Article

Journal of Mixed Methods Research

2018, Vol. 12(1) 31–54
An Exploration of the Effects Ó The Author(s) 2016
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DOI: 10.1177/1558689816645005
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Experience of Lymphoma: An
Experimental Embedded
Mixed Methods Study

Isabel Leal1, Joan Engebretson2, Lorenzo Cohen1,

Maria Eugenia Fernandez-Esquer3, Gabriel Lopez1,
Tenzin Wangyal4, and Alejandro Chaoul1

Abstract
As an emergent care model combining conventional with complementary therapies, integrative
interventions challenge evaluation, necessitating approaches capable of capturing complex, mul-
tilevel interactions. This article evaluates the effects of a Tibetan yoga intervention on lym-
phoma patients’ quality of life and cancer experience. Our methodological aims were to explore
differences in therapeutic effect between treatment and control group using qualitative data, and
explain equivocal findings between data sets. Use of both data transformation techniques—
qualitizing and quantitizing—within an experimental embedded design comparing and integrating
data between data sets and treatment groups allowed us to develop this innovative evaluative
approach. Findings clarify convergence and divergence between data sets, explore participants’
complex cancer experience, and capture dimensions and intervention effects inaccessible
through either method alone.

Keywords
integrative medicine, cancer, Tibetan yoga, psychological quality of life, experimental embedded
design

1
The University of Texas MD Anderson Cancer Center, Houston, TX, USA
2
University of Texas Health Science Center at Houston, TX, USA
3
University of Texas School of Public Health at Houston, TX, USA
4
Ligmincha Institute, Charlottesville, VA, USA

Corresponding Author:
Lorenzo Cohen, Department of Palliative, Rehabilitation and Integrative Medicine, Unit 462, The University of Texas
MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA.
Email: lcohen@mdanderson.org
32 Journal of Mixed Methods Research 12(1)

Mind–body modalities, part of the emerging field of integrative medicine, focus on the interac-
tions between the mind, body, and behavior emphasizing the use of the mind to affect physical
functioning and the promotion of health (National Center for Complementary and Integrative
Health, 2015). Researchers have debated whether the emergence of such a new model of care may
not also require an innovative evaluative approach (Bell & Koithan, 2006; Giordano, Engebretson,
& Garcia, 2005). Yoga, which literally means “to yoke or unite,” is a complex, integrated practice
combining physical postures coordinated with controlled breathing, mental concentration, mindful-
ness, and visualization practices. Evaluation of such a multimodal practice calls for an approach
capable of capturing complex, multilevel interactions and processes where effects are not simply
additive but synergistic and potentially transformative in nature (Rioux, 2012).
This study is exploratory, illustrating the use of a novel evaluative approach to mixing quan-
titative and qualitative methods to more effectively capture and assess the effects of a Tibetan
yoga randomized controlled trial (RCT) on the quality of life (QOL) of people with lymphoma
and their cancer experience. Lymphoma refers to two types of cancer, Hodgkin’s and non-
Hodgkin’s lymphoma, of the lymphatic system, and as such, we use the terms lymphoma and
cancer interchangeably within this study. As mixed methods studies are complex and lengthy,
with space considerations precluding a full accounting of findings from both components, we
followed one recommendation by Stange, Crabtree, and Miller (2006) to report and publish the
quantitative analyses (Cohen, Warneke, Fouladi, Rodriguez, & Chaoul-Reich, 2004) and quali-
tative analyses (Leal et al., 2015) separately, before embarking on the mixed methods analyses.
Extending beyond the two prior publications (Cohen et al., 2004; Leal et al., 2015), the pres-
ent study focuses on additional cross-cutting analyses across the two methods, reporting on
emergent, congruent, discrepant, and contradictory findings resulting from this comparison and
integration. Within an experimental embedded design our methodological aims were to (1) on
the level of interpretation—through “quantitizing” qualitative findings—explore differences in
therapeutic effects between treatment and control group using qualitative data; (2) on the level
of analysis, interrogate divergent, convergent, and contradictory qualitative and quantitative
data by “qualitizing” quantitative data to understand the process of psychological adjustment;
and (3) explore how interrogating and integrating both types of data and findings can generate a
synergistic approach providing a more comprehensive and insightful analysis of complex inter-
ventions not available through either method alone.
Incorporating a qualitative component on patients’ experiences of change within a Tibetan
yoga RCT that focused on psychological adjustment elucidated, as well as captured, differences
in experiential effects of the intervention between groups. We report the development of an
innovative evaluative approach for assessing complex interventions through this expanded
application of mixed methods research. While the present study is concerned with the evaluation
of a yoga intervention, these strategies are applicable to other areas of research involving com-
plex interventions (e.g., palliative care, health services, health promotion and prevention, mental
health) where participants’ experience of the intervention—both processes and outcomes—is an
important outcome that requires exploration.

An Integrative Approach
The diagnosis and treatment of cancer is accompanied by various fears, distress, and uncertain-
ties for patients affecting all aspects of life—the psychosocial, existential, spiritual, and physical
(Andrykowski, Lykins, & Floyd, 2008). While survivors report receiving satisfactory medical
care throughout the cancer trajectory most lack adequate psychosocial attention (McQuellon &
Danhauer, 2007). Many patients are therefore turning to integrative medicine that incorporates
conventional treatments with mind–body practices such as yoga (Carlson et al., 2004; Mansky
Leal et al. 33

& Wallerstedt, 2006). Recent reviews of yoga trials indicate the benefits of yoga for people with
cancer include statistically significant improvements in anxiety, stress, irritability, emotional
well-being, cognitive function, pain, energy, appetite, depression, and cancer symptoms (Culos-
Reed, Carlson, Daroux, & Hately-Aldous, 2006; Stan, Collins, Olsen, Croghan, & Pruthi, 2012);
increased relaxation, mindfulness, and subjective measures of well-being and decreased symp-
tom burden (Deng et al., 2009); management of symptoms and tolerance of cancer treatments
and side effects (nausea and vomiting; Duncan, Leis, & Taylor-Brown, 2008).
While researchers stress the importance of validating integrative practices using rigorous
RCTs, they also note various methodological challenges of this design in evaluating integrative
care (Mason, Tovey, & Long, 2002). including (1) limited detail on the process leading to bene-
ficial effects; (2) difficulty of identifying appropriate outcome measures given systemic effects,
requiring attention to both specific and nonspecific outcome measures; and (3) designing experi-
ential outcome measures that account for variation.

Incorporation of a Qualitative Component Within an Experimental

Trial
The central premise of mixed research is that combining qualitative and quantitative evaluative
approaches provides a more complete understanding of research issues and greater knowledge
yield than either method could alone (O’Cathain, Murphy, & Nicholl, 2007). It is precisely this
integrated and comprehensive perspective that identifies mixed methods as particularly effec-
tive for evaluating integrative therapies. Both rigorous trials to ensure the efficacy and safety of
integrative practices, and in-depth qualitative studies are needed to understand the complexities
of the human illness experience and inform the development of patient-relevant outcome mea-
sures. Such a unified approach provides a wide-ranging evaluation, adept at the analysis of com-
plex data through innovative analytic approaches and capturing the combined integral effects of
integrative care. Incorporating a qualitative component within an experimental trial embeds
quantitative outcomes within the context, processes, and meanings of participants’ experiences
as captured by qualitative methods (Creswell & Plano-Clark, 2011).
The embedding of a qualitative component within an experimental trial is becoming more
common. According to the timing of the qualitative component in the intervention, this design
has been used to (before) develop quantitative measures of complex constructs; (during) under-
stand the intervention process and participants’ experience of it; assess the fidelity of an inter-
vention; and (after) understand why an intervention was effective or not (Curry et al., 2013). In
a review of studies using an embedded design, Lewin, Glenton, and Oxman (2009) note most
undertook the qualitative component before the trial, thus losing a valuable opportunity to
understand the comprehensive effects and process of the intervention and how participants expe-
rience them. How to address discrepant findings in a mixed methods study embedding the quali-
tative component within an RCT framework can present methodological challenges. Moffat,
White, Mackintosh, and Howel (2006) report discrepant findings from a pilot health services
trial with a concurrent qualitative component and explore six different approaches for managing
and explaining discrepancies, including a return to the data for a further exploration in terms of
rigor of each component, comparability of data sets, and the intervention process.
Although there are clear benefits in applying mixed methods in evaluating integrative inter-
ventions in cancer care, few studies exist. Prior studies of integrative care using a mixed meth-
ods approach have mostly focused on the effects of combined integrative practices (Brazier,
Cooke, & Moravan, 2008; Seers et al., 2009; Selman, Williams, & Simms, 2012), rather than
on yoga alone (Duncan et al., 2008; Galantino et al., 2012), and none used a control group.
34 Journal of Mixed Methods Research 12(1)

Although a Mindfulness Based Stress Reduction1 intervention study of women with breast
cancer, by Dobkin (2008), used a mixed methods approach, it was a single-arm study.
Unlike previous studies, this study is unique in using an experimental design, thus extending
the application of mixed methods analysis to comparing and exploring the effects of a
Tibetan yoga intervention on participants’ QOL and cancer experiences both between the
two data sets (quantitative and qualitative) and between the yoga and control groups. Thus,
this article contributes to the discussion on the methodological challenges and possibilities
of the embedded design, presenting an analytic approach in which the initially subordinate
qualitative component gains equal prominence in an RCT design through a qualitatively dri-
ven analysis (Mason, 2006). Using an analytic approach that reframes the evaluative capaci-
ties of each method, highlighting that through complementarity of methods, a synergistic
integration can be achieved.

Theoretical Framework
This study adopts a dialectical pragmatic, also known as a dialectical pluralist, approach regard-
ing combining the different worldviews of postpositivist quantitative methods and constructivist
qualitative methods (Johnson, 2008). A dialectic approach recognizes the differences between
these theoretical viewpoints, juxtaposing them to encourage the emergence of novel designs and
evaluative frameworks. Thus, more integrated understandings of complex phenomena emerge
through the comparative analysis of data from each perspective (Greene, 2007; Johnson, 2008).
Pragmatism focuses on finding what “works best” for addressing the specific research questions,
adapting and challenging different methods to achieve this end (Johnson & Onwuegbuzie,
2004). Johnson’s (2012) conception of dialectical pluralism combines the pragmatic recognition
of the existence of multiple realities and perspectives embodied by quantitative and qualitative
approaches, with a dialectical stance reliant on learning from the juxtaposition of differences,
acknowledging the complementary nature of these two methods. Johnson (2008) recognizes this
dialectical process as integral to mixed methods research, as the purposive juxtaposition of
worldviews gives rise to contradictions, resolved through what Greene (2007, p. 69) calls
“enhanced, reframed or new understandings,”

Study-Specific Aims
The aim of the quantitative analyses (Cohen et al., 2004) was to evaluate the QOL outcomes of
the yoga intervention, while the qualitative analysis (Leal et al., 2015) focused on understand-
ing the psychological dynamics of participants’ cancer experience as a process over time. The
mixed research objectives guiding the present study incorporate and extend these prior content
aims, yet are distinct in their methodological focus on comparing and integrating these prior
analyses across the two methods and different time points on two different levels of analysis.
Our methodological aims were (1) at the interpretation stage, through quantitizing qualitative
findings, use qualitative data to explore differences in therapeutic effects between treatment
and control groups; (2) at the analysis stage, through qualitizing quantitative data, interrogate
divergent, convergent, and contradictory qualitative and quantitative data to gain insight into
the psychological adjustment process; and (3) to explore how integrating both types of data and
findings can generate a synergistic approach yielding insights and outcomes of complex inter-
ventions not available through either method singularly (see Figure 1).
Leal et al. 35

Figure 1. Embedded mixed methods design.

Method
Mixed Methods Model
This research uses an experimental embedded mixed methods design in which the qualitative
data set is embedded within and generally plays a supportive role in a trial primarily based on
the quantitative data (Figure 2). Data collection was conducted concurrently from the same par-
ticipants. Qualitative data were collected after the intervention to explore participants’ experi-
ences of cancer and the therapeutic effects of the experimental trial. These data are mixed at
the level of (1) data collection; (2) data analysis—comparing the qualitative and the quantita-
tive data sets; and (3) data interpretation—comparing the results of the quantitative analyses to
the qualitative findings. Given the nature of the embedded design, the two components interact
during the design and research process (Plano-Clark et al., 2013).

Participants and Human Subjects Protection

Patients with lymphoma receiving or having received treatment within the past 12 months were
recruited from the MD Anderson Cancer Center. Inclusion criteria were the following:  18
years of age, English speaking, and receiving standard medical regimens (Cohen et al., 2004).
Of the 39 patients registered in the clinical trial, 16 provided complete data sets. The present
mixed study used a total sample of these 16 patients, representing 7 and 9 of the treatment and
control groups, respectively (Table 1). Our focus is on a rich, in-depth understanding of the
phenomena of interest rather than breadth or obtaining a sample sufficiently large to accurately
represent a random portion of the population to ensure generalizability (Sandelowski, 1995a).
The study was approved by the institutional review board, and all participants provided written
consent.
36 Journal of Mixed Methods Research 12(1)

Figure 2. Tibetan yoga intervention design.

The Tibetan Yoga Program

The authors chose Tibetan yoga, as this form of yoga may be especially beneficial for people
with cancer undergoing and recovering from chemotherapy. The Tibetan yoga program included
the combined practice of controlled breathing and visualization, mindfulness, and gentle yoga
postures. The postures were simple and easy for individuals with cancer to perform, done while
seated on a cushion or chair and entailed slow rotations of the head, arms, and hips. The pro-
gram consisted of seven-weekly sessions at the Integrative Medicine Center at MD Anderson
Cancer Center, a center dedicated to the evidence-based clinical delivery of integrative thera-
pies. Following the final class, participants were provided with audiotaped instructions of the
program techniques and encouraged to practice them daily. After completion of the 3-month
follow-up assessments, wait-list control patients were invited to participate in the Tibetan yoga
program.

Quantitative Data
The pilot study examined the feasibility and initial efficacy of a 7-week Tibetan yoga interven-
tion, using an RCT design. The focus of this trial was QOL outcomes for 39 lymphoma patients
undergoing or within 1 year of completing treatment; quantitative outcomes in treatment and
control groups have been reported (Cohen et al., 2004). Group assignment was conducted
sequentially after completion of baseline assessment using a randomization process called mini-
mization (Taves, 1974). Participant characteristics used for group assignment included type of
lymphoma, age, gender, status of treatment (active or completed), and baseline state anxiety
scores.

Data Collection and Measures. Quantitative measures were collected at baseline and at 1 week, 1
month, and 3 months postintervention. Quantitative and qualitative data were collected concur-
rently (Table 2). Various measures were used to assess different domains of psychological
Leal et al. 37

Table 1. Demographic and Medical Characteristics of Participants (N = 16).

Characteristic n Range
Gender
Female 10
Male 6
Age 24-78
Education
Some college 4
College graduate (4 year) 6
Some graduate school after college 1
Graduate degree after college 5
Ethnicity
Caucasian 12
African American 1
Latino 3
Household income
Less than $5,000 1
$20,000-$50,000 2
$50,000-75,000 3
$75,000-100,000 1
More than $100,000 7
Declined to answer 2
Cancer diagnosis
Non-Hodgkin’s lymphoma 6
Hodgkin’s lymphoma 10
Current treatment stage
Active 5
Follow-up 11
Time since diagnosis
0-5 months 2
6-10 months 4
11-15 months 5
16-20 months 3
More than 20 months 2

adjustment, including anxiety and depression. Both negative (fatigue, sleep disturbance) and
positive (increased spirituality, benefit finding) components of the cancer experience were also
measured. Only those measures pertinent to the present mixed methods study are described
below; see Cohen et al. (2004) for the complete list.
Anxiety was assessed with the Speilberger State/Trait Anxiety Inventory (STAI), a 20-item
self-report scale measuring current levels of anxiety (Speilberger, Gorsuch, & Lushene, 1970).
The Center for Epidemiologic Studies Depression Scale (CES-D), a 20-item self-report instru-
ment, measured depression with a focus on affective aspects (Radloff, 1977). Sleep disturbances
were measured with the Pittsburgh Sleep Quality Index (PSQI), a 15-item, self-report instrument
assessing sleep disturbances and overall quality of sleep over the course of 1 month (Buysse,
Reynolds, Monk, & Berman, 1989). PSQI consists of seven subscales: subjective sleep quality,
sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medi-
cations, daytime dysfunction, as well as a total score. Higher scores on these measures denote
greater severity of symptoms.
Spirituality was evaluated with the Functional Assessment of Chronic Illness Therapy–
Spiritual (FACIT-Sp), a 12-item health-related QOL self-report scale (Peterman, Fitchett,
38
Table 2. Quantitative and Qualitative Data Collection Instruments.

Conceptual domain
Both facets of general anxiety:
transient state and enduring
(trait) presence of anxiety
Affective components of
depression
Quality of sleep
Spiritual well-being
Meaning making
Analytical categories
Changes in current levels
of anxiety
Depressive symptoms
Sleep disturbances and
various dimensions of
quality of sleep
Spiritual well-being as
reflected in three
subdomains: meaning,
peace, and faith
Finding benefit in the
cancer experience in
different domains
QUAN data source and time
Speilberger State/Trait
Anxiety Inventory (STAI)
(T1-T4)
Centers for Epidemiological
Studies–Depression (CES-
D) (T1-T4)
Pittsburgh Sleep Quality
Index (PSQI) (T1-T4)
Functional Assessment of
Chronic Illness Therapy–
Spirituality (FACIT-Sp.) (T1-
T4)
Finding Meaning in Cancer
Scale (FMCS) (T1-T4)
QUAL data source and time
Narrative writings on: feelings
about being diagnosed, impact
on present and future, and
changes in experiences over
times collected at end of
packet of surveys (T2, T4)
Corresponding qual content
Accounts of experiences and
changes in psychological,
existential, and physical
unease, anxiety, and stress
Descriptions of feelings of loss,
sadness, despondency,
hopelessness, and loneliness
Reports of problems sleeping
and subsequent negative
effects
Descriptions of spiritual well-
being through finding meaning,
faith, and connecting with
others
Accounts of finding meaning and
transforming the purpose of
life by acceptance of cancer,
oneself and others and
reevaluating priorities

Note. T1 = baseline; T2 = 1-week postintervention; T3 = 1-month postintervention; T4 = 3-month postintervention.

Leal et al. 39

Table 3. Participant Questions.

Q1. How did you react when you were first told that you had cancer? What went through your mind on
that day and the next few days?
Q2. Between the day you were diagnosed and right now, what changes have occurred in how you feel
about your cancer? What changes have occurred in the way you see or react to things day to day?
How have your relationships changed with your friends and family?
Q3. How do you feel when you think about the future and continuing to cope with your cancer? Is there
anything you think you will do differently because of your cancer?

Brady, Hernandez, & Cella, 2002). Benefit finding was assessed with the Finding Meaning in
Cancer Scale (FMCS), a 17-item self-report scale assessing the sense of meaning, purpose, con-
nectedness, and emotional and spiritual development patients derived from their cancer experi-
ence (Antoni et al., 2001). Higher scores on these measures indicate greater spirituality and
benefit finding.

Data Analyses. As previously reported about the quantitative findings (Cohen et al., 2004),
mixed-model regression analyses were conducted to examine group differences over time on
depressive symptoms (CES-D), anxiety (STAI), sleep disturbances (PSQI), spirituality (FACIT-
S), and finding-meaning (FMCS) scores by regressing follow-up assessments on group, time of
follow-up assessment, and the group by time interaction controlling for the corresponding base-
line measure and patient medical and demographic characteristics (age, gender, status of treat-
ment and type of cancer, Hodgkin’s or non-Hodgkin’s lymphoma).

Qualitative Data
Qualitative data were analyzed and reported separately (Leal et al., 2015) and focused on captur-
ing participants’ experiences and feelings concerning their cancer diagnosis, the impact of this
illness on their present and future, and novel and subtle intervention effects. Researchers devel-
oped narrative questions according to the aims of the qualitative component of this study to be
broad and exploratory, focusing on capturing participants’ feelings of being diagnosed with can-
cer and changes in their experiences over time. The yoga and control groups were intentionally
asked the same broad, open-ended questions so as not to introduce bias in the collection of qua-
litative data between groups.

Data Collection. The qualitative data collected at 1-week and 3-month postintervention consisted
of written reflections from 28 participants contributing writings at both time points, to three
open-ended questions totaling 116 pages of text (Table 3). Narrative questions were included at
the end of a package of surveys. Although the specific aims guiding the collection of quantita-
tive and qualitative data were different, they also overlap in investigating whether qualitative
data could reveal experiential effects not amenable to quantitative measurement alone.

Data Analyses. Qualitative data were analyzed using framework analysis, a content analysis
method involving summarization and classification of data within a thematic framework
(Ritchie & Lewis, 2005). Participants’ responses to questions varied in length, ranging from
half a page to three or four pages long, per question. As with all qualitative studies, some
respondents revealed little about their feelings while others plunged in more deeply. Qualitative
analysis focused on mapping the range and nature of patients’ experience of cancer over time.
40 Journal of Mixed Methods Research 12(1)

Researchers were blinded to respondents’ group affiliation and used a number of strategies to
ensure rigor of findings, described in Leal et al. (2015).

Integration of Methods
Mixed Methods Analyses
Different analytic techniques outlined in Figure 1 were used to merge results, assess whether
findings from the two databases converge or diverge, and in cases where divergence was found,
to further analyze data to reconcile discrepancies (Creswell & Plano-Clark, 2011). Data trans-
formation, involving the transformation of qualitative data into quantitative data and vice-versa,
was used to facilitate comparison of databases for further analysis and integration; both data
transformation techniques are detailed in the following sections on comparisons between groups
and between data sets. A joint display table was also employed to directly compare transformed
quantitative data to qualitative data, integrating the two analyses.

Comparative Analyses Between Groups. Initially, analyses were undertaken on the level of inter-
pretation or inference, that is, comparing results of data analyses to assess the effects of the
yoga intervention on participants and their cancer experience. Two comparisons explored out-
come differences between treatment groups. The qualitative findings of the yoga and control
groups were compared with each other by reviewing participants’ narratives according to group,
looking for recurrent themes within each separately and then comparing these findings between
groups. To facilitate this comparison, recurrent themes in each group were counted and trans-
formed into percentages, “quantitizing” qualitative findings. The quantitized qualitative results
were then compared with the quantitative outcomes between groups. The outcomes of the afore-
mentioned analyses led researchers to return to the data to examine whether further querying on
the level of analysis could clarify discrepancies noted between the qualitative and quantitative
findings (Moffat et al., 2006). Findings from the different components of this study were ana-
lyzed to explore what kinds of experiential effects these distinct research approaches yielded
(Sandelowski, 1995b).

Comparative Analyses Between Qualitative and Quantitative Data Sets. This second analysis reviews
each participant’s quantitative profile, comparing data points from the different time points
examining changes in scores across time on the selected quantitative measures of anxiety
(STAI), depression (CES-D), spirituality (FACIT-S), and benefit finding (FMCS). We purpo-
sely selected quantitative measures revealing participants’ psychological states also reflected in
their qualitative narratives to explore how comparing and combining these data analyses across
the two methods and across time clarified findings. Using coding, all participants’ scores on the
four instruments were compared within and across individual profiles. Changes from baseline
(T1) to 3-month follow-up assessment (T4) were noted, revealing recurrent patterns within the
data set. Codifying quantitative scores transformed numerical data into observable patterns,
facilitating comparison and integration of the distinct data sets.
After data transformation, respondent’s quantitative profiles were directly compared with
their narrative writings using a joint display table to reveal and explain congruent and divergent
patterns between the data sets. Both qualitative and quantitative data were analyzed and
reviewed for all 16 participants. Results of this analysis will be discussed in terms of group pat-
terns and individual cases selected as exemplars of the characteristics and dynamics of the
observed pattern.
Leal et al. 41

Validation: Quantitative, Qualitative, and Mixed Methods

Quantitative results were validated for internal and external validity using minimization, blind-
ing, statistical methods including descriptive analyses and mixed-model regression analyses
(Cohen et al., 2004). In the qualitative analysis, validation of findings entailed using a transpar-
ent audit trail, researcher triangulation, peer debriefing, and use of quotes (Leal et al., 2015).
Mixed methods findings were validated using multiple methods of triangulation. Triangulation
uses more than one method, researcher, theory, or data source comparing results from each to
increase the validation and credibility of results (Bryman, 2007). We used researcher triangula-
tion involving various researchers in the analytic process. The findings from each individual
analyst were compared to ensure congruency between researchers and credibility of results.
Second, we employed methodological triangulation, comparing the results from qualitative and
quantitative methods to elucidate each other. Figure 1 and Table 4 both provide more details on
these procedures. The strength of methodological triangulation lies in challenging the biases
resulting from using only a singular perspective, serving to offset the weaknesses associated
with each method (Bryman, 2007).

Findings
Quantitative Results
No statistically significant group differences were found for medical and demographic charac-
teristics and baseline measures. The mixed model analyses revealed a significant group main
effect for sleep disturbances total scores, with no group by time interaction. Examining mean
sleep disturbances total scores across the 3-month follow-up revealed the Tibetan yoga group
reported statistically significant lower overall sleep disturbances (PSQI; p \ .004) than the con-
trol group. Subscale differences showed better perceived sleep quality (p \ .02), faster sleep
latency (time to fall asleep; p \ .01), longer sleep duration (p \ .03), and taking fewer sleep
medications (p \ .02) for the yoga group than the control group (Cohen et al., 2004). No statis-
tically significant group main effects or group by time interactions were found for scores of psy-
chological adjustment, depression, and anxiety (CES-D and STAI), spirituality (FACIT-S), or
finding benefit (FMCS; see Table 5).

Qualitative Findings
Analysis of qualitative data revealed the thematic framework living with paradox (Leal et al.,
2015), consisting of four interrelated themes: (1) sources, (2) experiences, (3) resolution of par-
adox, and (4) challenges with medical culture. Respondents described moving through an emo-
tionally tumultuous and contradictory experience across the trajectory of living with cancer that
was paradoxical in nature, expressing the concept of living with paradox. The primary theme
was of moving through a dualistic and complex cancer experience consisting of concurrent neg-
ative and positive emotional states throughout their cancer journey as they reevaluated the
deeper meaning of their lives. Participants indicated cycling through this contradictory trajec-
tory was neither linear, nor singular nor conclusive in nature, but reiterative across time.

Mixed Methods Findings

Specific Aim 1: Comparison on the Level of Interpretation (Between Groups). To our knowledge, this
is the first mixed study to use qualitative data to explore differences in therapeutic effects
42
Table 4. Summary of Quantitative, Qualitative and Mixed Methods Findings.
Quantitative results
Mixed model regression analyses
between groups reported significant
improvements in sleep, both total
score and on subscales, in yoga group
No statistically significant differences
were found between groups on
measures of psychological adjustment
Qualitative findings
Framework analysis yielded the
conceptual framework of living with
paradox, the overarching theme of
cycling through a contradictory,
complex cancer experience of
concurrent negative and positive
emotional states that was iterative
Mixed methods findings
(1) Comparison of quantized qualitative findings between groups
showed significantly greater development of acceptance among yoga
compared to control group indicating increased psychological
adjustment
(2) Comparison of qualitized quantitative data with qualitative data:
Combining explained divergent findings between data sets,
contextualizing and clarifying convergence and individuals’
psychological adjustment process
Integrating findings and data captured differences in therapeutic effects
of the intervention and how variations in outcomes were influenced
by participant’s process of psychological adjustment, yielding results
not accessible through either method alone
 Table 5. Joint Display Table: Between-Group Comparisons of Quantitative and Qualitative Findings and Mixed Methods Interpretation.

Quantitized qualitative findings Mixed methods interpretation and

Quantitative resultsa between yoga and control groups integration

Measure Yoga group Wait-list control p value 95%CI 1. Comparing quantized qualitative Integration of quantitized qual. data and
(M6SD), groupb (M6SD), findings between yoga and control groups: quant. results captured dimensions of
N = 16 N = 14 the therapeutic effects of the yoga trial
Baseline Follow-up Baseline Follow-up Yoga Group Control Group not measured by the quant.
Almost all, 6 out of Only 2 of 9 patients instruments and not accessible through
7 patients expressed expressed acceptance the qual. data but only through
acceptance of cancer, infrequently within integration of both components
themselves and others their narratives Quantitizing of qualitative findings
repeatedly in their within this embedded experimental trial
narratives integrated and extended the capabilities
PSQI (Sleep) 2. Comparing quantized qualitative findings of each method allowing for the novel
Total 6.5 6 5.0 5.8 6 2.3 7.2 6 4.7 8.1 6 2.4 .004 23.8 to 20.8 between groups with quantitative application of a qualitative component
Quality 0.90 6 8.5 0.81 6 0.52 1.11 6 0.94 1.22 6 0.56 .02 20.7 to 20.08 between group outcomes: to report on outcomes
Latency 1.10 6 0.97 0.75 6 0.68 1.05 6 0.91 1.33 6 0.71 .01 21.0 to 20.1 Comparison of quantized qualitative findings
Duration 0.85 6 1.09 0.89 6 0.64 1.32 6 1.29 1.35 6 0.64 .03 20.9 to 20.04 between groups revealed significantly greater
Efficiency 0.65 6 1.09 0.87 6 0.68 0.84 6 1.07 0.95 6 0.67 .72 20.5 to 20.4 development of acceptance among yoga
Disturbances 1.40 6 0.68 1.23 6 0.40 1.37 6 0.76 1.33 6 0.37 .47 20.3 to 0.16 participants compared to control,
Medications 0.80 6 1.28 0.48 6 0.88 0.58 6 1.07 1.21 6 0.93 .02 21.3 to 20.2 indicating increased
Daytime Dysfunction 0.80 6 0.62 0.96 6 0.60 0.95 6 0.71 0.93 6 0.64 .89 20.4 to 0.4 psychological adjustment
STAI (Anxiety) 34.3 6 12.3 34.1 6 8.4 37.8 6 14.6 33.8 6 8.5 .90 25 to 25.7
CES-D (Depression) 10.2 6 11.0 9.0 6 4.2 9.6 6 4.2 9.7 6 3.8 .56 23.3 to 1.9
FACIT-Sp. (Spirituality) 36.9 6 9.9 40.5 6 4.8 37.1 6 6.7 39.0 6 4.7 0.32 24.4 to 1.5
FMCS (Benefit-finding) 40.1 6 14.2 45.3 6 8.2 44.6 6 16.3 44.8 6 8.5 0.81 26.1 to 4.8

Note. PSQI = Pittsburgh Sleep Quality Index; STAI = State Anxiety/Trait Index; CES-D = Center for Epidemiologic Studies Depression Scale; BFI = Brief Fatigue Index; FACIT-Sp. = Functional
Assessment of Chronic Illness Therapy–Spirituality; FMCS = Finding Meaning in Cancer Scale; CI = confidence interval. Note that follow-up scores represent least-square means adjusted for
baseline value of outcome measure and state anxiety, age, gender, treatment status, and the type of cancer (Hodgkin or non-Hodgkin lymphoma) using the final mixed methods regression
models.
a
Quantitative results shown are for measures of psychological adjustment; see Cohen et al. (2004) for complete results. bP values and 95% CIs are in relation to the group comparisons for the
follow-up data.

43
44 Journal of Mixed Methods Research 12(1)

between treatment and control groups. Between-group comparisons yielded significant results
of this unique application of a qualitative component within a mixed methods study. Analyses
on the level of interpretation involved two comparisons. First, comparing the qualitative find-
ings between the treatment and control groups revealed salient differences. The theme of accep-
tance of themselves, others, and life in its current form was notably more prominent in the
narratives of the Tibetan yoga participants quoted below, compared with the control group.

I take things as they come. I try not to judge people. I will be more aware of the possible limit of
my time on earth and not [be] surprised by anything. What will be will be. [#16]

I feel I have gone through all of the stages of dying—anger, denial, bargaining and finally accep-
tance. I feel my future is good. I feel I will be able to cope—because I have accepted the fact I
have/had CA. [#123]

I reacted in disbelief and denial. But after a span of time, I accepted my cancer and try to deal with
it taking proper care of myself physically and emotionally . . . and if things change for better or
worse, it will happen according to God’s plan for me. Whatever happens I will accept. [#43]

The majority of participants in the yoga group—six out of the total seven—expressed accep-
tance repeatedly within their narratives compared with its infrequent mention by only two of
the nine in the control group. Second, quantitative instruments did not capture variance in thera-
peutic effect between the yoga and control groups, although the benefit finding scale (FMCS)
contained three questions related to acceptance. The development of acceptance indicates psy-
chological adjustment. Table 5 shows between-group comparisons.

Specific Aim 2: Comparison on Level of Data Analysis (Between Research Methods). Comparison of
qualitative and quantitative data sets revealed congruence and divergence between individual’s
quantitative scores and qualitative accounts. In codifying respondents’ quantitative profiles on
the selected measures for anxiety (STAI), depression (CES-D), spirituality (FACIT-S), and ben-
efit finding (FMCS), we observed four general patterns and themes categorizing results: (1)
minimum variation, theme: consistency; (2) maximum variation, theme: transformation; (3)
congruent, theme: moderate change; and (4) incongruent, theme: conflict. Exemplar cases from
each of the observed patterns are presented jointly in Table 6, which compared individual’s
quantitative data directly to their qualitative data indicating congruence or divergence between
the data sets and integrated, illustrating how through integration mixed research enhances inter-
pretation of findings from both methods. Also included are participant quotes expressing inter-
nal contradictions in their narratives revealing a dimension of their experiences not addressed
in their quantitative profiles.
Minimum variation. Two cases exhibited the minimum variation pattern consisting of almost
no variation on any of the four measures over time, associated with the theme consistency. In
the exemplar case of minimum variation, Participant #102 showed extreme consistency, and
therefore congruence, between quantitative scores and narrative writings, except in one signifi-
cant regard. Participant #102 consistently exhibited a high level of psychological well-being in
scoring at the bottom of the depression (CES-D) and anxiety (STAI) instruments, at the top of
the spirituality scale (FACIT-S), yet shows a decline in benefit finding (FMCS) over time with
the lowest score among all participants. In contrast, other participants’ profiles show a direct
rather than an inverse correlation between the spirituality and benefit finding scales. The benefit
finding scale (FMCS) measures constructs related to spirituality, including the deeper meaning
of life, altruism, patience, acceptance, connectedness, and emotional and spiritual growth, the
 Table 6. Joint Display on Level of Analysis Linking “Qualitized” Quantitative Profiles With Individual’s Qualitative Data.

Qualitative—Patient’s quotes and related thematic concepts

Contradictory (neither Mixed methods interpretation—

Patient Exemplar case—Illustrating the characteristics of the Congruent (with Divergent (from quantitative divergent nor congruent (How qualitative elucidates
no. observed quantitative pattern and theme quantitative profile) profile) w/ profile) quantitative findings)

Patient Pattern: Minimum Variation—Across all 4 measures “Cancer hasn’t provided “I’ve had a long military “I was initially very shocked Integration explains
#102 Theme: CONSISTENCY (Extremely stable scores) me a serious physical and medical career so the biopsy revealed inconsistencies between
or emotional situation. I’ve learned to ‘suck it up’ lymphoma since I’d been quantitative scores, i.e.,
Anxiety Depression Spirituality Benefit-finding It’s made me aware of quickly and get on with feeling very good and had stability across all scores
(STAI) (CES-D) (FACIT-S) (FMCS) my potential human life. I related to our pastor just returned from skiing except decline in benefit
T1 20 0 47 0.94 vulnerability, but I have that I was disillusioned and outdoor activities in finding (FMCS). Qualitative
T2 20 1 48 1.82 never let it get me down. for 32 seconds and then the mountains (T2) data explains divergence
T3 20 0 48 1.00 I am a very happy, busy my faith in Christ took between FMCS scores
T4 20 1 48 0.74 person and I will not let over.” (T2) and other psychological
this disease process make adjustment measures due
me less.” (T4) to personal interpretation
of FMCS.
(Equilibrium) (Doubt) (Incongruous—Feeling
healthy/Being ill)

Patient Pattern: Maximum Variation—Across all 4 measures “Since NHL was my 2nd “I felt that secretly people “I’m afraid to plan too far in Qualitative findings illustrate
#38 Theme: TRANSFORMATION (Marked positive changes) cancer in my life, I think were thinking that I the future. Cancer puts the participant’s quantitative
I’ve learned how to react must have the ‘cancer’ brakes on long-range plans. results, providing depth and
Anxiety Depression Spirituality Benefit-finding to stress differently. I personality. I felt less than It’s a series of losses— context for understanding
(STAI) (CES-D) (FACIT-S) (FMCS) know there are certain normal somehow dirty.” body parts, lifestyle process of positive
T1 80 32 26 2.59 things I cannot change (T2) changes, relationship transformation.
and need to accept.” (T4) changes; optimism
T2 46 25 30 2.00 becomes resignation at
T3 61 31 21 2.18 times. I feel out of control,
but then I try to focus on
T4 44 15 38 2.59
God being in control not
me.” (T2)
(Growing) (Tainted) Loss/Out of control)

45
(continued)
 Table 6. (continued)

46
Patient Pattern: Congruent—Little variation across all 4 measures, “I feel like I’ll appreciate my “I’ll forever be a cancer “Cancer causes mixed Qualitative findings only
#63 upward or downward trend life more and the people survivor whether cancer is emotions and thoughts. partially congruent with
Theme: MODERATE (Slight positive change) around me. I’ll take better physically in my body or not The word itself doesn’t quantitative profile,
care of my body, yet let I will forever live every day scare me as much as showing intensely positive
Anxiety Depression Spirituality Benefit-finding myself indulge in things I with cancer.And I wouldn’t the sense that I would transformation, while
(STAI) (CES-D) (FACIT-S) (FMCS) enjoy and not let myself have it any other way. It has associate it with death. quantitative scores show
T1 32 6 40 3.65 worry about things so allowed me to live a much I know cancer doesn’t only moderate positive
T2 33 1 42 3.82 much.” (T4) healthier, happier life. I know mean that you will die. It change.
T3 26 1 36 3.82 what fear is and I know does scare me more in Reflective writings provided
T4 26 2 48 3.94 I can overcome it when that I know it can happen an alternative mode for
necessary. I’ve been chosen to me.” (T2) expressing, capturing and
to receive this gift (cancer) engendering changes in
because God wants me to participant experiences.
know, really know, the joys
of this life.” (T4)
(Acceptance) (Fundamentally (Mixed emotions)
transformative)

Patient Pattern: Incongruent—Internal contradiction between measures, “I have a very positive “I have a more ‘go with “At first it was a great Qualitative writings contradict
#19 i.e., decreasing STAI attitude. My family the flow’ attitude. I value shock. I was prepared for conflicting increasing
STAI with increasing CES-D scores has been wonderfully the things that matter— an immediate death— depression coupled with
Theme: CONFLICT (Both positive and negative changes) supportive. My friends family, friends, faith—and and expected it. I was decreasing anxiety scores in
have been caring. With rid myself to the best disappointed. I have a quantitative profile.
Anxiety Depression Spirituality Benefit-finding all these things and my of my ability of all the very positive attitude.” Reflective writings reported
(STAI) (CES-D) (FACIT-S) (FMCS) faith in God and prayer unnecessary things.” (T4) (T2) the development of a
my expectations are for a positive and accepting
T1 29 2 43 3.35 complete recovery.” (T2) attitude, a nuanced process
T2 31 6 47 3.88 difficult to capture via
T3 23 3 48 3.12 quantitative measures alone.
T4 21 8 44 3.35 (Positive) (Shifting priorities) (Incongruous)

Note. STAI = State Anxiety/Trait Index; CES-D = Center for Epidemiologic Studies Depression Scale; FACIT-S = Functional Assessment of Chronic Illness Therapy–Spirituality; FMCS =
Finding Meaning in Cancer Scale.
Anxiety (STAI), the higher the score the greater the level of anxiety.
Depression (CES-D), the higher the score, the greater the level of depression.
Spirituality (FACIT-S), the higher the score, the greater the degree of spirituality.
Benefit-finding (FMCS), higher scores indicate finding greater benefit/meaning in the cancer experience.
Time of assessment T1 = baseline; T2 = 1-week postintervention; T3 = 1-month postintervention; T4 = 3-month postintervention.
Leal et al. 47

last three constructs being frequently mentioned in his narratives. Scoring low on this scale con-
tradicts all his other results and indicates discordance between narrative writings and quantita-
tive data. As this patient already has given primacy to spirituality in his life, a high score on the
benefit finding scale (FMCS) could mean cancer had changed his life. He insists, on the con-
trary, God is the source of his strength, he has “never let it get me down,” cancer is not a big
concern as it “hasn’t provided me a serious physical or emotional situation.” In this instance,
the participant’s personal interpretation of an instrument resulted in a skewed finding that dis-
torted outcomes. The benefit finding scale is not faulty but open to interpretation, as suggested
by the incongruity present in this profile.
Maximum variation. Although there are differences regarding degree of change experienced
by the maximum variation and the congruent cases, the observed pattern is similar indicating
congruence and divergence between participant’s qualitative accounts and quantitative measures
and some fluctuation with an overall increase, or conversely, decrease, in all four measures. The
exemplar cases indicate after the initial trauma of a cancer diagnosis, these individuals are pro-
gressing on a trajectory of improving overall psychological well-being evident across the differ-
ent measures. The congruence of their respective quotes with quantitative scores reveals
acceptance of their situation, contextualizing, and clarifying their increasing psychological
adjustment.
Three cases of maximum variation exhibited the greatest change within any of the four mea-
sures over time following an upward or downward trend, expressing the theme transformation.
The maximum variation example, Participant #38, shows a woman expressing intense emo-
tional turmoil and inner conflict in her narratives, also reflected by the extreme variation seen
among her quantitative scores. Her high score (80) on the anxiety scale (STAI) is 50% higher
than the median score of 36 for this sample. Her narratives chronicle the greatest mood swings
and degree of transformation than any other participant. This woman suggests the intensity of
the struggles she faced was the source of her transformation. Her divergence quote demon-
strates inner turmoil, experienced in the midst of growing spirituality and decreasing anxiety
and depression, seemingly contradicting her marked movement toward positive psychological
adjustment.
Congruent. Most participants fell into the congruent category. Seven congruent cases demon-
strated slight variation across the four measures following a general upward or downward trend,
exhibiting consistency between measures and the theme moderate change. The exemplar case of
Participant #63 is interesting as her narratives consistently express that cancer has transformed
her life and gratitude for this experience: “I’ve been chosen to receive this gift (cancer) because
God wants me to know, really know, the joys of this life.” This woman’s writings reveal her
cancer experience was profoundly transformative, altering life perspectives, and relationships
with self and others. Her quantitative profile, however, indicates only a slight positive change in
psychological adjustment, contradicting the magnitude and intensity of her qualitative account
of these transformative experiences.
Incongruent. Four incongruent cases show contradictory patterns between measures, that is,
decreasing anxiety coupled with increasing depression. The incongruent case of Participant #19
shows internal contradiction between a decreasing anxiety (STAI), an increasing depression
(CES-D) score, coupled with a minimal fluctuation in the spirituality (FACIT-S), and benefit
finding scales (FMCS). As this profile shows incongruence between different scores, the exem-
plar congruent and divergent quotes both confirm and contradict the different scores. This parti-
cipant’s qualitative accounts do not reflect the fluctuating depression (CES-D) scores on her
profile but contradict them. Other than initial disappointment at diagnosis, there is no expres-
sion of depression, anxiety, or hopelessness in her writings, consistent with the sample quotes
provided.
48 Journal of Mixed Methods Research 12(1)

Contradictions
The quotes illustrating contradiction demonstrate participants’ conflicted or paradoxical cancer
experience. Our qualitative analysis indicated the overarching theme framing participants’ expe-
rience of cancer was “living with paradox,” a contradictory experience of positive and negative
emotional states occurring concurrently. Respondents expressed fear of death, loss, and being
out of control, while simultaneously expressing spirituality and acceptance of death. The experi-
ence of contradiction participants report has been characterized as inherent to the cancer jour-
ney as a traumatic and life-threatening event consistent with posttraumatic growth, the seeming
contradiction of growth through suffering.
Participants’ narratives relate paradox is the fluctuating context within which they experience
cancer irrespective of group affiliation. This is an important point as the contradiction demon-
strated in respondents’ narratives, that simultaneously confirm and conflict with their psycholo-
gical scores, also serves to account for these discrepancies. Thus, contradiction or paradox is not
only an analytic category describing participants’ experience of cancer but also an explanatory
tool elucidating discrepant findings between methods. Although the quantitative measures
reveal some fluctuation in scores across time, they do not capture the inherent contradiction
experienced by these individuals or offer us an understanding of their meaning as expressed
through participants’ own words.

Discussion
To our knowledge, this is the first mixed methods study to explore differences in therapeutic
effect between treatment and control groups based on comparison of qualitative findings rather
than quantitative results. Our aim in the analytic strategy of quantitizing qualitative findings
was to explore how through mixed methods integration the addition of an interpretive qualita-
tive component within an RCT enhances the evaluative capabilities of both methods.
Comparing qualitative findings between groups and with quantitative results and the examina-
tion of exemplar cases through comparison of data sets both helped explain equivocal findings
and extended the evaluation of the effects of the yoga intervention on patients’ psychological
well-being, demonstrating (1) the incongruity and complexity of the cancer experience, (2) how
combining these distinct methods can enhance the interpretation process of discrepant and con-
vergent data and findings, and (3) captures dimensions and more subtle intervention effects
inaccessible through either method singularly.

Incongruity
The existential plight of life-threatening diseases such as cancer and the effects of integrative
interventions are complex and multidimensional, eluding simple, linear interpretations.
Situating participants’ psychological adjustment outcomes within the context and meaning of
their experiences revealed the complexity and provided both an in-depth view of the overall
pattern of psychological adjustment as well as detailed and clarified this process, resolving
apparently incongruous quantitative outcomes. Comparing participants’ quantitative profiles
with their qualitative data suggests the experience of emotional turmoil and contradiction can
indicate increased psychological adjustment. The narratives of Participant #38 chronicle how
increased anxiety and depression were part of her process of developing acceptance of cancer
and greater spirituality and benefit finding. This revealed “incongruity” as a conceptual bias, or
assumption, which views distress and psychological growth as being at opposite poles of a con-
tinuum, rather than the former possibly promoting the development of the latter. The finding
Leal et al. 49

that suffering contributes to growth is supported by posttraumatic growth models (Costanzo,

Ryff, & Singer, 2009; Tedeschi & Calhoun, 2004) and research on the process of psychological
adjustment (Taylor, 1983) as well as by scholars over the centuries (Frankl, 1959; Fromm,
1973; Nietzsche, 1955).

Enhanced Interpretation
At the points where the data sets corresponded, integrating qualitative and quantitative data elu-
cidated each, resulting in a synergistic and enriched understanding of patterns across time.
Where they diverged, contextualizing quantitative data within participant’s narratives allowed
for the clarification of discrepancies, making inconsistencies between the various quantitative
measures intelligible, as demonstrated in Participant #102’s idiosyncratic understanding of the
benefit finding (FMCS) measure in the context of his narratives, while qualitized quantitative
profiles demarcated participants’ psychological trends over time.
The expression of congruence and divergence between the quantitative and qualitative data
sets also reveals the reality and nuances of participants’ cancer experiences. Although our study
participants may exhibit overall positive or negative psychological adjustment on quantitative
measures, their words tell us a deeper and at times a contradictory story. Embedding partici-
pants’ qualitative narratives within a Tibetan yoga RCT provided the context that granted mean-
ing to their isolated and abstract scores.

Capturing Other Dimensions and Effects

Pilot studies are by nature exploratory. Determining what constructs are meaningful to individu-
als and warrant attention requires research. This study explored and substantiated the aim that
participants, if given the space provided by the incorporation of open-ended qualitative ques-
tions within an RCT, might express experiential intervention effects not captured by quantitative
instruments. Together, the integration of both arms of the study contributed to addressing the
QOL benefits of yoga for participants. Capturing differences in the development of acceptance
and psychological well-being through comparison of qualitative findings between the yoga and
control groups was only possible within the expanded parameters of this mixed methods design.
Such an integrated design extends the capabilities of each method by surmounting the structural
constraints each places on patient responses and researcher perspectives.

Methodological Implications
The suggestion that yoga can lead to greater acceptance and, thus, increased psychological
adjustment for cancer patients raises questions that could not be validated or explored in greater
depth within this study. Further in-depth studies are needed to investigate and verify whether
this proposition can be attributed to the effects of yoga. Interrogating and integrating trans-
formed qualitative and quantitative data across methods addressed the following methodologi-
cal challenges of evaluating integrative therapies: (1) limited data on the process involved in
beneficial effects, by contextualizing psychological outcomes measures within participants’
experiences of the process of psychological adjustment; (2) difficulty in identifying appropriate
outcome measures given the systemic effects of mind–body practices, by identifying and cap-
turing the novel therapeutic outcome of increased acceptance in the yoga group; and (3) taking
variation into account in assessing experiential outcome measures, by situating the understand-
ing of the findings on psychological adjustment within the context and meaning of individual
participants’ experiences. Our findings imply that the results of quantitative and qualitative
50 Journal of Mixed Methods Research 12(1)

analyses, by themselves, are not sufficient to capture and understand the multidimensional
effects and interactions of complex interventions. Without the integration of quantitative and
qualitative data across strands, we would have missed that the yoga intervention did result in
therapeutic outcomes for the treatment group as well as understanding how variations in these
outcomes were influenced, and can be explained, by contextualization within participant’s psy-
chological adjustment process. These are complementary findings with important implications
for the design of future research of complex, multidimensional interventions.

Integration
Within the context of an experimental embedded design, this study demonstrates how use of
both qualitizing and quantitizing allowed for integration on the levels of analysis, interpretation,
methodology, and dominance. Incorporating the qualitative component after the intervention
allowed us to draw meta-inferences across the different strands addressing intervention out-
comes and processes. At the analysis stage, qualitizing transformed quantitative data into quali-
tative categories, so that integration with qualitative data revealed greater insight into the
psychological adjustment process and clarified discrepancies both within quantitative profiles
and between data sets (Table 6). On the interpretation level, quantitizing qualitative findings
allowed us to query this transformed data quantitatively, that is, in terms of outcomes between
groups, integration with quantitative results revealed a dimension of therapeutic effect that
could not be captured by either method alone (Table 4). Both these data transformation proce-
dures integrated qualitative and quantitative methodologies, as they merged analytic methods,
purposes, interpretations, and worldviews of each generating a new synergistic composite of
qualitative/quantitative. Hence, qualitative data could be used to explore intervention outcomes,
and quantitative to provide insight into psychological adjustment processes, revealing the inter-
play between process and outcomes. Integration provided an enhanced understanding of how
the process of, and variations within, psychological adjustment informs and queries outcomes
to reveal alternative dimensions of therapeutic effect.
Although the qualitative component generally plays a secondary role within an experimental
embedded mixed model, the dominance between the two methods can vary during different
phases of the research process (Farquhar, Ewing, & Booth, 2011). Within this study rather than
seeking a singular, objective account, we adopted a dialectical pluralist approach to represent
the multidimensional, dynamic, and complex experiences of people with cancer over time to
capture between-group differences. The interactions and integrations of both components dur-
ing the different stages of the research process extended the results of each, granting both meth-
ods equal roles in understanding the effects of Tibetan yoga on participants.
Using qualitative methods to explore differences in intervention outcomes between the treat-
ment and control groups is unconventional yet possible within an integrative mixed methods
framework that encourages the interrogation and redrawing of disciplinary borders. The use of
qualitizing and quantitizing within an experimental embedded mixed methods framework
allowed for an unusual application of this research approach and yielded significant results.

Limitations
Limitations of this study include a small sample size that did not allow for the assessment of
changes on a moderate scale and possible low sensitivity of the quantitative instruments not sui-
ted to capture more subtle program effects. Although no statistically significant improvements
were seen in the psychological adjustment measures, neither were significant declines seen, a
reasonable expectation in a population with lymphoma over this time period. The concurrent
Leal et al. 51

collection of both quantitative and qualitative data in a single written survey from the same par-
ticipants could also result in each data method unintentionally influencing the other
(Onwuegbuzie & Johnson, 2006). Additionally, the use of mixed instruments—adding open-
ended questions to quantitative survey instruments—has been shown to limit participants’
responses when compared with use of qualitative-only surveys (Vitale, Armenakis, & Field,
2008). Our particular study, however, yielded rich qualitative data generating findings complex
and informative enough to merit publication as a stand-alone manuscript (Leal et al., 2015).
Except for the collection of baseline quantitative data, quantitative and qualitative data were
collected concurrently postintervention, to avoid introducing any potential treatment bias affect-
ing intervention outcomes. However, as the process of narrative writing has proven beneficial to
psychological adjustment (Hydén, 1997), participants possibly benefited from this reflective
practice. As participants in both the treatment and control groups engaged in the same number
of writings, and responded to the same questions within the same context, no treatment bias was
introduced. Using only written responses also resulted in a static data set that did not allow for
clarification from participants regarding themes, limiting the possibilities for establishing rigor
of qualitative findings. The richness of participants’ narratives, however, is a strength allowing
access to the insights and complexity of their cancer experience. We discover what they find
meaningful in that experience which elucidates and informs patient outcomes.

Conclusion
It is important to recognize combining and juxtaposing these distinct modes of research give
rise to contradictions between the two that can be resolved through synthesis or acknowledge-
ment of complementarity. Adopting a dialectical pragmatic approach in integrating these differ-
ent methods and worldviews allowed tensions existing between the two to be resolved through
reframing. From this reframing emerged an alternative and novel approach to evaluating com-
plex interventions. This dialectical relationship is also mirrored in the experience of paradox
reported by study participants. Contradiction emerged as inherent to the nature of cancer as a
persisting challenge for participants. The development of acceptance—reported as substantially
greater among the yoga compared with the control group—worked to synthesize the contradic-
tory nature of this experience, indicating enhanced psychological adjustment. Our findings indi-
cate that for some, suffering or distress—far from being incongruous with growth and
acceptance—may be a necessary component for its development within a dialectical process.
The finding that the theme of acceptance was significantly more prominent among the yoga
group compared with the control group has value whether taken as a truth claim or as a descrip-
tion of participants’ subjective experience of cancer. For in either case this finding demonstrates
that combining these different research modes can reframe both, so together they are capable of
capturing the more elusive and experiential outcomes of integrative treatments by attending to
participants’ perspectives. Understanding the experiences of people living with cancer is critical
to providing good care. The synergistic integration of qualitative and quantitative approaches,
and of mind–body medicine and biomedicine in integrative care, results in a “whole greater
than the sum of the parts” (Barbour, 1999)—suggesting the appropriateness of mixed research
in evaluating complex psychosocial interventions. Greater mixed methods research is needed in
integrative care to develop interventions and outcome measures informed by patient perspec-
tives. Future mixed methods studies should investigate and challenge current criteria of what
constitutes valid evidence and outcomes in evaluation research. As this study indicates, mixed
methods analysis can bolster the strengths and temper the weaknesses of each method resulting
in greater methodological rigor. Additionally, this research method yielded unique insights
52 Journal of Mixed Methods Research 12(1)

inaccessible via a singular quantitative or qualitative study by providing an integrative frame-

work for extending study objectives that would otherwise not have been possible.

Acknowledgments
We thank the Bruce S. Gelb Foundation and the Estate of Jerry J. Moore for partial funding of this project.
We would also like to thank Qi Wei for assisting with statistical data analyses. The authors are grateful to
the patients who shared with us their innermost feelings and thoughts during this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or pub-
lication of this article.

Funding
The author(s) declared the following potential conflicts of interest with respect to the research, authorship,
and/or publication of this article: The Bruce S. Gelb Foundation and the Estate of Jerry J. Moore provided
partial funding for this project.

Note
1. Mindfulness Based Stress Reduction joins simple yoga-like movements and mindfulness meditation,
holding the mind in a focused and alert state open to mental and emotional events as they arise and
subside within the field of awareness without judgment.

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