mixed methods case study research

• Research article
• Open access
• Published: 24 September 2018

A mixed methods case study exploring the impact of membership of a multi-activity, multicentre community group on social wellbeing of older adults

• Gabrielle Lindsay-Smith   ORCID: orcid.org/0000-0003-3864-1412 1 ,
• Grant O’Sullivan 1 ,
• Rochelle Eime 1 , 2 ,
• Jack Harvey 1 , 2 &
• Jannique G. Z. van Uffelen 1 , 3  

BMC Geriatrics volume  18 , Article number:  226 ( 2018 ) Cite this article

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Social wellbeing factors such as loneliness and social support have a major impact on the health of older adults and can contribute to physical and mental wellbeing. However, with increasing age, social contacts and social support typically decrease and levels of loneliness increase. Group social engagement appears to have additional benefits for the health of older adults compared to socialising individually with friends and family, but further research is required to confirm whether group activities can be beneficial for the social wellbeing of older adults.

This one-year longitudinal mixed methods study investigated the effect of joining a community group, offering a range of social and physical activities, on social wellbeing of adults with a mean age of 70. The study combined a quantitative survey assessing loneliness and social support ( n  = 28; three time-points, analysed using linear mixed models) and a qualitative focus group study ( n  = 11, analysed using thematic analysis) of members from Life Activities Clubs Victoria, Australia.

There was a significant reduction in loneliness ( p  = 0.023) and a trend toward an increase in social support ( p  = 0.056) in the first year after joining. The focus group confirmed these observations and suggested that social support may take longer than 1 year to develop. Focus groups also identified that group membership provided important opportunities for developing new and diverse social connections through shared interest and experience. These connections were key in improving the social wellbeing of members, especially in their sense of feeling supported or connected and less lonely. Participants agreed that increasing connections was especially beneficial following significant life events such as retirement, moving to a new house or partners becoming unwell.

Conclusions

Becoming a member of a community group offering social and physical activities may improve social wellbeing in older adults, especially following significant life events such as retirement or moving-house, where social network changes. These results indicate that ageing policy and strategies would benefit from encouraging long-term participation in social groups to assist in adapting to changes that occur in later life and optimise healthy ageing.

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Ageing population and the need to age well

Between 2015 and 2050 it is predicted that globally the number of adults over the age of 60 will more than double [ 1 ]. Increasing age is associated with a greater risk of chronic illnesses such as cardio vascular disease and cancer [ 2 ] and reduced functional capacity [ 3 , 4 ]. Consequently, an ageing population will continue to place considerable pressure on the health care systems.

However, it is also important to consider the individuals themselves and self-perceived good health is very important for the individual wellbeing and life-satisfaction of older adults [ 5 ]. The terms “successful ageing” [ 6 ] and “healthy ageing” [ 5 ] have been used to define a broader concept of ageing well, which not only includes factors relating to medically defined health but also wellbeing. Unfortunately, there is no agreed definition for what exactly constitutes healthy or successful ageing, with studies using a range of definitions. A review of 28 quantitative studies found that successful ageing was defined differently in each, with the majority only considering measures of disability or physical functioning. Social and wellbeing factors were included in only a few of the studies [ 7 ].

In contrast, qualitative studies of older adults’ opinions on successful ageing have found that while good physical and mental health and maintaining physical activity levels are agreed to assist successful ageing, being independent or doing something of value, acceptance of ageing, life satisfaction, social connectedness or keeping socially active were of greater importance [ 8 , 9 , 10 ].

In light of these findings, the definition that is most inclusive is “healthy ageing” defined by the World Health Organisation as “the process of developing and maintaining the functional ability (defined as a combination of intrinsic capacity and physical and social environmental characteristics), that enables well-being in older age” (p28) [ 5 ].This definition, and those provided in the research of older adults’ perceptions of successful ageing, highlight social engagement and social support as important factors contributing to successful ageing, in addition to being important social determinants of health [ 11 , 12 ].

Social determinants of health, including loneliness and social support, are important predictors of physical, cognitive and mental health and wellbeing in adults [ 12 ] and older adults [ 13 , 14 , 15 ]. Loneliness is defined as a perception of an inadequacy in the quality or quantity of one’s social relationships [ 16 ]. Social support, has various definitions but generally it relates to social relationships that are reciprocal, accessible and reliable and provide any or a combination of supportive resources (e.g. emotional, information, practical) and can be measured as perceived or received support [ 17 ]. These types of social determinants differ from those related to inequality (health gap social determinants) and are sometimes referred to as ‘social cure’ social determinants [ 11 ]. They will be referred to as ‘social wellbeing’ outcome measures in this study.

Unfortunately, with advancing age, there is often diminishing social support, leading to social isolation and loneliness [ 18 , 19 ]. Large nationally representative studies of adults and older adults reported that social activity predicted maintenance or improvement of life satisfaction as well as physical activity levels [ 20 ], however older adults spent less time in social activity than middle age adults.

Social wellbeing and health

A number of longitudinal studies have found that social isolation for older adults is a significant predictor of mortality and institutionalisation [ 21 , 22 , 23 ]. A meta-analysis by Holt-Lunstadt [ 12 ] reported that social determinants of health, including social integration and social support (including loneliness and lack of perceived social support) to be equal to, or a greater risk to mortality as common behavioural risk factors such as smoking, physical inactivity and obesity. Loneliness is independently associated with poor physical and mental health in the general population, and especially in older adults [ 13 , 14 , 15 ]. Adequate perceived social support has also been consistently associated with improved mental and physical health in both general and older adults [ 20 , 24 , 25 , 26 , 27 , 28 , 29 ]. The mechanism suggested for this association is that social support buffers the negative impacts of stressful situations and life events [ 30 ]. The above research demonstrates the benefit of social engagement for older adults; in turn this highlights the importance of strategies that reduce loneliness and improve social support and social connectedness for older adults.

Socialising in groups seems to be especially important for the health and wellbeing of older adults who may be adjusting to significant life events [ 26 , 31 , 32 , 33 ]. This is sometimes referred to as social engagement or social companionship [ 26 , 30 , 31 ]. It seems that the mechanism enabling such health benefits with group participation is through strengthening of social identification, which in turn increases social support [ 31 , 34 , 35 ]. Furthermore, involvement in community groups can be a sustainable strategy to reduce loneliness and increase social support in older adults, as they are generally low cost and run by volunteers [ 36 , 37 , 38 , 39 ].

Despite the demonstrated importance of social factors for successful ageing and the established risk associated with reduced social engagement as people age, few in-depth studies have longitudinally investigated the impact of community groups on social wellbeing. For example, a non-significant increase in social support and reduction in depression was found in a year-long randomised controlled trial conducted in senior centres in Norway with lonely older adults in poor physical and mental health [ 37 ]. Some qualitative studies have reported that community groups and senior centres can contribute to fun and socialisation for older adults, however social wellbeing was not the primary focus of the studies [ 38 , 40 , 41 ]. Given that social wellbeing is a broad and important area for the health and quality of life in older adults, an in-depth study is warranted to understand how it can be maximised in older adults. This mixed methods case study of an existing community aims to: i) examine whether loneliness and social support of new members of Life Activities Clubs (LACs) changes in the year after joining and ii) conduct an in-depth exploration of how social wellbeing changes in new and longer-term members of LACs.

A mixed methods study was chosen as the design for this research to enable an in-depth exploration of how loneliness and social support may change as a result of joining a community group. A case study was conducted using a concurrent mixed-methods design, with a qualitative component giving context to the quantitative results. Where the survey focused on the impact of group membership on social support and loneliness, the focus groups were an open discussion of the benefits in the lived context of LAC membership. The synthesis of the two sections of the study was undertaken at the time of interpretation of the results [ 42 ].

The two parts of our study were as follows:

a longitudinal survey (three time points over 1 year: baseline, 6 and 12 months). This part of the study formed the quantitative results;

a focus group study of members of the same organisation (qualitative).

Ethics approval to conduct this study was obtained from the Victoria University Human Research Ethics Committee (HRE14–071 [survey] and HRE15–291 [focus groups]) All participants provided informed consent to partake in the study prior to undertaking the first survey or focus group.

Setting and participants

Life activities clubs victoria.

Life Activities Clubs Victoria (LACVI) is a large not-for-profit group with 23 independently run Life Activities Clubs (LACs) based in both rural and metropolitan Victoria. It has approximately 4000 members. The organisation was established to assist in providing physical, social and recreational activities as well as education and motivational support to older adults managing significant change in their lives, especially retirement.

Eighteen out of 23 LAC clubs agreed to take part in the survey study. During the sampling period from May 2014 to December 2016, new members from the participating clubs were given information about the study and invited to take part. Invitations took place in the form of flyers distributed with new membership material.

Inclusion/ exclusion criteria

Community-dwelling older adults who self-reported that they could walk at least 100 m and who were new members to LACVI and able to complete a survey in English were eligible to participate. New members were defined as people who had never been members of LACVI or who had not been members in the last 2 years.

To ensure that the cohort of participants were of a similar functional level, people with significant health problems limiting them from being able to walk 100 m were excluded from participating in the study.

Once informed consent was received, the participants were invited to complete a self-report survey in either paper or online format (depending on preference). This first survey comprised the baseline data and the same survey was completed 6 months and 12 months after this initial time point. Participants were sent reminders if they had not completed each survey more than 2 weeks after each was delivered and then again 1 week later.

Focus groups

Two focus groups (FGs) were conducted with new and longer-term members of LACs. The first FG ( n  = 6) consisted of members who undertook physical activity in their LAC (e.g. walking groups, tennis, cycling). The second FG ( n  = 5) consisted of members who took part in activities with a non-physical activity (PA) focus (e.g. book groups, social groups, craft or cultural groups). LACs offer both social and physical activities and it was important to the study to capture both types of groups, but they were kept separate to assist participants in feeling a sense of commonality with other members and improving group dynamic and participation in the discussions [ 43 ]. Of the people who participated in the longitudinal survey study, seven also participated in the FGs.

The FG interviews were facilitated by one researcher (GLS) and notes around non-verbal communication, moments of divergence and convergence amongst group members, and other notable items were taken by a second researcher (GOS). Both researchers wrote additional notes after the focus groups and these were used in the analysis of themes. Focus groups were recorded and later transcribed verbatim by a professional transcriptionist, including identification of each participant speaking. One researcher (GLS) reviewed each transcription to check for any errors and made any required modifications before importing the transcriptions into NVivo for analysis. The transcriber identified each focus group participant so themes for individuals or other age or gender specific trends could be identified.

Dependent variables

• Social support

Social support was assessed using the Duke–UNC Functional Social support questionnaire [ 44 ]. This scale specifically measures participant perceived functional social support in two areas; i) confidant support (5 questions; e.g. chances to talk to others) and ii) affective support (3 questions; e.g. people who care about them). Participants rated each component of support on a 5-item likert scale between ‘much less than I would like’ (1 point) to ‘as much as I would like’ (5 points). The total score used for analysis was the mean of the eight scores (low social support = 1, maximum social support = 5). Construct validity, concurrent validity and discriminant validity are acceptable for confidant and affective support items in the survey in the general population [ 44 ].

Loneliness was measured using the de Jong Gierveld and UCLA-3 item loneliness scales developed for use in many populations including older adults [ 45 ]. The 11-item de Jong Gierveld loneliness scale (DJG loneliness) [ 46 ] is a multi-dimensional measure of loneliness and contains five positively worded and six negatively worded items. The items fall into four subscales; feelings of severe loneliness, feelings connected with specific problem situations, missing companionship, feelings of belongingness. The total score is the sum of the items scores (i.e. 11–55): 11 is low loneliness and 55 is severe loneliness. Self-administered versions of this scale have good internal consistency (> = 0.8) and inter-item homogeneity and person scalability that is as good or better than when conducted as face-to face interviews. The validity and reliability for the scale is adequate [ 47 ]. The UCLA 3-item loneliness scale consists of three questions about how often participants feel they lack companionship, feel left out and feel isolated. The responses are given on a three-point scale ranging from hardly ever (1) to often (3). The final score is the sum of these three items with the range being from lowest loneliness (3) to highest loneliness (9). Reliability of the scale is good, (alpha = 0.72) as are discriminant validity and internal consistency [ 48 ]. The scale is commonly used to measure loneliness with older adults ([ 49 ] – review), [ 50 , 51 ].

Sociodemographic variables

The following sociodemographic characteristics were collected in both the survey and the focus groups: age, sex, highest level of education, main life occupation [ 52 ], current employment, ability to manage on income available, present marital status, country of birth, area of residence [ 53 ]. They are categorised as indicated in Table  2 .

Health variables

The following health variables were collected: Self-rated general health (from SF-12) [ 54 ] and Functional health (ability to walk 100 m- formed part of the inclusion criteria) [ 55 ]. See Table 2 for details about the categories of these variables.

The effects of becoming a member on quantitative outcome variables (i.e. Social support, DJG loneliness and UCLA loneliness) were analysed using linear mixed models (LMM). LMM enabled testing for the presence of intra-subject random effects, or equivalently, correlation of subjects’ measures over time (baseline, 6-months and 12 months). Three correlation structures were examined: independence (no correlation), compound symmetry (constant correlation of each subjects’ measures over the three time points) and autoregressive (correlation diminishing with increase in spacing in time). The best fitting correlation structure was compound symmetry; this is equivalent to a random intercept component for each subject. The LMM incorporated longitudinal trends over time, with adjustment for age as a potential confounder. Statistical analyses were conducted using SPSS for windows (v24).

UCLA loneliness and social support residuals were not normally distributed and these scales were Log10 transformed for statistical analysis.

Analyses were all adjusted for age, group attendance (calculated as average attendance at 6 and 12 months) and employment status at baseline (Full-time, Part-time, not working).

Focus group transcripts were analysed using thematic analysis [ 56 , 57 ], a flexible qualitative methodology that can be used with a variety of epistemologies, approaches and analysis methods [ 56 ]. The transcribed data were analysed using a combination of theoretical and inductive thematic analysis [ 56 ]. It was theorised that membership in a LAC would assist with social factors relating to healthy ageing [ 5 ], possibly through a social identity pathway [ 58 ], although we wanted to explore this. Semantic themes were drawn from these codes in order to conduct a pragmatic evaluation of the LACVI programs [ 56 ]. Analytic rigour in the qualitative analysis was ensured through source and analyst triangulation. Transcriptions were compared to notes taken during the focus groups by the researchers (GOS and GLS). In addition, Initial coding and themes (by GLS) were checked by a second researcher (GOS) and any disagreements regarding coding and themes were discussed prior to finalisation of codes and themes [ 57 ].

Sociodemographic and health characteristics of the 28 participants who completed the survey study are reported in Table  1 . The mean age of the participants was 66.9 and 75% were female. These demographics are representative of the entire LACVI membership. Education levels varied, with 21% being university educated, and the remainder completing high school or technical certificates. Two thirds of participants were not married. Some sociodemographic characteristics changed slightly at 6 and 12 months, mainly employment (18% in paid employment at baseline and 11% at 12-months) and ability to manage on income (36% reporting trouble managing on their income at baseline and 46% at 12 months). Almost 90% of the participants described themselves as being in good-excellent health.

Types of activities

There were a variety of types of activities that participants took part in: physical activities such as walking groups ( n  = 7), table tennis ( n  = 5), dancing class ( n  = 2), exercise class ( n  = 1), bowls ( n  = 2), golf ( n  = 3), cycling groups ( n  = 1) and non-physical leisure activities such as art and literature groups ( n  = 5), craft groups ( n  = 5), entertainment groups ( n  = 12), food/dine out groups ( n  = 18) and other sedentary leisure activities (e.g. mah jong, cards),( n  = 4). A number of people took part in more than one activity.

Frequency of attendance at LACVI and changes in social wellbeing

At six and 12 months, participants indicated how many times in the last month they attended different types of activities at their LAC. Most participants maintained the same frequency of participation over both time points. Only four people participated more frequently at 12 than at 6 months and nine reduced participation levels. The latter group included predominantly those who reduced from more than two times per week at 6 months to 2×/week at 6 months to one to two times per week ( n  = 5) or less than one time per week ( n  = 2) at 12 months. Average weekly club attendance at six and 12 months was included as a covariate in the statistical model.

Outcome measures

Overall, participants reported moderate social support and loneliness levels at baseline (See Table 2 ). Loneliness, as measured by both scales, reduced significantly over time. There was a significant effect of time on the DJG loneliness scores (F (2, 52) = 3.83, p  = 0.028), with Post-Hoc analysis indicating a reduction in DJG loneliness between baseline and 12 months ( p  = 0.008). UCLA loneliness scores (transformed variable) also changed significantly over time (F (2, 52) = 4.08, p  = 0.023). Post hoc tests indicated a reduction in UCLA loneliness between baseline and 6 months ( p  = 0.007). There was a small non-significant increase in social support (F (2, 53) =2.88, p  = 0.065) during the first year of membership (see Table 2 and Figs. 1 and 2 ).

DJG loneliness for all participants over first year of membership at LAC club ( n  = 28).

*Represents significant difference compared to baseline ( p  < 0.01)

UCLA loneliness score for all participants over first year of membership at LAC club ( n  = 28).

*Indicates log values of the variable at 6-months were significantly different from baseline ( p  < 0.01)

In total, 11 participants attended the two focus groups, six people who participated in PA clubs (four women) and five who participated in social clubs (all women). All focus group participants were either retired ( n  = 9) or semi-retired ( n  = 2). The mean age of participants was 67 years (see Table 2 for further details). Most of the participants (82%) had been members of a LAC for less than 2 years and two females in the social group had been members of LAC clubs for 5 and 10 years respectively.

Analysis of the focus group transcripts identified two themes relating to social benefits of group participation; i) Social resources and ii) Social wellbeing (see Fig. 3 ). Group discussion suggested that membership of a LAC provides access to more social resources through greater and diverse social contact and opportunity. It is through this improvement in social resources that social wellbeing may improve.

Themes arising from focus group discussion around the benefits of LAC membership

Social resources

The social resources theme referred to an increase in the availability and variety of social connections that resulted from becoming a member of a LAC. The social nature of the groups enabled an expansion and diversification of members’ social network and improved their sense of social connectedness. There was widespread agreement in both the focus groups that significant life events, especially retirement, illness or death of spouse and moving house changes one’s social resources. Membership of the LAC had benefits especially at these times and these events were often motivators to join such a club. Most participants found that their social resources declined after retirement and even felt that they were grieving for the loss of their work.

“ I just saw work as a collection of, um, colleagues as opposed to friends. I had a few good friends there. Most were simply colleagues or acquaintances …. [interviewer- Mmm.] ..Okay, you’d talk to them every day. You’d chatter in the kitchen, oh, pass banter back and forth when things are busy or quiet, but... Um, in terms of a friendship with those people, like going to their home, getting to know them, doing other things with them, very few. But what I did miss was the interaction with other people. It had simply gone….. But, yeah, look, that, the, yeah, that intervening period was, oh, a couple of months. That was a bit tough…. But in that time the people in LAC and the people in U3A…. And the other dance group just drew me into more things. Got to know more people. So once again, yeah, reasonable group of acquaintances.” (Male, PAFG)

Group members indicated general agreement with these two responses, however one female found she had a greater social life following retirement due to the busy nature of her job.

Within the social resources theme, three subthemes were identified, i) Opportunity for social connectedness, ii) Opportunity for friendships, and iii) Opportunity for social responsibility/leadership . Interestingly, these subthemes were additional to the information gathered in the survey. This emphasises the power of the inductive nature of the qualitative exploration employed in the focus groups to broaden the knowledge in this area.

The most discussed and expanded subtheme in both focus groups was Opportunity for social connectedness , which arose through developing new connections, diversifying social connections, sharing interests and experiences with others and peer learning. Participants in both focus groups stated that being a member of LAC facilitated their socialising and connecting with others to share ideas, skills and to do activities with, which was especially important through times of significant life events. Furthermore, participants in each of the focus groups valued developing diverse connections:

“ Yeah, I think, as I said, I finished up work and I, and I had more time for wa-, walking. So I think a, in meeting, in going to this group which, I saw this group of women but then someone introduced me to them. They were just meeting, just meeting a new different set of people, you know? As I said, my work people and these were just a whole different group of women, mainly women. There’s not many men. [Interviewer: Yes.]….. Although our leader is a man, which is ironic and is about, this man out in front and there’s about 20 women behind him, but, um, so yeah, and people from different walks of life and different nationalities there which I never knew in my work life, so yeah. That’s been great. So from that goes on other things, you know, you might, uh, other activities and, yeah, people for coffee and go to the pictures or something, yeah. That’s great.” (Female, PAFG)

Simply making new connections was the most widely discussed aspect related to the opportunity for social connectedness subtheme, with all participants agreeing that this was an important benefit of participation in LAC groups.

“Well, my experience is very similar to everybody else’s…….: I, I went from having no social life to a social life once I joined a group.” (Female, PAFG)

There was agreement in both focus groups that these initial new connections made at a LAC are strengthened through development of deeper personal connections with others who have similar demographics and who are interested in the same activities. This concurs with the Social Identity Theory [ 58 ] discussed previously.

“and I was walking around the lake in Ballarat, like wandering on my own. I thought, This is ridiculous. I mean, you’ve met all those groups of women coming the opposite way, so I found out what it was all about, so I joined, yeah. So that’s how I got into that.[ Interviewer: Yeah.] Basically sick of walking round the lake on my own. [Interviewer: Yeah, yeah.] So that’s great. It’s very social and they have coffee afterwards which is good.” (female, PAFG)

The subtheme Opportunity for development of friendships describes how, for some people, a number of LAC members have progressed from being just initial social connections to an established friendship. This signifies the strength of the connections that may potentially develop through LAC membership. Some participants from each group mentioned friendships developing, with slightly more discussion of this seen in the social group.

“we all have a good old chat, you know, and, and it’s all about friendship as well.” (female, SocialFG)

The subtheme Opportunity for social responsibility or leadership was mentioned by two people in the active group, however it was not brought up in the social group. This opportunity for leadership is linked with the development of a group identity and desiring to contribute meaningfully to a valued group.

“with our riding group, um, you, a leader for probably two rides a year so you’ve gotta prepare for it, so some of them do reccie rides themselves, so, um, and also every, uh, so that’s something that’s, uh, a responsibility.” (male, PAFG)

Social wellbeing

The social resources described above seem to contribute to a number of social, wellbeing outcomes for participants. The sub themes identified for Social wellbeing were , i) Increased social support, ii) Reduced loneliness, iii) Improved home relationships and iv) Improved social skills.

Increased social support

Social support was measured quantitatively in the survey (no significant change over time for new members) and identified as a benefit of LAC membership during the focus group discussions. However, only one of the members of the active group mentioned social support directly.

‘it’s nice to be able to pick up the phone and share your problem with somebody else, and that’s come about through LAC. ……‘Cos before that it was through, with my family (female, PAFG)

There was some agreement amongst participants of the PA group that they felt this kind of support may develop in time but most of them had been members for less than 2 years.

“[Interviewer: Yeah. Does anyone else have that experience? (relating to above quote)]” There is one lady but she’s actually the one that I joined with anyway. [Interviewer: Okay.] But I, I feel there are others that are definitely getting towards that stage. It’s still going quite early days. (female1, PAFG) [Interviewer: I guess it’s quite early for some of you, yeah.] “yeah” (female 2, PAFG)

Social support through sharing of skills was mentioned by one participant in the social group also, with agreement indicated by most of the others in the social focus group.

Discussion in the focus groups also touched on the subthemes Reduced loneliness and Improved home relationships, which were each mentioned by one person. And focus groups also felt that group membership Improved social skills through opening up and becoming more approachable (male, PAFG) or enabling them to become more accepting of others’ who are different (general agreement in Social FG).

This case study integrated results from a one-year longitudinal survey study and focus group discussions to gather rich information regarding the potential changes in social wellbeing that older adults may experience when joining community organisations offering group activities. The findings from this study indicate that becoming a member of such a community organisation can be associated with a range of social benefits for older adults, particularly related to reducing loneliness and maintaining social connections.

Joining a LAC was associated with a reduction in loneliness over 1 year. This finding is in line with past group-intervention studies where social activity groups were found to assist in reducing loneliness and social isolation [ 49 ]. This systematic review highlighted that the majority of the literature explored the effectiveness of group activity interventions for reducing severe loneliness or loneliness in clinical populations [ 49 ]. The present study extends this research to the general older adult population who are not specifically lonely and reported to be of good general health, rather than a clinical focus. Our findings are in contrast to results from an evaluation of a community capacity-building program aimed at reducing social isolation in older adults in rural Australia [ 59 ]. That program did not successfully reduce loneliness or improve social support. The lack of change from pre- to post-program in that study was reasoned to be due to sampling error, unstandardised data collection, and changes in sample characteristics across the programs [ 59 ]. Qualitative assessment of the same program [ 59 ] did however suggest that participants felt it was successful in reducing social isolation, which does support our findings.

Changes in loneliness were not a main discussion point of the qualitative component of the current study, however some participants did express that they felt less lonely since joining LACVI and all felt they had become more connected with others. This is not so much of a contrast in results as a potential situational issue. The lack of discussion of loneliness may have been linked to the common social stigma around experiencing loneliness outside certain accepted circumstances (e.g. widowhood), which may lead to underreporting in front of others [ 45 ].

Overall, both components of the study suggest that becoming a member of an activity group may be associated with reductions in loneliness, or at least a greater sense of social connectedness. In addition to the social nature of the groups and increased opportunity for social connections, another possible link between group activity and reduced loneliness is an increased opportunity for time out of home. Previous research has found that more time away from home in an average day is associated with lower loneliness in older adults [ 60 ]. Given the significant health and social problems that are related to loneliness and social isolation [ 13 , 14 , 15 ], the importance of group involvement for newly retired adults to prevent loneliness should be advocated.

In line with a significant reduction in loneliness, there was also a trend ( p  = 0.056) toward an increase in social support from baseline to 12 months in the survey study. Whilst suggestive of a change, it is far less conclusive than the findings for loneliness. There are a number of possible explanations for the lack of statistically significant change in this variable over the course of the study. The first is the small sample size, which would reduce the statistical power of the study. It may be that larger studies are required to observe changes in social support, which are possibly only subtle over the course of 1 year. This idea is supported by a year-long randomised controlled trial with 90 mildly-depressed older adults who attended senior citizen’s club in Norway [ 37 ]. The study failed to see any change in general social support in the intervention group compared to the control over 1 year. Additional analysis in that study suggested that people who attended the intervention groups more often, tended to have greater increases in SS ( p  = 0.08). The researchers stated that the study suffered from significant drop-out rates and low power as a result. In this way, it was similar to our findings and suggests that social support studies require larger numbers than we were able to gain in this early exploratory study. Another possible reason for small changes in SS in the current study may be the type of SS measured. The scale used gathered information around functional support or support given to individuals in times of need. Maybe it is not this type of support that changes in such groups but more specific support such as task-specific support. It has been observed in other studies and reviews that task-specific support changes as a result of behavioural interventions (e.g. PA interventions) but general support does not seem to change in the time frames often studied [ 61 , 62 , 63 ].

There were many social wellbeing benefits such as increased social connectivity identified in focus group discussion, but the specific theme of social support was rarely mentioned. It may be that general social support through such community groups may take longer than 1 year to develop. There is evidence that strong group ties are sequentially positively associated between social identification and social support [ 34 ], suggesting that the connections formed through the groups may lead increased to social support from group members in the future. This is supported by results from the focus group discussions, where one new member felt she could call on colleagues she met in her new group. Other new members thought it was too soon for this support to be available, but they could see the bonds developing.

Other social wellbeing changes

In addition to social support and loneliness that were the focus of the quantitative study, the focus group discussions uncovered a number of other benefits of group membership that were related to social wellbeing (see Fig. 3 ). The social resources theme was of particular interest because it reflected some of the mechanisms that appeared enable social wellbeing changes as a result of being a member of a LAC but were not measured in the survey. The main social resources relating to group membership that were mentioned in the focus groups were social connectedness, development of friendships and opportunity for social responsibility or leadership. As mentioned above, there was wide-spread discussion within the focus groups of the development of social connections through the clubs. Social connectedness is defined as “the sense of belonging and subjective psychological bond that people feel in relation to individuals and groups of others.” ([ 25 ], pp1). As well as being an important predecessor of social support, greater social connectedness has been found to be highly important for the health of older adults, especially cognitive and mental health [ 26 , 32 , 34 , 35 , 64 ]. One suggested theory for this health benefit is that connections developed through groups that we strongly identify with are likely to be important for the development of social identity [ 34 ], defined by Taifel as: “knowledge that [we] belong to certain social groups together with some emotional and value significance to [us] of this group membership” (Tajfel, 1972, p. 31 in [ 58 ] p 2). These types of groups to which we identify may be a source of “personal security, social companionship, emotional bonding, intellectual stimulation, and collaborative learning and……allow us to achieve goals.” ([ 58 ] p2) and an overall sense of self-worth and wellbeing. There was a great deal of discussion relating to the opportunity for social connectedness derived through group membership being particularly pertinent following a significant life event such as moving to a new house or partners becoming unwell or dying and especially retirement. This change in their social circumstance is likely to have triggered the need to renew their social identity by joining a community group. Research with university students has shown that new group identification can assist in transition for university students who have lost their old groups of friends because of starting university [ 65 ]. In an example relevant to older adults, maintenance or increase in number of group memberships at the time of retirement reduced mortality risk 8 years later compared to people who reduce their number of group activities in a longitudinal cohort study [ 66 ]. This would fit with the original Activity Theory of ageing; whereby better ageing experience is achieved when levels of social participation are maintained, and role replacement occurs when old roles (such as working roles) must be relinquished [ 67 ]. These connections therefore appear to assist in maintaining resilience in older adults defined as “the ability to maintain or improve a level of functional ability (a combination of intrinsic physical and mental capacity and environment) in the face of adversity” (p29, [ 5 ]). Factors that were mentioned in the focus groups as assisting participants in forming connections with others were shared interest, learning from others, and a fun and accepting environment. It was not possible to assess all life events in the survey study. However, since the discussion from the focus groups suggested this to be an important motivator for joining clubs and potentially a beneficial time for joining them, it would be worth exploring in future studies.

Focus group discussion suggested that an especially valuable time for joining such clubs was around retirement, to assist with maintaining social connectivity. The social groups seem to provide social activity and new roles for these older adults at times of change. It is not necessarily important for all older adults but maybe these ones identify themselves as social beings and therefore this maintenance of social connection helps to continue their social role. Given the suggested importance of social connectivity gained through this organisation, especially at times of significant life events, it would valuable to investigate this further in future and consider encouragement of such through government policy and funding. The majority of these types of clubs exist for older adults in general, but this study emphasises the need for groups such as these to target newly retired individuals specifically and to ensure that they are not seen as ‘only for old people’.

Strengths and limitations

The use of mixed –methodologies, combining longitudinal survey study analysed quantitatively, with a qualitative exploration through focus group discussions and thematic analysis, was a strength of the current study. It allowed the researchers to not only examine the association between becoming a member of a community group on social support and loneliness over an extended period, but also obtain a deeper understanding of the underlying reasons behind any associations. Given the variability of social support definitions in research [ 17 ] and the broad area of social wellbeing, it allowed for open exploration of the topic, to understand associations that may exist but would have otherwise been missed. Embedding the research in an existing community organisation was a strength, although with this also came some difficulties with recruitment. Voluntary coordination of the community groups meant that informing new members about the study was not always feasible or a priority for the volunteers. In addition, calling for new members was innately challenging because they were not yet committed to the club fully. This meant that so some people did not want to commit to a year-long study if they were not sure how long they would be a member of the club. This resulted in slow recruitment and a resulting relatively low sample size and decreased power to show significant statistical differences, which is a limitation of the present study. However, the use of Linear Mixed Models for analysis of the survey data was a strength because it was able to include all data in the analyses and not remove participants if one time point of data was missing, as repeated measures ANOVAs would do. The length of the study (1 year) is another strength, especially compared to previous randomised controlled studies that are typically only 6–16 weeks in length. Drop-out rate in the current study is very low and probably attributable to the benefits of working with long-standing organisations.

The purpose of this study was to explore in detail whether there are any relationships between joining existing community groups for older adults and social wellbeing. The lack of existing evidence in the field meant that a small feasibility-type case study was a good sounding-board for future larger scale research on the topic, despite not being able to answer questions of causality. Owing to the particularistic nature of case studies, it can also be difficult to generalise to other types of organisations or groups unless there is a great deal of similarity between them [ 68 ]. There are however, other types of community organisations in existence that have a similar structure to LACVI (Seniors centres [ 36 , 40 ], Men’s Sheds [ 38 ], University of the Third Age [ 34 , 69 ], Japanese salons [ 70 , 71 ]) and it may be that the results from this study are transferable to these also. This study adds to the literature around the benefits of joining community organisations that offer social and physical activities for older adults and suggests that this engagement may assist with reducing loneliness and maintaining social connection, especially around the time of retirement.

Directions for future research

Given that social support trended toward a significant increase, it would be useful to repeat the study on a larger scale in future to confirm this. Either a case study on a similar but larger community group or combining a number of community organisations would enable recruitment of more participants. Such an approach would also assist in assessing the generalisability of our findings to other community groups. Given that discussions around social benefits of group membership in the focus groups was often raised in conjunction with the occurrence of significant life events, it would be beneficial to include a significant life event scale in any future studies in this area. The qualitative results also suggest that it would be useful to investigate whether people who join community groups in early years post retirement gain the same social benefits as those in later stages of retirement. Studies investigating additional health benefits of these community groups such as physical activity, depression and general wellbeing would also be warranted.

With an ageing population, it is important to investigate ways to enable older adults to age successfully to ensure optimal quality of life and minimisation of health care costs. Social determinants of health such as social support, loneliness and social contact are important contributors to successful ageing through improvements in cognitive health, quality of life, reduction in depression and reduction in mortality. Unfortunately, older adults are at risk of these social factors declining in older age and there is little research investigating how best to tackle this. Community groups offering a range of activities may assist by improving social connectedness and social support and reducing loneliness for older adults. Some factors that may assist with this are activities that encourage sharing interests, learning from others, and are conducted in a fun and accepting environment. Such groups may be particularly important in developing social contacts for newly retired individuals or around other significant life events such as moving or illness of loved ones. In conclusion, ageing policy and strategies should emphasise participation in community groups especially for those recently retired, as they may assist in reducing loneliness and increasing social connections for older adults.

Abbreviations

Focus group

Life Activities Club

Life Activities Clubs Victoria

Linear mixed model

Physical activity

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The primary author contributing to this study (GLS) receives PhD scholarship funding from Victoria University. The other authors were funded through salaries at Victoria University.

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GLS, RE and JVU made substantial contributions to the conception and design of the study. GLS and GOS supervised data collection for the surveys (GLS) and focus groups (GOS and GLS). GLS, GOS, RE, JH and JVU were involved in data analysis and interpretation. All authors were involved in drafting, the manuscript and approved the final version.

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Lindsay-Smith, G., O’Sullivan, G., Eime, R. et al. A mixed methods case study exploring the impact of membership of a multi-activity, multicentre community group on social wellbeing of older adults. BMC Geriatr 18 , 226 (2018). https://doi.org/10.1186/s12877-018-0913-1

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• Mixed Methods Research | Definition, Guide & Examples

Mixed Methods Research | Definition, Guide & Examples

Published on August 13, 2021 by Tegan George . Revised on June 22, 2023.

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, advantages of mixed methods research, disadvantages of mixed methods research, other interesting articles, frequently asked questions.

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:

• Generalizability : Qualitative research usually has a smaller sample size , and thus is not generalizable. In mixed methods research, this comparative weakness is mitigated by the comparative strength of “large N,” externally valid quantitative research.
• Contextualization: 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.

But mixed methods might be a good choice if you want to meaningfully integrate both of these questions in one research study.

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, and comes with the same risk of research biases as standalone studies, so it’s a less common choice than standalone qualitative or qualitative research.

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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 analyze them separately. After both analyses are complete, compare your results to draw overall conclusions.

• On the qualitative side, you analyze 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 analyze 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 analyze 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 contextualize 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, contextualized insights of qualitative data and the generalizable , 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 generalizable, 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 labor-intensive. Collecting, analyzing, and synthesizing 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.

Due to the fact that quantitative and qualitative data take two vastly different forms, it can also be difficult to find ways to systematically compare the results, putting your data at risk for bias in the interpretation stage.

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If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

• Degrees of freedom
• Null hypothesis
• Discourse analysis
• Control groups
• Non-probability sampling
• Quantitative research
• Inclusion and exclusion criteria

Research bias

• Rosenthal effect
• Implicit bias
• Cognitive bias
• Selection bias
• Negativity bias
• Status quo bias

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

Quantitative methods allow you to systematically measure variables and test hypotheses . Qualitative methods allow you to explore concepts and experiences in more detail.

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 organizations.

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 analyzed 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 analyzed first, followed by qualitative data. You can use this design if you think your qualitative data will explain and contextualize your quantitative findings.
• Exploratory sequential: Qualitative data is collected and analyzed 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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• 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 .

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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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Generalization practices in qualitative research: a mixed methods case study

• Published: 09 May 2009
• Volume 44 , pages 881–892, ( 2010 )

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• Anthony J. Onwuegbuzie 1 &
• Nancy L. Leech 2  

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The purpose of this mixed methods case study was to examine the generalization practices in qualitative research published in a reputable qualitative journal. In order to accomplish this, all qualitative research articles published in Qualitative Report since its inception in 1990 ( n =  273) were examined. A quantitative analysis of the all 125 empirical qualitative research articles revealed that a significant proportion (i.e., 29.6%) of studies involved generalizations beyond the underlying sample that were made inappropriately by the author(s). A qualitative analysis identified the types of over-generalizations that occurred, which included making general recommendations for future practice and providing general policy implications based only on a few cases. Thus, a significant proportion of articles published in Qualitative Report lack what we call interpretive consistency.

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Onwuegbuzie, A.J., Leech, N.L. Generalization practices in qualitative research: a mixed methods case study. Qual Quant 44 , 881–892 (2010). https://doi.org/10.1007/s11135-009-9241-z

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Published : 09 May 2009

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DOI : https://doi.org/10.1007/s11135-009-9241-z

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• Published: 02 April 2024

Towards universal health coverage in Vietnam: a mixed-method case study of enrolling people with tuberculosis into social health insurance

• Rachel Forse   ORCID: orcid.org/0000-0002-0716-3342 1 , 2 ,
• Clara Akie Yoshino 2 ,
• Thanh Thi Nguyen 1 ,
• Thi Hoang Yen Phan 3 ,
• Luan N. Q. Vo 1 , 2 ,
• Andrew J. Codlin 1 , 2 ,
• Lan Nguyen 4 ,
• Chi Hoang 4 ,
• Lopa Basu 5 ,
• Minh Pham 5 ,
• Hoa Binh Nguyen 6 ,
• Luong Van Dinh 6 ,
• Maxine Caws 7 , 8 ,
• Tom Wingfield 2 , 7 ,
• Knut Lönnroth 2 &
• Kristi Sidney-Annerstedt 2  

Health Research Policy and Systems volume  22 , Article number:  40 ( 2024 ) Cite this article

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Vietnam’s primary mechanism of achieving sustainable funding for universal health coverage (UHC) and financial protection has been through its social health insurance (SHI) scheme. Steady progress towards access has been made and by 2020, over 90% of the population were enrolled in SHI. In 2022, as part of a larger transition towards the increased domestic financing of healthcare, tuberculosis (TB) services were integrated into SHI. This change required people with TB to use SHI for treatment at district-level facilities or to pay out of pocket for services. This study was conducted in preparation for this transition. It aimed to understand more about uninsured people with TB, assess the feasibility of enrolling them into SHI, and identify the barriers they faced in this process.

A mixed-method case study was conducted using a convergent parallel design between November 2018 and January 2022 in ten districts of Hanoi and Ho Chi Minh City, Vietnam. Quantitative data were collected through a pilot intervention that aimed to facilitate SHI enrollment for uninsured individuals with TB. Descriptive statistics were calculated. Qualitative interviews were conducted with 34 participants, who were purposively sampled for maximum variation. Qualitative data were analyzed through an inductive approach and themes were identified through framework analysis. Quantitative and qualitative data sources were triangulated.

We attempted to enroll 115 uninsured people with TB into SHI; 76.5% were able to enroll. On average, it took 34.5 days to obtain a SHI card and it cost USD 66 per household. The themes indicated that a lack of knowledge, high costs for annual premiums, and the household-based registration requirement were barriers to SHI enrollment. Participants indicated that alternative enrolment mechanisms and greater procedural flexibility, particularly for undocumented people, is required to achieve full population coverage with SHI in urban centers.

Conclusions

Significant addressable barriers to SHI enrolment for people affected by TB were identified. A quarter of individuals remained unable to enroll after receiving enhanced support due to lack of required documentation. The experience gained during this health financing transition is relevant for other middle-income countries as they address the provision of financial protection for the treatment of infectious diseases.

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Contributing to universal health coverage (UHC) by improving access to fair and sustainable health financing, of which one mechanism is health insurance, has become a priority among low- and middle-income countries [ 1 , 2 ]. Many countries in the Asia Pacific region have made steady progress towards UHC coverage through sustained political commitments and fiscal policy aligned with their commitment [ 3 ]. By 2020, 27 countries had implemented a social health insurance (SHI) financing mechanism, which typically includes open enrollment for the full population along with partial or full subsidization of healthcare costs for vulnerable groups [ 4 ].

Vietnam’s first SHI scheme was piloted in 1989 and grew through successive pilots and expansions. In 2009 the national-level Health Insurance Law (HIL) went into effect, uniting the existing health insurance programs and schemes for the poor [ 5 ]. Amendments to the HIL effective in 2015 made SHI compulsory for all and pooled risk by re-structuring registration around the household unit [ 4 ]. A household in Vietnam is defined by inclusion in the ‘family book ’, the national system of family and address registration [ 6 ].

Access to SHI in Vietnam increased rapidly, principally through subsidization of premiums. Specific groups were enrolled automatically with full subsidy, including vulnerable populations (e.g., households classified as ‘poor’, children aged < 6, people aged > 80), pensioners and meritorious groups (e.g., veterans). Partial premium subsidization was also available for students, households classified as ‘near-poor’ and some farmers [ 7 ]. More than half of SHI members are entitled to 80% coverage with a 20% co-payment for services [ 8 ]. However, co-payments are reduced to 5% or are eliminated for subsidized groups (e.g., households classified as ‘poor’ and ‘near-poor’, children < 6) [ 4 ].

By 2020, Vietnam recorded a 91% national SHI coverage rate [ 7 ]. Those remaining uninsured mainly consisted of informally employed individuals [ 7 ]. Enrollment rates were highest among low- and high-income groups, leaving the so-called “missing middle” of uninsured [ 5 ].

Vietnam continues to transition to domestic financing of healthcare from donor financing by expanding the breadth of the national SHI. The Ministry of Health and Vietnam Social Security (VSS) have begun to close service gaps and integrate vertical health programs (e.g., those with stand-alone budget allocations and/or direct donor financing) into SHI financing [ 7 ]. The costs for antiretroviral therapy (ART) were transitioned from donor funding to SHI in 2019 [ 9 ], COVID-19 treatments were covered by SHI in 2020, and financing for tuberculosis (TB) care was fully transitioned to SHI in 2022 [ 7 ].

Until this financing transition, anti-TB medications and consultations were provided free of charge in the public sector, funded by a mixture of domestic and international funding [ 10 ]. While first-line TB medications were included in the SHI-reimbursable list of essential medicines, the government network of District TB Units (DTUs) were ineligible for registration with VSS, or reimbursement for services provided. Since July 2022, TB health facilities that met certain conditions could register with VSS and receive reimbursements for TB consultations, diagnostics and anti-TB medications [ 11 ]. The financing for drug-resistant (DR-)TB tests and medications remains largely unchanged, co-financed by the Global Fund and domestic budgets [ 12 ].

This transition of the TB financing model in Vietnam is a large undertaking as the country has the world’s 10th highest TB burden and the SHI benefits package is already considered to be generous, and the sustainability of the SHI fund is a concern [ 4 , 13 ] An estimated 169,000 individuals developed TB in 2021, and the disease killed approximately 14,200 [ 14 ]. A national costing survey of TB-affected households showed that 63% experienced catastrophic costs, spending ≥ 20% of their annual income on TB [ 10 ]. Many face food insecurity and cope with TB-related costs by taking loans, dissavings and informally borrowing money [ 10 , 15 , 16 ].

As Vietnam continues to expand SHI financing for the TB program, it is now vital for people with TB to have SHI. Those without SHI coverage will need to finance their care out of pocket (OOP) or purchase SHI and make co-payments for their care to be subsidized. For these reasons, it is important to understand why certain people with TB are uninsured, the feasibility of enrolling them in insurance when they begin treatment, and the challenges they may face with enrolling in SHI.

We conducted a convergent parallel mixed-method case study [ 17 ]. A case study was selected because it is well-suited to describe a complex issue in a real-life setting [ 18 ]. We used a naturalistic design with theoretical sampling of uninsured persons with TB using an interpretivist approach [ 19 ]. Mixed methods were selected to facilitate comparisons between quantitative and qualitative data and interpretation of the findings. An intervention, assisting TB-affected households to enroll in SHI, was conducted between November 2019 and January 2022, prior to the integration of the TB program into the SHI financing scheme. Quantitative data collection sought to answer questions regarding enrollment success rate, time to enrollment and cost of SHI enrollment for uninsured TB-affected households upon TB treatment initiation. The qualitative data explored barriers to SHI enrollment to explain and contextualize the quantitative findings. The quantitative and qualitative data were weighted equally [ 17 ].

Intervention description

A pilot intervention was conducted to facilitate SHI enrollment for people with TB in ten districts of Ha Noi and Ho Chi Minh City (HCMC). The standard process for first-time enrollment into SHI was mapped and costed from a household’s perspective (Additional file 1 ). Uninsured individuals were identified from the TB treatment register when they were enrolled in drug-susceptible (DS-)TB treatment at DTUs [ 20 ]. Study staff then attempted to facilitate enrollment of the person with TB and up to three household members into SHI.

SHI enrollment support included home visits by study staff to provide detailed information and counseling about the process of SHI enrollment, assistance with SHI application preparation including obtaining photocopies of all required documents, follow-up to obtain missing documentation within the household, accompaniment to the SHI office for application submission, and direct payment of the annual SHI premium for the household. For people who did not have the paperwork certifying temporary residence in Hanoi or Ho Chi Minh City, staff visited the local government office to obtain the information about the process for individual cases to obtain residency certificates and support participants with navigation of the bureaucracy. TB-affected people and their household members were also provided with a hotline number to call and receive support during working hours from the social workers who were employed by the study. Study staff attempted to facilitate the SHI enrollment process throughout the entire 6-month duration of DS-TB treatment. After a TB treatment outcome was recorded by the DTU, study staff stopped assisting with SHI enrollment and participants were recorded as ‘not enrolled in SHI’ in the study’s evaluation.

Quantitative methods

Case-level TB treatment notification data and SHI status were exported from VITIMES, the government-implemented electronic TB register for Vietnam, for all individuals who started TB treatment during the intervention period. The pilot intervention recruited participants from two TB treatment support projects (Project 1, n  = 59 and Project 2, n  = 56) [ 21 , 22 ] and tracked study forms housed in ONA.io. The sample size was determined by the availability of funding provided by the donor for treatment support service delivery, rather than to measure a specific end point of SHI enrollment. Descriptive statistics summarizing the enrollment cascade and turnaround time of enrollment were calculated using Stata v17 (Stata17 Corp, College Station, USA). To obtain the mean costs for household SHI enrollment, total direct costs for purchasing SHI were summed and divided by the total number of participants. Costs were captured in Vietnamese Dong (VND) and converted to United States Dollars (USD) using the exchange rate from the mid-point of the pilot intervention (1 June 2020) from OANDA.com.

Qualitative methods

Individuals were purposively sampled for maximum variation to ensure representation of all implementation areas and provide gender balance [ 23 ].The concept of information power guided the sample size [ 24 ]. Given the well-defined study aim, high quality in-depth responses from the participants and the authors’ expertise in the subject area, the sample size of 19 individual interviews and three focus group discussions was deemed appropriate. These were conducted in Ha Noi and HCMC. A total of 34 individuals participated in the interviews (Table  1 ).

They included 14 people enrolled in the pilot intervention, five community members who were non-beneficiaries of the treatment support intervention, 13 TB program staff from the national-, provincial- and district-levels and two study staff. Interviews were conducted at two time points: June 2019 and 2020. SHI enrollment barriers were collected as part of a qualitative study on the acceptability of providing cash transfers and SHI enrollment to adults with TB [ 25 ]. During the second round of interviews in 2020, study staff were included due to their in-depth knowledge of the challenges faced by TB-affected households when attempting to enroll in SHI and their ability to suggest programmatic-level solutions to these challenges. These interviews were conducted one-on-one, after the other interviews and focus groups had been conducted to reduce bias. The interviews were conducted at the National Lung Hospital, HCMC Provincial Lung Hospital, study office or DTUs. All interviews were conducted and transcribed in Vietnamese, translated into English, checked and finalized by a lead translator.

The interviews were analyzed through an inductive approach and themes were drawn through a framework analysis [ 26 ] to identify barriers to enrolling in SHI using Dedoose Version 7.0.23 (SocioCultural Research Consultants, Los Angeles, USA).

Data triangulation

Quantitative and qualitative data were collected in parallel. Triangulation of quantitative and qualitative data was conducted to synthesize findings and assess the level of agreement, convergence, and divergence from the findings generated by the different methods [ 17 ].

During the study, 5887 individuals were treated for DS-TB across the 10 intervention districts (Table  2 ). TB registers indicated that 2846 (48.3%) individuals were uninsured upon treatment initiation, or their SHI enrollment status was not recorded. Among 115 uninsured study participants, 88 (76.5%) were successfully enrolled in SHI before the end of their TB treatment. Among those, the household had an average of two members, resulting in a total of 206 individuals living in TB-affected households receiving SHI coverage through the pilot intervention.

The median time between DS-TB treatment initiation and SHI card issuance was 34.5 days (IQR 24–68): 11 days (IQR 5–23) between treatment initiation and pilot enrollment, 7 days (IQR 1–19.5) for SHI application preparation and submission, and 12 days (IQR 9–20) for application processing and SHI card provision.

The qualitative data showed that participants across all participant groups broadly understood that SHI is a system designed to prevent catastrophic OOP medical expenditure. As shown in Table  3 , National and provincial-level TB staff described SHI as a human right and spoke about achieving UHC as a nation; no other participant groups discussed SHI in this way. However, district-level doctors and intervention beneficiaries spoke in greater details about coverage and service gaps, and the practicalities of utilizing SHI. These participant groups expressed that when individuals purchase SHI only after a negative health event, such as a TB diagnosis, then the social safety net is unavailable to provide support until SHI coverage begins. Drawn from these views, the first theme indicated that the optimal time to purchase SHI is prior to a TB diagnosis.

One DTU staff member described how the standard processing time, or delays in processing SHI applications led to periods of high OOP expenditure:

“Unfortunately, claims are not immediately paid upon [SHI registration] submission. They may be handled in about 2 or 3 weeks, or even one month. That is why the insurance is not available at the time that they want to go for an examination and treat their condition using insurance.” (Female, District-level TB staff)

A complementary theme was that perceived lack of knowledge about SHI enrollment procedures prevents or delays enrollment. District-level TB doctors and program staff identified a lack of understanding and knowledge of the SHI enrollment process as a main contributor to lack of insurance or delays in obtaining coverage.

“Actually, for some people [with TB] who do not clearly understand the [enrollment] procedures… it will take a lot of time [to obtain SHI]. It also depends on the staff who handle the files at the commune; some staff are very enthusiastic and they help patients complete forms. There are cases [...] where they [people with TB] are required to fill in all information and write specific codes of each insurance card [from other family members] on a form. Meanwhile some people in their family work far from home and cannot send their insurance cards home in a timely manner.” (Female, program staff)

Participants tended to believe that individuals who lacked information about SHI made up the small minority of uninsured people in Vietnamese society. The above quote illustrated that the complicated administrative process prohibits enrollment; however, a factor potentially facilitating SHI enrollment may be the helpfulness of the person processing the SHI application.

The average cost per household to obtain SHI enrollment for one year (Table  2 ) was VND 1,503,313 (USD 65.52). (For detailed information on the costs of SHI enrollment, see Additional file 1 ). A third theme contextualized this finding and showed that SHI enrollment costs were perceived as prohibitively high for some. Cost was a greater challenge for lower income families, who did not meet the government’s criterion of households classified as ‘poor’ or ‘near-poor’, and were therefore ineligible for premium subsidies and SHI registration with lower co-payment rates. One DTU doctor reported that:

“We think that it is simple to buy health insurance cards, but that is only true for those who have sustainable income - when our income is much higher than the fee for buying health insurance. For some people, buying health insurance is a luxury.” (Male, District-level TB staff)

Twenty-seven people with TB (23.5%) were unable to obtain SHI coverage. The primary reason (70.4%) was missing documentation. In four instances (14.8%) a household member other than the person with TB refused to enroll in SHI. One individual (3.7%) died during the enrollment process. Three individuals (11.1%) did not enroll for other reasons.

SHI refusal by household members was not identified as a barrier to SHI enrollment in the qualitative data. However, a fourth theme confirmed the primary reason for non-enrollment by showing that some individuals do not possess the required documentation to obtain SHI, such as their identity card or ‘family book.’ [See Supplementary File] Even with six months of support from study staff, some TB-affected households were unable to gather the required documents for enrollment. The following quotation by an undocumented, elderly woman with TB illustrates the prolonged challenges she faced with obtaining formal employment, access to government services and SHI:

“I have had problems with my personal papers for a few decades and I cannot adjust my papers because I don’t have the money. […] I searched for my Identity Card and found out that I had lost it. Then I came back there [my hometown] to get the family book, to reissue my ID and to get my CV certified so I could join a company. I was very young at that time, just a little bit more than thirty years old, and I learned that I was cut from the family book.” (Female, pilot beneficiary)

To address challenges with documentation, one DTU officer in HCMC suggested that individuals who had never been insured required a change to the SHI registration requirements to ensure that everyone in Vietnam can access SHI:

“I think we should be flexible with these cases or we can find another way. Normally, the people who really need the support and the insurance or cash support, they are the people who have less information. […] We cannot have the same requirements for these people as for other people. Actually, for those who have [met] all conditions, they already have health insurance cards.” (Male, District-level TB staff)

Participants expressed that the uninsured had often not purchased SHI for a reason, and alternative registration procedures were needed to make SHI accessible for all. A fifth theme was identified indicating that current SHI enrollment procedures may prevent full population coverage.

Beyond the undocumented, some participants reported the enrollment mandate for the entire household (made under the Amendment to the HIL) for first-time enrollees was viewed as prohibitive of SHI coverage.

“Because in the old days, health insurance was sold individually for each person, but now it is sold to households, and many households do not have as good economic [situation]… so they can only afford to buy it for 50% or 60% of the household. Unskilled labor or low-income labor cannot afford to buy it for the whole family. That is to say, it is easier to buy it for each individual and it is difficult to buy for the whole family.” (Male, community member)

Though individual registration would make SHI more accessible to individuals with TB due to lower annual costs, household members with high vulnerability to TB would not be covered if policy promoted individual enrollment solely for TB.

This mixed-methods case study showed that by providing full subsidy and registration assistance, most uninsured people with TB could access SHI. However, the median time to insurance coverage meant that approximately 20% of a person’s DS-TB treatment duration remained uncovered by SHI despite successful enrollment. A substantial number of participants were unable to enroll in SHI and are likely to be perpetually locked out of SHI due to lack of personal documentation. Additional barriers to SHI enrollment were found to be lack of knowledge, the cost of obtaining coverage, and the household-based registration requirement.

The pilot intervention had dedicated staff who facilitated SHI application development and submission, yet it still took a median of 34.5 days for SHI coverage to take effect. In a context where this level of support is not available to all people with TB, it is likely that the turnaround time for SHI coverage is longer due to the complicated bureaucracy involved. This poses a major challenge, as TB-affected households incur the highest cost during the first two months of treatment [ 15 ]. One cost avoidance/mitigation strategy that people with a TB diagnosis may employ following the health financing transition is delaying TB treatment initiation until SHI coverage commences. This will likely lead to worse outcomes and sustained community transmission. The time between diagnosis and treatment should be rigorously monitored to ensure that this coping strategy is not employed, and alternative support should be made available to ensure that people diagnosed with TB are able to receive immediate treatment.

With the TB health financing transition, the uninsured will be asked to pay OOP for TB treatment and most insured individuals must co-pay for TB services which were previously provided free of cost. A national patient cost survey in 2018 found that 63% of TB-affected households experienced catastrophic costs under the previous health financing model [ 10 ]. There is a risk that the proportion of TB-affected households experiencing catastrophic costs could increase with the introduction of fees. This was not found to be the case for people living with HIV (PLHIV) when the costs of ART transitioned to SHI in Vietnam, but a new nationally representative TB costing survey is needed to assess this risk [ 9 ]. Several domestic solutions could ameliorate these challenges. As suggested for the Indian context, domestic revenues allocated by the Ministry of Finance to VSS could be increased to better support TB care [ 27 ]. VSS could also reclassify the category of TB disease and thus ensure that SHI paid for all diagnostics and drugs associated with TB treatment, without the need for a co-payment. A mid-term review of the Global Fund program in Vietnam has also called for a SHI package specifically designed to cover the OOP medical costs of TB care [ 28 ]. There are several potential mechanisms to prevent costs from falling on TB-affected households. A deeper investigation is needed to understand the fiscal space available within the Vietnamese government to cover such costs.

This case study showed that 23.5% of the uninsured people with TB were never able to enroll for the duration of their treatment, primarily due to lack of documentation. Specific provisions need to be made for the undocumented to receive free TB diagnosis, consultations, and medications through routine practice of the TB program. Multi- and bi-lateral funding mechanisms can also play a role in filling gaps by paying for TB tests for the uninsured, purchasing SHI for those diagnosed with TB, subsidizing or reimbursing OOP expenditure in the period before SHI coverage takes effect, and fully financing TB care for the undocumented. Furthermore, longer-term health system strengthening initiatives, such as creating a legal mechanism for the undocumented to obtain SHI, are likely needed to address the challenges faced by the 9% of the general population that remain uninsured. The ILO has called for “determining new strategies, which may include extension of state budget-funded subsidies to further support the participation of workers in the informal economy [ 7 ].” These forms of inclusive initiatives would solve the TB-specific challenges identified in this study and have a large positive impact on society.

We found that addressing the cost of SHI premiums and knowledge gaps in the enrollment procedures may improve SHI coverage. These findings mirror those following the transition of HIV financing to SHI in 2017. A study among PLHIV identified burdensome processes, lack of information about SHI registration procedures, and high SHI premium costs for a household as key barriers to SHI coverage [ 29 ]. However, a cluster randomized control trial which provided education, a 25% premium subsidy, or both to uninsured households found that these interventions had limited effects on SHI enrollment. Yet, “less healthy” individuals had higher SHI enrollment rates [ 30 ]. This suggests that people who have just received a TB diagnosis could be more receptive to interventions promoting SHI enrollment through premium subsidization and education. Vietnam’s National TB Program (NTP) has established a fund to subsidize SHI enrollment costs for TB-affected individuals. The size of the fund could be increased with additional support while access to the fund and the procedures for receiving support could be optimized [ 31 ]. Given the SHI transition, the NTP should also consider providing educational materials about the SHI enrollment process through the DTU network to uninsured persons with TB.

TB registers indicated that 52% of people starting TB treatment in the urban intervention districts had recorded SHI coverage. This rate is lower than other recent SHI coverage reports. A 2018–2022 DS-TB costing survey reported a SHI coverage of 70% [ 32 ], while in a DR-TB costing survey (2020–2022) it was 85% [ 16 ]. All available data sources indicate that SHI coverage among people with TB is lower than the general population, which is indicative of their socioeconomic vulnerability [ 33 ]. However, this large SHI coverage rate discrepancy may be explained by people with TB not revealing they had SHI coverage, or DTU staff could have also inconsistently recorded an individual’s SHI status in the paper TB registers since these data did not have much clinical relevance for TB treatment at the time. Now that DTUs receive financial reimbursements for the TB services from VSS, SHI coverage rates in treatment registers are likely to increase. Further research should be conducted to understand the national SHI coverage rate for people receiving TB treatment, along with the risk factors associated with being uninsured.

Limitations

This case study was conducted in the two largest cities of Vietnam and findings may not be representative of the entire country. Quantitative data were collected in a programmatic setting, and SHI coverage data for all individuals initiating TB treatment in the intervention areas appear to be underreported for reasons described above. Lastly, we were unable to collect SHI enrollment data from a control population, either prospectively during the pilot intervention or retrospectively during the pilot evaluation. As a result, we do not have information on the enrollment status or time to obtain SHI coverage among a population that did not receive assistance from the pilot intervention. However, given the substantial additional support provided by study staff for the enrollment process, we believe it is safe to assume that if left alone, TB-affected households would be slower in the enrollment process and likely enroll in lower rates.

Vietnam is viewed as a leader among Southeast Asian nations in its commitment and progress towards UHC. This mixed-methods case study illustrated the progress that Vietnam has made in its path to greater domestic financing of healthcare through SHI. This study is one of the first to examine the integration of TB services into SHI in Vietnam and define the challenges that people with TB face while attempting to gain access to financial protection after receiving a TB diagnosis. In order to make strides towards UHC in Vietnam and to close population coverage gaps, initiatives are required to specifically address the barriers faced by the uninsured. This study found that the majority of the uninsured were able to gain access to SHI through full subsidization of premiums, enrollment assistance and education. However, initiating TB care and SHI enrollment concomitantly left a significant portion of the 6-month TB treatment duration without financial protection. Additionally, a quarter of the uninsured with TB were unable to gain access to SHI during treatment, primarily due to a lack of documentation. There is great need for official mechanisms to be in place that enable those without sufficient state documents to access the TB program and to address the time-sensitive nature of providing effective financial protection during treatment of an infectious disease. These findings are relevant for other high TB burden, middle-income countries who are on a similar pathway for transitioning away from donor-financed TB programs to ones supported with a higher proportion of domestic resources.

Availability of data and materials

The quantitative dataset used and analyzed during the current study are available from the corresponding author on reasonable request. Seven anonymized transcripts of interviews with the people enrolled in the pilot intervention and non-beneficiaries have been uploaded to the following URL: https://doi.org/ https://doi.org/10.5281/zenodo.7736220 .

Abbreviations

Anti antiretroviral therapy

Drug resistant tuberculosis

Drug susceptible tuberculosis

District TB Unit

Ho Chi Minh City

Health Insurance Law

Human immunodeficiency virus

International Labour Organization

Interquartile range

National Tuberculosis Program

Out of pocket

People Living with HIV

Social Health Insurance

• Tuberculosis

Universal Health Coverage

United States Dollar

Vietnamese Dong

Vietnam Social Security

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Acknowledgements

The authors would like to acknowledge the contributions of Hoang Thi My Linh, Chu Thi Hoang Anh, Nguyen Khac Cuong, Nham Thi Yen Ngoc and Tran Thai Hiep for conducting qualitative interviews and assisting with SHI enrollment activities. Special thanks to Dr. Kerri Viney for providing insightful comments on an early draft of this manuscript; they greatly strengthened the final version. This work was graciously supported by the staff of Vietnam’s National TB Program, the Hanoi Lung Hospital, Pham Ngoc Thach Provincial TB Hospital and 10 District TB Units. Lastly, we would like to thank the interview participants who shared their time and insights.

Open access funding provided by Karolinska Institute. The European Commission's Horizon 2020 program supported the provision of SHI and all data collection in 2019 through the IMPACT-TB study under grant agreement number 733174. For the period of 2020–2022, support to implement the pilot and conduct the evaluation was made possible by the generous support of the American people through the USAID under award number 72044020FA00001. TW was supported by grants from: the Wellcome Trust, UK ( Seed Award, grant number 209075/Z/17/Z); the Department of Health and Social Care (DHSC), the Foreign, Commonwealth & Development Office (FCDO), the Medical Research Council (MRC) and Wellcome, UK (Joint Global Health Trials, MR/V004832/1); the Medical Research Council (Public Health Intervention Development Award “PHIND”, APP2293); and the Medical Research Foundation (Dorothy Temple Cross International Collaboration Research Grant, MRF-131–0006-RG-KHOS-C0942). KSA was supported by the ASPECT Trial funded the Swedish Research Council (2022-00727). The contents of this study are the responsibility of the listed authors, and do not necessarily reflect the views of USAID or the United States Government.

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Contributions

This study was conceived of by RF, KSA, TTN, THYP, CAY, AJC, LNQV. The study was administered by RF, YP, TTN, AJC. Support from Vietnam’s National TB program was provided by HBN and LVD. The methodology was developed by RJ, CAY, KV, KL, KSA. The analysis was carried out by RF, CAY, TTN, and THYP. LNQV, AJC, TW, LN, CH, LB, MP, HBN, LVD, MC, KV, KL, and KSA supported the interpretation of findings. The first manuscript was written by RF. All co-authors reviewed and commented on the initial manuscript. The final manuscript was approved and reviewed by all authors.

Corresponding author

Correspondence to Rachel Forse .

Ethics declarations

Ethics approval and consent to participate.

All study procedures were conducted in strict adherence to the Declaration of Helsinki. Ethical approvals were granted by the National Lung Hospital Institutional Review Board (114/19/CT-HĐKH-ĐĐ), the Pham Ngoc Thach Hospital Institutional Review Board (1225/PNT-HĐĐĐ) and Ha Noi University of Public Health Institutional Review Board (300/2020/YTCC-HD3). All participants provided written informed consent and individual-level data were pseudonymized prior to analysis.

Consent for publication

Informed written consent was obtained for all individuals who the study attempted to enroll in SHI, as part of the pilot intervention. It was also obtained for all individuals who participated in the qualitative interviews.

Competing interests

Ten of the authors received salary support from one of the funding agencies to implement the pilot interventions and their evaluation. Two of the authors were employed by United States Agency for International Development (USAID), which funded one of the two pilot interventions. They played no role in the design or implementation of the pilot interventions or their evaluation, but during the development of the manuscript, they provided their insights about the context of the results and Vietnam’s health financing transition as experts in the field.

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Supplementary Information

Additional file 1..

Mapping of procedures and costs for first-time enrollment into Vietnam's social health insurance scheme.

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Forse, R., Yoshino, C.A., Nguyen, T.T. et al. Towards universal health coverage in Vietnam: a mixed-method case study of enrolling people with tuberculosis into social health insurance. Health Res Policy Sys 22 , 40 (2024). https://doi.org/10.1186/s12961-024-01132-8

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Using mixed-methods in evidence-based nursing: a scoping review guided by a socio-ecological perspective

Associated data.

Supplemental Material for Using mixed-methods in evidence-based nursing: a scoping review guided by a socio-ecological perspective by a socio-ecological perspective by Lieu Thompson and Nataliya Ivankova in Journal of Research in Nursing

Increased pressure for evidence-based practice in nursing necessitates that researchers use effective approaches. Mixed-methods research (MMR) has potential to improve the knowledge and implementation of evidence-based nursing (EBN) by generating outcome-based and contextually-focused evidence.

To identify methodological trends in how MMR is used in EBN research.

Searches were completed in PubMed, CINAHL, and Google Scholar using the terms “nursing”, “mixed-methods”, and “evidence-based”. Seventy-two articles using MMR to address EBN and published 2000–2021 were reviewed across content themes and methodological domains of the Socio-Ecological Framework for MMR.

Mixed-methods research has been used to study how EBN strategies are perceived, developed and assessed, and implemented or evaluated. A few studies provided an MMR definition reflecting the methods perspective, and the dominant MMR rationale was gaining a comprehensive understanding of the issue. The leading design was concurrent, and half of studies intersected MMR with evaluation, action/participatory, and/or case-study approaches. Research quality was primarily assessed using criteria specific to quantitative and qualitative approaches.

Conclusions

Mixed-methods research has great potential to enhance EBN research by generating more clinically useful findings and helping nurses understand how to identify and implement the best available research evidence in practice.

Introduction

There has been increased pressure from diverse stakeholders for healthcare professionals to utilise evidence-based practices (EBP), which integrate research evidence, patient preference, and clinical expertise to provide quality patient care ( Breimaier et al., 2015 ; Gorsuch et al., 2020 ; Melnyk et al., 2018 ; Sackett et al., 1996 ). Many studies have shown that EBP improves patient safety and clinical results and reduces healthcare costs and variation in patient outcomes ( Black et al., 2015 ; Laibhen-Parkes et al., 2018 ). It is particularly important that nurses use EBP as they make up the largest group of healthcare professionals and play a major role in improving the safety and quality of care. Therefore, it is not surprising that the Institute of Medicine has identified EBP as a core competency of nursing ( American Nurses Association, 2015 ).

Nevertheless, nurses’ use of EBP remains inconsistent ( Breimaier et al., 2015 ; Laibhen-Parkes et al., 2018 ), and they continue to have difficulty implementing EBP knowledge and skills in practice ( Camargo et al., 2018 ; Gorsuch et al., 2020 ). Longstanding barriers to nurses’ use of EBP include a lack of access to research-based evidence and educational tools, lack of authority and organisational support to change clinical practice, and lack of time to implement new ideas ( Black et al., 2019 ; Gorsuch et al., 2020 ). These factors constrain nurses’ EBP knowledge and competence, which can lead to ineffective practices that jeopardise patient safety and well-being ( Black et al., 2015 ; Camargo et al., 2018 ). U.S. national surveys have found that nurses do not feel competent in any of the 24 competencies necessary to implement EBP ( Melnyk et al., 2018 ) and that nurse leaders lack competencies in several basic steps in the EBP process ( Harper et al., 2017 ). Given the high stakes of poor quality of care, it is imperative to leverage research strategies that can fully illuminate the complex challenges of EBP use in nursing care contexts.

Evidence-based nursing (EBN) has been defined as “the conscientious, explicit and judicious use of theory-derived, research-based information in making decisions about care delivery…in consideration of individual needs and preferences” ( Ingersoll, 2000 : 152). Although randomised controlled trials have been considered the gold standard of evidence, context, and experience of nursing care require the use of multiple methods that can generate both contextualised and outcome-oriented forms of evidence ( Ingersoll, 2000 ). Mixed-methods research (MMR) that integrates quantitative and qualitative approaches is becoming increasingly used in nursing research to address a wide range of health care issues ( Bressan et al., 2017 ; Halcomb and Hickman, 2015 ; Shorten and Smith, 2017 ; Younas et al., 2019 ). There has been a steady rise in MMR studies in nursing journals, and some nursing journals have published special issues devoted to MMR. For instance, the Journal of Research in Nursing’s June 2017 special issue highlighted how MMR can generate findings that are more readily adopted in health care practice ( Lesser, 2017 ).

Mixed-methods research has been recognised to have potential to improve the knowledge base for EBN by capitalising on the MMR advantages to generate both outcome-based and contextually focused evidence ( Breimaier et al., 2015 ; Flemming, 2007 ; Mathieson et al., 2018 ). Qualitative research, as part of an MMR approach, can inform the design and conduct of intervention effectiveness studies ( Flemming, 2007 ), secure patients’ and providers’ perspectives on EBP adoption and implementation ( Barbour, 2000 ), and provide the context for evaluating EBP in nursing ( Ailinger, 2003 ). Despite these advantages of MMR for optimising EBN practice, quantitative approaches continue to dominate EBN research ( Kidd and Twycross, 2019 ; Noble and Shorten, 2018 ). Recent reviews of EBN articles found that qualitative approaches were used in only 15–20% of studies, and MMR approaches were used in one study ( Kidd and Twycross, 2019 ; Noble and Shorten, 2018 ). Other review articles have displayed similar research designs with an emphasis on randomised controlled trials ( Adiewere et al., 2018 ).

To better understand how MMR can support EBN, we conducted a scoping literature review to identify methodological trends in how nursing researchers use MMR to address EBN problems. The review was guided by a comprehensive Socio-Ecological Framework for MMR ( Plano Clark and Ivankova, 2016 ) that shapes researchers’ decisions when applying MMR in EBN studies.

Methodology

Conceptual framework.

The Socio-Ecological Framework for MMR ( Plano Clark and Ivankova, 2016 ) aims to provide an understanding of how different MMR methodological components and study contexts influence researchers’ approaches to designing and implementing MMR studies and places the MMR process in the centre of the framework. Figure 1 presents the framework as consisting of five methodological domains including MMR definitions, rationales, designs, quality, and MMR intersection with other approaches and designs nested within three hierarchical layers representing the influences of personal, interpersonal, and social contexts on the MMR process.

Socio-ecological framework for mixed-methods research.

**Reprinted from Plano Clark and Ivankova (2016) with permission of SAGE Publications.

Literature search

Electronic searches were conducted in two prominent nursing research databases, PubMed and CINAHL, to identify empirical journal articles addressing various aspects of EBP in nursing. The review was limited to English-language studies published between 2000 and 2021. The search terms used were “nursing”, “mixed-method”, and “evidence-based”. The abstracts of identified articles were screened to determine their relevance to this review, and full texts were obtained for articles deemed as relevant. The full article texts were examined to determine their eligibility for inclusion in the review. The bibliographies of these articles were also examined to identify additional relevant studies.

The PRISMA diagram for the study selection process is presented in Figure 2 . Of the 262 articles identified, 85 duplicates were identified and excluded. Forty-eight articles were excluded because they were reviews, proposals, or commentaries, and 57 articles were excluded because they did not use MMR or address EBN. This resulted in a total of 72 articles for inclusion in this review.

PRISMA diagram. Source: Based on Moher et al. (2009) .

The selected articles were grouped into three content themes based on the aspect of EBN examined. In cases where an article reflected more than one theme, the content and research objectives of the article were used to determine the most appropriate classification. Articles were then analysed using the five methodological domains of the Socio-Ecological Framework for MMR to identify methodological trends in the use of MMR within and across themes.

Three themes emerged across the 72 reviewed studies: (1) perspectives on EBN strategies, (2) development and assessment of EBN strategies, and (3) implementation or evaluation of EBN strategies. The first theme describes the perspectives of different stakeholders (e.g., practitioners, patients, educators, researchers, and managers) on EBP and its role in nursing (e.g., beliefs, behaviours, and barriers/facilitators). The second theme refers to the development and assessment of EBN strategies such as interventions, practice guidelines, and measurement instruments. The third theme addresses the implementation and evaluation of EBN strategies in practice. Table S1 shows the distribution of the articles across the three themes. The most common theme was perspectives ( n = 31, 43%) followed by implementation/evaluation ( n = 30, 42%) and development and assessment ( n = 11, 15%). The findings for each content theme and methodological domain of the Socio-Ecological Framework for MMR are discussed next and summarised in Table 1 .

Results by content themes and methodological domains.

Defining MMR

Four major perspectives on defining MMR - method, methodology, philosophy, and community of research practice - were reported in the MMR literature ( Plano Clark and Ivankova, 2016 ). These perspectives reflect different views on what constitutes MMR and what aspects of mixing are emphasised in the MMR process. In our review, only seven (9%) articles included a definition of MMR. Most articles ( n = 6, 8%) defined MMR from a methods perspective, which implies mixing quantitative and qualitative methods of data collection and analysis within a single study. This perspective on MMR was observed mostly among development and assessment ( n = 2, 18%) and implementation/evaluation ( n = 3, 10%) articles. O’Brien et al. (2012) applied “quantitative and qualitative methods” (p. 2, development and assessment theme) to identify predictors of participant attrition and home visit completion…in a… nurse-family partnership programme. Nordsteien et al. (2017) used “quantitative data collection and analysis...supported by qualitative data” (p. 24, implementation/evaluation theme) to evaluate the influence of a collaborative library-faculty teaching intervention on nursing students’ use of evidence-based research tools.

The methodology definition of MMR, which supports mixing qualitative and qualitative approaches throughout the entire research process, was only reflected in Strandberg et al.’s (2014) perspectives article. The authors used “quantitative and subsequent qualitative approaches” (p. 57) to examine how nurses understand the concept of research utilisation. Six studies (8%) provided a citation to an underlying methodological source instead of defining MMR. The general absence of an MMR definition in the reviewed articles aligns with existing literature indicating that the reporting of MMR approaches in nursing research is incomplete and inconsistent, and that this significantly limits nurses’ ability to understand and utilise MMR evidence in clinical practice ( Bressan et al., 2017 ).

Rationales for MMR

Rationales for MMR are the arguments that researchers make to justify their decision to use MMR in a single study. A wide range of rationales have been discussed in the literature indicating the extensive applicability of MMR to address a variety of complex problems including EBP ( Ivankova et al., 2018 ; Plano Clark and Ivankova, 2016 ; Shorten and Smith, 2017 ). About half of the reviewed studies ( n = 42, 54%) stated rationales for using MMR to address the research purpose. Thirteen articles (17%) provided separate rationales for using quantitative and qualitative methods in the study, and this was mostly present within the perspectives ( n = 7, 23%) and implementation/evaluation ( n = 5, 14%) themes. Three major rationales for using MMR were identified in the reviewed articles: (1) gaining a comprehensive understanding of the issue, (2) using a qualitative approach to gain a deeper understanding of quantitative results, and (3) strengthening validity (see Table 2 for examples of rationales across three themes).

Examples of rationales for mixed-methods research.

The most frequently stated rationale was gaining a comprehensive understanding of the issue ( n = 19, 24%), and it was observed mostly in the articles focused on EBN implementation / evaluation ( n = 12, 34%). The second most common rationale, using a qualitative approach to gain a deeper understanding of quantitative results, ( n = 17, 22%), was noted primarily within the perspectives ( n = 9, 29%) and development and assessment ( n = 3, 25%) themes. The least stated rationale, using MMR to strengthen the validity of results ( n = 6, 8%), was most commonly used within the development and assessment ( n = 2, 17%) and implementation/evaluation ( n = 3, 9%) themes. In addition to the three major reasons for using MMR, some articles provided EBN-focused rationales. Horwood et al. (2021) stated that “real world evaluation based on mixed-methods including routine data” (p. 9, implementation/evaluation theme) was needed to test the feasibility and acceptability of implementing a nurse-led, telephone management service for patients diagnosed with chlamydia or gonorrhea.

MMR designs

Three core mixed-methods designs have been advanced in the MMR literature: a concurrent Quan + Qual and two sequential Quan → Qual and Qual →Quan ( Creswell and Plano Clark, 2018 ; Plano Clark and Ivankova, 2016 ). A concurrent Quan + Qual design, in which quantitative and qualitative components are implemented independently and both sets of results are combined to produce integrated conclusions, was the dominant design in the reviewed studies. It was used in two-thirds of studies across themes ( n = 52, 67%) and in over half of studies within each theme. Parsons et al. (2021) integrated quantitative survey results with qualitative interview findings to… determine the acceptability and feasibility of a referral and case management intervention ( development and assessment theme). Eaton et al. (2015) explored the EBP beliefs and behaviours of nurses who provide cancer pain management by collecting and analysing survey and interview data separately, and then interpreting both sets of results together ( perspectives theme).

Among sequential designs, in which one study phase is completed first and its findings inform the next phase, Quan → Qual design ( n = 15, 19%) was observed more often than Qual → Quan ( n = 11, 14%) design. Quan → Qual design was used equally across the themes, accounting for seven (20%) implementation/evaluation articles, two (19%) perspectives articles, and two (17%) development and assessment articles. De La Rue-Evans et al. (2013) conducted qualitative interviews to determine when and why nurses performed specific activities and then used the findings to inform the implementation and evaluation of new guidelines for preventing sleep disturbances among patients with traumatic brain injury ( implementation/evaluation theme). Lam and Schubert (2019) used quantitative survey results on organisational drivers of EBP to guide qualitative interviews exploring factors impacting nursing students’ understanding of EBP and information-seeking behaviours ( perspectives theme)

Compared to Quan→ Qual design, Qual→ Quan design was used differently among the themes. The design prevailed within the perspectives ( n = 7, 23%) theme and was equally common within the implementation/evaluation ( n = 3, 9%) and development and assessment ( n = 1, 8%) themes. Dale et al. (2005) used qualitative interview data to develop a quantitative survey measuring perceived versus actual barriers and facilitators to protocol uptake ( perspectives theme). De La Rue-Evans et al. (2013) analysed qualitative interview data to inform the implementation and quantitative evaluation of new sleep hygiene guidelines ( implementation/evaluation theme).

MMR and other approaches

Mixed-methods research has methodological flexibility to intersect or meaningfully combine with another design or methodology to form complex designs ( Creswell and Plano Clark, 2018 ; Plano Clark and Ivankova, 2016 ). Such intersection allows for addressing multifaceted research problems by using MMR to enhance another design or approach. In this review, intersecting MMR with another approach was observed in about one-third of studies ( n = 25, 35%) and mostly in implementation/evaluation ( n = 25, 50%) and perspectives ( n = 9, 29%) studies. Intersecting with evaluation approaches was most common, occurring in 12 (15%) studies. This is not surprising since EBN employs evaluation to continuously test and refine practices to improve patients’ and clinician’ outcomes. Using MMR with evaluation was most commonly noted in implementation/evaluation ( n = 9, 27%) and development and assessment ( n = 1, 9%) studies. Amacher et al. (2016) embedded an MMR design within an evaluation methodology to assess the satisfaction of patients and providers with a fall prevention programme ( implementation/evaluation theme). Parsons et al. (2021) embedded MMR design in a process evaluation to develop and refine an intervention to promote earlier return to work among staff with common mental health disorders ( development and assessment theme).

Some studies intersected MMR with action/participatory or case study approaches. Each approach was observed in six studies (8%) and only in perspectives and implementation/evaluation studies. Mixed-methods research with action/participatory approaches was noted in three studies (10%) in each theme, Breimaier et al. (2015) collected and analysed quantitative and qualitative data using participatory action research to assess the effectiveness of a fall-prevention guideline in an acute care hospital setting ( implementation/evaluation theme). Combining MMR with case study research was noted twice as often in the perspectives theme ( n = 4, 13%) than in the implementation/evaluation theme ( n = 2, 7%). Russell et al. (2019) used data from quantitative clinical records and qualitative interviews to construct case studies on eight family practices describing factors affecting their uptake of an intervention to prevent vascular disease ( perspectives theme).

MMR quality

Mixed-methods research quality are the decisions that researchers make about how to assess the quality of an MMR study ( Creswell and Plano Clark, 2018 ; Plano Clark and Ivankova, 2016 ). Among the reviewed articles, the leading strategy was separately reporting the quality of quantitative and qualitative study components ( n = 69, 88%), which occurred mostly within the development and assessment ( n = 12, 100%) and perspectives ( n = 29, 94%) themes. Gifford et al. (2012) engaged multiple investigators in a quantitative randomised controlled trial and used research-based guides for qualitative interviews to pilot an intervention to promote guideline adherence ( development and assessment theme). Lin et al. (2020) administered a previously validated quantitative survey, collected qualitative data until data saturation was reached, and maintained audit trails and memos throughout the research process ( implementation/evaluation ).

Quality assurance was discussed in some studies for only the quantitative component ( n = 4, 6%) or the qualitative component ( n = 3, 4%). These articles focused exclusively on EBN perspectives or implementation/evaluation . Miller et al. (2018) used a quantitative instrument shown to have “superior sensitivity and specificity” (p.91) in accurately identifying alcohol misuse in comparable target populations ( implementation/evaluation theme). Ersek and Jablonski (2014) employed multiple investigators to develop and confirm qualitative themes on barriers and facilitators to protocol adoption ( implementation/evaluation theme). No studies discussed quality assurance for the overall MMR process, which is not surprising since quality criteria for MMR studies remain one of the most debated topics ( Plano Clark and Ivankova, 2016 ; Tashakkori et al., 2021 ).

This paper synthesised 72 empirical MMR articles in EBN to explore how researchers employ MMR within and across three content themes addressing various aspects of EBN: stakeholder perspectives on EBN, development and assessment of EBN strategies, and implementation/evaluation of EBN strategies. Our review was guided by five methodological domains of the Socio-Ecological Framework for MMR including MMR definitions, rationales, designs, quality, and MMR intersection with other approaches and designs. The findings suggest that this framework is a useful tool for identifying methodological trends in EBN research and understanding how EBN researchers approach MMR, justify the choice of MMR, and design and implement MMR to address a variety of EBN issues.

Summary of methodological trends

Most studies in this review did not provide a definition or citation for MMR, and the definitions provided overwhelmingly reflected the methods perspective. In contrast, most articles reported a rationale for using MMR. Gaining a comprehensive understanding of the issue was the most frequently cited rationale, particularly in the studies aimed at evaluating EBN practices. Some EBN-specific rationales were also noted that emphasised the advantages of using MMR for addressing clinical questions within a context.

Another clear trend is the dominant use of a concurrent Quan + Qual design, which is consistent with the noted popularity of this design in health science research due to its relative time efficiency ( Curry and Nunez-Smith, 2015 ; Ivankova and Kawamura, 2010 ). Meanwhile, evaluation, action/participatory, and case study were the primary approaches that embedded MMR to form complex designs, and study quality was assessed using criteria traditionally associated with quantitative and qualitative approaches rather than MMR-specific criteria. To better understand these trends in MMR use in EBN, it is important to examine the contexts that may have influenced how the researchers designed, conducted and reported MMR ( Plano Clark and Ivankova, 2016 ).

The influence of MMR contexts

According to the Socio-Ecological Framework for MMR, three types of study contexts influence a researcher’s decision for how to apply MMR in a study: personal, interpersonal, and social. Personal contexts include researchers’ background knowledge, philosophical assumptions, and use of theoretical models. Interpersonal contexts incorporate relations with study participants, research teams, and editors/reviewers of the journals that publish MMR. Social contexts include institutional structures, disciplinary conventions, and societal priorities related to promoting MMR ( Plano Clark and Ivankova, 2016 ). These contexts directly and indirectly influence the study process and the use of MMR and likely played a role in how MMR was applied to address EBN issues.

Researchers’ focus on EBN along with their knowledge of and an adopted worldview on MMR may have influenced their perspectives on MMR, rationales for using MMR as a methodology of choice, and use of quality criteria associated with either quantitative or qualitative approaches. It is not surprising that EBN researchers elected to use MMR since it can provide a more complete understanding of EBN issues ( Shorten and Smith, 2017 ). The tendency to define MMR as the mixing of different methods is consistent with how researchers design and report MMR in health sciences ( Curry and Nunez-Smith, 2015 ; Wisdom et al., 2012 ).

At the interpersonal level, the interdisciplinary nature of most research teams, availability of resources and access to study participants may have affected methodological decisions about the type and sequence of quantitative and qualitative data collection and analysis ( Creswell and Plano Clark, 2018 ) resulting in the dominant use of concurrent Quan + Qual design. Concurrent designs often associated with time constraints to complete funded research capitalise on teamwork and the skills each team member brings into an MMR project ( Curry et al., 2012 ). The diversity of research skills also likely facilitated intersecting MMR with other approaches and designs and provided opportunities for more informed discussions of quality considerations related to different study components.

The influence of social contexts is evident in the adoption of MMR in nursing research ( Halcomb and Hickman, 2015 ). Evidence-based nursing authors may expect readers to be familiar with MMR so feel no need to define or describe it. In contrast, it is possible that the authors expected some pushback regarding their choice of MMR, so they felt the need to provide a rationale for using it. Support from universities and funding agencies, which is evident from authors’ affiliations in most studies may have made concurrent designs more likely due to budget constraints and improved access to participants (e.g., patients and health care providers) through existing academic networks.

Implications for using MMR in EBN research and practice

Mixed-methods research has the potential to advance knowledge of EBN and its impact on EBN outcomes. In the traditional hierarchy of evidence that clinicians and researchers often rely on, evidence from quantitative research designs such as clinical trials ranks as the strongest form of evidence ( Melnyk and Fineout-Overholt, 2019 ). This creates a dilemma for researchers debating whether to use qualitative and MMR approaches to generate evidence to include in nursing curricula as well as for nurses aiming to interpret and apply MMR findings in practice. It also increases the likelihood that nursing researchers and educators are more familiar with quantitative methodologies compared to qualitative and mixed-methods methodologies and thus, need more comprehensive guidance on the strengths of MMR ( Bressan et al., 2017 ).

Nurse researchers can help address this dilemma by clearly explaining their approaches to MMR, rationales for using MMR to address the EBN problems, decisions about MMR designs, and criteria for assessing MMR study quality. Doing so may mitigate the continued dominance of quantitative methodologies in EBN ( Kidd and Twycross, 2019 ; Noble and Shorten, 2018 ) by encouraging researchers to consider less traditional evidence hierarchies when designing their studies and by illustrating the feasibility of applying MMR to a range of EBN problems and contexts. The emphasis on methodological pluralism that characterises MMR also encourages researchers to use multiple methods and different data sources to produce alternative types of evidence on important antecedents and outcomes of EBN care that may not be apparent in quantitative data. For example, a researcher can use quantitative data to draw generalisations about the prevalence of adherence to nursing guidelines and use qualitative data to develop transferable findings on nurses' and doctors’ perceived barriers to EBP as in Storm-Versloot et al. (2012) .

Advancing MMR application in EBN research may subsequently result in the use of research designs that yield more clinically and contextually relevant study designs given that the traditional hierarchy of evidence does not fit all clinical questions ( Melnyk and Fineout-Overholt, 2019 : 192). It can also improve the quality of nursing care by increasing the likelihood that nurses make clinical decisions that consider the needs of patients and clinicians, a key component of EBN highlighted in this review that may not be reflected in quantitative research evidence.

Limitations

This review has several limitations. The selected articles are primarily from two prominent nursing databases, and the search terms used may have influenced the resulting pool of papers. Another limitation is the subjectivity involved in classifying articles into mutually exclusive themes and methodological content domains. Additionally, it was necessary to draw inferences based on the provided information in cases of ambiguity.

This review provides insight into the variety of MMR approaches nursing researchers use to generate new types of evidence in support of EBN practice. Mixed-methods research has significant potential to enhance EBN research aimed at improving patient care and outcomes by producing more clinically useful findings and helping nurses understand how to identify and implement the available research evidence in practice. We hope that this paper encourages nurses and policymakers searching for effective strategies to apply MMR-generated evidence by illustrating the ways in which MMR has been used to inform the development, implementation, and evaluation of EBN strategies.

Key points for policy, practice, and/or research

• • Mixed-methods research has the potential and utility to advance knowledge of EBN research by providing a multifaceted understanding of complex EBN issues.
• • The Socio-Ecological Framework for MMR can facilitate an understanding of the varied ways in which EBN researchers apply MMR to design studies addressing different aspects of EBN.
• • Using MMR can help nurses and policymakers develop and implement strategies to facilitate the translation of research into real-world improvement in patient safety and quality care.

Supplemental Material

Lieu Thompson is a doctoral candidate in Health Services Administration at the University of Alabama at Birmingham. She has interdisciplinary training in quantitative and qualitative methodologies and strategic management research.

Nataliya V Ivankova is a Professor at the University of Alabama at Birmingham. She is an applied research methodologist working at the intersection of mixed-methods, qualitative, community-based and translational research.

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

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval: Ethical approval was not needed to conduct this literature review.

Supplemental material: Supplemental material for this article is available online.

Lieu Thompson https://orcid.org/0000-0003-2721-5215

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• Published: 07 April 2024

GIS-based intelligent planning approach of child-friendly pedestrian pathway to promote a child-friendly city

• Kailun Fang 1 ,
• Suzana Ariff Azizan 2 &
• Huiming Huang 1  

Scientific Reports volume  14 , Article number:  8139 ( 2024 ) Cite this article

Metrics details

• Engineering
• Environmental social sciences
• Health care

Pedestrian safety, particularly for children, relies on well-designed pathways. Child-friendly pathways play a crucial role in safeguarding young pedestrians. Shared spaces accommodating both vehicles and walkers can bring benefits to pedestrians. However, active children playing near these pathways are prone to accidents. This research aims to develop an efficient method for planning child-friendly pedestrian pathways, taking into account community development and the specific needs of children. A mixed-methods approach was employed, utilizing the Datang community in Guangzhou, China, as a case study. This approach combined drawing techniques with GIS data analysis. Drawing methods were utilized to identify points of interest for children aged 2–6. The qualitative and quantitative fuzzy analytic hierarchy process assessed factors influencing pathway planning, assigning appropriate weights. The weighted superposition analysis method constructed a comprehensive cost grid, considering various community elements. To streamline the planning process, a GIS tool was developed based on the identified factors, resulting in a practical, child-friendly pedestrian pathway network. Results indicate that this method efficiently creates child-friendly pathways, ensuring optimal connectivity within the planned road network.

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Introduction

With 18 percent of China’s population under the age of 14, children constitute a significant demographic segment 1 , 2 . However, many Chinese metropolitan areas, characterized by expansive low-density urban landscapes and auto-dependent transit systems, lack adequate provisions for children. Recognizing this deficiency, there is an imperative to initiate child-friendly planning and research.

The concept of a child-friendly city, inspired by the UN Convention on the Rights of the Child, aligns seamlessly with Sustainable Development Goals (SDG) 3 and 16 3 . SDG3 addresses crucial child health issues, while SDG16 aims to create inclusive societies with equal access to justice. Ensuring children's well-being involves protection, a secure environment, and access to essentials, harmonizing with both SDG’s objectives 4 , 5 .

Children’s unique requirements are frequently disregarded in the setting of fast urban growth and high-rise constructions, which leaves a shortage of basic amenities and open spaces 6 . Smaller families and changing demographics underscore the need for adaptive infrastructure prioritizing children’s needs 7 .

Public health experts emphasize the pivotal role of social spaces, highlighting informal areas like pocket parks as popular playgrounds for children 8 . The quality of these spaces significantly influences children's well-being 9 . Access to play areas, independence, and parenting norms crucially determine children’s attraction to community play spaces. Establishing connections between these spaces is a key strategy for fostering children’s well-being 10 .

In historical contexts, pedestrian pathways were insufficient, posing risks to children sharing space with vehicles 11 , 12 . Existing standards often overlooked the specific needs of children, as design decisions were primarily adult-centric. Recognizing the importance of considering children's preferences in Child-Friendly Pedestrian Pathways (CFPP) planning is pivotal 13 . Traditional planning methods are deemed inefficient, prompting a shift towards exploring intelligent CFPP planning for more effective and previously overlooked insights 14 , 15 .

The research aims to analyze and synthesize the concept of a child-friendly environment and its application in existing literature, enhancing our understanding of socio-physical attributes and actors contributing to its realization. The study’s foundation lies in two research questions: (1) What socio-physical factors are crucial for implementing a child-friendly pedestrian pathway? (2) How can we intelligently plan a child-friendly pedestrian pathway?

The paper consists of three parts, with the second section summarizing recent scholarship on child-friendly cities, pathways, and intelligent planning. The methodology, including case studies and drawing methods, explores intelligent planning. The paper concludes with a summary of the CFPP plan and the broader field of childhood research.

Literature review

Child-friendly city (cfc).

The foundation of the Child-Friendly Cities (CFC)initiative is rooted in a renewed emphasis on the "right to the city," aligning seamlessly with the latest normative frameworks and action plans introduced by UN-Habitat and UNICEF, dedicated to upholding human rights 16 . UNICEF 17 defines a CFC as “a city, town, municipality, or any system of local governance committed to fulfilling child rights as articulated in the UN Convention on the Rights of the Child (CRC). It is a city or municipality where the voices, needs, priorities, and rights of children are an integral part of public policies, programs, and decisions” (p.10).

“Child-Friendly Cities” (CFC) are pivotal for prioritizing children’s rights and needs in urban development. Originating in East Asia and the Pacific in 1999, the concept gained momentum amid rapid urbanization. Despite new potential, challenges like increased vulnerabilities for children, socio-economic concerns, and infrastructure difficulties arise. Ensuring cities meet the needs of all citizens, especially the young, becomes paramount 18 .

The CFC Index, as explained in the report, is anchored in four fundamental principles derived from the ‘Convention on the Rights of the Child’ 17 . These principles focus on equity, education, health and well-being, and security and protection, intricately interwoven with communal participation 17 . The guiding principles for building a child-friendly city include non-discrimination, making the best interests of children a primary consideration, recognizing the right to life, survival, and development, and respecting the views of the child 18 .

The development of child-friendly cities requires meticulous consideration of various parameters 9 , each playing a pivotal role in the planning and establishment of an environment conducive to children. These parameters cover safety, green spaces, diverse activities, independent mobility, social interaction, and involving children in decision-making 9 , 19 . Enhancing the physical environment aligns with meeting children's rights, involving creating and maintaining parks, play spaces, and children's services.

In a recent study, researchers identified four key features characterizing a child-friendly city were identified: (1) The presence of 'green lungs’; (2) Opportunities for creative and challenging play; (3) Spaces suitable for the entire family; and (4) Safe playgrounds and walking routes 20 . This research underscores the significance of these specific features in shaping urban environments that cater to the diverse needs and overall well-being of children.

A child-friendly environment ensures safety, access to services, cleanliness, and opportunities for play and learning. It promotes independent mobility, emphasizing overall growth and well-being 17 , 19 , 21 .

Crucial to determining the child-friendliness of a built environment is children's independent mobility 22 , 23 , 24 . Children residing in urban areas often experience growing limitations on their independent spatial mobility. These restrictions stem, in part, from safety concerns associated with traffic designed to accommodate the mobility needs of other citizens 25 . As the challenge of diminishing independent mobility for children in urban areas becomes apparent, addressing safety concerns comprehensively becomes paramount. Children’s restrictions underscore the need for proactive measures, shaping the built environment to support their autonomy. Urban planners and policymakers play a pivotal role in prioritizing children's needs and contributing to their well-being.

To enhance child-friendly urban spaces, a specific avenue is the focus on Child-Friendly Pedestrian Pathways (CFPP). Addressing challenges in children's navigation, CFPPs offer safe routes, actively encouraging autonomy and engagement with the urban landscape. This shift aligns with the broader goal of fostering urban spaces that comprehensively cater to the well-being and developmental needs of children.

Child-friendly pedestrian pathway (CFPP)

Child-Friendly Pedestrian Pathways (CFPP) are purpose-built walkways exclusively designed for children, with a primary focus on meeting their needs and ensuring safety. Despite the perceived safety of pedestrian pathways for adults, persistent parental concerns regarding their children's safety highlight the paramount goal of CFPP—ensuring safety 26 . Additionally, CFPP strives to align with children’s interests, offering both formal and informal play environments by differentiating between structured and unstructured play. This approach creates a comprehensive and engaging pedestrian pathway system that is tailored specifically to children's needs, fostering a sense of security, and promoting active lifestyles 27 .

Pedestrian pathways, often perceived as functional conduits for movement, undergo a transformative shift in the context of child-friendly urban planning. CFPPs are envisioned to transcend mere functionality, evolving into vibrant spaces for play and exploration. This transformation includes the incorporation of playful elements such as interactive installations, colourful markers, and designated play zones strategically integrated along the pathways 28 . According to Makalew et al. 28 the design of child-friendly pathways should ensure a safe surface for children's activities, considering their environment and movement patterns, and be effective and efficient in school and housing areas. These additions not only serve to promote physical activity but also play a crucial role in stimulating cognitive and social development among children. This guiding principle seamlessly translates into the strategic placement of child-friendly pedestrian paths within the urban fabric. These pathways are envisioned to traverse areas that genuinely capture children's attention, connecting key locations such as parks, schools, and cultural spaces. By establishing an interconnected network of pathways, the urban environment becomes not only traversable but also inherently attractive to children, fostering a sense of community and enhancing their overall urban experience.

Building on the idea of empowerment through participation, the design and use of child-friendly pedestrian pathways transcend the realm of mere physical infrastructures. These pathways become powerful tools for empowering children by providing safe, accessible routes that significantly contribute to their overall well-being. Through active involvement in the planning process, children develop a profound sense of ownership and agency in shaping their urban surroundings. This empowerment extends to their use of the pathways, fostering independence, confidence, and a positive connection to their environment.

The general principles outlined in the broader discussion about child-friendly cities find a specific and tangible application in the design and implementation of child-friendly pedestrian paths. By transforming pathways into playful, strategically located, and collaboratively designed spaces, urban planners can create environments that prioritize children's needs, fostering a sense of community, empowerment, and well-being. In doing so, cities not only become more accessible for their youngest residents but also set a precedent for inclusive and sustainable urban development.

Child participation in planning

Creating a child-friendly city involves community engagement, urban planning, and effective policymaking, relying on a clear understanding of factors promoting children's well-being and development.

Urban planning assesses city design for children’s needs, ensuring accessible playgrounds, parks, and safe pedestrian pathways. An integral aspect of child-friendly urban planning revolves around the careful selection of engaging locations that align with children’s interests, ensuring they are safe, healthy, comfortable, and convenient 29 , 30 . To truly capture the essence of a child-friendly city, it requires public spaces equipped with appealing facilities for children to play, including specific sites that, although not explicitly identified by children, manifest as their own 31 , 32 . Prior research often neglects choosing places that truly interest children—a critical oversight in creating child-friendly cities. Identifying engaging locations, like parks and playgrounds, is crucial for effective planning.

At the heart of child-friendly urban planning lies an interactive process that actively incorporates the perspectives and voices of children. Collaborative methodologies 33 , 34 , 35 , including workshops, interactive sessions, and participatory design activities, emerge as essential tools for ensuring that cities are not only safe and functional but also resonate with the preferences and needs of their inhabitants. Research strongly suggests that involving children in the planning process is crucial for understanding their perspectives and empowering them to influence the shaping of their neighborhoods and cities 33 . Simultaneously, this approach guarantees that cities authentically reflect the identity of the community they serve.

Identifying the most optimal method for involving children in the community design process is critical. Six suggested methodologies involve research with young children: (1) multi-method and the Mosaic approach; (2) observation and ethnography; (3) language-based methods; (4) visual method; (5) creative and playful methods; and (6) children as co-researchers 36 , 37 , 38 . These methods involve children in planning, ensuring their perspectives shape child-friendly urban development. Participation in decision-making and urban planning involves adults and children, prioritizing well-being and ensuring inclusive, sustainable development.

Urban planning theories: shaping cities through time

Urban planning evolves through diverse theories to understand and enhance urban dynamics. Tracing back to historical movements in the mid-nineteenth century, these aim to bring order to the chaos of industrial towns 39 . The late twentieth century witnessed the introduction of the phrase “sustainable development,” encapsulating the vision of an ideal societal state 40 . This era marked the inception of a paradigm shift towards sustainable building practices, gaining popularity for their environmentally beneficial attributes, including the use of renewable resources and materials 41 .

Urban planning theories, diverse in ideas, shape city development over time. Classifiable into pre-history, foundation years, modernism, post-modernism, and current eras, they signify distinct phases in the field’s evolution 42 . Each phase mirrors prevailing ideological challenges, shaping the overall evolution of urban planning.

Pre-history planned cities around social, cultural, and religious hierarchies. Early urban planning, influenced by anarchist movements, introduced concepts like Garden City, Radiant City, and Broadacre 43 . In the modernist era, emphasis on efficiency prioritized optimized land use through zoning and transportation 42 . Post-modernism in urban planning shifted from practice to academia, challenging practical links. Suburbanization caused a political economy shift as the middle class left the city core, impacting the historical urban fabric 42 . The current era emphasizes connected cities with transit-oriented development and environmental conservation 42 .

Urban planning evolves for better cities, integrating diverse strategies from industrialization to sustainability. Historical theories inform intelligent planning, utilizing advanced tech for adaptive, inclusive urban environments.

• Intelligent planning

In child-friendly city planning, intelligent planning, driven by technologies like AI, brings a promising paradigm shift. Traditional methods, well-intentioned but resource-consuming, can be made more efficient through AI integration, opening innovative avenues for child-friendly cities.

AI's capabilities extend to improving transportation efficiency and safety, optimizing electricity and water services, and reducing construction costs and unplanned overruns in the urban environment 43 . Using this technology, child-friendly city planning gains efficiency and streamlined processes. Intelligent planning methods, focusing on technology and data-driven insights, provide a more efficient alternative compared to traditional approaches.

As urban areas continue to evolve, the need for child-friendly spaces becomes increasingly crucial. Incorporating AI into the planning process allows for a more nuanced understanding of children's needs, preferences, and requirements 32 , 44 . AI can analyze vast amounts of data to identify optimal locations for playgrounds, safe pedestrian pathways, and other child-centric spaces 45 . The technology's ability to process and interpret information quickly contributes to creating environments that are not only functional but also tailored to the specific needs of young residents 16 , 45 .

Intelligent planning, like GIS-based smart transportation systems, enhances efficiency and safety in child-friendly city planning. These systems prioritize safety and convenience, fostering an environment for children's independent mobility 46 .

Despite these advancements, there exists a critical gap in integrating professional planning knowledge into the analysis of people's needs in GIS-based intelligent planning, as previous research often overlooked the expertise of professional planners 47 , 48 . To bridge this gap, a comprehensive approach that incorporates professional planning knowledge is crucial for child-friendly city planning. This integration ensures that the unique needs of children and communities are not only considered but deeply understood, leading to more effective and responsive planning strategies 49 , 50 .

AI and intelligent planning transform child-friendly city planning, prioritizing children's well-being and shaping technologically advanced, inclusive cities for the next generation.

Methodology

All methods were carried out in accordance with relevant guidelines and regulations. The drawing research was approved by the Ethics Committee of Guangzhou Urban Planning and Design Co. Ltd. Informed consent was obtained from the legal guardian in Guangzhou, China.

Case study method

The research selected the Datang Community as a case, which is located north of Guangzhou, China. Guangzhou is a major economic hub in South China, which is the second city to promote child-friendly cities (See Fig.  1 ).

The Location of Datang Communality (Drawn by author).

This tool focused on the Datang case for two main reasons: First, Guangzhou aimed for urban sustainability through child-friendly city guidelines, with the community as the basic unit. Datang, a 38 ha child-friendly community project, was chosen for its emphasis on childcare, pedestrian pathways, and playgrounds. Second, the community's role in child development, highlighted in various studies, underscored the importance of the built environment, particularly pedestrian pathways, in facilitating social interaction, recreation, play, and learning.

Drawing method

Children's drawings offer a glimpse into their thoughts and emotions, serving as a reflection of their inner world. As children are often naturally shy and find it challenging to express themselves verbally, drawing tests provide a quick, easy, and enjoyable method for them to communicate. Analyzing children's drawings had long been regarded as a systematic approach to evaluating their perceptions and experiences of the surrounding environment. Numerous studies have shown that children's drawings can provide indicators of various issues and potential solutions.

This study selected ‘Drawing’ as a tool for collecting primary data with 50 children, aged 2–6 years on their favorite spaces had been used by means of cluster random sampling method. The drawings were held in the kindergarten and daycare in the community. Through drawing, children were able to organize their internal thoughts and emotions and delivered clearer and more detailed narratives. This age group of children was selected as they can express their thoughts and opinions through drawings, but it needed to be further communicated with them about what they want to express, and the parents had done this with children. Additionally, they possessed a wish for their drawings to accurately portray real images of pictures or photographs.

The children were given instructions to draw places that interested them and where they desired to play. Prior to starting the drawing activity, they were provided with an explanation of the research’s objective. They were also informed about the materials they could use for the exercise. To facilitate computer scanning, the children were asked to draw on one paper. They were given the option to create black-and-white or color drawings. The children were given complete freedom to express themselves through their drawings. Oral consent for participation was obtained from the children, and they were informed that they could withdraw from the study at any time and that their identities would be kept confidential. Permission was also obtained from their teachers and parents.

Survey method

Questionnaires were held to the kindergarten about the suggestions of the CFPP, the sample was 30. The sample aged from 3–4 was 44% and 4–6 was 56%. Girls were 45%, boys were 65%. Based on the correlation analysis, it was observed that children between the ages of 2 and 4 exhibited a higher tendency to visit green spaces, whereas those aged 4 to 6 showed a greater interest in educational resources. The preferences for other places were relatively consistent across different age groups.

Data analysis method

Define criteria.

Examine the essential considerations when formulating a pedestrian pathway plan that was specifically designed to be child-friendly. The criteria encompass various factors, such as the proximity of the pathway to schools, the incorporation of safety features, the availability and quality of sidewalks, the evaluation of traffic volume, adherence to appropriate speed the limits, presence of well-marked crosswalks, and convenient access to nearby parks or recreational areas. By taking these aspects into account, a comprehensive and well-rounded CFPP plan can be developed (See Fig.  2 ).

Framework of Data Analysis Method (Drawn by author).

Data preparation

To adequately prepare the collected data for comprehensive analysis, it was essential to undertake the necessary steps before importing it into GIS software. By ensuring that all data was in a compatible format, it can seamlessly integrate with the chosen GIS software. Additionally, to facilitate meaningful spatial analysis, it was crucial to project the data onto a common coordinate system. This ensures that the spatial relationships and measurements within the data were accurately represented. By meticulously tending to these details, the data can be effectively utilized within the GIS software, enabling robust analysis and informed decision-making.

Weighting and prioritization

Assign weights to different criteria based on their relative importance. The fuzzy analytic hierarchy process (FAHP) was used to determine the influencing factors and weights of child pedestrian-friendly pathway planning, which were divided into four steps: (1) a hierarchical structure model was constructed to sort out the influencing factors and their relationships of community road planning; (2) the evaluation index was improved by a triangular fuzzy number. The fuzzy judgment matrix was constructed by pairwise comparison of rows. (3) checking the consistency of the fuzzy judgment matrix, and adjusting the fuzzy judgment matrix if it was inconsistent with the consistency; (4) calculating the weight of each index. To utilize the suitability modeling capabilities of GIS software to generate a composite score for each pathway segment, indicating its suitability as a CFPP. Prioritizing segments with higher scores for further consideration in the pathway plan.

Data analysis

Utilized network analysis tools to identify the most suitable routes for CFPPs, considering the defined criteria. Weighted overlay analysis was an important GIS spatial analysis that could assign weights to different criteria or factors and combine them to generate a final output map that represents the overall suitability or desirability of a location for a specific purpose. The calculation model was as follows.

where: S was the multi-factor comprehensive cost; Fi is the grid value of a single influencing factor; Wi is the weight corresponding to a single influence factor. n was the number of influencing factors involved in the cost calculation.

Visualization and mapping

To generate visual depictions or representations of the plan for the child-friendly pedestrian pathway. It suggests the creation of visual materials that illustrate how the pathway will be designed, its layout, and other relevant aspects. These visual representations could take the form of maps, diagrams, or conceptual illustrations that help communicate the intended design and features of the child-friendly pedestrian pathway (See Fig.  2 ).

Children's point of interest (CPOI)

In the results, between the ages of 2 and 4, as children engage in scribbling activities, discernible shapes resembling cars or houses may begin to emerge in their drawings. When children reach the age of 4–6, their drawings tend to include simple elements like faces, stick figures, cars, trucks, trees, and houses. Understanding the specific areas of interest can be gleaned by examining the emotions conveyed through their drawings. For instance, bold and closely spaced strokes may indicate stress, strong emotions, determination, or anger, while softer marks suggest a more gentle disposition. The quality of lines drawn also holds significance; a figure created with light, wavering, and broken lines may suggest a hesitant and insecure child who is formulating thoughts as they go, whereas bold, continuous, and freely drawn lines express self-confidence and a sense of security.

The adjacent neighborhoods surrounding the school boasted a plethora of well-designed and accessible public spaces that held immense potential for children to actively partake in play and recreational endeavors. These carefully curated areas serve as enticing hubs for young individuals to unleash their energy, engage in physical activities, and enjoy leisurely pursuits, fostering a vibrant atmosphere of health and well-being. Children expressed a strong preference for outdoor spaces that were roomy, well-maintained, and had attractive landscaping. They emphasized the importance of cleanliness and the promotion of good health in these areas. Additionally, their artwork and designs frequently highlighted the significance of green, open spaces for engaging in various outdoor activities. Figure  3 demonstrates the types of places that children are interested in and use for active play, including public spaces such as school playgrounds and playing fields, and a large library. However, they were more likely to choose a mini-public space to play in, like the pocket park (small urban green space for recreation and relaxation in dense areas) with a pool, fish, or slides. In addition, the children often went to private spaces for play, including the shopping mall, where they travel with their family to eat and play on the indoor playground, and the private garden inside the neighborhood. And some interesting shops were also the main attractions, like pet shops or flower shops. Some children told parents they liked to visit the pet cat in one shop every day because their moms did not allow them to have pets (See Fig.  4 ).

Examples of Children’s Painting.

Map of CPOI.

Data analysis in datang community

Pedestrians who rely on active transportation required adequate facilities, including child pedestrian pathways. Children, as pedestrians, were vulnerable to accidents due to their active movement and tendency to play while walking along the pedestrian pathway. Their unpredictable movements resulted in collisions with other users, such as pedestrians, cyclists, motorcyclists, and cars. When designing and planning a prototype for a child pedestrian pathway, it was important to consider the active movement of children and the objects they may use for play. Proper design and construction were crucial for ensuring the safety of child pedestrians in areas with high pedestrian and street user traffic. Therefore, the data selection focused on this specific target. The specific data processing processes for each type were as follows:

The assessment criteria tool for pedestrian assessment included three dimensions: (1) educational resources; (2) safety; and (3) play and recreation 51 . This study incorporated collinearity analysis for each dimension. In the initial dimension, the Variance Inflation Factor (VIF) ranged from 1.229 to 1.557, indicating that the collinearity coefficients were deemed credible (See Table 1 ). In terms of educational resources, the pedestrian pathways were designed to connect kindergartens or daycares, providing convenient access to schools. Safety and the inclusion of interesting points were identified as two crucial factors for a successful pedestrian pathway. Regarding safety, it was ensured that the pedestrian pathways were designed to be safe, with walkability and appropriate gradients. Additionally, measures were taken to separate pedestrians from vehicular traffic, including the proper separation of sidewalks and streets using landscape buffers. On-street parking along the sidewalk and bike lanes provided a safety barrier between pedestrians and motor vehicles. This was specifically important for children’s safety because their walking patterns are less predictable and more spontaneous 27 . Play and recreation mean the pedestrian pathway links to CPOI for children.

Data preparation and weighting

Guidelines were formulated drawing from existing literature. The concept of CFC played a significant role in fostering the satisfaction of children within neighborhoods. This involved ensuring easy access to a safe and clean environment, essential amenities and services, educational opportunities, green spaces, and the opportunity for children to forge new friendships and engage in play within a secure setting 28 , 32 . These factors were succinctly summarized as follows.

Current pedestrian data: the planned pedestrian pathway network will make maximum use of the existing roads and lanes. This study obtained the distance grid data of the existing roads and lanes.

Land use: the pedestrian pathway was built on the built land and to avoid parks or rivers.

Residential data: represented the potential walking demand, which was translated into population density. The larger the value, the stronger the walking demand. And the pedestrian pathway would link the residential area with other points.

Barriers: the safety of pedestrian pathways for children necessitates their isolation from vehicular traffic. Firstly, the road should implement traffic calming measures, such as speed humps, traffic islands, raised crosswalks, and chicanes, to reduce vehicle speeds and create safer environments for child pedestrians. The second goal was to create and maintain pedestrian infrastructure that was especially tailored to meet the requirements of children pedestrians. This included constructing and maintaining sidewalks, crosswalks, pedestrian bridges, and underpasses. Ensure that these facilities were well-maintained, clearly marked, and accessible.

Children's point of interest (CPOI): mainly in the form of children’s point of interest data. When planning steps, pay attention to contacting children's points of interest.

Trees: these provided comfortable places for children. Trees offer shade, creating cool and pleasant environments where children can seek respite from the heat and enjoy outdoor activities. Moreover, the presence of trees contributes to improved air quality by filtering pollutants and releasing oxygen, creating a healthier and more refreshing environment for children to play and explore. The calming effect of nature, combined with the visual appeal of trees, promotes a sense of tranquility and peace, creating a welcoming atmosphere for children to relax, engage in imaginative play, or simply enjoy the beauty of nature. Furthermore, trees provide opportunities for interactive experiences, such as climbing, swinging from branches, or building treehouses, fostering physical activity, and enhancing children's motor skills and coordination.

The classification scores of various factors were shown in Table 2 in AHP processing. . The AHP is generally employed for expert scoring. It involves having four experts directly provide scoring judgments for the relative importance, creating a judgment matrix. Subsequently, the scores are consolidated to obtain the final judgment matrix. Finally, the weights for each factor are calculated based on this matrix. The consistency testing of Cronbach's Alpha is 0.774, indicating its reliability (See Table 3 ).

The mutual importance of each element was determined by the fuzzy analytic hierarchy process and determined its weight, as shown in Table 4 . Based on the raster data of the cost of each factor, the weight was combined by superposition analysis, the comprehensive cost was obtained from the comprehensive consideration. However, engineering, social, and population factors of road planning and construction cost.

The developed GIS analysis model has been carefully packaged and consolidated, resulting in the creation of a highly functional process tool, as visually represented in Fig.  5 . This tool served a crucial purpose by facilitating the efficient planning of a child-friendly pedestrian pathway. Notably, it offered the advantage of avoiding areas with high costs, such as water bodies and heritage buildings, thus minimizing potential financial burdens. Additionally, the tool optimized the utilization of existing CPOI, harnessing their potential benefits while simultaneously mitigating negative impacts on the environment. By incorporating these considerations, the tool contributed to a more sustainable and economically viable road planning process.

Data Analysis Result.

After conducting the spatial superposition analysis, the results were influenced by the existing lanes and roads. These lanes were able to be found on one or both sides of the roadway and serve to bridge gaps between important destinations within a community. In most plans, the pathways tended to rely more on the existing roads and overlook the importance of utilizing the lanes. However, it was worth noting that a pedestrian lane could serve as an interim or temporary pedestrian facility, particularly suitable for roads with low to moderate speeds and volumes (See Fig.  4 ).

Based on the data analysis, the urban planner designed the safest pathway for children in the community. The pedestrian environment, consisting of paving and brick pavements, connected all CPOI and promotes children's growth and family comfort through appropriate design. The outcome included separate lanes for bicycles and pedestrians, aiming to contribute to Guangzhou becoming a more CFC.

CFPP planning result

The results of testing the algorithm's response to different combinations of user preferences are presented in Fig.  5 . The algorithm was tested on a specific case using the settings illustrated in Fig.  6 . This case aimed to identify a child-friendly pedestrian pathway.

Walking routes proposed by the algorithm to meet the preferences of child (Legend: Map is made by ArcGIS 10.3.1 URL: https://www.arcgis.com/index.html ).

In the future, there are plans to develop an application that could be installed on mobile phones and similar devices, making it accessible to the general public. This application would enable cross-analysis between user behavior and the suggested routes generated by the algorithm. Additionally, user feedback regarding their satisfaction with the application could be used to validate the model (See Fig.  7 ).

Flow chart of Child-Friendly Pathway intelligent planning based on GIS.

CFPP mechanism

Feedback mechanisms within the context of CFPP play a crucial role in engaging with children, parents, and communities. Social media platforms, particularly popular among older adolescents and young individuals with mobile connectivity, serve as a means to receive information, report incidents, and offer feedback or file complaints. Following the release of CFPP results, establishing feedback mechanisms becomes essential for collecting suggestions and ensuring continuous improvement of CFPP initiatives.

Efforts can be made to integrate consultations into existing programs and activities within established structures. It is advisable to centralize all gathered feedback into a dedicated database. A central database facilitates the tracking of feedback, documents actions taken to address complaints or suggestions, and provides analytical tools to discern trends in feedback. Viable database tools for this purpose include Excel, Microsoft Access, or an SPSS database.

Conclusion and discussion

The study focused on two main objectives: first, to examine children's perceptions and meanings associated with a Child-Friendly City (CFC) and second, to explore the implications of these perceptions on children's interest in various spaces within their community. The findings highlighted the influence of the social milieu on the perceived child-friendliness and environmental friendliness of the community. Notably, Critical Points of Interest (CPOIs), spaces considered child-friendly, often emerged organically in inconspicuous places, demonstrating the importance of understanding the community from the perspective of its youngest members.

The innovative creation and application of an algorithm to automate the computation of child-friendly pedestrian routes (CFPP) was a major advancement in the study. This algorithm has proven to be an effective tool for managing large amounts of spatial data in Guangzhou, despite obstacles to user preferences. This methodology provides urban planners with a crucial tool for designing safe and child-friendly infrastructure, indicating a substantial development in intelligent planning methodologies.

The study emphasized the significance of creating child-friendly play areas along the CFPP, integrating basic utilities, and separating spaces based on the individual needs of different age groups. This insight provides a framework for more inclusive and personalized infrastructure in future urban planning and development efforts.

Moreover, the study highlighted the significance of ensuring safety, security, and the presence of adults within play spaces. These factors were identified as crucial elements contributing to the overall success of CFPPs in promoting active transportation for children. Child-friendly environments foster a sense of community and social integration among children by supporting their physical health, independence, and well-being.

Policy implications

This study holds significant implications for urban planning policy, particularly concerning Child-Friendly Pedestrian Pathways (CFPP). Firstly, research findings can guide the selection of appropriate pathways, emphasizing regions aligned with children's views and preferences, fostering a sense of belonging and well-being. Secondly, develop and implement pathway guidelines, including child-friendly regulatory signs, enhancing visibility and appeal. Thirdly, implement protective measures, addressing damages promptly for ongoing safety and performance. Planning for CFPP involves considering suitable amenities, safety signage, and visual appeal. Implementation strategies include creating kid-friendly signs, ensuring access to facilities, and adding eye-catching elements. These policies underscore the importance of a thorough, child-centered approach for creating secure, accessible, and engaging urban spaces, ensuring a sustainable and child-friendly future as cities expand globally.

The study offers a comprehensive examination of children's perceptions and meanings regarding Child-Friendly Cities (CFC). The development and successful implementation of an algorithm for Child-Friendly Pedestrian Pathways signify a significant advancement in intelligent planning methods, providing urban planners with an effective tool to prioritize children's safety and well-being.

It provides valuable insights into the significance of integrating child-friendly playgrounds alongside pedestrian walkways, emphasizing the need for specifically designed amenities catering to various age groups. The emphasis on security, safety, and adult presence in play areas underscores the necessity for implementing a comprehensive strategy to create spaces that genuinely meet the requirements of children.

However, this study acknowledges its limitations, notably its focus on a specific community, which restricts the generalizability of the results. Future studies should broaden the focus to encompass more cases to provide a more thorough understanding of the planning of child-friendly pedestrian pathways. Further research examining the qualitative features of Critical Points of Interest (CPOI) and possible losses and deteriorations in these areas offers a more nuanced perspective on the caliber of child-friendly settings.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

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Fang Kailun wrote the main manuscript text and prepared figures. Fang Kailun did the research and data collection. Suzana Ariff Azizan developed the manuscript. Suzana Ariff Azizan did data analysis Huang Huiming checked the main manuscript text Huang Huiming did the survey. All authors reviewed the manuscript.

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Fang, K., Azizan, S.A. & Huang, H. GIS-based intelligent planning approach of child-friendly pedestrian pathway to promote a child-friendly city. Sci Rep 14 , 8139 (2024). https://doi.org/10.1038/s41598-024-58712-5

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