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Qualitative Content Analysis

Qualitative Content Analysis

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Qualitative content analysis in nursing research:concepts, procedures and measures to achievetrustworthiness
U.H. Graneheim
*
, B. Lundman
Department of Nursing, Ume
a University, Ume
a 90187, Sweden
Accepted 8 October 2003
Summary
Qualitative content analysis as described in published literature showsconflicting opinions and unsolved issues regarding meaning and use of concepts,procedures and interpretation. This paper provides an overview of importantconcepts (manifest and latent content, unit of analysis, meaning unit, condensation,abstraction, content area, code, category and theme) related to qualitative contentanalysis; illustrates the use of concepts related to the research procedure; andproposes measures to achieve trustworthiness (credibility, dependability and trans-ferability) throughout the steps of the research procedure. Interpretation inqualitative content analysis is discussed in light of Watzlawick et al.’s [Pragmaticsof Human Communication. A Study of Interactional Patterns, Pathologies andParadoxes. W.W. Norton & Company, New York, London] theory of communication.
c
2003 Elsevier Ltd. All rights reserved.
KEYWORDS
Credibility;Dependability;Latent content;Manifest content;Nursing;Qualitative contentanalysis;Transferability;Trustworthiness
Introduction
Initially content analysis dealt with ‘the objective,systematic and quantitative description of themanifest content of communication’ (Berelson,1952, p. 18) but, over time, it has expanded to alsoinclude interpretations of latent content. Manyauthors, from a variety of research traditions, haveaddressed content analysis (for example, Berelson,1952; Krippendorff, 1980; Findahl and H
oijer,1981; Woods and Catanzaro, 1988; Downe-Wam-boldt, 1992; Burnard, 1991, 1996; Polit and Hun-gler, 1999). The first descriptions date from the1950s and are predominately quantitative. Cur-rently, two principal uses of content analysis areevident. One is a quantitative approach often usedin, for example, media research, and the other is aqualitative approach often used in, for example,nursing research and education. Qualitative con-tent analysis in nursing research and education hasbeen applied to a variety of data and to variousdepths of interpretation (for example, O’Brienet al., 1997; Latter et al., 2000; Berg and WelanderHansson, 2000; S
oderberg and Lundman, 2001).A review of literature based on common data-bases (Cinahl, Medline and Sociological Abstracts)as well as references from articles and books showsdifferent opinions and unsolved issues regardingmeaning and use of concepts, procedures and in-terpretation in qualitative content analysis. Thediversities can be understood partly from a histor-ical point of view and partly from various beliefs ofthe nature of reality among researchers.
*
Corresponding author. Tel.: +46-90-786-9258; fax: +46-90-786-9169.
E-mail address:
ulla.hallgren.graneheim@nurs.umu.se(U.H.Graneheim).0260-6917/$ - see front matter
c
2003 Elsevier Ltd. All rights reserved.doi:10.1016/j.nedt.2003.10.001Nurse Education Today (2004)
24
, 105–112intl.elsevierhealth.com/journals/nedt
NurseEducationToday
 
An assumption underlying our paper is that re-ality can be interpreted in various ways and theunderstanding is dependent on subjective inter-pretation. Qualitative research, based on datafrom narratives and observations, requires under-standing and co-operation between the researcherand the participants, such that texts based on in-terviews and observations are mutual, contextualand value bound (Lincoln and Guba, 1985; Mishler,1986). Thus, our presumption is that a text alwaysinvolves multiple meanings and there is alwayssome degree of interpretation when approaching atext. This is an essential issue when discussingtrustworthiness of findings in qualitative contentanalysis.Another issue is that concepts within the quan-titative research tradition still predominate whendescribing qualitative content analysis (for exam-ple, Krippendorff, 1980; Burnard, 1991; Downe-Wamboldt, 1992), especially the use of conceptsdescribing trustworthiness. This causes confusionand paradigmatic uncertainty among authors andreaders of scientific papers.The purpose of this paper was threefold: first, toprovide an overview of concepts of importancerelated to qualitative content analysis in nursingresearch; second, to illustrate the use of conceptsrelated to the research procedure; and third, toaddress measures to achieve trustworthiness.
Overview of concepts
The following provides an overview of conceptsrelated to qualitative content analysis and is to beseen as a contribution to a debate rather than anendeavour to find consensus. First, we presentvarious uses of concepts found in the literature,and then we give reasons for our stance. The con-cepts are manifest and latent content, unit ofanalysis, meaning unit, condensing, abstracting,content area, code, category and theme.A basic issue when performing qualitative con-tent analysis is to decide whether the analysisshould focus on manifest or latent content. Analysisof what the text says deals with the content aspectand describes the visible, obvious components, re-ferred to as the
manifest content
(Downe-Wam-boldt, 1992; Kondracki et al., 2002). In contrast,analysis of what the text talks about deals with therelationship aspect and involves an interpretationof the underlying meaning of the text, referred toas the
latent content
(Downe-Wamboldt, 1992;Kondracki et al., 2002). Both manifest and latentcontent deal with interpretation but the interpre-tations vary in depth and level of abstraction.One of the most basic decisions when usingcontent analysis is selecting the
unit of analysis
. Inthe literature, unit of analysis refers to a greatvariety of objects of study, for example, a person,a program, an organisation, a classroom or a clinic(Mertens, 1998), or a community, state or nation(Patton, 1987). Other authors have considered theunit of analysis as interviews or diaries in theirentity, and the amount of space allocated to atopic or an interaction under study (Downe-Wam-boldt, 1992). Parts of the text that are abstractedand coded (Weber, 1990), or every word or phrasewritten in the transcript (Feeley and Gottlieb,1998), have also been considered as units of anal-ysis. We suggest that the most suitable unit ofanalysis is whole interviews or observational pro-tocols that are large enough to be considered awhole and small enough to be possible to keep inmind as a context for the meaning unit, during theanalysis process.A
meaning unit
, that is, the constellation ofwords or statements that relate to the same cen-tral meaning, has been referred to as a contentunit or coding unit (Baxter, 1991), an idea unit(Kovach, 1991), a textual unit (Krippendorff,1980), a keyword and phrase (Lichstein and Young,1996), a unit of analysis (Downe-Wamboldt, 1992),and a theme (Polit and Hungler, 1991). We considera meaning unit as words, sentences or paragraphscontaining aspects related to each other throughtheir content and context.In the literature, shortening the text includesthe concepts of reduction (Findahl and H
oijer,1981), distillation (Cavanagh, 1997) and conden-sation (Coffey and Atkinson, 1996). Reduction re-fers to decreasing the size, but it indicates nothingabout the quality of what remains. Distillationdeals with the abstracted quality of a text, whichwe see as a further step in the analysis process. Weprefer
condensation
, as it refers to a process ofshortening while still preserving the core.The process whereby condensed text is ab-stracted has been called aggregation (Barrosso,1997) and ‘grouping together under higher orderheadings’ (Burnard, 1991, p. 462). We suggest
ab-straction
, since it emphasises descriptions and in-terpretations on a higher logical level. Examples ofabstraction include the creations of codes, cate-gories and themes on varying levels.Parts of a text dealing with a specific issue havebeen referred to as a domain or rough structure(Patton, 1990), a cluster (Barrosso, 1997) and acontent area (Baxter, 1991). We prefer
contentarea
since it sheds light on a specific explicit areaof content identified with little interpretation. Acontent area can be parts of the text based on106 U.H. Graneheim, B. Lundman
 
theoretical assumptions from the literature, orparts of the text that address a specific topic in aninterview or observation guide.The label of a meaning unit has been referred toas a
code
. There seems to be agreement in theliterature about the use and the meaning of a code.According to Coffey and Atkinson (1996, p. 32)‘codes are tools to think with’ and ‘heuristic de-vices’ since labelling a condensed meaning unitwith a code allows the data to be thought about innew and different ways. A code can be assigned to,for example, discrete objects, events and otherphenomena, and should be understood in relationto the context.Creating
categories
is the core feature of qual-itative content analysis. A category is a group ofcontent that shares a commonality (Krippendorff,1980). Patton (1987) describes categories as in-ternally homogeneous and externally heteroge-neous. Krippendorff (1980) emphasises thatcategories must be exhaustive and mutually ex-clusive. This means that no data related to thepurpose should be excluded due to lack of a suit-able category. Furthermore, no data should fallbetween two categories or fit into more than onecategory. However, owing to the intertwined na-ture of human experiences, it is not always possibleto create mutually exclusive categories when atext deals with experiences. A category answersthe question ‘What?’ (Krippendorff, 1980) and canbe identified as a thread throughout the codes. Aswe see it, a category refers mainly to a descriptivelevel of content and can thus be seen as an ex-pression of the manifest content of the text. Acategory often includes a number of sub-categoriesor sub-subcategories at varying levels of abstrac-tion. The sub-categories can be sorted and ab-stracted into a category or a category can bedivided into sub-categories.The concept of
theme
has multiple meaningsand creating themes is a way to link the underlyingmeanings together in categories. Polit and Hungler(1999) describe a theme as a recurring regularitydeveloped within categories or cutting across cat-egories. Baxter (1991) defines themes as threads ofmeaning that recur in domain after domain. Theconcept of theme is also used in literature in otherqualitative methods. van Manen (1990, p. 87)considers a theme to ‘describe an aspect of thestructure of experience’ and emphasises that atheme can not be an object or a thing. A themeanswers the question ‘How?’ We consider a themeto be a thread of an underlying meaning through,condensed meaning units, codes or categories, onan interpretative level. A theme can be seen as anexpression of the latent content of the text. Sinceall data have multiple meanings (Krippendorff,1980; Downe-Wamboldt, 1992), themes are notnecessarily mutually exclusive. A condensedmeaning unit, a code or a category can fit intomore than one theme. A theme can be constructedby sub-themes or divided into sub-themes.
Illustrations of the use of concepts
In the following we illustrate the use of conceptsand analysis procedures for two texts based on in-terviews and observations respectively. One ratio-nale behind giving two examples is to show variousways to develop themes. The processes of analysisare described and shown in Figs. 1–3. Even if thesedescriptions point to a linear process, it is impor-tant to bear in mind that the process of analysisinvolves a back and forth movement between thewhole and parts of the text.
Qualitative content analysis of aninterview text
The
unit of analysis
in this example is interviewtext about experiences of having hypoglycaemia.The context consists of a larger study aimed atdescribing coping strategies related to the every-day strains of living with diabetes (Lundman andNorberg, 1993). Twenty adults with Type 1-diabe-tes, aged 25–59 years, participated in the study.Interviews were performed addressing various as-pects of living with Type 1-diabetes. The interview
Meaning unitCondensed meaning unitCode
there is a curious feeling in the head insome way, empty in some waycurious feeling of emptiness in the heademptiness in theheadit is more unpredictable so to say, youcan never be sure about anythingAn unpredictable andunsure situationuncertainty
Figure 1
Examples of meaning units, condensed meaning units and codes.
Qualitative content analysis in nursing research 107

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