Article Reviewed Hsieh, H. F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis.

Qualitative health research, 15(9), 1277-1288.

By Farrah Zeba and Sharda Singh

Conducted by Dr Abhilash Ponnam and Dr Shirshendu Ganguli

Content analysis History: Shift from Quantitative Analysis of Qualitative data to Qualitative Content Analysis
Content analysis has a long history in research, dating back to the 18th century in Scandinavia (Rosengren, 1981).

In the United States, content analysis was first used as an analytic technique at the beginning of the 20th century (Barcus, 1959).

Initially, researchers used content analysis as either a qualitative or quantitative method in their studies
(Berelson, 1952)

Later, content analysis was used primarily as a quantitative research method, with text data coded into explicit categories and then described using statistics.
This article is focused on QUALITATIVE CONTENT ANALYSIS

This approach is sometimes referred to as quantitative analysis of qualitative data (Morgan, 1993) and is not the primary focus in this article.

Content Analysis: Analyze text data

Goal of content analysis is to provide knowledge and understanding of the phenomenon under study (Downe-Wamboldt, 1992, p. 314) Qualitative content analysis Goes beyond merely counting words (Weber, 1990) A similar initial analytical approach like (Hsieh and Shannon, 2005) Grounded theory and phenomenology

Develop theory To examine meanings, themes and patterns that may be manifest (Expicit) or latent (Inferred) in a particular text (Zhang and Wildemuth, 2009)

Nuanced understanding of the lived experience

Concept development or model building (Lindkvist, 1981)

Text data might be in verbal, print, or electronic form and might have been obtained from narrative responses, openended survey questions, interviews, focus groups, observations, or print media such as articles, books, or manuals (Kondracki &Wellman, 2002)

Three approaches to qualitative content analysis

Hsieh and Shannon (2005) discussed three approaches to qualitative content analysis, based on the degree of involvement of inductive reasoning The first is conventional qualitative content analysis, in which coding categories are derived directly and inductively from the raw data The second approach is directed content analysis, in which initial coding starts with a theory or relevant research findings Then, during data analysis, the researchers immerse themselves in the data and allow themes to emerge from the data

The purpose of this approach usually is to validate or extend a conceptual framework or theory
The third approach is summative content analysis, which starts with the counting of words or manifest content, then extends the analysis to include latent meanings and themes This approach seems quantitative in the early stages, but its goal is to explore the usage of the words/indicators in an inductive manner

Preparation Phase

Research Objective and Research Question Preparations Phase

Conventional Researcher X Directed Researcher X Wanted to test the KublerRosss (1969) five stages of grief (denial, anger, bargaining, depression, and acceptance) Summative Researcher X

To learn more about the emotional experiences of hospice patients

Taboo in US Society was hindering the communication between patients and doctors Euphemisms like passing, going to a better place used to describe sensitive terms like die, dying, and death

To be able to address their needs more effectively

How well this theory described the patients experiences with imminent death?
How well does Kbler-Rosss model (1282) describe the emotional passages or journeys of patients who have been diagnosed with a terminal illness?

What are the emotional reactions of terminally ill patients who are receiving hospice care?

How are the terms die, dying, and death used in clinicianpatient communication when discussing hospice care, and what alternative terms are used?

Data Collection (Sampling, Approval and Interview) Preparation Phase

Conventional Researcher X Directed Researcher X Summative Researcher X

Stratified Sampling Technique New to hospice care vs. Longer period in hospice care Home hospice care vs. In-patient hospice care Men vs. Women Older and Middle-aged Individual Interviews with open ended questions and probing What has it been like to be in hospice care?

Maximise the chance of recruiting participants at different stages

Diff Stages of Medication: Continuing, refused and contemplating the diagnosis Gender balance Diagnostic balance (Oncology vs. Non-Oncology) Individual Interviews with open ended questions and probing What has your emotional journey been since being diagnosed with this illness? Probing based on Kubler-Rosss theory

Demographic characteristics of both the clinician and the patient/family

Patients Gender, age, diagnosis, and ethnic background Clinician Gender, Discipline, Area of Specialisation Two communication events : Transferring vs. Set-up General Interview questions based on key terms - die, dying, and death

Have you felt angry since your diagnosis?

Organising Phase

Analysis Organising Phase Researcher X (Conventional Approach)

Then the remaining transcripts were coded on these preliminary codes

Reference Fig 1 and Fig 2 of second article (PP 107 & 108)

Final codes were organised into the hierarchical structure

Coining words (codes) to capture emotional reaction at the margin

New Codes are generated for those which cannot be explained by preliminary codes

Read the transcripts like a novel then started highlighting text describing emotional reaction

After three to four transcripts PRELIMINARY CODES were generated.

Some codes are combined and others are split into categories

Analysis Organising Phase Researcher Y (Directed Approach) Predetermined categories were developed based on the known theory (Kubler Rosss)
Kbler-Rosss (1969) five stages of grief (denial, anger, bargaining, depression, and acceptance)

Testing or Extension of the theory

Text that did not fall under the predetermined code were used to generate new codes

All the highlighted text describing an emotional response were coded using these predetermine categories

Subcategories were determined (anger toward self, anger toward doctor, anger toward spiritual being)

New codes were re-examined to describe new emotional reactions apart from the five mentioned in Kubler Rosss Theory

Analysis Organising Phase Researcher Z (Summative Approach Approach)

Frequency Count of key terms using computer-assisted searches (Communication event by Identity of the speaker) Communication during transferring to the Hospice Care Communication during set-up activity for the out-patients for home care

Physician

Nurse

Patient

Family

These frequency counts were then compared with to the total number of terms calculated to capture the latent meaning

Reporting Phase

Findings Reporting Phase REPORTING (Presenting and Researcher X (Conventional Approach) Discussion) to increase
TRUSTWORTHYNESS

Conventional

Directed
Described the incidence of codes representing the emotional stages suggested by Kbler-Ross with those that represented different emotional responses by comparing the rank order of all codes

Summative
The major study findings described the occurrences of the three explicit terms used in clinician-patient communication as compared to euphemistic terms. Comparisons across type of speaker and characteristics of clinicians and patients were made.

The emotional responses of the hospice patients were described using identified codes and hierarchical structure

In discussion of the findings, the results from this content analysis were compared and contrasted In the discussion section, with Kbler-Rosss (1969) model Researcher Y summarized how the to highlight similarities and study validated KblerDifferences (Additional emotional Rosss model and what new reactions like the process of tying perspectives were added up loose ends (financial and social arrangements)

The discussion of this study focused on exploring possible explanations for differences in the use of explicit versus euphemistic terms when discussing EOL care for different groups and in different situations.

Quick Recap Phenomena drawn from the area of end-of-life (EOL) research (Bottled up feelings) Conventional: Researcher X Directed: Researcher Y Summative: Researcher Z
What are the emotional reactions of terminally ill patients who are receiving hospice care? How well does Kbler-Rosss model (1282) describe the emotional passages or journeys of patients who have been diagnosed with a terminal illness? How are the terms die, dying, and death used in clinicianpatient communication when discussing hospice care, and what alternative terms are used?

Study Starts With Timing of Defining Codes or Keywords

Observation Codes are defined during data analysis

Theory Codes are defined before and during data analysis Codes are derived from theory or relevant research findings

Keywords Keywords are identified before and during data analysis Keywords are derived from interest of researchers or review of literature

Source of Codes or Keywords

Codes are derived from data

Advantages and Disadvantages of the three approaches to qualitative content analysis

Conventional Approach 1. Failing to identify key categories - Findings that do not accurately represent the data (Hsieh and Shanon, 2005) Peer debriefing, prolonged engagement, persistent observation, triangulation, negative case analysis, referential adequacy, and menber check (Lincoln & Guba, 1985; Manning, 1997) 2. Confused with other qualitative methods (Grounded Theory & Phenomenology) Directed Approach 1. Approach the data with an informed but, nonetheless, strong bias (Hsieh and Shanon, 2005) Summative Approach 1. Unobtrusive and nonreactive way to study phenomena of interest (Babbie,1992)

2. Participants might get cues to answer (Hsieh and Shanon, 2. Limited by the studys 2005) inattention to the broader meaning 3.Limiting affect on the study present in the data (Lincoln and Guba, 1985) (Hsieh and Shanon, Auditor review and 2005) examine the operational definitions of the theory 3. Validation by content to increase the accuracy experts and member of predetermine check (Lincoln & Guba, categories (Hsieh and 1985) Shanon, 2005)

Thank you!!!

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