Designing a mixed methods study in primary care

BACKGROUND Mixed methods or multimethod research holds potential for rigorous, methodologically sound investigations in primary care. The objective of this study was to use criteria from the literature to evaluate 5 mixed methods studies in primary care and to advance 3 models useful for designing such investigations.     

Excellence in regional stroke care: An evaluation of the implementation of a stroke care unit in regional Australia

Objective: To assess the effectiveness of a formalised stroke service in a regional hospital. Design: A pretest post‐test design. Setting: An acute stroke unit in a regional health service. Participants: Overall sample comprised 80 patients with 36 (45.0%) men. Forty patients (19 men, 21 women) comprised pre‐intervention group and 40 (17 men, 23 women) post‐intervention group. Interventions: Establishment of an acute stroke unit. Main outcome measure(s): Increased frequency in meeting key performance indicators for acute stroke care as recommended by National Stroke Foundation. Results: On discharge, fewer survivors in the pre‐intervention group were independent (n = 5) and returned home (n = 9) than the post‐intervention group (n = 13) for both independent and returned home. More survivors in the pre‐intervention group were discharged to aged care or inpatient rehab (n = 22) than the post‐intervention group (n = 12). Within required time frames, the frequency of CT scans (χ² (1, 80) = 4.1, P < 0.05), swallow assessments (χ² (1, 80) = 9.0, P < 0.01), occupational therapy assessments (χ² (1, 80) = 14.5, P < 0.0001), multidisciplinary meetings involving patient and family (χ² (1, 80) = 19.9, P < 0.0001) and self‐management plans (χ² (1, 80) = 10.9, P < 0.05) all increased significantly. Conclusions: Our evaluation demonstrated that introduction of formalised stroke care to a regional hospital resulted in improved compliance with key performance indicators and better patient outcomes. Thus evidence‐based specialised stroke care can be offered with confidence in regional populations.     

Adoption decisions and implementation of a community-based physical activity program: a mixed methods study

The purpose of this study was to determine the attributes of a community physical activity (PA) program that Kansas State Research & Extension System agents considered in the adoption decision-making process (DMP) and their understanding of evidence-based program principles. Ninety-nine percent of the eligible agents completed a survey that included quantitative and qualitative assessments of program attributes, delivery, and adaptations. The community PA program's effectiveness, compatibility within the system, high reach, and ease of delivery most influenced the DMP. Success in other counties was also indicated as influential in the DMP by those who decided to deliver the program after its initial year. Concepts of group dynamics were accurately identified and adaptations were consistent with these principles. The results indicate that agents consider multiple factors during the adoption DMP for a PA program and are able to articulate and propose adaptations that align with the evidence-based principles.     

Older carers in ageing societies:an evaluation of a respite care program for older carers in Western Australia

The Australian Red Cross Older Carers Program was developed in 2003 to support the unique needs of "older carers" aged 65 and older (50 if Indigenous) who care for a person (a care recipient, usually a family member) aged 18 or older who have a permanent disability. The aim of the program was to provide intensive case planning, management, and volunteer support that would assist older carers to more readily access respite and continue their caring role in the home. To help achieve this end, ongoing individualised and holistic assistance involving older carers in decision making was an integral component of the Older Carers Program, as was the use of regular home visits by program staff. The Older Carers Program evaluation was both a process and outcome evaluation. Much of the evaluation research focused on the extent to which it had met its stated aims and objectives. However, because the program was quite new and innovative there was a significant further focus upon the processes and activities within the program. At the time the evaluation research was conducted (May 2005), the program had been in operation for 22 months. The population group was identified as those persons (older carers) who had been part of the program between July 2003 and March 2005. Of the 96 older carers who had accessed the program in the specified period, 62 agreed to participate in our research. The methodology consisted of an audit or the program database, in-depth interviews with older carers, and contextual data collection involving program staff and other stakeholders.     

Effect of a change management program in a medical device reprocessing department: A mixed methods study

Faced with a variety of challenges in relation to performance, quality, staff engagement and morale in the Medical Device Reprocessing Department, managers at St. Michael’s Hospital developed and implemented several innovative approaches including combining staff training and performance metrics. The results of these initiatives included a substantial reduction in the departmental budget along with higher productivity, output and quality; better staff morale; an improved relationship between management and the union; and a stronger partnership between the department and its institutional customers.     

Staff perceptions of care for deliberate self-harm patients in rural Western Australia: a qualitative study

ABSTRACT: Suicide has been a major community concern in Esperance, a geographically isolated port on the south coast of Western Australia. This study to explores the views of regional health staff on barriers to the effective management of deliberate self-harm (DSH) and ways in which those barriers could be addressed. Semi-structured interviews were tape-recorded, transcribed and subjected to qualitative content analysis. Interviewees included 77% of general practitioners (n = 7), 18% of nurses ( n = 13) and 55% of mental health professionals (n = 5). The most important barrier was a lack of structure to treating DSH, resulting in deficiencies and inconsistencies in its management. Suggestions to improve the management of DSH included better communication between services, support for nurses in raising the issue of suicide, use of a simple risk assessment tool, the development of a nurse liaison position, and a multidisciplinary planning group.
The higher rates of DSH and completed suicide in rural and remote regions compared with metropolitan areas make secondary prevention particularly important.     

The impact of Saudi hospital accreditation on quality of care: a mixed methods study

In 2005, the Central Board for Accreditation of Healthcare Institutions (CBAHI) was launched in Saudi Arabia in order to improve the quality of care. By 2010, the first hospital was accredited by CBAHI, followed by many hospitals in following years. The aim of this study is to examine the impact of CBAHI on quality of care. In this study we used a mixed methods approach involving surveys, documentary analyses and semi‐structure interviews. Surveys data were collected from 669 staff. Documentary analyses included mortality, infection and length of stay. The semi‐structure interview data were gathered from 12 senior managers. Data were collected from three accredited public hospitals. Although some improvements in procedure were recognised, CBAHI does not monitor the continuity of health care delivery and had no effect on quality outcomes in our analysis. This study illustrates a need to sustain improvements over time in the accreditation cycle. Copyright © 2016 John Wiley & Sons, Ltd.     

The cost of in-patient care in Western Australia in the last years of life: a population-based data linkage study

OBJECTIVES: This study aimed to explore patterns of health expenditure for in-patient care in the last 3 years of life so as to understand how age and time to death contribute to health-care expenditure. METHOD: Records of all deaths occurring in Western Australia from 1997 to 2000 inclusive were extracted from the WA mortality register and linked to records from the hospital morbidity data system (HMDS) via the WA Data Linkage System. Inflation adjusted hospital costs were assigned to all in-patient events occurring within 3 years of death from five major causes of death using DRG costing information. RESULTS: Prior to the last 5 months of life the mean cost of hospitalisation was positively associated with age; however, the magnitude of the cost increase in the last 5 months of life was inversely related to age such that the cost in the last month of life was similar across age groups. CONCLUSION: The finding that increased costs are associated with proximity to death, but that the magnitude of the increase is inversely associated with age, has implications for the ongoing debate about whether proximity to death or age is the dominant driver of health-care costs. The results of this study suggest that models forecasting future health-care expenditure should take into account the interaction of age, time to death and cause of death. In addition, we propose that due to the differences observed across causes of death it may be that a single general population model may not be capable of fully capturing the relationship and that this may be why the debate regarding age and time to death has yet to be resolved in the literature.     

Evaluation of a national health promotion program in South Australia

Abstract: This paper reports the findings of the evaluation of the South Australian component of the National Better Health Program. The evaluation used analysis of focus-group interviews and key documents to assess the value of the state program. The evaluation demonstrated that for a relatively small investment ($2.4 million was allocated to the project over four years, representing only 0.5 per cent of the annual budget for teaching hospitals in South Australia), much can be achieved by harnessing the energy of local communities. The evaluation concluded that more attention should be directed to structural change, with an emphasis on collaboration across sectors, and community participation. Some key issues for the planning and implementation of health promotion were highlighted: the challenge of marrying local initiatives based on community development with national health promotion objectives; the importance of dedicated cind assured funding; the need for increased training and support for health promotion workers; and the importance of continuing a focus on equity in the implementation of health promotion. The paper concludes by questioning the value of the current Australian goals, targets and strategies for health, given the findings from this evaluation.     

Practitioners' validation of framework of team-oriented practice models in integrative health care: a mixed methods study

Background  

Biomedical and Complementary and Alternative Medicine (CAM) academic and clinical communities have yet to arrive at a common understanding of what Integrative healthcare (IHC) is and how it is practiced. The Models of Team Health Care Practice (MTHP) framework is a conceptual representation of seven possible practice models of health care within which teams of practitioners could elect to practice IHC, from an organizational perspective. The models range from parallel practice at one end to integrative practice at the other end. Models differ theoretically, based on a series of hypotheses. To date, this framework has not been empirically validated. This paper aims to test nine hypotheses in an attempt to validate the MTHP framework.     

The effectiveness of a primary care nursing-led dietary intervention for prediabetes: a mixed methods pilot study

Background

Primary care nurse-led prediabetes interventions are seldom reported. We examined the implementation and feasibility of a 6-month multilevel primary care nurse-led prediabetes lifestyle intervention compared with current practice in patients with prediabetes, with weight and glycated haemoglobin (HbA1c) as outcomes.

Methods

This study used a convergent mixed methods design involving a 6-month pragmatic non-randomised pilot study with a qualitative process evaluation, and was conducted in two neighbouring provincial cities in New Zealand, with indigenous Māori populations comprising 18.2% and 23.0%, respectively. Participants were non-pregnant adults aged ≤?70 years with newly diagnosed prediabetes (HbA1c 41-49 mmol/mol), body mass index (BMI) ≥?25 kg/m² and not prescribed Metformin. A structured dietary intervention tool delivered by primary care nurses with visits at baseline, 2–3 weeks, 3 months and 6 months was implemented in four intervention practices. Four control practices continued to provide usual care. Primary quantitative outcome measures were weight and HbA1c. Linear and quantile regression models were used to compare each outcome between the two groups at follow-up. Qualitative data included: observations of nurse training sessions and steering group meetings; document review; semi-structured interviews with a purposive sample of key informants (n?=?17) and intervention patients (n?=?20). Thematic analysis was used.

Results

One hundred fifty-seven patients with prediabetes enrolled (85 intervention, 72 control), 47.8% female and 31.2% Māori. Co-morbidities were common, particularly hypertension (49.7%), dyslipidaemia (40.1%) and gout (15.9%). Baseline and 6 month measures were available for 91% control and 79% intervention participants. After adjustment, the intervention group lost a mean 1.3 kg more than the control group (p?<?0.001). Mean HbA1c, BMI and waist circumference decreased in the intervention group and increased in the control group, but differences were not statistically significant. Implementation fidelity was high, and it was feasible to implement the intervention in busy general practice settings. The intervention was highly acceptable to both patients and key stakeholders, especially primary care nurses.

Conclusions

Study findings confirm the feasibility and acceptability of primary care nurses providing structured dietary advice to patients with prediabetes in busy general practice settings. The small but potentially beneficial mean weight loss among the intervention group supports further investigation.

Trial Registration

ANZCTR ACTRN12615000806561. Registered 3 August 2015 (Retrospectively registered).

     

Evaluation of a community dental clinic providing care to people experiencing homelessness: A mixed methods approach

BackgroundPeople who experience homelessness have higher dental treatment needs compared to the general population. However, their utilization of dental services and levels of treatment completion are low. Peninsula Dental Social Enterprise, a not‐for‐profit organization in the United Kingdom, established a community dental clinic to improve access to dental care for this population.ObjectivesTo evaluate the impact and acceptability of the community dental service for patients and examine the barriers and enablers to using and providing the service.MethodsThe evaluation included a retrospective assessment of anonymous patient data and thematic analysis of semi‐structured interviews with patients, support staff and service providers. The interviews were thematically analysed. A cost analysis of the dental service was also conducted.ResultsBy 18 February 2020, 89 patients had attended the clinic. These included 62 males (70%) and 27 females (30%), aged 38.43 years on average (SD ± 11.07). Of these, 42 (47%) patients have completed their treatment, 23 (26%) are in active treatment and 24 (27%) left treatment. In total, 684 appointments (541.5 hours clinical time) were given. Of these, 82% (562) of appointments were attended (452.5 hours clinical time). The 22 interviews that were conducted identified flexibility, close collaboration with support services and health‐care team attitudes as key factors influencing service utilization and continuity of care.ConclusionsThis study provides details of a highly acceptable and accessible dental care model for people experiencing homelessness, with recommendations at research, practice and commissioning levels.     

Indigenous health program evaluation design and methods in Australia: a systematic review of the evidence

Objective: Indigenous Australians experience a disproportionately higher burden of disease compared to non‐Indigenous Australians. High‐quality evaluation of Indigenous health programs is required to inform health and health services improvement. We aimed to quantify methodological and other characteristics of Australian Indigenous health program evaluations published in the peer‐reviewed literature. Methods: Systematic review of peer‐reviewed literature (November 2009–2014) on Indigenous health program evaluation. Results: We identified 118 papers describing evaluations of 109 interventions; 72.0% were university/research institution‐led. 82.2% of evaluations included a quantitative component; 49.2% utilised quantitative data only and 33.1% used both quantitative and qualitative data. The most common design was a before/after comparison (30.5%, n=36/118). 7.6% of studies (n=9/118) used an experimental design: six individual‐level and three cluster‐randomised controlled trials. 56.8% (67/118) reported on service delivery/process outcomes (versus health or health risk factor outcomes) only. Conclusions: Given the number of Indigenous health programs that are implemented, few evaluations overall are published in the peer‐reviewed literature and, of these, few use optimal methodologies such as mixed methods and experimental design. Implications for public health: Multiple strategies are required to increase high‐quality, accessible evaluation in Indigenous health, including supporting stronger research‐policy‐practice partnerships and capacity building for evaluation by health services and government.     

Health care access and the Americans with Disabilities Act: A mixed methods study

BackgroundThe Americans with Disabilities Act (ADA) requires that health care entities provide full and equal access to people with disabilities. However, results of previous studies have indicated that the ADA has been largely ineffective at creating systemic change in the delivery of health care.ObjectiveThe objective of this study was to examine the current barriers to health care access experienced by people with disabilities under Titles II and III of the ADA.MethodsThis study utilized a mixed methods multiphase design. In phase one, a survey and focus groups were conducted with individuals with disabilities who experienced barriers to health care access. In phase two, key informant interviews were conducted with individuals who had a role in ensuring equal access to health care for people with disabilities.ResultsIn the current context of health care reform, people with disabilities continue to experience multiple barriers to health care access under Titles II and III of the ADA. However, a notable result is that several provisions of the Patient Protection and Affordable Care Act (ACA) have likely bolstered existing directives implementing requirements for health care access under the ADA.ConclusionsThe results of this study provide additional support for a comprehensive examination of both the national standards for accessible health care and the enforcement of laws that prohibit discrimination on the basis of disability.