Enhancing Nonverbal Communication Through Virtual Human Technology: Protocol for a Mixed Methods Study.

BACKGROUND: Communication is a critical component of the patient-provider relationship; however, limited research exists on the role of nonverbal communication. Virtual human training is an informatics-based educational strategy that offers various benefits in communication skill training directed at providers. Recent informatics-based interventions aimed at improving communication have mainly focused on verbal communication, yet research is needed to better understand how virtual humans can improve verbal and nonverbal communication and further elucidate the patient-provider dyad. OBJECTIVE: The purpose of this study is to enhance a conceptual model that incorporates technology to examine verbal and nonverbal components of communication and develop a nonverbal assessment that will be included in the virtual simulation for further testing. METHODS: This study will consist of a multistage mixed methods design, including convergent and exploratory sequential components. A convergent mixed methods study will be conducted to examine the mediating effects of nonverbal communication. Quantitative (eg, MPathic game scores, Kinect nonverbal data, objective structured clinical examination communication score, and Roter Interaction Analysis System and Facial Action Coding System coding of video) and qualitative data (eg, video recordings of MPathic-virtual reality [VR] interventions and student reflections) will be collected simultaneously. Data will be merged to determine the most crucial components of nonverbal behavior in human-computer interaction. An exploratory sequential design will proceed, consisting of a grounded theory qualitative phase. Using theoretical, purposeful sampling, interviews will be conducted with oncology providers probing intentional nonverbal behaviors. The qualitative findings will aid the development of a nonverbal communication model that will be included in a virtual human. The subsequent quantitative strand will incorporate and validate a new automated nonverbal communication behavior assessment into the virtual human simulation, MPathic-VR, by assessing interrater reliability, code interactions, and dyadic data analysis by comparing Kinect responses (system recorded) to manually scored records for specific nonverbal behaviors. Data will be integrated using building integration to develop the automated nonverbal communication behavior assessment and conduct a quality check of these nonverbal features. RESULTS: Secondary data from the MPathic-VR randomized controlled trial data set (210 medical students and 840 video recordings of interactions) were analyzed in the first part of this study. Results showed differential experiences by performance in the intervention group. Following the analysis of the convergent design, participants consisting of medical providers (n=30) will be recruited for the qualitative phase of the subsequent exploratory sequential design. We plan to complete data collection by July 2023 to analyze and integrate these findings. CONCLUSIONS: The results from this study contribute to the improvement of patient-provider communication, both verbal and nonverbal, including the dissemination of health information and health outcomes for patients. Further, this research aims to transfer to various topical areas, including medication safety, informed consent processes, patient instructions, and treatment adherence between patients and providers. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/46601.

Understanding mechanisms of change in a family-based preventive mental health intervention for refugees by refugees in New England.

Transnational migration of refugees is associated with poor mental health, particularly among children. We conducted a pilot trial of the Family Strengthening Intervention for Refugees (FSI-R), using a community-based participatory research (CBPR) approach to deliver a home-based intervention "for refugees by refugees" to improve family functioning and child mental health. N = 80 refugee families in the Greater Boston area participated in the study (n = 40 Somali Bantu families; n = 40 Bhutanese families) with n = 41 families randomized to care-as-usual. Of the 39 families who received FSI-R, n = 36 caregivers and children completed qualitative exit interviews. We present findings from these interviews to identify the mechanisms through which a family-strengthening intervention for refugees can be acceptable, feasible, and effective at improving family functioning and children's mental health outcomes. Authors applied Grounded Theory to code interview transcripts and detailed field notes and used an iterative process to arrive at final codes, themes, and a theoretical framework. The greatest contributors to acceptability and feasibility included flexibility in scheduling intervention sessions, the interventionist being a community member, and improvements to family communication and time spent together. All of these factors were made possible by the CBPR approach. Our findings suggest that given the socio-political context within the U.S. and the economic challenges faced by refugee families, the successful implementation of such interventions hinges on culturally-grounding the intervention design process, drawing heavily on community input, and prioritizing community members as interventionists.

Family-Based Mental Health Promotion for Somali Bantu and Bhutanese Refugees: Feasibility and Acceptability Trial.

PURPOSE: There are disparities in mental health of refugee youth compared with the general U.S. POPULATION: We conducted a pilot feasibility and acceptability trial of the home-visiting Family Strengthening Intervention for refugees (FSI-R) using a community-based participatory research approach. The FSI-R aims to promote youth mental health and family relationships. We hypothesized that FSI-R families would have better psychosocial outcomes and family functioning postintervention compared with care-as-usual (CAU) families. We hypothesized that FSI-R would be feasible to implement and accepted by communities. METHODS: A total of 40 Somali Bantu (n = 103 children, 58.40% female; n = 43 caregivers, 79.00% female) and 40 Bhutanese (n = 49 children, 55.30% female; n = 62 caregivers, 54.00% female) families were randomized to receive FSI-R or CAU. Refugee research assistants conducted psychosocial assessments pre- and post-intervention, and home visitors delivered the preventive intervention. Multilevel modeling assessed the effects of FSI-R. Feasibility was measured from retention, and acceptability was measured from satisfaction surveys. RESULTS: The retention rate of 82.50% indicates high feasibility, and high reports of satisfaction (81.50%) indicate community acceptance. Across communities, FSI-R children reported reduced traumatic stress reactions, and caregivers reported fewer child depression symptoms compared with CAU families (ß = -.42; p = .03; ß = -.34; p = .001). Bhutanese FSI-R children reported reduced family arguing (ß = -1.32; p = .04) and showed fewer depression symptoms and conduct problems by parent report (ß = -9.20; p = .04; ß = -.92; p = .01) compared with CAU. There were no significant differences by group on other measures. CONCLUSIONS: A family-based home-visiting preventive intervention can be feasible and acceptable and has promise for promoting mental health and family functioning among refugees.

A Glaucoma-Specific Brief Motivational Interviewing Training Program for Ophthalmology Para-professionals: Assessment of Feasibility and Initial Patient Impact.

Our objective was to test the feasibility of, fidelity to, and initial impact of a brief, glaucoma-specific motivational interviewing (MI) training program for ophthalmic para-professionals. This prospective, mixed-methods study had two components, one for staff and one for patients. Staff fidelity to MI principles was graded through audio-recorded encounters after initial and final training sessions. After training, patients graded staff for adherence to autonomy supportive care. Semi-structured interviews with para-professionals elicited feedback about the training and about their ability to implement MI in the clinic. The impact on patient satisfaction with staff communication, eye drop instillation self-efficacy, and overall health activation was assessed using a survey pre- and post-training. Para-professionals met two of three program goals for MI skills and improved in their overall scores for MI fidelity. Para-professionals noted lack of time in the clinic as a significant barrier to implementing counseling. Patient satisfaction with staff communication increased after the training (p = 0.04) among patients who rated their staff above the mean for providing autonomy supportive care. The intervention did not improve patients' eye drop instillation self-efficacy or overall health activation. Training para-professional staff in brief, glaucoma-specific MI techniques is feasible and may improve patient satisfaction, though dedicated time in clinic is needed to implement MI counseling into glaucoma practice.

Mixed methods grant applications in the health sciences: An analysis of reviewer comments.

Our aim was to understand how reviewers appraise mixed methods research by analyzing reviewer comments for grant applications submitted primarily to the National Institutes of Health. We requested scholars and consultants in the Mixed Methods Research Training Program (MMRTP) for the Health Sciences to send us summary statements from their mixed methods grant applications and obtained 40 summary statements of funded (40%) and unfunded (60%) mixed methods grant applications. We conducted a document analysis using a coding rubric based on the NIH Best Practices for Mixed Methods Research in the Health Sciences and allowed inductive codes to emerge. Reviewers favorably appraised mixed methods applications demonstrating coherence among aims and research design elements, detailed methods, plans for mixed methods integration, and the use of theoretical models. Reviewers identified weaknesses in mixed methods applications that lacked methodological details or rationales, had a high participant burden, and failed to delineate investigator roles. Successful mixed methods applications convey assumptions behind the methods chosen to accomplish specific aims and clearly detail the procedures to be taken. Investigators planning to use mixed methods should remember that reviewers are looking for both points of view.

The Importance of Evaluating Health Disparities Research.

Health disparity populations are socially disadvantaged, and the multiple levels of discrimination they often experience mean that their characteristics and attributes differ from those of the mainstream. Programs and policies targeted at reducing health disparities or improving minority health must consider these differences. Despite the importance of evaluating health disparities research to produce high-quality data that can guide decision-making, it is not yet a customary practice. Although health disparities evaluations incorporate the same scientific methods as all evaluations, they have unique components such as population characteristics, sociocultural context, and the lack of health disparity common indicators and metrics that must be considered in every phase of the research. This article describes evaluation strategies grouped into 3 components: formative (needs assessments and process), design and methodology (multilevel designs used in real-world settings), and summative (outcomes, impacts, and cost). Each section will describe the standards for each component, discuss the unique health disparity aspects, and provide strategies from the National Institute on Minority Health and Health Disparities Metrics and Measures Visioning Workshop (April 2016) to advance the evaluation of health disparities research.

Methodological Approaches to Understanding Causes of Health Disparities.

Understanding health disparity causes is an important first step toward developing policies or interventions to eliminate disparities, but their nature makes identifying and addressing their causes challenging. Potential causal factors are often correlated, making it difficult to distinguish their effects. These factors may exist at different organizational levels (e.g., individual, family, neighborhood), each of which needs to be appropriately conceptualized and measured. The processes that generate health disparities may include complex relationships with feedback loops and dynamic properties that traditional statistical models represent poorly. Because of this complexity, identifying disparities' causes and remedies requires integrating findings from multiple methodologies. We highlight analytic methods and designs, multilevel approaches, complex systems modeling techniques, and qualitative methods that should be more broadly employed and adapted to advance health disparities research and identify approaches to mitigate them.

Mixed methods and survey research in family medicine and community health.

Many family medicine and community health researchers use surveys as an original research methodology. Our purpose is to illustrate how survey research provides an important form of quantitative research that can be effectively combined with qualitative data to form a mixed methods study. We first provide an overview of the key principles in survey research and in mixed methods research. We review the various ways that survey can be used in mixed methods studies, citing options such as beginning a study with a survey, using a survey as the second form of data collection, or combining a survey and a form of qualitative data in a single data collection procedure. Finally, we illustrate in a specific example six steps in conducting a mixed methods study using survey research. In a mixed methods study using a survey, primary care researchers should consider six steps. Step 1. Articulate the rationale for mixed methods study. Step 2. Detail quantitative and qualitative databases. Step 3. Identify a mixed methods design. Step 4. Analyse and report the results of the quantitative and qualitative databases. Step 5. Present and show integration. Step 6. Explicate the value of using mixed methods. The ability to combine and integrate survey research into a mixed methods study provides a more rigorous approach to research than conducting only a survey or conducting just a qualitative interview. While requiring skills beyond traditional survey approaches, surveys in primary care offers an opportunity for a high level of sophistication in research methodology.

A Web-Based Decision Tool to Improve Contraceptive Counseling for Women With Chronic Medical Conditions: Protocol For a Mixed Methods Implementation Study.

BACKGROUND: Women with chronic medical conditions, such as diabetes and hypertension, have a higher risk of pregnancy-related complications compared with women without medical conditions and should be offered contraception if desired. Although evidence based guidelines for contraceptive selection in the presence of medical conditions are available via the United States Medical Eligibility Criteria (US MEC), these guidelines are underutilized. Research also supports the use of decision tools to promote shared decision making between patients and providers during contraceptive counseling. OBJECTIVE: The overall goal of the MiHealth, MiChoice project is to design and implement a theory-driven, Web-based tool that incorporates the US MEC (provider-level intervention) within the vehicle of a contraceptive decision tool for women with chronic medical conditions (patient-level intervention) in community-based primary care settings (practice-level intervention). This will be a 3-phase study that includes a predesign phase, a design phase, and a testing phase in a randomized controlled trial. This study protocol describes phase 1 and aim 1, which is to determine patient-, provider-, and practice-level factors that are relevant to the design and implementation of the contraceptive decision tool. METHODS: This is a mixed methods implementation study. To customize the delivery of the US MEC in the decision tool, we selected high-priority constructs from the Consolidated Framework for Implementation Research and the Theoretical Domains Framework to drive data collection and analysis at the practice and provider level, respectively. A conceptual model that incorporates constructs from the transtheoretical model and the health beliefs model undergirds patient-level data collection and analysis and will inform customization of the decision tool for this population. We will recruit 6 community-based primary care practices and conduct quantitative surveys and semistructured qualitative interviews with women who have chronic medical conditions, their primary care providers (PCPs), and clinic staff, as well as field observations of practice activities. Quantitative survey data will be summarized with simple descriptive statistics and relationships between participant characteristics and contraceptive recommendations (for PCPs), and current contraceptive use (for patients) will be examined using Fisher exact test. We will conduct thematic analysis of qualitative data from interviews and field observations. The integration of data will occur by comparing, contrasting, and synthesizing qualitative and quantitative findings to inform the future development and implementation of the intervention. RESULTS: We are currently enrolling practices and anticipate study completion in 15 months. CONCLUSIONS: This protocol describes the first phase of a multiphase mixed methods study to develop and implement a Web-based decision tool that is customized to meet the needs of women with chronic medical conditions in primary care settings. Study findings will promote contraceptive counseling via shared decision making and reflect evidence-based guidelines for contraceptive selection. TRIAL REGISTRATION: ClinicalTrials.gov NCT03153644; https://clinicaltrials.gov/ct2/show/NCT03153644 (Archived by WebCite at http://www.webcitation.org/6yUkA5lK8).

Journal article reporting standards for qualitative primary, qualitative meta-analytic, and mixed methods research in psychology: The APA Publications and Communications Board task force report.

The American Psychological Association Publications and Communications Board Working Group on Journal Article Reporting Standards for Qualitative Research (JARS-Qual Working Group) was charged with examining the state of journal article reporting standards as they applied to qualitative research and with generating recommendations for standards that would be appropriate for a wide range of methods within the discipline of psychology. These standards describe what should be included in a research report to enable and facilitate the review process. This publication marks a historical moment-the first inclusion of qualitative research in APA Style, which is the basis of both the Publication Manual of the American Psychological Association (APA, 2010) and APA Style CENTRAL, an online program to support APA Style. In addition to the general JARS-Qual guidelines, the Working Group has developed standards for both qualitative meta-analysis and mixed methods research. The reporting standards were developed for psychological qualitative research but may hold utility for a broad range of social sciences. They honor a range of qualitative traditions, methods, and reporting styles. The Working Group was composed of a group of researchers with backgrounds in varying methods, research topics, and approaches to inquiry. In this article, they present these standards and their rationale, and they detail the ways that the standards differ from the quantitative research reporting standards. They describe how the standards can be used by authors in the process of writing qualitative research for submission as well as by reviewers and editors in the process of reviewing research. (PsycINFO Database Record

Skills Development and Academic Productivity of Scholars in the NIH Mixed Methods Research Training Program for the Health Sciences.

The Mixed Methods Research Training Program (MMRTP) for the Health Sciences is a mentoring-based program to train faculty in mixed methods research. We administered a Mixed Methods Skills Self-Assessment instrument with domains of "research questions," "design/approach," "sampling," "analysis," and "dissemination." For each item (i.e., skill), we requested three ratings on a 5-point Likert-format scale drawn from an educational competency ratings scale: "My ability to define/explain," "My ability to apply to practical problems," and "Extent to which I need to improve my skill." To assess productivity, we administered a survey with questions related to grants funded, grants submitted, publications, presentations, instances of serving as an institutional resource for mixed methods, and other comments. The results showed that 29 scholars in the first two cohorts represented a diverse set of disciplines and research topics. Although scholars expressed a strong interest in learning mixed methods skills, they came into the program with limited professional experiences with mixed methods. Scholars reported statistically significantly increased confidence in ability to define or explain concepts and in ability to apply the concepts to practical problems. Only practical applications of case studies and ethical principles of research did not show statistically significant improvement after the retreat. Scholars reported substantial productivity in mixed methods and described leadership in mixed methods at their institutions. Participation in an interactive program statistically significantly improved the confidence of scholars. The MMRTP holds promise to bridge the gap between complex research questions in the health sciences and investigators suitably trained in mixed methods.

Vietnamese Refugee Elderly Women and Their Experiences of Social Support: A Multiple Case Study.

This study sought to address the gaps in the literature on Asian American gerontology with a multiply marginalized group in terms of gender, immigration status, and context. Guided by a multiple case study approach, we sought to explore how social support was experienced by four Vietnamese elderly refugee women residing in different living arrangements (i.e., alone, with spouse, with adult children, or in a multigenerational household). Within-case analyses were conducted to yield descriptive information about each individual. Additionally, three overarching themes emerged across each of the living arrangements: (1) Burden of care-taking, (2) Distinguishing family from nonfamily help, and (3) Ambivalence toward government-sponsored services. Our findings provide a contextualized understanding of social support to explain the inconsistencies that have been found in the literature on Asian American gerontology and family support. The benefits of living alone are described, along with the potential risks of coresidency.

Development of a Self-Rated Mixed Methods Skills Assessment: The National Institutes of Health Mixed Methods Research Training Program for the Health Sciences.

INTRODUCTION: Demand for training in mixed methods is high, with little research on faculty development or assessment in mixed methods. We describe the development of a self-rated mixed methods skills assessment and provide validity evidence. The instrument taps six research domains: "Research question," "Design/approach," "Sampling," "Data collection," "Analysis," and "Dissemination." Respondents are asked to rate their ability to define or explain concepts of mixed methods under each domain, their ability to apply the concepts to problems, and the extent to which they need to improve. METHODS: We administered the questionnaire to 145 faculty and students using an internet survey. We analyzed descriptive statistics and performance characteristics of the questionnaire using the Cronbach alpha to assess reliability and an analysis of variance that compared a mixed methods experience index with assessment scores to assess criterion relatedness. RESULTS: Internal consistency reliability was high for the total set of items (0.95) and adequate (≥0.71) for all but one subscale. Consistent with establishing criterion validity, respondents who had more professional experiences with mixed methods (eg, published a mixed methods article) rated themselves as more skilled, which was statistically significant across the research domains. DISCUSSION: This self-rated mixed methods assessment instrument may be a useful tool to assess skills in mixed methods for training programs. It can be applied widely at the graduate and faculty level. For the learner, assessment may lead to enhanced motivation to learn and training focused on self-identified needs. For faculty, the assessment may improve curriculum and course content planning.

Integrating Quantitative and Qualitative Results in Health Science Mixed Methods Research Through Joint Displays.

PURPOSE: Mixed methods research is becoming an important methodology to investigate complex health-related topics, yet the meaningful integration of qualitative and quantitative data remains elusive and needs further development. A promising innovation to facilitate integration is the use of visual joint displays that bring data together visually to draw out new insights. The purpose of this study was to identify exemplar joint displays by analyzing the various types of joint displays being used in published articles. METHODS: We searched for empirical articles that included joint displays in 3 journals that publish state-of-the-art mixed methods research. We analyzed each of 19 identified joint displays to extract the type of display, mixed methods design, purpose, rationale, qualitative and quantitative data sources, integration approaches, and analytic strategies. Our analysis focused on what each display communicated and its representation of mixed methods analysis. RESULTS: The most prevalent types of joint displays were statistics-by-themes and side-by-side comparisons. Innovative joint displays connected findings to theoretical frameworks or recommendations. Researchers used joint displays for convergent, explanatory sequential, exploratory sequential, and intervention designs. We identified exemplars for each of these designs by analyzing the inferences gained through using the joint display. Exemplars represented mixed methods integration, presented integrated results, and yielded new insights. CONCLUSIONS: Joint displays appear to provide a structure to discuss the integrated analysis and assist both researchers and readers in understanding how mixed methods provides new insights. We encourage researchers to use joint displays to integrate and represent mixed methods analysis and discuss their value.

Achieving integration in mixed methods designs-principles and practices.

Mixed methods research offers powerful tools for investigating complex processes and systems in health and health care. This article describes integration principles and practices at three levels in mixed methods research and provides illustrative examples. Integration at the study design level occurs through three basic mixed method designs-exploratory sequential, explanatory sequential, and convergent-and through four advanced frameworks-multistage, intervention, case study, and participatory. Integration at the methods level occurs through four approaches. In connecting, one database links to the other through sampling. With building, one database informs the data collection approach of the other. When merging, the two databases are brought together for analysis. With embedding, data collection and analysis link at multiple points. Integration at the interpretation and reporting level occurs through narrative, data transformation, and joint display. The fit of integration describes the extent the qualitative and quantitative findings cohere. Understanding these principles and practices of integration can help health services researchers leverage the strengths of mixed methods.

Mixed methods research in music therapy research.

BACKGROUND: Music therapists have an ethical and professional responsibility to provide the highest quality care possible to their patients. Much of the time, high quality care is guided by evidence-based practice standards that integrate the most current, available research in making decisions. Accordingly, music therapists need research that integrates multiple ways of knowing and forms of evidence. Mixed methods research holds great promise for facilitating such integration. At this time, there have not been any methodological articles published on mixed methods research in music therapy. OBJECTIVE: The purpose of this article is to introduce mixed methods research as an approach to address research questions relevant to music therapy practice. METHODS: This article describes the core characteristics of mixed methods research, considers paradigmatic issues related to this research approach, articulates major challenges in conducting mixed methods research, illustrates four basic designs, and provides criteria for evaluating the quality of mixed methods articles using examples of mixed methods research from the music therapy literature. CONCLUSIONS: Mixed methods research offers unique opportunities for strengthening the evidence base in music therapy. Recommendations are provided to ensure rigorous implementation of this research approach.

The Racial and Ethnic Identity Formation Process of Second-Generation Asian Indian Americans: A Phenomenological Study.

This phenomenological study elucidates the identity development processes of 12 second-generation adult Asian Indian Americans. The results identify salient sociocultural factors and multidimensional processes of racial and ethnic identity development. Discrimination, parental, and community factors seemed to play a salient role in influencing participants' racial and ethnic identity development. The emergent Asian Indian American racial and ethnic identity model provides a contextualized overview of key developmental periods and turning points within the process of identity development.

The effect of telephone support on depressive symptoms among HIV-infected pregnant women in Thailand: an embedded mixed methods study.

Depressive symptoms negatively impact the lives of HIV-infected individuals and are correlated with faster progression to AIDS. Our embedded mixed methods study examined and described the effects of telephone support on depressive symptoms in a sample of HIV-infected pregnant Thai women. HIV-infected pregnant Thai women (n = 40) were randomly assigned to either the control or the intervention group. A registered nurse provided telephone support to the intervention group. Depressive symptoms were measured at three points in both groups. In-depth interviews were conducted at Time 2 and Time 3. Results show that depressive symptoms in the intervention group decreased over time. Qualitative results describe how telephone support can work, but also reveal that telephone support did not work for everyone. We recommend that a larger mixed methods study be conducted to examine the effects of telephone support on depressive symptoms among HIV-infected women, including the costs and benefits of such support.