The concept of integration in mixed methods research: a step-by-step guide using an example study in physiotherapy

Policy Challenges in Ultra-Rare Cancers: Ethical, Social, and Legal Implications of Melanoma Prevention and Diagnosis in Children, Adolescents, and Young Adults

Background: The ultra-rare nature of melanoma in children, adolescents, and young adults poses significant challenges to the development and implementation of effective prevention and diagnostic strategies. This article delves into the ELSIs surrounding these strategies, placing particular emphasis on the transformative potential of AI-driven tools and applications. Methods: Using an exploratory sequential mixed methods approach, this study integrated a PICO-guided literature review and qualitative insights from two focus groups. The review included 26 peer-reviewed articles published in English from January 2019 to January 2024, addressing ELSIs in melanoma, rare diseases, and AI in dermatology. Focus groups included a March 2024 session in Berlin with 15 stakeholders (patients, caregivers, advocates, healthcare professionals) and a November 2024 online session with 5 interdisciplinary experts. Results: Six key priorities for healthcare policies emerged: addressing cultural factors, such as the glorification of tanned skin; enhancing professional training for accurate diagnosis; balancing the risks of overdiagnosis and underdiagnosis; promoting patient autonomy through transparent communication; reducing inequalities to ensure equitable access to care; and making ethical and legal use of AI in healthcare. Conclusion: These priorities provide a comprehensive framework for advancing the prevention and diagnosis of melanoma in children, adolescents, and young adults, leveraging AI technologies while prioritizing equitable and patient-centered healthcare delivery.

Integrating evidence from lived experience of Aboriginal people and clinical practice guidelines to develop arthritis educational resources: a mixed-methods study

BACKGROUND

Globally, osteoarthritis, rheumatoid arthritis, and gout (arthritis conditions) result in considerable pain and suffering and disproportionately affect First Nations Peoples, who are more likely than non-First Nations Peoples to have an arthritis condition and to experience a higher burden of disease. Access to culturally appropriate health information supports the health and wellbeing of First Nations Peoples. The aim of this study was to identify evidence-based, culturally appropriate recommendations to inform the development of arthritis educational resources for Aboriginal and Torres Strait Islander Peoples (First Nations Peoples in Australia).

METHODS

This mixed-methods study using community-based participatory action research had three phases: interviews (research yarns) with Aboriginal people to explore their informational needs and preferences for arthritis educational resources; systematic reviews and synthesis of education recommendations from high-quality arthritis clinical practice guidelines; and integration and interpretation of datasets from the first two phases. Details of the three systematic reviews have been published previously. We only included clinical practice guidelines that met our inclusion criterion of high quality, assessed using the Appraisal of Guidelines for Research and Evaluation II instrument.

FINDINGS

Between Dec 24, 2020, and Nov 2, 2022, 30 Aboriginal people participated in research yarns. 21 (70%) participants were female and nine (30%) were male, with median age 60 years (range 22-75). All participants identified as Aboriginal and no participants identified as Torres Strait Islander. Research yarn data was combined with education recommendations from 18 clinical practice guidelines. Synthesis of the two datasets generated the following recommendations for inclusion in educational resources: the impact of arthritis on health and wellbeing, when and how to access care, management options (eg, benefits and risks), and disease knowledge (eg, prognosis and addressing misconceptions). In addition, educational resources should be jargon-free and include positive lived experience stories, flags, and colourful local art. Educational resources should be created by Aboriginal people and delivered by health professionals, family, or Aboriginal Community members in the form of brochures, videos, or yarning circles.

INTERPRETATION

The recommendations from this study will inform the development of arthritis educational resources for Aboriginal Peoples. The findings can also support health professionals to deliver evidenced-based arthritis care to Aboriginal Peoples. Internationally, a community-based participatory action research approach can be applied to develop educational resources for First Nations Peoples and communities.

FUNDING

Australian Commonwealth Government through Arthritis Australia.

Implementation Outcomes and Recommendations of Two Physical Activity Interventions: Results from the Danish ACTIVE SCHOOL Feasibility Study

Physical activity (PA) should be an essential part of all children's lives, as it can promote physical and mental health, enhance general well-being, and positively impact learning outcomes. Schools offer an ideal setting to encourage physical activity during the school day, as nearly all children attend school. However, schools present a complex environment for implementing PA, and sedentary behavior is common in classroom teaching. This study explores the feasibility of two types of school-based physical activity interventions: one based on research in exercise and cognition (Run, Jump & Fun) and another grounded in embodied learning (Move & Learn). Run, Jump & Fun can be conceptualized as extra non-curricular physical activity implemented into the school day while Move & Learn is integrated into curricular time. The 8-week study involved third-grade students and their teachers from seven schools, with educational strategies applied to support adoption. Quantitative and qualitative data were collected before, during, and after the 8-week period. The results indicated that both interventions were feasible to implement, leading to a series of recommendations for further refinement. These recommendations can guide the development of future school-based PA interventions and inspire other researchers to assess and improve their implementation strategies.

Using mixed methods research to study research integrity: Current status, issues, and guidelines

Background: The multifaceted nature of research integrity (RI) calls for the adoption of innovative methodologies to achieve a more thorough understanding. Mixed methods research (MMR) provides a valuable framework by combining diverse data sources, enabling a more nuanced exploration of complex research questions.Methods: This paper reviews seven RI studies employing MMR to identify methodological shortcomings. It introduces key concepts and typologies of MMR and proposes actionable strategies to enhance methodological rigor and innovation.Results: The review identified three key issues in current MMR applications: 1. Insufficient articulation of methodological contributions. 2. Limited visualization of quantitative and qualitative data integration. 3. Minimal engagement with recent MMR advancements. To address these gaps, a targeted To-Do List was created, offering actionable strategies for improving methodological rigor. Additionally, underutilized MMR designs, such as convergent and exploratory sequential designs, were recommended to strengthen data synthesis and expand analytical perspectives.Conclusions: MMR provides valuable opportunities to enhance RI research. This paper offers practical guidance for adopting MMR, addressing methodological gaps, and fostering robust, integrative research practices.

Investigating pre-registration podiatry students approaches to identifying dermatology conditions in different skin tones: A mixed methods protocol

BACKGROUND

Health inequalities are a well-known and widespread phenomenon throughout health care settings. In particular, people of color experience higher rates of delayed and/or misdiagnosis contributing to poorer outcomes and an increased mortality risk. Research suggests that health care professionals find it more difficult to correctly diagnose dermatological conditions in the non-White patient demographic. Although podiatrists routinely examine and assess skin lesions, there is a paucity of research exploring their accuracy or confidence in recognizing skin pathologies. This study aims to investigate podiatry student's ability, confidence, approaches, and perceptions in diagnosing dermatology pathologies in different skin tones. A mixed methods exploratory sequential design is proposed. In stage one, podiatry students from different higher education institutions will be invited to complete a pictorial survey. We have designed a survey comprising six validated images of inflammatory skin pathology (either eczema or psoriasis) in three different skin tone categories, standardized using the Fitzpatrick scale. Data from the survey in stage one will then be utilized to inform the next stage of the research. In stage two, respondents who completed the initial survey will be invited to participate in focus groups to explore their perceptions surrounding diagnostic approaches, confidence, and perceptions of skin conditions in different skin tone. A process of thematic analysis will be employed to identify emergent themes from these data.

METHODS

A mixed methods exploratory sequential design is proposed. In stage one, podiatry students from different higher education institutions will be invited to complete a pictorial survey. We have designed a survey comprising six validated images of inflammatory skin pathology (either eczema or psoriasis) in three different skin tone categories, standardized using the Fitzpatrick scale. Data from the survey in stage one will then be utilized to inform the next stage of the research. In stage two, respondents who completed the initial survey will be invited to participate in focus groups to explore their perceptions surrounding diagnostic approaches, confidence, and perceptions of skin conditions in different skin tone. A process of thematic analysis will be employed to identify emergent themes from these data.

A convergent mixed methods to study registration on kidney transplantation waiting list refusal by women and men on dialysis in France

Not all patients on dialysis want to be registered on the kidney transplantation (KT) waiting list and undergo transplantation. The aim of this convergent mixed methods study was to determine the features of patients refusing to be registered on the KT waiting list and the reasons. Quantitative data on all 2017-2019 incident 18-85-year-old dialysis patients, eligible for KT, were extracted from the REIN registry in France. Qualitative data were collected through semi-structured interviews with patients on dialysis and nephrologists from the Bretagne, Île-de-France and Normandie French regions. The binary logistic regression method was used to identify factors/reasons associated with registration refusal and an inductive thematic analysis was performed on qualitative data. The quantitative analysis included data of 10,512 patients (mean age = 57.5 years). Among them, 860 (8.18%) refused to be registered on the KT waiting list. The multivariate analysis showed that women were 83% more likely to refuse registration compared with men. The qualitative analysis included 21 patients and 11 nephrologists. The integration of the results from the quantitative and qualitative analyses allowed identifying some factors associated with the registration refusal. Most of these factors converged across analyses. These included age, sex/gender, autonomy on dialysis and comorbidities. The integration of the results highlighted some divergence concerning sex/gender and autonomy and an area of expansion related to comorbidities. In conclusion, the patient age, sex/gender and comorbidities appear to play an important role in the refusal to be registered on the waiting list. Interventions focused on these factors might help to improve KT accessibility in France.

An exploration of person-centredness among emergency department physiotherapists: a mixed methods study

PURPOSE

There is a growing number of primary contact physiotherapists based in United Kingdom emergency departments (ED) who are expected to deliver person-centred practices. Perceptions of physiotherapists working in these high-pressure environments on person-centredness are currently unknown. A mixed methods exploration of person-centredness among ED physiotherapists targeted this knowledge gap to inform future clinical practice.

METHODS

Online survey and semi-structured interviews followed a convergent mixed methods design with sequential explanatory features. Data sets were analysed separately using descriptive statistics and thematic analysis, respectively, before merged analysis using joint display.

RESULTS

Twenty-six surveys and 11 in-depth interviews were completed. The three overarching themes of ED patients, ED physiotherapists, and ED environment were generated. Themes were integrated and analysed alongside quantitative survey findings. This produced three novel contributions that further our understanding of person-centred practices among ED physiotherapists.

CONCLUSION

ED physiotherapists were mindful of an apparent, yet unspoken struggle between the competing philosophies of biomedicine and person-centredness. The results here support entering a patient's world as a person-centred approach to help navigate the line between what an ED attender wants and the clinical need of their visit.

Exploring a pilot alcohol and other drug (AOD) nurse practitioner mentoring program: Empirical research mixed methods: A pilot nurse practitioner mentoring program

AIM

To explore the effectiveness and acceptability of a pilot mentoring program for alcohol and other drug (AOD) nurse practitioners (also known globally as addiction nurse practitioners).

DESIGN

Mixed method evaluation.

METHODS

Two-phase evaluation comprising survey (demographics, pre- and post-program perceived competency and confidence) with 15 participants completing the pre survey and 10 participants completing the post survey, and qualitative interviews after the program with 10 participants.

RESULTS

The quantitative results indicate statistically significant increases in some domains of perceived competence and confidence in treatment. Qualitative findings indicate that participants valued peer support and mentoring from experienced nurse practitioners. Where formal residency or internship programs for nurse practitioners do not exist, informal mentoring programs may address issues inherent in nurse practitioner transition that may impact retention. We recommend further exploration of mentoring programs with larger sample sizes to determine if self-reported clinical improvements are noted.

IMPLICATIONS FOR PROFESSION AND/OR PATIENT CARE

Nurse practitioners are a vital part of the healthcare system; their advanced skills and knowledge place them in an ideal position to address prescriber shortages and access to care for populations underserved by healthcare. However, literature indicates that they are often underutilised, and transition to autonomous practice remains a challenge. Our exploration of a pilot mentoring program for nurse practitioners shows that their knowledge and perceived skills are high, yet peer assistance is valued in transitioning from advanced practice registered nurse to autonomous nurse practitioner. We recommend further trialling and evaluation of nurse practitioner mentoring programs to both increase supply of nurse practitioners and provide greater access to quality healthcare for underserved populations.

IMPACT

What problem did the study address? The ability of nurse practitioners to offer advanced practice interventions such as diagnosis and medication management potentially provides a solution to healthcare resource shortages. However, current literature indicates that advanced nurses transitioning to nurse practitioner roles suffer transition shock, leading to burnout and poor retention. What were the main findings? Although this pilot mentoring program shows significant improvements in survey responses on confidence and capability, qualitative data shows that neophyte nurse practitioners value peer support and mentoring from more experienced practitioners. Participants described maintaining ongoing connections with both mentors and fellow mentees, which aided transition to the role of autonomous nurse practitioner. Where and on whom will the research have an impact? The results of this pilot mentoring program indicate that there is benefit to these programs for neophyte nurse practitioners in many specialties. This paper indicates that mentoring programs for nurse practitioners may provide a community of practice and may have a positive impact on transition shock.

REPORTING METHOD

Good Reporting of a Mixed Methods Study (GRAMMS) checklist.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Preliminary mixed-methods investigation: Impact and acceptability of a combined life skills and adventure therapy program for adolescents

INTRODUCTION

Meaningful occupational therapy interventions for neurodivergent, transition-age adolescents are understudied, and novel intervention approaches that are motivating to this population are needed. Accordingly, in this study we explored the acceptability and impact of a combined life skills/adventure therapy (LS/AT) intervention program for addressing self-identified goals for adolescents with regulation- and sensory-based challenges.

METHODS

We used a convergent mixed-methods design. All adolescents accepted into the intervention program were invited to participate. We described our sample using data from the Child Occupational Self-Assessment. Participants created and rated goals through a modified Canadian Occupational Performance Measure interview before intervention, after intervention and 3 months post-intervention and participated in semi-structured interviews pre- and post-intervention. We calculated COPM change scores, analysed qualitative interview data, and integrated findings into a joint display for interpretation following recommended procedures for mixed-methods data.

RESULTS

Ten adolescents consented to participate (n = 6 males, n = 4 females; mean age 13.92 years, SD = 0.54). Mean COPM performance change scores were 3.72 (SD = 1.39) from pre- to post-intervention and 2.40 (SD = 1.19) from pre- to 3 months post-intervention, with the largest change scores for goals related to life skills. Data from semi-structured interviews expanded on these findings, revealing that participants made changes related to being in the moment, finding a sense of purpose and achieving a sense of belonging. Participants reported high acceptability of the intervention.

CONCLUSION

This exploratory research supports the use of combined LS/AT intervention with transition-age adolescents experiencing sensory and regulation-based limitations on participation. Preliminary data shows positive changes in performance and satisfaction in self-identified goal areas as well as changes related to mindfulness, a personal sense of competence and relatedness. In practice, occupational therapists should consider integrating elements of this LS/AT intervention to support this population, including addressing life skills through engagement in unique and motivating activities.

Co-design of a voice-based app to monitor long COVID symptoms with its end-users: A mixed-method study

Background

People living with Long COVID (PWLC), which is still a poorly understood disease, often face major issues accessing proper care and frequently feel abandoned by the healthcare system. PWLC frequently report impaired quality of life because of the medical burden, the variability and intensity of symptoms, and insecurity toward the future. These particular needs justify the development of innovative, minimally disruptive solutions to facilitate the monitoring of this complex and fluctuating disease. Voice-based interactions and vocal biomarkers are promising digital approaches for such health monitoring.

Methods

Based on a mixed-method approach, this study describes the entire co-design process of Long COVID Companion, a voice-based digital health app to monitor Long COVID symptoms. Potential end-users of the app, both PWLC and healthcare professionals (HCP) were involved to (1) understand the unmet needs and expectations related to Long COVID care and management, (2) to assess the barriers and facilitators regarding a health monitoring app, (3) to define the app characteristics, including future potential use of vocal biomarkers and (4) to develop a first version of the app.

Results

This study revealed high needs and expectations regarding a digital health app to monitor Long COVID symptoms and the readiness to use vocal biomarkers from end-users. The main expectations included improved care and daily life, and major concerns were linked to accessibility and data privacy. Long COVID Companion was developed as a web application and is composed of a health monitoring component that allows auto-evaluation of symptoms, global health, and scoring relevant symptoms and quality of life using standardized questionnaires.

Conclusions

The Long COVID Companion app will address a major gap and provide day-to-day support for PWLC. However, further studies will be needed following its release, to evaluate its acceptability, usability and effectiveness.

Patient expectations and levels of satisfaction in chiropractic treatment for lumbar radiculopathy. A mixed methods study

BACKGROUND

Chiropractic patients are generally satisfied with the care received. It is unclear if this also applies to Danish patients with lumbar radiculopathy included in a standardised chiropractic care package (SCCP). This study aimed to investigate patient satisfaction and explore perspectives on the SCCP for lumbar radiculopathy.

METHODS

An explanatory sequential mixed methods design with three separate phases was used. Phase one was a quantitative analysis based on a survey in a prospective cohort of patients with lumbar radiculopathy in an SCCP from 2018 to 2020. Patients rated their satisfaction with the examination, information, treatment effect, and overall management of their problem on a 0-10 scale. In phase two, six semi-structured interviews conducted in 2021 were used to gain further explanatory insights into the findings from phase one. Data were analysed using systematic text condensation. In phase three, the quantitative and qualitative data were merged in a narrative joint display to obtain a deeper understanding of the overall results.

RESULTS

Of 303 eligible patients, 238 responded to the survey. Of these, 80-90% were very satisfied (≥ 8) when asked about the examination, information, and overall management, whereas 50% were very satisfied with the treatment effect. The qualitative analysis led to the emergence of four themes: 'Understanding the standardised care packages', 'Expectations regarding consultation and treatment effect', 'Information about diagnosis and prognosis', and 'Interdisciplinary collaboration'. The joint display analysis showed that high patient satisfaction with the examination could be explained by the patients' feeling of being carefully and thoroughly examined by the chiropractor and by referrals to MRI. Advice and information given to patients on variations in symptoms and the expected prognosis were considered reassuring. Satisfaction with the chiropractor's coordination of care and with referral to other healthcare professionals was explained by the patients' positive experiences of coordinated care and their sense of alleviated responsibility.

CONCLUSION

Overall, patients were satisfied with the SCCP for lumbar radiculopathy. From a patient's perspective, the consultation should include a thorough examination and a focus on communication and information relating to symptoms and prognosis, while expectations regarding the content and efficacy of the treatment should be addressed and aligned.

Barriers and facilitators to becoming an alcohol and other drug nurse practitioner in Australia: A mixed methods study

Alcohol and other drug (AOD) nurse practitioners have an advanced scope of practice that allows them to diagnose, prescribe pharmacological treatments for alcohol and other substance use disorders, and monitor physical and mental health. The Behaviour Change Wheel (BCW) is used to understand barriers and facilitators to implementation by applying three conditions of behaviour change (capability, opportunity, and motivation-the COM-B framework). The aim of this paper is to describe the current AOD nurse practitioner workforce, and to explore barriers and facilitators to AOD nurse practitioner uptake in Australia. A mixed method approach was used in this study: a survey to determine the current state of the AOD nurse practitioner workforce (n = 41) and qualitative interviews with 14 participants to determine barriers to endorsement and ongoing work as a nurse practitioner. Interview transcripts were analysed using thematic analysis and mapped to the COM-B framework. The AOD nurse practitioner is a highly specialized provider of holistic care to people who use alcohol and other drugs, with AOD nurse practitioners performing advanced roles such as prescribing and medication management. However, there are several barriers to the further uptake of AOD nurse practitioners in Australia, including varied organizational support, a lack of support for the higher study required to become a nurse practitioner and a lack of available positions. Arguably, nurse practitioners are key to addressing prescriber shortages inherent in AOD treatment settings. In addition, they are equipped to provide true holistic care. We recommend that barriers are addressed to expand the AOD nurse practitioner workforce in Australia.