SOCW 6311 wk 5 Discussion: Qualitative Findings and Social Work Interventions

All questions in bold then answers 300 to 500 words without questions

Evidence-based social work practice calls for the use of research data to guide the development of social work interventions on the micro, mezzo and/or macro-levels. Kearney (2001) described ways qualitative research findings can inform practice. Qualitative findings can help social workers understand the clients’ experiences and “what it may feel like” (Kearney, 2001). Therefore, social workers can develop clinical interventions that take into account the experiences of their clients. Qualitative findings can also help social workers monitor their clients. For example, if after reading a qualitative study on how domestic violence survivors respond to stress, they can monitor for specific stress behaviors and symptoms (Kearney, 2001). In addition, they can educate their client what stress behaviors to look for and teach them specific interventions to reduce stress (Kearney, 2001)

Given the increasing diversity that characterizes the landscape in the United States, social workers need to take into account culture when formulating interventions. Social workers can utilize qualitative findings to plan interventions in a culturally meaningful manner for the client.

To prepare for this Discussion, read Knight et al.’s (2014) study from this week’s required resources. Carefully review the findings, the photographs, and how the researchers wrote up the findings. Finally, review the specific macro-, meso-, and micro-oriented recommendations.

Then read Marsigilia and Booth’s article about how to adapt interventions so that they are culturally relevant and sensitive to the population the intervention is designed for. Finally, review the chapter written by Lee et al. on conducting research in racial and ethnic minority communities.

Kearney, M. (2001). Levels and applications of qualitative research evidence. Research in Nursing and Health, 24, 145–153.

Post the following:

1. Using      one of the direct quotes and/or photos from Knight et al.’s study, analyze      it by drawing up a tentative meaning. 

Discuss how this would specifically inform one intervention recommendation you would make for social work practice with the homeless. 

This recommendation can be on the micro, meso, or macro level.

1. Next,      explain how you would adapt the above practice recommendation that you      identified so that it is culturally sensitive and relevant for African      Americans, Hispanics, or Asian immigrants. (Select only 1 group). 

Apply one of the cultural adaptations that Marsigilia and Booth reviewed (i.e., content adaption to include surface and/or deep culture, cognitive adaptations, affective-motivational adaptations, etc.)(pp. 424-426). 

Be as specific as you can, using citations to support your ideas.

Resources

Knight, K. R., Lopez, A. M., Comfort, M., Shumway, M., Cohen, J., & Riley, E.D. (2014). Single room occupancy (SRO) hotels as mental health risk environment among impoverished women.: The intersection of policy, drug use, trauma, and urban space. International Journal of Drug Policy, 25(3), 556-561

https://www-ncbi-nlm-nih-gov.ezp.waldenulibrary.org/pmc/articles/PMC4014526 /

 

Research Article

Cultural Adaptation of Interventions
in Real Practice Settings

Flavio F. Marsiglia1 and Jamie M. Booth2

Abstract
This article provides an overview of some common challenges and opportunities related to cultural adaptation of behavioral
interventions. Cultural adaptation is presented as a necessary action to ponder when considering the adoption of an evidence-based
intervention with ethnic and other minority groups. It proposes a roadmap to choose existing interventions and a specific approach
to evaluate prevention and treatment interventions for cultural relevancy. An approach to conducting cultural adaptations is
proposed, followed by an outline of a cultural adaptation protocol. A case study is presented, and lessons learned are shared as
well as recommendations for culturally grounded social work practice.

Keywords
evidence-based practice, literature

Culture influences the way in which individuals see themselves

and their environment at every level of the ecological system

(Greene & Lee, 2002). Cultural groups are living organisms

with members exhibiting different levels of identification with

their common culture and are impacted by other intersecting

identities. Because culture is fluid and ever changing, the process

of cultural adaptation is complex and dynamic. Social work and

other helping professions have attempted over time to integrate

culture of origin into the interventions applied with ethnic

minorities and other vulnerable communities in the United

States and globally (Sue, Arredondo, & McDavis, 1992). In

an ever-changing cultural landscape, there is a renewed need

to examine social work education and the interventions social

workers implement with cultural diverse communities.

Culturally competent social work practice is well established

in the profession and it is rooted in core social work practice

principles (i.e., client centered and strengths based). It strives

to work within a client’s cultural context to address risks and

protective factors. Cultural competency is a social work ethical

mandate and has the potential for increasing the effectiveness

of interventions by integrating the clients’ unique cultural assets

(Jani, Ortiz, & Aranda, 2008). Culturally competent or culturally

grounded social work incorporates culturally based values,

norms, and diverse ways of knowing (Kumpfer, Alvarado,

Smith, & Bellamy, 2002; Morano & Bravo, 2002).

Despite the awareness about the importance of implementing

culturally competent approaches, practitioners often struggle

with how to integrate the client’s worldview and the application

of evidence-based practices (EBPs). When selecting and

implementing social work interventions, practitioners often

continue to unconsciously place themselves at the center of

the provider–consumer relationship. Being unaware of their

power in the relationship and undervaluing the clients per-

spective in the selection of EBPs tends to result in a type

of social work practice that is culturally incompetent and

nonefficacious (Kirmayer, 2012). This ineffectiveness can

be experienced and interpreted by practitioners in several

ways. In instances when clients do not conform to the content

and format of existing interventions, they are easily labeled as

being resistant to treatment (Lee, 2010). In other cases, when

clients fail to adapt to a given intervention that does not feel

comfortable to them, the relationship is terminated or the

client simply does not return to services. Thus, terms such

as noncompliance and nonadherence may hide deeper issues

related to cultural mismatch or a lack of cultural competency

in the part of the practitioner.

Culturally grounded social work challenges practitioners to

see themselves as the other and to recognize that the responsi-

bility of cultural adaptation resides not solely on the clients but

involves everyone in the relationship (Marsiglia & Kulis,

2009). In order to do this, practitioners need to have access

to interventions or tools that are consistent with the culturally

grounded approach. A culturally grounded approach starts with

assessing the appropriateness of existing evidence-based inter-

ventions and adapting when necessary, so that they are more

1
Southwest Interdisciplinary Research Center (SIRC), School of Social Work,

Arizona State University, Phoenix, AZ, USA
2 School of Social Work, University of Pittsburgh, Pittsburgh, PA, USA

Corresponding Author:

Jamie M. Booth, School of Social Work, University of Pittsburgh, 2117

Cathedral of Learning, 4200 Fifth Avenue, Pittsburgh, PA 15260, USA.

Email: jmbooth2@outlook.com

Research on Social Work Practice
2015, Vol. 25(4) 423-432
ª The Author(s) 2014
Reprints and permission:
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DOI: 10.1177/1049731514535989
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relevant and engaging to clients from diverse cultural back-

grounds, without compromising their effectiveness. This process

of assessment, refinement, and adaptation of interventions will

lead to a more equitable and productive helping relationship.

The ecological systems approach provides a structure for

understanding the importance of cultural adaptation in social

work practice. Situated on the outer level (macro level) of

the ecological system, culture frames the norms, values, and

behaviors that operate on every other level: individual beliefs

and behaviors (micro level), family customs and communica-

tion patterns (mezzo level), and how that individual perceives

and interacts with the larger structures (exo level), such as

the school system or local law enforcement (Szapocznik &

Coatsworth, 1999). In this approach, the relationships between

individuals, institutions, and the larger cultural context within

the ecological framework are bidirectional, creating a dynamic

and rapidly evolving system (Bronfenbrenner, 1977; Gitterman,

2009). The bidirectional nature of relationships is an important

concept to consider when discussing the cultural adaptation

of social work interventions for two reasons: (1) regardless

of the setting, in social work practice, the clients and the

social workers engage in work partnerships in which both par-

ties must adapt to achieve a point of mutual understanding and

communication and (2) culture is in constant flux, as individ-

uals interact with actors and institutions which either maintain

or shift cultural norms and values over time.

Although culturally tailoring prevention and treatment

approaches to fit every individual may not be feasible, cultu-

rally grounded social work may require the adaptation of

existing interventions when necessary while maintaining the

fidelity or scientific merit of the original evidence-based

intervention (Sanders, 2000). This article discusses the need

for cultural adaptation, presents a model of adaptation from

an ecological perspective, and reviews the adaptations con-

ducted by the Southwest Interdisciplinary Research Center

(SICR) as a case study. The recommendations section con-

nects the premises of this article with the existing literature

on cultural adaptation and identifies some specific unresolved

challenges that need to be addressed in future research.

Empirically Supported Interventions (ESIs) in
Social Work Practice

EBP has become the gold standard in social work practice and

involve the ‘‘conscientious’’ and ‘‘judicious’’ application of

the best research available in practice (Sackett, 1997, p. 2).

It is commonly believed that utilizing EBP simply requires the

practitioner to locate interventions that have been rigorously

tested using scientific methods, implement them, and evaluate

their effect; however, EBP acknowledges the role of individ-

uals and relationships in this process. EBP requires the inte-

gration of evidence and scientific methods with practice

wisdom, the worldview of the practitioner, and the client’s

perspectives and values (Howard, McMillen, & Pollio, 2003;

Regehr, Stern, & Shlonsky, 2007). The clinician’s judgment and

the client’s perspective are not only utilized in the selection of

the EBP intervention; they are also influential in how the inter-

vention is applied within the context of the clinical interaction

(Straus & McAlister, 2000). Achieving a balance between both

the client and the practitioner’s perspective in the application of

ESIs is essential for bridging the gap between research and prac-

tice (Howard et al., 2003). However, the inclusion of the clini-

cian’s judgment and the client’s history potentially muddles

the scientific merit of the intervention being implemented. This

is the fundamental tension and challenge when implementing

EBP and a key reason why the gap between research and prac-

tice exists (Regehr et al., 2007).

The attraction of EBP is clear; locating and potentially

utilizing empirically tested treatment and prevention inter-

ventions allow social workers to feel more confident that they

will achieve the desired outcomes and provide clients with

the best possible treatment, thereby fulfilling their ethical

responsibility (Gilgun, 2005). Despite this clear rationale, the

utilization of EBP is limited (Mullen & Bacon, 2006) and

when it is applied, research-supported interventions may not

be implemented in the manner the authors of the intervention

intended.

This lack of treatment fidelity when implementing EBP

may be due to practitioner’s awareness that the evidence

generated by randomized control trials (RCTs) may not be

applicable to the diverse needs of their clients or adequately

address the complexity of the clients’ life (Webb, 2001;

Witkin, 1998). Practitioners have natural tendency to adapt

interventions to better fit their clients (Kumpfer et al.,

2002). Some adaptations are made consciously, but others are

made quickly during the course of implementation and based

on clinical judgment (Bridge, Massie, & Mills, 2008; Castro,

Barrera, & Martinez, 2004). ESIs, however, can only be

expected to achieve the same results as those observed when

originally tested, if they are implemented with fidelity or

strict adherence to the program structure, content, and dosage

(Dumas, Lynch, Laughlin, Phillips Smith, & Prinz, 2001;

Solomon, Card, & Malow, 2006). Although adaptations are

typically made in response to a perceived need, when they

are not done systematically, based on evidence and with the

core elements of the intervention preserved, the efficacy that

was previously achieved in the more controlled environment

may not be replicated (Kumpfer et al., 2002). Informal adap-

tation has the potential for compromising the integrity of

the original intervention, thus negating the value of the accu-

mulated evidence that supports the intervention’s effective-

ness. This tension between fidelity and fit has generated a

need for strategies to create fit while insuring fidelity.

Cultural Adaptation

The primacy of scientific rigor over cultural congruence may

be a limitation in applying ESIs and a standard that should not

be maintained in culturally competent social work practice.

When working with real communities, both must be satisfied

to the highest degree possible (Regehr et al., 2007). One solu-

tion to tension between using culturally relevant practices and

424 Research on Social Work Practice 25(4)

ESIs is locating interventions that have been designed for and

tested with a given cultural group. However, the limited avail-

ability of culturally specific interventions with strong empiri-

cal support may create barriers to this approach. Despite the

progress that has been made to date, most ESIs are developed

for and tested with middle-class White Americans, with the

assumption that evidence of efficacy with this group can be

transferred to nonmajority cultures, which may or may not

be the case (Kumpfer et al., 2002).

For example, a prevention intervention with Latino parents

found that assimilated, highly educated Latino parents were

responsive to the prevention interventions presented to them,

while immigrant parents with less education were less likely

to benefit (Dumka, Lopez, & Jacobs-Carter, 2002). This high-

lights the differential effects of an intervention based on culture

as well as a clear need for a more culturally relevant interven-

tion for immigrant parents. Despite a clear need for adaptation

in some circumstances, there is a strong risk of compromising

the effectiveness of the ESI when unstructured cultural adapta-

tions are implemented in response to perceived cultural incon-

gruence (Kirk & Reid, 2002; Kumpfer & Kaftarian, 2000;

Miller, Wilbourne, & Hettema, 2003; Solomon et al., 2006).

For that reason, when culturally and contextually specific inter-

ventions exist with strong evidence, it is certainly preferable to

select that intervention; however, in the absence of an ESI

designed and tested for the population being served, adaptation

may be a more viable and cost-effective option for scientifi-

cally merging a client’s cultural perspectives/values and the

ESI (Howard et al., 2003; Steiker et al., 2008). Systematically

adapting an intervention may increase the odds that the treat-

ment will achieve similar results than those found in more

controlled environments by minimizing the amount of sponta-

neous adaptations that the practitioner feels that they must

make to communicate within the client cultural frame

(Ferrer-Wreder, Sundell, & Mansoory, 2012).

Cultural adaptation may not only preserve the ESI’s effi-

cacy but also enhance the results attained in clinical trials

(Kelly et al., 2000). Culturally adapted interventions have the

potential to improve both client engagement in treatment and

outcomes and might be indicated when either rates fall below

what could be expected based on previous evidence (Lau,

2006). In an evaluation of a culturally adapted version of

the Strengthening Families intervention, there was a 40%
increase in program retention in the culturally adapted version

of the intervention (Kumpfer et al., 2002). Although outcomes

were not found to be significantly better in the adapted version

of the intervention, the increase in retention is a significant

improvement. Improving retention expands the intervention’s

potential to reach and impact individuals who would not

typically remain in treatment. Despite the lack of difference

in outcomes in the Strengthening Families intervention, some

evidence has emerged that culturally adapted interventions

not only increase retention but are also more effective. In a

recent meta-analysis, culturally adapted treatments had a

greater impact than standard treatments, produced better out-

comes, and were most successful when they were culturally

tailored to a single ethnic minority group (Smith, Domenech

Rodrı́guez, & Bernal, 2010).

Adapting interventions in partnership with communities also

enhances the community’s commitment to the implementation

and the chances that the program will be sustained overtime

(Castro et al., 2004). For example, efforts to adapt HIV pre-

vention programs by modifying the messages and protocols

in order for them to sound and feel natural or familiar intellec-

tually and emotionally to individuals, families, groups, and

communities have improved the communities’ receptiveness,

retention, outcomes, and overall satisfaction, in addition to

retaining high levels of fidelity (Kirby, 2002; Raj, Amaro,

& Reed, 2001; Wilson & Miller, 2003).

Finally, cultural adaptation is advantageous because it

allows the social worker to address culturally specific risk

factors and build on identified protective factors. In the case

of Latino families, differential rates of acculturation between

parents and youth appear to be a risk factor for substance use

and delinquency among youth, indicating that family-based

interventions may be the most culturally relevant intervention

(Martinez, 2006). In addition to a source of risk, cultural

norms that place a high value on family loyalty are protective

factors against a variety of negative outcomes (German,

Gonzales, & Dumka, 2009; Marsiglia, Nagoshi, Parsai, &

Castro, 2012). Identifying risk and protective factors unique

to a community and addressing these within an intervention

have the potential to increase the efficacy of

the intervention.

The importance of EBP and culturally competent practice

has created tension in the field of social work. Evidence

has landed support to both claims: (1) interventions are more

effective when implemented with fidelity (Durlak & DuPre,

2008) and (2) interventions are more effective when they are

culturally adapted because they ensure a good fit (Jani et al.,

2008). These different perspectives highlight the tension in

the field between implementing manualized interventions

exactly as they were written versus to adjusting them to fit the

targeted population or community (Norcross, Beutler, &

Levant, 2006). Although this debate is far from resolved, the-

ories of adaptation have been developed that allow the

researcher/practitioner to adjust the fit without compromising

the integrity of the intervention (Ferrer-Wreder et al., 2012).

If the cultural adaptation is done systematically, it has the

potential for maximizing the benefit of the fit, as well as the

benefit of the ESI, thus providing a strategy that addresses

many of the concerns surrounding EBP’s applicability in

social work practice (Castro et al., 2004).

An Emerging Roadmap for Cultural Adaptation

Cultural adaptation is an emerging science that aims at

addressing these challenges and opportunities to enhance the

effectiveness of interventions by grounding them in the lived

experience of the participants. Strategies and processes to sys-

tematically adapt interventions while insuring a more optimal

cultural fit without compromising the integrity of scientific

merit have been proposed and are beginning to be tested

Marsiglia and Booth 425

(La Roche & Christopher, 2009). The first step in all adaptation

models is determining that the cultural adaptation of an interven-

tion should be perused. Adaptation of an ESI is indicated when

(1) a client’s engagement in services falls below what is

expected, (2) expected outcomes are not achieved, and (3) iden-

tified culturally specific risks and/or protective factors need to

be incorporated into the intervention (Barrera & Castro, 2006).

Once the determination is made to conduct an adaptation,

there are a variety of models that one could follow all of which

fall into two categories: content and process (Ferrer-Wreder

et al., 2012). Although most current adaptation models have

merged the discussions regarding the content that should be

modified and process by which this modification takes place,

it is useful to consider them separately.

Content models identify an array of domains that may be

crucial to address when conducting an adaptation. The ecolo-

gical validity model, for example, focuses on eight dimensions

of culture: language, persons, metaphors, content, concepts,

goals, methods, and social context (Bernal, Jiménez-Chafey,

& Domenech Rodrı́guez, 2009). The cultural sensitivity model,

also a content model, identifies two distinct content areas: deep

culture, which includes aspects of culture such as thought pat-

terns, value systems, and norms, and surface culture, which refers

to elements, such as language, food, and customs (Resnicow,

Soler, Braithwaite, Ahluwailia, & Butler, 2000). Proponents of

the cultural sensitivity model argue that both aspects of culture

should be assessed and potentially addressed if areas of conflict

or incongruence between the culture and the intervention are

identified (Resnicow et al., 2000). Surface adaptations allow the

participants to identify with the messages, potentially enhancing

engagement; while, deep culture adaptations ensure that the

outcomes are impacted (Resnicow et al., 2000).

Castro, Barrera, and Martinez (2004) and Castro, Barrera,

and Steiker, 2010 have proposed a content model that identifies

a set of specific dimensions—at the surface and deep levels—

that are essential to consider in the adaptation process: cogni-

tive, affective, and environmental. Cognitive adaptations are

considered when participants cannot understand the content

that is being presented due to language barriers or the use of

information that is not relevant in an individual’s cultural

frame. Vignettes given by the original intervention, for exam-

ple, may not be relevant to the participants or may be offensive

due to spiritual or religious taboos. The content may create a

negative reaction from the participants which in turn may block

their ability to hear and integrate the message. It is that content

that needs to be modified while the core elements of the inter-

vention are respected. Affective-motivational adaptations are

indicated when program messages are contrary to cultural

norms and values, creating a resistance to change within the

individual (Castro, Rawson, & Obert, 2001). Environmental

factors (later referred to as relevance) make sure that the con-

tents and structure are applicable to the participants in their

daily lived experience (Castro et al., 2010).

While content models of adaptation tell adaptors where to

look for cultural mismatch, process models provide a frame-

work for making systematic assessments of cultural match,

adjustments to the original intervention, and tests of the adap-

tations effectiveness. At a minimum adaption process, models

follow two systematic steps: (1) identifying mismatches

between the original intervention and the client’s culture and

(2) testing/evaluating changes that have been made to rectify

these disparities (Ferrer-Wreder et al., 2012).

Most process models of adaptation begin with building a

partnership or coalition with members of targeted community

(Castro et al., 2010; Harris et al., 2001; Wingood & DiCle-

mente, 2008). Sometimes the ESI that will be adapted is

selected at this stage; however, more information is often gath-

ered about the targeted population before selecting the inter-

vention that would provide the best fit (Kumpfer, Pinyuchon,

Teixeriade de Melo, & Whiteside, 2008; Mckleroy et al.,

2006; Wingood & DiClemente, 2008). Whether the interven-

tion has yet to be selected, extensive formative research is con-

ducted to assess the etiology of the social problem that is the

target of the intervention, possible population-specific risks

and protective factors, and measurement equivalence to insure

and accurate evaluation of intervention outcomes (Harris et al.,

2001). Some information about the target community may be

gained by reviewing relevant literature; however, interviews,

focus groups, and surveys are also used to collect primary data

about the social and cultural context that may impact the out-

come of the intervention or conflict with the program’s mes-

sages/implementation strategies.

At this point in the process, some adaptation models recom-

mend making changes based on the formative research

(Domenech-Rodriguez & Wieling, 2004; Harris et al., 2001), while

others suggest implementing the intervention with minimal

changes and assessing the need for further adaption. In an innova-

tive approach, the Planned Intervention Adaptation model suggests

making significant changes to one version of the intervention

while making minimal changes to another and implementing them

both simultaneously to test the differential effects (Castro et al.,

2010; Ferrer-Wreder et al., 2012; Kumpfer et al., 2008).

Regardless of the level of adaptation, the modified inter-

vention is pilot tested and based on the outcomes subsequent

adaptations are made (Ferrer-Wreder et al., 2012). Once a

final adaptation has been made, further testing takes place

in effectiveness trials. Across all theories of adaptation, the

process is iterative with refinements made to the intervention

at every stage based on the evidence generated in the prior

stage (Domenech-Rodriguez & Wieling, 2004). Regardless

of the depth of changes made, the adapted intervention must

be rigorously tested to ensure that the effects of the original

ESI are preserved after changes have been made.

Case Study: Adaptations of Keepin’it REAL
(KiR), the Southwest Interdisciplinary
Research Center (SIRC) Approach

Over the past 10 years of health disparities research, the SIRC

has developed a process of cultural adaptation that includes

most of the elements outlined previously. The specific

426 Research on Social Work Practice 25(4)

adaptation model utilized at SIRC is an expanded version

of the Barrera and Castro (2006) model as illustrated by

Figure 1.

KiR is the flagship empirically supported treatment SIRC

(Marsiglia & Hecht, 2005). KiR is a manualized school-

based substance abuse prevention program for middle school

students. It was designed to (a) increase drug resistance skills

among middle school students, (b) promote antisubstance use

norms and attitudes, and (c) develop effective drug resistance

and communication skills (Gosin, Dustman, Drapeau, &

Harthun, 2003). It was created and evaluated in Arizona

through many years of community-based research funded by

the National Institutes on Drug Abuse of the National Insti-

tutes of Health. It is a model program listed under Substance

Abuse and Mental Health Services Administration’s National

Registry of Evidence-Based Programs and Practices. There is

strong evidence about the efficacy of the intervention with

middle school Mexican American students (Marsiglia, Kulis,

Wagstaff, Elek, & Dran, 2005), however the community-

identified need to reach out to younger students and to stu-

dents of other ethnic groups generated a set of adaptation

efforts summarized in Figure 2.

As Figure 2 illustrates, KiR was adapted for fifth-grade stu-

dents (Harthun, Dustman, Reeves, Marsiglia, & Hecht, 2009)

following the SIRC adaptation model and an RCT was con-

ducted to test whether the effects of the intervention increased

by intervening earlier (fifth grade vs. seventh grade). Students

who received the intervention in both the fifth and seventh

grade were no different in their self-reported use of alcohol

and other drugs than students who received the intervention

only on the seventh grade (Marsiglia, Kulis, Yabiku, Nieri,

& Coleman, 2011). This effort did no yield the expected

results but provided evidence from a developmental perspec-

tive that starting earlier was not cost effective.

The second adaptation presented in Figure 2 was also

community-generated and supported from the evidence gath-

ered during the initial RCT of KiR. Urban American Indian

(AI) youth were not benefiting from KiR as much as other

children (Dixon et al., 2007). Following the principles of

community-based participatory research, a steering group,

including leaders from the local urban AI community and

school district personnel in charge of AI programs, was

formed to guide the adaptation process. In addition to enga-

ging community members and setting up a structure to ensure

a collaborative partnership, before beginning the adaptation

process, formative information was collected by consulting

the literature to identify culturally specific risks and protec-

tive factors and focus groups. Focus groups were conducted

with both Native American adults and youth to explore cultu-

rally specific drug resistance strategies that were frequently

applied by urban Native American youth (Kulis & Brown,

2011; Kulis, Dustman, Brown, & Martinez, 2013).

Based on this information, collected in conjunction with

four Native American curriculum development experts, KiR

was adapted, and while maintaining its core elements, the

content and structure were changed to be more culturally rel-

evant to Native American youth (Kulis et al., 2013). Changes

to the curriculum included (1) new drug resistant strategies

that were identified by the AI youth as being more culturally

relevant to them, (2) lesson plans designed to teach strategies

in a more culturally relevant way, (3) more comprehensive

content focusing on ethnic identity (a protective factor identi-

fied in the literature), and (5) a narrative approach in teaching

content (Kulis et al., 2013). In the initial pilot test of the

intervention, results showed an increase in the use of REAL

strategies indicating a promising effect. Based on pilot test

feedback, the intervention has been further adapted and

implemented on a larger scale through an RCT. The research

team at SIRC is currently in the process of developing a

Identification
of EBP with
community.
Preliminary
adaptation

Pilot-testing
of the

adpated
version

Integration of
the results.

Further
adaptation if

needed

RCT
of the final

adapted
version

Community
Engegament

& Needs
Assessment

Figure 1. The SIRC adaptation model (Barrera & Castro, 2006).
Note. SIRC ¼ Southwest Interdisciplinary Research Centre.

keepin’t REAL
Phoenix efficacy

trial: EBP
N = 6,035

(1997-2002)

Adapted with Jalisco-Mexico
middle schools

N = 431
(2011-2013)

Adapted with Phoenix urban American
Indian middle schools

N = 247
(2007-2012)

Adapted with Phoenix 5th graders
N = 3,038

(2003-2008)

Figure 2. The SIRC family of adapted interventions.
Note. SIRC ¼ Southwest Interdisciplinary Research Centre.

Marsiglia and Booth 427

parenting component to this intervention using the processes

that were established in the development of the youth version.

Implementing and adapting KiR for the Mexican context is

the most recent adaptations done at SIRC. Collaborators in

Jalisco-Mexico identified Keepin’ it as an ESI suitable for

Mexico. The initial review of the intervention resulted in a

‘‘surface’’ adaptation consisting mostly of translating the

manuals from English to Spanish and changing some of the

vignettes that were not appropriate for Mexico. The Jalisco

team recruited two middle schools to participate in a pilot

study of the initial adapted version of KiR. The schools were

randomized to control and experimental conditions. Imple-

menters (teachers) and student participants participated in

the regular classroom-based intervention for 10 weeks and

were also a part of a simultaneous intensive review process

of the intervention through focus groups. The overall level

of comfort and satisfaction with the intervention was high and

the pre- and posttest survey results were also favorable. The

main concern for teachers and students was the videos that

illustrate the REAL resistance strategies. The original videos

were dubbed into Spanish, but the story lines, the music, and

even the clothing felt foreign to the youth in Jalisco. As a

result, new scripts and new videos were produced by and for

youth in Jalisco. This method of adaptation did not change the

core elements of the original intervention but did address

aspects of deep culture (Steiker et al., 2008). Because the

youth wrote and acted in the videos, they were able to con-

struct scenarios that accurately reflected their cultural norms

and values.

The results of the pilot also provided additional feedback to

edit the content and format of the manuals. See Figure 3 for

the pilot results on alcohol, cigarette, and marijuana use.

The results of the pilot were very promising and identified

female students at a greater risk. Females in the control group

(not receiving the intervention) reported the greatest increase in

substance use between the pre- and posttest. The pilot results

illustrate the need for the cyclical and continuous adaptation

process. This case study highlights the need to conduct a gender

adaptation in addition to an ethnic or nation of origin adapta-

tion. With the adapted manual and the new videos, the bina-

tional team of researchers is applying for funding to conduct

an RCT in Mexico of the revised intervention now called

‘‘Mantente REAL.’’

Adaptation in Social Work Practice

The previously discussed models, including the SIRC model,

are based on collaborations between practitioners and research-

ers, where researchers take the lead in the formative assess-

ments, adaptations, and evaluations of effectiveness. In many

social work practice settings, this process might look different,

although it is recommended that regardless of the setting, a

partnership with the intervention designers is developed if

significant modifications are going to be made to the original

intervention. The Centers for Disease Control and Prevention

(CDC) has devised a set of practical guidelines for practitioners

adopting an ESI and strongly discourages adaptors to change

the deep structures of the intervention (McKleroy et al., 2006).

In the CDC model, as in the SIRC model, the adaptation

process starts with the selection of an ESI that best matches the

population and context (Solomon et al., 2006). The selection of

an intervention is based on an initial assessment of the targeted

population and an exploration of possible intervention varia-

tions (Ferrer-Wreder et al., 2012). Assessments of the pop-

ulation can be made through a review of the literature and by

conducting interviews with key informants or focus groups

with potential participants. The initial assessment of the popu-

lation should go beyond potential participants’ ethnicities to

include multiple and intersecting identities. Cultural adaptation

frequently starts and stops with the identification of race, with-

out examining how age, gender, sexual orientation, religion,

acculturation, and geography shape culture. The lack of such

identification information could potentially impact the partici-

pants’ experience with the intervention (Wilson & Miller,

2003). A thorough assessment includes consideration for both

deep and surface culture, as well as population-specific risks

and protective factors (Solomon et al., 2006). During this initial

0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9

Wave 1 Wave 2

Wave 1 Wave 2
Wave 1 Wave 2

Alcohol Frequency

Male (E)
Male (C)
Female (E)
Female (C)

0
0.05
0.1

0.15
0.2

0.25
0.3

0.35
0.4

0.45

Cigarette Frequency

Male (E)
Male (C)
Female (E)
Female (C)
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45

Cigarette Amount

Male (E)
Male (C)
Female (E)
Female (C)

Figure 3. Pilot results of ‘‘Mantente REAL.’’

428 Research on Social Work Practice 25(4)

phase, social workers strive to find the best possible fit because

the fewer modifications they make, the less likely the fidelity of

the intervention will be compromised in the adaptation process.

After the intervention is selected, the practitioner thoroughly

evaluates the theoretical underpinnings of the intervention and

assesses the intervention in light of the cultural norms and values

of the clients being served (Green & Glasgow, 2006). The

practitioner then systematically works to reconcile any mis-

matches between the intervention and the participants’ lived

experiences without altering the core components of the inter-

vention or features of the intervention that are responsible for

the intervention’s effectiveness (Green & Glasgow, 2006;

Kelly et al., 2000; Solomon et al., 2006). When it is deter-

mined that elements of deep culture need to be changed and

these changes have the potential of altering core elements of

the curriculum, the evidence previously found for effective-

ness may be negated indicating the need to retest the interven-

tion in an RCT (see Figure 4 ).

Although some interventionists have explicitly identified

core components that must be preserved to ensure effective-

ness, others have not. In the case when they are not explicitly

stated, it becomes the implementer’s responsibility to uncover

aspects of the intervention that cannot be changed or removed.

Identifying the theory of change (i.e., cognitive behavioral

theory, reasoned action, and communication competency) is

the most practical way of identifying core elements, although

contacting the authors and conducting experiments are also

possibilities (Solomon et al., 2006).

After the intervention has been adapted to reconcile any

conflicting mismatches, a pilot test is recommended of the

adapted intervention with a small group of participants (at

least N ¼ 10) using pre- or postsurveys and focus groups
(McKleroy et al., 2006). Any information gleaned from this

data will be used to further incorporate any adaptations into

the intervention.

The extent of adaptation must be determined by the level of

mismatch between the intervention and the population being

served (Barrera & Castro, 2006). Frequently, cultural adapta-

tions only address surface aspects of culture while neglecting

the deeper messages being communicated in the intervention.

This is not necessarily bad practice. It is possible that chang-

ing the language, photographs, and the scenarios in an inter-

vention is all that is needed to make it culturally relevant.

There are, however, situations in which this is not sufficient

(Resnicow et al., 2000). As mentioned previously, surface

adaptation allows participants in the program to identify

themselves with the intervention, but it could fail to address

the larger cultural norms that may be impacting the target

behaviors or decision-making process. If it is determined that

significant and/or deep changes are needed, the developers of

the intervention need to be contacted and asked to assist the

social worker in the process. It should be remembered that any

changes have the potential to compromise the intervention’s

effectiveness and need to be implemented with extreme cau-

tion. Social workers adapting interventions should document

all changes made to the original intervention and systemati-

cally evaluate the outcomes in order to ensure that the desired

results are being achieved.

Recommendations

Social work ethics clearly instruct social workers to provide

culturally competent practice and to implement interventions

with the best possible evidence of efficacy. Due to the vast

diversity in the human family, these imperatives can be in con-

flict. This conflict highlights many of the questions that still

linger in the discussion of the value of implementing social

work interventions with fidelity versus adapting them to better

achieve a cultural fit. It has been suggested that one way to rec-

tify this tension is to adapt interventions in a systematic manner

based on scientifically validated methods. Despite the apparent

clarity of this task, the adaptation process can be challenging.

The theories of adaptation that have emerged in several differ-

ent fields put forward similar processes of adaptation. These

may require an extensive assessment of the etiology of social

problems, an understanding of the deep theoretical structure

of the original intervention, and rigorous evaluation that may

be beyond the capacity of individual practitioners. To this end,

more work needs to be done to build the capacities of social

workers and social work agencies for utilizing and conducting

Figure 4. The continuum of adaptation: Balancing the fidelity and fit.

Marsiglia and Booth 429

rigorous research that would enable them to reliably adapt

social work research theories and practices. In the absence of

needed resources, social workers are encouraged to build

relationships with research institution that can help them sys-

tematically assess and adapt interventions, so that they can

provide the most culturally competent services. When adapta-

tions cannot be reliably implemented, efforts need to be made

to identify interventions that have been previously adapted

and tested with a given population, such as those in the SIRC

model, and implement them with fidelity. With the ever

expanding number of rigorously tested, culturally specific,

and culturally grounded interventions, it may seem feasible

at some point to have an ESI for every population in every

context; however, the dynamic nature of culture and the vast

diversity among humans ensure that cultural adaptation will

continue to be a likely necessity in the future.

Authors’ Note

This article was previously presented at the conference on Bridging

the Research and Practice gap: A Symposium on Critical Considera-

tions, Successes and Emerging Ideas, sponsored by the University of

Houston Graduate College of Social Work, Houston, TX, April 5–6,

2013. This article was invited and accepted by the Guest Editor of this

special issue, Danielle E. Parrish, PhD The content of this article is

solely the responsibility of the authors and does not necessarily repre-

sent the official views of NIMHD or the NIH.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the

research, authorship, and/or publication of this article: This research

was supported by the National Institute on Minority Health and Health

Disparities (NIMHD) of the National Institutes of Health (NIH Grant

P20MD002316-05, to Flavio F. Marsiglia, principal investigator).

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conducting a qualitative descriptive study

Mojtaba Vaismoradi, PhD, MScN, BScN,1,3 Hannele Turunen, PhD, RN2 and Terese Bondas, PhD, RN2,3
1College of Human and Health Sciences, Swansea University, Swansea, UK, 2Department of Nursing Science, Kuopio
Campus, University of Eastern Finland, Kuopio, Finland and 3Faculty of Professional Studies, University of Nordland,
Bodø, Norway

Abstract Qualitative content analysis and thematic analysis are two commonly used approaches in data analysis of
nursing research, but boundaries between the two have not been clearly specified. In other words, they are
being used interchangeably and it seems difficult for the researcher to choose between them. In this respect,
this paper describes and discusses the boundaries between qualitative content analysis and thematic analysis
and presents implications to improve the consistency between the purpose of related studies and the method
of data analyses. This is a discussion paper, comprising an analytical overview and discussion of the definitions,
aims, philosophical background, data gathering, and analysis of content analysis and thematic analysis, and
addressing their methodological subtleties. It is concluded that in spite of many similarities between the
approaches, including cutting across data and searching for patterns and themes, their main difference lies in
the opportunity for quantification of data. It means that measuring the frequency of different categories and
themes is possible in content analysis with caution as a proxy for significance.

Key words content analysis, nursing, qualitative descriptive research, thematic analysis.

INTRODUCTION

In health care, qualitative methodologies aim to explore
complex phenomena encountered by nurses, other providers,
policy makers, and patients (Denzin & Lincoln, 2000;
Sandelowski & Barroso, 2003a; Tong et al., 2007). The phi-
losophy and the basic principles of methodologies, study
aims and questions, and designs and data gathering criteria
provide key differences between qualitative and quantitative
methodologies (Ayres, 2007a). A belief in multiple realities, a
commitment to identifying an approach to in-depth under-
standing of the phenomena, a commitment to participants’
viewpoints, conducting inquiries with the minimum disrup-
tion to the natural context of the phenomenon, and reporting
findings in a literary style rich in participant commentaries
are the main characteristics of qualitative methodologies
(Streubert Speziale & Carpenter, 2007).

Qualitative methodologies consist of the philosophical
perspectives, assumptions, postulates, and approaches that
researchers employ to render their work open to analysis,
critique, replication, repetition, and/or adaptation and to
choose research methods. In this respect, qualitative method-
ologies refer to research approaches as the tools with which

researchers design their studies, and collect and analyse their
data (Given, 2008). Qualitative methodologies are not a
single research approach, but different epistemological per-
spectives and pluralism have created a range of “approaches”
such as grounded theory, phenomenology, ethnography,
action research, narrative analysis, and discourse analysis.

Qualitative research in the field of health has, at times,
been undertaken without identification of the specific meth-
odology used. The term “approach” is used in this article to
differentiate it from the narrower term “methods.” This indi-
cates a coherent epistemological viewpoint about the nature
of enquiry, the kind of knowledge discovered or produced,
and the kind of strategies that are consistent with this
(Giorgi, 1970; Holloway & Todres, 2005).

Qualitative approaches share a similar goal in that they
seek to arrive at an understanding of a particular phenom-
enon from the perspective of those experiencing it. There-
fore, the researcher needs to determine which research
approach can answer their research questions (Streubert
Speziale & Carpenter, 2007). There is a considerable overlap
among available qualitative approaches in terms of methods,
procedures, and techniques. Such an overlap of epistemologi-
cal, aesthetic, ethical, and procedural concerns can encour-
age a generic view of qualitative research, considering it a
“family” approach in which the similarities are more impor-
tant than the differences, and where the notion of flexibility
becomes an important value and quest. However, there is
another point of view, concerned with how such flexibility can
lead to inconsistency and a lack of coherence (Holloway &

Correspondence address: Hannele Turunen, Department of Nursing Science, Kuopio
Campus, University of Eastern Finland, Kuopio, Finland. PO Box 1627, 70211
Kuopio. Email: hannele.turunen@uef.fi
Conflict of interest: None.
Received 20 March 2012; revision received 30 December 2012; accepted 28 January
2013.

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Nursing and Health Sciences (2013), 15, 398–405

© 2013 Wiley Publishing Asia Pty Ltd.

doi: 10.1111/nhs.12048

Todres, 2003). It should not be forgotten that consumers of
research assess the quality of evidence offered in a study by
evaluating the conceptual and methodological decisions the
researchers have made. Therefore, the researcher needs to
make good decisions to produce evidence of the highest pos-
sible quality (Polit & Beck, 2003; Høye & Severinsson, 2007).

Aim

Nurse researchers need to delineate and recognize the char-
acteristics of the approach they are going to use in their
studies to improve validity, and the consistency between the
purpose of the study and the method of data analysis. There-
fore, this article describes and discusses the boundaries
between two commonly used qualitative approaches, content
analysis and thematic analysis, and presents implications to
improve the consistency between the purpose of studies and
the related method of data analysis.

FINDINGS

This article continues with a classification of content analysis
and thematic analysis as descriptive qualitative approaches
to data analysis, and an analytical overview and comparative
discussion of the approaches’ definitions, aims, philosophical
background, and data analysis process. Figure 1 summarizes
the comparison of the main characteristics of thematic analy-
sis and content analysis in the continuum of qualitative
research.

Content analysis and thematic analysis as qualitative
descriptive approaches
According to Sandelowski and Barroso (2003b) research
findings can be placed on a continuum indicating the degree
of transformation of data during the data analysis process
from description to interpretation. The use of qualitative
descriptive approaches such as descriptive phenomenology,
content analysis, and thematic analysis is suitable for
researchers who wish to employ a relatively low level of
interpretation, in contrast to grounded theory or herme-
neutic phenomenology, in which a higher level of interpretive
complexity is required. It is noted that there are different
views with respect to the meaning of description and
interpretation in qualitative research, depending on the
methodological approach. Many researchers believe that
both descriptive and interpretative approaches entail inter-
pretation, even if the interpretive component is downplayed
or masked in discussions of its broader narrative and explo-
ration (Sandelowski, 2010). The value of qualitative descrip-
tion lies not only in the knowledge that can originate from it,
but also because it is a vehicle for presenting and treating
research methods as living entities that resist simple classifi-
cation, and can result in establishing meaning and solid find-
ings (Giorgi, 1992; Holloway & Todres, 2005; Sandelowski,
2010).

Nursing researchers frequently use qualitative content
analysis and thematic analysis as two analysis approaches
in the qualitative descriptive study. However, because the
boundaries and the division between the two have not been

Qualifying Qualita ve design Quan fying

Aims and
concentra ons

Analyzing narra ve
materials of life

stories

Realist/essen alist

and construc onist,
fac st

perspec ve

Descrip on and
interpreta on, both
induc ve and
deduc ve,
emphasizing context,
integra on of
manifest and latent
contents, drawing
thema c map, non-
linear analysis
process, no peer
checking

Analyzing nursing
sensi ve

phenomena,
exploratory work on

the unknown
phenomenon

Communica on
theory, fac st

perspec ve

Descrip on and
more interpreta on,
both induc ve and
deduc ve, danger
of missing context,
possibility of finding
a theme based on
the frequency of its
occurrence, division
of manifest and
latent contents, non-
linear analysis
process

Thema c analysis Content analysis

Philosophical
background

Analysis process

Figure 1. Main characteristics of thematic analysis and qualitative content analysis in the continuum of the qualitative methodology.

Qualitative descriptive study 399

© 2013 Wiley Publishing Asia Pty Ltd.

clearly specified, they are often used interchangeably and
there is confusion about their similarities and differences
(Sandelowski & Leeman, 2012), as well as how researchers
should choose between them (Braun & Clarke, 2006). For
instance, it has not been uncommon to find that qualitative
content analysis is classified as a type of narrative analysis
(Sandelowski & Barroso, 2003a; Sparker, 2005). Similarly,
thematic analysis has sometimes been introduced as one
part of phenomenology (Holloway & Todres, 2005) or even
simply ignored in textbooks of qualitative methods. Addition-
ally, a lack of consistency and the absence of a clear boundary
between thematic analysis and qualitative content analysis,
and other analytical qualitative approaches, have resulted in
the application of titles such as “phenomenological thematic
analysis” (Sandelowski & Barroso, 2003a) or “thematic
content analysis” (Green & Thorogood, 2004). Interestingly,
much of the analysis presented in published papers is essen-
tially thematic, but is either described as something else such
as content analysis or simply not identified as a particular
method. For instance, it has been stated that data were sub-
jected to qualitative analysis for commonly recurring themes
(Braun & Clarke, 2006), or there is a lack of identification of
the explicit methodological orientation (Sandelowski &
Barroso, 2003b). Also, some researchers merely describe the
use of qualitative data gathering techniques, such as inter-
views and focus groups, and not enough effort is made to
qualify individual elements of methods other than signaling
the data analysis process as either content or thematic analy-
sis (Sandelowski & Barroso, 2003b). In this respect, there is
a need to clarify and introduce methodological approaches
rarely identified as independent methods (Sandelowski,
2010).

Definition of content analysis and thematic analysis

Content analysis is a general term for a number of different
strategies used to analyse text (Powers & Knapp, 2006). It is
a systematic coding and categorizing approach used for
exploring large amounts of textual information unobtrusively
to determine trends and patterns of words used, their fre-
quency, their relationships, and the structures and discourses
of communication (Mayring, 2000; Pope et al., 2006; Gbrich,
2007).

The purpose of content analysis is to describe the charac-
teristics of the document’s content by examining who says
what, to whom, and with what effect (Bloor & Wood, 2006).
On the other hand, thematic analysis often is seen as a poorly
branded method, in that it does not appear to exist as a
named method of analysis in the same way that content
analysis does. Thematic analysis as an independent qualita-
tive descriptive approach is mainly described as “a method
for identifying, analysing and reporting patterns (themes)
within data” (Braun & Clarke, 2006: 79). It has also been
introduced as a qualitative descriptive method that provides
core skills to researchers for conducting many other forms of
qualitative analysis. In this respect, qualitative researchers
should become more familiar with thematic analysis as an
independent and a reliable qualitative approach to analysis.

Aim and focus of data analysis

It seems that both content analysis and thematic analysis
share the same aim of analytically examining narrative mate-
rials from life stories by breaking the text into relatively
small units of content and submitting them to descriptive
treatment (Sparker, 2005). Both content and thematic analy-
sis approaches are suitable for answering questions such as:
what are the concerns of people about an event? What
reasons do people have for using or not using a service or
procedure? (Ayres, 2007b). Content analysis is well-suited to
analyse the multifaceted, important, and sensitive phenom-
ena of nursing (Elo & Kyngäs, 2008; Vaismoradi et al., 2011).
If conducting exploratory work in an area where not much is
known, content analysis may be suitable for the simple
reporting of common issues mentioned in data (Green &
Thorogood, 2004). It has been suggested that thematic analy-
sis, as a flexible and useful research tool, provides a rich and
detailed, yet complex, account of the data (Braun & Clarke,
2006). Clearly, thematic analysis involves the search for and
identification of common threads that extend across an entire
interview or set of interviews (DeSantis & Noel Ugarriza,
2000).

It should be noted that both approaches allow for a quali-
tative analysis of data. By using content analysis, it is possible
to analyse data qualitatively and at the same time quantify
the data (Gbrich, 2007). Content analysis uses a descriptive
approach in both coding of the data and its interpretation of
quantitative counts of the codes (Downe-Wamboldt, 1992;
Morgan, 1993). Conversely, thematic analysis provides a
purely qualitative, detailed, and nuanced account of data
(Braun & Clarke, 2006).

Philosophical backgrounds

When qualitative approaches are introduced in qualitative
research textbooks, each approach is discussed in the context
of its historical and philosophical background (Streubert
Speziale & Carpenter, 2007). Generally, qualitative
approaches share a broad philosophy, such as person-
centeredness, and a certain open-ended starting point
(Holloway & Todres, 2003).

Communication theory has been introduced as a way to
address the issue of interpretation and to clarify the under-
lying assumptions of content analysis (Graneheim &
Lundman, 2004). Thematic analysis can be conducted within
both realist/essentialist and constructionist paradigms,
although the outcome and focus will be different for each
(Braun & Clarke, 2006). It has also been noted that both
approaches are largely based on the “factist” perspective. A
factist perspective assumes data to be more or less accurate
and truthful indexes of the reality out there (Sandelowski,
2010). In other words, the researcher wants to find out about
the actual behaviour, attitudes, or real motives of the people
being studied, or to detect what has happened (Ten Have,
2004).

According to Sandelowski (2010), a lot of energy is spent
focusing on philosophical details, which often have little or
nothing to do with what the researchers actually do.

400 M. Vaismoradi et al.

© 2013 Wiley Publishing Asia Pty Ltd.

However, the philosophical starting points of the study
should not be forgotten when seeking differences and simi-
larities in the approaches (Bondas & Hall, 2007). The actual
implementation of the methods and understanding their sub-
tleties in the data analysis process should receive greater
attention from nurse educators and qualitative researchers.

Exploration of the data analysis process

Both content analysis and thematic analysis are used in
nursing studies. Nevertheless, a scarcity of information about
the process of data analysis in nursing literature has resulted
in a diversity of perspectives on how the approaches are used
in research practice (Braun & Clarke, 2006; Elo & Kyngäs,
2008). A unified and standard data analysis protocol is pre-
ferred to be implemented by all researchers, because differ-
ent results may be produced if different protocols are
followed (Gbrich, 2007).

Regarding the data analysis process, different research
approaches can be compared based on aspects such as
“description and interpretation,” “modalities of approaches,”
“consideration of context of data,” “data analysis process,”
and “evaluation of the analysis process.”

Description and interpretation

When using content analysis, the primary aim is to describe
the phenomenon in a conceptual form (Elo & Kyngäs, 2008).
The content analyst views data as representations not of
physical events but of texts, images, and expressions created
to be seen, read, interpreted, and acted on for their meanings,
and must therefore be analyzed with such uses in mind
(Krippendorff, 2004). However, it has been claimed that
content analysis in nursing research can be applied to various
levels of interpretation (Graneheim & Lundman, 2004). In
contrast, thematic analysis applies minimal description to
data sets, and interprets various aspects of the research topic
(Braun & Clarke, 2006).

Modalities of approaches

The current application of both content analysis and the-
matic analysis similarly, is associated with two modalities:
inductive and deductive. Inductive content analysis and the-
matic analysis is used in cases where there are no previous
studies dealing with the phenomenon, and therefore the
coded categories are derived directly from the text data
(Hsieh & Shannon, 2005). A deductive approach is useful if
the general aim of thematic analysis and content analysis is to
test a previous theory in a different situation, or to compare
categories at different periods (Hsieh & Shannon, 2005;
Elo & Kyngäs, 2008). This form tends to provide a less rich
description of the data overall, and a more detailed analysis
of some aspect of the data (Braun & Clarke, 2006). It should
be noted that both the approaches may begin with a theory
about the target phenomenon or a framework for collecting
or analysing data, but that does not mean there is a commit-
ment to stay within this theory or framework (Sandelowski,
2010). The question of whether a study needs to use an induc-

tive or directed approach can be answered in both methods
by matching the specific research purpose and the state of
science in the area of interest to the appropriate analysis
technique (Hsieh & Shannon, 2005).

Consideration of context of data

Every analysis requires a context within which the available
texts are examined. The researcher must construct a world in
which the texts make sense allowing them to answer research
questions (Krippendorff, 2004). The researcher, who has a
broader understanding of the context influencing the stories
of the study participants, may develop a wider understanding
of what is going on, in addition to the understanding that
she or he may share with those participating in the re-
search (Downe-Wamboldt, 1992). Both approaches provide
researchers with a framework of analysis within which the
context of data is apparent. Certainly, content analysis makes
sense of what is mediated between people including textual
matter, symbols, messages, information, mass-media content,
and technology supported social interactions (Krippendorff,
2004; Hsieh & Shannon, 2005). On the other hand, thematic
analysis is able to offer the systematic element characteristic
of content analysis, and also permits the researcher to
combine analysis of their meaning within their particular
context (Loffe & Yardley, 2004).

If in content analysis only the frequency of codes is
counted to find significant meanings in the text, there is the
danger of missing the context (Morgan, 1993). Therefore,
researchers employing content analysis are sometimes
accused of removing meaning from its context. The problem
is that a word or coding category may occur more frequently
in the speech of one person or group of people than another
for different reasons. Frequent occurrence could indicate
greater importance, but it might simply reflect greater will-
ingness or ability to talk at length about the topic (Loffe &
Yardley, 2004; Shields & Twycross, 2008).

Data analysis process

Like other qualitative methods, gathering and analysing
data are conducted concurrently in descriptive qualitative
approaches, thus adding to the depth and quality of data
analysis. However, it is also common to collect all the
data before examining it to determine what it reveals
(Chamberlain et al., 2004).

The process of data analysis in content analysis according
to Elo and Kyngäs (2008), and in thematic analysis according
to Braun and Clarke (2006) is shown in Table 1. According to
the table, the preparation phase in content analysis and the
phase of familiarizing with data in thematic analysis are
equivalent. In both phases, the researcher is expected to tran-
scribe the interview, and obtain the sense of the whole
through reading the transcripts several times. While the the-
matic analysis researcher is mainly advised to consider both
latent and manifest content in data analysis, the content
analyst can choose between manifest (developing categories)
and latent contents (developing themes) before proceed-
ing to the next stage of data analysis. Open coding,

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collecting codes under potential subcategories/subthemes or
categories/themes, and comparing the emerged coding’s clus-
ters together and in relation to the entire data set conprise
the next stage of data analysis, which is named the organizing
phase in content analysis. The same set of analytical interven-
tions used in content analysis is applied in thematic analysis
under the classifications of generating initial codes, defining
and naming themes, reviewing themes, and searching for
themes.

The final stage of data analysis in both approaches is
related to reporting the result of the previous stages. This
stage is especially highlighted as the final opportunity of data
analysis in thematic analysis. In addition, in both approaches,
the creativity of the researcher for presenting the result in
terms of a story line, a map, or model is encouraged.

It is noted that in both approaches, high quality data analy-
sis depends on gathering high quality data. It is the respon-
sibility of researchers to conduct data gathering in such a way
that any complex data would be suitable to present interest-
ing findings. After data gathering and transcribing and paying
particular attention to respondents’ emotions besides their
behaviours, it is recommended that the data analyst immerses
himself/herself in data in order to obtain the sense of the
whole through reading and rereading (Polit & Beck, 2003).

As mentioned previously, there are many similarities
between the processes of data analysis presented at the dif-
ferent stages. The terminology used during the data analysis
process in the approaches is comparable and equivalent to
each other (Table 1). Data corpus, data item, data extract,
code, and theme in thematic analysis are equivalent in

content analysis to the unit of analysis, meaning unit, con-
densed meaning unit, code, and category/theme, respectively
(Graneheim & Lundman, 2004; Braun & Clarke, 2006; Elo &
Kyngäs, 2008).

The final product of analysis, namely the tool for present-
ing findings, is much debated in both content and thematic
analyses. At the most abstract level, emergence of the theme/
themes can be considered to be the result or final product of
data analysis. The term theme has been associated with many
definitions and is used interchangeably with a vast number
of other terms such as category, domain, unit of analysis,
phase, process, consequence, and strategy (DeSantis & Noel
Ugarriza, 2000). In this respect, there is considerable diver-
sity in nursing and qualitative research literature associated
with the identification of themes, the interpretation of the
concept, and its function in data analysis (DeSantis & Noel
Ugarriza, 2000). A theme is defined as a coherent integration
of the disparate pieces of data that constitute the findings
(Sandelowski & Leeman, 2012). It captures something
important about data in relation to the research question, and
represents some level of response pattern or meaning within
the data set (Braun & Clarke, 2006). A pragmatic way to state
the difference between a theme and a category is that the
latter refers mainly to a descriptive level of content and can
thus be seen as an expression of the manifest content of the
text, whilst the former is the expression of the latent content
(Graneheim & Lundman, 2004). Especially in thematic
analysis, themes are usually quite abstract, and therefore
difficult to identify (DeSantis & Noel Ugarriza, 2000;
Spencer et al., 2003). Furthermore, in thematic analysis the

Table 1. Processes of data analysis in thematic analysis and qualitative content analysis

Analysis phases and their descriptions

Thematic analysis (Braun & Clarke, 2006: 87) Content analysis (Elo & Kyngäs, 2008: 110)

Familiarising with data
Transcribing data, reading and rereading the data, noting down

initial ideas.

Preparation
Being immersed in the data and obtaining the sense of whole,

selecting the unit of analysis, deciding on the analysis of manifest
content or latent content.

Generating initial codes
Coding interesting features of the data systematically across the

entire data set, collating data relevant to each code.
Searching for themes
Collating codes into potential themes, gathering all data relevant to

each potential theme.
Reviewing themes
Checking if the themes work in relation to the coded extracts and

the entire data set, generating a thematic map.
Defining and naming themes
Ongoing analysis for refining the specifics of each theme and the

overall story that the analysis tells, generating clear definitions
and names for each theme.

Organising
Open coding and creating categories, grouping codes under higher

order headings, formulating a general description of the research
topic through generating categories and subcategories as
abstracting.

Producing the report
The final opportunity for analysis. Selection of vivid, compelling

extract examples, final analysis of selected extracts, relating back
of the analysis to the research question and literature, producing
a report of the analysis.

Reporting
Reporting the analysing process and the results through models,

conceptual systems, conceptual map or categories, and a story
line.

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© 2013 Wiley Publishing Asia Pty Ltd.

importance of a theme is not necessarily dependent on quan-
tifiable measures, but rather on whether it captures some-
thing important in relation to the overall research question
(Spencer et al., 2003; Braun & Clarke, 2006). The latter per-
spective is different from the current idea in content analysis,
where it is possible to reach a theme based on the frequency
of its occurrence in the text. This approach is objective, sys-
tematic, and concerned with the surface meaning of the docu-
ment rather than hidden agenda (Bloor & Wood, 2006).

One of the first decisions that should be taken when con-
ducting content analysis is whether to concentrate analysis
on the manifest or latent content of data. It is said that both
manifest and latent content deal with interpretation, but
the interpretation varies in depth and level of abstraction
(Graneheim & Lundman, 2004; Powers & Knapp, 2006). In
contrast, thematic analysis incorporates both manifest and
latent aspects. It means that the analysis of latent content of
data is an inseparable part of the manifest analysis approach
(Braun & Clarke, 2006).

Another characteristic of data analysis in thematic analysis
is drawing a thematic map. This refers to the visual presenta-
tion of themes, codes, and their relationships, involving a
detailed account and description of each theme, their criteria,
exemplars and counter examples, and other similar details. As
one part of data analysis, it helps with reviewing themes and
achieving the aim of identifying coherent but distinctive
themes (Ryan & Bernard, 2000; Braun & Clarke, 2006). It
should not be forgotten that data analysis processes in both
approaches are not linear, simply moving from one phase to
another phase, but should be recursive with frequent reviews.
In addition, the result should be the identification of a story,
which the researcher tells about the data in relation to the
research question or questions.

Evaluation of the analysis process

Evaluating the validity or rigour of a qualitative study
requires reviewers to distinguish between researchers’ errors
during data analysis (Sandelowski & Barroso, 2003a). One
criticism that has been leveled in all qualitative approaches is
that they lack the scientific rigour and credibility associated
with traditionally accepted quantitative methods. It means
that the quantitative inquiry is assumed to occur within a
value-free framework and which rely on the measurement
and analysis of causal relationships between variables
(Horsburgh, 2003). Scientific qualitative research must yield
valid results, in the sense that the research effort is open for
careful scrutiny and it should be possible for any resulting
claims to be upheld in the face of independently available
evidence (Krippendorff, 2004). As an unavoidable part of all
qualitative approaches, both researchers and readers should
be helped to look for alternative interpretations. Credibility,
dependability, confirmability, and transferability are the most
common measures to achieve rigour in qualitative studies
(Lincoln & Guba, 1985). Although the assessment of rigour
in content and thematic analysis shares many similarities,
some differences emphasize the separate and unique identi-
ties of each approach. For instance, intercoder reliability
(analogous to interrater reliability) refers to the extent to

which more than one coder independently classifies material
in the same way as peer researchers. It is commonly used in
content analysis and has been introduced as a measure for
improving the approach’s reliability (Cavanagh, 1997).
However, because of the pure qualitative nature of thematic
analysis, peer checking of intercoder reliability is not always
possible since there is scepticism about the value of such
testing. It has been discussed that one researcher merely
trains another to think as she or he does when looking at a
fragment of text. Thus, the reliability check does not establish
that codes are objective, and merely two people can apply the
same subjective perspective to the text (Loffe & Yardley,
2004). As a practical way to improve rigour in both app-
roaches, researchers are encouraged to maintain a personal
research diary. As a word of caution, the status of these
additional materials in relation to raw data or field notes is
sometimes unclear, as is the way in which they are expected
to contribute to any interpretation. A conscious decision is
made to include and code personal memoranda alongside
field notes, and the same coding scheme is used for both types
of data (Ballinger et al., 2004; Rolfe, 2006). Finally, one of the
best ways for judging the quality of findings is whether new
insights into the studied phenomenon have been provided;
if so, the study should have increased the understanding
of particular phenomena or informed practical actions
(Krippendorff, 2004).

DISCUSSION

A comparative overview of the differences and similarities
between the approaches of content analysis and thematic
analysis was presented in order to help qualitative research-
ers choose the appropriate approach to answer their study
questions and conduct a methodologically robust study. A
limited number of publications about the two approaches
were available to be consulted for an in-depth comparison.
However, the chosen references are central to this area of
nursing research.

While the two approaches can answer the same set of
research questions, some researchers are suspicious about the
strength of both content analysis and thematic analysis in
terms of providing high quality data as exploratory qualita-
tive research. However, the authors believe that the
approaches are robust enough to be used for conducting an
introductory study on a novel phenomenon, for which the
quality of its data depends on the amount of energy and time
the researcher spends on the process of data gathering and
analysis.

Furthermore, there is a stereotype among qualitative
researchers that portrays content analysis and thematic
analysis as the easiest research approaches within qualitative
methodologies. The authors assume that as distinct and fun-
damental qualitative approaches, the two should be used by
qualitative researchers at the beginning of their research
careers. The approaches benefit from transparent structures
that, with a defined sequence of analytical stages, provide
researchers with clear and user-friendly methods for analyz-
ing data.

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Although the approaches are generally considered the
most fundamental, this does not mean that they necessarily
produce simple and low quality findings. In other words, it is
possible that underlying themes/categories may not be imme-
diately apparent, but the researcher needs to be reflective,
frequently review the data from different perspectives, and
follow the stages of data analysis (DeSantis & Noel Ugarriza,
2000).

In this paper, thematic analysis was introduced as an
independent approach within the qualitative descriptive
methodologies and its differences and similarities with
content analysis were highlighted. It is emphasized that
clarifying the boundaries between qualitative approaches
may improve coherence and consistency in qualitative
research (Holloway & Todres, 2003). Following and accu-
rately describing the type of approach used in studies can
provide a universal language for nurse researchers and
strengthen the scientific base of any approach to research
(Hsieh & Shannon, 2005). In this respect, there has recently
been an effort to distinguish thematic analysis from content
analysis, its most similar qualitative research approach
(Braun & Clarke, 2006). Such a distinction between
approaches brings clarity to the data analysis process, thus
increases its rigour. An approach that is inexact and fits into
different methodologies can be seen as merely a tool
(Graneheim & Lundman, 2004). It is important for nurse
researchers to delineate and recognize the characteristics of
the approach they are going to use in their studies before
beginning data analysis (Hsieh & Shannon, 2005).

CONCLUSION

Only a few papers are available in the nursing literature to
introduce content analysis and thematic analysis. Therefore, it
can be concluded that the approaches have not been com-
pletely described, and there are many unanswered questions
about them. Moreover, both these research approaches
should be clarified in relation to their epistemological roots
and connections, which may settle researchers’ debates on
the meta-language and meaning of category and theme, and
also result in their development of the qualitative research
tradition.

In the field of qualitative research, there are overlaps
between content analysis and thematic analysis. Thematic
analysis is widely used, but there is no clear agreement
about what thematic analysis is and how researchers should
go about conducting it. Therefore, comparing the approach
with content analysis, which is more familiar to nurse
researchers may prove helpful in enhancing our under-
standing of it and defending it as a research approach in its
own right.

In summary, in spite of many similarities between content
and thematic analysis, for instance cutting across data, and
searching for patterns and themes, their main difference lies
in the possibility of quantification of data in content analysis
by measuring the frequency of different categories and
themes, which cautiously may stand as a proxy for signifi-
cance. Thus, nursing researchers must address the specific

characteristics, differences, and similarities between content
and thematic analysis to choose the appropriate research
approach.

ACKNOWLEDGMENTS

University of Swansea, United Kingdom and University of
Eastern Finland, Kuopio campus, Finland provided both
financial support and facilities to make conducting this schol-
arly research project possible. Moreover, the authors would
like to sincerely thank Immy Holloway, Professor Emeritus
in the School of Health and Social Care at Bournemouth
University, United Kingdom for her precious scientific
support and comments throughout the review process.

CONTRIBUTIONS

Conception, Design and Drafting: MV, HT, and TB.
Critical Revisions and Final Document: HT and TB.

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