The planning and reporting of mixed methods studies on the built environment and health

The Connections among Interacting with Nature, Nature Relatedness and Dietary Choices: A Pilot Mixed Methods Study

Interacting with nature and a connection to nature (Nature Relatedness [NR]) have been associated with better mental and physical health as well as higher levels of physical activity. However, limited research has explored how interacting with nature and NR may promote healthful dietary behaviors. The purpose of this pilot convergent mixed methods study was to explore the connections between interacting with nature, NR, and dietary choices. For descriptive purposes, we measured participants' (n = 25) interactions with nature, NR (total, experience, perspective, and self) scores, physical activity, and Healthy Eating Index-2020 scores. In-depth interviews (n = 13) explored the factors that influence interacting with nature and food choices. Quantitative and qualitative data were analyzed separately, and later integrated to yield a more complete understanding of the research inquiry than either form of data would have provided alone. The results from this pilot mixed methods study indicate that there are connections between the variables of interest and that NR may play a pivotal role in how interacting with nature may promote sustainable dietary behaviors. These findings could promote the potential for utilizing nature-based experiences to improve dietary intake.

Experience and usability of a website containing research-based knowledge and tools for pain self-management: a mixed-method study in people with high-impact chronic pain

OBJECTIVES

Smerteinfo.dk is a freely accessible Danish website containing research-based, up-to-date knowledge on chronic pain, written in lay language, with a focus on information, guidance and self-management tools, developed in collaboration between health professionals and persons with high-impact chronic pain. This mixed-method study explored experiences, perceived usability, and challenges of Smerteinfo among patients with high-impact chronic pain.

METHODS

Semi-structured interviews enabling thinking-aloud and participant observation while using Smerteinfo were performed in 11 patients with high-impact chronic pain. Survey data were collected three months after being invited to use Smerteinfo among 200 patients on waiting-list at a Pain Center in Denmark.

RESULTS

Three themes captured the depth and variation in patterns of experiences, usability and challenges using Smerteinfo during interviews: 1) Appreciated easy access to new knowledge yet strived for more personalized information, 2) Experienced incentives as well as challenges when navigating the website, and 3) Suggested earlier introduction to the website. Challenges concerned the unknown update frequency of the website, information consisting of mostly text and many links, lack of material to improve self-management and too general information. Survey data revealed that 87 % found the language in the articles easy to understand and 73 % could recognize themselves and their challenges in the articles. A proportion of the respondents reported improved understanding of their pain condition (56 %), improved coping (33 %), and that they had made changes in their everyday life after reading on the website (33 %).

CONCLUSIONS

Patients with high-impact chronic pain found Smerteinfo valuable. The results suggest attention towards spreading knowledge of the website to general practitioners, who could introduce the site at an earlier stage of illness. Continuously improving the site and expand the applicable tools based on scientific evidence and in collaboration with end-users are crucial to ensure the usability of the website in the future.

Translating results into action: the global impact of the World Breastfeeding Trends Initiative

The World Breastfeeding Trends Initiative (WBTi) provides a participative framework to bridge the gaps in policies and programs on breastfeeding. This concurrent mixed-methods study investigated how and why carrying out WBTi evaluations in countries influences their breastfeeding policies and outcomes. We used data from WBTi's Global Repository to evaluate performance scores in 98 countries and conducted semi-structured in-depth interviews to investigate the impact of WBTi process, using the Managing for Development Results structure and actor-network theory. Countries that conducted WBTi multiple times seem to have better breastfeeding policies and practices than countries that have assessed only once. The central feature of the process and its subsequent impact is the dialectical interaction between the technical and political elements of the WBTi exercise. We believe that WBTi's framework is a promising monitoring and evaluation tool that could be used to engage dialogue in other public health areas.

Physical Activity Surveillance in the United States for Work and Commuting: Understanding the Impact on Population Health and Well-being

OBJECTIVE

To summarize and describe the current US surveillance systems that assess physical activity (PA) for work and commuting.

METHODS

An expert group conducted an environmental scan, generating a list (n = 18) which was ultimately reduced to 12, based on the inclusion of PA and/or sedentary behavior data.

RESULTS

The 12 surveys or surveillance systems summarized provide nationally representative data on occupational-level PA or individual-level PA at work, data on active commuting, some are scorecards that summarize workplace health best practices and allow benchmarking, and one is a comprehensive nationally representative survey of employers assessing programs and practices in different worksites.

CONCLUSIONS

The various surveillance systems and surveys/scorecards are disparate and need to be better analyzed and summarized to understand the impact of occupational-level PA and commuting on population health and well-being, life expectancy, and workforce productivity.

Exploring learning processes associated with a cancer pain self-management intervention in patients and family caregivers: A mixed methods study

AIM

Explore learning processes associated with a psychoeducational pain selfmanagement intervention.

BACKGROUND

Self-management of cancer pain is challenging for patients and their family caregivers (FCs). While psychoeducational interventions can support them to handle these tasks, it remains unclear how learning processes are hampered or facilitated.

METHODS

A convergent parallel mixed methods design with qualitative data collection embedded in a randomized controlled trial (RCT) was used. Outpatients with cancer and FCs were recruited from three Swiss university hospitals. The six-week intervention consisted of education, skills building, and nurse coaching. Quantitative data on pain management knowledge and self-efficacy were analyzed using multilevel models. Patients and FCs were interviewed post-RCT regarding their learning experiences. Qualitative data analysis was guided by interpretive description. Finally, quantitative and qualitative data were integrated using case level comparisons and a meta-matrix.

RESULTS

Twenty-one patients and seven FCs completed this study. The group-by-time effect showed increases in knowledge (p = 0.035) and self-efficacy (p = 0.007). Patients' and FCs' learning through experience was supported by an intervention nurse, who was perceived as competent and trustworthy. After the study, most intervention group participants felt more confident to implement pain self-management. Finally, data integration showed that declining health hampered some patients' pain self-management.

CONCLUSIONS

Competent and trustworthy nurses can support patients' and FCs' pain self-management by providing individualized interventions. Using a diary, jointly reflecting on the documented experiences, and addressing knowledge deficits and misconceptions through the use of academic detailing can facilitate patients' and FCs' learning of critical skills.

Cultural Sets Shape Adult Conceptualizations and Relationships to Nature

The variability of nature and the nature construct have complicated interpretations of empirical evidence from nature-based health studies. The challenge of defining nature exposure for purposes of methodological standardization may encompass constructs beyond vegetated landcover. This study offers a new construct for defining 'nature exposure' that considers cultural sets and nature familiarity. Focus group discussions across the United States (N = 126) explored the concept of what constitutes the relationship to nature. The participant diversity included regions, cultural demographics, cumulative nature experience, and everyday nature exposure. Mixed methods of semi-structured discussion and a photo exercise that prompted nature connectedness allowed for data triangulation and the detection of contradictions between approaches. Individuals conceptualized nature in ways reflecting highly personal and differentiated experiences, which defied consensus toward a single nature construct. The group scoring of photo imagery showed consistent high and low levels of nature connectedness with respect to wildness and outdoor urban venues, respectively, but diverged in the assessment of nature within the built environment. Everyday nature exposure significantly differentiated how groups conceptualized and related to nature imagery. This result may indicate an unmet biophilic need among groups with low backgrounds of nature exposure. The contrasts between the discussion content and the observed reactions to nature imagery showed the value of using mixed methods in qualitative research.

Taking a critical stance towards mixed methods research: A cross-disciplinary qualitative secondary analysis of researchers' views

Recent growth and institutionalization in the field of mixed methods research has provided fertile ground for a wide range of thoughtful criticism of how this research approach has been developed and conceptualized by some members of the mixed methods community. This criticism reflects the increasing maturity of the field as well as the different theoretical perspectives and methodological practices of researchers in different disciplines. While debates addressing these criticisms are likely to lead to valuable insights, no empirical studies have been carried out to date that have investigated researchers' critical views on the development and conceptualization of mixed methods research. This study examines the criticisms of the mixed methods field raised by a cross-national sample of researchers in education, nursing, psychology, and sociology. We carried out a secondary analysis of semi-structured interviews with 42 researchers and identified 11 different criticisms, which we classified in four domains: essence of mixed methods, philosophy, procedures, and politics. The criticisms related to the procedures domain were equally distributed among the four disciplines, while those related to the essence, philosophy and politics domains were more common among sociologists. Based on our findings, we argue that the divergence of views on foundational issues in this field reflects researchers' affiliation to different communities of practice, each having its own principles, values, and interests. We suggest that a greater awareness of this divergence of perspectives could help researchers establish effective collaboration and anticipate potential challenges when working with researchers having different methodological approaches.

Methods to Address Self-Selection and Reverse Causation in Studies of Neighborhood Environments and Brain Health

Preliminary evidence suggests that neighborhood environments, such as socioeconomic disadvantage, pedestrian and physical activity infrastructure, and availability of neighborhood destinations (e.g., parks), may be associated with late-life cognitive functioning and risk of Alzheimer’s disease and related disorders (ADRD). The supposition is that these neighborhood characteristics are associated with factors such as mental health, environmental exposures, health behaviors, and social determinants of health that in turn promote or diminish cognitive reserve and resilience in later life. However, observed associations may be biased by self-selection or reverse causation, such as when individuals with better cognition move to denser neighborhoods because they prefer many destinations within walking distance of home, or when individuals with deteriorating health choose residences offering health services in neighborhoods in rural or suburban areas (e.g., assisted living). Research on neighborhood environments and ADRD has typically focused on late-life brain health outcomes, which makes it difficult to disentangle true associations from associations that result from reverse causality. In this paper, we review study designs and methods to help reduce bias due to reverse causality and self-selection, while drawing attention to the unique aspects of these approaches when conducting research on neighborhoods and brain aging.

Safety perceptions of older adults on an urban greenway: Interplay of the social and built environment

BACKGROUND

Creating neighbourhood places for older adults to be socially and physically active is a global health priority. Safety is integral to older adult mobility. In greenway research, perceived safety is often only partially or superficially explored. Our study comprehensively examines older adults' experiences and perceived safety for walking on a new urban greenway in Vancouver, Canada-the Arbutus Greenway.

METHODS

We integrated mixed methods: i) observational count data to describe the use and context of the greenway over 3 years (2017; 2018; 2019), and; ii) semi-structured interviews with older adults at two time points (2017, n = 27; 2019, n = 16).

RESULTS

and discussion: We conducted thematic analysis to illuminate older adults' experiences across three safety domains: personal safety, traffic safety, and security. Built environment features such as benches, paving, road markings, and natural foliage buffers intersected with elements of the social environment to influence older adults' perceived safety. While the greenway supported active transportation, leisure, and social engagement for many older adults, certain factors also provoked fears, especially for older adults with mobility limitations. We advocate for a multidimensional lens to better understand how urban interventions influence perceived safety, and identify practical solutions to encourage mobility for all ages and abilities.

Effects of the COVID-19 pandemic on the sexual and mental health of adolescent and adult men who have sex with men and transgender women participating in two PrEP cohort studies in Brazil: COBra study protocol

INTRODUCTION

The COVID-19 pandemic and its control measures have impacted health and healthcare provision in various levels. Physical distancing measures, for instance, may affect sexual health, impacting access to HIV prevention supplies and changing sexual behaviour, as well as mental health, increasing feelings of unsafety and weakening community support ties. These effects can be worsened among socially marginalised groups, such as men who have sex with men (MSM) and transgender women (TGW). Brazil is among the countries most affected by COVID-19 in the world, where control measures have been inconsistently implemented. We aim to investigate the effects of the COVID-19 pandemic on the sexual and mental health of adolescent and adult MSM and TGW in Brazil.

METHODS

Convergent mixed-method prospective cohort study, nested in two ongoing HIV pre-exposure prophylaxis (PrEP) cohorts in Brazil, named PrEP1519 and Combina. Participants will be invited to answer, at baseline and after 6 months, a questionnaire about the effects of the COVID-19 pandemic on sexual behaviour, HIV prevention and mental health. Data on HIV infection and sexually transmitted infections (STI) will be collected as part of routine follow-up from the cohorts. Main outcome measures (HIV infection, STI and depression symptoms) will be observed within 12 months after baseline. Sample size is estimated at 426 participants. Complementarily, 50 participants will be invited to in-depth interviews through video calls or interactive voice response, and 20 will be invited to chronicle their lives during the pandemic through digital diaries. Triangulation will be done across qualitative methods and with the quantitative data.

ETHICS AND DISSEMINATION

The study was approved by Research Ethics Committees from the Brazilian Universities coordinating the study. Findings will be published in scientific journals and presented at meetings. Informative flyers will be elaborated to communicate study findings to participants and key stakeholders.

Moving to policy-amenable options for built environment research: The role of micro-scale neighborhood environment in promoting walking

BACKGROUND

Altering micro-scale features of neighborhoods (e.g., the presence and condition of benches, sidewalks, trees, crossing signals, walking paths) could be a relatively cost-effective method of creating environments that are conducive to physical activity. The Virtual Systematic Tool for Evaluating Pedestrian Streetscapes (Virtual-STEPS) was created to virtually audit the microscale environment of cities using Google Street View (GSV). The objective of this study was to evaluate the collective influence of items from the Virtual-STEPS tool on walking outcomes (utilitarian walking and walking for leisure), while accounting for self-selection of walkers into walking-friendly neighborhoods.

METHODS

Adults (N = 1403) were recruited from Montreal and Toronto from neighborhoods stratified by their level of macro-scale walking-friendliness and walking rates. The micro-scale environment of 5% of street segments from the selected neighborhoods was audited using the Virtual-STEPS tool and a micro-scale environment score was assigned. The scores were then linked to each respondent from the survey. A multilevel logistic regression analysis was used to model the relationship between the micro-scale environment score and odds of both utilitarian walking (i.e., walking for purpose such as to go shopping or go to work or school) and walking for leisure for at least 150 min per week, while accounting for environmental and demographic covariates as well as self-selection.

RESULTS

Micro-scale neighborhood features were associated with elevated odds of walking for leisure (OR: 1.14, CI: 1.04-1.25). The association between micro-scale neighborhood features and walking for utilitarian purposes was, however, inconclusive (OR: 1.01, CI: 0.90-1.13). On the other hand, macro-scale walk-friendliness was associated with elevated odds of walking for utilitarian purposes (OR: 2.01, CI:1.42-2.84) and the association between macro-scale features and leisure walking was inconclusive (OR: 1.02, CI: 0.78-1.34).

CONCLUSIONS

Our results imply that micro-scale features of neighborhoods collectively promote leisure walking but not necessarily utilitarian walking, even after accounting for self-selection. In contrast, macro-scale features may collectively promote utilitarian walking, but not leisure walking. Micro scale features of neighborhoods fall within the budget of local jurisdictions and our results suggest that jurisdictions that improve micro-scale features may expect increased leisure walking in populations.

Self-Reflection as a Support to Evidence-Based Practice: A Grounded Theory Exploration

The purpose of this study was to explore how reflective practice is experienced by occupational therapists. Thirty participants were purposefully sampled to explore reflective practice experiences using a critical reflection inquiry model as a theoretical framework. Grounded theory using a constant comparative analysis method was used to analyze interview data. Three categories emerged: triggers to reflection, depth of reflection, and actions taken. The frequency of statements compared across survey groups showed that participants with high reflection behaviors made more critical reflections, used steps of the EBP cycle, and took actions to correct practice. Results inform practice in three ways: (1) practitioner experiences were analyzed through the complete reflective practice construct, (2) findings indicated that greater depth of reflective thinking promotes EBP use and actions taken to correct practice, and (3) narrative content analysis was found to be a credible method of assessing reflection within practice narratives, suggesting it as useful for education and promoting continuing competency.