Mixed method design is often noted as a methodology capitalizing on the advantage of in-depth study in qualitative approaches and the power of generalization in quantitative approaches. To be useful, acknowledging the fundamental assumption underpinning these two approaches is paramount. Qualitative approach is individualistic where the findings are rich in explaining a phenomenon of interest in context while quantitative approach is normative where the findings represent an average pattern of a phenomenon of interest in a population.

1. Making Sense of Mixed Methods
Design in Health Research:
Reconciliation of the Findings in the
Study of the Doctors’ Decision Making Process in
Engaging Male Patients in Health Checks
Tong SF (PhD)
Department of Family Medicine, Faculty of Medicine UKM
Low WY (PhD)
Faculty of Medicine, UM
https://www.researchgate.net/publication/296486855_Making_Sense_of_Mixed_Method_Design_in_Health_
Research_Reconciliation_of_the_Findings_in_a_Study_of_the_Doctors%27_Decision_Making_Process_in_Enga
ging_Male_Patients_in_Health_Checks
Full text is
available at:

2. Mixed methods: what it is?
“mixed methods research is the type of
research in which a researcher or team of
researchers combines elements of qualitative
and quantitative research approaches for the
broad purpose of breadth and depth of
understanding and corroboration”
Jonson, Onwuegbuzie and Turner, 2007

3. Current uses (purpose) of
mixed methods
• Triangulation (tap on the strength of each
method)
• Provides a better understanding
• Exploratory concept
• Explanatory concept
 understanding human phenomena
Creswell, 2009
Webb et al 1996
Plano Clark, Creswell, 2007

4. The beginning of mixed methods
• Evolves from a single study using multi-trait or
multi-method research – 1959 by Campbell &
Fiske
• Started off as mixing of methods
– Later, the debates focus on the validity of findings,
missing philosophical underpinning
 interpretation of findings
(sense making)

5. The debate on mixed methods
It is about researchers’ worldview
The 2 contradicting worldviews are incompatible and
incommensurable.
Trapped in these two paradigm (Symonds, 2008)
Quantitative Qualitative
Objective reality that is observable
and discoverable
Multiple reality as constructed by
society
Post-positivist Constructivist
Objective Interpretive
Distancing researchers from
researched
Researchers actively contribute to
data, analysis, results and
interpretation

6. Further development to
reconcile the debate
• Need to have philosophical assumptions that
guide the direction of data collection and
analysis(Bryman, 1984; Sale, 2002; Creswell and clark 2007; Biesta, 2010)
– Guide researcher on what is researchable
– Anchor the interpretation of results

7. Pragmatism
• Pragmatism: American philosophy
• Focus on the purpose of the research and its
practicality (Tashakkori & Teddlie, 1998; Nastasi & Hitchcock & Brown, 2010;
Biesta, 2010)

8. Pragmatism
Knowledge
• is regarded both as constructed and as a function of a
people environment interaction
• is meaningful if there is a practical consequence to it
(Biesta, 2010; Greene, 2010)
The practicality was not highlighted in the traditional
debates about
ontology and epistemology
(positivist vs constructivist)

9. Purpose & Assumptions
Purpose of the
study
Lived-experience
Social processes –
theory building
Representativeness
in a population
Methods (comes with
assumptions)
Phenomenology
GTM
Quantitative
It is from the assumptions that we draw and
limit our inferences – avoiding over claiming

10. The fundamental assumptions
• qualitative approach is individualistic where the
findings are rich in explaining a phenomenon of
interest in an individual context
 purpose: to infer the findings to the understanding of an
individual (or a phenomenon)
• quantitative approach is normative where the
findings represent an average pattern of a
phenomenon of interest in a population
 purpose: to infer the findings to a population

11. This presentation:
• To demonstrate logic reconciliation of study
findings from two methods with different
assumptions with an example
Doctors’ Decision Making Process in Engaging Male
Patients in Health Checks

12. Background of the study
0
100
200
300
400
500
600
Netherlands
Australia
Singapore
Japan
Canada
NewZealand
UnitedKingdom
Belgium
Denmark
USA
China
Argentina
Malaysia
Brazil
Indonesia
Bangladesh
India
Bhutan
Cambodia
Russian
Uganda
UnitedTanzania
Afghanistan
Adultmortalityrate(per1,000population)
Male
Female
World Health Statistics 2010

13. Disease burden of
Malaysian men
20%
13%
10%
8%7%
6%
5%
4%
4%
4%
19%
Disability adjusted life years (DALYs) by disease categories, male,
Malaysia, 2000
Cardiovascular diseases
Unintentional injuiries
Infectious diseases
Mental disorders
Respiratory disorders
Cancer
Sense organ disorders
Respiratory infections
Perinatal conditions
Digestive system disorders
Others
Ministry of health, Malaysia 2004
• Many of the illness can be treated or prevented
• Primary care doctors have a role of engaging male
patients into health care

14. Objectives (purpose) of the study
To develop an explanatory model of the process of how
primary care doctors (PCDs) make the decision to undertake
men’s health check-ups in Malaysia
1. First, it aims to identify the determinants and process of
individual doctors’ decision making.
2. Second, to quantify the average impact of each determinant,
and rank its average significance on the decision-making
processes among Malaysian PCDs.

15. Study design
Phase I: Grounded
theory:
development of a
substantive theory
Theoretical
framework
Phase II:
Quantitative
survey with
multivariate
analysis
Conceptual
framework
Questionnaire
Qualitative Quantitative
Interpretation
of findings from
phase I and II
Areas where mixing occurs
The overall design of sequential exploratory mixed methods

16. Study design
Phase I: Grounded
theory:
development of a
substantive theory
Theoretical
framework
Phase II:
Quantitative
survey with
multivariate
analysis
Conceptual
framework
Questionnaire
Qualitative Quantitative
Interpretation
of findings from
phase I and II
Areas where mixing occurs
The overall design of sequential exploratory mixed methods
Interest at
individual level
Interest at
population level

17. Results: a brief account

18. Negotiating
health check-
up
Weighing the
medical
importance of
men’s health
check-up
Competency in
undertaking
health check-up
Considering
external
factors
Weighing
men’s
receptivity
Balancing
between
men’s
receptivity
and medical
importance
Perceived doctor’s
image to men
Perception of men’s
help seeking
behaviour
Physician’s
philosophy of
health
promotional
activity
Topic for health
check-up:
•Defining the
scope
of men’s health
Substantive theoretical model of the doctor’s decision
making to engage men in health check-ups
Intention to
initiate
health
check-up
Agenda for visits
core category
Tong , Low, Willcock, Trevana, Shaiful, 2010

19. Intention to
initiate check-
ups in the
specific topic of
men’s health
within the
specific context
Perceived
personal
competency
Perceived
men’s
receptivity in
specific topic
Attitude towards
the medical
importance of a
specific topic of
men’s health
Perceived
receptivity in
specific topic
and specific
context
Perceived
external
barriers to
men’s health
check-ups
Perceived
men’s help
seeking
behaviour
Attitude towards
the medical
importance of
health check-ups
in general
Attitude towards
the medical
importance of
men’s health
check-ups
Conceptual framework in phase II: the doctors’ decision making
process of whether to initiate men’s health check-ups
Male patient’s receptivity
Medical importance

20. Areas of men’s health concern Context of consultation
Cardiovascular risk screening Acute minor complaint
Follow-up
Health check-up
Asking about sexual dysfunction Acute minor complaint
Follow-up
Health check-up
Psychosocial health assessment Acute minor complaint
Follow-up
Health check-up
Asking about smoking habit Acute minor complaint
Follow-up
Health check-up
Discussing colon cancer screening Acute minor complaint
Follow-up
Health check-up

21. Total doctors invited‡, n= 280
Participated,
n=12 (80.0%)
KL/Sel*, n=143
Kelantan,
n=15
Public sector, n=122Private sector, n=158
KL/Sel*, n=98Kelantan, n=24
Participated,
n=86 (59.4%)
Participated,
n=19 (79.2%)
Participated,
n=81 (82.7%)
Overall doctors’
response rate:
70.4%
Response to the process of doctor recruitment

22. Table 1 Summary statistics for usefulness of the models in explaining doctors’ intention to initiate health check-ups and their significant determinants
Topic of men’s health
check-ups
Contexts of
consultation
R2 /
Nagelkerke
R2
Significant determinants arranging, from the left to right, in descending order of importance
β β β β
Cardiovascular risk
screening
Acute minor
complaint
0.293 Receptivity‡ 0.331 Male patients’
HSB†
-0.227 Male
patients’
expectation
0.193 Referral
network
-0.152
Follow-up 0.276 Receptivity‡ 0.267 Male patients’
HSB†
-0.237 Attitudes
towards
HCKǁ
0.195 Male patients’
comfort
0.168
Health check-up 0.252 Attitudes§ 0.231 Receptivity‡ 0.183
Asking about sexual
dysfunction
Acute minor
complaint
0.132 Receptivity‡ 0.237
Follow-up 0.316 Receptivity‡ 0.806 Competency¶ 0.482 Male
patients’
HSB†
-0.413 Cost
constraint
-0.399
Health check-up 0.205 Competency¶ 0.383 Receptivity‡ 0.288
Psychosocial health
assessment
Acute minor
complaint
0.219 Receptivity‡ 0.312 Attitudes§ 0.199
Follow-up 0.261 Attitudes§ 0.303 Receptivity‡ 0.224
Health check-up 0.247 Attitudes§ 0.346
Asking about
smoking habit
Acute minor
complaint
0.245 Receptivity‡ 0.651 Male patients’
HSB†
-0.217
Follow-up 0.258 Receptivity‡ 0.389 Referral network 0.353 Attitudes
towards
HCKǁ
0.292 Clinic system -0.262
Health check-up 0.339 Receptivity‡ 0.720 Referral network 0.456 Attitudes§ 0.276
Discussing colon
cancer screening
Acute minor
complaint
0.078 * Receptivity‡ 0.198
Follow-up 0.097 * - -
Health check-up 0.210 Competency¶ 0.415 Referral network -0.214
* p > 0.05
‡ Perceptions of male patients’ receptivity to the assessment in the corresponding context
§ Attitudes towards the medical importance of proactive assessment
† Perceptions of male patient’s help-seeking behaviour in relation to health check-ups
ǁ Attitudes towards medical importance of health check-ups
¶ perceived personal competency in the management or assessment

23. Topic Contexts of consultation
Significant determinants:
More important Less important
Cardiovascular
risk screening
Acute minor complaint Receptivity Male patients’ HSB† Male patients’
expectation
Referral
network
Follow-up Receptivity Male patients’ HSB Attitudes
towards HCK
Male patients’
comfort
Health check-up Attitudes Receptivity
Asking about
sexual
dysfunction
Acute minor complaint Receptivity
Follow-up Receptivity Competency Male patients’
HSB
Cost
constraint
Health check-up Competency Receptivity
Psychosocial
health
assessment
Acute minor complaint Receptivity Attitudes
Follow-up Attitudes Receptivity
Health check-up Attitudes
Asking about
smoking habit
Acute minor complaint Receptivity Male patients’ HSB
Follow-up Receptivity Referral network Attitudes
towards HCK
Clinic system
Health check-up Receptivity Referral network Attitudes
Discussing
colon cancer
screening
Acute minor complaint Receptivity
Follow-up -
Health check-up Competency Referral network

24. Comparing the findings
from the two methods
GTM Survey with multivariate analysis
Perceived receptivity
health seeking behaviour
receptivity to topics of men’s health
in a receptivity at specific context
Perceived medical importance
Topic related
Attitude about men’s health check
External barriers:
Cost constraint
Network support
Time constraints
Conducive clinic system
Privacy
Competency in handling men’s health issue
Perception of receptivity
Health seeking behaviour 3/15 models
in a specific context: 12/15 models
Attitudinal concept: 7/15 models
Cost constrain 1/15 models
Referral network 3/15 models
clinic system 1/15 models
Perceived competency: 3 /15 models

25. Issues in comparing
the two results
• Why is there a discrepancy?
– Which are the important determinants?
– Which one do we trust?
– Which is more valid?
The answer:
Which perspective are we coming from?

26. The fundamental assumptions
• qualitative approach is individualistic where the
findings are rich in explaining a phenomenon of
interest in an individual context
 purpose: to infer the findings to the understanding of an
individual (or a phenomenon)
• quantitative approach is normative where the
findings represent an average pattern of a
phenomenon of interest in a population
 purpose: to infer the findings to a population
A revisit to slide 10

27. The relevance of qualitative
findings: understanding a doctor
My main concern is what
would men think about me if
I am to engage them in
health check
I am worry that I am not
competent enough to offer
men’s health check

28. The relevance of quantitative
findings: understanding Malaysian PCDs
Most would think perception of receptivity to discuss men’s health
determines their decision to engage them with health checks

29. Combining the two
• They simply explain two different phenomena
• Helping a doctor: understand him/her as an
individual PCD
• Helping to draft a policy/group interventions:
understand what most PCDs think

30. Practicality of mixed methods
Most people
are unhappy
about seeing
doctors, but
what about
you?
Applying an understanding about an
average to an individual

31. Conclusion
• Mixed methods: what is the purpose and
phenomena of interest.
• Assumptions must be acknowledged
• Appropriate inference depends on the rigor of
methodology and interpretation of findings
• Correct inference leads to appropriate
practical solution