In this section, the rationale for adopting systematic reviews and MM as the pragmatic research methodology for this PhD thesis is articulated. This decision is based on three key issues; first, the methodological limitations around existing work within the field of research on ‘Delivering diabetes care to EMGs’ within the chosen location, secondly, the researcher’s pragmatic philosophical stance to ensure that the chosen topic is better understood by diabetes service providers. Thirdly, the interest in Morgan’s pragmatic framework approach to methodology in the Social Sciences (2007). In fact, the Morgan’s framework to methodology advocates a ‘pragmatic approach’ as a new guiding paradigm, both as a basis for supporting work that combines qualitative and quantitative methods and as a way to redirect researchers’ attention to methodology rather than metaphysical concerns (epistemological stances), which is concordant with this study. Further underlying motivations and reasons for selecting this approach are placed within the historical overview of MM and the debates around the ‘paradigm differences’ as discussed above.
To further comprehend the rationale for choosing this methodology, it is essential to consider the research questions for this thesis and the sequence of the methodological approaches, summarised in Figure 4.1 below. The primary research question is: How could NHS health care professionals work with EMGs in primary care to provide effective
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culturally-competent care and services tailored to the needs of EMGs with diabetes? This question is further underpinned and informed by the additional questions:
1. What are the cultural barriers to people with diabetes from EMGs in accessing effective diabetes care services
2. What is the impact of culturally-competent diabetes care interventions for improving diabetes-related outcomes in EMGs
3. What is the diabetes primary care service provision for EMGs and how are these services commissioned in a typical medium sized UK ethnically mixed city?
4. Using evidence from questions 1-3 above, how can an effective culturally- competent diabetes care service be designed and implemented in primary care for EMGs with diabetes?
5. What are the national and international practice and policy recommendations to promote the designing and implementation of effective culturally competent services to meet the needs of EMGs with diabetes?
The first four research questions, which are linked, are considered to each constitute standalone studies, which would be reported as individual chapters. Question 5 represents the recommendations arising from all the studies. In considering the most appropriate paradigm to select, these research questions were taken into account. First and foremost, the relevance of the positivist paradigm was considered, whilst reflecting upon the existing knowledge of cultural barriers and culturally-competent diabetes-related interventions for ethnic minority people with diabetes and the research gaps found in the scoping and literature reviews. It can be evident that positivist paradigm may only partly address some of the research questions, such as question 1 (Chapter Two), where a systematic review included studies of relevant designs, (quantitative or qualitative or mixed methods), in the analysis to identify and explore cultural barriers impeding EMGs with diabetes from
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accessing effective diabetes care services. The second systematic review (Chapter Three) included relevant quantitative and qualitative study designs reporting on any culturally- competent intervention to examine the impact of culturally-competent diabetes care interventions for improving diabetes-related outcomes in EMGs. Although these different study designs were included to answer these two questions, the heterogeneous nature of the included studies required a narrative analysis, which is often associated with the constructivist paradigm. It can be seen that the narrative data analyses in both reviews are in line with pragmatist philosophy of mixing in ways that offer the best opportunities for answering important research questions (Johnson and Onwuegbuzie, 2004).
The use of mono-methodology which is underpinned by positivist or constructivist paradigms could not fully address these two questions. In study 3, which addresses research question 3 (Chapter Five), a positivist paradigm via a population survey method, including a structured survey comprising mostly closed questions, was considered to be most appropriate to address the research questions. However, in the data analysis, the constructivist paradigm approach would be adapted to thematically analyse part of the data, such as describing the various cultural barriers that may be reported by staff in the questionnaire, to bring out the lived experiences of staff to these cultural barriers in their daily interactions with ethnic minority patients. Therefore, the use of the positivist paradigm alone to examine the social aspects of human life and the lived experience cannot completely address the research question (Pearson et al., 2007). This implies that the pragmatism worldview of MM was considered to facilitate the full exploration of this question by mapping out how much culturally-competent diabetes care services are being delivered within Coventry from participating general practices.
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Based on the evidence likely to emerge from the first 2 studies (questions 1-2), in addition to study 3, it was considered that there would be sufficient evidence to investigate how an effective culturally-competent diabetes care service can be designed and implemented in primary care for EMGs with diabetes to bridge the gaps emerging from the existing literature. The constructivist paradigm would attempt to explore the social context and the lived experiences of both patients and general practice staff in their natural settings (Pope and Mays, 2006; Pearson et al., 2007). This methodology can be used to examine what could be done to improve the social aspects and lived experiences regarding cultural and linguistic barriers impeding access to effective diabetes care services. The same constructivist paradigm was considered to address research question 4, facilitated by a participatory research design, constituting Chapter Six. However, descriptive statistics may be used in addition to qualitative methods, to analyse data, such as the characteristics of participants (number of participants, participants’ attendance rates, and average age of participants), which are associated with the positivist paradigm, thereby validating the constructivist paradigm on the same social phenomena (Pope and Mays, 2006). Therefore, it can be seen that the constructivist paradigm alone cannot completely address this research question, which the pragmatist paradigm would aid in the research process.
To address question 5 above, a combination of both positivist and constructivist paradigms was considered to reflect upon all the evidence and gaps identified in the four studies used (questions 1-4 above). This evidence should provide the national and international practice and policy recommendations that would promote the designing and implementation of effective culturally competent services to meet the needs of EMGs with diabetes. The combination of these two paradigms is pragmatic, by combining all the evidence from the research questions to address the primary research question. Therefore, this researcher would contend that in considering the three paradigms (positivist, constructivist, and
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pragmatist), the use of a mixed methodology proposed within this research process is appropriate as it is based on a rationale of making a number of pragmatic decisions in line with Morgan’s Pragmatic Approach to Methodology in the Social Sciences (Morgan, 2007). This methodological approach will inform the primary research question: ‘How could NHS health care professionals (HCPs) work with EMGs in primary care to provide effective culturally-competent care and services tailored to the needs of EMGs with diabetes?’ in addition to the sub research questions. It is worth noting that both the positivist and constructivist paradigms complement each other where the researcher mixes or combines quantitative and qualitative research techniques, methods, approaches, concepts or language into a workable solution in this single study, which are concordant with the pragmatist paradigm (Johnson and Onwuegbuzie, 2004; Morgan, 2007).
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Figure 4.1: Flow diagram of the thesis methodological approaches