Achieving Integration in Mixed Methods Designs—Principles and Practices

Mixed methods research offers powerful tools for investigating complex processes and systems in health and health care. This article describes integration principles and practices at three levels in mixed methods research and provides illustrative examples. Integration at the study design level occurs through three basic mixed method designs—exploratory sequential, explanatory sequential, and convergent—and through four advanced frameworks—multistage, intervention, case study, and participatory. Integration at the methods level occurs through four approaches. In connecting, one database links to the other through sampling. With building, one database informs the data collection approach of the other. When merging, the two databases are brought together for analysis. With embedding, data collection and analysis link at multiple points. Integration at the interpretation and reporting level occurs through narrative, data transformation, and joint display. The fit of integration describes the extent the qualitative and quantitative findings cohere. Understanding these principles and practices of integration can help health services researchers leverage the strengths of mixed methods.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/101791/1/hesr12117.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/101791/2/hesr12117-sup-0001-AuthorMatrix.pd

Produce Sections, Town Squares, and Farm Stands: Comparing Local Food Systems in Community Context

A growing literature has grappled with the emergence of local food systems as an alternative to the conventional agricultural model and assumes that the development of local food system venues, such as farmers’ markets, are positive community-building initiatives. Too often left out of this discourse are empirical assessments of the community characteristics that lend themselves to the success of farmers’ markets or similar initiatives. Further, when farmers’ markets are not significantly patronized by community members, does this necessarily mean that people do not value local produce? This article uses the results from surveys of farmers’ market consumers and case studies of local foods initiatives in parts of Illinois to answer these questions and applies the community capitals framework and convention theory to help categorize communities according to their acceptance of farmers’ markets. Our findings demonstrate that consumers value locally-grown food despite location, but seek it out through different channels. The implications are that building successful local food systems is not simply about changing consumer opinion or applying a one-size-fits-all approach to local markets, but will require creativity in developing local markets that build on the current shopping behaviors of consumers

Managing health worker migration: A qualitative study of the Philippine response to nurse brain drain

Background: The emigration of skilled nurses from the Philippines is an ongoing phenomenon that has impacted the quality and quantity of the nursing workforce, while strengthening the domestic economy through remittances. This study examines how the development of brain drain-responsive policies is driven by the effects of nurse migration and how such efforts aim to achieve mind-shifts among nurses, governing and regulatory bodies, and public and private institutions in the Philippines and worldwide. Methods:Interviews and focus group discussions were conducted to elicit exploratory perspectives on the policy response to nurse brain drain. Interviews with key informants from the nursing, labour and immigration sectors explored key themes behind the development of policies and programmes that respond to nurse migration. Focus group discussions were held with practising nurses to understand policy recipients’ perspectives on nurse migration and policy. Results: Using the qualitative data, a thematic framework was created to conceptualize participants’ perceptions of how nurse migration has driven the policy development process. The framework demonstrates that policymakers have recognised the complexity of the brain drain phenomenon and are crafting dynamic policies and programmes that work to shift domestic and global mindsets on nurse training, employment and recruitment. Conclusions: Development of responsive policy to Filipino nurse brain drain offers a glimpse into a domestic response to an increasingly prominent global issue. As a major source of professionals migrating abroad for employment, the Philippines has formalised efforts to manage nurse migration. Accordingly, the Philippine paradigm, summarised by the thematic framework presented in this paper, may act as an example for other countries that are experiencing similar shifts in healthcare worker employment due to migration

Effect of Water Depth on Heart Rate and Core Temperature During Underwater Treadmill Walking

Exercising using an underwater treadmill (UTM) has become a popular modality; however, few studies have focused on the physiological demands of UTM walking at varying water depths. Thus, the objective of this study was to investigate changes in heart rate (HR) and core temperature (CT) values in college-aged males and females while exercising at different water immersion depths using an UTM. Twenty participants (age = 21.50 ± 2.19 years; height = 169.04 ± 10.85cm; weight = 75.56 ± 22.28kg) walked at water depths of 10cm below the xiphoid process and at the level of the superior iliac crest (I.C.). Each UTM session lasted 15 minutes, consisting of 5-minute bouts at 1, 2, and 3 mph. Polar HR monitors and ingestible thermoregulatory pills were used to measure HR and CT. Results indicated that HR at 1 (p = .305) and 2 mph (p = .864) were not significantly different between water depths. Heart rate was significantly higher at 3 mph (p = .003) at the I.C. water level. No significant differences were found in CT at 1 (p = .919), 2 (p = .392), or 3 mph (p = .310) during either immersion depth. As a result, higher immersion depths resulted in a lower average HR during higher intensity exercise due to the increased buoyancy effects and the reduced gravity environment of the water. Thus, exercising in higher immersion depths allows participants to exercise at a higher intensity with less overall stress placed on the lower extremities

Characterizing performance improvement in primary care systems in Mesoamerica: A realist evaluation protocol [version 1; referees: 2 approved, 1 approved with reservations]

Background. Improving performance of primary care systems in low- and middle-income countries (LMICs) may be a necessary condition for achievement of universal health coverage in the age of Sustainable Development Goals. The Salud Mesoamerica Initiative (SMI), a large-scale, multi-country program that uses supply-side financial incentives directed at the central-level of governments, and continuous, external evaluation of public, health sector performance to induce improvements in primary care performance in eight LMICs. This study protocol seeks to explain whether and how these interventions generate program effects in El Salvador and Honduras. Methods. This study presents the protocol for a study that uses a realist evaluation approach to develop a preliminary program theory that hypothesizes the interactions between context, interventions and the mechanisms that trigger outcomes. The program theory was completed through a scoping review of relevant empirical, peer-reviewed and grey literature; a sense-making workshop with program stakeholders; and content analysis of key SMI documents. The study will use a multiple case-study design with embedded units with contrasting cases. We define as a case the two primary care systems of Honduras and El Salvador, each with different context characteristics. Data will be collected through in-depth interviews with program actors and stakeholders, documentary review, and non-participatory observation. Data analysis will use inductive and deductive approaches to identify causal patterns organized as ‘context, mechanism, outcome’ configurations. The findings will be triangulated with existing secondary, qualitative and quantitative data sources, and contrasted against relevant theoretical literature. The study will end with a refined program theory. Findings will be published following the guidelines generated by the Realist and Meta-narrative Evidence Syntheses study (RAMESES II). This study will be performed contemporaneously with SMI’s mid-term stage of implementation. Of the methods described, the preliminary program theory has been completed. Data collection, analysis and synthesis remain to be completed

Scaling up depot medroxyprogesterone acetate (DMPA): a systematic literature review illustrating the AIDED model

BACKGROUND: Use of depot medroxyprogesterone acetate (DMPA), often known by the brand name Depo-Provera, has increased globally, particularly in multiple low- and middle-income countries (LMICs). As a reproductive health technology that has scaled up in diverse contexts, DMPA is an exemplar product innovation with which to illustrate the utility of the AIDED model for scaling up family health innovations. METHODS: We conducted a systematic review of the enabling factors and barriers to scaling up DMPA use in LMICs. We searched 11 electronic databases for academic literature published through January 2013 (n = 284 articles), and grey literature from major health organizations. We applied exclusion criteria to identify relevant articles from peer-reviewed (n = 10) and grey literature (n = 9), extracting data on scale up of DMPA in 13 countries. We then mapped the resulting factors to the five AIDED model components: ASSESS, INNOVATE, DEVELOP, ENGAGE, and DEVOLVE. RESULTS: The final sample of sources included studies representing variation in geographies and methodologies. We identified 15 enabling factors and 10 barriers to dissemination, diffusion, scale up, and/or sustainability of DMPA use. The greatest number of factors were mapped to the ASSESS, DEVELOP, and ENGAGE components. CONCLUSIONS: Findings offer early empirical support for the AIDED model, and provide insights into scale up of DMPA that may be relevant for other family planning product innovations

Research in action: using positive deviance to improve quality of health care

Background Despite decades of efforts to improve quality of health care, poor performance persists in many aspects of care. Less than 1% of the enormous national investment in medical research is focused on improving health care delivery. Furthermore, when effective innovations in clinical care are discovered, uptake of these innovations is often delayed and incomplete. In this paper, we build on the established principle of 'positive deviance' to propose an approach to identifying practices that improve health care quality. Methods We synthesize existing literature on positive deviance, describe major alternative approaches, propose benefits and limitations of a positive deviance approach for research directed toward improving quality of health care, and describe an application of this approach in improving hospital care for patients with acute myocardial infarction. Results The positive deviance approach, as adapted for use in health care, presumes that the knowledge about 'what works' is available in existing organizations that demonstrate consistently exceptional performance. Steps in this approach: identify 'positive deviants,' i.e., organizations that consistently demonstrate exceptionally high performance in the area of interest (e.g., proper medication use, timeliness of care); study the organizations in-depth using qualitative methods to generate hypotheses about practices that allow organizations to achieve top performance; test hypotheses statistically in larger, representative samples of organizations; and work in partnership with key stakeholders, including potential adopters, to disseminate the evidence about newly characterized best practices. The approach is particularly appropriate in situations where organizations can be ranked reliably based on valid performance measures, where there is substantial natural variation in performance within an industry, when openness about practices to achieve exceptional performance exists, and where there is an engaged constituency to promote uptake of discovered practices. Conclusion The identification and examination of health care organizations that demonstrate positive deviance provides an opportunity to characterize and disseminate strategies for improving quality