making sense of mixed methods design in health research
TRANSCRIPT
Making Sense of Mixed Methods Design in Health Research:
Reconciliation of the Findings in the Study of the Doctors’ Decision Making Process in
Engaging Male Patients in Health ChecksTong SF (PhD)Department of Family Medicine, Faculty of Medicine UKM
Low WY (PhD)Faculty of Medicine, UM
https://www.researchgate.net/publication/296486855_Making_Sense_of_Mixed_Method_Design_in_Health_Research_Reconciliation_of_the_Findings_in_a_Study_of_the_Doctors%27_Decision_Making_Process_in_Engaging_Male_Patients_in_Health_Checks
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Mixed methods: what it is?
“mixed methods research is the type of research in which a researcher or team of researchers combines elements of qualitative and quantitative research approaches for the broad purpose of breadth and depth of understanding and corroboration”
Jonson, Onwuegbuzie and Turner, 2007
Current uses (purpose) of mixed methods
• Triangulation (tap on the strength of each method)
• Provides a better understanding• Exploratory concept• Explanatory concept
understanding human phenomena
Creswell, 2009
Webb et al 1996
Plano Clark, Creswell, 2007
The beginning of mixed methods
• Evolves from a single study using multi-trait or multi-method research – 1959 by Campbell & Fiske
• Started off as mixing of methods– Later, the debates focus on the validity of findings,
missing philosophical underpinning interpretation of findings
(sense making)
The debate on mixed methods
It is about researchers’ worldview The 2 contradicting worldviews are incompatible and
incommensurable. Trapped in these two paradigm (Symonds, 2008)
Quantitative Qualitative Objective reality that is observable and discoverable
Multiple reality as constructed by society
Post-positivist Constructivist Objective Interpretive Distancing researchers from researched
Researchers actively contribute to data, analysis, results and interpretation
Further development to reconcile the debate
• Need to have philosophical assumptions that guide the direction of data collection and analysis(Bryman, 1984; Sale, 2002; Creswell and clark 2007; Biesta, 2010)
– Guide researcher on what is researchable – Anchor the interpretation of results
Pragmatism
• Pragmatism: American philosophy
• Focus on the purpose of the research and its practicality (Tashakkori & Teddlie, 1998; Nastasi & Hitchcock & Brown, 2010; Biesta, 2010)
Pragmatism
Knowledge • is regarded both as constructed and as a function of a
people environment interaction• is meaningful if there is a practical consequence to it
(Biesta, 2010; Greene, 2010)
The practicality was not highlighted in the traditional debates about
ontology and epistemology(positivist vs constructivist)
Purpose & Assumptions
Purpose of the study
Lived-experience
Social processes – theory building
Representativeness in a population
Methods (comes with assumptions)
Phenomenology
GTM
Quantitative
It is from the assumptions that we draw and limit our inferences – avoiding over claiming
The fundamental assumptions
• qualitative approach is individualistic where the findings are rich in explaining a phenomenon of interest in an individual context
purpose: to infer the findings to the understanding of an individual (or a phenomenon)
• quantitative approach is normative where the findings represent an average pattern of a phenomenon of interest in a population
purpose: to infer the findings to a population
This presentation:
• To demonstrate logic reconciliation of study findings from two methods with different assumptions with an example
Doctors’ Decision Making Process in Engaging Male Patients in Health Checks
Background of the study
Net
herla
nds
Aust
ralia
Sing
apor
e
Japa
n
Cana
da
New
Zea
land
Uni
ted
King
dom
Belg
ium
Den
mar
k
USA
Chin
a
Arge
ntina
Mal
aysia
Braz
il
Indo
nesia
Bang
lade
sh
Indi
a
Bhut
an
Cam
bodi
a
Russ
ian
Uga
nda
Uni
ted
Tanz
ania
Afgh
anist
an
0
100
200
300
400
500
600
Male
Female
Adul
t mor
talit
y ra
te (p
er 1
,000
pop
ulati
on)
World Health Statistics 2010
Disease burden of Malaysian men
20%
13%
10%
8%7%6%
5%4%
4%4%
19%
Disability adjusted life years (DALYs) by disease categories, male, Malaysia, 2000
Cardiovascular diseasesUnintentional injuiriesInfectious diseasesMental disordersRespiratory disordersCancerSense organ disordersRespiratory infectionsPerinatal conditionsDigestive system disordersOthers
Ministry of health, Malaysia 2004
•Many of the illness can be treated or prevented • Primary care doctors have a role of engaging male
patients into health care
Objectives (purpose) of the studyTo develop an explanatory model of the process of how primary care doctors (PCDs) make the decision to undertake men’s health check-ups in Malaysia
1. First, it aims to identify the determinants and process of individual doctors’ decision making.
2. Second, to quantify the average impact of each determinant, and rank its average significance on the decision-making processes among Malaysian PCDs.
Study design
Phase I: Grounded theory:
development of a substantive theory
Theoretical framework
Phase II: Quantitative survey with multivariate
analysis
Conceptual framework
Questionnaire
Qualitative
Quantitative
Interpretation of findings from
phase I and II
Areas where mixing occurs
The overall design of sequential exploratory mixed methods
Study design
Phase I: Grounded theory:
development of a substantive theory
Theoretical framework
Phase II: Quantitative survey with multivariate
analysis
Conceptual framework
Questionnaire
Qualitative
Quantitative
Interpretation of findings from
phase I and II
Areas where mixing occurs
The overall design of sequential exploratory mixed methods
Interest at individual level
Interest at population level
Results: a brief account
Negotiating health check-
up
Weighing the medical
importance of men’s health
check-up
Competency in undertaking
health check-up
Considering external factors
Weighing men’s
receptivity
Balancing between
men’s receptivity
and medical importance
Perceived doctor’s image to men
Perception of men’s help seeking behaviour
Physician’s philosophy of health promotional activity
Topic for health check-up: •Defining the scope of men’s health
Substantive theoretical model of the doctor’s decision making to engage men in health check-ups
Intention to initiate health
check-up
Agenda for visits
core category
Tong , Low, Willcock, Trevana, Shaiful, 2010
Intention to initiate check-ups in the specific topic of men’s health within the specific context
Perceived personal competency
Perceived men’s receptivity in specific topic
Attitude towards the medical importance of a specific topic of men’s health
Perceived receptivity in specific topic and specific context
Perceived external barriers to men’s health check-ups
Perceived men’s help seeking behaviour
Attitude towards the medical importance of health check-ups in general
Attitude towards the medical importance of men’s health check-ups
Conceptual framework in phase II: the doctors’ decision making process of whether to initiate men’s health check-ups
Male patient’s receptivity
Medical importance
Areas of men’s health concern Context of consultation
Cardiovascular risk screening Acute minor complaint
Follow-upHealth check-up
Asking about sexual dysfunction Acute minor complaint Follow-upHealth check-up
Psychosocial health assessment Acute minor complaint Follow-upHealth check-up
Asking about smoking habit Acute minor complaint Follow-upHealth check-up
Discussing colon cancer screening Acute minor complaint Follow-upHealth check-up
Total doctors invited‡, n= 280
Participated, n=12 (80.0%)
KL/Sel*, n=143Kelantan, n=15
Public sector, n=122Private sector, n=158
KL/Sel*, n=98Kelantan, n=24
Participated, n=86 (59.4%)
Participated, n=19 (79.2%)
Participated, n=81 (82.7%)
Overall doctors’ response rate:
70.4%
Response to the process of doctor recruitment
Table 1 Summary statistics for usefulness of the models in explaining doctors’ intention to initiate health check-ups and their significant determinants Topic of men’s health check-ups
Contexts of consultation
R2 /
Nagelkerke R2 Significant determinants arranging, from the left to right, in descending order of importance β β β β
Cardiovascular risk screening
Acute minor complaint
0.293 Receptivity‡ 0.331 Male patients’ HSB†
-0.227 Male patients’ expectation
0.193 Referral network
-0.152
Follow-up 0.276 Receptivity‡ 0.267 Male patients’ HSB†
-0.237 Attitudes towards HCKǁ
0.195 Male patients’ comfort
0.168
Health check-up 0.252 Attitudes§ 0.231 Receptivity‡ 0.183Asking about sexual dysfunction
Acute minor complaint
0.132 Receptivity‡ 0.237
Follow-up 0.316 Receptivity‡ 0.806 Competency¶ 0.482 Male patients’ HSB†
-0.413 Cost constraint
-0.399
Health check-up 0.205 Competency¶ 0.383 Receptivity‡ 0.288
Psychosocial health assessment
Acute minor complaint
0.219 Receptivity‡ 0.312 Attitudes§ 0.199
Follow-up 0.261 Attitudes§ 0.303 Receptivity‡ 0.224Health check-up 0.247 Attitudes§ 0.346
Asking about smoking habit
Acute minor complaint
0.245 Receptivity‡ 0.651 Male patients’ HSB†
-0.217
Follow-up 0.258 Receptivity‡ 0.389 Referral network 0.353 Attitudes towards HCKǁ
0.292 Clinic system -0.262
Health check-up 0.339 Receptivity‡ 0.720 Referral network 0.456 Attitudes§ 0.276
Discussing colon cancer screening
Acute minor complaint
0.078 * Receptivity‡ 0.198
Follow-up 0.097 * - -Health check-up 0.210 Competency¶ 0.415 Referral network -0.214
* p > 0.05‡ Perceptions of male patients’ receptivity to the assessment in the corresponding context§ Attitudes towards the medical importance of proactive assessment † Perceptions of male patient’s help-seeking behaviour in relation to health check-ups
Attitudes towards medical importance of health check-upsǁ¶ perceived personal competency in the management or assessment
Topic Contexts of consultationSignificant determinants:More important Less important
Cardiovascular risk screening
Acute minor complaint Receptivity Male patients’ HSB† Male patients’ expectation
Referral network
Follow-up Receptivity Male patients’ HSB Attitudes towards HCK
Male patients’ comfort
Health check-up Attitudes ReceptivityAsking about sexual dysfunction
Acute minor complaint ReceptivityFollow-up Receptivity Competency Male patients’
HSBCost constraint
Health check-up Competency ReceptivityPsychosocial health assessment
Acute minor complaint Receptivity AttitudesFollow-up Attitudes ReceptivityHealth check-up Attitudes
Asking about smoking habit
Acute minor complaint Receptivity Male patients’ HSBFollow-up Receptivity Referral network Attitudes
towards HCKClinic system
Health check-up Receptivity Referral network AttitudesDiscussing colon cancer screening
Acute minor complaint ReceptivityFollow-up -Health check-up Competency Referral network
Comparing the findings from the two methods
GTM Survey with multivariate analysis Perceived receptivity health seeking behaviour receptivity to topics of men’s health in a receptivity at specific context
Perceived medical importance Topic related Attitude about men’s health check
External barriers: Cost constraint Network support Time constraints Conducive clinic system Privacy
Competency in handling men’s health issue
Perception of receptivity Health seeking behaviour 3/15 models
in a specific context: 12/15 models
Attitudinal concept: 7/15 models
Cost constrain 1/15 models Referral network 3/15 models
clinic system 1/15 models
Perceived competency: 3 /15 models
Issues in comparing the two results
• Why is there a discrepancy?– Which are the important determinants?– Which one do we trust?– Which is more valid?
The answer: Which perspective are we coming from?
The fundamental assumptions
• qualitative approach is individualistic where the findings are rich in explaining a phenomenon of interest in an individual context
purpose: to infer the findings to the understanding of an individual (or a phenomenon)
• quantitative approach is normative where the findings represent an average pattern of a phenomenon of interest in a population
purpose: to infer the findings to a population
A revisit to slide 10
The relevance of qualitative findings: understanding a doctor
My main concern is what would men think about me if I am to engage them in health check
I am worry that I am not competent enough to offer men’s health check
The relevance of quantitative findings: understanding Malaysian PCDs
Most would think perception of receptivity to discuss men’s health determines their decision to engage them with health checks
Combining the two
• They simply explain two different phenomena
• Helping a doctor: understand him/her as an individual PCD
• Helping to draft a policy/group interventions: understand what most PCDs think
Practicality of mixed methods
Most people are unhappy about seeing doctors, but what about
you?
Applying an understanding about an average to an individual
Conclusion
• Mixed methods: what is the purpose and phenomena of interest.
• Assumptions must be acknowledged • Appropriate inference depends on the rigor of
methodology and interpretation of findings• Correct inference leads to appropriate
practical solution