Family Practice, 2019, 365–368

doi:10.1093/fampra/cmy127

CASFM Methods Briefs

Why and how to use mixed methods in primary

health care research
Isabelle Vedel*, Navdeep Kaur, Quan Nha Hong, Reem El Sherif,
Vladimir Khanassov, Claire Godard-Sebillotte, Nadia Sourial,
Xin Qiang Yang and Pierre Pluye
Department of Family Medicine, McGill University, Montreal, Quebec, Canada.

*Correspondence to Isabelle Vedel, Department of Family Medicine, McGill University, 5858, Chemin de la Côte-des-Neiges,
Suite 300, Montreal, Quebec H3S 1Z1, Canada; E-mail: isabelle.vedel@mcgill.ca

Key words: Data collection/methods, dementia, mixed methods, primary health care, qualitative research, research design.

Introduction the socio-cultural context and the real-world environment (8). In

MM, the data collected are more comprehensive and provide a more
Mixed methods (MM) are increasingly popular in primary care
complete understanding of the problem and potential solutions. In a
research (1). It consists of using both qualitative (QUAL) and quan-
review of 232 MM studies (9), 16 reasons for conducting MM have
titative (QUAN) methods and integrating them to study complex
been identified including (i) enhance or build upon QUAL findings
phenomena. In MM, integration of QUAL and QUAN is done at
with QUAN findings, and vice versa; (ii) provide a comprehensive
some levels and stages of the research process (research questions,
understanding of a phenomenon (e.g. variables and viewpoints); (iii)
methodological approaches, designs, procedures, results and inter-
triangulate results; (iv) combine diverse viewpoints; (v) facilitate the
pretation) (2,3). However, planning, and conducting MM studies, as
sampling (e.g. using a survey to select interview participants); and
well as training graduate students in family medicine is challenging
(vi) develop and test instruments (e.g. develop a questionnaire using
for clinicians and academics. Several MM designs and integration
focus groups).
strategies have been proposed. However, there is a need for practical
guidance on MM in primary health care (MM-PHC) research in two
areas: (i) why and how to design MM-PHC research? (ii) How to What are the types of mixed method designs?
integrate QUAL and QUAN methods? Addressing this need will con-
Several MM designs have been developed to guide researchers on the
tribute to upskill primary care clinicians and researchers to conduct
integration of the QUAL and QUAN methods. The three common
MM research.
types are convergent, sequential exploratory and sequential explana-
Based on a literature review (2,4) and our experience in teaching
tory (Fig. 1).
and performing MM-PHC research, we first explain the rationale
for using MM-PHC and then propose a twofold practical guide on
(i) how to design an MM-PHC study and (ii) integrate QUAL and Convergent MM design
QUAN methods. In addition, this article provides links and refer- This design combines the QUAL and QUAN methods during data
ences to freely accessible resources and illustrates three common collection and analysis steps. The QUAL and QUAN methods are
MM designs with real field studies that are conducted by graduate usually (but not necessarily) concomitant. The results of the QUAL
students. and QUAN are compared or combined.

Why to use mixed methods in primary care
research?
Primary care research is complex and multifaceted (5,6), and MM
research has been advocated to provide new insights into this com-
plexity (7). Integrating both QUAN and QUAL methods can opti-
mize the breadth and depth of a study and help taking into account
Sequential MM design
This design involves two phases where one method (either QUAL
or QUAN) is used first, and its results inform the other. The two
subtypes of sequential designs are as follows:
(i) Sequential exploratory: QUAN method is informed by results
obtained using a QUAL method. For example, QUAL results are

© The Author(s) 2019. Published by Oxford University Press. All rights reserved.
365
For permissions, please e-mail: journals.permissions@oup.com.
366 Family Practice, 2019, Vol. 36, No. 3

first obtained, and then the QUAN methods are used to statisti-
cally generalize the QUAL results.
(ii) Sequential explanatory: QUAL method is informed by results
obtained using a QUAN method. For example, QUAN results
are first obtained and then QUAL methods, and results are used
to interpret the QUAN results.
How to choose an appropriate study design?
Choosing an appropriate study design requires logical and purposeful
planning. Two key decisions can help for planning an MM design (10):
(i) Timing of the QUAL and QUAN methods
Determine when QUAN and QUAL data will be collected. For
example, in a sequential study design, researchers inevitably choose
to start by collecting and analysing QUAN or QUAL data first.
(ii) Level of integration of the QUAL and QUAN methods
Determine whether the mixing will occur during data collection,
data analysis or during interpretation. Integration—the explicit
interrelation of the QUAN and QUAL methods (11)—is crucial
in MM. Three main strategies of integration can be used: con-
nection of phases, comparison of results and assimilation of data
(Table 1) (4).
Three practical examples: the pan-Canadian
research program on dementia care
Major neurocognitive disorders (dementia) are characterized by
progressive cognitive decline, leading to increased morbidity and
mortality (12). It is the seventh leading cause of death globally
(13). As part of the Canadian Consortium on Neurodegeneration
in Aging (14), we developed a research program combining several
MM studies.
We will present three practical examples: (i) a convergent design
study evaluating innovative collaborative care models (collCMs) for
persons living with dementia (PWD); (ii) a sequential exploratory
study of inappropriate acute hospital use in PWD; and (iii) a sequen-
tial explanatory study aiming to understand the various reasons why
case management does not address PWDs’ needs.
Convergent mixed method design
CollCMs are complex interventions providing patient-centred, com-
prehensive, continuous and interprofessional care to PWDs. They
are difficult to implement. Evaluation of these complex interventions
necessitate going beyond evaluation of the impact on outcomes. It
requires the assessment of characteristics of the models, as well as
their implementation dynamics (15–17). Our objectives are:
1. To identify the facilitators and barriers for the successful imple-
mentation of collCMs in Ontario and Quebec;
2. To determine the association between key factors (organizational,
individual and clinical characteristics) and quality of follow-up
care; and
3. To understand why some key factors are associated with better
quality of follow-up care based on the implementation strategy
put in place.
A convergent MM design involving 22 family medicine groups
(FMGs) is used. QUAN and QUAL methods are conducted in paral-
lel and then integrated.

QUAL methods (objective 1)

We are using a multiple case study approach. We selected cases
(FMGs) using a purposeful maximum variation sampling method
based on type of collCM and rural/urban location. We now analyse
data from documents, interviews and focus groups with managers,
clinicians and patients-caregivers.

QUAN methods (objective 2)

We are performing a cross-sectional observational study using chart
reviews and surveys on the same FMGs (35 charts per FMG). The
primary outcome is a quality of dementia follow-up score.

Integration
Comparison of data (strategy 2.1, Table  1): We will merge QUAL
Figure 1.  Common mixed method designs. and QUAN data to jointly review both data types using a matrix

Table 1.  Common types and strategies of integration used in mixed method research

Types of integration Integration strategies

1.Connection of phases 1.1.Connecting the results of the QUAL phase to data collection of the QUAN phase
1.2.Connecting the results of the QUAN phase to data collection of the QUAL phase
1.3.Following a thread
2.Comparison of results 2.1.Comparing QUAL and QUAN results obtained from separate data collection and analysis
2.2.Comparing QUAL and QUAN results obtained from interdependent data collection and analysis
2.3.Comparing divergences of QUAL and QUAN results
3.Assimilation of data 3.1.Transforming QUAL data into QUAN data (quantitizing)
3.2.Transforming QUAN data into QUAL data (qualitizing)
3.3.Merging QUAL and QUAN data

Adapted from Pluye et al. (4).

Mixed methods in primary health care research
(18), with columns representing sites and rows representing findings,
both QUAN data (outcome) and QUAL data (case summaries of
facilitators and barriers). It will allow drawing conclusions on the
link between implementation strategies, models of care used and
quality of dementia follow-up. In this study, using both QUAN and
QUAL data will provide a better understanding of the implementa-
tion strategies put in place (as identified in the QUAL data) and the
factors associated with better quality of follow-up care (as measured
using QUAN methods).
Sequential exploratory design
Evaluation of primary health care performance requires accur-
ate indicators. To date, accurate indicators are lacking to measure
potentially inappropriate acute hospital use in PWDs. We will use
an MM sequential exploratory design to develop accurate indicators
and measure the trends of inappropriate acute hospital use over the
last decade in PWDs using administrative databases in Quebec and
Ontario.
Phase 1: QUAL methods
To better understand the phenomenon of inappropriate acute hos-
pital use, we will conduct a qualitative descriptive study using inter-
views, focus groups and thematic analyses among four groups of
stakeholders: decision-makers, clinicians, PWDs-caregivers and
researchers. It will allow us to identify different themes on inappro-
priate acute hospital use and their determinants.
Phase 2: QUAN methods
To measure trends over time of inappropriate acute hospital use,
the themes derived from Phase 1 will be converted into indicators
and operationalized, into the provincial administrative databases.
Repeated, yearly cohorts of adults, aged 65  years and older, in
Ontario and Quebec with a new diagnosis of dementia between
2002 and 2014 will be used. Administrative data on inappropriate
hospital acute use for PWDs will be collected on each subject for
1 year following their index date of diagnosis of dementia.
Integration
Connection of phases (strategy 1.1, Table 1): We will analyse QUAL
data and select significant QUAL findings (Phase 1) that will be used
in the QUAN data collection (Phase 2). In this study, because of
the paucity of the literature on this topic, the first QUAL phase is
essential to inform the selection of indicators to measure potentially
inappropriate acute hospital use in PWDs that will be used for the
second QUAN phase.
Sequential explanatory design
The Quebec Alzheimer Plan introduced case managers in FMGs.
Often nurses and social workers help to empower PWDs and their
informal caregivers in their own decision-making, in addition to
coordinating their care. Though case management may be an effect-
ive approach to dementia care (19), little is known about how this
model of care handles the cultural diversity of patients. Given the
rich ethnic landscape of Quebec, Canada, we want to assess whether
cultural tensions and conflicts exist in the complex and challenging
environment of dementia care.
To face this gap, our research questions are as follows: (i) What
is the number of met and unmet needs across different ethnic groups
of PWDs and their informal caregivers under case management? (ii)
367
What are the PWDs and caregivers’ accounts of their experiences
with the illness through case management?
We will use a sequential explanatory MM design. We will first
perform a quantitative phase to measure the number of met and
unmet needs of PWDs and caregivers. Afterwards, we will perform a
qualitative phase to explain the quantitative results.
Phase 1: QUAN methods
We will conduct a cross-sectional clinical study in four following
steps: First, we will recruit 180 pairs of PWDs and their main infor-
mal caregiver across six FMGs in Quebec where case management
is implemented. Second, we will collect socio-demographic data and
pay special attention to ethnicity, language, immigration history and
spiritual beliefs. Third, we will use two validated questionnaires to
assess the met and unmet needs of PWDs and their caregivers: (i) the
Camberwell Assessment of Need for Elderly for the needs of PWDs
and (ii) Carers’ Needs Assessment for Dementia for the needs of car-
egivers. Fourth, we will compare questionnaire scores across differ-
ent ethnic groups using multiple linear regression.
Phase 2: QUAL methods
We will then conduct a qualitative descriptive study to understand
PWDs’ and caregivers’ accounts of their experiences (who, what and
where) and to explain the quantitative results. We will purposively
sample 20 pairs of PWDs-caregivers who took part in Phase 1 based
on ethnic groups and the level of their met and unmet needs. We will
conduct individual semi-structured interviews and apply inductive
thematic analysis (20).
Integration
This will occur twice, between QUAN and QUAL phases and at the
end of the study. The QUAN results will inform the sampling of the
QUAL study (connection of phases, strategy 1.2, Table 1). Then, the
QUAL results will serve to enrich, justify or challenge QUAN results
(comparison of results, strategy 2.2, Table 1). They will also explain
the results on the number of met and unmet needs and their vari-
ation across ethnic groups as measured in the first QUAN phase.
Conclusion
The use of MM is growingly popular in primary care research. This
article has described three main designs and integration strategies of
QUAL and QUAN methods by using practical examples. While we
have completed an extensive number of MM research (e.g. (19,21–
24)), the examples provided in this article are from our current
research program on dementia and mainly combine QUAL studies
with QUAN cross-sectional studies and administrative databases.
Several other combinations of QUAL and QUAN studies can be
found in MM (4) such as merging a QUAL study with a randomized
controlled trial to better understand how and why a program works
or does not work (25). It can serve as a basis for those engaged
in PHC research to gain better understanding of why and how to
use MM.
If you are interested in learning more on MM research, here are
some freely accessible resources:
http://www.mixedmethods.org/resources.html
https://study.sagepub.com/creswell3e
https://obssr.od.nih.gov/training/mixed-methods-research/
http://mmira.wildapricot.org/
http://methodesmixtesfrancophonie.pbworks.com/ (French)
368
Acknowledgement
We thank Ms Marine Hardouin for her assistance with editing.
Declaration
Funding: Canadian Institutes of Health Research; the Canadian Consortium
on Neurodegeneration in Aging (CCNA); or the Fonds de recherche du
Québec–Santé (FRQS).
Ethical approval: ethical boards of the West-Central Montreal Health Center
Research Review Office; the Institute for Clinical Evaluative Sciences (ICES);
or the Institut national de santé publique du Québec (INSPQ).
Conflict of interest: none.
References
1. Burt J. Following the mixed methods trail: some travel advice. Br J Gen
Pract 2015; 65: 264–5.
2. Pluye P, Hong QN. Combining the power of stories and the power of
numbers: mixed methods research and mixed studies reviews. Annu Rev
Public Health 2014; 35: 29–45.
3. Creswell JW, Fetters MD, Ivankova NV. Designing a mixed methods study
in primary care. Ann Fam Med 2004; 2: 7–12.
4. Pluye P, Garcia Bengoechea E, Granikov V, Kaur N, Tang DL. A world of
possibilities in mixed methods: review of the combinations of strategies
used to integrate the phases, results, and qualitative and quantitative data.
Int J Mult Res Approach 2018; 10: 41–56.
5. De Maeseneer JM, De Sutter A. Why research in family medicine? A super-
fluous question. Ann Fam Med 2004; 2(suppl 2): S17–22.
6. van Weel C, Rosser WW. Improving health care globally: a critical review
of the necessity of family medicine research and recommendations to build
research capacity. Ann Fam Med 2004; 2(suppl 2): S5–16.
7. Borkan JM. Mixed methods studies: a foundation for primary care
research. Ann Fam Med 2004; 2: 4–6.
8. Shaw RL, Larkin M, Flowers P. Expanding the evidence within evidence-
based healthcare: thinking about the context, acceptability and feasibility
of interventions. Evid Based Med 2014; 19: 201–3.
9. Bryman A. Integrating quantitative and qualitative research: how is it
done? Qual Res 2006; 6: 97–113.
10. Creswell JW, Plano Clark V. Designing and Conducting Mixed Methods
Research, 2nd ed. Thousand Oaks, CA: Sage, 2011.
Family Practice, 2019, Vol. 36, No. 3
11. Plano Clark VL, Ivankova NV (eds). Mixed Methods Research: A Guide to
the Field. Thousand Oaks, CA: Sage, 2015.
12. Hugo J, Ganguli M. Dementia and cognitive impairment: epidemiology,
diagnosis, and treatment. Clin Geriatr Med 2014; 30: 421–42.
13. World Health Organization. Dementia: Fact Sheets 2017. http://www.
who.int/en/news-room/fact-sheets/detail/dementia (accessed on 1 January
2018).
14. Canadian Consortium on Neurodegeneration in Aging. Team 19: Research
on Organization of Healthcare Services for Alzheimers. http://ccna-ccnv.
ca/theme-3-quality-life/team-19/ (accessed on 1 January 2018).
15. Oakley A, Strange V, Bonell C, Allen E, Stephenson J. Process evaluation in ran-
domised controlled trials of complex interventions. BMJ 2006; 332: 413–6.
16. May CR, Mair FS, Dowrick CF, Finch TL. Process evaluation for complex
interventions in primary care: understanding trials using the normaliza-
tion process model. BMC Fam Pract 2007; 8: 42.
17. Lilford RJ, Chilton PJ, Hemming K, Girling AJ, Taylor CA, Barach P.
Evaluating policy and service interventions: framework to guide selection
and interpretation of study end points. BMJ 2010; 341: c4413.
18. Caracelli VJ, Greene JC. Data analysis strategies for mixed-method evalu-
ation designs. Educ Eval Policy Anal 1993; 15: 195–207.
19. Khanassov V, Vedel I. Family physician–case manager collaboration and
needs of patients with dementia and their caregivers: a systematic mixed
studies review. Ann Fam Med 2016; 14: 166–77.
20. Boyatzis RE. Transforming Qualitative Information: Thematic Analysis
and Code Development. Case Western Reserve University: Sage, 1998.
21. Pluye P, Grad R, Repchinsky C et al. Four levels of outcomes of informa-
tion-seeking: a mixed methods study in primary health care. J Am Soc Inf
Sci Technol 2013; 64: 108–25.
22. Pluye P, Grad RM, Johnson-Lafleur J et al. Number needed to benefit from
information (NNBI): proposal from a mixed methods research study with
practicing family physicians. Ann Fam Med 2013; 11: 559–67.
23. Lewis D, Pluye P, Rodriguez C et al. Taking the pulse of Canadian family
physicians: using a mixed methods approach to explore physician learning
needs. Fam Med 2011; 43(suppl 1).
24. Khanassov V, Vedel I, Pluye P. Barriers to implementation of case manage-
ment for patients with dementia: a systematic mixed studies review. Ann
Fam Med 2014; 12: 456–65.
25. O’Cathain A. A Practical Guide to Using Qualitative Research with
Randomized Controlled Trials. Oxford, UK:  Oxford University Press,
2018.