Methodological rigour is associated with priority, sequencing and stages of integration.
Taking each one of these in turn, and for ease of explanation, each of these concepts will be contextualised to this study.
3.5.1 Priority of methods
Priority of methods means emphasis, or weighting, placed on each stage of the study.
Each stage may have either equal weighting or greater emphasis may be placed on either the qualitative or quantitative (Teddlie & Tashakkori, 2009). The primary aim of this study was to establish associations between dependent and independent factors in the IDD and non-IDD population, therefore greater priority and weighting was placed on the quantitative stage.
3.5.2 Sequencing
In explanatory mixed methods the collection and analysis of quantitative data is followed by collection and analysis of qualitative data (Cresswell et al, 2007). The benefits of this approach are that it has two distinct stages that are straightforward to implement, and, for a lone researcher, allows one stage of data to be collected at a time. In this study, preliminary analysis of stage one data before qualitative interviews with carers supported triangulation of stage one results.
Stage two was particularly important for the IDD population. Despite a high proportion of people with ID affected by diabetes and other medical conditions (Amanda & Hayley, 2011;
Haveman et al, 2011; Torjesen, 2013) they are rarely recruited to, and, often excluded from, research (Witham, Beddow, & Haigh, 2015). During research design, discussions with experts in the field of ID and scoping of the ID research literature, highlighted barriers to recruitment that risked the ID sample being insufficiently powered to produce credible and reliable associations between adherence and associated factors.
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Barriers to recruitment are practical, ethical and restricted by using gatekeepers for access to potential participants (Jepson, 2015; Witham et al, 2015). A systematic review reported recruitment to studies was far greater when ID participants were recruited directly rather than through a carer or significant other (Cleaver, Ouellette-Kuntz, & Sakar, 2010). This suggests carers exercise caution when nominating people with ID for research. Their intention is to protect the interests of this vulnerable group perhaps fearing participation will unnecessarily burden a person with ID (Jepson, 2015; McDonald, Keys, & Henry, 2008;
Morrisey, 2012). This may be because of limited understanding of the value of research, or a fear of exploitation of vulnerable groups based on unethical practice in previous research (Kars et al, 2016).
To mitigate barriers, triangulating the first stage with a second qualitative stage was agreed by the research team to be methodologically viable, and aligned to previous studies in people with ID (Cuthill, Espie, & Cooper, 2003; Tveter, Bakken, Røssberg, Bech-Pedersen, &
Bramness, 2016). This approach provided a carer perspective of stage one results, and, if results from stage one and two were consistent and coherent, evidenced carer and stage one participant perspectives were aligned. Conversely, incongruous views of adherence and associated factors between stage one and two would require further exploration.
Although using face-to-face interviews, rather than online or postal questionnaires, facilitated accuracy of stage one data collection, it did not fully explain anomalies emerging from the quantitative data. If, for example, there was a mismatch between HbA1c and medicines adherence scores in the one population, but not in the other, exploration of other aspects of diabetes care with carers would be required to provide more in-depth explanation.
Therefore, the second stage provided an opportunity for further investigation and explanation of potential anomalies.
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Finally, there is very limited evidence on factors associated with adherence in the IDD population. To identify new and emergent themes, it was important to explore with carers whether there were any additional factors that influenced diabetes medicines adherence in the IDD population. Acknowledging effective glycaemic control involves a healthy lifestyle and adherence to medicines, an exploration of which were perceived by carers to be most challenging was important. A qualitative approach was therefore essential to validity and reliability of results, to explain any inconsistencies in the data and to identify any additional factors associated with diabetic treatment adherence.
3.5.3 Stages of integration
Integrating data in mixed methods research is achieved by comparing and contrasting results after analysis of each stage, or, analysing the data collected from each stage simultaneously (Teddlie and Tashakkori, 2009). Analysing the two data sets separately using recognised methods of data analysis preserves the integrity of each and permits flexibility when reporting and publishing results. In this study, the results from each stage are reported separately in chapters 4, 5, and 6. Integration occurred during design of topic guide, analysis and reporting of results. Thematic analysis of data in stage two was based around the topic guide and preliminary results from stage one. In chapter 6, stage two results are considered in the context of preliminary stage one results. Full integration and triangulation of results did not occur until the discussion chapter of this thesis where both sets of results were compared, contrasted and analysed.
3.5.4 Limitations of research approach
In a systematic review (Brown et al, 2015) of 23 mixed methods studies in education research, it was reported that none of the studies fully met the above criteria. This was largely because rigour in each research approach was not fully explained in the selected review papers.
O’Cathain’s (2007b) review of 75 health services research papers published over a 10 year
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period revealed similar findings, but also suggested that integration of qualitative and quantitative results was rarely discussed in proposals or papers. This suggests that in mixed methods research qualitative and quantitative stages are presented independently resulting in a consecutive rather than integrated reporting of results (Brown et al, 2015). O’Cathain (2007a).
This lack of integration during the results stage of a research study may affect the credibility of this research approach.
Pragmatic paradigms and, specifically, mixed methods approaches can test the skills, resources and philosophical standpoint of the researcher and often will require a large multi skilled research team to effectively implement. Although this does not lend itself to PhD research the skills of the supervisory team and previous knowledge and skills of this PhD student facilitated mixed methods research in this study. In this study, the supervisory team had expertise in qualitative and quantitative research and the PhD student had carried out both qualitative and quantitative research previously, therefore this experience supported a mixed methods approach. Although the process is resource intensive and results in an extensive report, agreement within the team was there was no alternative paradigm to comprehensively answer the research questions.
In summary, this section of the thesis has provided a justification for the study design, and has justified the mixed methods approach, sequencing and weighting of stages taking into consideration context of this research project. In accordance with GRAMMS6 criteria, the next section of this chapter will outline the methods for each stage of the study.
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3.6 Methods
A breakdown of each stage of the study outlining the hypotheses or, in the qualitative stage, aims to be explored will be presented. Following an outline of service user and key stakeholder feedback, a detailed description of procedure and timeline, sampling, recruitment, data collection, and data analysis for stages one and two will be presented. As ethical considerations in stages one and two are similar these will be discussed in the final section of the chapter.