What is so new about mixed methods?

In this article, I dispute claims that mixed methods research emerged only recently in the social sciences. I argue that some anthropologists and sociologists (and others) have used mixed methods in fieldwork for at least 80 years, and there are studies from early in the 20th century that clearly fall within the definition of "mixed methods." I explore some of the history of the mixing of qualitative and quantitative data in earlier ethnographic works and show that in some sectors of social science research, the "emergence" and proliferation of mixed methods were particularly notable around the middle of the 20th century. Furthermore, concerning issues about "paradigms of research" in the social sciences, I identify some of the types of research in which the mixing of QUAL and QUAN approaches was more likely to occur. I suggest that some of the literature about research paradigms has involved a certain amount of "myth-making" in connection with descriptions of qualitative and quantitative research assumptions and styles.

A model for translating ethnography and theory into culturally constructed clinical practices.

This article describes the development of a dynamic culturally constructed clinical practice model for HIV/STI prevention, the Narrative Intervention Model (NIM), and illustrates its application in practice, within the context of a 6-year transdisciplinary research program in Mumbai, India. Theory and research from anthropology, psychology, and public health, and mixed-method ethnographic research with practitioners, patients, and community members, contributed to the articulation of the NIM for HIV/STI risk reduction and prevention among married men living in low-income communities. The NIM involves a process of negotiation of patient narratives regarding their sexual health problems and related risk factors to facilitate risk reduction. The goal of the NIM is to facilitate cognitive-behavioral change through a three-stage process of co-construction (eliciting patient narrative), deconstruction (articulating discrepancies between current and desired narrative), and reconstruction (proposing alternative narratives that facilitate risk reduction). The NIM process extends the traditional clinical approach through the integration of biological, psychological, interpersonal, and cultural factors as depicted in the patient narrative. Our work demonstrates the use of a recursive integration of research and practice to address limitations of current evidence-based intervention approaches that fail to address the diversity of cultural constructions across populations and contexts.

Community street theatre as a tool for interventions on alcohol use and other behaviors related to HIV risks.

This paper presents data on the role and implementation of street theatre as a communications technique for HIV behavioral interventions in low income slum communities in Mumbai. Second, we situate the uses of street theatre as a social intervention strategy within a long history of outdoor drama as entertainment and social action in India. Street theatre with accompanying activities was a central element of the RISHTA project's communications strategy in communities in Mumbai, designed to deliver tailored risk reduction messages to married men who were involved in extramarital relationships. The paper presents examples of the contents and delivery of alcohol risk reduction messages through street plays that were developed and performed by actors from low income communities. The paper situates street plays as part of the domain of prevention strategies, which can be effective in reducing HIV risks, including those related to alcohol use.

The evolution of alcohol use in India.

This paper traces the role of alcohol production and use in the daily lives of people in India, from ancient times to the present day. Alcohol use has been an issue of great ambivalence throughout the rich and long history of the Indian subcontinent. The behaviors and attitudes about alcohol use in India are very complex, contradictory and convoluted because of the many different influences in that history. The evolution of alcohol use patterns in India can be divided into four broad historical periods (time of written records), beginning with the Vedic era (ca. 1500-700 BCE). From 700 BCE to 1100 CE, ("Reinterpretation and Synthesis") is the time of emergence of Buddhism and Jainism, with some new anti-alcohol doctrines, as well as post-Vedic developments in the Hindu traditions and scholarly writing. The writings of the renowned medical practitioners, Charaka and Susruta, added new lines of thought, including arguments for "moderate alcohol use." The Period of Islamic Influence (1100-1800 CE), including the Mughal era from the 1520s to 1800, exhibited a complex interplay of widespread alcohol use, competing with the clear Quranic opposition to alcohol consumption. The fourth period (1800 to the present) includes the deep influence of British colonial rule and the recent half century of Indian independence, beginning in 1947. The contradictions and ambiguities-with widespread alcohol use in some sectors of society, including the high status caste of warriors/rulers (Kshatriyas), versus prohibitions and condemnation of alcohol use, especially for the Brahmin (scholar-priest) caste, have produced alcohol use patterns that include frequent high-risk, heavy and hazardous drinking. The recent increases in alcohol consumption in many sectors of the general Indian population, coupled with the strong evidence of the role of alcohol in the spread of HIV/STI infections and other health risks, point to the need for detailed understanding of the complex cross-currents emerging from the past history of alcohol use and abuse in India.

The psychological and social contexts of complaints of abnormal vaginal discharge: a study of illness narratives in India.

OBJECTIVE: Epidemiological studies have reported strong associations between psychosocial adversity and complaints of abnormal vaginal discharge (AVD) in South Asia. We aimed to explore the mechanism of these associations through qualitative research. METHOD: We carried out serial in-depth interviews with 42 married women with the complaint of AVD who were purposively selected from a sample of 2494 women recruited into a population-based cohort study in Goa, India. The interviews elicited illness narratives of their complaint, focusing on causal attributions and help-seeking behaviors. RESULTS: Women explicitly link their personal experiences of social adversity and stress (such as marital problems and heavy workloads) with their complaints of AVD. The complaint of tiredness, a core feature of depressive and somatoform disorders, and complaint of "tension" were commonly associated with AVD through bidirectional causal interpretations. Reproductive events, particularly related to the menstrual cycle and contraception, comprise another set of causal attributions. Many women hold multiple causal attributions. Most women sought health care, both biomedical and traditional, and their narratives indicate reinforcement of their causal attributions by health care providers. However, treatments were often discontinued or changed due to lack of symptomatic relief, side effects, or costs. CONCLUSIONS: Reproductive health policy and practice must explicitly acknowledge and integrate research findings on psychosocial associations of AVD to promote a holistic and evidence-based approach for this common complaint in women in South Asia.

Medical abortion in rural Tamil Nadu, South India: a quiet transformation.

The medical abortion drugs mifepristone and misoprostol are now widely available in rural Tamil Nadu, India, and the practice of abortion is being transformed. This paper reports on current attitudes and practices concerning medical abortion among qualified abortion providers in a rural area of Tamil Nadu. Interviews were carried out with a purposive sample of 40 doctors, 15 informants at chemist shops, 10 village health nurses and 23 women who had recently had an abortion. Twelve of the 37 private doctors who were providing abortions, were providing medical abortion to 70-80% of their patients and 12 others to a selected minority. Eleven had largely rejected it and still used D&C, two had never heard of it. A number of doctors were using misoprostol for cervical dilatation prior to D&C. Some doctors and women who were concerned about incomplete abortion and heavy bleeding did not have a clear idea of what normal bleeding with medical abortion was. Incorrect regimens with second trimester medical abortions might have been responsible for cases of excessive bleeding. Most chemist shops said they were selling the tablets only on prescription, but doctors reported widespread over-the-counter sales. Medical abortion appeared to be quite acceptable to most women, and women were increasingly requesting it. Mechanisms are needed for sharing information about medical abortion among professionals, community health workers and rural families. The state government should develop a comprehensive plan for incorporating medical abortion into the public health system.

Coping with a nutrient deficiency: cultural models of vitamin A deficiency in northern Niger.

Cultural explanations and management strategies for specific signs and symptoms of vitamin A deficiency are explored in a Hausa-speaking community in northern Niger. Their interpretations of the etiology of nightblindness in young children and pregnant women focus on food-related causes, in which "lack of good food" is central. In parallel with the significance of food in the etiology of nightblindness, the recommended treatments are home food remedies, primarily involving liver, meat, or green leaves. The locally attributed etiology for the more severe manifestation of vitamin A deficiency, xerophthalmia, stands in sharp contrast to this. People believe the primary cause is "heat" produced by acute infectious disease (particularly measles). A trip to the medical dispensary or a reliance upon home remedies are the preferred treatment options for this condition. We explore the striking correspondence between local interpretations of nightblindness and contemporary medical knowledge and treatment in relation to the very different explanations and curative measures offered for more serious manifestations of vitamin A deficiency.

Abortion providers and safety of abortion: a community-based study in a rural district of Tamil Nadu, India.

This paper reports on a community-based study in 2001-02 in a rural district of Tamil Nadu, India, among 97 women who had had recent abortions, to examine their decision-making processes, the types of facility they attended and the extent of post-abortion complications they experienced. The 36 facilities they attended, both government and private, were ranked by 18 village health nurses, acting as key informants, as regards safety and quality of care. Three categories qualified and safe, intermediate or unqualified and unsafe - were identified. Most of the providers were medically trained, and 75 of the 97 women went to facilities that were ranked as high or intermediate in quality. Government abortion services were mostly ranked intermediate in quality, and criticised by both women and village health nurses. There has been a substantial decrease in the numbers of traditional and unqualified providers. However, about 30% of the women experienced moderate to serious post-abortion complications, including women who went to facilities ranked high. We recommend that government facilities, both the district hospital and primary health centres, should improve their quality of care, that unqualified providers should be stopped from practising, and that all providers should be using the safer methods of vacuum aspiration and medical methods to reduce post-abortion complications.

The role of village health nurses in mediating abortions in rural Tamil Nadu, India.

This paper reports on qualitative research on abortion services in the Coimbatore district of Tamil Nadu in south India, and the role of government village health nurses (VHNs) in assisting women to obtain abortions. The aim of the research, carried out in 1997, was to document the process married women go through to obtain abortions in both the public and private sectors, particularly women in rural areas, and why they preferred private clinics. The research consisted of direct observation of "sterilization/medical termination of pregnancy camps" at rural primary health centres and in hospital settings, plus informal and in-depth, open-ended interviews with medical officers, gynaecologists, government medical administrators, VHNs and other health care personnel. It found that VHNs were not only helping their clients to obtain abortions in government facilities but also and more often with qualified private providers. Unmarried girls were excluded from this process by the need for secrecy, however, and were perceived to still be going to unqualified providers. Government records show that there were clear reductions in the availability of public abortion services in the rural areas throughout the 1990s. The widespread perception that private services were safer and treated women better, the increased availability of qualified private abortion providers and the help of VHNs to access private services all encouraged married women to use the private sector.