use of mixed methods in the evaluation of suicide prevention strategies and interventions stephen...
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Use of mixed methods in Use of mixed methods in the evaluation of suicide the evaluation of suicide prevention strategies and prevention strategies and interventionsinterventions
Stephen Platt
Qualitative research and suicideQualitative research and suicide
Seminar, Cardiff University, 2 July Seminar, Cardiff University, 2 July 20072007
Structure of presentationStructure of presentation
Mixed methods research Suicide in Scotland: trends and context Choose Life strategy and action plan Evaluation plan Selected main findings Selected recommendations
Mixed methods researchMixed methods research
Adoption of a research strategy involving more than one type of research method
May be mix of qualitative and quantitative methods or mix of quantitative methods or mix of qualitative methods
Increasing use of mixed methods strategies, especially combining qualitative and quantitative approaches
Many reasons why this is occurring
Why the increasing popularity Why the increasing popularity of mixed methods research? of mixed methods research? (1)(1)
Opportunity for skills enhancement Broadening methodological repertoire
mitigates vs. “trained incapacities” (Reiss)
Encourages thinking ‘outside the box’ Cross-national research (e.g. EU)
provides increased opportunities for mixed methods research
Why the increasing popularity Why the increasing popularity of mixed methods research? of mixed methods research? (2)(2)
Fits with political currency accorded to ‘practical enquiry’ that speaks to policy/ makers and informs practice “Whole industry” (Brannen) of mixed methods
research created around evidence-based policy and in policy evaluation
Increasing emphasis upon dissemination Researchers need to communicate in “double
speak” (Brannen): technical/specialised language of research and popular language that can easily communicate findings/messages to ‘users’
Words as important as numbers in writing up research
Misconceptions of ‘the Misconceptions of ‘the other’ other’
Quantitative attitudes qualitative: Too context specific Selection of data to fit preconceptions Unrepresentative samples/examples Unwarranted claims
Qualitative attitudes quantitative: Overly simplistic Decontextualised Reductionist in terms of generalisations Failing to capture subjective meaning
Rationales underlying choice Rationales underlying choice of method(s) of method(s) (1)(1)
Paradigms/philosophical assumptions Qualitative and quantitative research seen
as intrinsically different (particularly with regard to philosophical traditions)
But surveys not necessarily conducted on basis of positivist assumptions and qualitative researchers using participant observation often work in realist tradition
Micro-level emphasises subjective interpretations. Macro-level concerned with larger patterns/ trends and seeks structural explanations. But all aim to understand individuals in society. Methods need to be congruent with this quest.
Rationales underlying choice Rationales underlying choice of method(s) of method(s) (2)(2)
Pragmatics Commonplace to argue that methods should
be appropriate (and subordinate) to research Q
But usually many research Qs. Some may be underpinned by realist assumptions, others by interpretevist assumptions.
And practicalities of research process may change original intention anyway, with outcomes of research taking precedence
Mixed methods believed/claimed to produce “better” outcomes than reliance on single method (pragmatic orientation linked to emphasis upon policy/practice application)
Rationales underlying choice Rationales underlying choice of method(s) of method(s) (3)(3)
Politics Political rationales for using mixed methods Example: addressing condition of women in
society requires use of large-scale quantitative data (structural) as well as in-depth qualitative data (personal experience/perspective) in order to understand/expose gendered inequalities
Crucial issue is the purpose to which methods are put rather than the methods per se
Combining methods in Combining methods in research process: context of research process: context of justificationjustification
Stage of data analysis and interpretation Data derived from different methods cannot
be added together to produce unitary reality Possible outcomes when methods are
combined Corroboration (‘triangulation’) (‘same’
findings from different methods) Elaboration (one method exemplifies how
findings apply in particular cases) Complementarity (findings differ but together
– synergistically – they generate insights) Contradiction (findings from different methods
conflict)
Mixed methods designs: Mixed methods designs: key dimensionskey dimensions
Logic of enquiry: inductive (aimed at discovery) or deductive (aimed at hypothesis testing) No one-to-one correspondence between one
particular logic of enquiry and one type of method
(If mixed method approach is warranted) the ordering of methods needs to be considered: sequential or simultaneous?
How dominant is a particular method going to be (consider scarce resources)?
Possible permutations of Possible permutations of mixed methods designsmixed methods designs
Examples of simultaneous designs QUAL + quan QUAN + qual QUAL + QUAL QUAL + qual
Examples of sequential designs Qual QUAN QUAL quan Quan QUAL QUAN qual Qual QUAL QUAL QUAL QUAL QUAL
Suicide rates across the world Suicide rates across the world (2002)(2002)
Age-standardised suicide Age-standardised suicide rates, by country, 1991/93-rates, by country, 1991/93-2002/04, males2002/04, males
0
5
10
15
20
25
30
35
1991/ 93
1992/ 94
1993/ 95
1994/ 96
1995/ 97
1996/ 96
1997/ 99
1998/ 2000
1999/ 2001
2000/ 02
2001/ 03
2002/ 04
Sta
ndar
dis
ed s
uic
ide
rate
England
Wales
Scotland
N Ireland
Age-standardised suicide rates, Age-standardised suicide rates, by country, 1991/93-2002/04, by country, 1991/93-2002/04, femalesfemales
0
3
6
9
12
15
1991/ 93
1992/ 94
1993/ 95
1994/ 96
1995/ 97
1996/ 96
1997/ 99
1998/ 2000
1999/ 2001
2000/ 02
2001/ 03
2002/ 04
Sta
ndar
dis
ed s
uic
ide
rate
England
Wales
Scotland
N Ireland
Intentional self harm & Intentional self harm & undetermined deaths, Scotland, 15+ undetermined deaths, Scotland, 15+ years, 1970-2005years, 1970-2005
0
5
10
15
20
25
30
35
40
1970 1974 1978 1982 1986 1990 1994 1998 2002
Year
Suic
ide
rate
per
100,0
00
MaleFemale
Scotland’s national suicide Scotland’s national suicide prevention strategy & action plan: prevention strategy & action plan: Choose LifeChoose Life
Launched in December 2002 Major element of Scottish Executive’s
work on health improvement and mental health
Plan being implemented in phases Budget for phase 1 (April 2003-March
2006) was £12m Additional £8.4m allocated for first two
years of phase 2 (2006-08) Overall aim: to reduce suicide rate in
Scotland by 20% in 2013 (cf 2002)
Choose LifeChoose Life: national and national and local infrastructurelocal infrastructure
Designated National Implementation Support Team (NIST) co-ordinates and supports national development and implementation
NIST’s core functions include: awareness raising/campaigning; working with the media; development/dissemination of information and knowledge; and guiding and supporting local implementation
In each local authority Choose Life action plans have been developed by the Community Planning Partnership (CPP)
National and local budgetary allocation
Evaluation: main objectivesEvaluation: main objectives
Assess whether sustainable infrastructure is being developed nationally and locally to support achievement of Choose Life strategy
Measure and review progress towards implementation of Choose Life milestones
Examine whether and how Choose Life is stimulating effective forms of practice
Provide detailed recommendations to guide the next phase of the action plan
Theory-based evaluationTheory-based evaluation
Theory-driven approaches are intended to address needs of programme implementers
Aims to articulate and test the explicit and implicit theories that shape the design and planned implementation of a programme
Attempts to determine whether a programme has been delivered
as intended what aspects of the programme work, for
whom and in what circumstances/contexts/settings
Theory of change: “a systematic and cumulative study of the links between activities, outcomes and contexts…” (Weiss)
Theory-based evaluation: Theory-based evaluation: the role of contextthe role of context
Context as a powerful ingredient in programme evolution and success – not a variable to be ‘controlled for’
Social programmes can’t be tested/rolled out in laboratories, so getting to grips with the interface between context and intervention is of fundamental importance
Qualitative approaches can do this to a degree but rarely in a way that address concerns about programme impact
Theory-based evaluation: Theory-based evaluation: the processthe process
Through a collective/collaborative process, the evaluator encourages programme stakeholders to articulate at the earliest possible stage : The programme’s rationale Its intended outcomes The activities that will be implemented to
achieve these Contextual factors and their influence
The ensuing ‘theory of change’ can be used to improve programme planning and of make evaluation decisions
Main methodsMain methods
Two electronic surveys of local co-ordinators
Two rounds of interviews with key informants at national level (including NIST)
Detailed and in-depth exploration of theories of change in 8 selected local areas (using interviews, workshops, observation, documentary analysis)
Two workshops with local coordinators and national informants
Co-ordinator surveysCo-ordinator surveys Covering range of areas:
(Progress towards) Local vision for change Progress in the development of the local infrastructure Resource allocation and generation Examples of innovative and effective practice Monitoring and evaluation Sustainability and mainstreaming Collection of data on suicide and deliberate self-harm Reflections on national support and on local progress
Open and closed questions Rating scales to measure satisfaction with
national action towards achievement of milestones and to review local implementation progress
Interviews with key Interviews with key informantsinformants
Key elements of semi-structured interviews: Considering progress towards the achievement of
the national milestones set out in Choose Life Understanding the criteria applied at the national
level to assess local implementation Considering the quality of collaboration between the
NIST and major national agencies for the achievement of Choose Life objectives.
Interviews with members of NIST and sample of key national informants (e.g. ChildLine, Samaritans, SAMH, NUJ)
Additional component: exploration of the NIST ‘story’ via individual interviews and joint workshop
Local area case studies Local area case studies (1)(1)
Case studies were main vehicles for exploring implementation process identifying overall theoretical framework within
which local suicide prevention teams worked Representative sample selected by:
Geographical type (rural/remote, urban and mixed) [1º criterion]
Local suicide rate, focus on priority groups, interaction between national and local levels, and approaches to coordination [2º criteria]
Two fieldwork visits 6 months apart
Local area case studies Local area case studies (2)(2)
Interviews with case study informants Purposive sampling: 4 key informants involved
in decision-making process (e.g. members Choose Life partnership responsible for priority setting) and 2 representatives involved in Choose Life funded activities
16 project activities selected for more detailed examination (2 per case study site) Intended to provide representative selection
across Choose Life priority groups and objectives
Selection negotiated with coordinators Interviews conducted with project
representative, usually project lead/manager
Local area case studies Local area case studies (3)(3)
Observational activities and collection of documentation Observation of Choose Life events (usually
partnership meetings but also training days, evaluation days and practitioner fora)
Key documents included: minutes of Choose Life partnership meetings, locality reports on progress, reports of previous needs assessment
Evaluation team aimed to understand theories of change at overall programme level as well as at project level
Local area case studies Local area case studies (4)(4)
Changes to approach Workshops replaced individual interviews with
stakeholders at second fieldwork visit Provided opportunity for joint testing of, and
reflection on, local area theories of change Local participants encouraged to assess
progress towards Choose Life objectives and milestones, and how this could be demonstrated
Problems created as result of mixed levels and responsibilities of participants (e.g. strategic versus operational)
National workshops National workshops (1)(1)
Two workshops one year apart brought together evaluation team, NIST, local coordinators and several key stakeholders
1st workshop aimed to: develop understanding of the different
models of national and local actions and activities being put in place
explore the evolving relationship between the approaches of the centre and of local areas
identify ways in which progress could be measured.
National workshops National workshops (2)(2)
2nd workshop aimed to: Review progress and learning in relation to
objectives of Choose Life Test out key themes emerging from
evaluation Identify future priorities for development,
support required, measures of progress and outcome, and implications for information collection and research
Data analysis Data analysis (1)(1)
Continuous (iterative) process throughout study Evaluation database designed and used to store
(and retrieve) data on all 32 local areas Findings from each element of data collection
(case studies, workshops, national interviews, surveys) written up in detailed reports which were then used for comparative analysis
Data analysed according to predefined themes (e.g. sustainability, partnerships) …
… and themes also developed from inductive analysis conducted at each phase of evaluation
Data analysis Data analysis (2)(2)
Analytic framework developed to guide team through the evaluation This was expanded and changed according
to themes emerging from data Analysis primarily drew on ‘charting’
method of systematically handling complex datasets by drawing out dimensions relating to each theme across all ‘cases’
Evaluation: main findingsEvaluation: main findings
Sustainable infrastructures for implementation
Allocation and use of resources Innovative practice and use of
evidence Sustainability Decision making processes and
learning
Sustainable infrastructures Sustainable infrastructures for implementationfor implementation
Demonstrable progress made by NIST CPP successes … but not as evident in
less ‘mature’ partnerships and in engaging with clinical services
Various models of local coordination developed Preference for a dedicated (full-time)
coordination post … … but evaluation unable to demonstrate the
superiority of this model
Allocation and use of Allocation and use of resourcesresources
CPPs have attracted considerable additional investment at local level and in-kind contribution …
… but areas have not been equally successful in raising additional funding …
… and there has been unnecessary duplication of effort at local level
Choose Life has stimulated a considerable amount of activity relating to self-harm …
… but local areas have different understandings of ‘high risk’ suicidal behaviour and have adopted different responses to address the problem
Innovative practice and Innovative practice and use of evidenceuse of evidence
Many examples of locally defined innovative practice …
… and multiple sources of information and evidence used to inform local planning and activity …
… but research rarely used systematically
SustainabilitySustainability
NIST identified several achievements in building a sustainable infrastructure for suicide prevention
At local level, most success achieved in mainstreaming training activities
Decision making processes Decision making processes and learningand learning
Local stakeholder consultation: key approach to set implementation priorities
Short timescale to develop first action plan was a major challenge
National support for learning has been delivered through diverse routes
NIST has highlighted a strong commitment to evaluation …
… but a national framework for evaluation remains to be completed
In local areas different levels of priority and attention have been attached to evaluation.
Recommendations: Recommendations: mainstreaming at national mainstreaming at national levellevel
Incorporate Choose Life objectives and priorities into other policy streams/initiatives
Involve clinical services in population-based suicide prevention activities
Involve national voluntary sector organisations in awareness raising and campaigning
Engage in purposive innovation to test out, evaluate, learn and implement
Recommendations: Recommendations: mainstreaming at local levelmainstreaming at local level
Using intelligence from a range of sources, as tools in planning for sustainability
Building in mechanisms to track and review progress towards objectives across policy areas
More focused targeting of action is required
Recommendations: self-Recommendations: self-harmharm
More consideration to be given in phase 2 to the integration of self-harm into Choose Life
The strategy should continue to encompass high risk self-harm …
… but the less ‘serious’ component of self-harm cannot be ignored
Recommendations: CPPRecommendations: CPP
The CPP remains the most appropriate vehicle for developing strategy and overseeing delivery in relation to Choose Life at the local level
But its limitations should be recognised Need to examine the necessary partnerships
that have yet to be put in place Priority should be given to establishing/building
on effective links with clinical & drug/alcohol services
NIST should continue to work closely with CPPs to ensure that Choose Life budgets are fully spent on suicide prevention activities
Recommendations: central Recommendations: central coordination bodycoordination body
Some type of central coordination body will continue to be required in the immediate future
Key tasks: provide national oversight, assess and support performance and ensure accountability at local level, promote learning and effective knowledge transfer, and co-ordinate action.
There should be a review of how the central coordinating function is delivered and where it is situated
Choose Life evaluation (first phase):Choose Life evaluation (first phase):research teamresearch team
University of EdinburghStephen Platt (RUHBC)Emma Halliday (RUHBC)Margaret Maxwell (General Practice)Scottish Development Centre for Mental HealthJoanne McLeanAllyson McCollamAmy WoodhouseLondon School of EconomicsDave McDaid (Health & Social Care)Glasgow UniversityMhairi Mackenzie (Public Health & Health Policy)Avril Blamey (Public Health & Health Policy)