretation. It encourages researchers to delve deeper into their data and recognize underlying themes and patterns, thus transcending the conventional descriptive approach. The framework culminates in the development of a robust ...
Thematic analysis is a useful method for research seeking to understand people's views, opinions, knowledge, experiences, or values from qualitative data. This method is widely used in various fields, including psychology, sociology, and health sciences. Thematic analysis minimally organizes and describes a data set in rich detail.
When undertaking thematic analysis, you'll make use of codes. A code is a label assigned to a piece of text, and the aim of using a code is to identify and summarise important concepts within a set of data, such as an interview transcript. For example, if you had the sentence, "My rabbit ate my shoes", you could use the codes "rabbit ...
There are various approaches to conducting thematic analysis, but the most common form follows a six-step process: Familiarisation. Coding. Generating themes. Reviewing themes. Defining and naming themes. Writing up. This process was originally developed for psychology research by Virginia Braun and Victoria Clarke.
Organize your papers in one place. Try Paperpile. No credit card needed. Get 30 days free. A six-step system was developed to help establish clarity and rigor around this process, and it is this system that is most commonly used when conducting a thematic analysis. The six steps are: Familiarization.
The thematic analysis process is similar to sorting different-colored marbles. Instead of sorting colors, you are sorting themes in a data set to determine which themes appear the most often or to identify patterns among these themes. After your initial analysis, you can take this one step further and separate "dark" colors from "light" colors ...
Based on: Virginia Braun and Victoria Clarke, Thematic analysis: A practical guide.SAGE Publications, 2021. ISBN 978-1-4739-5323-9.
A theme is a pattern that you identify within the data. Relevant steps may vary based on the approach and type of thematic analysis, but these are the general steps you'd take: 1. Familiarize yourself with the data (pre-coding work) Before you can successfully work with data, you need to understand it.
Thematic analysis, the often-used methods of qualitative research, provides concise description and interpretation in terms of themes and patterns from a data set. The application of thematic analysis requires trained expertise and should not be used in a prescriptive, linear, and inflexible manner while analyzing data.
Thematic Analysis - A Guide with Examples. Thematic analysis is one of the most important types of analysis used for qualitative data. When researchers have to analyse audio or video transcripts, they give preference to thematic analysis. A researcher needs to look keenly at the content to identify the context and the message conveyed by the ...
Facilitates comparative analysis and integration of findings. A thematic literature review excels in synthesizing findings from diverse studies, enabling a coherent and integrated overview. By concentrating on themes rather than individual studies, the review can draw comparisons and contrasts across different research contexts and methodologies.
ABSTRACT. Thematic analysis (TA) is the most widely used method for analysing qualitative data. Recent debates, highlighting the binary distinctions between reflexive TA grounded within the qualitative paradigm and codebook TA with neo-positivist orientations, have emphasized the existence of numerous tensions that researchers must navigate to produce coherent and rigorous research.
Thematic analysis is a widely used, yet often misunderstood, method of qualitative data analysis. It is a useful and accessible tool for qualitative researchers, but confusion regarding the method's philosophical underpinnings and imprecision in how it has been described have complicated its use and acceptance among researchers.
Thematic analysis is also useful for summarizing key features of a large data set, as it forces the researcher to take a well-structured approach to handling data, helping to produce a clear and organized final report . Although there are many advantages to using thematic analysis, it is important to also acknowledge the disadvantages of this ...
What is thematic analysis? Thematic analysis is a common method used in the analysis of qualitative data to identify, analyse and interpret meaning through a systematic process of generating codes (see Chapter 20) that leads to the development of themes. 1 Thematic analysis requires the active engagement of the researcher with the data, in a process of sorting, categorising and interpretation ...
An example of a description of the thematic analysis process: Coding and analysis were guided by Braun and Clarke's (2006, 2013) guidelines for using thematic analysis. Each stage of the coding and theme development process described below was clearly documented ensuring that the evolution of themes was clear and traceable.
Qualitative research methods explore and provide deep contextual understanding of real world issues, including people's beliefs, perspectives, and experiences. Whether through analysis of interviews, focus groups, structured observation, or multimedia data, qualitative methods offer unique insights in applied health services research that other approaches cannot deliver. However, many ...
Values often manifest themselves in texts, and thematic analysis is one way of making them emerge from those texts. This chapter has suggested a few ways of doing so. As a stepwise approach, thematic analysis of values can be summarized in the following way: (1) Assign codes, (2) generate themes, and if possible, (3) organize themes, (4) create ...
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 ...
Thematic analysis involves a process of assigning data to a number of codes, grouping codes into themes and then identifying patterns and interconnections between these themes. 2 Thematic analysis allows for a nuanced understanding of what people say and do within their particular social contexts. Of note, thematic analysis can be used with interviews and focus groups and other sources of data ...
Thematic analysis (TA) is a commonly used qualitative data analysis approach in psychology (Braun & Clarke, 2006), health care (Braun & Clarke, 2014), sport and exercise (Braun et al., 2017), and many other fields (Boyatzis, 1998).However, a lack of description about the process and details of analysis often leads the TA report readers to wonder how exactly qualitative information is ...
A thematic analysis (Braun & Clarke, 2006) identified overarching themes evident across all groups, suggesting the key concepts that contribute to children's understandings of obesity are "Knowledge through Education," "Role Models," "Fat is Bad," and "Mixed Messages.". The implications of these findings and considerations of ...
The calibration of monetary policy is particularly challenging at a time of large shocks. Interest rates in Hungary rose sharply in response a significant increase in inflation and depreciation in the forint in 2022. As inflationary pressures have eased, the base rate has been reduced but remains restrictive. Balancing the risks of loosening too quickly and inflation taking longer to return to ...