Using Framework Analysis in Applied Qualitative Research

Framework analysis and applied qualitative research can be a perfect match, in large part because framework analysis was developed for the explicit purpose of analyzing qualitative data in applied policy research. Framework analysis is an inherently comparative form of thematic analysis which employs an organized structure of inductively- and deductively-derived themes (i.e., a framework) to conduct cross-sectional analysis using a combination of data description and abstraction. The overall objective of framework analysis is to identify, describe, and interpret key patterns within and across cases of and themes within the phenomenon of interest. This flexible and powerful method of analysis has been applied to a variety of data types and used in a range of ways in applied research. Framework analysis consists of two major components: creating an analytic framework and applying this analytic framework. This paper details the five steps in framework analysis (data familiarization, framework identification, indexing, charting, and mapping and interpretation) through conducting secondary analysis on this special issue’s common dataset. This worked example adds to the existing framework analysis methodology literature both through describing the analysis specifics and through highlighting the importance of multiple considerations of units of analysis. This paper also includes reflection on the myriad reasons that framework analysis is valuable for applied research

Access to Health Care for Disadvantaged Individuals: A Qualitative Inquiry

Despite access to health care long being central in health services research and policy, we still seek answers to fundamental questions. Access theory has also been criticized for being unsuccessful at predicting and explaining health care use, for being inapplicable to disadvantaged populations, and for treating access as a static phenomenon. I argue that we need a better understanding of the mechanisms and context of access and must pay attention to theory development. I designed this study to address these criticisms and better understand access to care. Using grounded theory, I examined the contextual and holistic nature of access by conducting an inductive investigation of disadvantaged individual's experiences in four rural communities. I conducted 42 individual and two-person in-depth, unstructured interviews on getting and using health care. Individuals in this study consisted of persons most likely to experience trouble using the health care system and to have the most need for care. The communities used in this study illustrated a variety of approaches to and problems with rural health care delivery in North Carolina and Ontario. Participants' access narratives described dealing with and struggling with competing needs and demands to achieve or maintain a state of balance in having their needs met. Achieving and maintaining balance is part of a dynamic process with four stages in the balance process: seeking balance, achieving balance, maintaining balance, and balance upsets. This continual process requires tradeoffs and adaptation as circumstances change. Getting stuck or being unable to achieve balance results in adverse consequences for the individual and the individual's relationship with the health care system. The balance process operates throughout an individual's life, reflecting careers with health needs and the health care system. This conceptualization of access as a balance process shares commonalities with existing access theories as well as contributing new concepts including the iterative nature of access and the importance of personal interactions and community context. Conceptualizing access as a staged process of achieving balance also provides multiple distinct policy intervention opportunities

In Search Of Attachment: A Qualitative Study Of Chronically Ill Women Transitioning Between Family Physicians in Rural Ontario, Canada

Background Most Canadians receive basic health services from a family physician and these physicians are particularly critical in the management of chronic disease. Canada, however, has an endemic shortage of family physicians. Physician shortages and turnover are particularly acute in rural regions, leaving their residents at risk of needing to transition between family physicians. The knowledge base about how patients manage transitioning in a climate of scarcity remains nascent. The purpose of this study is to explore the experience of transitioning for chronically ill, rurally situated Canadian women to provide insight into if and how the system supports transitioning patients and to identify opportunities for enhancing that support. Methods Chronically ill women managing rheumatic diseases residing in two rural counties in the province of Ontario were recruited to participate in face-to-face, semi-structured interviews. Interview transcripts were analysed thematically to identify emergent themes associated with the transitioning experience. Results Seventeen women participated in this study. Ten had experienced transitioning and four with long-standing family physicians anticipated doing so soon. The remaining three expressed concerns about transitioning. Thematic analysis revealed the presence of a transitioning trajectory with three phases. The detachment phase focused on activities related to the termination of a physician-patient relationship, including haphazard notification tactics and the absence of referrals to replacement physicians. For those unable to immediately find a new doctor, there was a phase of unattachment during which patients had to improvise ways to receive care from alternative providers or walk-in clinics. The final phase, attachment, was characterized by acceptance into the practice of a new family physician. Conclusions Participants often found transitioning challenging, largely due to perceived gaps in support from the health care system. Barriers to a smooth transition included inadequate notification procedures, lack of formal assistance finding new physicians, and unsatisfactory experiences seeking care during unattachment. The participants’ accounts reveal opportunities for a stronger system presence during transition and a need for further research into alternative models of primary care delivery

Teleoncology in the Department of Defense: A tale of two systems

ABSTRACT Two telemedicine networks were developed for the purpose of conducting multidisciplinary oncology ("teleoncology") conferences. The infrastructure of each system differed: one system was Internet-based; the other was delivered via Integrated Services Digital Network (ISDN) lines. The purpose of this study was to describe the infrastructure and cost, consultative process, technical aspects, and conference format of the two teleoncology programs. The two systems' technical aspects, participant satisfaction with the systems, and conference participation were compared qualitatively. Assessment of the technical aspects of the systems suggested that each had distinct advantages. Survey results indicated that provider satisfaction with the technical and logistical aspects of each type of teleoncology conference was high. The present study may prove helpful for individuals who are considering implementing their own teleoncology programs. T ELEM ED ICIN E H A S BEEN D ESCRIBED as the practice of medicine at a distance. 1 Telemedicine applications have been used in nearly every field of medicine, including radiology, psychiatry, dermatology, and cardiology. One aspect of telemedicine that has become increasingly common is teleoncology, the delivery of oncology services from a distance. 1 Teleoncology programs offer a variety of potential benefits, including enhancing primary care managers' access to referrals, expand opportunities for continuing medical education (CME) credits, reduction of unnecessary referrals, and smooth coordination of patient care. To date, only a handful of studies have examined the topic of teleoncology. Investigators have looked at the use of interactive video to provide psychosocial support, 2 the use of interactive video and proxy examiners to provide direct patient care, 3 and the use of teleoncology to facilitate consultation by cancer specialists to geographically remote primary care providers

Developing Co-Funded Multi-Sectoral Partnerships for Chronic Disease Prevention: A Qualitative Inquiry Into Federal Governmental Public Health Staff Experience

Background Multi-sectoral partnerships (MSPs) are frequently cited as a means by which governments can improve population health while leveraging the resources and expertise of the private and non-profit sectors. As part of their efforts in this area, the Public Health Agency of Canada (the Agency) introduced a novel funding programme requiring applicants to procure matched resources from private sources to support large-scale interventions for chronic disease prevention. The current literature on MSPs is limited in its applicability to this model of multi-sectoral engagement. The purpose of this study was to explore the experiences of Agency staff working with potential partners to develop programme applications, such that we might identify lessons from adopting this type of partnership approach. Methods Semi-structured interviews were conducted with the 12 staff working in the MSP programme. Interviews were recorded, transcribed and analysed using thematic analysis. Preliminary themes were used to inform follow up focus-groups sessions. A second round of analysis was conducted guided by a coding paradigm focused on understanding process. Results We identified “experiencing uncertainty” to be a central concept in participants’ accounts of the MSP process, related specifically to the MSP programme’s novel conditions, shifts that occurred in sectoral roles and demands for new capacities. In response, Agency staff employed strategies to clarify partner interests, build trust in inter-sectoral relationships, and support internal and partner capacity. Outcomes associated with this process include impacts on trust between the Agency and potential partners, a deeper understanding of other sectors, and programme adaptations and refinements to address challenges related to the programme model. Conclusions The co-funding model employed by the Agency is a potentially popular one for government bodies wanting to leverage funding from private sector sources. Our study identifies the potential challenges that can occur under this model. Some challenges are related to addressing material conditions related to partner capacity, whereas other challenges speak to deeper and more difficult to address concerns regarding trust and alignment of motivations and interests between partners. Future research exploring the challenges associated with specific models of MSP engagement is necessary to inform approaches to addressing complex problems through collaborative efforts

In search of attachment: a qualitative study of chronically ill women transitioning between family physicians in rural Ontario, Canada

Abstract Background Most Canadians receive basic health services from a family physician and these physicians are particularly critical in the management of chronic disease. Canada, however, has an endemic shortage of family physicians. Physician shortages and turnover are particularly acute in rural regions, leaving their residents at risk of needing to transition between family physicians. The knowledge base about how patients manage transitioning in a climate of scarcity remains nascent. The purpose of this study is to explore the experience of transitioning for chronically ill, rurally situated Canadian women to provide insight into if and how the system supports transitioning patients and to identify opportunities for enhancing that support. Methods Chronically ill women managing rheumatic diseases residing in two rural counties in the province of Ontario were recruited to participate in face-to-face, semi-structured interviews. Interview transcripts were analysed thematically to identify emergent themes associated with the transitioning experience. Results Seventeen women participated in this study. Ten had experienced transitioning and four with long-standing family physicians anticipated doing so soon. The remaining three expressed concerns about transitioning. Thematic analysis revealed the presence of a transitioning trajectory with three phases. The detachment phase focused on activities related to the termination of a physician-patient relationship, including haphazard notification tactics and the absence of referrals to replacement physicians. For those unable to immediately find a new doctor, there was a phase of unattachment during which patients had to improvise ways to receive care from alternative providers or walk-in clinics. The final phase, attachment, was characterized by acceptance into the practice of a new family physician. Conclusions Participants often found transitioning challenging, largely due to perceived gaps in support from the health care system. Barriers to a smooth transition included inadequate notification procedures, lack of formal assistance finding new physicians, and unsatisfactory experiences seeking care during unattachment. The participants’ accounts reveal opportunities for a stronger system presence during transition and a need for further research into alternative models of primary care delivery.</p

Economic Evaluation Across the Four Faces of Prevention: A Canadian Perspective

In 1986, Louise Russell published her landmark book, “Is Prevention Better Than Cure?”, in which she evaluated the health and economic benefits of preventive health care interventions and tested the validity of the common assumption that prevention saves money. While debunking the myth that prevention is invariably cost-saving, Russell insisted that prevention is only rightfully judged on whether it is a worthwhile investment in health, rather than on its cost-saving potential. Almost three decades later, the notion that “an ounce of prevention is worth a pound of cure” still grips the imagination of policymakers and members of the public. We were commissioned by the Canadian Medical Association to review the economic evaluation evidence on prevention in the hope that such a review would assist health and health care priority setting in Canada. Prevention Versus Cure? In discussions of health policy and resource allocation, prevention is often pitted against cure and illness care. Prevention and illness care are not inherently competitive for resources. They serve different objectives and respond to different needs. In the quest for resources, prevention faces a difficult challenge in obtaining public and political support. In contrast to illness care, prevention has no identifiable beneficiaries and is usually characterized by immediate costs and delayed benefits. Economic Evaluation and its Use in Priority Setting It is widely argued that evidence of efficiency derived from economic evaluations should play an important role in health care priority setting and coverage decisions. Indeed, to our knowledge, every recently proposed priority-setting framework includes efficiency assessment as a crucial step. A limited number of jurisdictions require and use evidence of efficiency as part of coverage decision-making within public health care insurance programs. These examples are notable, however, precisely because they are exceptions. Overall, the use of economic evaluation evidence in priority setting lags far behind both the prescriptions of priority-setting frameworks and the expectations of many health policy makers and analysts. A number of factors are likely responsible for this. Some stem from the fact that integration of economic evaluation evidence into decision-making is neither simple nor straightforward. But more fundamentally, most health care interventions have never been subject to an economic evaluation and the interventions that have been assessed tend to be those that are most easily studied (rather than those for which the need for such evidence is most pressing). Many more economic evaluations exist for clinical prevention interventions, for example, with more easily defined populations, interventions, and settings, and more easily measured outcomes, than for interventions drawn from the areas of health promotion, health protection or healthy public policies. To the extent that priority-setting exercises restrict consideration to interventions for which such evidence exists, only a limited and non-representative set of interventions can be considered. One hope, of course, is that in the long run demand by those setting priorities and making coverage decisions will bring forth a larger supply of such studies. Economic Evaluation Evidence for Preventive Interventions. Deciding which topics to include in this review was a formidable task. While economic evaluation of preventive activities is not as frequent as for treatment, the volume of the prevention literature is vast. (Initial explorations of potentially relevant literature for this paper, for example, yielded over 5000 articles.) To guide our work, we identified 290 recommended prevention interventions and an additional 23 preventive interventions with potentially large population health impacts. We found no economic evaluations for 159 of the 290 recommended interventions (55 percent). Our literature identified 672 economic evaluations of the remaining 154 preventive interventions. The majority (55 percent) evaluated clinical prevention interventions. The next largest group of evaluations assessed health protection interventions (31 percent), a significant proportion of which were universal or mandatory screening or immunization programs. Health promotion interventions represented 12 percent of the evaluations and healthy public policy interventions represented 2 percent. The volume of relevant economic evaluations was far greater than we anticipated at the outset of the project. Accordingly, after categorizing available economic evaluations of recommended preventive interventions by type of intervention, the condition or issue targeted by the intervention, the study setting, and the availability and strength of effectiveness evidence, we summarized the results of economic evaluations of a sample of five diverse interventions that are not universally provided in Canada and for which a considerable body of economic evaluation evidence is available. Synthesis of Economic Evaluation Evidence for Five Selected Preventive Interventions • Varicella vaccination • Colorectal cancer screening using fecal occult blood testing (FOBT) • Needle exchange programs • Community water fluoridation • Day care or preschool programs In summarizing and interpreting the results of economic evaluation evidence for these five syntheses, we addressed three questions: • Does the intervention produce a net benefit from the societal perspective? • Is the intervention cost-saving from the payer perspective? • Where cost-benefit from a societal perspective has not been adequately assessed and the intervention is not cost-saving from the payer perspective, might the intervention nonetheless be a worthwhile investment in health (i.e., give value for money)? For each intervention we found a high degree of consistency among economic evaluation studies, despite differences in methods and settings. In particular, we did not observe systematic differences in findings between economic evaluations set inside or outside of Canada. All of the interventions we examined produce a net benefit to society. Needle exchange programs and water fluoridation are also cost-saving from a payer perspective. In both cases, there are sometimes multiple payers, which means that program costs may be born primarily by one payer while another payer may be the principal beneficiary of cost-savings resulting from the intervention (e.g., reduced treatment costs). The remaining interventions—varicella vaccination, colorectal cancer screening with FOBT, and day care or preschool programs—while not cost saving from the payer perspective (with the possible exception of preteen varicella vaccination), may still be sound investments in health. Decisions about whether to make those investments will appropriately depend on a variety of factors, some related to and others external to the economic evaluation evidence. Next Steps. A large volume of unappraised and unsynthesized economic evaluation evidence is available for many preventive interventions. On the other hand, economic evaluation evidence is completely lacking for the majority of recommended preventive interventions. If economic evaluation evidence on prevention is to be used to assist health and health care priority setting in Canada, the gaps that we have identified need to be filled. Critical activities include: • Systematic reviews of effectiveness evidence for health promotion, health protection, and healthy public policy interventions • Economic evaluations of individual preventive interventions for which economic evaluation evidence is currently lacking • Systematic reviews of economic evaluation evidence for effective preventive interventions These activities will require substantial resources. Significant work in this area has been and continues to be undertaken outside of Canada, particularly in the United States. Application of Economic Evaluation Evidence to Policy Decision Making. Policy decision making that incorporates economic evaluation evidence cannot be reduced to rank ordering of programs by summary measures of efficiency and the mechanical application of thresholds to determine which programs will be implemented or continued. Even if such an approach were desirable, its feasibility is questionable given that economic evaluation evidence based on a common metric and common comparator is unlikely to be available across a full range of programs under consideration. Decisions regarding public investments in health care programs are inevitably influenced by a variety of factors—some economic, some political, and some having to do with social values and preferences. These include: • Differential timing of costs and benefits • Opportunity costs • Availability of required technology and human resources • Program scope • Nature of benefits • Who benefits • Who pays Economic evaluation evidence can make a useful contribution to policy decision making. Given the dearth of economic evaluation evidence for preventive interventions, however, it is not reasonable to make such formal evidence a pre-requisite for policy action. Requiring economic evidence as a mandatory input to decision making would, in the short term, delay the implementation of preventive programs with demonstrated large population health effects that had not yet been subjected to economic evaluation. Perhaps more importantly, in the long term such a requirement would discriminate against health promotion, health protection and healthy public policy interventions whose costs and consequences are often difficult to measure credibly because they are spread across multiple health and social domains. In spite of these challenges, we hope that this review demonstrates the value of increasing the use of economic evaluation methods to inform decision making for preventive interventions.