sample thesis using mixed methods

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Language: English | German

How to Construct a Mixed Methods Research Design

Wie man ein mixed methods-forschungs-design konstruiert, judith schoonenboom.

1 Institut für Bildungswissenschaft, Universität Wien, Sensengasse 3a, 1090 Wien, Austria

R. Burke Johnson

2 Department of Professional Studies, University of South Alabama, UCOM 3700, 36688-0002 Mobile, AL USA

This article provides researchers with knowledge of how to design a high quality mixed methods research study. To design a mixed study, researchers must understand and carefully consider each of the dimensions of mixed methods design, and always keep an eye on the issue of validity. We explain the seven major design dimensions: purpose, theoretical drive, timing (simultaneity and dependency), point of integration, typological versus interactive design approaches, planned versus emergent design, and design complexity. There also are multiple secondary dimensions that need to be considered during the design process. We explain ten secondary dimensions of design to be considered for each research study. We also provide two case studies showing how the mixed designs were constructed.

Zusammenfassung

Der Beitrag gibt einen Überblick darüber, wie das Forschungsdesign bei Mixed Methods-Studien angelegt sein sollte. Um ein Mixed Methods-Forschungsdesign aufzustellen, müssen Forschende sorgfältig alle Dimensionen von Methodenkombinationen abwägen und von Anfang an auf die Güte und damit verbundene etwaige Probleme achten. Wir erklären und diskutieren die für Forschungsdesigns relevanten sieben Dimensionen von Methodenkombinationen: Untersuchungsziel, Rolle von Theorie im Forschungsprozess, Timing (Simultanität und Abhängigkeit), Schnittstellen, an denen Integration stattfindet, systematische vs. interaktive Design-Ansätze, geplante vs. emergente Designs und Komplexität des Designs. Es gibt außerdem zahlreiche sekundäre Dimensionen, die bei der Aufstellung des Forschungsdesigns berücksichtigt werden müssen, von denen wir zehn erklären. Der Beitrag schließt mit zwei Fallbeispielen ab, anhand derer konkret gezeigt wird, wie Mixed Methods-Forschungsdesigns aufgestellt werden können.

What is a mixed methods design?

This article addresses the process of selecting and constructing mixed methods research (MMR) designs. The word “design” has at least two distinct meanings in mixed methods research (Maxwell 2013 ). One meaning focuses on the process of design; in this meaning, design is often used as a verb. Someone can be engaged in designing a study (in German: “eine Studie konzipieren” or “eine Studie designen”). Another meaning is that of a product, namely the result of designing. The result of designing as a verb is a mixed methods design as a noun (in German: “das Forschungsdesign” or “Design”), as it has, for example, been described in a journal article. In mixed methods design, both meanings are relevant. To obtain a strong design as a product, one needs to carefully consider a number of rules for designing as an activity. Obeying these rules is not a guarantee of a strong design, but it does contribute to it. A mixed methods design is characterized by the combination of at least one qualitative and one quantitative research component. For the purpose of this article, we use the following definition of mixed methods research (Johnson et al. 2007 , p. 123):

Mixed methods research is the type of research in which a researcher or team of researchers combines elements of qualitative and quantitative research approaches (e. g., use of qualitative and quantitative viewpoints, data collection, analysis, inference techniques) for the broad purposes of breadth and depth of understanding and corroboration.

Mixed methods research (“Mixed Methods” or “MM”) is the sibling of multimethod research (“Methodenkombination”) in which either solely multiple qualitative approaches or solely multiple quantitative approaches are combined.

In a commonly used mixed methods notation system (Morse 1991 ), the components are indicated as qual and quan (or QUAL and QUAN to emphasize primacy), respectively, for qualitative and quantitative research. As discussed below, plus (+) signs refer to concurrent implementation of components (“gleichzeitige Durchführung der Teilstudien” or “paralleles Mixed Methods-Design”) and arrows (→) refer to sequential implementation (“Sequenzielle Durchführung der Teilstudien” or “sequenzielles Mixed Methods-Design”) of components. Note that each research tradition receives an equal number of letters (four) in its abbreviation for equity. In this article, this notation system is used in some depth.

A mixed methods design as a product has several primary characteristics that should be considered during the design process. As shown in Table  1 , the following primary design “dimensions” are emphasized in this article: purpose of mixing, theoretical drive, timing, point of integration, typological use, and degree of complexity. These characteristics are discussed below. We also provide some secondary dimensions to consider when constructing a mixed methods design (Johnson and Christensen 2017 ).

List of Primary and Secondary Design Dimensions

On the basis of these dimensions, mixed methods designs can be classified into a mixed methods typology or taxonomy. In the mixed methods literature, various typologies of mixed methods designs have been proposed (for an overview see Creswell and Plano Clark 2011 , p. 69–72).

The overall goal of mixed methods research, of combining qualitative and quantitative research components, is to expand and strengthen a study’s conclusions and, therefore, contribute to the published literature. In all studies, the use of mixed methods should contribute to answering one’s research questions.

Ultimately, mixed methods research is about heightened knowledge and validity. The design as a product should be of sufficient quality to achieve multiple validities legitimation (Johnson and Christensen 2017 ; Onwuegbuzie and Johnson 2006 ), which refers to the mixed methods research study meeting the relevant combination or set of quantitative, qualitative, and mixed methods validities in each research study.

Given this goal of answering the research question(s) with validity, a researcher can nevertheless have various reasons or purposes for wanting to strengthen the research study and its conclusions. Following is the first design dimension for one to consider when designing a study: Given the research question(s), what is the purpose of the mixed methods study?

A popular classification of purposes of mixed methods research was first introduced in 1989 by Greene, Caracelli, and Graham, based on an analysis of published mixed methods studies. This classification is still in use (Greene 2007 ). Greene et al. ( 1989 , p. 259) distinguished the following five purposes for mixing in mixed methods research:

1.  Triangulation seeks convergence, corroboration, correspondence of results from different methods; 2.  Complementarity seeks elaboration, enhancement, illustration, clarification of the results from one method with the results from the other method; 3.  Development seeks to use the results from one method to help develop or inform the other method, where development is broadly construed to include sampling and implementation, as well as measurement decisions; 4.  Initiation seeks the discovery of paradox and contradiction, new perspectives of frameworks, the recasting of questions or results from one method with questions or results from the other method; 5.  Expansion seeks to extend the breadth and range of inquiry by using different methods for different inquiry components.

In the past 28 years, this classification has been supplemented by several others. On the basis of a review of the reasons for combining qualitative and quantitative research mentioned by the authors of mixed methods studies, Bryman ( 2006 ) formulated a list of more concrete rationales for performing mixed methods research (see Appendix). Bryman’s classification breaks down Greene et al.’s ( 1989 ) categories into several aspects, and he adds a number of additional aspects, such as the following:

(a)  Credibility – refers to suggestions that employing both approaches enhances the integrity of findings. (b)  Context – refers to cases in which the combination is justified in terms of qualitative research providing contextual understanding coupled with either generalizable, externally valid findings or broad relationships among variables uncovered through a survey. (c)  Illustration – refers to the use of qualitative data to illustrate quantitative findings, often referred to as putting “meat on the bones” of “dry” quantitative findings. (d)  Utility or improving the usefulness of findings – refers to a suggestion, which is more likely to be prominent among articles with an applied focus, that combining the two approaches will be more useful to practitioners and others. (e)  Confirm and discover – this entails using qualitative data to generate hypotheses and using quantitative research to test them within a single project. (f)  Diversity of views – this includes two slightly different rationales – namely, combining researchers’ and participants’ perspectives through quantitative and qualitative research respectively, and uncovering relationships between variables through quantitative research while also revealing meanings among research participants through qualitative research. (Bryman, p. 106)

Views can be diverse (f) in various ways. Some examples of mixed methods design that include a diversity of views are:

• Iteratively/sequentially connecting local/idiographic knowledge with national/general/nomothetic knowledge;
• Learning from different perspectives on teams and in the field and literature;
• Achieving multiple participation, social justice, and action;
• Determining what works for whom and the relevance/importance of context;
• Producing interdisciplinary substantive theory, including/comparing multiple perspectives and data regarding a phenomenon;
• Juxtaposition-dialogue/comparison-synthesis;
• Breaking down binaries/dualisms (some of both);
• Explaining interaction between/among natural and human systems;
• Explaining complexity.

The number of possible purposes for mixing is very large and is increasing; hence, it is not possible to provide an exhaustive list. Greene et al.’s ( 1989 ) purposes, Bryman’s ( 2006 ) rationales, and our examples of a diversity of views were formulated as classifications on the basis of examination of many existing research studies. They indicate how the qualitative and quantitative research components of a study relate to each other. These purposes can be used post hoc to classify research or a priori in the design of a new study. When designing a mixed methods study, it is sometimes helpful to list the purpose in the title of the study design.

The key point of this section is for the researcher to begin a study with at least one research question and then carefully consider what the purposes for mixing are. One can use mixed methods to examine different aspects of a single research question, or one can use separate but related qualitative and quantitative research questions. In all cases, the mixing of methods, methodologies, and/or paradigms will help answer the research questions and make improvements over a more basic study design. Fuller and richer information will be obtained in the mixed methods study.

Theoretical drive

In addition to a mixing purpose, a mixed methods research study might have an overall “theoretical drive” (Morse and Niehaus 2009 ). When designing a mixed methods study, it is occasionally helpful to list the theoretical drive in the title of the study design. An investigation, in Morse and Niehaus’s ( 2009 ) view, is focused primarily on either exploration-and-description or on testing-and-prediction. In the first case, the theoretical drive is called “inductive” or “qualitative”; in the second case, it is called “deductive” or “quantitative”. In the case of mixed methods, the component that corresponds to the theoretical drive is referred to as the “core” component (“Kernkomponente”), and the other component is called the “supplemental” component (“ergänzende Komponente”). In Morse’s notation system, the core component is written in capitals and the supplemental component is written in lowercase letters. For example, in a QUAL → quan design, more weight is attached to the data coming from the core qualitative component. Due to the decisive character of the core component, the core component must be able to stand on its own, and should be implemented rigorously. The supplemental component does not have to stand on its own.

Although this distinction is useful in some circumstances, we do not advise to apply it to every mixed methods design. First, Morse and Niehaus contend that the supplemental component can be done “less rigorously” but do not explain which aspects of rigor can be dropped. In addition, the idea of decreased rigor is in conflict with one key theme of the present article, namely that mixed methods designs should always meet the criterion of multiple validities legitimation (Onwuegbuzie and Johnson 2006 ).

The idea of theoretical drive as explicated by Morse and Niehaus has been criticized. For example, we view a theoretical drive as a feature not of a whole study, but of a research question, or, more precisely, of an interpretation of a research question. For example, if one study includes multiple research questions, it might include several theoretical drives (Schoonenboom 2016 ).

Another criticism of Morse and Niehaus’ conceptualization of theoretical drive is that it does not allow for equal-status mixed methods research (“Mixed Methods Forschung, bei der qualitative und quantitative Methoden die gleiche Bedeutung haben” or “gleichrangige Mixed Methods-Designs”), in which both the qualitative and quantitative component are of equal value and weight; this same criticism applies to Morgan’s ( 2014 ) set of designs. We agree with Greene ( 2015 ) that mixed methods research can be integrated at the levels of method, methodology, and paradigm. In this view, equal-status mixed methods research designs are possible, and they result when both the qualitative and the quantitative components, approaches, and thinking are of equal value, they take control over the research process in alternation, they are in constant interaction, and the outcomes they produce are integrated during and at the end of the research process. Therefore, equal-status mixed methods research (that we often advocate) is also called “interactive mixed methods research”.

Mixed methods research can have three different drives, as formulated by Johnson et al. ( 2007 , p. 123):

Qualitative dominant [or qualitatively driven] mixed methods research is the type of mixed research in which one relies on a qualitative, constructivist-poststructuralist-critical view of the research process, while concurrently recognizing that the addition of quantitative data and approaches are likely to benefit most research projects. Quantitative dominant [or quantitatively driven] mixed methods research is the type of mixed research in which one relies on a quantitative, postpositivist view of the research process, while concurrently recognizing that the addition of qualitative data and approaches are likely to benefit most research projects. (p. 124) The area around the center of the [qualitative-quantitative] continuum, equal status , is the home for the person that self-identifies as a mixed methods researcher. This researcher takes as his or her starting point the logic and philosophy of mixed methods research. These mixed methods researchers are likely to believe that qualitative and quantitative data and approaches will add insights as one considers most, if not all, research questions.

We leave it to the reader to decide if he or she desires to conduct a qualitatively driven study, a quantitatively driven study, or an equal-status/“interactive” study. According to the philosophies of pragmatism (Johnson and Onwuegbuzie 2004 ) and dialectical pluralism (Johnson 2017 ), interactive mixed methods research is very much a possibility. By successfully conducting an equal-status study, the pragmatist researcher shows that paradigms can be mixed or combined, and that the incompatibility thesis does not always apply to research practice. Equal status research is most easily conducted when a research team is composed of qualitative, quantitative, and mixed researchers, interacts continually, and conducts a study to address one superordinate goal.

Timing: simultaneity and dependence

Another important distinction when designing a mixed methods study relates to the timing of the two (or more) components. When designing a mixed methods study, it is usually helpful to include the word “concurrent” (“parallel”) or “sequential” (“sequenziell”) in the title of the study design; a complex design can be partially concurrent and partially sequential. Timing has two aspects: simultaneity and dependence (Guest 2013 ).

Simultaneity (“Simultanität”) forms the basis of the distinction between concurrent and sequential designs. In a  sequential design , the quantitative component precedes the qualitative component, or vice versa. In a  concurrent design , both components are executed (almost) simultaneously. In the notation of Morse ( 1991 ), concurrence is indicated by a “+” between components (e. g., QUAL + quan), while sequentiality is indicated with a “→” (QUAL → quan). Note that the use of capital letters for one component and lower case letters for another component in the same design suggest that one component is primary and the other is secondary or supplemental.

Some designs are sequential by nature. For example, in a  conversion design, qualitative categories and themes might be first obtained by collection and analysis of qualitative data, and then subsequently quantitized (Teddlie and Tashakkori 2009 ). Likewise, with Greene et al.’s ( 1989 ) initiation purpose, the initiation strand follows the unexpected results that it is supposed to explain. In other cases, the researcher has a choice. It is possible, e. g., to collect interview data and survey data of one inquiry simultaneously; in that case, the research activities would be concurrent. It is also possible to conduct the interviews after the survey data have been collected (or vice versa); in that case, research activities are performed sequentially. Similarly, a study with the purpose of expansion can be designed in which data on an effect and the intervention process are collected simultaneously, or they can be collected sequentially.

A second aspect of timing is dependence (“Abhängigkeit”) . We call two research components dependent if the implementation of the second component depends on the results of data analysis in the first component. Two research components are independent , if their implementation does not depend on the results of data analysis in the other component. Often, a researcher has a choice to perform data analysis independently or not. A researcher could analyze interview data and questionnaire data of one inquiry independently; in that case, the research activities would be independent. It is also possible to let the interview questions depend upon the outcomes of the analysis of the questionnaire data (or vice versa); in that case, research activities are performed dependently. Similarly, the empirical outcome/effect and process in a study with the purpose of expansion might be investigated independently, or the process study might take the effect/outcome as given (dependent).

In the mixed methods literature, the distinction between sequential and concurrent usually refers to the combination of concurrent/independent and sequential/dependent, and to the combination of data collection and data analysis. It is said that in a concurrent design, the data collection and data analysis of both components occurs (almost) simultaneously and independently, while in a sequential design, the data collection and data analysis of one component take place after the data collection and data analysis of the other component and depends on the outcomes of the other component.

In our opinion, simultaneity and dependence are two separate dimensions. Simultaneity indicates whether data collection is done concurrent or sequentially. Dependence indicates whether the implementation of one component depends upon the results of data analysis of the other component. As we will see in the example case studies, a concurrent design could include dependent data analysis, and a sequential design could include independent data analysis. It is conceivable that one simultaneously conducts interviews and collects questionnaire data (concurrent), while allowing the analysis focus of the interviews to depend on what emerges from the survey data (dependence).

Dependent research activities include a redirection of subsequent research inquiry. Using the outcomes of the first research component, the researcher decides what to do in the second component. Depending on the outcomes of the first research component, the researcher will do something else in the second component. If this is so, the research activities involved are said to be sequential-dependent, and any component preceded by another component should appropriately build on the previous component (see sequential validity legitimation ; Johnson and Christensen 2017 ; Onwuegbuzie and Johnson 2006 ).

It is under the purposive discretion of the researcher to determine whether a concurrent-dependent design, a concurrent-independent design, a sequential-dependent design, or a sequential-dependent design is needed to answer a particular research question or set of research questions in a given situation.

Point of integration

Each true mixed methods study has at least one “point of integration” – called the “point of interface” by Morse and Niehaus ( 2009 ) and Guest ( 2013 ) –, at which the qualitative and quantitative components are brought together. Having one or more points of integration is the distinguishing feature of a design based on multiple components. It is at this point that the components are “mixed”, hence the label “mixed methods designs”. The term “mixing”, however, is misleading, as the components are not simply mixed, but have to be integrated very carefully.

Determining where the point of integration will be, and how the results will be integrated, is an important, if not the most important, decision in the design of mixed methods research. Morse and Niehaus ( 2009 ) identify two possible points of integration: the results point of integration and the analytical point of integration.

Most commonly, integration takes place in the results point of integration . At some point in writing down the results of the first component, the results of the second component are added and integrated. A  joint display (listing the qualitative and quantitative findings and an integrative statement) might be used to facilitate this process.

In the case of an analytical point of integration , a first analytical stage of a qualitative component is followed by a second analytical stage, in which the topics identified in the first analytical stage are quantitized. The results of the qualitative component ultimately, and before writing down the results of the analytical phase as a whole, become quantitative; qualitizing also is a possible strategy, which would be the converse of this.

Other authors assume more than two possible points of integration. Teddlie and Tashakkori ( 2009 ) distinguish four different stages of an investigation: the conceptualization stage, the methodological experimental stage (data collection), the analytical experimental stage (data analysis), and the inferential stage. According to these authors, in all four stages, mixing is possible, and thus all four stages are potential points or integration.

However, the four possible points of integration used by Teddlie and Tashakkori ( 2009 ) are still too coarse to distinguish some types of mixing. Mixing in the experiential stage can take many different forms, for example the use of cognitive interviews to improve a questionnaire (tool development), or selecting people for an interview on the basis of the results of a questionnaire (sampling). Extending the definition by Guest ( 2013 ), we define the point of integration as “any point in a study where two or more research components are mixed or connected in some way”. Then, the point of integration in the two examples of this paragraph can be defined more accurately as “instrument development”, and “development of the sample”.

It is at the point of integration that qualitative and quantitative components are integrated. Some primary ways that the components can be connected to each other are as follows:

(1) merging the two data sets, (2) connecting from the analysis of one set of data to the collection of a second set of data, (3) embedding of one form of data within a larger design or procedure, and (4) using a framework (theoretical or program) to bind together the data sets (Creswell and Plano Clark 2011 , p. 76).

More generally, one can consider mixing at any or all of the following research components: purposes, research questions, theoretical drive, methods, methodology, paradigm, data, analysis, and results. One can also include mixing views of different researchers, participants, or stakeholders. The creativity of the mixed methods researcher designing a study is extensive.

Substantively, it can be useful to think of integration or mixing as comparing and bringing together two (or more) components on the basis of one or more of the purposes set out in the first section of this article. For example, it is possible to use qualitative data to illustrate a quantitative effect, or to determine whether the qualitative and the quantitative component yield convergent results ( triangulation ). An integrated result could also consist of a combination of a quantitatively established effect and a qualitative description of the underlying process . In the case of development, integration consists of an adjustment of an, often quantitative, for example, instrument or model or interpretation, based on qualitative assessments by members of the target group.

A special case is the integration of divergent results. The power of mixed methods research is its ability to deal with diversity and divergence. In the literature, we find two kinds of strategies for dealing with divergent results. A first set of strategies takes the detected divergence as the starting point for further analysis, with the aim to resolve the divergence. One possibility is to carry out further research (Cook 1985 ; Greene and Hall 2010 ). Further research is not always necessary. One can also look for a more comprehensive theory, which is able to account for both the results of the first component and the deviating results of the second component. This is a form of abduction (Erzberger and Prein 1997 ).

A fruitful starting point in trying to resolve divergence through abduction is to determine which component has resulted in a finding that is somehow expected, logical, and/or in line with existing research. The results of this research component, called the “sense” (“Lesart”), are subsequently compared to the results of the other component, called the “anti-sense” (“alternative Lesart”), which are considered dissonant, unexpected, and/or contrary to what had been found in the literature. The aim is to develop an overall explanation that fits both the sense and the anti-sense (Bazeley and Kemp 2012 ; Mendlinger and Cwikel 2008 ). Finally, a reanalysis of the data can sometimes lead to resolving divergence (Creswell and Plano Clark 2011 ).

Alternatively, one can question the existence of the encountered divergence. In this regard, Mathison ( 1988 ) recommends determining whether deviating results shown by the data can be explained by knowledge about the research and/or knowledge of the social world. Differences between results from different data sources could also be the result of properties of the methods involved, rather than reflect differences in reality (Yanchar and Williams 2006 ). In general, the conclusions of the individual components can be subjected to an inference quality audit (Teddlie and Tashakkori 2009 ), in which the researcher investigates the strength of each of the divergent conclusions. We recommend that researchers first determine whether there is “real” divergence, according to the strategies mentioned in the last paragraph. Next, an attempt can be made to resolve cases of “true” divergence, using one or more of the methods mentioned in this paragraph.

Design typology utilization

As already mentioned in Sect. 1, mixed methods designs can be classified into a mixed methods typology or taxonomy. A typology serves several purposes, including the following: guiding practice, legitimizing the field, generating new possibilities, and serving as a useful pedagogical tool (Teddlie and Tashakkori 2009 ). Note, however, that not all types of typologies are equally suitable for all purposes. For generating new possibilities, one will need a more exhaustive typology, while a useful pedagogical tool might be better served by a non-exhaustive overview of the most common mixed methods designs. Although some of the current MM design typologies include more designs than others, none of the current typologies is fully exhaustive. When designing a mixed methods study, it is often useful to borrow its name from an existing typology, or to construct a superior and nuanced clear name when your design is based on a modification of one or more of the designs.

Various typologies of mixed methods designs have been proposed. Creswell and Plano Clark’s ( 2011 ) typology of some “commonly used designs” includes six “major mixed methods designs”. Our summary of these designs runs as follows:

• Convergent parallel design (“paralleles Design”) (the quantitative and qualitative strands of the research are performed independently, and their results are brought together in the overall interpretation),
• Explanatory sequential design (“explanatives Design”) (a first phase of quantitative data collection and analysis is followed by the collection of qualitative data, which are used to explain the initial quantitative results),
• Exploratory sequential design (“exploratives Design”) (a first phase of qualitative data collection and analysis is followed by the collection of quantitative data to test or generalize the initial qualitative results),
• Embedded design (“Einbettungs-Design”) (in a traditional qualitative or quantitative design, a strand of the other type is added to enhance the overall design),
• Transformative design (“politisch-transformatives Design”) (a transformative theoretical framework, e. g. feminism or critical race theory, shapes the interaction, priority, timing and mixing of the qualitative and quantitative strand),
• Multiphase design (“Mehrphasen-Design”) (more than two phases or both sequential and concurrent strands are combined over a period of time within a program of study addressing an overall program objective).

Most of their designs presuppose a specific juxtaposition of the qualitative and quantitative component. Note that the last design is a complex type that is required in many mixed methods studies.

The following are our adapted definitions of Teddlie and Tashakkori’s ( 2009 ) five sets of mixed methods research designs (adapted from Teddlie and Tashakkori 2009 , p. 151):

• Parallel mixed designs (“paralleles Mixed-Methods-Design”) – In these designs, one has two or more parallel quantitative and qualitative strands, either with some minimal time lapse or simultaneously; the strand results are integrated into meta-inferences after separate analysis are conducted; related QUAN and QUAL research questions are answered or aspects of the same mixed research question is addressed.
• Sequential mixed designs (“sequenzielles Mixed-Methods-Design”) – In these designs, QUAL and QUAN strands occur across chronological phases, and the procedures/questions from the later strand emerge/depend/build on on the previous strand; the research questions are interrelated and sometimes evolve during the study.
• Conversion mixed designs (“Transfer-Design” or “Konversionsdesign”) – In these parallel designs, mixing occurs when one type of data is transformed to the other type and then analyzed, and the additional findings are added to the results; this design answers related aspects of the same research question,
• Multilevel mixed designs (“Mehrebenen-Mixed-Methods-Design”) – In these parallel or sequential designs, mixing occurs across multiple levels of analysis, as QUAN and QUAL data are analyzed and integrated to answer related aspects of the same research question or related questions.
• Fully integrated mixed designs (“voll integriertes Mixed-Methods-Design”) – In these designs, mixing occurs in an interactive manner at all stages of the study. At each stage, one approach affects the formulation of the other, and multiple types of implementation processes can occur. For example, rather than including integration only at the findings/results stage, or only across phases in a sequential design, mixing might occur at the conceptualization stage, the methodological stage, the analysis stage, and the inferential stage.

We recommend adding to Teddlie and Tashakkori’s typology a sixth design type, specifically, a  “hybrid” design type to include complex combinations of two or more of the other design types. We expect that many published MM designs will fall into the hybrid design type.

Morse and Niehaus ( 2009 ) listed eight mixed methods designs in their book (and suggested that authors create more complex combinations when needed). Our shorthand labels and descriptions (adapted from Morse and Niehaus 2009 , p. 25) run as follows:

• QUAL + quan (inductive-simultaneous design where, the core component is qualitative and the supplemental component is quantitative)
• QUAL → quan (inductive-sequential design, where the core component is qualitative and the supplemental component is quantitative)
• QUAN + qual (deductive-simultaneous design where, the core component is quantitative and the supplemental component is qualitative)
• QUAN → qual (deductive-sequential design, where the core component is quantitative and the supplemental component is qualitative)
• QUAL + qual (inductive-simultaneous design, where both components are qualitative; this is a multimethod design rather than a mixed methods design)
• QUAL → qual (inductive-sequential design, where both components are qualitative; this is a multimethod design rather than a mixed methods design)
• QUAN + quan (deductive-simultaneous design, where both components are quantitative; this is a multimethod design rather than a mixed methods design)
• QUAN → quan (deductive-sequential design, where both components are quantitative; this is a multimethod design rather than a mixed methods design).

Notice that Morse and Niehaus ( 2009 ) included four mixed methods designs (the first four designs shown above) and four multimethod designs (the second set of four designs shown above) in their typology. The reader can, therefore, see that the design notation also works quite well for multimethod research designs. Notably absent from Morse and Niehaus’s book are equal-status or interactive designs. In addition, they assume that the core component should always be performed either concurrent with or before the supplemental component.

Johnson, Christensen, and Onwuegbuzie constructed a set of mixed methods designs without these limitations. The resulting mixed methods design matrix (see Johnson and Christensen 2017 , p. 478) contains nine designs, which we can label as follows (adapted from Johnson and Christensen 2017 , p. 478):

• QUAL + QUAN (equal-status concurrent design),
• QUAL + quan (qualitatively driven concurrent design),
• QUAN + qual (quantitatively driven concurrent design),
• QUAL → QUAN (equal-status sequential design),
• QUAN → QUAL (equal-status sequential design),
• QUAL → quan (qualitatively driven sequential design),
• qual → QUAN (quantitatively driven sequential design),
• QUAN → qual (quantitatively driven sequential design), and
• quan → QUAL (qualitatively driven sequential design).

The above set of nine designs assumed only one qualitative and one quantitative component. However, this simplistic assumption can be relaxed in practice, allowing the reader to construct more complex designs. The Morse notation system is very powerful. For example, here is a three-stage equal-status concurrent-sequential design:

The key point here is that the Morse notation provides researchers with a powerful language for depicting and communicating the design constructed for a specific research study.

When designing a mixed methods study, it is sometimes helpful to include the mixing purpose (or characteristic on one of the other dimensions shown in Table  1 ) in the title of the study design (e. g., an explanatory sequential MM design, an exploratory-confirmatory MM design, a developmental MM design). Much more important, however, than a design name is for the author to provide an accurate description of what was done in the research study, so the reader will know exactly how the study was conducted. A design classification label can never replace such a description.

The common complexity of mixed methods design poses a problem to the above typologies of mixed methods research. The typologies were designed to classify whole mixed methods studies, and they are basically based on a classification of simple designs. In practice, many/most designs are complex. Complex designs are sometimes labeled “complex design”, “multiphase design”, “fully integrated design”, “hybrid design” and the like. Because complex designs occur very often in practice, the above typologies are not able to classify a large part of existing mixed methods research any further than by labeling them “complex”, which in itself is not very informative about the particular design. This problem does not fully apply to Morse’s notation system, which can be used to symbolize some more complex designs.

Something similar applies to the classification of the purposes of mixed methods research. The classifications of purposes mentioned in the “Purpose”-section, again, are basically meant for the classification of whole mixed methods studies. In practice, however, one single study often serves more than one purpose (Schoonenboom et al. 2017 ). The more purposes that are included in one study, the more difficult it becomes to select a design on the basis of the purpose of the investigation, as advised by Greene ( 2007 ). Of all purposes involved, then, which one should be the primary basis for the design? Or should the design be based upon all purposes included? And if so, how? For more information on how to articulate design complexity based on multiple purposes of mixing, see Schoonenboom et al. ( 2017 ).

It should be clear to the reader that, although much progress has been made in the area of mixed methods design typologies, the problem remains in developing a single typology that is effective in comprehensively listing a set of designs for mixed methods research. This is why we emphasize in this article the importance of learning to build on simple designs and construct one’s own design for one’s research questions. This will often result in a combination or “hybrid” design that goes beyond basic designs found in typologies, and a methodology section that provides much more information than a design name.

Typological versus interactive approaches to design

In the introduction, we made a distinction between design as a product and design as a process. Related to this, two different approaches to design can be distinguished: typological/taxonomic approaches (“systematische Ansätze”), such as those in the previous section, and interactive approaches (“interaktive Ansätze”) (the latter were called “dynamic” approaches by Creswell and Plano Clark 2011 ). Whereas typological/taxonomic approaches view designs as a sort of mold, in which the inquiry can be fit, interactive approaches (Maxwell 2013 ) view design as a process, in which a certain design-as-a-product might be the outcome of the process, but not its input.

The most frequently mentioned interactive approach to mixed methods research is the approach by Maxwell and Loomis ( 2003 ). Maxwell and Loomis distinguish the following components of a design: goals, conceptual framework, research question, methods, and validity. They argue convincingly that the most important task of the researcher is to deliver as the end product of the design process a design in which these five components fit together properly. During the design process, the researcher works alternately on the individual components, and as a result, their initial fit, if it existed, tends to get lost. The researcher should therefore regularly check during the research and continuing design process whether the components still fit together, and, if not, should adapt one or the other component to restore the fit between them. In an interactive approach, unlike the typological approach, design is viewed as an interactive process in which the components are continually compared during the research study to each other and adapted to each other.

Typological and interactive approaches to mixed methods research have been presented as mutually exclusive alternatives. In our view, however, they are not mutually exclusive. The interactive approach of Maxwell is a very powerful tool for conducting research, yet this approach is not specific to mixed methods research. Maxwell’s interactive approach emphasizes that the researcher should keep and monitor a close fit between the five components of research design. However, it does not indicate how one should combine qualitative and quantitative subcomponents within one of Maxwell’s five components (e. g., how one should combine a qualitative and a quantitative method, or a qualitative and a quantitative research question). Essential elements of the design process, such as timing and the point of integration are not covered by Maxwell’s approach. This is not a shortcoming of Maxwell’s approach, but it indicates that to support the design of mixed methods research, more is needed than Maxwell’s model currently has to offer.

Some authors state that design typologies are particularly useful for beginning researchers and interactive approaches are suited for experienced researchers (Creswell and Plano Clark 2011 ). However, like an experienced researcher, a research novice needs to align the components of his or her design properly with each other, and, like a beginning researcher, an advanced researcher should indicate how qualitative and quantitative components are combined with each other. This makes an interactive approach desirable, also for beginning researchers.

We see two merits of the typological/taxonomic approach . We agree with Greene ( 2007 ), who states that the value of the typological approach mainly lies in the different dimensions of mixed methods that result from its classifications. In this article, the primary dimensions include purpose, theoretical drive, timing, point of integration, typological vs. interactive approaches, planned vs. emergent designs, and complexity (also see secondary dimensions in Table  1 ). Unfortunately, all of these dimensions are not reflected in any single design typology reviewed here. A second merit of the typological approach is the provision of common mixed methods research designs, of common ways in which qualitative and quantitative research can be combined, as is done for example in the major designs of Creswell and Plano Clark ( 2011 ). Contrary to other authors, however, we do not consider these designs as a feature of a whole study, but rather, in line with Guest ( 2013 ), as a feature of one part of a design in which one qualitative and one quantitative component are combined. Although one study could have only one purpose, one point of integration, et cetera, we believe that combining “designs” is the rule and not the exception. Therefore, complex designs need to be constructed and modified as needed, and during the writing phase the design should be described in detail and perhaps given a creative and descriptive name.

Planned versus emergent designs

A mixed methods design can be thought out in advance, but can also arise during the course of the conduct of the study; the latter is called an “emergent” design (Creswell and Plano Clark 2011 ). Emergent designs arise, for example, when the researcher discovers during the study that one of the components is inadequate (Morse and Niehaus 2009 ). Addition of a component of the other type can sometimes remedy such an inadequacy. Some designs contain an emergent component by their nature. Initiation, for example, is the further exploration of unexpected outcomes. Unexpected outcomes are by definition not foreseen, and therefore cannot be included in the design in advance.

The question arises whether researchers should plan all these decisions beforehand, or whether they can make them during, and depending on the course of, the research process. The answer to this question is twofold. On the one hand, a researcher should decide beforehand which research components to include in the design, such that the conclusion that will be drawn will be robust. On the other hand, developments during research execution will sometimes prompt the researcher to decide to add additional components. In general, the advice is to be prepared for the unexpected. When one is able to plan for emergence, one should not refrain from doing so.

Dimension of complexity

Next, mixed methods designs are characterized by their complexity. In the literature, simple and complex designs are distinguished in various ways. A common distinction is between simple investigations with a single point of integration versus complex investigations with multiple points of integration (Guest 2013 ). When designing a mixed methods study, it can be useful to mention in the title whether the design of the study is simple or complex. The primary message of this section is as follows: It is the responsibility of the researcher to create more complex designs when needed to answer his or her research question(s) .

Teddlie and Tashakkori’s ( 2009 ) multilevel mixed designs and fully integrated mixed designs are both complex designs, but for different reasons. A multilevel mixed design is more complex ontologically, because it involves multiple levels of reality. For example, data might be collected both at the levels of schools and students, neighborhood and households, companies and employees, communities and inhabitants, or medical practices and patients (Yin 2013 ). Integration of these data does not only involve the integration of qualitative and quantitative data, but also the integration of data originating from different sources and existing at different levels. Little if any published research has discussed the possible ways of integrating data obtained in a multilevel mixed design (see Schoonenboom 2016 ). This is an area in need of additional research.

The fully-integrated mixed design is more complex because it contains multiple points of integration. As formulated by Teddlie and Tashakkori ( 2009 , p. 151):

In these designs, mixing occurs in an interactive manner at all stages of the study. At each stage, one approach affects the formulation of the other, and multiple types of implementation processes can occur.

Complexity, then, not only depends on the number of components, but also on the extent to which they depend on each other (e. g., “one approach affects the formulation of the other”).

Many of our design dimensions ultimately refer to different ways in which the qualitative and quantitative research components are interdependent. Different purposes of mixing ultimately differ in the way one component relates to, and depends upon, the other component. For example, these purposes include dependencies, such as “x illustrates y” and “x explains y”. Dependencies in the implementation of x and y occur to the extent that the design of y depends on the results of x (sequentiality). The theoretical drive creates dependencies, because the supplemental component y is performed and interpreted within the context and the theoretical drive of core component x. As a general rule in designing mixed methods research, one should examine and plan carefully the ways in which and the extent to which the various components depend on each other.

The dependence among components, which may or may not be present, has been summarized by Greene ( 2007 ). It is seen in the distinction between component designs (“Komponenten-Designs”), in which the components are independent of each other, and integrated designs (“integrierte Designs”), in which the components are interdependent. Of these two design categories, integrated designs are the more complex designs.

Secondary design considerations

The primary design dimensions explained above have been the focus of this article. There are a number of secondary considerations for researchers to also think about when they design their studies (Johnson and Christensen 2017 ). Now we list some secondary design issues and questions that should be thoughtfully considered during the construction of a strong mixed methods research design.

• Phenomenon: Will the study be addressing (a) the same part or different parts of one phenomenon? (b) different phenomena?, or (c) the phenomenon/phenomena from different perspectives? Is the phenomenon (a) expected to be unique (e. g., historical event, particular group)?, (b) something expected to be part of a more regular and predictable phenomenon, or (c) a complex mixture of these?
• Social scientific theory: Will the study generate a new substantive theory, test an already constructed theory, or achieve both in a sequential arrangement? Or is the researcher not interested in substantive theory based on empirical data?
• Ideological drive: Will the study have an explicitly articulated ideological drive (e. g., feminism, critical race paradigm, transformative paradigm)?
• Combination of sampling methods: What specific quantitative sampling method(s) will be used? What specific qualitative sampling methods(s) will be used? How will these be combined or related?
• Degree to which the research participants will be similar or different: For example, participants or stakeholders with known differences of perspective would provide participants that are quite different.
• Degree to which the researchers on the research team will be similar or different: For example, an experiment conducted by one researcher would be high on similarity, but the use of a heterogeneous and participatory research team would include many differences.
• Implementation setting: Will the phenomenon be studied naturalistically, experimentally, or through a combination of these?
• Degree to which the methods similar or different: For example, a structured interview and questionnaire are fairly similar but administration of a standardized test and participant observation in the field are quite different.
• Validity criteria and strategies: What validity criteria and strategies will be used to address the defensibility of the study and the conclusions that will be drawn from it (see Chapter 11 in Johnson and Christensen 2017 )?
• Full study: Will there be essentially one research study or more than one? How will the research report be structured?

Two case studies

The above design dimensions are now illustrated by examples. A nice collection of examples of mixed methods studies can be found in Hesse-Biber ( 2010 ), from which the following examples are taken. The description of the first case example is shown in Box 1.

Box 1

Summary of Roth ( 2006 ), research regarding the gender-wage gap within Wall Street securities firms. Adapted from Hesse-Biber ( 2010 , pp. 457–458)

Louise Marie Roth’s research, Selling Women Short: Gender and Money on Wall Street ( 2006 ), tackles gender inequality in the workplace. She was interested in understanding the gender-wage gap among highly performing Wall Street MBAs, who on the surface appeared to have the same “human capital” qualifications and were placed in high-ranking Wall Street securities firms as their first jobs. In addition, Roth wanted to understand the “structural factors” within the workplace setting that may contribute to the gender-wage gap and its persistence over time. […] Roth conducted semistructured interviews, nesting quantitative closed-ended questions into primarily qualitative in-depth interviews […] In analyzing the quantitative data from her sample, she statistically considered all those factors that might legitimately account for gendered differences such as number of hours worked, any human capital differences, and so on. Her analysis of the quantitative data revealed the presence of a significant gender gap in wages that remained unexplained after controlling for any legitimate factors that might otherwise make a difference. […] Quantitative findings showed the extent of the wage gap while providing numerical understanding of the disparity but did not provide her with an understanding of the specific processes within the workplace that might have contributed to the gender gap in wages. […] Her respondents’ lived experiences over time revealed the hidden inner structures of the workplace that consist of discriminatory organizational practices with regard to decision making in performance evaluations that are tightly tied to wage increases and promotion.

This example nicely illustrates the distinction we made between simultaneity and dependency. On the two aspects of the timing dimension, this study was a concurrent-dependent design answering a set of related research questions. The data collection in this example was conducted simultaneously, and was thus concurrent – the quantitative closed-ended questions were embedded into the qualitative in-depth interviews. In contrast, the analysis was dependent, as explained in the next paragraph.

One of the purposes of this study was explanation: The qualitative data were used to understand the processes underlying the quantitative outcomes. It is therefore an explanatory design, and might be labelled an “explanatory concurrent design”. Conceptually, explanatory designs are often dependent: The qualitative component is used to explain and clarify the outcomes of the quantitative component. In that sense, the qualitative analysis in the case study took the outcomes of the quantitative component (“the existence of the gender-wage gap” and “numerical understanding of the disparity”), and aimed at providing an explanation for that result of the quantitative data analysis , by relating it to the contextual circumstances in which the quantitative outcomes were produced. This purpose of mixing in the example corresponds to Bryman’s ( 2006 ) “contextual understanding”. On the other primary dimensions, (a) the design was ongoing over a three-year period but was not emergent, (b) the point of integration was results, and (c) the design was not complex with respect to the point of integration, as it had only one point of integration. Yet, it was complex in the sense of involving multiple levels; both the level of the individual and the organization were included. According to the approach of Johnson and Christensen ( 2017 ), this was a QUAL + quan design (that was qualitatively driven, explanatory, and concurrent). If we give this study design a name, perhaps it should focus on what was done in the study: “explaining an effect from the process by which it is produced”. Having said this, the name “explanatory concurrent design” could also be used.

The description of the second case example is shown in Box 2.

Box 2

Summary of McMahon’s ( 2007 ) explorative study of the meaning, role, and salience of rape myths within the subculture of college student athletes. Adapted from Hesse-Biber ( 2010 , pp. 461–462)

Sarah McMahon ( 2007 ) wanted to explore the subculture of college student athletes and specifically the meaning, role, and salience of rape myths within that culture. […] While she was looking for confirmation between the quantitative ([structured] survey) and qualitative (focus groups and individual interviews) findings, she entered this study skeptical of whether or not her quantitative and qualitative findings would mesh with one another. McMahon […] first administered a survey [instrument] to 205 sophomore and junior student athletes at one Northeast public university. […] The quantitative data revealed a very low acceptance of rape myths among this student population but revealed a higher acceptance of violence among men and individuals who did not know a survivor of sexual assault. In the second qualitative (QUAL) phase, “focus groups were conducted as semi-structured interviews” and facilitated by someone of the same gender as the participants (p. 360). […] She followed this up with a third qualitative component (QUAL), individual interviews, which were conducted to elaborate on themes discovered in the focus groups and determine any differences in students’ responses between situations (i. e., group setting vs. individual). The interview guide was designed specifically to address focus group topics that needed “more in-depth exploration” or clarification (p. 361). The qualitative findings from the focus groups and individual qualitative interviews revealed “subtle yet pervasive rape myths” that fell into four major themes: “the misunderstanding of consent, the belief in ‘accidental’ and fabricated rape, the contention that some women provoke rape, and the invulnerability of female athletes” (p. 363). She found that the survey’s finding of a “low acceptance of rape myths … was contradicted by the findings of the focus groups and individual interviews, which indicated the presence of subtle rape myths” (p. 362).

On the timing dimension, this is an example of a sequential-independent design. It is sequential, because the qualitative focus groups were conducted after the survey was administered. The analysis of the quantitative and qualitative data was independent: Both were analyzed independently, to see whether they yielded the same results (which they did not). This purpose, therefore, was triangulation. On the other primary dimensions, (a) the design was planned, (b) the point of integration was results, and (c) the design was not complex as it had only one point of integration, and involved only the level of the individual. The author called this a “sequential explanatory” design. We doubt, however, whether this is the most appropriate label, because the qualitative component did not provide an explanation for quantitative results that were taken as given. On the contrary, the qualitative results contradicted the quantitative results. Thus, a “sequential-independent” design, or a “sequential-triangulation” design or a “sequential-comparative” design would probably be a better name.

Notice further that the second case study had the same point of integration as the first case study. The two components were brought together in the results. Thus, although the case studies are very dissimilar in many respects, this does not become visible in their point of integration. It can therefore be helpful to determine whether their point of extension is different. A  point of extension is the point in the research process at which the second (or later) component comes into play. In the first case study, two related, but different research questions were answered, namely the quantitative question “How large is the gender-wage gap among highly performing Wall Street MBAs after controlling for any legitimate factors that might otherwise make a difference?”, and the qualitative research question “How do structural factors within the workplace setting contribute to the gender-wage gap and its persistence over time?” This case study contains one qualitative research question and one quantitative research question. Therefore, the point of extension is the research question. In the second case study, both components answered the same research question. They differed in their data collection (and subsequently in their data analysis): qualitative focus groups and individual interviews versus a quantitative questionnaire. In this case study, the point of extension was data collection. Thus, the point of extension can be used to distinguish between the two case studies.

Summary and conclusions

The purpose of this article is to help researchers to understand how to design a mixed methods research study. Perhaps the simplest approach is to design is to look at a single book and select one from the few designs included in that book. We believe that is only useful as a starting point. Here we have shown that one often needs to construct a research design to fit one’s unique research situation and questions.

First, we showed that there are there are many purposes for which qualitative and quantitative methods, methodologies, and paradigms can be mixed. This must be determined in interaction with the research questions. Inclusion of a purpose in the design name can sometimes provide readers with useful information about the study design, as in, e. g., an “explanatory sequential design” or an “exploratory-confirmatory design”.

The second dimension is theoretical drive in the sense that Morse and Niehaus ( 2009 ) use this term. That is, will the study have an inductive or a deductive drive, or, we added, a combination of these. Related to this idea is whether one will conduct a qualitatively driven, a quantitatively driven, or an equal-status mixed methods study. This language is sometimes included in the design name to communicate this characteristic of the study design (e. g., a “quantitatively driven sequential mixed methods design”).

The third dimension is timing , which has two aspects: simultaneity and dependence. Simultaneity refers to whether the components are to be implemented concurrently, sequentially, or a combination of these in a multiphase design. Simultaneity is commonly used in the naming of a mixed methods design because it communicates key information. The second aspect of timing, dependence , refers to whether a later component depends on the results of an earlier component, e. g., Did phase two specifically build on phase one in the research study? The fourth design dimension is the point of integration, which is where the qualitative and quantitative components are brought together and integrated. This is an essential dimension, but it usually does not need to be incorporated into the design name.

The fifth design dimension is that of typological vs. interactive design approaches . That is, will one select a design from a typology or use a more interactive approach to construct one’s own design? There are many typologies of designs currently in the literature. Our recommendation is that readers examine multiple design typologies to better understand the design process in mixed methods research and to understand what designs have been identified as popular in the field. However, when a design that would follow from one’s research questions is not available, the researcher can and should (a) combine designs into new designs or (b) simply construct a new and unique design. One can go a long way in depicting a complex design with Morse’s ( 1991 ) notation when used to its full potential. We also recommend that researchers understand the process approach to design from Maxwell and Loomis ( 2003 ), and realize that research design is a process and it needs, oftentimes, to be flexible and interactive.

The sixth design dimension or consideration is whether a design will be fully specified during the planning of the research study or if the design (or part of the design) will be allowed to emerge during the research process, or a combination of these. The seventh design dimension is called complexity . One sort of complexity mentioned was multilevel designs, but there are many complexities that can enter designs. The key point is that good research often requires the use of complex designs to answer one’s research questions. This is not something to avoid. It is the responsibility of the researcher to learn how to construct and describe and name mixed methods research designs. Always remember that designs should follow from one’s research questions and purposes, rather than questions and purposes following from a few currently named designs.

In addition to the six primary design dimensions or considerations, we provided a set of additional or secondary dimensions/considerations or questions to ask when constructing a mixed methods study design. Our purpose throughout this article has been to show what factors must be considered to design a high quality mixed methods research study. The more one knows and thinks about the primary and secondary dimensions of mixed methods design the better equipped one will be to pursue mixed methods research.

Acknowledgments

Open access funding provided by University of Vienna.

Biographies

1965, Dr., Professor of Empirical Pedagogy at University of Vienna, Austria. Research Areas: Mixed Methods Design, Philosophy of Mixed Methods Research, Innovation in Higher Education, Design and Evaluation of Intervention Studies, Educational Technology. Publications: Mixed methods in early childhood education. In: M. Fleer & B. v. Oers (Eds.), International handbook on early childhood education (Vol. 1). Dordrecht, The Netherlands: Springer 2017; The multilevel mixed intact group analysis: A mixed method to seek, detect, describe and explain differences between intact groups. Journal of Mixed Methods Research 10, 2016; The realist survey: How respondents’ voices can be used to test and revise correlational models. Journal of Mixed Methods Research 2015. Advance online publication.

1957, PhD, Professor of Professional Studies at University of South Alabama, Mobile, Alabama USA. Research Areas: Methods of Social Research, Program Evaluation, Quantitative, Qualitative and Mixed Methods, Philosophy of Social Science. Publications: Research methods, design and analysis. Boston, MA 2014 (with L. Christensen and L. Turner); Educational research: Quantitative, qualitative and mixed approaches. Los Angeles, CA 2017 (with L. Christensen); The Oxford handbook of multimethod and mixed methods research inquiry. New York, NY 2015 (with S. Hesse-Biber).

Bryman’s ( 2006 ) scheme of rationales for combining quantitative and qualitative research 1

• Triangulation or greater validity – refers to the traditional view that quantitative and qualitative research might be combined to triangulate findings in order that they may be mutually corroborated. If the term was used as a synonym for integrating quantitative and qualitative research, it was not coded as triangulation.
• Offset – refers to the suggestion that the research methods associated with both quantitative and qualitative research have their own strengths and weaknesses so that combining them allows the researcher to offset their weaknesses to draw on the strengths of both.
• Completeness – refers to the notion that the researcher can bring together a more comprehensive account of the area of enquiry in which he or she is interested if both quantitative and qualitative research are employed.
• Process – quantitative research provides an account of structures in social life but qualitative research provides sense of process.
• Different research questions – this is the argument that quantitative and qualitative research can each answer different research questions but this item was coded only if authors explicitly stated that they were doing this.
• Explanation – one is used to help explain findings generated by the other.
• Unexpected results – refers to the suggestion that quantitative and qualitative research can be fruitfully combined when one generates surprising results that can be understood by employing the other.
• Instrument development – refers to contexts in which qualitative research is employed to develop questionnaire and scale items – for example, so that better wording or more comprehensive closed answers can be generated.
• Sampling – refers to situations in which one approach is used to facilitate the sampling of respondents or cases.
• Credibility – refer s to suggestions that employing both approaches enhances the integrity of findings.
• Context – refers to cases in which the combination is rationalized in terms of qualitative research providing contextual understanding coupled with either generalizable, externally valid findings or broad relationships among variables uncovered through a survey.
• Illustration – refers to the use of qualitative data to illustrate quantitative findings, often referred to as putting “meat on the bones” of “dry” quantitative findings.
• Utility or improving the usefulness of findings – refers to a suggestion, which is more likely to be prominent among articles with an applied focus, that combining the two approaches will be more useful to practitioners and others.
• Confirm and discover – this entails using qualitative data to generate hypotheses and using quantitative research to test them within a single project.
• Diversity of views – this includes two slightly different rationales – namely, combining researchers’ and participants’ perspectives through quantitative and qualitative research respectively, and uncovering relationships between variables through quantitative research while also revealing meanings among research participants through qualitative research.
• Enhancement or building upon quantitative/qualitative findings – this entails a reference to making more of or augmenting either quantitative or qualitative findings by gathering data using a qualitative or quantitative research approach.
• Other/unclear.
• Not stated.

1 Reprinted with permission from “Integrating quantitative and qualitative research: How is it done?” by Alan Bryman ( 2006 ), Qualitative Research, 6, pp. 105–107.

Contributor Information

Judith Schoonenboom, Email: [email protected] .

R. Burke Johnson, Email: ude.amabalahtuos@nosnhojb .

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• Teddlie CB, Tashakkori A. Foundations of mixed methods research: Integrating quantitative and qualitative approaches in the social and behavioral sciences. Los Angeles: Sage; 2009. [ Google Scholar ]
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A mixed methods study exploring the barriers and facilitators of screening for autism spectrum disorder in Oman

Al Maskari, Turkiya Saleh (2018) A mixed methods study exploring the barriers and facilitators of screening for autism spectrum disorder in Oman. PhD thesis, University of Glasgow.

Background: Within the routine practice, specific screening for autism spectrum disorder (ASD) has been recommended, in order to facilitate early intervention and improve outcomes. Despite the substantial advantages of this process, it has also presented a variety of challenges, across clinical settings, which have not yet been explored sufficiently. There is little information available to support the introduction of ASD screening in Oman. Research is required to identify the potential facilitators of and barriers to ASD screening in Oman, prior to the implementation of a screening programme, to ensure its successful introduction.

Method: An exploratory mixed-methods design was adopted, in two sequential phases. Phase 1 involved two focus group discussions, with seven nurses and six GPs, from primary health care (PHC) settings in Oman. The participants were recruited using a purposive and snowballing technique. The discussions were audio-taped and transcribed verbatim. Framework Analysis was used to identify recurrent themes within and across groups. Data from the focus groups was then used to inform the development of a questionnaire, which was piloted on a sub-sample of volunteers from both groups. Phase two (quantitative phase) comprised of sending the final draft of the questionnaire to a random sample of primary health care providers (PHPs) (n=571) across Oman. The returned data was analysed statistically with the software program SPSS (Statistical Package for Social Sciences version 22.0). The Social Ecological Model (SEM) was then applied to interpret the final data from both phases and to draw conclusions.

Results: Qualitative data analysis revealed five themes, which voiced the major challenges facing ASD screening in Oman, as well as highlighting a few facilitators. The findings revealed that both nurses and GPs believed that introducing screening for ASD would be a positive step. However, they felt overwhelmed by their responsibilities and believed that their workplaces lacked the necessary infrastructure. Practitioners’ awareness of ASD services was identified as poor, as were the essential skills required for undertaking screening. Additionally, limited public awareness of ASD and a strong interest in traditional medicine, as well as the social stigma attributed to ASD, were thought to create barriers to screening. The groups also discussed their preference for a clear, simple, paper-based questionnaire, supported with guidance and researcher availability to reward their willingness to participate. The findings from the focus group informed the development of a 38-item questionnaire to explore the potential barriers to and facilitators of the introduction of ASD screening in Oman. The questionnaire was short so that it could be completed within 15 minutes.

Five hundred and seventy-one questionnaires were sent to a random sample of PHP providers across Oman. Of those, five hundred and sixteen questionnaires were returned, in phase 2 (response rate 90.37%). The quantitative results of this phase were congruent with the qualitative findings, in that they suggested a deficit in the knowledge of professionals, among both older respondents and nurse respondents. In addition, a lack of resources, time constraints, workload issues and staff shortages were highlighted. The respondents also emphasised the ambiguity surrounding their role and the lack of guidance on protocols to identify or refer suspected cases. This was compounded by a lack of public awareness and knowledge of ASD identification and its potential causes, as well as the attributed social stigma.

Conclusions: The root challenges and potential facilitators for screening for ASD were examined, through the SEM. Challenges were addressed and resolved across three levels (intrapersonal, organisational, and community). At the intrapersonal level, more training and knowledge regarding ASD is required. Organisations need to implement a clear protocol, to guide the process, with greater coordination and collaboration among services. A country-wide awareness campaign, targeting social issues, may reduce the stigma and improve the uptake of screening.

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Mixed methods research is an approach that combines both quantitative and qualitative forms. It involves philosophical assumptions, and the mixing of qualitative and quantitative approaches in tandem so that the overall strength of a study is greater than either qualitative or quantitative methods ( Creswell, 2007 ) .

Video: Mixed Methods Research

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• What is mixed methods research?

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

Analyze your mixed methods research

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

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

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

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

• When to use mixed methods research

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

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

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

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

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

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

• Mixed methods research design

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

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

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

• Types of mixed method research designs

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

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

Convergent parallel

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

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

Embedded design

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

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

Explanatory sequential design

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

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

Exploratory sequential design

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

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

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

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

• Strengths of mixed methods research

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

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

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

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

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

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

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

• Challenges of mixed methods research

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

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

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

• Advanced frameworks in mixed methods research

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

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

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

Intervention

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

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

Participatory

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

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

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

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

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

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

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

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

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

• Techniques for integrating data in mixed method studies

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

Triangulation protocol

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

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

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

Following a thread

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

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

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

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

Mixed methods matrix

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

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

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

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

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

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

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

What is an example of mixed methods research?

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

Which sampling method is best for mixed methods?

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

What is the difference between mixed methods and multiple methods?

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

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Qualitative, quantitative and mixed methods dissertations

What are they and which one should i choose.

In the sections that follow, we briefly describe the main characteristics of qualitative, quantitative and mixed methods dissertations. Rather than being exhaustive, the main goal is to highlight what these types of research are and what they involve. Whilst you read through each section, try and think about your own dissertation, and whether you think that one of these types of dissertation might be right for you. After reading about these three types of dissertation, we highlight some of the academic, personal and practical reasons why you may choose to take on one type over another.

• Types of dissertation: Qualitative, quantitative and mixed methods dissertations
• Choosing between types: Academic, personal and practical justifications

Types of dissertation

Whilst we describe the main characteristics of qualitative, quantitative and mixed methods dissertations, the Lærd Dissertation site currently focuses on helping guide you through quantitative dissertations , whether you are a student of the social sciences, psychology, education or business, or are studying medical or biological sciences, sports science, or another science-based degree. Nonetheless, you may still find our introductions to qualitative dissertations and mixed methods dissertations useful, if only to decide whether these types of dissertation are for you. We discuss quantitative dissertations , qualitative dissertations and mixed methods dissertations in turn:

Quantitative dissertations

When we use the word quantitative to describe quantitative dissertations , we do not simply mean that the dissertation will draw on quantitative research methods or statistical analysis techniques . Quantitative research takes a particular approach to theory , answering research questions and/or hypotheses , setting up a research strategy , making conclusions from results , and so forth. Classic routes that you can follow include replication-based studies , theory-driven research and data-driven dissertations . However, irrespective of the particular route that you adopt when taking on a quantitative dissertation, there are a number of core characteristics to quantitative dissertations:

They typically attempt to build on and/or test theories , whether adopting an original approach or an approach based on some kind of replication or extension .

They answer quantitative research questions and/or research (or null ) hypotheses .

They are mainly underpinned by positivist or post-positivist research paradigms .

They draw on one of four broad quantitative research designs (i.e., descriptive , experimental , quasi-experimental or relationship-based research designs).

They try to use probability sampling techniques , with the goal of making generalisations from the sample being studied to a wider population , although often end up applying non-probability sampling techniques .

They use research methods that generate quantitative data (e.g., data sets , laboratory-based methods , questionnaires/surveys , structured interviews , structured observation , etc.).

They draw heavily on statistical analysis techniques to examine the data collected, whether descriptive or inferential in nature.

They assess the quality of their findings in terms of their reliability , internal and external validity , and construct validity .

They report their findings using statements , data , tables and graphs that address each research question and/or hypothesis.

They make conclusions in line with the findings , research questions and/or hypotheses , and theories discussed in order to test and/or expand on existing theories, or providing insight for future theories.

If you choose to take on a quantitative dissertation , go to the Quantitative Dissertations part of Lærd Dissertation now. You will learn more about the characteristics of quantitative dissertations, as well as being able to choose between the three classic routes that are pursued in quantitative research: replication-based studies , theory-driven research and data-driven dissertations . Upon choosing your route, the Quantitative Dissertations part of Lærd Dissertation will help guide you through these routes, from topic idea to completed dissertation, as well as showing you how to write up quantitative dissertations.

Qualitative dissertations

Qualitative dissertations , like qualitative research in general, are often associated with qualitative research methods such as unstructured interviews, focus groups and participant observation. Whilst they do use a set of research methods that are not used in quantitative dissertations, qualitative research is much more than a choice between research methods. Qualitative research takes a particular approach towards the research process , the setting of research questions , the development and use of theory , the choice of research strategy , the way that findings are presented and discussed, and so forth. Overall, qualitative dissertations will be very different in approach, depending on the particular route that you adopt (e.g., case study research compared to ethnographies). Classic routes that you can follow include autoethnographies , case study research , ethnographies , grounded theory , narrative research and phenomenological research . However, irrespective of the route that you choose to follow, there are a number of broad characteristics to qualitative dissertations:

They follow an emergent design , meaning that the research process , and sometimes even the qualitative research questions that you tackle, often evolve during the dissertation process.

They use theory in a variety of ways - sometimes drawing on theory to help the research process; on other occasions, using theory to develop new theoretical insights ; sometimes both - but the goal is infrequently to test a particular theory from the outset.

They can be underpinned by one of a number of research paradigms (e.g., interpretivism , constructivism , critical theory , amongst many other research paradigms).

They follow research designs that heavily influence the choices you make throughout the research process, as well as the analysis and discussion of 'findings' (i.e., such research designs differ considerably depending on the route that is being followed, whether an autoethnography , case study research , ethnography , grounded theory , narrative research , phenomenological research , etc.).

They try to use theoretical sampling - a group of non-probability sampling techniques - with the goal of studying cases (i.e., people or organisations) that are most appropriate to answering their research questions.

They study people in-the-field (i.e., in natural settings ), often using multiple research methods , each of which generate qualitative data (e.g., unstructured interviews , focus groups , participant observation , etc.).

They interpret the qualitative data through the eyes and biases of the researcher , going back-and-forth through the data (i.e., an inductive process ) to identify themes or abstractions that build a holistic/gestalt picture of what is being studied.

They assess the quality of their findings in terms of their dependability , confirmability , conformability and transferability .

They present (and discuss ) their findings through personal accounts , case studies , narratives , and other means that identify themes or abstracts , processes , observations and contradictions , which help to address their research questions.

They discuss the theoretical insights arising from the findings in light of the research questions, from which tentative conclusions are made.

If you choose to take on a qualitative dissertation , you will be able to learn a little about appropriate research methods and sampling techniques in the Fundamentals section of Lærd Dissertation. However, we have not yet launched a dedicated section to qualitative dissertations within Lærd Dissertation. If this is something that you would like us to do sooner than later, please leave feedback .

Mixed methods dissertations

Mixed methods dissertations combine qualitative and quantitative approaches to research. Whilst they are increasingly used and have gained greater legitimacy, much less has been written about their components parts. There are a number of reasons why mixed methods dissertations are used, including the feeling that a research question can be better addressed by:

Collecting qualitative and quantitative data , and then analysing or interpreting that data, whether separately or by mixing it.

Conducting more than one research phase ; perhaps conducting qualitative research to explore an issue and uncover major themes, before using quantitative research to measure the relationships between the themes.

One of the problems (or challenges) of mixed methods dissertations is that qualitative and quantitative research, as you will have seen from the two previous sections, are very different in approach. In many respects, they are opposing approaches to research. Therefore, when taking on a mixed methods dissertation, you need to think particularly carefully about the goals of your research, and whether the qualitative or quantitative components (a) are more important in philosophical, theoretical and practical terms, and (b) should be combined or kept separate.

Again, as with qualitative dissertations, we have yet to launch a dedicated section of Lærd Dissertation to mixed methods dissertations . However, you will be able to learn about many of the quantitative aspects of doing a mixed methods dissertation in the Quantitative Dissertations part of Lærd Dissertation. You may even be able to follow this part of our site entirely if the only qualitative aspect of your mixed methods dissertation is the use of qualitative methods to help you explore an issue or uncover major themes, before performing quantitative research to examine such themes further. Nonetheless, if you would like to see a dedicated section to mixed methods dissertations sooner than later, please leave feedback .

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• Published: 16 May 2024

Developing practical strategies to reduce addiction-related stigma and discrimination in public addiction treatment centers: a mixed-methods study protocol

• Maryam Khazaee-Pool   ORCID: orcid.org/0000-0002-2587-3460 1 ,
• Seyed Abolhassan Naghibi 1 ,
• Tahereh Pashaei 2 &
• Koen Ponnet 3  

Addiction Science & Clinical Practice volume  19 , Article number:  40 ( 2024 ) Cite this article

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People with substance use disorders (SUDs) have restricted engagement with health-care facilities and describe repeated experiences of stigma, discrimination, and mistreatment when receiving care at health-care and public addiction treatment centers (PATCs). The purpose of the current study is to design practical cultural-based strategies to reduce addiction-related stigma and discrimination at PATCs.

Methods/design

The present study will use a mixed-methods design with an explanatory sequential approach. Phase 1 of the study will combine a cluster sampling technique combined with a cross-sectional survey of Patients with Substance Use Disorders (SUDs) in Mazandaran, Iran. A total of three hundred and sixty individuals with SUDs will be selected to assess their experiences of stigma and factors predicting stigma. Phase 2 will involve qualitative study aimed at exploring participants’ perceptions regarding the aspects and determinants of their stigma experience. The participants will include two groups: people with SUDs and staff/health-care providers at PATCs. Participants for Phase 2 will be purposively sampled from those involved in Phase 1.Qualitative data will be collected using in-depth semi-structured interviews and focus group discussions and analyzed using content analysis with a conventional approach. Phase 3 will focus on the development of new strategies to reduce the experiences of stigma among people with SUDs at PATCs. These strategies will be formulated based on the findings derived from the qualitative and quantitative data obtained in Phases 1 and 2, a comprehensive review of the literature, and expert opinions gathered using the nominal group technique.

This is one of the few studies conducted within the domain of stigma pertaining to individuals who use drugs within the context of Iranian culture employing a mixed-methods approach, this study aims to develop culturally sensitive strategies to reduce such problems from the perspective of Iranian people who use drugs. It is anticipated that the study will yield evidence-based insights and provide practical strategies to reduce the stigma and discrimination experienced by people who use drugs at PATCs. Such outcomes are important for informing policymaking and designing healthcare interventions tailored to the needs of individuals grappling with substance dependency.

Introduction

Substance use disorders (SUDs) represent complex illnesses that disrupt brain activity and function resulting in significant personal and societal repercussions [ 1 , 2 , 3 , 4 ]. Recognizing the detrimental impact of SUD-related stigma, The National Institute on Drug Abuse has prioritized efforts to understand and diminish this stigma [ 5 ]. Research on mental illness stigma has consistently revealed its association with adverse outcomes, including exacerbated symptoms and impaired social functioning [ 6 ]. With the increasing prevalence of SUDs within the general population [ 1 , 2 , 3 , 4 , 7 ] and the necessity to inform policymakers and allocate legislative resources effectively [ 8 , 9 ], it becomes crucial to raise awareness about the stigma surrounding SUDs in society. Studies investigating SUD-related stigma have documented various forms of prejudice and discrimination experienced by people who use drugs, particularly from healthcare providers, which are correlated with detrimental health outcomes, including mental health disorders and compromised physical health [ 10 , 11 , 12 , 13 , 14 ].

Part of the stigmatization faced by healthcare providers stems from the inaction of public health leaders [ 15 ], while another part arises from the lack of training among healthcare workers in SUD treatment [ 16 , 17 ], both of which contribute to inadequate implementation of effective remedies. Numerous studies have demonstrated the persistent and entrenched nature of stigma, often rooted in the misconception that drug addiction reflects a personal choice, indicating a lack of self-control and moral failure. Stigma and discrimination levels are notably high both within the general population and among professions that interact with individuals with SUDs, such as the healthcare industry. Some studies have demonstrated that stigma and prejudice harm SUD patients’ health and cause delays in the delivery of high-quality care in venues for public addiction treatment. Individuals with SUDs frequently encounter stigma and discrimination across all levels of care at public addiction treatment centers (PATCs) [ 17 , 18 , 19 , 20 , 21 , 22 ].

The World Health Organization is working with several countries to train medical professionals in screening, brief intervention, and referral to treatment (SBIRT) [ 23 , 24 , 25 , 26 , 27 ]. SBIRT is a treatment strategy that encourages all medical professionals to identify patients who are taking drugs at statistically dangerous levels, provide brief interventions to promote drug use reduction, and then refer patients who meet criteria for drug use or addiction for more intensive treatments. According to some studies, screening and brief interventions (SBI) have the greatest effect on reducing the use of psychoactive substances [ 20 , 23 , 26 , and 28 ]. SBI is a simple, quick advisory intervention that stresses several types of specific behavior. It may be used by professionals in a variety of situations [ 29 ].

Unfortunately, societal acceptability of evidence-based initiatives does not always come easily [ 30 ]. The allocation of healthcare interventions is influenced by various factors, including the novelty of characteristics, healthcare worker attitudes, and the stigma associated with a health condition. Research has consistently demonstrated that negative attitudes among healthcare professionals can impede the adoption of innovative practices, the quality of services provided, and clients’ adherence to preventive and therapeutic measures [ 31 , 32 , 33 , 34 , 35 , 36 ]. Therefore, education and training programs should prioritize the modification of attitudes and beliefs among healthcare providers to promote the uptake of SBI for drug addiction [ 37 , 38 ].

Research in health has linked stigma from service providers at care or treatment centers with poor utilization of preventive programs and reduced accessibility for stigmatized individuals to access effective interventions [ 39 , 40 ]. Efforts to mitigate stigmatization are underway, particularly for individuals living with mental health conditions [ 40 , 41 ]. Studies have identified three main approaches: (i) providing educational interventions to dispel misconceptions about mental illnesses, (ii) facilitating interactions between individuals with mental illnesses and the community to challenge community attitudes, and (iii) exposing stigmatizing beliefs and behaviors in the hope of eliciting public condemnation and reducing their acceptance [ 41 , 42 , 43 ]. Although anti-stigma strategies are sometimes inaccessible or unproven, the aforementioned techniques aim to change community perceptions of people facing such circumstances [ 39 , 41 ].

To reduce the stigma associated with mental illness, several national and international strategies have been developed, and the range of programs continues to expand. However, stigma and discrimination against individuals with SUDs remain poorly understood [ 44 , 45 ]. Moreover, there has been limited research investigating the creation and execution of practices or interventions aimed at reducing SUD-related stigma and discrimination among people who use drugs by PHC professionals [ 46 , 47 , 48 , 49 , 50 ]. When developing anti-stigma strategies, it is essential to consider the cultural norms and different behaviors of specific groups, including healthcare professionals, youth, police, and policymakers [ 14 , 38 , 40 , 45 , 49 ].

For many years, stigma related to SUDs has posed challenges in Iran [ 51 , 52 , 53 ]. One of the most significant obstacles to improving the well-being and health of individuals with SUDs is the stigmatization and discrimination they face within the healthcare system [ 52 , 54 ]. This results in disparities in healthcare facilities, including limited availability, accessibility, and quality of services for individuals with SUDs [ 54 ]. Stigmatization negatively impacts help-seeking behavior from official healthcare facilities, leading to poorer outcomes and perpetuating the misconception that SUDs are untreatable. individuals with SUDs may be more prone to engaging in unhealthy behaviors, refusing treatment, non-compliance with prescription instructions, weakened immune systems, and experiencing adverse consequences [ 55 ].

Comprehensive plans for the promotion, prevention, treatment, and recovery of individuals with substance use disorders (SUDs) should consider numerous socioeconomic variables. Adopting a “health-in-all policies” approach is crucial in addressing these challenges. Strategies to increase access to treatment and reduce stigma and discrimination towards individuals with SUDs may involve integrating SUD care and fostering collaboration between primary care clinicians and other healthcare providers [ 22 , 38 , 39 , 40 , 53 ]. International efforts to combat addiction-related stigma have emphasized the importance of lowering barriers to a variety of health treatments for individuals with SUDs. Despite this emphasis and the widespread consensus that reducing stigma associated with SUDs is important, progress in this area has been slow [ 40 , 49 , 56 , 57 , 58 ]. While strategies to reduce SUD-related stigma have gained traction in Western industrial nations in recent years [ 59 , 60 ]. They remain largely absent from national and government policies, information, and healthcare plans in many parts of the world [ 40 , 42 , 44 , 53 , 58 , 61 ].

Longitudinal data on behavior changes in response to stigma and discrimination related to SUDs in Iran are lacking, making it challenging to develop effective strategies to reduce such stigma, especially in PATCs. The most widely recognized solutions are those that are acceptable, suitable, and adaptable across cultural contexts. Further research and needs assessments are required to identify additional strategies for addressing addiction-related stigma [ 42 , 47 , 56 ]. To address the stigma associated with addiction, it is necessary to study the effectiveness and feasibility of stigma-reducing interventions [ 55 , 58 , 62 ].

In Iran, as in many other countries, there is a lack of comprehensive strategies aimed at reducing stigma related to SUDs. Additionally, there is a dearth of studies providing practical strategies, both quantitative and qualitative, to address addiction-related stigma and discrimination specifically within PATCs for individuals with SUDs in Iran. Mixed-method analyses focusing on this issue are also lacking. While there have been some studies conducted in Iran to explore stigma toward individuals with SUDs, none have offered strategies or methods to mitigate stigma within public treatment settings. Although limited, existing data from small-scale qualitative studies in Iranian healthcare settings indicate the prevalence of discriminatory attitudes toward people with SUDs, manifesting as care refusal, substandard care, excessive precautions, physical distancing, humiliation, and blame [ 30 , 51 , 52 , 55 , 62 , 63 , 64 ].

Iran’s unique cultural characteristics [ 65 ] including demographic factors [ 66 ], cultural norms [ 67 ], ethnic identity [ 68 ], social customs, traditions, peer relationships, and poverty [ 69 ] shape the societal landscape and perceptions surrounding behaviors, including those related to SUDs. Consequently, addressing addiction-related stigma and its impact on individuals who use drugs in Iran requires sensitivity to these cultural nuances [ 64 , 70 ]. In Iran, SUDs are not solely viewed as medical issues but also as a socio-cultural problem. This perspective can lead to delays in treatment and pose significant challenges for patients and their families. Consequently, reducing stigma and discrimination associated with the rising prevalence of addiction among Iranians has been identified as a pressing priority within the healthcare system [ 70 ].

In Iranian society, plays a significant role in shaping perceptions and experiences of SUD across various demographic groups, including differences related to age, gender, socioeconomic status, and education level [ 64 ]. Research in Iran has extensively explored how cultural influences manifest in SUDs, examining factors such as demographic characteristics, regional prevalence patterns, gender dynamics, religious beliefs, and the stigma associated with drug use. These studies highlight the complex interplay between cultural norms, individual behaviors, and societal attitudes toward SUDs within the Iranian context [ 66 , 67 , 68 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 ].

Of course, the stigma surrounding drug addiction in Iran exhibits variations based on factors such as gender, the specific type of drug used, and residential location [ 81 , 82 ]. Interestingly, a study examining literary works in Iran reveals a historical acceptance of opium as a medicinal remedy by prominent Iranian poets. Opium has been portrayed positively, with references to its purported benefits such as regulating blood pressure and relieving pain [ 83 ]. This cultural perspective reflects a nuanced view of drug consumption in Iranian society, indicating that stigma surrounding certain drugs may not be uniform. Rather, stigma appears to evolve dynamically within social contexts, presenting new challenges that may differ from those associated with more entrenched forms of stigma.

Although previous qualitative studies have provided valuable insights into the experiences of individuals with SUD interacting with healthcare professionals, our understanding of SUD-related stigma within the Iranian healthcare system remains limited. A comprehensive, multiphase study employing a mixed-methods approach is needed to systematically assess the experiences of Iranian people who use drugs regarding stigma and to develop evidence-based guidelines and strategies for reducing stigma and discrimination against individuals with SUDs at PATCs. The importance and the impact of stigma and discrimination related to SUDs within Iranian culture as well as the influence of cultural differences on patients’ healthcare-seeking attitudes and the support services provided by the healthcare system, form the foundation of this mixed-method study. Given these considerations, it is imperative to address cultural factors associated with substance use disorders and the stigma stemming from substance consumption in Iranian society. This is because the cultural, economic, and social variations across different societies warrant an examination of human experiences within each unique cultural context. Therefore, the aim of this study is to explore comprehensive and culturally sensitive strategies in order to reduce addiction-related stigma and discrimination at PATCs.

The study aims

This mixed-methods study aims to identify strategies to reduce stigma and discrimination against Iranian people who use drugs at PATCs. The specific objectives of the study can be categorized into three phases as follows:

To measure the perceived stigma score among people with substance use disorders (SUDs) who were referred to PATCs in Mazandaran, Iran.

To evaluate professionals’ attitudes towards people with SUDs receiving treatment at PATCs in Mazandaran, Iran.

To measure the social distance score towards people with substance use disorders seeking treatment at PATCs in Mazandaran, Iran.

To examine the relationship between socio-demographic characteristics and perceived stigma among individuals with substance use disorders.

To investigate the relationship between perceived stigma, social distance, and professionals’ attitudes toward people with SUDs.

To explore the perspectives and experiences of people who use drugs concerning the various aspects and determinants of stigma and discrimination stemming from the community, healthcare centers, or PATCs due to drug use.

To examine healthcare providers’ perspectives on stigma against individuals who use drugs.

To develop evidence-based cultural strategies aimed at diminishing stigma and discrimination at PATCs against Iranian people who use drugs faced health challenges.

Study design

This study will employ a mixed-methods technique with an explanatory sequential approach for data collection and analysis. Grounded in pragmatic principles and logic, the mixed-methods paradigm combines quantitative and qualitative methodologies to provide a comprehensive understanding of the research questions. In this methodology, the researcher first gathers quantitative data to identify patterns or trends requiring further exploration. Subsequently, qualitative data are collected from individuals who can offer insights to enhance the understanding and interpretation of the quantitative findings [ 84 ]. According to this paradigm, merging qualitative and quantitative methods results in a deeper comprehension of the issue [ 85 , 86 ].

This study will be conducted in three phases. The first phase will be a quantitative study, during which, quantitative data will be gathered. The second phase of this project will be a more detailed exploratory qualitative study of participants’ experiences regarding SUD-related stigma toward and discrimination against people who use drugs at PATCs. At the end of the second phase, the qualitative and quantitative findings will be integrated. The third phase of the study will involve the development of evidence-based and culturally sensitive strategies based on a literature review, the results of Phases 1 and 2, and experts’ opinions using the nominal group technique (NGT) (Fig.  1 ). Full explanations of each part of the study are provided below.

Study visual diagram

Phase 1: quantitative study

The quantitative phase will be a descriptive-analytic cross-sectional study conducted among Iranian people with SUDs living in Mazandaran, Iran. In this phase, we will assess perceived stigma experiences and their relationship with social distance, perceived dangerousness, experts’ discrimination or acceptance, and sociodemographic characteristics among the participants. The target population will consist of people who are referred to PATCs in Mazandaran, Iran. The Perceived Stigma of Addiction Scale (PSAS), Health Professionals’ Attitude Towards Substance Abusers Scale (HPA-SAS), and Social Distance Scale (SDS) will be used. These scales will be validated for use among Iranian people.

Sample size and sampling method

There is no shortage of research on stigma toward and discrimination against people with SUDs at PATCs and other health-care settings in Iran. Therefore, the sample size is calculated based on Matsumoto’s study [ 87 ]. Following Matsumoto et al. [ 87 ], the calculated sample size is 240, based on the largest standard deviation related to the sub dimension of stigma (SD = 12.39), with a precision (d) of 0.05 around the mean (m = 35.01), and α = 0.05. In most cases, the design effect’s numerical value is about 1.5–2. In this study, we will apply 1.5, and the final sample size will be increased to 360 substance users, based on cluster sampling.

For this project, fifteen PATCs in Mazandaran will be selected. A cluster sampling method will be employed, with each cluster comprising a comparable number of respondents. Mazandaran will be divided into three areas (west, central, and east). All PATCs within these areas will be enumerated, and five PATCs will be randomly chosen from each area. Individuals with SUDs who are referred to the PATCs will be invited to participate in the project.

The participants will be offered comprehensive explanations of the goals and methods of the research. The sociodemographic questions, the PSAS, HPA-SAS, and SDS will be administered in a “quiet setting” [questionnaire will be presented while maintaining patient privacy] by a research group member and then collected in person. The investigator will fill out the scales to ensure that the same data collection method is used for all individuals. Informed consent will be obtained from the individuals prior to the data collection.

Inclusion criteria

Individuals will be eligible for the current project if they are adults (aged 20 years or older), reside in Mazandaran province, have a history of any kind of substance use, and have no severe mental difficulties that prevent them from answering the items in the questionnaires.

Exclusion criteria

The exclusion criteria for participants will be: having a mental disability, having psychiatry history like active bipolar disease, depression with psychosis, or schizophrenia, being deaf or mute, showing unwillingness to continue participating in the study, and not fully completing the questionnaires.

Questionnaires and data collection

Quantitative data will be collected utilizing sociodemographic variables and the PSAS, HPA-SAS, and SDS scales. The sociodemographic section will include questions on age, gender, occupation, duration of employment, and education. The PSAS comprises eight items to measure the perceived stigma towards individuals with substance use disorders. Initially developed and validated among patients undergoing treatment for substance use–related issues in the United States [ 88 ]. he items were adapted from a study conducted by Link and colleagues on perceived discrimination-devaluation processes, Content validity was established through review by stigma professionals in the substance use field the PSAS was related to adopted shame, self-concealment, adopted stigma, and depression [ 89 ]. The PSAS employs a four-point Likert scale ranging from “strongly disagree” to “strongly agree” for participants to rate their agreement or disagreement with each item. Scores range from 8 to 32, with higher scores indicating greater perceived stigma. The PSAS has demonstrated good reliability, with a Cronbach’s alpha of 0.71 and a reliability coefficient of 0.79 based on the test-retest method in American society [ 88 ]. In an Iranian study, the reliability of the PSAS was found to be 0.85, with a test-retest correlation coefficient of 0.81 [ 90 ].

The HPA-SAS consists of 10 items, with questions addressing the attitudes and/or views of health professionals toward people with SUD, their knowledge of addiction, and their training in substance use. The constructs of attitudes will focus on discrimination and acceptance towards people who use drugs. The HPA-SAS was developed utilizing a Likert scale format, with each item offering four response options: (1) strongly disagree (2), disagree (3), agree, and (4) strongly agree, resulting in total scores ranging from 10 to 40. The validity and reliability of the HPA-SAS were established through research conducted by a team of psychological counseling and medical care professionals. The overall Cronbach’s alpha of the original HPA-SAS has been reported as 0.79 [ 91 ]. In this study, the validity and reliability of the questionnaire were assessed prior to data collection with a sample of Iranian people who use drugs. The overall Cronbach’s alpha of the HPA-SAS was found to be 0.76, and the test–retest correlation coefficient of this scale was 0.74.

The seven-item SDS, which was created by Bogardus et al. (1925) [ 92 ] and then modified by Link et al. (1987) [ 89 ], measures the social distance that interviewees wish to keep toward a person with a particular condition (diverse social, ethnic, or racial backgrounds). This scale focuses on respondents’ willingness to engage in a relationship with someone who is dependent on illegal substances. In particular, it measures people’s willingness to take part in a variety of social contacts with a particular group. The SDS consists of seven items presented as multiple-choice questions, which assess social distance by probing the respondent’s willingness to engage in various social interactions with stigmatized individuals: These interactions include scenarios such as being a sub-lessee, neighbor, co-worker, spouse of a family member, caretaker of one’s child, and member of the same social group. Participants will be asked to rate their level of willingness or unwillingness for each item using a four-point Likert scale with the following options: (0) definitely willing [ 1 ], willing [ 2 ], unwilling, and [ 3 ] definitely unwilling. The total score ranges from 0 to 21; scores higher than the mean identify higher social distance. The overall Cronbach’s alpha of the original SDS is 0.75 [ 89 ]. The Iranian version of the SDS has found to have a Cronbach’s alpha value of 0.92. The test–retest reliability coefficient for the SDS was 0.89, and the content validity coefficient was 0.75 [ 90 ].

Data analysis

The data from the first phase of the study will be analyzed using SPSS Statistics Version 26.0 for Windows (IBM Inc., Armonk, NY, USA). In the cross-sectional phase, descriptive statistics will be applied to describe the sociodemographic factors and perceived stigma of addiction, experts’ attitudes toward people with SUD, and social distance. Univariate analytical statistics will be used to test the correlation between the sociodemographic variables and perceived stigma, experts’ attitudes toward people with SUD, and social distance. Variables with a correlation of p  < 0.1 in the univariate analysis will be included in the multivariable logistic model. All statistical tests will be two-tailed, and a p -value < 0.05 will be considered statistically significant. To ensure data quality during this phase of the study, measures such as double data entry and range checks for data values will be implemented.

Phase 2: qualitative study

In Phase 2, an exploratory qualitative study will be conducted utilizing a conventional content analysis method to explore the experiences of people who use drugs regarding stigma and discrimination stemming from the community, health-care centers, or PATCs as a result of drug use. Additionally, this phase will aim to gain insight into healthcare providers’ perspectives on stigma against people who use drugs in greater detail. Given the objectives of the project’s qualitative phase, employing this method will enable the investigator to gain a comprehensive understanding of the situation, facilitating the clarification of the impact of stigma and discrimination on Iranian people who use drugs at PATCs.

Participants and sampling method

A purposive sampling approach will be used in the second phase of the study. The target population will consist of two groups of people, namely, those who have experienced drug use and staff members at PATCs. The first group of participants (people who use drugs) will be selected from those willing to participate in the quantitative phase of the study and will be based on the mean total score of the stigma experience, which will be collected in Phase 1 of the study. People with 10% upper and lower stigma experience scores will be selected as extreme cases, and will be retained for the next phase. We will seek to interview people with either a stigma or discrimination experience in order to collect more comprehensive information about their stigma experiences and its related factors. Efforts will be made to have variety in terms of gender, level of education, religion, age, socioeconomic situation, and the use of different types of drugs.

The second group of participants will consist of health-care workers and providers at PATCs. This sample will include agents from (i) PATC management, (ii) clinical and medical teams, (iii) health-care program teams and (iv)others according to the setting (e.g., finance). Health-care workers will be enlisted using purposive sampling methods. Four of them will be contacted through education programs with a specific focus on staff involved in drug treatment. The retained persons will be invited to register, and a member of the research team will be in touch to schedule an interview. Health-care workers in specific treatment centers will also receive direct invitations from the investigation team.

Data analysis will commence after the first interview, focusing on elucidating the intricacies and interactions among key concepts and categories derived from the exploration of the primary data. Consequently, the selection of participants will persist until theoretical saturation is achieved, ensuring a comprehensive understanding of the relationships between the study concepts and components [ 93 ]. In the current study, sampling will continue until the investigator determines that no further data can be garnered through data analysis and coding, signifying theoretical saturation. However, it is recommended by experts that a minimum of 12 participants be interviewed for a qualitative study to ensure a robust and comprehensive analysis [ 94 ].

Data collection

Data will be collected by two methods: in-depth interviews with individuals with SUDs and focus group discussions with PATC staff members.

Semi-structured, in-depth interviews

Individual, in-depth, semi-structured interviews featuring open-ended questions will be employed to gather data. These interviews will focus on exploring participants’ perspectives and experiences related to stigma and discrimination against individuals with (SUDs within healthcare settings. The target group for this part of the study will consist of people who use drugs who have been referred to PATCs in Mazandaran, Iran. Before the qualitative phase of the study, the interview protocol questions will be prepared based on the results of the first phase of the study as well as the literature review. Interviews will be held in locations, such as clinics, where respondents will feel safe and relaxed. All individual in-depth interviews will be recorded using a digital tape recorder after the applicant’s permission. In addition to the audio recordings, the interviewer will take notes. If participants decline to be audio-recorded, only notes will be employed for data gathering. Furthermore, non-verbal cues, such as facial expressions, tone of voice, and the respondents’ state, will also be noted by the interviewer, together with the date and place of the interview.

All interviews will be conducted by the first author of this study, who is familiar with qualitative research methods and the topic, and who has conducted similar studies on addiction,. Participants will be encouraged to discuss their experiences related to strategies to reduce addiction-related stigma and discrimination in public addiction treatment centers. Further, they will be encouraged to discuss sociocultural and ecological components that might have had an effect on the level of using these strategies in this regard.

The interviews will be focused on the following three main questions:

How was the experience with stigma toward and discrimination in health-care settings?

What strategy and procedure have they applied to reduce and cope with stigma and discrimination in health-care settings?

How have the strategies and procedures affected their coping strategies in this regard?

Based on the responses to these questions, follow-up questions will be asked. After each question, participants will be invited to explain more thoroughly their answer, by probing questions such as “What do you mean?” or “can you explain this more”.

Interviews will be performed during a single meeting with each participant and is estimated to last between 40 and 60 min, although this can differ slightly based on the experiences of each participant. The investigator will start with explaining the significance of the study in order to gain their confidence. All interview questions will be reviewed after the first interview, and all interviews will be taped. Data collection will be continued until saturation is reached.

Focus group discussions

Following semi-structured interviews, the principal researcher (first author), who is an expert in qualitative studies, an expert in qualitative studies, will conduct focus group discussions with staff members at Patients with Substance Use Disorders Treatment Centers (PATCs), which comprise the second target group of this phase of the study. These focus group discussions aim to validate the emerging themes from the individual interviews and gain deeper insights into the identified themes. The focus group discussions will be guided by the two main research questions: (i) What is providers’ understanding of stigma towards and discrimination against persons with SUDs? and [ 2 ] What are the providers’ opinions regarding a response to stigma and discrimination? Furthermore, more detailed investigative questions will be incorporated, such as: What types of SUDs do your clients typically present with? Are there any other community-level factors that could influence experiences of stigma and discrimination against individuals with SUDs?

Immediately following data collection, the coding process will be initiated, and the data will be analyzed. The main themes will be identified using a conventional content analysis method of Graneheim and Lundman [ 95 ], in which themes and subthemes are identified to reveal participants’ perceptions and experiences toward stigma and discrimination against Iranian people who use drugs at PATCs. This process will employ inductive reasoning, which introduces concepts and categories via a detailed exploration of the data by the researcher.

In Graneheim and Lundman’s method, qualitative content analysis addresses the obvious content of an interview, along with explanations of content that can be construed or added from the interview but are not obviously detailed in the transcript [ 95 ]. Further, coding classifications are derived directly from the transcription data. Without laying on preset themes or prior theoretical opinions to categorize extracted codes from interviews, the conventional content analysis method is a suitable technique for advancing coding categorizations from the raw interview transcripts.

In this method, data analysis begins with a comprehensive reading of the entire text to ensure a thorough understanding. Subsequently, the text is examined word by word to extract codes, initially identifying specific words that may encapsulate the main concepts. These texts are derived from notes documenting the initial opinions of the interviewees and the preliminary analysis conducted. Codes that are indicative of more than one main thought are tagged and then categorized based on their dissimilarities and similarities. The greatest benefit of a conventional content analysis is attaining data directly from the study without imposing preplanned and defined categories, themes, or theories. However, one problem with this kind of analysis is that it interjects with other qualitative methods (i.e., grounded theory or phenomenology). While these approaches share similarities with initial analysis, they are emphasized for their relevance to theory advancement. Additionally, they hold significance for model development. To evaluate the trustworthiness of the results in this phase of the study, four criteria —reliability, portability, credibility, and verifiability— will be employed [ 96 ]. MAXQDA software will be used for data processing.

Phase three: integration of quantitative and qualitative data and the development of strategies

In this phase, cultural evidence-based strategies aimed at reducing stigma and discrimination associated with substance use of Iranian people at PATCs will be developed This will involve integrating insights from the literature review, the findings of the preceding study phases, and input from experts. The target group for this aspect of the study will comprise PATC experts residing in Mazandaran, Iran.

Upon completion of the second phase of the study, the quantitative and qualitative results will be merged to glean additional insights that will inform the design and implementation of appropriate strategies to mitigate stigma and discrimination against individuals with SUDs at PATCs. Three techniques can be employed to integrate the quantitative and qualitative findings: combining the data into a discussion, utilizing a matrix for combination, or employing a side-by-side display and transformation. n this study, the data will be combined into a discussion format. Some researchers often commence this approach with a section outlining the quantitative findings, followed by a section detailing the qualitative findings. Alternatively, researchers may present the quantitative findings while substantiating claims with quotes extracted from them. Another less common technique involves initially presenting the quantitative results and subsequently confirming and validating them with descriptive qualitative findings [ 97 , 98 ].

To develop strategies for reducing stigma and discrimination against people who use drugs at PATCs, the research team will start with formulating guidelines after a comprehensive review of the available literature. Systematic review and interventional studies will be conducted to find approaches. The search will encompass English-language databases (including Cochrane Library, APA PsycNET, MEDLINE, Web of Science, Embase, Scopus, ProQuest) as well as Persian databases (such as Magiran, Irandoc, SID, and Barakat). No restrictions will be imposed, particularly with regard to publication dates, to ensure comprehensive coverage of relevant studies. A uniform search strategy will be applied across all databases, utilizing the intersection of three fields via the Boolean AND operator. To define search terms, the Medical Subject Headings (MeSH) dictionary will be referenced. Upon identification of relevant documents, their quality will be assessed using the GRADE approach, followed by evidence analysis. Insights gleaned from the literature review will also be incorporated. Subsequently, the recommended strategies developed will be offered to Nominal Group Technique (NGT) experts.

NGT will be applied will be employed to devise and implement effective strategies aimed at diminishing stigma and discrimination against individuals with SUDs at PATCs. NGT is a structured, group-based method utilized to achieve consensus. Participants are encouraged to independently generate viewpoints based on predetermined and organized questions facilitated by a moderator [ 99 ]. To initiate the NGT process, primary strategies will be extracted from the findings of the first and second phases of the study, in addition to insights gathered from a literature review and examination of relevant rules and regulations A meeting will then be held with the experts who must meet the inclusion criteria of being residents of Mazandaran, Iran, possessing a minimum of one year of relevant work experience, having comprehensive familiarity with Iranian culture and customs, and being employed in a clinic associated with the treatment of people who use drugs. During this meeting, specialists will be invited to share their opinions on the developed strategies in relation to the key study questions, with all ideas and suggestions being meticulously recorded. Subsequently, these suggestions will be organized and prioritized to formulate consensus-driven strategies for effectively reducing stigma and discrimination against Iranian individuals with SUDs.

Ethical approval

The Ethics Committee of the Mazandaran University of Medical Sciences in Mazandaran, Sari, Iran, has approved the protocol for the present study [code number: IR.MAZUMS.REC.1401.192]. Informed written consent will be obtained from all participants during the quantitative and qualitative stages. Participants will be assured of the confidentiality of their data and identities. Additionally, they will be informed that they have the right to withdraw from the project at any phase of the intervention, and that their decision to refuse participation at any time will not impact or alter the quality of services provided to them.

The study is still ongoing, and no results have yet been generated. We will wait until the completion of our first data collection before disseminating any findings.

This article outlines the protocol for a mixed-method study aimed at identifying and formulating appropriate strategies to mitigate addiction-related stigma and discrimination at PATCs. The study will offer comprehensive insights into the stigma encountered by a cohort of Iranian people who use drugs and the factors influencing their experiences. The findings of this study will be utilized to develop and implement culturally tailored strategies geared towards reducing stigma and discrimination associated with substance use among Iranian people who use drugs attending PATCs.

While stigma and discrimination linked with drug addiction is a global concern, their nature and expression are contingent upon the religious, social, and cultural frameworks prevalent in various societies. Operating as a multilevel phenomenon, stigma arises when harm resulting from unfavorable status, labeling, or discrimination transpires within a power structure that perpetuates and reinforces social inequalities among those labeled [ 100 ]. Stigma toward substance use can profoundly impact an individual’s social and personal connections, often resulting in feelings of worthlessness. Such stigma may provoke negative responses and behaviors from various organizations and individuals towards the affected person [ 101 , 102 ]. These behaviors can impede access to treatment for individuals with substance use disorders. Moreover, they contribute to social, financial, and health discrimination within these communities, fostering the perception that individuals with SUDs are undeserving of the opportunity to address their condition [ 103 ].

Stigma significantly impacts the spectrum of care for individuals with SUDs, influencing aspects such as treatment seeking, preference, maintenance, and adherence, consequently leading to poorer health outcomes within this population or ever, stigma may exacerbate disparities in accessing medical and health services, as individuals with SUDs may be hesitant to pursue and adhere to health-oriented measures [ 104 ].

Studies evaluating the stigma experiences of persons with SUDs are mainly qualitative in nature [ 21 , 52 , 62 , 98 , 105 , 106 ]. The present study will be one of the few studies addressing addiction-related stigma in Iran that applies a mixed-methods technique to identify suitable strategies to reduce addiction-related stigma and discrimination at PATCs from the perspective of Iranian people who use drugs. It is expected that the current work, by using quantitative and qualitative methods, will offer valid data regarding suitable cultural strategies to reduce stigma against persons with SUDs at health-care and treatment centers.

The findings of the current study hold potential significance for healthcare specialists and policymakers shedding light on the pivotal role of cultural strategies in mitigating stigma against individuals with SUDs within healthcare and treatment settings employing a culturally sensitive approach Furthermore, the study aims to elucidate the needs of individuals with SUDs and provide insights into the factors influencing addiction-related stigma that require attention. Effective strategies emerging from this research may encompass interventions geared towards enhancing the health outcomes of Iranian people who use drugs and their families, as well as those from other nationalities and countries sharing similar cultural contexts with Iran. Additionally, the study’s findings are anticipated to inform stigma-reduction education and healthcare support initiatives tailored to the Iranian population, underpinned by a culture-based approach.

Potential strengths of the study

This study has several advantages. The results will potentially fill some of the gaps in research on people with SUDs who encounter stigma and discrimination at PATCs thus holding significant clinical implications. By employing a mixed-methods approach, this study facilitates the integration of diverse approaches and methodologies. The collection of both qualitative and quantitative data will provide a comprehensive understanding of. People who use drugs’ experiences of stigma and discrimination at PATCs. Moreover, the qualitative component of the study involves various participants directly or indirectly associated with this phenomenon, including individuals with SUDs and staff/clinicians. Conducting interviews with substance users and clinicians will enable a deeper understanding of how the phenomenon is perceived by those directly affected by stigma/discrimination, as well as by individuals closely involved in the patients’ daily lives and clinicians, who play a crucial role in both the phenomenon and its treatment.

Potential limitations of the study

The researchers acknowledge several limitations in the current study although the developed strategies will be evaluated upon achievement to ascertain their suitability and effectiveness, detailed descriptions will be necessary to design appropriate interventions and allow for generalization in similar contexts. One limitation is related to the sampling, which will be conducted in only one province in Iran. To mitigate this weakness, we will try to use maximum variation in the study phases. Another limitation is the possibility that the participants will not cooperate and drop out before the end of the study. Additionally, the scarcity of research and literature reviews regarding the stigma experienced by this population at PATCs poses a challenge. Furthermore, there is limited available data on how stigma varies among different subgroups, such as based on gender, race, religion, or socioeconomic status. These limitations will be considered during the interpretation of the study results and may influence the generalizability of findings to broader contexts.

The stigma and discrimination faced by individuals’ with SUDs experience persist not only in the community but also within PATCs, and medical settings. This Stigmatization adversely affects the accessibility and acceptability of care, as the lack of anonymity limits the willingness of this population to seek SUD treatment. The present study aims to provide comprehensive insights into the development of appropriate strategies to reduce addiction-related stigma and discrimination at PATCs. By incorporating evidence-based practice principles, insights from people who use drugs’ experiences, and input from PATC staff, these strategies can offer valuable guidance for healthcare professionals, policymakers, and managers seeking to enhance the quality of care for individuals with a history of drug use worldwide. Furthermore, the strategies developed may serve as a blueprint for adapting interventions for patients with SUDs in various settings, including other healthcare treatment centers, clinics, and within the broader public community.

Data availability

Not applicable.

Abbreviations

substance use disorder

public addiction treatment centers

Perceived Stigma of Addiction Scale

Professional’s Discrimination, Acceptance, Attitude, and Training toward Substance Abusers

Social Distance Scale

focus group discussions

screening, brief intervention and referral to treatment

in-depth interviews

nominal group technique

standard deviation

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Khazaee-Pool, M., Naghibi, S.A., Pashaei, T. et al. Developing practical strategies to reduce addiction-related stigma and discrimination in public addiction treatment centers: a mixed-methods study protocol. Addict Sci Clin Pract 19 , 40 (2024). https://doi.org/10.1186/s13722-024-00472-8

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Mixed Methods Research | Definition, Guide, & Examples

Published on 4 April 2022 by Tegan George . Revised on 25 October 2022.

Mixed methods research combines elements of quantitative research and qualitative research in order to answer your research question . Mixed methods can help you gain a more complete picture than a standalone quantitative or qualitative study, as it integrates benefits of both methods.

Mixed methods research is often used in the behavioral, health, and social sciences, especially in multidisciplinary settings and complex situational or societal research.

• To what extent does the frequency of traffic accidents ( quantitative ) reflect cyclist perceptions of road safety ( qualitative ) in Amsterdam?
• How do student perceptions of their school environment ( qualitative ) relate to differences in test scores ( quantitative ) ?
• How do interviews about job satisfaction at Company X ( qualitative ) help explain year-over-year sales performance and other KPIs ( quantitative ) ?
• How can voter and non-voter beliefs about democracy ( qualitative ) help explain election turnout patterns ( quantitative ) in Town X?
• How do average hospital salary measurements over time (quantitative) help to explain nurse testimonials about job satisfaction (qualitative) ?

Table of contents

When to use mixed methods research, mixed methods research designs, benefits of mixed methods research, disadvantages of mixed methods research, frequently asked questions about mixed methods research.

Mixed methods research may be the right choice if your research process suggests that quantitative or qualitative data alone will not sufficiently answer your research question. There are several common reasons for using mixed methods research:

• Generalisability : Qualitative research usually has a smaller sample size , and thus is not generalisable . In mixed methods research, this comparative weakness is mitigated by the comparative strength of ‘large N’, externally valid quantitative research.
• Contextualisation: Mixing methods allows you to put findings in context and add richer detail to your conclusions. Using qualitative data to illustrate quantitative findings can help ‘put meat on the bones’ of your analysis.
• Credibility: Using different methods to collect data on the same subject can make your results more credible. If the qualitative and quantitative data converge, this strengthens the validity of your conclusions. This process is called triangulation .

As you formulate your research question , try to directly address how qualitative and quantitative methods will be combined in your study. If your research question can be sufficiently answered via standalone quantitative or qualitative analysis, a mixed methods approach may not be the right fit.

Keep in mind that mixed methods research doesn’t just mean collecting both types of data; you need to carefully consider the relationship between the two and how you’ll integrate them into coherent conclusions. Mixed methods can be very challenging to put into practice, so it’s a less common choice than standalone qualitative or qualitative research.

Prevent plagiarism, run a free check.

There are different types of mixed methods research designs . The differences between them relate to the aim of the research, the timing of the data collection , and the importance given to each data type.

As you design your mixed methods study, also keep in mind:

• Your research approach ( inductive vs deductive )
• Your research questions
• What kind of data is already available for you to use
• What kind of data you’re able to collect yourself.

Here are a few of the most common mixed methods designs.

Convergent parallel

In a convergent parallel design, you collect quantitative and qualitative data at the same time and analyse them separately. After both analyses are complete, compare your results to draw overall conclusions.

• On the qualitative side, you analyse cyclist complaints via the city’s database and on social media to find out which areas are perceived as dangerous and why.
• On the quantitative side, you analyse accident reports in the city’s database to find out how frequently accidents occur in different areas of the city.

In an embedded design, you collect and analyse both types of data at the same time, but within a larger quantitative or qualitative design. One type of data is secondary to the other.

This is a good approach to take if you have limited time or resources. You can use an embedded design to strengthen or supplement your conclusions from the primary type of research design.

Explanatory sequential

In an explanatory sequential design, your quantitative data collection and analysis occurs first, followed by qualitative data collection and analysis.

You should use this design if you think your qualitative data will explain and contextualise your quantitative findings.

Exploratory sequential

In an exploratory sequential design, qualitative data collection and analysis occurs first, followed by quantitative data collection and analysis.

You can use this design to first explore initial questions and develop hypotheses. Then you can use the quantitative data to test or confirm your qualitative findings.

‘Best of both worlds’ analysis

Combining the two types of data means you benefit from both the detailed, contextualised insights of qualitative data and the generalisable, externally valid insights of quantitative data. The strengths of one type of data often mitigate the weaknesses of the other.

For example, solely quantitative studies often struggle to incorporate the lived experiences of your participants, so adding qualitative data deepens and enriches your quantitative results.

Solely qualitative studies are often not very generalisable, only reflecting the experiences of your participants, so adding quantitative data can validate your qualitative findings.

Method flexibility

Mixed methods are less tied to disciplines and established research paradigms. They offer more flexibility in designing your research, allowing you to combine aspects of different types of studies to distill the most informative results.

Mixed methods research can also combine theory generation and hypothesis testing within a single study, which is unusual for standalone qualitative or quantitative studies.

Mixed methods research is very labour-intensive. Collecting, analysing, and synthesising two types of data into one research product takes a lot of time and effort, and often involves interdisciplinary teams of researchers rather than individuals. For this reason, mixed methods research has the potential to cost much more than standalone studies.

Differing or conflicting results

If your analysis yields conflicting results, it can be very challenging to know how to interpret them in a mixed methods study. If the quantitative and qualitative results do not agree or you are concerned you may have confounding variables , it can be unclear how to proceed.

Quantitative research deals with numbers and statistics, while qualitative research deals with words and meanings.

Quantitative methods allow you to test a hypothesis by systematically collecting and analysing data, while qualitative methods allow you to explore ideas and experiences in depth.

In mixed methods research , you use both qualitative and quantitative data collection and analysis methods to answer your research question .

Data collection is the systematic process by which observations or measurements are gathered in research. It is used in many different contexts by academics, governments, businesses, and other organisations.

Triangulation in research means using multiple datasets, methods, theories and/or investigators to address a research question. It’s a research strategy that can help you enhance the validity and credibility of your findings.

Triangulation is mainly used in qualitative research , but it’s also commonly applied in quantitative research . Mixed methods research always uses triangulation.

These are four of the most common mixed methods designs :

• Convergent parallel: Quantitative and qualitative data are collected at the same time and analysed separately. After both analyses are complete, compare your results to draw overall conclusions. 
• Embedded: Quantitative and qualitative data are collected at the same time, but within a larger quantitative or qualitative design. One type of data is secondary to the other.
• Explanatory sequential: Quantitative data is collected and analysed first, followed by qualitative data. You can use this design if you think your qualitative data will explain and contextualise your quantitative findings.
• Exploratory sequential: Qualitative data is collected and analysed first, followed by quantitative data. You can use this design if you think the quantitative data will confirm or validate your qualitative findings.

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Tegan George

• Open access
• Published: 14 May 2024

Developing a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study

• Jocelyn Schroeder 1 ,
• Barbara Pesut 1 , 2 ,
• Lise Olsen 2 ,
• Nelly D. Oelke 2 &
• Helen Sharp 2  

BMC Nursing volume  23 , Article number:  326 ( 2024 ) Cite this article

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Medical Assistance in Dying (MAiD) was legalized in Canada in 2016. Canada’s legislation is the first to permit Nurse Practitioners (NP) to serve as independent MAiD assessors and providers. Registered Nurses’ (RN) also have important roles in MAiD that include MAiD care coordination; client and family teaching and support, MAiD procedural quality; healthcare provider and public education; and bereavement care for family. Nurses have a right under the law to conscientious objection to participating in MAiD. Therefore, it is essential to prepare nurses in their entry-level education for the practice implications and moral complexities inherent in this practice. Knowing what nursing students think about MAiD is a critical first step. Therefore, the purpose of this study was to develop a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context.

The design was a mixed-method, modified e-Delphi method that entailed item generation from the literature, item refinement through a 2 round survey of an expert faculty panel, and item validation through a cognitive focus group interview with nursing students. The settings were a University located in an urban area and a College located in a rural area in Western Canada.

During phase 1, a 56-item survey was developed from existing literature that included demographic items and items designed to measure experience with death and dying (including MAiD), education and preparation, attitudes and beliefs, influences on those beliefs, and anticipated future involvement. During phase 2, an expert faculty panel reviewed, modified, and prioritized the items yielding 51 items. During phase 3, a sample of nursing students further evaluated and modified the language in the survey to aid readability and comprehension. The final survey consists of 45 items including 4 case studies.

Systematic evaluation of knowledge-to-date coupled with stakeholder perspectives supports robust survey design. This study yielded a survey to assess nursing students’ attitudes toward MAiD in a Canadian context.

The survey is appropriate for use in education and research to measure knowledge and attitudes about MAiD among nurse trainees and can be a helpful step in preparing nursing students for entry-level practice.

Peer Review reports

Medical Assistance in Dying (MAiD) is permitted under an amendment to Canada’s Criminal Code which was passed in 2016 [ 1 ]. MAiD is defined in the legislation as both self-administered and clinician-administered medication for the purpose of causing death. In the 2016 Bill C-14 legislation one of the eligibility criteria was that an applicant for MAiD must have a reasonably foreseeable natural death although this term was not defined. It was left to the clinical judgement of MAiD assessors and providers to determine the time frame that constitutes reasonably foreseeable [ 2 ]. However, in 2021 under Bill C-7, the eligibility criteria for MAiD were changed to allow individuals with irreversible medical conditions, declining health, and suffering, but whose natural death was not reasonably foreseeable, to receive MAiD [ 3 ]. This population of MAiD applicants are referred to as Track 2 MAiD (those whose natural death is foreseeable are referred to as Track 1). Track 2 applicants are subject to additional safeguards under the 2021 C-7 legislation.

Three additional proposed changes to the legislation have been extensively studied by Canadian Expert Panels (Council of Canadian Academics [CCA]) [ 4 , 5 , 6 ] First, under the legislation that defines Track 2, individuals with mental disease as their sole underlying medical condition may apply for MAiD, but implementation of this practice is embargoed until March 2027 [ 4 ]. Second, there is consideration of allowing MAiD to be implemented through advanced consent. This would make it possible for persons living with dementia to receive MAID after they have lost the capacity to consent to the procedure [ 5 ]. Third, there is consideration of extending MAiD to mature minors. A mature minor is defined as “a person under the age of majority…and who has the capacity to understand and appreciate the nature and consequences of a decision” ([ 6 ] p. 5). In summary, since the legalization of MAiD in 2016 the eligibility criteria and safeguards have evolved significantly with consequent implications for nurses and nursing care. Further, the number of Canadians who access MAiD shows steady increases since 2016 [ 7 ] and it is expected that these increases will continue in the foreseeable future.

Nurses have been integral to MAiD care in the Canadian context. While other countries such as Belgium and the Netherlands also permit euthanasia, Canada is the first country to allow Nurse Practitioners (Registered Nurses with additional preparation typically achieved at the graduate level) to act independently as assessors and providers of MAiD [ 1 ]. Although the role of Registered Nurses (RNs) in MAiD is not defined in federal legislation, it has been addressed at the provincial/territorial-level with variability in scope of practice by region [ 8 , 9 ]. For example, there are differences with respect to the obligation of the nurse to provide information to patients about MAiD, and to the degree that nurses are expected to ensure that patient eligibility criteria and safeguards are met prior to their participation [ 10 ]. Studies conducted in the Canadian context indicate that RNs perform essential roles in MAiD care coordination; client and family teaching and support; MAiD procedural quality; healthcare provider and public education; and bereavement care for family [ 9 , 11 ]. Nurse practitioners and RNs are integral to a robust MAiD care system in Canada and hence need to be well-prepared for their role [ 12 ].

Previous studies have found that end of life care, and MAiD specifically, raise complex moral and ethical issues for nurses [ 13 , 14 , 15 , 16 ]. The knowledge, attitudes, and beliefs of nurses are important across practice settings because nurses have consistent, ongoing, and direct contact with patients who experience chronic or life-limiting health conditions. Canadian studies exploring nurses’ moral and ethical decision-making in relation to MAiD reveal that although some nurses are clear in their support for, or opposition to, MAiD, others are unclear on what they believe to be good and right [ 14 ]. Empirical findings suggest that nurses go through a period of moral sense-making that is often informed by their family, peers, and initial experiences with MAID [ 17 , 18 ]. Canadian legislation and policy specifies that nurses are not required to participate in MAiD and may recuse themselves as conscientious objectors with appropriate steps to ensure ongoing and safe care of patients [ 1 , 19 ]. However, with so many nurses having to reflect on and make sense of their moral position, it is essential that they are given adequate time and preparation to make an informed and thoughtful decision before they participate in a MAID death [ 20 , 21 ].

It is well established that nursing students receive inconsistent exposure to end of life care issues [ 22 ] and little or no training related to MAiD [ 23 ]. Without such education and reflection time in pre-entry nursing preparation, nurses are at significant risk for moral harm. An important first step in providing this preparation is to be able to assess the knowledge, values, and beliefs of nursing students regarding MAID and end of life care. As demand for MAiD increases along with the complexities of MAiD, it is critical to understand the knowledge, attitudes, and likelihood of engagement with MAiD among nursing students as a baseline upon which to build curriculum and as a means to track these variables over time.

Aim, design, and setting

The aim of this study was to develop a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context. We sought to explore both their willingness to be involved in the registered nursing role and in the nurse practitioner role should they chose to prepare themselves to that level of education. The design was a mixed-method, modified e-Delphi method that entailed item generation, item refinement through an expert faculty panel [ 24 , 25 , 26 ], and initial item validation through a cognitive focus group interview with nursing students [ 27 ]. The settings were a University located in an urban area and a College located in a rural area in Western Canada.

Participants

A panel of 10 faculty from the two nursing education programs were recruited for Phase 2 of the e-Delphi. To be included, faculty were required to have a minimum of three years of experience in nurse education, be employed as nursing faculty, and self-identify as having experience with MAiD. A convenience sample of 5 fourth-year nursing students were recruited to participate in Phase 3. Students had to be in good standing in the nursing program and be willing to share their experiences of the survey in an online group interview format.

The modified e-Delphi was conducted in 3 phases: Phase 1 entailed item generation through literature and existing survey review. Phase 2 entailed item refinement through a faculty expert panel review with focus on content validity, prioritization, and revision of item wording [ 25 ]. Phase 3 entailed an assessment of face validity through focus group-based cognitive interview with nursing students.

Phase I. Item generation through literature review

The goal of phase 1 was to develop a bank of survey items that would represent the variables of interest and which could be provided to expert faculty in Phase 2. Initial survey items were generated through a literature review of similar surveys designed to assess knowledge and attitudes toward MAiD/euthanasia in healthcare providers; Canadian empirical studies on nurses’ roles and/or experiences with MAiD; and legislative and expert panel documents that outlined proposed changes to the legislative eligibility criteria and safeguards. The literature review was conducted in three online databases: CINAHL, PsycINFO, and Medline. Key words for the search included nurses , nursing students , medical students , NPs, MAiD , euthanasia , assisted death , and end-of-life care . Only articles written in English were reviewed. The legalization and legislation of MAiD is new in many countries; therefore, studies that were greater than twenty years old were excluded, no further exclusion criteria set for country.

Items from surveys designed to measure similar variables in other health care providers and geographic contexts were placed in a table and similar items were collated and revised into a single item. Then key variables were identified from the empirical literature on nurses and MAiD in Canada and checked against the items derived from the surveys to ensure that each of the key variables were represented. For example, conscientious objection has figured prominently in the Canadian literature, but there were few items that assessed knowledge of conscientious objection in other surveys and so items were added [ 15 , 21 , 28 , 29 ]. Finally, four case studies were added to the survey to address the anticipated changes to the Canadian legislation. The case studies were based upon the inclusion of mature minors, advanced consent, and mental disorder as the sole underlying medical condition. The intention was to assess nurses’ beliefs and comfort with these potential legislative changes.

Phase 2. Item refinement through expert panel review

The goal of phase 2 was to refine and prioritize the proposed survey items identified in phase 1 using a modified e-Delphi approach to achieve consensus among an expert panel [ 26 ]. Items from phase 1 were presented to an expert faculty panel using a Qualtrics (Provo, UT) online survey. Panel members were asked to review each item to determine if it should be: included, excluded or adapted for the survey. When adapted was selected faculty experts were asked to provide rationale and suggestions for adaptation through the use of an open text box. Items that reached a level of 75% consensus for either inclusion or adaptation were retained [ 25 , 26 ]. New items were categorized and added, and a revised survey was presented to the panel of experts in round 2. Panel members were again asked to review items, including new items, to determine if it should be: included, excluded, or adapted for the survey. Round 2 of the modified e-Delphi approach also included an item prioritization activity, where participants were then asked to rate the importance of each item, based on a 5-point Likert scale (low to high importance), which De Vaus [ 30 ] states is helpful for increasing the reliability of responses. Items that reached a 75% consensus on inclusion were then considered in relation to the importance it was given by the expert panel. Quantitative data were managed using SPSS (IBM Corp).

Phase 3. Face validity through cognitive interviews with nursing students

The goal of phase 3 was to obtain initial face validity of the proposed survey using a sample of nursing student informants. More specifically, student participants were asked to discuss how items were interpreted, to identify confusing wording or other problematic construction of items, and to provide feedback about the survey as a whole including readability and organization [ 31 , 32 , 33 ]. The focus group was held online and audio recorded. A semi-structured interview guide was developed for this study that focused on clarity, meaning, order and wording of questions; emotions evoked by the questions; and overall survey cohesion and length was used to obtain data (see Supplementary Material 2  for the interview guide). A prompt to “think aloud” was used to limit interviewer-imposed bias and encourage participants to describe their thoughts and response to a given item as they reviewed survey items [ 27 ]. Where needed, verbal probes such as “could you expand on that” were used to encourage participants to expand on their responses [ 27 ]. Student participants’ feedback was collated verbatim and presented to the research team where potential survey modifications were negotiated and finalized among team members. Conventional content analysis [ 34 ] of focus group data was conducted to identify key themes that emerged through discussion with students. Themes were derived from the data by grouping common responses and then using those common responses to modify survey items.

Ten nursing faculty participated in the expert panel. Eight of the 10 faculty self-identified as female. No faculty panel members reported conscientious objector status and ninety percent reported general agreement with MAiD with one respondent who indicated their view as “unsure.” Six of the 10 faculty experts had 16 years of experience or more working as a nurse educator.

Five nursing students participated in the cognitive interview focus group. The duration of the focus group was 2.5 h. All participants identified that they were born in Canada, self-identified as female (one preferred not to say) and reported having received some instruction about MAiD as part of their nursing curriculum. See Tables  1 and 2 for the demographic descriptors of the study sample. Study results will be reported in accordance with the study phases. See Fig.  1 for an overview of the results from each phase.

Fig. 1  Overview of survey development findings

Phase 1: survey item generation

Review of the literature identified that no existing survey was available for use with nursing students in the Canadian context. However, an analysis of themes across qualitative and quantitative studies of physicians, medical students, nurses, and nursing students provided sufficient data to develop a preliminary set of items suitable for adaptation to a population of nursing students.

Four major themes and factors that influence knowledge, attitudes, and beliefs about MAiD were evident from the literature: (i) endogenous or individual factors such as age, gender, personally held values, religion, religiosity, and/or spirituality [ 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 ], (ii) experience with death and dying in personal and/or professional life [ 35 , 40 , 41 , 43 , 44 , 45 ], (iii) training including curricular instruction about clinical role, scope of practice, or the law [ 23 , 36 , 39 ], and (iv) exogenous or social factors such as the influence of key leaders, colleagues, friends and/or family, professional and licensure organizations, support within professional settings, and/or engagement in MAiD in an interdisciplinary team context [ 9 , 35 , 46 ].

Studies of nursing students also suggest overlap across these categories. For example, value for patient autonomy [ 23 ] and the moral complexity of decision-making [ 37 ] are important factors that contribute to attitudes about MAiD and may stem from a blend of personally held values coupled with curricular content, professional training and norms, and clinical exposure. For example, students report that participation in end of life care allows for personal growth, shifts in perception, and opportunities to build therapeutic relationships with their clients [ 44 , 47 , 48 ].

Preliminary items generated from the literature resulted in 56 questions from 11 published sources (See Table  3 ). These items were constructed across four main categories: (i) socio-demographic questions; (ii) end of life care questions; (iii) knowledge about MAiD; or (iv) comfort and willingness to participate in MAiD. Knowledge questions were refined to reflect current MAiD legislation, policies, and regulatory frameworks. Falconer [ 39 ] and Freeman [ 45 ] studies were foundational sources for item selection. Additionally, four case studies were written to reflect the most recent anticipated changes to MAiD legislation and all used the same open-ended core questions to address respondents’ perspectives about the patient’s right to make the decision, comfort in assisting a physician or NP to administer MAiD in that scenario, and hypothesized comfort about serving as a primary provider if qualified as an NP in future. Response options for the survey were also constructed during this stage and included: open text, categorical, yes/no , and Likert scales.

Phase 2: faculty expert panel review

Of the 56 items presented to the faculty panel, 54 questions reached 75% consensus. However, based upon the qualitative responses 9 items were removed largely because they were felt to be repetitive. Items that generated the most controversy were related to measuring religion and spirituality in the Canadian context, defining end of life care when there is no agreed upon time frames (e.g., last days, months, or years), and predicting willingness to be involved in a future events – thus predicting their future selves. Phase 2, round 1 resulted in an initial set of 47 items which were then presented back to the faculty panel in round 2.

Of the 47 initial questions presented to the panel in round 2, 45 reached a level of consensus of 75% or greater, and 34 of these questions reached a level of 100% consensus [ 27 ] of which all participants chose to include without any adaptations) For each question, level of importance was determined based on a 5-point Likert scale (1 = very unimportant, 2 = somewhat unimportant, 3 = neutral, 4 = somewhat important, and 5 = very important). Figure  2 provides an overview of the level of importance assigned to each item.

Ranking level of importance for survey items

After round 2, a careful analysis of participant comments and level of importance was completed by the research team. While the main method of survey item development came from participants’ response to the first round of Delphi consensus ratings, level of importance was used to assist in the decision of whether to keep or modify questions that created controversy, or that rated lower in the include/exclude/adapt portion of the Delphi. Survey items that rated low in level of importance included questions about future roles, sex and gender, and religion/spirituality. After deliberation by the research committee, these questions were retained in the survey based upon the importance of these variables in the scientific literature.

Of the 47 questions remaining from Phase 2, round 2, four were revised. In addition, the two questions that did not meet the 75% cut off level for consensus were reviewed by the research team. The first question reviewed was What is your comfort level with providing a MAiD death in the future if you were a qualified NP ? Based on a review of participant comments, it was decided to retain this question for the cognitive interviews with students in the final phase of testing. The second question asked about impacts on respondents’ views of MAiD and was changed from one item with 4 subcategories into 4 separate items, resulting in a final total of 51 items for phase 3. The revised survey was then brought forward to the cognitive interviews with student participants in Phase 3. (see Supplementary Material 1 for a complete description of item modification during round 2).

Phase 3. Outcomes of cognitive interview focus group

Of the 51 items reviewed by student participants, 29 were identified as clear with little or no discussion. Participant comments for the remaining 22 questions were noted and verified against the audio recording. Following content analysis of the comments, four key themes emerged through the student discussion: unclear or ambiguous wording; difficult to answer questions; need for additional response options; and emotional response evoked by questions. An example of unclear or ambiguous wording was a request for clarity in the use of the word “sufficient” in the context of assessing an item that read “My nursing education has provided sufficient content about the nursing role in MAiD.” “Sufficient” was viewed as subjective and “laden with…complexity that distracted me from the question.” The group recommended rewording the item to read “My nursing education has provided enough content for me to care for a patient considering or requesting MAiD.”

An example of having difficulty answering questions related to limited knowledge related to terms used in the legislation such as such as safeguards , mature minor , eligibility criteria , and conscientious objection. Students were unclear about what these words meant relative to the legislation and indicated that this lack of clarity would hamper appropriate responses to the survey. To ensure that respondents are able to answer relevant questions, student participants recommended that the final survey include explanation of key terms such as mature minor and conscientious objection and an overview of current legislation.

Response options were also a point of discussion. Participants noted a lack of distinction between response options of unsure and unable to say . Additionally, scaling of attitudes was noted as important since perspectives about MAiD are dynamic and not dichotomous “agree or disagree” responses. Although the faculty expert panel recommended the integration of the demographic variables of religious and/or spiritual remain as a single item, the student group stated a preference to have religion and spirituality appear as separate items. The student focus group also took issue with separate items for the variables of sex and gender, specifically that non-binary respondents might feel othered or “outed” particularly when asked to identify their sex. These variables had been created based upon best practices in health research but students did not feel they were appropriate in this context [ 49 ]. Finally, students agreed with the faculty expert panel in terms of the complexity of projecting their future involvement as a Nurse Practitioner. One participant stated: “I certainly had to like, whoa, whoa, whoa. Now let me finish this degree first, please.” Another stated, “I'm still imagining myself, my future career as an RN.”

Finally, student participants acknowledged the array of emotions that some of the items produced for them. For example, one student described positive feelings when interacting with the survey. “Brought me a little bit of feeling of joy. Like it reminded me that this is the last piece of independence that people grab on to.” Another participant, described the freedom that the idea of an advance request gave her. “The advance request gives the most comfort for me, just with early onset Alzheimer’s and knowing what it can do.” But other participants described less positive feelings. For example, the mature minor case study yielded a comment: “This whole scenario just made my heart hurt with the idea of a child requesting that.”

Based on the data gathered from the cognitive interview focus group of nursing students, revisions were made to 11 closed-ended questions (see Table  4 ) and 3 items were excluded. In the four case studies, the open-ended question related to a respondents’ hypothesized actions in a future role as NP were removed. The final survey consists of 45 items including 4 case studies (see Supplementary Material 3 ).

The aim of this study was to develop and validate a survey that can be used to track the growth of knowledge about MAiD among nursing students over time, inform training programs about curricular needs, and evaluate attitudes and willingness to participate in MAiD at time-points during training or across nursing programs over time.

The faculty expert panel and student participants in the cognitive interview focus group identified a need to establish core knowledge of the terminology and legislative rules related to MAiD. For example, within the cognitive interview group of student participants, several acknowledged lack of clear understanding of specific terms such as “conscientious objector” and “safeguards.” Participants acknowledged discomfort with the uncertainty of not knowing and their inclination to look up these terms to assist with answering the questions. This survey can be administered to nursing or pre-nursing students at any phase of their training within a program or across training programs. However, in doing so it is important to acknowledge that their baseline knowledge of MAiD will vary. A response option of “not sure” is important and provides a means for respondents to convey uncertainty. If this survey is used to inform curricular needs, respondents should be given explicit instructions not to conduct online searches to inform their responses, but rather to provide an honest appraisal of their current knowledge and these instructions are included in the survey (see Supplementary Material 3 ).

Some provincial regulatory bodies have established core competencies for entry-level nurses that include MAiD. For example, the BC College of Nurses and Midwives (BCCNM) requires “knowledge about ethical, legal, and regulatory implications of medical assistance in dying (MAiD) when providing nursing care.” (10 p. 6) However, across Canada curricular content and coverage related to end of life care and MAiD is variable [ 23 ]. Given the dynamic nature of the legislation that includes portions of the law that are embargoed until 2024, it is important to ensure that respondents are guided by current and accurate information. As the law changes, nursing curricula, and public attitudes continue to evolve, inclusion of core knowledge and content is essential and relevant for investigators to be able to interpret the portions of the survey focused on attitudes and beliefs about MAiD. Content knowledge portions of the survey may need to be modified over time as legislation and training change and to meet the specific purposes of the investigator.

Given the sensitive nature of the topic, it is strongly recommended that surveys be conducted anonymously and that students be provided with an opportunity to discuss their responses to the survey. A majority of feedback from both the expert panel of faculty and from student participants related to the wording and inclusion of demographic variables, in particular religion, religiosity, gender identity, and sex assigned at birth. These and other demographic variables have the potential to be highly identifying in small samples. In any instance in which the survey could be expected to yield demographic group sizes less than 5, users should eliminate the demographic variables from the survey. For example, the profession of nursing is highly dominated by females with over 90% of nurses who identify as female [ 50 ]. Thus, a survey within a single class of students or even across classes in a single institution is likely to yield a small number of male respondents and/or respondents who report a difference between sex assigned at birth and gender identity. When variables that serve to identify respondents are included, respondents are less likely to complete or submit the survey, to obscure their responses so as not to be identifiable, or to be influenced by social desirability bias in their responses rather than to convey their attitudes accurately [ 51 ]. Further, small samples do not allow for conclusive analyses or interpretation of apparent group differences. Although these variables are often included in surveys, such demographics should be included only when anonymity can be sustained. In small and/or known samples, highly identifying variables should be omitted.

There are several limitations associated with the development of this survey. The expert panel was comprised of faculty who teach nursing students and are knowledgeable about MAiD and curricular content, however none identified as a conscientious objector to MAiD. Ideally, our expert panel would have included one or more conscientious objectors to MAiD to provide a broader perspective. Review by practitioners who participate in MAiD, those who are neutral or undecided, and practitioners who are conscientious objectors would ensure broad applicability of the survey. This study included one student cognitive interview focus group with 5 self-selected participants. All student participants had held discussions about end of life care with at least one patient, 4 of 5 participants had worked with a patient who requested MAiD, and one had been present for a MAiD death. It is not clear that these participants are representative of nursing students demographically or by experience with end of life care. It is possible that the students who elected to participate hold perspectives and reflections on patient care and MAiD that differ from students with little or no exposure to end of life care and/or MAiD. However, previous studies find that most nursing students have been involved with end of life care including meaningful discussions about patients’ preferences and care needs during their education [ 40 , 44 , 47 , 48 , 52 ]. Data collection with additional student focus groups with students early in their training and drawn from other training contexts would contribute to further validation of survey items.

Future studies should incorporate pilot testing with small sample of nursing students followed by a larger cross-program sample to allow evaluation of the psychometric properties of specific items and further refinement of the survey tool. Consistent with literature about the importance of leadership in the context of MAiD [ 12 , 53 , 54 ], a study of faculty knowledge, beliefs, and attitudes toward MAiD would provide context for understanding student perspectives within and across programs. Additional research is also needed to understand the timing and content coverage of MAiD across Canadian nurse training programs’ curricula.

The implementation of MAiD is complex and requires understanding of the perspectives of multiple stakeholders. Within the field of nursing this includes clinical providers, educators, and students who will deliver clinical care. A survey to assess nursing students’ attitudes toward and willingness to participate in MAiD in the Canadian context is timely, due to the legislation enacted in 2016 and subsequent modifications to the law in 2021 with portions of the law to be enacted in 2027. Further development of this survey could be undertaken to allow for use in settings with practicing nurses or to allow longitudinal follow up with students as they enter practice. As the Canadian landscape changes, ongoing assessment of the perspectives and needs of health professionals and students in the health professions is needed to inform policy makers, leaders in practice, curricular needs, and to monitor changes in attitudes and practice patterns over time.

Availability of data and materials

The datasets used and/or analysed during the current study are not publicly available due to small sample sizes, but are available from the corresponding author on reasonable request.

Abbreviations

British Columbia College of Nurses and Midwives

Medical assistance in dying

Nurse practitioner

Registered nurse

University of British Columbia Okanagan

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Acknowledgements

We would like to acknowledge the faculty and students who generously contributed their time to this work.

JS received a student traineeship through the Principal Research Chairs program at the University of British Columbia Okanagan.

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JS made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and drafting and substantively revising the work. JS has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. BP made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and drafting and substantively revising the work. BP has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. LO made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and substantively revising the work. LO has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. NDO made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and substantively revising the work. NDO has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. HS made substantial contributions to drafting and substantively revising the work. HS has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

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Schroeder, J., Pesut, B., Olsen, L. et al. Developing a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study. BMC Nurs 23 , 326 (2024). https://doi.org/10.1186/s12912-024-01984-z

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Received : 24 October 2023

Accepted : 28 April 2024

Published : 14 May 2024

DOI : https://doi.org/10.1186/s12912-024-01984-z

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