Physicians’ Communication in a Sexual Health Consultation
Chapter 3: Methodology A Mixed-Methods Approach
3.3 Mixed-Methods Approach in this Thesis
Qualitative and quantitative methods were employed in this study primarily to determine different aspects of the overarching research question that examines PCPs’ knowledge of, attitudes towards, and practices with middle-aged and older patients with sexual health needs accessing primary care services. Semi-structured interviews were conducted with a proportion of PCPs to explore their in-depth views on sexual healthcare with middle and old aged patients. Subsequently, a survey was designed and administered to all PCPs nationwide to measure overall knowledge, attitudes, and sexual healthcare practices. Data for each component were collected and analysed separately to produce separate findings as presented
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in chapters 4, 5, and 6. Chapter 7 presents an integration of these findings analysed via methodological triangulation. Some researchers refer to this integration method as the “third effort” because it occurred after analysis of the qualitative and the quantitative components and required a lot of time and energy.234Notably, the term triangulation can be confusing because it has more than one meaning. It can be used to describe corroboration between two sets of findings or to describe a process of studying a problem using different methods to gain a more complete picture.214 The latter meaning is commonly used in mixed-methodsresearch including this study. Integration of the methods was possible at two points in this study: when the qualitative data analyses lead to quantitative data collection and when the overarching results were being reported.
3.3.1 Mixed-Model Study Design
This study primarily employed an instrument design model. However, the difference was that equal priority was given to both qualitative and quantitative data collection and analysis unlike the typical sequential approach. Implementation was a two-phase project that began with qualitative data collection and analysis and moved to quantitative instrument design and testing. Integration occurred at the data analysis stage, when the analysed qualitative data was used to develop the survey instrument for a second round of data collection. The intent of this approach was to develop an instrument that was grounded in the views and cultural and clinical context of the setting of the PCPs rather than using a readymade instrument that might not reflect their views. This sequential approach made the study easy to conduct and logical, but it was time-consuming and challenging to code and analyse qualitative data into a measurable instrument.235
The triangulation model is used in primary care research and the intent is to reconcile and bring together numeric (quantitative) and text (qualitative) data.236 This component was added to our existing sequential model of this study. However, this study did not follow the exact structure of the triangulation model where both quantitative and qualitative data is usually gathered at the same time; but we followed the intent of the model which was to
integrate the two forms of data to best understand the overarching research problem.216The
phases were equally prioritised similar to the triangulation model design, as they were both important in weighting for answering the study’s research questions. This is unlike the
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common instrument model design where there is a qualitative priority, and the quantitative method is used in a secondary role.Figure 10: Mixed-model study design
Interaction between Phases
This mixed model study illustrates a direct level of interaction between its qualitative and quantitative phases as the two methods are mixed before a final interpretation. This interaction occurs as the initiation, design, and conduct of one phase is completely dependent on the result of the other. The temporal relationship is therefore sequential as the arms are implemented in two distinct phases: the data collection and analysis of the first phase— qualitative arm (interviews with PCPs regarding their attitudes to sexual healthcare of middle-aged and older patients)—preceded the second phase—quantitative arm (a national knowledge, attitudes, and practices, KAP survey, for PCPs regarding sexual healthcare for middle-aged and older patients). Building from the exploratory results of the first phase, some of the resulting categories became variables and a quantitative instrument was developed and used for the second phase to test and generalise the initial findings. The mixing strategy therefore allowed for connecting from the analysis of the first (qualitative) data set to direct data collection of the second (quantitative) set. Therefore, how the quantitative results built on the initial qualitative results could be assessed. The second opportunity for interaction occurred at the triangulation stage where both findings were assessed together to derive interpretation of the overall findings (See Methodological Triangulation, section, 7.1.1.1).
1st phase
Qualitative Method
i.Data Collection (Semi-Structured Interviews)
ii. Data Analysis (Framework/Thematic) iii. Interpretation 2nd phase Quantitative Method i. Data Collection (KAP Questionnaire)
ii. Data Analysis (Statistical) iii. Interpretation 3rd Triangulation Process In teg ra ti o n p o in t
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3.3.2 Strengths and Limitations of this Mixed-Methods Approach
There were several theories and studies conducted in primary care that fuelled my interest in conducting this mixed-methods research as it can address some research questions more comprehensively than by using either quantitative or qualitative methods alone. From the supportive body of literature on mixed-methods, research questions that profit most from a mixed-methods design tend to be broad and complex, with multiple facets so that they may each be best explored by quantitative or qualitative methods.233,278 I felt reassured that I was
generally on the right track with this approach as my research question has many facets as presented at the beginning of this chapter and described prior in section 3.3 (Mixed-Methods Design). Overall, I felt that I was able to attain a more meaningful interpretation of PCPs’ knowledge, attitudes, and clinical practices to sexual health care in later life.236 Another
strength I observed was experiencing the dynamic between the qualitative and quantitative arms of the study and seeing how each of the datasets mirrored and offered much complementarity in the other’s findings and, moreover, the few but interesting differences
attained in the triangulation.237 Regardless, there were several overarching advantages and
notable weaknesses with regard to the mixed-methods design I employed for this research:
3.3.2.1.1 Overview of the Strengths
The two-phased approach followed by triangulation was straightforward to justify,
implement, describe, and report.
The individual approaches were strong methods and were acceptable to both
qualitative and quantitative biased audiences.
As suitable survey instruments were not readily available, a new instrument (the KAP
survey) was produced as a product of this research process.
The mixing phase (interaction) allowed for the designed instrument to be grounded
by the views of and fitting to the participants and research setting.
The approach was useful as lessons learned in the first phase influenced the design of
the second phase and much complementarity was found in triangulation of the data sets, in the end.
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3.3.2.1.2 Overview of Possible Limitations of this Design Ethical approvals took time and for this two-phase study, each required their own ethical approvals to be procured.
Time-consuming data collection process: These methods required a considerable
amount of time to implement both phases as time was needed prior to analyse the qualitative results, then convert them into measurable concepts and design a new instrument.
Interpreting data using can be complicated and time intensive from these various methods and via methodological triangulation.
Triangulation was difficult at times since not all the data could be triangulated as some themes were not measurable quantitatively.
Pilot testing was needed on this new survey instrument before the questionnaire was
administered – additional time.
There was so much quantitative data that not all of it could have been incorporated
into a measurable construct into the instrument, as this would have made the survey instrument too long and would have deceased its chances of being completed (it was already quite long).
In hindsight, some of the limitations of the mixed method were only made clearer after various stages of establishing and executing the methods. Firstly, after in-depth review of the various definitions of mixed-methods to be used and understanding the philosophical issues and paradigms that support the version of the mixed-methods approach I considered, this process could be quite time consuming and purist audiences (preferential to solely one method) may not agree with this approach.238,239 Secondly, after confirming the design typologies (type of qualitative approach via semi-structured interviews and selecting the type of quantitative approach – survey method) that theoretically were suitable for the research questions, I would have not been able to predict problems with execution of the survey in the field with the national sample (discussed in Chapter 5, Quantitative Phase).240 Finally, after confirmation of the method of integration to be used for this study (and there were a few other options to consider such as reversing the order starting with a national survey versus interviews or using observational study method in addition (these are discussed in Chapter 8), there were barriers in the mixing phase.241 Having a prior quantitative background, during
RABATHALY, P. A. (2018) London School of Hygiene & Tropical Medicine PhD Thesis |