Mixed methods in health services research: Doing what comes naturally to clinicians AcademyHealth Meeting June 8, 2004 San Diego, California

Author Anton J. Kuzel, MD, MHPE Professor of Family Medicine Virginia Commonwealth University Presenter Steven H. Woolf, MD, MPH Professor of Family Medicine, Preventive Medicine and Community Health Virginia Commonwealth University Executive Vice President for Policy Development, Partnership for Prevention

Goals of this talk Briefly describe how clinicians appear to effortlessly use at least two basic “ways of knowing” in caring for their patients Briefly describe how clinicians appear to effortlessly use at least two basic “ways of knowing” in caring for their patients Summarize typical reasons for using “mixed methods” in health services research, and suggest analogies in the clinical enterprise Summarize typical reasons for using “mixed methods” in health services research, and suggest analogies in the clinical enterprise Illustrate a simple application of “mixed methods” in a recent study of medical errors in primary health care Illustrate a simple application of “mixed methods” in a recent study of medical errors in primary health care

Two classic ways of knowing in clinical medicine “Objectifying” “Objectifying” Patient as “body machine” Patient as “body machine” Appropriate for action that is not dependent upon patient’s conscious behavior Appropriate for action that is not dependent upon patient’s conscious behavior

Two classic ways of knowing in clinical medicine “Subjectifying” “Subjectifying” Patient as maker of meaning Patient as maker of meaning Appropriate for action that is dependent upon patient’s conscious behavior Appropriate for action that is dependent upon patient’s conscious behavior

“Body machine” model has validity Similar anatomy and physiology among humans is foundational for much of Western medicine Similar anatomy and physiology among humans is foundational for much of Western medicine Western medicine can reduce suffering and prolong life, hence “body machine” appears ethical Western medicine can reduce suffering and prolong life, hence “body machine” appears ethical Skillful clinicians know that there is more to it than this Skillful clinicians know that there is more to it than this

“Maker of meaning” model Most clearly needed when task is behavior change (e.g., taking medicines, stopping smoking) Most clearly needed when task is behavior change (e.g., taking medicines, stopping smoking) “Transtheoretical” model of behavior change requires particularized understanding of the meaning of current and imagined future behavior “Transtheoretical” model of behavior change requires particularized understanding of the meaning of current and imagined future behavior

Integration of the two models Explanatory models of signs or symptoms Explanatory models of signs or symptoms Hypertension as a disorder of vascular and fluid regulatory mechanisms (body machine model) Hypertension as a disorder of vascular and fluid regulatory mechanisms (body machine model) Hypertension as a literal translation (too much tension – maker of meaning model) Hypertension as a literal translation (too much tension – maker of meaning model) Skillful clinician respects patient model and works to “co-create” the meaning of the hypertension Skillful clinician respects patient model and works to “co-create” the meaning of the hypertension

Analogies with “mixed methods” research At least five typical reasons for using “mixed methods” in health services research At least five typical reasons for using “mixed methods” in health services research Each has an analogy in clinical medicine, in which the objective and subjective models are integrated Each has an analogy in clinical medicine, in which the objective and subjective models are integrated

1. Instrument creation Research: Making quantitative tools using qualitative methods Research: Making quantitative tools using qualitative methods Clinical analogy: Clinical inventories (e.g., depression screening instruments) were initially developed by observations and interviews Clinical analogy: Clinical inventories (e.g., depression screening instruments) were initially developed by observations and interviews

2. Triangulation Research: Looking at something using more than one way of knowing, or more than one viewpoint Research: Looking at something using more than one way of knowing, or more than one viewpoint Clinical analogy: Hypertension as a result of disordered regulatory mechanisms (clinician view); hypertension as a result of too much stress (patient view) Clinical analogy: Hypertension as a result of disordered regulatory mechanisms (clinician view); hypertension as a result of too much stress (patient view)

3. Data transformation Research: Initial qualitative analysis of data to develop codes, then using descriptive statistics to describe how often they are observed Research: Initial qualitative analysis of data to develop codes, then using descriptive statistics to describe how often they are observed Clinical analogy: Astute clinicians recognize patterns in their everyday experience, and apply quantitative data to help characterize patterns, suggest path of investigation Clinical analogy: Astute clinicians recognize patterns in their everyday experience, and apply quantitative data to help characterize patterns, suggest path of investigation Illustration from our work Illustration from our work

Harms Reported by Patients Source: Kuzel et al.

4. Explanatory model Research: Qualitative data and analysis are used to explain quantitative data (e.g., patterns in the data, or the meaning of outliers) Research: Qualitative data and analysis are used to explain quantitative data (e.g., patterns in the data, or the meaning of outliers) Clinical analogy: Blood pressure logs show elevations on Mondays – eventually found to be result of weekend binge drinking Clinical analogy: Blood pressure logs show elevations on Mondays – eventually found to be result of weekend binge drinking

5. “Nested” design Research: Both quantitative and qualitative questions are asked and answered in the same study using appropriate methods Research: Both quantitative and qualitative questions are asked and answered in the same study using appropriate methods Clinical analogy: What is the efficacy of a new blood pressure medication, and what is the patient’s experience of taking the new medicine? Clinical analogy: What is the efficacy of a new blood pressure medication, and what is the patient’s experience of taking the new medicine?

Coming full circle A pragmatist will employ values, beliefs, and methods that seem likely to result in desired consequences. A pragmatist will employ values, beliefs, and methods that seem likely to result in desired consequences. Adhering to a narrow set of options reduces the possibilities for positive action. Adhering to a narrow set of options reduces the possibilities for positive action. As Borkan suggests, we should embrace numbers and narratives ( Ann Fam Med 2004;2:4-6) As Borkan suggests, we should embrace numbers and narratives ( Ann Fam Med 2004;2:4-6)

References for typology of mixed methods models in primary care research Cresswell JW, Fetters MD, Ivankova NV. Designing a mixed methods study in primary care. Ann Fam Med 2004;2:7-12 Cresswell JW, Fetters MD, Ivankova NV. Designing a mixed methods study in primary care. Ann Fam Med 2004;2:7-12 Stange KC, Zyzanski SJ. Integrating qualitative and quantitative research methods. Fam Med 1989;21: Stange KC, Zyzanski SJ. Integrating qualitative and quantitative research methods. Fam Med 1989;21: