Theoretical Framework

The role of theory in a research project can be described as a “lens” through which phenomena are studied. It enables the researcher to illuminate specific aspects of the phenomena while masking others (Anfara Jr. & Mertz, 2006, p. 15). The theory, therefore, plays a critical role in framing and conducting every phase of a research study (Anfara Jr. & Mertz, 2006). As such, a theoretical framework is used to guide an investigation by connecting assumptions, fundamental beliefs and purposes for conducting the specific study (Anfara Jr. & Mertz, 2006).

The “lens” I wanted to use while looking at the perceptions and frustrations experienced by HCPs and THPs had to be narrow enough to focus on the HCP and THP individually, but also broad enough to embrace the landscape surrounding them. To include the surrounding

environment, I looked at ecological models that include a focus on the individual. For purposes of this study, ecology can be defined as “the interrelations between human beings and their environments” (L. W. Green, Richard, & Potvin, 1996, p. 270). Two models that focus on the interrelationships between individual behaviour and its environmental determinants are the social ecological model (McLeroy, Bibeau, Steckler, & Glanz, 1988), which explains human behaviour at the hand of five levels of analysis (intrapersonal factors, interpersonal processes, institutional factors, community factors and public policy) and Bronfenbrenner’s earlier ecological systems theory (EST) (1977, 1979), which states that forces surrounding the individual comprise of interdependent systems that constitute the ecological environment.

The difference between the two theories mentioned above is the direction from which it approaches the research problem. The social ecological model focuses its attention on

environmental interventions that change individual behaviour, whereas EST allows for attention to “both behaviour and its individual and environmental determinants” (McLeroy et al., 1988, p. 354). It was for this reason that I chose EST. It places emphasis on the processes in and between interrelated social systems and the individual, which enables one to investigate the perceptions and frustrations of HCPs and THPs and how these impact on patients, other healthcare

professionals and the broader social context but also how these impact on the HCP and the THP (Bronfenbrenner, 1977). Bronfenbrenner seemed to be his own fiercest critic and continually revised, altered and extended his theory. This ultimately led to the development of the

bioecological theory of human development, which was published in 2005, also the year of his death (Tudge, Mokrova, Hatfield, & Karnik, 2009). However, EST is not without its critics, as Watling Neal and Neal (2013, p. 723) reveal in an article that argues that “the precise

relationship of subsystems to one another remain elusive.” In their article, they point out that the various relationships between the systems are obscured when seen as ‘nested’ within one another. These relationships should rather be conceptualized as ‘networked’, in other words, overlapping but non-nested. They also offer alternative descriptions for the micro-, meso-, exo-

and macro-systems that align with the networked view. They conclude that this view provides EST with greater flexibility and a better understanding of the relationships between the different systems (Watling Neal & Neal, 2013). Notwithstanding this criticism, EST provides me with the most suitable framework with which to view the perceptions and frustrations of HCPs and THPs.

According to Bronfenbrenner’s EST (1979), human behaviour can be considered in terms of a hierarchy of related systems with interactional patterns between and within the systems (Moore, 2003). Bronfenbrenner describes it as “a nested arrangement of structures, each contained within the next” (Bronfenbrenner, 1977, p. 514). The EST is used in the present study as it enables one to describe how the perceptions of HCPs and THPs could influence the various interrelated systems that form part of the diagnosis and treatment of seizures.

Four levels of interaction are outlined in the EST (Bronfenbrenner, 1977) namely the micro-, meso-, exo- and macro-systems. Bronfenbrenner (2005) added another dimension to later work, namely the chronosystem. The different levels describe individuals as part of subsystems, which in turn form part of a larger supra-system. The person as an individual is seen as the centre of the entire system, with the various systems forming permeable and bidirectional layers around the person. The key to this theory lies in the “interaction within the layers of the structures and the interaction of the structures between the layers” (Härkönen, 2007, p. 7). The person is made up of various levels of knowledge, skills, self-confidence, perceptions, frustrations and

motivations and has different roles, that influence the patterns of interaction with and within the different systems (Gregson et al., 2001; McLeroy et al., 1988). The person in the present study is the HCP or THP in the role of service provider, rendering a service as a private practitioner. The HCP or THP have varying levels of training and expertise and have certain attitudes and beliefs. The first layer surrounding the person is called the microsystem.

The microsystem can be described as the pattern of the activities and the interpersonal relationships of a person who assumes a specific role in a particular place, with another person in a face-to-face setting (Bronfenbrenner, 1977; Härkönen, 2007; Visser, 2012). Bidirectional interactions are strongest in the microsystem and behaviours can be influenced by the attitudes and actions of others (Gregson et al., 2001; Härkönen, 2007). In this study, the pattern of interaction between the HCP or THP, the patient, the family of the patient and other HCPs and THPs can be described as forming the microsystem of the HCP and the THP.

The mesosystem refers to the linkages between the various microsystems in which the HCP or THP participates and can be described as a system of microsystems (Bronfenbrenner, 1979). The inter-relationships between the different microsystems can play a major role in how the person experiences the mesosystem (Härkönen, 2007). Conflict or disagreements may arise in the mesosystem if the structures in the microsystems oppose each other or cultivate different beliefs and expectations (Härkönen, 2007). An example of this level of influence would be the

positive or negative interactions that take place between the patient, family members of the patient and other HCPs and THPs without the direct involvement of the HCP or THP who forms the centre of the system.

The exosystem can be seen as an extension of the mesosystem and includes both formal and informal social structures that influence and delimit the person, even though these structures do not directly contain the person (Bronfenbrenner, 1977; Visser, 2012). Therefore, the person may be seen as a participant in these structures, but not necessarily a member (Härkönen, 2007). Structures in the exosystem may include institutions or organizations responsible for regulating or providing services to the healthcare industry. This may include medical aid funds,

professional organizations, and healthcare infrastructure such as hospitals, clinics, providers of equipment and medication and referral practices. Once again, the relationships between the various structures in the exosystem are rated as positive or negative, and this will ultimately affect the HCP or THP’s perception of the exosystem.

The macrosystem refers to the wider societal and cultural norms, such as policies regarding health and economic standards, legal and political systems, attitudes and belief systems, as well as cultural values (Bronfenbrenner, 1977; Visser, 2012). Bronfenbrenner explains that “Macrosystems are conceived and examined not only in structural terms but as carriers of information and ideology that, both explicitly and implicitly, endow meaning and motivation to particular agencies, social networks, roles, activities, and their interrelations” (1977, p. 515). The macrosystem encompasses all the other layers and as such penetrates and influences every structure in the micro-, meso-, and exosystems. An example could include the government’s decision to move the responsibility of providing healthcare services to individual communities without offering adequate infrastructure to support this decision or formally recognizing the role of THPs in these communities.

The EST was used to interpret and describe the perceptions and frustrations experienced by HCPs and THPs holistically by interpreting the ideas and understandings they have of seizures, themselves and their environments.