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  • 00:04

    [RESEARCH METHODS case study][Using Mixed Methods to Research the Impact of Housingon Health Wellbeing]

  • 00:14

    LISA GARNHAM: I'm Dr. Lisa Garnham.[Lisa Garnham, Public Health Research Specialist,Glasgow Centre for Population Health]I'm a Public Health Research Specialist at the GlasgowCenter for Population Health.I mainly work research in the social determinants of health.So trying to think about how the various aspectsof our day-to-day lives influence our healthand well-being.And that can be quite diverse.So it can include everything from housing, to food,

  • 00:37

    LISA GARNHAM [continued]: to exercise, and so on.But in the last few years, I've mainlybeen focusing on research on housing.And that's because my background is in geography.And I've got an interest and the ways in which the placesthat we live in and that we move through everyday influenceour actions, our decisions, the resourceswe have available to us.

  • 00:57

    LISA GARNHAM [continued]: And through those pathways impact upon our health.So in this video, I'm going to talk about the housingthrough social enterprise study, which was a mixed methods longdid you study.It looked at the impacts of tenanciesand the behavior of housing providerson tenants in West Central Scotland,and it sought to attract tenants over the first yearof their tenancy looking at the ways in which the housing

  • 01:20

    LISA GARNHAM [continued]: experience impacted on their healthand especially their mental well-being.[How did you plan and design the study?]So in the house and through social enterprise study,we partnered with three housing organizationswho agreed to send us the contactdetails of all new tenants applying to their housing

  • 01:42

    LISA GARNHAM [continued]: organization for a new tenancy.They emailed that to securely.And when we received that, we called each new tenantto inform them about the study, and tell themwhat the study was going to be about,and also what their options were for taking part,and the benefits that we were offering for taking part.And then when if they consented to take part in the study,

  • 02:03

    LISA GARNHAM [continued]: we did a short quantitative questionnaire with themon the phone there.And the idea was to capture their housing experiencesbefore they moved into their new tenancy.Once three months had passed in their new tenancy,we called them again, and we arrangedto do a face to face interview with them.And this was a qualitative interviewthat asked them about their experiences

  • 02:24

    LISA GARNHAM [continued]: in their new tenancy so far, and any changesthey'd experienced in the health and well-being.And we followed that up for a third timewith a third interview once they've been in their tenancyfor 9 to 12 months.So again, we called them check that they still wantedto take part in the study, and then arranged a faceto face interview in their home with them to talkabout how that first year in their new tenancy had gone.

  • 02:46

    LISA GARNHAM [continued]: [How did you track changes in health and wellbeing?]So in order to measure changes in tenants well-beingacross the first year of a tenancy,we use the WHO-5 mental well-being scale.The WHO-5 scale offers five states of mood or statesof mind that tenants can think about how much they've

  • 03:07

    LISA GARNHAM [continued]: experienced that in the last two weeks before the interview.And they have seven options to choosefrom in terms of how often they've experienced that moodor state of mind.Using that measure allowed us to understand the differenceor the change in tenants well-beingacross that first year of their tenancybecause we collected it just before they moved

  • 03:27

    LISA GARNHAM [continued]: into their new tenancy at three months and at 9 to 12 monthsinto their tenancy.So although most of the questions that we were askingin the qualitative interviews at three months and 9 to 12 monthswere qualitative questions, we were stillgathering that measure of mental well-beingand that allowed us to track themin a measurable way across that first year of their tenancy.

  • 03:49

    LISA GARNHAM [continued]: It also allowed us to compare the experiencesof different groups of tenants in different kindsof situations.So we had a measure by which we couldsee how much different factors relating to housingwere affecting tenants mental well-being.And because we asked tenants to rate the various aspectsof their property, so things like property quality,

  • 04:11

    LISA GARNHAM [continued]: and things like the cost of their tenancy,we were able to look at correlationsbetween those impacts.So things related to the housing and thena measure of their mental well-beingfor which we use the WHO-5.The reason we use the WHO-5 was because itwas a really quick and simple measurethat we could use with tenants.When we were designing the study,we looked at various options, including

  • 04:34

    LISA GARNHAM [continued]: mental health diagnostic tools.Some of which have up to 25 questions.And when we piloted these with tenants,we were told quite often that tenantswere used to seeing these tools being usedby their GP and other services to diagnose mental healthconditions.So not only were they already familiar with the questions

  • 04:56

    LISA GARNHAM [continued]: in the questionnaire, which might be considereda good thing, they also associated themwith difficult conversations with medical practitioners.So we had many tenants say to us I don't likeanswering these questionnaires.It reminds me of that time I was having a hard time.And I went to see my GP, or I went to see my doctor,or I ended up in agony.And so what we decided to do was to use

  • 05:18

    LISA GARNHAM [continued]: something that was not related to mental health diagnosis.But something which just rated low level changes in moodon a day-to-day basis, so that we were justcapturing a change in more change in people'squality of life rather than trying to diagnose or identifydiagnose mental health conditions.

  • 05:44

    LISA GARNHAM [continued]: So when we plant our data collection,we spent a lot of time figuring outwhether we were asking for the experiences of the individualswe were interviewing, or all of the membersof the household within the householdthat we were interviewing.So from previous experience, we knewthat by going into people's homes to interview them,it was likely that they would want somebodywith them in order to be interviewed, especially if we

  • 06:07

    LISA GARNHAM [continued]: were asking about experiences of the home, experiencesof the tenancy which are not an individual experience,but our household experience.And normally, this would be great.It would mean that we would get to speak to more people,we could potentially have a more in-depth discussionif there were several members of the household there.But the difficulty that created for us

  • 06:28

    LISA GARNHAM [continued]: was that we wanted to talk to people about their healthand well-being which is potentially very sensitive.And so we had a dilemma.We didn't want to say to people, no, youhave to be interviewed alone because that might put them offand it's not very fair.But we also needed them to have a wayto answer the questions about health and well-beingwithout feeling like someone else was there,

  • 06:48

    LISA GARNHAM [continued]: someone else was watching, or theywere having to change what they wantedto say about their health and well-beingbecause they were being observed by someone else.So in the end, what we decided to dowas to carry out the qualitative interviewswith whoever the main interviewee wantedto have with them.So for some people that was a partner, or someone else

  • 07:10

    LISA GARNHAM [continued]: a child that they live with, and for other people,it was a shared tenancy, so it was their housematesor their flatmates.And we asked the qualitative questionsabout the housing experience, about what the tenancywas like of the group.And then in order to gather the more sensitive questionsabout health and well-being, we took the WHO-5 questionnaire,

  • 07:32

    LISA GARNHAM [continued]: and we put it on a folded piece of paper inside an envelope,and we handed that to each individual who wastaking part in the research.And we asked them to go away and complete that awayfrom our eyes and away from the eyes of other peoplein the household.Once they had completed that, they folded it,and put it inside the envelope.And their name and address did not appear anywhere

  • 07:53

    LISA GARNHAM [continued]: on that piece of paper.We used an anonymous code, which we attached to their interviewtranscript.And that helped them to feel as if the answers that they hadgiven to the WHO-5 questionnaire were anonymous,they were confidential, and they were private from other peoplethat they were being interviewed with, and also from usto a certain extent.After they had sat in the room and talked to us

  • 08:15

    LISA GARNHAM [continued]: for over an hour about their housing experiences,people may not have wanted us to see their responsesto questions about their state of mind and state of mind.So the envelope and the codes allowedus to keep that private.[How did you analyse the quantitative and qualitativedata?]

  • 08:35

    LISA GARNHAM [continued]: So first of all, we analyze the quantitative databy looking at correlations between people's healthand well-being as measured by the WHO-5 well-beingscale and various aspects of their tendency.So we asked them about lots of different aspectsof their housing including the physical qualityof the property, costs associated with their tenancy,

  • 08:60

    LISA GARNHAM [continued]: various aspects of their neighborhood,and the housing service that they were receivingfrom the housing provider.And we looked at correlations between allof those different aspects of housingthat we measured and their well-being outcomes.And when we looked at those, we use the positive correlations,the significant correlations to design a model that

  • 09:20

    LISA GARNHAM [continued]: allowed us to see which of the pathways from housing provisionwere impacting on people's health and well-being.And what we saw were there were four aspectsof the tenancy that were impacting on people'smental health and well-being.And they were the physical qualityof the property, the overall cost of the tenancy.

  • 09:43

    LISA GARNHAM [continued]: So not just the rent but various other aspects of the tenancy.The location of the property and particularly the wayit suited the tenant, and the level of service theyfelt that they were receiving from their housing provider.And it was that model that we got from the quantitative datathat allowed us to go on and searchfor the detail in the qualitative data.So once we had the outline model from the quantitative data,

  • 10:06

    LISA GARNHAM [continued]: they gave us the four outline pathways from the housingexperience to mental being.We were able to analyze the qualitative data to lookfor the detail of that, to try to understand exactlyhow those aspects of the housing experiencewere impacting our mental well-being.So for example, thinking about the quality of the property

  • 10:26

    LISA GARNHAM [continued]: that people were living in physical qualityof those properties.We knew that poor quality properties that were notwind watertight, for example, wouldbe having a negative impact on mental being.But what the qualitative data showedus was that actually the interior of the properties

  • 10:46

    LISA GARNHAM [continued]: and particularly the decor, the furnishings,the furnishings were really important to tenantsfrom day one in shaping their experiences of the tenancy,and therefore, their mental being.Similarly, with the tenancy affordability,we had assumed that rent would bethe most important aspect of the affordability of the tenancy.But actually, the qualitative interviews

  • 11:08

    LISA GARNHAM [continued]: showed us that it was the affordability of other aspectsof the tenancy like the deposits thathad to be paid, for gas and electricity bills thathad to be paid upfront, and so on, and so forththat were most important to tenants.And this was tenants across various types of circumstances.Thinking about that relationship with the housing providerand the level of service that they were providing,

  • 11:30

    LISA GARNHAM [continued]: trust came up over and over again as an issuethat tenants found so important in shapingtheir experience of the tenancy, and their mental being.And the location of the property,we had assumed that properties in less deprived locationswould be preferred by tenants.And that those would lead to greater mental being.

  • 11:52

    LISA GARNHAM [continued]: But actually, the qualitative datashowed that all that needed to happenwas the location needed to seat the tenant.And for some tenants those were different locationsthan for other tenants, it was notabout the objective measurable qualityof the area that was important.It was about whether the tenant hadchosen to live there or not.Altogether together these four aspectscame together to create either a positive sense of home

  • 12:16

    LISA GARNHAM [continued]: for tenants, or they failed to allow the tenantto establish a sense of home.And it was this sense of home that wecould see from the qualitative datawas the key mechanism through which tenantsmental well-being was being impacted by the housingexperience.So the real value of the mixed methods approachwas that we were able to use the quantitative data to look

  • 12:40

    LISA GARNHAM [continued]: at the scale and the broad outlineof the impacts of housing on mental well-being.And then the qualitative data came behindthat to allow us to really explorethe detail in all of its richness of the waysin which tenants were really experiencingthose quantitative aspects, and how they were impactingon their mental being.Without the quantitative data, we

  • 13:01

    LISA GARNHAM [continued]: would have been lost in the amount of qualitative datathat we gathered.It would have been quite difficult for us to pick outthemes or to look for specific coherent pathwayswithin the data that we had.And without the quantitative data,we wouldn't have been able to explore the extent to whichor the scale to which certain aspects wereimportant for tenants of different demographics.

  • 13:23

    LISA GARNHAM [continued]: So it was in bringing the quantitative and qualitativedata together in a mixed-methods approachthat we really got the best out of both of them.And together, they created somethingmore than they would have been we use them separately.[Did you face any challenges in conducting a mixed methodsstudy?]

  • 13:45

    LISA GARNHAM [continued]: So this was a longitudinal mixed-method studythat presented many challenges right from research designall the way through data collectionto the dissemination of the findings.First of all, we faced challengesin deciding how many participantsto enroll in the study.And we knew that we needed to gather data from enough tenantsto make our quantitative analysis robust enough,

  • 14:08

    LISA GARNHAM [continued]: so that it was useful to us and acceptable in publication.However, we also knew that if we enrolled too many tenantsin the study.We would have too much qualitative data.And that would make it much more difficultfor us to analyze the results of the study,and to get some meaningful findings from it.So we had a balance to strike in terms

  • 14:29

    LISA GARNHAM [continued]: of enough for the quantitative data,but not so much for the qualitative data.The other challenge that we faced in using mixed methodswas in the approach that we used with tenants.So making sure that we were open enough in the beginningparts of the interviews, in the qualitative parts, wherewe wanted people to tell us the story, to tell us

  • 14:50

    LISA GARNHAM [continued]: their narrative, but also being rigid enoughin the quantitative part of the interviews,so that people knew that they had multiple choice options,and that we did need them to select the optionsthat we had to negotiate that with tenantsduring the interviews.The other challenge in carrying out a mixed message studywas in data analysis, and how to bring the two parts of the data

  • 15:12

    LISA GARNHAM [continued]: together.The quantitative and qualitative.In order to deal with this, we used a real estate evaluationframework.So that enabled us to look at the quantitative datato map out our pathways, and thenuse the qualitative data to and getto interrogate what was working for whom and in whatcircumstances.So the qualitative data brought to the fore.

  • 15:34

    LISA GARNHAM [continued]: The real detail of how the context of the tenantslife and their characteristics wereimportant in shaping the pathways from housingto mental well-being.And the relist evaluation frameworkenabled us to bring those two types of data together reallyfuse them together I guess in a way that,

  • 15:54

    LISA GARNHAM [continued]: and they complemented one another,and allowed us to map out those pathways using not justthe scale of what we were seeing amongst our tenant cohort,but also the detail as well.[What advice would you give to researchers planning a mixedmethods study?]

  • 16:15

    LISA GARNHAM [continued]: I would say that mixed methods research is extremely valuable.And particularly, in trying to figure outthe longer and more complex pathwaysfrom various aspects of our lives,the social determinants of health,and our health and well-being.However, it does come with its challenges.I think quite often we talk about the practical challenges

  • 16:36

    LISA GARNHAM [continued]: of carrying out mixed methods.But there is a fundamental challengethat comes from mixed methods research, whichis about the need for qualitative and quantitativeresearchers to talk to one another,and to respect one another's position,and to try to understand perspectives from completelydifferent academic backgrounds.So for example, we have had some difficulty

  • 16:60

    LISA GARNHAM [continued]: in publishing some aspects of the findings of this study.We get criticism from quantitative researcherswho want to see a larger number of tenantsenrolled in the study.And they want to see a more robust statistical analysis.And we received some criticism from qualitative researcherswho would like to see a lot more social theory appliedto some of the aspects of the analysis of the data.

  • 17:24

    LISA GARNHAM [continued]: Instead, we used realist evaluation,which allows us to focus really specificallyon what works for whom in what circumstances, and mapthe pathways from housing to mental well-beingback up to the actions of housing organizationsand housing providers.What mixed methods has allowed us to do

  • 17:45

    LISA GARNHAM [continued]: is to really focus on the length of that pathway.So to look all the way from what housing providers are doing,how their organizations are working,what their day to day practices are through tenants housingexperiences, and their ability to establish a sense of homeall the way through to their mental well-being.

  • 18:05

    LISA GARNHAM [continued]: How do we just focus on quantitative or juston qualitative data?It wouldn't really have been possible for us to do that.But as I say, has created its own challenges.So in carrying out mixed message research,you don't just need to have researcherswho have quantitative experience and researchers who

  • 18:26

    LISA GARNHAM [continued]: have qualitative experience, you needto have researchers and data that is actuallyable to talk to each other, to work together, and cometogether in a way that benefits both sides and mutually.

  • 18:48

    LISA GARNHAM [continued]: The need to move beyond that dichotomybetween the quantitative and qualitativeis especially important in public health research.We have a tendency in public health researchto focus on hard outcomes particularlythrough quantitative studies, where what we want to seeand diagnosed conditions, we wantto see mortality or morbidity, because those

  • 19:11

    LISA GARNHAM [continued]: are absolutely definitive.We know that something has gone wrong with healthwhen we see those things.The problem with that is that really we'rereaching the problem too late for the people whoare participating in those kinds of studies.And more to the point, we miss all of the small aspects of dayto day life that build up to those diagnosed problems,

  • 19:34

    LISA GARNHAM [continued]: especially mental health problemswhen we only focus on hard outcomes.If we ignore the soft outcomes, it's very difficult for usto then later on unpick the pathwaysthrough which people's day-to-day experiences,their day-to-day mood changes in their quality of lifehave impacted on the health and wellbeing across the life course.

  • 19:56

    LISA GARNHAM [continued]: This research that looks at softer outcomes insteadof focusing on hard outcomes like mortality and comorbidityis especially important when thinking about mental healthand particularly when thinking about well-being.For example, in the current context of COVID-19.We have focused a lot on the numbersof deaths that have been created by infection of the virus.

  • 20:18

    LISA GARNHAM [continued]: But there is a huge impact on people's mental healthof lockdowns of economic recession, of social isolation,and so on, and so forth.Now, much of this won't result in diagnosed mental healthconditions.Although some of it will.Much of the impact is much more low level,it's much longer term.

  • 20:38

    LISA GARNHAM [continued]: And it impacts people's mood and stateof mind and their well-being.And this accumulates across the life course.It's really important for us to understand not justwhat creates poor health, so whatcreates diagonalizable mental health conditions,but also what generates good health, good well-being.Because if we are to recover from the situation,

  • 20:58

    LISA GARNHAM [continued]: we need to understand how we needto work with the limited resourcesthat we have in order to recover our mental well-beingand improve our health, so that in 20, 30, 40 years time,we're not looking at increased levels of morbidityand mortality from this event.Mixed methods research allows us to look at those softer

  • 21:20

    LISA GARNHAM [continued]: outcomes if we're able to use the quantitative andqualitative data together to focuson the detail of the pathways between these socialdeterminants of health and mental well-beingboth in the short term and across the life course.[Are there any resources you would recommend to otherresearchers?]

  • 21:41

    LISA GARNHAM [continued]: Thanks very much for watching this video.I hope I convinced you that mixed methods research is worthdoing even though it is quite challenging.If you're interested in more of the housingthrough social enterprise study, including the methodology,there are resources on the Glasgow Centerfor Population Health Website, including research reports.And there are also various resources about the WHO-5

  • 22:04

    LISA GARNHAM [continued]: well-being scale, as well as a longer versionof the WHO-5 on the World Health Organization website.And there are a number of resources available on realistsevaluation if that is of interest to you.Thank you very much.

  • 22:37

    LISA GARNHAM [continued]: nbsp;

Abstract

Dr. Lisa Garnham, Public Health Research Specialist at the Glasgow Centre for Population Health, discusses using mixed methods to research the impact of housing on health and wellbeing, including study design, data collection and analysis, challenges faced, advice, and resources.

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Using Mixed-Methods to Research the Impact of Housing on Health and Wellbeing

Dr. Lisa Garnham, Public Health Research Specialist at the Glasgow Centre for Population Health, discusses using mixed methods to research the impact of housing on health and wellbeing, including study design, data collection and analysis, challenges faced, advice, and resources.

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