title: Discrepancies between qualitative and quantitative evaluation of randomised controlled trial results: achieving clarity through mixed methods triangulation.
abstract: BACKGROUND
  Mixed methods are commonly used in health services research; however, data are not often integrated to explore complementarity of findings. A triangulation protocol is one approach to integrating such data. A retrospective triangulation protocol was carried out on mixed methods data collected as part of a process evaluation of a trial. The multi-country randomised controlled trial found that a web-based training in communication skills (including use of a patient booklet) and the use of a C-reactive protein (CRP) point-of-care test decreased antibiotic prescribing by general practitioners (GPs) for acute cough. The process evaluation investigated GPs' and patients' experiences of taking part in the trial.
  
  
  METHODS
  Three analysts independently compared findings across four data sets: qualitative data collected view semi-structured interviews with (1) 62 patients and (2) 66 GPs and quantitative data collected via questionnaires with (3) 2886 patients and (4) 346 GPs. Pairwise comparisons were made between data sets and were categorised as agreement, partial agreement, dissonance or silence.
  
  
  RESULTS
  Three instances of dissonance occurred in 39 independent findings. GPs and patients reported different views on the use of a CRP test. GPs felt that the test was useful in convincing patients to accept a no-antibiotic decision, but patient data suggested that this was unnecessary if a full explanation was given. Whilst qualitative data indicated all patients were generally satisfied with their consultation, quantitative data indicated highest levels of satisfaction for those receiving a detailed explanation from their GP with a booklet giving advice on self-care. Both qualitative and quantitative data sets indicated higher patient enablement for those in the communication groups who had received a booklet.
  
  
  CONCLUSIONS
  Use of CRP tests does not appear to engage patients or influence illness perceptions and its effect is more centred on changing clinician behaviour. Communication skills and the patient booklet were relevant and useful for all patients and associated with increased patient satisfaction. A triangulation protocol to integrate qualitative and quantitative data can reveal findings that need further interpretation and also highlight areas of dissonance that lead to a deeper insight than separate analyses.
authors.affiliation: Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK. sarah.tonkin-crine@phc.ox.ac.uk.
authors.forename: Sarah
authors.initials: S
authors.lastname: Tonkin-Crine
authors.affiliation: Department of Primary Care and Interdisciplinary Care, University of Antwerp, Wilrijk, Antwerp, Belgium.
authors.forename: Sibyl
authors.initials: S
authors.lastname: Anthierens
authors.affiliation: South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK.
authors.forename: Kerenza
authors.initials: K
authors.lastname: Hood
authors.affiliation: Academic Unit of Psychology, University of Southampton, Southampton, UK.
authors.forename: Lucy
authors.initials: L
authors.lastname: Yardley
authors.affiliation: Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.
authors.forename: Jochen W L
authors.initials: JW
authors.lastname: Cals
authors.affiliation: Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK.
authors.forename: Nick A
authors.initials: NA
authors.lastname: Francis
authors.affiliation: Department of Primary Care and Interdisciplinary Care, University of Antwerp, Wilrijk, Antwerp, Belgium.|Vaccine and Infectious Disease Institute (VAXINFECTIO), Laboratory of Microbiology, University of Antwerp, Antwerp, Belgium.
authors.forename: Samuel
authors.initials: S
authors.lastname: Coenen
authors.affiliation: Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Alike W
authors.initials: AW
authors.lastname: van der Velden
authors.affiliation: Faculty of Health Sciences, Medical University of Lodz, Lodz, Poland.
authors.forename: Maciek
authors.initials: M
authors.lastname: Godycki-Cwirko
authors.affiliation: Primary Healthcare Centre Via Roma, Barcelona, Spain.
authors.forename: Carl
authors.initials: C
authors.lastname: Llor
authors.affiliation: Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
authors.forename: Chris C
authors.initials: CC
authors.lastname: Butler
authors.affiliation: Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Theo J M
authors.initials: TJ
authors.lastname: Verheij
authors.affiliation: Vaccine and Infectious Disease Institute (VAXINFECTIO), Laboratory of Microbiology, University of Antwerp, Antwerp, Belgium.
authors.forename: Herman
authors.initials: H
authors.lastname: Goossens
authors.affiliation: Primary Care and Population Sciences, University of Southampton, Southampton, UK.
authors.forename: Paul
authors.initials: P
authors.lastname: Little
mesh_terms: D000208:Acute Disease; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001291:Attitude of Health Personnel; D003371:Cough / Q000188:drug therapy*; D005069:Evaluation Studies as Topic; D058005:General Practitioners; D058015:Health Communication; D006302:Health Services Research / Q000706:statistics & numerical data; D006801:Humans; D017060:Patient Satisfaction; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D016032:Randomized Controlled Trials as Topic / Q000706:statistics & numerical data*; D012107:Research Design; D012189:Retrospective Studies; D011795:Surveys and Questionnaires
chemical_list: D000900:Anti-Bacterial Agents
keywords: Antibiotic; Intervention; Mixed methods; Qualitative; Respiratory infection; Triangulation