[Qualitative Research in Health Services Research - Discussion Paper, Part 3: Quality of Qualitative Research]

[Mixed Methods Studies in Health Services Research: Requirements, Challenges and the Question of Integration - a Discussion Paper from the Perspective of Qualitative Researchers]

With this discussion paper, the subgroup Mixed Methods of the working group Qualitative Research Methods in the non-profit organization German Network Health Services Research (DNVF) is taking up the topic of three previous discussion papers on the significance and potentials of qualitative research methods in health services research. Mixed methods are being increasingly used and demanded in health services research. However, there are also areas of conflict in the planning and implementation of mixed methods studies, and these are addressed in this paper from the perspective of qualitative research. Special attention is given to the aspect of integration as the fundamental signature of mixed methods research. With this discussion paper, our aim was to stimulate critical as well as constructive exchange of ideas on what constitutes high-quality health services research characterised by a diversity of methods and the framework conditions under which this can succeed.

Does one size fit all? A qualitative study about the need for individualized information transfer for orthognathic patients

Aims

For any orthodontic-orthognathic treatment, it is crucial that patients are provided with enough and proper information in order to make evidence-based decisions- not only prior to treatment start, but also throughout the course of therapy. Thus, the objectives of this qualitative study were to identify information needs of patients undergoing combined orthodontic-orthognathic treatment. Additionally, professionals’ perspectives were evaluated.

Methods

A qualitative research approach was chosen in order to determine crucial aspects of information needs before and throughout treatment. With respect to a purposive sampling strategy and thematic saturation, we conducted ten semi-structured interviews with patients who had finished their orthodontic-orthognathic surgery treatments (five women, five men; being 21 to 34 years old). The indications for the combination treatment were severe skeletal Class IIs to Class IIIs with various vertical and transverse discrepancies. In addition, a multidisciplinary focus-group with six professionals from the maxillofacial surgery and orthodontic department (three women, three men; being 30 to 38 years old) helped to reflect about the experts’ point of views.

After transcription, data was categorized and analyzed by Mayring’s content analysis.

Results

We identified three key themes. During this analysis, we focused on theme (1) ‘information transfer’ with its corresponding categories ‘information needs’ – depending on different treatment stages –, ‘source of information’ and ‘doctor-patient-communication’. The affected patients ranked individualized patient information and empathetic doctor-patient-communication high.

This was mostly in line with the professionals’ point of view. Verbal communication was seen as being the best way to communicate throughout treatment. The role of the internet as a source of information was seen diversely.

Conclusion

This qualitative study highlights the need for individualized patient information and reveals both met and unmet information needs by patients. Although evidence-based written information is highly necessary for orthognathic patients and their families alike, it cannot replace an empathetic way of direct verbal doctor-patient-communication. It seems crucial to give specific individualized information at different treatment stages, starting at a thoroughly interdisciplinary screening at the very beginning.

RubiN - continuous care in regional networks: a study protocol for a prospective controlled trial

Background

The health care situation of geriatric patients is often multifaceted, complex and often overlaps with social living conditions. Due to the lack of cross-sectoral and interprofessional health care geriatric patients often, receive insufficient care. Only a holistic view enables a comprehensive evaluation of the complex health risks, but also the potential to preserve the health of geriatric patients. The implementation of cross-sectoral, multi-professional case management could reduce the gaps in care, improve the autonomy of the geriatric patients in their own homes, and allow them to retain it as long as possible.

The “RubiN” project examines the effects of multi-professional, cross-sectoral and assessment-based case management on the quality of the care of geriatric patients. The results of the study aim to show whether geriatric patients receive better care using case management than patients who receive standard health care. In addition, data on the effects of case management on practices of general practitioners (GP), the satisfaction with the care concept amongst the case managers, patients and relatives will be collected. Furthermore, a health economic analysis will be carried out.

Methods

The project is designed as a prospective controlled study and compares geriatric patients from practice networks in different regions in Germany. Inclusion criteria are: Age ≥ 70 years and care requirements from two different care complexes (identified with the screening instrument ‘Angelina’-questionnaire). The intervention is the use of a geriatric case management, where health care is organised based on patient-specific care requirements. Five practice networks of physicians will implement the intervention (n = 3200 patients) and three practice networks will serve as the control group (n = 1200 patients). The primary endpoint is the ability to manage activities of daily living, measured using the Barthel Index. The patients in the intervention group receive geriatric case management and the patients in the control networks receive standard care (“care as usual”). The analysis of the primary data, which is pseudonymised, occurs according to the intention-to-treat principle. For this purpose, the endpoints will be analysed using a group comparison after 12 months. For the health economic analysis, secondary data from the statutory health insurance providers will be included in the analysis, in addition to the primary data. Data for the analysis of the effects the concept has on the GP practices as well as on the satisfaction of the project participants will be collected with questionnaires and interviews with experts.

Discussion

The implementation of cross-sectoral and interdisciplinary geriatric case management has been a topic of discussion for years, whereby positive effects have already been-shown. This planned study will be the first evaluation of the effect of case management for geriatric patients with a very large sample. In addition, the effects of case management on the GP practices and also on the relatives of the geriatric patients will be shown. It is intended that the study results pave the way for a widespread implementation of this concept.

Trial registration

German Clinical Trials Register, ID: DRKS00016642. Registered on 29 October 2019 - Retrospectively registered.

Treatment Complexity in Primary Open-Angle Glaucoma (POAG): Perspectives on Patient Selection in Micro-Invasive Glaucoma Surgery (MIGS) Using Stents

BACKGROUND

Primary open-angle glaucoma (POAG) is still one of the most common causes of impaired vision worldwide, despite the further development of therapy options, and can lead to blindness. Micro-invasive glaucoma surgery (MIGS) using stents aims at reducing intraocular pressure (IOP), as it is the main risk factor. With regard to adherence and adverse drug reactions it also aims at reducing the drug burden on patients. The study investigates under everyday conditions the criteria according to which ophthalmologists in Germany select patients for MIGS using stents. In addition, it will be investigated which patients (could) benefit most from the therapy.

MATERIAL AND METHODS

In this qualitative study, 11 narrative interviews were conducted between May 2017 and July 2018 with ophthalmologists working in the hospital or in a private practice. They were interviewed on their experiences in the treatment of POAG with microstents. The interviews were analysed by an interdisciplinary team using the qualitative content analysis.

RESULTS

The stages of therapy escalation form the frame of reference for patient selection in MIGS using stents. Only if the IOP cannot be sufficiently reduced by drop therapy or when this causes drug-related side effects that are intolerable for the patients, stents are apparently used as the next higher escalation stage. The intensive post-operative medication and the frequent check-up appointments are perceived as barriers by the interviewees, especially for people with or without disabilities, who are dependent on external help and/or those living in rural areas. The active cooperation of the patients in the demanding aftercare seems to be indispensable for the ophthalmologists. In addition, necessary revisions are sometimes stressful for patients (physical/psychological) and doctors (work organisation/therapy). Against the background of the organisational and economic challenges in the outpatient spectrum of tasks, especially physicians in private practice seem to weigh up carefully for which patients microstent therapy would be reasonable.

CONCLUSION

In view of the therapeutic requirements, the current microstent therapy seems to be used in a selected, adherent patient group. Further qualitative and quantitative studies (in other health care regions and structures) are necessary to verify and extend the available results.

[Perspectives and Potentials in Qualitative Health Research: A Plea for an Interdisciplinary Approach]

In order to show perspectives and potentials of qualitative health and health care research, the article explains special features of this research field. It points out the significance of more recent social science theories, which are closely linked to empirical analyses of various disease and health topics. This allows a more systematic view of health care issues, which is illustrated by the example of the increased demands for participation and the importance of patient organizations in planning and designing health care. Thus, these remarks tie in with current debates in (qualitative) health services research and supplement them with further perspectives from social science health research. The aim of the article is to illustrate the benefits of interdisciplinary cooperation between medicine and the social sciences in research. For example, drawing on current social science, theorizing in empirical analyses can bring to the fore historically specific ideas of the ̒good patient̓. By interpreting research results accordingly, the scope for action and reflection of health service professionals can be expanded, and the planning of care-related interventions can receive new impulses. This article should help readers in three ways: to assess the significance of qualitative methods and social science theories for interdisciplinary health research, to see the importance of a focus of health services research on the role of patient organisations and movements, and to understand that health research that is less strongly oriented towards instrumental use and direct application orientation can also provide useful extensions of perspectives for the design of health care in the future.

Integrativer Modellentwurf zu Coping und Abwehr ehemaliger BundeswehrsoldatInnen

Verglichen mit dem profunden Wissen über die Erfahrungen und Bedürfnisse US-amerikanischer Soldaten, ist der Kenntnisstand über die psychische Gesundheit und die Bewältigungsmechanismen aktiver deutscher BundeswehrsoldatInnen eher gering. Über ehemalige EinsatzsoldatInnen, die inzwischen aus dem militärischen System ausgeschieden und Teil der deutschen Zivilgesellschaft geworden sind, ist noch viel weniger bekannt. Ziel der Pilotstudie war die Identifikation und Darstellung von Coping- und Abwehrmechanismen ehemaliger BundeswehrsoldatInnen mithilfe einer methodisch-strukturierten, qualitativen Datenerhebung. Zu diesem Zweck wurden 43 Interviews mit ehemaligen EinsatzsoldatInnen geführt, transkribiert und der thematischen Analyse unterzogen. Die identifizierten Coping- und Abwehrmechanismen wurden den Bereichen Verhalten, Beziehung, Emotion, Reflexion und Zeit zugewiesen und modellhaft in Achsenform veranschaulicht. Durch die bewusste Synthese von kognitiv-behavioralen und psychoanalytischen Perspektiven konnte ein differenziertes Bild erstellt sowie ein eigenständiges, schulenübergreifendes, integratives Achsenmodell zur Darstellung der bewussten und unbewussten Bewältigung belastender Erfahrungen entwickelt werden.

Health Literacy as Communicative Action-A Qualitative Study among Persons at Risk in the Context of Predictive and Preventive Medicine

Predictive and preventive medicine play an increasingly important role in public debates on health, providing cutting-edge technologies with the potential to measure and predict individual risks of getting ill. This leads to an ever-expanding definitional space between being "healthy" and being "ill", challenging the individual's everyday life, attitudes and perceptions towards the self and the process of health-related decision-making. "How do the condition of 'being at risk' and individual health literacy interrelate?" is the leading question of the current contribution. Drawing on empirical qualitative data, collected by means of narrative interviews with persons at risk in four clinical fields, a bottom-up ethnographic and health sciences perspective on health literacy (with an emphasis on critical health literacy) is employed. The findings will be embedded within theoretical approaches dealing with power relations and communication in healthcare encounters, particularly Habermas' theory of communicative action. The core outcome of our study is a concept for an overarching model of health literacy in the context of health-related risk prediction across indications, based on empirical insights gained through interpretative analysis of the four clinical domains.

Fighter, Corpsman, Partisan an Attempt to Typify Former Soldiers Based on their Coping and Defense Mechanisms

This work strives to develop a typological classification of the use of conscious and unconscious defense and coping mechanisms based on methodically and structurally collected data from a qualitative survey of 43 former soldiers in Germany. Seven coping and defense types were identified: the Fighter, the Comrade, the Corpsman, the Strategist, the Partisan, the Self-Protector and the Infantryman. The types identified differed with regard to the accumulation, combination, and use of their conscious and unconscious defense and coping mechanisms in the superordinate areas of behaviour, relationships, emotions, reflexivity and time focus. The typological classification could offer psychotherapeutic interventions tailored to individuals and their defense and coping mechanisms, which could lead to improved therapy use and compliance.

[What motivates patients with atopic diseases to search the internet-a focus group study on expectations and demands]

BACKGROUND

People affected by allergies with mild-to-moderate symptoms are often not treated adequately, despite the availability of prevention and self-therapy measures. Given their good and quick accessibility when seeking information, evidence- and web-based services that are user-friendly may strengthen a more independent way of handling an allergy and may also increase health literacy. In order for such services to be found and read, developers and providers need to know about information needs, demands and users' behavior.

OBJECTIVES

On which occasions does the target group search for allergy-specific information? Which preferences and demands do affected persons have regarding a web-based service?

MATERIALS AND METHODS

Three individual interviews and four focus groups with 37 participants (19-81 years; hay fever, n = 30; asthma, n = 17; eczema, n = 15) were conducted in four German cities. These were recorded and transcribed verbatim. A multiprofessional team developed a system for coding the texts (two independent encoders, MAXQDA analysis software).

RESULTS

Those who are affected usually seek information only in case of a concrete need for action. Impulses are, among others, symptoms, suggestions from the social environment, the beginning of the allergy season or an allergy-related contact with the health system. A web-based service should primarily include information about treatment options, provide individualized support for everyday life action strategies, and promote adequate self-management skills.

DISCUSSION

In order to promote self-management skills, a web-based service should focus on allergy symptoms, treatment options and day-to-day help.

[Group Discussions in Health Services Research - Part 2: Reflections on The Concept of Group, Moderation and Analysis of Group Discussions as well as Online Group Discussion]

This article is the second of 2 articles on group discussions in health services research, written by the Qualitative Methods Working Group of the German Network for Health Care Research (DNVF). It starts with theoretical considerations on the concept of groups, and provides specific knowledge about groups in general and the behaviour of individual group members in particular, which is relevant for the design and interpretation of interaction processes in the group context. The following sections deal with the processuality of group discussions, moderation styles and techniques as well as reflections on possible subjects and methods of analysis. Presentation of results and text passages which unveil the interaction structure of several discussion participants are also discussed here. Finally, insights into the special features, potentials and challenges of group discussions via online platforms are provided. Together, the two articles provide an overview of the most important aspects of the application of group discussions in the field of health services research.

Stigma and its impact on the families of former soldiers of the German Armed Forces: an exploratory study

BACKGROUND

Military families who have a family member with a mental illness see themselves confronted with many demands. Stigmatization is one of these challenges. Stigmatization affects not only the individual who suffers from a mental illness but also other family members via stigma by association and vicarious stigma. Stigma by association occurs when mental illness stigma spills over to individuals associated with an individual with a mental illness. Vicarious stigma describes the suffering of family members when they note the impact of stigma on their relative with mental illness. As a societal phenomenon, stigma plays out in social interactions and might therefore influence the social networks of families. It is also associated with healthcare utilization.

METHOD

Narrative interviews were conducted with 15 family members (partners, spouses, parents and children) of former soldiers of the German Armed Forces with a service-induced mental illness. The transcribed interview data were analyzed using a thematic analysis approach, in which codes were formed and emerging themes were systemized. Relationships between stigma, the families' reactions to it, its effects on their social relationships and its interference with their healthcare utilization were analyzed.

RESULTS

This study provides a detailed description of how relatives of former German soldiers with mental health problems experience stigma by association and vicarious stigma. Their perceptions are shown in a model that describes stigma-related attitudes, reactions to them and their effects on the social relationships of former soldiers' families. These families felt stigmatized because of the former soldiers' mental illness (mental illness stigma) and the military context in which it occurred (former soldier stigma). They reacted with nondisclosure, anger, acceptance and self-blame. Stigma was associated with smaller and weaker social networks that were characterized by social exclusion, self-segregation and conflicts with extended family, friends and colleagues. Stigma also affected the families' healthcare utilization.

CONCLUSIONS

Urgently needed anti-stigma campaigns, particularly in the civilian context, should address the stigmatization of both mental illness and the military participation of the families affected. They should consider the needs of both former soldiers with a mental illness and their families.

Understanding health care avoidance and initial help-seeking behavior in German veterans: a theory of planned behavior

Objective

To gain initial insights into salient beliefs of former German soldiers (veterans) about the use of mental health services.

Data source

Narrative interviews with former German soldiers (veterans) were conducted in 2016.

Data collection/extraction method

Forty-three interviews were transcribed and analyzed thematically based on the theoretical framework of the theory of planned behavior. From within the behavorial, normative, and control beliefs, the salient beliefs were identified.

Principal findings

Four groups of salient beliefs were identified, described, and named: "Autarky", "Ineffectiveness", "Heteronomy", and "Incapacity".

Conclusion

Interventions and campaigns addressing these four specific groups of beliefs may lead to higher health service use rates. However, as a result of methodological limitations of the study design, the conclusion remains tentative.

How Do Patients with Chronic Neck Pain Experience the Effects of Qigong and Exercise Therapy? A Qualitative Interview Study

Background. The high prevalence of chronic neck pain in high income countries impacts quality of life and the social and work-related activities of those afflicted. We aimed to understand how mind-body therapies and exercise therapy may influence the experience of pain among patients with chronic neck pain. Methods. This qualitative interview study investigated how patients with chronic neck pain experienced the effects of exercise or qigong therapy at two time points: during an intervention at three months and after the intervention at six months. Interviews were analysed thematically across interviews and within person-cases. Based on other qualitative studies, a sample size of 20 participants was deemed appropriate. Results. The sample (n = 20) consisted of 16 women and four men (age range: 29 to 59). Patients' experiences differed according to the therapies' philosophies. Exercise therapy group interviewees described a focus on correct posture and muscle tension release. Qigong group interviewees discussed calming and relaxing effects. Maintaining regular exercise was easier to achieve with exercise therapy. Conclusions. The findings of this study may help health care providers when counselling chronic pain patients on self-help interventions by informing them of different bodily and emotional experiences of mind-body interventions compared to exercise therapy.