Research Methodology Series

An Introduction to Qualitative and Mixed Methods Study Designs in Health Research

MANOJA KUMAR DAS

FromThe INCLEN Trust International, F1/5, Okhla Industrial Area, Phase 1, New Delhi.

Correspondence to: Manoja Kumar Das, Director Projects, The INCLEN Trust International, F1/5,
Okhla Industrial Area, Phase 1, New Delhi [email protected]

PII: S097475591600357

Note: This early-online version of the article is an unedited manuscript that has been accepted for
publication. It has been posted to the website for making it available to readers, ahead of its
publication in print. This version will undergo copy-editing, typesetting, and proofreading, before final
publication; and the text may undergo minor changes in the final version.

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MANOJA KUMAR DAS QUALITATIVE AND MIXED METHODS STUDY DESIGNS
ABSTRACT
With the recognition of different population behavior and relevance of socio-cultural factors in health,
health services and public health program contexts, qualitative research is increasingly being used in
health research, including clinical trials. Qualitative research follows an inductive framework to
explore and gain an in-depth understanding of the phenomena, especially why and how aspects,
through techniques including interviews, focus groups and observations. It analyzes the textual data
collected following one of the common analysis approaches: grounded theory, phenomenology,
ethnography or participatory action research. Despite the divergence in principles, mixed methods
research designs systematically combine the quantitative and qualitative methods for a comprehensive
understanding on the issue. The commonly used mixed methods designs variably combine the purpose,
priority, sequence, embedding and data integration. Mixed methods analysis requires strategic
synthesis of the results to gain comprehensive knowledge for appropriate clinical or public health
action.
Keywords: Focus group, implementation, interviewing, Participatory research, Social research.

Traditional clinical research is dominated by quantitative study designs that document different
variables (exposure, outcome and confounders) as measurable parameters and examines the
relationship between them using statistical analysis principles. Much of the clinical and public health
research happens within the clinical, social, population and interpersonal context where the numeric
data and statistical methods may be inadequate to document the patients, public and healthcare
provider’s experiences about the care and services. It is commonly observed that the outcomes and
degree of associations vary across different populations or individuals, which are not explainable
quantitatively. The quantitative study is unable to tell about ‘why’ people behave in the observed
manner and the reasons thereof. It is important to move beyond ‘what works’ documented in
quantitative research and understand ‘what works for whom, why, how and when’ to improve or
customize the interventions or processes, and this is where qualitative research comes into play. The
individual and population characteristics, experiences, behaviors and practices play a significant role in
health and clinical practice. For documenting the possible reasons and identifying potential solutions
for the observed patterns, qualitative research is needed. Moreover, qualitative research is critical for
exploring new areas or issues of research, and identification of items of enquiry for documentation and
quantification.
QUALITATIVE RESEARCH
Qualitative research is the systematic enquiry to obtain an in-depth understanding on the nature of
phenomena in their natural setting, which may include but is not limited to, people’s experience,
individual and/or group behavior, and organizational function [1]. Several definitions for qualitative
research have been proposed (Suppl. Document 1). Qualitative research explores people's perceptions,
experiences, attitudes, behavior, and interactions with others related to the phenomena or topic under

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study in the specific context. The researcher is the key instrument for data collection. It does not
attempt to generalize the findings to the larger populations or other phenomena.
It was initially used by sociologists and anthropologists to study cultures and practices in their
own and foreign contexts. Over the last few decades, it is increasingly used in clinical and public
health research. As qualitative research does not attempt enumerating and generalizing the findings,
some view this as the opposite of quantitative research. Although the methods are contrasting, the two
research methods may overlap somewhat and complement each other. The key differences between
quantitative and qualitative research are summarized in Table I. Qualitative research has been used in
clinical trials and intervention studies to optimize interventions, trial procedures, improving the
external validity, facilitating the interpretation of the findings, making trials human sensitive, and
assisting in improving the effectiveness of future trials[2].
Qualitative Study Designs
The taxonomy of qualitative research has evolved over time[3-5]. In 2007, Cress well proposed five
qualitative study designs: Narrative research, Case studies, Grounded theory, Phenomenology and
Participatory action research (PAR)[6]. Broadly, these are categorized into non-participatory types (the
researcher only observes and does not participate in the activities) and participatory (the researcher
participates in the process in the community and usually attempts to influence some activities).All
study designs except PAR fall under the non-participatory category. The case studies have several
subtypes: snapshot, comparative, longitudinal, pre-post, and patchwork case studies. In health
research, the grounded theory, phenomenology, ethnography and PAR are commonly used. The
grounded theory explores a less-well-understood problem, situation, or context to generate a general
hypothesis or explanation based on the views of a large number of participants. Phenomenology
focuses on the essence of the ‘lived experiences’ of the person (or group),regarding an issue that
becomes embedded in the consciousness and what meaning that carries for the person or group.
Ethnography focuses on the cultural and social systems (structure and function) of a particular group
and may cover various aspects like religion, economy, politics, environment and history. This may
require immersion of the researcher in the society to study everyday life and relies on participant
observation along with interviews. PAR focuses on finding suitable solutions for a social problem
through researcher-community collaboration at all levels. The PAR may involve mixed (both
qualitative and quantitative) methods designs.
Choosing Qualitative Study Design
Qualitative research designs do not follow strict taxonomy with fixed boundaries or strict stages like
quantitative research. The data collection, analysis, research question refinement, theory modification,
and addressing validity proceed more or less simultaneously and each step influences the others. The
researcher has the flexibility to revise or modify the design and methods during the study based on the
new developments and experiences. It does not imply a lack of study design in qualitative research, but
the concept of a broader design. While choosing a study design and methods, the researchers consider
various aspects including research question, context, conceptual framework, appropriate data types,

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validity and ethical considerations. Apart from these, the researcher’s skills, participant and
community concerns, piloting experience, and larger goals also influence study design selection. Table
II summarizes the characteristics of the qualitative study designs. Qualitative research question can
focus on any one or combination of these: (i) understanding the meaning of the events, situations, and
participants actions based on their lived experiences; (ii) understanding the specific context within
which the participants live and operate for their action; (iii) identifying unknown, unanticipated
phenomena and influences to generate new theories; (iv) understanding the processes of occurrence of
events and actions and their interconnections; and (v) developing causal explanations and relationships
between the different segments[7].
Data Collection Methods
The most commonly used qualitative data collection methods in health research are interviews, focus
group discussions (FGDs), observations, and analysis of documents.
Qualitative interviews: These are conversations between the researchers and participants to gain
insights into their subjective experiences, perceptions, motivations and knowledge. The interviews
may be of three types: structured, semi-structured and unstructured. In structured interviews, the
interviewer refers to a predetermined list of questions, which allows consistency across participants
and interviewers (multiple), but limits additional exploration. In semi-structured interviews, the
interviewer(s)refer to some questions but have the flexibility to adapt and add questions based on the
responses and context, which allows more intuitive and natural conversations with the participants.
Unstructured interviews aim to gather in-depth information from key informants and usually donot
have a pre-planned set of questions and are instantaneously generated during the interview. Thus, it
resembles more with free-flowing conversation than an interview. The semi-structured and
unstructured interviews are also known as in-depth interviews (IDIs). For conducting IDIs, the
interviewers must be researchers themselves or have a good understanding on the topic. The topics,
questions, sub-questions and probes are developed based on the available literature, previous research
and piloting, which may be revised during data collection. Interviews must primarily focus on being
interactive and allowing unexpected issues to emerge and be explored. The interviewer can audio- or
video-record the conversation with the consent of participants for transcription later[5,7.8].
Focus group discussion: This involves discussion among the participants (preferably of similar
background) to explore their experiences, perceptions, knowledge and how and why people behave in
certain ways. A FGD usually involves 6-10 people and is facilitated by an experienced moderator
using a topic guide. Topic guide or interview guide is compilation of the list of topics or questions that
the interviewer plans to cover during an interview. It is called a guide, because it is used to guide the
interviewer, but not rigid like the questionnaire in quantitative studies. Topic guide include the topics
or open-ended questions organized like a funnel; starting with warm-up discussion and easy questions,
more detailed exploration, key areas of discussion, pulling out the essential insights, summarization.
Additional observers and note-takers may be involved to record the verbal and nonverbal expressions.
The discussions preferably are audio- or video-recorded with participants’ permission and transcribed

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later[9]. To review the quality of conversation, moderator’s technique and compare between FGDs, a
sociogram for each FGD is drawn. Sociogram reflects the flow of discussions in the group [10]. FGDs
allow obtaining information from many people quickly representing the community view and
supplement the interviews. FGD may be inappropriate for exploring sensitive topics.
Observation: This involves documentation of activities, behaviors, conversations, organization or
community processes or other aspects of observable human experiences[11].Observation may be
reactive (with participant’s knowledge) or non-reactive (without participant’s knowledge). Observation
is critical in both interviews and FGDs to identify nonalignment between verbal and nonverbal data.
Observation can also be a stand-alone method with or without the participation of the researcher.
Observation provides information about the setting, context and actual behavior, which may not be
possible in reported behavior or opinions. Observations can be either participant (observer is part of
the observed setting) or non-participant (observer neither participates nor influences the setting) in
nature. While observation allows deeper insights into the real-world setting and capturing issues not
already considered, it also has the risk of the Hawthorne effect with the presence of an observer[12].
Written or audio-visual documents: These may be reviewed to gain information about the issue under
study[9].
Qualitative research assumes no objective hierarchy of evidence and methods and the selection
of methods (single or combined) must be based on the research question and suitability and feasibility
of method(s) for the question and setting. The selection of method must be justified and documented.
The use of multiple methods may allow a more comprehensive understanding of the issue under study
and comparison between findings from different methods, which is referred as triangulation.
Sample Size and Sampling
Unlike a quantitative study, qualitative research follows no fixed rule for sample size. The data
collection usually continues until data saturation, i.e., no new information or opinion emerges. The
sample size depends on the richness and type of participants. Usually, 15-20 participants per
stakeholder category may be adequate, but the number may be decided depending on the research
issue, context, stakeholders and anticipated differences in that phenomenon [13]. The researcher may
choose a small homogenous sample for in-depth study on the group and particular subgroups[11].
Sampling is usually non-probability and purposive. In qualitative research, the researcher attempts to
gain in-depth understanding of the issues and dependent on the richness of the information shared by
the participants/informants, not generalizability. Thus, the research selects the participants subjectively
rather than random selection according to the likelihood of obtaining rich and in-depth information.
The researchers often use purposive sampling and choose participants based on the specific expertise
or insight regarding the phenomenon of interest.
Data Management and Analysis
The field notes and recordings of interviews, FGDs, observations are transcribed verbatim and checked
for accuracy with the source documents. As needed, the narratives may be translated into the language
of analysis, but care must be taken to ensure no loss of the essence and meanings.

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Qualitative data analysis involves reading the texts and understanding its essence from the
participant’s perspective. The raw data (statements or segments of narratives) are coded either
manually or using software. Coding is the process of organizing the sections of the data according to
their meaning, sentiment and relationships. The codes bearing similar meanings are grouped into
conceptual codes and categories. Linkages and connections between the conceptual codes and
categories are explored (axial coding). Based on the emerging hypothesis, the conceptual codes and
categories are organized under few themes (selective coding). The data is presented under the themes
identified and compared across the data collection methods, stakeholders and contexts to identify the
similarities and differences along with the potential reasons. The coding and data organization is an
iterative process till an agreement between the researchers is achieved. The results are organized under
the themes as the headings, the codes as the sub-headings with the researcher’s interpretation and
statements or narratives as ‘quotable quotes’. Apart from textual format, data can be displayed in any
form: boxed display, decision tree model, flow chart, ladder, matrix, metaphorical display, modified
Venn diagram, network and taxonomy [14].
Use of Software and Challenges
Several free and license-based software programs (Ethnograph, NVivo, Atlas-Ti, NUD.IST,
WInMAX, MAXQDA, HyperRESEARCH, HubSpot, FreeQDA, RQDA, etc.) are available(14).
International Clinical Epidemiology Network(INCLEN) qualitative data analysis software (IQDAS) is
an in-house developed program being used by us. Although software programs improve the efficiency
of data management, purists claim it to distance the researcher from the data.
Biases
Qualitative studies are at risk of biases from the data collection method or analysis based on the
researcher’s knowledge, preconception, theory and values. Although rigorous and standardized
training may improve the quality of data collection, the influence of researcher and data collector
cannot be eliminated[7].
Validity Tests
Validity of the data and credibility of the interpretation can be increased with: (i) repeated observation
over a longer period; (ii) in-depth exploration using probes; (iii) respondent validation (soliciting
feedback on the conclusions from the study population to avoid misinterpretation); (iv) data
triangulation (comparison across participants, settings and methods); (v) comparison (with the control
group) [7].
Quality Assurance
Quality assurance is a systematic approach to review the practices and procedures followed in a
research to document whether things are being done according to the standards/best practices as well
as they could/should be and identify possible improvements. It is a continuous and on-going process
throughout the study and dissemination. Rigorous quality assurance measures must be adopted at all
levels including (i) selection of appropriate research methods and data collection techniques; (ii)
selection and appropriate training of the research team; (iii) audio- or video-recording of the interviews

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and FGDs; (iv) correct and complete transcription and translation; (v) data analysis by multiple
researchers and discussion to generate consensus on the code mapping; and (vi) adopting validation
methodology.
Ethical Issues
Although qualitative methods appear harmless compared to the biological sample collection, they may
have unintended consequences at individual, group, organizational and societal levels. Thus,
anonymity and confidentiality of participants must be ensured.
Some examples of qualitative research are given as Supplementary material.
Mixed Methods Research
Mixed methods research (MMR) combines the quantitative and qualitative methods (questions, data
collection, analysis, interpretation) in the same study. Despite the contrasting assumptions, principles
and cultures, increasingly both quantitative and qualitative research methods are being used to
complement and supplement the hypothesis and findings. Several definitions for this have been
proposed (Supplementary material). For denoting the emphasis and contribution of research method
types, the components are indicated as QUAL or qual and QUAN or quan (capital indicates primacy)
for qualitative and quantitative research, respectively. The purposes of using mixed methods research
include: complementarity, completeness, triangulation of results; development (one method informs
the other), initiation (discovers new perspectives), explanation, expansion (expands the breadth and
range of inquiry), instrument development, credibility and contextualization[15,16].
Designing Mixed Methods Research
Four issues must be addressed for planning mixed methods research: theoretical basis, priority, data
collection sequence and data integration. The theoretical basis and research question inform the
dominance, sequence and integration of methods. Based on the dominance, MMR may be considered
as qualitative dominant, quantitative dominant or equal status. MMR may use the methods in either a
sequential or concurrent manner, based on the need. The qualitative and quantitative approaches may
integrate at five possible points: planning, research question, tool development and data collection,
analysis and result presentation[17,18]. The mixed methods research framework is summarized in
Table III.MMR is broadly divided into six types: three concurrent or convergent (triangulation,
embedded/nested and transformative) and three sequential (explanatory, exploratory and
transformative). Additionally, sequential embedded and multiphase mixed methods research designs
may also be adopted. The architecture of these mixed methods research study designs is shown in Fig.
1.These designs are selected according to the research purpose, conduct, priority, analysis, integration
and presentation. Mixed methods research design involves several steps and considerations which
guide the selection of the type of study design: research question, the purpose of mixed methods
research, method priority, data collection sequence, embedding and data integration[19,20]. Fig. 2
shows the steps in mixed methods research study design selection. Mixed methods research is being
used in health behavior, implementation researches and clinical research[2]. Some examples of MMR
are given in the supplementary material.

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CONCLUSIONS
Qualitative research has a unique position in socio-behavioural research in health and significant value
addition if used with the quantitative research. Qualitative research would enhance the etiological, risk
factor and health behaviour understanding in clinical practice and public health programs. Qualitative
research involves critical thinking and much dependent on the competence of the researcher(s).
Despite the contrasting methodologies and dissimilarities, mixed methods research designs enable
combining the qualitative and quantitative study designs in a meaningful and symbiotic manner to
address the questions. While combining and selecting these study designs, careful planning must
consider the research purpose, data dominance, dependence, sequence, sampling, data integration and
analysis. While the research purpose and theoretical conceptual framework are the primary drives, the
practical aspects like timing, context, sampling, feasibility and competency of the research team are to
be considered.
Note: Supplementary material related to this manuscript is available at www. indianpediatrics.net
Contributor: MKD: Conceptualisation, data collation, data analysis, manuscript writing, final approval
of the manuscript.
Funding: None; Competing interest: None stated.

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REFERENCES
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Sage Publications Ltd; 2009.
2. O’Cathain A, Thomas KJ, Drabble SJ, et al. What can qualitative research do for randomised
controlled trials? A systematic mapping review. BMJ. 2013;3:e002889.
3. Wolcott HF. Posturing in qualitative inquiry. In: LeCompte MD, Millroy WL, Preissle J, editors.
The Handbook of Qualitative Research in Education. Academic Press; 1992. p. 3-52.
4. Norman KD, Yvonna SL. The Sage Handbook of Qualitative Research. 3rd Edition. Sage
Publications Inc; 2005.
5. Tesch R. Qualitative Research: Analysis Types and Software [Internet]. 1st ed. Routledge; 2013.
Accessed October 8, 2020. Available from: https://www.taylorfrancis.com/books/9781315067339
6. Creswell JW, Hanson WE, Clark Plano VL, Morales A. Qualitative research designs: Selection
and implementation. Couns Psychol. 2007;35:236-64.
7. Maxwell J. Designing a qualitative study. In: Bickman L, Rog DJ, editors. The SAGE Handbook
of Applied Social Research Methods. SAGE Publications; 2009.p.214-53.
8. Jamshed S. Qualitative research method-Interviewing and observation. J Basic Clin Pharm.
2014;5:87.
9. Busetto L, Wick W, Gumbinger C. How to use and assess qualitative research methods. Neurol
Res Pract. 2020;2:14.
10. Drahota A, Dewey A. The Sociogram: A useful tool in the analysis of focus groups. Nurs Res.
2008;57:293-7.
11. Patton MQ. Qualitative Research & Evaluation Methods: Integrating Theory and Practice. 4th ed.
SAGE Publications Inc.; 2014.
12. Austin Z, Sutton J. Qualitative research: Getting started. Can J Hosp Pharm. 2014;67:436-40.
13. Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: Guided by
information power. Qual Health Res. 2016;26:1753-60.
14. Verdinelli S, Scagnoli NI. Data display in qualitative research. Int J Qual Methods. 2013;12:359-
81.
15. Greene JC, Caracelli VJ, Graham WF. Toward a conceptual framework for mixed-method
evaluation designs. Educ Eval Policy Anal. 1989;11:255-74.
16. Bryman A. Integrating quantitative and qualitative research: How is it done? Qual Res. 2006;6:97-
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17. Creswell JW. Mixed methods designs (Chapter 16). In: Creswell JW, editor. Educational Research:
Planning, Conducting, and Evaluating Quantitative and Qualitative Research, 4th ed. Pearson;
2012. p. 534–75.
18. Ponce OA, Pagán-Maldonado N. Mixed methods research in education: Capturing the complexity
of the profession. Int J Educ Excell. 2015;1:111-35.

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19. Creswell JW, Clark VLP. Choosing a mixed methods design (Chapter 4). In: Creswell JW, Clark
VLP, editors. Designing and Conducting Mixed Methods Research. SAGE Publication; 2006. p.
58–88.
20.Hanson WE, Creswell JW, Clark VLP, et al. Mixed methods research designs in counseling
psychology. J Couns Psychol. 2005;52:224-35.

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Table I Differences Between Quantitative and Qualitative Research for Various Domains

Quantitative research Qualitative research

Theory orientation
• Deductive; tests to confirm hypothesis • Inductive; generates theory or explores phenomena
about phenomena
Epistemology orientation
• Positivism; only includes scientifically • Interpretivist; interprets the meanings that humans
verifiable ones attach to their actions
Ontology orientation
• Objectivism; asserts the validity of • Constructivism: allows people to actively construct
objective phenomena over subjective their own knowledge
experience • Reality is determined by researcher’s experiences
Methods
• Follows designs and tools fixed prior to • Allows flexibility in designs to emerge during study
data collection
Data collection
• Precise measurement and objective data • Accurate description of the processes and
collection observations (words, texts, etc.)
• Uses standardized tests, instruments and • Adopts interviews, discussions, observations and
measurement tools document reviews
• Close ended and objective questions • Open ended questions
• Often involves large sample sizes • Often involves smaller sample sizes and
estimated by formula or software observations, no sample size formula
• Participants selected following • Participants selected purposively
randomness approach • Participant responses are affected by how questions
• Participant responses not affected by are asked and sequence
how questions are asked and sequence
Interpretation
• Conducts analysis after data collection • Conducts analysis during data collection
• Numerical data (assigns values to • Accommodates complexities and multiple realities
responses as numbers, scales, • Textual data (uses text, notes, audios/videos,
categories) observation narratives)
• Explores single truth and often • Flexible and iterative analysis approach
measures single outcome • Can obtain multiple outcomes and accommodate
• Performs data analysis in prescribed and multiple sources of data (triangulation)
standardized method(s) • Performs data analysis in creative, iterative,
• Analysis attempts achieving nonlinear and holistic manner
significance level • Analysis attempts insight and metaphor
• Statistics complexities • Conceptual complexities
• Generalizes the findings from sample to • Specific to the sample and context, does not
population generalize to the population
Reporting
• Quantifies the observations and • Describes the observations and variations
variations • Allows variability with expressive language and
• Follows standardized format personal voices
Epistemology is a branch of philosophy that investigates the origin, nature, methods, and limits of
human knowledge.
Ontology is a branch of philosophy that explores the types, properties, and interrelationships of the
entities that really or fundamentally exist for a particular domain of discourse.

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Table II Qualitative Study Designs and Their Characteristics

Study Type of research Context Unit of Data Data analysis

designs question analysis collection strategy
forms
A. Non-participatory research
Narrative Questions about the Stories to One or more Interviews, Chronology,
research life experiences of understanding individuals document story elements
an/few individuals the problem review; Little set
and how they chronological, structure
unfold over time story-oriented
Case study Questions about Explores a An event, Interviews, Case
developing an in- case bounded program, observations, description,
depth by time, place activity documents, themes of the
understanding that inform a One or more artefacts case and
about how different problem individuals cross-case
cases provide themes;
insight into an issue Some structure
or a unique case
Grounded Questions about No theory Process, Interviews, Open coding,
theory experiences over exists or action or may include axial coding
time or changes existing ones interaction others and selective
that have stages and are inadequate involving coding;
phases many High level
individuals structure
Phenomenol Questions about To understand Several Interviews, Statements
ogy what is at the the lived individuals documents, textual
essence that all experiences of with observations, description on
persons experience persons about experience other items phenomenon;
about a a phenomenon Structured
phenomenon approach
Ethnography Questions about the Cultural and Group of Observations, Themes,
structure and social system population interviews, statements;
function of a group of a group; documents, textual
of people natural setting immersion description;
High level
structure
B. Participatory research
Participatory Questions about To address Entire Interviews, Combination
action how changes occur community community, documents, of different
research in a community issues for multiple observations, options;
bringing stakeholders other items Little set
change structure
adapted from Cresswell, et al. 2007 [7]

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Table III Mixed Method Research Design and Integration Framework for Each Level

Levlels and types Characteristic

Conduct
Concurrent Data collection and analysis for both done concurrently
Sequential Data collection and analysis of one precedes the other
Multistage Multiple stages of data collection, variable combinations
Priority/
Dominance One method is dominant based on research question
Dominant Both methods contribute equally according to the question
Equal
Intervention
Observational No intervention
Interventional Intervention
Hybrid Observation and intervention combined variably
Study designs
Triangulation Comparison and/or validation of the quantitative results with qualitative data
or expand quantitative findings with qualitative data;
Includes data transformation: one type of data is converted into the other type
and integrated/compared with the data not transformed for analysis
Second method helps to explain the findings from first method
Results of first method (usually qualitative) informs the second method
Explanatory (identify variables, develop instrument)
Exploratory Second method (qualitative/quantitative) is needed to answer a research
question within larger quantitative or qualitative study
Embedded/ Nested One type of data is converted into the other type and this data is integrated
with the data not transformed for analysis
Transformative
Database linkages
Connecting One database is linked to the other through sampling
Building Results from one database informs the data collection approach of the other
Both databases are brought together for analysis
Merging Data collection and analysis are linked at multiple points
Embedding
Interpretation
Narrative Describe findings from both methods in same report
- Weaving: both findings presented together, either theme- or concept-wise
- Contiguous: findings presented in separate sections
- Staged: findings presented step/stage wise as conducted
One type of data is converted into the other type or consolidated into new
Transformative variables for analysis
Data from both components integrated and presented together in figure, table,
Joint display matrix or graph

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Fig. 1 Types of mixed method research study designs (adapted from Cresswell, et al. with permission [17]).

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a. Research purpose (question/objective)

Triangulation Transformation Exploration Explanation

b. Method priority

Equal weightage Unequal weightage

QUAN+ Quantitative priority Qualitative priority

QUAL QUAN+qual QUAL+quan

c. Sequence of data collection

Concurrent Sequential

QUAN+ QUAN+ QUAL+ QUAN → qual QUAL → quan

QUAL qual quan

d. Method embedding

No embedding Embedding

qual embedded in larger quan embedded in

QUAN study larger QUAL study

e. Data integration and analysis

Data merged Data embedded Data connected

Merging Merging Qualitative Quantitative Qualitative Quantitative

during during embedded in embedded in data informs data informs
analysis interpretation quantitative qualitative quantitative qualitative
design design

QUAL: Qualitative data is given higher priority; qual: Qualitative data is given lower priority;
QUAN: Quantitative data is given higher priority; quan: Quantitative data is given lower priority.

Fig. 2 The steps in mixed method research design selection.

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Supplementary Document 1
The available definitions of qualitative research
“Qualitative research involves any research that uses data that do not indicate ordinal values” (Nkwi
PN, Nyamongo IK, Ryan GW) (1). “Qualitative research is a situated activity that locates the observer
in the world. It consists of a set of interpretive, material practices that makes the world visible. These
practices transform the world. They turn the world into a series of representations, including field
notes, interviews, conversations, photographs, recordings, and memos to the self. At this level,
qualitative research involves an interpretive, naturalistic approach to the world. This means that
qualitative researchers study things in their natural settings, attempting to make sense of, or to
interpret, phenomena in terms of the meanings people bring to them” (Denzin NK, Lincoln YS) (2).
“Qualitative researchers are interested in understanding the meaning people have constructed, that is,
how people make sense of their world and the experiences they have in the world” (Merriam SB,
Tisdell EJ) (3).
“Qualitative research is research using methods such as participant observation or case studies which
result in a narrative, descriptive account of a setting or practice. Sociologists using these methods
typically reject positivism and adopt a form of interpretive sociology” (Drislane R, Parkinson G) (4).
“Qualitative research as an iterative process in which improved understanding to the scientific
community is achieved by making new significant distinctions resulting from getting closer to the
phenomenon studied” (Aspers P, Corte U) (5).
REFERENCES
1. Nkwi PN, Nyamongo IK, Ryan GW. Field research into socio-cultural issues :
methodological guidelines. Yaoundé, Cameroon: International Center for Applied Social
Sciences, Research, and Training; 2001.
2. Denzin NK, Lincoln YS. The SAGE Handbook of Qualitative Research. 3rd Edition.
Thousand Oaks, California: SAGE Publications, Inc.; 2005.
3. Merriam SB, Tisdell EJ. Qualitative Research: A Guide to Design and Implementation. 4th
Edition. San Francisco, CA: Jossey-Bass, A Willey Brand; 2016.
4. Drislane R, Parkinson G. Qualitative Research. In: Online Dictionary of The Social Sciences.
Athabasca University and ICAAP; 2002.Accessed Jun 4, 2021. Available from:
https://bitbucket.icaap.org/dict.pl?term=QUALITATIVE%20RESEARCH
5. Aspers P, Corte U. What is Qualitative in Qualitative Research.QualSociol. 2019;42:139-60.

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Supplementary Document 2
Examples of published literature using Qualitative Research Method
Case study 1: Qualitative research using in-depth interviews and observations
Perceptions of the parents of deceased children and of healthcare providers about endof-life
communication and breaking bad news
Parents of dying children face unique challenge and expect compassionate support from health care
providers (HCPs). There is limited documentation from Indian context on the experiences of the
parents and HCPs on end-of-life care for dying children and breaking the bad news around death. This
study explored the experiences of the parents and HCPs about the end-oflife care and breaking bad
news and related positive and negative factors in Indian context. This qualitative study was conducted
at a tertiary care hospital. The data collection included in-depth interviews with the parents (n=49) and
family members (n=21) of the children died at the hospital and HCPs (n=16; 6 doctors, 6 nurses and 4
support staffs) were conducted. The events and communication around death (n=8) for the children
were observed. Data were inductively analysed using thematic content analysis method to identify
emerging themes and codes.
The study observed that the doctors were the lead communicators for end-of-life
communication. Majority of parents perceived the attitude, communication and language used as by
resident doctors as brief, insensitive and sometimes inappropriate or negative. They perceived that the
attitude and communication by senior doctor’s as empathetic, positive and complete. Parents recalled
the death declaration by resident doctors as non-empathetic, blunt and cold. Most parents received no
emotional support from HCPs during and after death of their child. All doctors expressed that death of
their patients affected them and their emotions, which they coped through different activities. The
overcrowded wards, high workload, infrastructural limitation and no formal communication training
added to the emotional stress of the HCPs.

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The study highlights the communication by HCPs and support for parents during the end-
oflife communication and breaking bad news. Majority of the communication by the HCPs during the
hospitalisation and end-of-life period were perceived as suboptimal by the parents. The HCPs were
emotionally affected and faced end-of-life communication challenges. There is need for adoption of
context specific communication protocol and materials and training of HCPs in communication to
improve the quality of care and communication during the crisis periods.
REFERENCE
Das MK, Arora NK, Chellani HK, et al. Perceptions of the parents of deceased children and of
healthcare providers about end-of-life communication and breaking bad news at a tertiary care public
hospital in India: A qualitative exploratory study. PLoS ONE. 2021; 16(3): e0248661. Doi:
10.1371/journal.pone.0248661.

Case study 2: Multisite qualitative research using in-depth interviews, focus-group discussions
and informal interactions to explore the determinants of undernutrition
The high levels of under-nutrition in India persists despite economic growth and multiple multisectoral
interventions and continue to challenge political leadership and policy makers. This multisite
qualitative research was conducted to map the perceptions of mothers and other key stakeholders, to
identify emerging drivers of childhood undernutrition.
This multi-centric qualitative research was conducted across six states of India with high
burden of undernutrition. The study sample included 509 in-depth interviews with mothers of
undernourished and normal nourished children, policy makers, district level managers, implementer
and facilitators. Sixty six focus group discussions and 72 non-formal interactions were conducted in
two rounds with primary caretakers of undernourished children, Anganwadi Workers and Auxiliary
Nurse Midwives.
Based on the perceptions of the participants, a model was inductively developed showing core
themes as drivers of under-nutrition. The most forceful emerging themes were: multitasking, time
constrained mother with dwindling family support; fragile food security or seasonal food paucity;
child targeted market with wide availability and consumption of ready-to-eat market food items; rising
non-food expenditure, in the context of rising food prices; inadequate and inappropriate feeding;
delayed recognition of under-nutrition and delayed care seeking; and inadequate responsiveness of
health care system and Integrated Child Development Services (ICDS). The study emphasized that the
persistence of child malnutrition in India is also tied closely to the high workload and consequent time
constraint of mothers who are increasingly pursuing income generating activities and enrolled in paid
labour force, without robust institutional support for childcare.
The models identified from the data are shown in Figure 1 and 2.

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Figure 2: The linkages between childhood under-

nutrition and obesity (double Burden) with changing
economic condition and food security at household
level

Figure 1: Emerging model of childhood under-nutrition.

The study findings identified the factors beyond the health sector with influence of the business and
contextual issues on the food behaviour of the families and societies, which contribute to persistence of
the child undernutrition burden.
REFERENCE
Chaturvedi S, Ramji S, Arora NK, Rewal S, Dasgupta R, Deshmukh V; for INCLEN Study Group.
Time-constrained mother and expanding market: emerging model of under-nutrition in India. BMC
Public Health.2016; 16: 632.doi: 10.1186/s12889-016-3189-4.

Case study 3: Using qualitative research for improving implementation of complex community
intervention
The lay health workers (LHWs) are increasingly engaged to complement health services at community
level. Their perceptions of the interventions they implement and their experiences in delivering
community based interventions in India have been infrequently studied. A LHW led intervention was
implemented to improve anemia cure rates in rural community dwelling children attending village day
care centers in South India. To improve the implementation, a qualitative study was undertaken to
understand the LHWs’ acceptance of and perspectives regarding the intervention, particularly in
relation to factors affecting daily implementation. The study used focus group discussions (FGDs)
were conducted with the trained LHWs assigned to deliver the educational intervention. These were
complemented by non-participant observations of LHWs delivering the intervention.
The study identified several factors related to the implementation of the intervention effort
including pre-implementation training modules, intervention simplicity, and ability to incorporate the

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intervention into the routine work schedule. LHWs felt that the intervention impacted negatively on
their preexisting workload. Fluctuating relationships with mothers weakened the LHWs position as
providers of the intervention and hampered efficient implementation, despite the LHWs’ highly valued
position in the community. Modifiable barriers to the successful implementation of this intervention
were seen at two levels. At a broader contextual level, hindering factors included the LHW being
overburdened, inadequately reimbursed, and receiving insufficient employer support. At the health
system level, lack of streamlining of LHW duties, inability of LHWs to diagnose anemia and
temporary shortfalls in the availability of iron supplements constituted potentially modifiable barriers.
This qualitative study identified some of the practical challenges as experienced by LHWs
while delivering a community health intervention in India. Methodologically, it highlighted the value
of qualitative research in understanding implementation of complex community interventions.
REFERENCE
Shet A.S., Rao A., Jebaraj P., Mascarenhas M., Zwarenstein M., Galanti M.R., Atkins S. Lay health
workers perceptions of an anemia control intervention in Karnataka, India: a qualitative study. BMC
Public Health 2017; 17: 720. Doi: 10.1186/s12889-017-4758-x

Case study 4: Using photovoice for capturing the community perceptions on child health
The Sundarbans (West Bengal, India) has several inhospitable terrain and is at risk for frequent
climatic shocks which challenge the access to healthcare for the inhabitants. Community members, and
women in particular, have few means to communicate their concerns to local decision makers.
Photovoice is one way in which communities can raise their local health challenges with decision
makers. This study attempted to capture the mothers’ voices on the determinants of their children’s
health to inform local level decision-making.
A photovoice action research was conducted in three blocks in the Sundarbans region. The
project involved eight groups of eight to ten mothers who had at least one child below 6 years of age
across four villages. The mothers were trained on photo documentation and ethical concerns before
taking two rounds of photographs within 6 months, interspersed by fortnightly group meetings
facilitated by researchers. Photographs and key messages were communicated to local decision makers
during block and village level interface sessions with the mothers and researchers.
Mothers’ photos focused on specific determinants of health, such as water and sanitation;
health status, such as malnutrition and non-communicable diseases; service accessibility; climate
conditions; and social issues such as early marriage and recurrent pregnancy. Some issues were not
captured by photos but were discussed in group meetings, including domestic violence and the non-
availability of medical practitioners. Differences in perceptions and photographs taken were observed
according to the mother’s educational status, livelihood and caste identity.
Photovoice has the potential to capture the voices of vulnerable and special group
communities regarding their perceived health needs and challenges, which can help communicating
these to the local decision makers for health policy and planning.

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REFERENCE
Ghosh, U., Bose, S., Bramhachari, R., Mandal S. Expressing collective voices on children’s health:
photovoice exploration with mothers of young children from the Indian Sundarbans. BMC Health Serv
Res. 2016; 16: 625. Doi: 10.1186/s12913-016-1866-8.

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Supplementary Document 3
Examples of published literature using Mixed-Method Research
Case study 1: The relevance of qualitative research The poliomyelitis eradication effort in India
As a commitment under the Global Polio Eradication Initiative (GPEI), India accelerated its effort
towards improving oral polio vaccine coverage through the routine immunization and Supplementary
Immunization Activities (SIA, also known as the pulse polio immunization). With these intensified
immunization efforts, the number of reported acute flaccid paralysis (AFP) cases decreased from 134
in 2004 to 66 in 2005. However, the cases resurged in 2006 and concentrated in western Uttar Pradesh
and Bihar. The routine vaccination coverage with 3 doses of OPV was low in the polio-endemic states
(Bihar, 27%; western UP, 38%; and eastern UP, 45%). (1)
The causes of the social resistance and low coverage of OPV vaccines could not be identified
through the quantitative research approach. To document the determinants of social resistance and low
OPV acceptance in the western UP districts, a qualitative research was conducted. This qualitative
research used in-depth interviews (IDIs, with mothers, healthcare providers and community leaders),
focus group discussions (FGDs, with mothers and healthcare providers), non-formal interactions (with
community leaders, parents, businessmen, journalists, mobilizers, vaccinators and supervisors) and
observations of the vaccination and mobilisation. The researchers documented a distinct machination
of social resistance and rumors against OPV during the SIA in some minority dominated areas. While,
most parents in minority areas supported the SIAs, a few clusters from extremely marginalized
sections continued to evade SIAs, with an endemic pattern. The rumors circulated through varous
channels reached majority community as well parents (2).
The findings of this research was used for appropriate programmatic modification and
adoption of strategic communication approach targeting the resistant communities and pockets. With
these refinements in the communication and community mobilisation approaches, the polio eradication
was achieved in the country.
REFERENCES
1. Centers for Disease Control and Prevention. Progress Toward Poliomyelitis Eradication - --
India, January 2005--June 2006. Morb Mortal Wkly Rep. 2006;55(28):772–6.
2. Chaturvedi S, Dasgupta R, Adhish V, Ganguly KK, Rai S, Sushant L, et al. Deconstructing
social resistance to pulse polio campaign in two North Indian districts. Indian Pediatr.
2009;46(11):963–74.

Case study 2
Sequential mixed-method research- quantitative research followed by qualitative research and
Integrationat interpretation phase
Documenting the performance of electronic health records app and barriers in implementation
Electronic health record (HER) capturing is being promoted to improve the health services delivery,
documentation and planning. A study documented the performance of “Comprehensive Public Health

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Management” application (CPHM App) in Karnataka forcing on the family based maternal and child
health
(MCH) services and the challenges.
This research compared the completeness and consistency of selected MCH indicators from
paper-based records and the CPHM App and also the implementation enablers, barriers, and suggested
solutions from the user perspective. A sequential mixed-method study design was followed. The first
phase involved quantitative research focusing on the consistency of selected MCH indicators followed
by in-depth interviews of healthcare providers (users). The quantitative research findings for
consistency was expressed as percentages. In the qualitative phase, IDIs with various cadres of
healthcare providers (ANMs, MHW, ASHA, and administrator) were conducted. The findings were
integrated at the analysis phase to triangulate the findings from quantitative and qualitative phases and
identify the potential reasons for the gaps and challenges faced by the users (3).
REFERENCE
Shilpa D, Naik P, Shewade H, Sudarshan H. Assessing the implementation of a mobile App-based
electronic health record: A mixed-method study from South India. J Educ Health Promot.
2020;9(1):102.
Case study 3:
Sequential mixed-method research- qualitative research for tool development followed by
quantitative research
Development of a composite Slum Adversity Index and factors affecting the mental health of
individuals living in slums
The persons staying in slums are exposed to several adversities and have higher risk of common
mental disorders (CMDs). There was no suitable tool and index to capture the risk for developing these
CMDs in Mumbai slum. This mixed-method research used qualitative research (focus group
discussions and in-depth interviews) to develop the tool and indices for slum adversity quantitative
survey. The quantitative survey used the slum adversity questionnaire along with the other standard
tools, which were used to create a composite Slum Adversity Index (SAI) score. The qualitative data
were also used to identify the potential factors and their sources contributing and triggering the
psychological distress in the inhabitants (4).
REFERENCE
Subbaraman R, Nolan L, Shitole T, Sawant K, Shitole S, Sood K, et al. The psychological toll of slum
living in Mumbai, India: A mixed methods study. SocSci Med. 2014;119:155–69.

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