A Methodological Review of Mixed Methods Research in Palliative and End-of-Life Care (2014-2019)

"Being an informal caregiver - strengthening resources": mixed methods evaluation of a psychoeducational intervention supporting informal caregivers in palliative care

BACKGROUND

Informal caregivers are key support for patients with progressive incurable diseases. However, their own needs often remain unmet. Therefore, we developed, manualised and implemented the intervention "Being an informal caregiver - strengthening resources" aiming to support and empower informal caregivers by addressing relevant information-related, physical, psychological and social needs.

METHODS

In this pilot study, we evaluated the acceptance and experiences with this psychoeducational intervention. The study was conducted over two years (2019-2021). Informal caregivers were recruited from the University Medical Centre Hamburg-Eppendorf and the metropolitan region of Hamburg, Germany. The intervention was aimed at adult persons who identified themselves as an informal caregiver to an adult patient with a progressive incurable cancer and non-cancer disease. For the evaluation we used a mixed methods approach, combining a longitudinal questionnaire survey (pre-intervention, after each module, 3-months follow-up) and semi-structured interviews post-intervention. Quantitative data were analysed using descriptive statistics and a paired t-Test, interviews were analysed based on the qualitative content analysis according to Mayring. Results were triangulated using a convergent triangulation design.

RESULTS

Of 31 informal caregivers who received the intervention, 25 returned the follow-up questionnaire and 20 informal caregivers were interviewed. Triangulated results showed a high satisfaction with the implementation of the intervention. Of a broad range of subjective benefits, gaining knowledge, self-awareness and self-efficacy were most apparent. Informal caregivers reported improved preparedness, awareness of own needs as well as confidence regarding handling own emotions and interacting with the ill person. However, implementing the learned skills into daily life can be challenging due to internal and external factors. Motivations and challenges for participating as well as potential for improvement were identified.

CONCLUSIONS

This pilot study showed an overall positive evaluation and several subjective benefits of the psychoeducational intervention "Being an informal caregiver - strengthening resources". Further research is needed to measure the efficacy of this intervention on informal caregivers' outcomes. Therefore, a multicentre randomized prospective study is planned.

Palliative clinical trials in advanced chronic liver disease: Challenges and opportunities

Patients with advanced chronic liver disease have a complex symptom burden and many are not candidates for curative therapy. Despite this, provision of palliative interventions remains woefully inadequate, with an insufficient evidence base being a contributory factor. Designing and conducting palliative interventional trials in advanced chronic liver disease remains challenging for a multitude of reasons. In this manuscript we review past and ongoing palliative interventional trials. We identify barriers and facilitators and offer guidance on addressing these challenges. We hope that this will reduce the inequity in palliative care provision in advanced chronic liver disease.

A Mixed Methods Evaluation of a Pilot Multidisciplinary Breathlessness Support Service

Breathlessness support services have demonstrated benefits for breathlessness mastery, quality of life and psychosocial outcomes for people living with breathlessness. However, these services have predominantly been implemented in hospital and home care contexts. This study aims to evaluate the adaptation and implementation of a hospice-based outpatient Multidisciplinary Breathlessness Support Service (MBSS) in Ireland. A sequential explanatory mixed methods design guided this study. People with chronic breathlessness participated in longitudinal questionnaires (n = 10), medical record audit (n = 14) and a post-discharge interview (n = 8). Caregivers (n = 1) and healthcare professionals involved in referral to (n = 2) and delivery of (n = 3) the MBSS participated in a cross-sectional interview. Quantitative and qualitative data were integrated deductively via the pillar integration process, guided by the RE-AIM framework. Integration of mixed methods data enhanced understanding of factors influencing the reach, adoption, implementation and maintenance of the MBSS, and the potential outcomes that were most meaningful for service users. Potential threats to the sustainability of the MBSS related to potential preconceptions of hospice care, the lack of standardized discharge pathways from the service and access to primary care services to sustain pharmacological interventions. This study suggests that an adapted multidisciplinary breathlessness support intervention is feasible and acceptable in a hospice context. However, to ensure optimal reach and maintenance of the intervention, activities are required to ensure that misconceptions about the setting do not influence willingness to accept referral to MBSS services and integration of services is needed to enable consistency in referral and discharge processes.

Quality of Reporting Using Good Reporting of A Mixed Methods Study Criteria in Chiropractic Mixed Methods Research: A Methodological Review

OBJECTIVE

The purpose of this review was to examine the reporting in chiropractic mixed methods research using Good Reporting of A Mixed Methods Study (GRAMMS) criteria.

METHODS

In this methodological review, we searched MEDLINE, Embase, CINAHL, and the Index to Chiropractic Literature from the inception of each database to December 31, 2020, for chiropractic studies reporting the use of both qualitative and quantitative methods or mixed qualitative methods. Pairs of reviewers independently screened titles, abstracts, and full-text studies, extracted data, and appraised reporting using the GRAMMS criteria and risk of bias with the Mixed Methods Appraisal Tool (MMAT). Generalized estimating equations were used to explore factors associated with reporting using GRAMMS criteria.

RESULTS

Of 1040 citations, 55 studies were eligible for review. Thirty-seven of these 55 articles employed either a multistage or convergent mixed methods design, and, on average, 3 of 6 GRAMMS items were reported among included studies. We found a strong positive correlation in scores between the GRAMMS and MMAT instruments (r = 0.78; 95% CI, 0.66-0.87). In our adjusted analysis, publications in journals indexed in Web of Science (adjusted odds ratio = 2.71; 95% CI, 1.48-4.95) were associated with higher reporting using GRAMMS criteria. Three of the 55 studies fully adhered to all 6 GRAMMS criteria, 4 studies adhered to 5 criteria, 10 studies adhered to 4 criteria, and the remaining 38 adhered to 3 criteria or fewer.

CONCLUSION

Our findings suggest that reporting in chiropractic mixed methods research using GRAMMS criteria was poor, particularly among studies with a higher risk of bias.

How to use mixed methods in oral health research

Wicked problems exist in the realm of oral health research. Due to their inherent complexity, using qualitative or quantitative methods alone may not be adequate for resolving them. Mixed methods approaches combine qualitative and quantitative methods, and thus, can provide a powerful tool for understanding and solving complex problems in dental public health. However, using mixed methods does not come without its challenges. This commentary outlines four main tips for researchers to consider when applying mixed methods to their research projects.

Use of mixed methods research in intervention studies to increase young people's interest in STEM: A systematic methodological review

Introduction

Mixed methods research intervention studies integrate quantitative evaluation approaches, such as randomized controlled trials and quasi-experimental designs, with qualitative research to evaluate the effectiveness, efficacy, or other results of an intervention or program. These types of studies, which have attracted growing attention in recent years, enhance the scope and rigor of the evaluation. While various frameworks that summarize the justifications for carrying out these types of studies and provide implementation guidance have been published in the last few years in the health sciences, we do not know whether such frameworks have been properly implemented in the social and educational sciences. This review examined the methodological features and reporting practices of mixed methods intervention studies aimed at increasing young people's interest in STEM.

Methods

A systematic search was carried out in APA PsycNET, ERIC, ProQuest, Scopus, and Web of Science, and a hand search in 20 journals. We included peer-reviewed English-language articles that reported intervention studies with a quantitative component measuring outcomes specific to increasing secondary school students' interest in STEM fields, a qualitative component conducted before, during, or after the quantitative component, and evidence of integration of both components. Qualitative content analysis and ideal-type analysis were used to synthesize the findings.

Results

We found 34 studies; the majority published in the last ten years. Several patterns of mixed methods application were described in these studies, illustrating the unique insights that can be gained by employing this methodology. The reporting quality of the included studies was generally adequate, especially regarding the justification for using a mixed methods intervention design and the integration of the quantitative and qualitative components. Nonetheless, a few reporting issues were observed, such as a lack of detail in the presentation of the mixed methods design, an inadequate description of the qualitative sampling and analysis techniques, and the absence of joint displays for representing integration.

Discussion

Authors must pay attention to these issues to ensure that the insights obtained by the use of mixed methods research are effectively communicated.

The association between chiropractic integration in an Ontario community health centre and continued prescription opioid use for chronic non-cancer spinal pain: a sequential explanatory mixed methods study

BACKGROUND

Emerging evidence suggests that access to chiropractic care may reduce the likelihood of initiating an opioid prescription for spinal pain; however, the impact of chiropractic care for patients already prescribed opioids is uncertain. We undertook a sequential explanatory mixed methods study to evaluate the association between initiating chiropractic care and continued opioid use among adult patients attending an Ontario community health centre (CHC) and receiving opioid therapy for chronic non-cancer spinal pain.

METHODS

We conducted a retrospective cohort study of 210 patient records between January 1, 2014 and December 31, 2020. We used generalized estimating equations, adjusted for patient demographics, co-morbidities, visit frequency, and calendar year, to evaluate the association between receipt versus non-receipt of chiropractic services and continued opioid use (e.g., unique opioid fills, number of refills, and dosages) up to one year following the index chiropractic visit. We also completed follow-up interviews with 14 patients and nine general practitioners from the CHC and integrated these data with our quantitative findings.

RESULTS

Over 12-month follow-up, there were lower rates of opioid fills (incidence rate ratio [IRR] = 0.66; 95% confidence interval [CI], 0.52-0.83) and refills (IRR = 0.27; 95% CI, 0.17-0.42) among chiropractic recipients (n = 49) versus non-recipients (n = 161). Although patients who did and did not receive chiropractic care began the study with the same dose of opioids, recipients were less likely to be prescribed higher-dose opioids (i.e., ≥ 50 mg morphine equivalents daily) compared to non-recipients at three months (odds ratio [OR] = 0.14; 95% CI, 0.04-0.47), six months (OR = 0.14; 95% CI, 0.05-0.40), nine months (OR = 0.19; 95% CI, 0.07-0.57), and 12 months (OR = 0.22; 95% CI, 0.08-0.62). Interviews suggested that patient self-efficacy, limited effectiveness of opioids for chronic pain, stigma regarding use of opioids, and access to chiropractic treatment were important influencing factors.

CONCLUSION

We found that continued prescription opioid use among patients with chronic non-cancer spinal pain who received chiropractic care was lower than in patients who did not receive chiropractic care. Four themes emerged in our qualitative interviews to help provide a richer understanding of this association. Randomized controlled trials are needed to establish the effect of chiropractic care on opioid use for chronic spinal pain.

Emotional availability in mothers and their children with spinal muscular atrophy type 1 who require augmentative and alternative communication: a mixed-methods pilot study

Emotional availability in parent-child interactions fosters children's socioemotional development. Little is known about the emotional availability of parents and children with profound motor disabilities and complex communication needs or the contributions of augmentative and alternative communication (AAC) to emotional availability. To begin addressing these gaps, this pilot study focused on three mothers and their children with spinal muscular atrophy Type 1 who could not speak and required AAC. The study used a mixed-methods design. Mother-child interactions were rated using the Emotional Availability Scales. Semi-structured in-depth interviews with the mothers were qualitatively analyzed. Emotional availability in mother-child dyads was adequate. In the interviews, mothers addressed significant challenges but described mainly typical parent-child relationships and adaptive child and mother coping attributable to the use of AAC. Results suggest that emotional availability is possible and can be facilitated by AAC, even with children with profound motor disabilities and limited ability to communicate needs and desires. The findings highlight the importance of targeting children's socioemotional needs and parent-child emotional availability in AAC interventions with families of children with profound motor disabilities.

Association of Chiropractic Care With Receiving an Opioid Prescription for Noncancer Spinal Pain Within a Canadian Community Health Center: A Mixed Methods Analysis

OBJECTIVE

The purpose of this study was to examine the association between receipt of chiropractic services and initiating a prescription for opioids among adult patients with noncancer spinal pain in a Canadian community health center.

METHODS

In this sequential explanatory mixed methods analysis, we conducted a retrospective study of 945 patient records (January 2014 to December 2020) and completed interviews with 14 patients and 9 general practitioners. We used Cox proportional hazards regression analyses, adjusted for patient demographics, comorbidities, visit frequency, and calendar year to evaluate the association between receipt of chiropractic care and time to first opioid prescription up to 1 year after presentation. Qualitative data were analyzed thematically and integrated with our quantitative findings.

RESULTS

There were 24% of patients (227 of 945) with noncancer spinal pain who received a prescription for opioids. The risk of initiating a prescription for opioids at 1 year after presentation was 52% lower in chiropractic recipients vs nonrecipients (hazard ratio [HR], 0.48; 99% confidence interval [CI], 0.29-0.77) and 71% lower in patients who received chiropractic services within 30 days of their index visit (HR, 0.29; 99% CI, 0.13-0.68). Patients whose index visit date was in a more recent calendar year were also less likely to receive opioids (HR, 0.86; 99% CI, 0.76-0.97). Interviews suggested that self-efficacy, access to chiropractic services, opioid stigma, and treatment impact were influencing factors.

CONCLUSION

Patients with noncancer spinal pain who received chiropractic care were less likely to obtain a prescription for opioids than patients who did not receive chiropractic care.

Mixed methods research in complementary and alternative medicine: a scoping review

OBJECTIVE

To update the current characteristics about the scope and quality of mixed methods research (MMR) in complementary and alternative medicine (CAM) after nearly 10 years.

METHODS

A 5-stage approach for conducting a scoping review was adopted. Articles published on the top 10 journals in CAM with the highest impact factor in 2020 were screened for MMR. Information of included articles were extracted, and then synthesized to illustrate the current state. Methodological quality was evaluated according to the Mixed Method Appraisal Tool (MMAT) 2018 version.

RESULTS

A total of 55 (55/2991, 2%) articles using mixed methods were retrieved, including 17 medical studies and 38 ethnobotanical studies. We performed an in-depth analysis on the 17 medical studies, which studied cancer, stress, pain, fatigue, exercises, mindfulness intervention, herbal medicine use, art and acupuncture. Thirteen pilot studies applied MMR to evaluate the feasibility of interventions or programs (13/17, 76%); phenomenology was inferred as the most common philosophical assumptions (13/17, 76%); the most applied type of MMR was convergent design (16/17, 94%); integration often took place at integration (12/17, 71%). Among the 16 eligible studies for quality appraisal, majority were rated as good (14/16, 88%), whereas two studies were rated as poorly described. Primarily, a poor rating was due to incomplete reporting of data analysis and citations in qualitative components; lack of confounder controlling and the sampling strategy in quantitative components; poor description of integration and justification for mixed methods. Comparing with the previous review, fewer MMR were published in 2020 in CAM, but the proportion of studies that clearly reported MMR has increased by 4 times (4%→15%).

CONCLUSION

CAM researchers need to realize the benefits that MMR can have on conducting further health care research. Our findings highlight that applying MMR will be helpful to understand the complex dynamics and interdisciplinary nature of complex intervention. In addition, addressing a standardized reporting criteria for MMR is recommended.

Mixed methods intervention studies in children and adolescents with emotional and behavioral disorders: A methodological review

BACKGROUND

Mixed methods intervention studies can improve the accuracy of interventional evaluations in the field of emotional and behavioral disorders by helping researchers gain a more nuanced understanding of how a particular intervention works. However, no studies to date have systematically examined the ways in which this type of studies have been carried out and reported.

AIM

To examine the methodological features and reporting practices found in mixed methods intervention studies in children and adolescents with emotional and behavioral disorders.

METHOD

Methodological review based on a systematic search from inception to July 2021 in Embase, Medline, PsycINFO, and SCOPUS, and a hand search in seven journals.

RESULTS

We found 30 studies, most of them published since 2019. These studies reported several patterns of mixed methods use which illustrated the unique insights that researchers can gain by using this approach. We identified several ways that authors could more clearly report the justification for using a mixed methods approach, the description of the design used, and the evidence of integration of the quantitative and qualitative components.

CONCLUSION

We make recommendations for improving the reporting quality of mixed methods intervention studies in the field of emotional and behavioral disorders.

Tripartite Analysis: A Data Analysis Technique for Convergent Mixed Methods Designs

BACKGROUND

Effective data integration is a daunting task in mixed methods research. Several frameworks for data integration exist, but the choice of and the technique for integration depends upon the research question and design. Innovative integration techniques continuously need to be developed to tackle the integration challenge and provide alternative ways for researchers to generate plausible mixed inferences.

OBJECTIVES

To describe a new data analysis technique, tripartite analysis (TriPA), and illustrate its use in a convergent mixed methods study.

METHODS

This technique was developed based on a convergent mixed methods study underpinned by dialectical pluralism aimed to understand Pakistani nursing students' perspectives about compassion and compassionate care and how these perspectives are consistent with the conceptualizations of compassion in nursing literature.

RESULTS

TriPA entails analysis and integration using joint displays at three levels: case-by-case integrated analysis, separate and then merged quantitative and qualitative analysis, and comparative and integrated analysis of Levels I and II findings.

DISCUSSION

TriPA can enable researchers to develop a more nuanced understanding of a given phenomenon through integration at various levels by identifying linkages within cases and across the whole data set and recognizing relational connections and emerging patterns.

Quality of reporting in chiropractic mixed methods research: a methodological review protocol

Background

Mixed methods designs are increasingly used in health care research to enrich findings. However, little is known about the frequency of use of this methodology in chiropractic research, or the quality of reporting among chiropractic studies using mixed methods.

Objective

To quantify the use and quality of mixed methods in chiropractic research, and explore the association of study characteristics (e.g., authorship, expertise, journal impact factor, country and year of publication) with reporting quality.

Methods

We will conduct a systematic search of MEDLINE, EMBASE, CINAHL, and the Index to Chiropractic Literature to identify all chiropractic mixed methods studies published from inception of each database to December 31, 2020. Articles reporting the use of both qualitative and quantitative methods, or mixed qualitative methods, will be included. Pairs of reviewers will perform article screening, data extraction, risk of bias with the Mixed Methods Appraisal Tool (MMAT), and appraisal of reporting quality using the Good Reporting of A Mixed Methods Study (GRAMMS) guideline. We will explore the correlation between GRAMMS and MMAT scores, and construct generalized estimating equations to explore factors associated with reporting quality.

Discussion

This will be the first methodological review to examine the reporting quality of published mixed methods studies involving chiropractic research. The results of our review will inform opportunities to improve reporting in chiropractic mixed methods studies. Our results will be disseminated in a peer-reviewed publication and presented publicly at conferences and as part of a doctoral thesis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-021-00395-0.

Prevalence vs impact: a mixed methods study of survivorship issues in colorectal cancer

Purpose

This study aims to explore the prevalence of CRC survivorship issues and their impact on survivors’ quality of life (QoL).

Methods

This study utilised a mixed methods sequential explanatory design. Adult CRC survivors between 6- and 60-months post-diagnosis (n = 304) were purposively recruited from three hospitals and twenty-one cancer support centres in Ireland. QoL was evaluated using the EuroQol and FACT-C questionnaires and results compared to population norms. 22 survey participants took part in semi-structured interviews exploring the impact of survivorship issues on their daily lives.

Results

While CRC survivors reported QoL outcomes comparable to or better than normative populations, 54% were dissatisfied with their QoL. The most common survivorship issues reported included negative body image (74%), fatigue (68%), sexual dysfunction (66%) and sleep disturbance (59%). Thematic analysis of the qualitative data illustrated survivors’ attempts to live with the impact of cancer and its treatment (loss, fear, impact) and striving to contextualise, reframe and understand the consequences of cancer and its treatment (control, vigilance, benefit). Within these themes, the cross-domain impact of less prevalent symptoms including bowel dysfunction (28–57%) and peripheral neuropathy (47%) were widely discussed.

Conclusions

Although cancer survivors report positive QoL outcomes, many experience distressing physical, psychological and social effects. The findings suggest less common and difficult to manage symptoms are the greatest source of distress and unmet need. Support and information must be tailored to address survivors’ individual needs and preferences for support, informed by holistic person-centred assessment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-021-02975-2.

Gamification for promoting advance care planning: A mixed-method systematic review and meta-analysis

BACKGROUND

Gamification has been adopted in the health care field for broaching sensitive topics and increasing motivation for behavior changes. Games developed to stimulate discussion surrounding end-of-life issues, and thereby promoting advance care planning also emerged.

AIM

The aim is to integrate the quantitative evidence and qualitative evidence to understand the effectiveness of and experience with games for advance care planning.

DESIGN

A mixed-methods systematic review and meta-analysis (PROSPERO ID: CRD42020163312) was undertaken. Joanna Briggs Institute Critical Appraisal tools were used for quality appraisal. Data were synthesized and pooled for meta-analysis or meta-aggregation when appropriate.

DATA SOURCES

We searched MEDLINE, CINAHL, EMBASE, PsycINFO, Cochrane Library, WanFang, China Knowledge Resource Integrated Database, and Chinese Biomedical Literature Database from the inception of the databases for qualitative, quantitative, and mixed-method studies.

RESULTS

Eleven articles of ten studies were included, six of which were feasibility studies. The quality of the quantitative component of most included studies (7/8) was rated as low, and the qualitative component of most included studies (7/8) was rated as moderate. The meta-analysis showed that games for advance care planning are effective to increase self-efficacy, readiness, knowledge, and process of advance care planning behaviors. The meta-aggregation showed that games for advance care planning are highly acceptable and the participants perceived the game experience as fun and enjoyable.

CONCLUSIONS

Advance care planning games seem to be a promising intervention for increasing the uptake of advance care planning behaviors. Well-designed randomized controlled trials evaluating the effectiveness of games for advance care planning are needed in the future.

Palliative and End-of-Life Care: More Work is Required

There is currently growing recognition of the complex care needs of patients with life-limiting conditions and their family members, prompting the need to revisit the goals of medicine. This Special Issue reflects a broad research agenda in the field of palliative and end-of-life care. A total of 16 papers of empirical studies and systematic review are included spanning five domains, namely, patient, caregiver, healthcare provider, policy, and methodology. The results generally suggest the merits of palliative care and reveal room for further improvement in palliative care education, manpower, infrastructure, and legal and policy frameworks.