mixed method case study research

• 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.

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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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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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A Correction to this article was published on 06 May 2019

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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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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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By blending both quantitative and qualitative data, mixed methods research allows for a more thorough exploration of a research question. It can answer complex research queries that cannot be solved with either qualitative or quantitative research .

Analyze your mixed methods research

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Mixed methods research combines the elements of two types of research: quantitative and qualitative.

Quantitative data is collected through the use of surveys and experiments, for example, containing numerical measures such as ages, scores, and percentages. 

Qualitative data involves non-numerical measures like beliefs, motivations, attitudes, and experiences, often derived through interviews and focus group research to gain a deeper understanding of a research question or phenomenon.

Mixed methods research is often used in the behavioral, health, and social sciences, as it allows for the collection of numerical and non-numerical data.

• When to use mixed methods research

Mixed methods research is a great choice when quantitative or qualitative data alone will not sufficiently answer a research question. By collecting and analyzing both quantitative and qualitative data in the same study, you can draw more meaningful conclusions. 

There are several reasons why mixed methods research can be beneficial, including generalizability, contextualization, and credibility. 

For example, let's say you are conducting a survey about consumer preferences for a certain product. You could collect only quantitative data, such as how many people prefer each product and their demographics. Or you could supplement your quantitative data with qualitative data, such as interviews and focus groups , to get a better sense of why people prefer one product over another.

It is important to note that mixed methods research does not only mean collecting both types of data. Rather, it also requires carefully considering the relationship between the two and method flexibility.

You may find differing or even conflicting results by combining quantitative and qualitative data . It is up to the researcher to then carefully analyze the results and consider them in the context of the research question to draw meaningful conclusions.

When designing a mixed methods study, it is important to consider your research approach, research questions, and available data. Think about how you can use different techniques to integrate the data to provide an answer to your research question.

• Mixed methods research design

A mixed methods research design  is   an approach to collecting and analyzing both qualitative and quantitative data in a single study.

Mixed methods designs allow for method flexibility and can provide differing and even conflicting results. Examples of mixed methods research designs include convergent parallel, explanatory sequential, and exploratory sequential.

By integrating data from both quantitative and qualitative sources, researchers can gain valuable insights into their research topic . For example, a study looking into the impact of technology on learning could use surveys to measure quantitative data on students' use of technology in the classroom. At the same time, interviews or focus groups can provide qualitative data on students' experiences and opinions.

• Types of mixed method research designs

Researchers often struggle to put mixed methods research into practice, as it is challenging and can lead to research bias. Although mixed methods research can reveal differences or conflicting results between studies, it can also offer method flexibility.

Designing a mixed methods study can be broken down into four types: convergent parallel, embedded, explanatory sequential, and exploratory sequential.

Convergent parallel

The convergent parallel design is when data collection and analysis of both quantitative and qualitative data occur simultaneously and are analyzed separately. This design aims to create mutually exclusive sets of data that inform each other. 

For example, you might interview people who live in a certain neighborhood while also conducting a survey of the same people to determine their satisfaction with the area.

Embedded design

The embedded design is when the quantitative and qualitative data are collected simultaneously, but the qualitative data is embedded within the quantitative data. This design is best used when you want to focus on the quantitative data but still need to understand how the qualitative data further explains it.

For instance, you may survey students about their opinions of an online learning platform and conduct individual interviews to gain further insight into their responses.

Explanatory sequential design

In an explanatory sequential design, quantitative data is collected first, followed by qualitative data. This design is used when you want to further explain a set of quantitative data with additional qualitative information.

An example of this would be if you surveyed employees at a company about their satisfaction with their job and then conducted interviews to gain more information about why they responded the way they did.

Exploratory sequential design

The exploratory sequential design collects qualitative data first, followed by quantitative data. This type of mixed methods research is used when the goal is to explore a topic before collecting any quantitative data.

An example of this could be studying how parents interact with their children by conducting interviews and then using a survey to further explore and measure these interactions.

Integrating data in mixed methods studies can be challenging, but it can be done successfully with careful planning.

No matter which type of design you choose, understanding and applying these principles can help you draw meaningful conclusions from your research.

• Strengths of mixed methods research

Mixed methods research designs combine the strengths of qualitative and quantitative data, deepening and enriching qualitative results with quantitative data and validating quantitative findings with qualitative data. This method offers more flexibility in designing research, combining theory generation and hypothesis testing, and being less tied to disciplines and established research paradigms.

Take the example of a study examining the impact of exercise on mental health. Mixed methods research would allow for a comprehensive look at the issue from different angles. 

Researchers could begin by collecting quantitative data through surveys to get an overall view of the participants' levels of physical activity and mental health. Qualitative interviews would follow this to explore the underlying dynamics of participants' experiences of exercise, physical activity, and mental health in greater detail.

Through a mixed methods approach, researchers could more easily compare and contrast their results to better understand the phenomenon as a whole.  

Additionally, mixed methods research is useful when there are conflicting or differing results in different studies. By combining both quantitative and qualitative data, mixed methods research can offer insights into why those differences exist.

For example, if a quantitative survey yields one result while a qualitative interview yields another, mixed methods research can help identify what factors influence these differences by integrating data from both sources.

Overall, mixed methods research designs offer a range of advantages for studying complex phenomena. They can provide insight into different elements of a phenomenon in ways that are not possible with either qualitative or quantitative data alone. Additionally, they allow researchers to integrate data from multiple sources to gain a deeper understanding of the phenomenon in question.  

• Challenges of mixed methods research

Mixed methods research is labor-intensive and often requires interdisciplinary teams of researchers to collaborate. It also has the potential to cost more than conducting a stand alone qualitative or quantitative study . 

Interpreting the results of mixed methods research can be tricky, as it can involve conflicting or differing results. Researchers must find ways to systematically compare the results from different sources and methods to avoid bias.

For example, imagine a situation where a team of researchers has employed an explanatory sequential design for their mixed methods study. After collecting data from both the quantitative and qualitative stages, the team finds that the two sets of data provide differing results. This could be challenging for the team, as they must now decide how to effectively integrate the two types of data in order to reach meaningful conclusions. The team would need to identify method flexibility and be strategic when integrating data in order to draw meaningful conclusions from the conflicting results.

• Advanced frameworks in mixed methods research

Mixed methods research offers powerful tools for investigating complex processes and systems, such as in health and healthcare.

Besides the three basic mixed method designs—exploratory sequential, explanatory sequential, and convergent parallel—you can use one of the four advanced frameworks to extend mixed methods research designs. These include multistage, intervention, case study , and participatory. 

This framework mixes qualitative and quantitative data collection methods in stages to gather a more nuanced view of the research question. An example of this is a study that first has an online survey to collect initial data and is followed by in-depth interviews to gain further insights.

Intervention

This design involves collecting quantitative data and then taking action, usually in the form of an intervention or intervention program. An example of this could be a research team who collects data from a group of participants, evaluates it, and then implements an intervention program based on their findings .

This utilizes both qualitative and quantitative research methods to analyze a single case. The researcher will examine the specific case in detail to understand the factors influencing it. An example of this could be a study of a specific business organization to understand the organizational dynamics and culture within the organization.

Participatory

This type of research focuses on the involvement of participants in the research process. It involves the active participation of participants in formulating and developing research questions, data collection, and analysis.

An example of this could be a study that involves forming focus groups with participants who actively develop the research questions and then provide feedback during the data collection and analysis stages.

The flexibility of mixed methods research designs means that researchers can choose any combination of the four frameworks outlined above and other methodologies , such as convergent parallel, explanatory sequential, and exploratory sequential, to suit their particular needs.

Through this method's flexibility, researchers can gain multiple perspectives and uncover differing or even conflicting results when integrating data.

When it comes to integration at the methods level, there are four approaches.

Connecting involves collecting both qualitative and quantitative data during different phases of the research.

Building involves the collection of both quantitative and qualitative data within a single phase.

Merging involves the concurrent collection of both qualitative and quantitative data.

Embedding involves including qualitative data within a quantitative study or vice versa.

• Techniques for integrating data in mixed method studies

Integrating data is an important step in mixed methods research designs. It allows researchers to gain further understanding from their research and gives credibility to the integration process. There are three main techniques for integrating data in mixed methods studies: triangulation protocol, following a thread, and the mixed methods matrix.

Triangulation protocol

This integration method combines different methods with differing or conflicting results to generate one unified answer.

For example, if a researcher wanted to know what type of music teenagers enjoy listening to, they might employ a survey of 1,000 teenagers as well as five focus group interviews to investigate this. The results might differ; the survey may find that rap is the most popular genre, whereas the focus groups may suggest rock music is more widely listened to. 

The researcher can then use the triangulation protocol to come up with a unified answer—such as that both rap and rock music are popular genres for teenage listeners. 

Following a thread

This is another method of integration where the researcher follows the same theme or idea from one method of data collection to the next. 

A research design that follows a thread starts by collecting quantitative data on a specific issue, followed by collecting qualitative data to explain the results. This allows whoever is conducting the research to detect any conflicting information and further look into the conflicting information to understand what is really going on.

For example, a researcher who used this research method might collect quantitative data about how satisfied employees are with their jobs at a certain company, followed by qualitative interviews to investigate why job satisfaction levels are low. They could then use the results to explore any conflicting or differing results, allowing them to gain a deeper understanding of job satisfaction at the company. 

By following a thread, the researcher can explore various research topics related to the original issue and gain a more comprehensive view of the issue.

Mixed methods matrix

This technique is a visual representation of the different types of mixed methods research designs and the order in which they should be implemented. It enables researchers to quickly assess their research design and adjust it as needed. 

The matrix consists of four boxes with four different types of mixed methods research designs: convergent parallel, explanatory sequential, exploratory sequential, and method flexibility. 

For example, imagine a researcher who wanted to understand why people don't exercise regularly. To answer this question, they could use a convergent parallel design, collecting both quantitative (e.g., survey responses) and qualitative (e.g., interviews) data simultaneously.

If the researcher found conflicting results, they could switch to an explanatory sequential design and collect quantitative data first, then follow up with qualitative data if needed. This way, the researcher can make adjustments based on their findings and integrate their data more effectively.

Mixed methods research is a powerful tool for understanding complex research topics. Using qualitative and quantitative data in one study allows researchers to understand their subject more deeply. 

Mixed methods research designs such as convergent parallel, explanatory sequential, and exploratory sequential provide method flexibility, enabling researchers to collect both types of data while avoiding the limitations of either approach alone.

However, it's important to remember that mixed methods research can produce differing or even conflicting results, so it's important to be aware of the potential pitfalls and take steps to ensure that data is being correctly integrated. If used effectively, mixed methods research can offer valuable insight into topics that would otherwise remain largely unexplored.

What is an example of mixed methods research?

An example of mixed methods research is a study that combines quantitative and qualitative data. This type of research uses surveys, interviews, and observations to collect data from multiple sources.

Which sampling method is best for mixed methods?

It depends on the research objectives, but a few methods are often used in mixed methods research designs. These include snowball sampling, convenience sampling, and purposive sampling. Each method has its own advantages and disadvantages.

What is the difference between mixed methods and multiple methods?

Mixed methods research combines quantitative and qualitative data in a single study. Multiple methods involve collecting data from different sources, such as surveys and interviews, but not necessarily combining them into one analysis. Mixed methods offer greater flexibility but can lead to differing or conflicting results when integrating data.

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• Mixed methods research: expanding the evidence base
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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.

Provenance and peer review Commissioned; internally peer reviewed.

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Qualitative Research

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Designing and Analyzing Multi-Method Data / Conducting Mixed Methods Research

• RWJF - Qualitative Research Guidelines Project | Common Analytical Approaches | Common Analytical Approaches

Broad Approaches: Cohen D, Crabtree B. "Qualitative Research Guidelines Project." July 2006.  http://www.qualres.org/HomeComm-3821.html

Concurrent design

• Definition : two independent studies are conducted on the same study population, and the results are converged. For example, interventions might be enhanced if the researchers concurrently conduct an interpretive study to examine the process of implementing the intervention or improvement.

Nested design

• Definition : qualitative and quantitative methods can be integrated into a single research study. For example, qualitative studies can be used to understand and operationalize key variables while outcomes are evaluated.

Sequential design

• Definition : the result of one method informs the results of another study. For example, field methods can be used to develop key variables before developing measurement instruments.

Combination design

• Definition : case study design that combines multiple methods to understand the complexity of a setting. For example, a researcher may combine field methods sequentially with survey techniques, interviewing, and record or chart review.
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Systematic review on the frequency and quality of reporting patient and public involvement in patient safety research

• Sahar Hammoud   ORCID: orcid.org/0000-0003-4682-9001 1 ,
• Laith Alsabek 1 , 2 ,
• Lisa Rogers 1 &
• Eilish McAuliffe 1  

BMC Health Services Research volume  24 , Article number:  532 ( 2024 ) Cite this article

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In recent years, patient and public involvement (PPI) in research has significantly increased; however, the reporting of PPI remains poor. The Guidance for Reporting Involvement of Patients and the Public (GRIPP2) was developed to enhance the quality and consistency of PPI reporting. The objective of this systematic review is to identify the frequency and quality of PPI reporting in patient safety (PS) research using the GRIPP2 checklist.

Searches were performed in Ovid MEDLINE, EMBASE, PsycINFO, and CINAHL from 2018 to December, 2023. Studies on PPI in PS research were included. We included empirical qualitative, quantitative, mixed methods, and case studies. Only articles published in peer-reviewed journals in English were included. The quality of PPI reporting was assessed using the short form of the (GRIPP2-SF) checklist.

A total of 8561 studies were retrieved from database searches, updates, and reference checks, of which 82 met the eligibility criteria and were included in this review. Major PS topics were related to medication safety, general PS, and fall prevention. Patient representatives, advocates, patient advisory groups, patients, service users, and health consumers were the most involved. The main involvement across the studies was in commenting on or developing research materials. Only 6.1% ( n  = 5) of the studies reported PPI as per the GRIPP2 checklist. Regarding the quality of reporting following the GRIPP2-SF criteria, our findings show sub-optimal reporting mainly due to failures in: critically reflecting on PPI in the study; reporting the aim of PPI in the study; and reporting the extent to which PPI influenced the study overall.

Conclusions

Our review shows a low frequency of PPI reporting in PS research using the GRIPP2 checklist. Furthermore, it reveals a sub-optimal quality in PPI reporting following GRIPP2-SF items. Researchers, funders, publishers, and journals need to promote consistent and transparent PPI reporting following internationally developed reporting guidelines such as the GRIPP2. Evidence-based guidelines for reporting PPI should be encouraged and supported as it helps future researchers to plan and report PPI more effectively.

Trial registration

The review protocol is registered with PROSPERO (CRD42023450715).

Peer Review reports

Patient safety (PS) is defined as “the absence of preventable harm to a patient and reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum” [ 1 ]. It is estimated that one in 10 patients are harmed in healthcare settings due to unsafe care, resulting in over three million deaths annually [ 2 ]. More than 50% of adverse events are preventable, and half of these events are related to medications [ 3 , 4 ]. There are various types of adverse events that patients can experience such as medication errors, patient falls, healthcare-associated infections, diagnostic errors, pressure ulcers, unsafe surgical procedures, patient misidentification, and others [ 1 ].

Over the last few decades, the approach of PS management has shifted toward actively involving patients and their families in managing PS. This innovative approach has surpassed the traditional model where healthcare providers were the sole managers of PS [ 5 ]. Recent research has shown that patients have a vital role in promoting their safety and decreasing the occurrence of adverse events [ 6 ]. Hence, there is a growing recognition of patient and family involvement as a promising method to enhance PS [ 7 ]. This approach includes involving patients in PS policy development, research, and shared decision making [ 1 ].

In the last decade, research involving patients and the public has significantly increased. In the United Kingdom (U.K), the National Institute for Health Research (NIHR) has played a critical role in providing strategic and infrastructure support to integrate Public and Patient Involvement (PPI) throughout publicly funded research [ 8 ]. This has established a context where PPI is recognised as an essential element in research [ 9 ]. In Ireland, the national government agency responsible for the management and delivery of all public health and social services; the National Health Service Executive (HSE) emphasise the importance of PPI in research and provide guidance for researchers on how to involve patients and public in all parts of the research cycle and knowledge translation process [ 10 ]. Similar initiatives are also developing among other European countries, North America, and Australia. However, despite this significant expansion of PPI research, the reporting of PPI in research articles continues to be sub-optimal, inconsistent, and lacks essential information on the context, process, and impact of PPI [ 9 ]. To address this problem, the Guidance for Reporting Involvement of Patients and the Public (GRIPP) was developed in 2011 following the EQUATOR methodology to enhance the quality, consistency, and transparency of PPI reporting. Additionally, to provide guidance for researchers, patients, and the public to advance the quality of the international PPI evidence-base [ 11 ]. The first GRIPP checklist was a significant start in producing higher-quality PPI reporting; however, it was developed following a systematic review, and did not include any input from the international PPI research community. Given the importance of reaching consensus in generating current reporting guidelines, a second version of the GRIPP checklist (GRIPP2) was developed to tackle this problem by involving the international PPI community in its development [ 9 ]. There are two versions of the GRIPP2 checklist, a long form (GRIPP2-LF) for studies with PPI as the primary focus, and a short form (GRIPP2-SF) for studies with PPI as secondary or tertiary focus.

Since the publication of the GRIPP2 checklist, several systematic reviews have been conducted to assess the quality of PPI reporting on various topics. For instance, Bergin et al. in their review to investigate the nature and impact of PPI in cancer research, reported a sub-optimal quality of PPI reporting using the GRIPP2-SF, mainly due to failure to address PPI challenges [ 12 ]. Similarly, Owyang et al. in their systematic review to assess the prevalence, extent, and quality of PPI in orthopaedic practice, described a poor PPI reporting following the GRIPP2-SF checklist criteria [ 13 ]. While a few systematic reviews have been conducted to assess theories, strategies, types of interventions, and barriers and enablers of PPI in PS [ 5 , 14 , 15 , 16 ], no previous review has assessed the quality of PPI reporting in PS research. Thus, our systematic review aims to address this knowledge gap. The objective of this review is to identify the frequency PPI reporting in PS research using the GRIPP2 checklist from 2018 (the year after GRIPP2 was published) and the quality of reporting following the GRIPP2-SF. The GRIPP2 checklist was chosen as the benchmark as it is the first international, evidence-based, community consensus informed guideline for the reporting of PPI in research and more specifically in health and social care research [ 9 ]. Additionally, it is the most recent report-focused framework and the most recommended by several leading journals [ 17 ].

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to plan and report this review [ 18 ]. The review protocol was published on PROSPERO the International Database of Prospectively Registered Systematic Reviews in August 2023 (CRD42023450715).

Search strategy

For this review, we used the PICo framework to define the key elements in our research. These included articles on patients and public (P-Population) involvement (I- phenomenon of Interest) in PS (C-context). Details are presented in Table  1 . Four databases were searched including Ovid MEDLINE, EMBASE, PsycINFO, and CINAHL to identify papers on PPI in PS research. A systematic search strategy was initially developed using MEDLINE. MeSH terms and keywords relevant to specific categories (e.g., patient safety) were combined using the “OR” Boolean term (i.e. patient safety OR adverse event OR medical error OR surgical error) and categories were then combined using the “AND” Boolean term. (i.e. “patient and public involvement” AND “patient safety”). The search strategy was adapted for the other three databases. Full search strategies are provided in Supplementary file 1 . The search was conducted on July 27th, 2023, and was limited to papers published from 2018. As the GRIPP2 tool was published in 2017, this limit ensured the retrieval of relevant studies. An alert system was set on the four databases to receive all new published studies until December 2023, prior to the final analysis. The search was conducted without restrictions on study type, research design, and language. To reduce selection bias, hand searching was carried out on the reference lists of all the eligible articles in the later stages of the review. This was done by the first author. The search strategy was developed by the first author and confirmed by the research team and a Librarian. The database search was conducted by the first author.

Inclusion and exclusion criteria

Studies on PPI in PS research with a focus on health/healthcare were included in this review. We defined PPI as active involvement which is in line with the NIHR INVOLVE definition as “research being carried out ‘with’ or ‘by’ members of the public rather than ‘to’, ‘about’ or ‘for’ them” [ 19 ]. This includes any PPI including, being a co-applicant on a research project or grant application, identifying research priorities, being a member of an advisory or steering group, participating in developing research materials or giving feedback on them, conducting interviews with study participants, participating in recruitment, data collection, data analysis, drafting manuscripts and/or dissemination of results. Accordingly, we excluded studies where patients or the public were only involved as research participants.

We defined patients and public to include patients, relatives, carers, caregivers and community, which is also in line with the NIHR PPI involvement in National Health Service [ 19 ].

Patient safety included topics on medication safety, adverse events, communication, safety culture, diagnostic errors, and others. A full list of the used terms for PPI and PS is provided in Supplementary file 1 . Regarding the research type and design, we included empirical qualitative, quantitative, mixed methods, and case studies. Only articles published in peer-reviewed journals and in English were included.

Any article that did not meet the inclusion criteria was excluded. Studies not reporting outcomes were excluded. Furthermore, review papers, conference abstracts, letters to editor, commentary, viewpoints, and short communications were excluded. Finally, papers published prior to 2018 were excluded.

Study selection

The selection of eligible studies was done by the first and the second authors independently, starting with title and abstracts screening to eliminate papers that failed to meet our inclusion criteria. Then, full text screening was conducted to decide on the final included papers in this review. Covidence, an online data management system supported the review process, ensuring reviewers were blinded to each other’s decisions. Disagreements between reviewers were discussed first, in cases where the disagreement was not resolved, the fourth author was consulted.

Data extraction and analysis

A data extraction sheet was developed using excel then piloted, discussed with the research team and modified as appropriate. The following data were extracted: citation and year of publication, objective of the study, country, PS topic, design, setting, PPI participants, PPI stages (identifying research priorities, being a member of an advisory or steering group, etc.…), frequency of PPI reporting as per the GRIPP2 checklist, and the availability of a plain language summary. Additionally, data against the five items of GRIPP2-SF (aim of PPI in the study, methods used for PPI, outcomes of PPI including the results and the extent to which PPI influenced the study overall, and reflections on PPI) were extracted. To avoid multiple publication bias and missing outcomes, data extraction was done by the first and the second authors independently and then compared. Disagreements between reviewers were first discussed, and then resolved by the third and fourth authors if needed.

Quality assessment

The quality of PPI reporting was assessed using GRIPP2-SF developed by Staniszewska et al. [ 9 ] as it is developed to improve the quality, consistency, and reporting of PPI in social and healthcare research. Additionally the GRIPP2-SF is suitable for all studies regardless of whether PPI is the primary, secondary, or tertiary focus, whereas the GRIPP2-LF is not suitable for studies where PPI serves as a secondary or tertiary focus. The checklist includes five items (mentioned above) that authors should include in their studies. It is important to mention that Staniszewska et al. noted that “while GRIPP2-SF aims to guide consistent reporting, it is not possible to be prescriptive about the exact content of each item, as the current evidence-base is not advanced enough to make this possible” ([ 9 ] p5). For that reason, we had to develop criteria for scoring the five reporting items. We used three scoring as Yes, No, and partial for each of the five items of the GRIPP2-SF. Yes, was given when authors presented PPI information on the item clearly in the paper. No, when no information was provided, and partial when the information partially met the item requirement. For example, as per GRIPP2-SF authors should provide a clear description of the methods used for PPI in the study. In the example given by Staniszewska et al., information on patient/public partners and how many of them were provided, as well as the stages of the study they were involved in (i.e. refining the focus of the research questions, developing the search strategy, interpreting results). Thus, in our evaluation of the included studies, we gave a yes if information on PPI participants (i.e. patient partners, community partners, or family members etc..) and how many of them were involved was provided, and information on the stages or actions of their involvement in the study was provided. However, we gave a “partial” if information was not fully provided (i.e. information on patient/public partners and how many were involved in the study without describing in what stages or actions they were involved, and vice versa), and a “No” if no information was presented at all.

The quality of PPI reporting was done by the first and the second authors independently and then compared. Disagreements between reviewers were first discussed, and then resolved by the third and fourth author when needed.

Assessing the quality or risk of bias of the included studies was omitted, as the focus in this review was on appraising the quality of PPI reporting rather than assessing the quality of each research article.

Data synthesis

After data extraction, a table summarising the included studies was developed. Studies were compared according to the main outcomes of the review; frequency of PPI reporting following the GRIPP2 checklist and the quality of reporting as per GRIPP2-SF five items, and the availability of a plain language summary.

Search results and study selection

The database searches yielded a total of 8491 studies. First, 2496 were removed as duplicates. Then, after title and abstract screening, 5785 articles were excluded leaving 210 articles eligible for the full text review. After a careful examination, 68 of these studies were included in this review. A further 38 studies were identified from the alert system that was set on the four databases and 32 studies from the reference check of the included studies. Of these 70 articles, 56 were further excluded and 14 were added to the previous 68 included studies. Thus, 82 studies met the inclusion criteria and were included in this review. A summary of the database search results and the study selection process are presented in Fig.  1 .

PRISMA flow diagram of the study selection process. The PRISMA flow diagram details the review search results and selection process

Overview of included studies

Details of the study characteristics including first author and year of publication, objective, country, study design, setting, PS topic, PPI participants and involvement stages are presented in Supplementary file 2 . The majority of the studies were conducted in the U.K ( n  = 24) and the United States of America ( n  = 18), with the remaining 39 conducted in other high income countries, the exception being one study in Haiti. A range of study designs were identified, the most common being qualitative ( n  = 31), mixed methods ( n  = 13), interventional ( n  = 5), and quality improvement projects ( n  = 4). Most PS topics concerned medication safety ( n  = 17), PS in general (e.g., developing a PS survey or PS management application) ( n  = 14), fall prevention ( n  = 13), communication ( n  = 11), and adverse events ( n  = 10), with the remaining PS topics listed in Supplementary file 2 .

Patient representatives, advocates, and patient advisory groups ( n  = 33) and patients, service users, and health consumers ( n  = 32) were the main groups involved. The remaining, included community members/ organisations. Concerning PPI stages, the main involvement across the studies was in commenting on or developing research materials ( n  = 74) including, patient leaflets, interventional tools, mobile applications, and survey instruments. Following this stage, involvement in data analysis, drafting manuscripts, and disseminating results ( n  = 30), and being a member of a project advisory or steering group ( n  = 18) were the most common PPI evident in included studies. Whereas the least involvement was in identifying research priorities ( n  = 5), and being a co-applicant on a research project or grant application ( n  = 6).

Regarding plain language summary, only one out of the 82 studies (1.22%) provided a plain language summary in their paper [ 20 ].

Frequency and quality of PPI reporting

The frequency of PPI reporting following the GRIPP2 checklist was 6.1%, where only five of the 82 included studies reported PPI in their papers following the GRIPP2 checklist. The quality of PPI reporting in those studies is presented in Table  2 . Of these five studies, one study (20%) did not report the aim of PPI in the study and one (20%) did not comment on the extent to which PPI influenced the study overall.

The quality of PPI reporting of the remaining 77 studies is presented in Table  3 . The aim of PPI in the study was reported in 62.3% of articles ( n  = 48), while 3.9% ( n  = 3) partially reported this. A clear description of the methods used for PPI in the study was reported in 79.2% of papers ( n  = 61) and partially in 20.8% ( n  = 16). Concerning the outcomes, 81.8% of papers ( n  = 63) reported the results of PPI in the study, while 10.4% ( n  = 8) partially did. Of the 77 studies, 68.8% ( n  = 53) reported the extent to which PPI influenced the study overall and 3.9% ( n  = 3) partially reported this. Finally, 57.1% ( n  = 44) of papers critically reflected on the things that went well and those that did not and 2.6% ( n  = 2) partially reflected on this.

Summary of main findings

This systematic review assessed the frequency of reporting PPI in PS research using the GRIPP2 checklist and quality of reporting using the GRIPP2-SF. In total, 82 studies were included in this review. Major PS topics were related to medication safety, general PS, and fall prevention. Patient representatives, advocates, patient advisory groups, patients, service users, and health consumers were the most involved. The main involvement across the studies was in commenting on or developing research materials such as educational and interventional tools, survey instruments, and applications while the least was in identifying research priorities and being a co-applicant on a research project or grant application. Thus, significant effort is still needed to involve patients and the public in the earlier stages of the research process given the fundamental impact of PS on their lives.

Overall completeness and applicability of evidence

A low frequency of reporting PPI in PS research following the GRIPP2 guidelines was revealed in this review, where only five of the 82 studies included mentioned that PPI was reported as per the GRIPP2 checklist. This is despite it being the most recent report-focused framework and the most recommended by several leading journals [ 17 ]. This was not surprising as similar results were reported in recent reviews in other healthcare topics. For instance, Musbahi et al. in their systematic review on PPI reporting in bariatric research reported that none of the 90 papers identified in their review mentioned or utilised the GRIPP2 checklist [ 102 ]. Similarly, a study on PPI in orthodontic research found that none of the 363 included articles reported PPI against the GRIPP2 checklist [ 103 ].

In relation to the quality of reporting following the GRIPP2-SF criteria, our findings show sub-optimal reporting within the 77 studies that did not use GRIPP2 as a guide/checklist to report their PPI. Similarly, Bergin et al. in their systematic review to investigate the nature and impact of PPI in cancer research concluded that substandard reporting was evident [ 12 ]. In our review, this was mainly due to failure to meet three criteria. First, the lowest percentage of reporting (57.1%, n  = 44) was related to critical reflection on PPI in the study (i.e., what went well and what did not). In total, 31 studies (42.9%) did not provide any information on this, and two studies were scored as partial. The first study mentioned that only involving one patient was a limitation [ 27 ] and the other stated that including three patients in the design of the tool was a strength [ 83 ]. Both studies did not critically comment or reflect on these points so that future researchers are able to avoid such problems and enhance PPI opportunities. For instance, providing the reasons/challenges behind the exclusive inclusion of a single patient and explaining how this limits the study findings and conclusion would help future researchers to address these challenges. Likewise, commenting on why incorporating three patients in the design of the study tool could be seen as a strength would have been beneficial. This could be, fostering diverse perspectives and generating novel ideas for developing the tool. Similar to our findings, Bergin et al. in their systematic review reported that 40% of the studies failed to meet this criterion [ 12 ].

Second, only 48 out of 77 articles (62.3%) reported the aim of PPI in their study, which is unlike the results of Bergin et al. where most of the studies (93.1%) in their review met this criterion [ 12 ]. Of the 29 studies which did not meet this criterion in our review, few mentioned in their objective developing a consensus-based instrument [ 41 ], reaching a consensus on the patient-reported outcomes [ 32 ], obtaining international consensus on a set of core outcome measures [ 98 ], and facilitating a multi-stakeholder dialogue [ 71 ] yet, without indicating anything in relation to patients, patient representatives, community members, or any other PPI participants. Thus, the lack of reporting the aim of PPI was clearly evident in this review. Reporting the aim of PPI in the study is crucial for promoting transparency, methodological rigor, reproducibility, and impact assessment of the PPI.

Third, 68.8% ( n  = 53) of the studies reported the extent to which PPI influenced the study overall including positive and negative effects if any. This was again similar to the findings of Bergin et al., where 38% of the studies did not meet this criterion mainly due to a failure to address PPI challenges in their respective studies [ 12 ]. Additionally, Owyang et al. in their review on the extent, and quality of PPI in orthopaedic practice, also described a poor reporting of PPI impact on research [ 13 ]. As per the GRIPP2 guidelines, both positive and negative effects of PPI on the study should be reported when applicable. Providing such information is essential as it enhances future research on PPI in terms of both practice and reporting.

Reporting a clear description of the methods used for PPI in the study was acceptable, with 79.2% of the papers meeting this criterion. Most studies provided information in the methods section of their papers on the PPI participants, their number, stages of their involvement and how they were involved. Providing clear information on the methods used for PPI is vital to give the reader a clear understanding of the steps taken to involve patients, and for other researchers to replicate these methods in future research. Additionally, reporting the results of PPI in the study was also acceptable with 81.8% of the papers reporting the outcomes of PPI in the results section. Reporting the results of PPI is important for enhancing methodological transparency, providing a more accurate interpretation for the study findings, contributing to the overall accountability and credibility of the research, and informing decision making.

Out of the 82 studies included in this review, only one study provided a plain language summary. We understand that PS research or health and medical research in general is difficult for patients and the public to understand given their diverse health literacy and educational backgrounds. However, if we expect patients and the public to be involved in research then, it is crucial to translate this research that has a huge impact on their lives into an easily accessible format. Failing to translate the benefits that such research may have on patient and public lives may result in them underestimating the value of this research and losing interest in being involved in the planning or implementation of future research [ 103 ]. Thus, providing a plain language summary for research is one way to tackle this problem. To our knowledge, only a few health and social care journals (i.e. Cochrane and BMC Research Involvement and Engagement) necessitate a plain language summary as a submission requirement. Having this as a requirement for submission is crucial in bringing the importance of this issue to researchers’ attention.

Research from recent years suggests that poor PPI reporting in articles relates to a lack of submission requirements for PPI reporting in journals and difficulties with word limits for submitted manuscripts [ 13 ]. Price et al. assessed the frequency of PPI reporting in published papers before and after the introduction of PPI reporting obligations by the British Medical Journal (BMJ) [ 104 ]. The authors identified an increase in PPI reporting in papers published by BMJ from 0.5% to 11% between the periods of 2013–2014 and 2015–2016. The study findings demonstrate the impact of journal guidelines in shaping higher quality research outputs [ 13 ]. In our review, we found a low frequency of PPI reporting in PS research using the GRIPP2 checklist, alongside sub-optimal quality of reporting following GRIPP2-SF. This could potentially be attributed to the absence of submission requirements for PPI reporting in journals following the GRIPP2 checklist, as well as challenges posed by word limits.

Strengths and limitations

This systematic review presents an overview on the frequency of PPI reporting in PS research using the GRIPP2 checklist, as well as an evaluation of the quality of reporting following the GRIPP2-SF. As the first review to focus on PS research, it provides useful knowledge on the status of PPI reporting in this field, and the extent to which researchers are adopting and adhering to PPI reporting guidelines. Despite these strengths, our review has some limitations that should be mentioned. First, only English language papers were included in this review due to being the main language of the researchers. Thus, there is a possibility that relevant articles on PPI in PS research may have been omitted. Another limitation is related to our search which was limited to papers published starting 2018 as the GRIPP2 guidelines were published in 2017. Thus it is probable that the protocols of some of these studies were developed earlier than the publication of the GRIPP2 checklist, meaning that PPI reporting following GRIPP2 was not common practice and thus not adopted by these studies. This might limit the conclusions we can draw from this review. Finally, the use of GRIPP2 to assess the quality of PPI reporting might be a limitation as usability testing has not yet been conducted to understand how the checklist works in practice with various types of research designs. However, the GRIPP2 is the first international, evidence-based, community consensus informed guideline for the reporting of PPI in health and social care research. Reflections and comments from researchers using the GRIPP2 will help improve its use in future studies.

Implications for research and practice

Lack of PPI reporting not only affects the quality of research but also implies that others cannot learn from previous research experience. Additionally, without consistent and transparent reporting it is difficult to evaluate the impact of various PPI in research [ 9 ]: “if it is not reported it cannot be assessed” ([ 105 ] p19). Enhanced PPI reporting will result in a wider range and richer high-quality evidence-based PPI research, leading to a better understanding of PPI use and effectiveness [ 103 ]. GRIPP2 reporting guidelines were developed to provide guidance for researchers, patients, and the public to enhance the quality of PPI reporting and improve the quality of the international PPI evidence-base. The guidance can be used prospectively to plan PPI or retrospectively to guide the structure or PPI reporting in research [ 9 ]. To enhance PPI reporting, we recommend the following;

Publishers and journals

First, we encourage publishers and journals to require researchers to report PPI following the GRIPP2 checklist. Utilising the short or the long version should depend on the primary focus of the study (i.e., if PPI is within the primary focus of the research then the GRIPP2-LF is recommended). Second, we recommend that journals and editorial members advise reviewers to evaluate PPI reporting within research articles following the GRIPP2 tool and make suggestions accordingly. Finally, we encourage journals to add a plain language summary as a submission requirement to increase research dissemination and improve the accessibility of research for patients and the public.

Researchers

Though there is greater evidence of PPI in research, it is still primarily the researchers that are setting the research agenda and deciding on the research questions to be addressed. Thus, significant effort is still needed to involve patients and the public in the earlier stages of the research process given the fundamental impact of PS on their lives. To enhance future PPI reporting, perhaps adding a criterion following the GRIPP2 tool to existing EQUATOR checklists for reporting research papers such as STROBE, PRISMA, CONSORT, may support higher quality research. Additionally, currently, there is no detailed explanation paper for the GRIPP2 where each criterion is explained in detail with examples. Addressing this gap would be of great benefit to guide the structure of PPI reporting and to explore the applicability of each criterion in relation to different stages of PPI in research. For instance, having a detailed explanation for each criterion across different research studies having various PPI stages would be of high value to improve future PPI reporting given the growing interest in PPI research in recent years and the relatively small PPI evidence base in health and medical research.

Funding bodies can also enhance PPI reporting by adding a requirement for researchers to report PPI following the GRIPP2 checklist. In Ireland, the National HSE has already initiated this by requiring all PPI in HSE research in Ireland to be reported following the GRIPP2 guidelines [ 10 ].

This study represents the first systematic review on the frequency and quality of PPI reporting in PS research using the GRIPP2 checklist. Most PS topics were related to medication safety, general PS, and fall prevention. The main involvement across the studies was in commenting on or developing research materials. Thus, efforts are still needed to involve patients and the public across all aspects of the research process, especially earlier stages of the research cycle. The frequency of PPI reporting following the GRIPP2 guidelines was low, and the quality of reporting following the GRIPP2-SF criteria was sub-optimal. The lowest percentages of reporting were on critically reflecting on PPI in the study so future research can learn from this experience and work to improve it, reporting the aim of the PPI in the study, and reporting the extent to which PPI influenced the study overall including positive and negative effects. Researchers, funders, publishers, journals, editorial members and reviewers have a responsibility to promote consistent and transparent PPI reporting following internationally developed reporting guidelines such as the GRIPP2. Evidence-based guidelines for reporting PPI should be supported to help future researchers plan and report PPI more effectively, which may ultimately improve the quality and relevance of research.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its Supplementary information files.

Abbreviations

• Patient safety

United Kingdom

National Institute for Health Research

Public and Patient Involvement

Health Service Executive

Guidance for Reporting Involvement of Patients and the Public

Second version of the GRIPP checklist

Long form of GRIPP2

Short form of GRIPP2

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

The International Database of Prospectively Registered Systematic Reviews

British Medical Journal

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Acknowledgements

This research is funded as part of the Collective Leadership and Safety Cultures (Co-Lead) research programme which is funded by the Irish Health Research Board, grant reference number RL-2015–1588 and the Health Service Executive. The funders had no role in the study conceptualisation, design, data collection, analysis, decision to publish, or preparation of the manuscript.

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S.H and E.M.A designed the study. S.H developed the search strategies with feedback from L.A, L.R, and E.M.A. S.H conducted all searches. S.H and L.A screened the studies, extracted the data, and assessed the quality of PPI reporting. S.H analysed the data with feedback from E.M.A. S.H drafted the manuscript. All authors revised and approved the submitted manuscript. All authors agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Hammoud, S., Alsabek, L., Rogers, L. et al. Systematic review on the frequency and quality of reporting patient and public involvement in patient safety research. BMC Health Serv Res 24 , 532 (2024). https://doi.org/10.1186/s12913-024-11021-z

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Received : 10 January 2024

Accepted : 21 April 2024

Published : 26 April 2024

DOI : https://doi.org/10.1186/s12913-024-11021-z

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