Sage Journals: Discover world-class research

Abstract

Mixed methods research (MMR) studies using health administrative data (HAD) coupled with qualitative methods can offer unique insight into the health inequities experienced by marginalized populations. However, little guidance exists on how and why to mix HAD and qualitative research. This methodology paper uses the real-life experiences of conducting an explanatory sequential mixed methods study to discuss methodological considerations when combining health administrative and qualitative data for equity-oriented research. This study focused on access to mental healthcare for transgender and gender diverse (TGD) individuals in Ontario, Canada. We illustrate the foundational importance of paradigmatic considerations, theory, and reflexivity in the research process; providing practical examples of their impact on data collection, analysis, and integration in such a study.

Keywords

mixed methods research health administrative data paradigms reflexivity health equity trans health

Get full access to this article

View all access options for this article.

References

Abramovich

de Oliveira

Kiran

Iwajomo

Ross

L. E.

Kurdyak

(2020). Assessment of health conditions and health service use among transgender patients in Canada. JAMA Network Open, 3(8), e2015036. https://doi.org/10.1001/jamanetworkopen.2020.15036

Abramovich

Lam

J. S. H.

Chowdhury

(2020). A transgender refugee woman experiencing posttraumatic stress disorder symptoms and homelessness. Canadian Medical Association Journal, 192(1), E9–E11. https://doi.org/10.1503/cmaj.190974

Adams

Pearce

Veale

Radix

Castro

Sarkar

Thom

K. C.

(2017). Guidance and ethical considerations for undertaking transgender health research and institutional review boards adjudicating this research. Transgender Health, 2(1), 165–175. https://doi.org/10.1089/trgh.2017.0012

Anzani

De Panfilis

Scandurra

Prunas

(2020). Personality disorders and personality profiles in a sample of transgender individuals requesting gender‐affirming treatments. International Journal of Environmental Research and Public Health, 17(5), 5–7. https://doi.org/10.3390/ijerph17051521

Arayasirikul

Wilson

E. C.

(2019). Spilling the T on trans-misogyny and microaggressions: An intersectional oppression and social process among trans women. Journal of Homosexuality, 66(10), 1415–1438. https://doi.org/10.1080/00918369.2018.1542203

Baeza

F. L. C.

da Rocha

N. S.

Fleck

M. P. de A.

(2018). Readmission in psychiatry inpatients within a year of discharge: The role of symptoms at discharge and post-discharge care in a Brazilian sample. General Hospital Psychiatry, 51, 63–70. https://doi.org/10.1016/j.genhosppsych.2017.11.008

Barker

L. C.

Brown

H. K.

Bronskill

S. E.

Kurdyak

Austin

P. C.

Hussain-Shamsy

Fung

Vigod

S. N.

(2022). Follow-up after post-partum psychiatric emergency department visits: An equity-focused population-based study in Canada. The Lancet Psychiatry, 9(5), 389–401. https://doi.org/10.1016/S2215-0366(22)00099-2

Barker

L. C.

Sunderji

Kurdyak

Stergiopoulos

Gonzalez

Kopp

Vigod

S. N.

(2020). Urgent outpatient care following mental health ED visits: A population-based study. Psychiatric Services, 71(6), 616–619. https://doi.org/10.1176/appi.ps.201900466

Bauer

G. R.

Scheim

A. I.

Pyne

Travers

Hammond

(2015). Intervenable factors associated with suicide risk in transgender persons: A respondent driven sampling study in Ontario, Canada. BMC Public Health, 15, 525. https://doi.org/10.1186/s12889-015-1867-2

10.

Bauer

G. R.

Pyne

Francino

M. C.

Hammond

(2013). Suicidality among trans people in Ontario: Implications for social work and social justice. Service Social, 59(1), 35–62.

11.

Bauer

G. R.

Scheim

A. I.

Deutsch

M. B.

Massarella

(2010). Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: Results from a respondent-driven sampling survey. Annals of Emergency Medicine, 63(6), 713–720. https://doi.org/10.1016/j.annemergmed.2013.09.027

12.

Bauer

G. R.

Zong

Scheim

A. I.

Hammond

Thind

(2015). Factors impacting transgender patients’ discomfort with their family physicians: A respondent-driven sampling survey. PLoS One, 10(12), 1–16. https://doi.org/10.1371/journal.pone.0145046

13.

Becker

H. S.

(1967). Whose side are we on? Social Problems, 14(3), 239–247. https://doi.org/10.1093/rheumatology/10.8.435

14.

Binnie

Le Brocque

Jessup

Johnston

A. N. B.

(2021). Illustrating a novel methodology and paradigm applied to Emergency Department research. Journal of Advanced Nursing, 77(10), 4045–4054. https://doi.org/10.1111/jan.15017

15.

Breton

A. R.

Taira

D. A.

Burns

O’leary

Chung

R. S.

(2007). Follow-up services after an emergency department visit for substance abuse. American Journal of Managed Care, 13(9), 497–505. https://www.ajmc.com

16.

Brooks

(1981). Minority stress and lesbian women. Lexington Books.

17.

Charmaz

(2014). An Invitation to Grounded Theory. In Seaman

(Ed.), Constructing grounded theory (2nd ed.). Sage Publications Ltd.

18.

Chih

Wilson-Yang

Dhaliwal

Khatoon

Redman

Malone

Islam

Persad

on behalf of the Trans PULSE Canada Team . (2020). Health and well-being among racialized trans and non-binary people in Canada. https://transpulsecanada.ca/research-type/reports

19.

Chiu

(2017). Ethnic differences in mental health and race-based data collection. Healthcare Quarterly, 20(3), 6–9. https://doi.org/10.12927/hcq.2017.25296

20.

Chiu

Gatov

Zaheer

Lebenbaum

Newman

Kurdyak

(2018). Postdischarge service utilisation and outcomes among Chinese and South Asian psychiatric inpatients in Ontario, Canada: A population-based cohort study. BMJ Open, 8(1), 1–10. https://doi.org/10.1136/bmjopen-2017-020156

21.

Collins

P. H.

(2015). Intersectionality’s definitional dilemmas. Annual Review of Sociology, 41, 1–20. https://doi.org/10.1146/annurev-soc-073014-112142

22.

Creswell

J. W.

Plano Clark

V. L.

(2017). Designing and conducting mixed methods research (Third Ed). Sage.

23.

Crissman

H. P.

Berger

M. B.

Graham

L. F.

Dalton

V. K.

(2017). Transgender demographics: A household probability sample of US adults, 2014. American Journal of Public Health, 107(2), 213–215. https://doi.org/10.2105/AJPH.2016.303571

24.

Croake

Brown

J. D.

Miller

Darter

Patel

M. M.

Liu

Scholle

S. H.

(2017). Follow-up care after emergency department visits for mental and substance use disorders among Medicaid beneficiaries. Psychiatric Services, 68(6), 566–572. https://doi.org/10.1176/appi.ps.201500529

25.

Crotty

(1998). Constructionism: The making of meaning. In The foundations of social research: Meaning and perspective in the research process (1st ed., pp. 42–65). Sage.

26.

Curry

L. A.

Krumholz

H. M.

O’Cathain

Plano Clark

V. L.

Cherlin

Bradley

E. H.

(2013). Mixed methods in biomedical and health services research. Circulation: Cardiovascular Quality and Outcomes, 6(1), 119–123. https://doi.org/10.1161/CIRCOUTCOMES.112.967885

27.

Dickson-Swift

James

E. L.

Kippen

Liamputtong

(2007). Doing sensitive research: What challenges do qualitative researchers face? Qualitative Research, 7(3), 327–353. https://doi.org/10.1177/1468794107078515

28.

Dinno

(2017). Homicide rates of transgender individuals in the United States: 2010-2014. American Journal of Public Health, 107(9), 1441–1447. https://doi.org/10.2105/AJPH.2017.303878

29.

England

K. V. L.

(1994). Getting personal: Reflexivity, positionality, and feminist research. The Professional Geographer, 46(1), 80–89. https://doi.org/10.1111/j.0033-0124.1994.00080.x

30.

Eubanks-Carter

Goldfried

M. R.

(2006). The impact of client sexual orientation and gender on clinical judgments and diagnosis of borderline personality disorder. Journal of Clinical Psychology, 62(6), 751–770.

31.

Fetters

M. D.

Curry

L. A.

Creswell

J. W.

(2013). Achieving integration in mixed methods designs - Principles and practices. Health Services Research, 48(6 PART2), 2134–2156. https://doi.org/10.1111/1475-6773.12117

32.

Friesen

E. L.

Buajitti

Selby

Rosella

Kurdyak

(2023). Clarifying rural-urban disparities in alcohol-related emergency department visits and hospitalizations in Ontario, Canada: A spatial analysis. The Journal of Rural Health, 39(1), 223–232. https://doi.org/10.1111/jrh.12702

33.

Gatov

Koziel

Kurdyak

Saunders

N. R.

Chiu

Lebenbaum

Chen

Vigod

S. N.

(2020). Discharge and post-discharge outcomes of psychiatric inpatients with a lifetime history of exposure to interpersonal trauma: A population-based study. General Hospital Psychiatry, 65, 82–90. https://doi.org/10.1016/j.genhosppsych.2020.05.015

34.

Giacomini

(2010). 7. Theory matters in qualitative health research. In Bourgeault

Dingwall

De Vries

(Eds.), The Sage handbook qualitative methods health research (pp. 1–45). Sage Publications Ltd.

35.

Glaser

Strauss

(1967). The discovery of grounded theory: Strategies for qualitative research. Walter de Gruyter.

36.

Goldhammer

Crall

Keuroghlian

(2019). Distinguishing and addressing gender minority stress and borderline personality symptoms. Harvard Review of Psychiatry, 27(5), 317–325.

37.

Grinshpoon

Lerner

Hornik-Lurie

Zilber

Ponizovsky

A. M.

(2011). Post-discharge contact with mental health clinics and psychiatric readmission: A 6-month follow-up study. Israel Journal of Psychiatry and Related Sciences, 48(4), 262–267.

38.

Guetterman

T. C.

Fetters

M. D.

Creswell

J. W.

(2015). Integrating quantitative and qualitative results in health science mixed methods research through joint displays. The Annals of Family Medicine, 13(6), 554–561. https://doi.org/10.1370/afm.1865

39.

Hall

Howard

(2008). A synergistic approach: Conducting mixed methods research with typological and systemic design considerations. Journal of Mixed Methods Research, 2(3), 248–269. https://doi.org/10.1177/1558689808314622

40.

Hanna

Desai

Parekh

Guirguis

Kumar

Sachdeva

(2019). Psychiatric disorders in the U.S. transgender population. Annals of Epidemiology, 39, 1–7. https://doi.org/10.1016/j.annepidem.2019.09.009

41.

Hatzenbuehler

M. L.

Pachankis

J. E.

(2016). Stigma and minority stress as social determinants of health among lesbian, gay, bisexual, and transgender youth: Research evidence and clinical implications. Pediatric Clinics of North America, 63(6), 985–997. https://doi.org/10.1016/j.pcl.2016.07.003

42.

ICES . (2023). Guidance document and framework for anti-racist approaches to research and analytics at ICES. https://www.ices.on.ca

43.

Jacobson

Mustafa

(2019). Social identity map: A reflexivity tool for practicing explicit positionality in critical qualitative research. International Journal of Qualitative Methods, 18, 1–12. https://doi.org/10.1177/1609406919870075

44.

Jäggi

Jellestad

Corbisiero

Schaefer

D. J.

Jenewein

Schneeberger

Kuhn

Garcia Nuñez

(2018). Gender minority stress and depressive symptoms in transitioned Swiss transpersons. BioMed Research International, 2018. https://doi.org/10.1155/2018/8639263

45.

Jutte

D. P.

Roos

L. L.

Brownell

M. D.

(2011). Administrative record linkage as a tool for public health research. Annual Review of Public Health, 32, 91–108. https://doi.org/10.1146/annurev-publhealth-031210-100700

46.

Kapur

Cooper

King-Hele

Webb

Lawlor

Rodway

Appleby

(2006). The repetition of suicidal behavior: A multicenter cohort study. The Journal of Clinical Psychiatry, 67(10), 1599–1609. https://doi.org/10.4088/jcp.v67n1016

47.

Lam

J. S. H.

Abramovich

(2019). Transgender-inclusive care. Canadian Medical Association Journal, 191(3), Article E79. https://doi.org/10.1503/cmaj.180954

48.

Lam

J. S. H.

Abramovich

Victor

J. C.

Zaheer

Kurdyak

(2022). Characteristics of transgender individuals with emergency department visits and hospitalizations for mental health. Psychiatric Services (Washington, D.C.), 73(7), 722–729. https://doi.org/10.1176/appi.ps.202100306

49.

Lam

J. S. H.

Abramovich

Victor

J. C.

Zaheer

Kurdyak

(2025). Physician follow-up among transgender and gender diverse individuals after psychiatric emergency department visits and hospitalizations: A retrospective population-based cohort study. Transgender Health. Advanced Online Publication. https://doi.org/10.1089/trgh.2024.0102

50.

Lam

J. S. H.

Links

P. S.

Shera

Law

Fung

W. L. A.

Tsang

A. K. T.

Eynan

Zhang

Liu

Zaheer

(2020). Lessons from a Canada-China cross-national qualitative suicide research collaboration. Global Public Health, 15(11), 1730–1739. https://doi.org/10.1080/17441692.2020.1771394

51.

Malterud

Siersma

V. D.

Guassora

A. D.

(2016). Sample size in qualitative interview studies: Guided by information power. Qualitative Health Research, 26(13), 1753–1760. https://doi.org/10.1177/1049732315617444

52.

Matheson

Moloney

van Ingen

(2018). 2016 Ontario marginalization Index user guide october 2018. https://www.publichealthontario.ca/-/media/documents/o/2017/on-marg-userguide.pdf

53.

McLane

Bill

Healy

Barnabe

Plume

T. B.

Bird

Colquhoun

Holroyd

B. R.

Janvier

Louis

Rittenbach

Curtin

K. D.

Fitzpatrick

K. M.

Mackey

MacLean

Rosychuk

R. J.

(2024). Leaving emergency departments without completing treatment among first nations and non–first nations patients in Alberta: A mixed-methods study. Canadian Medical Association Journal, 196(15), E510–E523. https://doi.org/10.1503/cmaj.231019

54.

Meehan

Kapur

Hunt

I. M.

Turnbull

Robinson

J. O.

Bickley

Parsons

Flynn

Burns

Amos

T. I. M.

Appleby

Flynn

S. A

Shaw

(2006). Suicide in mental health in-patients and within 3 months of discharge: National clinical survey. British Journal of Psychiatry, 188, 129–134. https://doi.org/10.1192/bjp.188.2.129

55.

Meyer

I. H.

(2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. https://doi.org/10.1037/0033-2909.129.5.674

56.

Niederberger

Keller

(2018). Mixed methods studies in health promotion: A case-study based on the life situations of young people of refugee backgrounds in Germany. In Majumder

Md. A. A.

Kabir

Rahman

(Eds.), Public health - emerging and Re-emerging issues (pp. 75–90). IntechOpen. https://doi.org/10.5772/intechopen.76711

57.

Nixon

S. A.

(2019). The coin model of privilege and critical allyship: Implications for health. BMC Public Health, 19(1), 1–13. https://doi.org/10.1186/s12889-019-7884-9

58.

Nzabonimpa

J. P.

(2018). Quantitizing and qualitizing (im-)possibilities in mixed methods research. Methodological Innovations, 11(2). https://doi.org/10.1177/2059799118789021

59.

O’Cathain

Murphy

Nicholl

(2008). The quality of mixed methods studies in health services research. Journal of Health Services Research and Policy, 13(2), 92–98. https://doi.org/10.1258/jhsrp.2007.007074

60.

Pinto

A. D.

Aratangy

Abramovich

Devotta

Nisenbaum

Wang

Kiran

(2019). Routine collection of sexual orientation and gender identity data: A mixed-methods study. Canadian Medical Association Journal, 191(3), E63–E67. https://doi.org/10.1503/cmaj.180839

61.

Progovac

A. M.

Cook

B. L.

Mullin

B. O.

McDowell

Maria Jose Sanchez

Wang

Creedon

T. B.

Schuster

M. A.

(2018). Identifying gender minority patients’ health and health care needs in administrative claims data. Health Affairs, 37(3), 413–420. https://doi.org/10.1377/hlthaff.2017.1295

62.

Progovac

A. M.

Mullin

B. O.

Creedon

T. B.

McDowell

Sanchez-Roman

M. J.

Hatfield

L. A.

Schuster

M. A.

Cook

B. L.

(2019). Trends in mental health care use in Medicare from 2009 to 2014 by gender minority and disability status. LGBT Health, 6(6), 297–305. https://doi.org/10.1089/lgbt.2018.0221

63.

Regnault

Willgoss

Barbic

(2018). Towards the use of mixed methods inquiry as best practice in health outcomes research. Journal of Patient-Reported Outcomes, 2, 2–5. https://doi.org/10.1186/s41687-018-0043-8

64.

Reisner

S. L.

Poteat

Keatley

J. A.

Cabral

Mothopeng

Dunham

Holland

C. E.

Max

Baral

S. D.

(2016). Global health burden and needs of transgender populations: A review. The Lancet, 388(10042), 412–436.

65.

Reisner

S. L.

Vetters

Leclerc

Zaslow

Wolfrum

Shumer

Mimiaga

M. J.

(2015). Mental health of transgender youth in care at an adolescent urban community health center: A matched retrospective cohort study. Journal of Adolescent Health, 56(3), 274–279. https://doi.org/10.1016/j.jadohealth.2014.10.264

66.

Ritchie

Lewis

Elam

(2003). Designing and selecting samples. In Ritchie

Lewis

(Eds.), Qualitative research practice: A guide for social science students and researchers (pp. 77–109). Sage Publications.

67.

Rodriguez-Seijas

Morgan

T. A.

Zimmerman

(2021). Is there a bias in the diagnosis of borderline personality disorder among lesbian, gay, and bisexual patients? Assessment, 28(3), 724–738. https://doi.org/10.1177/1073191120961833

68.

Rotenberg

Gozdyra

Anderson

K. K.

Kurdyak

(2023). The role of geography and distance on physician follow-up after a first hospitalization with a diagnosis of a schizophrenia spectrum disorder: A retrospective population-based cohort study in Ontario, Canada. PLoS One, 18(6 JUNE), e0287334. https://doi.org/10.1371/journal.pone.0287334

69.

Rotondi

N. K.

Bauer

G. R.

Scanlon

Kaay

Travers

(2011). Prevalence of and risk and protective factors for depression in female-to-male transgender Ontarians: Trans PULSE Project. Can J Commun Ment Health, 30(2), 135–155. https://doi.org/10.7870/cjcmh-2011-0021

70.

Rotondi

N. K.

Bauer

G. R.

Travers

Scanlon

Kaay

(2011). Depression in male-to-female transgender Ontarians: Results from the trans PULSE project. Can J Commun Ment Health, 30(2), 113–133. https://doi.org/10.7870/cjcmh-2011-0020

71.

Scanlon

Travers

Coleman

Bauer

Boyce

(2010). Ontario’s trans communities and suicide: Transphobia is bad for our health. Ontario, Canada. Trans PULSE E-Bulletin. https://transpulseproject.ca/research/ontarios-trans-communities-and-suicide/

72.

Scheim

A. I.

Appenroth

M. N.

Beckham

S. W.

Goldstein

Grinspan

M. C.

Keatley

J. A. G.

Radix

(2019). Transgender HIV research: Nothing about us without us. The Lancet HIV, 6(9), e566–e567. https://doi.org/10.1016/S2352-3018(19)30269-3

73.

Shannon-Baker

(2016). Making paradigms meaningful in mixed methods research. Journal of Mixed Methods Research, 10(4), 319–334. https://doi.org/10.1177/1558689815575861

74.

Suess Schwend

(2020). Trans health care from a depathologization and human rights perspective. Public Health Reviews, 41(1), 1–17. https://doi.org/10.1186/s40985-020-0118-y

75.

Tarasuk

Cheng

de Oliveira

Dachner

Gundersen

Kurdyak

(2015). Association between household food insecurity and annual health care costs. Canadian Medical Association Journal, 187(14), E429–E436. https://doi.org/10.1503/cmaj.150644

76.

Tariq

Woodman

(2010). Using mixed methods in health research. JRSM Short Reports, 1–8. https://doi.org/10.1177/2042533313479197

77.

Testa

R. J.

Habarth

Peta

Balsam

Bockting

(2015). Development of the gender minority stress and resilience measure. Psychology of Sexual Orientation and Gender Diversity, 2(1), 65–77. https://doi.org/10.1037/sgd0000081

78.

Vedel

Kaur

Hong

Q. N.

El Sherif

Khanassov

Godard-Sebillotte

Sourial

Yang

X. Q.

Pluye

(2018). Why and how to use mixed methods in primary health care research. Family Practice, 36(3), 365–368. https://doi.org/10.1093/fampra/cmy127

79.

Vigod

S. N.

Kurdyak

P. A.

Dennis

C. L.

Leszcz

Taylor

V. H.

Blumberger

D. M.

Seitz

D. P.

(2013). Transitional interventions to reduce early psychiatric readmissions in adults: Systematic review. British Journal of Psychiatry, 202(3), 187–194. https://doi.org/10.1192/bjp.bp.112.115030

80.

Watkins

D. C.

(2023). Secondary data in mixed methods research. Sage Publications, Inc.

81.

Watt

(2007). On becoming a qualitative researcher: The value of reflexivity. The Qualitative Report, 12(1), 82–101. https://doi.org/10.46743/2160-3715/2007.1645

82.

Wesp

L. M.

Malcoe

L. H.

Elliott

Poteat

(2019). Intersectionality research for transgender health justice: A theory-driven conceptual framework for structural analysis of transgender health inequities. Transgender Health, 4(1), 287–296. https://doi.org/10.1089/trgh.2019.0039

83.

Wilkinson

Pearson

Liu

(2018). Educational attainment of transgender adults: Does the timing of transgender identity milestones matter? Social Science Research, 74(December 2016), 146–160.

84.

Winter

Diamond

Green

Karasic

Reed

Whittle

Wylie

(2016). Transgender people: Health at the margins of society. The Lancet, 388(10042), 390–400. https://doi.org/10.1016/S0140-6736(16)00683-8

85.

Wong

S. P. Y.

(2021). Mixed methods research to advance Nephrology. Kidney360, 2(6), 1011–1014. https://doi.org/10.34067/kid.0005972020

86.

Woods

Gapp

King

M. A.

(2016). Generating or developing grounded theory: Methods to understand health and illness. International Journal of Clinical Pharmacy, 38(3), 663–670. https://doi.org/10.1007/s11096-016-0260-2

Leveraging Health Administrative and Qualitative Data to Understand Mental Health Experiences of Transgender and Gender Diverse People: An Explanatory Sequential Mixed Methods Study

Abstract

Keywords

Get full access to this article

References