critical reflection on educational theory

Critical Reflection

Critical reflection is a “meaning-making process” that helps us set goals, use what we’ve learned in the past to inform future action and consider the real-life implications of our thinking. It is the link between thinking and doing, and at its best, it can be transformative (Dewey, 1916/1944; Schön, 1983; Rodgers, 2002). Without reflection, experience alone might cause us to “reinforce stereotypes…, offer simplistic solutions to complex problems and generalize inaccurately based on limited data” (Ash & Clayton, 2009, p.26). Engaging in critical reflection, however, helps us articulate questions, confront bias, examine causality, contrast theory with practice and identify systemic issues all of which helps foster critical evaluation and knowledge transfer (Ash & Clayton, 2009, p. 27).  While critical reflection may come more easily for some students than others, it is a skill that can be learned through practice and feedback (Dewey, 1933, Rodgers, 2002).  

Guidelines for Integrating Reflections into Your Course

Incorporating the following characteristics into the design of your reflective activities can help make the reflective process as effective as possible.  

Create Curiosity.  When students learn new concepts or subject matter, they often experience a sense of uncertainty and disequilibrium until they can make sense of the new information. Critical reflection is necessary to assimilate the new information and resolve the state of disequilibrium. It takes time to do well; sparking students’ curiosity can motivate them to engage in the reflective process(Dewey, 1933; Rodgers, 2002). Providing appropriate question prompts, activities, problems and tasks can help spark the necessary curiosity. See CTE's online resource: Reflection Framework and Prompts .

Make it Continual.  Build in “periodic, structured opportunities to reflect and integrate learning” (Kuh, O’Donnell & Reed, 2013). Because critical reflection is a defined way of thinking, students have to have numerous opportunities throughout the course and the program to practice and receive feedback.

Connect It.  Activities to promote reflection can range from writing/rewriting exercises, problem solving activities, discussions, role playing/simulations, and group work to name a few. To be effective, though, be sure to explicitly connect the reflective activities to course/program learning outcomes, specific assignments, course concepts or experiences .  For an example of role playing/simulations, please see CTE's resource, an interview (YouTube) with Dr. Veronica Kitchen about Using Simulations in the Classroom .

Give it Context.  Design reflective activities to support integration of learning across courses and to engage students with “big questions” related to community/public issues that matter beyond the classroom. Ideally, reflective activities should ask students to consider messy, ill-defined problems that do not have a ‘right’ answer (Moon, 1999).  This helps move them towards higher order thinking and higher levels of reflection. 

Consider your Class Size.  Assessing and providing feedback to reflections require time and resources. For smaller classes, it might be manageable to assess individual reflections through journals, logs, and blogs. For larger classes, consider facilitating whole class discussions and opportunities for peer feedback. Dividing a large class into smaller groups for discussions and small group brainstorming sessions can provide the practice and feedback students need without all the feedback having to come from you, the instructor. Having students share reflections through ePortfolios is yet another way for students to receive feedback from peers. See CTE's online resource about ePortfolios .

Model the Reflective Process.  During class discussions, model the reflective process by asking the kinds of questions that members of your discipline ask. Explicitly point out how you support a claim with evidence. As you go through the process, explain how you are modeling the critical reflection process. Providing students with a rubric may help them practice the process themselves.  

Breakdown the Assignment.  When you provide students with details for a particular assignment, lead a discussion asking them as a group to outline a process for tackling the assignment. Have each student then create a personal plan for addressing the areas which might cause them more difficulty.  Ask students to hand in different pieces of the assignment throughout the term, providing feedback to the various components. Over time, less guidance and feedback will be required to help students with the reflective thinking process. 

Encourage Multiple Perspectives.  Being exposed to different perspectives (through discussions with classmates, or through resources such readings, websites, case studies, simulations that represent different points of view), and being able to participate in a dialogue with others (peers, instructors) about matters of importance is critical to the reflective thinking process. Having students work on collaborative projects can facilitate this; they learn to listen to others and consider different approaches to solving problems.

Provide a Safe Environment  where students can explore and articulate emotional responses. Students might not mind sharing their knowledge and understanding about content with their classmates but may be less inclined to share emotional responses with others. In these cases, consider splitting up the task so that the descriptive, non-personal component is done in class and the articulation of learning part is handed in individually to a TA or instructor.    

Assess It.  Making reflections part of a course grade encourages students to engage in the reflective process, helps them track their growth and development over time, and signals to them that critical reflection is a worthwhile and valued activity. Provide students with ‘frequent, timely and constructive feedback’ to the reflective activities.

Provide Clear Marking Criteria and Exemplars.  Clearly state the criteria for success and show students an example of a good reflection. Explain why the example is a good one (e.g., show how the reflection provides concrete examples to support the observations, and ties the observations back to the course content/learning outcome). Provide students with opportunities to self-assess or provide peer-feedback using the rubric that you will use to assess their reflections. 

Assignment and Rubric Examples:

See the links below for examples of critical reflection assignments that have been shared with CTE. Some of the instructors have also included their assessment rubrics along with the assignment instructions. 

• Reflecting on Professional Skill Development
• Becoming Reflexive Practitioners
• ePortfolio: Inspired Insights, Magnificent Failures, and Unanticipated Connections
• AAC&U Integrative Learning VALUE rubric
• Higher Levels of Reflection Rubric

Choose Prompts that Suit Your Goals    

Use language that suits your course and discipline.  The term ‘reflection’ has come to mean different things to different people (Rodgers, 2002). Use a term that makes sense to your discipline. Science students might roll their eyes if asked to reflect on personal development in a chemistry course. Is there a term that your discipline uses instead of the term reflection (design notes, lab notes, documentation of bugs)? 

Choose the type of reflection that suits your goals.  Reflective activities can be of two types: one type helps students focus on their growth and development, and on their personal learning process and another type fosters students’ capacity to think deeply about content and concepts. Be sure to choose reflective prompts that align with your course goals.  

• Process Reflection.  This type of reflection promptsstudents to think about their progress and the strategies they are using while they are working on a project or assignment (e.g., where are you with your project? What challenges are you having? What are you planning to do about those challenges? What problems did you encounter in completing the assignment? How did you troubleshoot them? What still needs work?) This can be done individually or, in large classes, consider using small group discussions.
• Inward-Looking Reflection.  When reflecting inward, students focus on their personal strengths, gaps, resources, standards, values, response to challenges, strategies, etc. 
• Outward-Looking Reflection.  By observing others, students can build their awareness of alternative perspectives and ways of doing things. When contrasts are noted, students can give examples to support their observations.
• Forward-Looking Reflection.  At the beginning of a course, project, or assignment, prompt students to think about which components look familiar and which look more challenging and difficult, and why. Towards the end of the course, hand these lists back to the students and have them discuss whether they have met their goals. As a class, have the students list which of the goals they believe they achieved, and which they did not. Alternatively, have students write a letter to the students who take the course next, giving advice and encouragement.
• Backward-Looking Reflection . At the end of a project, work term or volunteer experience a backward-looking reflection is a good way for students to take stock of their experience.

Examples of Reflection Models and Reflection Questions:

• Sample Reflection Questions
• Eight Reflection Models
• Reflections to Foster Deep Thinking & Connection Making

If you would like support applying these tips to your own teaching, CTE staff members are here to help.  View the  CTE Support  page to find the most relevant staff member to contact. 

• AAC&U Integrative Learning VALUE rubrics retrieved from  https://www.aacu.org/value-rubrics
• Habits of Mind: The Questions Intelligent Thinkers Ask that Help Them Solve Problems and Make Decisions retrieved from  https://www.edutopia.org/pdfs/stw/edutopia-stw-assessment-high-sch-humanities-habits-of-mind.pdf
• Sample reflection questions retrieved from  https://www.edutopia.org/pdfs/stw/edutopia-stw-replicatingPBL-21stCAcad-reflection-questions.pdf
• Teaching Metacognitive Skills CTE tipsheet retrieved from  https://uwaterloo.ca/centre-for-teaching-excellence/teaching-resources/teaching-tips/metacognitive
• Ash, S.L., & Clayton, P. H. (2009). Generating, deepening, and documenting learning: The power of critical reflection in applied learning. Journal of Applied Learning in Higher Education, 1(1), 25-48.
• Boss, S. (2009). High tech reflection strategies make learning stick retrieved from  http://www.edutopia.org/student-reflection-blogs-journals-technology
• Dewey, J. (1916/1944). Democracy and education: An introduction to the philosophy of education. New York: The Free Press.
• Kalman, C.S., Sobhanzadeh, M., Thompson, R., Ibrahim, A., Wang, X. (2015). Combination of interventions can change students’ epistemological beliefs.  Physical Review Special Topics Physics Education Research,  11(2):020136-. doi:10.1103/PhysRevSTPER.11.020136
• Kuh, G. D., O’Donnell, K., & Reed, S. (2013). Ensuring quality and taking high-impact practices to scale.  Washington, DC: Association of American Colleges and Universities .
• Moon, J. (1999). Reflection in learning and professional development. Abingdon, Oxon: RoutledgeFalmer.
• Rodgers, C. (2002). Defining reflection: Another look at John Dewey and reflective thinking.  The Teachers College Record ,  104 (4), 842-866.
• Schön, D. A. (1983).  The reflective practitioner: How professionals think in action  (Vol. 5126). Basic books.

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Conceptualizing the complexity of reflective practice in education

Misrah mohamed.

1 Centre for Enhancement of Learning and Teaching, University of West London, London, United Kingdom

Radzuwan Ab Rashid

2 Faculty of Languages and Communication, Universiti Sultan Zainal Abidin, Terengganu, Malaysia

Marwan Harb Alqaryouti

3 Department of English Language, Literature and Translation, Zarqa University, Zarqa, Jordan

In higher education, reflective practice has become a dynamic, participatory, and cyclical process that contributes to educators’ professional development and personal growth. While it is now a prominent part of educators, many still find it challenging to apply the concept for it carries diverse meaning for different people in different contexts. This article attempts to (re)conceptualize the complexity of reflective practice in an educational context. Scholars in this field have taken different approaches to reflective practice, but all these approaches consist of four main components in common: (i) reflecting; (ii) planning for future action; (iii) acting; and (iv) evaluating the outcomes. We extend the existing literature by proposing a model which integrates these four components with three key aspects of reflection: problem-solving, action orientation, and criticality. The novelty of this model lies within its alignment of the three key aspects with different levels of criticality in a comprehensive framework with detailed descriptors provided. The model and its descriptors are useful in guiding individuals who directly or indirectly involve in critical reflection, especially educators, in appraising their levels of criticality and consequently engage in a meaningful reflection.

Introduction

In the field of education, reflective practice has been recognized as an important aspect in continuing professional development. Through reflective practice, we can identify the factors, the consequences of and the assumptions that underlie our actions. In higher education, reflective practice has become a dynamic, participatory, and cyclical process ( Ai et al., 2017 ) that contributes to educators’ professional development and personal growth ( McAlpine et al., 2004 ; De Geest et al., 2011 ; Davies, 2012 ; Marshall, 2019 ). It enables professional judgment ( Day, 1999 ) and fosters professional competence through planning, implementing and improving performance by rethinking about strengths, weaknesses and specific learning needs ( Huda and Teh, 2018 ; Cirocki and Widodo, 2019 ; Zahid and Khanam, 2019 ; Seyed Abolghasem et al., 2020 ; Huynh, 2022 ). Without routinely engaging in reflective practice, it is unlikely that educators will comprehend the effects of their motivations, expectations and experiences upon their practice ( Lubbe and Botha, 2020 ). Thus, reflective practice becomes an important tool that helps educators to explore and articulate lived experiences, current experience, and newly created knowledge ( Osterman and Kottkamp, 2004 ). Educators are continually recommended to apply reflective practice in getting a better understanding of what they know and do as they develop their knowledge of practice ( Loughran, 2002 ; Lubbe and Botha, 2020 ). In fact, reflective practice is now a prominent part of training for trainee teachers (e.g., Shek et al., 2021 ; Childs and Hillier, 2022 ; Ruffinelli et al., 2022 ) because it can help future teachers review their own practices and develop relevant skills where necessary.

Despite the wide acceptance of the concept of reflective practice, the notion of ‘reflection’ in itself is still broad. Our review of literature reveals that reflection is a term that carries diverse meaning. For some, “it simply means thinking about something” or “just thinking” (e.g., Loughran, 2002 , p. 33), whereas for others, it is a well-defined practice with very specific purpose, meaning and action (e.g., Dewey, 1933 ; Schön, 1983 ; Grimmett and Erickson, 1988 ; Richardson, 1990 ; Loughran, 2002 ; Spalding et al., 2002 ; Paterson and Chapman, 2013 ). We found many interesting interpretations made along this continuum, but we believe the most appealing that rings true for most people is that reflection is useful and informing in the development and understanding of teaching and learning (e.g., Seitova, 2019 ; McGarr, 2021 ; Huynh, 2022 ). This, however, is not enough to signify the characteristics of reflection. Consequently, many teachers find it hard to understand the concept and engage in reflective practice for their professional development ( Bennett-Levy and Lee, 2014 ; Burt and Morgan, 2014 ; Haarhoff et al., 2015 ; Marshall, 2019 ; Huynh, 2022 ; Knassmüller, 2022 ; Kovacs and Corrie, 2022 ). For example, some teachers from higher arts education have considered reflective practice as antithetical to practical learning ( Guillaumier, 2016 ; Georgii-Hemming et al., 2020 ) as they often frame explicit reflection as assessed reflective writing, which is “disconnected from the embodied and non-verbal dimensions of making and reflecting on art” ( Treacy & Gaunt, 2021 , p. 488). The lack of understanding of the concept has created disengagement in reflection and reflective practice ( Aliakbari and Adibpour, 2018 ; Huynh, 2022 ; Knassmüller, 2022 ) which resulted in poor insight and performance in practice ( Davies, 2012 ). To overcome this, educators should foster their understanding of the reflective practice, so they not only can reap its benefits for their own learning, but also facilitate and maximize reflective skills within their students.

In this paper, we aim to provide an overview of the concepts of effective reflective practice and present the value of reflective practice that can help teachers to professionally develop. First, we situate our conceptual understanding of reflective practice by discussing key issues surrounding reflection and reflective practice. Second, we present the key aspects of effective reflective practice. Finally, based on our discussion of key aspects of effective reflective practice, we introduce a revised model of reflective practice that may serve as a guide for educators to professionally develop. Although the model is but one approach, we believe it holds promise for others grappling as we are with efforts to encourage reflective practices among educators who find reflection in and on their practices a complex concept.

Key issues in reflective practice

The concepts of “reflection,” “reflective thought,” and “reflective thinking” have been discussed since 1904, when John Dewey claimed that an individual with good ethical values would treat professional actions as experimental and reflect upon their actions and consequences. Dewey defined reflection as the “active, persistent, and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusions to which it tends” ( Dewey, 1904 , p. 10). His basic notion is that reflection is an active, deliberative cognitive process involving a sequence of interconnected ideas that include the underlying beliefs and knowledge of an individual.

Following Dewey’s original work and its subsequent interpretation, four key thought-provoking issues are worthy of discussion: reflective thinking versus reflective action; time of reflection; reflection and problem solving; and critical reflection. The first concern is whether reflection is a process limited to thinking about action or also bound up in action ( Grant and Zeichner, 1984 ; Noffke and Brennan, 1988 ; Hatton and Smith, 1995 ). There seems to be broad agreement that reflection is a form of thought process ( Ross, 1989 ; McNamara, 1990 ; Sparks-Langer et al., 1991 ; Hatton and Smith, 1995 ) even though some do not lead to action. However, Dewey’s first mention of “reflective action” suggests he was concerned with the implementation of solutions after thinking through problems. Therefore, reflective practice, in our view, is bound up with the constant, careful consideration of practice in the light of knowledge and beliefs. The complete cycle of reflection should then lead to clear, modified action and this needs to be distinguished from routine action derived from impulse, tradition, or authority ( Noffke and Brennan, 1988 ; Gore and Zeichner, 1991 ; Hatton and Smith, 1995 ).

The time frames within which reflection takes place, needs to be addressed—relatively immediate and short term, or rather more extended and systematic. Schön (1983) holds that professionals should learn to frame and reframe the problems they often face and after trying out various interpretations, modify their actions as a result. He proposes “reflection-in-action,” which requires conscious thinking and modification, simultaneously reflecting and doing almost immediately. Similar to this concept is “technical reflection,” involving thinking about competencies or skills and their effectiveness and occurs almost immediately after an implementation and can then lead to changes in subsequent action ( Cruickshank, 1985 ; Killen, 1989 ). While the notion of immediacy in reflective practice seems appropriate, some argue that the process should involve conscious detachment from an activity after a distinct period of contemplation ( Boud et al., 1985 ; Buchmann, 1990 ). This is because reflection demands contemplating rational and moral practices in order to make reasoned judgments about better ways to act. Reflective practice often involves looking back at actions from a distance, after they have taken place ( Schön, 1983 ; Gore and Zeichner, 1991 ; Smith and Lovat, 1991 ). While immediate and extended “versions” of reflections are both recognized, we suppose no one is better than another. However, we believe that being able to think consciously about what is happening and respond instantaneously makes for a higher level of reflective competence.

The third issue identified from our literature review is whether reflection by its very nature is problem orientated ( Calderhead, 1989 ; Adler, 1991 ). Reflection is widely agreed to be a thought process concerned with finding solutions to real problems ( Calderhead, 1989 ; Adler, 1991 ; Hatton and Smith, 1995 ; Loughran, 2002 ; Choy and Oo, 2012 ). However, it is unclear whether solving problems is an inherent characteristic of reflection. For example, Schön’s (1983) reflection-in-action involves thought processing simultaneously with a group event taking place, and reflection-on-action refers to a debriefing process after an event. Both aims to develop insights into what took place—the aims, the difficulties during the event or experience and better ways to act. While focusing on reacting to practical events, these practices do not often intend to find solutions to specific practical problems. Instead, reflective practitioners are invited to think about a new set of actions from if not wider, at least different perspectives.

The fourth issue in the literature revolves around “critical reflection.” Very often critical reflection is concerned with how individuals consciously consider their actions from within wider historical, cultural and political beliefs when framing practical problems for which to seek solutions ( Gore and Zeichner, 1991 ; Hatton and Smith, 1995 ; Choy and Oo, 2012 ). It is a measure of a person’s acceptance of a particular ideology, its assumptions and epistemology, when critical reflection is developed within reflective practice ( McNamara, 1990 ; Hatton and Smith, 1995 ). It implies the individual locates any analysis of personal action within her/his wider socio-historical and political-cultural contexts ( Noffke and Brennan, 1988 ; Smith and Lovat, 1991 ; Hatton and Smith, 1995 ). While this makes sense, critical reflection in the literature appears to loosely refer to an individual’s constructive self-criticism of their actions to improve in future ( Calderhead, 1989 ), not a consideration of personal actions with both moral and ethical criteria ( Senge, 1990 ; Adler, 1991 ; Gore and Zeichner, 1991 ). Thus, we see a need to define critical reflection in line with the key characteristics of reflective practice.

Effective reflective practice

Reflecting on the issues discussed above, we conclude that for reflective practice to be effective, it requires three key aspects: problem-solving, critical reflection and action-orientation. However, these aspects of reflective practice have different levels of complexity and meaning.

Problem-solving

A problem is unlikely to be acted upon if it is not viewed as a problem. Thus, it is crucial to problematize things during reflection, to see concerns that require improvement. This is not a simple process as people’s ability to perceive things as problems is related to their previous experiences. For example, a senior teacher with years of teaching experience and a rapport with the students s/he teaches will be immediately aware of students experiencing difficulties with current teaching strategies. However, a junior teacher whose experience is restricted to a three-month placement and who has met students only a few times will be less aware. The differences in experience also influence the way people interpret problems. For example, the senior teacher may believe his/her teaching strategy is at fault if half the students cannot complete the given tasks. A junior teacher with only 2 weeks teaching experience may deduce that the students were not interested in the topic, and that is why they cannot complete the tasks given. This example illustrates the range of ways a problem can be perceived and the advantages of developing the ability to frame and reframe a problem ( Schön, 1983 ). Problems can also be perceived differently depending on one’s moral and cultural beliefs, and social, ethical and/or political values ( Aliakbari and Adibpour, 2018 ; Karnieli-Miller, 2020 ). This could be extended to other factors such as institutional, educational and political system ( Aliakbari and Adibpour, 2018 ).

Framing and reframing a problem through reflection can influence the practice of subsequent actions ( Loughran, 2002 ; Arms Almengor, 2018 ; Treacy and Gaunt, 2021 ). In the example above, the junior teacher attributes the problem to the students’ attitude, which gives her/him little to no incentive to address the situation. This is an ineffective reflective practice because it has little impact on the problem. Thus, we believe it is crucial for individuals to not only recognize problems but to examine their practices ( Loughran, 2002 ; Arms Almengor, 2018 ; Zahid and Khanam, 2019 ) through a different lens to their existing perspectives so solutions can be developed and acted upon. This requires critical reflection.

Critical reflection

We believe it is the critical aspect of reflection that makes reflective practice effective and more complex, formulated by various scholars as different stages of reflection. Zeichner and Liston (1987) proposed three stages of reflection similar to those described by Van Manen (1977) . They suggested the first stage was “technical reflection” on how far the means to achieve certain end goals were effective, without criticism or modification. In the second stage, “practical reflection,” both the means and the ends are examined, with the assumptions compared to the actual outcomes. This level of reflection recognizes that meanings are embedded in and negotiated through language, hence are not absolute. The final stage, “critical reflection,” combined with the previous two, considers both the moral and ethical criteria of the judgments about professional activity ( Senge, 1990 ; Adler, 1991 ; Gore and Zeichner, 1991 ).

While the three stages above capture the complexity of reflection, individuals will only reach an effective level of reflection when they are able to be self-critical in their judgments and reasoning and can expand their thinking based on new evidence. This aligns with Ross’ (1989) five stages of reflection (see Table 1 ). In her five stages of reflection, individuals do not arrive at the level of critical reflection until they get to stages 4 and 5, which require them to contextualize their knowledge and integrate the new evidence before making any judgments or modification ( Van Gyn, 1996 ).

Five stages of reflections ( Ross, 1989 ).

Action-orientation

We believe it is important that any reflections should be acted upon. Looking at the types and stages of reflection discussed earlier, there is a clear indication that reflective practice is a cyclical process ( Kolb, 1984 ; Richards and Lockhart, 2005 ; Taggart and Wilson, 2005 ; Clarke, 2008 ; Pollard et al., 2014 ; Babaei and Abednia, 2016 ; Ratminingsih et al., 2018 ; Oo and Habók, 2020 ). Richards and Lockhart (2005) suggest this cyclical process comprises planning, acting, observing, and reflecting. This is further developed by Hulsman et al. (2009) who believe that the cyclical process not only involves action and observation, but also analysis, presentation and feedback. In the education field, reflective practice is also considered cyclical ( Clarke, 2008 ; Pollard et al., 2014 ; Kennedy-Clark et al., 2018 ) because educators plan, observe, evaluate, and revise their teaching practice continuously ( Pollard et al., 2014 ). This process can be done through a constant systematic self-evaluation cycle ( Ratminingsih et al., 2018 ) which involves a written analysis or an open discussion with colleagues.

From the descriptions above, it seems that cyclical reflective practice entails identifying a problem, exploring its root cause, modifying action plans based on reasoning and evidence, executing and evaluating the new action and its results. Within this cyclical process, we consider action as a deliberate change is the key to effective reflective practice, especially in the field of education. Reflection that is action-oriented is an ongoing process which refers to how educators prepare and teach and the methods they employ. Educators move from one teaching stage to the next while gaining the knowledge through experience of the importance/relevance of the chosen methods in the classroom situation ( Oo and Habók, 2020 ).

While reflection is an invisible cognitive process, it is not altogether intuitive ( Plessner et al., 2011 ). Individuals, especially those lacking experience, may lack adequate intuition ( Greenhalgh, 2002 ). To achieve a certain level of reflection, they need guidance and this can be done with others either in groups ( Gibbs, 1988 ; Grant et al., 2017 ) or through one-on-one feedback ( Karnieli-Miller, 2020 ). The others, who can be peers or mentors, can help provide different perspectives in exploring alternative interpretations and behaviors. Having said this, reflecting with others may not always feasible as it often requires investment of time and energy from others ( Karnieli-Miller, 2020 ). Therefore, teachers must learn how to scaffold their own underlying values, attitudes, thoughts, and emotions, and critically challenge and evaluate assumptions of everyday practice on their own. With this in mind, we have created a cyclical process of reflective practice which may help in individual reflections. It captures the three key aspects of reflective practice discussed above. This model may help teachers having a range of experience enhance their competence through different focus and levels of reflection (see Figure 1 ).

Cyclical reflective practice model capturing problem-solving, action-oriented critical reflection.

The model illustrates the cyclical process with three stages: reflection, modification and action. At the reflection stage, a problem and the root of the problem is explored so it can be framed as it is/was and then reframed to identify a possible solution. This is followed by a modification for change based on the reasoning and evidence explored during the reflection stage. Finally, the action stage involves executing action (an event), followed by the reflection stage to begin another cycle and continue the process.

As presented earlier, it is crucial for individuals to be able to frame and reframe problems through a different lens to their existing perspectives so solutions can be developed and acted upon. Thus, the model above expands Tsangaridou and O’Sullivan’s (1994) framework by adding together the element of problematizing. The current revised framework highlights the four focuses of reflection; technical addresses the management or procedural aspects of teaching practice; situational addresses the context of teaching; sensitizing involves reflecting upon the social, moral, ethical or political concerns of teaching; and problematizing concerns the framing and reframing of the problem identified within the teaching context. Considering the different levels of critical reflection, we extend the four focuses of reflection to three different levels of critical reflection: descriptive involves reflection of the four focuses without reasoning or criticism; descriptive with rationale involves reflection of the four focuses with reasoning; and descriptive with rationale and evaluation involves reflection of the four focuses with both reasoning and criticism (see Table 2 ). Each of these levels requires different degrees of critical analysis and competence to extract information from actions and experiences. Overall, level three best captures effective critical reflection for each focus.

A framework of reflection.

This revised model that we proposed encompasses different levels of critical reflection and is action-oriented. There is also a clear link to problem-solving which requires framing and reframing problems to accurately identify them, which may influence the value and effectiveness of the actions that follow ( Loughran, 2002 ). Thus, this model may help people, especially those with lack experience to recognize the different aspects of reflection so they can make better assessments of and modifications to their procedures ( Ross, 1989 ; Van Gyn, 1996 ).

The meaning of reflection and reflective practice is not clear cut. However, we believe a reflective educator should cultivate a set of responses to how their teaching operates in practice. As Dewey (1933) suggested, educators must find time to reflect on their activity, knowledge, and experience so that they can develop and more effectively serve their community, nurturing each student’s learning. However, this does not always happen. Some educators do not reflect on their own practice because they find the concept of reflective practice difficult to put into practice for their professional development ( Jay and Johnson, 2002 ; Bennett-Levy and Lee, 2014 ; Burt and Morgan, 2014 ; Haarhoff et al., 2015 ; Marshall, 2019 ; Huynh, 2022 ).

Our review of the literature indicates that reflective practice is a complex process and some scholars argue that it should involve active thinking that is more bound up with action ( Grant and Zeichner, 1984 ; Noffke and Brennan, 1988 ; Hatton and Smith, 1995 ). Thus, the complete cycle of reflective practice needs to be distinguished from routine action which may stem from impulse, tradition, or authority ( Noffke and Brennan, 1988 ; Gore and Zeichner, 1991 ; Hatton and Smith, 1995 ). In addition, some also argue that reflective practice involves the conscious detachment from an activity followed by deliberation ( Boud et al., 1985 ; Buchmann, 1990 ), and therefore reflective practice should not occur immediately after action. Although this is acceptable, we believe that instant reflection and modification for future action can be a good indicator of an individual’s level of reflective competence.

Reflective practice is an active process that requires individuals to make the tacit explicit. Thus, it is crucial to acknowledge that reflection is, by its very nature, problem-centered ( Calderhead, 1989 ; Adler, 1991 ; Hatton and Smith, 1995 ; Loughran, 2002 ; Choy and Oo, 2012 ). Only with this in mind can individuals frame and reframe their actions or experiences to discover specific solutions. Reflective practice is also complex, requiring critical appraisal and consideration of various aspects of thought processes. Individuals must play close attention to what they do, evaluate what works and what does not work on a personal, practical and professional level ( Gore and Zeichner, 1991 ; Hatton and Smith, 1995 ; Choy and Oo, 2012 ). However, some would consider critical reflection as no more than constructive self-criticism of one’s actions with a view to improve ( Calderhead, 1989 ). Consequently, scholars have taken different approaches to reflective practice in teaching areas that include critical thinking (e.g., Ross, 1989 ; Tsangaridou and O’Sullivan, 1994 ; Loughran, 2002 ). These approaches had four components in common: reflecting (observing actions, reviewing, recollecting), planning for future action (thinking and considering), acting (practice, experience, and learning), and evaluating (interpreting and assessing outcomes). We propose a model that embraces these four sub-areas and three key aspects of reflection: problem-solving, action orientation and critical reflection. We align these key aspects with level of criticality in a framework with detailed descriptors. It is hoped that these elements, combined together, demonstrate the complexities of reflection in a better, clearer way so that those struggling to adopt reflective practice will now be able to do so without much difficulty.

Author contributions

MM contributed to conception and written the first draft of the manuscript. RR contributed in the discussion of the topic. All authors contributed to the article and approved the submitted version.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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4 Models of reflection – core concepts for reflective thinking

The theories behind reflective thinking and reflective practice are complex. Most are beyond the scope of this course, and there are many different models. However, an awareness of the similarities and differences between some of these should help you to become familiar with the core concepts, allow you to explore deeper level reflective questions, and provide a way to better structure your learning.

Boud’s triangular representation (Figure 2) can be viewed as perhaps the simplest model. This cyclic model represents the core notion that reflection leads to further learning. Although it captures the essentials (that experience and reflection lead to learning), the model does not guide us as to what reflection might consist of, or how the learning might translate back into experience. Aligning key reflective questions to this model would help (Figure 3).

This figure contains three boxes, with arrows linking each box. In the boxes are the words ‘Experience’, ‘Learning’ and ‘Reflection’.

This figure contains three triangles, with arrows linking each one. In the top triangle is the text ‘Experience - what? (Description of events)’. In the bottom-left triangle is the text ‘Learning - now what? (What has been learned? What is the impact of the learning?’. In the bottom-right triangle is the text ‘Reflection - so what? (Unpicking the events)’.

Gibbs’ reflective cycle (Figure 4) breaks this down into further stages. Gibbs’ model acknowledges that your personal feelings influence the situation and how you have begun to reflect on it. It builds on Boud’s model by breaking down reflection into evaluation of the events and analysis and there is a clear link between the learning that has happened from the experience and future practice. However, despite the further break down, it can be argued that this model could still result in fairly superficial reflection as it doesn’t refer to critical thinking or analysis. It doesn’t take into consideration assumptions that you may hold about the experience, the need to look objectively at different perspectives, and there doesn’t seem to be an explicit suggestion that the learning will result in a change of assumptions, perspectives or practice. You could legitimately respond to the question ‘what would you do or decide next time?’ by answering that you would do the same, but does that constitute deep level reflection?

This figure shows a number of boxes containing text, with arrows linking the boxes. From the top left (and going clockwise) the boxes display the following text: ‘Experience. What happened?’; ‘Feeling. What were you feeling?’; ‘Evaluation. What was good or bad about the situation?’; ‘Analysis. To make sense of the situation’; ‘Conclusion. What else could you have done?’; ‘Action plan. What would you do next time?’.

Atkins and Murphy (1993) address many of these criticisms with their own cyclical model (Figure 5). Their model can be seen to support a deeper level of reflection, which is not to say that the other models are not useful, but that it is important to remain alert to the need to avoid superficial responses, by explicitly identifying challenges and assumptions, imagining and exploring alternatives, and evaluating the relevance and impact, as well as identifying learning that has occurred as a result of the process.

This figure shows a number of boxes containing text, with arrows linking the boxes. From the top (and going clockwise) the boxes display the following text: ‘Awareness. Of discomfort, or action/experience’; ‘Describe the situation. Include saliant feelings, thoughts, events or features’; ‘Analyse feeling and knowledge. Identify and challenge assumptions - imagine and explore alternatives’; ‘Evaluate the relevance of knowledge. Does it help to explain/resolve the problem? How was your use of knowledge?’; ‘Identify any learning. Which has occurred?’

You will explore how these models can be applied to professional practice in Session 7.

Reflective Practice in Health Professions Education

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• Jennifer M. Weller-Newton 5 , 6 , 7 &
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In health professions, reflection is a central tenet that assists practitioners in development of their professional knowledge and practice. Indeed, for many health professions, critical reflectivity has become a core competency within registration standards. This chapter presents the theory that underpins reflective practice beginning with a historical overview. John Dewey’s seminal work How We Think (1933) paved the way for the current thinking on reflective practice. In presenting the theoretical underpinnings of reflective practice, pedagogical examples are provided. Discussion on the tensions between reflective practice as a pedagogy, service learning, where the reflective learning activity is given lip-service by students, versus clinical practice is provided. We explore how reflective practice in theory can become reflective practice in action. The exciting opportunities that current technologies afford in being creative with reflective practice are presented along with suggested pedagogical activities in scaffolding reflective practice.

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The UCLA School of Law Critical Race Studies Program (CRS) launched CRT Forward, an initiative to address the current attacks on Critical Race Theory (CRT) while also highlighting the past, present and future contributions of the theory.

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A pilot to infuse Black history and culture in social studies curriculum is gaining ground in the nation’s largest school district, offering a potential model to overcome widespread political debates over how to teach race in public schools.

In a symposium on the project at the American Educational Research Association’s annual conference last week, M.C. Brown II, the executive director at the Thurgood Marshall College Fund, called New York City’s $3.25 million Black studies curriculum “a nationally historic moment.”

The curriculum “acknowledges the history and the contributions of Black Americans predating slavery, which is where much of American social studies begins,” Brown said, “and provides a paradigm for professional learning that can support effective implementation, not just in New York City, but around the world.”

The project comes amid vicious political fights over critical race theory , which holds that race is a social construct, and racism can be embedded in policies and laws (such as enrollment policies that tend to segregate schools), not just personal prejudice. The legal concept is separate from but often conflated with culturally responsive teaching , which holds that students learn more effectively when teachers use their customs, experiences, and identities as tools in the classroom.

The New York curriculum, developed in collaboration between local educators and the Black Education Research Center at Columbia University Teachers College, includes pre-K-12 lessons aligned with the state’s language arts and social studies standards, designed to be used throughout the year. If it proves successful in an ongoing evaluation, the collaborative plans to roll it out to more schools in New York and other states.

Dawn Brooks DeCosta, the deputy superintendent of the 6,500-student Harlem Community School District 5, said its 23 schools piloted units of the curriculum this year across different grades.

Harlem District 5 recruited elementary and secondary teachers with backgrounds and interests in Black studies. They met biweekly with researchers from the Black Education Research Center at neighboring Teachers College, Columbia University to design curricular standards and units, as well as professional development needed for teachers.

“As teachers were contributing and helping to refine and design the lesson, … they didn’t understand what it means to co-design,” said Rodney Hopson, acting education co-dean and professor at American University, who is leading an evaluation of the curriculum. “It wasn’t just like, ‘Here’s a [curriculum] package, run with it,’ ... we were actually trying to collaboratively build this thing together.”

For example, Samantha Chung, a Teachers College doctoral researcher, helped design a unit for 5th grade in which students read and listen to Black poets and discuss the literary form’s use in advocacy.

“Black studies started out with a pedagogical mission, not just content,” said Joyce King, the chair for Urban Teaching, Learning and Leadership and an education policy professor at Georgia State University, during the discussion at AERA. “… That includes inspiring people to learn deeply and critically about the African diaspora histories and contemporary social formation, to recognize and affirm our peoplehood—that we are a people across many different cultures.”

In New York, that’s particularly important, according to Linda Tillman, chairman of BERC’s advisory board. Tillman said teachers and researchers worked to incorporate Dominican, Puerto Rican, and other Black students’ cultures into the curriculum “to combat misconceptions about the history of African Americans and Black people throughout the global diaspora.”

For example, in one of the earliest units, kindergarten students explore the meanings and origins of their names, and talk about the importance of pronouncing names correctly. Studies find name mispronunciations are often one of the earliest and most common alienating experiences, particularly for children of color.

Beyond ‘Critical Race Theory’ debates

The curriculum offers a holistic way for teachers to discuss the role of culture and race in American and world history at a time when many educators face restrictions on how they can approach the subject. As of 2023, at least 18 states have passed bans or limits on how teachers can discuss race or gender in class, and the research firm RAND Corp. found half of K-12 teachers nationwide said they face state and/or local restrictions on teaching about race.

Yet in a nationally representative survey this fall, more than 8 in 10 registered voters told the Black Education Research Center that public school students should learn both about the history of racism and slavery in the United States and how it affects students and communities today.

“Students should gain skills in biology and chemistry, physics, business, et cetera, and then use their Black studies knowledge, the curriculum, to gain an understanding of the significance of a role of those subject areas in the development of the Black community,” said Kofi Lomotey, the chancellor and professor of educational leadership at Western Carolina University.

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• Published: 16 April 2024

Development of a program theory for osteoporosis patient education in Denmark: a qualitative study based on realist evaluation

• Mette Rubæk   ORCID: orcid.org/0000-0002-2591-9457 1 , 2 ,
• Marie Broholm-Jørgensen   ORCID: orcid.org/0000-0001-9005-0754 1 ,
• Susan Andersen   ORCID: orcid.org/0000-0002-2741-0742 1 ,
• Pernille Ravn Jakobsen   ORCID: orcid.org/0000-0002-0199-1972 3 ,
• Mette Juel Rothmann   ORCID: orcid.org/0000-0001-6505-4163 4 , 5 , 6 ,
• Bente Langdahl   ORCID: orcid.org/0000-0002-8712-7199 7 , 8 ,
• Mette Friberg Hitz   ORCID: orcid.org/0000-0003-2195-8552 2 &
• Teresa Holmberg   ORCID: orcid.org/0000-0002-4671-3810 9  

BMC Geriatrics volume  24 , Article number:  346 ( 2024 ) Cite this article

Metrics details

Osteoporosis patient education is offered in many countries worldwide. When evaluating complex interventions like these, it is important to understand how and why the intervention leads to effects. This study aimed to develop a program theory of osteoporosis patient education in Danish municipalities with a focus on examining the mechanisms of change i.e. what is about the programs that generate change.

The program theory was developed in an iterative process. The initial draft was based on a previous published systematic review, and subsequently the draft was continually refined based on findings from observations (10 h during osteoporosis patient education) and interviews (individual interviews with six employees in municipalities and three health professionals at hospitals, as well as four focus group interviews with participants in patient education (in total 27 informants)). The transcribed interviews were analyzed using thematic analysis and with inspiration from realist evaluation the mechanisms as well as the contextual factors and outcomes were examined.

Based on this qualitative study we developed a program theory of osteoporosis patient education and identified four mechanisms: motivation, recognizability, reassurance, and peer reflection. For each mechanism we examined how contextual factors activated the mechanism as well as which outcomes were achieved. For instance, the participants’ motivation is activated when they meet in groups, and thereafter outcomes such as more physical activity may be achieved. Recognizability is activated by the participants’ course of disease, which may lead to better ergonomic habits. Reassurance may result in more physical activity, and this mechanism is activated in newly diagnosed participants without previous fractures. Peer reflection is activated when the participants meet in groups, and the outcome healthier diet may be achieved.

Conclusions

We developed a program theory and examined how and why osteoporosis patient education is likely to be effective. Understanding these prerequisites is important for future implementation and evaluation of osteoporosis patient education.

Peer Review reports

Osteoporosis is a common chronic bone disease with an estimated prevalence of 27.6 million people in Europe [ 1 ]. The prevalence increases markedly with age; among people aged 80 + the prevalence is 37% [ 1 ]. Osteoporosis has consequences for the individual, primarily due to the related risk of fractures. Globally, 158 million people were estimated to be at high fracture risk in 2010 and this number is likely to double by 2040 [ 2 ]. The occurrence of fractures may result in decreased quality of life [ 3 , 4 ], pain [ 5 , 6 ], institutionalization, and death [ 7 ]. Osteoporosis can be treated, and the related fracture risk may be prevented by initiating pharmacological treatment as well as improving diet, considering supplements, being physical active, and preventing falls [ 8 , 9 , 10 , 11 , 12 ].

When diagnosed with osteoporosis, the patient's self-image may change, as they can feel older and embarrassed, which can affect their social life [ 13 ]. Patients with osteoporosis may also experience dependency on others and shifting roles at home because they cannot maintain their daily activities [ 13 ]. Therefore, some patients find it helpful to discuss these problems and share experiences with other patients [ 14 ].

Patient education is often used by patients to gain support and be able to manage the consequences of osteoporosis. According to WHO, osteoporosis patient education should give the participants the opportunity to express their concerns and discuss their expectations with a health professional and gain support from other participants. Further, WHO recommends that osteoporosis patient education consist of training and information about the disease, available treatment, diet, exercise, lifestyle, and prevention of falls and fractures, [ 10 ] and thereby encourage bone healthy behaviors. A multifaceted and multidisciplinary approach is also recommended in other studies [ 15 , 16 , 17 , 18 ]. Osteoporosis patient education is carried out in many countries worldwide [ 19 , 20 , 21 ]. The content of the programs differs, but most programs include information about osteoporosis [ 15 , 22 , 23 , 24 , 25 , 26 , 27 ], medication and diet [ 15 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ], prevention of falls and fractures [ 15 , 22 , 26 , 28 ], as well as training and information about physical exercise [ 24 , 26 , 30 , 31 ].

Osteoporosis patient education could be defined as a complex intervention, as it includes different components, it targets different behaviors, and it requires different skills from health professionals [ 32 , 33 ]. Furthermore, complexity may arise when the intervention or program in this case interacts with the context at the patient education sessions or outside the sessions [ 32 ].

The effectiveness of osteoporosis patient education has been evaluated worldwide in previous studies [ 15 , 24 , 26 , 27 , 28 , 29 , 30 , 31 ], but because of inconsistent findings it is difficult to draw overall conclusions about its effect [ 21 ]. When evaluating complex interventions, the Medical Research Counsel (MRC) highlights the importance of developing a program theory that illustrates how the intervention could lead to effects and under what circumstances [ 34 ]. The program theory should be described clearly, and a visual presentation may be helpful [ 34 ].

We are not aware of any studies presenting a program theory of osteoporosis patient education. Moreover, prior studies have not shown how the effects of patient education are dependent on contextual factors and do not examine how and why the interventions work (i.e., they do not examine the mechanisms of change). In a previous published systematic review, we found that examination of mediators is absent in many effectiveness studies, and therefore we recommended that future studies should examine mediators, which could contribute to an understanding of the mechanisms of osteoporosis patient education [ 21 ]. Likewise, other researchers have highlighted the need for studies examining the mechanism of the interventions, rather than only examining the effects [ 35 , 36 , 37 , 38 ]. When examining the mechanisms, it is possible to find an explanation for the effectiveness of an intervention [ 39 ] and thereby open the ‘black box’ that describes how and why the intervention works [ 40 ]. Moreover, the mechanisms contribute with important information for future implementation and evaluation of the interventions.

A program theory and an examination of the mechanisms is essential for the development, for implementation, and evaluation of new osteoporosis patient education programs. Furthermore, as osteoporosis patient education in Danish municipalities has not been evaluated systematically, a program theory and an understanding of the mechanisms are important prerequisites for evaluation of these existing programs and the selection of relevant outcomes for the evaluation.

When examining mechanisms of change qualitative studies should preferably be conducted [ 35 , 41 ]. This study aimed to develop a program theory of osteoporosis patient education in Danish municipalities with a focus on examining the mechanisms of change i.e. what is about the programs that generate change.

The study was conducted as an explorative study, including observations and interviews and with realist evaluation [ 39 ] as theoretical inspiration. Moreover, it was based on knowledge from a systematic review undertaken by the research group, which has been published [ 21 ].

Theoretical inspiration

Realist evaluation is a theory-driven approach, which examines how and why interventions work, as well as under what circumstances [ 39 ], hence aiming to describe the process by which the effects occur, rather than just describing whether effects occur. This is done by developing, testing and refining context-mechanism-outcome (CMO) configurations [ 39 ]. A CMO configuration can be defined as a part of a program theory by representing assumptions about how and why interventions work. In this study, we examined the contextual factors, the mechanisms of change, as well as the outcomes of osteoporosis patient education while describing important paths in the program theory, which is of special importance for future implementation and evaluation of osteoporosis patient education.

The development of our program theory was based on the elements put forward by Gertler et al. [ 42 ], meaning that the program theory outlined inputs, activities, outputs, and outcomes. Moreover, we identified the mechanisms of osteoporosis patient education using a definition within realist evaluation, in which a mechanism describes what it is about the programs that generate change (i.e., outcomes) [ 44 ]. In particular we are inspired by Dalkin and colleagues (2015) definition of mechanism that contains two components, namely the resources from the intervention and the derived reasoning in the individual [ 39 , 43 ]. In this line of thought, the mechanisms are the response the intervention activities trigger from the individual participant. Of relevance for this study, the premise of this definition is, that it is the participants in the osteoporosis patient education that make it work (or not) depending on how they respond to the resources it offers to them [ 44 ]. Thus, a mechanism is a theory describing the association between an exposure and an outcome [ 39 ]. In realist evaluation the context activates the mechanisms, i.e., a particular contextual factor triggers a specific mechanism, which again results in an outcome [ 39 ]. Therefore, we examined not only the mechanisms, but also which contextual factors activate the mechanisms as well as which outcomes may be achieved.

Study setting

In Denmark, osteoporosis patient education is offered at hospitals as well as in municipalities, although most osteoporosis patient education is carried out in municipalities that have the main responsibility for rehabilitation. Each municipality can decide whether they will implement osteoporosis patient education, and it is estimated that around 22 of 98 municipalities offer osteoporosis patient education [ 45 ]. The programs differ across municipalities, but typically the participants meet face-to-face in groups of approximately 10 persons, once a week for eight weeks. The programs most often include a combination of knowledge dissemination and physical exercises [ 46 , 47 ]. The physical exercises vary across municipalities but often they focus on balance, strength training, and aerobic exercises. The referral differs as well, as some municipalities require a referral from General Practitioner (GP) or hospital, whereas others do not. For this study, we chose six municipalities, which were widely representative regarding the location (rural or urban as well as distribution across the country) and size of the municipality, the participants, the content, and referral to the program. Information about the municipalities offering osteoporosis patient education was retrieved from existing overviews [ 45 , 46 ]. The programs in the six municipalities are described in Table  1 .

We developed the program theory based on a qualitative study and a previously published systematic review of osteoporosis patient education [ 21 ]. During the qualitative study, different stakeholders were involved in exploring their shared understanding [ 34 ]. The decision about who should be involved and which methods should be used depends on the purpose of developing a program theory [ 48 ]. Our aim was to get an understanding of the elements in osteoporosis patient education to be used in future implementation and evaluation of the programs. We conducted observation and interviews, as it is advantageous to combine them if each method is used to elaborate the other [ 49 ]. In addition, a multimethod evidence base is recommended within realist evaluation [ 39 ].

In the first draft of the program theory, we included the outcomes identified in the previously published systematic review in which we examined the effectiveness of osteoporosis patient education [ 21 ]. Thereafter we continuously added the other elements of the program theory based on observations and interviews in the qualitative study. During this process, the draft was revised several times and carefully aligned with the findings. Lastly, a final version of the program theory was decided by researchers within the field of intervention and osteoporosis research. Consequently, the development of the program theory was an iterative process as described in realist evaluation [ 39 , 50 ] and recommended for research in complex interventions [ 34 ], and therefore the development of the program theory followed an abductive argument.

Observation and interviews were conducted from May 2021 until December 2021. The research project has been approved by Research Ethics Committee, University of Southern Denmark (approval ID 20/70420). Informed consent was retrieved from participants in osteoporosis patient education (hereafter also called participants) after they were provided with written and oral information. All methods were performed in accordance with the Declaration of Helsinki.

Observation

To get first-hand experience with the activities in osteoporosis patient education as well as the interactions between participants, the setting, and the atmosphere [ 51 ] i.e., the context, we carried out observations in four municipalities while sessions were held. Municipalities were eligible for observation if they provided osteoporosis patient education conducted in group settings and delivered face-to-face. A combination of observation and participant observation was conducted dependent on the content of the session. Observation implies no involvement from the researcher [ 51 ], and this was primarily carried out during educational sessions as participant observation would have been difficult without an osteoporosis diagnosis. Conversely, participant observation implies that the researcher takes part in an action [ 51 ], and this was carried out during physical exercises to avoid the participants feeling observed by the researcher. Observation and participant observation was carried out by the first author who has a background within public health and has experience with observations. Intermediate feedback was provided by several co-authors. No further observations were carried out when findings appeared across settings. 10 h of observations and participant observations was carried out (see Table  2 ).

Interviews were conducted to gain insight into the informants’ knowledge, experiences, and understandings [ 51 ]. We conducted interviews with three groups of informants: participants in patient education, employees in municipalities (hereafter also called employees), and health professionals at hospitals (hereafter called health professionals). Interviews with participants provided insight into their experiences with the programs, and therefore participants who had completed most of a program were eligible for interviews. Interviews with employees in municipalities gave insight into the planning and execution of the programs, and therefore employees were eligible if they had been planning or executing programs. As some Danish hospitals also conduct osteoporosis patient education, interviews with health professionals gave insight into their knowledge about such programs. The health professionals were eligible for interviews if they had in-dept knowledge about a program at a hospital.

Interviews with health professionals and employees were conducted as individual interviews to explore their experiences with their specific programs [ 51 ]. Interviews with participants were conducted as focus group interviews to elicit reflection from them during interaction with other participants [ 51 ]. A total of 13 interviews were conducted: three interviews with health professionals, six interviews with employees, and four focus group interviews with participants, amounting to a total of 18 participants (three to five participants in each group). The average time per interview was 53 min.

Interviews with health professionals and employees took place online, whereas interviews with participants took place at facilities provided by the municipalities and were familiar to the participants. All interviews were performed by the first author who has experience with interviewing in health care settings. Several co-authors with similar experiences provided feedback between interviews. No further interviews were conducted when saturation was obtained, i.e. findings were mentioned by more informants. All interviews were recorded and afterwards transcribed verbatim (approximately 179 pages).

Characteristics of informants

The characteristics of the 18 informants (participants in osteoporosis patient education) are shown in Table  3 . Most of the participants were women (88%). Their ages ranged from 50 to 84 years (mean age 71 years). Most of the participants had completed the full program (61%), while others had yet to complete the last sessions. Their year of diagnosis ranged from 1995 until present, though most of them (56%) were diagnosed within the past two years. Eight participants had experienced vertebral fractures, and three had experienced other osteoporotic fractures. Most of them were retired and had an upper secondary or higher level of education.

Among the six employees in municipalities, five were physiotherapists, and one was a nurse. Five of them were currently teaching on an osteoporosis patient education program. Most of them had participated in both the development and implementation of the programs.

The three health professionals at hospitals were nurses and had experience with osteoporosis patient education: two of them were currently teaching on the programs, and one was a researcher in the field of osteoporosis.

Observation and interview guides

During observations unstructured field notes containing descriptions of the setting, content of the session, and the interaction between participants were collected.

For the interviews three different but related interview guides were developed. With inspiration from literature on program theory development [ 48 ], we developed the interview guides to contain questions regarding: barriers for osteoporosis patients, what the participants may achieve during patient education, why they achieve it, who needs to be involved, etc. The themes were related to the elements of the program theory, e.g., the effects of patient education, the mechanisms, and the contextual factors. In all interviews the interviewer began with an introduction of herself, the project, and the publication of results and afterwards the informants introduced themselves. In the focus group interviews, the interviewer asked questions which were then answered by informants, or the informants asked each other questions in a natural dialog. Furthermore, the participants were asked to write down the effects of patient education on Post-it notes, which were then discussed. During interviews with health professionals and employees the first draft of the program theory was presented to and commented on by the informants.

Due to our theoretical inspiration in realist evaluation, the analysis focused on the mechanisms, contextual factors, and outcomes. The interviews were analyzed using thematic analysis [ 52 ], which contains six steps: 1) Get familiar with data, 2) Generate initial codes, 3) Search for themes, 4) Review themes, 5) Define and name themes, 6) Report findings. Therefore, we initially listened to the recordings and read the transcriptions (step 1), whereafter we generated codes, e.g., “others” and “geography and practical matters” (step 2). Then, we found candidate themes, e.g., “surroundings” and “distance and duration” (step 3). Thereafter we read data within one theme as well as the entire data set across themes. In this process, some data were moved to another theme, some additional data were coded, and some themes were renamed (step 4). In the final steps, we described the essence of each theme (step 5) and wrote the results section (step 6). Examples from steps 2 to 5 are provided in Table  4 . During the analysis, the field notes from observation were also examined to ensure that the themes were adequate and comprehensive. As the themes from the analysis emerged, relevant theories were identified and included to support our understanding and interpretation of the themes. Therefore, the application of theories comprised an additional analytical step (step 7).

The coding of data was both theory-driven and data-driven [ 52 ] as we coded the interviews into the overall elements of the program theory, i.e., inputs, activities, outputs, outcomes, context, and mechanisms. Furthermore, we added codes while reading the interviews without considering these overall elements to explore which other codes might appear. This was in accordance with our abductive approach.

The analysis was conducted in NVivo. The first author took the lead on step 1–3 with ongoing discussion with co-authors with experiences in qualitative research that collaboratively identified and developed themes within the data. This process also involved discussing emergent themes, examining supporting evidence from the data, and refining the themes (step 4–5). Moreover, the findings were also discussed at a workshop with all co-authors, who are researchers within intervention and osteoporosis research, and they were discussed with a team of qualitative researchers at the University of Southern Denmark (step 4–5). First author summarized and reported findings (step 6), which all co-authors commented on.

Below, the results of the analysis are described. For each mechanism, we examined which contextual factors activate the mechanism as well as which outcomes appear. This is in accordance with our theoretical inspiration, and moreover this description aims to illustrate the paths in the program theory.

From our analysis and in accordance with our research question, we identified the elements of a program theory of osteoporosis patient education with special attention to examining the mechanisms.

• Program theory

Our program theory for osteoporosis patient education is presented in Fig.  1 . Each element is described in Additional file 1, together with examples of empirical data. The inputs, activities, outputs, outcomes, and contextual factors are briefly described below, and the mechanisms are examined in detail in the following.

Program theory developed

The inputs in the program theory include the means, which are necessary to carry out the program [ 42 ]. From our analysis, we found that staff is needed but different staff should also be able to cooperate across professional competences (interdisciplinarity). For instance, in one municipality it was observed that two physiotherapists and one nurse held a session with physical exercises, and afterwards they met to talk about the session and ensure interdisciplinarity. Pedagogic tools are also needed, as well as proper facilities (classrooms, training facilities, and perhaps a kitchen for training of ergonomic habits).

The activities consist of the work performed in the program [ 42 ]. Our analysis show how osteoporosis patient education should include dissemination of information, for instance, one employee in a municipality described which information they provide:

Emp5: […] so we get into, well, what is it you, I mean, what is osteoporosis and how does it come about, and how many people get it? […] And what lies, what are the recommendations about it? And, well, about diet, but also about ergonomics, and about physical exercises.

Furthermore, we found that the activities should include time for exchanging experiences. The participants should also do physical exercises as well as ergonomic movements during the sessions with a combination of theory and practice. The information and the exercises should be repeated, and there should be homework between each session. Finally, the teachers should be able to adapt the exercises to the participants’ functional capacity (differentiation).

The inputs and activities may result in outputs, which are the goods and services the program produces [ 42 ]. For osteoporosis patient education, we found that the outputs include the fact that the program is conducted and that the participants attend the whole program. In the six municipalities, the programs are conducted during 6–12 weeks with attendance 1–2 times a week, and from our analysis it seemed to be necessary to achieve the intended outcomes. One employee in a municipality described why it is necessary that they meet several times:

Emp1: […] But I would say that, you know, we’ve been together 16 times […] So that’s a long time to be able to carry out a process, instead of that you just get told things. I mean, if all of this, if it was boiled down to just two theme days, for example, I don’t think you would get the same out of it, because people, they just need to go home and work with it.

As a result of these outputs, several outcomes may be achieved. They are divided into short-term, medium-term, and long-term outcomes (presented in Fig.  1 ). For instance, one employee in a municipality described one of the overall goals of osteoporosis patient education:

Emp3: The long-term aim is hopefully to prevent fractures. You could say that the citizens who come here to the group, they’ve already had this diagnosis, so it’s not to prevent them getting osteoporosis, but in the long term to prevent fractures.

From our analysis, several contextual factors influence whether the outcomes are achieved, for instance, the participants’ course of disease (such as fractures, pain, or functional impairments). Furthermore, meeting in groups is influential including the size and the heterogeneity of the group. For instance, it was observed that some participants differ regarding age and functional abilities. Training communities in the participants’ local areas are important for doing physical exercises, and, finally, transportation is important for attending the patient education sessions.

Four mechanisms of osteoporosis patient education were identified: motivation, recognizability, reassurance, and peer reflection. In accordance with our theoretical inspiration from realist evaluation, we will describe the resources and reasoning of the mechanisms (Path 2) as well as which outputs and outcomes might occur (Paths 3–6). Finally, we will examine the contextual factors that activate each mechanism (Path 1).

Motivation was mentioned by the majority of informants. Motivation is initiated when the participants receive information and do homework (the resources of the intervention), whereby the participants are encouraged to engage in bone healthy activities (the reasoning in the individual).

Motivation was related to the performance of bone healthy activities, for instance, physical exercises and ergonomic habits. Motivation was interpreted with the Information-Motivation-Behavioral Skills Model (IBM) as described by Fisher & Fisher [ 53 ], in which motivation consists of personal motivation (attitudes toward personal performance of health promotion behaviors) and social motivation (social support for enactment of health promotion behaviors) [ 53 , 54 ]. Therefore, motivation to engage in bone healthy activities consists of the participants’ attitudes towards these activities and the outcomes they would achieve, as well as their perceived support from others and willingness to comply with this.

Two activities were of importance for the participants’ motivation for initiating bone healthy activities: homework and dissemination of information. Several informants mentioned the importance of homework (Path 2), for instance, in one focus group where the participants talked about the homework consisting of physical exercises they were given for each session:

Par16: Well, I find it very difficult to motivate myself to do things on my own at home, that now you’ve got to get yourself together and do the exercises. But because you’ve signed up for this program, and you’re told that, well, there’s this homework, so suddenly it has become homework. Then you have to do it. When you’ve signed up for something, you have to do the things that come with it.

In this case, the homework motivated the participants to do physical exercises at home, thereby the outcome of more physical activity (Path 4) may be achieved. As well as doing homework, it is also important that the participants receive information on bone healthy activities during the program (Path 2). For instance, a health professional at a hospital explained that the participants need information in order to become motivated to engage in bone healthy activities:

Hea3: […] And then there’s still the concrete information about osteoporosis medicine and all that, which I actually think, if we didn’t include it, they would really miss it because they need to have some kind of motivation to do all the other things [bone healthy activities].

The participants also mentioned that the information provided motivated them to engage in bone healthy activities. Therefore, information and motivation were linked, which is in accordance with the IMB model. In the IMB model, information and motivation primarily work through behavioral skills to affect behavioral change. Behavioral skills includes both the patients’ objective abilities and their self-efficacy related to the particular behavioral change [ 54 ]. During osteoporosis patient education, the participants may achieve both of these skills, as they might obtain abilities, e.g., to be physically active, as well as self-efficacy related to physical activity. According to the Information-Motivation-Behavioral Skills Model (IBM model), these behavioral skills result in behavioral change, i.e., more physical activity (Path 4), as shown above.

Contextual factors activating motivation

Contextual factors which were described to activate motivation were group education, the heterogeneity of the group, and the course of the disease. In the majority of interviews with participants, it was mentioned that meeting in groups (Path 1) increases their motivation to engage in bone healthy activities. In a focus group, one participant mentioned that being in a group motivated her to turn up and do physical exercises:

Par7: I think it’s really good to be in a group. Then you’re told how you should do it, and you get going and do it properly. I mean, I try to do it at home as well, but it’s not the same.

In this case, the participant’s motivation caused her to turn up for the sessions (Path 3) and do physical exercises.

On the other hand, the heterogeneity of the group (Path 1) can decrease motivation if one participant is quite different from the other participants. For instance, a health professional mentioned that if one participant smokes and has an unhealthy lifestyle compared to the others, then this participant may not be motivated because she feels that she is left out of the group.

Moreover, the contextual factor related to the course of the disease, for instance, the pain some participants experience (Path 1), was described to be of importance for motivating the participants. Several participants mentioned that their back pain motivates them to protect their back when they clean the house. This was discussed by two participants in a focus group:

Par13: when you say that you’ve figured out to take breaks, is it because you are in so much pain that you take breaks? Par12: it’s to avoid pain.

In this case, the participants were motivated to take breaks when cleaning the house. They explained that they have learnt during patient education that they should take a break even before they feel pain. For these participants, the breaks are a good ergonomic habit, and therefore the outcome of better ergonomic habits (Path 4) may be achieved.

Besides showing how meeting in groups, the heterogeneity of the group, and the course of the disease can activate motivation to engage in bone healthy activities, we have also shown how motivation is initiated when the participants receive information and do homework. When the participants are motivated, outcomes such as more physical activity and better ergonomic habits may be achieved.

Recognizability

Recognizability is a mechanism that appeared in many interviews. It is initiated, for example, when the participants do physical exercises and ergonomic movements (the resources of the intervention), and thereafter they find it easier to remember and perform these actions (the reasoning in the individual).

Recognizability means that the participants can recall what they have learnt on the program because they have learnt it with their bodies. This is comparable with embodied knowledge as defined by Merleau-Ponty [ 54 ]. Embodied knowledge means that “the body knows how to act”, and therefore one of the important features “is that the body, not the mind, is the knowing subject” [ 55 ]. The participants in osteoporosis patient education learn how to do the physical exercises and ergonomic movements, and this knowledge can become embodied knowledge. In a focus group, one participant described how the ergonomic movements in relation to laundry and cleaning had become embodied knowledge:

Par4: There are a lot of things [ergonomic movements], well, I just think it’s kind of second nature. There are a lot of things like that.

Activities that initiate this recognizability are physical exercises, ergonomic movements, a combination of theory and practice, repetitions, and homework (Path 2). Several informants mentioned that the participants do physical exercises, thereby becoming familiar with the physical feeling in the body. One employee in a municipality described how the participants learn to recognize the feeling of doing strength training. He described that many participants are unfamiliar with strength training, but during patient education they become familiar with the feeling of using their muscles and getting tired. This was also observed during the sessions, where some participants seemed to be unfamiliar with strength training in particular. Besides practicing physical exercises, the participants also practice ergonomic movements (e.g., related to gardening, cleaning, and cooking).

Embodied knowledge “can be better presented by performance than by verbal explanation” [ 55 ], and therefore it is useful that physical exercises and ergonomic movements are demonstrated and practiced. However, many informants mentioned that the participants should not only do physical exercises but they should also have a combination of theory and practice and they should do repetitions. One employee in a municipality described how she ensures this in her sessions:

Emp1: […] So it’s very much about getting the repetitions in. […] But because we keep talking about it, and we keep on with, well, quite simply, trying things out. So maybe that gives them an idea. Because, you know, we go out for a walk, and we see how it feels. Now we know where the muscle is, we can feel where it is ourselves, have I found it, haven’t I found it. Well, so, what happens when I walk slowly, oh, so then it disappears. What happens when I walk quickly, oh yes, then it perks up.

Homework between the sessions was mentioned by few informants. The homework gives the participant an opportunity to ask questions at the upcoming session. One employee in a municipality described the importance of homework:

Emp6: […] We have more success when we get them to go home and try during the program. […] Because then we see that when they do it during the program, there’s better potential for development afterwards. So, they don’t have to go home and reinvent the wheel when we’ve let them go, because then they won’t be able to ask the questions about it, and all that, which means that they actually succeed in getting started with some of it.

When the participants do the mentioned activities, the mechanism recognizability is initiated, and thereafter we have seen that outcomes such as more physical activity and better ergonomic habits (Path 4) may be achieved. Furthermore, several employees and health professionals described how recognizability is important for the overall outcome retention, i.e., that the participants continue doing the bone healthy activities. They explained that to do the bone healthy activities in the long run it is important to do, for example, homework, as mentioned by the employee above (Emp6).

Contextual factors activating recognizability

Training communities (Path 1) were of importance for participants to implement the bone healthy activities. Because the participants do physical exercises together with a group of people during the sessions, recognizability can also be related to the feeling of practicing with other people (during the program). Therefore, recognizability can also be activated in the long run if the participants have training communities to do physical exercises with (after the program has ended). Some participants described how they need other people to do physical exercises with; otherwise, they would not do physical exercises:

Par12: I mean, I go to the gym because training alone – well, that’s probably not going to happen. So, I need all that with being with other people and…

The contextual factor related to the course of the disease (Path 1) can also activate recognizability. Few participants mentioned that during the sessions they discovered that they performed worse in physical exercises than they thought they would. The course of the disease may have left marks on their physical health, which they had not discovered. When they do physical exercises, they realize how their body feels now, and they learn to recognize this feeling. Thereby, they acquire new (or updated) embodied knowledge regarding physical exercises.

Therefore, contextual factors related to the course of the disease and training communities can activate the mechanism recognizability. As we have shown, five activities, namely physical exercises, ergonomic movements, a combination of theory and practice, repetitions, and homework, initiate the mechanism. As a result, outcomes such as more physical activity, better ergonomic habits, and retention may be achieved.

Reassurance

Reassurance was a consistent theme in the vast majority of the interviews. Reassurance is initiated when the participants receive information and do physical exercises (the resources of the intervention), whereby the participants become calmer (the reasoning in the individual).

Reassurance means that the participants become calm after feeling fear. Reassurance was interpreted with elements of the Extended Parallel Process Model (EPPM) formulated by Witte [ 56 ], using which we examined the process whereby the participants move from being afraid to being calm.

Several employees and health professionals mentioned that osteoporosis patients may experience fear when they are diagnosed, which was also expressed by few participants. They worried about fracturing their bones, and this fear may itself result in physical inactivity. However, the participants can be reassured by receiving information and doing physical exercises (Path 2). One employee in a municipality mentioned an example of a participant who was on sick leave from work:

Emp3: […] But she was nervous, and she was scared of moving her body in general… But via that we could give her… We could help her feel safe to move during the session, we could give her knowledge about what is it you’re suffering from, what’s happening in the body when you have this osteoporosis. Well, then we got her ready to be able to start going to work again…

In this and many other examples, the participants were reassured that they can be physically active without being afraid of fractures. During observations, the participants also seemed to be calm when they performed aerobic exercises, even if this included running, jumping, etc.

The EPPM describes how a person experiencing fear should receive efficacy information containing two components: 1. response efficacy , which is information about the effectiveness of a recommendation and 2. self-efficacy information , which includes arguments that the person is able to follow the recommendation. This information should lead to a danger control process in which the person initiates the recommended activity [ 57 ]. As we have seen above, the participants in osteoporosis patient education receive this efficacy information, for instance, when they are informed about why it is important to be physically active (response efficacy) and when they participate in physical exercises and experience that they are able to do it (self-efficacy information). Thereby, the participants are reassured, and the outcome physical activity (Path 4) may be achieved.

Even though most participants are reassured, there is also a risk that their fear increases. One employee in a municipality mentioned that they had included sessions about pain and assistive technology, but these were dropped because they experienced that the participants became more afraid when hearing about how their life could turn out.

Although this fear should be avoided, experiencing fear can lead to the participants trying to prevent having more complications, as mentioned by one employee in a municipality:

Emp6: Well, sometimes at the start of our program we see that, actually some of the participants with less pain, that they get scared by hearing stories from the others. And of course, that’s where you have to turn it around and say: it’s okay to be nervous, it’s okay, because you should know that it is a risk, but you should also, to avoid getting to that point, then we should tackle these things, and these, and these.

Even though it is not the intention to evoke fear in the participants, the fear that does appear can be useful to achieve behavior change, which is also described in the EPPM model, in which fear is evoked more intentionally [ 58 ].

Contextual factors activating reassurance

The course of the disease is a contextual factor of importance for activating reassurance (Path 1). Several employees and health professionals mentioned that it is especially the newly diagnosed as well as the participants without previous fractures who experience fear and therefore are reassured during patient education.

We highlighted above how some activities unintentionally may increase fear. One contextual factor can trigger the fear as well, namely the heterogeneity of the group (Path 1). Many employees and health professionals mentioned that the newly diagnosed may be afraid to hear stories from participants with more complications. Therefore, the participants at hospitals are divided into groups reflecting whether they have had vertebral fractures or not. One health professional described why it is important to separate them:

Hea3: […] And so we make groups with vertebral fractures and without vertebral fractures, because it can be kind of scary to be surrounded by participants that have had vertebral fractures and who have lots of stories about, so I sneezed and my vertebra collapsed. You know, these horror stories that participants who haven’t had a vertebral fracture don’t necessarily benefit from, because that doesn’t need to be their story. At the same time, we also have to include those who have had a vertebral fracture, and that this is their story, so they get acknowledgement, that this is happening for you, and how can we then help you in all of this?

Therefore, it was described as advantageous to ensure some homogeneity of the groups to minimize the risk of evoking fear.

We have shown how the mechanism reassurance is initiated when the participants receive information and when they do physical exercises, i.e., they receive efficacy information as described by Witte [ 57 ]. Thereby, they may achieve outcomes such as more physical activity. Reassurance is primarily activated in participants who are newly diagnosed and without previous fractures, whereas unintended fear can be activated in heterogeneous groups.

Peer reflection

Peer reflection is a mechanism that is mainly initiated when the participants exchange experiences (the resources of the intervention) and thereby relate to one another (the reasoning in the individual).

Peer reflection means that the participants see themselves in one another and learn from each other. This is in accordance with peer support as defined by Mead et al. [ 58 ], which “is a system of giving and receiving help founded on key principles of respect, shared responsibility and mutual agreement of what is helpful” [ 58 ]. Peer reflection is initiated when the participants exchange experiences (Path 2), which was mentioned by almost all informants.

For instance, one employee in a municipality gave an example of a participant who was traveling across the country by train. She was in doubt if she could lift her suitcase into the train and was about to cancel the trip. However, when experiences were exchanged in the group, she was given advice on how to handle the problem with the suitcase, for instance ordering assistance from the staff. She could see herself and her situation in other participants’ similar situations. In the end, she went on the trip because of the advice she was given.

Moreover, exchange of experience was observed during more sessions as well as during almost all interviews where the participants asked each other questions related to bone healthy activities. For instance, during a focus group interview the participants discussed the importance of vitamin K and helped each other find out if they should take this supplement:

Par17: yes, but some of the calcium pills you get with [name on calcium pills], they have it with both D3 and K2, don’t they? And some places they write that it’s fine, and other places, well, we get the vitamin K we need through a normal diet? […]. Par15: but is vitamin K broken down, or does it build up [in the body]? Par17: there’s K1 and K2. Par14: it can definitely build up. Par17: ah, but you can get very confused about that, if you ask me.

In this case, the participants exchanged experiences regarding vitamin K; they gave and received help from each other as described by Mead et al. [ 58 ]. During the interview, the participants indicated that they pay a great deal of attention to their diet, and therefore they could see themselves in one another and take examples from each other. They can help each other align their supplements to their diet, and therefore the outcome healthier diet (Path 4) may be achieved.

Exchange of experience is an important activity, but one health professional mentioned that the health professionals to some degree can imitate and replace this activity if they include patient stories in their teaching. However, one important advantage of exchange of experience between the participants themselves is that the participants can challenge each other in a way that health professionals cannot. Mead et al. [ 58 ] find that “as trust in the relationship builds, both people are able to respectfully challenge each other when they find themselves in conflict”. The aforementioned health professional also found it an advantage that the participants can challenge each other:

Hea1: […] What is also important in exchange of experience is that you as patient to patient, you can perhaps challenge each other in a different way than you sometimes think you can as a health professional. I mean, for example, say ‘so, are you going to go home and take some osteoporosis medicine after everything you’ve heard now?’ to someone who has never done it, because she doesn’t think she would do it.

Therefore, exchange of experience between participants allows them to challenge each other, which may be important for activating the mechanism of peer reflection.

Contextual factors activating peer reflection

Two contextual factors were of importance, namely the size of the group and the heterogeneity of the group. As mentioned above, the heterogeneity of the group (Path 1) can have a negative influence if the participants become afraid when hearing the other participants’ stories. Conversely, the heterogeneity can also have a positive influence, as the participants get advice from those who are at another stage in the disease. For instance, during a focus group interview the participants agreed that even though they are at different stages, they all have challenges which the others benefit from hearing about.

When meeting in groups, the size of the group (Path 1) may be of importance for peer reflection, which was mentioned by many informants. One employee in a municipality explained how a group of 10 may interact better than a group of four:

Emp3: […] You could say, when we have 10 participants in a group […] it often gives a bigger, how shall I put it, a bigger kind of flow in the group in relation to the contact they seek out in each other, conversation, ping pong between the participants.

We have shown how the mechanism peer reflection is influenced by the size of the group as well as the heterogeneity of the group, which can have both positive and negative influence. The mechanism is initiated when the participants exchange experiences, thereby the outcome healthier diet may be achieved.

In this study, we developed a program theory of osteoporosis patient education, with a focus on examining the mechanisms of change. This theory describes what it is about the programs that lead change (i.e., outcomes). Four mechanisms explained how and why the programs work: motivation, recognizability, reassurance, and peer reflection. We have shown how the mechanisms are evoked by activities such as dissemination of information, exchange of experience, physical exercises, ergonomic movements, a combination of theory and practice, repetitions, and homework. A number of contextual factors activated the mechanisms: factors related to group education including the size and the heterogeneity of the group, the course of the disease, and training communities. Subsequently, more physical activity, better ergonomic habits, healthier diet, and retention may be achieved.

In accordance with our study, Jensen et al. (2016) identified factors, which are associated with implementing a bone healthy lifestyle after attending patient education [ 59 ]. One factor includes that the participants experience a need and motivation to implement the activities. Motivation may be evoked if the participants experience pain, which is similar to our findings. Another factor includes that the participants incorporate a bone healthy lifestyle into social activities. Likewise, we found that training communities play an important role for behavior change and doing physical exercises in the long run to achieve the medium and long-term outcomes.

We found that the participants may experience fear when diagnosed with osteoporosis but that they are reassured during patient education. This could be compared to Weston et al., who found that women diagnosed with osteoporosis were reassured regarding their treatment during consultations with their GP [ 60 ]. However, in our study we found that the participants are reassured because they receive information and do physical exercises, whereas Weston et al. found that trust in the GP was important for reassurance.

Furthermore, we found that the participants in some cases become more afraid during patient education sessions. Similarly, Nielsen et al., found that patients handle knowledge either by retaining hope or producing fear [ 61 ]. Nielsen et al. additionally found that patients participating in patient education in which experiences are exchanged become more confident and secure regarding their everyday life. Likewise, we found that exchange of experience is an important activity, which may result in undertaking more bone healthy activities.

Implication of findings

This study contributes with insights and explanations about how and why osteoporosis patient education can work.

Our findings show what activities in osteoporosis patient education and what contextual factors activate the mechanisms of change and thereby potentially causing the intended outcomes short-term (more knowledge, more physical activity, healthier diet, better ergonomic habits, more sense of control in the health sector), medium-term (more self-efficacy, better physical function, better balance, better adherence to medication, better pain management, better psychological well-being) and long-term (better quality of life, fewer fractures, better daily functional capacity). Therefore, to implement osteoporosis patient education in practice one should consider these activities and contextual factors. We have shown that activities such as exchange of experience and a combination of theory and practice should be implemented, and contextual factors related to the course of the disease and meeting in groups should be considered.

Furthermore, we examined four mechanisms, that may result in intended outcomes. However, the mechanism motivation may be a prerequisite for achievement of more short-term outcomes, namely more physical activity, healthier diet, and better ergonomic habits, as one can ask whether, e.g., more physical activity can be achieved without motivation. Therefore, motivation probably should be activated in cases when patient education aims to improve physical activity, diet, and ergonomic habits, and maybe it should be activated together with other mechanisms. Future research should explore the specific role of motivation and the possible combination with other mechanisms in order to enable behavior change on the longer run.

In our program theory, we have illustrated how participation in osteoporosis patient education may result in several short-term, medium-term, and long-term outcomes. Nevertheless, most examples of achieved outcomes were related to short-term outcomes (Path 4), probably due to the design of the study. Most of the participants had just finished the patient education and therefore they could only provide examples of the short-term outcomes. Moreover, in cases where the municipalities had not made evaluations of the effectiveness of the programs, they could not provide evidence, but only assumptions, of the medium-term and long-term outcomes. To gain evidence, epidemiological studies are needed, which we will conduct at a later stage. In our program theory, we did include medium-term and long-term outcomes based on a systematic review [ 21 ], data from observations and interviews, as well as expert knowledge from researchers in intervention and osteoporosis research as described.

From the examples of short-term outcomes, we saw a focus on physical activity and ergonomic habits, which may reflect the activities in the programs as well as the competences of the teachers. The programs allocate a great deal of time to physical activity and ergonomic movements, whereas medication takes up less time. Physical activity and ergonomic movements are important for prevention of falls, management of pain and quality of life [ 26 , 30 , 62 , 63 , 64 ], however, adherence to medication is the most important intervention for prevention of fractures [ 8 ]. Therefore, the municipalities may benefit from even more interdisciplinarity and involvement, such as from physicians who could conduct sessions about medication. However, many employees described that most participants adhere to their medication, and therefore adherence may not be a problem for most of the participants.

To achieve long-term outcomes, participants' behavioral changes are crucial, meaning that participants should maintain bone-healthy activities, such as physical activity, healthier diets, and better ergonomic habits, over an extended period [ 8 ]. These behaviors require ongoing commitment and reinforcement to become integrated into individuals' daily routines and should endure over time. Therefore, consistent behavioral changes are vital for realizing the full potential of osteoporosis patient education in obtaining medium- and long-term outcomes (e.g., fewer fractures). However, it is important to note, that the recommendations for these bone-healthy activities depend on the course of the disease [ 65 ]. Therefore, the recommendations may change over the life course, and therefore it may be difficult for the teachers to disseminate information that the participants can use in the longer term, potentially decreasing the likelihood of the behavior change on the long run. This is a general limitation related to patient education conducted once in life. Maybe, the program should be repeated and adjusted several times during the life course or at least if the disease progresses [ 66 ]. This may apply for patient education but also for lifestyle interventions in general.

Furthermore, we have described how the groups in osteoporosis patient education in some respects seem to be heterogeneous, for instance, regarding age and functional abilities, but in other aspects they seem homogeneous, as they primarily consist of socioeconomically advantaged citizens. This is another limitation related to the programs, as socioeconomically disadvantaged citizens are not necessarily recruited. It may be because participation to some degree requires that the citizens are aware of the program and contact the municipality [ 67 , 68 ]. Therefore, strategies to recruit socioeconomically disadvantaged citizens should be developed so that citizens from all social classes participate in osteoporosis patient education. Moreover, future research should examine to which extent our findings also apply to socioeconomically disadvantaged citizens.

Most of the mechanisms of change are initiated by activities which require a large number of resources. For instance, the mechanism recognizability is initiated when the participants do physical exercises, ergonomic movements, repetitions, homework, and when they have a combination of theory and practice. All of this requires resources such as staff, pedagogic tools, classrooms, and training facilities, and in addition it requires that the participants meet several times. Therefore, our findings indicate that osteoporosis patient education may require some resources and should be conducted over several sessions, and consequently one session would not be sufficient.

Finally, we found some examples of the participants experiencing fear. As described, this fear may be useful for motivating the participants, but evoking fear is not the intention of the patient education programs. At hospitals, the participants are divided into groups reflecting whether they have had vertebral fractures, and this may reduce the risk of evoking fear. Therefore, it may be beneficial to divide the participants in the municipalities in the same way, although this probably would not be a realistic setup as it requires many participants. However, the municipalities could make groups across municipalities, and to minimize transportation online participation or via other technology could be considered. Such solutions could be relevant for other countries as well, and future research should therefore examine these possibilities.

Strengths and limitations

This qualitative study has several strengths. Firstly, we included different methods (results from a systematic review, observations, and interviews) as well as different stakeholders (health professionals at hospitals, employees in municipalities, and participants in patient education), which is recommended within realist evaluation [ 39 ]. As a mechanism is an underlying construct [ 39 ], it is possible that the mechanisms are not discovered by the informants and revealed during the interviews, and therefore it is of special importance that we also conducted observation to get experience with the programs. Moreover, it is of importance that we applied theories to understand and interpret our findings. Secondly, we developed the program theory in an iterative process, which allowed an ongoing and careful refinement. Finally, we chose the informants for interviews and the locations for observation, so that these were widely represented with respect to geography, the size of the municipality, the participants, the content, and the referral to patient education.

The study also has some limitations. Among the participants from patient education, we only included those who had completed all or almost all sessions. Therefore, we did not include informants who had dropped out of the program, and thus we attained information from only those who presumably were satisfied with the program. Moreover, the participants chose to participate in group education, whereas others might refuse this offer because they are not interested in or able to be in a group. Consequently, we also attained information from only those who find it beneficial to be in a group. Another limitation concerns the size of the focus groups, as there were five participants in most groups. Some of the participants had little to say, perhaps because the group was too big to discuss sensitive subjects with, and therefore an individual interview could have benefitted them. Finally, the majority of the participants had just finished the program, and therefore we do not have a long follow-up period, though it could have provided us with more examples of the long-term outcomes. On the other hand, it is more likely that the participants better remember their experiences with the program when the follow-up period is short, and therefore this limitation is also a strength.

No previous studies have developed a program theory of osteoporosis patient education. In this qualitative study, we developed a program theory illustrating the elements in osteoporosis patient education that provides an explanation of the potential effectiveness of such programs, which will we evaluated in a future study. We examined the mechanisms of change, including which activities should be implemented and which contextual factors should be considered to achieve potential outcomes. The findings show that activities, such as dissemination of information, exchange of experience, physical exercises, ergonomic movements, a combination of theory and practice, repetitions, and homework in osteoporosis patient education evoke motivation, recognizability, reassurance, and peer reflection. Additionally, we show that the following contextual factors activated the mechanisms: factors related to group education including the size and the heterogeneity of the group, the course of the disease, and training communities. This is of special importance for future implementation and evaluation of osteoporosis patient education.

Availability of data and materials

The data analyzed during the current study are not publicly available before the termination of a subsequent study but are available from the corresponding author on reasonable request.

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Acknowledgements

The authors would like to thank all informants contributing to the study.

The research was supported by National Research Center for Bone Health, Zealand University Hospital and National Institute of Public Health, University of Southern Denmark.

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Mette Rubæk, Marie Broholm-Jørgensen & Susan Andersen

National Research Center for Bone Health, Zealand University Hospital, Køge, Denmark

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Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark

Pernille Ravn Jakobsen

Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark

Mette Juel Rothmann

Department of Endocrinology, Odense University Hospital, Odense, Denmark

Department of Clinical Research, University of Southern Denmark, Odense, Denmark

Department of Endocrinology, Aarhus University Hospital, Aarhus, Denmark

Bente Langdahl

Department of Clinical Medicine, Aarhus University, Aarhus, Denmark

Centre for Childhood Health, Copenhagen, Denmark

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Contributions

MR, TH, SA, MFH, and BL planned the study including protocol formulation, data collection and analysis. MB-J, TH, and MR developed the interview guides. MJR and BL contributed to the recruitment of informants. MR conducted observations and interviews with ongoing feedback from MB-J, TH, SU, and MFH. MR analyzed data with ongoing feedback from MB-J and all authors at a workshop. All authors contributed to the final analysis, formulation of program theory, and identification of mechanisms. All authors were contributors in writing the manuscript. All authors read and approved the final manuscript.

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Correspondence to Teresa Holmberg .

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The research project was approved by Research Ethics Committee, University of Southern Denmark (approval ID 20/70420). Informed consent was retrieved from participants in osteoporosis patient education after providing written and oral information. All methods were performed in accordance with the Declaration of Helsinki.

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Competing interests.

Mette Friberg Hitz has received grants from Orkla Care, Denmark, UCB, Ellab Fond, and Amgen and received personal payment in relation to lectures and advisory board meetings. All other authors have no competing interests.

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Supplementary Information

Additional file 1. .

Description of elements in program theory with examples of empirical data. 

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Rubæk, M., Broholm-Jørgensen, M., Andersen, S. et al. Development of a program theory for osteoporosis patient education in Denmark: a qualitative study based on realist evaluation. BMC Geriatr 24 , 346 (2024). https://doi.org/10.1186/s12877-024-04957-8

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Received : 15 December 2023

Accepted : 08 April 2024

Published : 16 April 2024

DOI : https://doi.org/10.1186/s12877-024-04957-8

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