Mixed methods in health Mixed methods in health services research: services research:

Doing what comes naturally to Doing what comes naturally to cliniciansclinicians

AcademyHealth MeetingAcademyHealth Meeting

June 8, 2004June 8, 2004

San Diego, CaliforniaSan 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 talkGoals of this talk Briefly describe how clinicians appear to Briefly describe how clinicians appear to

effortlessly use at least two basic “ways effortlessly use at least two basic “ways of knowing” in caring for their patientsof knowing” in caring for their patients

Summarize typical reasons for using Summarize typical reasons for using “mixed methods” in health services “mixed methods” in health services research, and suggest analogies in the research, and suggest analogies in the clinical enterpriseclinical enterprise

Illustrate a simple application of “mixed Illustrate a simple application of “mixed methods” in a recent study of medical methods” in a recent study of medical errors in primary health careerrors in primary health care

Two classic ways of Two classic ways of knowing in clinical knowing in clinical

medicinemedicine ““Objectifying”Objectifying”

Patient as “body machine”Patient as “body machine” Appropriate for action that is not Appropriate for action that is not

dependent upon patient’s dependent upon patient’s conscious behaviorconscious behavior

Two classic ways of Two classic ways of knowing in clinical knowing in clinical

medicinemedicine ““Subjectifying”Subjectifying”

Patient as maker of meaningPatient as maker of meaning Appropriate for action that is Appropriate for action that is

dependent upon patient’s dependent upon patient’s conscious behaviorconscious behavior

““Body machine” model has Body machine” model has validityvalidity

Similar anatomy and physiology Similar anatomy and physiology among humans is foundational for among humans is foundational for much of Western medicinemuch of Western medicine

Western medicine can reduce Western medicine can reduce suffering and prolong life, hence suffering and prolong life, hence “body machine” appears ethical“body machine” appears ethical

Skillful clinicians know that there is Skillful clinicians know that there is more to it than thismore to it than this

““Maker of meaning” Maker of meaning” modelmodel

Most clearly needed when task is Most clearly needed when task is behavior change (e.g., taking behavior change (e.g., taking medicines, stopping smoking)medicines, stopping smoking)

““Transtheoretical” model of behavior Transtheoretical” model of behavior change requires particularized change requires particularized understanding of the meaning of understanding of the meaning of current and imagined future current and imagined future behaviorbehavior

Integration of the two Integration of the two modelsmodels

Explanatory models of signs or symptomsExplanatory models of signs or symptoms Hypertension as a disorder of vascular Hypertension as a disorder of vascular

and fluid regulatory mechanisms (body and fluid regulatory mechanisms (body machine model)machine model)

Hypertension as a literal translation (too Hypertension as a literal translation (too much tension – maker of meaning model)much tension – maker of meaning model)

Skillful clinician respects patient model Skillful clinician respects patient model and works to “co-create” the meaning of and works to “co-create” the meaning of the hypertensionthe hypertension

Analogies with “mixed Analogies with “mixed methods” researchmethods” research

At least five typical reasons for using At least five typical reasons for using “mixed methods” in health services “mixed methods” in health services researchresearch

Each has an analogy in clinical Each has an analogy in clinical medicine, in which the objective and medicine, in which the objective and subjective models are integratedsubjective models are integrated

1. Instrument creation1. Instrument creation

Research: Making quantitative tools Research: Making quantitative tools using qualitative methodsusing qualitative methods

Clinical analogy: Clinical inventories Clinical analogy: Clinical inventories (e.g., depression screening (e.g., depression screening instruments) were initially instruments) were initially developed by observations and developed by observations and interviewsinterviews

2. Triangulation2. Triangulation

Research: Looking at something Research: Looking at something using more than one way of using more than one way of knowing, or more than one knowing, or more than one viewpointviewpoint

Clinical analogy: Hypertension as a Clinical analogy: Hypertension as a result of disordered regulatory result of disordered regulatory mechanisms (clinician view); mechanisms (clinician view); hypertension as a result of too much hypertension as a result of too much stress (patient view)stress (patient view)

3. Data transformation3. Data transformation

Research: Initial qualitative analysis of Research: Initial qualitative analysis of data to develop codes, then using data to develop codes, then using descriptive statistics to describe how descriptive statistics to describe how often they are observedoften they are observed

Clinical analogy: Astute clinicians Clinical analogy: Astute clinicians recognize patterns in their everyday recognize patterns in their everyday experience, and apply quantitative data experience, and apply quantitative data to help characterize patterns, suggest to help characterize patterns, suggest path of investigationpath of investigation

Illustration from our workIllustration from our work

Harms Reported by Harms Reported by PatientsPatients

Physical23%

Economic7%

Personal worth11%

Relationship effects10%

Anxiety about health6%

Opportunity costs7%

Other emotions2%

Psychological70%

Anger and related emotions34%

Source: Kuzel et al.

4. Explanatory model4. Explanatory model

Research: Qualitative data and Research: Qualitative data and analysis are used to explain analysis are used to explain quantitative data (e.g., patterns in quantitative data (e.g., patterns in the data, or the meaning of outliers)the data, or the meaning of outliers)

Clinical analogy: Blood pressure logs Clinical analogy: Blood pressure logs show elevations on Mondays – show elevations on Mondays – eventually found to be result of eventually found to be result of weekend binge drinkingweekend binge drinking

5. “Nested” design5. “Nested” design

Research: Both quantitative and Research: Both quantitative and qualitative questions are asked and qualitative questions are asked and answered in the same study using answered in the same study using appropriate methodsappropriate methods

Clinical analogy: What is the efficacy Clinical analogy: What is the efficacy of a new blood pressure medication, of a new blood pressure medication, and what is the patient’s experience and what is the patient’s experience of taking the new medicine?of taking the new medicine?

Coming full circleComing full circle

A pragmatist will employ values, A pragmatist will employ values, beliefs, and methods that seem likely beliefs, and methods that seem likely to result in desired consequences. to result in desired consequences.

Adhering to a narrow set of options Adhering to a narrow set of options reduces the possibilities for positive reduces the possibilities for positive action.action.

As Borkan suggests, we should As Borkan suggests, we should embrace numbers and narratives embrace numbers and narratives ((Ann Fam Med Ann Fam Med 2004;2:4-6)2004;2:4-6)

References for typology References for typology of mixed methods models of mixed methods models in primary care researchin primary care research

Cresswell JW, Fetters MD, Ivankova Cresswell JW, Fetters MD, Ivankova NV. Designing a mixed methods NV. Designing a mixed methods study in primary care. study in primary care. Ann Fam Med Ann Fam Med 2004;2:7-122004;2:7-12

Stange KC, Zyzanski SJ. Integrating Stange KC, Zyzanski SJ. Integrating qualitative and quantitative research qualitative and quantitative research methods. methods. Fam Med Fam Med 1989;21:448-1989;21:448-451.451.