Theoretical perspective

To address the research aim and objectives would require a mixture of study methods. Where quantitative research uses numerical data to formulate fact and uncover

patterns about the natural world, qualitative research explores understanding about the social world (Creswell and Creswell, 2017). Mixed methods research combines

elements of qualitative and quantitative research approaches in order to achieve breadth and depth of understanding and corroboration (Johnson et al., 2007). Researchers tend to undertake one of these types of research and often regard the others with suspicion for a range of reasons, including from a philosophical perspective (Hammarberg et al., 2016).

2.3.1 Philosophical assumptions

The term ‘research paradigm’ was coined by Kuhn whilst unravelling the reason behind ‘the number and extent of overt disagreements between social science researchers about the nature of scientific problems and methods’ (Kuhn, 1962). He described them as ‘scientific achievements which, for a time, provide model problems and solutions to a community of practitioners.’ Over time, the term has evolved to become the

philosophical approach underpinning research which takes the research process in a particular direction. As shown Table 2-1, three components of the research paradigm are: ontology, epistemology and methods (Ritchie et al., 2013) (Mackenzie and Knipe, 2006).

Table 2-1 Description of research paradigm components adapted from (Ritchie et al., 2013) (Mackenzie and Knipe, 2006).

Components of the research paradigm Description

Ontology Assumptions about the nature of reality

and what exists in the world.

Epistemology Assumptions about how we can come to

know about what exists in the world and learn from reality.

Methods Combination of approaches to data

collection and analysis.

Quantitative and qualitative research paradigms differ markedly in their ontological and epistemological assumptions. Quantitative research is generally positivist or post- positivist in nature and is explored using objective ‘scientific method.’ For qualitative research, there are a plethora of paradigms from which researchers may choose, depending on the researcher’s view of the world. As shown in Table 2-2, these include interpretivist, constructivist, and pragmatist.

Table 2-2 Examples of research paradigms. Adapted from (Ritchie et al., 2013). and (Hallberg and Richards, 2015).

Paradigms Ontology Epistemology Methods

Positivism Reality exists independent of our beliefs. Reality is objective and perceived Acquisition of knowledge is independent of morals or values Quantitative Interpretivism/ constructivism No external reality exists independent of our beliefs and understanding. Reality is affected by the research process. Knowledge is actively constructed by humans Qualitative Pragmatism Reality is ambiguous. Multiple ways of perceiving the world. Knowledge is formed by both objective and subjective values Quantitative and/or qualitative

2.3.2 Mixed methods – the third way

Mixed methods research is the type of research in which a researcher or team of researchers combines qualitative and quantitative elements to gain breadth and depth of understanding and corroboration (Johnson et al., 2007). Mixed methods research has emerged as the ‘third methodological movement’(Denzin, 2010). These names recognise the strict polarisation between quantitative research (the first) and qualitative (the second) to which has already been alluded (Hallberg and Richards, 2015). Whilst some researchers place no importance on the differences at either the level of practice or that of epistemology, for others the mixing of incompatible approaches within mixed methods research has been controversial (Denzin, 2010) (Howe, 2012).

More recently, it has become a more accepted norm to use quantitative and qualitative methods together for empirical inquiries (Tashakkori and Teddlie, 2010) (Johnson et al., 2007). Proponent researchers favoured a ‘what works’ pragmatic argument which has become known as ‘evidence-based research’ (Denzin, 2010).

2.3.3 Evidence-based research

Evidence-based research originating in pragmatism was characterised by the importance given to the research objective, which governed the direction of the research (Hallberg and Richards, 2015). A pluralistic approach to addressing the objective from more than one perspective was equally important. For this reason, the need to choose between world views was replaced by embracing a range of

approaches and perspective, thus allowing the best evidence to be sought with which to address the question/objective. Both inductive and deductive approaches are used within mixed methods research, allowing theory generation and verification. Use of pragmatism also means the research can take place in context, allowing consideration of the complexity of healthcare’s social, historical and political factors.

The MRC’s 2013 complex interventions guidance advocated an iterative and pragmatic approach to intervention development (Craig et al., 2013). In contrast to mono-method studies, mixed methods can allow for modification of the research question(s) and research design during the course of the study (Hallberg and Richards, 2015). A range of mixed methods designs exist in which the various strands of research are

undertaken concurrently, sequentially or as a multi-phase design in which each subsequent phase uses a study design to build on the research finds of the previous study in order to build towards achieving the project’s overall objective. This study used a multi-phase design (qualitative – quantitative – qualitative) and the follow-on study would refine components of the complex intervention through iterations leading to a feasibility and then full trial to evaluate the complex intervention.

2.3.4 Theory-informed behaviour change interventions

Interventions to support behaviour change tend to be more successful when underpinned by behavioural theory (Abraham et al., 2009). Whilst a plethora of

behaviour change theories and models exist, Asimakopoulou & Newton (2015) contend that even two of the most commonly used and researched (Theory of Planned

Behaviour and Trans-Theoretical Model) have been poor at explaining actual behaviour and proved rather unconvincing in supporting behaviour change in the dental setting (Asimakopoulou and Newton, 2015). By combining existing theories and models, however, a new paradigm for behavioural theory to underpin understanding about behaviours and approaches to tackling them was developed: a coherent suite of theories, techniques and tools developed by the University College London (UCL) Centre for Behaviour Change (CBC) and its partners (Michie et al., 2014). Further descriptions are presented in the relevant Chapters of the thesis: TDF (Chapter 3), Capability-Opportunity-Motivation-Behaviour (COM-B) model (Chapter 5), Behaviour Change Techniques (BCTs) (Chapter 6) and Theory & Techniques Tool (TTT) (Chapter 6).

2.3.5 Implementation science

Implementation science has been defined as: ‘the scientific study of methods to

promote the systematic uptake of research findings and other evidence-based

practices into routine practice, and, hence, to improve the quality and effectiveness of health services and care’ (Eccles and Mittman, 2006). It is a relatively new discipline

dating back to around 2006 and has tended to be based on a ‘clockwork universe

paradigm with a step-by-step approach to interventions’ (Braithwaite et al., 2018). By

contrast, complexity is described as ‘a dynamic and constantly emerging set of

processes and objects that not only interact with each other, but come to be defined by those interactions’ (Cohn et al., 2013). Scholars of complexity increasingly draw

distinctions between complicated and complex interventions. Complicated interventions work roughly the same way in different settings whereas complex interventions adapt in response to changes in social systems (Mills et al., 2019). Conventional healthcare interventions have tended to be predicated on linearity and predictability, which works well for complicated interventions (Greenhalgh and Papoutsi, 2018). Non-linear

approaches to test and evaluate complex interventions are increasingly advocated and it is anticipated that the new MRC guidance will provide an impetus for natural

2.3.6 Complex interventions

Complex interventions are described in current MRC guidance as ‘interventions with

several interacting components’ (Craig et al., 2008). An on-going review of this

guidance, however, has found its current definition is somewhat outdated and relates to multifaceted rather than complex interventions. A revised definition of complex

interventions is anticipated which will draw upon ‘a wider understanding of the complex

contexts (systems) in which interventions are delivered and evaluated’ (Craig et al.,

2019) (Skivington et al., 2018). The consultation draft of the updated MRC/NIHR guidance on complex interventions also included a revised model for developing and evaluating complex infections which reflects its new emphasis on context and

overarching considerations as well as the importance of combining interventions which act at both local and wider levels (Craig et al., 2019).

The way in which an intervention is expected to lead to its effects and under what conditions is described as ‘programme theory’ (Rogers, 2008). The APTiTUDE

intervention programme theory will be presented in Chapter 6, based on evidence and behavioural theory identified in Chapter 5. Logic models are visual representations of the programme theory (Moore et al., 2015). A logic model to describe the dental antimicrobial stewardship intervention being developed will be presented in Chapter 6. With increasing emphasis on the dynamic context within which complex interventions are implemented, the APTiTUDE logic model will include evidence from Chapter 5 about the context of urgent NHS dental appointments within which dentists and adult patients share decisions about whether to prescribe antibiotics for acute dental conditions in England.

2.3.7 Story-based interventions

Stories and anecdotes are a powerful way to communicate ideas, increase knowledge and trigger action, including modifying existing mind lines (short cuts in thinking) (Gabbay and le May, 2010). The ‘stickiness of stories’ make them a very good way to spread information, although conversely they may also spread misinformation. During their ethnographic research Gabbay & Le May noted clinicians were routinely sharing stories which allowed continual checking and upgrading of their practice (Gabbay and le May, 2004). They also found that theoretical knowledge is better retained when linked to a narrative, especially if the story is oral rather than written as the listener can actively engage (Connell et al., 2004). Furthermore, because stories often contain metaphor, analogy and other expressive imagery, they are highly effective in conveying tacit information that is otherwise difficult to articulate (Nonaka, 1994).

2.3.8 Participatory research

Participatory research is an umbrella term for a school of approaches that share a core philosophy of inclusivity and of recognising the value of engaging in the research process (rather than including only as subjects of the research) those who are intended to be the beneficiaries, users, and stakeholders of the research (Cargo and Mercer, 2008). INVOLVE defines Patient and Public Involvement & Engagement (PPIE) in research as ‘research that is carried out with and by patients and the public, not to, for

or about them’(NIHR, 2019c).

Together and individually, a stakeholder group was convened to help shape the research questions. Through the course of the research, it will guide the sampling strategies, research site recruitment, analysis and prioritisation of the research results, design of the interventions and dissemination of the findings – very much aimed at a co-production approach.

2.3.9 Quality in research

High quality research is more likely to produce reliable high quality results. Concern about assessing quality has manifested itself in the proliferation of guidelines for doing so (Mays and Pope, 2000). The EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network was established to improve the reliability and value of published health research literature by promoting transparent and accurate reporting and wider use of robust reporting guidelines (EQUATOR, 2019). Each Chapter of this thesis is underpinned by an appropriate reporting framework: PRIMSA for the

systematic review(Moher et al., 2009); RECORD for the analysis of routinely-collected data(Benchimol et al., 2015). and SRQR for the qualitative research(O’Brien et al., 2014). Two frameworks are considered for reporting the intervention development: CReDECI2 and TIDieR (Hoffmann et al., 2014) (Möhler et al., 2015).