R

Rr

KLa

b

c

a

ARRA

KQMI

I

tmstrcliwi

0d

International Journal of Drug Policy 23 (2012) 54– 61

Contents lists available at ScienceDirect

International Journal of Drug Policy

journa l h o me pa ge: www.elsev ier .com/ locate /drugpo

esearch methods

econciling incongruous qualitative and quantitative findings in mixed methodsesearch: Exemplars from research with drug using populations

arla D. Wagnera,∗ , Peter J. Davidsona , Robin A. Pollini a , Steffanie A. Strathdeea , Rachel Washburnb ,awrence A. Palinkasc

Division of Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive MC 0507, La Jolla, CA 92093-0507, USADepartment of Sociology, Loyola Marymount University, One LMU Drive, Suite 4314, Los Angeles, CA 90045-2659, USASchool of Social Work, University of Southern California, Montgomery Ross Fisher Building, Los Angeles, CA 90089-0411, USA

r t i c l e i n f o

rticle history:eceived 23 November 2010eceived in revised form 11 May 2011ccepted 14 May 2011

eywords:ualitative methodsixed methods research

njection drug use

a b s t r a c t

Mixed methods research is increasingly being promoted in the health sciences as a way to gain morecomprehensive understandings of how social processes and individual behaviours shape human health.Mixed methods research most commonly combines qualitative and quantitative data collection and anal-ysis strategies. Often, integrating findings from multiple methods is assumed to confirm or validate thefindings from one method with the findings from another, seeking convergence or agreement betweenmethods. Cases in which findings from different methods are congruous are generally thought of asideal, whilst conflicting findings may, at first glance, appear problematic. However, the latter situationprovides the opportunity for a process through which apparently discordant results are reconciled, poten-tially leading to new emergent understandings of complex social phenomena. This paper presents threecase studies drawn from the authors’ research on HIV risk amongst injection drug users in which mixedmethods studies yielded apparently discrepant results. We use these case studies (involving injectiondrug users [IDUs] using a Needle/Syringe Exchange Program in Los Angeles, CA, USA; IDUs seeking topurchase needle/syringes at pharmacies in Tijuana, Mexico; and young street-based IDUs in San Fran-cisco, CA, USA) to identify challenges associated with integrating findings from mixed methods projects,

summarize lessons learned, and make recommendations for how to more successfully anticipate andmanage the integration of findings. Despite the challenges inherent in reconciling apparently conflictingfindings from qualitative and quantitative approaches, in keeping with others who have argued in favourof integrating mixed methods findings, we contend that such an undertaking has the potential to yieldbenefits that emerge only through the struggle to reconcile discrepant results and may provide a sumthat is greater than the individual qualitative and quantitative parts.

ntroduction

Mixed methods research is a re-emerging area of interest inhe field of drug use research, and has received attention across

ultiple disciplines, including anthropology, epidemiology andociology (Bourgois, 2002; Moss, 2003; Rhodes, 2009). Whilsthere are increasing calls for and advocates of mixed methodsesearch designs, combining qualitative and quantitative strategiesan present a number of distinct philosophical and logistical chal-enges, including whether and how to integrate findings that may

nitially appear to conflict. Methodological scholars have engaged

ith the process of how and when to combine findings from qual-tative and quantitative research (for reviews see Denzin, 2010;

∗ Corresponding author. Tel.: +1 619 543 0857; fax: +1 858 534 7566.E-mail address: kdwagner@ucsd.edu (K.D. Wagner).

955-3959/$ – see front matter © 2011 Elsevier B.V. All rights reserved.oi:10.1016/j.drugpo.2011.05.009

© 2011 Elsevier B.V. All rights reserved.

Kelle, 2001). In its most recent iteration, termed the “third method-ological moment” (Denzin, 2010, p. 422), researchers conductingmixed methods research have revisited the discussion, and somenote a resurgence of interest in integration in the design, analysis,and interpretation of mixed methods studies (e.g. Bazeley, 2009).Some have noted that the process of integration, particularly inte-gration of apparently discrepant data, can itself be a productiveenterprise (Fielding, 2009); though the success of such integra-tion efforts may depend on the perspective with which researchersapproach the discrepancies.

At first glance, integration is often thought of in terms of seek-ing consistency between qualitative and qualitative findings. Inone commonly used form, integration through the “triangulation”

of findings from multiple methods implies a search for increasedvalidity; the use of multiple methods producing similar resultssuggests that the phenomenon of interest has been more accu-rately measured than it could have been using a single method

Journa

(ibgtst(oou

htaCTo1cmtaqblfeq“(paaytisagf

ppsbIoftwPpaTgntsrommtsm

K.D. Wagner et al. / International

Moran-Ellis et al., 2006). In the social sciences, triangulation hasts roots in the classic multitrait-multimethod matrices proposedy Campbell and Fiske (1959) as a means of establishing conver-ent validity of psychological scales. Though ultimately favouringhe classic conceptualisation of triangulation in the trigonometricalense, Kelle (2001) also offers a third interpretation of triangula-ion: triangulation as a means of integrating multiple perspectivescomplementarity). From a more postmodern perspective, the usef multiple methods can been seen to extend the “scope and depthf understanding” (Fielding, 2009, p. 429), and can provide a richernderstanding of complex social issues.

In the fields of drug use and HIV prevention research, scholarsave increasingly employed mixed methods designs to investigatehe complex environmental, social, and individual factors that aressociated with negative health outcomes (Bourgois et al., 2006;latts, Welle, Goldsamt, & Lankenau, 2002; Pollini et al., 2010;orrone et al., 2010), though the complementary use of epidemi-logy and ethnography in the study of drug use is not new (Agar,997; Clatts, Southeran, Heimer, & Goldsamt, 1999). In the pro-ess, some have noted difficulties in integrating findings fromixed methods research. Critical to this discourse is attention to

he assumptions that underlie the methods that researchers arettempting to combine. Whilst differences between qualitative anduantitative approaches to complex social situations can oftene reduced to differences in data collection processes and ana-

ytic methodologies, these superficial differences can mask moreundamental epistemological differences – quantitative methodsmphasize deductive approaches that test a priori hypotheses;ualitative methodologies emphasize inductive approaches thatstress how social experience is created and given meaning”Denzin & Lincoln, 2000, p. 8, emphasis in the original). For exam-le, in complementary articles Bourgois (2002) and Moss (2003)rticulate some of the challenges experienced in the context of

large mixed methods study of disease transmission amongstoung injection drug users, which employed participant observa-ion, ethnographic interviews, and epidemiological surveys. Thesencluded reconciling differences between clinical and statisticalignificance, discipline-specific constructions of scientific validitynd reliability, and different levels of disciplinary focus (i.e., ethno-raphic focus on macro-level social structures vs. epidemiologicalocus on individual-level behaviour).

In this paper, we extend this discussion and argue that therocess of engaging with divergent results can yield a more com-rehensive and nuanced understanding of the situation undertudy, offering multiple viewpoints and encouraging a “dialogueetween differently committed minds” (Fielding, 2009, p. 436).n an effort to engage critically and reflexively with the processf doing mixed methods research, we present three case studiesrom our own research focused on the association between injec-ion drug use and HIV infection as exemplars (for more detailse refer the reader to the original publications: Davidson, 2009;

ollini et al., 2010; Wagner et al., 2010; Wagner et al., 2011). Therojects differ in their specific research questions, research designsnd in their methods of attempting to reconcile conflicting findings.he common theme, however, is that the work of seeking to inte-rate initially conflicting findings yielded rich insights into both theature of the phenomena and of the methods used to investigatehem. We provide a descriptive account of each case study, brieflyummarising the study design and implementation, analysis andesults; and discuss the efforts to reconcile apparently incongru-us results. We conclude with a discussion of the theoretical andethodological lessons learned from implementing these mixed

ethods projects, and with recommendations for how investiga-

ors engaged in research with drug using populations may moreuccessfully anticipate and manage the integration of findings fromultiple methods.

l of Drug Policy 23 (2012) 54– 61 55

Case Study 1: the role of “dopesickness” in influencing riskyinjection behaviour amongst IDUs

Background

Current public health recommendations hold that using a newneedle/syringe for every injection event is necessary to avoid thespread of HIV and other blood-borne viruses amongst IDUs (Gayle,O’Neill, Gust, & Mata, 1997). Considerable research has examinedthe role of the perceived risks associated with sharing injec-tion equipment in influencing needle/syringe sharing behaviour.However, less research has been dedicated to the converse – under-standing the influence of the perceived risk of refusing to shareinjection equipment. That is, the consequences that IDUs associatewith engaging in “safer” behaviour than can reduce the risk for HIVinfection. Epidemiological and ethnographic studies have identi-fied some factors that might be identified as potential consequencesof refusing to share needle/syringes, such as the threat of becom-ing “dopesick” (i.e., experiencing withdrawal symptoms associatedwith the delayed use of opioids), risking citation or arrest for pos-session of drug injection paraphernalia or violating social normsassociated with sharing. This study was designed to qualitativelyidentify the consequences that IDUs associate with refusing toshare injection equipment, and to examine the quantitative associ-ations amongst those perceived consequences, other psychosocialcorrelates of injection risk behaviour and needle/syringe and para-phernalia sharing.

Method

This study was designed as a two-phase, sequential mixed meth-ods study, in which the exploratory qualitative phase provided datathat were used to inform the development of items for a quanti-tative questionnaire. In Phase I, semi-structured interviews wereconducted with 26 IDUs recruited from a single Needle/SyringeExchange Program (SEP) in Los Angeles, CA, USA. The interviewsfocused on the most recent injection event in which the partici-pant shared injection equipment, and participants were asked todescribe the potential consequences to them if they had refused toshare equipment at that time. Interviews were digitally recordedand transcribed in their entirety. A theoretical framework that pro-vided some a priori thematic codes derived from the ethnographicand epidemiological literature guided the qualitative analysis, andemergent codes were added to the codebook throughout the anal-ysis.

For the second phase of the study, 187 IDUs were recruitedfrom the same SEP to participate in a structured interview usingAudio Computer Assisted Self Interview (ACASI). Qualitative datawere distilled into 11 possible consequences of refusing to share,and in the quantitative survey participants were asked how fre-quently each of the 11 consequences “influenced their decisionwhether or not to share injection equipment in the past 30 days”.The consequences were weighted by their importance (e.g. “howmuch of a problem would [that consequence] be for you?”), sincemore severe consequences may be more salient in their influence(Fishbein, 1967). The perceived consequence and importance ques-tions were included in the quantitative survey, along with measuresof other psychosocial constructs commonly used to explain injec-tion risk behaviour (e.g., perceived risk of HIV or HCV, self-efficacyfor safer injection, response efficacy, perceived severity of HIV orHCV, knowledge and peer norms for safer injection).

The aim of the quantitative analysis was to determine

whether the perceived consequences of refusing to share injec-tion equipment were associated with injection risk behaviour whencontrolling for other theoretically relevant psychosocial correlates.To investigate this question, we first created two sub-scales cre-

5 Journa

affarnrq

R

rw“hdcsioedbebitcdtrse

I

qeufitfiardr

ohacppibticwfdti

6 K.D. Wagner et al. / International

ted from the perceived consequences items using exploratoryactor analysis, which largely conformed to the theory that emergedrom the qualitative interviews: social/internal consequencesnd structural/external consequences. We then employed logisticegression analysis in which two dependent variables (receptiveeedle/syringe sharing and receptive paraphernalia sharing) wereegressed on the psychosocial correlates and the perceived conse-uences sub-scales.

esults

In the qualitative narratives, almost all participants describedisky injection events in which they were already experiencing, orere trying to avoid, the intense drug withdrawal symptoms (i.e.

dopesickness”) that results from delayed use of heroin amongsteroin-dependent injectors. They described events in which, if theyid not use the available injection equipment, they would mostertainly become dopesick, and therefore said they injected withhared equipment in an attempt to avoid it. However, this key find-ng from the qualitative analysis – that risky injection events wereverwhelmingly contextualized by an omnipresent risk of experi-ncing dopesickness – was less clearly borne out by the quantitativeata. In the quantitative analyses, the perceived consequence ofecoming “dopesick” yielded slightly inconsistent results in thexploratory factor analysis, showing moderate double loadings onoth sub-scales. Due to the salience of this particular consequence

n the qualitative narratives, this finding inspired additional quan-itative analyses in which we removed the item from the perceivedonsequences scales and evaluated its significance as an indepen-ent covariate. Results from these supplemental analyses showedhat, on its own, “dopesickness” was not associated with eithereceptive or distributive sharing, and removing it from the sub-cales did not substantially change the findings regarding the mainffects of the perceived consequences on injection risk behaviour.

ntegration challenges and lessons learned

Rather than use this discrepancy between the quantitative andualitative findings as a rationale for discrediting the results ofither analysis, we attempted to understand the circumstancesnder which such a discrepancy could arise, and its implications foruture research of this type, in which qualitative data are collectedn order to inform the design of a quantitative survey. We suggestwo potential frameworks for understanding this discrepancy: therst rooted in an understanding of the politics of representationnd social roles and biases inherent in the conduct of public healthesearch amongst drug users, and the second grounded in a studyesign perspective that emphasizes a reciprocal, rather than linear,elationship between quantitative and qualitative data.

This particular case study highlights issues related to the politicsf representation that result from the interaction between publicealth researchers and IDUs. Though the interviewer/author hadn ongoing collaborative relationship with the SEP where the dataollection took place and had interacted with many of the interviewarticipants for over two years at the time that the interviews tooklace, she was not a member of the target population. Also, since the

nterviews occurred at the SEP, the researcher was often identifiedy participants as part of the SEP staff (even though she emphasizedhat she was not employed by the SEP). The findings from the qual-tative portion of the project, then, must be understood within thisontext. It is possible that the emphasis on the role of dopesicknessas offered as a way to avert anticipated blame from the researcher

or engaging in behaviour that both parties understood to confer aisease transmission risk. Attributing their risky behaviour to thehreat of drug withdrawal, then, could represent an attempt bynterview participants to avoid violating the shared expectations

l of Drug Policy 23 (2012) 54– 61

of the participant and the SEP regarding acceptable behaviour. Inthe quantitative interviews, on the other hand, participants hadthe freedom to enter their responses to questions about the impor-tance of dopesickness in influencing their behaviour directly intothe computer without having to explain or justify their actions theresearch team. Thus, one explanation for the observed discrepancybetween the relative importance of dopesickness in the two phasesof the study may have to do with the social context of describingrisky injection events to a researcher. In short, this finding couldhave been influenced by social desirability bias (a risk faced in allbehavioural research relying on respondent self-report). Whilst theabsence of statistical correlation in the quantitative phase neitherconfirms nor refutes the presence of social desirability bias, it doeshighlight the need for sensitivity to and discussion of its potentialeffects. One contribution of the mixed methods approach, in thiscase, is its ability to highlight the need for a reflexive examinationof identity politics and the influence of the social-spatial context inwhich research occurs (Bourgois, 2002).

The discrepancies highlighted in this case study also pointtowards another contribution of the mixed methods approach –the ability of a mixed methods design to create a reciprocal dia-logue between quantitative and qualitative data, such that findingsfrom one method inform the development and analysis of thenext, which can then be used to refine subsequent phases of theinvestigation. This study was designed in two phases, in which thequalitative results were used to inform the development of a quan-titative scale. Unexpectedly, the initial lack of agreement betweenthe qualitative and quantitative results on the importance of theinfluence of “dopesickness” inspired the investigators to pursueadditional quantitative analyses that would have remained unex-plored in the absence of the compelling qualitative results. Thoughnot feasible under the funding mechanism and timeline for the cur-rent study, a more comprehensive use of a mixed methods designcould capitalise on the apparently discrepant results to refine thedata collection instruments based on lessons learned through theattempt to reconcile the results. For example, it is possible that thequantitative questions did not accurately measure the same con-struct that was discussed in the qualitative interviews, or that thedifference in referent timeframes in the two phases influenced theresults (i.e. the most recent risky injection event described in thequalitative interviews versus quantitative questions that asked par-ticipants to think more generally about behaviour over the past 30days). Simply piloting the quantitative interviews (which was alsodone in this study) would not have identified this issue. Additionaldata collection in the form of cognitive interviews to understandhow participants interpret the quantitative questions or “member-checking” interviews or focus groups to discuss with participantswhether the findings from the research resonate with their experi-ence, could shed some light onto the validity of the findings. In theabsence of the mixed methods design that explicitly attempted tointegrate the findings from the two phases, however, the discrep-ancies may not have been discovered and the lessons for futurestudy designs, data collection instruments and analysis strategieswould have been lost.

Case Study 2: barriers to needle/syringe purchase at retailpharmacies in Tijuana, Mexico

Background

In Mexico, it is legal to purchase and possess sterile nee-

dle/syringes without a prescription. However, findings fromqualitative research with IDUs in the north-western border city ofTijuana, Baja California, Mexico, suggested that some pharmaciesrefuse to sell or charge higher prices to persons suspected of being

Journa

IdattscfthI

M

p(dat2aoapnpawprw

odpfesar1uitn

R

rMiabbppdn

tb(st

K.D. Wagner et al. / International

DUs (Strathdee et al., 2005). In prior qualitative interviews, IDUsirectly linked these pharmacy-based barriers to needle/syringeccess to the practice of needle/syringe sharing, thus increasingheir risk for HIV infection. To understand more completely the con-ext of pharmacy sales in Tijuana, we undertook a mixed methodstudy designed to (1) quantify the frequency of refusals and over-harges reported by IDUs attempting to purchase needle/syringesrom pharmacies in Tijuana, (2) identify correlates of experiencinghese barriers to needle/syringe access and (3) provide a compre-ensive understanding of these correlates within the context of

DUs’ experiences.

ethod

A detailed account of the study methods and results has beenublished elsewhere (Pollini et al., 2010). Briefly, the parent studyProyecto El Cuete Phase III) recruited 1056 IDUs via respon-ent driven sampling (RDS; Heckathorn, 1997) between 2006nd 2007 into a longitudinal study of behavioural and contex-ual risk factors for HIV, syphilis and TB infection (Strathdee et al.,008). Participants completed an interviewer-administered surveyt baseline and every six months thereafter that included questionsn demographics, drug use behaviours, needle/syringe acquisitionnd use and experiences with police. At the second study visit,articipants were asked whether they had attempted to purchaseeedle/syringes at a pharmacy in the past six months and, if so, torovide information on the outcome of the most recent purchasettempt. IDUs who reported being overcharged and/or refusedere defined as having experienced barriers to pharmacy-basedurchase and were compared to those who did not experience bar-iers using univariable and multiple logistic regression methodsith RDS adjustment.

Between October 2008 and March 2009 we recruited a subsetf 47 IDUs from the parent study to participate in focus groupsesigned to provide detailed accounts of experiences related toharmacy-based needle/syringe purchase. We conducted sevenocus groups, of which five consisted entirely of males and twontirely of females. The focus groups were audio recorded, tran-cribed verbatim, translated into English by a certified translatornd then double-coded using a descriptive and thematic approachooted in Grounded Theory (Glaser & Strauss, 1967; Willms et al.,990). An explanatory design was then used to explain or buildpon the quantitative results (Creswell & Plano Clark, 2006); that

s, we used themes from the focus groups to elucidate why cer-ain characteristics were associated with experiencing barriers toeedle/syringe purchase.

esults

Overall, 649 IDUs completed the visit 2 survey and 627 (96.6%)esponded to the question on pharmacy needle/syringe purchase.ost (80.7%) reported purchasing a needle/syringe in a pharmacy

n the past 6 months and 71.6% of all participants cited pharmaciess their primary source of needle/syringes. Only 16.0% experiencedarriers to pharmacy-based needle/syringe purchase, includingeing refused purchase, being overcharged or both. Factors inde-endently associated with experiencing barriers to needle/syringeurchase were being homeless, engaging in receptive nee-le/syringe sharing, reporting an average of more than five uses pereedle/syringe and having a greater number of lifetime abscesses.

These quantitative findings directly contradicted earlier quali-ative interviews by our research team in which pharmacy-based

arriers to needle/syringe access emerged as a key themeStrathdee et al., 2005). We investigated this discrepancy in theeven focus groups by inviting participating IDUs to help us explainhese discordant findings. Participants described a scenario in

l of Drug Policy 23 (2012) 54– 61 57

which pharmacies are reluctant to sell needle/syringes to personssuspected of illicit drug use, reportedly because of fear of police(despite the fact that needle/syringes can be legally sold and pos-sessed without a prescription), fear of IDU theft and violence andoverall concerns about the impact IDU customers would have onthe “image” of their business. They explained that IDUs adapt to thisrestrictive purchasing environment by working to develop a per-sonal relationship with staff at a single pharmacy; by building thisrelationship the IDU becomes “known” to the staff as someone whowill not cause trouble for them, thus increasing their willingness tosell needle/syringes. This pharmacy becomes the primary source ofneedle/syringes for that IDU, with purchases attempted elsewhereonly when that pharmacy is not available (e.g., after hours, immedi-ately after release from jail when withdrawal requires immediateinjection). It is in these latter cases that IDUs are most likely toencounter refusals or overcharging.

Integration challenges and lessons learned

Lessons learned from this case study again point to in part toa methodological issue that would not have been identified in asingle-method study – our discrepant findings were likely due inpart to how we worded the questions in Phases I and III of theparent study. In the Phase I qualitative study we asked “Will mostpharmacies sell syringes to drug users in this city?” followed byprobes designed to ascertain the nature of any barriers cited (e.g.requiring a prescription). In doing so, we asked IDUs to describeneedle/syringe access at the community level. In contrast, the PhaseIII quantitative study asked: “In the last 6 months, did you purchasea syringe from a pharmacy in Tijuana?” thus focusing on accessat the individual level. Whilst the wording of these questions maynot have been optimal, it is often the case with multi-year studiesthat question wording and emphasis changes. In this case, using amixed methods approach that included a third type of data collec-tion – focus groups in which participants offered their opinions ofand explanations for the data from the contradictory qualitativeand quantitative data – allowed us to provide another perspec-tive that enhanced our understanding of the IDU risk environment.Specifically, the “member checking” focus groups revealed theadaptive process of becoming “known” to pharmacies, which wouldhave remained unobserved in the absence of the discussions aboutthe apparently contradictory results. Relying on the qualitative orquantitative interviews alone would have resulted in a highly dis-torted view of the needle/syringe access situation in Tijuana.

This case study also points to the value of conducting mixedmethods studies that employ a sequential design that explicitlyallowed for an ongoing dialogue between the quantitative andqualitative phases. The subsequent focus groups afforded us anopportunity to examine the reasons for our discrepant findingsfrom El Cuete using input from the participants themselves. Wespecifically asked them to identify reasons for the discrepant find-ings, and what emerged was a very richly detailed account of adynamic adaptive process designed to negotiate needle/syringeaccess in a highly restrictive and complex environment. This levelof detail would not have been obtained had the previously identi-fied discrepancy not been used as the starting point for our focusgroup discussions.

Case Study 3: young injectors, policing and SEP access in SanFrancisco, CA, USA

Background

Currently San Francisco, CA, USA has fifteen legal SEP sites,eleven run by a city agency and the remainder by non-profit organi-

5 Journa

sSnwdesppiWBMitalftbhwpat

M

icoFcawshmiaIuotns3

twaptraseat

y(qd

8 K.D. Wagner et al. / International

ations receiving most of their funding from the city (NASEN, 2010;AFAF, 2010). In 2005, the city took advantage of a change in Califor-ia State law to formally legalise the possession of needle/syringesithout a prescription. However, a considerable body of literatureescribes social and logistical barriers to accessing sterile injectingquipment, even in jurisdictions such as San Francisco that are well-erved by SEPs and where the legal consequences of needle/syringeossession have been minimised. These barriers include fear ofolice, fear of being identified as a drug user and limited open-

ng hours and/or service location (Bluthenthal, Kral, Lorvick, &atters, 1997; Case, Meehan, & Jones, 1998; Gostin, 1998; Heimer,

luthenthal, Singer, & Khoshnood, 1996; Rich, Strong, Towe, &cKenzie, 1999). Whilst “fear of police” is frequently cited in stud-

es of barriers to utilisation of SEPs, little work has been doneo explore this finding in more detail in order to examine whichspects of interaction with the judicial system are particularlyikely to influence access to SEPs and injecting equipment. Oneactor that has not been sufficiently examined is how mobility pat-erns amongst young, homeless IDUs may mediate the associationetween contact with law enforcement and access to services. Weypothesized that young IDUs’ experiences with law enforcementould influence their comfort travelling to various parts of the city,articularly those neighbourhoods where HIV prevention servicesre located (e.g. SEPs), and that would in turn influence their accesso injecting equipment via SEPs.

ethod

Simultaneous cross-sectional quantitative (N = 455) and qual-tative interviews (N = 17 interviews with 16 individuals) wereonducted as a sub-study within a larger epidemiological studyf HCV transmission amongst young (<30 year old) IDUs in Sanrancisco. Quantitative interviews assessed two sets of measures:urrent judicial status and injection risk behaviour. Variablesssessing current judicial status included: whether someone hadarrants out for their arrest, was on probation or parole, had been

topped by police for any purpose in the past three months orad been incarcerated overnight or longer within the past threeonths. Lifetime history of incarceration (ever incarcerated, and

f so for how long in total; ever been on probation or parole) waslso recorded. To assess injection risk behaviour, we created a Safernjection Indicator (SII), which measured how closely each individ-al approximated the U.S. Public Health Service standard of usingne new needle/syringe for every injection (Gayle et al., 1997) inhe last 30 days. The SII was constructed by taking the number ofeedle/syringes acquired in the last 30 days from any source andubtracting the number of self-reported injection events in the last0 days.

Qualitative interviews were semi-structured and carried out athe field sites of the parent study with a sub-sample of individualsho were or had been in the parent study and who were present

t the parent study field site. Qualitative interviews addressed theossible relationships between engagement with the judicial sys-em and access to SEPs, by more broadly exploring how and whereespondents moved through the city; what made them go to orvoid certain areas; what role their interactions with the judicialystem and police had in influencing these movements and throughxploration of how these patterns of movement through the citynd their relationships with the judicial system affected their abilityo visit SEP sites.

Qualitative transcripts were coded and thematically anal-

sed based on Grounded Theory/Situational Analysis approachesClarke, 2003; Glaser & Strauss, 1967; Strauss & Corbin, 1998). Foruantitative data, the Mann–Whitney U-test was used to compareifferences between the median SII values grouped by judicial sta-

l of Drug Policy 23 (2012) 54– 61

tus measures. For non-parametric continuous variables, variableswere categorised and compared using a chi-square test.

Results

In the quantitative analysis, those who had been stopped bypolice within the past three months were significantly less likelythan those who had not been stopped to report obtaining enoughneedle/syringes to meet their injecting needs. No other measureof judicial status had a statistically significant association with SIIin either direction. These data suggest a direct negative associa-tion between frequent contact with police and access to sufficientneedle/syringes to meet one’s needs.

However, in the qualitative interviews, it appeared that therewas very little association between being stopped by police andIDUs’ ability to access needle/syringes; participants did not identifycontact with police as a barrier to needle/syringe access. Instead,participants in the qualitative interviews described a situationin which contact with police influenced where and how theymoved around the city (i.e. an association between police con-tact and mobility), an association that itself was largely influencedby participants’ strategies for income generation. Those who usedtechniques such as panhandling (i.e. begging), for example, wereused to endemic but “trivial” contact with police, and expressed rel-atively little concern about police contact. In contrast, those whoshoplifted or sold drugs usually had less contact with police butthe contact that did occur was of more substantial legal signifi-cance and hence of higher concern. The combination of economicnecessity and relative attitudes towards contact with police shapedwhere people spent time and how comfortable they were in thoseareas – a panhandler would, out of necessity, spend a lot of timein parts of the city with high levels of foot traffic; would be very“visible” in those places; would be relatively unconcerned that shewas “known” to police in the area and would subsequently haverelatively few barriers to accessing services such as needle/syringeexchange in those parts of the city. By contrast, a shoplifter wouldspend relatively brief periods of time in parts of the city withspecific types of retail stores; would attempt to be “invisible” inthose places; would be highly concerned about becoming “known”to police anywhere in the city and would have relatively strongincentives to avoid going to commercial districts other than whenshoplifting due to fear of recognition by merchants or police.

Most SEPs in San Francisco are deliberately located in parts ofthe city with a visible population of IDUs – i.e. in commercial areaswith high levels of foot traffic where panhandling is common. Assuch, our qualitative data described a situation where frequencyof contact with police did not in itself appear to affect people’swillingness and ability to visit SEPs. Rather, willingness and abil-ity to visit parts of the city where SEPs were located was shaped byhow someone earned money, and the consequences of that methodof income generation on the nature of their relations with police.Through integrating the findings from the two methods – one thatfound an association between police contact and needle/syringeaccess and the other that found an association between police con-tact and mobility/income generation – we were able to arrive at amore complete understand of the factors and underlying processesassociated with needle/syringe access.

Integration challenges and lessons learned

The apparent discrepancies between quantitative and quali-tative results (that frequent contact with police was statistically

associated with less access to needle/syringes, but qualitativelythe association was less apparent and was mediated by incomegeneration strategies and consequent physical movement aroundthe city) are a reminder of the basic truism that correlation is not

Journa

ctcItatdddigfaaaaIspm

D

wicmeormiutofaeetocItbtpmmatp

lqaivopacT

K.D. Wagner et al. / International

ausation. Unmeasured in the quantitative data, identification ofhis third variable through the qualitative interviews helped addomplexity and nuance to an apparently simple direct association.n doing so, the qualitative approach suggested both future direc-ions for research (such as systematically attempting to measuressociations between income generation strategies, criminal jus-ice consequences and access to needle/syringes), and differentirections for possible interventions designed to improve nee-le/syringe access (such as delivering needle/syringes in moreispersed locations, such as community health clinics, or conduct-

ng designing satellite exchange programs specifically targetingroups who under-utilize SEPs). This case study also highlights dif-erences in the level of focus that can be obtained from quantitativend qualitative data collection. Quantitative assessments are adeptt measuring discrete events (i.e. being stopped by police) andnalyses focuses on determining whether statistically significantssociations exist between those events and pre-defined outcomes.n contrast, qualitative interviews can reveal larger cultural andocial processes and dynamics (e.g. relations between IDUs andolice) that are more difficult to distill into discrete items to beeasured by a quantitative survey (Bourgois, Prince, & Moss, 2004).

iscussion

We have described three case studies from our own researchith IDUs in which mixed methods designs were employed to

nvestigate barriers to safer injection. Our selection of these threease studies is not meant to be globally representative of all mixedethods research with drug users. Instead, we present them as

xamples of different designs and approaches to mixed meth-ds research that share a common theme of working towards aeconciliation of apparently discordant findings from their mixedethods designs. By working to integrate initially conflicting qual-

tative and quantitative findings, we achieved a more nuancednderstanding of the issues than may have been achieved throughhe use of a single method. It should be noted, however, thatur interpretations of the mechanisms behind the observed dif-erences are both speculative and partial. Similar to any othernalysis, it is possible that other researchers could identify differ-nt explanations. Nonetheless, all three projects served to set a newxpectation regarding agreement between quantitative and quali-ative data and highlighted the unique challenges and contributionsf the mixed methods approach when faced with apparently dis-repant data. In our case studies, these came in two primary forms:n Case Studies 1 and 2, our conflicting findings highlighted a needo be attuned to the methodological differences that may emergeetween quantitative and qualitative data collection phases, andhe implications of those differences for the integration and inter-retation of findings. In Case Studies 2 and 3, the use of multipleethods allowed for different levels of focus, contrasting theeasurement of associations between discrete factors with the

ssessment of underlying social, behavioural or cultural processeshat are less easily measured and were not initially identified as arimary variable or issue under study.

These contributions underscore some of the primary epistemo-ogical and methodological differences between quantitative andualitative methods. The power to define the issue under studynd the acceptable response options a priori is situated with thenvestigator in quantitative research, whilst in qualitative inter-iews the respondent has more freedom to introduce new topicsr define unexpected response options. Qualitative methods are

articularly useful in highlighting the participant’s “voice” andllowing him/her to explain responses or provide conditions oraveats that could be lost in a strictly quantitative assessment.hey also allow the investigator to develop insights that might

l of Drug Policy 23 (2012) 54– 61 59

be difficult to infer quantitatively, working from the “ground up”to identify variability in behaviour and environmental influences(Clatts et al., 2002). For example, in Case Study 2, focus group inter-views allowed participants to explain the unexpected quantitativefindings and contextualize them in their descriptions of an adaptiveprocess that was unanticipated and unmeasured in the quanti-tative survey. However, some qualitative methods may be morevulnerable to issues of personal representation or social biasesthat influence how information is exchanged between respon-dent and interviewer, encouraging a more reflexive examinationof the process that can be incorporated into the analysis. Qualita-tive methods such as ethnography are able to uncover cultural andsocial meanings and processes that can help explain and contextu-alize quantitative associations, whilst quantitative methods such asepidemiological surveys may reveal associations between discrete,measured variables that participants are unaware of or unable toexplain (Agar, 1997). For example, in Case Study 3, respondentsin the qualitative component spontaneously introduced incomegeneration techniques as an important factor and made associa-tions between those techniques and their relationships with police.Through integration of the qualitative results with the quantitativefindings, the investigators were able to provide a more holistic viewof the complex system influencing respondents’ risk for HIV. Theseunderlying issues should be considered in advance when designinga mixed methods study, and the different methods can be used tocapitalise on their unique strengths.

Whilst we acknowledge that not all mixed methods researchprojects will produce conflicting findings, anticipating that pos-sibility may serve to benefit future projects that employ similardesigns. Based on the lessons learned from these case studies weconclude with a brief discussion of some logistical challenges thatface investigators implementing mixed methods studies, includingchallenges to study design, grant writing and manuscript publica-tion.

In terms of the design and implementation of mixed methodsstudies, several issues can be considered in advance. These includeproject timelines, sampling schemes, and the use of additionalmethods. Planning for the work of integrating findings during thestudy design process and developing project timelines in advancethat allow time for integration and/or subsequent data collec-tion phases is a critical factor in ensuring the success of mixedmethods studies. Study designs that are flexible enough to incor-porate emerging findings during the research process and to allowone phase to inform the next (rather than holding all integra-tion activities for the end) may have a greater chance of success.However, funding mechanisms are often oriented around linearrather than iterative or reciprocal study designs. More complexiterative designs may require longer timelines than are allowableunder most common funding mechanisms. Successful integrationof discrepant findings will be more likely if project timelines are suf-ficient, or supplementary funding is specifically available for mixedmethods projects.

Another design issue to be addressed in mixed methods studiesis that of sampling. Priorities for both sample size and samplingstrategy may differ between qualitative and quantitative meth-ods – whilst quantitative methods are concerned primarily withdemonstrating sufficient statistical power, qualitative methods aremore concerned with achieving conceptual or theoretical satura-tion. Planning a mixed methods study that allows for the collectionof qualitative data in a way that is sufficiently flexible to achievesaturation can be challenging, particularly given the requirementsof the grant development and ethical review process that sample

sizes be determined a priori (Mason, 2010). Long standing qualita-tive approaches such as Grounded Theory (Charmaz, 2006; Glaser &Strauss, 1967; Strauss & Corbin, 1997), in which sampling is guidedby a search for theoretical saturation and can evolve to address

6 Journa

eTi(

d(ceipasota(i

rmiimrmec2ra&

C

mmidfoWmvpiiqisottqiagimflscnd

0 K.D. Wagner et al. / International

mergent issues in the data, may be particularly informative here.he use of participant observation or ethnographic methods tonform quantitative sampling strategies may also be recommendedClatts, Davis, & Atillasoy, 1995).

Planning for subsequent phases of data collection that areesigned to enlist the respondents in the reconciliation processe.g. “member checking” in Case Study 2) can aid in the recon-iliation of findings from multiple methods, and can provide anxplicit forum for one phase to inform the other. Other designs maynclude the use of additional methods of data collection. Whilst therojects described here made use of particular forms of qualitativend quantitative methods, including other data collection methodsuch as GIS mapping, participant observation, visual ethnographyr social network analysis could provide yet another perspec-ive on the phenomenon under study. Importantly, none of thesepproaches negate the need for thorough piloting of interviewsboth qualitative and quantitative). Including community membersn this process may further enhance validity.

Finally, compared to single method studies, manuscripts thateport integrated findings from mixed methods studies are oftenore challenging to publish. They are often longer, frequently

nclude more complicated methods sections, and are likely tonclude a range of results from qualitative, quantitative or other

ethods. They can also be challenging for both readers and peer-eviewers, who may have greater expertise or confidence in oneethod but not others (Bryman, 2007). Epistemological differ-

nces that underpin journal publishing preferences may furtherompound these difficulties (Rhodes, Stimson, Moore, & Bourgois,010). Perhaps as a result of some of these challenges, there are stillelatively few published papers available to serve as exemplars ofn integrative mixed methods approach (Bryman, 2007; Creswell

Tashakkori, 2007).

onclusion

Though methodologists and scholars continue to debate theerits of various theoretical approaches to the integration of mixedethods research, the use of mixed methods designs is increas-

ngly being used in public health research, including research withrug using populations. Whether these approaches are employedrom a purely pragmatic perspective or from a more theoreticalne, they have the potential to present challenges to integration.hether one subscribes to a positivist view of a single, empiricallyeasurable “truth” that can be derived, or to a more postmodern

iew of reality in which findings are viewed as socially situated andartial, researchers will face challenges in the integration of find-

ngs from mixed methods studies. Despite the challenges inherentn reconciling apparently conflicting findings from qualitative anduantitative approaches, in keeping with others who have argued

n favour of integrating mixed methods findings, we contend thatuch an undertaking has the potential to yield benefits that emergenly through the struggle to reconcile discrepant results. That is,he integration of mixed methods results (even if they initially seemo disagree) may provide a sum that is greater that the individualualitative and quantitative parts (Bryman, 2007), and the reflex-

ve process of engaging with the discrepant findings can itself be useful undertaking (Fielding, 2009). On a practical level, we sug-est that when planning a mixed methods research project theres considerable value in preparing for the possibility that different

ethodological approaches may produce different and often con-icting results, that processes for engaging with these differences

hould be planned in advance, and that engaging with the pro-ess of integrating results has the potential to produce richer, moreuanced, and ultimately more useful results than either methodoes alone.

l of Drug Policy 23 (2012) 54– 61

Acknowledgements

This research was supported by the following fundingsources: NIDA 2R01DA016017-07, NIDA 1R36DA024968, NIDAT32DA023356, NIDA R01DA019829, NIDA K01DA022923, NIDAK01DA031031, and the California HIV/AIDS Research Program D06-SF-424.

References

Agar, M. (1997). Recasting the “Ethno” in “Epidemiology”. Medical Anthropology, 16,391–403.

Bazeley, P. (2009). Integrating data analyses in mixed methods research. Journal ofMixed Methods Research, 3(3), 203–207.

Bluthenthal, R. N., Kral, A. H., Lorvick, J., & Watters, J. K. (1997). Impact of law enforce-ment on syringe exchange programs: A look at Oakland and San Francisco.Medical Anthropology, 18(1), 61–83.

Bourgois, P. (2002). Anthropology and epidemiology on drugs: The challenges ofcross-methodological and theoretical dialogue. International Journal of Drug Pol-icy, 13, 259–269.

Bourgois, P., Martinez, A., Kral, A., Edlin, B. R., Schonberg, J., & Ciccarone, D. (2006).Reinterpreting ethnic patterns among White and African American men whoinject heroin: A social science of medicine approach. PLoS Medicine, 3(10), e452.

Bourgois, P., Prince, B., & Moss, A. (2004). The everyday violence of hepatitis C amongyoung women who inject drugs in San Francisco. Human Organization, 63(3),253–264.

Bryman, A. (2007). Barriers to integrating quantitative and qualitative research.Journal of Mixed Methods Research, 1(1), 8–22.

Campbell, D. T., & Fiske, D. W. (1959). Convergent and discriminant validation bythe multitrait-multimethod matrix. Psychological Bulletin, 56(2), 81–105.

Case, P., Meehan, T., & Jones, T. S. (1998). Arrests and incarceration of injection drugusers for syringe possession in Massachusetts: Implications for HIV preven-tion. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology,18(Suppl. 1 (1)), S71–S75.

Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualita-tive analysis. London: Sage.

Clarke, A. E. (2003). Situational analysis: Grounded theory after the postmodernturn. Symbolic Interaction, 26(4), 553–576.

Clatts, M. C., Davis, W. R., & Atillasoy, A. (1995). Hitting a moving target: The useof ethnographic methods in the development of sampling strategies for theevaluation of AIDS Outreach Programs for Homeless Youth in New York City.Qualitative methods in drug abuse and HIV Research. NIDA Research Monograph,157, 117–135.

Clatts, M. C., Southeran, J. L., Heimer, R., & Goldsamt, L. A. (1999). Interdisciplinaryresearch on transmission of blood-borne pathogens among drug injectors:Applications of ethnography in epidemiology and public health. In P. A. Mar-shall, M. Singer, M. C. Clatts, R. H. Needle, & E. Lambert (Eds.), Integrating cultural,observational, and epidemiology approaches in the prevention of drug abuse andHIV/AIDS: Current status and future prospects (pp. 74–93). Rockville, MD: NationalInstitutes on Drug Abuse.

Clatts, M. C., Welle, D. L., Goldsamt, L. A., & Lankenau, S. E. (2002). An ethno-epidemiological model for the study of trends in illicit drug use: Reflectionson the ‘emergence’ of crack injection. International Journal of Drug Policy, 13(4),285–295.

Creswell, J. W., & Plano Clark, V. L. (2006). Designing and conducting mixed methodsresearch. Thousand Oaks, CA: Sage Publications Inc.

Creswell, J. W., & Tashakkori, A. (2007). Developing publishable mixed methodsmanuscripts. Journal of Mixed Methods Research, 1(2), 107–111.

Davidson, P. J. (2009). Space, Place, and Young Injecting Drug Users in San Francisco.Unpublished Ph.D. Dissertation, University of California, San Francisco.

Denzin, N. K. (2010). Moments, mixed methods, and paradigm dialogs. QualitativeInquiry, 16(6), 419–427.

Denzin, N. K., & Lincoln, Y. S. (2000). The discipline and practice of qualitativeresearch. In N. K. Denzin, & Y. S. Lincoln (Eds.), Handbook of qualitative research.Thousand Oaks, CA: Sage.

Fielding, N. G. (2009). Going out on a limb: Postmodernism and multiple methodresearch. Current Sociology, 57(3), 427–447.

Fishbein, M. (Ed.). (1967). Readings in attitude theory and measurement. New York:Wiley.

Gayle, H. D., O’Neill, J. F., Gust, S. W., & Mata, A. (1997). HIV prevention bul-letin: Medical advice for persons who inject illicit drugs. Retrieved fromhttp://www.cdc.gov/idu/pubs/hiv prev.htm [Electronic Version].

Glaser, B., & Strauss, A. (1967). The discovery of grounded theory. Chicago: Aldine.Gostin, L. O. (1998). The legal environment impeding access to sterile syringes and

needles: The conflict between law enforcement and public health. Journal ofAcquired Immune Deficiency Syndromes and Human Retrovirology, 18(Suppl 1.(1)), S60–S70.

Heckathorn, D. D. (1997). Respondent-driven sampling: A new approach to the studyof hidden populations. Social Problems, 44(2), 174–199.

Heimer, R., Bluthenthal, R. N., Singer, M., & Khoshnood, K. (1996). Structural impedi-ments to operational syringe-exchange programs. AIDS and Public Policy Journal,11(4), 169–184.

Journa

K

M

M

M

NP

R

R

R

K.D. Wagner et al. / International

elle, U. (2001). Sociological explanations between micro and macro andthe integration of qualitative and quantitative methods. Forum Qualita-tive Sozialforschung/Forum: Qualitative Social Research, 2. Retrieved fromhttp://qualitative-research.net/fqs/fqs-eng.htm [Electronic Version, On-lineJournal]

ason, M. (2010). Sample size and saturation in PhD studies usingqualitative interviews. Forum Qualitative Sozialforschung/Forum:Qualitative Social Research, 11. Retrieved from http://www.qualitative-research.net/index.php/fqs/article/view/1428/3027 [Electronic Version]

oran-Ellis, J., Alexander, V. D., Cronin, A., Dickinson, M., Fielding, J., Sleney, J.,et al. (2006). Triangulation and integration: Processes, claims and implications.Qualitative Research, 6(1), 45–59.

oss, A. (2003). Put down that shield and war rattle: Response to Philippe Bourgois.International Journal of Drug Policy, 14(1), 105–109.

ASEN. (2010). Retrieved from http://www.nasen.org/programs/us/ca/ollini, R. A., Lozada, R., Gallardo, M., Rosen, P., Vera, A., Macias, A., et al. (2010).

Barriers to pharmacy-based syringe purchase among injection drug users inTijuana, Mexico: A mixed methods study. AIDS and Behavior, 14(3), 679–687.

hodes, T. (2009). Risk environments and drug harms: A social science forharm reduction approach. International Journal of Drug Policy, 20, 193–201.

hodes, T., Stimson, G. V., Moore, D., & Bourgois, P. (2010). Qualitative social research

in addictions publishing: Creating an enabling journal environment. Interna-tional Journal of Drug Policy, 21(6), 441–444.

ich, J. D., Strong, L., Towe, C. W., & McKenzie, M. (1999). Obstacles to needleexchange participation in Rhode Island. Journal of Acquired Immune DeficiencySyndromes, 21(5), 396–400.

l of Drug Policy 23 (2012) 54– 61 61

SAFAF. (2010). Retrieved from http://www.sfaf.org/prevention/hiv-prevention-project-needle-exchange.html

Strathdee, S. A., Fraga, W. D., Case, P., Firestone, M., Brouwer, K. C., Perez, S. G., et al.(2005). “Vivo para consumirla y la consumo para vivir” – [“I live to inject andinject to live”]: High risk injection behaviors in Tijuana, Mexico. Journal of UrbanHealth, 82(3), IV58–IV73.

Strathdee, S. A., Lozada, R. M., Pollini, R. A., Brouwer, K. C., Mantsios, A., Abramovitz,D. A., et al. (2008). Individual, social, and environmental influences associatedwith HIV infection among injection drug users in Tijuana, Mexico. Journal ofAcquired Immune Deficiency Syndromes, 47(3), 369–376.

Strauss, A. L., & Corbin, J. (Eds.). (1997). Grounded theory in practice. Thousand Oaks,CA: Sage.

Strauss, A. L., & Corbin, J. M. (1998). Basics of qualitative research: Techniques andprocedure for developing grounded theory. Thousand Oaks, CA: Sage.

Torrone, E. A., Thomas, J. C., Maman, S., Pettifor, A. E., Kaufman, J. S., Sena, A. C., et al.(2010). Risk behavior disclosure during HIV test counseling. AIDS Patient Careand STDs, 24(9), 551–561.

Wagner, K. D., Lankenau, S. E., Palinkas, L. A., Richardson, J. L., Chou, C.-P., & Unger,J. B. (2010). The perceived consequences of safer injection: An exploration ofqualitative findings and gender differences. Psychology, Health & Medicine, 15(5),560–573.

Wagner, K. D., Lankenau, S. E., Palinkas, L. A., Richardson, J. L., Chou, C.-P., & Unger,J. B. (2011). The influence of the perceived consequences of refusing to share

injection equipment among injection drug users: Balancing competing risks.Addictive Behaviors, 36, 835–842.

Willms, D. G., Best, J. A., Taylor, D. W., Gilbert, J. R., Wilson, D. M. C., Lindsay, E. A.,et al. (1990). A systematic approach for using qualitative methods in primaryprevention research. Medical Anthropology Quarterly, 4(4), 391–409.