1. Use of mixed methods in the evaluation of suicide prevention strategies and interventions
Stephen Platt
Qualitative research and suicide
Seminar, Cardiff University, 2 July 2007

2. Structure of presentation
Mixed methods research
Suicide in Scotland: trends and context
Choose Life strategy and action plan
Evaluation plan
Selected main findings
Selected recommendations

3. Mixed 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

4. Why the increasing popularity of mixed methods research? (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

5. Why the increasing popularity of mixed methods research? (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

6. Misconceptions of ‘the 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

7. Rationales underlying choice of method(s) (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.

8. Rationales underlying choice of method(s) (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)

9. Rationales underlying choice of method(s) (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

10. Combining methods in research process: context of justification
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)

11. Mixed methods designs: key 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)?

12. Possible permutations of mixed 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

13. Suicide rates across the world (2002)

14. Age-standardised suicide rates, by country, 1991/93-2002/04, males

15. Age-standardised suicide rates, by country, 1991/93-2002/04, females

16. Intentional self harm & undetermined deaths, Scotland, 15+ years, 1970-2005

17. Scotland’s national suicide prevention strategy & action plan: Choose 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 ( )
Overall aim: to reduce suicide rate in Scotland by 20% in 2013 (cf 2002)

18. Choose Life: national and local 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

19. Evaluation: 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

20. Theory-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)

21. Theory-based evaluation: the 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
A further criticism of traditional experimental approaches is that it strips programmes of their context by controlling for intervening variables. For evaluators of a qualitative and theory-based bent this is anathema.
Qualitative approaches have been able to provide some answers to questions about how certain programme processes interact with their contexts and participants – for example, work looking at the circumstances in which partnership working will flourish, or the reasons that smokers engage with smoking cessation programmes but those who design policy programmes whilst they can be convinced that process and contextual information is valuable usually require some focus on outcome and effectiveness.

22. Theory-based evaluation: the 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
Through a collective and collaborative process involving documentary review, stakeholder interview and groups discussion…
The ensuing ‘theory of change’ can be used to improve programme planning and of make evaluation decisions about what processes, impacts and outcomes need to be captured and when.

23. Main 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

24. Co-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

25. Interviews with key informants
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

26. Local area case studies (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

27. Local area case studies (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

28. Local area case studies (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

29. Local area case studies (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)

30. National workshops (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.

31. National workshops (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

32. Data analysis (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

33. Data analysis (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’

34. Evaluation: main findings
Sustainable infrastructures for implementation
Allocation and use of resources
Innovative practice and use of evidence
Sustainability
Decision making processes and learning

35. Sustainable infrastructures for 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

36. Allocation and use of resources
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

37. Innovative practice and use 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

38. Sustainability
NIST identified several achievements in building a sustainable infrastructure for suicide prevention
At local level, most success achieved in mainstreaming training activities

39. Decision making processes and 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.

40. Recommendations: mainstreaming at national level
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

41. Recommendations: mainstreaming 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

42. Recommendations: self-harm
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

43. Recommendations: 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

44. Recommendations: central coordination 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

45. Choose Life evaluation (first phase): research team
University of Edinburgh
Stephen Platt (RUHBC)
Emma Halliday (RUHBC)
Margaret Maxwell (General Practice)
Scottish Development Centre for Mental Health
Joanne McLean
Allyson McCollam
Amy Woodhouse
London School of Economics
Dave McDaid (Health & Social Care)
Glasgow University
Mhairi Mackenzie (Public Health & Health Policy)
Avril Blamey (Public Health & Health Policy)