Mixed Methods Methodology 4.1 Introduction 4.1 Introduction 4.1 Introduction

This chapter sets out the mixed methods methodology utilised by this study, with a definition and description of the issues confronting researchers undertaking this approach. The

justification for using this method is set out, and details of the research design with consideration of research quality and data integration.

4.2 Mixed Methods Approach

Mixed methods are a relatively recent research method (Creswell 2003), and are defined as

“investigations involv[ing] integrating quantitative and qualitative data collection and analysis in a single study or program of inquiry” (Cresswell, Fetters & Ivankova 2004, page 7). The approach which is distinct from multi-method studies which do not ‘mix’ the qualitative and quantitative elements (Bryman 2007, Tashakkkori & Creswell 2007), has become more popular in recent times and there are now journals and textbooks dedicated to the subject, and an increasing number of mixed methods studies undertaken within the field of health (O’Cathain et al 2007). Researchers undertaking a mixed methods study face a number of challenges, from epistemological issues around the different traditions of qualitative and quantitative research methods, and the additional work and skill required to collect and analyse both data types (Cresswell 2003, Bergman 2008) and draw the findings together.

4.3 Epistemological Issues

Epistemological issues arise out the differing stances traditionally applied in quantitative and qualitative research: with a positive/postpositive stance applied in quantitative research whereby a theory is developed and tested via data measures in a logical manner; however within qualitative research there is a more complex view of reality with social constructivism stances taking account of individuals’ constructions of their social situation, or

advocacy/participatory stances seeking to understand the position of subgroups within the power structure of society (Creswell 2003). However for Bergman (2008a) the positions of the two camps are less distinct and within each there is tremendous heterogeneity; and therefore there is more scope for mixed methods research to move beyond these perceived hurdles.

A solution to this apparent dichotomy is to base the choice of research methods on

appropriateness for the research question and the situation in which the research takes place (Devine & Heath 1999, Silverman 2006). In a study of health services researchers, a common motive for utilising a mixed methods approach was for pragmatic reasons - that an approach

67 utilising a single research method would not capture the complexity of participants and the situation being explored (O’Cathain et al 2007). Such considerations were of greater

importance than ideological issues. A pragmatic approach is often utilised by mixed methods researchers because this ontological approach is more concerned with using a variety of methods best suited to the issue under examination, rather than being limited by a single approach (Creswell 2003). Clashes may arise within research teams conducting mixed

methods, because of differing methodological expectations (O’Cathain & Thomas 2006); but in a project undertaken by a single researcher these issues would not arise.

4.4 Justification for the Mixed Methods Approach

A mixed methods approach has a number of advantages, and these are generally stated to be:

comprehensiveness, complexity, and confirmation. A mixed methods study is thought to be more comprehensive because the dual methods produce a broader picture of the research topic; and this is the key reason why health services researchers favour this approach

(O’Cathain et al 2007). This method is also considered to be suitable for researchers studying complex issues or environments (Moffatt et al 2006), or for researchers seeking to address complex research questions, as is the case typically in the health sphere (O’Cathain et al 2007).

Moffatt et al (2006) argue that the use of a mixed methods approach to study complex health issues “…increase[s] the likelihood of arriving at a more thoroughly researched and better understood set of results” (page 10). A third motive for mixed methods is the use of the second method to confirm findings from the first method, and thus to strengthen the evidence; however this idea is problematic since the differing research methods would not necessarily “give” the same answer anyway (Moran-Ellis et al 2006, O’Cathain & Thomas 2006). Although it is argued that by exploring whether the findings from the dual methods converge, diverge, or contradict each other, valuable insights can be gained (Sandelowski 1995). And finally, mixed methods can be used as an emergent methodology when an initial method is found to be inadequate to explore the research question; this is known as an emergent mixed methods design (Cresswell & Plano Clark 2011).

A mixed methods approach was chosen for this study as the best means to answer the

different aspects of the research questions, and to garner the strengths and insights from each research method. The study was not initially conceptualised as using a mixed methods

approach, but for the reasons explained as follows, the study design altered in an iterative way to meet the changing needs of the study. An initial quantitative approach was undertaken to analyse the relationship between measures of health and proxy measures of activity, in order

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to explore this under-researched topic and to test whether there were any statistically significant differences in activity according to gradients of self-reported health. The

quantitative findings presented a complex picture, with no observable pattern between the activity and health measures, and thus further methods of explanation were sought. A follow-up qualitative study was undertaken in order to understand more about the experience of living with a long-term condition, and its impact on everyday activity within the complexity of an individual’s life. The qualitative study sought to address some of the deficits of the quantitative study, chiefly that the quantitative data did not elucidate what was going on within the home, and it did not explain the lack of uniformity in the findings. The quantitative findings were therefore used to inform the development of the interview questions for the qualitative phase of the study, which was designed to elaborate and explain the initial findings, and to expand the understanding utilising the strengths of qualitative investigation (Pill 1995).

Within the field of research into older people, and more specifically of researching everyday activities, there have been a number of mixed methods studies (e.g. Bowling & Gabriel 2007, Moffatt et al 2006).

The study design was also developed for pragmatic reasons, since the planned second phase of the study focussing on participants with recurrent urinary tract infection, did not come to fruition. Opportunities to further the study were sought, and when the opportunity arose to undertake a qualitative study of activities undertaken whilst living with heart failure; this was considered a better fit than the initial planned second phase study, since it was the same health condition, and enabled further exploration of the quantitative phase. This change in methods was undertaken with an awareness of the importance of the balance between pragmatic and methods-driven research (Kazi 2003).

4.5 Research Paradigm

One criticism of the pragmatic approach utilised by many mixed methods researchers is that the researchers may not pay sufficient attention to the epistemological ideas that underlie the different research methods that are utilised (Richie & Lewis 2003). In order to counter this, an epistemological stance was taken for this research, and this was understood to be a world view and a set of beliefs that would influence how the research questions are phrased and the undertaking of the research (although it is acknowledged that this is a subject area with many definitions (Morgan 2007)). A subtle realist stance was taken (Hammersley 1992), as this was a

69 paradigm that is appropriate for both elements of the research process, and also fitted with my own world view. Subtle realists believe that there are multiple non-contradictory versions of reality, and although the accounts differ they may all reflect reality (Murphy & Dingwall 2007). However the approach rejects the possibility of multiple contradictory statements of events representing reality. The role of the researcher is therefore to cast a critical eye over the accounts given by participants to find a version of events that can be reasonably believed to be true, “…whose validity we are reasonably confident” (Hammersley 1992, page 50).

However it is essential that researchers should also be aware of their own influence on the research, and through reflexivity seek to identify any erroneous assumptions, attitudes or beliefs; O’Cathain (2009) called this process “situating” yourself within the research.

In the following paragraph I will used the first person to describe my philosophical position, and I will use this approach for periods of reflexivity within the thesis, a method recommended by O’Cathain 2009:-

As a subtle realist I believe that there are various versions of events portrayed as the ‘truth’

and it is my role to appraise the most likely version of reality. Within this process I was aware of the influence of myself on the research (of my values, beliefs, attitudes, and past

experiences) to impact on both the undertaking of the research and the interpretation of the findings; and this was addressed by a process of reflexivity which will be described later.

4.6 Research Design

The study was designed to have two stages, quantitative and qualitative, in order to address different aspects of the research question; with both elements acting both as complementary parts of the whole study, and as stand-alone studies in their own right (O’Cathain 2009). The study design also played a part in developing the focus of the study, with the first stage (the quantitative data analysis and findings) informing the design of the interview questions in the qualitative study. This mixed methods approach is defined as a sequential explanatory strategy with a first stage of quantitative data collection and analysis, followed by qualitative stage; such an approach is particularly useful when the initial quantitative findings are unexpected (as was the case in this study) (Creswell 2003, Morse 1991), and works well for researchers working alone as each step is taken sequentially.

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Both sections of the study were given equal weighting, which means that both sections of the study were considered of equal importance and given equal priority within the study; as both elements were thought to be of merit in understanding the research topic. However it should be acknowledged that the final study was primarily a qualitative study. The mixed methods research design is represented by the following diagram 4.1:-

Diagram 4.1: Mixed Methods Design

(Based on Cresswell 2003)

The process of the mixed methods research is illustrated by diagram 4.2, with the quantitative research testing the theoretical assumption that proxy activity levels would vary according to self-reported levels of health. In the event, the statistical tests revealed a complex picture without the expected pattern of lower activity in the worst levels of self-reported health, and thus the qualitative research was designed to explore and explain this finding. The sampling strategy was designed to reflect the original sample, and the interview questions were devised to explore activities within differing health states, and to also seek information about other factors influencing everyday activity.

4.7 Quality Checks

Quality in mixed methods comes from utilising sound methods in both the quantitative and qualitative elements, and ensuring that the inferences that are drawn out of the mixed methods are also based on sound practice (Teddlie & Tashakkori 2009). The essential

ingredients of a quality mixed methods research project have been defined by O’Cathain et al (2008), and this study set out to ensure that attention was paid to each quality criterion:-

i) Justification of a mixed methods approach for the research question

ii) Description of mixed methods research design (including purpose, priority, and sequence)

QUAN

Data