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• v.12(1); 2022 Mar

The Growing Importance of Mixed-Methods Research in Health

Sharada prasad wasti.

1,2 School of Human and Health Sciences, University of Huddersfield, United Kingdom

Padam Simkhada

3 Centre for Midwifery, Maternal and Perinatal Health, Bournemouth University, Bournemouth, United Kingdom

Edwin R. van Teijlingen

Brijesh sathian.

4 Geriatrics and long term care Department, Rumailah Hospital, Hamad Medical Corporation, Doha, Qatar

Indrajit Banerjee

5 Sir Seewoosagur Ramgoolam Medical College, Belle Rive, Mauritius

All authors have made substantial contributions to all of the following: (1) the conception and design of the study (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted

There is no conflict of interest for any author of this manuscript.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sector.

This paper illustrates the growing importance of mixed-methods research to many health disciplines ranging from nursing to epidemiology. Mixed-methods approaches requires not only the skills of the individual quantitative and qualitative methods but also a skill set to bring two methods/datasets/findings together in the most appropriate way. Health researchers need to pay careful attention to the ‘best’ approach to designing, implementing, analysing, integrating both quantitative (number) and qualitative (word) information and writing this up in a way offers greater insights and enhances its applicability. This paper highlights the strengths and weaknesses of mixed-methods approaches as well as some of the common mistakes made by researchers applying mixed-methods for the first time.

Quantitative and qualitative research methods each address different types of questions, collect different kinds of data and deliver different kinds of answers. Each set of methods has its own inherent strengths and weaknesses, and each offers a particular approach to address specific types of research questions (and agendas). Health disciplines such as dentistry, nursing, speech and language therapy, and physiotherapy often use either quantitative or qualitative research methods on their own. However, there is a steadily growing literature showing the advantages of mixed-methods research is used in the health care and health service field [ 1-2 ]. Although we have advocated the use of mixed-methods in this journal eight years ago [ 3 ], there is still not enough mixed-methods research training in the health research field, particularly for health care practitioners, such as nurses, physiotherapists, midwives, and doctors, wanting to do research. Mixed-methods research has been popular in the social sciences since the twentieth century [ 4 ], and it has been growing in popularity among healthcare professionals [ 5 ], although it is still underdeveloped in disciplines such nursing and midwifery [ 6 , 7 ].

Underpinning philosophies

To help understand that mixed-methods research is not simply employing two different methods in the same study, one needs to consider their underpinning research philosophies (also called paradigms). First, quantitative research is usually underpinned by positivism. This includes most epidemiological studies; such research is typically based on the assumption that there is one single real world out there that can be measured. For example, quantitative research would address the question “What proportion of the population of India drinks coffee?” Secondly, qualitative research is more likely to be based on interpretivism. This includes research based on interviews and focus groups, research which us is typically based on the assumption that we all experience the world differently. Since we all live in a slightly different world in our heads the task of qualitative research is to analyse the interpretations of the people in the sample. For example, qualitative research would address the question “How do people experience drinking coffee in India?”, and “What does drinking coffee mean to them?”

Mixed-methods research brings together questions from two different philosophies in what is being referred to as the third path [ 8 ], third research paradigm [ 9 , 10 ], the third methodology movement [ 11 , 12 ] and pragmatism [ 5 ]. The two paradigms differ in key underlying assumptions that ultimately lead to choices in research methodology and methods and often give a breadth by answering more complicated research questions [ 4 ]. The roles of mixed-methods are clear in an understanding of the situation (the what), meaning, norms, values (the why or how) within a single research question which combine the strength of two different method and offer multiple ways of looking at the research question [ 13 ]. Epidemiology sits strongly in the quantitative research corner, with a strong emphasis on large data sets and sophisticated statistical analysis. Although the use of mixed methods in health research has been discussed widely researchers raised concerns about the explanation of why and how mixed methods are used in a single research question [ 5 ].

The relevance of mixed-methods in health research

The overall goal of the mixed-methods research design is to provide a better and deeper understanding, by providing a fuller picture that can enhance description and understanding of the phenomena [ 4 ]. Mixed-methods research has become popular because it uses quantitative and qualitative data in one single study which provides stronger inference than using either approach on its own [ 4 ]. In other words, a mixed-methods paper helps to understand the holistic picture from meanings obtained from interviews or observation to the prevalence of traits in a population obtained from surveys, which add depth and breadth to the study. For example, a survey questionnaire will include a limited number of structured questions, adding qualitative methods can capture other unanticipated facets of the topic that may be relevant to the research problem and help in the interpretation of the quantitative data. A good example of a mixed-methods study, it one conducted in Australia to understand the nursing care in public hospitals and also explore what factors influence adherence to nursing care [ 14 ]. Another example is a mixed-methods study that explores the relationship between nursing care practices and patient satisfaction. This study started with a quantitative survey to understand the general nursing services followed by qualitative interviews. A logistic regression analysis was performed to quantify the associations between general nursing practice variables supplemented with a thematic analysis of the interviews [ 15 ]. These research questions could not be answered if the researchers had used either qualitative or quantitative alone. Overall, this fits well with the development of evidence-based practice.

Despite the strengths of mixed-methods research but there is not much of it in nursing and other fields [ 7 ]. A recent review paper shows that the prevalence of mixed-methods studies in nursing was only 1.9% [ 7 ]. Similarly, a systematic review synthesised a total of 20 papers [ 16 ], and 16 papers [ 17 ] on nursing-related research paper among these only one mixed-methods paper was identified. Worse, a further two mixed-methods review recently revealed that out of 48 [ 18 , 19 ] synthesised nursing research papers, not one single mixed-methods paper was identified. This clearly depicts that mixed-methods research is still in its infancy stage in nursing but we can say there is huge scope to implement it to understand research questions on both sides of coin [ 4 ]. Therefore, there is a great need for mixed-methods training to enhance the evidence-based decision making in health and nursing practices.

Strengths and weaknesses of mixed-methods

There are several challenges in identifying expertise of both methods and in working with a multidisciplinary, interdisciplinary, or transdisciplinary team [ 20 ]. It increases costs and resources, takes longer to complete as mixed-methods design often involves multiple stages of data collection and separate data analysis [ 4 , 5 ]. Moreover, conducting mixed-methods research does not necessarily guarantee an improvement in the quality of health research. Therefore, mixed-methods research is only appropriate when there are appropriate research questions [ 4 , 6 ].

Identifying an appropriate mixed-methods journal can also be challenging when writing mixed-methods papers [ 21 ]. Mixed-methods papers need considerably more words than single-methods papers as well as sympathetic editors who understand the underlying philosophy of a mixed-methods approach. Such papers, simply require more words. The mixed-methods researcher must be reporting two separate methods with their own characteristics, different samples, and ways of analysing, therefore needs more words to describe both methods as well as both sets of findings. Researcher needs to find a journal that accepts longer articles to help broaden existing evidence-based practice and promote its applicability in the nursing field [ 22 ].

Common mistakes in applying mixed-methods

Not all applied researchers have insight into the underlying philosophy and/or the skills to apply each set of methods appropriately. Younas and colleagues’ review identified that around one-third (29%) of mixed-methods studies did not provide an explicit label of the study design and 95% of studies did not identify the research paradigm [ 7 ]. Whilst several mixed-methods publications did not provide clear research questions covering both quantitative and qualitative approaches. Another common issue is how to collect data either concurrent or sequential and the priority is given to each approach within the study where equal or dominant which are not clearly stated in writing which is important to mention while writing in the methods section. Similarly, a commonly overlooked aspect is how to integrate both findings in a paper. The responsibility lies with the researcher to ensure that findings are sufficiently plausible and credible [ 4 ]. Therefore, intensive mixed-methods research training is required for nursing and other health practitioners to ensure its appropriate.

The way forward

Despite the recognised strengths and benefits of doing mixed-methods research, there is still only a limited number of nursing and related-health research publications using such this approach. Researchers need training in how to design, conduct, analyse, synthesise and disseminate mixed-methods research. Most importantly, they need to consider appropriate research questions that can be addressed using a mixed methods approach to add to our knowledge in evidence-based practice. In short, we need more training on mixed-methods research for a range of health researchers and health professionals.

Acknowledgement

Mixed methods research: what it is and what it could be

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• Published: 29 March 2019
• Volume 48 , pages 193–216, ( 2019 )

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A Correction to this article was published on 06 May 2019

This article has been updated

Combining methods in social scientific research has recently gained momentum through a research strand called Mixed Methods Research (MMR). This approach, which explicitly aims to offer a framework for combining methods, has rapidly spread through the social and behavioural sciences, and this article offers an analysis of the approach from a field theoretical perspective. After a brief outline of the MMR program, we ask how its recent rise can be understood. We then delve deeper into some of the specific elements that constitute the MMR approach, and we engage critically with the assumptions that underlay this particular conception of using multiple methods. We conclude by offering an alternative view regarding methods and method use.

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Mixed Methods

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The interest in combining methods in social scientific research has a long history. Terms such as “triangulation,” “combining methods,” and “multiple methods” have been around for quite a while to designate using different methods of data analysis in empirical studies. However, this practice has gained new momentum through a research strand that has recently emerged and that explicitly aims to offer a framework for combining methods. This approach, which goes by the name of Mixed Methods Research (MMR), has rapidly become popular in the social and behavioural sciences. This can be seen, for instance, in Fig.  1 , where the number of publications mentioning “mixed methods” in the title or abstract in the Thomson Reuters Web of Science is depicted. The number increased rapidly over the past ten years, especially after 2006. Footnote 1

Fraction of the total of articles mentioning Mixed Method Research appearing in a given year, 1990–2017 (yearly values sum to 1). See footnote 1

The subject of mixed methods thus seems to have gained recognition among social scientists. The rapid rise of the number of articles mentioning the term raises various sociological questions. In this article, we address three of these questions. The first question concerns the degree to which the approach of MMR has become institutionalized within the field of the social sciences. Has MMR become a recognizable realm of knowledge production? Has its ascendance been accompanied by the production of textbooks, the founding of journals, and other indicators of institutionalization? The answer to this question provides an assessment of the current state of MMR. Once that is determined, the second question is how MMR’s rise can be understood. Where does the approach come from and how can its emergence and spread be understood? To answer this question, we use Pierre Bourdieu’s field analytical approach to science and academic institutions (Bourdieu 1975 , 1988 , 2004 , 2007 ; Bourdieu et al. 1991 ). We flesh out this approach in the next section. The third question concerns the substance of the MMR corpus seen in the light of the answers to the previous questions: how can we interpret the specific content of this approach in the context of its socio-historical genesis and institutionalization, and how can we understand its proposal for “mixing methods” in practice?

We proceed as follows. In the next section, we give an account of our theoretical approach. Then, in the third, we assess the degree of institutionalization of MMR, drawing on the indicators of academic institutionalization developed by Fleck et al. ( 2016 ). In the fourth section, we address the second question by examining the position of the academic entrepreneurs behind the rise of MMR. The aim is to understand these agents’ engagement in MMR, as well as its distinctive content as being informed by their position in this field. Viewing MMR as a position-taking of academic entrepreneurs, linked to their objective position in this field, allows us to reflect sociologically on the substance of the approach. We offer this reflection in the fifth section, where we indicate some problems with MMR. To get ahead of the discussion, these problems have to do with the framing of MMR as a distinct methodology and its specific conceptualization of data and methods of data analysis. We argue that these problems hinder fruitfully combining methods in a practical understanding of social scientific research. Finally, we conclude with some tentative proposals for an alternative view on combining methods.

A field approach

Our investigation of the rise and institutionalization of MMR relies on Bourdieu’s field approach. In general, field theory provides a model for the structural dimensions of practices. In fields, agents occupy a position relative to each other based on the differences in the volume and structure of their capital holdings. Capital can be seen as a resource that agents employ to exert power in the field. The distribution of the form of capital that is specific to the field serves as a principle of hierarchization in the field, differentiating those that hold more capital from those that hold less. This principle allows us to make a distinction between, respectively, the dominant and dominated factions in a field. However, in mature fields all agents—dominant and dominated—share an understanding of what is at stake in the field and tend to accept its principle of hierarchization. They are invested in the game, have an interest in it, and share the field’s illusio .

In the present case, we can interpret the various disciplines in the social sciences as more or less autonomous spaces that revolve around the shared stake in producing legitimate scientific knowledge by the standards of the field. What constitutes legitimate knowledge in these disciplinary fields, the production of which bestows scholars with prestige and an aura of competence, is in large part determined by the dominant agents in the field, who occupy positions in which most of the consecration of scientific work takes place. Scholars operating in a field are endowed with initial and accumulated field-specific capital, and are engaged in the struggle to gain additional capital (mainly scientific and intellectual prestige) in order to advance their position in the field. The main focus of these agents will generally be the disciplinary field in which they built their careers and invested their capital. These various disciplinary spaces are in turn part of a broader field of the social sciences in which the social status and prestige of the various disciplines is at stake. The ensuing disciplinary hierarchy is an important factor to take into account when analysing the circulation of new scientific products such as MMR. Furthermore, a distinction needs to be made between the academic and the scientific field. While the academic field revolves around universities and other degree-granting institutions, the stakes in the scientific field entail the production and valuation of knowledge. Of course, in modern science these fields are closely related, but they do not coincide (Gingras and Gemme 2006 ). For instance, part of the production of legitimate knowledge takes place outside of universities.

This framework makes it possible to contextualize the emergence of MMR in a socio-historical way. It also enables an assessment of some of the characteristics of MMR as a scientific product, since Bourdieu insists on the homology between the objective positions in a field and the position-takings of the agents who occupy these positions. As a new methodological approach, MMR is the result of the position-takings of its producers. The position-takings of the entrepreneurs at the core of MMR can therefore be seen as expressions in the struggles over the authority to define the proper methodology that underlies good scientific work regarding combining methods, and the potential rewards that come with being seen, by other agents, as authoritative on these matters. Possible rewards include a strengthened autonomy of the subfield of MMR and an improved position in the social-scientific field.

The role of these entrepreneurs or ‘intellectual leaders’ who can channel intellectual energy and can take the lead in institution building has been emphasised by sociologists of science as an important aspect of the production of knowledge that is visible and recognized as distinct in the larger scientific field (e.g., Mullins 1973 ; Collins 1998 ). According to Bourdieu, their position can, to a certain degree, explain the strategy they pursue and the options they perceive to be viable in the trade-off regarding the risks and potential rewards for their work.

We do not provide a full-fledged field analysis of MMR here. Rather, we use the concept as a heuristic device to account for the phenomenon of MMR in the social context in which it emerged and diffused. But first, we take stock of the current situation of MMR by focusing on the degree of institutionalization of MMR in the scientific field.

The institutionalization of mixed methods research

When discussing institutionalization, we have to be careful about what we mean by this term. More precisely, we need to be specific about the context and distinguish between institutionalization in the academic field and institutionalization within the scientific field (see Gingras and Gemme 2006 ; Sapiro et al. 2018 ). The first process refers to the establishment of degrees, curricula, faculties, etc., or to institutions tied to the academic bureaucracy and academic politics. The latter refers to the emergence of institutions that support the autonomization of scholarship such as scholarly associations and scientific journals. Since MMR is still a relatively young phenomenon and academic institutionalization tends to lag scientific institutionalization (e.g., for the case of sociology and psychology, see Sapiro et al. 2018 , p. 26), we mainly focus here on the latter dimension.

Drawing on criteria proposed by Fleck et al. ( 2016 ) for the institutionalization of academic disciplines, MMR seems to have achieved a significant degree of institutionalization within the scientific field. MMR quickly gained popularity in the first decade of the twenty-first century (e.g., Tashakkori and Teddlie 2010c , pp. 803–804). A distinct corpus of publications has been produced that aims to educate those interested in MMR and to function as a source of reference for researchers: there are a number of textbooks (e.g., Plowright 2010 ; Creswell and Plano Clark 2011 ; Teddlie and Tashakkori 2008 ); a handbook that is now in its second edition (Tashakkori and Teddlie 2003 , 2010a ); as well as a reader (Plano Clark and Creswell 2007 ). Furthermore, a journal (the Journal of Mixed Methods Research [ JMMR] ) was established in 2007. The JMMR was founded by the editors John Creswell and Abbas Tashakkori with the primary aim of “building an international and multidisciplinary community of mixed methods researchers.” Footnote 2 Contributions to the journal must “fit the definition of mixed methods research” Footnote 3 and explicitly integrate qualitative and quantitative aspects of research, either in an empirical study or in a more theoretical-methodologically oriented piece.

In addition, general textbooks on social research methods and methodology now increasingly devote sections to the issue of combining methods (e.g., Creswell 2008 ; Nagy Hesse-Biber and Leavy 2008 ; Bryman 2012 ), and MMR has been described as a “third paradigm” (Denscombe 2008 ), a “movement” (Bryman 2009 ), a “third methodology” (Tashakkori and Teddlie 2010b ), a “distinct approach” (Greene 2008 ) and an “emerging field” (Tashakkori and Teddlie 2011 ), defined by a common name (that sets it apart from other approaches to combining methods) and shared terminology (Tashakkori and Teddlie 2010b , p. 19). As a further indication of institutionalization, a research association (the Mixed Methods International Research Association—MMIRA) was founded in 2013 and its inaugural conference was held in 2014. Prior to this, there have been a number of conferences on MMR or occasions on which MMR was presented and discussed in other contexts. An example of the first is the conference on mixed method research design held in Basel in 2005. Starting also in 2005, the British Homerton School of Health Studies has organised a series of international conferences on mixed methods. Moreover, MMR was on the list of sessions in a number of conferences on qualitative research (see, e.g., Creswell 2012 ).

Another sign of institutionalization can be found in efforts to forge a common disciplinary identity by providing a narrative about its history. This involves the identification of precursors and pioneers as well as an interpretation of the process that gave rise to a distinctive set of ideas and practices. An explicit attempt to chart the early history of MMR is provided by Johnson and Gray ( 2010 ). They frame MMR as rooted in the philosophy of science, particularly as a way of thinking about science that has transcended some of the most salient historical oppositions in philosophy. Philosophers like Aristotle and Kant are portrayed as thinkers who sought to integrate opposing stances, forwarding “proto-mixed methods ideas” that exhibited the spirit of MMR (Johnson and Gray 2010 , p. 72, p. 86). In this capacity, they (as well as other philosophers like Vico and Montesquieu) are presented as part of MMR providing a philosophical validation of the project by presenting it as a continuation of ideas that have already been voiced by great thinkers in the past.

In the second edition of their textbook, Creswell and Plano Clark ( 2011 ) provide an overview of the history of MMR by identifying five historical stages: the first one being a precursor to the MMR approach, consisting of rather atomised attempts by different authors to combine methods in their research. For Creswell and Plano Clark, one of the earliest examples is Campbell and Fiske’s ( 1959 ) combination of quantitative methods to improve the validity of psychological scales that gave rise to the triangulation approach to research. However, they regard this and other studies that combined methods around that time, as “antecedents to (…) more systematic attempts to forge mixed methods into a complete research design” (Creswell and Plano Clark 2011 , p. 21), and hence label this stage as the “formative period” (ibid., p. 25). Their second stage consists of the emergence of MMR as an identifiable research strand, accompanied by a “paradigm debate” about the possibility of combining qualitative and quantitative data. They locate its beginnings in the late 1980s when researchers in various fields began to combine qualitative and quantitative methods (ibid., pp. 20–21). This provoked a discussion about the feasibility of combining data that were viewed as coming from very different philosophical points of view. The third stage, the “procedural development period,” saw an emphasis on developing more hands-on procedures for designing a mixed methods study, while stage four is identified as consisting of “advocacy and expansion” of MMR as a separate methodology, involving conferences, the establishment of a journal and the first edition of the aforementioned handbook (Tashakkori and Teddlie 2003 ). Finally, the fifth stage is seen as a “reflective period,” in which discussions about the unique philosophical underpinnings and the scientific position of MMR emerge.

Creswell and Plano Clark thus locate the emergence of “MMR proper” at the second stage, when researchers started to use both qualitative and quantitative methods within a single research effort. As reasons for the emergence of MMR at this stage they identify the growing complexity of research problems, the perception of qualitative research as a legitimate form of inquiry (also by quantitative researchers) and the increasing need qualitative researchers felt for generalising their findings. They therefore perceive the emergence of the practice of combining methods as a bottom up process that grew out of research practices, and at some point in time converged towards a more structural approach. Footnote 4 Historical accounts such as these add a cognitive dimension to the efforts to institutionalize MMR. They lay the groundwork for MMR as a separate subfield with its own identity, topics, problems and intellectual history. The use of terms such as “third paradigm” and “third methodology” also suggests that there is a tendency to perceive and promote MMR as a distinct and coherent way to do research.

In view of the brief exploration of the indicators of institutionalisation of MMR, it seems reasonable to conclude that MMR has become a recognizable and fairly institutionalized strand of research with its own identity and profile within the social scientific field. This can be seen both from the establishment of formal institutions (like associations and journals) and more informal ones that rely more on the tacit agreement between agents about “what MMR is” (an example of this, which we address later in the article, is the search for a common definition of MMR in order to fix the meaning of the term). The establishment of these institutions supports the autonomization of MMR and its emancipation from the field in which it originated, but in which it continues to be embedded. This way, it can be viewed as a semi-autonomous subfield within the larger field of the social sciences and as the result of a differentiation internal to this field (Steinmetz 2016 , p. 109). It is a space that is clearly embedded within this higher level field; for example, members of the subfield of MMR also qualify as members of the overarching field, and the allocation of the most valuable and current form of capital is determined there as well. Nevertheless, as a distinct subfield, it also has specific principles that govern the production of knowledge and the rewards of domination.

We return to the content and form of this specific knowledge later in the article. The next section addresses the question of the socio-genesis of MMR.

Where does mixed methods research come from?

The origins of the subfield of MMR lay in the broader field of social scientific disciplines. We interpret the positions of the scholars most involved in MMR (the “pioneers” or “scientific entrepreneurs”) as occupying particular positions within the larger academic and scientific field. Who, then, are the researchers at the heart of MMR? Leech ( 2010 ) interviewed 4 scholars (out of 6) that she identified as early developers of the field: Alan Bryman (UK; sociology), John Creswell (USA; educational psychology), Jennifer Greene (USA; educational psychology) and Janice Morse (USA; nursing and anthropology). Educated in the 1970s and early 1980s, all four of them indicated that they were initially trained in “quantitative methods” and later acquired skills in “qualitative methods.” For two of them (Bryman and Creswell) the impetus to learn qualitative methods was their involvement in writing on, and teaching of, research methods; for Greene and Morse the initial motivation was more instrumental and related to their concrete research activity at the time. Creswell describes himself as “a postpositivist in the 1970s, self-education as a constructivist through teaching qualitative courses in the 1980s, and advocacy for mixed methods (…) from the 1990s to the present” (Creswell 2011 , p. 269). Of this group, only Morse had the benefit of learning about qualitative methods as part of her educational training (in nursing and anthropology; Leech 2010 , p. 267). Independently, Creswell ( 2012 ) identified (in addition to Bryman, Greene and Morse) John Hunter, Allen Brewer (USA; Northwestern and Boston College) and Nigel Fielding (University of Surrey, UK) as important early movers in MMR.

The selections that Leech and Creswell make regarding the key actors are based on their close involvement with the “MMR movement.” It is corroborated by a simple analysis of the articles that appeared in the Journal of Mixed Methods Research ( JMMR ), founded in 2007 as an outlet for MMR.

Table 1 lists all the authors that have published in the issues of the journal since its first publication in 2007 and that have either received more than 14 (4%) of the citations allocated between the group of 343 authors (the TLCS score in Table 1 ), or have written more than 2 articles for the Journal (1.2% of all the articles that have appeared from 2007 until October 2013) together with their educational background (i.e., the discipline in which they completed their PhD).

All the members of Leech’s selection, except for Morse, and the members of Creswell’s selection (except Hunter, Brewer, and Fielding) are represented in the selection based on the entries in the JMMR . Footnote 5 The same holds for two of the three additional authors identified by Creswell. Hunter and Brewer have developed a somewhat different approach to combining methods that explicitly targets data gathering techniques and largely avoids epistemological discussions. In Brewer and Hunter ( 2006 ) they discuss the MMR approach very briefly and only include two references in their bibliography to the handbook of Tashakkori and Teddlie ( 2003 ), and at the end of 2013 they had not published in the JMMR . Fielding, meanwhile, has written two articles for the JMMR (Fielding and Cisneros-Puebla 2009 ; Fielding 2012 ). In general, it seems reasonable to assume that a publication in a journal that positions itself as part of a systematic attempt to build a research tradition, and can be viewed as part of a strategic effort to advance MMR as a distinct alternative to more “traditional” academic research—particularly in methods—at least signals a degree of adherence to the effort and acceptance of the rules of the game it lays out. This would locate Fielding closer to the MMR movement than the others.

The majority of the researchers listed in Table 1 have a background in psychology or social psychology (35%), and sociology (25%). Most of them work in the United States or are UK citizens, and the positions they occupied at the beginning of 2013 indicates that most of these are in applied research: educational research and educational psychology account for 50% of all the disciplinary occupations of the group that were still employed in academia. This is consistent with the view that MMR originated in applied disciplines and thematic studies like education and nursing, rather than “pure disciplines” like psychology and sociology (Tashakkori and Teddlie ( 2010b ), p. 32). Although most of the 20 individuals mentioned in Table 1 have taught methods courses in academic curricula (for 15 of them, we could determine that they were involved in the teaching of qualitative, quantitative, or mixed methods), there are few individuals with a background in statistics or a neighbouring discipline: only Amy Dellinger did her PhD in “research methodology.” In addition, as far as we could determine, only three individuals held a position in a methodological department at some time: Dellinger, Tony Onwuegbuzie, and Nancy Leech.

The pre-eminence of applied fields in MMR is supported when we turn our attention to the circulation of MMR. To assess this we proceeded as follows. We selected 10 categories in the Web of Science that form a rough representation of the space of social science disciplines, taking care to include the most important so-called “studies.” These thematically orientated, interdisciplinary research areas have progressively expanded since they emerged at the end of the 1960s as a critique of the traditional disciplines (Heilbron et al. 2017 ). For each category, we selected the 10 journals with the highest 5-year impact factor in their category in the period 2007–2015. The lists were compiled bi-annually over this period, resulting in 5 top ten lists for the following Web of Science categories: Economics, Psychology, Sociology, Anthropology, Political Science, Nursing, Education & Educational Research, Business, Cultural Studies, and Family Studies. After removing multiple occurring journals, we obtained a list of 164 journals.

We searched the titles and abstracts of the articles appearing in these journals over the period 1992–2016 for occurrences of the terms “mixed method” or “multiple methods” and variants thereof. We chose this particular period and combination of search terms to see if a shift from a more general use of the term “multiple methods” to “mixed methods” occurred following the institutionalization of MMR. In total, we found 797 articles (out of a total of 241,521 articles that appeared in these journals during that time), published in 95 different journals. Table 2 lists the 20 journals that contain at least 1% (8 articles) of the total amount of articles.

As is clear from Table 2 , the largest number of articles in the sample were published in journals in the field of nursing: 332 articles (42%) appeared in journals that can be assigned to this category. The next largest category is Education & Educational Research, to which 224 (28 percentage) of the articles can be allocated. By contrast, classical social science disciples are barely represented. In Table 2 only the journal Field Methods (Anthropology) and the Journal of Child Psychology and Psychiatry (Psychology) are related to classical disciplines. In Table 3 , the articles in the sample are categorized according to the disciplinary category of the journal in which they appeared. Overall, the traditional disciplines are clearly underrepresented: for the Economics category, for example, only the Journal of Economic Geography contains three articles that make a reference to mixed methods.

Focusing on the core MMR group, the top ten authors of the group together collect 458 citations from the 797 articles in the sample, locating them at the center of the citation network. Creswell is the most cited author (210 citations) and his work too receives most citations from journals in nursing and education studies.

The question whether a terminological shift has occurred from “multiple methods” to “mixed methods” must be answered affirmative for this sample. Prior to 2001 most articles (23 out of 31) refer to “multiple methods” or “multi-method” in their title or abstract, while the term “mixed methods” gains traction after 2001. This shift occurs first in journals in nursing studies, with journals in education studies following somewhat later. The same fields are also the first to cite the first textbooks and handbooks of MMR.

Taken together, these results corroborate the notion that MMR circulates mainly in nursing and education studies. How can this be understood from a field theoretical perspective? MMR can be seen as an innovation in the social scientific field, introducing a new methodology for combining existing methods in research. In general, innovation is a relatively risky strategy. Coming up with a truly rule-breaking innovation often involves a small probability of great success and a large probability of failure. However, it is important to add some nuance to this general observation. First, the risk an innovator faces depends on her position in the field. Agents occupying positions at the top of their field’s hierarchy are rich in specific capital and can more easily afford to undertake risky projects. In the scientific field, these are the agents richest in scientific capital. They have the knowledge, authority, and reputation (derived from recognition by their peers; Bourdieu 2004 , p. 34) that tends to decrease the risk they face and increase the chances of success. Moreover, the positions richest in scientific capital will, by definition, be the most consecrated ones. This consecration involves scientific rather than academic capital (cf. Wacquant 2013 , p. 20) and within disciplines these consecrated positions often are related to orthodox position-takings. This presents a paradox: although they have the capital to take more risks, they have also invested heavily in the orthodoxy of the field and will thus be reluctant to upset the status quo and risk destroying the value of their investment. This results in a tendency to take a more conservative stance, aimed at preserving the status quo in the field and defending their position. Footnote 6

For agents in dominated positions this logic is reversed. Possessing less scientific capital, they hold less consecrated positions and their chances of introducing successful innovations are much lower. This leaves them too with two possible strategies. One is to revert to a strategy of adaptation, accepting the established hierarchy in the field and embarking on a slow advancement to gain the necessary capital to make their mark from within the established order. However, Bourdieu notes that sometimes agents with a relatively marginal position in the field will engage in a “flight forward” and pursue higher risk strategies. Strategies promoting a heterodox approach challenge the orthodoxy and the principles of hierarchization of the field, and, if successful (which will be the case only with a small probability), can rake in significant profits by laying claim to a new orthodoxy (Bourdieu 1975 , p. 104; Bourdieu 1993 , pp. 116–117).

Thus, the coupling of innovative strategies to specific field positions based on the amount of scientific capital alone is not straightforward. It is therefore helpful to introduce a second differentiation in the field that, following Bourdieu ( 1975 , p. 103), is based on the differences between the expected profits from these strategies. Here a distinction can be made between an autonomous and a heteronomous pole of the field, i.e., between the purest, most “disinterested” positions and the most “temporal” positions that are more pervious to the heteronomous logic of social hierarchies outside the scientific field. Of course, this difference is a matter of degree, as even the works produced at the most heteronomous positions still have to adhere to the standards of the scientific field to be seen as legitimate. But within each discipline this dimension captures the difference between agents predominantly engaged in fundamental, scholarly work—“production solely for the producers”—and agents more involved in applied lines of research. The main component of the expected profit from innovation in the first case is scientific, whereas in the second case the balance tends to shift towards more temporal profits. This two-fold structuring of the field allows for a more nuanced conception of innovation than the dichotomy “conservative” versus “radical.” Holders of large amounts of scientific capital at the autonomous pole of the field are the producers and conservators of orthodoxy, producing and diffusing what can be called “orthodox innovations” through their control of relatively powerful networks of consecration and circulation. Innovations can be radical or revolutionary in a rational sense, but they tend to originate from questions raised by the orthodoxy of the field. Likewise, the strategy to innovate in this sense can be very risky in that success is in no way guaranteed, but the risk is mitigated by the assurance of peers that these are legitimate questions, tackled in a way that is consistent with orthodoxy and that does not threaten control of the consecration and circulation networks.

These producers are seen as intellectual leaders by most agents in the field, especially by those aspiring to become part of the specific networks of production and circulation they maintain. The exception are the agents located at the autonomous end of the field who possess less scientific capital and outright reject this orthodoxy produced by the field’s elite. Being strictly focused on the most autonomous principles of legitimacy, they are unable to accommodate and have no choice but to reject the orthodoxy. Their only hope is to engage in heterodox innovations that may one day become the new orthodoxy.

The issue is less antagonistic at the heteronomous side of the field, at least as far as the irreconcilable position-takings at the autonomous pole are concerned. The main battle here is also for scientific capital, but is complemented by the legitimacy it brings to gain access to those who are in power outside of the scientific field. At the dominant side, those with more scientific capital tend to have access to the field of power, agents who hold the most economic and cultural capital, for example by holding positions in policy advisory committees or company boards. The dominated groups at this side of the field will cater more to practitioners or professionals outside of the field of science.

Overall, there will be fewer innovations on this side. Moreover, innovative strategies will be less concerned with the intricacies of the pure discussions that prevail at the autonomous pole and be of a more practical nature, but pursued from different degrees of legitimacy according to the differences in scientific capital. This affects the form these more practical, process-orientated innovations take. At the dominant side of this pole, agents tend to accept the outcome of the struggles at the autonomous pole: they will accept the orthodoxy because mastery of this provides them with scientific capital and the legitimacy they need to gain access to those in power. In contrast, agents at the dominated side will be more interested in doing “what works,” neutralizing the points of conflict at the autonomous pole and deriving less value from strictly following the orthodoxy. This way, a four-fold classification of innovative strategies in the scientific field emerges (see Fig.  2 ) that helps to understand the context in which MMR was developed.

Scientific field and scientific innovation

In summary, the small group of researchers who have been identified as the core of MMR consist predominantly of users of methods, who were educated and have worked exclusively at US and British universities. The specific approach to combining methods that is proposed by MMR has been successful from an institutional point of view, achieving visibility through the foundation of a journal and association and a considerable output of core MMR scholars in terms of books, conference proceedings, and journal articles. Its origins and circulation in vocational studies rather than classical academic disciplines can be understood from the position these studies occupy in the scientific field and the kinds of position-taking and innovations these positions give rise to. This context allows a reflexive understanding of the content of MMR and the issues that are dominant in the approach. We turn to this in the next section.

Mixed methods research: Position-taking

The position of the subfield of MMR in the scientific field is related to the position-takings of agents that form the core of this subfield (Bourdieu 1993 , p. 35). The space of position takings, in turn, provides the framework to study the most salient issues that are debated within the subfield. Since we can consider MMR to be an emerging subfield, where positions and position takings are not as clearly defined as in more mature and settled fields, it comes as no surprise that there is a lively discussion of fundamental matters. Out of the various topics that are actively discussed, we have distilled three themes that are important for the way the subfield of MMR conveys its autonomy as a field and as a distinct approach to research. Footnote 7 In our view, these also represent the main problems with the way MMR approaches the issue of combining methods.

Methodology making and standardization

The first topic is that the approach is moving towards defining a unified MMR methodology. There are differences in opinion as to how this is best achieved, but there is widespread agreement that some kind of common methodological and conceptual foundation of MMR is needed. To this end, some propose a broad methodology that can serve as distinct marker of MMR research. For instance, in their introduction to the handbook, Tashakkori and Teddlie ( 2010b ) propose a definition of the methodology of mixed methods research as “the broad inquiry logic that guides the selection of specific methods and that is informed by conceptual positions common to mixed methods practitioners” (Tashakkori and Teddlie 2010b , p. 5). When they (later on in the text) provide two methodological principles that differentiate MMR from other communities of scholars, they state that they regard it as a “crucial mission” for the MMR community to generate distinct methodological principles (Tashakkori and Teddlie 2010b , pp. 16–17). They envision an MMR methodology that can function as a “guide” for selecting specific methods. Others are more in favour of finding a philosophical foundation that underlies MMR. For instance, Morgan ( 2007 ) and Hesse-Biber ( 2010 ) consider pragmatism as a philosophy that distinguishes MMR from qualitative (constructivism) and quantitative (positivist) research and that can provide a rationale for the paradigmatic pluralism typical of MMR.

Furthermore, there is wide agreement that some unified definition of MMR would be beneficial, but it is precisely here that there is a large variation in interpretations regarding the essentials of MMR. This can be seen in the plethora of definitions that have been proposed. Johnson et al. ( 2007 ) identified 19 alternative definitions of MMR at the time, out of which they condensed their own:

[MMR] is the type of research in which a researcher or team of researchers combines elements of qualitative and quantitative research approaches (e.g., use of qualitative and quantitative viewpoints, data collection, analysis, inference techniques) for the broad purpose of breath and depth of understanding and corroboration. Footnote 8

Four years later, the issue is not settled yet. Creswell and Plano Clark ( 2011 ) list a number of authors who have proposed a different definition of MMR, and conclude that there is a common trend in the content of these definitions over time. They take the view that earlier texts on mixing methods stressed a “disentanglement of methods and philosophy,” while later texts locate the practice of mixing methods in “all phases of the research process” (Creswell and Plano Clark 2011 , p. 2). It would seem, then, that according to these authors the definitions of MMR have become more abstract, further away from the practicality of “merely” combining methods. Specifically, researchers now seem to speak of mixing higher order concepts: some speak of mixing methodologies, others refer to mixing “research approaches,” or combining “types of research,” or engage in “multiple ways of seeing the social world” (Creswell and Plano Clark 2011 ).

This shift is in line with the direction in which MMR has developed and that emphasises practical ‘manuals’ and schemas for conducting research. A relatively large portion of the MMR literature is devoted to classifications of mixed methods designs. These classifications provide the basis for typologies that, in turn, provide guidelines to conduct MMR in a concrete research project. Tashakkori and Teddlie ( 2003 ) view these typologies as important elements of the organizational structure and legitimacy of the field. In addition, Leech and Onwuegbuzie ( 2009 ) see typologies as helpful guides for researchers and of pedagogical value (Leech and Onwuegbuzie 2009 , p. 272). Proposals for typologies can be found in textbooks, articles, and contributions to the handbook(s). For example, Creswell et al. ( 2003 , pp. 169-170) reviewed a number of studies and identified 8 different ways to classify MMR studies. This list was updated and extended by Creswell and Plano Clark ( 2011 , pp. 56-59) to 15 typologies. Leech and Onwuegbuzie ( 2009 ) identified 35 different research designs in the contributions to Teddlie and Tashakkori (2003) alone, and proposed their own three-dimensional typology that resulted in 8 different types of mixed methods studies. As another example of the ubiquity of these typologies, Nastasi et al. ( 2010 ) classified a large number of existing typologies in MMR into 7”meta-typologies” that each emphasize different aspects of the research process as important markers for MMR. According to the authors, these typologies have the same function in MMR as the more familiar names of “qualitative” or “quantitative” methods (e.g., “content analysis” or “structural equation modelling”) have: to signal readers of research what is going on, what procedures have been followed, how to interpret results, etc. (see also Creswell et al. 2003 , pp. 162–163). The criteria underlying these typologies mainly have to do with the degree of mixing (e.g., are methods mixed throughout the research project or not?), the timing (e.g., sequential or concurrent mixing of methods) and the emphasis (e.g., is one approach dominant, or do they have equal status?).

We find this strong drive to develop methodologies, definitions, and typologies of MMR as guides to valid mixed methods research problematic. What it amounts to in practice is a methodology that lays out the basic guidelines for doing MMR in a “proper way.” This entails the danger of straight-jacketing reflection about the use of methods, decoupling it from theoretical and empirical considerations, thus favouring the unreflexive use of a standard methodology. Researchers are asked to make a choice for a particular MMR design and adhere to the guidelines for a “proper” MMR study. Such methodological prescription diametrically opposes the initial critique of the mechanical and unreflexive use of methods. The insight offered by Bourdieu’s notion of reflexivity is, on the contrary, that the actual research practice is fundamentally open in terms of being guided by a logic of practice that cannot be captured by a preconceived and all-encompassing logic independent of that practice. Reflexivity in this view cannot be achieved by hiding behind the construct of a standardized methodology—of whatever signature—it can only be achieved by objectifying the process of objectification that goes on within the context of the field in which the researcher is embedded. This reflexivity, then, requires an analysis of the position of the researcher as a critical component of the research process, both as the embodiment of past choices that have consequences for the strategic position in the scientific field, and as predispositions regarding the choice for the subject and content of a research project. By adding the insight of STS researchers that the point of deconstructing science and technology is not so much to offer a new best way of doing science or technology, but to provide insights into the critical moments in research (for a take on such a debate, see, for example, Edge 1995 , pp. 16–20), this calls for a sociology of science that takes methods much more seriously as objects of study. Such a programme should be based on studying the process of codification and standardization of methods in their historical context of production, circulation, and use. It would provide a basis for a sociological understanding of methods that can illuminate the critical moments in research alluded to above, enabling a systematic reflection on the process of objectification. This, in turn, allows a more sophisticated validation of using—and combining—methods than relying on prescribed methodologies.

The role of epistemology

The second theme discussed in a large number of contributions is the role epistemology plays in MMR. In a sense, epistemology provides the lifeblood for MMR in that methods in MMR are mainly seen in epistemological terms. This interpretation of methods is at the core of the knowledge claim of MMR practitioners, i.e., that the mixing of methods means mixing broad, different ways of knowing, which leads to better knowledge of the research object. It is also part of the identity that MMR consciously assumes, and that serves to set it apart from previous, more practical attempts to combine methods. This can be seen in the historical overview that Creswell and Plano Clark ( 2011 ) presented and that was discussed above. This reading, in which combining methods has evolved from the rather unproblematic level (one could alternatively say “naïve” or “unaware”) of instrumental use of various tools and techniques into an act that requires deeper thinking on a methodological and epistemological level, provides the legitimacy of MMR.

At the core of the MMR approach we thus find that methods are seen as unproblematic representations of different epistemologies. But this leads to a paradox, since the epistemological frameworks need to be held flexible enough to allow researchers to integrate elements of each of them (in the shape of methods) into one MMR design. As a consequence, the issue becomes the following: methods need to be disengaged from too strict an interpretation of the epistemological context in which they were developed in order for them to be “mixable,”’, but, at the same time, they must keep the epistemology attributed to them firmly intact.

In the MMR discourse two epistemological positions are identified that matter most: a positivist approach that gives rise to quantitative methods and a constructivist approach that is home to qualitative methods. For MMR to be a feasible endeavour, the differences between both forms of research must be defined as reconcilable. This position necessitates an engagement with those who hold that the quantitative/qualitative dichotomy is unbridgeable. Within MMR an interesting way of doing so has emerged. In the first issue of the Journal of Mixed Methods Research, Morgan ( 2007 ) frames the debate about research methodology in the social sciences in terms of Kuhnian paradigms, and he argues that the pioneers of the emancipation of qualitative research methods used a particular interpretation of the paradigm-concept to state their case against the then dominant paradigm in the social sciences. According to Morgan, they interpreted a paradigm mainly in metaphysical terms, stressing the connections among the trinity of ontology, epistemology, and methodology as used in the philosophy of knowledge (Morgan 2007 , p. 57). This allowed these scholars to depict the line between research traditions in stark, contrasting terms, using Kuhn’s idea of “incommensurability” in the sense of its “early Kuhn” interpretation. This strategy fixed the contrast between the proposed alternative approach (a “constructivist paradigm”), and the traditional approach (constructed as “the positivist paradigm”) to research as a whole, and offered the alternative approach as a valid option rooted in the philosophy of knowledge. Morgan focuses especially on the work of Egon Guba and Yvonne Lincoln who developed what they initially termed a “naturalistic paradigm” as an alternative to their perception of positivism in the social sciences (e.g., Guba and Lincoln 1985 ). Footnote 9 MMR requires a more flexible or “a-paradigmatic stance” towards research, which would entail that “in real-world practice, methods can be separated from the epistemology out of which they emerged” (Patton 2002 , quoted in Tashakkori and Teddlie 2010b , p. 14).

This proposal of an ‘interpretative flexibility’ (Bijker 1987 , 1997 ) regarding paradigms is an interesting proposition. But it immediately raises the question: why stop there? Why not take a deeper look into the epistemological technology of methods themselves, to let the muted components speak up in order to look for alternative “mixing interfaces” that could potentially provide equally valid benefits in terms of the understanding of a research object? The answer, of course, was already seen above. It is that the MMR approach requires situating methods epistemologically in order to keep them intact as unproblematic mediators of specific epistemologies and, thus, make the methodological prescriptions work. There are several problems with this. First, seeing methods solely through an epistemological lens is problematic, but it would be less consequential if it were applied to multiple elements of methods separately. This would at least allow a look under the hood of a method, and new ways of mixing methods could be opened up that go beyond the crude “qualitative” versus “quantitative” dichotomy. Second, there is also the issue of the ontological dimension of methods that is disregarded in an exclusively epistemological framing of methods (e.g., Law 2004 ). Taking this ontological dimension seriously has at least two important facets. First, it draws attention to the ontological assumptions that are woven into methods in their respective fields of production and that are imported into fields of users. Second, it entails the ontological consequences of practising methods: using, applying, and referring to methods and the realities this produces. This latter facet brings the world-making and boundary-drawing capacities of methods to the fore. Both facets are ignored in MMR. We say more about the first facet in the next section. With regard to the second facet, a crucial element concerns the data that are generated, collected, and analysed in a research project. But rather than problematizing the link between the performativity of methods and the data that are enacted within the frame of a method, here too MMR relies on a dichotomy: that between quantitative and qualitative data. Methods are primarily viewed as ways of gathering data or as analytic techniques dealing with a specific kind of data. Methods and data are conceptualised intertwiningly: methods too are seen as either quantitative or qualitative (often written as QUANT and QUAL in the literature), and perform the role of linking epistemology and data. In the final analysis, the MMR approach is based on the epistemological legitimization of the dichotomy between qualitative and quantitative data in order to define and combine methods: data obtain epistemological currency through the supposed in-severable link to certain methods, and methods are reduced to the role of acting as neutral mediators between them.

In this way, methods are effectively reduced to, on the one hand, placeholders for epistemological paradigms and, on the other hand, mediators between one kind of data and the appropriate epistemology. To put it bluntly, the name “mixed methods research” is actually a misnomer, because what is mixed are paradigms or “approaches,” not methods. Thus, the act of mixing methods à la MMR has the paradoxical effect of encouraging a crude black box approach to methods. This is a third problematic characteristic of MMR, because it hinders a detailed study of methods that can lead to a much richer perspective on mixing methods.

Black boxed methods and how to open them

The third problem that we identified with the MMR approach, then, is that with the impetus to standardize the MMR methodology by fixing methods epistemologically, complemented by a dichotomous view of data, they are, in the words of philosopher Bruno Latour, “blackboxed.” This is a peculiar result of the prescription for mixing methods as proposed by MMR that thus not only denies practice and the ontological dimensions of methods and data, but also casts methods in the role of unyielding black boxes. Footnote 10 With this in mind, it will come as no surprise that most foundational contributions to the MMR literature do not explicitly define what a method is, nor that they do not provide an elaborative historical account of individual methods. The particular framing of methods in MMR results in a blind spot for the historical and social context of the production and circulation of methods as intellectual products. Instead it chooses to reify the boundaries that are drawn between “qualitative” and “quantitative” methods and reproduce them in the methodology it proposes. Footnote 11 This is an example of “circulation without context” (Bourdieu 2002 , p. 4): classifications that are constructed in the field of use or reception without taking the constellation within the field of production seriously.

Of course, this does not mean that the reality of the differences between quantitative and qualitative research must be denied. These labels are sticky and symbolically laden. They have come, in many ways, to represent “two cultures” (Goertz and Mahony 2012 ) of research, institutionalised in academia, and the effects of nominally “belonging” to (or being assigned to) one particular category have very real consequences in terms of, for instance, access to research grants and specific journals. However, if the goal of an approach such as MMR is to open up new pathways in social science research, (and why should that not be the case?) it is hard to see how that is accomplished by defining the act of combining methods solely in terms of reified differences between research using qualitative and quantitative data. In our view, methods are far richer and more interesting constructs than that, and a practice of combining methods in research should reflect that. Footnote 12

Addressing these problems entices a reflection on methods and using (multiple) methods that is missing in the MMR perspective. A fruitful way to open up the black boxes and take into account the epistemological and ontological facets of methods is to make them, and their use, the object of sociological-historical investigation. Methods are constituted through particular practices. In Bourdieusian terms, they are objectifications of the subjectively understood practices of scientists “in other fields.” Rather than basing a practice of combining methods on an uncritical acceptance of the historically grown classification of types of social research (and using these as the building stones of a methodology of mixing methods), we propose the development of a multifaceted approach that is based on a study of the different socio-historical contexts and practices in which methods developed and circulated.

A sociological understanding of methods based on these premises provides the tools to break with the dichotomously designed interface for combining methods in MMR. Instead, focusing on the historical and social contexts of production and use can reveal the traces that these contexts leave, both in the internal structure of methods, how they are perceived, how they are put into practice, and how this practice informs the ontological effects of methods. Seeing methods as complex technologies, with a history that entails the struggles among the different agents involved in their production, and use opens the way to identify multiple interfaces for combining them: the one-sided boxes become polyhedra. The critical study of methods as “objects of objectification” also entices analyses of the way in which methods intervene between subject (researcher) and object and the way in which different methods are employed in practice to draw this boundary differently. The reflexive position generated by such a systematic juxtaposition of methods is a fruitful basis to come to a richer perspective on combining methods.

We critically reviewed the emerging practice of combining methods under the label of MMR. MMR challenges the mono-method approaches that are still dominant in the social sciences, and this is both refreshing and important. Combining methods should indeed be taken much more seriously in the social sciences.

However, the direction that the practice of combining methods is taking under the MMR approach seems problematic to us. We identified three main concerns. First, MMR scholars seem to be committed to designing a standardized methodological framework for combining methods. This is unfortunate, since it amounts to enforcing an unnecessary codification of aspects of research practices that should not be formally standardized. Second, MMR constructs methods as unproblematic representations of an epistemology. Although methods must be separable from their native epistemology for MMR to work, at the same time they have to be nested within a qualitative or a quantitative research approach, which are characterized by the data they use. By this logic, combining quantitative methods with other quantitative methods, or qualitative methods with other qualitative methods, cannot offer the same benefits: they originate from the same way of viewing and knowing the world, so it would have the same effect as blending two gradations of the same colour paint. The importance attached to the epistemological grounding of methods and data in MMR also disregards the ontological aspects of methods. In this article, we are arguing that this one-sided perspective is problematic. Seeing combining methods as equivalent to combining epistemologies that are somehow pure and internally homogeneous because they can be placed in a qualitative or quantitative framework essentially amounts to reifying these categories.

It also leads to the third problem: the black boxing of methods as neutral mediators between these epistemologies and data. This not only constitutes a problem for trying to understand methods as intellectual products, but also for regarding the practice of combining methods, because it ignores the social-historical context of the development of individual methods and hinders a sociologically grounded notion of combining methods.

We proceed from a different perspective on methods. In our view, methods are complex constructions. They are world-making technologies that encapsulate different assumptions on causality, rely on different conceptual relations and categorizations, allow for different degrees of emergence, and employ different theories of the data that they internalise as objects of analysis. Even more importantly, their current form as intellectual products cannot be separated from the historical context of their production, circulation, and use.

A fully developed exposition of such an approach will have to await further work. Footnote 13 So far, the sociological study of methods has not (yet) developed into a consistent research programme, but important elements can be derived from existing contributions such as MacKenzie ( 1981 ), Chapoulie ( 1984 ), Platt ( 1996 ), Freeman ( 2004 ), and Desrosières ( 2008a , b ). The work on the “social life of methods” (e.g., Savage 2013 ) also contains important leads for the development of a systematic sociological approach to method production and circulation. Based on the discussion in this article and the contributions listed above, some tantalizing questions can be formulated. How are methods and their elements objectified? How are epistemology and ontology defined in different fields and how do those definitions feed into methods? How do they circulate and how are they translated and used in different contexts? What are the main controversies in fields of users and how are these related to the field of production? What are the homologies between these fields?

Setting out to answer these questions opens up the possibility of exploring other interesting combinations of methods that emerge from the combination of different practices, situated in different historical and epistemological contexts, and with their unique set of interpretations regarding their constituent elements. One of these must surely be the data-theoretical elements that different methods incorporate. The problematization of data has become all the more pressing now that the debate about the consequences of “big data” for social scientific practices has become prominent (Savage and Burrows 2007 ; Levallois et al. 2013 ; Burrows and Savage 2014 ). Whereas MMR emphasizes the dichotomy between qualitative and quantitative data, a historical analysis of the production and use of methods can explore the more subtle, different interpretations and enactments of the “same” data. These differences inform method construction, controversies surrounding methods and, hence, opportunities for combining methods. These could then be constructed based on alternative conceptualisations of data. Again, while in some contexts it might be enlightening to rely on the distinction between data as qualitative or quantitative, and to combine methods based on this categorization, it is an exciting possibility that in other research contexts other conceptualisations of data might be of more value to enhance a specific (contextual) form of knowledge.

Change history

06 may 2019.

Unfortunately, figure 2 was incorrectly published.

The search term used was “mixed method*” in the “topic” search field of SSCI, A&HCI, and CPCI-SSH as contained in the Web of Science. A Google NGram search (not shown) confirmed this pattern. The results of a search for “mixed methods” and “mixed methods research” showed a very steep increase after 1994: in the first case, the normalized share in the total corpus increased by 855% from 1994 till 2008. Also, Creswell ( 2012 ) reports an almost hundred-fold increase in the number of theses and dissertations with mixed methods’ in the citation and abstract (from 26 in 1990–1994 to 2524 in 2005–2009).

Retrieved from https://uk.sagepub.com/en-gb/eur/journal-of-mixed-methods-research/journal201775#aims-and-scope on 1/17/2019.

In terms of antecedents of mixed methods research, it is interesting to note that Bourdieu, whose sociology of science we draw on, was, from his earliest studies in Algeria onwards, a strong advocate of combining research methods. He made it into a central characteristic of his approach to social science in Bourdieu et al. ( 1991 [1968]). His approach, as we see below, was very different from the one now proposed under the banner of MMR. Significantly, there is no mention of Bourdieu’s take on combining methods in any of the sources we studied.

Morse’s example in particular warns us that restricting the analysis to the authors that have published in the JMMR runs the risk of missing some important contributors to the spread of MMR through the social sciences. On her website, Morse lists 11 publications (journal articles, book chapters, and books) that explicitly make reference to mixed methods (and a substantial number of other publications are about methodological aspects of research), so the fact that she has not (yet) published in the JMMR cannot, by itself, be taken as an indication of a lesser involvement with the practice of combining methods. See the website of Janice Morse at https://faculty.utah.edu/u0556920-Janice_Morse_RN,_PhD,_FAAN/hm/index.hml accessed 1/17/2019.

Bourdieu ( 1999 , p. 26) mentions that one has to be a scientific capitalist to be able to start a scientific revolution. But here he refers explicitly to the autonomy of the scientific field, making it virtually impossible for amateurs to stand up against the historically accumulated capital in the field and incite a revolution.

The themes summarize the key issues through which MMR as a group comes “into difference” (Bourdieu 1993 , p. 32). Of course, as in any (sub)field, the agents identified above often differ in their opinions on some of these key issues or disagree on the answer to the question if there should be a high degree of convergence of opinions at all. For instance, Bryman ( 2009 ) worried that MMR could become “a ghetto.” For him, the institutional landmarks of having a journal, conferences, and a handbook increase the risk of “not considering the whole range of possibilities.” He added: “I don’t regard it as a field, I kind of think of it as a way of thinking about how you go about research.” (Bryman, cited in Leech 2010 , p. 261). It is interesting to note that Bryman, like fellow sociologists Morgan and Denscombe, had published only one paper in the JMMR by the end of 2016 (Bryman passed away in June of 2017). Although these papers are among the most cited papers in the journal (see Table 1 ), this low number is consistent with the more eclectic approach that Bryman proposed.

Johnson, Onwuegbuzie, and Turner ( 2007 , p. 123).

Guba and Lincoln ( 1985 ) discuss the features of their version of a positivistic approach mainly in ontological and epistemological terms, but they are also careful to distinguish the opposition between naturalistic and positivist approaches from the difference between what they call the quantitative and the qualitative paradigms. Since they go on to state that, in principle, quantitative methods can be used within a naturalistic approach (although in practice, qualitative methods would be preferred by researchers embracing this paradigm), they seem to locate methods on a somewhat “lower,” i.e., less incommensurable level. However, in their later work (both together as well as with others or individually) and that of others in their wake, there seems to have been a shift towards a stricter interpretation of the qualitative/quantitative divide in metaphysical terms, enabling Teddlie and Tashakkori (2010b) to label this group “purists” (Tashakkori and Teddlie 2010b , p. 13).

See, for instance, Onwuegbuzie et al.’s ( 2011 ) classification of 58 qualitative data analysis techniques and 18 quantitative data analysis techniques.

This can also be seen in Morgan’s ( 2018 ) response to Sandelowski’s ( 2014 ) critique of the binary distinctions in MMR between qualitative and quantitative research approaches and methods. Morgan denounces the essentialist approach to categorizing qualitative and quantitative research in favor of a categorization based on “family resemblances,” in which he draws on Wittgenstein. However, this denies the fact that the essentialist way of categorizing is very common in the MMR corpus, particularly in textbooks and manuals (e.g., Plano Clark and Ivankova 2016 ). Moreover, and more importantly, he still does not extend this non-essentialist model of categorization to the level of methods, referring, for instance, to the different strengths of qualitative and quantitative methods in mixed methods studies (Morgan 2018 , p. 276).

While it goes beyond the scope of this article to delve into the history of the qualitative-quantitative divide in the social sciences, some broad observations can be made here. The history of method use in the social sciences can briefly be summarized as first, a rather fluid use of what can retrospectively be called different methods in large scale research projects—such as the Yankee City study of Lloyd Warner and his associates (see Platt 1996 , p. 102), the study on union democracy of Lipset et al. ( 1956 ), and the Marienthal study by Lazarsfeld and his associates (Jahoda et al. 1933 ); see Brewer and Hunter ( 2006 , p. xvi)—followed by an increasing emphasis on quantitative data and the objectification and standardization of methods. The rise of research using qualitative data can be understood as a reaction against this use and interpretation of method in the social sciences. However, out of the ensuing clash a new, still dominant classification of methods emerged, one that relies on the framing of methods as either “qualitative” or “quantitative.” Moreover, these labels have become synonymous with epistemological positions that are reproduced in MMR.

A proposal to come to such an approach can be found in Timans ( 2015 ).

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Acknowledgments

This research is part of the Interco-SSH project, funded by the European Union under the 7th Research Framework Programme (grant agreement no. 319974). Johan Heilbron would like to thank Louise and John Steffens, members of the Friends Founders’ Circle, who assisted his stay at the Princeton Institute for Advanced Study in 2017-18 during which he completed his part of the present article.

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Timans, R., Wouters, P. & Heilbron, J. Mixed methods research: what it is and what it could be. Theor Soc 48 , 193–216 (2019). https://doi.org/10.1007/s11186-019-09345-5

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• Allison Shorten 1 ,
• Joanna Smith 2
• 1 School of Nursing , University of Alabama at Birmingham , USA
• 2 Children's Nursing, School of Healthcare , University of Leeds , UK
• Correspondence to Dr Allison Shorten, School of Nursing, University of Alabama at Birmingham, 1720 2nd Ave South, Birmingham, AL, 35294, USA; [email protected]; ashorten{at}uab.edu

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Introduction

‘Mixed methods’ is a research approach whereby researchers collect and analyse both quantitative and qualitative data within the same study. 1 2 Growth of mixed methods research in nursing and healthcare has occurred at a time of internationally increasing complexity in healthcare delivery. Mixed methods research draws on potential strengths of both qualitative and quantitative methods, 3 allowing researchers to explore diverse perspectives and uncover relationships that exist between the intricate layers of our multifaceted research questions. As providers and policy makers strive to ensure quality and safety for patients and families, researchers can use mixed methods to explore contemporary healthcare trends and practices across increasingly diverse practice settings.

What is mixed methods research?

Mixed methods research requires a purposeful mixing of methods in data collection, data analysis and interpretation of the evidence. The key word is ‘mixed’, as an essential step in the mixed methods approach is data linkage, or integration at an appropriate stage in the research process. 4 Purposeful data integration enables researchers to seek a more panoramic view of their research landscape, viewing phenomena from different viewpoints and through diverse research lenses. For example, in a randomised controlled trial (RCT) evaluating a decision aid for women making choices about birth after caesarean, quantitative data were collected to assess knowledge change, levels of decisional conflict, birth choices and outcomes. 5 Qualitative narrative data were collected to gain insight into women’s decision-making experiences and factors that influenced their choices for mode of birth. 5

In contrast, multimethod research uses a single research paradigm, either quantitative or qualitative. Data are collected and analysed using different methods within the same paradigm. 6 7 For example, in a multimethods qualitative study investigating parent–professional shared decision-making regarding diagnosis of suspected shunt malfunction in children, data collection included audio recordings of admission consultations and interviews 1 week post consultation, with interactions analysed using conversational analysis and the framework approach for the interview data. 8

What are the strengths and challenges in using mixed methods?

Selecting the right research method starts with identifying the research question and study aims. A mixed methods design is appropriate for answering research questions that neither quantitative nor qualitative methods could answer alone. 4 9–11 Mixed methods can be used to gain a better understanding of connections or contradictions between qualitative and quantitative data; they can provide opportunities for participants to have a strong voice and share their experiences across the research process, and they can facilitate different avenues of exploration that enrich the evidence and enable questions to be answered more deeply. 11 Mixed methods can facilitate greater scholarly interaction and enrich the experiences of researchers as different perspectives illuminate the issues being studied. 11

The process of mixing methods within one study, however, can add to the complexity of conducting research. It often requires more resources (time and personnel) and additional research training, as multidisciplinary research teams need to become conversant with alternative research paradigms and different approaches to sample selection, data collection, data analysis and data synthesis or integration. 11

What are the different types of mixed methods designs?

Mixed methods research comprises different types of design categories, including explanatory, exploratory, parallel and nested (embedded) designs. 2   Table 1 summarises the characteristics of each design, the process used and models of connecting or integrating data. For each type of research, an example was created to illustrate how each study design might be applied to address similar but different nursing research aims within the same general nursing research area.

• View inline

Types of mixed methods designs*

What should be considered when evaluating mixed methods research?

When reading mixed methods research or writing a proposal using mixed methods to answer a research question, the six questions below are a useful guide 12 :

Does the research question justify the use of mixed methods?

Is the method sequence clearly described, logical in flow and well aligned with study aims?

Is data collection and analysis clearly described and well aligned with study aims?

Does one method dominate the other or are they equally important?

Did the use of one method limit or confound the other method?

When, how and by whom is data integration (mixing) achieved?

For more detail of the evaluation guide, refer to the McMaster University Mixed Methods Appraisal Tool. 12 The quality checklist for appraising published mixed methods research could also be used as a design checklist when planning mixed methods studies.

• Elliot AE , et al
• Creswell JW ,
• Plano ClarkV L
• Greene JC ,
• Caracelli VJ ,
• Ivankova NV
• Shorten A ,
• Shorten B ,
• Halcomb E ,
• Cheater F ,
• Bekker H , et al
• Tashakkori A ,
• Creswell JW
• 12. ↵ National Collaborating Centre for Methods and Tools . Appraising qualitative, quantitative, and mixed methods studies included in mixed studies reviews: the MMAT . Hamilton, ON : BMJ Publishing Group , 2015 . http://www.nccmt.ca/resources/search/232 (accessed May 2017) .

Competing interests None declared.

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Taking a critical stance towards mixed methods research: A cross-disciplinary qualitative secondary analysis of researchers’ views

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Software, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected] , [email protected]

Affiliation Department of Psychology and Education, Universitat Oberta de Catalunya, Barcelona, Spain

Roles Conceptualization, Methodology, Validation, Writing – review & editing

Affiliation Department of Education, Universidad del Norte, Barranquilla, Colombia

Roles Conceptualization, Formal analysis, Methodology, Validation, Writing – review & editing

Affiliation Department of Management, Universidad de Alicante, Alicante, Spain

Roles Conceptualization, Validation, Writing – review & editing

Affiliation Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre), University College London, London, United Kingdom

Roles Conceptualization, Supervision, Writing – review & editing

Affiliation Centre d’Estudis Sociologics sobre la Vida Quotidiana i el Treball (Sociological Research Centre on Everyday Life and Work—QUIT), Universitat Autonoma de Barcelona, Barcelona, Spain

• Sergi Fàbregues, 
• Elsa Lucia Escalante-Barrios, 
• José Francisco Molina-Azorin, 
• Quan Nha Hong, 
• Joan Miquel Verd

• Published: July 9, 2021
• https://doi.org/10.1371/journal.pone.0252014
• Peer Review
• Reader Comments

Recent growth and institutionalization in the field of mixed methods research has provided fertile ground for a wide range of thoughtful criticism of how this research approach has been developed and conceptualized by some members of the mixed methods community. This criticism reflects the increasing maturity of the field as well as the different theoretical perspectives and methodological practices of researchers in different disciplines. While debates addressing these criticisms are likely to lead to valuable insights, no empirical studies have been carried out to date that have investigated researchers’ critical views on the development and conceptualization of mixed methods research. This study examines the criticisms of the mixed methods field raised by a cross-national sample of researchers in education, nursing, psychology, and sociology. We carried out a secondary analysis of semi-structured interviews with 42 researchers and identified 11 different criticisms, which we classified in four domains: essence of mixed methods, philosophy, procedures, and politics. The criticisms related to the procedures domain were equally distributed among the four disciplines, while those related to the essence, philosophy and politics domains were more common among sociologists. Based on our findings, we argue that the divergence of views on foundational issues in this field reflects researchers’ affiliation to different communities of practice, each having its own principles, values, and interests. We suggest that a greater awareness of this divergence of perspectives could help researchers establish effective collaboration and anticipate potential challenges when working with researchers having different methodological approaches.

Citation: Fàbregues S, Escalante-Barrios EL, Molina-Azorin JF, Hong QN, Verd JM (2021) Taking a critical stance towards mixed methods research: A cross-disciplinary qualitative secondary analysis of researchers’ views. PLoS ONE 16(7): e0252014. https://doi.org/10.1371/journal.pone.0252014

Editor: Adam T. Perzynski, The MetroHealth System and Case Western Reserve University, UNITED STATES

Received: July 24, 2020; Accepted: May 7, 2021; Published: July 9, 2021

Copyright: © 2021 Fàbregues et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data cannot be shared publicly as participants did not give consent for their transcripts to be shared in this manner. Since the consent statement approved by the Institutional Review Board (IRB) of the Universitat Autònoma de Barcelona, and signed by the participants, did not include the provision that data would be made publicly available, we do not have participant consent to share this data. Also, the content is sensitive, and participants could be identified. Requests for anonymized data can be made to the Principal Investigator of the study, Sergi Fàbregues ( [email protected] ) or the Institutional Review Board (IRB) of the Universitat Autònoma de Barcelona ( [email protected] ).

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Since the 1990s, mixed methods research as a distinct methodology has seen vigorous institutionalization [ 1 , 2 ] with the launch of a specialized journal ( Journal of Mixed Methods Research ) in 2007, the establishment of the Mixed Methods International Research Association (MMIRA) in 2013, and the publication of a stream of handbooks, textbooks, and articles on the philosophy and practice of mixed methods. Mixed methods research is increasingly used in a wide range of disciplines, particularly in the social, educational, behavioral and health sciences [ 3 – 6 ]. Several scholars have argued that mixed methods inquiry can help researchers arrive at a more complete understanding of research problems, develop more robust quantitative instruments, and integrate several worldviews in a single research study [ 7 , 8 ].

A clear indication of the institutionalization of mixed methods research as a field is the expansion of the mixed methods community. Tashakkori, Johnson and Teddlie [ 9 ] have characterized this community as a group of scholars who share similar backgrounds, methodological orientations, philosophical assumptions, and views on research and practice. As distinct from researchers using only qualitative or quantitative approaches, these scholars often share similarities in training, research background, and professional affiliation. Those authors’ view of the mixed methods community is consistent with Thomas Kuhn’s preferred definition of paradigms, as cited by Morgan [ 10 ]. In disagreement with the view of paradigms as incompatible epistemological stances, Morgan [ 10 ], following Kuhn [ 11 ], advanced a more integrative notion of paradigms focused on shared beliefs and joint actions in a community of researchers. Denscombe [ 12 ] took this perspective one step further by proposing the notion of communities of practice , an idea originally developed by the educationalist Étienne Wenger. This notion brings us closer to a definition of paradigms as shared beliefs able to accommodate the diversity of perspectives and approaches that currently exists within the mixed methods community [ 12 , 13 ].

While the institutionalization of mixed methods as a field has helped to formalize and clarify research practices [ 14 ], this trend has also led to some criticism of the ways in which this approach has been developed and conceptualized by some members of the mixed methods community [ 15 , 16 ]. The critiques of the mixed methods field have already been summarized in two overviews published in the early 2010s. In the second edition of the Handbook , Tashakkori and Teddlie [ 17 ] outlined four frequent criticisms raised in the mixed methods literature, including overreliance on typologies and the higher status of quantitative versus qualitative research. One year later, Creswell [ 18 ] described some of the same criticisms in a summary of 11 key controversies. The emergence of this criticism testifies to the increasing maturity of the field and its progress towards what Creswell and Plano Clark [ 7 ] define as the period of reflection and refinement in mixed methods research. In their view, the mixed methods community should be honored that it has attracted critical attention and it should stimulate debate around the issues raised. Therefore, it is crucially important to address these criticisms in greater detail because such engagement will lead to valuable insights that could lay the basis for further discussion needed to ensure the healthy development of the field. Furthermore, addressing those criticisms is essential to enhance researchers’ understanding of the complexity of the mixed methods field and to provide them with the awareness needed to deal with tensions that might emerge when working in teams with researchers subscribing to different methodological viewpoints [ 19 , 20 ].

Most of the criticisms of mixed methods so far have been formulated in the literature by several scholars specialized in theoretical aspects of methodology. However, it would be useful to find out whether other researchers share these criticisms and whether they may have formulated others. Scholars with an interest in mixed methods research come from different academic disciplines that embody different theoretical and methodological perspectives. As Plano Clark and Ivankova [ 3 ] argue, these differences are highly likely to influence the ways in which those scholars view mixed methods as well as the questions they might raise regarding current ideas in the field. Therefore, it would be useful to examine the ways in which researchers’ criticisms differ according to discipline.

The aim of the present study is to examine the criticisms of the mixed methods field raised by a cross-national sample of 42 researchers working in the disciplines of education, nursing, psychology, and sociology. We report a secondary analysis of semi-structured interviews originally conducted to describe how researchers operationalize and conceptualize the quality of mixed methods research [ 14 ]. The contribution of this article is twofold: (a) it is, to our knowledge, the first study based on an empirical approach to examining researchers’ critical views on the development and conceptualization of mixed methods research, and (b) it enhances our understanding of the ways in which these critical views may be associated with different academic disciplines.

This article reports a secondary analysis of data originally collected in a multiple-case study of the quality of mixed methods based on semi-structured interviews with researchers in the disciplines of education, nursing, psychology, and sociology. In line with Heaton’s [ 21 ] definition of secondary analysis — which he calls supplementary analysis — as an “in-depth investigation of an emergent issue or aspect of the data which was not considered or fully addressed in the primary study” [ 21 ], in this article we re-analyze the original interview data in order to address the following two research questions (RQs): (RQ1) What criticisms of the mixed methods field are made by researchers in education, nursing, psychology, and sociology? and (RQ2) What differences and similarities can be identified in the criticisms reported by researchers working in different disciplines? In the following subsections, we provide a brief description of the sampling and data collection methods used in the original study, and of the procedures used in the secondary analysis of data. A more detailed explanation of procedures followed in the original study can be found in Fàbregues, Paré, and Meneses [ 22 ].

The original study

Sampling and recruitment of participants..

The disciplines of education, nursing, psychology, and sociology were selected for four main reasons: (1) professionals working in these disciplines contribute a relatively high proportion of mixed methods empirical articles and other methodological publications, (2) a considerable number of prevalence studies and methodological reviews on the use of mixed methods in subfields of these disciplines have been published, and (3) these disciplines are characterized by their clear disciplinary boundaries, and this characteristic offers the possibility of gaining useful comparative insights [ 6 ]. Criterion and maximum variation sampling were used to select the researchers who participated in the study [ 23 ]. In the criterion sampling, participants fulfilled two inclusion criteria: (1) they had carried out research primarily in one of the four disciplines mentioned above, and (2) they had contributed to at least one methodological publication on mixed methods research. Participant identification started with a systematic search for methodological publications on mixed methods published in English during or after 2003. Selected publications fulfilled the definitions of mixed methods suggested by either Creswell and Tashakkori [ 24 ] or Johnson, Onwuegbuzie, and Turner [ 25 ]. A number of characteristics of the first authors’ profiles were extracted, including the field of expertise, the country of affiliation, and the job title. To ensure heterogeneity of the sample, maximum variation sampling was applied to authors meeting the two inclusion criteria. An iterative approach was used to recruit 11 participants for each discipline. Sample size was based on recommendations found in the literature [ 26 ]. Potential participants were contacted using a prioritized list until a total of 44 participants had been recruited.

Data collection.

Data collection involved semi-structured interviews. Questions from the interview guide were focused on the following topics: (a) participants’ research background and methodological expertise, (b) participants’ conceptualization of mixed methods research, and (c) how participants perceived the quality of the mixed methods approach in practice. Interviews were conducted using Skype, telephone and, in two cases, e-mail correspondence. Interviews were audio-recorded and transcribed, and average interview length was 49 minutes. We carried out a member-checking process by sending back to participants the transcriptions and summaries of key points of the interviews to confirm that the data accurately represented their views. At this stage, we also gave participants an opportunity to clarify or expand the statements they made during the interview.

Trustworthiness.

Four strategies were used to enhance the trustworthiness of the original study. First, as explained above, all participants member-checked their transcribed interviews and summaries to confirm accuracy. Second, peer-debriefing was carried out during data collection by one researcher working together with another researcher familiar with mixed methods research who was not included in the sample. Third, an audit trail was used to record the decisions made during the study and to help researchers to reflect on the influence on the study findings of their own assumptions and disciplines. Fourth, the decisions taken during the analysis and interpretation of the data, as well as the disagreements arising during this stage, were discussed by the researchers until a consensus was reached.

The secondary data analysis

While the original study aimed to examine researchers’ views on the conceptualization and operationalization of the quality of mixed methods research, the aim of this secondary analysis of the same data is to examine researchers’ critical views of commonly accepted concepts and practices in the mixed methods field. Ethical approval for secondary data analysis was included in the ethics application for the original study, which was approved by the Institutional Review Board of the Universitat Autònoma de Barcelona. Participants signed an informed consent before the interview. Of the 44 researchers who participated in the original study, two did not consent to the subsequent use of their interview data for a secondary analysis. Therefore, the information provided by these two researchers was not used in the present study. Table 1 shows the characteristics of the 42 participants finally included in this secondary analysis.

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https://doi.org/10.1371/journal.pone.0252014.t001

Qualitative content analysis as described by Graneheim & Lundman [ 27 ] was used to carry out the secondary analysis of the interview data. This form of analysis is especially appropriate when, as in this study, researchers are interested in systematically describing only the topics of interest indicated by the research questions, and not in obtaining a holistic overview of all of the data [ 28 ]. The data analysis was carried out in three stages using NVivo 12 for Mac (QSR International Pty Ltd, Victoria, Australia). In the first stage, the interview transcripts were read thoroughly in order to extract the sections of text in which the participants raised criticisms of the mixed methods field. These sections of text constituted the unit of analysis. In the second stage, the extracted sections were divided into meaning units, which were subsequently condensed, abstracted and labelled with codes. Each code included a description of the meaning of the code, an indicator to identify its presence in the data, and an example of a passage coded as belonging to that code. In the third stage, the codes were compared for similarities and differences, and clustered into several categories. The underlying meaning of these categories was then examined and formulated into themes. These themes represented the study participants’ criticisms of mixed methods as a field, which were the focus of RQ1. Decisions made in this phase of the study, along with any disagreements, were discussed by the researchers until a consensus was reached.

In order to answer RQ2, a multiple correspondence analysis [ 29 – 31 ] was carried out. This technique is a non-inferential form of statistical analysis designed to analyze the multivariate association of categorical variables by generating a representation of the underlying structure of a dataset. Since the statistical requirements of multiple correspondence analysis (i.e., sampling, linearity, and normality) are highly flexible, this method is especially suited for examining qualitative interview data transformed into quantitative data [ 32 ]. The output of the multiple correspondence analysis is a scatterplot representing the spatial grouping of categories and participants. The distances between plotted points represent the degree of similarity in the patterns of participants’ responses. Multiple correspondence analysis was used to examine the relationship between the participants’ discipline and the themes relating to criticisms. To perform this analysis, we used the NVivo “matrix coding query” function to generate a matrix in which binary codes related to criticisms identified in the qualitative content analysis (the mention or failure to mention the criticism) were displayed in the columns, while the 42 participants were displayed in the rows. The matrix output was exported to XLSTAT Version 2018.1 (Addinsoft, Paris, France), which was used to perform the analysis, using the binary codes for the criticisms as active variables and the participants’ discipline as supplementary variables. Following the recommendations of Bazeley [ 32 ], after carrying out the multiple correspondence analysis, we checked the results against the qualitative data to verify the interpretation of the statistical analysis.

RQ1; What criticisms of the mixed methods field are made by researchers in education, nursing, psychology, and sociology?

Eleven criticisms of how some members of the mixed methods community have developed and conceptualized this research approach were identified in 27 of the 42 interviews included in this secondary analysis. These criticisms were then grouped into the four domains used by Creswell [ 33 ] to map the landscape of mixed methods research: (1) the essence of mixed methods research (definitions and nomenclature), (2) philosophy (philosophical assumptions and paradigmatic stances), (3) procedures ( methods and techniques for carrying out mixed methods research), and (4) politics (justification of the use of mixed methods research). Each of these four domains and the corresponding criticisms are discussed in the following sections with the support of verbatim quotes from the interviews. Table 2 shows the criticisms for each domain and the number of participants making each criticism.

https://doi.org/10.1371/journal.pone.0252014.t002

Domain 1: The essence of mixed methods research.

Criticism 1 : The accepted definition of mixed methods research takes into account only the mixing of both quantitative and qualitative methods . Some participants objected that the most common definition of mixed methods research that usually prevails in the literature conceives the approach as being limited to the use of quantitative and qualitative methods. These participants believe that the field should adopt a broader definition that would also include the mixing of methods within the same tradition in a single design, that is, the combination of two or more quantitative methods or qualitative methods:

“(…) for me mixed methods is not only mixing qualitative and quantitative methods , but it could also be qualitative + qualitative or quantitative + quantitative methods” (Sociologist #4).

These participants argued that the current definition of mixed methods implies that mixing the two distinct families of methods is often the only appropriate approach while in fact this definition obviates the contingent nature of research. Certain research questions might be better answered by using a combination of methods from a single tradition. Furthermore, combining two methods from the same tradition can be as valuable and as challenging as combining two methods from different traditions. One participant used the term “pressure” to describe the feeling that he was obliged to mix quantitative and qualitative methods even when this approach was not the most appropriate one:

“ … combining methods isn’t just a matter of combining quantitative and qualitative methods . You can combine different methods that are both qualitative or both quantitative and that’s , that’s valuable in it- itself , and I am worried about the kind of pressure to combine quantitative and qualitative as if that would always be appropriate” (Sociologist #2).

Criticism 2 : The terminology used in mixed methods reflects a lack of agreement among its proponents . Several participants noted the lack of clear agreement on the terminology generally used to describe the concepts and procedures that pertain to mixed methods research. They also cited a tendency to use multiple definitions for the same term and different terms to refer to similar notions. One participant cited as problematic the use of several different terms (e.g., legitimation, validity, rigor) to refer to the quality of mixed methods research:

“I would like to see a word that’s used by as many people as possible to describe that [quality]… . But , you know , I , I just think if we , everybody continues to use different terms , that could be problematic” (Educationalist #8).

According to this participant, while synonymous terms might add some precision when used to describe the complexities of implementing mixed methods research, their use can also generate confusion, especially among reviewers, editors and researchers who are trying to familiarize themselves with the field:

“…it just gets to the point where if everyone has a different definition , then how useful is that ? And that gets confusing for those who review manuscripts , or editors , when people are using in different ways that exact same term” (Educationalist #8).

Participants suggested two possible reasons for this lack of agreement. First, the tendency among some scholars to consider that mixed methods researchers should be able to use whatever terminology they may find convenient. Second, the desire of some authors to claim priority for the terminology that defines a particular method or typology. In order to resolve this lack of agreement, participants suggested that members of the mixed methods community should work towards building a greater consensus on terminology:

“There needs to be a common language” (Educationalist #9).

Criticism 3 : Mixed methods research is not a new type of methods practice . Some participants noted the tendency in the literature to present mixed methods as a new type of research practice that emerged during the past three decades. They pointed out that the use of mixed methods has a prior history that considerably predates the time when it became formalized as a research field. These participants cited examples of studies in sociology by Jahoda and Zeisel (Marienthal study of unemployment) and fieldwork in anthropology by Margaret Mead, both dating from the early 20th century. While these studies had an influence on methodology in the social sciences on account of the ways in which they creatively combined multiple quantitative and qualitative data sources, they have been generally overlooked in the mixed methods literature:

“I don’t particularly think that [mixed methods research has allowed us to answer research questions which were left unanswered in the past] but what I do think is that , you know , do remember as well that mixed methods research does actually have a long history in Sociology” (Sociologist #7).

Domain 2: Philosophy.

Criticism 4 : Mixed methods research is not a third paradigm . A considerable number of participants argued against the idea of characterizing mixed methods research as a third paradigm. They found two major faults with this characterization. First, it relies on the idea of mixed methods research as an approach that is distinct from quantitative and qualitative methodologies. In the view of these participants, mixed methods approaches do not rely on singular elements that are distinct in their nature, philosophy, or procedures:

“So no , I think , ultimately , I’m probably , I’m not really convinced that is a distinct methodology (…) So I worry when , when the idea of something that’s very special about mixed methods is given a lot , is given too much primacy” (Sociologist #3). “I don’t think it’s helpful to see it as a separate approach in terms of actually conducting , you know , planning and conducting , the research…I certainly think it’s stretching it to see it as a different , as a separate paradigm…I think the whole idea of ‘paradigm’ is a little bit difficult” (Sociologist #5).

Second, the conceptualization of mixed methods as a paradigm presupposes a strong link between epistemology and method, that is, the identification of the use of mixed methods with a particular epistemological or ontological view, whereas, in fact, these are separate entities. Attaching epistemological and ontological assumptions to mixed methods research would weaken its functionality and creative potential:

“…if we restrict mixed methods to only one paradigm then we’re bottlenecking mixed methods into a certain area , and we restrict the functionality of it” (Nurse, #10).

Criticism 5 : Current discussions of mixed methods research conceive quantitative and qualitative research as separate paradigms . Related to the previous criticism, a number of participants noted that current conceptualizations of mixed methods take for granted the nature of the quantitative and qualitative approaches, conceiving them as separate paradigms based on particular philosophical assumptions, thus reinforcing the conventional divide between them and accentuating their differences:

“…the whole purpose , of course , of mixed methods is that it’s , that’s a paradigm , but I’m not convinced it is because it still draws on those conventional traditional paradigms…I find that’s likely less helpful because again it starts from the assumption that there is a strong division between qualitative and quantitative research” (Educationalist #2).

These participants stated that the mixed methods literature may have uncritically incorporated the methodological “rules” (conventions) that were dominant in the 1980s by associating qualitative research with the constructivist paradigm and quantitative research with the positivist paradigm. This linkage between philosophy and method may have been a result of the process of formalization of the methodology carried out by the “second generation of mixed methods researchers” (from 1980s to present), while the “first generation” (i.e., from the 1900s to 1980s) might not have had a philosophical problem:

“I think the biggest problem that mixed methods research is in right now is having adopted , without reflection the rules that were established in the mid 80’s on , on paradigms in quali and quanti…we have these pillars , these quali-quanti pillars and we’re working on these rooms…All these classical studies [from the first generation] had no problems in doing quali-quanti , it was only the attempt to formalize it which has actually created these , these problems” (Sociologist #6).

According to this participant, the association of the quantitative and qualitative approaches with particular epistemological stances contradicts the very nature of the mixed methods approach: if such philosophical and methodological differences between quantitative and qualitative research really existed, then the integration of the two approaches would not be possible:

“…the big problem with having adopted this [association] , on the one hand , it actually makes mixed methods impossible . So , it is not possible within one single design to argue that your da- , that there is a single and objectifiable reality out there , on the other hand , and there are multiple or no reality , there’s no reality” (Sociologist #6).

In the view of another participant, part of the mixed methods literature may have accentuated the differences between the two methodologies by representing their characteristics in different columns in a table, while ignoring the existence of methods that incorporate features of both approaches (e.g., survey containing both open and closed ended questions or qualitative studies that include descriptive statistics):

“I know what’s been recently suggested in the literature (…) I’m not even sure that I would say that we should have drawn a line between qualitative and quantitative as firmly as we have . A lot of the qualitative work that I do includes descriptive statistics” (Educationalist #7).

Criticism 6 : Superficiality of pragmatism . Some participants argued that authors in the mixed methods community sometimes characterize the notion of pragmatism in a superficial way by reducing it to merely eclecticism and confusing it with “practicalism”. In this way, these authors advocate a “what works” approach which may be useful when justifying the integration of the quantitative and qualitative methods, but this attitude distorts the nature of pragmatism by failing to consider its underlying theoretical and philosophical assumptions:

“…they tend to think that pragmatism is just the practicalities , and it’s just the technicalities…” (Educationalist #2).

One participant noted that the feebly argued debates on pragmatism to date may have led the mixed methods community to undervalue the important contribution this paradigm has made to the philosophical basis of empirical inquiry:

“I’ve probably never in my life seen such weak debates on pragmatism as I have in mix- , in the mixed methods debate . I mean if I think of this fabulous contribution that , that pragmatism as a philosophical discipline has made” (Sociologist #6).

Moreover, another participant observed that many researchers in the field have acquired their knowledge of pragmatism mainly from the descriptions of the mixed methods paradigm found in the literature, whereas a sound basis for pragmatism in mixed methods research practice would require consulting the seminal papers on pragmatism, such as those by John Dewey, Charles Sanders Pierce or William James:

“… from what I’ve read anything about pragmatism that’s in a mixed methods paper does tend to be superficial…you have to go right back to the original authors of pragmatism and I think sometimes when we speak about pragmatism in mixed methods research , students particularly ten- tend , maybe just read some articles in pragmatism and think they know about this , but I think it is important to go right back to Dewey and James and Pierce” (Nurse, #6).

Criticism 7 : Mixed methods research aligns with positivism . A few participants noted that some members of the mixed methods community tend to accord a higher status to the quantitative component because they consider that it is more objective and more closely embodies the scientific method. In their view, some researchers regard the qualitative component as mainly a supplement to the quantitative component. Consequently, researchers may fail to appreciate the added value that may be gained by using mixed methods research:

“qualitative research [is often used] to almost to kind of flesh out the , the , the quantitative aspects , so it’s a kind of embellishment rather than seeing it as something that might challenge some of the quantitative findings or might contribute to , to ultimately rephrasing the research question or to reanalyzing the , the quantitative data” (Sociologist #5).

Domain 3: Procedures.

Criticism 8 : Limitations of typologies . A number of participants criticized the tendency of some authors to present mixed methods designs and procedures from a typological perspective. Typologies are used in the mixed methods literature as classifications of methodological features, such as the timing and priority of the quantitative and qualitative components and the stage at which integration is carried out [ 7 , 9 ]. In the view of those participants, typologies are presented in the literature in a way that is excessively mechanical and prescriptive, unnecessarily simplifying the process of carrying out a mixed methods study by suggesting that a successful implementation of a mixed methods design can be carried out only by following a predefined set of steps:

“I’m arguing against approaches that I think are too sort of mechanical in the sense of laying out : ‘Ok , here’s categories A , B , C , D and E , and here are the rules for applying them . And if you just follow the rules , then you’ll be ok’” (Educationalist #1).

Participants noted that this approach entails four problems. First, in order to adapt their approach to the research questions that they need to answer, researchers may need to modify the guidelines suggested in the literature. Therefore, guidelines for the use of mixed methods designs should be only “guiding principles” that are adaptable to varying circumstances and able to take into account the interactions between the different elements of the design. One of these participants stated the following:

“I think , I mean , I started off by using…the sort of prescription…and it’s only when you start to get delve more into mixed methods… So , it’s , it’s really , I think [they should be] just guiding principles” (Nurse, #5).

Second, the typologies may curtail the creativity of researchers by restricting them to a series of predefined models that are considered the “correct” ways of combining quantitative and qualitative methods. As expressed by the following participant:

“…researchers are using mixed methods in such creative ways , it’s like , it’s just , when you read these designs and they can be just so , so different and they just don’t fit into , you know , the typologies” (Nurse, #3).

Third, rather than being empirically generated by examining how mixed methods research is actually carried out in practice, these typologies are the highly formalized result of a list of ideal designs formulated by mixed methods theorists, as noted by this participant:

“There were basically two different approaches [to the development of typologies] and the one that was most common was the sort of develop very formal systems…The opposite of that was Bryman who went out and interviewed qualitative researchers about what they did…he talked to people about what they really did rather than coming up with formal systems” (Sociologist #1).

Fourth, the existing typologies are too extensive, which makes them difficult for inexperienced researchers to apply, as we can see in the following quote:

“…there must be forty or fifty different designs associated with mixed methods and I think it’s , you know , I think that’s confusing to people and it’s … in some way I think it becomes irrelevant” (Psychologist #9).

Criticism 9 : Procedures described in the literature are not aligned with mixed methods practice . Some participants mentioned occasional discrepancies between the procedures explained in textbooks and articles and the implementation and reporting of mixed methods in practice, which may not always conform to published guidelines and typologies.

“you , you open any textbook…and the rules that are proposed there are broken every day very successfully by researchers who , who actually conduct the research…the practice and the debate need to run parallel and they probably , right now I think they are a bit too separate from each other” (Sociologist #3).

Participants attributed this disjuncture to the fact that a few influential authors probably lacked sufficient practical experience in using mixed methods. These authors may have tended to suggest methodological guidelines “from their desk” without testing them in practice or reviewing the empirical work of other researchers:

“…there might be a gap that , that a lot of researchers talk about using mixed methods , but I’m not sure if they actually do it in practice” (Psychologist #2).

Furthermore, participants also noted that in some cases those authors may have placed greater emphasis on the philosophical and theoretical basis of mixed methods than on describing the techniques involved in implementing mixed methods research:

“…people spend far too much time talking about epistemology , most of those discussions are actually very simple , but people make them very complicate…I think…technical questions about how you work with the data and what it means [are more important]” (Educationalist #6).

Domain 4: Politics.

Criticism 10 : Mixed methods research is not better than monomethod research . Some participants pointed out a tendency among some members of the mixed methods community to consider this type of research to be inherently superior to monomethod research:

“…thinking about the , the papers that I’ve reviewed have been for the kind of applied end journals…I think the main issue for me has been in terms of , you know , the purpose of using mixed methods; that I think there’s a tendency to slip into thinking that more is necessarily better” (Sociologist #9).

Participants noted that to attribute a higher status to mixed methods research is wrong because this view could lead to the oversimplification of other approaches, which would undermine their prestige. Furthermore, participants argued that a mixed methods approach is not always the best research option and a fully integrated design may not be the most appropriate. What really determines the suitability of an approach or a design is the research question of a study, so that a monomethod design is sometimes the most appropriate.

Criticism 11 : Homogenization of mixed methods research . A few participants criticized a tendency in the mixed methods field to homogenize terminology and procedures. In their view, some members of the community have tried to develop a “mixed methods way of doing things” which would be acceptable to all researchers and would require them to write in a particular way using particular terminologies and strategies:

“They’re , they’re trying to develop a language , they’re trying to develop an approach , a strategy that , that is going to be acceptable by all mixed methods researchers , which really is , is unacceptable” (Educationalist #2).

This attitude towards homogenization of mixed methods research could hinder the advancement of the field since it promotes a uniform approach, suppresses intellectual disputes and ignores the diversity of approaches and attitudes regarding mixed methods found in the literature. As one participant argued, to find space for legitimate difference in the field is very difficult due to the protectionist attitude of some prominent authors who are interested in propagating their own ideas rather than incorporating the ideas of other authors:

“I fear that there’s , among , among those who have some prominence , there are some who would be very eager to protect their own turf and not wanting to come together for some kind of joint effort” (Educationalist #3).

RQ2: What differences and similarities can be identified in the criticisms reported by researchers working in different disciplines?

Of the 27 participants who raised criticisms, ten were sociologists, eight were educationalists, five were nurses, and four were psychologists. Multiple correspondence analysis was used to analyze the differences, depending on their discipline, in the types of criticisms the participants raised. Fig 1 shows the multiple correspondence analysis map for the first two axes. Highly associated categories are plotted near to one another on the basis of their loading to the corresponding axes, while the least associated categories are plotted far from one another. Therefore, the axes should be interpreted based on the grouping seen on the map of the relative positions of the categories, which are expressed by the magnitude of the coordinates. The measures known as eigenvalues indicate how much of the categorical information is explained by each dimension. Higher eigenvalues indicate a greater amount of variance of the variables in that dimension [ 29 , 30 ].

Note: The Yes label indicates that the criticism was mentioned, while the No label indicates that the criticism was not mentioned.

https://doi.org/10.1371/journal.pone.0252014.g001

On Axis 1, which accounts for most of the variation in the data (eigenvalue of 92.4%), the yes categories of the criticisms associated with the domains of philosophy, politics and the essence of mixed methods are plotted on the right-hand side of the map, while the no categories of the same domains are on the left-hand side of the map. As shown in the figure, sociologists were more likely to formulate criticisms associated with the three abovementioned domains while psychologists and nurses were less likely to formulate criticisms associated with any of these three domains. Educationalists were less inclined than sociologists to formulate criticisms associated with those domains, as indicated by the proximity of the education category to the centroid (the center of the axis). Finally, the fact that the yes and no categories of the procedures domain are plotted on Axis 2, which has very low explanatory power (eigenvalue of 7.6%), reveals that participants in the four disciplines showed no relevant differences in formulating this criticism.

Summary of findings

The aim of this study, based on a secondary analysis of interview data, was to describe the criticisms of mixed methods as a field raised by a sample of researchers in the disciplines of education, nursing, psychology, and sociology. Overall, the findings revealed a number of criticisms related to several different issues. These criticisms were initially identified by the first author in the data analysis phase of the original study, which was focused on the conceptualization and operationalization of quality in mixed methods research. The criticisms were particularly relevant since they were unprompted, that is, they were spontaneously given by the participants in response to questions about another subject, rather than to questions about criticisms. Furthermore, the original study was based on a broad and diverse sample of participants; it included a few researchers from the disciplines of sociology and education known for their criticisms as well as a considerable number of researchers whose publications seemed to be neutral on the subject of criticisms of the mixed methods field. To this latter group of researchers, the interviews afforded an opportunity to express their disagreement with some predominant notions in the mixed methods field which they otherwise might not have published. Another key element of this study is the examination of the relationship between the discipline of the participants and the frequency and type of criticisms they made. This has been possible since the sample is relatively balanced in terms of the number of participants from each of the four disciplines included in the study.

In response to RQ1, participants raised a total of eleven unprompted critical remarks, categorized in the following four domains: the essence of mixed methods (three criticisms), philosophy (four criticisms), procedures (two criticisms), and politics (two criticisms). Nine of the eleven critical comments have been previously mentioned in the literature. For instance, on the essence of mixed methods domain, some authors have alluded to problems such as the narrow definition of mixed methods research [ 15 , 34 – 36 ], the lack of agreement on the terminology used [ 16 , 37 ] and the inappropriateness of considering mixed methods a new methodology [ 35 , 38 , 39 ]. In the philosophical domain, several authors have criticized the dominance of a positivist approach to mixed methods research in some disciplines [ 37 , 40 , 41 ] while some authors have pointed out that considering as a separate or distinct paradigm can lead to an artificial separation of the quantitative and qualitative approaches [ 42 – 45 ]. In the procedures domain, a number of authors cited the problems inherent in conceptualizing mixed methods designs typologically, since such a view is restrictive and unable to reflect the variety of mixed methods designs used in practice [ 38 , 46 , 47 ]. Finally, in the politics domain, a few authors have criticized a tendency, in some of the literature, to homogenize the field [ 48 ], while others have critically noted the occasional adoption of a universalist position based on the idea that the mixed methods approach is inherently superior to monomethod research [ 44 , 47 ]. However, we also identified two criticisms not previously mentioned in the literature: the excessively superficial characterizations of pragmatism (criticism 6) found occasionally in the mixed methods literature and the description of procedures that are not necessarily in line with research practice (criticism 9).

Regarding criticism 6, some participants noted a tendency on the part of some researchers in the field to cite, when writing about pragmatism, what other mixed methods researchers had written about this paradigm rather than citing foundational writings, such as those by John Dewey, William James, or Charles Sanders Peirce. In fact, none of the most influential and most frequently cited textbooks on mixed methods research in the four disciplines we studied cites any work by key authors in the pragmatist tradition. Therefore, it could be useful to learn whether these authors’ highly synthetic explanation of foundational knowledge leads inexperienced researchers to only weakly engage with this paradigm, or, on the other hand, whether this simplification might help them to grasp the basic principles of pragmatism more quickly while leading them to consult first-hand the foundational writings.

With respect to criticism 9, participants reported that researchers do not always follow in practice all of the procedures described in mixed methods textbooks. This disjuncture between textbook guidance and research practice has been described in several methodological reviews of the use of mixed methods in the four disciplines we included in our study. Features such as explicitly stating the mixed methods design used, reporting mixed methods research questions, or explicitly stating the limitations associated with the use of a mixed methods design are regarded by some authors as key characteristics of mixed methods studies (Creswell and Plano Clark, 2018; Plano Clark and Ivankova, 2016; Onwuegbuzie and Corrigan, 2014; O’Cathain et al, 2008). However, Bartholomew & Lockard (2018) reported that very few of the studies included in their review of the use of mixed methods in psychotherapy explicitly stated the mixed methods design used (13%) or reported mixed methods research questions (29%). Additionally, Bressan et al. (2017) and Irvine et al. (2021), in their reviews on mixed methods in nursing, found that most of the studies they included failed to report the limitations associated with the use of a mixed methods design. Therefore, it could be of great interest to study whether the omission of these characteristic features of mixed methods studies reflects the researchers’ view that these features are unimportant, or whether they are unfamiliar with reporting standards. Identifying this latter criticism is a particularly relevant finding of this study, since the intimate context of the interview might have led to the expression of subjective judgments that otherwise might not have come to light (i.e., the participant’s perception that some authors may not habitually carry out empirical research).

With respect to RQ2, we found relevant differences in the type of criticisms raised across disciplines. In fact, one of our key findings is that criticisms in the procedures domain were equally distributed across the four disciplines, while criticisms in the essence of mixed methods, philosophy and politics domains were clearly more common in sociology. First, these findings are consistent with statements made by Plano Clark and Ivankova [ 3 ] regarding the ways in which the sociocultural context of researchers — including the discipline in which they work — can shape their beliefs, knowledge and even experiences with regards to mixed methods. Indeed, the greater number of criticisms made by sociologists categorized in three of the four domains shows how disciplinary conventions might affect how researchers think about mixed methods and judge the acceptability of certain predominant conceptualizations. According to several authors [ 49 – 51 ], critique is a foundational and distinct feature of the discipline of sociology. Therefore, the generalized tendency among sociologists to question traditional assumptions about the order of the world and to detach themselves from predominant belief systems and ideologies might help to explain why many sociologists in our sample criticized ideas such as the conceptualization of quantitative and qualitative research as separate entities and the consideration of mixed methods as inherently better than monomethod research.

Theoretical implications of the study

The findings of our study highlight several differences in opinion in the mixed methods field previously identified by authors such as Greene [ 52 ], Tashakkori and Teddlie [ 17 ], Leech [ 53 ] and Maxwell, Chmiel, and Rogers [ 54 ], among others. Those authors showed that, owing to differences in philosophical and theoretical stances and their adherence to different research cultures, researchers in this field sometimes disagree on foundational issues such as nomenclature, the need for consensus, and the definition of mixed methods research. In our study, the participants, particularly those in the field of sociology, made several criticisms about how some foundational and philosophical aspects of mixed methods research have been conceptualized by the mixed methods community, including how mixed methods has been defined and accorded status as a third paradigm. Furthermore, our findings showed contradictory criticisms formulated by the participants as a group: while some researchers criticized the lack of a consensus in the field on the terminology used to describe mixed methods research (criticism 2), others criticized a tendency by some authors to homogenize terminology (criticism 11).

This divergence of views is consonant with the notion of communities of practice suggested by Denscombe [ 12 ]. Departing from Kuhn’s notion of paradigms as “shared beliefs among the members of a specialty area” (as cited by Morgan [ 10 ]), in Denscombe’s view, the broader mixed methods community is a paradigm encompassing a conglomerate of multiple research communities shaped by the principles, values and interests prevailing in their disciplines and research orientations. In line with that author’s view that methodological decisions and viewpoints “will be shaped by a socialization process involving the influence of peers” [ 12 ], our findings suggest that the disciplinary community of our participants is likely to have informed their criticisms of the mixed methods field. Although this divergence of views suggests that complete agreement and unhindered communication among researchers is not possible [ 55 ], Ghiara [ 56 ] argued that, in Kuhn’s view, some form of communication is always possible; and furthermore, conflicting viewpoints can be reconciled to a certain extent. Similarly, Johnson [ 57 ] has argued that this diversity of critical voices, rather than being a problem, merely indicates that “reality is likely plural”—there is no single set of ontological assumptions underlying mixed methods—and, furthermore, knowledge is articulated on the basis of “multiple standpoints and strategies for learning about our world” that can be reconciled to some degree. An example of the healthy coexistence of divergent viewpoints within the mixed methods community can be found in the Journal of Mixed Methods Research , the leading journal in the field, described in its webpage as a “primary forum for the growing community of international and multidisciplinary scholars of mixed methods research”. The journal publishes a wide range of manuscripts, including articles revealing approaches to mixed methods research that rest on divergent foundational and philosophical perspectives.

The desire for inclusion of divergent viewpoints should not lead researchers to ignore the challenges posed by this divergence. Due to the interdisciplinary nature of mixed methods research, Curry et al. [ 58 ] argue that mixed methods teams often include researchers with different methodological backgrounds and propensities. Occasionally, these differences may pose challenges for establishing effective collaboration and for efficiently integrating research methods. A greater awareness of multiple perspectives on mixed methods research, including divergent critical views like those reported in our study, could help researchers better anticipate difficulties that might present themselves in the course of working with researchers who hold differing viewpoints. Furthermore, as Maxwell, Chmiel, and Rogers [ 54 ] have suggested, a better understanding on the part of mixed methods researchers of the perspectives of others in the field who embrace a differing approach should facilitate the process of integrating quantitative and qualitative methods in studies where different ontological positions coincide. In a similar vein, such an understanding could also help overcome a form of methodological tokenism described by Hancock, Sykes and Verma [ 59 ]. This can occur when mixed methods researchers fail to attend to, and therefore align, the distinct epistemological and ontological premises that underlie the methodological orientations that are integrated in a mixed methods design.

Furthermore, the recognition of mixed methods researchers’ divergence of views should be an integral part in any effort to design and implement a curriculum for mixed methods research. Plano Clark and Ivankova [ 13 ] have pointed out that any lack of clarity concerning the existing disagreements about foundational elements of the mixed methods approach could be confusing to researchers inexperienced in this field. Therefore, it is essential that courses and workshops on mixed methods research take note of these criticisms. This last point is particularly important since the topic of critical viewpoints is not included in any of the mixed methods syllabus exemplars published in the literature, including those by Earley [ 60 ], Christ [ 61 ], and Ivankova and Plano Clark [ 13 ].

Limitations, strengths, and possibilities for future research

Our findings are subject to a few limitations. First of all, the interviews were carried out by Skype and telephone. While these two forms of communication allowed us to interview participants residing in various locations around the world, they limited the possibilities for building the sort of rapport that might have encouraged some participants to elaborate more in their responses. To minimize this limitation, participants were given the opportunity in the member-checking phase to add additional insights to their initial statements. Second, the transferability of our findings is limited by our decision to include only four disciplines while excluding the views of researchers working in other disciplines that also have a high prevalence of mixed methods studies, such as medicine, business, and information science. From our findings alone, it is not possible to infer how frequent these criticisms are and what types of criticisms may be more prevalent in each of the disciplines. Third, multiple correspondence analysis is an exploratory method not appropriate for testing hypotheses or statistical significance. In other words, the method is designed to describe associations between categorical variables rather than to make predictions about a population [ 31 ]. Therefore, in light of the limitations of multiple correspondence analysis for drawing deeper inferences, the findings regarding RQ2 should be considered provisional and subject to further investigation. Finally, since this study is based on a secondary analysis, the interview questions did not specifically prompt the participants to bring up criticisms since the questions were focused on participants’ views related to the quality of mixed methods research. If we had specifically prompted participants to report their own criticisms, it is likely that more critical opinions would have been gathered.

While the use of secondary data entailed certain limitations, it also conferred some advantages. Participants’ critical statements were entirely spontaneous since they were not explicitly solicited. This spontaneity probably helped to reduce the social desirability bias, that is, a presumed tendency for respondents to dissimulate their own critical views in a way that might seem professionally and socially more acceptable. Furthermore, despite the limitations of multiple correspondence analysis, this method allowed us to generate a parsimonious visual representation of the underlying patterns of relationships among the criticisms and the disciplines. This representation helped us to improve our interpretation of the qualitative findings and to identify useful leads for carrying our further analysis. A further strength is that the study included a broad sample of participants in terms of their geographic location, academic position, seniority, and methodological expertise. This diversity probably also afforded us access to a wider range of views. Finally, a key strength of our study is that, to our knowledge, it is the first empirical study that has addressed the topic of criticisms of mixed methods as a field.

This study represents a step towards a better understanding of some current criticisms of mixed methods research. However, further research will be needed to confirm and expand our findings. Future research based on a larger and more diverse sample of mixed methods researchers could extend the scope of our research questions and help researchers generalize from our findings. Such studies might help us discover whether researchers from other disciplines share the criticisms made by the participants in our study and whether those researchers harbor other criticisms of their own. Other analytical tools could be used to examine in greater detail how the circumstances and attributes of researchers — including their disciplinary background, methodological expertise and paradigmatic viewpoints — influence the way these scholars formulate their criticisms of the mixed methods field. Finally, future research is needed to examine the critical accounts of researchers less experienced in methodological writing and probably less exposed to current theoretical debates and developmental issues in the field.

Acknowledgments

The authors would like to acknowledge the help of Dick Edelstein in editing the final manuscript. The first draft of this paper was written while the first author was a visiting scholar in the Mixed Methods Program of the University of Michigan, directed by Michael D. Fetters, John W. Creswell, and Timothy D. Guetterman. This author would like to thank these three scholars for their support and, particularly Michael D. Fetters for his invaluable mentorship over the past few years.

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• Research article
• Open access
• Published: 24 September 2018

A mixed methods case study exploring the impact of membership of a multi-activity, multicentre community group on social wellbeing of older adults

• Gabrielle Lindsay-Smith   ORCID: orcid.org/0000-0003-3864-1412 1 ,
• Grant O’Sullivan 1 ,
• Rochelle Eime 1 , 2 ,
• Jack Harvey 1 , 2 &
• Jannique G. Z. van Uffelen 1 , 3  

BMC Geriatrics volume  18 , Article number:  226 ( 2018 ) Cite this article

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Social wellbeing factors such as loneliness and social support have a major impact on the health of older adults and can contribute to physical and mental wellbeing. However, with increasing age, social contacts and social support typically decrease and levels of loneliness increase. Group social engagement appears to have additional benefits for the health of older adults compared to socialising individually with friends and family, but further research is required to confirm whether group activities can be beneficial for the social wellbeing of older adults.

This one-year longitudinal mixed methods study investigated the effect of joining a community group, offering a range of social and physical activities, on social wellbeing of adults with a mean age of 70. The study combined a quantitative survey assessing loneliness and social support ( n  = 28; three time-points, analysed using linear mixed models) and a qualitative focus group study ( n  = 11, analysed using thematic analysis) of members from Life Activities Clubs Victoria, Australia.

There was a significant reduction in loneliness ( p  = 0.023) and a trend toward an increase in social support ( p  = 0.056) in the first year after joining. The focus group confirmed these observations and suggested that social support may take longer than 1 year to develop. Focus groups also identified that group membership provided important opportunities for developing new and diverse social connections through shared interest and experience. These connections were key in improving the social wellbeing of members, especially in their sense of feeling supported or connected and less lonely. Participants agreed that increasing connections was especially beneficial following significant life events such as retirement, moving to a new house or partners becoming unwell.

Conclusions

Becoming a member of a community group offering social and physical activities may improve social wellbeing in older adults, especially following significant life events such as retirement or moving-house, where social network changes. These results indicate that ageing policy and strategies would benefit from encouraging long-term participation in social groups to assist in adapting to changes that occur in later life and optimise healthy ageing.

Peer Review reports

Ageing population and the need to age well

Between 2015 and 2050 it is predicted that globally the number of adults over the age of 60 will more than double [ 1 ]. Increasing age is associated with a greater risk of chronic illnesses such as cardio vascular disease and cancer [ 2 ] and reduced functional capacity [ 3 , 4 ]. Consequently, an ageing population will continue to place considerable pressure on the health care systems.

However, it is also important to consider the individuals themselves and self-perceived good health is very important for the individual wellbeing and life-satisfaction of older adults [ 5 ]. The terms “successful ageing” [ 6 ] and “healthy ageing” [ 5 ] have been used to define a broader concept of ageing well, which not only includes factors relating to medically defined health but also wellbeing. Unfortunately, there is no agreed definition for what exactly constitutes healthy or successful ageing, with studies using a range of definitions. A review of 28 quantitative studies found that successful ageing was defined differently in each, with the majority only considering measures of disability or physical functioning. Social and wellbeing factors were included in only a few of the studies [ 7 ].

In contrast, qualitative studies of older adults’ opinions on successful ageing have found that while good physical and mental health and maintaining physical activity levels are agreed to assist successful ageing, being independent or doing something of value, acceptance of ageing, life satisfaction, social connectedness or keeping socially active were of greater importance [ 8 , 9 , 10 ].

In light of these findings, the definition that is most inclusive is “healthy ageing” defined by the World Health Organisation as “the process of developing and maintaining the functional ability (defined as a combination of intrinsic capacity and physical and social environmental characteristics), that enables well-being in older age” (p28) [ 5 ].This definition, and those provided in the research of older adults’ perceptions of successful ageing, highlight social engagement and social support as important factors contributing to successful ageing, in addition to being important social determinants of health [ 11 , 12 ].

Social determinants of health, including loneliness and social support, are important predictors of physical, cognitive and mental health and wellbeing in adults [ 12 ] and older adults [ 13 , 14 , 15 ]. Loneliness is defined as a perception of an inadequacy in the quality or quantity of one’s social relationships [ 16 ]. Social support, has various definitions but generally it relates to social relationships that are reciprocal, accessible and reliable and provide any or a combination of supportive resources (e.g. emotional, information, practical) and can be measured as perceived or received support [ 17 ]. These types of social determinants differ from those related to inequality (health gap social determinants) and are sometimes referred to as ‘social cure’ social determinants [ 11 ]. They will be referred to as ‘social wellbeing’ outcome measures in this study.

Unfortunately, with advancing age, there is often diminishing social support, leading to social isolation and loneliness [ 18 , 19 ]. Large nationally representative studies of adults and older adults reported that social activity predicted maintenance or improvement of life satisfaction as well as physical activity levels [ 20 ], however older adults spent less time in social activity than middle age adults.

Social wellbeing and health

A number of longitudinal studies have found that social isolation for older adults is a significant predictor of mortality and institutionalisation [ 21 , 22 , 23 ]. A meta-analysis by Holt-Lunstadt [ 12 ] reported that social determinants of health, including social integration and social support (including loneliness and lack of perceived social support) to be equal to, or a greater risk to mortality as common behavioural risk factors such as smoking, physical inactivity and obesity. Loneliness is independently associated with poor physical and mental health in the general population, and especially in older adults [ 13 , 14 , 15 ]. Adequate perceived social support has also been consistently associated with improved mental and physical health in both general and older adults [ 20 , 24 , 25 , 26 , 27 , 28 , 29 ]. The mechanism suggested for this association is that social support buffers the negative impacts of stressful situations and life events [ 30 ]. The above research demonstrates the benefit of social engagement for older adults; in turn this highlights the importance of strategies that reduce loneliness and improve social support and social connectedness for older adults.

Socialising in groups seems to be especially important for the health and wellbeing of older adults who may be adjusting to significant life events [ 26 , 31 , 32 , 33 ]. This is sometimes referred to as social engagement or social companionship [ 26 , 30 , 31 ]. It seems that the mechanism enabling such health benefits with group participation is through strengthening of social identification, which in turn increases social support [ 31 , 34 , 35 ]. Furthermore, involvement in community groups can be a sustainable strategy to reduce loneliness and increase social support in older adults, as they are generally low cost and run by volunteers [ 36 , 37 , 38 , 39 ].

Despite the demonstrated importance of social factors for successful ageing and the established risk associated with reduced social engagement as people age, few in-depth studies have longitudinally investigated the impact of community groups on social wellbeing. For example, a non-significant increase in social support and reduction in depression was found in a year-long randomised controlled trial conducted in senior centres in Norway with lonely older adults in poor physical and mental health [ 37 ]. Some qualitative studies have reported that community groups and senior centres can contribute to fun and socialisation for older adults, however social wellbeing was not the primary focus of the studies [ 38 , 40 , 41 ]. Given that social wellbeing is a broad and important area for the health and quality of life in older adults, an in-depth study is warranted to understand how it can be maximised in older adults. This mixed methods case study of an existing community aims to: i) examine whether loneliness and social support of new members of Life Activities Clubs (LACs) changes in the year after joining and ii) conduct an in-depth exploration of how social wellbeing changes in new and longer-term members of LACs.

A mixed methods study was chosen as the design for this research to enable an in-depth exploration of how loneliness and social support may change as a result of joining a community group. A case study was conducted using a concurrent mixed-methods design, with a qualitative component giving context to the quantitative results. Where the survey focused on the impact of group membership on social support and loneliness, the focus groups were an open discussion of the benefits in the lived context of LAC membership. The synthesis of the two sections of the study was undertaken at the time of interpretation of the results [ 42 ].

The two parts of our study were as follows:

a longitudinal survey (three time points over 1 year: baseline, 6 and 12 months). This part of the study formed the quantitative results;

a focus group study of members of the same organisation (qualitative).

Ethics approval to conduct this study was obtained from the Victoria University Human Research Ethics Committee (HRE14–071 [survey] and HRE15–291 [focus groups]) All participants provided informed consent to partake in the study prior to undertaking the first survey or focus group.

Setting and participants

Life activities clubs victoria.

Life Activities Clubs Victoria (LACVI) is a large not-for-profit group with 23 independently run Life Activities Clubs (LACs) based in both rural and metropolitan Victoria. It has approximately 4000 members. The organisation was established to assist in providing physical, social and recreational activities as well as education and motivational support to older adults managing significant change in their lives, especially retirement.

Eighteen out of 23 LAC clubs agreed to take part in the survey study. During the sampling period from May 2014 to December 2016, new members from the participating clubs were given information about the study and invited to take part. Invitations took place in the form of flyers distributed with new membership material.

Inclusion/ exclusion criteria

Community-dwelling older adults who self-reported that they could walk at least 100 m and who were new members to LACVI and able to complete a survey in English were eligible to participate. New members were defined as people who had never been members of LACVI or who had not been members in the last 2 years.

To ensure that the cohort of participants were of a similar functional level, people with significant health problems limiting them from being able to walk 100 m were excluded from participating in the study.

Once informed consent was received, the participants were invited to complete a self-report survey in either paper or online format (depending on preference). This first survey comprised the baseline data and the same survey was completed 6 months and 12 months after this initial time point. Participants were sent reminders if they had not completed each survey more than 2 weeks after each was delivered and then again 1 week later.

Focus groups

Two focus groups (FGs) were conducted with new and longer-term members of LACs. The first FG ( n  = 6) consisted of members who undertook physical activity in their LAC (e.g. walking groups, tennis, cycling). The second FG ( n  = 5) consisted of members who took part in activities with a non-physical activity (PA) focus (e.g. book groups, social groups, craft or cultural groups). LACs offer both social and physical activities and it was important to the study to capture both types of groups, but they were kept separate to assist participants in feeling a sense of commonality with other members and improving group dynamic and participation in the discussions [ 43 ]. Of the people who participated in the longitudinal survey study, seven also participated in the FGs.

The FG interviews were facilitated by one researcher (GLS) and notes around non-verbal communication, moments of divergence and convergence amongst group members, and other notable items were taken by a second researcher (GOS). Both researchers wrote additional notes after the focus groups and these were used in the analysis of themes. Focus groups were recorded and later transcribed verbatim by a professional transcriptionist, including identification of each participant speaking. One researcher (GLS) reviewed each transcription to check for any errors and made any required modifications before importing the transcriptions into NVivo for analysis. The transcriber identified each focus group participant so themes for individuals or other age or gender specific trends could be identified.

Dependent variables

• Social support

Social support was assessed using the Duke–UNC Functional Social support questionnaire [ 44 ]. This scale specifically measures participant perceived functional social support in two areas; i) confidant support (5 questions; e.g. chances to talk to others) and ii) affective support (3 questions; e.g. people who care about them). Participants rated each component of support on a 5-item likert scale between ‘much less than I would like’ (1 point) to ‘as much as I would like’ (5 points). The total score used for analysis was the mean of the eight scores (low social support = 1, maximum social support = 5). Construct validity, concurrent validity and discriminant validity are acceptable for confidant and affective support items in the survey in the general population [ 44 ].

Loneliness was measured using the de Jong Gierveld and UCLA-3 item loneliness scales developed for use in many populations including older adults [ 45 ]. The 11-item de Jong Gierveld loneliness scale (DJG loneliness) [ 46 ] is a multi-dimensional measure of loneliness and contains five positively worded and six negatively worded items. The items fall into four subscales; feelings of severe loneliness, feelings connected with specific problem situations, missing companionship, feelings of belongingness. The total score is the sum of the items scores (i.e. 11–55): 11 is low loneliness and 55 is severe loneliness. Self-administered versions of this scale have good internal consistency (> = 0.8) and inter-item homogeneity and person scalability that is as good or better than when conducted as face-to face interviews. The validity and reliability for the scale is adequate [ 47 ]. The UCLA 3-item loneliness scale consists of three questions about how often participants feel they lack companionship, feel left out and feel isolated. The responses are given on a three-point scale ranging from hardly ever (1) to often (3). The final score is the sum of these three items with the range being from lowest loneliness (3) to highest loneliness (9). Reliability of the scale is good, (alpha = 0.72) as are discriminant validity and internal consistency [ 48 ]. The scale is commonly used to measure loneliness with older adults ([ 49 ] – review), [ 50 , 51 ].

Sociodemographic variables

The following sociodemographic characteristics were collected in both the survey and the focus groups: age, sex, highest level of education, main life occupation [ 52 ], current employment, ability to manage on income available, present marital status, country of birth, area of residence [ 53 ]. They are categorised as indicated in Table  2 .

Health variables

The following health variables were collected: Self-rated general health (from SF-12) [ 54 ] and Functional health (ability to walk 100 m- formed part of the inclusion criteria) [ 55 ]. See Table 2 for details about the categories of these variables.

The effects of becoming a member on quantitative outcome variables (i.e. Social support, DJG loneliness and UCLA loneliness) were analysed using linear mixed models (LMM). LMM enabled testing for the presence of intra-subject random effects, or equivalently, correlation of subjects’ measures over time (baseline, 6-months and 12 months). Three correlation structures were examined: independence (no correlation), compound symmetry (constant correlation of each subjects’ measures over the three time points) and autoregressive (correlation diminishing with increase in spacing in time). The best fitting correlation structure was compound symmetry; this is equivalent to a random intercept component for each subject. The LMM incorporated longitudinal trends over time, with adjustment for age as a potential confounder. Statistical analyses were conducted using SPSS for windows (v24).

UCLA loneliness and social support residuals were not normally distributed and these scales were Log10 transformed for statistical analysis.

Analyses were all adjusted for age, group attendance (calculated as average attendance at 6 and 12 months) and employment status at baseline (Full-time, Part-time, not working).

Focus group transcripts were analysed using thematic analysis [ 56 , 57 ], a flexible qualitative methodology that can be used with a variety of epistemologies, approaches and analysis methods [ 56 ]. The transcribed data were analysed using a combination of theoretical and inductive thematic analysis [ 56 ]. It was theorised that membership in a LAC would assist with social factors relating to healthy ageing [ 5 ], possibly through a social identity pathway [ 58 ], although we wanted to explore this. Semantic themes were drawn from these codes in order to conduct a pragmatic evaluation of the LACVI programs [ 56 ]. Analytic rigour in the qualitative analysis was ensured through source and analyst triangulation. Transcriptions were compared to notes taken during the focus groups by the researchers (GOS and GLS). In addition, Initial coding and themes (by GLS) were checked by a second researcher (GOS) and any disagreements regarding coding and themes were discussed prior to finalisation of codes and themes [ 57 ].

Sociodemographic and health characteristics of the 28 participants who completed the survey study are reported in Table  1 . The mean age of the participants was 66.9 and 75% were female. These demographics are representative of the entire LACVI membership. Education levels varied, with 21% being university educated, and the remainder completing high school or technical certificates. Two thirds of participants were not married. Some sociodemographic characteristics changed slightly at 6 and 12 months, mainly employment (18% in paid employment at baseline and 11% at 12-months) and ability to manage on income (36% reporting trouble managing on their income at baseline and 46% at 12 months). Almost 90% of the participants described themselves as being in good-excellent health.

Types of activities

There were a variety of types of activities that participants took part in: physical activities such as walking groups ( n  = 7), table tennis ( n  = 5), dancing class ( n  = 2), exercise class ( n  = 1), bowls ( n  = 2), golf ( n  = 3), cycling groups ( n  = 1) and non-physical leisure activities such as art and literature groups ( n  = 5), craft groups ( n  = 5), entertainment groups ( n  = 12), food/dine out groups ( n  = 18) and other sedentary leisure activities (e.g. mah jong, cards),( n  = 4). A number of people took part in more than one activity.

Frequency of attendance at LACVI and changes in social wellbeing

At six and 12 months, participants indicated how many times in the last month they attended different types of activities at their LAC. Most participants maintained the same frequency of participation over both time points. Only four people participated more frequently at 12 than at 6 months and nine reduced participation levels. The latter group included predominantly those who reduced from more than two times per week at 6 months to 2×/week at 6 months to one to two times per week ( n  = 5) or less than one time per week ( n  = 2) at 12 months. Average weekly club attendance at six and 12 months was included as a covariate in the statistical model.

Outcome measures

Overall, participants reported moderate social support and loneliness levels at baseline (See Table 2 ). Loneliness, as measured by both scales, reduced significantly over time. There was a significant effect of time on the DJG loneliness scores (F (2, 52) = 3.83, p  = 0.028), with Post-Hoc analysis indicating a reduction in DJG loneliness between baseline and 12 months ( p  = 0.008). UCLA loneliness scores (transformed variable) also changed significantly over time (F (2, 52) = 4.08, p  = 0.023). Post hoc tests indicated a reduction in UCLA loneliness between baseline and 6 months ( p  = 0.007). There was a small non-significant increase in social support (F (2, 53) =2.88, p  = 0.065) during the first year of membership (see Table 2 and Figs. 1 and 2 ).

DJG loneliness for all participants over first year of membership at LAC club ( n  = 28).

*Represents significant difference compared to baseline ( p  < 0.01)

UCLA loneliness score for all participants over first year of membership at LAC club ( n  = 28).

*Indicates log values of the variable at 6-months were significantly different from baseline ( p  < 0.01)

In total, 11 participants attended the two focus groups, six people who participated in PA clubs (four women) and five who participated in social clubs (all women). All focus group participants were either retired ( n  = 9) or semi-retired ( n  = 2). The mean age of participants was 67 years (see Table 2 for further details). Most of the participants (82%) had been members of a LAC for less than 2 years and two females in the social group had been members of LAC clubs for 5 and 10 years respectively.

Analysis of the focus group transcripts identified two themes relating to social benefits of group participation; i) Social resources and ii) Social wellbeing (see Fig. 3 ). Group discussion suggested that membership of a LAC provides access to more social resources through greater and diverse social contact and opportunity. It is through this improvement in social resources that social wellbeing may improve.

Themes arising from focus group discussion around the benefits of LAC membership

Social resources

The social resources theme referred to an increase in the availability and variety of social connections that resulted from becoming a member of a LAC. The social nature of the groups enabled an expansion and diversification of members’ social network and improved their sense of social connectedness. There was widespread agreement in both the focus groups that significant life events, especially retirement, illness or death of spouse and moving house changes one’s social resources. Membership of the LAC had benefits especially at these times and these events were often motivators to join such a club. Most participants found that their social resources declined after retirement and even felt that they were grieving for the loss of their work.

“ I just saw work as a collection of, um, colleagues as opposed to friends. I had a few good friends there. Most were simply colleagues or acquaintances …. [interviewer- Mmm.] ..Okay, you’d talk to them every day. You’d chatter in the kitchen, oh, pass banter back and forth when things are busy or quiet, but... Um, in terms of a friendship with those people, like going to their home, getting to know them, doing other things with them, very few. But what I did miss was the interaction with other people. It had simply gone….. But, yeah, look, that, the, yeah, that intervening period was, oh, a couple of months. That was a bit tough…. But in that time the people in LAC and the people in U3A…. And the other dance group just drew me into more things. Got to know more people. So once again, yeah, reasonable group of acquaintances.” (Male, PAFG)

Group members indicated general agreement with these two responses, however one female found she had a greater social life following retirement due to the busy nature of her job.

Within the social resources theme, three subthemes were identified, i) Opportunity for social connectedness, ii) Opportunity for friendships, and iii) Opportunity for social responsibility/leadership . Interestingly, these subthemes were additional to the information gathered in the survey. This emphasises the power of the inductive nature of the qualitative exploration employed in the focus groups to broaden the knowledge in this area.

The most discussed and expanded subtheme in both focus groups was Opportunity for social connectedness , which arose through developing new connections, diversifying social connections, sharing interests and experiences with others and peer learning. Participants in both focus groups stated that being a member of LAC facilitated their socialising and connecting with others to share ideas, skills and to do activities with, which was especially important through times of significant life events. Furthermore, participants in each of the focus groups valued developing diverse connections:

“ Yeah, I think, as I said, I finished up work and I, and I had more time for wa-, walking. So I think a, in meeting, in going to this group which, I saw this group of women but then someone introduced me to them. They were just meeting, just meeting a new different set of people, you know? As I said, my work people and these were just a whole different group of women, mainly women. There’s not many men. [Interviewer: Yes.]….. Although our leader is a man, which is ironic and is about, this man out in front and there’s about 20 women behind him, but, um, so yeah, and people from different walks of life and different nationalities there which I never knew in my work life, so yeah. That’s been great. So from that goes on other things, you know, you might, uh, other activities and, yeah, people for coffee and go to the pictures or something, yeah. That’s great.” (Female, PAFG)

Simply making new connections was the most widely discussed aspect related to the opportunity for social connectedness subtheme, with all participants agreeing that this was an important benefit of participation in LAC groups.

“Well, my experience is very similar to everybody else’s…….: I, I went from having no social life to a social life once I joined a group.” (Female, PAFG)

There was agreement in both focus groups that these initial new connections made at a LAC are strengthened through development of deeper personal connections with others who have similar demographics and who are interested in the same activities. This concurs with the Social Identity Theory [ 58 ] discussed previously.

“and I was walking around the lake in Ballarat, like wandering on my own. I thought, This is ridiculous. I mean, you’ve met all those groups of women coming the opposite way, so I found out what it was all about, so I joined, yeah. So that’s how I got into that.[ Interviewer: Yeah.] Basically sick of walking round the lake on my own. [Interviewer: Yeah, yeah.] So that’s great. It’s very social and they have coffee afterwards which is good.” (female, PAFG)

The subtheme Opportunity for development of friendships describes how, for some people, a number of LAC members have progressed from being just initial social connections to an established friendship. This signifies the strength of the connections that may potentially develop through LAC membership. Some participants from each group mentioned friendships developing, with slightly more discussion of this seen in the social group.

“we all have a good old chat, you know, and, and it’s all about friendship as well.” (female, SocialFG)

The subtheme Opportunity for social responsibility or leadership was mentioned by two people in the active group, however it was not brought up in the social group. This opportunity for leadership is linked with the development of a group identity and desiring to contribute meaningfully to a valued group.

“with our riding group, um, you, a leader for probably two rides a year so you’ve gotta prepare for it, so some of them do reccie rides themselves, so, um, and also every, uh, so that’s something that’s, uh, a responsibility.” (male, PAFG)

Social wellbeing

The social resources described above seem to contribute to a number of social, wellbeing outcomes for participants. The sub themes identified for Social wellbeing were , i) Increased social support, ii) Reduced loneliness, iii) Improved home relationships and iv) Improved social skills.

Increased social support

Social support was measured quantitatively in the survey (no significant change over time for new members) and identified as a benefit of LAC membership during the focus group discussions. However, only one of the members of the active group mentioned social support directly.

‘it’s nice to be able to pick up the phone and share your problem with somebody else, and that’s come about through LAC. ……‘Cos before that it was through, with my family (female, PAFG)

There was some agreement amongst participants of the PA group that they felt this kind of support may develop in time but most of them had been members for less than 2 years.

“[Interviewer: Yeah. Does anyone else have that experience? (relating to above quote)]” There is one lady but she’s actually the one that I joined with anyway. [Interviewer: Okay.] But I, I feel there are others that are definitely getting towards that stage. It’s still going quite early days. (female1, PAFG) [Interviewer: I guess it’s quite early for some of you, yeah.] “yeah” (female 2, PAFG)

Social support through sharing of skills was mentioned by one participant in the social group also, with agreement indicated by most of the others in the social focus group.

Discussion in the focus groups also touched on the subthemes Reduced loneliness and Improved home relationships, which were each mentioned by one person. And focus groups also felt that group membership Improved social skills through opening up and becoming more approachable (male, PAFG) or enabling them to become more accepting of others’ who are different (general agreement in Social FG).

This case study integrated results from a one-year longitudinal survey study and focus group discussions to gather rich information regarding the potential changes in social wellbeing that older adults may experience when joining community organisations offering group activities. The findings from this study indicate that becoming a member of such a community organisation can be associated with a range of social benefits for older adults, particularly related to reducing loneliness and maintaining social connections.

Joining a LAC was associated with a reduction in loneliness over 1 year. This finding is in line with past group-intervention studies where social activity groups were found to assist in reducing loneliness and social isolation [ 49 ]. This systematic review highlighted that the majority of the literature explored the effectiveness of group activity interventions for reducing severe loneliness or loneliness in clinical populations [ 49 ]. The present study extends this research to the general older adult population who are not specifically lonely and reported to be of good general health, rather than a clinical focus. Our findings are in contrast to results from an evaluation of a community capacity-building program aimed at reducing social isolation in older adults in rural Australia [ 59 ]. That program did not successfully reduce loneliness or improve social support. The lack of change from pre- to post-program in that study was reasoned to be due to sampling error, unstandardised data collection, and changes in sample characteristics across the programs [ 59 ]. Qualitative assessment of the same program [ 59 ] did however suggest that participants felt it was successful in reducing social isolation, which does support our findings.

Changes in loneliness were not a main discussion point of the qualitative component of the current study, however some participants did express that they felt less lonely since joining LACVI and all felt they had become more connected with others. This is not so much of a contrast in results as a potential situational issue. The lack of discussion of loneliness may have been linked to the common social stigma around experiencing loneliness outside certain accepted circumstances (e.g. widowhood), which may lead to underreporting in front of others [ 45 ].

Overall, both components of the study suggest that becoming a member of an activity group may be associated with reductions in loneliness, or at least a greater sense of social connectedness. In addition to the social nature of the groups and increased opportunity for social connections, another possible link between group activity and reduced loneliness is an increased opportunity for time out of home. Previous research has found that more time away from home in an average day is associated with lower loneliness in older adults [ 60 ]. Given the significant health and social problems that are related to loneliness and social isolation [ 13 , 14 , 15 ], the importance of group involvement for newly retired adults to prevent loneliness should be advocated.

In line with a significant reduction in loneliness, there was also a trend ( p  = 0.056) toward an increase in social support from baseline to 12 months in the survey study. Whilst suggestive of a change, it is far less conclusive than the findings for loneliness. There are a number of possible explanations for the lack of statistically significant change in this variable over the course of the study. The first is the small sample size, which would reduce the statistical power of the study. It may be that larger studies are required to observe changes in social support, which are possibly only subtle over the course of 1 year. This idea is supported by a year-long randomised controlled trial with 90 mildly-depressed older adults who attended senior citizen’s club in Norway [ 37 ]. The study failed to see any change in general social support in the intervention group compared to the control over 1 year. Additional analysis in that study suggested that people who attended the intervention groups more often, tended to have greater increases in SS ( p  = 0.08). The researchers stated that the study suffered from significant drop-out rates and low power as a result. In this way, it was similar to our findings and suggests that social support studies require larger numbers than we were able to gain in this early exploratory study. Another possible reason for small changes in SS in the current study may be the type of SS measured. The scale used gathered information around functional support or support given to individuals in times of need. Maybe it is not this type of support that changes in such groups but more specific support such as task-specific support. It has been observed in other studies and reviews that task-specific support changes as a result of behavioural interventions (e.g. PA interventions) but general support does not seem to change in the time frames often studied [ 61 , 62 , 63 ].

There were many social wellbeing benefits such as increased social connectivity identified in focus group discussion, but the specific theme of social support was rarely mentioned. It may be that general social support through such community groups may take longer than 1 year to develop. There is evidence that strong group ties are sequentially positively associated between social identification and social support [ 34 ], suggesting that the connections formed through the groups may lead increased to social support from group members in the future. This is supported by results from the focus group discussions, where one new member felt she could call on colleagues she met in her new group. Other new members thought it was too soon for this support to be available, but they could see the bonds developing.

Other social wellbeing changes

In addition to social support and loneliness that were the focus of the quantitative study, the focus group discussions uncovered a number of other benefits of group membership that were related to social wellbeing (see Fig. 3 ). The social resources theme was of particular interest because it reflected some of the mechanisms that appeared enable social wellbeing changes as a result of being a member of a LAC but were not measured in the survey. The main social resources relating to group membership that were mentioned in the focus groups were social connectedness, development of friendships and opportunity for social responsibility or leadership. As mentioned above, there was wide-spread discussion within the focus groups of the development of social connections through the clubs. Social connectedness is defined as “the sense of belonging and subjective psychological bond that people feel in relation to individuals and groups of others.” ([ 25 ], pp1). As well as being an important predecessor of social support, greater social connectedness has been found to be highly important for the health of older adults, especially cognitive and mental health [ 26 , 32 , 34 , 35 , 64 ]. One suggested theory for this health benefit is that connections developed through groups that we strongly identify with are likely to be important for the development of social identity [ 34 ], defined by Taifel as: “knowledge that [we] belong to certain social groups together with some emotional and value significance to [us] of this group membership” (Tajfel, 1972, p. 31 in [ 58 ] p 2). These types of groups to which we identify may be a source of “personal security, social companionship, emotional bonding, intellectual stimulation, and collaborative learning and……allow us to achieve goals.” ([ 58 ] p2) and an overall sense of self-worth and wellbeing. There was a great deal of discussion relating to the opportunity for social connectedness derived through group membership being particularly pertinent following a significant life event such as moving to a new house or partners becoming unwell or dying and especially retirement. This change in their social circumstance is likely to have triggered the need to renew their social identity by joining a community group. Research with university students has shown that new group identification can assist in transition for university students who have lost their old groups of friends because of starting university [ 65 ]. In an example relevant to older adults, maintenance or increase in number of group memberships at the time of retirement reduced mortality risk 8 years later compared to people who reduce their number of group activities in a longitudinal cohort study [ 66 ]. This would fit with the original Activity Theory of ageing; whereby better ageing experience is achieved when levels of social participation are maintained, and role replacement occurs when old roles (such as working roles) must be relinquished [ 67 ]. These connections therefore appear to assist in maintaining resilience in older adults defined as “the ability to maintain or improve a level of functional ability (a combination of intrinsic physical and mental capacity and environment) in the face of adversity” (p29, [ 5 ]). Factors that were mentioned in the focus groups as assisting participants in forming connections with others were shared interest, learning from others, and a fun and accepting environment. It was not possible to assess all life events in the survey study. However, since the discussion from the focus groups suggested this to be an important motivator for joining clubs and potentially a beneficial time for joining them, it would be worth exploring in future studies.

Focus group discussion suggested that an especially valuable time for joining such clubs was around retirement, to assist with maintaining social connectivity. The social groups seem to provide social activity and new roles for these older adults at times of change. It is not necessarily important for all older adults but maybe these ones identify themselves as social beings and therefore this maintenance of social connection helps to continue their social role. Given the suggested importance of social connectivity gained through this organisation, especially at times of significant life events, it would valuable to investigate this further in future and consider encouragement of such through government policy and funding. The majority of these types of clubs exist for older adults in general, but this study emphasises the need for groups such as these to target newly retired individuals specifically and to ensure that they are not seen as ‘only for old people’.

Strengths and limitations

The use of mixed –methodologies, combining longitudinal survey study analysed quantitatively, with a qualitative exploration through focus group discussions and thematic analysis, was a strength of the current study. It allowed the researchers to not only examine the association between becoming a member of a community group on social support and loneliness over an extended period, but also obtain a deeper understanding of the underlying reasons behind any associations. Given the variability of social support definitions in research [ 17 ] and the broad area of social wellbeing, it allowed for open exploration of the topic, to understand associations that may exist but would have otherwise been missed. Embedding the research in an existing community organisation was a strength, although with this also came some difficulties with recruitment. Voluntary coordination of the community groups meant that informing new members about the study was not always feasible or a priority for the volunteers. In addition, calling for new members was innately challenging because they were not yet committed to the club fully. This meant that so some people did not want to commit to a year-long study if they were not sure how long they would be a member of the club. This resulted in slow recruitment and a resulting relatively low sample size and decreased power to show significant statistical differences, which is a limitation of the present study. However, the use of Linear Mixed Models for analysis of the survey data was a strength because it was able to include all data in the analyses and not remove participants if one time point of data was missing, as repeated measures ANOVAs would do. The length of the study (1 year) is another strength, especially compared to previous randomised controlled studies that are typically only 6–16 weeks in length. Drop-out rate in the current study is very low and probably attributable to the benefits of working with long-standing organisations.

The purpose of this study was to explore in detail whether there are any relationships between joining existing community groups for older adults and social wellbeing. The lack of existing evidence in the field meant that a small feasibility-type case study was a good sounding-board for future larger scale research on the topic, despite not being able to answer questions of causality. Owing to the particularistic nature of case studies, it can also be difficult to generalise to other types of organisations or groups unless there is a great deal of similarity between them [ 68 ]. There are however, other types of community organisations in existence that have a similar structure to LACVI (Seniors centres [ 36 , 40 ], Men’s Sheds [ 38 ], University of the Third Age [ 34 , 69 ], Japanese salons [ 70 , 71 ]) and it may be that the results from this study are transferable to these also. This study adds to the literature around the benefits of joining community organisations that offer social and physical activities for older adults and suggests that this engagement may assist with reducing loneliness and maintaining social connection, especially around the time of retirement.

Directions for future research

Given that social support trended toward a significant increase, it would be useful to repeat the study on a larger scale in future to confirm this. Either a case study on a similar but larger community group or combining a number of community organisations would enable recruitment of more participants. Such an approach would also assist in assessing the generalisability of our findings to other community groups. Given that discussions around social benefits of group membership in the focus groups was often raised in conjunction with the occurrence of significant life events, it would be beneficial to include a significant life event scale in any future studies in this area. The qualitative results also suggest that it would be useful to investigate whether people who join community groups in early years post retirement gain the same social benefits as those in later stages of retirement. Studies investigating additional health benefits of these community groups such as physical activity, depression and general wellbeing would also be warranted.

With an ageing population, it is important to investigate ways to enable older adults to age successfully to ensure optimal quality of life and minimisation of health care costs. Social determinants of health such as social support, loneliness and social contact are important contributors to successful ageing through improvements in cognitive health, quality of life, reduction in depression and reduction in mortality. Unfortunately, older adults are at risk of these social factors declining in older age and there is little research investigating how best to tackle this. Community groups offering a range of activities may assist by improving social connectedness and social support and reducing loneliness for older adults. Some factors that may assist with this are activities that encourage sharing interests, learning from others, and are conducted in a fun and accepting environment. Such groups may be particularly important in developing social contacts for newly retired individuals or around other significant life events such as moving or illness of loved ones. In conclusion, ageing policy and strategies should emphasise participation in community groups especially for those recently retired, as they may assist in reducing loneliness and increasing social connections for older adults.

Abbreviations

Focus group

Life Activities Club

Life Activities Clubs Victoria

Linear mixed model

Physical activity

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The primary author contributing to this study (GLS) receives PhD scholarship funding from Victoria University. The other authors were funded through salaries at Victoria University.

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Gabrielle Lindsay-Smith, Grant O’Sullivan, Rochelle Eime, Jack Harvey & Jannique G. Z. van Uffelen

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Contributions

GLS, RE and JVU made substantial contributions to the conception and design of the study. GLS and GOS supervised data collection for the surveys (GLS) and focus groups (GOS and GLS). GLS, GOS, RE, JH and JVU were involved in data analysis and interpretation. All authors were involved in drafting, the manuscript and approved the final version.

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Correspondence to Gabrielle Lindsay-Smith .

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Ethics approval to conduct this study was obtained from the Victoria University Human Research Ethics Committee (HRE14–071 [survey] and HRE15–291 [focus groups]). All survey participants provided informed consent to partake in the study prior to undertaking the first survey by clicking ‘agree’ in the survey software (online participants) or signing a written consent form (paper participants) after they had read all participant information relating to the study. Focus group participants also completed a written consent form after reading and understanding all participant information regarding the study.

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Lindsay-Smith, G., O’Sullivan, G., Eime, R. et al. A mixed methods case study exploring the impact of membership of a multi-activity, multicentre community group on social wellbeing of older adults. BMC Geriatr 18 , 226 (2018). https://doi.org/10.1186/s12877-018-0913-1

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ORIGINAL RESEARCH article

A mixed methods research study of parental perception of physical activity and quality of life of children under home lock down in the covid-19 pandemic.

• 1 Transdisciplinary Research Center in Psychology, Autonomous University of the State of Morelos, Cuernavaca, Mexico
• 2 Institute of Psychology and Special Education, Department of Applied Psychology, University Center for Health Sciences, University of Guadalajara, Guadalajara, Mexico
• 3 Facultad de Ciencias Sociales, Universidad Europea de Canarias, La Orotava, Spain
• 4 Faculty of Psychology and Speech Therapy, Department of Clinical Psychology, Psychobiology and Methodology, University of La Laguna, Santa Cruz de Tenerife, Spain

Household confinement due to the rapid spread of the pandemic caused by COVID-19 has brought very significant changes, such as the forced stay-at-home of children due to the closure of schools. This has meant drastic changes in the organization of daily life and restrictions on their activities, including exercise, which could affect the quality of life of the children due to its importance. In order to study the relationship between physical activity and psychological well-being of minors, a study has been carried out with Mixed Methods Research, combining survey methodology with transversal design with qualitative methodology using discourse analysis. A total of 234 parents of minors in Spain and several Spanish-speaking countries in America participated. The instrument was a questionnaire in Google Forms, which included the Kidscreen-27 quality of life scale. The results show significant differences in both the type of physical activity and its frequency due to age, and differences in parents’ perception of whether their children’s physical activity levels were sufficient or not, both on the health, mood and school subscales, and in the categorization of open responses referring to concerns due to the pandemic, analyzed with the ALCESTE technique. The relationship between physical activity of children and adolescents and quality of life is clearly concluded.

Introduction

At the end of December 2019, the first evidence appeared in Wuhan, China, that a new lethal viral disease had emerged, for which no vaccine or specific medication was available. In March the disease became a pandemic and a large majority of countries, either with specific regulations or through recommendations to the population, established confinement and social distance as the possible solution to prevent further spread of the disease, to avoid saturation of hospitals and curb the lethality of the virus. On March 10th, the global situation with regard to COVID-19 was 113,702 confirmed cases (4,125 new) and 4,012 deaths (203 new) ( World Health Organization [WHO], 2020a ). On December 29, the number of confirmed cases worldwide was to over 79 million, with a cumulative death toll of over 1.7 million ( World Health Organization [WHO], 2020b ).

In the field of Psychology, theoretical formulations have been made to explain the reasons why COVID-19 evolved so rapidly and was so widely spread. Urzúa et al. (2020) point out three factors: (a) illusory optimism; (b) inadequate perception of absence of contingencies produced by the population’s behavior; (c) optimistic risk perception. Vera-Villarroel (2020) has stated that physical and mental health are closely linked, and explains the expansion of the pandemic based on three psychological processes: cognitive, with the population having irrational beliefs about the disease and illusory optimism; emotional, with feelings such as fear, stress and anger; behavioral, with exposure and risk behaviors. The author points out that these factors must be considered in the intervention to save lives.

Several studies have shown the risk that social isolation caused by the pandemic implies not only for the most exposed groups (health workers), but also for the mental health of the general population. Problems of anxiety ( Chew et al., 2020 ; Holmes et al., 2020 ; Wang and Zhao, 2020 ), stress and psychological distress have been reported, both during and even after the biodisaster ( Liu D. et al., 2020 ). Along the same lines, the narrative review conducted by Huarcaya-Victoria (2020) points out three types of problems for the general population: health anxiety, depression and stress. Rajkumar (2020) groups the problems derived from the pandemic into four sections: general population, health workers, vulnerable people and therapeutic strategies and interventions. The author emphasizes the need to study the effect of the situation generated by the pandemic on children and adolescents.

A particularly vulnerable group in this whole situation is children and adolescents. Although results in children for Coronavirus-19 disease are still inconsistent. Changes produced in their environment since COVID-19, such as the restrictions that home isolation and not being able to access the main areas of socialization ( Socías et al., 2020 ), with risks such as stress from both them and their parents, since COVID-19 can cause psychological alterations in children such as those caused by other stressors ( Espada et al., 2020 ; Socías et al., 2020 ).

Certain factors can have effects not only during confinement but also afterward, such as the disappearance of healthy habits like attending classes, which have been replaced by unhealthy behaviors, such as sedentary lifestyles, inappropriate diets, excessive use of screens which can produce, in addition to weight gain, physical problems ( Brazendale et al., 2017 ; Wu et al., 2017 ). From this follows the importance of understanding the effects that a wide variety of personal and contextual factors ( Holgado-Tello et al., 2010 ) can have on children and adolescents and their interaction in the way they experience physical activity and sports during the pandemic situation. Other risks that have been highlighted, depending on age, include substance abuse, accommodation issues and overcrowding and change and disruption of social networks ( Holmes et al., 2020 ). It is expected that, after confinement, in most cases these problems will disappear ( Barlett et al., 2020 ), although some may persist after the situation generated by the pandemic has passed ( Espada et al., 2020 ). Space restrictions and not being able to go outside are especially important in childhood for the proper development of playing, which is essential for its maturation process ( García-Serrano and García-Fernández, 2015 ).

In view of the difficult situation experienced, the population has been provided with recommendations, some of which have been generated by institutions to support their citizens ( Socías et al., 2020 ). These guidelines have many points in common: maintaining routines, being active, supporting minors, carrying out social activities, in short, maintaining a normal life in safety ( Liu J. J. et al., 2020 ). The support of parents is important, who can strengthen family ties and meet the needs of children through appropriate parenting styles ( Wang et al., 2020 ). The need for physical exercise is also stressed ( Holmes et al., 2020 ; Mera-Mamián et al., 2020 ; Romero et al., 2020 ). Physical exercise plays a relevant role both on a physical level ( Vidarte Claros et al., 2011 ) and in mental processes ( Ramírez et al., 2004 ; Zhou et al., 2020 ) as well as on a psychological level ( Berger and Motl, 2000 ; Biddle and Mutrie, 2001 ; Tessier et al., 2007 ; Anderson and Brice, 2011 ). In particular, there is clear evidence of the contribution of physical activity to psychological well-being ( Molina-García et al., 2007 ; Jiménez et al., 2008 ; Romero et al., 2009 ; Fernández Ozcorta et al., 2015 ).

The relationship between physical activity and well-being linked to the quality of life has been the subject of multiple investigations in recent years, which have also emphasized its influence on the general health of the various sectors of the population ( Schwartzmann, 2003 ; Bize et al., 2007 ; Anokye et al., 2012 ). In particular, different studies have highlighted the association between high levels of physical activity, or the practice of sports, and the quality of life in children and adolescents ( Anokye et al., 2012 ; Marker et al., 2018 ; Luna et al., 2019 ).

Likewise, recent reviews of studies on interventions focused on the promotion of sports practices and their impact on issues such as mental health, self-esteem, anxiety levels, and perception of well-being in children and adolescents, underline the benefits of this kind of activities for the general health of this population in particular, showing that physical-sport education pilot programs might promoted significant improvements in specific indicators of subjective well-being and emotional intelligence of participating adolescents’ groups ( Bermejo-Cantarero et al., 2017 ; Luna et al., 2019 ).

The lack of physical activity is a widely reported public health problem ( Bermejo-Cantarero et al., 2017 ). For this reason, evaluation that focuses on the relationships between physical activity and health-related quality of life is an important focus of research in this field. On the other hand, there is little research aimed at exploring parents’ knowledge and perceptions of their children’s physical activity, their ideas about its importance and impact on the way they experience diverse dimensions of a stressful life ( Gallego-Méndez et al., 2020 ; Spinelli et al., 2020 ; Yarımkaya and Esentürk, 2020 ) particularly during the Coronavirus outbreak. Exploring these issues, including the different perspectives of persons involved in families’ life ( Izquierdo-Sotorrío et al., 2016 ), could help provide recommendations and support programs for parents to guide their children’s physical activity.

In the case of children and adolescents, physical activity has important benefits: it promotes growth and enhances both physical development ( Rosa et al., 2018 ) and psychomotor, cognitive and social development, and generally favors all body systems: metabolism of carbohydrates and lipids, control of blood pressure, decreases the risk of type 2 diabetes and improves body composition ( Camargo Lemos and Ortiz Dallos, 2010 ).

Physical activity also favors psychological factors: it helps to build a balanced self-concept and improves self-perception, mood, self-image, physical self-concept, perception of health and life satisfaction, and intellectual function ( Camargo Lemos and Ortiz Dallos, 2010 ; Reigal-Garrido et al., 2012 ; Rosa, 2015 ).

The home quarantine imposed by the COVID-19 may make physical activity more difficult, and as we have seen in the studies reviewed, this leads to a decline in the quality of life of children and adolescents. Quality of life (QoL) is understood as personal satisfaction (or dissatisfaction) with the cultural or intellectual conditions in which an individual lives. Health is one of the domains of quality of life, this domain comprises not only physical health but also psychological health, as well as the interaction that people have with others and with the community ( Ravens-Sieberer et al., 2005 ). For this research, we are interested in reviewing the quality of life, based on the assessment of the well-being perceived by parents.

Given that the collection of high quality data is a priority in order to understand the psychological effects that the quarantine may have produced in the population, and that there is an urgent need to discover, analyze and evaluate the psychological interventions that could alleviate the problems generated and minimize the risks that could occur in the mental health of society ( Holmes et al., 2020 ), the aim of this research is to analyze parents’ perceptions of their children’s quality of life in relation to observed physical activity in the conditions of staying in the housing due to the pandemic situation due to the COVID-19. It hypothesizes the existence of greater quality of life perceived by parents who consider their children to be sufficiently physically active.

In this sense, we try to find out if there is any difference in quality of life between children of different ages and sex in the conditions of staying in the housing due to the pandemic situation due to the COVID-19 as perceived by mothers and fathers. In addition, it is investigated whether the characteristics of the housing (the space) conditioned the perception of the parents about their children doing more or less physical activity, and whether there are differences between the age and the type of physical exercise done. It is also interesting to know the relationship between the level of physical activity and psychological well-being.

Materials and Methods

Methodology and design.

This is a non-experimental design. Mixed methodology was used (Mixed Methods Research, MMR; Johnson and Onwuegbuzie, 2004 ; Denscombe, 2008 ). The data was collected through a cross-sectional design with survey methodology, using an ex post facto design, and there are open questions that allow a qualitative analysis.

To determine the differences in physical activity, three independent variables were considered: age (children, adolescents), sex (male, female), as well as a third variable, grouping parents according to their opinion about the physical activity developed by their children in confinement (sufficient, insufficient). The dependent variables used has been the different scales that make up the KIDSCREEN test, which therefore requires multivariate analysis.

Participants

A total of 234 participants responded to the survey. The average age was 42.82 (SD = 7.10), with a range between 24 and 65. More mothers (203) than fathers (30) participated, and only one of the informants was guardian of the minors, relative in charge of the child. Table 1 presents the data regarding age (values corresponding to the percentiles 25, 50, 75, and over 75) and educational level. The procedure for selecting the sample was one of convenience.

Table 1. Parents’ age and educational level.

Parents and caregivers were asked to think of one of their children when answering the questionnaires. In this way, for the data analysis, they were grouped by the ages of the children, the largest group being children between 8 and 11 years old, 125 (52 female) and 109 adolescents between 12 and 17 (54 female).

The countries of origin of the participants were mainly Spain (134, 57.3%), and Mexico (86, 36.9%) and others American countries (Panamá, Colombia, Argentina, and Chile; 13, 5.8%).

Most families (230, 98.3%) reported not having been victims of the coronavirus. Only four families had a confirmed patient in the family unit, and in four other cases there was a suspicion that a family member had the disease.

In the questionnaire, a question was included about family and housing conditions. Most of the sample lived in the same dwelling with up to four family members (167, 71.4%), while it was less frequent for the family size to be greater than four (67, 28.6%). The average number of rooms, discounting common services, such as kitchen, living room and bathroom, was 3 (113 of the participants, 48.3%), with a range between 1 and 10 rooms. Most of the dwellings have at least one exterior space (177 of the participants, 75.6%).

Instruments

A questionnaire was designed to obtain data on parents’ perceptions of their children’s physical activity, some specific data on the type of housing during their child’s confinement. This questionnaire consists of 18 questions (15 closed, 3 open-ended) distributed in the following categories: (1) descriptive data of the participants (6 items); (2) family and housing conditions (5 items); (3) issues related to the situation produced by the COVID-19 pandemic (3 items); (4) complaints and needs caused by the situation produced by the COVID-19 pandemic (4 items) (see Supplementary Data Sheet 1 ). At the end of the questionnaire it was mentioned that if they wanted to ask for the results of the research they could leave their e-mail. All questions were marked as mandatory in the Google form, so there was no room for incomplete or missing data.

For the HRQoL measure, the Kidscreen-27 Parent Questionnaire ( Ravens-Sieberer et al., 2005 ). Spanish version was used, once the authorization for its use in this study was requested and obtained. This is a questionnaire that assesses health-related quality of life. This questionnaire was used because it provides a parameter to contrast the perception of psychological and health well-being in the child population with the physical activity observed by the parents. It consists of 27 items, which are answered in a Likert-type scale of five alternatives (from nothing to very much), structured in five scales: physical activity (4 items), mood (7 items), family life (7 items), friends (4 items), and school (4 items), and a single question about your child’s general state of health in the last week. The test is filled in by parents, for children and adolescents between the ages of 8 and 18. The original authors ( Ravens-Sieberer et al., 2005 ) offer evidence of the factorial validity of the test and its reliability in all the subscales of the test, in terms of internal consistency, with the total Cronbach’s Alpha value equal to 0.82. With our data, a similar Alpha of 0.831 has been obtained.

The questionnaires were assembled in electronic format with the Google Forms application. It was sent out by email and through social networks (Whatsapp, Facebook, and Twitter) to contacts in different educational associations, using the snowball technique. It was sent during the month of May 2020 (it can be defined as the first period of confinement). Only one of both parents was asked to answer the questionnaire with one of their children in mind (in case they have two or more), and who was in the age range of 8–17 years. The time required to fill in the questionnaire was 15 to 20 min.

At the time of data collection, all participants (regardless of country) were in the same conditions of confinement, leaving the home only for essential activities, with restrictions on going to school, physical activities or recreation outside the home.

As far as ethical aspects are concerned, the Commission on Ethics in Research and Animal Welfare of the University of La Laguna (CEIBA) was asked to authorize the study, which was granted (Registration Number: CEIBA2020-0396). In the questionnaire, the corresponding information for the participants was set out in the Organic Law 3/2018, of December 5th, on Personal Data Protection and guarantee of digital rights ( BOE, 2018 ), guaranteeing the anonymity and confidentiality of the data.

Data Analysis

The relationship between parental consideration of physical activity sufficiency and having or not having outdoor space in the home was calculated using the V of Cramer.

To check the absence of univariate outliers, we used Tukey’s test that takes as reference the difference in interquartile range, considering a slight outlier at 1.5 times this distance, and extreme when it is at three times that distance. To determine the existence of multivariate outliers, the Mahalanobis distance was calculated.

Regarding quality of life, it was analyzed in two ways taking three independent variables: age, sex and parents’ assessment. Since the quality of life variable, measured by Kidscreen, is split into several scales, it requires a multivariate approach, so three MANOVAs were carried out, one according to each independent variable studied. All quantitative analyses were conducted with the SPPS program, v.21.

For the qualitative analysis, the phenomenological discourse analysis method was used, which identifies the meanings of language, through lexical analysis using the ALCESTE software (in French: Analyse des Lexèmes Coocurrents dans les Enoncés Simples d’un Texte ) ( Reinert, 2003 ). This program facilitates the analysis of linguistic materials that generally arise in social research, such as answers to open-ended questions in questionnaires, in-depth interviews or answers based on projective techniques ( De Alba, 2004 ). The ALCESTE methodology consists of three stages: the construction of the data matrix, the classification of the context units (statements) and the description of the classes ( Gil et al., 1994 ). The methodology focuses on the statistical distribution of word succession, taking into account only the simultaneous presence of several words in the same statement. In this way, classes are identified as semantic fields, represented in trees or dendograms. In the ALCESTE method, the initial text is broken down into elementary contextual units (ECUs), which approximately match the size of a sentence.

The statistical analysis, although limited to explain in detail the meaning of a text, allows the elaboration of a “cartography” of the lexical worlds chosen by the speaker to express himself and, therefore, of the reference systems from which he constructs his way of seeing reality ( Gil et al., 1994 ; Reinert, 2003 ).

Quantitative Analysis

Physical activity.

In order to know if there is a relation between the participant’s perception of the sufficiency or not of the physical activity developed by his or her child and the space dedicated to exercises, these variables were analyzed, considering in the household conditions whether there was no outdoor space to carry out activities or if, on the contrary, there was. The results are shown in Table 2 . There is significant dependence between both variables (V of Cramer = 0.146; p = 0.026).

Table 2. Perception of adequacy of physical activity and space for it.

Elimination of Outsiders

Eleven extreme univariate cases were eliminated and none multivariate by Mahalanobis distance, with the criterion of probabilities less than 0.001.

Psychological Well-Being by Age and Sex

Most parents consider their child’s health to be excellent (88, 39.5%) or very good (114, 51.1%), while only 21 (9.4%) rate it as “fair.”

The group was divided into two ages: from 8 to 11 (children) and 12 and older (adolescents). Table 3 shows the descriptive statistics.

Table 3. Age and sex level descriptive statistics.

To know if there are differences by sex and age, a MANOVA was calculated, which was for sex (Wilk’s λ = 0.949, F 5 . 215 = 2.3, p = 0.046, Partial η 2 = 0.051), and for age (Wilk’s λ = 0.843, F 5 . 215 = 8.034, p = 0.001, Partial η 2 = 0.157) nor for interaction (Wilk’s λ = 0.982, F 5 . 215 = 0.796, p = 0.554, Partial η 2 = 0.018). Individual ANOVA results are only significant for the variable age in the health scale ( F 1 , 219 = 7.692, p = 0.006, Partial η 2 = 0.034), with a small effect size and in the friend one ( F 1 , 219 = 28.421, p < 0.001, Partial η 2 = 0.115), with a large effect size.

Physical Activity and Well-Being

In order to assess whether the children developed adequate physical activity, the parents were asked whether they considered it sufficient or insufficient. A total of 146 considered it to be insufficient and 77 sufficient. The informants were divided into two groups according to this variable and it was analyzed whether there were significant differences in their assessment of the psychological well-being of the children. Table 4 presents the mean values and standard deviations of each welfare scale.

Table 4. Descriptive statistics of physical activity and well-being.

The result of the MANOVA was significant (Wilk’s λ = 0.743, F 5 , 217 = 15.001, p < 0.001, Partial η 2 = 0.257). Individual ANOVA results are only significant for the health scale ( F 1 , 223 = 64.821, p < 0.001, Partial η 2 = 0.227), with a large effect size.

Qualitative Analysis

In order to find out the perceptions that families have regarding different aspects of stay-at-home confinement, both required by law and recommended, four open-ended questions were analyzed by ALCESTE, separating into two samples parents who considered that their children were getting enough exercise and those who thought it was insufficient: (a) Explain why you say you have sufficient or insufficient physical activity; (b) How did your child live it?; and (c) What or who does your child miss?

Analysis of the Question “Explain Why You Have Sufficient or Insufficient Physical Activity”

The analysis of ALCESTE, for the group of parents who consider that their children have sufficient physical activity (see Figure 1 ), the results are grouped into three classes, which explain 66% of textual units. The first class is linked to the link between the second and third classes. The most representative class is 1, as it groups the largest number of EUs. The details of the analysis, in terms of class name, UCEs grouped and percentage involved, most representative word and examples, are presented in Table 5 .

Figure 1. Dendogram corresponding to the question “Explain why you have sufficient physical activity.”

Table 5. Analysis of the question “Explain why you have sufficient or insufficient physical activity.”

The reasons given by parents for considering that their children could not get enough physical activity are more dispersed, as they have been grouped into six clases (see Figure 2 ). In this case, there are two groupings: on the one hand, class 2 connects with the union of classes 5 and 6, while class 1 connects with the link between classes 3 and 4. Classes 1, 5, and 6 are related to the impossibility of doing either exercise or sports that they did before the pandemic, while the difficulties of the other set of classes go in the direction of lack of space and the need to go outside.

Figure 2. Dendogram corresponding to the question “Explain why you have insufficient physical activity.”

Analysis of the Question “How Did Your Child Live Not Being Able to go Out on the Street?”

The analysis of the group that considers that their son or daughter has had enough activity explains 51% of the text corpus. The dendogram is shown in Figure 3 .

Figure 3. Dendogram of the question “How did your child live not being able to go outside?” Sufficient physical activity.

On the other hand, in the group of parents who consider the activity performed by their children insufficient, although it explains only 27% of the corpus, extracting only two classes ( Figure 4 ).

Figure 4. Dendogram of the question: “How did your child live not being able to go outside?” Insufficient physical activity.

Table 6 shows the detail of the classes, in terms of their name, number of UCEs they group, percentage of the corpus they explain and the most representative word, as well as representative examples of each class. In both groups, a distinction is made between positive aspects, of being at home, or pointing out some kind of problem.

Table 6. Information from the analysis to the question “How did your child live not being able to go out on the street?”

Analysis of the Question “What or Who Does Your Child Miss?”

The analysis of this question, for the group of parents who consider that the physical activity developed by their son or daughter is sufficient, gives two classes, which explain 65% of the textual units, that is, an average relevance of the treatment (see Figure 5 ). These are two antagonistic classes: the second is the one that groups the most textual units (71.70%), where it is clear that the child misses both the extended family and the people in his or her school environment. The first class includes those who responded that they have not missed anything or anyone and is quite homogeneous: they do not miss anyone (see Table 7 ).

Figure 5. Dendogram of the answers: What or who does your child miss? Sufficient physical activity.

Table 7. Information from the analysis to the question “What or who does your child miss?”

In the case of parents who feel that their son or daughter does not get enough physical activity, there are six classes, with a grouping of classes on a ladder: from class 1 to 4 are connected individually, linking class 5 with 6.

It explains 72% of the textual units, which means that the relevance of the treatment is high. They are presented in Figure 6 .

Figure 6. Dendogram of the answers: “What or who does your child miss?” Insufficient physical activity.

The first thing to note is that the data collection was done in the months of April and early May, at the time of the most severe confinement, as in Spain, Mexico, Panama, and Argentina ( BBC, 2020 ). It is true that the regulatory conditions regarding confinement have differed in the countries where the participants in this research live, in some cases, such as Spain, being obligatory by the State of Alarm, while in other countries governments strongly recommended avoiding going out and staying at home. This has meant 24-hour family life, with parents having to telework and children being taught online. The possibilities of exercising under these conditions have been very limited, which can have important effects on the psychological well-being of the minors.

As far as the health of their children is concerned, a large majority consider it to be good or very good. Furthermore, taking into account the five scales of quality of life in relation to age levels (children and adolescents), parents value the health of their children more the younger they are. In contrast, differences in contact with friends score higher for adolescents.

Parents’ perceptions of their children’s quality of life significant differences are observed with respect to sex at the global level, which is not maintained in the scales separately, but they do differ by age on two of the instrument’s scales: health, where younger children score higher, and friends, with the opposite result, as would be expected: adolescents score significantly higher on this scale.

Physical activity is conditioned by the type of housing. The results show that when there is no outdoor space to develop physical activity, parents find that exercise performed by their children is insufficient more often.

The objective of this study, to establish whether there is a relationship between physical activity and psychological quality of life in the conditions of confinement at home from the parents’ perspective, has been clearly corroborated, both in quantitative and qualitative analyses, finding differences between the two established groups of participants: those who considered that their children could develop sufficient physical exercise versus those who thought it was insufficient. Divergences are shown in both groups at the quantitative and qualitative levels.

With respect to the quality of life instrument, there are significant differences between the overall scores of the two groups; however, significant differences are only found in the health scale; when parents consider that the physical activity developed by their children is insufficient, lower scores are obtained in that scale. These results support the hypothesis of a positive relationship between quality of life and physical activity.

The differences found between the two groups of parents (those who consider their children’s physical activity sufficient and those who do not) in the quantitative analyses are also verified in the qualitative ones. The second group of parents shows more dispersion in the open responses given, as well as greater concern.

Thus, in the first open question analyzed qualitatively, “ Explain why you have sufficient or insufficient physical activity ,” the discourse of some parents differs significantly, as it is obvious, since the reasons they give for the physical activity done by their children being sufficient must be differentiated from those who consider it to be insufficient. In the latter, two perspectives are clearly distinguished in the two branches that appear in the dendogram: lack of space or impossibility of doing the exercise they would like to do. Moreover, it also confirms what has already been commented, that is, how there is a relationship between physical space and the facilities of households to exercise is related to the satisfaction or dissatisfaction with the physical activity performed by their children.

The second question, centered on their child’s experiences of not being able to go out, parents who feel their children have enough physical activity, report that their children experienced the lock down positively. On the other hand, in the other group there is a division of opinions: one part considers that their children lived the lock down without problems, but others think that their children lived it with stress, being this last one the most representative class. It confirms again a greater decline in the quality of life of their children for this group.

Finally, in the question relating to whether their child misses something or someone, there is greater variability among the children whose parents consider they do not have enough activity, since the answers are grouped together in one more class, where there is content where school life is missing.

The limitations of this work are about convenience samples, since there is no guarantee of absence of selection bias. However, having included several countries, all of them with a significant restriction on going out of the house, it gives indications of cross validity. This unusual development of the pandemic has evened out the differences between nations in a common struggle against an unprecedented biological crisis.

As far as the uncertainty of living under what has come to be called the new normality, together with the certainty that the threat of the pandemic is not over and that outbreaks, more or less virulent, may occur, it is particularly relevant to carry out research on mental health and psychological well-being, in order to be able to foresee more precisely the actions to be taken, knowing the dangers involved. Holmes et al. (2020) point out how important it is to accumulate experience based on the evidence that has provided the lessons learned so that those in power can coordinate measures that will damage the lives of citizens as little as possible, especially those who are most vulnerable. In this regard, since children are a vulnerable sector of the population, knowledge of their reactions and how they have been affected is particularly relevant. For future research, this could also include children’s self-report, comparing their perception with their mothers and fathers’s ( Izquierdo-Sotorrío et al., 2016 ). As a general recommendation in the light of the data collected, emphasizing the importance of exercise in guaranteeing the psychological well-being of minors is vital and must be conveyed to the population.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by The University of La Laguna’s Ethics Committee of Research and Animal Welfare has approved this research (Registration Number: CEIBA2020-0396). The patients/participants provided their written informed consent to participate in this study.

Author Contributions

ÁB, GL-A, MV, and DC-S had participated in theoretical review. ÁB, ER-N, GL-A, DC-S, and MV had participated in research design and instrument. ÁB had participated in the data analysis. ÁB, ER-N, GL-A, DC-S, and MV had participated in discussion. ÁB, ER-N, GL-A, DC-S, MV, and TA had participated in the study planning, writing, and revision of the article. All authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

The authors thank all the families that have participated in this research.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg.2021.649481/full#supplementary-material

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Keywords : home lock down, physical activity, quality of life, pandemic, mixed methods research

Citation: López-Aymes G, Valadez MD, Rodríguez-Naveiras E, Castellanos-Simons D, Aguirre T and Borges Á (2021) A Mixed Methods Research Study of Parental Perception of Physical Activity and Quality of Life of Children Under Home Lock Down in the COVID-19 Pandemic. Front. Psychol. 12:649481. doi: 10.3389/fpsyg.2021.649481

Received: 04 January 2021; Accepted: 16 February 2021; Published: 15 March 2021.

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Copyright © 2021 López-Aymes, Valadez, Rodríguez-Naveiras, Castellanos-Simons, Aguirre and Borges. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Elena Rodríguez-Naveiras, [email protected]

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• Open access
• Published: 29 May 2024

Evaluation of knowledge, attitude, practices and effectiveness of menstrual hygiene interventions in rural schools from Lilongwe, Malawi

• Russel Chidya 1 , 2 ,
• Olivia Kachuma 3 ,
• Tchaka Thole 3 ,
• Louis Banda 3 ,
• Mark Loewenberger 3 &
• Jennifer Nicholson 3  

BMC Public Health volume  24 , Article number:  1435 ( 2024 ) Cite this article

Metrics details

Menstrual hygiene management (MHM) is associated with the menstrual process in women and adolescent girls who face cultural and financial challenges in rural areas of many developing countries. As part of the pilot study, we assessed the sustainability and effectiveness of the approaches and lessons learned from the MHM project intervention in rural areas of Lilongwe, Malawi.

Rural primary schools ( n  = 4) were purposively selected where an MHM intervention was implemented in Lilongwe, Malawi. The study employed a mixed-method research design. Assessments and data collection were performed through surveys of learners, literature reviews, key informant interviews (KIIs) ( n  = 90), and 20 focus group discussions (FGDs). The study participants included boys and adolescent girls ( n  = 100, 11–19 years; grades 5–8), teachers, mother groups, and community leaders from the selected schools.

All the schools had water sanitation and hygiene facilities and latrines (45% improved, 54% ventilated improved pit latrines – VIPs) that promoted menstrual hygiene for adolescent girls. However, two of the schools studied (50%, n  = 4) did not have separate washrooms for changing sanitary materials. There was a slight increase in latrine coverage in Kabuthu zone communities (90% at baseline versus 93.4% at midterm). However, the coverage dropped to 85.7% at the final evaluation, which was attributed to too much rain received in the area that damaged most of the latrines. There was a significant reduction ( p  < 0.05) in the number of girls failing to attend classes due to menstruation (70% at baseline versus 14% at final evaluation). Furthermore, the project resulted in the majority of girls (94.4%) having access to school. There was a strong uptake and adoption of sanitary products (reusable pads and menstrual cups) among adolescent girls of all age groups. The study has demonstrated that the inclusion of key stakeholders such as health workers, parents, mother groups and community leaders promoted the uptake and sustainability of reusable pads and menstrual cups and MHM interventions and programs.

The MHM project implementation improved adolescent girls’ education in the area. The inclusion of boys and other key stakeholders in the health education talks addressed issues of stigma and discrimination. The study, therefore, calls for comprehensive training on MHM and hygiene education to remove discrimination and harmful cultural practices.

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Introduction

Background information.

Women and girls, especially from developing countries, are faced with problems in managing their menstruation as a result of cultural taboos, lack of knowledge, inadequate access to safe and secure water, sanitation, hygiene (WASH) services, and lack of affordable menstrual products [ 1 , 2 ]. According to WHO/UNICEF, menstrual hygiene management (MHM) is simply defined as the management of hygiene associated with the menstrual process. Furthermore, adequate MHM is ‘ access to clean absorbents including sufficient washing, drying, storage and wrapping of reusable absorbents; adequate frequency of absorbent change; washing the body with soap and water; adequate disposal facilities; privacy for managing menstruation; and basic understanding of menstruation and how to manage it with dignity and without fear or embarrassment’ [ 1 , 3 ]. The concept of MHM has been expanded to menstrual health and hygiene (MHH) to encompass the sociocultural and economic elements that influence the menstrual management of women and girls [ 3 , 4 ].

The provision of adequate MHH among girls and women is reported to contribute to the attainment of Sustainable Development Goals (SDGs) for good health (SDG 3), education (SDG 4), gender equality (SDG 5), and clean water and sanitation (SDG 6) [ 3 ]. However, many girls and women in low- and middle-income countries (LMICs) do not have adequate MHH services [ 3 , 4 ]. Access to WASH services for MHM and MHH must be considered a basic right of girls and women to lessen gender discrepancies in education, health and sociopolitical and economic participation [ 4 , 5 ]. Previous studies in Sub-Saharan Africa and elsewhere have shown that WASH interventions through the provision of sanitary materials, water, soap and privacy keep girls in school and have a mixed impact on school absenteeism and performance [ 6 , 7 , 8 ]. In Malawi, various institutional/legal frameworks and strategies on gender equality, the empowerment of women and girls and human dignity are employed by several key stakeholders and organizations. For example, the Canadian Physicians for Aid & Relief (CPAR) Malawi implemented an MHM project intervention in Lilongwe rural schools aligned with Global Affairs Canada’s Feminist International Assistance Policy (FIAP). Furthermore, the MHM project implementation is in line with the National Gender Policy (2015), which aims to increase advocacy for girls’ and boys’ conducive learning environment, and Malawi 2063, which stresses the need to reinforce the gender equality and empowerment of women and girls to shape their decisions at the household, community and national levels.

Malawi has approximately 50.7% of its population living below the poverty line and approximately 25% living in poverty, especially in rural areas [ 3 ]. Poverty is exacerbated by low educational outcomes, including failure to complete primary schooling, especially among girls and women in rural areas. As girls start menses, they begin to miss school activities to the point where they drop out of school entirely, jeopardizing their ability to contribute more effectively to their own and their families’ social and economic well-being. A study conducted under the Malawi Red Cross showed that girls in their menses had a significantly higher level of knowledge compared to boys, and knowledge in girls was associated with better MHM practices and with reduced absenteeism [ 9 ]. A study conducted in seven schools in and around Lilongwe, Malawi by WaterAid in 2021 concluded 3 recurring issues impacting MHM for adolescent girls: (a) cultural around menstruation – menstruation being seen as strictly secret, and parents do not talk to children about it; (b) ignorance about menstrual issues being prevalent among schoolgirls and in their communities; and (c) inadequate WASH facilities and infrastructure in visited schools. Several projects and interventions on MHM and MHH have been implemented in rural Malawi to address such issues and challenges [ 8 , 9 , 10 ].

Context of the study

Several studies on linkages between menstruation and school absenteeism have been widely conducted in Africa and elsewhere [ 8 , 11 , 12 , 13 ]. An earlier study by Grant et al. [ 14 ] on menstruation and absenteeism in rural Malawi noted several factors contributing to menstruation-related absenteeism. This included lack of school toilet privacy, lack of education by family and teachers on puberty and MHM, and physical menstrual discomfort. In the same study, long distances between home and school also prevented girls from going back and forth, hence contributing to absenteeism [ 14 ]. Such barriers and challenges significantly disrupt girls’ education and development, which later leads to ripple effects. There are no recent disaggregated data on school drop-out rates in Malawi [ 9 ]. However, UNICEF Malawi gathered significant anecdotal evidence that girls stay home while menstruating [ 10 ].

Menstrual cup promotion has been promoted among university girls at Mzuzu University in Malawi [ 10 ]. Although the project was successful, a small sample size (10 women) was used. Furthermore, the project did not target girls below university age, and there was no follow-up program. Many MHM projects in Malawi have focused simply on providing menstrual products and some WASH activities [ 8 , 9 , 10 ]. This addresses immediate short-term needs but does not incorporate the approach needed to promote sustainable change. The CPAR MHM project implemented an innovative MHM project in rural Lilongwe through a participatory approach by testing and promoting the use of menstrual cups and reusable pads alongside MHM behavior change interventions. The current study on MHM and MHH, therefore, provides a significant opportunity for knowledge sharing among WASH practitioners, education, and health promoters in the country. This study, therefore, assessed the sustainability and effectiveness of the approaches and lessons learned from the CPAR MHM/MHH project intervention for scaling up and replicability in other rural areas in Malawi and elsewhere. It aimed to evaluate knowledge, attitudes, and practices among learners, teachers and community members and the effectiveness and sustainability of menstrual hygiene interventions in rural schools from Traditional Authority (TA) Kabudula in Lilongwe, Malawi. The study aimed to achieve the following specific objectives: (a) to evaluate availability and access to water and sanitation facilities, menstrual products, and menstruation management among adolescent girls; (b) to assess the knowledge, attitude, and practices regarding MHM among learners (girls and boys), teachers and community members in the study area; (c) to assess the project intervention on feasibility, acceptability, and changes in menstruation-related knowledge, practices, perceptions, and self-reported school absenteeism from baseline to end line among girls; and (d) to determine the sustainability, replicability and scalability of the MHM interventions in rural schools from Malawi and elsewhere.

Theoretical framework of the study

This study is grounded on a general hypothesis that the inability of girls up to the age of 18 to effectively manage their menstrual health is a significant cause of absenteeism and school dropout and that the use of menstrual cups and/or reusable sanitary pads improves girls’ menstrual health management and reduces absenteeism and dropout rates. The implementation of the MHM project was centered on gender-based analysis (GBA). The GBA underpins an understanding that health variances between boys (or men) and girls (or women) can be related to the various roles and responsibilities that culture assigns to them. This study employed the “ Theory of Change ” ( ToC ) approach to evaluate the knowledge, attitudes, and practices among learners, teachers and community members and the effectiveness of menstrual hygiene interventions in rural schools from the study area. Furthermore, the study used the “ Theory of Planned Behavior ” (TPB) [ 15 ]. The ToC is a theory that gives a detailed description and illustration of how and why the desired change is expected to happen in a particular situation [ 16 ]. It explains how activities are understood to contribute to a series of results that produce the final intended impacts. The TPB depicts that human action is influenced by three major factors: a favorable or unfavorable evaluation of the behavior, perceived social pressure to perform or not perform the behavior, and perceived capability to perform the behavior [ 15 ].

Methodology

Study setting and mhm interventions.

This study was conducted in Lilongwe District located in the central region (Fig.  1 ). It is the capital city of Malawi, which stands at an altitude of 1,050 m. Specifically, the study was conducted in TA Kabudula under the Kabuthu education zone where rural primary schools ( n  = 4), namely, Kabuthu, Milala, Kamphelatsoka, and Chifeni, were selected. The schools under study were purposively selected based on the implementation of the MHM project by CPAR. The rural locations were initially identified by CPAR’s Rapid Gender Analysis (RGS) (September 2021) and more in-depth GBA (December 2021). The two analyses showed traditional and cultural beliefs being more ingrained, less available menstrual products and unaffordable, and having fewer opportunities to acquire information to dispel misconceptions and ignorance regarding MHM. The CPAR MHM/MHH project interventions implemented in the area included training and provision of menstrual cups and sanitary pads to adolescent girls from the four schools. Furthermore, the project involved MHM education, awareness campaigns and capacity building among adolescent boys, teachers, mother groups, girls’ councilors, traditional leaders, school and health management committees; parents and community members.

Source Authors

Map of Lilongwe showing the study area.

Study design, methods, and data collection tools

In July and August 2023, we implemented a mixed-methods research design where both quantitative and qualitative data were collected. Quantitative assessment was performed through school and household surveys. Quantitative data were collected through surveys of learners in the 4 selected schools, while qualitative data were collected using direct observations, key informant interviews (KIIs) or in-depth interviews (IDIs) and focus group discussions (FGDs). A literature review of project documents (baseline, midterm, and end-line progress reports) was made. Furthermore, community-level knowledge-sharing workshop reports and other related MHM/MHH project documents were reviewed and analyzed. The girl’s MHM questionnaire, boys’ FGD guide, household MHM questionnaire, and mother group’s FGD guide were prepared and implemented.

Participants, sample size and inclusion criteria

The study participants included adolescent boys and girls (11–19 years; grades 5–8), Teachers/Head Teachers, Mother Group members, Girls Councilors, Parent-Teacher Association (PTA), Chiefs/GVH, School Management Committees (SMCs), and Community Health Committees. We purposively selected and surveyed a total of 100 adolescents girls at the menarche stage to understand their level of knowledge, adoption, uptake and impact of the MHM interventions. Next, a total of 90 households where the adolescents came from were engaged in interviews to sort their understanding and support of the MHM to their adolescent girls. The study targeted households (HH) with adolescent girls only because of their experience in managing girls during menstruation. Due to the scarcity of such types of households, the study targeted the nearest HHs with such girls. In addition, 8 FGDs, 4 KIIs and 1 survey with boys on myths and misconceptions were conducted in each of the four schools. A total of 20 FGDs were conducted in all the schools, with groups of 5–10 people purposively selected for their first-hand information. Discussions were centered on selected topics specifically on WASH and menstruation while allowing for interesting, new, or unplanned follow-up questions to be asked. Concurrently, direct observation was used to confirm or triangulate the information given through the questionnaire survey and photographic pictures.

The sample size and distribution of participants are summarized and presented in Table  1 . The study used convenience and purposive sampling to identify study participants, namely, teachers, mother group members, PTAs, chiefs, health center management groups, youth groups, and parents. Participants who had stayed in the area for at least 6 months and/or were involved in the MHM/MHH interventions were engaged. To validate the quantitative data, KIIs targeting key districts and community-level informants connected to adolescent girls were employed. Furthermore, the study participants were selected using the inclusion and exclusion criteria summarized in Table  2 . Android tablets programmed in mWater were used for data collection to minimize errors since the program was developed with built-in data validation, skip rules, and constraints in the questionnaire.

Data management and statistical analysis

The qualitative data were analyzed manually through content analysis to contextualize quantitative findings. First, the qualitative data were entered into Microsoft Excel and Word for transcription, translation and cleaning. Preliminary reading of all reports was performed to identify initial key issues. All three approaches to qualitative content analysis as outlined in [ 17 ] were employed. The study assessed the MHM/MHH project intervention uptake and impact by computing prevalence differences at 95% confidence intervals using fixed-effects logistic regression. To ensure the validity and reliability of the results, the authenticity of statements and information received were verified with experts and stakeholders in the area. Furthermore, all the data collection tools were piloted and pretested for their efficiency and correctness before the actual data collection.

Ethical consideration

Ethical approval.

To conduct this study, ethical approval was obtained from the Mzuzu University Research Ethics Committee (MZUNIREC) (Ref. No. MZUNIREC/DOR/23/95). During the implementation of the MHM/MHH interventions in the area, permission and partnerships were made with all relevant government offices, including Ministries of Health, Education, and Community Health Centers outreach clinics. Confidentiality was followed, and instead of names, identification codes were used for analysis purposes. A written informed consent form was signed or thumb printed before any form of data collection. For adolescent boys and girls under 18, written informed assent was obtained from their parents, guardians, or teachers. The adolescent boys and girls aged 18 and above provided consent to take part in the interventions and study.

Access to water and sanitation facilities in schools and at home

The study findings showed that all schools had latrines (45% improved, and 54% ventilated improved pit latrines – VIPs, n  = 4). Despite having separate latrines for boys and girls, all the schools lacked handwashing facilities. As an alternative, schools drew water using basins and buckets and provided it to the students by placing them in front of classrooms for easy access. Although water was available for the students, no soap was provided for cleaning and handwashing. During midterm evaluation, it was noted that the Milala school had no water source following the theft of a pump and vandalized boreholes. At this school, students reportedly carried some water in small bottles to cater to all basic sanitation needs. Only the Milala and Kampheratsoka schools had separate washrooms for changing sanitary materials for adolescent girls. Coupled with the unavailability of water and soap in the washrooms and latrines, the study noted that adolescent girls had challenges cleaning themselves at school. However, this circumstance did not pose a significant impact ( p  < 0.05) on school attendance among the girls, as depicted by improved school attendance during the reporting period.

In communities surrounding the schools

The results showed that there was a significant variation ( p  > 0.05) in access to latrines in the communities surrounding the schools (Fig.  2 ). There was a slight increase in latrine coverage in the Kabuthu zone (90% at baseline (BL) versus 93.4% at midterm evaluation (MTE), n  = 4). However, the coverage dropped to 85.7% at the final evaluation (FE). During the final evaluation, the majority of people used traditional latrines (84.4%) (Fig.  3 ). Conversely, there was a moderate increase (11 to 36.4%) in the presence of hand-washing facilities in homes around the schools (Fig.  3 ). The increase was attributed to the engagement meetings where parents were urged to ensure girls had access to sanitation facilities at home. Improved access to water resulted in adolescent girls being able to clean up and maintain hygiene during menstruation.

Access to latrines in the communities surrounding the schools in the study area

Type of latrine ( a ) and hand-washing facilities ( b ) used in surrounding communities

Absenteeism from primary school

Girls missing out on classes because of menstruation.

The study showed a significant reduction ( p  < 0.05) in the number of girls failing to attend classes due to menstruation from 70% at baseline to 21% at midterm and 14% at the final evaluation. All the girls interviewed (100%, n  = 90) felt comfortable using sanitary products, hence resulting in girls having more classroom learning time, similar to their male counterparts. Furthermore, the FGDs conducted with both teachers and parents revealed that there had been an improvement in the performance of girls during the project compared to the pre-project period. Despite helping reduce absenteeism, the improved availability of menstrual services in the area were noted to bring enormous positive impact and reduction in stigma and discrimination against girls.

Number of days girls missed classes due to menstruation

The number of girls who missed classes and stayed away from school due to monthly periods of less than 3 days, 3 to 5 days and more than 5 days decreased significantly. The girls who missed classes for less than 3 days because of monthly periods reduced from 18 to 8%, while for 3 to 5 days, there was a significant reduction from 63 to 6% ( p  < 0.05). For girls missing classes for more than 5 days, the number reduced to 0% because of the availability of sanitary pads and menstrual cups that helped them manage their menses well. The reduction in the number of days girls stay away from school has had a positive change in school academic performance comparable to that of boys, owing to the availability of MHM services and products.

Improved access to schooling as a result of MHM support

Percentage of girls accessing improved education.

The majority of girls who participated in the program (94.4%, n  = 100) reported improved access to school as a result of overall MHM support provided during the project implementation (Fig.  4 ). Many adolescent girls sampled (83.2%, n  = 100) reported having used reusable sanitary materials compared to baseline findings where only 10% had access and used the same. Similarly, a considerable number of adolescent girls (70%) reportedly used menstrual cups. Thus, the increase in the percentage of girls accessing improved education was attributed to the availability and usage of sanitary pads and menstrual cups, hence resulting in reduced absenteeism. On average, each adolescent girl was reported to have a minimum of 5 reusable sanitary pads and 1 menstrual cup. In addition, the increase in the number of girls accessing improved education was attributed to awareness of menstrual hygiene among boys who stopped bullying girls when in menses. The awareness focused on myths and misconceptions related to MHM as well as the negative impacts of bullying that result in girls staying away from school or completely dropping out.

Percentage of girls accessing improved education after the project intervention

Number of learners comfortable attending school during menstruation

With the MHM project’s interventions, the majority of girl learners (97%, n  = 100) became more comfortable attending school during menstruation compared to the pre-project period (Fig.  5 ). This is an improvement from 26% at baseline to 79.2% during the mid-term evaluation. The girls felt comfortable because they had sanitary pads and menstrual cups that prevented them from messing up during menstruation, hence reducing absenteeism and dropping out. The results from the interviews with girl counselor teachers confirmed that the schools had reusable sanitary pads ready for girls who reached puberty and started menstruation. There was a strong adoption of sanitary products among all age groups, with 99% and 94% coverage for girls aged 10 to 14 and 15 to 18 years, respectively.

Percentage of girl learners comfortable attending school during menstruation

Use of reusable pads and menstrual cups

There was an increase in the number of girls ( n  = 100) using reusable pads (83.2%) compared to menstrual cups (70%). This is because the latter was introduced by the project lately, while the former was fairly being used by some of the students before the project. Furthermore, reusable sanitary pads were fairly cheaper and locally made compared to menstrual cups (Table  3 ). Analysis by schools showed that Milala (100%) was the best to use menstrual cups compared to Chifeni (32%). This was mainly because the large cup sizes purportedly caused pain to young adolescent girls at Chifeni. Chifeni School had younger adolescent girls who participated in the interventions compared to Milala School. The majority of girls (82%) preferred reusable sanitary pads over menstrual cups (Fig.  6 ). Very few girls (18%) reported using menstrual cups exclusively for several reasons, such as pain and difficulty to wear. Furthermore, it was revealed that some girls indicated that the cups were large. Through the provision of sewing machines and pad fabrication training, skills and knowledge were gained by women and adolescent girls to produce pads packaged as part of the MHM kit for girls who had just started their menses. Such an initiative was highlighted by both teachers and community members as a success and the project’s sustainability strategy.

Girls’ preference between reusable sanitary pads and menstrual cups

The majority of girls (60%, n  = 145) trained in the fabrication of reusable sanitary pads were actively involved in continuous production, surpassing the project target of 20%. Interestingly, the girls in the age group of 10–14 years scored the highest (99%) in fabricating reusable sanitary pads. Furthermore, the key informant interviews with mother group members, teachers and local leadership showed that mother group members were highly involved in the fabrication of reusable sanitary pads and training other learners, hence representing a great sign of sustainability. During health education talks and parent engagement meetings, men and boys were deliberately included to improve their knowledge and perceptions toward MHM. A total of 458 men and boys (10–14 years, n  = 187; 15–18 years, n  = 241 and 19 above, n  = 30) were reached during the MHM health talks and a quiz on myths and misconceptions. A total of 144 boys out of 180 managed to score 75% above, representing 80%, a percentage slightly higher than the midterm score of 45.2%.

Improved knowledge and attitudes toward the application of MHM solutions

Parents and community members.

The percentage of parents that encourage girls to attend primary school even during periods of menstruation was evaluated and disaggregated. This was done to assess their level of knowledge and support given to adolescent girls during the monthly periods. In the final evaluation of the project, the results showed that the majority of the parents (64%) encouraged their daughters to attend school even during monthly periods. This was significantly higher than the midterm (46%) and baseline evaluations (8%). After implementation of the MHM interventions, the majority of the parents and community members (62.3%, n  = 90) were comfortable with the menstrual products used by their daughters.

Boys and men

After MHM interventions and awareness campaigns, many boys gained knowledge about menstruation, especially myths and misconceptions. For example, approximately 80% of the boys trained on MHM were able to score above 75% in the post training quizzes compared to 45% during midterm and 0% during baseline. This is an indication of the absorption of knowledge on MHM. In addition, there were no fathers who felt that discussing issues of menstruation with their children was taboo and against cultural beliefs, with 2.40% at baseline, 1.3% at midterm to 0% at final evaluation. Furthermore, there was a significant difference ( p  < 0.05) in the reaction and attitudes of male parents responding to questions about the menstrual issues of their daughters between the baseline and the final evaluation assessments.

Availability of wash facilities in schools and surrounding communities

The four schools involved in our study had latrines separate for girls and boys (45% improved, 54% ventilated improved pit latrines – VIPs). However, these schools lacked handwashing facilities and soap for cleaning and handwashing. This is a problem considering that adolescent girls undergoing menstruation require handwashing facilities and soap for sanitary purposes. Correspondingly, two schools namely Chifeni and Kabuthu did not have separate washrooms for changing sanitary materials, hence depriving them of their privacy and dignity during menstruation. Similar results on the lack of washrooms for changing sanitary materials and poor access to clean water, sanitation and hygiene facilities have been reported in Malawi and elsewhere [ 8 , 18 ]. The lack of latrines both at school and at home has been reported widely in the literature to pose negative impacts on menstrual health for adolescent girls [ 2 , 13 , 19 ]. Furthermore, the absence of proper latrines both in schools and homes has globally been reported to deprive adolescent girls of privacy, safety and dignity to change used menstrual materials within the household in Zambia and Kenya [ 11 , 20 ]. The decrease in the latrine coverage from 90 to 85.7% at the final evaluation in Kabuthu zone (Chifeni school communities) was attributed to too much rain received in the area, which damaged most of the latrines constructed using unburnt bricks and mud. Although the schools are found within the same geographical area, Milala School communities did not receive too much rain naturally, hence managed to maintain their latrine coverage both at the project midterm and final evaluation (90.9%).

Absenteeism from school

The reduction in the number of girls failing to attend classes due to menstruation was attributed to the availability of reusable sanitary pads and menstrual cups provided during the MHM project implementation. During the study girls confessed that the pads and the cups gave them freedom and dignity to attend school even during monthly periods. The positive association between retention of girls and the implementation of MHM education talks, parent engagement meetings, and provision of sanitary pads and menstrual cups showed that the MHM interventions were successful. Generally, the tendency of girls to miss classes was attributed to menstrual-related health problems. The lack of medication for managing menstrual-related health problems (such as abdominal cramps, headaches, and backache) for adolescent girls was attributed to a lack of funding and poverty levels.

MHM products and training provided in project schools

The current study noted the need to procure age-specific menstrual cups to match the young adolescent age ranges that were prevalent at Chifeni School. The differences in adoption of MHM products among schools were attributed to opposing preferences and attitudes toward menstrual cups, hence a need for more awareness of the utilization of menstrual cups. Varied adoption and use of menstrual cups and reusable pads by adolescent girls have been reported in many countries, including rural Nepal [ 21 ], rural western Kenya [ 18 ], and in rural schools of Zambia [ 11 ]. In this study, at the time of the assessment, the project had made available a total of 3084 reusable pads and 580 cups. A total of 1534 reusable pads were locally produced by mother group members and students, while 1550 pads were procured and distributed to students. Conversely, a total of 580 menstrual cups were distributed to 366 adolescent girls, 23 mother group members, 35 female teachers, and 156 women from the community. Through the provision of reusable sanitary pads and menstrual cups in the four schools, the endline survey results showed a positive adoption and usage of the distributed reusable sanitary pads and menstrual cups. Generally, there was increased participation in reusable pad fabrication by students and mother group members in project schools and the community. The enormous leap in availability and usage of reusable sanitary pads after project implementation was attributed to the provision of reusable sanitary pads and training on the fabrication of pads conducted on 145 adolescent girls (representing 39% of adolescent girls in the Kabuthu education zone) and 30 mother group members from the four primary schools studied. Similar findings on MHM among women and girls in Malawi noted that the use of disposable pads was favored by most girls who participated in the study [ 8 ]. Conversely, studies conducted elsewhere showed that rural and poor women and girls resort to using old clothes for menstruation rather than menstrual cups and reusable sanitary pads due to their poor economic status, availability on the local market, cultural acceptability and personal preferences, among others [ 11 , 22 , 23 , 24 , 25 , 26 ]. The use of unsuitable and unhygienic menstrual products is reported to increase rates of pelvic pain, lower genital tract infections, and inflammatory conditions, further exacerbating absenteeism [ 10 ].

To ensure the sustainability of the MHM interventions in the study area, there is a need to make the menstrual products available on the local market. Furthermore, the project implementers and key stakeholders in the area should consider subsidizing menstrual products so that adolescent girls and women can afford to purchase them. Some scholars and previous researchers have advocated for all-inclusive sanitation and hygiene education in schools [ 8 , 27 , 28 ], and this is the same recommendation in the study area and elsewhere in the country and beyond. Thus, there is a need for comprehensive training on MHM and hygiene education so that all groups (boys, girls, women and men) fully understand and remove discrimination and harmful cultural practices.

Knowledge and MHM solutions for community leaders and health workers

The current study showed limited knowledge and understanding of MHM and menstruation by all study participants before MHM education implementation. Similar studies on limited knowledge of MHM by boys and men have been reported in Zambia [ 11 ] and in India [ 29 ]. However, after MHM project implementation in Kabuthu education zone in Lilongwe, the study demonstrated that MHM education talks and parent engagement meetings played a major role in the improved retention of girls throughout the project lifetime in the Kabuthu education zone. The comfortability of parents and community members with the menstrual products used by their daughters was attributed to increased awareness campaigns and engagement meetings, where information on proper MHM was shared. Such efforts and campaigns changed the attitude of parents toward the use of improved menstrual materials as well as offering MHM support to girls. Furthermore, community leaders and members hailed the MHM project for challenging harmful cultural norms that projected MHM talks to be feminine and taboo. There were 8 community engagement meetings conducted in all the schools (2 per school) where both men ( n  = 240) and women ( n  = 461) participated. The leaflets (400) and posters (32) distributed in the four schools played a crucial role in raising MHM awareness among adolescent girls and community members. Although the project engaged a few healthcare workers (35%, n  = 20) in facilitating MHM health talks and menstrual cup orientation, the impact was statistically significant ( p  < 0.05). Regarding the perception and knowledge of men and boys in MHM, deliberate efforts made to engage men and boys in addressing menstrual-related challenges such as stigma and bullying adolescent girls at school showed positive results. From the study findings, it is indeed vital that crucial stakeholders such as community members and health workers, parents and community leaders, among others, are included in MHM interventions and programs for sustainability. Such multistakeholder engagement and inclusion also ensure that MHM interventions are monitored and supported even when the project is finished [ 8 ].

Lessons learned and upscaling of the MHM elsewhere

The study has shown that during the implementation of the MHM project, several risks and challenges were encountered. These included cultural resistance to innovation adoption, especially menstrual cups; inflation (adjustment of all the planned activities); COVID-19 lockdowns and restrictions, limited access to MHM products (cups, reusable pad components); cholera outbreaks; and uncertainty of sustainability of the MHM products. To mitigate cultural resistance, the gatekeepers and all key communities and stakeholders were engaged through meetings and the adoption of engagement information, training, and constant impact monitoring of the project in communities surrounding the 4 schools. Several activities were implemented during the same field trip to reduce travel costs and other logistics. During the cholera outbreak, community members surrounding the schools and all members of the school community (learners and teachers) were sensitized to take precautionary measures on how to prevent cholera and to rush to the nearest health facilities in case of cholera cases. On the sustainability of the innovation, the mother group members were sensitized to continue producing the reusable pads and selling the extra ones to the community members so that they would be able to continue buying materials for sewing.

Other lessons learned during the implementation of the MHM in the study area showed that the inclusion and involvement of female teachers and other key stakeholders (mother groups and health officers) during MHM training increased ownership of the project interventions. On the one hand, the presence of female teachers as stakeholders made it easier to manage the delivery of MHM services, including health education. Furthermore, the inclusion of female teachers in the MHM solutions brought girls closer to their teachers and eventually opened up issues of menstruation. On the other hand, the inclusion of boys in the health education talks addressed issues of stigma and discrimination. This allowed for a holistic approach to MHM and helped the boys to better understand issues of MHM, hence support adolescent girls well.

The gender analysis revealed gender gaps in the Kabuthu education zone that exacerbated school absenteeism and dropout among girls. Menstruation was singled out as the main driver of school absenteeism and dropout among adolescent girls. Contributing to challenges of menstruation were cultural and traditional norms related to menstruation, lack of proper and adequate menstrual knowledge and products among girls and communities, lack of adequate female teachers to act as mentors and role models, and stigma and ignorance perpetuating bullying toward adolescent girls. Gratefully, the MHM project addressed these challenges to ensure equitable access to educational learning outcomes for both boys and girls and reduced school absenteeism and dropout related to menstruation among adolescent girls in the Kabuthu education zone. Such lessons learned can be implemented anywhere in Malawi and beyond. To ensure the sustainability and proper promotion of MHM products and hygiene education in the country, the Malawi Government is developing standard protocols, guidelines, and implementation strategies. The ongoing revised National Sanitation and Hygiene Policy (2024) and National Sanitation and Hygiene Strategy (2018–2024) aim to promote user-friendly sanitation and hygiene facilities; establishment of gender equality and social inclusion (GESI) in menstrual health and hygiene management in all sectors; and waste management and MHM in all schools and facilities. The established policy and strategies on sanitation and hygiene in Malawi will ensure that MHM is regulated and provide guidance for decision-making and that menstrual products and services are moderated and accepted for promotion.

Conclusion and recommendations

This study has confirmed that access to sanitary products in schools and at home is crucial for menstrual hygiene and reducing absenteeism for adolescent girls in Malawi. Some schools did not have separate washrooms for changing sanitary materials for adolescent girls. Furthermore, the use of unburnt bricks and nondurable materials was found to compromise the durability of latrines. The results suggest that there is a need for the construction of girl-friendly and durable WASH facilities and washrooms. Following MHM interventions and implementation, the study has shown a significant reduction in girls who missed classes. The awareness and involvement of boys, men and other community leaders and healthcare workers removed the myths and misconceptions related to menstrual hygiene and the impacts of bullying that result in girls staying away from school or completely dropping out. The study, therefore, calls for comprehensive training on MHM and hygiene education so that all groups (boys, girls, women and men) can remove discrimination and harmful cultural practices. Additionally, the study has shown that key stakeholders such as community members and healthcare workers, parents, mother groups and community leaders must be included to promote the uptake and sustainability of reusable pads and menstrual cups and MHM interventions and programs in general. Further areas of research would include longer-term evaluation of the impact and sustainability of the MHM project to support the observations of this study. Key areas would include assessment of continued access and use of menstrual health products, community involvement and impact on girls’ level of education.

Data availability

Useful data are presented in Tables and charts in the report. Additional datasets and files for the study are available from the corresponding author upon request.

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Acknowledgements

We thank teachers, mother groups, head teachers, girls, boys, and their parents for their participation in this study. We are grateful to field and office staff, community leaders and healthcare workers for their support during project implementation and study. Furthermore, we thank the Canadian Physician for Aid and Relief (CPAR), Fund for Innovation and Transformation (FIT), Global Affairs Canada (GAC), and ICN for providing funding for an independent study and assessment of the project implementation.

This study is part of the project “Freedom to Learn for Girls in Rural Malawi – Addressing the Menstruation Barrier” implemented in Lilongwe District, Malawi. The authors are grateful to Canadian Physician for Aid and Relief (CPAR), Fund for Innovation and Transformation (FIT), Global Affairs Canada (GAC), and ICN for the financial support of the study. Funders had no direct role in the study design, data collection, analysis or preparation of the manuscript.

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RC and OK conceptualized and drafted the paper; OK, TT, and LB supported data collection; RC and OK processed and analyzed the data. OK, TT, LB, JN and ML provided technical advice on reusable pads and menstrual cups and manuscript writing. All authors reviewed the manuscript.

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Ethical approval to conduct the study was provided by the Mzuzu University Research Ethics Committee (MZUNIREC) (Ref No. MZUNIREC/DOR/23/95). Further engagement and permission were sought from government authorities. Confidentiality was considered, and a written informed consent form was signed or thumb printed during data collection. For boys and adolescent girls under 18, written informed assent was obtained from their parents, guardians, or teachers.

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Chidya, R., Kachuma, O., Thole, T. et al. Evaluation of knowledge, attitude, practices and effectiveness of menstrual hygiene interventions in rural schools from Lilongwe, Malawi. BMC Public Health 24 , 1435 (2024). https://doi.org/10.1186/s12889-024-18940-w

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• Aram Ghanavatizadeh 1 ,
• Ghahraman Mahmoudi 1 ,
• Mohammad-Ali Jahani 2 ,
• Seyedeh Niko Hashemi 3 ,
• Hossein-Ali Nikbakht 2 ,
• Mahdi Abbasi 4 ,
• Alameh Darzi 5 &
• Seyed-Amir Soltani 6  

BMC Research Notes volume  17 , Article number:  148 ( 2024 ) Cite this article

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The aim of this study was to determine the challenges and opportunities of virtual education during the COVID-19 pandemic. This study was conducted in 2022–2023 with a mixed method. During the quantitative phase, we chose 507 students from Mazandaran Province medical universities (both governmental and non-governmental) by stratified random sampling and during the qualitative phase 16 experts were collected by purposive sampling until we reached data saturation. Data collecting tools consisted of questionnaires during the quantitative phase and semi-structured interview during the qualitative phase. Data was analyzed using SPSS21 and MAXQDA10. Mean scores of the total score was 122.28±23.96. We found a significant association between interaction dimension and background variables ( P  < 0.001). The most important privilege of virtual education is uploading the teaching material in the system so that students can access the material constantly and the most important challenge regarding virtual education is lack of proper network connection and limited bandwidth. Virtual education proved to be a suitable alternate to traditional methods of medical education during the COVID-19 pandemic in theoretical topics, we recommend that educational policymakers would take the necessary actions to provide the requirements and facilities needed to improve the quality of virtual education.

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Introduction

Given the adoption of technological advances in healthcare in the context of the COVID-19 pandemic, the dissemination of telehealth practices has dramatically increased between 2020 and 2021 [ 1 ]. Virtual education serves as a dynamic substitute for learners to constantly continue their educational journey and preserve their goals [ 2 ].

Virtual education is defined as the use of computer-based technology to provide education which consists of online learning, offline learning, or a combination of them [ 3 ]. In the web-based virtual educational platforms, students can continue to participate in the live academic lectures which they used to attend in class [ 4 ]. Virtual education varies significantly from in-person education [ 5 ]. The unavailability of necessary infrastructure and effective organizational strategies have been a major challenge for the integration of virtual education and face-to-face education [ 6 ]; [ 7 ] and this pandemic not only created the need but also provided the opportunity for accelerating digital transformation in medical education [ 8 ]. Using virtual education, learners can save and review the lectures whenever and wherever they want to. however, most professors have less experience with virtual teaching [ 9 ]. In this educational model, social interactions between the teachers and the students are solely through internet. Yet, how can a professor provide all the necessary communication, guidance, and feedback through internet alone so that learning process would be effective? Moreover, how can professors make sure that all students have access to the same content and same feedback equally? There are so many online educational activities that not all students can access equally due to differences in network conditions and inequal internet access [ 10 ]. Internet inequality could be defined as inequal distribution or access to the internet [ 11 ]. However, internet-based learning should be adjusted to different educational modalities so it would be effective [ 12 ]. Online education has played an important role in the education of undergraduate and graduate level students, and even continuing medical education (CME) of graduate doctors [ 13 ]. Learners can participate in the educational classes anytime it suits them [ 14 ].

one study conducted in Saudi Arabia revealed that using web-based video conferences during COVID-19 pandemic resulted in medical students’ satisfaction [ 15 ]. In another study by Cataudella et al. in Italy titled “Teaching During the COVID-19 Pandemic” showed that teachers exhibited lower self-esteem and self-efficacy while teaching virtually [ 16 ]. Rossi et al.’s study in Brazil demonstrated that active learning tools are helpful for students during the pandemic and they have succeeded at improving their critical thinking, motivation, and their contribution to science [ 17 ]. Khalili’s study in the United States showed that e-learning is becoming the new norm in the universities and this development can bring challenges to some, because some teachers lack the proper knowledge and expertise to create an supportive, positive and interesting environment to engage their students [ 18 ].

Currently the question is whether the implementation of virtual education has been able to satisfy students in their academic progress? Because learners are important stakeholders during the entire teaching and learning process in all educational institutions [ 19 ] and learners’ engagement in this process has positive effects on their active learning [ 20 ]. Therefore, due to widespread use of virtual education and online teaching during the pandemic, it is necessary to conduct more studies to examine the challenges and opportunities of this type of education during the COVID-19 pandemic.

Methodology

Study design.

The current study was conducted using a mixed (qualitative-quantitative) method in 2022–2023 in the north of Iran.

Sample size

The study population in the quantitative phase consisted of 13,500 medical science students of all the medical universities in the province, both public and private, who benefited from virtual education during the COVID-19 pandemic. In the qualitative phase the population included experts and university professors of the same aforementioned universities.

In order to determine the sample size, it is appropriate to use between 5 and 15 observations for each variable measured [ 21 ], in this study we considered between 12 and 13 times the number of questions in the questionnaire, that is in the range of 480 and 520 participants.

The sampling method implemented in the quantitative phase was cluster sampling; first the university, then the academic major, and finally the class was considered as the cluster. 507 students were selected. 194 students from Babol university, 225 students from Sari university of Medical Sciences, and 88 students from Azad university of Sari participated in this research. Inclusion criteria in quantitative phase of this study was that participants had to be a student in one of the medical universities of Mazandaran and also to have consent to participate in the study. participants were excluded if they did not use online education methods.

In the qualitative phase we selected 16 academic staff members of both basic science and clinical stage, using purposive sampling, who were policymakers and planners in their universities and had online educational activities alongside their executive posts.

Information gathering tools

After our proposal was accepted and we obtained the ethics committee approval, we commenced our executive phase of the research. For the literature review all the articles that were published between 2010 and 2021 in different national and international databases including ISI, Pubmed, Scopus, Google Scholar, Magiran, SID, and Irandoc were reviewed. We used Persian and English keywords including online teaching, virtual teaching, active learning, COVID-19, interaction in virtual education, feedback in online education, benefits of virtual learning, disadvantages of virtual learning, and types of virtual learning.

Data measurement tools

In the quantitative phase we used a questionnaire developed by Ünal Çakiroğlu and colleagues [ 22 ]. The questionnaire consists of 7 different principles. Each principle consists of approximately 5–6 questions and a total of 40 questions and answers vary between range of not satisfied to perfectly satisfied and each question has a score of 1 to 5.

In order to convert the English questionnaire to Persian we used the translation-retranslation method as described below. At first, two translator’s experts in this field translated the English version into Farsi. A conceptual translation instead of word-to-word translation was implemented; also, clarity, simplicity, brevity, type of audience, age and cultural factors were taken into consideration by the translators. In the second stage two translators fluent in English, who were not aware of the questionnaire’s content, translated the questionnaire back into English. In general, conceptual similarity was an important factor during the translation process. finally, in the third stage an expert panel consisting of people fluent in both languages reviewed the quality of the translations in the presence of researchers and in the case of inconsistency between translations, alternative words were suggested.

To perform face validity, the questionnaire was given to 20 students (10 males and 10 females) who met the inclusion criteria and a number of related experts. They were asked for feedback about the clarity of the questionnaire, its readability, writing style, easy understanding, confusing words, comprehensibility, disproportion and ambiguity. Any needed corrections were applied.

To check the reliability, Cronbach’s alpha was used as the index to evaluate internal consistency for the entire questionnaire and for each scale. Values above 0.7 were considered acceptable. To evaluate intraclass reliability, we used test-retest method. Data from 30 students, who met the inclusion criteria, were collected in two stages with a time interval of one month then the scores obtained in these two stages were evaluated using intraclass correlation coefficient (ICC).

To perform the qualitative phase, the data collection tool was semi-structured interview. We used the data from the quantitative phase of the study, the quantitative statistical outputs and items in the questionnaire that had the lowest points from the students’ point of view to formulate our interview questions. In the way that less favorable items from the students’ point of view were used as questions in the qualitative phase. At this point we used semi-structured interview and in-depth interview to gather our data. After conducting the interviews, handwriting, typing and listening to the files several times all the notes and writings were named and coded. in the initial coding process, the researcher reviewed the written and typed data line by line as analytical units; and then by identifying the related semantic units or determining the important parts of the text, the researchers would extract the explicit meanings and concepts from the interview texts and would write them next to the relevant sentence in the form of a code. At the same time in another text the researcher wrote down the codes with the relevant address.

Data analysis

After collecting the data and coding, the results of the quantitative phase were entered into the SPSS21 software. In order to perform the related statistical tests, first, the normality of the data was checked using the Kolmogorov-Smirnov test. In order to check the linear relationships between quantitative variables, Pearson correlation coefficient was used. Friedman’s test was used to rank principals and dimensions at a significance level of p  < 0.05. For analysis of the qualitative phase, content analysis method and MAXQDA10 software were carried out.

Results of the quantitative phase

From the 507 students participating in this study, regarding the demographic characteristics, the mean age of the participants was 21.47 ± 2.34 years with a range of 18 to 43 years. 319(62.92%) females and 174(34.32%) males participated in the study. The majority of the participants 145(28.6%) were medical students. (Table  1 )

Descriptive statistics of the scores of principles and dimensions of the questionnaire showed that the mean and standard deviation of the total score is 122.28±23.96 and for the three dimensions of interaction, learning and teaching. They were 34.54±8.23, 33.80±8.01 and 53.93±10.15. (Table  2 )

The results of the test about the correlation of the seven principles of the questionnaire showed that all seven principles had a positive correlation with each other and the correlation was of strong intensity. The strongest relationship was between high expectations and diverse talents ( r  = 0.73, p  < 0.001). The lowest correlations were found between cooperation among students and the time on task with other principles, the rest of the correlations are provided in the table. (Table  3 )

Also, in examining the relationship between the three dimensions of the questionnaire, the results showed that the highest correlation was between learning with teaching ( r  = 0.786, P  < 0.001) and the lowest correlation was between interaction with learning ( r  = 0.666, P  < 0.001), The correlation between teaching and interaction was ( r  = 0.738, P  < 0.001).

The result of the Friedman test showed that from the participants’ point of view, there was a difference between dimensions of online teaching including interaction, teaching and learning. In other words, according to participants, online teaching during the COVID-19 pandemic had the best performance in teaching and the weakest performance in learning. (Table  4 )

The results of the qualitative phase

In the qualitative phase of the research, interview method was used to collect the data. The characteristics of the interview participants are provided in Table  5 .

In Table  6 , there are Strengths, opportunities and challenges of virtual education according to experts. Some solutions were suggested to improve this teaching method.

Qualitative phase data analysis

One of the most important opportunities of virtual teaching according to experts is the possibility of uploading the educational material in the electronic domains. The most important challenge of virtual teaching was the lack of proper and desirable communication infrastructure (internet) and poor-quality internet. The first solution proposed by the professors to increase the quality and efficacy of online teaching is recognizing the problems related to this educational method. the most important influential weakness of this method was the lack of proper communication and internet infrastructure.

The results of the study showed that all the principles of the study were positively correlated to each other and this relation was strong. The strongest relation was between high expectations and diverse talents and also between active learning and diverse talents. The least correlation was between cooperation among students and time on activity with other principles. In a study conducted by Alahmadi et al. it was shown that students believe online classes help them overcome some learning obstacles for example the fear of communication in English. One can argue that virtual classes are helping learners, especially timid learners, to interact more and overcome their fears of interaction in face-to-face classes [ 23 ]. Tanis article revealed that quick interaction between peers is helpful for their learning, whereas isolation and lack of communication was harmful, However, group project was not the best way of learning. Students found delayed feedback and limited work by their peers harmful for learning and preferred to work at their own pace [ 24 ].

In investigating the relationship between different principles, the strongest relationship was between teaching and learning and the least relation was between interaction and learning. Alenezi study mentions that it is necessary to design an effective electronic learning environment in which the content is presented based on the characteristics of the teachers and learners, the structure of the educational material and interaction creation [ 25 ]. In another study by Adnan et al. inaccessibility to internet, lack of proper interaction among teachers and learners and inefficient technology were the major challenges of students [ 26 ].

The results of the Friedman test in the present study showed that there are differences between various dimensions of virtual teaching including interaction, teaching and learning. In other words, online teaching has had the best performance in the teaching dimension and the weakest in the learning dimension during the COVID-19 pandemic. Çakiroğlu observed in his study that although the electronic learning system has advantages, there are still challenges related to the cooperation between students, and active learning was very low in virtual education [ 22 ]. Other studies showed that active learning using simulations improves conceptual learning and memory, increases motivation and study intensity, and also reduces the achievement gap in basic students [ 27 , 28 ].

According to the results of the study, one of the most important opportunities of virtual teaching is the ability to upload the teaching material in the electronic system, because it enables the students to receive and use the material as many times as they need to; this will eventually result in improvement of learning quality provided that we address the issues and challenges related to this process [ 29 ]. In electronic teaching, educational content can be quickly delivered to learners and standardized and updated if necessary. The material can be delivered using different approaches including self-directed and coaching [ 30 ].

Another strong point in online and virtual education was the increased ability of professors in working with different educational software, uploading assignments, holding online exams, and learning different ways of feedback. In Bjekic’s study, a teacher’s capability in electronic teaching is considered a combination of educational, communicational and content creation capability [ 31 ] and teacher’s ability to conduct better tests results in students’ satisfaction [ 32 , 33 ]. In this regard the faculty can use both online and offline tools for the education of students [ 34 ]. However, we should keep in mind that medical education is not solely the theoretical matters, there are also other aspects of teaching including laboratory techniques, clinical skills and patient exposure; so electronic methods alone will not be sufficient for medical education [ 35 ].

One of the other opportunities provided by virtual teaching is decreased expenses of both teachers and students due to less commute and the easy access of students to their professors through social network and also lack of limitations because of geographical distance between one individual’s residence and the place of their institute, Fedynich states that one of the advantages of remote education is that it is not limited by the learners’ location [ 36 ], also, it can be provided by the professors regardless of their location [ 37 ], it decreases students’ expenses [ 33 , 38 ] and students can ask questions whenever they have trouble with their studies and receive answers in a short amount of time and they can also see questions asked by others [ 39 ].

Of the important challenges regarding virtual education, we can mention the lack of proper communication infrastructure (internet) and low-quality internet which can affect the quality of online classes as well as examinations. An important weakness of virtual teaching is inaccessibility to digital products needed for the education by the students [ 40 ]. Not having reliable internet connection [ 41 , 42 ], hardware and software issues of virtual educational platforms [ 43 , 44 ], problems related to speed and quality of internet [ 45 , 46 ] and audio and video streaming issues are other disadvantages of this teaching method [ 47 ].

Another engagement of professors in online education is the topic of conducting online examinations, because they believe online platforms do not hold the capacity to perform reliable and valid examinations, the results of several studies showed that due to the lack of supervision during the test, students’ grades are significantly higher compared to their previous educational records [ 37 , 48 , 49 ]. On the contrary, in Lara et al.’s study scores recorded from 49 medical students in OSCE did not have a significant difference from scores obtained from the same exam conducted in-person [ 50 ], it seems like there is a difference between the nature of theoretical and applied examinations.

The other challenge was organizing practical courses and clinical rotations. Due to several infrastructural and human limitations, holding online practical classes was not possible, and students passing their clinical rotations or those who had applied courses faced many problems. In this regard, the main issue is due to the very nature of medical education and the main problem is the inability to practice and obtain clinical skills online [ 51 ]. Clinical courses have suffered from the suspension/reduction of undergraduate student internships with a knock on impact on education. The fulfilment of professional skills in clinical training present both educational and professional challenges. Medical teachers will need to innovate and think outside the box to maintain the value of medical education in extreme circumstances. A solution may be represented and the introduction of telemedicine technologies that may contribute to the improvement of core competencies, medical knowledge, overall learning, and higher quality patient care [ 52 ]. We should keep in mind that online education cannot replace the face-to-face education of laboratory skills and techniques [ 53 ]. And most students do not feel good about learning practical skills alone or online [ 39 ].

Study limitations

This study was limited to Mazandaran Province. Also, the study population was limited to the students of the Medical Sciences universities. On the other hand, we evaluated all academic levels together, and considering the fact that challenges are different in various stages of training and in different majors this may affect the overall results. For example, students in their clinical rotations have very different problems than those passing theoretical courses and topics.

Since virtual education proved to be a suitable replacement for traditional educational methods in theoretical subjects during the COVID-19 pandemic and considering the recognition of factors affecting the quality of virtual teaching; it is crucial for policymakers in the field of education to take these factors into consideration, and implement goal-oriented plans and do their best to provide the necessary requirements to improve the quality of virtual teaching, so that it ultimately leads to an increase in the quality of learning of medical students.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

We would like to thank the officials of the universities of medical sciences as well as all the experts and experts who have helped us with their valuable views.

There was no Funding support in this article.

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Authors and affiliations.

Hospital Administration Research Center, Sari Branch, Islamic Azad University, Sari, Iran

Aram Ghanavatizadeh & Ghahraman Mahmoudi

Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran

Mohammad-Ali Jahani & Hossein-Ali Nikbakht

Doctorate of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran

Seyedeh Niko Hashemi

Department of Health Economics and Management, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

Mahdi Abbasi

Babol Education Department, Babol, Iran

Alameh Darzi

Golestan University of Medical Sciences, Gorgan, Iran

Seyed-Amir Soltani

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Contributions

Aram Ghanavatizadeh writing—original draft; writing—review and editing. Ghahraman Mahmoudi: Conceptualization; Formal analysis; Methodology. Mohammad-Ali Jahani: Conceptualization; data curation; formal analysis; investigation; methodology; project administration; software; super-vision; validation; visualization; writing—original draft; writing—review and editing. Hossein-Ali Nikbakht: Conceptualization; writing—original draft. Seyedeh Niko Hashemi: Formal analysis; investigation. Mahdi Abbas: data curation; Writing—original draft. Alameh Darzi writing—review and editing. Seyed Amir Soltani: writing—review and editing.

Corresponding author

Correspondence to Mohammad-Ali Jahani .

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Person-centred care and the work-related health and job satisfaction of health and social care professionals: protocol for a prospective longitudinal cohort study combined with qualitative studies (the PCC@Work project)

• Cornelia van Diepen 1 , 2 ,
• Qarin Lood 2 , 3 , 4 ,
• Kristoffer Gustavsson 2 , 5 ,
• Malin Axelsson 6 ,
• Monica Bertilsson 7 ,
• Gunnel Hensing 7 &
• Andreas Fors 2 , 5 , 8  

BMC Health Services Research volume  24 , Article number:  683 ( 2024 ) Cite this article

Metrics details

The interplay of ethical stress, heavy workloads, and job dissatisfaction poses challenges to both the recruitment and retention of health and social care professionals. Person-centred care, rooted in ethical principles, involves collaborative care, and is expected to improve care and job satisfaction. However, prior research on the impact of person-centred care practices on professionals’ work-related health and job satisfaction has yielded mixed results, and most studies emanate from residential care. Understanding how person-centred care practices influence health and social care professionals across different care settings thus requires further exploration through rigorous methodology. The overall aim of PCC@Work is to follow, describe, assess, and explore the impact of person-centred care practices in hospital wards, primary care centres and municipal care on health and social care professionals’ work-related health and job satisfaction.

PCC@Work is designed as a prospective, longitudinal cohort study combined with qualitative studies. A web-based questionnaire will be distributed on five occasions within two years to health and social care professionals in the three care settings. In addition, focus groups and interviews will be conducted with a selection of health and social care professionals to explore their experiences of work-related health and job satisfaction in relation to person-centred practices.

PCC@Work will highlight some of the knowledge gaps on the impact of person-centred care practices regarding work-related health and job satisfaction of health and social care professionals. The uniqueness of the project lies in the multi-method design, combining a prospective longitudinal cohort study with qualitative studies, and the involvement of various professions and settings. This means we will be able to provide a comprehensive and representative understanding of person-centred care practices as a critical component for effective change in the working conditions of health and social care.

Peer Review reports

There is a growing interest in person-centred care (PCC) since authorities, such as the World Health Organization (WHO), have called for enabling patients to engage in their care and treatment [ 1 ]. PCC has also been endorsed by health and social care professionals and patient organisations [ 2 , 3 ]. In Sweden, PCC stands as a pivotal element in the “Good quality, local healthcare reform” [ 4 ]. This reform necessitates substantial organisational changes to ensure integrated, proactive, and health-promoting PCC across various care settings, responsive to each person’s resources and needs. PCC has been developed to frame care in a holistic and ethical way by establishing a partnership between health and social care professionals and persons in need of care. The concept of PCC is based on ethical principles and has its roots in the holistic paradigm, which highlights the importance of knowing each person as a capable human being with needs and resources [ 5 , 6 , 7 ].

The Gothenburg Centre for Person-Centred Care (GPCC) has developed a PCC framework for applying PCC, i.e., PCC practices, serving as a lens for embodying ethical values, guiding professional actions, and enhancing well-being and work performance [ 6 ]. This framework describes a model, summarising PCC into three main practices [ 6 , 8 ]:

Initiating personal narratives to get to know each patient as a person, to identify their previous experiences, present situation, needs, abilities, and resources.

Co-creating a personal plan in line with identified resources and barriers combined with medical, health, and social research evidence.

Documenting and monitoring the plan and adapting it to changes in the goals and/or other circumstances.

Previous research evaluating PCC has to a large extent focused on patients with chronic conditions, showing that PCC could, e.g., improve patients’ self-efficacy, symptom control, satisfaction with care and reduce length of hospital stay and healthcare costs [ 5 ]. PCC practices have also shown positive associations with work-related health among health and social care professionals, but the vast majority of the studies are performed in residential care and have mainly addressed registered nurses and nurse assistants [ 9 ]. What is less known is to what extent PCC practices are applied, and what impact they have on health and social care professionals’ work-related health and job satisfaction across diverse health and social care settings. This project, PCC@Work, is developed to fill this knowledge gap, focusing on the impact and experiences of applying PCC practices in hospital wards, primary care units, and municipal care.

The work environment for health and social care professionals is characterised by demanding conditions, including high workloads, low control, ethical dilemmas, unclear roles, and demanding schedules which may lead to increased stress and job dissatisfaction [ 10 , 11 , 12 , 13 ]. Additionally, an unsatisfactory and stressful work setting, along with ethically challenging situations, often prompt health and social care professionals to seek alternative employment [ 10 , 12 , 14 , 15 ]. Notably, it is concerning that both newly graduated and experienced professionals show a significant likelihood of considering leaving their current positions [ 10 , 12 , 16 ]. The shortage of skilled professionals has detrimental effects on the workload, quality of care and patient safety [ 10 , 13 , 17 , 18 ]. This situation is untenable and requires immediate attention to ensure adequate staffing in the future of health and social care.

In response, PCC@Work aligns itself with the overarching goal of promoting health and well-being in the workplace, aiming to proactively address mental health challenges and mitigate sickness-related absences. One potential remedy is transitioning towards more PCC practices, which could reduce ethical stress and foster more meaningful human interactions in health and social care [ 7 , 19 ]. PCC practices reportedly foster a heightened ethical consciousness regarding the quality of care, grant greater control over daily tasks, and encourage social collaboration [ 20 ]. This is supposed to empower health and social care professionals to align their actions with their personal and professional values by effectively organising and coordinating care with both colleagues and patients [ 21 ]. However, adopting PCC practices may also present challenges, particularly due to time constraints, with barriers including traditional culture and practices, sceptical attitudes, structural factors, the time-consuming nature of actively listening to patient narratives, and engaging in the co-creation of health and social care plans [ 22 ].

A recent review from our research group [ 23 ] illustrates how the introduction of a new professional role through PCC practices could lead to feelings of disorientation and uncertainty among health and social care professionals. These feelings might initially increase stress, and repeated measures with a longitudinal design are therefore essential to show if PCC practices could influence work-related health and job satisfaction in the long run. Significantly, the results showed positive experiences of job satisfaction, including a sense of meaningfulness, enhanced relationships between professionals and persons in need of health and social care, as well as increased appreciation and collaboration [ 23 ]. These findings, in combination with the findings from a previous review [ 9 ], prompt an inquiry into the degree to which the outcomes were influenced by the specific context of applying PCC practices. This underscores the imperative for comprehensive research in diverse health and social care settings, employing both quantitative and qualitative methodologies, to assess the impact and experiences of PCC practices from the professionals’ perspective. We hypothesise that a development towards increased PCC practises may enhance the work-related health of health and social care professionals, potentially mitigating sources of stress, excessive workloads, and job dissatisfaction.

Providing a comprehensive and transparent protocol is crucial as it enables the conduct and evaluation of research projects by effectively communicating pertinent information to key stakeholders. As such, our intention with this protocol is to convey the complexity of the design of this multi-method project. The longitudinal aspect of the PCC@Work project will ensure that the complex relationship between PCC practices, work-related health, and job satisfaction is thoroughly researched so that fluctuations over time can be captured. This allows for the impact of PCC practices to be monitored and evaluated. Development of PCC may increase health and social care professionals’ perceived levels of stress at an early stage.

Methods/design

Project aim.

The overall aim of PCC@Work is to follow, describe, assess, and explore the impact of PCC practices in hospital wards, primary care centres and municipal care on health and social care professionals’ work-related health and job satisfaction.

Study design and setting

This project has a multi-method design combining a prospective, longitudinal dynamic cohort study with qualitative studies. A web-based questionnaire will be distributed on five occasions within two years to health and social care professionals in hospital wards, primary care centres, and municipal care in Sweden. Employing dynamic cohorts allows participants to leave and enter during the study period. Theoretically and pragmatically, dynamic cohorts are a relevant choice in this project in which we monitor the gradual development of PCC practices. With dynamic cohorts, we can follow the participants at several data collection points. The design allows us to perform repeated cross-sectional analyses using the entire, dynamic, cohort (hospital wards, primary care centres and municipal care) at each data collection point. These different data collection points can be used as cross-sectional studies but can also be compared and give data on changes over time. Moreover, it is possible to make longitudinal analyses by creating a fixed closed cohort identified within the open cohort, to follow participants that stay at the same workplace during the study period. The study design is illustrated in Fig.  1 .

Open cohort study design. The blue arrows represent participants remaining at each care setting during the study period, and the yellow arrows represent examples of several possible scenarios for participants starting and quitting at each care setting during the period

The multi-method design includes focus group discussions [ 24 ] to generate qualitative data from health and social care professionals from the three settings. Based on a social constructivist approach, the focus groups aim to capture the collective understanding of work-related health and job satisfaction in relation to PCC practices among health and social care professionals in diverse care settings. In addition, there is room for individual interviews with key participants to create a deeper understanding of social processes and contextual influences related to PCC practices through grounded theory [ 25 ].

Participants and recruitment process

PCC@Work addresses health and social care professionals working directly with persons in need of health or social care in hospital wards, primary care centres, and municipal care. Study participants are reached through their work e-mail addresses provided to the research group by each care organisation. All potential participants receive an e-mail, including detailed information on study design, what participation entails, and ethical topics such as voluntariness, consent, and the possibility to withdraw at any time without any negative consequences to participants’ employment. The e-mail also includes a personal link to a web-based questionnaire. Three reminders are sent to participants to facilitate and promote participation. The web-based questionnaires are operated in collaboration with a company with vast experience in using web-based questionnaires.

There is a baseline data collection for the longitudinal study which will have followed-up after six, 12, 18 and 24 months. The impact of PCC practices will be measured after the third (12 months follow-up) and fifth data collection point (24 months follow-up). Repeated cross-sectional analyses will be conducted at each data collection point to explore associations between PCC practices, work-related health, and job satisfaction. In addition, a subsample of these participants will be asked to participate in the focus groups.

Prospective longitudinal cohort study measures

Exposure variable.

The Person - Centred Care Assessment Tool (P‐CAT) [ 26 ] is chosen as the exposure variable representing self-reported levels of PCC. P-CAT comprises 13 items aimed at capturing the extent to which professionals perceive PCC practices in their daily work [ 26 ]. P-CAT consists of two subscales: the extent of personalising care (EPC; 8 items) and organisational and environmental support (OES; 5 items) [ 26 , 27 ]. A 5‐point scale from 1 (completely disagree) to 5 (strongly agree) is used for evaluation purposes. The sum score ranges from 13 to 65, with a high score indicating a greater extent of perceived PCC. P‐CAT has shown satisfactory validity and reliability in a Swedish aged care context [ 27 ], and has recently been modified by our research group for use in other care settings showing good internal consistency [ 28 ].

Outcome variables

The Stress of Conscience Questionnaire (SCQ) [ 29 ] is a 9-item measurement for assessing stressful situations and the degree to which they trouble the conscience. This questionnaire was designed in Sweden to explore perceived stress related to not providing the care or activities one wants to provide within a care setting [ 29 ]. It consists of nine items, each divided into two parts: an A question that evaluates the frequency of a selected stressful situation using a scale ranging from 0 (never) to 5 (every day), and a B question that evaluates the perceived degree of troubled conscience generated by the situation using a scale ranging from 0 (no troubled conscience at all) to 5 (a very troubled conscience). The A score is multiplied by the B score to reflect the total stress of conscience, ranging from 0 to 25 for each item. Adding the scores for all items gives a total score ranging from 0 to 225. A higher total score signifies a higher perceived stress of conscience. Satisfactory psychometric properties have been reported for the SCQ in a Swedish healthcare population [ 29 ].

The Copenhagen Psychosocial Questionnaire (COPSOQ III) [ 30 ] is a widely used and scientifically tested questionnaire for examining the organisational and social work environment, covering a broad range of domains which can be adopted depending on the aim [ 30 ]. We focus on the COPSOQ III domains Demands at Work (6 items), Work Organisation and Job Contents (6 items), Interpersonal Relations and Leadership (7 items), and Work-Individual Interface (5 items). These domains include questions on job strain, demand/control, job satisfaction, meaningfulness, and intent to leave. The item response alternatives correspond to a five-point Likert scale where the mean score between 0 and 100 is calculated for included scales. If > 50% of item responses in a scale are not recorded, the scale measurement will be considered missing. Studies across different professions have corroborated the internal consistency reliability and construct validity of the scales [ 30 ].

The Work Ability Index (WAI), developed by [ 31 ], has been widely used in research in different countries and settings and can be used to assess self-reported individual work ability regarding perceived resources, health, and physical and mental demands [ 32 ]. Four out of the seven items from the WAI are applicable to this project and included in the questionnaire. The index has shown very good predictive abilities for measuring nurses’ workability [ 33 ], and satisfactory values in a general Swedish population [ 34 ].

The Capacity to Work index (C2WI-cmd) [ 35 ] was developed for assessing capacity to work in relation to common mental disorders in general working populations. C2WI-cmd consists of 12 items. The items include statements covering the capacity to work the last week. The respondent reports to which degree they agree, with the five response alternatives ‘Not at all’; ‘To a low degree’; ‘To a moderate degree’; ‘To a high degree’; or ‘Not relevant’. Our research group tested the C2WI-cmd for reliability, validity and user-friendliness in a Swedish working sample including healthcare professionals [ 35 ].

The WHO mental well-being index (WHO-5) [ 36 ] is a measure of how the respondent has felt in the last two weeks regarding the more positive aspects of their emotional state. Increasingly, well-being has been shown to be important in relation to health and everyday functioning. WHO-5 has shown validity in assessing well-being over time and comparing well-being between groups. Apart from the positive aspects, WHO-5 also prove validity in screening for depression [ 36 ].

Demographics

Other parts of the questionnaire concern the demographic and confounding factors; gender, age, profession, workplace, type of employment, working hours, shift work, overtime, years working in health or social care and at their organisation, experience and opinion of PCC practices, sickness absence, general health and ongoing implementations or reorganisations in the care setting. All of these will be incorporated into the analyses.

Statistical analyses

Statistical analysis will focus on repeated cross-sectional and longitudinal analyses to assess changes over time within groups. Statistical analysis will be done at each data collection point. Regression analyses (linear, ANOVA, ANCOVA) will be applied. The primary efficacy analysis centres on the baseline to two-year change in SCQ with the P-CAT as exposure, with Fisher’s non-parametric permutation test for paired observations. Results will be presented at a 5% significance level on aggregated levels.

Power calculation

For the quantitative studies, a change of 5 units in the Stress of Conscience Questionnaire (SCQ) was considered an acceptable effect, in each of the three cohorts (hospital wards, primary care centres, and municipal care), from baseline to 24 months with a power of 80% with Fisher’s non-parametric permutation test for paired observations, and a significance level of 0.05. Thus, 285 health and social care professionals must be included in each of the three cohorts (= 855 in total). We expect a response rate of approximately 40% and therefore aim to invite a minimum of 2200 health and social care professionals at baseline to allow for both staff turnover and withdrawals. The standard deviation for change in SCQ (total score range from 0 to 225) has been estimated to be 30 based on the literature [ 37 ].

Qualitative studies

To allow for a deeper and broader understanding of PCC practices in relation to work-related health and job satisfaction, the e-mail sent out for the 12-month follow-up data collection will invite participants to focus group discussions. Participants interested in contributing to a focus group discussion will then be contacted by the research group for more detailed information and for setting up a time and place for the focus group. Homogeneity will be strived for in terms of care setting and profession, and heterogeneity will be strived for in terms of work experience, national background, age, and sex, to capture a diversity of experiences and broaden the discussions [ 24 ].

For the focus group discussions, our intention is to conduct at least two focus groups with health and social care professionals per care setting (a total of at least six focus groups), and we will strive for four to six professionals per group ( n  = 24–36). For the grounded theory study, an open sampling of approximately 15–20 health and social care professionals is estimated.

The focus groups will preferably be conducted in a venue accessible for the participants, or digitally if needed, and they are expected to last 60–90 min. Led by a moderator and co-moderator, discussions centre on key questions formulated by the research group to align with the study’s aim. The moderator guides the discussion, while the co-moderator observes, takes notes, and asks follow-up questions. Sessions begin with an introduction to the study’s aim and structure, followed by open-topic discussions. The moderators’ role is to ensure participant engagement, identify common themes, and pose specific questions to deepen the discussions. All sessions will be audio-recorded and transcribed for subsequent analyses. The grounded theory study will have a similar approach.

The focus groups will be iteratively analysed using a method developed explicitly for focus groups [ 24 ]. Focus group data will undergo multiple stages of analysis. Initially, repeated listening establishes an overall understanding. Each transcript is then independently examined to capture essential data. Preliminary themes are created by the researchers, guided by the study’s aim. Raw data is categorised, and descriptive statements are formed. Systematising data under themes involves aligning discussions with relevant categories. This continuous process ensures meaningful communication of discussion meanings. Finally, data is summarised and interpreted collaboratively to foster shared understanding. This analytical continuum transforms raw discussions into condensed, interpretable summaries, forming the basis for a collectively agreed-upon final interpretation. In addition, the individual interviews will be analysed by applying grounded theory [ 25 ], in which data collection and analysis will be conducted as simultaneous processes characterised by constant comparisons of data.

There are some limitations to this project. Various factors, including time constraints, lack of direct connection to researchers, survey fatigue, and insufficient interest or motivation, impact participation rates in research, particularly among care professionals [ 38 , 39 , 40 ]. Moreover, language barriers contribute to lower questionnaire participation rates for persons born outside the country of residence, affecting municipal care, where over one-third of care professionals are foreign-born [ 41 , 42 ].

For longitudinal research, fixed cohorts are ideal, but the dynamic nature of work-related studies, especially those involving PCC practices, necessitates following groups with similar exposure combinations. Additionally, uneven distribution among health and social care professionals, with assistant nurses being the largest group, poses challenges to achieve representative sampling. Sensitivity analyses comparing assistant nurses with other professionals can address this issue, and oversampling certain groups may be considered.

The definition of PCC varies across organisations and professions, emphasising the importance of using the P-CAT in the questionnaire to establish a common understanding. Ultimately, the study aims to uncover new insights into the impact of PCC practices on work-related health and job satisfaction among health and social care professionals in hospital wards, primary care centres, and municipal care.

Data availability

The datasets produced and analysed in this project are not publicly accessible to uphold the confidentiality commitments made to participants during the informed consent process. However, de-identified data can be provided upon reasonable request for review purposes.

Abbreviations

Person-Centred Care

Gothenburg centre for Person-Centred Care

Person- Centred Care Assessment Tool

Stress of Conscience Questionnaire

Copenhagen Psychosocial Questionnaire

Capacity to Work index

The WHO mental well-being index (5 statement version)

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Acknowledgements

Not applicable.

This project is supported by the Swedish Research Council for Health, Working life and Welfare (reference number 2022 − 00278). The Council employs an external peer-review process before decision on grants. Thus, the project application with study design and methodology has been peer-reviewed. The funding source has no role in the writing of this manuscript or the decision to it for publication.

Open access funding provided by University of Gothenburg.

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Authors and affiliations.

Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, Netherlands

Cornelia van Diepen

Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden

Cornelia van Diepen, Qarin Lood, Kristoffer Gustavsson & Andreas Fors

Institute of Neuroscience and Physiology, Department of Health and Rehabilitation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

Centre for Ageing and Health - AgeCap, University of Gothenburg, Gothenburg, Sweden

Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden

Kristoffer Gustavsson & Andreas Fors

Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden

Malin Axelsson

School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

Monica Bertilsson & Gunnel Hensing

Research, Education, Development and Innovation, Region Västra Götaland, Primary Health Care, Gothenburg, Sweden

Andreas Fors

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All authors were involved in the design of the protocol. CvD drafted the manuscript with critical input from all authors. AF is the principal investigator and grant holder of the investigation. All authors reviewed, edited, and approved the final version of the manuscript.

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Correspondence to Cornelia van Diepen .

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The project will be performed in accordance with the Declaration of Helsinki. The Swedish Ethical Review Authority (Dnr: 2019 − 01287, 2021–02821, 2021–05094, 2023-05980-02) has already approved recruitment and all other procedures involved in the study prior to any recruitment. The project participation is voluntary; participants receive adequate information about the specific study and data protection measures before giving consent. In the consent for participation in the project, participants will give permission to use their anonymised data for publication purposes. No third parties will access data, stored securely at the University of Gothenburg. All results will be presented on a group level, ensuring anonymity. Handling of personal data complies with the EU General Data Protection (GDPR EU 2016/679), highlighting our commitment to ethical standards and participant confidentiality.

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van Diepen, C., Lood, Q., Gustavsson, K. et al. Person-centred care and the work-related health and job satisfaction of health and social care professionals: protocol for a prospective longitudinal cohort study combined with qualitative studies (the PCC@Work project). BMC Health Serv Res 24 , 683 (2024). https://doi.org/10.1186/s12913-024-11148-z

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Determining capacity of people with dementia to take part in research: an electronic survey study of researcher confidence, competence and training needs

• Sarah Griffiths 1 ,
• Victoria Shepherd 2 &
• Anna Volkmer 3  

BMC Medical Ethics volume  25 , Article number:  65 ( 2024 ) Cite this article

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Researchers are required to determine whether a person has capacity to consent to a research study before they are able to participate. The Mental Capacity Act and accompanying Code of Practice for England and Wales provide some guidance on this process, but researchers have identified that it can be difficult to determine capacity to consent when a person has complex cognitive or communication needs. This study aimed to understand the experiences and opinions of researchers who recruit people with dementia to research projects, to inform the future development of training resources.

A mixed method, cross-sectional, electronic survey was circulated via social media and research networks in England and Wales. The survey remained open for ten weeks and included open and closed questions exploring respondents’ confidence in determining capacity in the context of recruiting people with dementia to consent, their views on training and support they have experienced and their suggestions for future training and support needs.

60 respondents completed the survey from across England and Wales. Although 75% of respondents had experience of determining capacity to consent with people with dementia to research, only 13% rated themselves as feeling ‘very confident’ in this. Qualitative content analysis of open responses led to the generation of six themes, explaining researchers’ confidence, competence and future training needs in this area: (1) Researcher uncertainties, (2) Lack of time, (3) Balancing information complexity with accessibility, (4) Gatekeepers, (5) Existing enablers and (6) Envisioning future training.

Conclusions

Researchers would benefit from specific training in undertaking conversations around consent with people with dementia. People with dementia may have fluctuating capacity, and despite support from caregivers, researchers have little practical guidance on methods of determining a person’s ability to understand or appreciate the information they have provided during the consent process. Given the development of large complex trials within dementia research, there is an urgency to develop specific and practical guidance and training for researchers working with people with dementia and their families.

Peer Review reports

Individuals with conditions affecting capacity are an under-represented population in research [ 1 ]. Inequity in consent processes likely contributes to this disparity; people with capacity affecting conditions are often assumed to be unable to make consent decisions and therefore routinely excluded from social, clinical and biomedical research [ 2 ]. Consequently, the evidence-base for care and support for populations who may lack mental capacity is inferior compared to other populations. This, in turn, contributes to societal healthcare inequalities, whereby people with dementia are less likely than other more researched groups to be able to access the care and support they need [ 3 ]. Conversely, including people with dementia, who may or may not lack capacity, in research will ensure that health and social care providers can understand and meet these needs. There is, therefore, an urgent need to address barriers to research participation for people who may lack mental capacity.

People with dementia are one such population who may lack the ability to consent [ 4 ] and are frequently excluded from research studies [ 5 ]. The Mental Capacity Act (MCA) [ 6 ] outlines the process to follow in England and Wales if an adult lacks capacity to make a certain decision at a specific time, due to an impairment or disturbance in the functioning of the brain or mind. Sections 30–34 of the MCA provide broad guidelines for conducting research with adults who lack capacity. Although clinical trials are governed under Clinical Trials Regulations [ 7 ] (schedule 1, Part 5) the MCA remains applicable to determining capacity of trial participants. The Mental Capacity Act 2005: Code of Practice [ 8 ] explains that ‘ Researchers should assume that a person has capacity, unless there is proof that they lack capacity to make a specific decision. The person must also receive support to try to help them make their own decision ’ (p204). The Code of Practice provides guidance on use of the MCA and includes advice on when and how to involve a consultee (ideally someone who is close to the person lacking capacity and knows them well personally, rather than a paid carer) to advise on the values and preferences of the person lacking capacity and whether they would have wished to take part in research had they been able to give consent. Whether or not a consultee is involved in the consent process, researchers should seek a person’s assent and respect any indication of their dissent to participating in research, expressed through verbal or non-verbal behaviour, and exclude those who dissent from the research [ 9 ].

Some researchers find the MCA and accompanying guidance difficult to interpret and implement (2, 10). Although the MCA’s vagueness around the meaning of capacity in relation to research allows researchers some flexibility, it also limits opportunities for a standardised process for determination of capacity and can cause researchers a great deal of unease [ 11 , 12 ]. Researchers are concerned about the subjectivity of determining capacity and the tensions between adhering to legislation and the principle of non-maleficence, due to the potential to cause distress by conducting unnecessary tests or over/underestimating a person’s capacity [ 11 , 12 ]. There is ambiguity around the logistics of determining capacity (e.g., measures to use and how to introduce the need for consultee involvement (11) and there are concerns about the time intensive nature of this work balanced against the demands of research timescales (10, 11).

Researchers who carry out stroke research have also reported a lack of knowledge, skills and confidence in supporting people with other capacity-affecting conditions such as stroke related aphasia (10), highlighting a lack of training, tools and time as particular barriers. Research studies including people with stroke aphasia as participants, rarely document study processes used to support their recruitment [ 13 ]. The authors [ 13 ] called for person-centred, individual tailored consent processes to address the complexity of consenting people with stroke-aphasia for research. The need to build capacity and capability within the wider dementia research workforce has been recognised [ 14 ], and programmes such as the National Institute for Health Research Three Schools Dementia Research Programme ( https://www.sscr.nihr.ac.uk/dementia-research-programme/about/ ) have been developed to target funding in this area. However, literature on, and initiatives around upskilling dementia researchers in consent processes are lacking.

There has been some work to develop resources and guidance to support researchers in consenting people who lack capacity such as the outputs from the CONSULT study ( https://www.capacityconsentresearch.com/ ), and training resources on broader aspects of inclusion of people with capacity and communication needs by the ASSENT team ( https://www.uea.ac.uk/web/groups-and-centres/assent ). A small number of tools have been developed, such as the Consent Support Tool ( 15 ) and The Evaluation to Sign Consent Tool [ 16 ]. Neither have been developed specifically for people with dementia, nor do they seek to incorporate informal person-centred approaches and minimise the use of formal testing, which can feel threatening to people with dementia [ 11 ]. There is also growing support for researchers, from organisations such as the Alzheimer’s Society, to ensure people with dementia are involved in shaping the research process from the very start, often as funded co-applicants. At the time of writing this article, a recent government response to the review of clinical trials outlined plans to accelerate dementia trial delivery [ 17 ]. Despite this, little is known about the challenges for, and training needs of researchers who are determining the capacity specifically of people with dementia to consent to research.

It is valuable to further understand the context for consent processes described in dementia research studies undertaken within England and Wales since the introduction of the MCA 2005. The National Institute for Health Research Clinical Research Network Portfolio, at the time of writing, has 383 completed studies on dementia on their database since 2008. A similar search of the Welsh database identified a further 33 studies. It was not within the scope of this paper to interrogate all of these studies, therefore a sample of 41 (10%) of these studies were randomly selected (using random.org) by the current authors to explore how consent processes were described. Of these 41 studies, 24 included people with dementia as participants, whilst others focused on caregivers or other participants. Ten of the 24 studies that included people with dementia as participants, included those who could and those who could not consent, whilst for a further seven it was unclear whether both these groups were included. Thirteen of the 24 studies that included people with dementia provided some description of a consent process (though five of these were very brief, and only 10 mentioned the MCA). Three of the 24 studies described used accessible information sheets, and one a validated questionnaire. Three of the studies described the skills of the researcher/s and the training given to support capacity assessment. This lack of information on consent processes potentially reflects underreporting, due to current journal and reporting standards not requiring this information. As a result, the opportunity for shared learning and improving process is lost.

Several authors [ 18 , 19 , 20 , 21 ] have, however, provided valuable work to inform researchers in supporting people with dementia to take part in research. People with dementia are often able to participate in decision-making in the mild stages of the condition, but this becomes more difficult as the disease progresses [ 18 ]. The literature on decision-making skills of people with dementia highlights specific areas of potential difficulty, such as language comprehension, and reasoning as the cognitive domains most likely to present a barrier [ 4 ]. Researchers in other legal jurisdictions have described person-centered, guiding principles and recommendations for researchers when seeking informed consent in studies involving people with dementia (e.g [ 19 ] - Ireland; [ 20 ] - India; [ 21 ] - Canada). They suggest strategies such as getting to know a person to prepare to provide appropriate support [ 18 ], simplifying consent forms, and using a visual memory aid [ 18 , 19 ]. However, there is still a lack of detailed guidance and training within England and Wales on the real-life application of these principles, to help researchers gauge capacity for decision-making during recruitment e.g., advice on effective practical strategies and ‘in the moment’ communication practices (10). Appropriate knowledge of, and skills in, determining capacity are an ethical imperative if potential research participants are not to be wrongly included or excluded from research.

There is a need for evidence-informed guidance and training for dementia researchers in all areas of dementia research, in determining capacity to consent to research. This would address inequalities, by enhancing opportunities for people with dementia to participate in research informing their care and support. However, to our knowledge, whilst reflective articles have highlighted the challenges and potential facilitators in this area [ 11 , 12 ], there is little understanding of the skills and needs of the researchers themselves.

This study aimed to understand the experiences and opinions of researchers who recruit people living with dementia to research projects, to inform the future development of training resources. We aimed to ascertain:

How confident and competent researchers feel about determining capacity in the context of recruiting people with dementia to research.

The nature of and their views on any training and support they have experienced.

Their perceptions of future training and support needs in this area and how these might be addressed.

Design and setting

A mixed method [ 22 ], cross-sectional, electronic survey was conducted. A survey was considered the most appropriate data collection method due to the lack of existing data on this topic and therefore the need to obtain a wide range of views to understand the broad landscape. It was anticipated that using anonymous survey methods would reach researchers from across England and Wales, with a range of experience and expertise. This article has been informed by the consensus-based checklist for reporting survey studies [ 23 ].

The study was approved by the Chairs of UCL Language and Cognition Department Ethics on 21st November 2022, Project ID LCD-2022-11. All work undertaken in this study was conducted in accordance with the Declaration of Helsinki. Informed consent to participate was obtained from all of the participants in the study. All data were anonymised and stored securely in line with the Data Protection Act, 2018 and UK General Data Protection Regulation guidance, 2016.

Survey development

Based on best practice guidance for survey research (American Association for Public Opinions Research: AAPOR - https://shorturl.at/azET4 ; [ 24 ]. we developed a prototype survey using Qualtrics (2009) software secure survey tool. This captured demographic data that would allow us to describe the respondent group (country of work, age, gender, ethnicity, professional background, length of time working in dementia research and qualification level). To address the research aims, questions were designed to ascertain confidence levels relating to determining capacity, perceived barriers and facilitators to determining capacity, previous training and what was helpful/not helpful about this, existing resources perceived as useful, potential benefits of future training and suggestions for the content of such training. We used a mix of closed questions, Likert scales [ 25 ] and open response fields to capture ‘the “ why” that complements quantitative results, helping to tell a more nuanced story with the data’ ( 26 : p1). To reduce participant burden, the survey was planned to take no longer than 15 min to complete.

The prototype survey was piloted by three researchers with experience of recruiting people with dementia to research projects, who were asked to comment on the design, wording (e.g., how easy the questions were to understand), ease and duration of completion and any other suggestions to improve the design. All three researchers took approximately 10 min to complete the survey. Based on their feedback several questions were refined to improve readability e.g., not to include all the response options in the question, given they are present as response options. Following refinement, the survey was published on Qualtrics. The final version is shown in Appendix One.

Participants and recruitment

Potential participants were eligible if they were researchers with experience of recruiting people with dementia within England or Wales, where MCA legislation applies. There is a lack of population size data for these target respondents. Therefore, rather than calculating a probability or non-probability sample size, it was more appropriate to take a pragmatic census approach to recruitment, whereby responses are desired from as many participants in the undefined target population as possible [ 27 ].

The survey was advertised via social media, dementia research networks, (the National Institute for Health Research Dementia Researcher [ 28 ], recipients of NIHR Dementia Research Fellowships and Career Development Awards, and DemiQual [ 29 ]), and emails to relevant university research departments. Before completing the survey, potential participants were able to click a link to access further study information and to provide consent. The survey was open for ten weeks, to capitalise on weekly social media reminders and encouragement to respondents to share the survey in a snowballing approach [ 30 ]. Responses were considered invalid and therefore excluded from analysis if: consent questions were started/completed but survey questions not attempted, only consent and demographics questions were answered, or respondents closed their browser mid-way through completing the survey (the latter was treated as withdrawal).

Closed field responses were analysed using descriptive statistics. The sample did not allow for the use inferential statistics, although some tentative comparisons have been made (see results).

Open field responses were analysed using content analysis, described by Patton ( 31 : p453). as a ‘qualitative data reduction and sense-making effort that takes a volume of qualitative material and attempts to identify core consistencies and meanings.’ Taking a more in-depth analytic approach such as reflexive thematic analysis [ 32 ] was not appropriate for data collected via online survey, where responses are typically brief, with no opportunities for researchers to probe for deeper understandings [ 33 ]. The open-ended responses were intended to enhance the quantitative fundings rather than produce standalone rich insights [ 34 ].

We followed the steps of ‘conventional content analysis’ [ 35 ]. SG and AV engaged in multiple readings of the entire data set and separately coded for initial categories derived directly from that data (inductively). Where meanings were unclear, data was left uncoded. SG and AV then compared categories and agreed how they could be merged and streamlined, thus deciding on the preliminary code set. They then recoded the data deductively and inductively, examined all data within each code, and agreed on codes that could be split, combined or abandoned. Finally, they considered how codes could be reframed into themes, to provide a coherent explanation of participants’ opinions on their confidence, competence and training needs relating to determining capacity.

There were 86 survey responses, 14 of which were excluded from the study as the consent section was not completed. Twelve were excluded from the study as participants completed the consent section but closed their browser mid-way through. 60 complete responses were included in the analysis.

Respondent demographics

Of the 60 respondents, three (5%) reported doing research in both England and Wales, 50 (83%) respondents reported doing research in England only and seven ( 12%) respondents did not complete this field. 49 respondents were women (82%; see further demographic data in Table  1 ).

Experience of determining capacity to consent

Nine respondents (15%) had no experience of determining a potential participant’s capacity to consent to a study (Fig.  1 ), whilst 43 (72%) had determined between one and 100 participants’ capacity to consent, and seven (12%) had determined more than 100 participants’ capacity to consent. Respondents with fewer years’ experience had generally recruited fewer participants. All respondents with less than one year of experience ( n  = 6) had recruited 1–20 participants, respondents with 1–2 years’ experience reported recruiting 0 ( n  = 1), 1–20 (= 3) or 20–40 participants ( n  = 4). Two participants with 1–2 years’ experience reported recruiting 40–100, or more than 200 participants respectively. Participants with 10–15 years’ experience reported recruiting 1–2 participants ( n  = 1), 40–100 ( n  = 3), 100–200 ( n  = 1) and participants with more than 15 years’ experience reported recruiting 40–100 ( n  = 1) or 100–200 ( n  = 2). Most respondents felt fairly confident (35, 58%) or very confident (8, 13%) in determining capacity to consent (Fig.  2 ). Six respondents were neither confident nor not confident, whilst eight (13%) were not very confident and three (5%) not at all confident. Of those who rated themselves as very confident or fairly confident, a total of eighteen had more than 15 years’ ( n  = 14) or 5–10 years’ ( n  = 4) experience in recruiting people with dementia to research, whilst ten had less than one year or 1–2 years’ experience. Similarly, of those who rated themselves as not very confident or not at all confident, one respondent had 10–15 years’ experience, and four had less than one year or 1–2 years’ experience. This suggests that experience in recruiting people with dementia to research did not necessarily mean respondents felt more confident about determining capacity.

Number of people for whom respondents had determined capacity

Confidence in determining capacity to consent

Training to determine capacity to consent

Two thirds of respondents (40, 66%) reported having had previous training on how to determine capacity to consent. Of these 40 respondents, 15 had clinical backgrounds (comprising 75% of the respondents with a clinical background). Just over two thirds of the entire respondent group (41, 68%) felt they would benefit from training or further training to address any uncertainties in their skills.

Analysis of open-ended responses

Data collected from respondents who answered open questions relating to researcher confidence, competence and future training needs informed the development of six main themes: (1) Researcher uncertainties ( subthemes: knowledge of, and confidence in, the process, determining understanding and retention, juggling family members, and managing the fluctuating nature of capacity) (2) Lack of time, (3) Balancing information complexity with accessibility, (4) Gatekeepers , (5) Existing enablers ( subthemes: training and background, tools and resources, communication strategies ), and (6) Envisioning future training ( subthemes: experiences of past training and future training needs). We now present these themes, illustrated with quotes from the online data where responses were expansive. The presented quotes are not linked to respondent characteristics, as this would threaten anonymisation, due to low numbers within some demographic categories.

1. Researcher uncertainties

Whilst a limited number of respondents reported having no uncertainties, the majority articulated their worries about how to go about aspects of determining capacity.

Knowledge of, and confidence, in the process

Respondents expressed uncertainties about who should determine capacity and where to start:

‘ Who is responsible for judging capacity?’ ‘ …not sure on what questions to ask and how.’ ‘ I don’t know all the steps I need to follow to determine if someone has capacity. I don’t know if there are any steps even.’

There was also uncertainty around how formal or informal the process should be:

‘ Knowing whether something formal needs to be in place or if it is sufficient to assume capacity unless there appears to be reason to be concerned.’

There was a sense of not knowing what is not known:

‘ I’m confident that I am able to follow ethical processes but am sometimes concerned there are legal processes that I am not aware of.’

Respondents expressed uncertainty over how to justify decisions:

‘ …making sure I have justifiable reasons for why I believe someone does, or does not, have capacity.’

This leads to a lack of confidence, worries about making mistakes, and fears that mistakes could have a negative emotional impact on people with dementia. For example, one participant expressed a ‘ fear of getting it wrong’ and another described worries about ‘inadvertently causing distress if judgment of capacity is incorrect.’

These fears are fuelled by the knowledge that capacity judgements are subjective; there will always be doubt and no way of checking:

‘ Can’t always confirm. Some degree of doubt is present.’

Determining understanding and retention

Whilst researchers were aware of the need to tailor research information to a person’s level of comprehension, they had uncertainties about how to determine whether the recipient has understood and retained enough information to make an informed decision regarding participation (MCA, 2005). For instance, speaking about people with dementia being recruited to studies, one respondent stated that it is:

‘ …sometimes difficult to ascertain if they understand the entire study if it is complex…difficult to tell…if they are quiet or give short answers.’

Respondents expressed concerns about the impact of power imbalance or social dynamics on determining understanding:

‘ I’m worried that someone with dementia might say they understand something when they don’t just out of social obligation or because they’re embarrassed.’

These uncertainties are amplified when the person with dementia gives brief answers to questions, is nervous, is adept at hiding their comprehension difficulties or has unmanaged hearing loss.

‘ Some people have very good masking/compensating mechanisms…excellent conversationalists.’

Juggling family members

Respondents were uncertain how to deal with situations where family members talk over or answer questions on behalf of people with dementia:

‘ It can be difficult to assess someone’s capacity when there is a family member answering questions for them.’

There may also be differing desires to participate in the research between the family members, and the person with dementia which can influence the dynamic, when carers are supporting communication:

‘ Those around the person being keen for them to take part, so interjecting in the assessment with their views and giving answers for the person.’

There can also be differing views on capacity within the family, which respondents felt could influence capacity decisions. At times, family members were said to:

‘…not want to accept that the person with dementia may not have capacity’ or ‘ …present biased views on [the person’s] capacity, which could all blur my clarity on the person’s capacity to give consent.’

Another respondent raised uncertainties around how to involve family carers in a way that does not cause the person with dementia to become embarrassed and/or disempowered:

‘ It’s difficult to include carers in the process without making the person with dementia feel embarrassed or that I’m implicitly implying that they lack capacity. But including a carer would be very helpful, so this is difficult to navigate .’

Managing the fluctuating nature of capacity

Respondents were particularly concerned about how to take account of day-to-day fluctuations in cognition associated with dementia. In one respondent’s words there were uncertainties around ‘how to incorporate ongoing capacity judgement throughout a study lifetime.’

There was also a worry that fluctuations in cognition might lead to unnecessary exclusion of people with dementia in research:

‘ My uncertainties are around fluctuating cognitive abilities…and the fact that capacity to consent in the here and now might not be there even after a short period of time. Or in the reverse circumstance, that I exclude someone from research based on their incapacity to give consent at a given time, when potentially shortly after they could be involved in research.’

2. Lack of time

Respondents felt strongly that determining capacity requires the development of trusting relationships over time, with researchers collecting background information (e.g., about how the person usually demonstrates a decision) and getting to know the person with dementia:

‘ When you don’t have much time to get to know a person prior to the start of the research, it can be more challenging to assess changes in capacity during the data capture.’

However, lack of time was commonly cited as a barrier to conducting such person-centred capacity judgements:

‘Only short amounts of time with the individual, over phone or zoom, is very hard .’

Respondents described trying to do this work whilst responding to the pressure of competing research priorities such as recruitment targets and tight timelines, resulting in ‘time constraints on [participant] visits.’ Respondents identified a perceived ‘…conflict between recruitment targets and doing an objective assessment of capacity.’

3. Balancing information complexity with accessibility

Respondents identified a conflict between ethical requirements to explain specific concepts such as study procedures, informed consent, anonymity and data protection on the one hand, and the communication needs of people with dementia:

‘The complexities of data protection are often poorly described in [study information] and consent forms and it is bewildering and can be difficult to explain the meaning.’

Presenting abstract concepts in accessible ways was seen as challenging, especially for complex research studies with several elements. Even respondents with experience of clinical capacity assessment and developing accessible resources, e.g., speech and language therapists, found that this experience was not necessarily transferable to the research context, and the need to balance ethical requirements with participants’ need for accessible research-specific information:

‘As someone with a clinical background, I have some experience of assessing capacity. However, formal assessment for capacity to consent to collection and, more importantly, use of data, I am less confident with. I am concerned that consenting […] might be too abstract a concept/process for some people with reduced/altered/changing cognition.’

4. Gatekeepers

Family members and formal carers were sometimes seen to function as gatekeepers to research participation, making decisions about whether person with dementia would be suitable for or would want to take part in the research, thus preventing researchers from even getting to the stage of determining capacity:

‘ Clinical staff and sometimes families gatekeep and don’t even let you talk with the person with dementia.’

Experiences of gatekeeping extended to regulatory bodies, seen to block researchers from engaging people with dementia in the process of establishing capacity to consent:

‘ …the ‘blanket’ label of vulnerable is applied to people living with dementia and is embedded in key processes such as seeking ethics approvals…it was suggested to me by an Ethics/REC some years ago that the care team should assess capacity rather than the researcher - this felt undermining.’

5. Existing enablers

Respondents identified existing sources of support, skills and personal attributes that they felt were enabling their capacity judgment work. These included their professional training and background, tools and resources, and communication strategies (sub-themes).

Training and background

Some respondents felt that formal training, such as that delivered by the National Institute for Health Research ( https://www.nihr.ac.uk/health-and-care-professionals/training/good-clinical-practice.htm ) and https://cpduk.co.uk/courses/nihr-clinical-research-network-informed-consent-with-adults-lacking-capacity ), had supported them to develop skills to involve people who may lack capacity in research. Other helpful sources of support included experiential learning, particularly talking to and observing more experienced researchers. Respondents also felt that having a secure and detailed understanding of the research study allowed them to feel more confident, as did having a clinical background, although as identified in theme 3 this was not always the case.

Tools and resources

Whilst resources to support capacity judgment were felt to be generally lacking, available tools which respondents reported as helpful were the MCA code of practice, the ‘capacity and consent to research resources’ website ( https://www.capacityconsentresearch.com/ ), homegrown checklists to guide determination of capacity and consent based on the four stages of the MCA, the ‘Dementia Enquirers Gold Standards for ethical research [ 36 ],’ Talking Mats [ 37 ] and research papers on this topic (e.g., 11). Respondents also explained that working with patient and public involvement and engagement (PPIE) contributors throughout a research project was a valuable resource, offering support and advice. PPIE involves people who have lived experience of an area of health or social care informing and shaping research and its dissemination in that area.

Communication strategies

Respondents described several communication strategies they felt they could use in supporting potential participants to consent including taking the time, wherever possible, to build relationships and trust with potential participants (although Theme 2 explores the barrier created by time constraints) and bringing an ‘openness’ and ‘willingness to engage in everyday informal conversation.’ Asking family members for advice on communication strategies specific to the individual, developing accessible Participant Information Sheets and consent documents, ensuring that there is a private space for consent conversations and having those conversations ‘over a cup of tea, ’ were also strategies cited as being within respondents’ existing ‘toolkits.’ In conversations, respondents identified several strategies including ‘providing a summary of information, and breaking things down into smaller chunks .’ They also described presenting graded information (the simplest messages first, becoming more complex to gauge understanding), checking comprehension by asking people what they have understood and/or inviting their questions about the research.

6. Envisioning future training

Where respondents had experienced some training in this area, they regarded the practical elements as most helpful e.g., shadowing and debriefing with colleagues. A lack of focus specifically on the challenges relating to dementia (as opposed to other conditions where capacity is relevant), was felt to be less helpful:

‘Some information seemed very detached from the reality of working with someone with dementia .’

They reported a tension between courses focusing on ensuring trainees understood the legal aspects (the MCA and its background) rather than the how of determining capacity. In respondents’ experience, training encountered had not provided sufficient in-depth and nuanced consideration of specific challenges and complexities related to involving people with dementia in research:

‘ It’s not all black and white, yes/no.’

Respondents overwhelmingly wished for future training in this area to be practical in nature. Table  2 summarises specific suggestions from respondents for future training in this area.

The findings from this study add to current research evidence on the experiences and opinions of researchers working with people who may lack capacity, specifically with people with dementia, an area as yet not explored in great detail. Similar to previous research in stroke aphasia (10), this survey study of English and Welsh researchers demonstrates that despite having experience in, and education on, the legislative aspects of capacity assessment, their levels of confidence in determining a person with dementia’s ability to consent to research were not consistently high. Their experiences of training highlighted a lack of training specific to working with people with dementia and their families, and a need for practical training to support them to assess a person’s ability to understand and weigh up information. Respondents emphasised a need for time, resources and tools to enable them to get to know a person with dementia and their communication needs, in order to provide appropriate supports in the decision-making process. They flagged the tensions in their role, and the pressure to recruit participants. Concerns expressed about clinical staff and regulatory bodies gatekeeping access to people with dementia, making decisions about their suitability for research involvement, is contrary to the MCA, which requires the decision-maker (researcher) to determine capacity, albeit alongside others with in-depth knowledge of the person. This indicates that there is confusion about implementing the MCA amongst not just researchers, but those with whom they need to collaborate. Data collected from respondents addressed the key objective of the study, by highlighting a need for specific training and guidance on how to overcome such challenges and how best to include people with dementia in research. Interestingly, uncertainly over recording the processes by which capacity is determined, and documenting the outcome, were not seen as strong themes, however future research could seek to explore this area.

This study builds on the current and contemporary literature in this field. Our findings fit with existing knowledge that researchers are uncertain about legal frameworks governing research with adults lacking capacity more broadly (not just regarding how to determine capacity) [ 38 ]. Lack of confidence about operationalising the MCA and of access to training have also been found amongst health care professionals (HCPs) carrying out capacity assessments in clinical settings [ 39 ]. Our respondents’ fears of getting it wrong resonate with the concerns of researchers and health care professionals about conducting trials involving people who lack capacity, that ‘the ethics police will come for you.’ ( 40 : p7). Like our respondents, HCPs wish for training to focus on practical issues [ 41 ]. Combined with this growing evidence, our findings make a clear case for a more joined up approach to research on the processes that embody the legislative components of assessing of decision-making capacity.

Understanding the needs of researchers undertaking capacity assessments will better inform the development of future guidance and training. This builds on previous work in this field demonstrating that researchers working with people with stroke-related aphasia do not feel confident in making judgments about people’s ability to consent (10). There is guidance for researchers, not least the MCA and accompanying Code of Practice, but also more specifically resources such as the capacity and consent to research resources’ website arising from the CONSULT study and resources developed by the ASSENT team. Whilst these resources do try to take account of complex situations, and cognitive and communication difficulties, they were not specifically designed for researchers working with people with dementia. This study extends previous reflective work [ 11 , 12 ] by identifying the specific and current needs of researchers working with people with dementia across England and Wales. There is great potential to contribute to a developing suite of researcher resources, with specialized training tools on determining capacity for research related to dementia.

People with dementia have unique support needs when being consented for participation in research. Future research to interrogate the reporting of consent procedures in research with people with dementia across England and Wales since the publication of the MCA (2005) would inform our understanding of current practice. Given current significant advances in the field of dementia research, potential participants are often making consent decisions about becoming involved in a variety of research, from small scale theory development projects to multicentre, multistage intervention trials, including a range of qualitative, quantitative and mixed methods. The need for inclusive consent processes applies across all these types of research. Survey respondents highlighted that people with dementia may need to understand a large amount of complex information in relation to their potential participation. They and their families may have personal agendas about participation, for instance where studies are trialling potential life changing, possibly curative interventions. Yet people with dementia may present with fluctuating capacity to consent over the course of a study, which respondents emphasised as being difficult for them to manage both practically and ethically. Dewing [ 42 ] describes the concept of process consent, providing principles to consider when supporting older people, including spending time getting to know them. Importantly, Dewing provides several examples of how to interpret what the person with dementia says, yet does not describe what the researcher should ask to check they understand information provided. Given researchers identified time as a barrier, it would be useful to explore how Dewing’s description of process consent could be modified in more time critical research. It seems timely that a set of reporting standards, guiding the appropriate enactment of the MCA, should be developed and implemented by peer reviewed journals to ensure transparency. Given the likely increase in the number and complexity of future trials in this field, evidenced by the recent UK government’s plans to pilot a new clinical trial delivery accelerator for dementia research [ 17 ], there is an urgent need for such reporting standards.

Survey respondents highlighted that care partners can be helpful in supporting communication between the researcher and the person with dementia during consent conversations. However, they also identified concerns about wanting to employ strategies that do not disempower the person living with dementia during these triadic interactions. Conversation Analysis (CA) is a method for examining the turn-by-turn detail of talk-in-interaction [ 43 ]. Using CA, several studies developed training to support health and social care professionals [ 44 ] or care partners [ 45 ] in interacting with people with dementia in a multimodal way that foregrounds relationships and power dynamics. These training programmes used CA to explore moment-by-moment phenomena within conversations and identify behaviours acting as barriers and facilitators to interactions. It seems logical that CA could provide an ecologically valuable method of understanding what researchers say and do that assist or hinder conversations around consent. Indeed, Wade et al. [46] used CA methods to understand how researchers can maintain equipoise during consent sessions, presenting information in an unbiased way. Similarly, future research using CA methods to explore interactions during consent sessions with people with dementia could inform methods for accessible presentation of information.

Limitations

Respondents in this study were recruited via online social media sites, and research networks known to the authors. This may have contributed to the gender bias in the respondent sample. Obtaining a representative sample in future research will be helpful to ensure the data collected is representative of the research community, and asking about whether respondents have undertaken clinical trials and other types of research would be useful. Additionally, whilst this study surveyed the views of researchers, future research in this field should ensure that the views of people with dementia and their care partners are considered. Any future training intervention must be situated in the needs of the people with dementia and their care partners and co-produced with them.

Despite the eligibility criteria outlined at the start of the survey, indicating respondents were eligible for participation only if they undertook research in England and Wales, seven respondents did not complete the field indicating whether they did research in England and/or Wales. A limitation of the survey design was that it was not compulsory for respondents to complete this question.

Survey studies are a useful method to reach a large number of respondents, however, the nature of the study design limited the qualitative data collected in that it is not possible to probe or clarify responses. Indeed, it might have been useful to explore the underlying meaning of several responses. Despite this, there was a large volume of qualitative data collected. In using a content analysis approach to identifying themes in the data the researchers themselves acknowledge their positions as both clinically trained speech and language therapists and dementia researchers may have biased their interpretation of the data. However, this position also enabled them to identify specific concerns voiced by researchers that might be addressed through the development of CA informed training.

This research has a particular focus on researchers within the legal jurisdiction of the MCA 2005: England and Wales. However, whilst the geographical legislative boundaries may mean subtle or larger differences in legal practice, many principles relating to supporting people in decision making are universal as advocated by the United Nations Convention of the Rights of People with Disabilities ( https://www.un.org/disabilities/documents/convention/convoptprot-e.pdf ). Consequently, the recommendations for researchers working with people with dementia outlined in this paper may be considered good practice at an international level.

This survey study of English and Welsh researchers demonstrates that despite having experience in, and education on, the legislative aspects of capacity assessment, they identified training needs in undertaking conversations around consent with people with dementia, who may have fluctuating capacity. Despite support from care givers, researchers have little practical guidance on methods of determining a person’s ability to understand or appreciate the information they have provided during the consent process. Given the development of large complex trials within dementia research, there is an urgency to develop specific and practical guidance and training for researchers working with people with dementia and their families.

Data availability

The deidentified data that support the findings of this study were collected through and are held by University College London. Quantitative data is available from the authors upon reasonable request to the first author: [email protected]. Qualitative data will not be available, to protect participant anonymity. Requests to use data will be submitted on a standard form and reviewed by the authors prior to data-sharing agreements being developed.

Abbreviations

Conversation Analysis

Healthcare professional

Mental Capacity Act

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Acknowledgements

We are grateful to all the researchers who completed the survey and informed the study.

SG receives support from the NIHR Applied Research Collaboration North Thames and Alzheimer’s Society and is funded through a Post-Doctoral Fellowship. The views expressed are those of the authors and not necessarily those of the funders, NHS or Department of Health and Social Care.

VS is supported by a National Institute of Health Research Advanced Fellowship (CONSULT) funded by the Welsh Government through Health and Care Research Wales (NIHR-FS(A)-2021). AV is funded by an NIHR Advanced Fellowship NIHR302240.

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SG and AV devised the project, collected and analysed the data and wrote the first draft. VS advised on methods and background and commented on drafts.

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Griffiths, S., Shepherd, V. & Volkmer, A. Determining capacity of people with dementia to take part in research: an electronic survey study of researcher confidence, competence and training needs. BMC Med Ethics 25 , 65 (2024). https://doi.org/10.1186/s12910-024-01056-6

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Current status of electronic health literacy among pregnant women with gestational diabetes mellitus and their perceptions of online health information: a mixed-methods study

• Jingqi Xu 1   na1 ,
• Yujia Chen 1   na1 ,
• Jing Zhao 1   na1 ,
• Jiarun Wang 1 ,
• Jianfei Chen 1 ,
• Xinlong Pan 1 ,
• Wei Zhang 1 ,
• Jin Zheng 2 ,
• Zhijie Zou 1 ,
• Xiaoli Chen 1 &
• Yingzi Zhang 3  

BMC Pregnancy and Childbirth volume  24 , Article number:  392 ( 2024 ) Cite this article

Metrics details

Women diagnosed with gestational diabetes mellitus often rely on internet-based health information for managing their condition. This study aims to investigate the present state of electronic health literacy among women with gestational diabetes mellitus, analyze the influencing factors, and explore their experiences regarding accessing, comprehending, evaluating, and applying online health information pertinent to gestational diabetes mellitus.

A sequential explanatory mixed methods research design was adopted in this study. Initially, 235 women with gestational diabetes mellitus participated in a cross-sectional survey. The research tools included general information and the Chinese version of the electronic Health Literacy Scale (eHEALS). Descriptive analyses were conducted to describe the characteristics of the sample, and multiple linear regression analyses were used to explore the factors influencing electronic health literacy among women with gestational diabetes mellitus. Secondly, 11 women with gestational diabetes mellitus joined semi-structured in-depth interviews to obtain their perceptions about online health information. The data were analyzed using inductive content analysis to develop themes.

The median score of eHEALS in the Chinese version among 235 women diagnosed with gestational diabetes mellitus was 29 (interquartile range [IQR], 26 to 32). Factors influencing electronic health literacy among these women included accessing health information from medical professionals (β = 0.137, p  = 0.029) and utilizing health information from applications (β = 0.159, p  = 0.013). From the qualitative phase of the study, four thematic categories emerged: reasons and basis for accessing health information from the Internet; address barriers to accessing and applying online health information; desires for a higher level of online health information services; outcomes of accessing and applying online health information.

The electronic health literacy of women diagnosed with gestational diabetes mellitus remains suboptimal and warrants improvement. The sources of access to health information affect electronic health literacy in women with gestational diabetes mellitus. Moreover, women facing gestational diabetes encounter numerous impediments when attempting to access health-related information online, underscoring the necessity for enhanced online health information services to meet their needs.

Peer Review reports

Gestational diabetes mellitus is a metabolic disorder occurring during pregnancy [ 1 ], primarily resulting from insulin resistance and the progressive dysfunction of pancreatic β-cell [ 2 ]. Symptoms of gestational diabetes mellitus often manifest insidiously, making detection challenging. Diagnosis typically occurs through the oral glucose tolerance test administered between the 24th and 28th weeks of gestation [ 3 ]. Although there have been some advancements in monitoring the fetal health of women with gestational diabetes [ 4 , 5 ], gestational diabetes mellitus remains one of the most important causes of adverse perinatal outcomes [ 6 , 7 ], which may also have a negative impact on maternal mental health [ 8 ]. To mitigate these adverse effects, a collaborative multidisciplinary approach is typically employed, with lifestyle and behavioral management serving as the preferred method of intervention [ 9 ]. Lifestyle and behavioral management strategies for gestational diabetes mellitus encompass a diverse array of medical knowledge, spanning medical nutrition therapy, physical activity recommendations, weight management strategies, and more [ 10 ]. Therefore, to effectively manage gestational diabetes mellitus, women typically require access to extensive health information regarding lifestyle and behavioral management strategies.

In recent years, with the development of information and communication technologies, electronic resources have been increasingly used in healthcare. The Internet, in particular, has emerged as a popular platform for accessing health information among women diagnosed with gestational diabetes mellitus [ 11 ]. However, despite the convenience afforded by the Internet for accessing health information, it is essential to acknowledge the challenges associated with online health information and services. These challenges include content duplication, the presence of unregulated information sources, inadequate quality control measures, and difficulty in verifying the credibility of information sources [ 12 ]. Therefore, for women managing gestational diabetes mellitus, discerning the most reliable and credible health information from the vast array of online resources is paramount.

According to Norman and Skinner, the ability of individuals to access reliable and credible health information from electronic resources hinges on their electronic health literacy, an extension of traditional health literacy within the digital realm [ 13 ]. Unlike traditional health literacy, which primarily emphasizes individual access to and understanding of health information [ 14 ], electronic health literacy focuses on the individual comprehensive ability to access, understand, and assess health information from electronic resources, and apply health information available online to address health issues or make health-related decisions [ 15 ]. Evidence suggests that individual electronic health literacy is positively associated with one’s health behaviors and health outcomes, including a higher level of medication adherence, psychosocial well-being, and quality of life, as well as adopting adaptive health behaviors [ 16 , 17 , 18 , 19 ]. Therefore, to enhance the health behaviors and outcomes of women diagnosed with gestational diabetes mellitus, a thorough understanding of their electronic health literacy is indispensable.

Most of the existing studies on electronic health literacy focus on adolescents, college students, and the elderly [ 20 , 21 , 22 ]. In recent years, a few researchers have explored electronic health literacy in people with chronic diseases and their caregivers, including cancer patients and their caregivers [ 23 , 24 ], individuals with systemic lupus erythematosus, and those diagnosed with diabetes [ 25 ]. To the best of our knowledge, there is relatively limited research on the electronic health literacy of pregnant women, and currently, no studies have investigated the electronic health literacy of women with gestational diabetes mellitus. Through a review of studies on electronic health literacy in other populations, it was found that demographic characteristics, pregnancy-related features, and sources of health information acquisition may influence the electronic health literacy of women with gestational diabetes mellitus, including factors such as age, education level, employment status, household income, residential location, gestational age, number of pregnancies, and online health information searching [ 26 , 27 , 28 , 29 , 30 , 31 ]. In addition, research on electronic health literacy is primarily quantitative, while comprehensive studies on the experience and needs related to electronic health information remain insufficient. Taking these factors into consideration, this study adopted a mixed-methods approach to investigate electronic health literacy among women with gestational diabetes mellitus. It thoroughly explored the factors that influence electronic health literacy in this population, while also delving into their experiences of accessing, comprehending, evaluating, and applying online health information. Based on the literature review above, before the study began, we hypothesized that demographic characteristics, pregnancy-related factors, and sources of health information acquisition are associated with the electronic health literacy of pregnant women with gestational diabetes.

A sequential explanatory mixed-methods research design was employed to investigate the current status of electronic health literacy and cognition of online health information among women diagnosed with gestational diabetes mellitus. This study is divided into two parts. The first part discusses the current status and influencing factors of electronic health literacy among women with gestational diabetes mellitus through quantitative analysis. In the second part, qualitative research was conducted to explore the perception and cognition of women with gestational diabetes mellitus on online health information.

Quantitative phase—questionnaire survey

Study design and setting.

The quantitative phase is a cross-sectional study conducted through questionnaire surveys. During this phase, we recruited pregnant women diagnosed with gestational diabetes mellitus from the obstetrics department of a tertiary maternity hospital in Wuhan City using a convenience sampling method. The inclusion criteria were as follows: (1) aged 18 years old and above; (2) diagnosed with gestational diabetes mellitus according to the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria; (3) native Chinese speakers or non-native Chinese speakers who could understand Chinese well; (4) no cognitive impairment and normal mental state; (5) signed informed consent. Exclusion criteria included the inability to complete the questionnaire due to poor physical condition.

The sample size for studies on variable influencing factors should be determined according to the requirements of statistical variable analysis, typically recommended to be at least 5 to 10 times the number of variables [ 32 ]. In this study, based on 19 variables (16 independent variables and the 3 dimensions of the electronic health literacy scale), the estimated sample size ranged from 95 to 190. Considering a 20% invalid questionnaire rate, this section ultimately included 235 participants.

Data collection

Data were obtained through a self-completed questionnaire between July 20, 2022 and September 10, 2022. The questionnaire included the collection of independent and dependent variable information. The collection of independent variable information was based on a review of previous studies, covering general data related to demographic characteristics, pregnancy features, and sources of obtaining healthcare information. The instrument for collecting dependent variable information is the Chinese version of the eHEALS.

The eHEALS is the original and most frequently used instrument for investigating electronic health literacy [ 33 ]. It was initially developed by Norman and Skinner in 2006 [ 34 ]. The Cronbach alpha coefficient of the original English version of eHEALS is 0.88. The Chinese version of eHEALS was translated by Guo in 2013 [ 35 ]. It consists of 3 dimensions with 8 items, scored on a 5-point Likert scale. The score of each item ranges from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating greater electronic health literacy. The Chinese version of eHEALS demonstrates good reliability and validity. Regarding reliability, the Cronbach’s α coefficient is 0.913 [ 35 ]. For validity, exploratory factor analysis reveals a KMO coefficient of 0.875 and a significant Bartlett’s test of sphericity with a χ2 value of 544.000 (df = 28); confirmatory factor analysis indicates factor loadings ranging from 0.692 to 0.869 [ 35 ]. In our study, the Cronbach’s alpha coefficient for eHEALS was 0.937.

Data analysis

IBM SPSS Statistics was employed for statistical analysis. Demographic and pregnancy characteristics of participants were presented using descriptive statistics. Continuous variables were described by means and standard deviations, or medians and interquartile, depending on the normality of the data. Categorical variables were described by frequencies and percentages. To investigate the correlation between general data and e-health literacy among pregnant women, univariate analysis was performed. Due to the non-normal distribution of the data, either the Mann-Whitney U test or Kruskal-Wallis H test was utilized. Subsequently, the general data of women with gestational diabetes mellitus ( p  < 0.05) from the univariate analysis were included as independent variables in a multiple linear regression model, with e-health literacy as the dependent variables, to explore the influencing factors of e-health literacy.

Qualitative phase—in-depth interviews

Study design and sample.

Qualitative data was collected through semi-structured in-depth interviews between September 1, 2022, and October 3, 2022. The sample size was determined based on the saturation principle, which means that sample recruitment continued until no new codes emerged [ 36 ]. Ultimately, a total of 11 participants were enrolled. Among these, four participants took part in both the qualitative and quantitative segments of the study, while the remaining seven exclusively contributed to the qualitative phase.

Before the interviews began, a survey was conducted on the personal basic information and electronic health literacy status of all 11 participants involved in the interviews.

The semi-structured interview instrument comprised 10 questions (Supplementary 1 ). The interview location was a quiet and clean reception room for pregnant women at the obstetrics clinic, which ensured the privacy of the interviews. Two researchers were involved: one recorded environmental information, interviewees’ non-verbal communication, and facial expressions, while the other conducted the interviews with pregnant women. Midway through the study, owing to the COVID-19 pandemic, researchers conducted interviews with pregnant women via online video calls. All interviews were audio-recorded and transcribed verbatim.

The qualitative data from 11 interview transcripts were coded using NVivo 11.0, and analyzed using the inductive content analysis method described by Elo and Kyngäs [ 37 ]. The process of inductive content analysis comprises three phases. Open coding (Phases 1): researchers immersed themselves in the text data, generating numerous notes and headings to capture the content comprehensively. Subsequently, the researchers organized the headings into coding sheets and freely generated categories. Creating categories (Phases 2): the researchers amalgamated akin or disparate categories into higher-order categories for reducing the number of categories. Abstraction (Phases 3): the researchers delineated research topics through the utilization of generalized descriptions, thereby shaping the themes.

Quantitative results

Description of the sample.

The eHEALS score in the Chinese version, obtained from 235 women diagnosed with gestational diabetes mellitus, spanned from 8 to 40, with a median score of 29 (IQR, 26 to 32). The median age of these participants was 31 (IQR, 29 to 34) years and their median gestational age was 34 (IQR, 32 to 36) weeks. All individuals involved in the study identified as Han Chinese. Further demographic and pregnancy characteristics of participants are shown in Table  1 .

Influencing factors of electronic health literacy in women with gestational diabetes mellitus

The results of single factor analysis indicated that educational status ( p  = 0.003), experience of accessing health information from clinicians or nurses ( p  = 0.022), experience of accessing health information from social forums or WeChat official accounts ( p  = 0.018), experience of accessing health information from applications ( p  = 0.016), experience of accessing health information from Internet pages ( p  = 0.046), and satisfaction with health information on the Internet ( p  = 0.002) had a statistically significant difference in electronic health literacy scores of women with gestational diabetes mellitus. The results are shown in Table  1 . Additionally, correlation analysis of gestational weeks and electronic health literacy scores showed that gestational weeks and electronic health literacy were not correlated in women with gestational diabetes mellitus ( p  = 0.346).

In the multiple linear regression analysis, the eHEALS score served as the dependent variable, while the statistically significant factors identified in the univariate analysis were considered independent variables. P  < 0.05 indicates statistical significance. Results showed that women with gestational diabetes mellitus who accessed health information from clinicians or nurses scored higher on the eHEALS than those who did not (β = 0.137, p  = 0.029). Similarly, women with gestational diabetes mellitus who accessed health information from applications demonstrated higher eHEALS scores than those who did not do (β = 0.159, p  = 0.013). These results are shown in Table  2 .

Qualitative findings

A total of 11 women with gestational diabetes mellitus participated in the interviews, designated with identifiers P1 to P11 based on the interview sequence. All interviewees were married and of Han nationality. Their age ranged from 27 to 36 years, with an average age of approximately 31 years. Three participants were in their second trimester, while the remaining were in their third trimester. Notably, only one interviewee, identified as P1, had prior pregnancy experience and already had one child. Furthermore, the ninth participant possessed a medical background and resided in a rural area. Among the participants, five individuals scored 32 points or more on the Chinese version of eHEALS (The score of eHEALS range from 26 to 40). The general information about the participants is presented in Supplementary 2 .

Based on the results of the interviews, a total of 4 themes and 12 sub-themes were identified. Supplementary 3 presents excerpts of selected quotes corresponding to each theme.

Reasons and basis for accessing health information from the internet

This theme revealed why and how women with gestational diabetes mellitus access health information from the Internet. They access information pertaining to maintaining a healthy pregnancy, managing their condition, monitoring fetal growth and development, and ensuring a successful delivery by utilizing Internet searches or subscribing to popular medical science articles disseminated via WeChat official accounts and pregnancy-related applications. The preference for electronic media among women with gestational diabetes mellitus is influenced by factors such as their previous information-seeking habits, recommendations from friends, and insights derived from data analysis. These information-seeking behaviors are motivated by concerns regarding health risks associated with disease exposure and perceived barriers to effective doctor-patient communication.

Reasons for accessing health information from the internet

The majority of interviewees reported actively seeking or passively receiving health information from the Internet. Their motivations included encountering abnormal prenatal examination results, experiencing personal or family physical discomfort, and lacking sufficient knowledge about various medical conditions.

Furthermore, some interviewees highlighted communication barriers between healthcare providers and patients, including distrust of doctors, dissatisfaction with their performance, and the impact of the COVID-19 pandemic, as factors prompting them to resort to the Internet for health information.

Basis for selecting electronic media providing health information

The interviewees utilize diverse electronic media platforms like Baidu, Little Red Book, and Baby Tree for accessing health information. Their choices are frequently influenced by previous preferences, recommendations from acquaintances, and the promotion of big data.

Address barriers to accessing and applying online health information

Many barriers impede women with gestational diabetes mellitus in accessing and applying health information available online, including advertising, inappropriate medical depth of health information, redundant and cluttered health information, conflicting opinions on the same health issue, wide period and content span for health information update, and difficulties in evaluating the quality, sources, and safety of online health information. In response, they adopted strategies to address these barriers, including asking for help, exploring and practicing independently, and assessing the credentials of health information providers.

Barriers abound

During the interviews, women with gestational diabetes mellitus indicated that they encountered many barriers in accessing information. Two interviewees noted excessive hidden advertisements in online health information. Additionally, two interviewees pointed out that the medical depth of the health information available online was inappropriate and they expressed that this health information was insufficient to address their health concerns. Furthermore, three interviewees expressed difficulty in making decisions due to the plethora of conflicting opinions encountered online regarding the same health issue. Two respondents highlighted that the frequency and scope of updates to online health information posed obstacles to their access. Three respondents expressed apprehensions regarding the quality, source, and safety of the information available online.

Respond to barriers

Whenever women with gestational diabetes mellitus encounter difficulties accessing valuable health information online or have doubts about the reliability of the information they find, they tend to seek guidance from individuals with more expertise or experience, such as hospital doctors, online healthcare professionals, and peers who have similar experiences. They said that if they did not know whether health information available online was credible, they would try to practice it personally and judge the truth of health information based on their health changes. In addition, they expressed that they would try to retrieve health information through multiple online sources, compare the information content, and finally trust the highly overlapping parts. Furthermore, they also evaluate the credibility of online health information by assessing the credentials of information providers.

Desires for a higher level of online health information services

Women diagnosed with gestational diabetes mellitus often turn to the Internet as a supplementary resource for obtaining health-related information, yet deficiencies persist within current online health information platforms. Their expressed aspirations for enhanced online health services manifest across four key dimensions, as outlined below.

Desires for online transmission media with simple design and easy-to-use search function

Women diagnosed with gestational diabetes mellitus express a preference for online health information platforms that prioritize user-friendly design and enhanced searchability. Such features streamline software navigation, thereby facilitating their information retrieval process.

Desires for diversified online transmission forms of health information

Women diagnosed with gestational diabetes mellitus expressed a clear preference for online health information dissemination to encompass not only simple textual descriptions but also incorporate videos and images, thereby enhancing the comprehensibility and appeal of the content.

Desires for online information platforms containing real cases and experience sharing

Women diagnosed with gestational diabetes mellitus articulated the wish for web-based platforms to feature shared experiences from pregnant women and real-life cases. This inclusion is seen as instrumental in fostering confidence in recovery, accessing credible health information, and gaining deeper insights into pregnancy-related matters.

Desires for online information platforms with strong interactivity and personalized health information push services

Women with gestational diabetes mellitus expressed their desire for the personalized push service of health information provided by the web-based platforms, preferably sending health information according to their pregnancy duration. They also seek increased interaction with medical professionals on web-based platforms to receive more personalized and relevant advice and guidance.

Outcomes of accessing and applying online health information

Women with gestational diabetes mellitus noted that applying and accessing online health information could not only enhance their health literacy but also foster greater awareness of adopting a healthy lifestyle and encourage increased involvement from their spouses. However, they also acknowledged potential adverse effects, such as heightened anxiety stemming from the treatment experiences shared by others.

Popularization of health knowledge

Women with gestational diabetes mellitus point out that accessing online health information has improved their health knowledge and helps them effectively control blood sugar levels.

Emotional feedback

Some women diagnosed with gestational diabetes mellitus remarked that the severity of the condition was often exaggerated on the Internet, leading to heightened anxiety. Furthermore, encountering accounts of successful disease management shared by others sometimes evoked feelings of self-doubt regarding their own ability to manage the condition, consequently causing stress and anxiety. Conversely, one woman with gestational diabetes mellitus expressed that upon encountering individuals facing similar health challenges online, she found solace in the shared experience of others facing similar struggles.

Increased awareness about adapting healthy lifestyles

Women diagnosed with gestational diabetes mellitus emphasized that their awareness of adopting healthy lifestyles had been heightened through their exploration of health information accessible on the Internet.

Increased husband’s sense of involvement and experience

Women diagnosed with gestational diabetes mellitus noted that their husbands also have the opportunity to access online health information, thereby enabling them to gain a deeper understanding of the pregnancy experience.

To the best of our knowledge, this is the first study to investigate electronic health literacy among women with gestational diabetes mellitus through a mixed-methods design. Our study indicates that the electronic health literacy of women with gestational diabetes warrants improvement. Additionally, we delved into reasons for seeking health information online, barriers encountered, aspirations for improved online health services, and the impacts of utilizing online health information.

In terms of the influencing factors on electronic health literacy, our results indicated that women with gestational diabetes mellitus who accessed health information from medical personnel scored higher on electronic health literacy compared to those who did not, which was inconsistent with Kim et al.‘s finding that there was no difference in electronic health literacy scores between those with type 2 diabetes who relied on health professionals for health information and those who did not [ 38 ]. One possible explanation for this discrepancy is the variation in disease self-management capabilities. The majority of people with type 2 diabetes surveyed had managed their diabetes for 1–10 years, while participants in our study were diagnosed with gestational diabetes for a maximum of three months. The duration of illness positively correlates with the level of self-management [ 39 ]. This suggests that gestational diabetes patients may have weaker disease self-management abilities compared to type 2 diabetes patients, leading to a greater need for healthcare professionals’ assistance in addressing more health issues and facilitating gestational diabetes women’s understanding and application of online health information [ 40 ]. Additionally, the reason for this outcome in our study may be attributed to inadequate communication between healthcare professionals and patients [ 41 ]. Evidence suggests that individuals turn to the internet for information when their health concerns are not addressed by healthcare providers during consultations [ 41 ]. In the qualitative portion of our study, some patients reported that their issues were not fully resolved after communication with healthcare providers or that new uncertainties arose from these interactions. Consequently, women diagnosed with gestational diabetes mellitus turn to the internet as an additional resource for health information, thereby augmenting their level of electronic health literacy [ 42 ].

The control of blood sugar levels is crucial for women with gestational diabetes mellitus, and continuous blood sugar monitoring, along with maintaining a healthy diet and lifestyle, is key to controlling blood sugar [ 43 , 44 , 45 , 46 ]. Our research findings indicate that by accessing online health information, women with gestational diabetes mellitus can gain a deeper understanding of information related to blood sugar control, thereby effectively managing their blood sugar levels. Amr Jamal et al. have also noted that patients who engage in online health information queries have a better understanding of diabetes-related knowledge and demonstrate stronger blood sugar management capabilities compared to those who do not [ 47 ]. Therefore, future research should continue to explore the impact of this online health information on blood sugar management among women with gestational diabetes mellitus, thus effectively improving the management and prognosis of the disease.

Studies have demonstrated that precise health guidance aids in both treating gestational diabetes and preventing its development in high-risk pregnant women [ 48 , 49 ]. Although the qualitative results of this study indicate that online health information searches play a role in health guidance, this depends on the quality of the information obtained. Accurate online medical information can assist patients in comprehending their condition and guide them toward suitable treatment options [ 50 ]. However, inaccurate or misleading information can result in confusion and treatment delays [ 51 ]. The results of our qualitative study showed that women with gestational diabetes mellitus were not competent in discerning the quality of health information available online. Therefore, it is necessary to evaluate the quality of online health information. Presently, several tools have been developed to assess the quality of websites providing health information, including DISCERN, HONcode, and CRAAP [ 52 ]. However, current investigations into the quality of online health information primarily focus on cancer patients [ 53 , 54 , 55 ], with relatively limited research on the quality of online health information for gestational diabetes. Future studies could address this gap to assist gestational diabetes women in better selecting online health information. Additionally, the authority of online health information publishers has a positive impact on the credibility of health information [ 56 ]. Medical professionals have traditionally been the primary source of health information for individuals, being widely regarded as the most authoritative [ 57 ]. In our study, participants expressed a greater willingness to trust online health information published by certified healthcare professionals. These indications suggest the necessity of encouraging healthcare professionals to take responsibility for providing online guidance and support to women with gestational diabetes, thereby facilitating their access to and utilization of high-quality online healthcare information.

In terms of the design of online health platforms, interviewees expressed desires for easy access to health information, receiving personalized push services of health information, and increased interaction with medical personnel through these platforms, aligning with findings by Nijland et al. [ 58 ]. These implied that at the outset of developing online health information platforms, platform designers need to consider how to deliver health information to users in an understandable and accessible manner, as well as how to tailor health information to users’ needs [ 59 ].

Due to the impact of the COVID-19 pandemic, we chose to conduct online video interviews with some participants. Compared to traditional offline interviews, online interviews offer more convenience in terms of time and space, but they also present some challenges [ 60 ]. Firstly, there are issues with internet connectivity, as online video interviews may be affected by network interruptions, thus disrupting the smooth progress of the interviews [ 61 ]. Secondly, online video interviews lack the emotional connection and interpersonal interaction of face-to-face communication, which may affect the richness of the information provided by the interviewees [ 62 ]. Lastly, due to issues with image quality and angles, online video interviews may not accurately capture the facial expressions and body language of the interviewees, thereby impacting the understanding and interpretation of the interview information [ 63 ]. The epidemic has sparked increased interest in video interviews, but video interviews should not be seen solely as expedient measures in response to the pandemic, but rather as an opportunity for long-term methodological advancement. Future research should further optimize the process of online video interviews to facilitate the development of virtual qualitative research methods.

Limitations

Some limitations needed to be reported. Firstly, the quantitative study utilized a self-assessment scale as the research instrument. Participants may have either exaggerated or minimized certain information to obtain more favorable results, potentially introducing reporting bias. Secondly, all participants were sourced from a single hospital, potentially impacting the generalizability of the findings. Lastly, participants who engaged in both quantitative and qualitative phases of the study appeared more prepared at qualitative interviews compared to those solely involved in the qualitative phase. This discrepancy may introduce bias into their responses.

Conclusions

Women with gestational diabetes mellitus have a low level of electronic health literacy and insufficient ability to assess online health information, and the source of health information could influence their electronic health literacy. They often accessed health information from the Internet due to perceived disease threats and blocked doctor-patient communication. Furthermore, they highlighted numerous barriers to accessing electronic health information and expressed a desire for enhanced quality in online information services. It is recommended to enhance doctor-patient communication and encourage medical staff to take on a guiding and supportive role to facilitate access to valuable information. Additionally, the development of assessment tools tailored to online health information suitable for women with gestational diabetes mellitus is proposed. Furthermore, improvements to online health information platforms are suggested to better align with user needs, thereby enhancing the electronic health literacy of women diagnosed with gestational diabetes mellitus.

Data availability

Owing to the confidentiality of the information, the datasets generated and analyzed in this study are not publicly available. Nevertheless, upon reasonable request, they can be made accessible through the corresponding author.

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Acknowledgements

We would like to thank all the pregnant women who participated in our study.

The Fundamental Research Funds for the Central Universities [grant number 2021PT073] supported this research.

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Jingqi Xu, Yujia Chen and Jing Zhao are considered as co-first authors.

Authors and Affiliations

School of Nursing, Wuhan University, No. 115, Donghu Road, Wuhan, Hubei, 430071, China

Jingqi Xu, Yujia Chen, Jing Zhao, Jiarun Wang, Jianfei Chen, Xinlong Pan, Wei Zhang, Zhijie Zou & Xiaoli Chen

Hospital of Stomatology, Wuhan University, 237 Luoyu Road, Wuhan, Hubei, 430079, China

Magnet Program & Nursing Research Department, UT Southwestern Medical Center, 8200 Brookriver Dr, Dallas, TX, 75247, USA

Yingzi Zhang

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Contributions

JX: Conceptualization, Methodology, Writing - Original Draft; YC: Methodology, Validation, Writing - Original Draft; JZ: Methodology, Investigation, Writing - Original Draft; JW: Methodology, Validation, Investigation; JC: Investigation, Data Curation; XP: Investigation, Data Curation; WZ: Validation, Data Curation; JZ: Conceptualization, Writing - Review & Editing, Supervision; ZZ: Conceptualization, Writing - Review & Editing, Supervision; XC: Conceptualization, Writing - Review & Editing, Supervision, Project administration; YZ: Validation, Data Curation.

Corresponding authors

Correspondence to Jin Zheng , Zhijie Zou or Xiaoli Chen .

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The study was conducted in accordance with the relevant guidelines and regulations outlined in the Declaration of Helsinki. All participants provided signed informed consent to participate in the study. Ethical approval for the study was granted by the Medical Ethics Committee of Wuhan University (2021YF0048).

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Participants were notified, at the time of signing their informed consent, that their data (including questionnaire information and audio recordings) would be encoded and utilized for the purpose of drafting and publishing the paper.

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The authors declare that they have no competing interests.

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Xu, J., Chen, Y., Zhao, J. et al. Current status of electronic health literacy among pregnant women with gestational diabetes mellitus and their perceptions of online health information: a mixed-methods study. BMC Pregnancy Childbirth 24 , 392 (2024). https://doi.org/10.1186/s12884-024-06594-w

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Received : 24 January 2024

Accepted : 20 May 2024

Published : 28 May 2024

DOI : https://doi.org/10.1186/s12884-024-06594-w

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• Gestational diabetes mellitus
• Electronic health literacy
• Online health information
• Pregnant women

BMC Pregnancy and Childbirth

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