Using quantitative and qualitative data in health services research - what happens when mixed method findings conflict? [ISRCTN61522618]

Discrepancies between qualitative and quantitative evaluation of randomised controlled trial results: achieving clarity through mixed methods triangulation

BACKGROUND

Mixed methods are commonly used in health services research; however, data are not often integrated to explore complementarity of findings. A triangulation protocol is one approach to integrating such data. A retrospective triangulation protocol was carried out on mixed methods data collected as part of a process evaluation of a trial. The multi-country randomised controlled trial found that a web-based training in communication skills (including use of a patient booklet) and the use of a C-reactive protein (CRP) point-of-care test decreased antibiotic prescribing by general practitioners (GPs) for acute cough. The process evaluation investigated GPs' and patients' experiences of taking part in the trial.

METHODS

Three analysts independently compared findings across four data sets: qualitative data collected view semi-structured interviews with (1) 62 patients and (2) 66 GPs and quantitative data collected via questionnaires with (3) 2886 patients and (4) 346 GPs. Pairwise comparisons were made between data sets and were categorised as agreement, partial agreement, dissonance or silence.

RESULTS

Three instances of dissonance occurred in 39 independent findings. GPs and patients reported different views on the use of a CRP test. GPs felt that the test was useful in convincing patients to accept a no-antibiotic decision, but patient data suggested that this was unnecessary if a full explanation was given. Whilst qualitative data indicated all patients were generally satisfied with their consultation, quantitative data indicated highest levels of satisfaction for those receiving a detailed explanation from their GP with a booklet giving advice on self-care. Both qualitative and quantitative data sets indicated higher patient enablement for those in the communication groups who had received a booklet.

CONCLUSIONS

Use of CRP tests does not appear to engage patients or influence illness perceptions and its effect is more centred on changing clinician behaviour. Communication skills and the patient booklet were relevant and useful for all patients and associated with increased patient satisfaction. A triangulation protocol to integrate qualitative and quantitative data can reveal findings that need further interpretation and also highlight areas of dissonance that lead to a deeper insight than separate analyses.

Using theory to improve low back pain care in Australian Aboriginal primary care: a mixed method single cohort pilot study

Background

Low back pain (LBP) care is frequently discordant with research evidence. This pilot study evaluated changes in LBP care following a systematic, theory informed intervention in a rural Australian Aboriginal Health Service. We aimed to improve three aspects of care; reduce inappropriate LBP radiological imaging referrals, increase psychosocial oriented patient assessment and, increase the provision of LBP self-management information to patients.

Methods

Three interventions to improve care were developed using a four-step systematic implementation approach. A mixed methods pre/post cohort design evaluated changes in the three behaviours using a clinical audit of LBP care in a six month period prior to the intervention and then following implementation. In-depth interviews elicited the perspectives of involved General Practitioners (GPs). Qualitative analysis was guided by the theoretical domains framework.

Results

The proportion of patients who received guideline inconsistent imaging referrals (GICI) improved from 4.1 GICI per 10 patients to 0.4 (95 % CI for decrease in rate: 1.6 to 5.6) amongst GPs involved in the intervention. Amongst non-participating GPs (locum/part-time GPs who commenced post-interventions) the rate of GICI increased from 1.5 to 4.4 GICI per 10 patients (95 % CI for increase in rate: .5 to 5.3). There was a modest increase in the number of patients who received LBP self-management information from participating GPs and no substantial changes to psychosocial oriented patient assessments by any participants; however GPs qualitatively reported that their behaviours had changed. Knowledge and beliefs about consequences were important behavioural domains related to changes. Environmental and resource factors including protocols for locum staff and clinical tools embedded in patient management software were future strategies identified.

Conclusions

A systematic intervention model resulted in partial improvements in LBP care. Determinants of practice change amongst GPs were increased knowledge of clinical guidelines, education delivered by someone considered a trusted source of information, and awareness of the negative consequences of inappropriate practices, especially radiological imaging on patient outcomes. Inconsistent and non-evidence based practices amongst locum GPs was an issue that emerged and will be a significant future challenge. The systematic approach utilised is applicable to other services interested in improving LBP care.

The clinical and cost effectiveness of a Breathlessness Intervention Service for patients with advanced non-malignant disease and their informal carers: mixed findings of a mixed method randomised controlled trial

BACKGROUND

Breathlessness is the most common and intrusive symptom of advanced non-malignant respiratory and cardiac conditions. The Breathlessness Intervention Service (BIS) is a multi-disciplinary complex intervention, theoretically underpinned by a palliative care approach, utilising evidence-based non-pharmacological and pharmacological interventions to support patients with advanced disease in managing their breathlessness. Having published the effectiveness and cost effectiveness of BIS for patients with advanced cancer and their carers, we sought to establish its effectiveness, and cost effectiveness, in advanced non-malignant conditions.

METHODS

This was a single-centre Phase III fast-track single-blind mixed method RCT of BIS versus standard care for breathless patients with non-malignant conditions and their carers. Randomisation was to one of two groups (randomly permuted blocks). Eighty-seven patients referred to BIS were randomised (intervention arm n = 44; control arm n = 43 received BIS after four-week wait); 79 (91 %) completed to key outcome measurement. The primary outcome measure was 0-10 numeric rating scale for patient distress due to breathlessness at four weeks. Secondary outcome measures were Chronic Respiratory Questionnaire, Hospital Anxiety and Depression Scale, Client Service Receipt Inventory, EQ-5D and topic-guided interviews.

RESULTS

Qualitative analyses showed the positive impact of BIS on patients with non-malignant conditions and their carers; quantitative analyses showed a non-significant greater reduction in the primary outcome ('distress due to breathlessness'), when compared to standard care, of -0.24 (95 % CI: -1.30, 0.82). BIS resulted in extra mean costs of £799, reducing to £100 when outliers were excluded; neither difference was statistically significant. The quantitative findings contrasted with those previously reported for patients with cancer and their carers, which showed BIS to be both clinically and cost effective. For patients with non-malignant conditions there was a notable trend of improvement over both trial arms to the key measurement point; participants may have experienced a therapeutic effect from the research interviews, diluting the intervention's impact.

CONCLUSIONS

BIS had a statistically non-significant effect for patients with non-malignant conditions, and slightly increased service costs, but had a qualitatively positive impact consistent with findings for advanced cancer. Trials of palliative care interventions should consider multiple, mixed method, primary outcomes and ensure that protocols limit potential contaminating therapeutic effects in study designs.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN04119516 (December 2008); ClinicalTrials.gov NCT00678405 (May 2008).

Adding Qualitative and Mixed Methods Research to Health Intervention Studies: Interacting With Differences

The purpose of this article is to explain how to improve intervention designs, such as randomized controlled trials (RCTs), in health science research using a process philosophy and theory known as dialectical pluralism (DP). DP views reality as plural and uses dialectical, dialogical, and hermeneutical approaches to knowledge construction. Using DP and its "both/and" logic, and its attempt to produce new creative syntheses, researchers on heterogeneous teams can better dialogue with qualitative and mixed methods approaches, concepts, paradigms, methodologies, and methods to improve their intervention research studies. The concept of reflexivity is utilized but is expanded when it is a component of DP. Examples of strategies for identifying, inviting, and creating divergence and integrative strategies for producing strong mixed methods intervention studies are provided and illustrated using real-life examples.

Children With Mild Bilateral and Unilateral Hearing Loss: Parents' Reflections on Experiences and Outcomes

Children with mild bilateral and unilateral hearing loss are now commonly identified early through newborn hearing screening initiatives. There remains considerable uncertainty about how to support parents and about which services to provide for children with mild bilateral and unilateral hearing loss. The goal of this study was to learn about parents' experiences and understand, from their perspectives, the impact of hearing loss in the mild range on the child's functioning. Parents of 20 children in Ontario, Canada, participated in the study. The median age of identification of hearing loss was 4.6 months (interquartile range: 3.6, 10.8). Parents appreciated learning early about hearing loss, but their experiences with the early process were mixed. Parents felt that professionals minimized the importance of milder hearing loss. There was substantial uncertainty about the need for hearing aids and the findings suggest that parents need specific guidance. Parents expressed concerns about the potential impact of hearing loss on their child's development, particularly at later ages.

Successful development and testing of a Method for Aggregating The Reporting of Interventions in Complex Studies (MATRICS)

OBJECTIVES

To develop a tool for the accurate reporting and aggregation of findings from each of the multiple methods used in a complex evaluation in an unbiased way.

STUDY DESIGN AND SETTING

We developed a Method for Aggregating The Reporting of Interventions in Complex Studies (MATRICS) within a gastroenterology study [Evaluating New Innovations in (the delivery and organisation of) Gastrointestinal (GI) endoscopy services by the NHS Modernisation Agency (ENIGMA)]. We subsequently tested it on a different gastroenterology trial [Multi-Institutional Nurse Endoscopy Trial (MINuET)]. We created three layers to define the effects, methods, and findings from ENIGMA. We assigned numbers to each effect in layer 1 and letters to each method in layer 2. We used an alphanumeric code based on layers 1 and 2 to every finding in layer 3 to link the aims, methods, and findings. We illustrated analogous findings by assigning more than one alphanumeric code to a finding. We also showed that more than one effect or method could report the same finding. We presented contradictory findings by listing them in adjacent rows of the MATRICS.

RESULTS

MATRICS was useful for the effective synthesis and presentation of findings of the multiple methods from ENIGMA. We subsequently successfully tested it by applying it to the MINuET trial.

CONCLUSION

MATRICS is effective for synthesizing the findings of complex, multiple-method studies.

Blue space geographies: Enabling health in place

Drawing from research on therapeutic landscapes and relationships between environment, health and wellbeing, we propose the idea of 'healthy blue space' as an important new development Complementing research on healthy green space, blue space is defined as; 'health-enabling places and spaces, where water is at the centre of a range of environments with identifiable potential for the promotion of human wellbeing'. Using theoretical ideas from emotional and relational geographies and critical understandings of salutogenesis, the value of blue space to health and wellbeing is recognised and evaluated. Six individual papers from five different countries consider how health can be enabled in mixed blue space settings. Four sub-themes; embodiment, inter-subjectivity, activity and meaning, document multiple experiences within a range of healthy blue spaces. Finally, we suggest a considerable research agenda - theoretical, methodological and applied - for future work within different forms of blue space. All are suggested as having public health policy relevance in social and public space.

The expression of perinatal depression in rural Ghana

In low- and middle-income countries, perinatal depression (PND) has been associated with poor infant health outcomes, including frequency of infant diarrheal episodes, preterm delivery and low birth weight, and discontinuation or problems breastfeeding. Yet little is known about the awareness or expression of PND depression in Ghana. A total of 12 in-depth key-informant interviews were conducted with women who had experienced PND within the previous two-and-a-half years. Three focus-group discussions were conducted with new mothers (n = 11), grandmothers (n = 8), and fathers (n = 9) for contextual and supporting information. 'Thinking too much' was the term most commonly used to describe PND. The women saw their distress as caused largely by poverty, lack of social support, and domestic problems. Women sought help through family and religious organizations, rather than through medical services. Problems producing breast milk or breastfeeding were nearly universal complaints and suggest significant effects on infant health in the study area. These results present evidence to support the increasing consensus that depression presents in similar and disabling ways across cultures and contexts. This formative qualitative data is required to tailor depression prevention or treatment interventions to this particular socio-cultural context.

Consistency of self-reported drug use events in a mixed methods study of people who inject drugs

BACKGROUND

Little is known about the consistency of information provided by people who inject drugs (PWID) during quantitative and qualitative interviews in mixed methods studies.

OBJECTIVES

We illustrate the use of the intraclass correlation coefficient, descriptive statistics, and regression to assess the consistency of information provided during a mixed methods study of PWID living in Los Angeles and San Francisco, California, USA.

METHODS

Age of first use of heroin, methamphetamine, marijuana, powder cocaine, and crack cocaine and first injection of heroin, methamphetamine, and powder cocaine were collected during an interviewer administered computer-assisted personal interview followed by an in-depth qualitative interview (n = 102).

RESULTS

Participants were 63% male, racially/ethnically diverse. 80.4% between the ages of 40 and 60 years old, 89% US-born, and 57% homeless. Consistency of self-reported data was adequate for most drug use events. Exact concordance between quantitative and qualitative measures of age of onset ranged from 18.2-50%. Event ordering was consistent across qualitative and quantitative results for 90.2% of participants. Analyses indicated that age of onset for heroin use, heroin injection, and injection of any drug was significantly lower when assessed by qualitative methods as compared to quantitative methods.

CONCLUSION

While inconsistency will emerge during mixed method studies, confidence in the timing and ordering of major types of events such as drug initiation episodes appear to be warranted.

Organisational culture and post-merger integration in an academic health centre: a mixed-methods study

BACKGROUND

Around the world, the last two decades have been characterised by an increase in the numbers of mergers between healthcare providers, including some of the most prestigious university hospitals and academic health centres. However, many mergers fail to bring the anticipated benefits, and successful post-merger integration in university hospitals and academic health centres is even harder to achieve. An increasing body of literature suggests that organisational culture affects the success of post-merger integration and academic-clinical collaboration.

METHODS

This paper reports findings from a mixed-methods single-site study to examine 1) the perceptions of organisational culture in academic and clinical enterprises at one National Health Service (NHS) trust, and 2) the major cultural issues for its post-merger integration with another NHS trust and strategic partnership with a university. From the entire population of 72 clinician-scientists at one of the legacy NHS trusts, 38 (53%) completed a quantitative Competing Values Framework survey and 24 (33%) also provided qualitative responses. The survey was followed up by semi-structured interviews with six clinician-scientists and a group discussion including five senior managers.

RESULTS

The cultures of two legacy NHS trusts differed and were primarily distinct from the culture of the academic enterprise. Major cultural issues were related to the relative size, influence, and history of the legacy NHS trusts, and the implications of these for respective identities, clinical services, and finances. Strategic partnership with a university served as an important ameliorating consideration in reaching trust merger. However, some aspects of university entrepreneurial culture are difficult to reconcile with the NHS service delivery model and may create tension.

CONCLUSIONS

There are challenges in preserving a more desirable culture at one of the legacy NHS trusts, enhancing cultures in both legacy NHS trusts during their post-merger integration, and in aligning academic and clinical cultures following strategic partnership with a university. The seeds of success may be found in current best practice, good will, and a near identical ideal of the future preferred culture. Strong, fair leadership will be required both nationally and locally for the success of mergers and post-merger integration in university hospitals and academic health centres.

Use of auricular acupressure to improve the quality of life in diabetic patients with chronic kidney diseases: a prospective randomized controlled trial

Background. Diabetic patients with chronic kidney disease (CKD) suffer from low quality of life (QOL). We aim to assess the effectiveness of auricular acupressure for QOL improvement in these patients. Materials and Methods. Sixty-two participants were randomly assigned to an auricular or a control arm in a randomized controlled trial. Participants in the auricular arm were instructed to perform auricular acupressure 3–5 times per day for 3 months, when they were receiving conventional treatments. Participants in the control arm received conventional treatments only. The primary outcome was the summarized score of Kidney Disease and Quality of Life Short-Form (KDQOL-SF) at 3 months after randomization. The secondary outcomes included the 36-Item Short Form Health Survey (SF-36), glycosylated hemoglobin (HbA1c), and estimated glomerular filtration rate (eGFR). Results. The summarized KDQOL differed significantly between the acupressure (76.6, 95% CI, 72.2 to 81.0) and the control group (61.8, 95% CI, 57.7 to 65.9). Similar results were found in the SF-36 scores. HbA1c and eGFR were not found to be significantly different between the arms and neither were the adverse events. Conclusion. Auricular acupressure was well tolerated in diabetic patients with chronic kidney diseases receiving hemodialysis. Future research is needed to confirm these results.

Using mixed methods research designs in health psychology: an illustrated discussion from a pragmatist perspective

PURPOSE

To outline some of the challenges of mixed methods research and illustrate how they can be addressed in health psychology research.

METHODS

This study critically reflects on the author's previously published mixed methods research and discusses the philosophical and technical challenges of mixed methods, grounding the discussion in a brief review of methodological literature.

RESULTS

Mixed methods research is characterized as having philosophical and technical challenges; the former can be addressed by drawing on pragmatism, the latter by considering formal mixed methods research designs proposed in a number of design typologies. There are important differences among the design typologies which provide diverse examples of designs that health psychologists can adapt for their own mixed methods research. There are also similarities; in particular, many typologies explicitly orient to the technical challenges of deciding on the respective timing of qualitative and quantitative methods and the relative emphasis placed on each method. Characteristics, strengths, and limitations of different sequential and concurrent designs are identified by reviewing five mixed methods projects each conducted for a different purpose.

CONCLUSIONS

Adapting formal mixed methods designs can help health psychologists address the technical challenges of mixed methods research and identify the approach that best fits the research questions and purpose. This does not obfuscate the need to address philosophical challenges of mixing qualitative and quantitative methods. Statement of contribution What is already known on this subject? Mixed methods research poses philosophical and technical challenges. Pragmatism in a popular approach to the philosophical challenges while diverse typologies of mixed methods designs can help address the technical challenges. Examples of mixed methods research can be hard to locate when component studies from mixed methods projects are published separately. What does this study add? Critical reflections on the author's previously published mixed methods research illustrate how a range of different mixed methods designs can be adapted and applied to address health psychology research questions. The philosophical and technical challenges of mixed methods research should be considered together and in relation to the broader purpose of the research.

Children's psychological and behavioral responses following pediatric intensive care unit hospitalization: the caring intensively study

BACKGROUND

Pediatric intensive care unit (PICU) hospitalization places children at increased risk of persistent psychological and behavioral difficulties following discharge. Despite tremendous advances in medical technology and treatment regimes, approximately 25% of children demonstrate negative psychological and behavioral outcomes within the first year post-discharge. It is imperative that a broader array of risk factors and outcome indicators be explored in examining long-term psychological morbidity to identify areas for future health promotion and clinical intervention. This study aims to examine psychological and behavioral responses in children aged 3 to 12 years over a three year period following PICU hospitalization, and compare them to children who have undergone ear, nose and/or throat (ENT) day surgery.

METHODS/DESIGN

This mixed-methods prospective cohort study will enrol 220 children aged 3 to 12 years during PICU hospitalization (study group, n = 110) and ENT day surgery hospitalization (comparison group, n = 110). Participants will be recruited from 3 Canadian pediatric hospitals, and followed for 3 years with data collection points at 6 weeks, 6 months, 1 year, 2 years and 3 years post-discharge. Psychological and behavioral characteristics of the child, and parent anxiety and parenting stress, will be assessed prior to hospital discharge, and again at each of the 5 subsequent time points, using standardized measures. Psychological and behavioral response scores for both groups will be compared at each follow-up time point. Multivariate regression analysis will be used to adjust for demographic and clinical variables at baseline. To explore baseline factors predictive of poor psychological and behavioral scores at 3 years among PICU patients, correlation analysis and multivariate linear regression will be used. A subgroup of 40 parents of study group children will be interviewed at years 1 and 3 post-discharge to explore their perceptions of the impact of PICU hospitalization on their children and enhance our understanding of findings generated from standardized measures in the larger cohort study. An interpretive descriptive approach will guide qualitative data collection and analysis.

DISCUSSION

This study aims to generate new information regarding the magnitude and duration of psychological and behavioral disturbances among children admitted to PICUs, potentially leading to remedial or preventive interventions.

Identifying culturally appropriate strategies for coronary heart disease secondary prevention in a regional Aboriginal Medical Service

Aboriginal Australians experience high rates of coronary heart disease (CHD) at an early age, highlighting the importance of effective secondary prevention. This study employed a two-stage process to evaluate CHD management in a regional Aboriginal Medical Service. Stage 1 involved an audit of 94 medical records of clients with documented CHD using the Audit and Best Practice in Chronic Disease approach to health service quality improvement. Results from the audit informed themes for focus group discussions with Aboriginal Medical Service clients (n=6) and staff (n=6) to ascertain barriers and facilitators to CHD management. The audit identified that chronic disease management was the focus of appointments more frequently than in national data (P<0.05), with brief interventions for lifestyle modification occurring at similar or greater frequency. However, referrals to follow-up support services for secondary prevention were lower (P<0.05). Focus groups identified psychosocial factors, systemic shortcomings, suboptimal medication use and variable awareness of CHD signs and symptoms as barriers to CHD management, whereas family support and culturally appropriate education promoted health care. To optimise CHD secondary prevention for Aboriginal people, health services require adequate resources to achieve best-practice systems of follow up. Routinely engaging clients is required to ensure services meet diverse community needs.

Narrative reviews

Although qualitative researches (QR) are invaluable in understanding complex healthcare situations, the quantitative systematic reviews could not treat them. To improve quality of healthcare services, results of QR should be considered in healthcare decision-making processes. Several methods and theories for synthesizing evidences of QR have been developed. In order to activate the narrative reviews and mixed methods reviews in Korean healthcare academies, I arranged the related nomenclatures and suggested some issues to conduct them.

Embodied accounts of HIV and hope: using audio diaries with interviews

Capturing the complexity of the experience of chronic illness over time presents significant methodological and ethical challenges. In this article, we present methodological and substantive insights from a longitudinal qualitative study with 20 people living with HIV in Serbia. We used both repeated in-depth interviews and audio diaries to explore the role of hope in coping with and managing HIV. Using thematic longitudinal analysis, we found that the audio diaries produced distinctive, embodied accounts that straddled the public/private divide and engaged with alternative social scripts of illness experience. We suggest that this enabled less socially anticipated accounts of coping, hoping, and distress to be spoken and shared. We argue that examining the influence of different methods on accounting not only illustrates the value of qualitative mixed-method study designs but also provides crucial insights to better understand the lived experience of chronic illness.

Long-term effects of group therapy for patients with mild cognitive impairment and their significant others: a 6- to 8-month follow-up study

The present study examines the long-term effects of a 10-session cognitive behavioural group therapy for patients with mild cognitive impairment (MCI) and their significant others 6 to 8 months after completion of the intervention. Forty-seven MCI patients and 47 significant others participated in the follow-up assessment. Results of the RAND-36, Illness Cognition Questionnaire, IQCODE, GDS-15 and Sense of Competence Questionnaire at follow-up were compared with the post-intervention assessment. Our findings showed that the increased level of acceptance in the MCI patients was maintained at follow-up, with an increased insight into their cognitive decline compared with post-intervention assessment (p < 0.001). In both the patients and the significant others, helplessness and wellbeing were worse at follow up (p < 0.05), but sense of competence increased in the significant others (p < 0.05). These results indicate a need for extension of the support after completion of the program, for example by providing regular booster sessions.

Feasibility, acceptability and outcomes at a 12-month follow-up of a novel community-based intervention to prevent type 2 diabetes in adults at high risk: mixed methods pilot study

OBJECTIVES AND DESIGN

Lifestyle interventions can prevent type 2 diabetes (T2D) in adults with impaired glucose tolerance. In a mixed methods pilot study, we aimed to assess the feasibility, acceptability and outcomes at a 12-month follow-up of a behavioural intervention for adults at risk of T2D.

PARTICIPANTS

Adults aged 45-65 years with a Finnish Diabetes Risk Score (FINDRISC) ≥11.

SETTING

The intervention was delivered in leisure and community settings in a local authority that ranks in the 10 most socioeconomically deprived in England.

INTERVENTION

A 10-week supported programme to promote increased physical activity (PA), healthy eating and weight loss was delivered by fitness trainers as twice-weekly group PA or cookery sessions, each followed by behavioural counselling with support to 12 months.

OUTCOME MEASURES

We assessed feasibility and acceptability of the intervention, and change in behavioural and health-related outcomes at 6 and 12 months.

RESULTS

From 367 registers of interest, 218 participants were recruited to the programme with baseline mean (SD): age 53.6 (6) years, FINDRISC 13.9 (3.1), body mass index 33.5 (5.9) kg/m(2), waist circumference 108.1 (13.7) cm, PA levels (self-report): daily total 49.1 (5.9) metabolic-equivalent (MET) h/day. Follow-up at 12 months was completed by 134 (61%) participants, with an estimated mean (95% CI) change from baseline in weight -5.7 (-7.8 to -2.8); -2.8 (-3.8 to -1.9) kg, waist circumference -7.2 (-9.2 to -5.2); -6.0 (-7.1 to -5.0) cm, and PA level 7.9 (5.8 to 10.1); 6.7 (5.2 to 8.2) MET h/day equivalent, for men and women, respectively (from covariance pattern mixed models). Participants reported an enjoyable, sociable and supportive intervention experience.

CONCLUSIONS

Participants' views indicated a high level of intervention acceptability. High retention and positive outcomes at 12 months provide encouraging indications of the feasibility and potential effectiveness of the intervention. A definitive trial of this intervention is warranted.

A feasibility study of expert patient and community mental health team led bipolar psychoeducation groups: implementing an evidence based practice

BACKGROUND

Group psychoeducation is a cost effective intervention which reduces relapse and improves functioning in bipolar disorder but is rarely implemented. The aim of this study was to identify the acceptability and feasibility of a group psychoeducation programme delivered by community mental health teams (CMHTs) and peer specialist (PS) facilitators. Organisational learning was used to identify and address systematically barriers and enablers, at organisational, health professional and patient levels, to its implementation into a routine service.

METHODS

A systematic examination of barriers and enablers to a three day training process informed the delivery of a first treatment group and a similar process informed the delivery of the second treatment group. Triangulation of research methods improved its internal validity: direct observation of training, self-rated surveys of participant experiences, group discussion, and thematically analysed individual participant and facilitator interviews were employed.

RESULTS

Barriers and enablers were identified at organisational, educational, treatment content, facilitator and patient levels. All barriers under the control of the research team were addressed with subsequent improvements in patient knowledge about the condition and about local service. In addition, self-management, agency and altruism were enhanced. Barriers that could not be addressed required senior clinical and education leadership outside the research team's control. PS and professional facilitators were successfully trained and worked together to deliver groups which were generally reported as being beneficial.

CONCLUSION

Psychoeducation groups involving CMHT and PS facilitators is acceptable and feasible but their sustainment requires senior leadership within and outside the organisation that control finance and education services.

Achieving integration in mixed methods designs-principles and practices

Mixed methods research offers powerful tools for investigating complex processes and systems in health and health care. This article describes integration principles and practices at three levels in mixed methods research and provides illustrative examples. Integration at the study design level occurs through three basic mixed method designs-exploratory sequential, explanatory sequential, and convergent-and through four advanced frameworks-multistage, intervention, case study, and participatory. Integration at the methods level occurs through four approaches. In connecting, one database links to the other through sampling. With building, one database informs the data collection approach of the other. When merging, the two databases are brought together for analysis. With embedding, data collection and analysis link at multiple points. Integration at the interpretation and reporting level occurs through narrative, data transformation, and joint display. The fit of integration describes the extent the qualitative and quantitative findings cohere. Understanding these principles and practices of integration can help health services researchers leverage the strengths of mixed methods.

Emotional communication in medical consultations with native and non-native patients applying two different methodological approaches

OBJECTIVE

To explore the potential agreement between two different methods to investigate emotional communication of native and non-native patients in medical consultations.

METHODS

The data consisted of 12 videotaped hospital consultations with six native and six non-native patients. The consultations were coded according to coding rules of the Verona Coding definitions of Emotional Sequences (VR-CoDES) and afterwards analyzed by discourse analysis (DA) by two co-workers who were blind to the results from VR-CoDES.

RESULTS

The agreement between VR-CoDES and DA was high in consultations with many cues and concerns, both with native and non-native patients. In consultations with no (or one cue) according to VR-CoDES criteria the DA still indicated the presence of emotionally salient expressions and themes.

CONCLUSION

In some consultations cues to underlying emotions are communicated so vaguely or veiled by language barriers that standard VR-CoDES coding may miss subtle cues. Many of these sub-threshold cues could potentially be coded as cues according to VR-CoDES main coding categories, if criteria for coding vague or ambiguous cues had been better specified.

PRACTICE IMPLICATIONS

Combining different analytical frameworks on the same dataset provide us new insights on emotional communication.

Participants' perspectives on making and maintaining behavioural changes in a lifestyle intervention for type 2 diabetes prevention: a qualitative study using the theory domain framework

OBJECTIVES

In a qualitative substudy, we sought to elicit participants' perspectives of their behavioural change and maintenance of new behaviours towards intervention optimisation.

SETTING

The intervention was delivered in leisure and community settings in a local authority, which according to the UK government statistics ranks as 1 of the 10 most socioeconomically deprived areas in England.

PARTICIPANTS

We recruited 218 adults aged 40-65 years at elevated risk of type 2 diabetes (Finnish Diabetes Risk Score≥11) to the intervention. Follow-up at 12 months was completed by 134 (62%). We recruited 15 participants, purposively sampled for physical activity increase, to the qualitative substudy.

INTERVENTION

Lifestyle intervention can prevent type 2 diabetes, but translation to service provision remains challenging. The 'New life, New you' intervention aimed to promote physical activity, healthy eating and weight loss, and included supervised group physical activity sessions. Behavioural change and weight loss at 12-month follow-up were encouraging.

DESIGN

We conducted 15 individual semistructured interviews. The Framework approach, with a comparison of emerging themes, was used in analysis of the transcribed data and complemented by the Theory Domains Framework.

RESULTS

Themes emerging from the data were grouped as perceptions that promoted initiating, enacting and maintaining behavioural change. The data were then categorised in accordance with the Theory Domains Framework: intentions and goals; reinforcement; knowledge; social role and identity; social influences; skills and beliefs about capabilities; behavioural regulation, memory, emotion, attention and decision processes and environmental context and resources. Participant perceptions of intervention features that facilitated behavioural change processes were then similarly analysed.

CONCLUSIONS

Social influences, reference to social role and identity (eg, peer support), and intentions and goals (eg, to lose weight) were dominant themes across the three phases of behavioural change. Reinforcement, regulation and decision processes were more evident in the maintenance phase. The socioeconomic status of participants was reflected in the environmental context and resource theme. Analysis of phases and theoretical domains of behavioural change added depth and utility to inform intervention optimisation. We will develop the intervention with improved peer support and explicit monitoring of the behavioural change techniques used, prior to a definitive trial.

Development and clinical gains of nurse-led medication monitoring profiles

AIM

This paper reports on the development of an instrument for nurse-led medication monitoring, the West Wales Adverse Drug Reaction profile for respiratory medicines, as part of a strategy to reduce avoidable adverse drug reactions.

BACKGROUND

Preventable adverse drug reactions account for 3.7% hospital admissions. Nurse-led medication monitoring may reduce drug-related harm. However, development of medication monitoring strategies is not reported elsewhere.

METHODS

The profile was developed by: (1) cognitive interviews (n = 4), (2) the content validity index (n = 10) involving academics, clinicians and service users prescribed respiratory medicines, (3) inter-rater reliability (n = 48) and clinical gains in a nurse-led outpatient clinic.

RESULTS

Cognitive interviews prompted more profile changes than either the content validity index or inter-rater reliability testing. Cohen's κ for inter-rater reliability for each item ranged from 0.73-1.00 (good to complete agreement). The profile identified previously unsuspected problems in all participants, including muscular weakness, skin and mouth problems.

CONCLUSIONS

The West Wales Adverse Drug Reaction profile was valid and reliable, and helped to detect and ameliorate drug-related harm.

IMPLICATIONS FOR NURSING MANAGEMENT

The West Wales Adverse Drug Reaction profile offers opportunities to improve care. Medication monitoring provides the structure to concurrently monitor known adverse drug reactions. Practice-based adverse drug reaction profiles benefit from cognitive, content validity and inter-rater reliability testing.

10 best resources on ... mixed methods research in health systems

Mixed methods research has become increasingly popular in health systems. Qualitative approaches are often used to explain quantitative results and help to develop interventions or survey instruments. Mixed methods research is especially important in low- and middle-income country (LMIC) settings, where understanding social, economic and cultural contexts are essential to assess health systems performance. To provide researchers and programme managers with a guide to mixed methods research in health systems, we review the best resources with a focus on LMICs. We selected 10 best resources (eight peer-reviewed articles and two textbooks) based on their importance and frequency of use (number of citations), comprehensiveness of content, usefulness to readers and relevance to health systems research in resource-limited contexts. We start with an overview on mixed methods research and discuss resources that are useful for a better understanding of the design and conduct of mixed methods research. To illustrate its practical applications, we provide examples from various countries (China, Vietnam, Kenya, Tanzania, Zambia and India) across different health topics (tuberculosis, malaria, HIV testing and healthcare costs). We conclude with some toolkits which suggest what to do when mixed methods findings conflict and provide guidelines for evaluating the quality of mixed methods research.

Expanding children's food experiences: the impact of a school-based kitchen garden program

OBJECTIVE

Evaluate achievement of the Stephanie Alexander Kitchen Garden Program in increasing child appreciation of diverse, healthy foods.

DESIGN

Comparative 2-year study.

SETTING

Six program and 6 comparison primary schools in rural and metropolitan Victoria, Australia, matched for socioeconomic status and size.

PARTICIPANTS

A total of 764 children in grades 3 to 6 (8-12 years of age) and 562 parents recruited. Retention rates at follow-up included 85% children and 75% parents.

INTERVENTION

Each week of the school year, children spent 45 to 60 minutes in a garden class and 90 minutes in a kitchen class.

PHENOMENON OF INTEREST

Program impact on children's willingness to try new foods, capacity to describe foods, and healthy eating.

ANALYSIS

Qualitative data analyzed using inductive thematic analysis. Quantitative data analyzed using random-effects linear regressions adjusted for school clustering.

RESULTS

Child and parent qualitative and quantitative measures (if never tried before, odds ratio 2.0; confidence interval, 1.06-3.58) showed increases in children's reported willingness to try new foods. No differences in articulation of food descriptions (program vs comparison groups). Qualitative evidence showed that the program extended its influence to healthy eating, but this was not reflected in the quantitative evidence.

CONCLUSIONS AND IMPLICATIONS

Findings indicate program success in achieving its primary objective, meriting further program research.

Qualitative research within trials: developing a standard operating procedure for a clinical trials unit

BACKGROUND

Qualitative research methods are increasingly used within clinical trials to address broader research questions than can be addressed by quantitative methods alone. These methods enable health professionals, service users, and other stakeholders to contribute their views and experiences to evaluation of healthcare treatments, interventions, or policies, and influence the design of trials. Qualitative data often contribute information that is better able to reform policy or influence design.

METHODS

Health services researchers, including trialists, clinicians, and qualitative researchers, worked collaboratively to develop a comprehensive portfolio of standard operating procedures (SOPs) for the West Wales Organisation for Rigorous Trials in Health (WWORTH), a clinical trials unit (CTU) at Swansea University, which has recently achieved registration with the UK Clinical Research Collaboration (UKCRC). Although the UKCRC requires a total of 25 SOPs from registered CTUs, WWORTH chose to add an additional qualitative-methods SOP (QM-SOP).

RESULTS

The qualitative methods SOP (QM-SOP) defines good practice in designing and implementing qualitative components of trials, while allowing flexibility of approach and method. Its basic principles are that: qualitative researchers should be contributors from the start of trials with qualitative potential; the qualitative component should have clear aims; and the main study publication should report on the qualitative component.

CONCLUSIONS

We recommend that CTUs consider developing a QM-SOP to enhance the conduct of quantitative trials by adding qualitative data and analysis. We judge that this improves the value of quantitative trials, and contributes to the future development of multi-method trials.

A mixed methods descriptive investigation of readiness to change in rural hospitals participating in a tele-critical care intervention

BACKGROUND

Telemedicine technology can improve care to patients in rural and medically underserved communities yet adoption has been slow. The objective of this study was to study organizational readiness to participate in an academic-community hospital partnership including clinician education and telemedicine outreach focused on sepsis and trauma care in underserved, rural hospitals.

METHODS

This is a multi-method, observational case study. Participants included staff from 4 participating rural South Carolina hospitals. Using a readiness-for-change model, we evaluated 5 general domains and the related factors or topics of organizational context via key informant interviews (n=23) with hospital leadership and staff, compared these to data from hospital staff surveys (n=86) and triangulated data with investigators' observational reports. Survey items were grouped into 4 categories (based on content and fit with conceptual model) and scored, allowing regression analyses for inferential comparisons to assess factors related to receptivity toward the telemedicine innovation.

RESULTS

General agreement existed on the need for the intervention and feasibility of implementation. Previous experience with a telemedicine program appeared pivotal to enthusiasm. Perception of need, task demands and resource need explained nearly 50% of variation in receptivity. Little correlation emerged with hospital or ED leadership culture and support. However qualitative data and investigator observations about communication and differing support among disciplines and between staff and leadership could be important to actual implementation.

CONCLUSIONS

A mixed methods approach proved useful in assessing organizational readiness for change in small organizations. Further research on variable operational definitions, potential influential factors, appropriate and feasible methods and valid instruments for such research are needed.

Assessing the health benefits of advice services: using research evidence and logic model methods to explore complex pathways

Poverty is positively associated with poor health; thus, some healthcare commissioners in the UK have pioneered the introduction of advice services in health service locations. Previous systematic reviews have found little direct evidence for a causal relationship between the provision of advice and physical health and limited evidence for mental health improvement. This paper reports a study using a broader range of types of research evidence to construct a conceptual (logic) model of the wider evidence underpinning potential (rather than only proven) causal pathways between the provision of advice services and improvements in health. Data and discussion from 87 documents were used to construct a model describing interventions, primary outcomes, secondary and tertiary outcomes following advice interventions. The model portrays complex causal pathways between the intervention and various health outcomes; it also indicates the level of evidence for each pathway. It can be used to inform the development of research designed to evaluate the pathways between interventions and health outcomes, which will determine the impact on health outcomes and may explain inconsistencies in previous research findings. It may also be useful to commissioners and practitioners in making decisions regarding development and commissioning of advice services.

Utilization of HIV and tuberculosis services by health care workers in Uganda: implications for occupational health policies and implementation

BACKGROUND

Access to HIV testing and subsequent care among health care workers (HCWs) form a critical component of TB infection control measures for HCWs. Challenges to and gaps in access to HIV services among HCWs may thus compromise TB infection control. This study assessed HCWs HIV and TB screening uptake and explored their preferences for provision of HIV and TB care.

METHODS

A cross-sectional mixed-methods study involving 499 HCWs and 8 focus group discussions was conducted in Mukono and Wakiso districts in Uganda between October 2010 and February 2011.

RESULTS

Overall, 5% of the HCWs reported a history of TB in the past five years. None reported routine screening for TB disease or infection, although 89% were willing to participate in a TB screening program, 77% at the workplace. By contrast, 95% had previously tested for HIV; 34% outside their workplace, and 27% self-tested. Nearly half (45%) would prefer to receive HIV care outside their workplace. Hypothetical willingness to disclose HIV positive status to supervisors was moderate (63%) compared to willingness to disclose to sexual partners (94%). Older workers were more willing to disclose to a supervisor (adjusted prevalence ratio [APR] = 1.51, CI = 1.16-1.95). Being female (APR = 0.78, CI = 0.68-0.91), and working in the private sector (APR = 0.81, CI = 0.65-1.00) were independent predictors of unwillingness to disclose a positive HIV status to a supervisor. HCWs preferred having integrated occupational services, versus stand-alone HIV care.

CONCLUSIONS

Discomfort with disclosure of HIV status to supervisors suggests that universal TB infection control measures that benefit all HCWs are more feasible than distinctions by HIVstatus, particularly for women, private sector, and younger HCWs. However, interventions to reduce stigma and ensuring confidentiality are also essential to ensure uptake of comprehensive HIV care including Isoniazid Preventive Therapy among HCWs.

Hidden yet visible: methodological challenges researching sexual health in Sudanese refugee communities

Research addressing sensitive topics with people from small, minority, ethnic communities can present challenges that are difficult to address using conventional methods. This paper reports on the methodological approach used to explore sexual health knowledge, attitudes and beliefs among the Sudanese community in Queensland, Australia. The multiphase, mixed-method study involved young people 16 to 24 years of age participating in a written survey and semi-structured interview and focus-group discussions with the broader Queensland Sudanese community members. Community collaboration, the key factor to the success of this research, optimised the development of a research environment that built trust and facilitated access and subsequent understanding. Research conducted in partnership with the target community can address methodological challenges and produce meaningful information when researching sensitive topics with small but 'highly-visible' populations.

The Change4Life convenience store programme to increase retail access to fresh fruit and vegetables: a mixed methods process evaluation

BACKGROUND

Consumption of fruit and vegetables is important for health, but is often lower than recommended and tends to be socio-economically patterned with lower consumption in more deprived groups. In 2008, the English Department of Health introduced the Change4Life convenience store programme. This aimed to increase retail access to fresh fruit and vegetables in deprived, urban areas by providing existing convenience stores with a range of support and branded point-of-sale materials and equipment.

METHODS

We undertook a mixed-methods study of the Change4Life convenience store programme in the North East of England around two years after initial implementation. Store mapping (n = 87; 100% stores) and systematic in-store observations (n = 74; 85% stores) provided information on intervention fidelity; the variety, purchase price and quality of fresh fruit and vegetables on sale; and purchase price compared to a major supermarket. Ten qualitative interviews with a purposive sample of retailers and other professionals explored experiences of the intervention and provided further insight on quantitative results.

RESULTS

Intervention stores were primarily located in socio-economically disadvantaged areas. Fidelity, in terms of presence of branded materials and equipment, was low and much was not being used as intended. Fresh fruit and vegetables on sale were of high quality and had a purchase price around 10% more than comparable products at a major supermarket. Interviewees were supportive of the health improvement aim of the intervention. Retailers were appreciative of part-funding for chill cabinets and free point-of-sale materials. The intervention suffered from: poor initial and on-going communication between the intervention delivery team and retailers; poor availability of replacement point-of-sale materials; and failure to cement intended links with health workers and community organisations.

CONCLUSIONS

Overall, intervention fidelity was low and the intervention is unlikely to have had a substantial or long-term effect on customers' consumption of fruit and vegetables.

The Do-Well study: protocol for a randomised controlled trial, economic and qualitative process evaluations of domiciliary welfare rights advice for socio-economically disadvantaged older people recruited via primary health care

Background

Older people in poor health are more likely to need extra money, aids and adaptations to allow them to remain independent and cope with ill health, yet in the UK many do not claim the welfare benefits to which they are entitled. Welfare rights advice interventions lead to greater welfare income, but have not been rigorously evaluated for health benefits. This study will evaluate the effects on health and well-being of a domiciliary welfare rights advice service provided by local government or voluntary organisations in North East England for independent living, socio-economically disadvantaged older people (aged ≥60 yrs), recruited from general (primary care) practices.

Methods/Design

The study is a pragmatic, individually randomised, single blinded, wait-list controlled trial of welfare rights advice versus usual care, with embedded economic and qualitative process evaluations. The qualitative study will examine whether the intervention is delivered as intended; explore responses to the intervention and examine reasons for the trial findings; and explore the potential for translation of the intervention into routine policy and practice. The primary outcome is the effect on health-related quality of life, measured using the CASP 19 questionnaire. Volunteer men and women aged ≥60 years (1/household) will be identified from general practice patient registers. Patients in nursing homes or hospitals at the time of recruitment will be excluded. General practice populations will be recruited from disadvantaged areas of North East England, including urban, rural and semi-rural areas, with no previous access to targeted welfare rights advice services delivered to primary care patients. A minimum of 750 participants will be randomised to intervention and control arms in a 1:1 ratio.

Discussion

Achieving a trial design that is both ethical and acceptable to potential participants, required methodological compromises. The choice of follow-up length required a trade-off between sufficient time to demonstrate health impact and the need to allow the control group access to the intervention as early as possible. The study will have implications for fundamental understanding of social inequalities and how to tackle them, and provides a model for similar evaluations of health-orientated social interventions. If the health benefits of this intervention are proven, targeted welfare rights advice services should be extended to ensure widespread provision for older people and other vulnerable groups.

Current Controlled Trials ISRCTN Number

ISRCTN37380518

Growing Community

This article presents results from a mixed-method evaluation of a structured cooking and gardening program in Australian primary schools, focusing on program impacts on the social and learning environment of the school. In particular, we address the Stephanie Alexander Kitchen Garden Program objective of providing a pleasurable experience that has a positive impact on student engagement, social connections, and confidence within and beyond the school gates. Primary evidence for the research question came from qualitative data collected from students, parents, teachers, volunteers, school principals, and specialist staff through interviews, focus groups, and participant observations. This was supported by analyses of quantitative data on child quality of life, cooperative behaviors, teacher perceptions of the school environment, and school-level educational outcome and absenteeism data. Results showed that some of the program attributes valued most highly by study participants included increased student engagement and confidence, opportunities for experiential and integrated learning, teamwork, building social skills, and connections and links between schools and their communities. In this analysis, quantitative findings failed to support findings from the primary analysis. Limitations as well as benefits of a mixed-methods approach to evaluation of complex community interventions are discussed.

Using mixed methods research to explore the effect of an adaptation exercise on general population valuations of health states

PURPOSE

To understand the effect of an adaptation exercise (AE) on general population values for rheumatoid arthritis (RA) states.

METHODS

A sequential mixed methods design was employed: an analysis of a dataset to develop RA states for valuing in later phases of the study; a qualitative interview study with members of the general population to identify how an AE affected valuing of the RA states and to help design a questionnaire for the final phase; and a quantitative quasi-experimental study to identify factors that influence change in values after being informed about adaptation.

RESULTS

Three RA states were developed using Rasch and cluster analyses. Participants in the qualitative phase identified a range of ways in which information about adaptation affected their values. For example, they realized they could adapt to RA because their family and friends who had RA, or similar conditions, could cope. A 25-item questionnaire was developed and used during the final phase to identify that younger and healthier individuals were more likely to increase their values after being informed about disease adaptation. The qualitative findings were revisited and found to support the quantitative results.

CONCLUSIONS

This approach facilitated understanding of whether and how an AE affected valuing of health states. Each phase affected the next phase of the study, leading to the conclusion that general population respondents who have little experience of disease will likely increase their health state values after being informed about adaptation because they understand that they could cope with the disease.

Exploratory study to evaluate the provision of additional midwifery support to teenage mothers

OBJECTIVE

To evaluate the provision of psychosocial interventions of potential benefit to pregnant teenage women.

STUDY DESIGN

Pre-test/post-test, controlled, experimental design.

METHODS

One hundred and sixty-four pregnant teenage women received usual midwifery care or usual midwifery care plus additional psychosocial support. Four outcomes were measured at baseline and 4 weeks after delivery: self-esteem (Rosenberg Self-Esteem Scale), physical activity (International Physical Activity Questionnaire), social support (Short Form Social Support Questionnaire) and smoking behaviour (yes/no).

RESULTS

At follow-up, there were no significant differences in any of these outcomes between the 65 women in the intervention group and the 64 women in the control group who completed both assessments (mean age 17.5 years). There was no difference in use of National Health Service (NHS) services, but the intervention group made greater use of non-NHS services, such as family planning or help with housing or benefits problems.

CONCLUSION

The very low self-esteem of the women in the study may indicate that the intervention was not sufficiently robust to impact on mental health and lifestyle, although a longer follow-up may be needed to confirm this. Discrepancy in the evidence provided by formal and informal data suggests that project benefits may have been more evident if the evaluation had included a qualitative element to address the complexity of the client group and intervention.

Helping boys at-risk of criminal activity: qualitative results of a multi-component intervention

BACKGROUND

This qualitative study examines parent and child experiences of participation in a multi-component community-based program aimed at reducing offending behaviour, and increasing social competence in boys 6 to 11 years old in Hamilton, Ontario, Canada. The program builds on the concept of crime prevention through social development, and includes structured groups for the identified boy, parents, and siblings.

METHODS

A sample of 35 families participating in the multi-component program took part in the qualitative study. Individual interviews with the boys, parents and siblings asked about changes in themselves, relationships with family and peers, and school after the group. Interviews were taped, transcribed and content analysis was used to code and interpret the data.

RESULTS

Parents reported improvement in parenting skills and attainment of more effective communication skills, particularly with their children. Parents also found the relationships they formed with other parents in the program and the advice that they gained to be beneficial. Boys who participated in the program also benefited, with both parents and boys reporting improvements in boys' anger management skills, social skills, impulse control, and ability to recognize potentially volatile situations. Both parents and boys described overall improvement in family relationships and school-related success.

CONCLUSIONS

The qualitative data revealed that parents and boys participating in the multi-component program perceived improvements in a number of specific areas, including social competence of the boys. This has not been demonstrated as clearly in other evaluations of the program.

Use of qualitative methods in published health services and management research: a 10-year review

Over the past 10 years, the field of health services and management research has seen renewed interest in the use of qualitative research methods. This article examines the volume and characteristics of qualitative research articles published in nine major health services and management journals between 1998 and 2008. Qualitative research articles comprise 9% of research articles published in these journals. Although the publication rate of qualitative research articles has not kept pace with that of quantitative research articles, citation analysis suggests that qualitative research articles contribute comparably to the field's knowledge base. A wide range of policy and management topics has been examined using qualitative methods. Case study designs, interviews, and documentary sources were the most frequently used methods. Half of qualitative research articles provided little or no detail about key aspects the study's methods. Implications are discussed and recommendations are offered for promoting the publication of qualitative research.

Mixing it but not mixed-up: mixed methods research in medical education (a critical narrative review)

BACKGROUND

Some important research questions in medical education and health services research need 'mixed methods research' (particularly synthesizing quantitative and qualitative findings). The approach is not new, but should be more explicitly reported.

AIM

The broad search question here, of a disjointed literature, was thus: What is mixed methods research - how should it relate to medical education research?, focused on explicit acknowledgement of 'mixing'.

METHODS

Literature searching focused on Web of Knowledge supplemented by other databases across disciplines.

FINDINGS

Five main messages emerged: - Thinking quantitative and qualitative, not quantitative versus qualitative - Appreciating that mixed methods research blends different knowledge claims, enquiry strategies, and methods - Using a 'horses for courses' [whatever works] approach to the question, and clarifying the mix - Appreciating how medical education research competes with the 'evidence-based' movement, health services research, and the 'RCT' - Being more explicit about the role of mixed methods in medical education research, and the required expertise

CONCLUSION

Mixed methods research is valuable, yet the literature relevant to medical education is fragmented and poorly indexed. The required time, effort, expertise, and techniques deserve better recognition. More write-ups should explicitly discuss the 'mixing' (particularly of findings), rather than report separate components.

Negotiating multiple barriers: health workers' access to counselling, testing and treatment in Malawi

Malawi is facing a severe HIV and AIDS epidemic with an estimated 12% of its population living with the virus. Health workers are on the front lines of the HIV epidemic and they face the risk of HIV infection in both their personal and professional lives. This mixed method study aimed to explore the enablers and barriers to HIV counselling and testing and antiretroviral therapy by health workers in Malawi. After qualitative data were collected through in-depth interviews with health workers in the Mchinji and Nsanje districts, a survey questionnaire was constructed and administered to 906 health workers in eight districts in Malawi. A majority (76%) of health workers surveyed reported having undergone HIV testing and counselling, of whom 74% reported repeat testing. A striking result of the study is that 22% of health workers reported testing after occupational exposure to HIV. The proportions of respondents reporting that they tested after experiencing symptoms, or self-testing for HIV were 11% each. The in-depth interviews and the survey revealed multiple challenges that health workers face to accessing HIV testing, counselling and treatment, including fear of a positive result, fear of stigma and lack of confidentiality. Additional barriers included health workers' personal acquaintance with those conducting testing, along with their perception of being "role models" which could exacerbate their fears about confidentiality. Given health workers' critical role in HIV delivery in Malawi, there is need to develop solutions to help health workers overcome these barriers.

Understanding how education/support groups help lone mothers

Background

Lone-mother led families are at increased risk of psychosocial disadvantage, social isolation and mental health morbidity. Community-based programs are more accessible for families seeking assistance. We examine the experiences of eight lone mothers participating in a larger randomized controlled trial (RCT) of a community-based education/support group program using mixed methods.

Methods

A purposeful sample of eight mothers participating in the intervention arm of an RCT of community-based support/education groups was selected for the qualitative study. Individual interviews asked mothers about themselves and their relationships with their children before and after the group. Interviews were taped, transcribed and content analysis was used to code and interpret the data. Quantitative data collected in the RCT were used to describe these mothers.

Results

Mothers participating in the RCT and qualitative study experienced multiple difficulties, including financial and mood problems. These mothers reported that before participating in the group, they had shared experiences of social isolation, stigma, a sense of failure, poor relationships with their children and difficulties with financial management. After the group, mothers identified improved self-esteem, support from other mothers, improved parenting skills and improved communication with their children as outcomes of group participation.

Conclusions

The qualitative data revealed mothers' perceptions of specific areas that improved by participating in the group. The utility of complementary information provided by qualitative and quantitative methods in understanding program impact, as well as the need for broader assistance is noted.

Understanding how education/support groups help lone mothers

BACKGROUND

Lone-mother led families are at increased risk of psychosocial disadvantage, social isolation and mental health morbidity. Community-based programs are more accessible for families seeking assistance. We examine the experiences of eight lone mothers participating in a larger randomized controlled trial (RCT) of a community-based education/support group program using mixed methods.

METHODS

A purposeful sample of eight mothers participating in the intervention arm of an RCT of community-based support/education groups was selected for the qualitative study. Individual interviews asked mothers about themselves and their relationships with their children before and after the group. Interviews were taped, transcribed and content analysis was used to code and interpret the data. Quantitative data collected in the RCT were used to describe these mothers.

RESULTS

Mothers participating in the RCT and qualitative study experienced multiple difficulties, including financial and mood problems. These mothers reported that before participating in the group, they had shared experiences of social isolation, stigma, a sense of failure, poor relationships with their children and difficulties with financial management. After the group, mothers identified improved self-esteem, support from other mothers, improved parenting skills and improved communication with their children as outcomes of group participation.

CONCLUSIONS

The qualitative data revealed mothers' perceptions of specific areas that improved by participating in the group. The utility of complementary information provided by qualitative and quantitative methods in understanding program impact, as well as the need for broader assistance is noted.

The perceptions and preferences of parents of children with tracheostomies in a study of humidification therapy

This article reports a grounded theory study which was the qualitative phase of a randomized-controlled trial in children with tracheostomies comparing two techniques for providing humidified inspired gases. Semi-structured interviews were conducted with eight mothers of children with tracheostomies recruited from the trial, one mother who was not involved in the trial and four experienced nurses. Data were analysed using open, selective and theoretical coding. A core category was identified of parents managing the child's care in response to a set of problematic and constraining states. Parents were seen to utilize strategies of constant checking, becoming the expert, the family pulling together and electing to use preferred technology. The findings of this study mirror those of previous studies and reinforce the primacy of caregivers as managers of their child's health care. Mothers elected to use or not use a given technology within this context, utilizing a process of balancing.