is critical analysis a research method

Qualitative Research Methods: A Critical Analysis

11 Pages Posted: 13 May 2021

Northern Caribbean University

Enid F. Newell-McLymont

Date Written: May 13, 2021

Creswell (2014) noted that qualitative research is an approach for exploring and understanding the meaning individuals or groups ascribe to a social or human problem. The article embodies a critical analysis of chapters one to twelve of Stake (2010). In chapter one, Qualitative research: How things work is seen as qualitative, is based on a comprehensive aim seeking to answer the questions why and how. It analyzes actions and interactions, taking into account the intentions of the actors. An analytic perspective on the interpretation of the Person as an instrument is the thrust of chapter two. Chapter three examines the experiential understanding: Most qualitative study is experiential, in this chapter stake (2010) discusses two common research approaches, qualitative and quantitative methods. Chapter four Stating the Problem: Questioning How This Thing Works. Chapter five deals with the Methods-Gatherings Data, while chapter six illuminates the Review of Literature: Zooming to See the Problem. In chapter seven, the author implores the evidence: Bolstering Judgment and Reconnoitering. Chapter eight propels Analysis and Synthesis: How Things Work. Chapter nine acts as a mirror that invites the researcher to examine their action research and Self-­Evaluation: Finding our Own How our Place Works. Finally, in chapters ten to twelve, the author compels Storytelling: Illustrating How Things Work, Writing the Final Report: An Iterative Convergence, and Advocacy and Ethics: Making Things Work Better. This work is expected to guide future researchers in developing their research in qualitative research.

Keywords: Qualitative Research, The Thing, Review of Literature, Evidence, Triangulation, Bias

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What do you critically analyse?

In a critical analysis you do not express your own opinion or views on the topic. You need to develop your thesis, position or stance on the topic from the views and research of others . In academic writing you critically analyse other researchers’:

• concepts, terms
• viewpoints, arguments, positions
• methodologies, approaches
• research results and conclusions

This means weighing up the strength of the arguments or research support on the topic, and deciding who or what has the more or stronger weight of evidence or support.

Therefore, your thesis argues, with evidence, why a particular theory, concept, viewpoint, methodology, or research result(s) is/are stronger, more sound, or more advantageous than others.

What does ‘analysis’ mean?

A critical analysis means analysing or breaking down the parts of the literature and grouping these into themes, patterns or trends.

In an analysis you need to:

1. Identify and separate out the parts of the topic by grouping the various key theories, main concepts, the main arguments or ideas, and the key research results and conclusions on the topic into themes, patterns or trends of agreement , dispute and omission .

2. Discuss each of these parts by explaining:

i. the areas of agreement/consensus, or similarity

ii. the issues or controversies: in dispute or debate, areas of difference

ii. the omissions, gaps, or areas that are under-researched

3. Discuss the relationship between these parts

4. Examine how each contributes to the whole topic

5. Make conclusions about their significance or importance in the topic

What does ‘critical’ mean?

A critical analysis does not mean writing angry, rude or disrespectful comments, or  expressing your views in judgmental terms of black and white, good and bad, or right and wrong.

To be critical, or to critique, means to evaluate . Therefore, to write critically in an academic analysis means to:

• judge the quality, significance or worth of the theories, concepts, viewpoints, methodologies, and research results
• evaluate in a fair and balanced manner
• avoid extreme or emotional language

• strengths, advantages, benefits, gains, or improvements
• disadvantages, weaknesses, shortcomings, limitations, or drawbacks

How to critically analyse a theory, model or framework

The evaluative words used most often to refer to theory, model or framework are a sound theory or a strong theory.

The table below summarizes the criteria for judging the strengths and weaknesses of a theory:

• comprehensive
• empirically supported
• parsimonious

Evaluating a Theory, Model or Framework

The table below lists the criteria for the strengths and their corresponding weaknesses that are usually considered in a theory.

Critical analysis examples of theories

The following sentences are examples of the phrases used to explain strengths and weaknesses.

Smith’s (2005) theory appears up to date, practical and applicable across many divergent settings.

Brown’s (2010) theory, although parsimonious and logical, lacks a sufficient body of evidence to support its propositions and predictions

Little scientific evidence has been presented to support the premises of this theory.

One of the limitations with this theory is that it does not explain why…

A significant strength of this model is that it takes into account …

The propositions of this model appear unambiguous and logical.

A key problem with this framework is the conceptual inconsistency between ….

How to critically analyse a concept

The table below summarizes the criteria for judging the strengths and weaknesses of a concept:

• key variables identified
• clear and well-defined

Evaluating Concepts

Critical analysis examples of concepts

Many researchers have used the concept of control in different ways.

There is little consensus about what constitutes automaticity.

Putting forth a very general definition of motivation means that it is possible that any behaviour could be included.

The concept of global education lacks clarity, is imprecisely defined and is overly complex.

Some have questioned the usefulness of resilience as a concept because it has been used so often and in so many contexts.

Research suggests that the concept of preoperative fasting is an outdated clinical approach.

How to critically analyse arguments, viewpoints or ideas

The table below summarizes the criteria for judging the strengths and weaknesses of an argument, viewpoint or idea:

• reasons support the argument
• argument is substantiated by evidence
• evidence for the argument is relevant
• evidence for the argument is unbiased, sufficient and important
• evidence is reputable

Evaluating Arguments, Views or Ideas

Critical analysis examples of arguments, viewpoints or ideas

The validity of this argument is questionable as there is insufficient evidence to support it.

Many writers have challenged Jones’ claim on the grounds that …….

This argument fails to draw on the evidence of others in the field.

This explanation is incomplete because it does not explain why…

The key problem with this explanation is that ……


The existing accounts fail to resolve the contradiction between …

However, there is an inconsistency with this argument. The inconsistency lies in…

Although this argument has been proposed by some, it lacks justification.

However, the body of evidence showing that… contradicts this argument.

How to critically analyse a methodology

The table below provides the criteria for judging the strengths and weaknesses of methodology.

An evaluation of a methodology usually involves a critical analysis of its main sections:

design; sampling (participants); measurement tools and materials; procedure

• design tests the hypotheses or research questions
• method valid and reliable
• potential bias or measurement error, and confounding variables addressed
• method allows results to be generalized
• representative sampling of cohort and phenomena; sufficient response rate
• valid and reliable measurement tools
• valid and reliable procedure
• method clear and detailed to allow replication

Evaluating a Methodology

Critical analysis examples of a methodology

The unrepresentativeness of the sample makes these results misleading.

The presence of unmeasured variables in this study limits the interpretation of the results.

Other, unmeasured confounding variables may be influencing this association.

The interpretation of the data requires caution because the effect of confounding variables was not taken into account.

The insufficient control of several response biases in this study means the results are likely to be unreliable.

Although this correlational study shows association between the variables, it does not establish a causal relationship.

Taken together, the methodological shortcomings of this study suggest the need for serious caution in the meaningful interpretation of the study’s results.

How to critically analyse research results and conclusions

The table below provides the criteria for judging the strengths and weaknesses of research results and conclusions:

• appropriate choice and use of statistics
• correct interpretation of results
• all results explained
• alternative explanations considered
• significance of all results discussed
• consistency of results with previous research discussed
• results add to existing understanding or knowledge
• limitations discussed
• results clearly explained
• conclusions consistent with results

Evaluating the Results and Conclusions

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Writing a Critical Analysis

What is in this guide, definitions, putting it together, tips and examples of critques.

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This guide is meant to help you understand the basics of writing a critical analysis. A critical analysis is an argument about a particular piece of media. There are typically two parts: (1) identify and explain the argument the author is making, and (2), provide your own argument about that argument. Your instructor may have very specific requirements on how you are to write your critical analysis, so make sure you read your assignment carefully.

Critical Analysis

A deep approach to your understanding of a piece of media by relating new knowledge to what you already know.

Part 1: Introduction

• Identify the work being criticized.
• Present thesis - argument about the work.
• Preview your argument - what are the steps you will take to prove your argument.

Part 2: Summarize

• Provide a short summary of the work.
• Present only what is needed to know to understand your argument.

Part 3: Your Argument

• This is the bulk of your paper.
• Provide "sub-arguments" to prove your main argument.
• Use scholarly articles to back up your argument(s).

Part 4: Conclusion

• Reflect on  how  you have proven your argument.
• Point out the  importance  of your argument.
• Comment on the potential for further research or analysis.
• Cornell University Library Tips for writing a critical appraisal and analysis of a scholarly article.
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What is Critical Research? | Definition, Examples & Methods

Introduction

What does critical research mean, what is an example of critical qualitative research, approaches to critical theory.

Critical research was created out of a need to examine power , inequities, and the resulting societal implications on the status quo in society. It is a necessary departure from traditional scientific research in that it looks beyond what is directly observable to analyze the social world and develop social theory from novel perspectives to address previous injustices. In this article, we'll look at what critical theory entails for qualitative research , as well as the different strands that make up critical research.

In specific terms, critical research examines the nature of power dynamics influencing the social world. More broadly, this has implications for understanding inequality and disparity across cleavages of race, gender, ethnicity, sexual orientation, and economic class, among other differences in identity.

While there are many different strands to critical research, there are a number of common characteristics that are shared by scholars of critical theory:

• Contextualization : Traditional research assumes a singular, almost absolutist approach to knowledge. In contrast, critical theory challenges the positivist outlook on scientific research and assumes a more sociocultural outlook to the social world. In adopting a more contextualized approach to any particular social phenomenon, scholars look to making propositions specific to different contexts rather than defining grand, unifying theories that explain socially constructed concepts regardless of individual or cultural circumstances.
• Subjectivity : Unlike more positivist approaches to research, critical research presupposes a lack of an ability to directly observe physical reality. Moreover, a researcher's perception is often confounded by culturally-reinforced presumptions such as stereotypes and other biases that privilege those in power. The possibility that the social world can be subjectively construed directly challenges assumptions of a positivist understanding of social phenomena. Instead, critical research encourages scholars and laypeople alike to consider the world from different points of view in order to identify problems and inequities that are otherwise invisible within traditional worldviews.
• Social change : Critical research is seldom interested in generating insights purely out of intellectual curiosity. Critical scholars tend to adopt a philosophy of social justice where research is aimed at benefiting marginalized or oppressed populations who lack the same opportunities and benefits that are otherwise granted to those in mainstream society. In this respect, research and analysis within a critical paradigm are merely preliminary steps in a process that appeals to institutions, stakeholders, and social activists to draw on actionable insights from the research and make tangible proposals for enacting change.
• Transformation : Similar to the imperative of social change, transformation deals with fundamentally altering contemporary paradigms. However, this aspect to critical research is more concerned with problematizing traditional perspectives of the social world and the phenomena within it, both from a layperson's point of view and from the view of traditional academic institutions that perpetuate mainstream scientific inquiry. Rather than simply acknowledge the subjective nature of the social world, critical research calls for fundamentally transforming perceptions and attitudes in a manner that views marginalized populations more equitably.

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One of the more famous studies to produce a critical analysis is the doll test first devised by Mamie Clark, then conducted with husband Kenneth Clark starting in the 1940s and replicated in later years. In the doll test, children were asked how they felt about dolls that were put in front of them. The children preferred to play with the dolls that looked white rather than the dolls that looked black, and had more positive views about the white-looking dolls. Children who were black also tended to share the same perception of black-looking dolls, which suggested that their surrounding environment - particularly the school system but more broadly the culture around them - profoundly impacted them by reinforcing negative stereotypes about racial minorities.

Critical theorists argue that such stereotypes, especially when perpetuated by institutions like education and mass media, further contribute to economic and social disparities when children of color experience exposure to negative attitudes about race and ethnicity. This novel research provided fundamental insights that led to the following real-world changes:

• Desegregation of schools : This research took place in the era where public schools in the United States were separated by race. The findings from the doll test helped make the case that institutionalized discrimination had effects on the educational and emotional development of children of color, ultimately leading to judicial rulings that contributed to school desegregation.
• Educational reforms : Subsequent discussions of racial stereotypes have helped to further promote initiatives for racial equity and equality in public education. While still undoubtedly controversial to this day, efforts to promote diversity training for teachers, multicultural curriculum development, and other policies to address racial disparities can be partly attributed to the findings of the doll test.
• Anti-discrimination policies : The findings from the doll test form a scientific basis for anti-discrimination frameworks for public policy, workplace organization, and other formal institutions. Where racism and equality might otherwise be abstract, potentially vague concepts, a scientific framework regarding discriminatory attitudes provides a language for discussing practical implications addressing racism.

Here are some of the various forms of critical research. Keep in mind that these approaches are not exclusive to each other, though they have their own distinct focus to shed light on specific issues relevant to the social sciences, nor are they exhaustive of the entire array of critical theory.

• Critical discourse analysis : Researchers who critically analyze communication look at how people exercise power through speech to manipulate or control others. This analytical method connects theories from linguistics, sociology, and anthropology to look at the power of language in constructing social reality.
• Critical ethnography : Ethnography is an all-encompassing approach to research aimed at capturing relationships, practices, and behaviors within any given context. Beyond a comprehensive examination of cultures, critical ethnographers use the resulting findings to advocate for social change.
• Critical methodology : Critical scholars may also look at how methods are used to construct scholars' epistemology about scientific knowledge and question approaches to science that emphasize objectivity to a fault. Critical methodology advocates for reflexivity and participatory research as a departure from traditional research methods.
• Critical race theory : Scholars engaged in critical race theory look at longstanding racial disparities to examine how institutions and power structures perpetuate racism and how people of color can challenge those structures from legal and advocacy standpoints in order to foster equity and equality.
• Decolonizing research : Focusing on the critique that most established research comes from a Western-based perspective, research on decolonization seeks to deconstruct established philosophical paradigms that disadvantage perspectives of indigenous populations, cultures from the Global South, and other communities that have long been ignored by mainstream scholarship.

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Critical analysis may or may not be a component of this particular course's evaluation, but it is an important component of any research process. 

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Critical thinking is at the heart of scientific inquiry. A good scientist is one who never stops asking why things happen, or how things happen. Science makes progress when we find data that contradicts our current scientific ideas.

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Hart, T. (2018, 18 October) Teaching critical thinking in science - the key to students' future success.  Brighter Thinking Blog . https://www.cambridge.org/us/education/blog/2018/10/18/teaching-critical-thinking-science-key-students-future-success/

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Critically appraising qualitative research

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• Ayelet Kuper , assistant professor 1 ,
• Lorelei Lingard , associate professor 2 ,
• Wendy Levinson , Sir John and Lady Eaton professor and chair 3
• 1 Department of Medicine, Sunnybrook Health Sciences Centre, and Wilson Centre for Research in Education, University of Toronto, 2075 Bayview Avenue, Room HG 08, Toronto, ON, Canada M4N 3M5
• 2 Department of Paediatrics and Wilson Centre for Research in Education, University of Toronto and SickKids Learning Institute; BMO Financial Group Professor in Health Professions Education Research, University Health Network, 200 Elizabeth Street, Eaton South 1-565, Toronto
• 3 Department of Medicine, Sunnybrook Health Sciences Centre
• Correspondence to: A Kuper ayelet94{at}post.harvard.edu

Six key questions will help readers to assess qualitative research

Summary points

Appraising qualitative research is different from appraising quantitative research

Qualitative research papers should show appropriate sampling, data collection, and data analysis

Transferability of qualitative research depends on context and may be enhanced by using theory

Ethics in qualitative research goes beyond review boards’ requirements to involve complex issues of confidentiality, reflexivity, and power

Over the past decade, readers of medical journals have gained skills in critically appraising studies to determine whether the results can be trusted and applied to their own practice settings. Criteria have been designed to assess studies that use quantitative methods, and these are now in common use.

In this article we offer guidance for readers on how to assess a study that uses qualitative research methods by providing six key questions to ask when reading qualitative research (box 1). However, the thorough assessment of qualitative research is an interpretive act and requires informed reflective thought rather than the simple application of a scoring system.

Box 1 Key questions to ask when reading qualitative research studies

Was the sample used in the study appropriate to its research question.

Were the data collected appropriately?

Were the data analysed appropriately?

Can I transfer the results of this study to my own setting?

Does the study adequately address potential ethical issues, including reflexivity?

Overall: is what the researchers did clear?

One of the critical decisions in a qualitative study is whom or what to include in the sample—whom to interview, whom to observe, what texts to analyse. An understanding that qualitative research is based in experience and in the construction of meaning, combined with the specific research question, should guide the sampling process. For example, a study of the experience of survivors of domestic violence that examined their reasons for not seeking help from healthcare providers might focus on interviewing a …

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How To Write A Critical Analysis Of A Research Paper

By Laura Brown on 29th May 2023

Conducting a critical analysis of a research paper includes the evaluation of its methodology, data sources, and findings. Alongside, it is necessary to assess the paper’s strengths and weaknesses, identify any biases or limitations, and examine its contribution to the respective field. Additionally, considering alternative interpretations and potential implications is key to providing a comprehensive analysis.

The art of critical analysis is a crucial skill for researchers and scholars alike. It allows us to delve deeper, question assumptions, and uncover the strengths and weaknesses of a research paper. This blog covers the essential steps to master the art of conducting a critical evaluation along with the examples.

Research papers serve as a foundation for advancing knowledge and shaping academic discourse. By critically analysing these papers, we can assess their validity, identify their contributions, and even influence the direction of future research. Throughout this post, we will guide you through the process of understanding a research paper, evaluating its strengths and weaknesses, assessing its contribution, formulating your analysis, considering alternative perspectives, and providing recommendations.

Whether you’re a student, a researcher, or an avid reader of scholarly work, developing the ability to critically analyse a research paper will enhance your understanding and engagement with academic literature and scientific articles. Let’s dive into the world of critical analysis and unlock the secret insights as you buy research paper from us or read this handy guide.

1. Understand The Research Paper

To effectively analyse a research paper, it is crucial to gain a comprehensive understanding of its content. You may begin by thoroughly reading the paper and paying attention to every detail. Further, you should identify the main research question or objective that the study aims to address. This will provide you with a focal point for your analysis.

Now, familiarise yourself with the methodology used and the data collected for the research. Moreover, evaluate the appropriateness and reliability of the chosen methodology, and assess the quality of the data collection and analysis. Understanding these aspects will help you gauge the validity and firmness of the research.

Additionally, take note of the key findings and conclusions presented in the paper and Analyse the supporting evidence along with evaluating the conclusions align with the research objectives. You should also consider any limitations or potential biases that might affect the interpretation of the results. By thoroughly understanding the scientific paper, you will lay a solid foundation for your critical analysis. In case you face any difficulty understanding the paper, you can always contact research paper service anytime, we will definitely help you.

2. Identify The Strengths And Weaknesses

In order to conduct a comprehensive critical analysis on research paper, it is essential to identify its strengths and weaknesses . Here are key aspects to consider during this evaluation process.

a. Evaluate The Research Paper’s Structure

First, assess whether it follows a logical flow and if the sections are well-developed and interconnected. Remember, a well-structured paper enhances readability and comprehension.

b. Assess The Clarity Of The Arguments

Next, look for concise statements and a logical progression of ideas. Moreover, analyse how well the author supports their arguments with relevant evidence and whether the reasoning is sound.

c. Analyse The Authenticity Of The Facts & Figures

Further, analyse the relevance of the data and sources used. You should examine the quality and appropriateness of the cited sources . Also, look at the facts presented if they adequately supports the claims made by the author and whether there is a robust foundation for the conclusions drawn.

d. Identifying Potential Limitations

Now, this is the time to identify the strengths and weaknesses of the research methods used. At this moment, you should also consider any limitations that may impact the validity or generalizability of the findings.

e. Determine Biases Or Conflicts Of Interest

Finally, consider the author’s affiliations, funding sources, or personal beliefs that could influence the research outcomes.

3. Evaluate The Research Paper’s Contribution

It is crucial to have a deeper look into the contribution while critically analysing a research paper. You may go through the following steps for critical evaluation.

a. Assess The Significance Of The Research

Firstly, determine whether the paper presents new ideas, approaches, or insights that contribute to the field. Additonally, assess its potential to advance knowledge and fill gaps in existing research.

b. Consider The Research Paper’s Contribution

Secondly, evaluate how the paper builds upon or challenges existing theories, concepts, or methodologies along with assessing its potential to expand understanding or provide novelty.

c. Find Potential Impact Of The Findings

Finally, analyse how the research paper’s findings may influence practice, policy, or future research directions. Also, consider the broader implications and relevance of the research within the context of the field or society.

4. Formulate Your Analysis

Formulating a strong and insightful analysis is a crucial aspect of research paper critical analysis. To effectively present your analysis, follow the below-mentioned steps:

• Begin by developing a clear thesis statement that reflects your overall analysis of the research paper. This statement should encapsulate the main point or argument you wish to convey.
• Next, support your analysis with specific examples from the research paper. Referencing specific sections, findings, or arguments helps substantiate your points and provides evidence for your analysis.
• Ensure that you present your analysis in a logical and organised manner. Structure your analysis in a way that flows coherently, with each point building upon the previous one. To achieve this, use clear and concise language that conveys your thoughts effectively.

Let’s see a critical analysis research paper example for initiating your analysis with a thesis statement.

The research paper’s findings on the impact of deforestation are valuable, but its failure to address socio-economic factors limits its comprehensive understanding of the issue.

5. Consider Alternative Perspectives

In a critical analysis of a scientific article or research paper it is essential to consider alternative perspectives to present a well-rounded evaluation. Follow these steps to effectively engage with different viewpoints.

• Start by acknowledging and discussing alternative interpretations or viewpoints that exist regarding the research paper. This demonstrates your openness to diverse perspectives and fosters a comprehensive analysis.
• Next, compare and contrast these different perspectives with your own analysis. Identify areas of agreement or disagreement and highlight any significant differences in the interpretation of the research findings or methodology.
• Provide reasoning and evidence to support your stance in the critical analysis. Present logical arguments and use relevant evidence to justify your perspective. Consider the strengths and weaknesses of alternative viewpoints and explain why you find your analysis to be more compelling.

Certainly! Here’s a critical evaluation of a research paper example for considering alternative perspectives in the context of a research paper on climate change:

It becomes evident that the paper’s findings on the impact of deforestation are valuable. The research provides insights into the ecological consequences and loss of biodiversity resulting from deforestation. However, a crucial limitation of the paper lies in its failure to address socio-economic factors. By neglecting the socio-economic aspects, such as the role of industries, government policies, and societal behaviours, the research paper lacks a comprehensive understanding of the issue. To gain a holistic understanding, it is recommended to consult the following additional resources.

Here you can present various resources as you need.

6. Provide Recommendations Or Suggestions

Considering critical analysis in a research paper, it is important to go beyond evaluating the strengths and weaknesses and offer constructive recommendations for improvement. Here’s a research paper example of how this section could be written.

Based on the critical analysis of the research paper on renewable energy sources, several recommendations emerge. Firstly, the paper could benefit from a more comprehensive discussion of the economic viability of renewable technologies. Incorporating an analysis of cost-effectiveness and potential financing models would strengthen the paper’s practical implications. Secondly, the authors should consider addressing potential limitations and uncertainties associated with the data sources used. Providing transparency and acknowledging any gaps would enhance the overall credibility of the research. Lastly, there is a need for further investigation into the social acceptance and adoption of renewable energy technologies, as understanding the human dimension is crucial for successful implementation. By offering these recommendations, the research paper can be enhanced and contribute more effectively to the field.

7. Writing The Conclusion

Students often ask how to write the conclusion of a report and critical analysis; here is how it is done. The conclusion of a critical analysis of scientific literature or research paper should succinctly summarise the key points and analysis, emphasising the significance of critical thinking. It should reinforce the importance of addressing any limitations or gaps in the research and encourage further exploration. The conclusion should leave readers with a clear understanding of the paper’s strengths and weaknesses, and inspire them to apply critical analysis principles in their own research endeavours. Here is an example of critical analysis of a research paper in regards to conclusion.

The critical analysis of the research paper on climate change brings to light the importance of addressing socio-economic factors for a comprehensive understanding of the issue. While the paper’s findings on the impact of deforestation are valuable, the omission of socio-economic considerations limits its applicability in developing effective solutions. It is crucial for future research to incorporate the interplay between environmental and socio-economic factors to devise holistic strategies. By recognising and rectifying these gaps, researchers can contribute to a more nuanced understanding of climate change and inform policies that foster sustainable development and resilience.

8. Additional Resources Or References

For readers seeking further exploration and a deeper understanding of the research paper, you can also put up some additional resources . However, this is not the part of the critical analysis, but still you can include it.

Summing Up The Tips For You

Here are 10 points for you as a summary of this blog. You may also consider it as a critical analysis of a research paper checklist while you prepare to conduct it.

• Thoroughly read the research paper to gain a deep understanding of its content.
• Evaluate the research question/objective and assess its relevance and significance.
• Assess the methodology and data used, considering their validity and reliability.
• Analyse the clarity and coherence of the arguments presented in the paper.
• Give a keen look at the relevance and sufficiency of the evidence and sources used.
• Critique the limitations and potential biases of the research.
• Consider alternative perspectives and compare them with your analysis.
• Assess the originality and contribution of the research to the existing knowledge.
• Examine the implications and potential impact of the research findings.
• Provide constructive criticism and suggestions for improvement, including areas for further research or investigation.

Follow this research paper checklist for critically analysing a research paper, and you will definitely rock it.

Laura Brown, a senior content writer who writes actionable blogs at Crowd Writer.

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• Critical Reviews

How to Write a Critical Analysis

Last Updated: August 3, 2024 Fact Checked

This article was co-authored by Jake Adams . Jake Adams is an academic tutor and the owner of Simplifi EDU, a Santa Monica, California based online tutoring business offering learning resources and online tutors for academic subjects K-College, SAT & ACT prep, and college admissions applications. With over 14 years of professional tutoring experience, Jake is dedicated to providing his clients the very best online tutoring experience and access to a network of excellent undergraduate and graduate-level tutors from top colleges all over the nation. Jake holds a BS in International Business and Marketing from Pepperdine University. This article has been fact-checked, ensuring the accuracy of any cited facts and confirming the authority of its sources. This article has been viewed 1,467,705 times.

How to Write a Critical Analysis Essay

When writing a critical analysis, take a moment to reflect on the source material and the author's main ideas to come up with your thesis statement . Be sure to write down your own responses to the points the author was making, and respond to each in a paragraph.

Reading Critically

• You may need to read the text more than once, especially if it is dense or complicated.

• It might be easier to find the thesis in an academic article than in a creative work, movie, or painting. If you’re critiquing a work of fiction or creative nonfiction, in either written form or film form, identify one of the main themes of the story instead. For a painting, identify what the painter may be trying to get across with their work of art.

• In an academic article, identify the topic sentences of each paragraph or section.
• For works of fiction or paintings, look for scenes and imagery that seem to support the thesis.

• If the text was a film or work of art, write a brief 1 to 2 paragraph synopsis of the film or description of the painting.

Analyzing the Text

• For example, if the text made you angry, what was it about the text that made you angry?
• If you found yourself laughing at the text, what about it was laughable?

• For example, if the author is an outspoken proponent of healthcare reform, then this would likely explain any bias in an argumentative essay on universal healthcare.
• The author’s background may also include credentials, such as a doctorate or medical degree. This is part of the ethos of the text since having credentials may help to bolster an author’s credibility.

• For example, if the author’s explanation of greenhouse gasses is long, full of jargon, and confusing, then you might focus on this as part of your critique.

Tip : Keep in mind that you can also have a positive critique of the text if you think it was effective. For example, if the author’s description of greenhouse gasses was written in simple, easy to understand language, you might note this as part of your analysis.

• For example, if the author has used a website that is known for being biased in favor of their argument, then this would weaken their position. However, if the author used sources that were fair and unbiased, then this would strengthen their position.
• Not all texts will incorporate evidence. For example, if you’re doing a critical analysis of a film or work of art, it probably won’t include secondary sources.

Drafting the Analysis

• For example, in the first sentence of your essay, provide the basic information on the text. Then, describe text’s argument in about 1 to 2 sentences.

• For example, you might write, “Darcy Gibbons’ essay on the environmental impact of consumerism provides a thorough and valuable overview of the problem.”
• Or, you might write, “Shannon Duperty’s mixed media painting, “Dove on Heroin,” falls short of its attempt at edgy political commentary.”

• Keep in mind that the summary paragraph is the only place in your essay where you may include summary. The rest of the essay should provide analysis of the essay.

• Organization. How did the author organize their argument? Was this a good strategy or not? Why?
• Style. What style did the author use to get their point across? How did the style hurt or help their argument?
• Effectiveness. In general, was the text effective at getting its point across? Why or why not?
• Fairness or bias. Did the author demonstrate a fair or biased perspective on their topic? How could you tell?
• Appeal to a specific audience. Did the author seem to have a specific audience in mind? If so, who were they and how well did the author meet their needs?

Tip : Check with your teacher for details on how to cite sources. They may want you to use a specific citation style, such as MLA, Chicago, or APA.

• For example, you might conclude by talking about how the author made a good effort in some regards, but ultimately their argument was ineffective, and then explain why in 2 to 3 sentences.

Sample Analyses

Expert Q&A

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• ↑ Jake Adams. Academic Tutor & Test Prep Specialist. Expert Interview. 20 May 2020.
• ↑ https://www.tru.ca/__shared/assets/Critical_Analysis_Template30565.pdf
• ↑ https://depts.washington.edu/pswrite/Handouts/CriticalAnalysisPapers.pdf
• ↑ https://content.nroc.org/DevelopmentalEnglish/unit09/Foundations/creating-a-thesis-and-an-outline-for-a-critical-analysis-essay.html
• ↑ https://writingcenter.fas.harvard.edu/pages/ending-essay-conclusions

About This Article

To write a critical analysis, first introduce the work you’re analyzing, including information about the work’s author and their purpose in writing it. As part of the introduction, briefly state your overall evaluation of the work. Then, summarize the author’s key points before you use the bulk of your paper to provide your full critique of the work. Try to put each point you want to make in a separate paragraph for clarity. Finally, write a concluding paragraph that restates your opinion of the work and offers any suggestions for improvement. To learn how to balance positive and negative comments in your critical analysis, keep reading! Did this summary help you? Yes No

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Methodology

• Critical Discourse Analysis | Definition, Guide & Examples

Critical Discourse Analysis | Definition, Guide & Examples

Published on August 23, 2019 by Amy Luo . Revised on June 22, 2023.

Critical discourse analysis (or discourse analysis) is a research method for studying written or spoken language in relation to its social context. It aims to understand how language is used in real life situations.

When you conduct discourse analysis, you might focus on:

• The purposes and effects of different types of language
• Cultural rules and conventions in communication
• How values, beliefs and assumptions are communicated
• How language use relates to its social, political and historical context

Discourse analysis is a common qualitative research method in many humanities and social science disciplines, including linguistics, sociology, anthropology, psychology and cultural studies.  

Table of contents

What is discourse analysis used for, how is discourse analysis different from other methods, how to conduct discourse analysis, other interesting articles.

Conducting discourse analysis means examining how language functions and how meaning is created in different social contexts. It can be applied to any instance of written or oral language, as well as non-verbal aspects of communication such as tone and gestures.

Materials that are suitable for discourse analysis include:

• Books, newspapers and periodicals
• Marketing material, such as brochures and advertisements
• Business and government documents
• Websites, forums, social media posts and comments
• Interviews and conversations

By analyzing these types of discourse, researchers aim to gain an understanding of social groups and how they communicate.

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Unlike linguistic approaches that focus only on the rules of language use, discourse analysis emphasizes the contextual meaning of language.

It focuses on the social aspects of communication and the ways people use language to achieve specific effects (e.g. to build trust, to create doubt, to evoke emotions, or to manage conflict).

Instead of focusing on smaller units of language, such as sounds, words or phrases, discourse analysis is used to study larger chunks of language, such as entire conversations, texts, or collections of texts. The selected sources can be analyzed on multiple levels.

Discourse analysis is a qualitative and interpretive method of analyzing texts (in contrast to more systematic methods like content analysis ). You make interpretations based on both the details of the material itself and on contextual knowledge.

There are many different approaches and techniques you can use to conduct discourse analysis, but the steps below outline the basic structure you need to follow. Following these steps can help you avoid pitfalls of confirmation bias that can cloud your analysis.

Step 1: Define the research question and select the content of analysis

To do discourse analysis, you begin with a clearly defined research question . Once you have developed your question, select a range of material that is appropriate to answer it.

Discourse analysis is a method that can be applied both to large volumes of material and to smaller samples, depending on the aims and timescale of your research.

Step 2: Gather information and theory on the context

Next, you must establish the social and historical context in which the material was produced and intended to be received. Gather factual details of when and where the content was created, who the author is, who published it, and whom it was disseminated to.

As well as understanding the real-life context of the discourse, you can also conduct a literature review on the topic and construct a theoretical framework to guide your analysis.

Step 3: Analyze the content for themes and patterns

This step involves closely examining various elements of the material – such as words, sentences, paragraphs, and overall structure – and relating them to attributes, themes, and patterns relevant to your research question.

Step 4: Review your results and draw conclusions

Once you have assigned particular attributes to elements of the material, reflect on your results to examine the function and meaning of the language used. Here, you will consider your analysis in relation to the broader context that you established earlier to draw conclusions that answer your research question.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

• Normal distribution
• Measures of central tendency
• Chi square tests
• Confidence interval
• Quartiles & Quantiles
• Cluster sampling
• Stratified sampling
• Thematic analysis
• Cohort study
• Peer review
• Ethnography

Research bias

• Implicit bias
• Cognitive bias
• Conformity bias
• Hawthorne effect
• Availability heuristic
• Attrition bias
• Social desirability bias

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33 Critical Analysis Examples

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Critical analysis refers to the ability to examine something in detail in preparation to make an evaluation or judgment.

It will involve exploring underlying assumptions, theories, arguments, evidence, logic, biases, contextual factors, and so forth, that could help shed more light on the topic.

In essay writing, a critical analysis essay will involve using a range of analytical skills to explore a topic, such as:

• Evaluating sources
• Exploring strengths and weaknesses
• Exploring pros and cons
• Questioning and challenging ideas
• Comparing and contrasting ideas

If you’re writing an essay, you could also watch my guide on how to write a critical analysis essay below, and don’t forget to grab your worksheets and critical analysis essay plan to save yourself a ton of time:

Grab your Critical Analysis Worksheets and Essay Plan Here

Critical Analysis Examples

1. exploring strengths and weaknesses.

Perhaps the first and most straightforward method of critical analysis is to create a simple strengths-vs-weaknesses comparison.

Most things have both strengths and weaknesses – you could even do this for yourself! What are your strengths? Maybe you’re kind or good at sports or good with children. What are your weaknesses? Maybe you struggle with essay writing or concentration.

If you can analyze your own strengths and weaknesses, then you understand the concept. What might be the strengths and weaknesses of the idea you’re hoping to critically analyze?

Strengths and weaknesses could include:

• Does it seem highly ethical (strength) or could it be more ethical (weakness)?
• Is it clearly explained (strength) or complex and lacking logical structure (weakness)?
• Does it seem balanced (strength) or biased (weakness)?

You may consider using a SWOT analysis for this step. I’ve provided a SWOT analysis guide here .

2. Evaluating Sources

Evaluation of sources refers to looking at whether a source is reliable or unreliable.

This is a fundamental media literacy skill .

Steps involved in evaluating sources include asking questions like:

• Who is the author and are they trustworthy?
• Is this written by an expert?
• Is this sufficiently reviewed by an expert?
• Is this published in a trustworthy publication?
• Are the arguments sound or common sense?

For more on this topic, I’d recommend my detailed guide on digital literacy .

3. Identifying Similarities

Identifying similarities encompasses the act of drawing parallels between elements, concepts, or issues.

In critical analysis, it’s common to compare a given article, idea, or theory to another one. In this way, you can identify areas in which they are alike.

Determining similarities can be a challenge, but it’s an intellectual exercise that fosters a greater understanding of the aspects you’re studying. This step often calls for a careful reading and note-taking to highlight matching information, points of view, arguments or even suggested solutions.

Similarities might be found in:

• The key themes or topics discussed
• The theories or principles used
• The demographic the work is written for or about
• The solutions or recommendations proposed

Remember, the intention of identifying similarities is not to prove one right or wrong. Rather, it sets the foundation for understanding the larger context of your analysis, anchoring your arguments in a broader spectrum of ideas.

Your critical analysis strengthens when you can see the patterns and connections across different works or topics. It fosters a more comprehensive, insightful perspective. And importantly, it is a stepping stone in your analysis journey towards evaluating differences, which is equally imperative and insightful in any analysis.

4. Identifying Differences

Identifying differences involves pinpointing the unique aspects, viewpoints or solutions introduced by the text you’re analyzing. How does it stand out as different from other texts?

To do this, you’ll need to compare this text to another text.

Differences can be revealed in:

• The potential applications of each idea
• The time, context, or place in which the elements were conceived or implemented
• The available evidence each element uses to support its ideas
• The perspectives of authors
• The conclusions reached

Identifying differences helps to reveal the multiplicity of perspectives and approaches on a given topic. Doing so provides a more in-depth, nuanced understanding of the field or issue you’re exploring.

This deeper understanding can greatly enhance your overall critique of the text you’re looking at. As such, learning to identify both similarities and differences is an essential skill for effective critical analysis.

My favorite tool for identifying similarities and differences is a Venn Diagram:

To use a venn diagram, title each circle for two different texts. Then, place similarities in the overlapping area of the circles, while unique characteristics (differences) of each text in the non-overlapping parts.

6. Identifying Oversights

Identifying oversights entails pointing out what the author missed, overlooked, or neglected in their work.

Almost every written work, no matter the expertise or meticulousness of the author, contains oversights. These omissions can be absent-minded mistakes or gaps in the argument, stemming from a lack of knowledge, foresight, or attentiveness.

Such gaps can be found in:

• Missed opportunities to counter or address opposing views
• Failure to consider certain relevant aspects or perspectives
• Incomplete or insufficient data that leaves the argument weak
• Failing to address potential criticism or counter-arguments

By shining a light on these weaknesses, you increase the depth and breadth of your critical analysis. It helps you to estimate the full worth of the text, understand its limitations, and contextualize it within the broader landscape of related work. Ultimately, noticing these oversights helps to make your analysis more balanced and considerate of the full complexity of the topic at hand.

You may notice here that identifying oversights requires you to already have a broad understanding and knowledge of the topic in the first place – so, study up!

7. Fact Checking

Fact-checking refers to the process of meticulously verifying the truth and accuracy of the data, statements, or claims put forward in a text.

Fact-checking serves as the bulwark against misinformation, bias, and unsubstantiated claims. It demands thorough research, resourcefulness, and a keen eye for detail.

Fact-checking goes beyond surface-level assertions:

• Examining the validity of the data given
• Cross-referencing information with other reliable sources
• Scrutinizing references, citations, and sources utilized in the article
• Distinguishing between opinion and objectively verifiable truths
• Checking for outdated, biased, or unbalanced information

If you identify factual errors, it’s vital to highlight them when critically analyzing the text. But remember, you could also (after careful scrutiny) also highlight that the text appears to be factually correct – that, too, is critical analysis.

8. Exploring Counterexamples

Exploring counterexamples involves searching and presenting instances or cases which contradict the arguments or conclusions presented in a text.

Counterexamples are an effective way to challenge the generalizations, assumptions or conclusions made in an article or theory. They can reveal weaknesses or oversights in the logic or validity of the author’s perspective.

Considerations in counterexample analysis are:

• Identifying generalizations made in the text
• Seeking examples in academic literature or real-world instances that contradict these generalizations
• Assessing the impact of these counterexamples on the validity of the text’s argument or conclusion

Exploring counterexamples enriches your critical analysis by injecting an extra layer of scrutiny, and even doubt, in the text.

By presenting counterexamples, you not only test the resilience and validity of the text but also open up new avenues of discussion and investigation that can further your understanding of the topic.

See Also: Counterargument Examples

9. Assessing Methodologies

Assessing methodologies entails examining the techniques, tools, or procedures employed by the author to collect, analyze and present their information.

The accuracy and validity of a text’s conclusions often depend on the credibility and appropriateness of the methodologies used.

Aspects to inspect include:

• The appropriateness of the research method for the research question
• The adequacy of the sample size
• The validity and reliability of data collection instruments
• The application of statistical tests and evaluations
• The implementation of controls to prevent bias or mitigate its impact

One strategy you could implement here is to consider a range of other methodologies the author could have used. If the author conducted interviews, consider questioning why they didn’t use broad surveys that could have presented more quantitative findings. If they only interviewed people with one perspective, consider questioning why they didn’t interview a wider variety of people, etc.

See Also: A List of Research Methodologies

10. Exploring Alternative Explanations

Exploring alternative explanations refers to the practice of proposing differing or opposing ideas to those put forward in the text.

An underlying assumption in any analysis is that there may be multiple valid perspectives on a single topic. The text you’re analyzing might provide one perspective, but your job is to bring into the light other reasonable explanations or interpretations.

Cultivating alternative explanations often involves:

• Formulating hypotheses or theories that differ from those presented in the text
• Referring to other established ideas or models that offer a differing viewpoint
• Suggesting a new or unique angle to interpret the data or phenomenon discussed in the text

Searching for alternative explanations challenges the authority of a singular narrative or perspective, fostering an environment ripe for intellectual discourse and critical thinking . It nudges you to examine the topic from multiple angles, enhancing your understanding and appreciation of the complexity inherent in the field.

A Full List of Critical Analysis Skills

• Exploring Strengths and Weaknesses
• Evaluating Sources
• Identifying Similarities
• Identifying Differences
• Identifying Biases
• Hypothesis Testing
• Fact-Checking
• Exploring Counterexamples
• Assessing Methodologies
• Exploring Alternative Explanations
• Pointing Out Contradictions
• Challenging the Significance
• Cause-And-Effect Analysis
• Assessing Generalizability
• Highlighting Inconsistencies
• Reductio ad Absurdum
• Comparing to Expert Testimony
• Comparing to Precedent
• Reframing the Argument
• Pointing Out Fallacies
• Questioning the Ethics
• Clarifying Definitions
• Challenging Assumptions
• Exposing Oversimplifications
• Highlighting Missing Information
• Demonstrating Irrelevance
• Assessing Effectiveness
• Assessing Trustworthiness
• Recognizing Patterns
• Differentiating Facts from Opinions
• Analyzing Perspectives
• Prioritization
• Making Predictions
• Conducting a SWOT Analysis
• PESTLE Analysis
• Asking the Five Whys
• Correlating Data Points
• Finding Anomalies Or Outliers
• Comparing to Expert Literature
• Drawing Inferences
• Assessing Validity & Reliability

Analysis and Bloom’s Taxonomy

Benjamin Bloom placed analysis as the third-highest form of thinking on his ladder of cognitive skills called Bloom’s Taxonomy .

This taxonomy starts with the lowest levels of thinking – remembering and understanding. The further we go up the ladder, the more we reach higher-order thinking skills that demonstrate depth of understanding and knowledge, as outlined below:

Here’s a full outline of the taxonomy in a table format:

• Chris Drew (PhD) https://helpfulprofessor.com/author/chris-drew-phd-2/ 25 Number Games for Kids (Free and Easy)
• Chris Drew (PhD) https://helpfulprofessor.com/author/chris-drew-phd-2/ 25 Word Games for Kids (Free and Easy)
• Chris Drew (PhD) https://helpfulprofessor.com/author/chris-drew-phd-2/ 25 Outdoor Games for Kids
• Chris Drew (PhD) https://helpfulprofessor.com/author/chris-drew-phd-2/ 50 Incentives to Give to Students

2 thoughts on “33 Critical Analysis Examples”

THANK YOU, THANK YOU, THANK YOU! – I cannot even being to explain how hard it has been to find a simple but in-depth understanding of what ‘Critical Analysis’ is. I have looked at over 10 different pages and went down so many rabbit holes but this is brilliant! I only skimmed through the article but it was already promising, I then went back and read it more in-depth, it just all clicked into place. So thank you again!

You’re welcome – so glad it was helpful.

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• Volume 25, Issue 1
• Critical appraisal of qualitative research: necessity, partialities and the issue of bias
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• http://orcid.org/0000-0001-5660-8224 Veronika Williams ,
• Anne-Marie Boylan ,
• http://orcid.org/0000-0003-4597-1276 David Nunan
• Nuffield Department of Primary Care Health Sciences , University of Oxford, Radcliffe Observatory Quarter , Oxford , UK
• Correspondence to Dr Veronika Williams, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; veronika.williams{at}phc.ox.ac.uk

https://doi.org/10.1136/bmjebm-2018-111132

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• qualitative research

Introduction

Qualitative evidence allows researchers to analyse human experience and provides useful exploratory insights into experiential matters and meaning, often explaining the ‘how’ and ‘why’. As we have argued previously 1 , qualitative research has an important place within evidence-based healthcare, contributing to among other things policy on patient safety, 2 prescribing, 3 4 and understanding chronic illness. 5 Equally, it offers additional insight into quantitative studies, explaining contextual factors surrounding a successful intervention or why an intervention might have ‘failed’ or ‘succeeded’ where effect sizes cannot. It is for these reasons that the MRC strongly recommends including qualitative evaluations when developing and evaluating complex interventions. 6

Critical appraisal of qualitative research

Is it necessary.

Although the importance of qualitative research to improve health services and care is now increasingly widely supported (discussed in paper 1), the role of appraising the quality of qualitative health research is still debated. 8 10 Despite a large body of literature focusing on appraisal and rigour, 9 11–15 often referred to as ‘trustworthiness’ 16 in qualitative research, there remains debate about how to —and even whether to—critically appraise qualitative research. 8–10 17–19 However, if we are to make a case for qualitative research as integral to evidence-based healthcare, then any argument to omit a crucial element of evidence-based practice is difficult to justify. That being said, simply applying the standards of rigour used to appraise studies based on the positivist paradigm (Positivism depends on quantifiable observations to test hypotheses and assumes that the researcher is independent of the study. Research situated within a positivist paradigm isbased purely on facts and consider the world to be external and objective and is concerned with validity, reliability and generalisability as measures of rigour.) would be misplaced given the different epistemological underpinnings of the two types of data.

Given its scope and its place within health research, the robust and systematic appraisal of qualitative research to assess its trustworthiness is as paramount to its implementation in clinical practice as any other type of research. It is important to appraise different qualitative studies in relation to the specific methodology used because the methodological approach is linked to the ‘outcome’ of the research (eg, theory development, phenomenological understandings and credibility of findings). Moreover, appraisal needs to go beyond merely describing the specific details of the methods used (eg, how data were collected and analysed), with additional focus needed on the overarching research design and its appropriateness in accordance with the study remit and objectives.

Poorly conducted qualitative research has been described as ‘worthless, becomes fiction and loses its utility’. 20 However, without a deep understanding of concepts of quality in qualitative research or at least an appropriate means to assess its quality, good qualitative research also risks being dismissed, particularly in the context of evidence-based healthcare where end users may not be well versed in this paradigm.

How is appraisal currently performed?

Appraising the quality of qualitative research is not a new concept—there are a number of published appraisal tools, frameworks and checklists in existence. 21–23  An important and often overlooked point is the confusion between tools designed for appraising methodological quality and reporting guidelines designed to assess the quality of methods reporting. An example is the Consolidate Criteria for Reporting Qualitative Research (COREQ) 24 checklist, which was designed to provide standards for authors when reporting qualitative research but is often mistaken for a methods appraisal tool. 10

Broadly speaking there are two types of critical appraisal approaches for qualitative research: checklists and frameworks. Checklists have often been criticised for confusing quality in qualitative research with ‘technical fixes’ 21 25 , resulting in the erroneous prioritisation of particular aspects of methodological processes over others (eg, multiple coding and triangulation). It could be argued that a checklist approach adopts the positivist paradigm, where the focus is on objectively assessing ‘quality’ where the assumptions is that the researcher is independent of the research conducted. This may result in the application of quantitative understandings of bias in order to judge aspects of recruitment, sampling, data collection and analysis in qualitative research papers. One of the most widely used appraisal tools is the Critical Appraisal Skills Programme (CASP) 26 and along with the JBI QARI (Joanna Briggs Institute Qualitative Assessment and Assessment Instrument) 27 presents examples which tend to mimic the quantitative approach to appraisal. The CASP qualitative tool follows that of other CASP appraisal tools for quantitative research designs developed in the 1990s. The similarities are therefore unsurprising given the status of qualitative research at that time.

Frameworks focus on the overarching concepts of quality in qualitative research, including transparency, reflexivity, dependability and transferability (see box 1 ). 11–13 15 16 20 28 However, unless the reader is familiar with these concepts—their meaning and impact, and how to interpret them—they will have difficulty applying them when critically appraising a paper.

The main issue concerning currently available checklist and framework appraisal methods is that they take a broad brush approach to ‘qualitative’ research as whole, with few, if any, sufficiently differentiating between the different methodological approaches (eg, Grounded Theory, Interpretative Phenomenology, Discourse Analysis) nor different methods of data collection (interviewing, focus groups and observations). In this sense, it is akin to taking the entire field of ‘quantitative’ study designs and applying a single method or tool for their quality appraisal. In the case of qualitative research, checklists, therefore, offer only a blunt and arguably ineffective tool and potentially promote an incomplete understanding of good ‘quality’ in qualitative research. Likewise, current framework methods do not take into account how concepts differ in their application across the variety of qualitative approaches and, like checklists, they also do not differentiate between different qualitative methodologies.

On the need for specific appraisal tools

Current approaches to the appraisal of the methodological rigour of the differing types of qualitative research converge towards checklists or frameworks. More importantly, the current tools do not explicitly acknowledge the prejudices that may be present in the different types of qualitative research.

Concepts of rigour or trustworthiness within qualitative research 31

Transferability: the extent to which the presented study allows readers to make connections between the study’s data and wider community settings, ie, transfer conceptual findings to other contexts.

Credibility: extent to which a research account is believable and appropriate, particularly in relation to the stories told by participants and the interpretations made by the researcher.

Reflexivity: refers to the researchers’ engagement of continuous examination and explanation of how they have influenced a research project from choosing a research question to sampling, data collection, analysis and interpretation of data.

Transparency: making explicit the whole research process from sampling strategies, data collection to analysis. The rationale for decisions made is as important as the decisions themselves.

However, we often talk about these concepts in general terms, and it might be helpful to give some explicit examples of how the ‘technical processes’ affect these, for example, partialities related to:

Selection: recruiting participants via gatekeepers, such as healthcare professionals or clinicians, who may select them based on whether they believe them to be ‘good’ participants for interviews/focus groups.

Data collection: poor interview guide with closed questions which encourage yes/no answers and/leading questions.

Reflexivity and transparency: where researchers may focus their analysis on preconceived ideas rather than ground their analysis in the data and do not reflect on the impact of this in a transparent way.

The lack of tailored, method-specific appraisal tools has potentially contributed to the poor uptake and use of qualitative research for informing evidence-based decision making. To improve this situation, we propose the need for more robust quality appraisal tools that explicitly encompass both the core design aspects of all qualitative research (sampling/data collection/analysis) but also considered the specific partialities that can be presented with different methodological approaches. Such tools might draw on the strengths of current frameworks and checklists while providing users with sufficient understanding of concepts of rigour in relation to the different types of qualitative methods. We provide an outline of such tools in the third and final paper in this series.

As qualitative research becomes ever more embedded in health science research, and in order for that research to have better impact on healthcare decisions, we need to rethink critical appraisal and develop tools that allow differentiated evaluations of the myriad of qualitative methodological approaches rather than continuing to treat qualitative research as a single unified approach.

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Contributors VW and DN: conceived the idea for this article. VW: wrote the first draft. AMB and DN: contributed to the final draft. All authors approve the submitted article.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Correction notice This article has been updated since its original publication to include a new reference (reference 1.)

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Home » Discourse Analysis – Methods, Types and Examples

Discourse Analysis – Methods, Types and Examples

Table of Contents

Discourse Analysis

Definition:

Discourse Analysis is a method of studying how people use language in different situations to understand what they really mean and what messages they are sending. It helps us understand how language is used to create social relationships and cultural norms.

It examines language use in various forms of communication such as spoken, written, visual or multi-modal texts, and focuses on how language is used to construct social meaning and relationships, and how it reflects and reinforces power dynamics, ideologies, and cultural norms.

Types of Discourse Analysis

Some of the most common types of discourse analysis are:

Conversation Analysis

This type of discourse analysis focuses on analyzing the structure of talk and how participants in a conversation make meaning through their interaction. It is often used to study face-to-face interactions, such as interviews or everyday conversations.

Critical discourse Analysis

This approach focuses on the ways in which language use reflects and reinforces power relations, social hierarchies, and ideologies. It is often used to analyze media texts or political speeches, with the aim of uncovering the hidden meanings and assumptions that are embedded in these texts.

Discursive Psychology

This type of discourse analysis focuses on the ways in which language use is related to psychological processes such as identity construction and attribution of motives. It is often used to study narratives or personal accounts, with the aim of understanding how individuals make sense of their experiences.

Multimodal Discourse Analysis

This approach focuses on analyzing not only language use, but also other modes of communication, such as images, gestures, and layout. It is often used to study digital or visual media, with the aim of understanding how different modes of communication work together to create meaning.

Corpus-based Discourse Analysis

This type of discourse analysis uses large collections of texts, or corpora, to analyze patterns of language use across different genres or contexts. It is often used to study language use in specific domains, such as academic writing or legal discourse.

Descriptive Discourse

This type of discourse analysis aims to describe the features and characteristics of language use, without making any value judgments or interpretations. It is often used in linguistic studies to describe grammatical structures or phonetic features of language.

Narrative Discourse

This approach focuses on analyzing the structure and content of stories or narratives, with the aim of understanding how they are constructed and how they shape our understanding of the world. It is often used to study personal narratives or cultural myths.

Expository Discourse

This type of discourse analysis is used to study texts that explain or describe a concept, process, or idea. It aims to understand how information is organized and presented in such texts and how it influences the reader’s understanding of the topic.

Argumentative Discourse

This approach focuses on analyzing texts that present an argument or attempt to persuade the reader or listener. It aims to understand how the argument is constructed, what strategies are used to persuade, and how the audience is likely to respond to the argument.

Discourse Analysis Conducting Guide

Here is a step-by-step guide for conducting discourse analysis:

• What are you trying to understand about the language use in a particular context?
• What are the key concepts or themes that you want to explore?
• Select the data: Decide on the type of data that you will analyze, such as written texts, spoken conversations, or media content. Consider the source of the data, such as news articles, interviews, or social media posts, and how this might affect your analysis.
• Transcribe or collect the data: If you are analyzing spoken language, you will need to transcribe the data into written form. If you are using written texts, make sure that you have access to the full text and that it is in a format that can be easily analyzed.
• Read and re-read the data: Read through the data carefully, paying attention to key themes, patterns, and discursive features. Take notes on what stands out to you and make preliminary observations about the language use.
• Develop a coding scheme : Develop a coding scheme that will allow you to categorize and organize different types of language use. This might include categories such as metaphors, narratives, or persuasive strategies, depending on your research question.
• Code the data: Use your coding scheme to analyze the data, coding different sections of text or spoken language according to the categories that you have developed. This can be a time-consuming process, so consider using software tools to assist with coding and analysis.
• Analyze the data: Once you have coded the data, analyze it to identify patterns and themes that emerge. Look for similarities and differences across different parts of the data, and consider how different categories of language use are related to your research question.
• Interpret the findings: Draw conclusions from your analysis and interpret the findings in relation to your research question. Consider how the language use in your data sheds light on broader cultural or social issues, and what implications it might have for understanding language use in other contexts.
• Write up the results: Write up your findings in a clear and concise way, using examples from the data to support your arguments. Consider how your research contributes to the broader field of discourse analysis and what implications it might have for future research.

Applications of Discourse Analysis

Here are some of the key areas where discourse analysis is commonly used:

• Political discourse: Discourse analysis can be used to analyze political speeches, debates, and media coverage of political events. By examining the language used in these contexts, researchers can gain insight into the political ideologies, values, and agendas that underpin different political positions.
• Media analysis: Discourse analysis is frequently used to analyze media content, including news reports, television shows, and social media posts. By examining the language used in media content, researchers can understand how media narratives are constructed and how they influence public opinion.
• Education : Discourse analysis can be used to examine classroom discourse, student-teacher interactions, and educational policies. By analyzing the language used in these contexts, researchers can gain insight into the social and cultural factors that shape educational outcomes.
• Healthcare : Discourse analysis is used in healthcare to examine the language used by healthcare professionals and patients in medical consultations. This can help to identify communication barriers, cultural differences, and other factors that may impact the quality of healthcare.
• Marketing and advertising: Discourse analysis can be used to analyze marketing and advertising messages, including the language used in product descriptions, slogans, and commercials. By examining these messages, researchers can gain insight into the cultural values and beliefs that underpin consumer behavior.

When to use Discourse Analysis

Discourse analysis is a valuable research methodology that can be used in a variety of contexts. Here are some situations where discourse analysis may be particularly useful:

• When studying language use in a particular context: Discourse analysis can be used to examine how language is used in a specific context, such as political speeches, media coverage, or healthcare interactions. By analyzing language use in these contexts, researchers can gain insight into the social and cultural factors that shape communication.
• When exploring the meaning of language: Discourse analysis can be used to examine how language is used to construct meaning and shape social reality. This can be particularly useful in fields such as sociology, anthropology, and cultural studies.
• When examining power relations: Discourse analysis can be used to examine how language is used to reinforce or challenge power relations in society. By analyzing language use in contexts such as political discourse, media coverage, or workplace interactions, researchers can gain insight into how power is negotiated and maintained.
• When conducting qualitative research: Discourse analysis can be used as a qualitative research method, allowing researchers to explore complex social phenomena in depth. By analyzing language use in a particular context, researchers can gain rich and nuanced insights into the social and cultural factors that shape communication.

Examples of Discourse Analysis

Here are some examples of discourse analysis in action:

• A study of media coverage of climate change: This study analyzed media coverage of climate change to examine how language was used to construct the issue. The researchers found that media coverage tended to frame climate change as a matter of scientific debate rather than a pressing environmental issue, thereby undermining public support for action on climate change.
• A study of political speeches: This study analyzed political speeches to examine how language was used to construct political identity. The researchers found that politicians used language strategically to construct themselves as trustworthy and competent leaders, while painting their opponents as untrustworthy and incompetent.
• A study of medical consultations: This study analyzed medical consultations to examine how language was used to negotiate power and authority between doctors and patients. The researchers found that doctors used language to assert their authority and control over medical decisions, while patients used language to negotiate their own preferences and concerns.
• A study of workplace interactions: This study analyzed workplace interactions to examine how language was used to construct social identity and maintain power relations. The researchers found that language was used to construct a hierarchy of power and status within the workplace, with those in positions of authority using language to assert their dominance over subordinates.

Purpose of Discourse Analysis

The purpose of discourse analysis is to examine the ways in which language is used to construct social meaning, relationships, and power relations. By analyzing language use in a systematic and rigorous way, discourse analysis can provide valuable insights into the social and cultural factors that shape communication and interaction.

The specific purposes of discourse analysis may vary depending on the research context, but some common goals include:

• To understand how language constructs social reality: Discourse analysis can help researchers understand how language is used to construct meaning and shape social reality. By analyzing language use in a particular context, researchers can gain insight into the cultural and social factors that shape communication.
• To identify power relations: Discourse analysis can be used to examine how language use reinforces or challenges power relations in society. By analyzing language use in contexts such as political discourse, media coverage, or workplace interactions, researchers can gain insight into how power is negotiated and maintained.
• To explore social and cultural norms: Discourse analysis can help researchers understand how social and cultural norms are constructed and maintained through language use. By analyzing language use in different contexts, researchers can gain insight into how social and cultural norms are reproduced and challenged.
• To provide insights for social change: Discourse analysis can provide insights that can be used to promote social change. By identifying problematic language use or power imbalances, researchers can provide insights that can be used to challenge social norms and promote more equitable and inclusive communication.

Characteristics of Discourse Analysis

Here are some key characteristics of discourse analysis:

• Focus on language use: Discourse analysis is centered on language use and how it constructs social meaning, relationships, and power relations.
• Multidisciplinary approach: Discourse analysis draws on theories and methodologies from a range of disciplines, including linguistics, anthropology, sociology, and psychology.
• Systematic and rigorous methodology: Discourse analysis employs a systematic and rigorous methodology, often involving transcription and coding of language data, in order to identify patterns and themes in language use.
• Contextual analysis : Discourse analysis emphasizes the importance of context in shaping language use, and takes into account the social and cultural factors that shape communication.
• Focus on power relations: Discourse analysis often examines power relations and how language use reinforces or challenges power imbalances in society.
• Interpretive approach: Discourse analysis is an interpretive approach, meaning that it seeks to understand the meaning and significance of language use from the perspective of the participants in a particular discourse.
• Emphasis on reflexivity: Discourse analysis emphasizes the importance of reflexivity, or self-awareness, in the research process. Researchers are encouraged to reflect on their own positionality and how it may shape their interpretation of language use.

Advantages of Discourse Analysis

Discourse analysis has several advantages as a methodological approach. Here are some of the main advantages:

• Provides a detailed understanding of language use: Discourse analysis allows for a detailed and nuanced understanding of language use in specific social contexts. It enables researchers to identify patterns and themes in language use, and to understand how language constructs social reality.
• Emphasizes the importance of context : Discourse analysis emphasizes the importance of context in shaping language use. By taking into account the social and cultural factors that shape communication, discourse analysis provides a more complete understanding of language use than other approaches.
• Allows for an examination of power relations: Discourse analysis enables researchers to examine power relations and how language use reinforces or challenges power imbalances in society. By identifying problematic language use, discourse analysis can contribute to efforts to promote social justice and equality.
• Provides insights for social change: Discourse analysis can provide insights that can be used to promote social change. By identifying problematic language use or power imbalances, researchers can provide insights that can be used to challenge social norms and promote more equitable and inclusive communication.
• Multidisciplinary approach: Discourse analysis draws on theories and methodologies from a range of disciplines, including linguistics, anthropology, sociology, and psychology. This multidisciplinary approach allows for a more holistic understanding of language use in social contexts.

Limitations of Discourse Analysis

Some Limitations of Discourse Analysis are as follows:

• Time-consuming and resource-intensive: Discourse analysis can be a time-consuming and resource-intensive process. Collecting and transcribing language data can be a time-consuming task, and analyzing the data requires careful attention to detail and a significant investment of time and resources.
• Limited generalizability: Discourse analysis is often focused on a particular social context or community, and therefore the findings may not be easily generalized to other contexts or populations. This means that the insights gained from discourse analysis may have limited applicability beyond the specific context being studied.
• Interpretive nature: Discourse analysis is an interpretive approach, meaning that it relies on the interpretation of the researcher to identify patterns and themes in language use. This subjectivity can be a limitation, as different researchers may interpret language data differently.
• Limited quantitative analysis: Discourse analysis tends to focus on qualitative analysis of language data, which can limit the ability to draw statistical conclusions or make quantitative comparisons across different language uses or contexts.
• Ethical considerations: Discourse analysis may involve the collection and analysis of sensitive language data, such as language related to trauma or marginalization. Researchers must carefully consider the ethical implications of collecting and analyzing this type of data, and ensure that the privacy and confidentiality of participants is protected.

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• Systematic review
• Open access
• Published: 07 August 2024

Models and frameworks for assessing the implementation of clinical practice guidelines: a systematic review

• Nicole Freitas de Mello   ORCID: orcid.org/0000-0002-5228-6691 1 , 2 ,
• Sarah Nascimento Silva   ORCID: orcid.org/0000-0002-1087-9819 3 ,
• Dalila Fernandes Gomes   ORCID: orcid.org/0000-0002-2864-0806 1 , 2 ,
• Juliana da Motta Girardi   ORCID: orcid.org/0000-0002-7547-7722 4 &
• Jorge Otávio Maia Barreto   ORCID: orcid.org/0000-0002-7648-0472 2 , 4  

Implementation Science volume  19 , Article number:  59 ( 2024 ) Cite this article

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The implementation of clinical practice guidelines (CPGs) is a cyclical process in which the evaluation stage can facilitate continuous improvement. Implementation science has utilized theoretical approaches, such as models and frameworks, to understand and address this process. This article aims to provide a comprehensive overview of the models and frameworks used to assess the implementation of CPGs.

A systematic review was conducted following the Cochrane methodology, with adaptations to the "selection process" due to the unique nature of this review. The findings were reported following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines. Electronic databases were searched from their inception until May 15, 2023. A predetermined strategy and manual searches were conducted to identify relevant documents from health institutions worldwide. Eligible studies presented models and frameworks for assessing the implementation of CPGs. Information on the characteristics of the documents, the context in which the models were used (specific objectives, level of use, type of health service, target group), and the characteristics of each model or framework (name, domain evaluated, and model limitations) were extracted. The domains of the models were analyzed according to the key constructs: strategies, context, outcomes, fidelity, adaptation, sustainability, process, and intervention. A subgroup analysis was performed grouping models and frameworks according to their levels of use (clinical, organizational, and policy) and type of health service (community, ambulatorial, hospital, institutional). The JBI’s critical appraisal tools were utilized by two independent researchers to assess the trustworthiness, relevance, and results of the included studies.

Database searches yielded 14,395 studies, of which 80 full texts were reviewed. Eight studies were included in the data analysis and four methodological guidelines were additionally included from the manual search. The risk of bias in the studies was considered non-critical for the results of this systematic review. A total of ten models/frameworks for assessing the implementation of CPGs were found. The level of use was mainly policy, the most common type of health service was institutional, and the major target group was professionals directly involved in clinical practice. The evaluated domains differed between the models and there were also differences in their conceptualization. All the models addressed the domain "Context", especially at the micro level (8/12), followed by the multilevel (7/12). The domains "Outcome" (9/12), "Intervention" (8/12), "Strategies" (7/12), and "Process" (5/12) were frequently addressed, while "Sustainability" was found only in one study, and "Fidelity/Adaptation" was not observed.

Conclusions

The use of models and frameworks for assessing the implementation of CPGs is still incipient. This systematic review may help stakeholders choose or adapt the most appropriate model or framework to assess CPGs implementation based on their specific health context.

Trial registration

PROSPERO (International Prospective Register of Systematic Reviews) registration number: CRD42022335884. Registered on June 7, 2022.

Peer Review reports

Contributions to the literature

Although the number of theoretical approaches has grown in recent years, there are still important gaps to be explored in the use of models and frameworks to assess the implementation of clinical practice guidelines (CPGs). This systematic review aims to contribute knowledge to overcome these gaps.

Despite the great advances in implementation science, evaluating the implementation of CPGs remains a challenge, and models and frameworks could support improvements in this field.

This study demonstrates that the available models and frameworks do not cover all characteristics and domains necessary for a complete evaluation of CPGs implementation.

The presented findings contribute to the field of implementation science, encouraging debate on choices and adaptations of models and frameworks for implementation research and evaluation.

Substantial investments have been made in clinical research and development in recent decades, increasing the medical knowledge base and the availability of health technologies [ 1 ]. The use of clinical practice guidelines (CPGs) has increased worldwide to guide best health practices and to maximize healthcare investments. A CPG can be defined as "any formal statements systematically developed to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances" [ 2 ] and has the potential to improve patient care by promoting interventions of proven benefit and discouraging ineffective interventions. Furthermore, they can promote efficiency in resource allocation and provide support for managers and health professionals in decision-making [ 3 , 4 ].

However, having a quality CPG does not guarantee that the expected health benefits will be obtained. In fact, putting these devices to use still presents a challenge for most health services across distinct levels of government. In addition to the development of guidelines with high methodological rigor, those recommendations need to be available to their users; these recommendations involve the diffusion and dissemination stages, and they need to be used in clinical practice (implemented), which usually requires behavioral changes and appropriate resources and infrastructure. All these stages involve an iterative and complex process called implementation, which is defined as the process of putting new practices within a setting into use [ 5 , 6 ].

Implementation is a cyclical process, and the evaluation is one of its key stages, which allows continuous improvement of CPGs development and implementation strategies. It consists of verifying whether clinical practice is being performed as recommended (process evaluation or formative evaluation) and whether the expected results and impact are being reached (summative evaluation) [ 7 , 8 , 9 ]. Although the importance of the implementation evaluation stage has been recognized, research on how these guidelines are implemented is scarce [ 10 ]. This paper focused on the process of assessing CPGs implementation.

To understand and improve this complex process, implementation science provides a systematic set of principles and methods to integrate research findings and other evidence-based practices into routine practice and improve the quality and effectiveness of health services and care [ 11 ]. The field of implementation science uses theoretical approaches that have varying degrees of specificity based on the current state of knowledge and are structured based on theories, models, and frameworks [ 5 , 12 , 13 ]. A "Model" is defined as "a simplified depiction of a more complex world with relatively precise assumptions about cause and effect", and a "framework" is defined as "a broad set of constructs that organize concepts and data descriptively without specifying causal relationships" [ 9 ]. Although these concepts are distinct, in this paper, their use will be interchangeable, as they are typically like checklists of factors relevant to various aspects of implementation.

There are a variety of theoretical approaches available in implementation science [ 5 , 14 ], which can make choosing the most appropriate challenging [ 5 ]. Some models and frameworks have been categorized as "evaluation models" by providing a structure for evaluating implementation endeavors [ 15 ], even though theoretical approaches from other categories can also be applied for evaluation purposes because they specify concepts and constructs that may be operationalized and measured [ 13 ]. Two frameworks that can specify implementation aspects that should be evaluated as part of intervention studies are RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) [ 16 ] and PRECEDE-PROCEED (Predisposing, Reinforcing and Enabling Constructs in Educational Diagnosis and Evaluation-Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development) [ 17 ]. Although the number of theoretical approaches has grown in recent years, the use of models and frameworks to evaluate the implementation of guidelines still seems to be a challenge.

This article aims to provide a complete map of the models and frameworks applied to assess the implementation of CPGs. The aim is also to subside debate and choices on models and frameworks for the research and evaluation of the implementation processes of CPGs and thus to facilitate the continued development of the field of implementation as well as to contribute to healthcare policy and practice.

A systematic review was conducted following the Cochrane methodology [ 18 ], with adaptations to the "selection process" due to the unique nature of this review (details can be found in the respective section). The review protocol was registered in PROSPERO (registration number: CRD42022335884) on June 7, 2022. This report adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 19 ] and a completed checklist is provided in Additional File 1.

Eligibility criteria

The SDMO approach (Types of Studies, Types of Data, Types of Methods, Outcomes) [ 20 ] was utilized in this systematic review, outlined as follows:

Types of studies

All types of studies were considered for inclusion, as the assessment of CPG implementation can benefit from a diverse range of study designs, including randomized clinical trials/experimental studies, scale/tool development, systematic reviews, opinion pieces, qualitative studies, peer-reviewed articles, books, reports, and unpublished theses.

Studies were categorized based on their methodological designs, which guided the synthesis, risk of bias assessment, and presentation of results.

Study protocols and conference abstracts were excluded due to insufficient information for this review.

Types of data

Studies that evaluated the implementation of CPGs either independently or as part of a multifaceted intervention.

Guidelines for evaluating CPG implementation.

Inclusion of CPGs related to any context, clinical area, intervention, and patient characteristics.

No restrictions were placed on publication date or language.

Exclusion criteria

General guidelines were excluded, as this review focused on 'models for evaluating clinical practice guidelines implementation' rather than the guidelines themselves.

Studies that focused solely on implementation determinants as barriers and enablers were excluded, as this review aimed to explore comprehensive models/frameworks.

Studies evaluating programs and policies were excluded.

Studies that only assessed implementation strategies (isolated actions) rather than the implementation process itself were excluded.

Studies that focused solely on the impact or results of implementation (summative evaluation) were excluded.

Types of methods

Not applicable.

All potential models or frameworks for assessing the implementation of CPG (evaluation models/frameworks), as well as their characteristics: name; specific objectives; levels of use (clinical, organizational, and policy); health system (public, private, or both); type of health service (community, ambulatorial, hospital, institutional, homecare); domains or outcomes evaluated; type of recommendation evaluated; context; limitations of the model.

Model was defined as "a deliberated simplification of a phenomenon on a specific aspect" [ 21 ].

Framework was defined as "structure, overview outline, system, or plan consisting of various descriptive categories" [ 21 ].

Models or frameworks used solely for the CPG development, dissemination, or implementation phase.

Models/frameworks used solely for assessment processes other than implementation, such as for the development or dissemination phase.

Data sources and literature search

The systematic search was conducted on July 31, 2022 (and updated on May 15, 2023) in the following electronic databases: MEDLINE/PubMed, Centre for Reviews and Dissemination (CRD), the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Epistemonikos, Global Health, Health Systems Evidence, PDQ-Evidence, PsycINFO, Rx for Change (Canadian Agency for Drugs and Technologies in Health, CADTH), Scopus, Web of Science and Virtual Health Library (VHL). The Google Scholar database was used for the manual selection of studies (first 10 pages).

Additionally, hand searches were performed on the lists of references included in the systematic reviews and citations of the included studies, as well as on the websites of institutions working on CPGs development and implementation: Guidelines International Networks (GIN), National Institute for Health and Care Excellence (NICE; United Kingdom), World Health Organization (WHO), Centers for Disease Control and Prevention (CDC; USA), Institute of Medicine (IOM; USA), Australian Department of Health and Aged Care (ADH), Healthcare Improvement Scotland (SIGN), National Health and Medical Research Council (NHMRC; Australia), Queensland Health, The Joanna Briggs Institute (JBI), Ministry of Health and Social Policy of Spain, Ministry of Health of Brazil and Capes Theses and Dissertations Catalog.

The search strategy combined terms related to "clinical practice guidelines" (practice guidelines, practice guidelines as topic, clinical protocols), "implementation", "assessment" (assessment, evaluation), and "models, framework". The free term "monitoring" was not used because it was regularly related to clinical monitoring and not to implementation monitoring. The search strategies adapted for the electronic databases are presented in an additional file (see Additional file 2).

Study selection process

The results of the literature search from scientific databases, excluding the CRD database, were imported into Mendeley Reference Management software to remove duplicates. They were then transferred to the Rayyan platform ( https://rayyan.qcri.org ) [ 22 ] for the screening process. Initially, studies related to the "assessment of implementation of the CPG" were selected. The titles were first screened independently by two pairs of reviewers (first selection: four reviewers, NM, JB, SS, and JG; update: a pair of reviewers, NM and DG). The title screening was broad, including all potentially relevant studies on CPG and the implementation process. Following that, the abstracts were independently screened by the same group of reviewers. The abstract screening was more focused, specifically selecting studies that addressed CPG and the evaluation of the implementation process. In the next step, full-text articles were reviewed independently by a pair of reviewers (NM, DG) to identify those that explicitly presented "models" or "frameworks" for assessing the implementation of the CPG. Disagreements regarding the eligibility of studies were resolved through discussion and consensus, and by a third reviewer (JB) when necessary. One reviewer (NM) conducted manual searches, and the inclusion of documents was discussed with the other reviewers.

Risk of bias assessment of studies

The selected studies were independently classified and evaluated according to their methodological designs by two investigators (NM and JG). This review employed JBI’s critical appraisal tools to assess the trustworthiness, relevance and results of the included studies [ 23 ] and these tools are presented in additional files (see Additional file 3 and Additional file 4). Disagreements were resolved by consensus or consultation with the other reviewers. Methodological guidelines and noncomparative and before–after studies were not evaluated because JBI does not have specific tools for assessing these types of documents. Although the studies were assessed for quality, they were not excluded on this basis.

Data extraction

The data was independently extracted by two reviewers (NM, DG) using a Microsoft Excel spreadsheet. Discrepancies were discussed and resolved by consensus. The following information was extracted:

Document characteristics : author; year of publication; title; study design; instrument of evaluation; country; guideline context;

Usage context of the models : specific objectives; level of use (clinical, organizational, and policy); type of health service (community, ambulatorial, hospital, institutional); target group (guideline developers, clinicians; health professionals; health-policy decision-makers; health-care organizations; service managers);

Model and framework characteristics : name, domain evaluated, and model limitations.

The set of information to be extracted, shown in the systematic review protocol, was adjusted to improve the organization of the analysis.

The "level of use" refers to the scope of the model used. "Clinical" was considered when the evaluation focused on individual practices, "organizational" when practices were within a health service institution, and "policy" when the evaluation was more systemic and covered different health services or institutions.

The "type of health service" indicated the category of health service where the model/framework was used (or can be used) to assess the implementation of the CPG, related to the complexity of healthcare. "Community" is related to primary health care; "ambulatorial" is related to secondary health care; "hospital" is related to tertiary health care; and "institutional" represented models/frameworks not specific to a particular type of health service.

The "target group" included stakeholders related to the use of the model/framework for evaluating the implementation of the CPG, such as clinicians, health professionals, guideline developers, health policy-makers, health organizations, and service managers.

The category "health system" (public, private, or both) mentioned in the systematic review protocol was not found in the literature obtained and was removed as an extraction variable. Similarly, the variables "type of recommendation evaluated" and "context" were grouped because the same information was included in the "guideline context" section of the study.

Some selected documents presented models or frameworks recognized by the scientific field, including some that were validated. However, some studies adapted the model to this context. Therefore, the domain analysis covered all models or frameworks domains evaluated by (or suggested for evaluation by) the document analyzed.

Data analysis and synthesis

The results were tabulated using narrative synthesis with an aggregative approach, without meta-analysis, aiming to summarize the documents descriptively for the organization, description, interpretation and explanation of the study findings [ 24 , 25 ].

The model/framework domains evaluated in each document were studied according to Nilsen et al.’s constructs: "strategies", "context", "outcomes", "fidelity", "adaptation" and "sustainability". For this study, "strategies" were described as structured and planned initiatives used to enhance the implementation of clinical practice [ 26 ].

The definition of "context" varies in the literature. Despite that, this review considered it as the set of circumstances or factors surrounding a particular implementation effort, such as organizational support, financial resources, social relations and support, leadership, and organizational culture [ 26 , 27 ]. The domain "context" was subdivided according to the level of health care into "micro" (individual perspective), "meso" (organizational perspective), "macro" (systemic perspective), and "multiple" (when there is an issue involving more than one level of health care).

The "outcomes" domain was related to the results of the implementation process (unlike clinical outcomes) and was stratified according to the following constructs: acceptability, appropriateness, feasibility, adoption, cost, and penetration. All these concepts align with the definitions of Proctor et al. (2011), although we decided to separate "fidelity" and "sustainability" as independent domains similar to Nilsen [ 26 , 28 ].

"Fidelity" and "adaptation" were considered the same domain, as they are complementary pieces of the same issue. In this study, implementation fidelity refers to how closely guidelines are followed as intended by their developers or designers. On the other hand, adaptation involves making changes to the content or delivery of a guideline to better fit the needs of a specific context. The "sustainability" domain was defined as evaluations about the continuation or permanence over time of the CPG implementation.

Additionally, the domain "process" was utilized to address issues related to the implementation process itself, rather than focusing solely on the outcomes of the implementation process, as done by Wang et al. [ 14 ]. Furthermore, the "intervention" domain was introduced to distinguish aspects related to the CPG characteristics that can impact its implementation, such as the complexity of the recommendation.

A subgroup analysis was performed with models and frameworks categorized based on their levels of use (clinical, organizational, and policy) and the type of health service (community, ambulatorial, hospital, institutional) associated with the CPG. The goal is to assist stakeholders (politicians, clinicians, researchers, or others) in selecting the most suitable model for evaluating CPG implementation based on their specific health context.

Search results

Database searches yielded 26,011 studies, of which 107 full texts were reviewed. During the full-text review, 99 articles were excluded: 41 studies did not mention a model or framework for assessing the implementation of the CPG, 31 studies evaluated only implementation strategies (isolated actions) rather than the implementation process itself, and 27 articles were not related to the implementation assessment. Therefore, eight studies were included in the data analysis. The updated search did not reveal additional relevant studies. The main reason for study exclusion was that they did not use models or frameworks to assess CPG implementation. Additionally, four methodological guidelines were included from the manual search (Fig.  1 ).

PRISMA diagram. Acronyms: ADH—Australian Department of Health, CINAHL—Cumulative Index to Nursing and Allied Health Literature, CDC—Centers for Disease Control and Prevention, CRD—Centre for Reviews and Dissemination, GIN—Guidelines International Networks, HSE—Health Systems Evidence, IOM—Institute of Medicine, JBI—The Joanna Briggs Institute, MHB—Ministry of Health of Brazil, NICE—National Institute for Health and Care Excellence, NHMRC—National Health and Medical Research Council, MSPS – Ministerio de Sanidad Y Política Social (Spain), SIGN—Scottish Intercollegiate Guidelines Network, VHL – Virtual Health Library, WHO—World Health Organization. Legend: Reason A –The study evaluated only implementation strategies (isolated actions) rather than the implementation process itself. Reason B – The study did not mention a model or framework for assessing the implementation of the intervention. Reason C – The study was not related to the implementation assessment. Adapted from Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. https://doi.org/10.1136/bmj.n71 . For more information, visit:

According to the JBI’s critical appraisal tools, the overall assessment of the studies indicates their acceptance for the systematic review.

The cross-sectional studies lacked clear information regarding "confounding factors" or "strategies to address confounding factors". This was understandable given the nature of the study, where such details are not typically included. However, the reviewers did not find this lack of information to be critical, allowing the studies to be included in the review. The results of this methodological quality assessment can be found in an additional file (see Additional file 5).

In the qualitative studies, there was some ambiguity regarding the questions: "Is there a statement locating the researcher culturally or theoretically?" and "Is the influence of the researcher on the research, and vice versa, addressed?". However, the reviewers decided to include the studies and deemed the methodological quality sufficient for the analysis in this article, based on the other information analyzed. The results of this methodological quality assessment can be found in an additional file (see Additional file 6).

Documents characteristics (Table  1 )

The documents were directed to several continents: Australia/Oceania (4/12) [ 31 , 33 , 36 , 37 ], North America (4/12 [ 30 , 32 , 38 , 39 ], Europe (2/12 [ 29 , 35 ] and Asia (2/12) [ 34 , 40 ]. The types of documents were classified as cross-sectional studies (4/12) [ 29 , 32 , 34 , 38 ], methodological guidelines (4/12) [ 33 , 35 , 36 , 37 ], mixed methods studies (3/12) [ 30 , 31 , 39 ] or noncomparative studies (1/12) [ 40 ]. In terms of the instrument of evaluation, most of the documents used a survey/questionnaire (6/12) [ 29 , 30 , 31 , 32 , 34 , 38 ], while three (3/12) used qualitative instruments (interviews, group discussions) [ 30 , 31 , 39 ], one used a checklist [ 37 ], one used an audit [ 33 ] and three (3/12) did not define a specific instrument to measure [ 35 , 36 , 40 ].

Considering the clinical areas covered, most studies evaluated the implementation of nonspecific (general) clinical areas [ 29 , 33 , 35 , 36 , 37 , 40 ]. However, some studies focused on specific clinical contexts, such as mental health [ 32 , 38 ], oncology [ 39 ], fall prevention [ 31 ], spinal cord injury [ 30 ], and sexually transmitted infections [ 34 ].

Usage context of the models (Table  1 )

Specific objectives.

All the studies highlighted the purpose of guiding the process of evaluating the implementation of CPGs, even if they evaluated CPGs from generic or different clinical areas.

Levels of use

The most common level of use of the models/frameworks identified to assess the implementation of CPGs was policy (6/12) [ 33 , 35 , 36 , 37 , 39 , 40 ]. In this level, the model is used in a systematic way to evaluate all the processes involved in CPGs implementation and is primarily related to methodological guidelines. This was followed by the organizational level of use (5/12) [ 30 , 31 , 32 , 38 , 39 ], where the model is used to evaluate the implementation of CPGs in a specific institution, considering its specific environment. Finally, the clinical level of use (2/12) [ 29 , 34 ] focuses on individual practice and the factors that can influence the implementation of CPGs by professionals.

Type of health service

Institutional services were predominant (5/12) [ 33 , 35 , 36 , 37 , 40 ] and included methodological guidelines and a study of model development and validation. Hospitals were the second most common type of health service (4/12) [ 29 , 30 , 31 , 34 ], followed by ambulatorial (2/12) [ 32 , 34 ] and community health services (1/12) [ 32 ]. Two studies did not specify which type of health service the assessment addressed [ 38 , 39 ].

Target group

The focus of the target group was professionals directly involved in clinical practice (6/12) [ 29 , 31 , 32 , 34 , 38 , 40 ], namely, health professionals and clinicians. Other less related stakeholders included guideline developers (2/12) [ 39 , 40 ], health policy decision makers (1/12) [ 39 ], and healthcare organizations (1/12) [ 39 ]. The target group was not defined in the methodological guidelines, although all the mentioned stakeholders could be related to these documents.

Model and framework characteristics

Models and frameworks for assessing the implementation of cpgs.

The Consolidated Framework for Implementation Research (CFIR) [ 31 , 38 ] and the Promoting Action on Research Implementation in Health Systems (PARiHS) framework [ 29 , 30 ] were the most commonly employed frameworks within the selected documents. The other models mentioned were: Goal commitment and implementation of practice guidelines framework [ 32 ]; Guideline to identify key indicators [ 35 ]; Guideline implementation checklist [ 37 ]; Guideline implementation evaluation tool [ 40 ]; JBI Implementation Framework [ 33 ]; Reach, effectiveness, adoption, implementation and maintenance (RE-AIM) framework [ 34 ]; The Guideline Implementability Framework [ 39 ] and an unnamed model [ 36 ].

Domains evaluated

The number of domains evaluated (or suggested for evaluation) by the documents varied between three and five, with the majority focusing on three domains. All the models addressed the domain "context", with a particular emphasis on the micro level of the health care context (8/12) [ 29 , 31 , 34 , 35 , 36 , 37 , 38 , 39 ], followed by the multilevel (7/12) [ 29 , 31 , 32 , 33 , 38 , 39 , 40 ], meso level (4/12) [ 30 , 35 , 39 , 40 ] and macro level (2/12) [ 37 , 39 ]. The "Outcome" domain was evaluated in nine models. Within this domain, the most frequently evaluated subdomain was "adoption" (6/12) [ 29 , 32 , 34 , 35 , 36 , 37 ], followed by "acceptability" (4/12) [ 30 , 32 , 35 , 39 ], "appropriateness" (3/12) [ 32 , 34 , 36 ], "feasibility" (3/12) [ 29 , 32 , 36 ], "cost" (1/12) [ 35 ] and "penetration" (1/12) [ 34 ]. Regarding the other domains, "Intervention" (8/12) [ 29 , 31 , 34 , 35 , 36 , 38 , 39 , 40 ], "Strategies" (7/12) [ 29 , 30 , 33 , 35 , 36 , 37 , 40 ] and "Process" (5/12) [ 29 , 31 , 32 , 33 , 38 ] were frequently addressed in the models, while "Sustainability" (1/12) [ 34 ] was only found in one model, and "Fidelity/Adaptation" was not observed. The domains presented by the models and frameworks and evaluated in the documents are shown in Table  2 .

Limitations of the models

Only two documents mentioned limitations in the use of the model or frameworks. These two studies reported limitations in the use of CFIR: "is complex and cumbersome and requires tailoring of the key variables to the specific context", and "this framework should be supplemented with other important factors and local features to achieve a sound basis for the planning and realization of an ongoing project" [ 31 , 38 ]. Limitations in the use of other models or frameworks are not reported.

Subgroup analysis

Following the subgroup analysis (Table  3 ), five different models/frameworks were utilized at the policy level by institutional health services. These included the Guideline Implementation Evaluation Tool [ 40 ], the NHMRC tool (model name not defined) [ 36 ], the JBI Implementation Framework + GRiP [ 33 ], Guideline to identify key indicators [ 35 ], and the Guideline implementation checklist [ 37 ]. Additionally, the "Guideline Implementability Framework" [ 39 ] was implemented at the policy level without restrictions based on the type of health service. Regarding the organizational level, the models used varied depending on the type of service. The "Goal commitment and implementation of practice guidelines framework" [ 32 ] was applied in community and ambulatory health services, while "PARiHS" [ 29 , 30 ] and "CFIR" [ 31 , 38 ] were utilized in hospitals. In contexts where the type of health service was not defined, "CFIR" [ 31 , 38 ] and "The Guideline Implementability Framework" [ 39 ] were employed. Lastly, at the clinical level, "RE-AIM" [ 34 ] was utilized in ambulatory and hospital services, and PARiHS [ 29 , 30 ] was specifically used in hospital services.

Key findings

This systematic review identified 10 models/ frameworks used to assess the implementation of CPGs in various health system contexts. These documents shared similar objectives in utilizing models and frameworks for assessment. The primary level of use was policy, the most common type of health service was institutional, and the main target group of the documents was professionals directly involved in clinical practice. The models and frameworks presented varied analytical domains, with sometimes divergent concepts used in these domains. This study is innovative in its emphasis on the evaluation stage of CPG implementation and in summarizing aspects and domains aimed at the practical application of these models.

The small number of documents contrasts with studies that present an extensive range of models and frameworks available in implementation science. The findings suggest that the use of models and frameworks to evaluate the implementation of CPGs is still in its early stages. Among the selected documents, there was a predominance of cross-sectional studies and methodological guidelines, which strongly influenced how the implementation evaluation was conducted. This was primarily done through surveys/questionnaires, qualitative methods (interviews, group discussions), and non-specific measurement instruments. Regarding the subject areas evaluated, most studies focused on a general clinical area, while others explored different clinical areas. This suggests that the evaluation of CPG implementation has been carried out in various contexts.

The models were chosen independently of the categories proposed in the literature, with their usage categorized for purposes other than implementation evaluation, as is the case with CFIR and PARiHS. This practice was described by Nilsen et al. who suggested that models and frameworks from other categories can also be applied for evaluation purposes because they specify concepts and constructs that may be operationalized and measured [ 14 , 15 , 42 , 43 ].

The results highlight the increased use of models and frameworks in evaluation processes at the policy level and institutional environments, followed by the organizational level in hospital settings. This finding contradicts a review that reported the policy level as an area that was not as well studied [ 44 ]. The use of different models at the institutional level is also emphasized in the subgroup analysis. This may suggest that the greater the impact (social, financial/economic, and organizational) of implementing CPGs, the greater the interest and need to establish well-defined and robust processes. In this context, the evaluation stage stands out as crucial, and the investment of resources and efforts to structure this stage becomes even more advantageous [ 10 , 45 ]. Two studies (16,7%) evaluated the implementation of CPGs at the individual level (clinical level). These studies stand out for their potential to analyze variations in clinical practice in greater depth.

In contrast to the level of use and type of health service most strongly indicated in the documents, with systemic approaches, the target group most observed was professionals directly involved in clinical practice. This suggests an emphasis on evaluating individual behaviors. This same emphasis is observed in the analysis of the models, in which there is a predominance of evaluating the micro level of the health context and the "adoption" subdomain, in contrast with the sub-use of domains such as "cost" and "process". Cassetti et al. observed the same phenomenon in their review, in which studies evaluating the implementation of CPGs mainly adopted a behavioral change approach to tackle those issues, without considering the influence of wider social determinants of health [ 10 ]. However, the literature widely reiterates that multiple factors impact the implementation of CPGs, and different actions are required to make them effective [ 6 , 46 , 47 ]. As a result, there is enormous potential for the development and adaptation of models and frameworks aimed at more systemic evaluation processes that consider institutional and organizational aspects.

In analyzing the model domains, most models focused on evaluating only some aspects of implementation (three domains). All models evaluated the "context", highlighting its significant influence on implementation [ 9 , 26 ]. Context is an essential effect modifier for providing research evidence to guide decisions on implementation strategies [ 48 ]. Contextualizing a guideline involves integrating research or other evidence into a specific circumstance [ 49 ]. The analysis of this domain was adjusted to include all possible contextual aspects, even if they were initially allocated to other domains. Some contextual aspects presented by the models vary in comprehensiveness, such as the assessment of the "timing and nature of stakeholder engagement" [ 39 ], which includes individual engagement by healthcare professionals and organizational involvement in CPG implementation. While the importance of context is universally recognized, its conceptualization and interpretation differ across studies and models. This divergence is also evident in other domains, consistent with existing literature [ 14 ]. Efforts to address this conceptual divergence in implementation science are ongoing, but further research and development are needed in this field [ 26 ].

The main subdomain evaluated was "adoption" within the outcome domain. This may be attributed to the ease of accessing information on the adoption of the CPG, whether through computerized system records, patient records, or self-reports from healthcare professionals or patients themselves. The "acceptability" subdomain pertains to the perception among implementation stakeholders that a particular CPG is agreeable, palatable or satisfactory. On the other hand, "appropriateness" encompasses the perceived fit, relevance or compatibility of the CPG for a specific practice setting, provider, or consumer, or its perceived fit to address a particular issue or problem [ 26 ]. Both subdomains are subjective and rely on stakeholders' interpretations and perceptions of the issue being analyzed, making them susceptible to reporting biases. Moreover, obtaining this information requires direct consultation with stakeholders, which can be challenging for some evaluation processes, particularly in institutional contexts.

The evaluation of the subdomains "feasibility" (the extent to which a CPG can be successfully used or carried out within a given agency or setting), "cost" (the cost impact of an implementation effort), and "penetration" (the extent to which an intervention or treatment is integrated within a service setting and its subsystems) [ 26 ] was rarely observed in the documents. This may be related to the greater complexity of obtaining information on these aspects, as they involve cross-cutting and multifactorial issues. In other words, it would be difficult to gather this information during evaluations with health practitioners as the target group. This highlights the need for evaluation processes of CPGs implementation involving multiple stakeholders, even if the evaluation is adjusted for each of these groups.

Although the models do not establish the "intervention" domain, we thought it pertinent in this study to delimit the issues that are intrinsic to CPGs, such as methodological quality or clarity in establishing recommendations. These issues were quite common in the models evaluated but were considered in other domains (e.g., in "context"). Studies have reported the importance of evaluating these issues intrinsic to CPGs [ 47 , 50 ] and their influence on the implementation process [ 51 ].

The models explicitly present the "strategies" domain, and its evaluation was usually included in the assessments. This is likely due to the expansion of scientific and practical studies in implementation science that involve theoretical approaches to the development and application of interventions to improve the implementation of evidence-based practices. However, these interventions themselves are not guaranteed to be effective, as reported in a previous review that showed unclear results indicating that the strategies had affected successful implementation [ 52 ]. Furthermore, model domains end up not covering all the complexity surrounding the strategies and their development and implementation process. For example, the ‘Guideline implementation evaluation tool’ evaluates whether guideline developers have designed and provided auxiliary tools to promote the implementation of guidelines [ 40 ], but this does not mean that these tools would work as expected.

The "process" domain was identified in the CFIR [ 31 , 38 ], JBI/GRiP [ 33 ], and PARiHS [ 29 ] frameworks. While it may be included in other domains of analysis, its distinct separation is crucial for defining operational issues when assessing the implementation process, such as determining if and how the use of the mentioned CPG was evaluated [ 3 ]. Despite its presence in multiple models, there is still limited detail in the evaluation guidelines, which makes it difficult to operationalize the concept. Further research is needed to better define the "process" domain and its connections and boundaries with other domains.

The domain of "sustainability" was only observed in the RE-AIM framework, which is categorized as an evaluation framework [ 34 ]. In its acronym, the letter M stands for "maintenance" and corresponds to the assessment of whether the user maintains use, typically longer than 6 months. The presence of this domain highlights the need for continuous evaluation of CPGs implementation in the short, medium, and long term. Although the RE-AIM framework includes this domain, it was not used in the questionnaire developed in the study. One probable reason is that the evaluation of CPGs implementation is still conducted on a one-off basis and not as a continuous improvement process. Considering that changes in clinical practices are inherent over time, evaluating and monitoring changes throughout the duration of the CPG could be an important strategy for ensuring its implementation. This is an emerging field that requires additional investment and research.

The "Fidelity/Adaptation" domain was not observed in the models. These emerging concepts involve the extent to which a CPG is being conducted exactly as planned or whether it is undergoing adjustments and adaptations. Whether or not there is fidelity or adaptation in the implementation of CPGs does not presuppose greater or lesser effectiveness; after all, some adaptations may be necessary to implement general CPGs in specific contexts. The absence of this domain in all the models and frameworks may suggest that they are not relevant aspects for evaluating implementation or that there is a lack of knowledge of these complex concepts. This may suggest difficulty in expressing concepts in specific evaluative questions. However, further studies are warranted to determine the comprehensiveness of these concepts.

It is important to note the customization of the domains of analysis, with some domains presented in the models not being evaluated in the studies, while others were complementarily included. This can be seen in Jeong et al. [ 34 ], where the "intervention" domain in the evaluation with the RE-AIM framework reinforced the aim of theoretical approaches such as guiding the process and not determining norms. Despite this, few limitations were reported for the models, suggesting that the use of models in these studies reflects the application of these models to defined contexts without a deep critical analysis of their domains.

Limitations

This review has several limitations. First, only a few studies and methodological guidelines that explicitly present models and frameworks for assessing the implementation of CPGs have been found. This means that few alternative models could be analyzed and presented in this review. Second, this review adopted multiple analytical categories (e.g., level of use, health service, target group, and domains evaluated), whose terminology has varied enormously in the studies and documents selected, especially for the "domains evaluated" category. This difficulty in harmonizing the taxonomy used in the area has already been reported [ 26 ] and has significant potential to confuse. For this reason, studies and initiatives are needed to align understandings between concepts and, as far as possible, standardize them. Third, in some studies/documents, the information extracted was not clear about the analytical category. This required an in-depth interpretative process of the studies, which was conducted in pairs to avoid inappropriate interpretations.

Implications

This study contributes to the literature and clinical practice management by describing models and frameworks specifically used to assess the implementation of CPGs based on their level of use, type of health service, target group related to the CPG, and the evaluated domains. While there are existing reviews on the theories, frameworks, and models used in implementation science, this review addresses aspects not previously covered in the literature. This valuable information can assist stakeholders (such as politicians, clinicians, researchers, etc.) in selecting or adapting the most appropriate model to assess CPG implementation based on their health context. Furthermore, this study is expected to guide future research on developing or adapting models to assess the implementation of CPGs in various contexts.

The use of models and frameworks to evaluate the implementation remains a challenge. Studies should clearly state the level of model use, the type of health service evaluated, and the target group. The domains evaluated in these models may need adaptation to specific contexts. Nevertheless, utilizing models to assess CPGs implementation is crucial as they can guide a more thorough and systematic evaluation process, aiding in the continuous improvement of CPGs implementation. The findings of this systematic review offer valuable insights for stakeholders in selecting or adjusting models and frameworks for CPGs evaluation, supporting future theoretical advancements and research.

Availability of data and materials

Abbreviations.

Australian Department of Health and Aged Care

Canadian Agency for Drugs and Technologies in Health

Centers for Disease Control and

Consolidated Framework for Implementation Research

Cumulative Index to Nursing and Allied Health Literature

Clinical practice guideline

Centre for Reviews and Dissemination

Guidelines International Networks

Getting Research into Practice

Health Systems Evidence

Institute of Medicine

The Joanna Briggs Institute

Ministry of Health of Brazil

Ministerio de Sanidad y Política Social

National Health and Medical Research Council

National Institute for Health and Care Excellence

Promoting action on research implementation in health systems framework

Predisposing, Reinforcing and Enabling Constructs in Educational Diagnosis and Evaluation-Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

International Prospective Register of Systematic Reviews

Reach, effectiveness, adoption, implementation, and maintenance framework

Healthcare Improvement Scotland

United States of America

Virtual Health Library

World Health Organization

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This study is supported by the Fundação de Apoio à Pesquisa do Distrito Federal (FAPDF). FAPDF Award Term (TOA) nº 44/2024—FAPDF/SUCTI/COOBE (SEI/GDF – Process 00193–00000404/2024–22). The content in this article is solely the responsibility of the authors and does not necessarily represent the official views of the FAPDF.

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NFM and JOMB conceived the idea and the protocol for this study. NFM conducted the literature search. NFM, SNS, JMG and JOMB conducted the data collection with advice and consensus gathering from JOMB. The NFM and JMG assessed the quality of the studies. NFM and DFG conducted the data extraction. NFM performed the analysis and synthesis of the results with advice and consensus gathering from JOMB. NFM drafted the manuscript. JOMB critically revised the first version of the manuscript. All the authors revised and approved the submitted version.

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Supplementary Information

13012_2024_1389_moesm1_esm.docx.

Additional file 1: PRISMA checklist. Description of data: Completed PRISMA checklist used for reporting the results of this systematic review.

Additional file 2: Literature search. Description of data: The search strategies adapted for the electronic databases.

13012_2024_1389_moesm3_esm.doc.

Additional file 3: JBI’s critical appraisal tools for cross-sectional studies. Description of data: JBI’s critical appraisal tools to assess the trustworthiness, relevance, and results of the included studies. This is specific for cross-sectional studies.

13012_2024_1389_MOESM4_ESM.doc

Additional file 4: JBI’s critical appraisal tools for qualitative studies. Description of data: JBI’s critical appraisal tools to assess the trustworthiness, relevance, and results of the included studies. This is specific for qualitative studies.

13012_2024_1389_MOESM5_ESM.doc

Additional file 5: Methodological quality assessment results for cross-sectional studies. Description of data: Methodological quality assessment results for cross-sectional studies using JBI’s critical appraisal tools.

13012_2024_1389_MOESM6_ESM.doc

Additional file 6: Methodological quality assessment results for the qualitative studies. Description of data: Methodological quality assessment results for qualitative studies using JBI’s critical appraisal tools.

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Freitas de Mello, N., Nascimento Silva, S., Gomes, D.F. et al. Models and frameworks for assessing the implementation of clinical practice guidelines: a systematic review. Implementation Sci 19 , 59 (2024). https://doi.org/10.1186/s13012-024-01389-1

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Factors critical for the successful delivery of telehealth to rural populations: a descriptive qualitative study

• Rebecca Barry   ORCID: orcid.org/0000-0003-2272-4694 1 ,
• Elyce Green   ORCID: orcid.org/0000-0002-7291-6419 1 ,
• Kristy Robson   ORCID: orcid.org/0000-0002-8046-7940 1 &
• Melissa Nott   ORCID: orcid.org/0000-0001-7088-5826 1  

BMC Health Services Research volume  24 , Article number:  908 ( 2024 ) Cite this article

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The use of telehealth has proliferated to the point of being a common and accepted method of healthcare service delivery. Due to the rapidity of telehealth implementation, the evidence underpinning this approach to healthcare delivery is lagging, particularly when considering the uniqueness of some service users, such as those in rural areas. This research aimed to address the current gap in knowledge related to the factors critical for the successful delivery of telehealth to rural populations.

This research used a qualitative descriptive design to explore telehealth service provision in rural areas from the perspective of clinicians and describe factors critical to the effective delivery of telehealth in rural contexts. Semi-structured interviews were conducted with clinicians from allied health and nursing backgrounds working in child and family nursing, allied health services, and mental health services. A manifest content analysis was undertaken using the Framework approach.

Sixteen health professionals from nursing, clinical psychology, and social work were interviewed. Participants mostly identified as female (88%) and ranged in age from 26 to 65 years with a mean age of 47 years. Three overarching themes were identified: (1) Navigating the role of telehealth to support rural healthcare; (2) Preparing clinicians to engage in telehealth service delivery; and (3) Appreciating the complexities of telehealth implementation across services and environments.

Conclusions

This research suggests that successful delivery of telehealth to rural populations requires consideration of the context in which telehealth services are being delivered, particularly in rural and remote communities where there are challenges with resourcing and training to support health professionals. Rural populations, like all communities, need choice in healthcare service delivery and models to increase accessibility. Preparation and specific, intentional training for health professionals on how to transition to and maintain telehealth services is a critical factor for delivery of telehealth to rural populations. Future research should further investigate the training and supports required for telehealth service provision, including who, when and what training will equip health professionals with the appropriate skill set to deliver rural telehealth services.

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Introduction

Telehealth is a commonly utilised application in rural health settings due to its ability to augment service delivery across wide geographical areas. During the COVID-19 pandemic, the use of telehealth became prolific as it was rapidly adopted across many new fields of practice to allow for healthcare to continue despite requirements for physical distancing. In Australia, the Medicare Benefits Scheme (MBS) lists health services that are subsidised by the federal government. Telehealth items were extensively added to these services as part of the response to COVID-19 [ 1 ]. Although there are no longer requirements for physical distancing in Australia, many health providers have continued to offer services via telehealth, particularly in rural areas [ 2 , 3 ]. For the purpose of this research, telehealth was defined as a consultation with a healthcare provider by phone or video call [ 4 ]. Telehealth service provision in rural areas requires consideration of contextual factors such as access to reliable internet, community members’ means to finance this access [ 5 ], and the requirement for health professionals to function across a broad range of specialty skills. These factors present a case for considering the delivery of telehealth in rural areas as a unique approach, rather than one portion of the broader use of telehealth.

Research focused on rural telehealth has proliferated alongside the rapid implementation of this service mode. To date, there has been a focus on the impact of telehealth on areas such as client access and outcomes [ 2 ], client and health professional satisfaction with services and technology [ 6 ], direct and indirect costs to the patient (travel cost and time), healthcare service provider staffing, lower onsite healthcare resource utilisation, improved physician recruitment and retention, and improved client access to care and education [ 7 , 8 ]. In terms of service implementation, these elements are important but do not outline the broader implementation factors critical to the success of telehealth delivery in rural areas. One study by Sutarsa et al. explored the implications of telehealth as a replacement for face-to-face services from the perspectives of general practitioners and clients [ 9 ] and articulated that telehealth services are not a like-for-like service compared to face-to-face modes. Research has also highlighted the importance of understanding the experience of telehealth in rural Australia across different population groups, including Aboriginal and Torres Strait Islander peoples, and the need to consider culturally appropriate services [ 10 , 11 , 12 , 13 ].

Research is now required to determine what the critical implementation factors are for telehealth delivery in rural areas. This type of research would move towards answering calls for interdisciplinary, qualitative, place-based research [ 12 ] that explores factors required for the sustainability and usability of telehealth in rural areas. It would also contribute to the currently limited understanding of implementation factors required for telehealth delivery to rural populations [ 14 ]. There is a reasonable expectation that there is consistency in the way health services are delivered, particularly across geographical locations. Due to the rapid implementation of telehealth services, there was limited opportunity to proactively identify factors critical for successful telehealth delivery in rural areas and this has created a lag in policy, process, and training. This research aimed to address this gap in the literature by exploring and describing rural health professionals’ experiences providing telehealth services. For the purpose of this research, rural is inclusive of locations classified as rural or remote (MM3-6) using the Modified Monash Model which considers remoteness and population size in its categorisation [ 15 ].

This research study adopted a qualitative descriptive design as described by Sandelowski [ 16 ]. The purpose of a descriptive study is to document and describe a phenomenon of interest [ 17 ] and this method is useful when researchers seek to understand who was involved, what occurred, and the location of the phenomena of interest [ 18 ]. The phenomenon of interest for this research was the provision of telehealth services to rural communities by health professionals. In line with this, a purposive sampling technique was used to identify participants who have experience of this phenomenon [ 19 ]. This research is reported in line with the consolidated criteria for reporting qualitative research [ 20 ] to enhance transparency and trustworthiness of the research process and results [ 21 ].

Research aims

This research aimed to:

Explore telehealth service provision in rural areas from the perspective of clinicians.

Describe factors critical to the successful delivery of telehealth in rural contexts.

Participant recruitment and data collection

People eligible to participate in the research were allied health (using the definition provided by Allied Health Professions Australia [ 22 ]) or nursing staff who delivered telehealth services to people living in the geographical area covered by two rural local health districts in New South Wales, Australia (encompassing rural areas MM3-6). Health organisations providing telehealth service delivery in the southwestern and central western regions of New South Wales were identified through the research teams’ networks and invited to be part of the research.

Telehealth adoption in these organisations was intentionally variable to capture different experiences and ranged from newly established (prompted by COVID-19) to well established (> 10 years of telehealth use). Organisations included government, non-government, and not-for-profit health service providers offering child and family nursing, allied health services, and mental health services. Child and family nursing services were delivered by a government health service and a not-for-profit specialist service, providing health professional advice, education, and guidance to families with a baby or toddler. Child and family nurses were in the same geographical region as the families receiving telehealth. Transition to telehealth services was prompted by the COVID-19 pandemic. The participating allied health service was a large, non-government provider of allied health services to regional New South Wales. Allied health professionals were in the same region as the client receiving telehealth services. Use of telehealth in this organisation had commenced prior to the COVID-19 pandemic. Telehealth mental health services were delivered by an emergency mental health team, located at a large regional hospital to clients in another healthcare facility or location to which the health professional could not be physically present (typically a lower acuity health service in a rural location).

Once organisations agreed to disseminate the research invitation, a key contact person employed at each health organisation invited staff to participate via email. Staff were provided with contact details of the research team in the email invitation. All recruitment and consent processes were managed by the research team to minimise risk of real or perceived coercion between staff and the key contact person, who was often in a supervisory or managerial position within the organisation. Data were collected using semi-structured interviews using an online platform with only the interviewer and participant present. Interviews were conducted by a research team member with training in qualitative data collection during November and December 2021 and were transcribed verbatim by a professional transcribing service. All participants were offered the opportunity to review their transcript and provide feedback, however none opted to do so. Data saturation was not used as guidance for participant numbers, taking the view of Braun and Clarke [ 23 ] that meaning is generated through the analysis rather than reaching a point of saturation.

Data analysis

Researchers undertook a manifest content analysis of the data using the Framework approach developed by Ritchie and Spencer [ 24 ]. All four co-authors were involved in the data analysis process. Framework uses five stages for analysis including (1) familiarisation (2) identifying a thematic framework based on emergent overarching themes, (3) application of the coding framework to the interview transcripts [indexing], (4) reviewing and charting of themes and subthemes, and (5) mapping and interpretation [ 24 , p. 178]. The research team analysed a common interview initially, identified codes and themes, then independently applied these to the remaining interviews. Themes were centrally recorded, reviewed, and discussed by the research team prior to inclusion into the thematic framework. Final themes were confirmed via collaborative discussion and consensus. The iterative process used to review and code data was recorded into an Excel spreadsheet to ensure auditability and credibility, and to enhance the trustworthiness of the analysis process.

This study was approved by the Greater Western NSW Human Research Ethics Committee and Charles Sturt University Human Research Ethics Committee (approval numbers: 2021/ETH00088 and H21215). All participants provided written consent.

Eighteen health professionals consented to be interviewed. Two were lost to follow-up, therefore semi-structured interviews were conducted with 16 of these health professionals, the majority of which were from the discipline of nursing ( n  = 13, 81.3%). Participant demographics and their pseudonyms are shown in Table  1 .

Participants mostly identified as female ( n  = 14, 88%) and ranged in age from 26 to 65 years with a mean age of 47 years. Participants all delivered services to rural communities in the identified local health districts and resided within the geographical area they serviced. The participants resided in areas classified as MM3-6 but were most likely to reside in an area classified MM3 (81%). Average interview time was 38 min, and all interviews were conducted online via Zoom.

Three overarching themes were identified through the analysis of interview transcripts with health professionals. These themes were: (1) Navigating the role of telehealth to support rural healthcare; (2) Preparing clinicians to engage in telehealth service delivery; and (3) Appreciating the complexities of telehealth implementation across services and environments.

Theme 1: navigating the role of telehealth to support rural healthcare

The first theme described clinicians’ experiences of using telehealth to deliver healthcare to rural communities, including perceived benefits and challenges to acceptance, choice, and access. Interview participants identified several factors that impacted on or influenced the way they could deliver telehealth, and these were common across the different organisational structures. Clinicians highlighted the need to consider how to effectively navigate the role of telehealth in supporting their practice, including when it would enhance their practice, and when it might create barriers. The ability to improve rural service provision through greater access was commonly discussed by participants. In terms of factors important for telehealth delivery in rural contexts, the participants demonstrated that knowledge of why and how telehealth was used were important, including the broadened opportunity for healthcare access and an understanding of the benefits and challenges of providing these services.

Access to timely and specialist healthcare for rural communities

Participants described a range of benefits using telehealth to contact small, rural locations and facilitate greater access to services closer to home. This was particularly evident when there was lack of specialist support in these areas. These opportunities meant that rural people could receive timely care that they required, without the burden of travelling significant distances to access health services.

The obvious thing in an area like this, is that years ago, people were being transported three hours just to see us face to face. It’s obviously giving better, more timely access to services. (Patrick)

Staff access to specialist support was seen as an important aspect for rural healthcare by participants, because of the challenges associated with lack of staffing and resources within these areas which potentially increased the risks for staff in these locations, particularly when managing clients with acute mental illnesses.

Within the metro areas they’ve got so many staff and so many hospitals and they can manage mental health patients quite well within those facilities, but with us some of these hospitals will have one RN on overnight and it’s just crappy for them, and so having us able to do video link, it kind of takes the pressure off and we’re happy to make the decisions and the risky decisions for what that person needs. (Tracey)

Participants described how the option to use telehealth to provide specialised knowledge and expertise to support local health staff in rural hospitals likely led to more appropriate outcomes for clients wanting to be able to remain in their community. Conversely, Amber described the implications if telehealth was not available.

If there was some reason why the telehealth wasn’t available… quite often, I suppose the general process be down to putting the pressure on the nursing and the medical staff there to make a decision around that person, which is not a fair or appropriate thing for them to do. (Amber)

Benefits and challenges to providing telehealth in rural communities

Complementing the advantage of reduced travel time to access services, was the ability for clients to access additional support via telehealth, which was perceived as a benefit. For example, one participant described how telehealth was useful for troubleshooting client’s problems rather than waiting for their next scheduled appointment.

If a mum rings you with an issue, you can always say to them “are you happy to jump onto My Virtual Care with me now?” We can do that, do a consult over My Virtual Care. Then I can actually gauge how mum is. (Jade)

While accessibility was a benefit, participants highlighted that rural communities need to be provided with choice, rather than the assumption that telehealth be the preferred option for everyone, as many rural clients want face-to-face services.

They’d all prefer, I think, to be able to see someone in person. I think that’s generally what NSW rural [want] —’cause I’m from country towns as well—there’s no substitute, like I said, for face-to-face assessment. (Adam)

Other, more practical limitations of broad adoption of telehealth raised by the participants included issues with managing technology and variability in internet connectivity.

For many people in the rural areas, it’s still an issue having that regular [internet] connection that works all the time. I think it’s a great option but I still think it’s something that some rural people will always have some challenges with because it’s not—there’s so many black spots and so many issues still with the internet connection in rural areas. Even in town, there’s certain areas that are still having lots of problems. (Chloe)

Participants also identified barriers related to assumptions that all clients will have access to technology and have the necessary data to undertake a telehealth consultation, which wasn’t always the case, particularly with individuals experiencing socioeconomic disadvantage.

A lot of [Aboriginal] families don’t actually have access to telehealth services. Unless they use their phone. If they have the technology on their phones. I found that was a little bit of an issue to try and help those particular clients to get access to the internet, to have enough data on their phone to make that call. There was a lot of issues and a lot of things that we were putting in complaints about as they were going “we’re using up a lot of these peoples’ data and they don’t have internet in their home.” (Evelyn).

Other challenges identified by the participants were related to use of telehealth for clients that required additional support. Many participants talked about the complexities of using an interpreter during a telehealth consultation for culturally and linguistically diverse clients.

Having interpreters, that’s another element that’s really, really difficult because you’re doing video link, but then you’ve also got the phone on speaker and you’re having this three-way conversation. Even that, in itself, that added element on video link is really, really tough. It’s a really long process. (Tracey)

In summary, this theme described some of the benefits and constraints when using telehealth for the delivery of rural health services. The participants demonstrated the importance of understanding the needs and contexts of individual clients, and accounting for this when making decisions to incorporate telehealth into their service provision. Understanding how and why telehealth can be implemented in rural contexts was an important foundation for the delivery of these services.

Theme 2: preparing clinicians to engage in telehealth service delivery

The preparation required for clinicians to engage with telehealth service delivery was highlighted and the participants described the unique set of skills required to effectively build rapport, engage, and carry out assessments with clients. For many participants who had not routinely used telehealth prior to the COVID-19 pandemic, the transition to using telehealth had been rapid. The participants reflected on the implications of rapidly adopting these new practices and the skills they required to effectively deliver care using telehealth. These skills were critical for effective delivery of telehealth to rural communities.

Rapid adoption of new skills and ways of working

The rapid and often unsupported implementation of telehealth in response to the COVID-19 pandemic resulted in clinicians needing to learn and adapt to telehealth, often without being taught or with minimal instruction.

We had to do virtual, virtually overnight we were changed to, “Here you go. Do it this way,” without any real education. It was learned as we went because everybody was in the same boat. Everyone was scrabbling to try and work out how to do it. (Chloe)

In addition to telehealth services starting quickly, telehealth provision requires clinicians to use a unique set of skills. Therapeutic interventions and approaches were identified as being more challenging when seeing a client through a screen, compared to being physically present together in a room.

The body language is hidden a little bit when you’re on teleconference, whereas when you’re standing up face to face with someone, or standing side by side, the person can see the whole picture. When you’re on the video link, the patient actually can’t—you both can’t see each other wholly. That’s one big barrier. (Adam)

There was an emphasis on communication skills such as active listening and body language that were required when engaging with telehealth. These skills were seen as integral to building rapport and connection. The importance of language in an environment with limited visualisation of body language, is further demonstrated by one participant describing how they tuned into the timing and flow of the conversation to avoid interrupting and how these skills were pertinent for using telehealth.

In the beginning especially, we might do this thing where I think they’ve finished or there’s a bit of silence, so I go to speak and then they go to speak at the same time, and that’s different because normally in person you can really gauge that quite well if they’ve got more to say. I think those little things mean that you’ve got to work a bit harder and you’ve got to bring those things to the attention of the client often. (Robyn)

Preparing clinicians to engage in telehealth also required skills in sharing clear and consistent information with clients about the process of interacting via telehealth. This included information to reassure the client that the telehealth appointment was private as well as prepare them for potential interruptions due to connection issues.

I think being really explicitly clear about the fact that with our setups we have here, no one can dial in, no one else is in my room even watching you. We’re not recording, and there’s a lot of extra information, I think around that we could be doing better in terms of delivering to the person. (Amber)

Becoming accustomed to working through the ‘window’

Telehealth was often described as a window and not a view of the whole person which presented limitations for clinicians, such as seeing nuance of expression. Participants described the difficulties of assessing a client using telehealth when you cannot see the whole picture such as facial expressions, movement, behaviour, interactions with others, dress, and hygiene.

I found it was quite difficult because you couldn’t always see the actual child or the baby, especially if they just had their phone. You couldn’t pick up the body language. You couldn’t always see the facial expressions. You couldn’t see the child and how the child was responding. It did inhibit a lot of that side of our assessing. Quite often you’d have to just write, “Unable to view child.” You might be able to hear them but you couldn’t see them. (Chloe)

Due to the window view, the participants described how they needed to pay even greater attention to eye contact and tone of voice when engaging with clients via telehealth.

I think the eye contact is still a really important thing. Getting the flow of what they’re comfortable with a little bit too. It’s being really careful around the tone of voice as well too, because—again, that’s the same for face-to-face, but be particularly careful of it over telehealth. (Amber)

This theme demonstrates that there are unique and nuanced skills required by clinicians to effectively engage in provision of rural healthcare services via telehealth. Many clinicians described how the rapid uptake of telehealth required them to quickly adapt to providing telehealth services, and they had to modify their approach rather than replicate what they would do in face-to-face contexts. Appreciating the different skills sets required for telehealth practice was perceived as an important element in supporting clinicians to deliver quality healthcare.

Theme 3: appreciating the complexities of telehealth implementation across services and environments

It was commonly acknowledged that there needed to be an appreciation by clinicians of the multiple different environments that telehealth was being delivered in, as well as the types of consultations being undertaken. This was particularly important when well-resourced large regional settings were engaging with small rural services or when clinicians were undertaking consultations within a client’s home.

Working from a different location and context

One of the factors identified as important for the successful delivery of services via telehealth was an understanding of the location and context that was being linked into. Participants regularly talked about the challenges when undertaking a telehealth consultation with clients at home, which impacted the quality of the consultation as it was easy to “ lose focus” (Kelsey) and become distracted.

Instead of just coming in with one child, they had all the kids, all wanting their attention. I also found that babies and kids kept pressing the screen and would actually disconnect us regularly. (Chloe)

For participants located in larger regional locations delivering telehealth services to smaller rural hospitals, it was acknowledged that not all services had equivalent resources, skills, and experience with this type of healthcare approach.

They shouldn’t have to do—they’ve gotta double-click here, login there. They’re relying on speakers that don’t work. Sometimes they can’t get the cameras working. I think telehealth works as long as it’s really user friendly. I think nurses—as a nurse, we’re not supposed to be—I know IT’s in our job criteria, but not to the level where you’ve got to have a degree in technology to use it. (Adam)

Participants also recognised that supporting a client through a telehealth consultation adds workload stress as rural clinicians are often having pressures with caseloads and are juggling multiple other tasks while trying to trouble shoot technology issues associated with a telehealth consultation.

Most people are like me, not great with computers. Sometimes the nurse has got other things in the Emergency Department she’s trying to juggle. (Eleanor)

Considerations for safety, privacy, and confidentiality

Participants talked about the challenges that arose due to inconsistencies in where and how the telehealth consultation would be conducted. Concerns about online safety and information privacy were identified by participants.

There’s the privacy issue, particularly when we might see someone and they might be in a bed and they’ve got a laptop there, and they’re not given headphones, and we’re blaring through the speaker at them, and someone’s three meters away in another bed. That’s not good. That’s a bit of a problem. (Patrick)

When telehealth was offered as an option to clients at a remote healthcare site, clinicians noted that some clients were not provided with adequate support and were left to undertake the consultation by themselves which could cause safety risks for the client and an inability for the telehealth clinician to control the situation.

There were some issues with patients’ safety though. Where the telehealth was located was just in a standard consult room and there was actually a situation where somebody self-harmed with a needle that was in a used syringe box in that room. Then it was like, you just can’t see high risk—environment. (Eleanor)

Additionally, participants noted that they were often using their own office space to conduct telehealth consultations rather than a clinical room which meant there were other considerations to think about.

Now I always lock my room so nobody can enter. That’s a nice little lesson learnt. I had a consult with a mum and some other clinicians came into my room and I thought “oh my goodness. I forgot to lock.” I’m very mindful now that I lock. (Jade)

This theme highlights the complexities that exist when implementing telehealth across a range of rural healthcare settings and environments. It was noted by participants that there were variable skills and experience in using telehealth across staff located in smaller rural areas, which could impact on how effective the consultation was. Participants identified the importance of purposely considering the environment in which the telehealth consultation was being held, ensuring that privacy, safety, and distractibility concerns have been adequately addressed before the consultation begins. These factors were considered important for the successful implementation of telehealth in rural areas.

This study explored telehealth service delivery in various rural health contexts, with 16 allied health and nursing clinicians who had provided telehealth services to people living in rural communities prior to, and during the COVID-19 pandemic. Reflections gained from clinicians were analysed and reported thematically. Major themes identified were clinicians navigating the role of telehealth to support rural healthcare, the need to prepare clinicians to engage in telehealth service delivery and appreciating the complexities of telehealth implementation across services and environments.

The utilisation of telehealth for health service delivery has been promoted as a solution to resolve access and equity issues, particularly for rural communities who are often impacted by limited health services due to distance and isolation [ 6 ]. This study identified a range of perceived benefits for both clients and clinicians, such as improved access to services across large geographic distances, including specialist care, and reduced travel time to engage with a range of health services. These findings are largely supported by the broader literature, such as the systematic review undertaken by Tsou et al. [ 25 ] which found that telehealth can improve clinical outcomes and increase the timeliness to access services, including specialist knowledge. Clinicians in our study also noted the benefits of using telehealth for ad hoc clinical support outside of regular appointment times, which to date has not been commonly reported in the literature as a benefit. Further investigation into this aspect may be warranted.

The findings from this study identify a range of challenges that exist when delivering health services within a virtual context. It was common for participants to highlight that personal preference for face-to-face sessions could not always be accommodated when implementing telehealth services in rural areas. The perceived technological possibilities to improve access can have unintended consequences for community members which may contribute to lack of responsiveness to community needs [ 12 ]. It is therefore important to understand the client and their preferences for using telehealth rather than making assumptions on the appropriateness of this type of health service delivery [ 26 ]. As such, telehealth is likely to function best when there is a pre-established relationship between the client and clinician, with clients who have a good knowledge of their personal health and have access to and familiarity with digital technology [ 13 ]. Alternatively, it is appropriate to consider how telehealth can be a supplementary tool rather than a stand-alone service model replacing face-to-face interactions [ 13 ].

As identified in this study, managing technology and internet connectivity are commonly reported issues for rural communities engaging in telehealth services [ 27 , 28 ]. Additionally, it was highlighted that within some rural communities with higher socioeconomic disadvantage, limited access to an appropriate level of technology and the required data to undertake a telehealth consult was a deterrent to engage in these types of services. Mathew et al. [ 13 ] found in their study that bandwidth impacted video consultations, which was further compromised by weather conditions, and clients without smartphones had difficulty accessing relevant virtual consultation software.

The findings presented here indicate that while telehealth can be a useful model, it may not be suitable for all clients or client groups. For example, the use of interpreters in telehealth to support clients was a key challenge identified in this study. This is supported by Mathew et al. [ 13 ] who identified that language barriers affected the quality of telehealth consultations and accessing appropriate interpreters was often difficult. Consideration of health and digital literacy, access and availability of technology and internet, appropriate client selection, and facilitating client choice are all important drivers to enhance telehealth experiences [ 29 ]. Nelson et al. [ 6 ] acknowledged the barriers that exist with telehealth, suggesting that ‘it is not the groups that have difficulty engaging, it is that telehealth and digital services are hard to engage with’ (p. 8). There is a need for telehealth services to be delivered in a way that is inclusive of different groups, and this becomes more pertinent in rural areas where resources are not the same as metropolitan areas.

The findings of this research highlight the unique set of skills required for health professionals to translate their practice across a virtual medium. The participants described these modifications in relation to communication skills, the ability to build rapport, conduct healthcare assessments, and provide treatment while looking at a ‘window view’ of a person. Several other studies have reported similar skillsets that are required to effectively use telehealth. Uscher-Pines et al. [ 30 ] conducted research on the experiences of psychiatrists moving to telemedicine during the COVID-19 pandemic and noted challenges affecting the quality of provider-patient interactions and difficulty conducting assessment through the window of a screen. Henry et al. [ 31 ] documented a list of interpersonal skills considered essential for the use of telehealth encompassing attributes related to set-up, verbal and non-verbal communication, relationship building, and environmental considerations.

Despite the literature uniformly agreeing that telehealth requires a unique skill set there is no agreement on how, when and for whom education related to these skills should be provided. The skills required for health professionals to use telehealth have been treated as an add-on to health practice rather than as a specialty skill set requiring learning and assessment. This is reflected in research such as that by Nelson et al. [ 6 ] who found that 58% of mental health professionals using telehealth in rural areas were not trained to use it. This gap between training and practice is likely to have arisen from the rapid and widespread implementation of telehealth during the COVID-19 pandemic (i.e. the change in MBS item numbers [ 1 ]) but has not been addressed in subsequent years. For practice to remain in step with policy and funding changes, the factors required for successful implementation of telehealth in rural practice must be addressed.

The lack of clarity around who must undertake training in telehealth and how regularly, presents a challenge for rural health professionals whose skill set has been described as a specialist-generalist that covers a significant breadth of knowledge [ 32 ]. Maintaining knowledge currency across this breadth is integral and requires significant resources (time, travel, money) in an environment where access to education can be limited [ 33 ]. There is risk associated with continually adding skills on to the workload of rural health professionals without adequate guidance and provision for time to develop and maintain these skills.

While the education required to equip rural health professionals with the skills needed to effectively use telehealth in their practice is developing, until education requirements are uniformly understood and made accessible this is likely to continue to pose risk for rural health professionals and the community members accessing their services. Major investment in the education of all health professionals in telehealth service delivery, no matter the context, has been identified as critical [ 6 ].

This research highlights that the experience of using telehealth in rural communities is unique and thus a ‘one size fits all’ approach is not helpful and can overlook the individual needs of a community. Participants described experiences of using telehealth that were different between rural communities, particularly for smaller, more remote rural locations where resources and staff support and experience using telehealth were not always equivalent to larger rural locations. Research has indicated the need to invest in resourcing and education to support expansion of telehealth, noting this is particularly important in rural, regional, and remote areas [ 34 ]. Our study recognises that this is an ongoing need as rural communities continue to have diverse experiences of using telehealth services. Careful consideration of the context of individual rural health services, including the community needs, location, and resource availability on both ends of the consultation is required. Use of telehealth cannot have the same outcomes in every area. It is imperative that service providers and clinicians delivering telehealth from metropolitan areas to rural communities appreciate and understand the uniqueness of every community, so their approach is tailored and is helpful rather than hindering the experience for people in rural communities.

Limitations

There are a number of limitations inherent to the design of this study. Participants were recruited via their workplace and thus although steps were taken to ensure they understood the research would not affect their employment, it is possible some employees perceived an association between the research and their employment. Health professionals who had either very positive or very negative experiences with telehealth may have been more likely to participate, as they may be more likely to want to discuss their experiences. In addition to this, only health services that were already connected with the researchers’ networks were invited to participate. Other limitations include purposive sampling, noting that the opinions of the participants are not generalisable. The participant group also represented mostly nursing professionals whose experiences with telehealth may differ from other health disciplines. Finally, it is important to acknowledge that the opinions of the health professionals who participated in the study, may not represent, or align with the experience and opinions of service users.

This study illustrates that while telehealth has provided increased access to services for many rural communities, others have experienced barriers related to variability in connectivity and managing technology. The results demonstrated that telehealth may not be the preferred or appropriate option for some individuals in rural communities and it is important to provide choice. Consideration of the context in which telehealth services are being delivered, particularly in rural and remote communities where there are challenges with resourcing and training to support health professionals, is critical to the success of telehealth service provision. Another critical factor is preparation and specific, intentional training for health professionals on how to transition to manage and maintain telehealth services effectively. Telehealth interventions require a unique skill set and guidance pertaining to who, when and what training will equip health professionals with the appropriate skill set to deliver telehealth services is still to be determined.

Data availability

The qualitative data collected for this study was de-identified before analysis. Consent was not obtained to use or publish individual level identified data from the participants and hence cannot be shared publicly. The de-identified data can be obtained from the corresponding author on reasonable request.

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Acknowledgements

The authors would like to acknowledge Georgina Luscombe, Julian Grant, Claire Seaman, Jennifer Cox, Sarah Redshaw and Jennifer Schwarz who contributed to various elements of the project.

The study authors are employed by Three Rivers Department of Rural Health. Three Rivers Department of Rural Health is funded by the Australian Government under the Rural Health Multidisciplinary Training (RHMT) Program.

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RB & EG contributed to the conceptualisation of the study and methodological design. RB & MN collected the research data. RB, EG, MN, KR contributed to analysis and interpretation of the research data. RB, EG, MN, KR drafted the manuscript. All authors provided feedback on the manuscript and approved the final submitted manuscript.

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Barry, R., Green, E., Robson, K. et al. Factors critical for the successful delivery of telehealth to rural populations: a descriptive qualitative study. BMC Health Serv Res 24 , 908 (2024). https://doi.org/10.1186/s12913-024-11233-3

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Critical threshold mining of landslide deformation and intelligent early-warning methods based on multi-factor fusion

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• Volume 83 , article number  352 , ( 2024 )

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• Dunlong Liu   ORCID: orcid.org/0000-0001-6256-5777 1 , 2 ,
• Dan Tang 1 , 2 ,
• Juan Ma 3 , 4 ,
• Shaojie Zhang 5 ,
• Hongjuan Yang 5 &
• Xuejia Sang 1 , 2  

Deformation and development of landslides are highly complex processes and relying solely on a single monitoring factor is insufficient to accurately assess the entire evolutionary trend of landslide deformation. Typically, multiple sensors should be deployed on a landslide mass to obtain multidimensional monitoring data and comprehensively analyze the landslide development process. Monitoring data obtained through multiple sensors exhibit certain randomness and redundancy. Effective processing of these data is the key to landslide warning systems. However, the deployment of various sensors on landslide masses incurs significant costs, which usually limits their application to key landslide-prone points rather than enabling landslide warning systems over large areas. To construct a low-cost and widely applicable landslide warning model, this study installed two types of conventional monitoring devices on a landslide mass (displacement meters and rain gauges). First, the Saito method was applied to identify the macroscopic deformation stages of the landslide and to calculate the daily average deformation rates at each stage. Subsequently, a five-level warning pattern based on deformation rates was established and the critical thresholds for each warning level was determined. Finally, using daily displacement and rainfall as well as bedrock hardness and slope as the factors, a feature vector set was constructed by associating the warning levels corresponding to the daily average deformation rates at each stage. An integrated machine learning network was employed to develop an intelligent landslide warning model, which enables the intelligent identification of landslide deformation stages and assists in decision-making for landslide warning over large areas.

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Relevant data supporting the findings of this study are detailed in the manuscript or included in the supplementary files. Additional data used in this analysis are available from the corresponding author upon reasonable request.

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Acknowledgements

This work was supported by National Natural Science Foundation of China (No. 42302336); Project of the Department of Science and Technology of Sichuan Province (No. 2024YFHZ0098; No. 2023NSFSC0751); Geological survey project (No. DD20211364); and Open Project of Chengdu University of Information Technology (KYQN202317; 760115027).

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College of Software Engineering, Chengdu University of Information and Technology, Chengdu, 610225, China

Dunlong Liu, Dan Tang & Xuejia Sang

Software Engineering Technology Research Support Center of Informatization Application of Sichuan, Chengdu, 610225, China

China Geological Environment Monitoring Institute, Beijing, 100081, China

China University of Geosciences, Beijing, 100083, China

Key Laboratory of Mountain Hazards and Earth Surface Process, Institute of Mountain Hazards and Environment, Chinese Academy of Sciences, Chengdu, 610041, China

Shaojie Zhang & Hongjuan Yang

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Liu, D., Tang, D., Ma, J. et al. Critical threshold mining of landslide deformation and intelligent early-warning methods based on multi-factor fusion. Bull Eng Geol Environ 83 , 352 (2024). https://doi.org/10.1007/s10064-024-03841-4

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Received : 27 October 2023

Accepted : 24 July 2024

Published : 10 August 2024

DOI : https://doi.org/10.1007/s10064-024-03841-4

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