Integrating Mixed Methods in Health Services and Delivery System Research

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Turbulence, change, fragmentation, and multiple disruptive innovations characterize the current dynamic state of health services and delivery systems in the United States. Recent efforts to redesign and transform care delivery are searching for ways to overcome the challenges of fragmentation, inequality, and inappropriate care use while advancing the triple aims of better health and better care at lower cost for everyone. Health services research can contribute to these efforts by providing valid characterizations of the complex interactions among components of the current care delivery systems and by assessing impacts of efforts to redesign and improve care delivery. Mixed methods research can help investigators fully capture the complex interactions among system components, including interactions among multiple levels of analysis and over time. Through mixed methods, researchers can identify social, organizational, technical, and market contexts that shape the course and outcomes of improvement initiatives. Use of mixed methods may also make it easier for researchers to engage in dialogues with decision makers who formulate and implement programs of delivery system change, and to better communicate with other participants in the delivery system, including its users. This special issue of Health Services Research, sponsored by the Agency for Healthcare Research and Quality, illustrates how mixed methods studies can make important contributions to health services research.1 Furthermore, it seeks to move the field of mixed methods research toward creating a methodological mosaic that better corresponds to the complex phenomena. In this introduction, we describe the papers and briefly indicate where they fit into the emerging mixed methods mosaic. Then we provide some suggestions about what may be missing and anticipate a future state of a more integrated approach to health services research and richer dialogue between researchers and those engaged in health care. The growing role of mixed methods in health services research is evident from the publication of hundreds of mixed methods studies and recent overviews of best practices in mixed methods research (Palinkas, Aarons et al. 2011; Creswell et al. 2011; Curry et al. 2013; Ozawa and Pongpirul 2013; Zhang and Watanabe-Galloway 2013). This growing success reflects the capacity of mixed methods studies to capture the experiences, emotions, and motivations of people providing and receiving health care, as well as the objective conditions of care delivery. This wider use of mixed methods also reflects the ability of mixed methods to meet practical needs for assessing and understanding the complexity of health service delivery, which often results in an underlying emphasis on pragmatism. By applying a pragmatic mix of methods that work best in real-world situations, researchers thus find ways to overcome the assumed incompatibilities among research paradigms (Sale, Lohfeld, and Brazil 2002) and between qualitative and quantitative methods (Howe 2003; Onwuegbuzie and Leech 2005). Nevertheless, the recent proliferation of mixed methods research has exposed four areas needing more attention. First, until recently, most mixed methods studies embodied a form of “separate and unequal” in the ways that methods are used, data collected, and results published. Thus, there has been limited discussion about how to actually integrate multiple methods. Second, there has been a lack of common terminology for describing mixed methods designs and the multiple ways of combining methods. Third, the literature provides limited guidance about how to build the collaborative, cross-disciplinary teams that are required to execute a complicated mixed methods project and effectively manage the accompanying methodological and epistemological challenges. Fourth, at times pragmatism is insufficient and some paradigm issues still require attention. The six manuscripts in this issue highlight many of the reasons that mixed methods research has become popular while also addressing these four challenges; thus, they should help move mixed methods research toward a more complete methodological mosaic.