Article Analysis 1, (ARTICLE 2 AND 3)

The interpretation of research in health care is essential to decision making. By understanding research, health care providers can identify risk factors, trends, outcomes for treatment, health care costs and best practices. To be effective in evaluating and interpreting research, the reader must first understand how to interpret the findings. You will practice article analysis in Topics 2, 3, and 5.

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Search the GCU Library and find three different health care articles that use quantitative research. Do not use articles that appear in the Topic Materials or textbook. Complete an article analysis for each using the “Article Analysis 1” template.

Refer to the “Patient Preference and Satisfaction in Hospital-at-Home and Usual Hospital Care for COPD Exacerbations: Results of a Randomised Controlled Trial,” in conjunction with the “Article Analysis Example 1,” for an example of an article analysis.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

Article Analysis 1

Article Citation and Permalink (APA format)

Article 1

Garí-Llanes, M., García-Nóbrega, Y., Chávez-González, E., González-Rodríguez, E., García-Sáez, J., & Llanes-Camacho, M. D. C. (2019). Biochemical markers and hypertension in children. MEDICC review, 21, 10-15.

Link: https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=edo&AN=1

9234963&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 x Citation Title:

Title:

Article 2

Thompson, K.L, & Wanqing

Zhang. (2020). Using Mixed

Methods Research to Better

Understand Pediatric Feeding Disorder.

Perspective of the ASHA Special interest Groups, 5(6), 1623

Link:

https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=edb&AN=147663110&site=eds-live&scope=site

Article 3

Point

Description

Broad Topic Area/Title

Confirm an association between biochemical risk markers of cardiovascular disease and hypertension in children aged 8 to 11 years.

Using Mixed Methods Research to Better Understand Pediatric Feeding Disorder.

Identify Independent and Dependent Variables and Type of Data for the Variables

The following variables will be considered, these are the age, sex of individual, height, systolic, and diastolic blood pressure, cholesterol level, triglycerides level, lipoproteins and Apo lipoproteins in the body respectively.

The children were reportedly classified as being either normotensive, with pre hypertensive or hypertensive, as applicable based on the assessment of blood pressure, based on both readings and the percentiles for the age, sex and height, of the individuals.

Population of Interest for the Study

The study is based on children between the ages of 8-11, selected from different background, and different school in a city known as Santa Clara in central Cuba

Sample

373 children

Sampling Method

Cross-sectional study of three primary schools was done

Descriptive Statistics (Mean, Median, Mode; Standard Deviation)

Identify examples of descriptive statistics in the article.

Example descriptive statistics:

Descriptive statistics were calculated for quantitative variables. A bi variate analysis, tests of independence for qualitative variables was conducted, and a mean comparison for quantitative variables (ANOVA and its nonparametric alternative, the Kruskal Wallis test) were also performed respectively. The Fisher’s F-test which is a test that is used in statistics, and its associated probability, which is known as the p value were employed.

A number of the children were normotensive while a percentage of them in total of 37.3% were both hypertensive and pre hypertensive.

Example of hypertensive, and pre hypertensive children in percentile is listed below as:

Percentile: 5.1% and 32.2%

Inferential Statistics

Identify examples of inferential statistics in the article.

Example of inferential statistics:

The inferential statistics used in the article compared the values, and levels of cholesterol, this is required by the body to make vitamins, and also build up cells, and that of triglycerides which is a fat like or lipid that is found in the blood, both were significantly higher in hypertensive children, in comparison to normotensive children (p = 0.028 and p = 0.047, respectively)

PERSPECTIVES

Tutorial

Using Mixed Methods Research to Better
Understand Pediatric Feeding Disorder

Kelsey L. Thompsona and Wanqing Zhangb

Purpose: Mixed methods research is a relatively new, but
growing, research methodology with particular relevance
to speech-language pathologists because of its utility in
translating research into practice. Mixed methods research
involves collection of both qualitative and quantitative data,
which is integrated to gain a deeper understanding of a
research question, particular population or intervention, or
to develop a tool. In particular, pediatric feeding disorder
(PFD) research stands to benefit from this methodology to
comprehensively and holistically report on this population.
Conclusions: This article focuses on introducing
researchers new to mixed methods, as well as clinicians, to
the four basic mixed methods study designs and considerations.
To establish a foundational understanding, examples of

published work specific to PFD are incorporated and a
framework for understanding mixed method study design
is proposed. Then, the four designs are examined from
the lens of critical appraisal, so that clinicians and researchers
are well prepared to critically evaluate mixed methods studies.
Finally, applications of mixed methods to PFD are explored,
with a commentary on how published examples could be
extended using mixed methods designs. This article provides
researchers and clinicians with a basic understanding of
mixed methods as well as a clear avenue for its application
to PFD. Mixed methods has the potential to advance our
understanding of the heterogenous population PFD impacts,
improve our use of interdisciplinary teams, examine holistic
interventions, and develop tools for clinical and research use.

The 2019 consensus definition of pediatric feedingdisorder (PFD) outlined four diagnostic compo-nents: medical, nutrition, feeding skill, and psycho-
social (Goday et al., 2019), emphasizing the fact that PFD
is a complex, multifaceted disorder. PFD stakeholders
have increasingly recognized the need for interdisciplinary
frameworks and evidence-based interventions that are easily
translated into clinical practice (McComish et al., 2016). As
such, PFD clinical practice stands to benefit from research
that integrates these four diagnostic components (Goday
et al., 2019), in order to advance our understanding of
PFD and its impacts, as well as to develop evidence-based
treatments that involve interdisciplinary collaboration.

While traditional quantitative and qualitative meth-
odologies demonstrate strengths in the systematic study of

phenomena, they often lack the rich understanding neces-
sary to extend findings to clinical practice (Robins et al.,
2008). However, mixed methods research involves the col-
lection and integration of both qualitative and quantitative
data, which provides a richer understanding of research
problems than quantitative or qualitative methods alone,
encourages interdisciplinary work, and emphasizes the
translation of research into evidence-based practice (Creswell
& Plano Clark, 2011). As such, mixed methods research has
been steadily growing in popularity in various fields, such
as health services (Zhang & Creswell, 2013), physical ther-
apy (Rauscher & Greenfield, 2009), and quality of life re-
search (Ring et al., 2010) as well as in randomized control
trials (Mertens & Hesse-Biber, 2013). Given its growing
popularity, and particular utility in translating research to
practice, it is important for clinicians and researchers to be
both aware of mixed methods research and able to critically
evaluate it in order to implement evidence-based practice.

Despite its strengths, the use of mixed methods re-
search design has been limited in speech-language pathol-
ogy, including PFD. However, mixed methods have the
potential to holistically and systematically capture all four
elements of PFD in a single research study. This integra-
tion provides flexibility and depth of insight in order to

SIG 13

aDivision of Speech & Hearing Sciences, University of North
Carolina–Chapel Hill
bDepartment of Allied Health Sciences, University of North
Carolina–Chapel Hill

Correspondence to Kelsey L. Thompson: kelsey_thompson@med.unc.edu

All authors approved the final article as submitted and agree to be
accountable for all aspects of the work.

Editor-in-Chief: Angela H. Ciccia
Editor: Aneesha Virani

Received May 27, 2020
Revision received August 25, 2020
Accepted September 30, 2020
https://doi.org/10.1044/2020_PERSP-20-00119

Disclosures
Financial: Kelsey L. Thompson has no relevant financial interests to disclose.
Wanqing Zhang has no relevant financial interests to disclose.
Nonfinancial: Kelsey L. Thompson has no relevant nonfinancial interests to
disclose. Wanqing Zhang has no relevant nonfinancial interests to disclose.

https://orcid.org/0000-0002-3309-9516

capture clinically significant data and dig deeper into this
complex diagnosis, which could not be achieved by using
either qualitative or quantitative methods alone. Although
some PFD studies have used both qualitative and quantita-
tive methods, they are unclear in their reasoning for this
approach and are lacking in their use of mixed methods strat-
egies, therefore limiting the utility of the research.

Given the growth of mixed methods research, and its
potential to advance the study of PFD, it is important that
both clinicians and researchers working with this popula-
tion are well informed about this methodology. While guide-
lines for using mixed methods research designs exist for
pediatric researchers in several fields, such as pediatric psy-
chology (Wu et al., 2019) and pediatric oncology nursing re-
search (Wilkins & Woodgate, 2008), there has not been any
explicit guidance for conducting mixed methods research in
the field of PFD. The purpose of this article is to provide
a practical guide to conducting mixed methods research in
PFD. This article serves as an introduction to mixed methods
research purpose, design, and critical appraisal, with specific
examples of how it has and can be, used in the context of
PFD. In particular, this article aims to (a) introduce re-
searchers new to mixed methods to basic design and consid-
erations in addressing their research questions and (b) help
clinicians understand the appropriate use and limitations of
this methodology, as well as its potential clinical implications.

Mixed Methods Research Design
In order to be considered mixed methods, a study

must meet three criteria (Creswell & Plano Clark, 2011):
(a) At least one qualitative and one quantitative

method are combined.
(b) Each method is used rigorously according to

the standard of that research methodology.
(c) The study must be carried out by using a mixed

methods design, which includes integration of the quantita-
tive and qualitative data.

There are four primary research designs used in mixed
methods, described below, all of which meet the aforemen-
tioned criteria (see Table 1).

Concurrent Triangulation/Convergent Parallel Design
The concurrent triangulation, or convergent parallel,

research design involves collection of both quantitative and
qualitative data in the same, single phase (Creswell & Plano
Clark, 2011). The purpose of this design is to merge the
quantitative and qualitative data during interpretation in or-
der to combine the results and gain a richer understanding
of the phenomenon being studied. These studies are efficient
and may be more intuitive to a researcher who is new to
mixed methods, but still require knowledge and expertise
in both quantitative and qualitative methods. Additionally,
it may be difficult to directly relate the two data types, par-
ticularly if they have conflicting results.

A general question that could be answered using a
concurrent triangulation design might be, “To what extent
do the qualitative results confirm the quantitative results?”

For example, a study of the psychological well-being and
medical guidance provided to parents of children with cleft
palate, specifically related to feeding problems, concurrently
measured parents’ well-being with questionnaires (quantita-
tive), and engaged parents in semistructured interviews
(qualitative; Mauriën et al., 2019). These researchers found
that quantitative and qualitative results confirmed that pa-
rental self-esteem was not impacted by the child’s feeding
problems but reported divergent results about stress and
depression.

Sequential Explanatory Design
A sequential explanatory design involves collecting

data in two or more phases, first quantitative data and then
qualitative data (Schoonenboom & Johnson, 2017). The
purpose of this design is to use the qualitative data collec-
tion to follow up on a quantitative finding of interest, con-
necting the first phase to the second to better explain or
interpret the quantitative findings (Creswell & Plano Clark,
2011). This design is relatively straightforward and easier to
implement for traditionally quantitative researchers but is
more time consuming than concurrent designs because it in-
volves two phases of research.

A question that could be answered using a sequential
explanatory design might be, “How does the qualitative
data explain these specific quantitative results (i.e., signifi-
cant or outlier results, specific population of interest?)” For
example, a study of children who have undergone intesti-
nal transplant (Mancell et al., 2020) first administered par-
ent report questionnaires and collected 3-day food diaries
(quantitative). Then, they followed up with semistructured
interviews with a subset of parents (qualitative) to clarify
information found in the quantitative phase and explore
caregiver perceptions about the children’s eating behaviors
and nutritional intake, as well as the influencing factors in
these outcomes.

Sequential Exploratory Design
A sequential exploratory design involves collecting

data in two or more phases, first qualitative data and then
quantitative. The purpose of this design is to use the quali-
tative data to inform or build a tool to be tested in the
quantitative phase (Creswell & Plano Clark, 2011). This
design has similar advantages and disadvantages as the
sequential explanatory design described above. That is, it
offers the relative simplicity of only collecting one type of
data in each phase but can be time consuming due to the
use of two or more research phases.

A sequential exploratory design can be used to help
develop an instrument or new intervention protocol or iden-
tify categories or a taxonomy for follow-up. For example,
this design is being used by a research team examining the
role of different diets for children who are gastronomy tube
fed (Taylor et al., 2019). In Phase 1, they will complete
semistructured interviews with parents and focus groups
with health professionals (qualitative) to determine appro-
priate outcome measures. In Phase 2, they will use the stan-
dardized measures and questionnaires developed in Phase 1

1624 Perspectives of the ASHA Special Interest Groups • Vol. 5 • 1623–1630 • December 2020

SIG 13 Swallowing and Swallowing Disorders (Dysphagia)

to collect data from parents, children, and clinicians (quan-
titative) to compare home-blended and formula groups.

Embedded Design or Intervention Design
An embedded, or intervention, design involves one

or two phases of data collection, with either quantitative or
qualitative data serving as the primary data, while the other
acts as supporting data (Creswell & Plano Clark, 2011). The
purpose of this design is to enhance traditional intervention
designs by collecting additional information about the inter-
vention (Palinkas et al., 2011). This design is more efficient
and may be more natural to traditionally quantitative re-
searchers. However, this design needs to be thoughtfully
implemented with a clear rationale for collecting the sup-
plemental data and awareness of the possibility of treatment
bias. That is, qualitative data collection often involves having
individuals reflect on their experiences, and this reflection

in itself may alter their engagement in and response to the
intervention being tested.

An embedded design is primarily used for enhancing
intervention trials and can enhance the interpretation of
the outcomes and feasibility. For example, this design has
been used with students to evaluate the benefits of an in-
tensive dysphagia clinical placement (Cocks et al., 2014) as
well as changes in student attitudes toward breastfeeding
(Mahurin-Smith, 2018). Both of these studies captured pre–
and post–quantitative and qualitative data to measure con-
structs such as knowledge gained, change in attitude, and
general feedback.

Other Considerations
When designing mixed methods research studies, re-

searchers must also consider design decisions such as:

Table 1. Framework for mixed methods research design.

Thompson & Zhang: Mixed Methods in Pediatric Feeding Disorder 1625

SIG 13 Swallowing and Swallowing Disorders (Dysphagia)

• Timing: Whether data collection will occur concurrently,
sequentially, or both (see Table 2).

• Weighting: Whether either the quantitative or quali-
tative data be given more weight, or if both will be
given equal weight in analysis (see Table 2).

• Mixing: When the two types of data will be mixed—
during design, at analysis, or to connect one phase to
another.

• Sampling: Whether the researcher will collect quanti-
tative and qualitative data from the same group, a
subset of the larger group, or two different groups.

• Sample Size: This will follow traditional methodology
for each sample, with quantitative sample size based
on statistical sample size calculation and qualitative
based on thematic saturation.

• Rigor: Mixed methods studies should still meet the
same standards of quality and rigor for both qualita-
tive and quantitative methodology, collection, analysis,
and interpretation (Zhang & Creswell, 2013).
These four basic designs are not mutually exclusive

and can be combined in any given study. We suggest that
researchers, particularly those new to designing and con-
ducting mixed methods studies, consider starting with these
four basic types of mixed methods designs. As researchers
gain more experiences with mixed methods, they are more
able to effectively design their studies using a more advanced
mixed methods approach.

Critical Appraisal of Mixed Methods Research
The critical appraisal of research is an important skill

for both clinicians and researchers. Appraisal of research re-
quires careful consideration of various elements, specific to
that methodology, that impact the study’s quality. While no
study is perfect, it is important that the authors have ad-
dressed these areas adequately and appropriately. The fol-
lowing critical appraisal questions are based on the Mixed
Methods Appraisal Tool (Version 2018; Hong et al., 2018)
to assist clinicians and researchers new to mixed methods
in assessing the quality of mixed methods research.

1. Is it mixed methods?
The use of the term mixed methods is relatively recent.

Earlier studies may use terminology like qualitative and
quantitative study or in their abstract discuss collecting both
quantitative and qualitative data. While these are not labeled

mixed methods, many of them certainly meet the criteria
outlined earlier. Readers should consider the following:

• Do the researchers collect both qualitative and quan-
titative data?

• Does the study design fit one of the four mixed methods
designs?

The reader can typically determine if the study is mixed
methods by examining the abstract, although they may have
to read further into the methods to determine if it truly meets
the necessary standards.

2. Does the chosen mixed methods design match the
research questions, and does the author provide a rationale
for this choice?

The research questions should be a good fit for a mixed
methods study and should not be able to be better answered
using qualitative or quantitative methods alone. There should
typically be at least three aims—one aimed at the quantitative
information, one aimed at the qualitative information, and
one aimed at integrating the two (Sadan, 2014). Addition-
ally, if a mixed methods study is appropriate, the research
questions should guide the choice of design, not the other
way around. The design type should be explicitly stated in
the abstract and purpose statement. With the four possible
designs in mind, the reader should consider the following:

• Are there separate aims for, at a minimum, the quan-
titative and qualitative research questions?

• Do the quantitative and qualitative portions each seem
to provide additional information to the study, or could
this question be answered with only one data source?

• Of the four mixed methods designs, is there a differ-
ent design that could provide more information about
this question?

These questions can be answered by examining the
study aims and/or the author’s rationale for choosing this
design, which usually is found near the purpose statement
in the introduction to the article. The purpose statement
should include qualitative and quantitative purpose state-
ments and the rationale for using mixed methods.

3. Are both the quantitative and qualitative data col-
lection and analysis methods sufficiently rigorous, consistent
with disciplinary standards for each of those methodological
approaches?

While collection of both quantitative and qualitative
data can be laborious, it does not mean the quality standards
are relaxed. Both the quantitative and qualitative portions of
the study should meet the quality standards of those method-
ologies. Both sections should have appropriate recruitment
strategies and sampling, data collection, robust data analysis,
ethical considerations, and sufficient reliability, validity, and
rigor. The reader should keep in mind the expectations of
quantitative and qualitative research and consider those
standards for both the quantitative and qualitative portions:

• Do the authors explain their recruitment and sam-
pling strategies for both? Are these valid procedures
for the study?

Table 2. Timing and weighting of mixed methods designs.

Variable Concurrent Sequential

Equal weighting QUAN+QUAL QUAN → QUAL
QUAL → QUAN

Dominant weighting QUAN+qual
QUAL+quan

QUAN → qual
Quan → QUAL
QUAL → quan
Qual → QUAN

1626 Perspectives of the ASHA Special Interest Groups • Vol. 5 • 1623–1630 • December 2020

SIG 13 Swallowing and Swallowing Disorders (Dysphagia)

• Do the authors describe data collection and analysis
for both? Are these valid and rigorous procedures for
this type of data?

• Do the authors describe methods and measures that
provide confidence in the validity and reliability for
both types of data?

• If one were to look at the quantitative and qualitative
portions of this study as stand-alone studies, would
they judge each portion to reflect high-quality research?

These questions can be answered by examining the
Method section of the study, which will include both quan-
titative and qualitative methods.

4. Are the Quantitative and Qualitative Components of
the Study Integrated or Mixed Effectively in Order to Answer
the Research Question(s)?

Mixed methods research stands out because of this
key component—mixing of quantitative and qualitative
data. In concurrent studies, qualitative and quantitative data
collection and analysis often occur in parallel and indepen-
dently from each other. The separate results are merged dur-
ing the interpretation part of the study (Zhang & Creswell,
2013). Sometimes, either qualitative or quantitative data
can be transformed in order to be directly comparable. In
sequential studies, the results of data analysis from the
first phase, whether this is quantitative or qualitative, should
then inform the next phase of data analysis (Zhang & Creswell,
2013). For example, a tool may be developed using quali-
tative measures in Phase 1 and then evaluated or used in
quantitative Phase 2, or Phase 1 may analyze quantitative
data, and based on that data, researchers may follow up
with a population who had a surprising or interesting result
using qualitative methods. Authors must be explicit about
how they mix data and must do it effectively to answer their
research question(s). They should also describe how they
weighted each data set, that is, how they decided which type
of data they would prioritize or give more emphasis to when
interpreting their results. The reader should keep in mind the
different methods of mixing and consider the following:

• Do the authors explain when they mixed their data?

• Are they explicit about how they mixed the data?

• Do they describe the joint picture the mixed data pro-
vides and how this relates to the study aims?

• Do the mixed results demonstrate the value added by
using both quantitative and qualitative data?

These questions can be answered by looking at the
Method, Results, and Discussion sections. Many authors
will provide visuals showing how the data were integrated.

5. Are the findings interpreted accurately and
meaningfully?

The goal of all research is to report accurate and
meaningful findings. The authors should use all of the data
collected to come to some conclusions about the aims they
set out for. This should be thoughtfully described and con-
sidered. Connections to prior research, acknowledgement

of limitations of the study, and suggestions about clinical
implications and/or future directions should be included.
When examining the results, the reader should consider the
following questions:

• Do the conclusions drawn match the data presented?

• Are the conclusions meaningful and specific?

• Does the author explain the results in the context of
other research?

• Is the author forthcoming in their acknowledgement
of the potential impact of study limitations?

These questions can be answered by examining the
discussion section of the article, which typically includes a
discussion of results, limitations, and future directions or
implications.

6. Are any divergences or inconsistencies between
the quantitative and qualitative components addressed
appropriately?

The potential benefit, and challenge, of using both
quantitative and qualitative methods is that quantitative
and qualitative results may not line up. This can be useful
in providing an opportunity for critical reflection on study
design and findings, as well as informative for future research.
While divergences or inconsistencies in the data do not make
it a poor study, they do need to be addressed and explained
by the author. For example, the author may treat the results
as complementary (Moffatt et al., 2006) or take steps to
explore the data in different ways (Pluye et al., 2009).

The readers should consider the methods for explain-
ing divergence and consider the following:

• Are there divergences or inconsistencies in the quanti-
tative and qualitative results?

• Does the author acknowledge and explain these in-
stances appropriately and thoroughly?

These questions can be answered by looking at the
Discussion section, which should acknowledge conflicting
results and explain possibilities for their cause.

Potential Use of Mixed Methods in Pediatric
Feeding Disorder Research

In the introduction to the article, we highlighted some
challenges in understanding PFD that might be productively
addressed through the use of mixed methods research de-
signs. Having provided an introduction to these approaches
and quality indicators for mixed methods research, we now
will provide specific examples of the application of these
approaches to PFD research questions and aims. In particu-
lar, mixed methods research design allows for research that
focuses on (a) understanding attitudes, preferences, and
knowledge; (b) exploring predictors, outliers, and specific
demographics; (c) developing tools; and (d) evaluating inter-
ventions (Creswell & Plano Clark, 2011). All four of these
areas are greatly needed in the PFD literature and to advance
clinical practice.

Thompson & Zhang: Mixed Methods in Pediatric Feeding Disorder 1627

SIG 13 Swallowing and Swallowing Disorders (Dysphagia)

Understanding Attitudes, Preferences, and
Knowledge

Traditionally associated with qualitative research, mixed
methods offer an opportunity to explore attitudes, preferences,
and the knowledge of key stakeholders from multiple per-
spectives. This may include parents, children, speech-lan-
guage pathologists (SLPs), nurses, occupational therapists,
gastroenterologists, and other related professionals. For ex-
ample, Simione et al. interviewed parents of children with
PFD and found themes such as impacts on daily life and
social participation, desires by parents for the health and
quality of life of their children, facilitators and barriers of
desired outcomes, and preference for family-centered treat-
ment approaches (Simione et al., 2020). They could have
extended this study by including a quantitative measure of
quality of life, such as the PedsQL Measurement Model
(Varni et al., 1999), to support their findings. Similarly, a
qualitative study of occupational therapists’ knowledge of
infant feeding assessments could have been extended with a
concurrent quantitative measure of knowledge, to determine
how the practitioners’ reflections on assessment integrated
with standard measures of knowledge, such as those commonly
used in clinical education (Subramaniam & Reid, 2003). In
such instances, mixed methods design can integrate survey,
in-depth interviews, and/or focus group discussions to better
understand the individual, social, and clinical factors associated
with PFD. This advanced understanding can aid clinicians
and researchers in developing specialized interventions for sub-
populations of PFD and in facilitating stakeholder buy-in
to intervention.

Exploring Predictors, Outliers, and Specific
Demographics

Mixed methods research offers an opportunity to take
traditional quantitative research one step further, by allow-
ing the researcher to immediately follow up on interesting
results. The sequential explanatory design produces a richer
description of the data and can answer questions about out-
liers, statistically significant results, key predictors, and spe-
cific demographics, rather than having to theorize based on
other studies. For example, a study of children with and with-
out feeding problems in Thailand found that the first child of
a family was more likely to have feeding problems and could
have explored this finding further by interviewing families
of first children with feeding problems (Benjasuwantep et al.,
2013). A study of longitudinal changes in feeding in children
with cerebral palsy found that most children’s skills were
stable over time and could have extended their findings
by conducting interviews with the parents of those children
whose skills were variable over time to better understand
that subset of the population (Clancy & Hustad, 2011). These
extended findings could unearth implications for the diagnosis
and treatment of PFD.

Developing Tools
Tools that are reliable, valid, and feasible can be de-

veloped to near completion with a mixed methods design.

The sequential exploratory design allows for qualitative
methods, such as interviews, focus groups, or expert panels,
to lead to the development of measurement tools that are
meaningful to the target population, which can then be vali-
dated with quantitative measures. For example, a qualitative
study of factors that impact school-based management of
pediatric dysphagia (Angell et al., 2008) could have used
their findings to develop and test a parent satisfaction tool
related to school-based management. Alternatively, the au-
thors of the Ability for Basic Feeding and Swallowing Scale
for Children (Kamide et al., 2015) could have first used an
expert panel to reach consensus on the items included in the
scale before then testing its reliability and validity. The addi-
tion of stakeholder perspectives can make the tool more
meaningful for the target population.

Evaluating Interventions
The use of mixed methods approach enables better

understanding of whether and how an intervention works
(Palinkas et al., 2011). Intervention research in the field of
PFD is much needed, particularly for children under three
and their families. An embedded research design would al-
low for an examination of not only the quantitative effects
of treatment but could also use qualitative methods to ex-
amine the feasibility of the intervention for families or SLPs.
This design can capture meaningful intervention outcome
data that is not easily assessed with quantitative methods,
such as how family dynamics change around mealtimes,
how a child’s mood changes with positive interventions, or
the impact on the dyad across daily living activities. For
example, in a study of the effects of oral motor stimulation
on feeding outcomes in infants with univentricle anatomy
(Coker-Bolt et al., 2013), the authors could have extended
the study by collecting pre– and post–qualitative data from
the therapists implementing the intervention to assess feasi-
bility. Similarly, a study of a pacing intervention for pre-
term infants could have conducted qualitative interviews
with the nurses who implemented the study to assess feasi-
bility and acceptability of the intervention (Law-Morstatt
et al., 2003). These additions can improve the development
of effective, feasible interventions.

Implications for Interdisciplinary Work in Pediatric
Feeding Disorder Research

Mixed methods research offers a way of conducting
research that meets the needs of interdisciplinary research
in PFD, particularly important given the growing acknowl-
edgement that PFD must be assessed and treated with an
interdisciplinary lens. Mixed methods lend itself well to in-
terdisciplinary teams, as it allows for different methods of
research to focus on different aspects of the same phenom-
enon (Bowers et al., 2013). For example, an interdisciplinary
team could participate in an embedded design and examine
medical, nutrition, feeding skill, and psychosocial outcomes
using qualitative and quantitative measures. An interdisci-
plinary team could also use a sequential exploratory design

1628 Perspectives of the ASHA Special Interest Groups • Vol. 5 • 1623–1630 • December 2020

SIG 13 Swallowing and Swallowing Disorders (Dysphagia)

to develop an appropriate outcome measure that integrates
medical, feeding skill, nutrition, and psychosocial outcomes.

Interdisciplinary teams are also advantageous in mixed
methods design for implementation of a rigorous study
(Bowers et al., 2013). An interdisciplinary team with diverse
experiences is critical because mixed methods research
necessitates inclusion of qualitative and quantitative re-
searchers for proper implementation. While potentially more
labor intensive than traditional single methodologies, the
information gained from these studies can be rich when
properly implemented, and team collaboration can ease
the burden on individual researchers or practitioners. Clini-
cians involved in clinical research may find this methodology
particularly exciting, as it allows for multiple perspectives
on a single phenomenon, such as understanding the SLPs’
or parents’ perspectives in addition to those of the re-
searchers. Additionally, mixed methods research design
could enhance the feasibility of implementing the interven-
tion into clinical practice, bridging research and clinical
practice more smoothly (Palinkas et al., 2011). Mixed methods
research design helps us answer whether an intervention
works (or not) and why (or why not), as well as assess its
fidelity of implementation (how it is being delivered).

Conclusions
This article highlights the benefits of mixed methods

research in the area of PFD, as this methodology holds po-
tential to advance our understanding of the heterogenous
populations PFD impacts, improve our use of interdisci-
plinary teams, examine holistic interventions, and develop
tools for clinical and research use that capture all four com-
ponents of PFD in a meaningful and feasible way. To aid
readers in considering applying mixed methods research
to PFD, we have described the necessary components for
rigorous mixed methods research and its critical appraisal.
Mixed methods research has much potential for exploring
phenomenon of interest in PFD. The application of mixed
methods designs results in deeper and broader information
about the subject of study that can enhance our under-
standing and measurement of phenomenon or interven-
tions, which makes it well suited to the interdisciplinary
nature of PFD research.

Author Contributions
Kelsey L. Thompson: Conceptualization (Equal),

Investigation (Lead), Writing – Original Draft (Lead),
Writing – Review & Editing (Supporting). Wanqing Zhang:
Conceptualization (Equal), Writing – Review & Editing
(Lead).

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European Journal of Social Work

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The use of health care services by homeless
shelter residents

Kateřina Glumbíková , Alice Gojová , Michal Burda , Radka Poláková & Pavel
Rusnok

To cite this article: Kateřina Glumbíková , Alice Gojová , Michal Burda , Radka Poláková & Pavel
Rusnok (2020) The use of health care services by homeless shelter residents, European Journal of
Social Work, 23:4, 699-710, DOI: 10.1080/13691457.2019.1583639

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The use of health care services by homeless shelter residents

Využívání služeb zdravotní péče osobami bez domova
Kateřina Glumbíkováa, Alice Gojováa, Michal Burdab, Radka Polákováb and Pavel Rusnokb

aDepartment of Social Work, Faculty of Social Studies, University of Ostrava, Ostrava, the Czech Republic; bInstitute
for Research and Applications of Fuzzy Modeling, University of Ostrava, Ostrava, the Czech Republic

ABSTRACT
This submitted article is based on partial data from the Health and Use of
Health Care Services by Shelters Users research, taking advantage of the
sequential synergy of qualitative and quantitative research strategies. The
quantitative research involved 192 respondents, while the qualitative
research involved 30 communication partners. The article aims at finding
out the relationship between selected health characteristics of the shelter
population and their impact on the use of health care services. The article
presents data from the quantitative research that are further illustrated by
qualitative data. The data were analysed using descriptive statistical
methods, a Fisher’s exact test, a Wilcoxon test and a Proportion Matching
Test. The relationship between mental health and use of health care
services (especially in the case of women) has been proven. Homeless
people who do not use any health care services are, on average, for a longer
period in temporary housing; whereas those who rated their health as more
serious used health care services more frequently. In the conclusion, the
authors present the implications for social work that resulted from the survey.

ABSTRAKT
Předložený článek je založen na dílčích údajích z oblasti zdravotní péče a
využívání služeb zdravotní péče obyvateli azylových domů, s využitím
sekvenční synergie kvalitativních a kvantitativních výzkumných strategií.
Kvantitativní výzkum zahrnoval 192 respondentů, zatímco kvalitativní
výzkum zahrnoval 30 komunikačních partnerů. Cílem článku je zjistit vztah
mezi vybranými zdravotními charakteristikami populace z azylových domů
a jejich dopadem na využívání zdravotnických služeb. Článek představuje
údaje z kvantitativního výzkumu, který je ilustrován kvalitativními údaji.
Data byla analyzována pomocí popisných statistických metod, Fisherova
exaktního testu, Wilcoxonova testu a testu shody proporc. Vztah mezi
duševním zdravím a využíváním služeb zdravotní péče (zejména u žen) byl
prokázán. Bezdomovci, kteří nevyužívají žádné zdravotnické služby, jsou v
prozatímním ubytování v průměru déle; zatímco ti, kteří považovali své
zdraví za důležitější, využívali služby zdravotní péče častěji. V závěru autoři
prezentují možné dopady na sociální práci, které vyplynuly z výzkumu.

KEYWORDS
Health; health care services;
shelter users; homelessness;
social work

KlÍČOVÁ SLOVA
Zdraví; služby zdravotní péče;
obyvatelé azylových domů;
bezdomovectví; sociální
práce

Introduction

Homelessness is an extreme form of poverty and a highly topical problem experienced worldwide.
From foreign (and also Czech) studies, we know that the health status of homeless people living

CONTACT Kateřina Glumbíková Katerina.Glumbikova@osu.cz Department of Social Work, Faculty of Social Studies, Uni-
versity of Ostrava, Fr. Šrámka 3, 708 00 Ostrava Mariánské Hory, the Czech Republic

EUROPEAN JOURNAL OF SOCIAL WORK
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mailto:Katerina.Glumbikova@osu.cz

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in shelters is very often worse both at a psychological and physical level than that of the majority
population (e.g. Brem & Seeberger, 2010; Fitzpatrick-Lewis et al., 2011) and health problems tend
to deepen with increasing age (e.g. Barták, 2011; Frey, 2013). A number of studies also describe
the co-morbidity of individual diseases in this target group (see, for example, Brem & Seeberger,
2010). A number of research surveys, e.g. Baggett, O’Connell, Singer, and Rigotti (2010), suggest
that homeless people do not often use health care services even if they experience acute health pro-
blems. This paper aims at identifying the relationship between the selected (health) characteristics of
shelter residents and their impact on their use of health care services. To achieve its objective, the
paper delivers: (a) the categorisation and systematisation of findings from foreign research on bar-
riers to access to health care for homeless people; (b) verification of hypotheses based on the
results of foreign research; and (c) illustration and deepening of knowledge from the quantitative
research through data obtained from the qualitative research.

Theoretical foundation

The theoretical foundation of the submitted article rests on two principal axes: the health status of
the homeless shelter1 residents and the use of health care services by this population.

Health status of the homeless shelter population

Fitzpatrick-Lewis et al. (2011) surveyed the health status of 1,192 residents of shelters, hostels and
night shelters. 85% of the persons stayed in chronically poor health conditions, and almost 50%
had been diagnosed with some medical or mental condition. Beijer, Wolf, and Fazel (2012)
focused on the incidence of tuberculosis, C-type jaundice and HIV in homeless people using night
shelters and regular shelters by analysing data from 43 published surveys (59,736 homeless
people). Prevalence of tuberculosis ranged from 0.2% to 7.7%, for C-type jaundice from 3.9 to
36.2% and for HIV from 0.3 to 21.1%. Folsom et al. (2002) note the incidence of diabetes, arthritis,
and hypertension.

Folsom et al. (2002) talk about the high incidence of psychiatric diagnoses, namely depression and
schizophrenia, in homeless people living in shelters. These two diagnoses were up to four times more
prevalent amongst the shelter population compared with the majority population. The so-called
SEEWOLF-Study2 (Bäuml, Brönner, Baur, Pitschel-Walz, & Janh, 2017) emphasises a higher risk of
depression, schizophrenia or anxiety disorders in the homeless population. A total of 232 randomly
selected individuals took part in the study, out of whom 80% were men and 20% were women. The
results of the study showed that approximately two thirds of the surveyed individuals suffered from a
mental illness, but usually from multiple illnesses at a time.

The use of health care services by shelter residents

In individual surveys, a number of barriers related to the use of health care services by homeless
people were pointed out. The first range of these barriers was a poor mental state. Gelberg, Andersen,
and Leake (2000) mention three areas of barriers to the use of health care services by homeless
people, namely the long-term situation of homelessness, mental problems and substance abuse.
The positive impact on use of health care services occurred when an individual had positive experi-
ence with a GP and therefore held the perception of a GP as a regular source of care and support. The
authors emphasise that the availability of health care services was not as important to people in shel-
ters as their quality. Salize et al. (2001) also point to the barrier of visiting a physician when one’s issue
is related to a mental illness. The researchers carried out the research with 102 probands suffering
from some kind of a mental illness. Most of them identified a visit of health care services as proble-
matic and did not use it.

700 K. GLUMBÍKOVÁ ET AL.

The second important factor influencing the use of health care services was the existence of social
support. For example, the research by Hwang et al. (2009) (carried out on 544 respondents) demon-
strates the relationship between social support and the scope of a social network with better mental
and physical health; the research by McCormack and MacIntosh (2001), based on the experience of 11
homeless people living in shelters, established an anchored theory of strategies that the homeless
people use to acquire, maintain and restore health. The model points to three paths leading to
health. Such paths are socially influenced, directly by the family and its beliefs, and indirectly by
values and beliefs in a particular society. Similarly, for example, Constantino, Yookyung, and Crane
(2005) emphasise the importance of a social support network, in particular accompaniment to
health care services. The women who had an accompaniment and a self-help group available to
them demonstrated a reduced emotional distress and an increased use of health care services.

The third identified factor that had an impact on the use of health care services was the duration of
stay in a temporary accommodation. Baggett et al. (2010) conducted a study of 966 homeless people
who were long-term users of night shelters and shelters. 73% of the respondents pointed out that
they were a subject to unmet health care needs, including the inability to receive medical or
nursing care (32%), difficulty in receiving prescribed medication (36%), problematic access to
mental health treatment (21%), problematic access to eyewear (41%) as well as a problematic
access to dental care (41%). A long-term life away from ‘home’was identified as a significant predictor
of unmet needs; other factors included insufficient nutrition, poor sight, and the absence of health
insurance.

The fourth factor influencing the use of health care services is the severity of physical problems.
Compared with the above-mentioned factors, this factor has a consolidating impact on the use of
health care services. For example, Gelberg et al. (2000) tried to find out in their study the factors pre-
dicting the use of health care services by homeless people living in shelters. They emphasise that
there is a high percentage of homeless people with high blood pressure (as much as 81%) and
with a positive tuberculosis test (78%) who use health care services. On the contrary, the use of
health care services is relatively low in people with visual impairment (33%), skin diseases or
walking difficulties (44%) (see also Hwang et al., 2009; Beijer et al., 2012).

The fifth factor having an effect on the use of health care services is the perceived quality of health
care services. In relation to this topic, Martins (2008) carried out a study aimed at understanding the
experience of homeless shelter users with medical services. The method used was qualitative
research based on in-depth interviews with 15 shelter residents. Barriers to access to health care
have been identified during the research, including: condemnation, ‘labelling’ and stigmatisation,
lack of systematic medical care for homeless people, feeling of ‘invisibility’ in relation to healthcare
providers, lack of respect when providing treatment, and ultimately the creation of ‘underground
movements’ in the area of provision of resources related to medical care.

Similarly, Lyon-Callo (2000) presents the results of his three-year ethnographic study from a home-
less shelter and describes the barriers this group had when trying to access health care services. The
first barrier is the concept of homelessness presented by mass media, which is reflected in the view of
homeless people in health care services. The prevailing view is that homeless people are to blame for
their situation. In addition, Laberge (2000) points out the barrier of homeless people’s access to health
care services in the form of symbolic exclusion. Homeless people, as a result of the symbolic exclu-
sion, can be perceived as being guilty of their ownmedical situation, as people who are dirty, as those
the doctors are squeamish about treating. These perceived attitudes of physicians trigger reluctance
to seek health care services and feelings of shame in homeless people.

Methodology of the research

The paper objective has been achieved through the presentation of partial data of a research survey
focused on the health of the population of homeless shelters and the use of health services, which
took place in 2018. The research used the sequential synergy of qualitative and quantitative research

EUROPEAN JOURNAL OF SOCIAL WORK 701

strategies. The aim of the research was to identify the key factors that, according to different shelter
user categories, affect their health and to determine the impact of these factors on the residents’
health and their use of health care services. The qualitative research was comprised of 30 semi-struc-
tured interviews with shelter residents (17 women and 13 men), which were then analysed using
Grounded Theory by K. Charmaz. The quantitative research was comprised of a questionnaire
used with 192 respondents.

The paper is based on outputs from the quantitative part of the research; the data from the quali-
tative part is used to illustrate and elaborate the interpretation of the quantitative data in more detail.
The hypotheses for the quantitative research were determined on the basis of the study of pro-
fessional literature (see The Theoretical Foundation section) and on the basis of a qualitative inves-
tigation, which preceded the quantitative research, and within which we examined the themes and
relationships between individual variables in the respondents’ narrations that we decided to verify in
the hypotheses.

H1: There is a relationship between mental health and the use of health care services.

For operationalisation purposes, we defined mental health as health self-assessed on a four-point scale and

the use of health care services as the frequency of use over a 6-month period.
H2: There is a relationship between the existence of social support, one’s health condition and the use of

health care services.
For operationalisation purposes, we defined the existence of social contacts (family, roommates (or house-

mates), friends, shelter staff) perceived by a person from a shelter in relation to going to see doctors as being
supportive. The health status was again self-assessed on a four-point scale, and the use of health care services
was defined as the frequency of use over a 6-month period.

H3: There is a relationship between the duration of a person’s stay in temporary accommodation and the use
of health care services.

The duration of stay in temporary accommodation was operationalised as the total duration of the stay in a
shelter, hostel and on the street. The use of health care services was defined as the frequency of use over a 6-
month period.

H4: There is a relationship between the severity of physical problems and the use of health care services.
The severity of physical problems was self-assessed on a four-point scale and the use of health care services

was again defined as the frequency of use over a 6-month period.

H5: There is a relationship between the quality of health care services and their use.

The quality of health care services was operationalised as an assessment of perceived physicians’ attitude to

homeless people on a four-point scale. The use of health care services was defined as the frequency of use over a
6-month period.

The respondents were selected on the basis of a quota sampling. The quota was set at 5% of the popu-
lation of homeless people living in shelters in the Czech Republic. According to the Statistical Yearbook
in the area of labour and social affairs (MoLSA, 2016), in 2015, 3,659 clients over 18 years old used shel-
ters. Our research survey involved 192 individuals (i.e. 5.2% of the population) from 7 different regions
(that is territorial-administrative units in the Czech Republic) out of a total of 14. The regions included in
the survey were drawn; the respondents involved were selected using a purposeful sampling through
an institution (a particular homeless shelter). 55% (n = 106) of the respondents were women. The
average age of the respondents was 44 years and each respondent had an average of 2 children
(who did not necessarily have to live in the shelter with them). 64% (n = 123) of the respondents
were not employed, 17% (n = 33) reported that they had jobs (and the rest of the respondents did
not answer the question). 55% (n = 106) of respondents said they had experienced ‘serious’ injuries
or surgeries, 43% (n = 83) of respondents said they should be on medication but only 36% (n = 69)
of them regularly took it. 33% (n = 63) of the respondents said they had the experience of drug addic-
tion. The average length of the respondents’ stay on the street was 8.5 months; the average length of
the respondents’ stay in the hostel was 12.6 months and the average length of their stay in the shelter
was 16 months. 57% (n = 109) of the respondents were living in the homeless shelter for the first time,
and 38% (n = 73) of the respondents repeatedly stayed in such a facility.

The data were obtained using a self-designed questionnaire, which consisted of 25 mostly scale-
based questions.3 The questions in the questionnaire were thematically inspired by findings from the

702 K. GLUMBÍKOVÁ ET AL.

qualitative research. The design of the questions was peer reviewed and piloted with two homeless
people who lived in a shelter at the time. The questionnaire’s limitation in relation to the research
results is that it is not a standardised questionnaire, which may negatively affect its reliability as a
research tool. The method of assisted administration of the questionnaire was used to fill out the
questionnaire. A social worker and/or a researcher assisted with the completion of the questionnaires.
If a social worker acted as an administrative assistant, he/she was trained beforehand regarding the
meanings of individual questions and the data anonymization (the questionnaires were collected and
put in an envelope which was immediately sealed after the data collection). The reason for these
measures was to make sure that the data would be influenced as little as possible by the presence
of a social worker in the research. Within the possible limits of the data obtained, it may be necessary
to reflect on the fact that the data originated on the basis of the self-assessment of communication
partners who could misunderstand a question, not respond to it, or try to make a better impression
within a certain social desirability. Another limitation of the research is that despite the fact that we
randomised the respondents by choosing regions involved in the research, the sampling of respon-
dents was purposeful, that is, non-random, which could have negatively affected the data validity.
The limitation in relation to the research results is the fact that as part of the data processing, we clus-
tered the data that could have affected the results.

The data was analysed using descriptive statistical methods, the Fisher’s exact test (Agresti, 1990),
the Wilcoxon test (Bauer, 1972), and the Newcombe’s Proportion Matching Test (1998).

The entire research has conformed to the Ethical Principles in Human Research adopted by the
American Psychological Association (APA, 2010). Each communication partner and respondent was
asked to sign an informed consent in both stages of the research (that is within the qualitative
and quantitative stages). The informed consent provided the research participants with all the
necessary research essentials: research objectives, further data handling, data anonymization4,
researchers’ discretion5, voluntary participation in research (the research participants had a possibility
to withdraw from the research at any time as well as to refuse to answer any question). Taking into
account the fact that the research target group can be considered a vulnerable human subject, we
emphasised to keep a non-judging and respectful attitude to each of the respondents. Moreover, we
also emphasised the necessity of their understanding of all information about the research, their
rights (see above), and all asked questions. We also tried to create the environment of safety and
trust and to provide the respondents enough time for their answers to the questions. (see
Miovský, 20066).

Results

The following text presents the results relating to individual hypotheses. In relation to the research
results, it is necessary to mention the acquired data and its interpretation cannot be generalised
to the whole population of homeless people nor to the population of homeless people living in a
shelter in the Czech Republic.

H1: There is a relationship between mental health and the use of health care services.

A total of 18% (n = 35) of the respondents reported that their mental status was ‘very good’, 59% (n =
113) of the respondents reported that it was ‘good’, 20% (n = 38) of the respondents perceived it as
being ‘poor’, and 3% (n = 6) of the respondents thought that their mental state was ‘very poor.’ A total
of 68% (n = 131) of the respondents reported that they went to see a doctor regularly, 28% (n = 54) of
the respondents did not go to see a doctor at all, and 4% (n = 7) of the respondents did not answer
the question.

In the evaluation of the results, the exact Fisher’s test was used, which showed existing depen-
dence between the above variables (p-value = 0.0250). The dependence is statistically significant
in women (p-value = 0.0233). However, the significance was not confirmed in men (p-value =
0.5854). As part of our further data processing, we ranked ‘very good-good’ as ‘good mental

EUROPEAN JOURNAL OF SOCIAL WORK 703

health’ and ‘poor-very poor’ as ‘poor mental health’ and then we compared them with each other.
The results showed that people with bad psychological health are less likely to seek the help of
any physician (the proportion is 65% (n = 89) versus 88% (n = 36), p-value = 0.0037). The difference
between groups is even greater in the case of women only (65% (n = 50) versus 91% (n = 22), p-
value = 0.0138). In the case of men, the significance was not confirmed (p-value = 0.2203). The
research findings can be also illustrated using the statements of the communication partners from
the qualitative part of the research. ‘When I had the depression and such, I wouldn’t go to see a
doctor at all’ (CP 8). ‘Well, those anxieties… they prevented me from going to the doctor’ (CP 6). ‘I
had different worries back then… I mean those in my mind’ (CP 3).

H2: There is a relationship between the existence of social support, health status and the use of health care
services.

As a result, 38% (n = 73) of the respondents reported that someone was there to help them to access
and use health care services; 60% (n = 115) of the respondents stated that nobody helped them, and
2% (n = 4) of the respondents did not respond to the question. The respondents reported that the
greatest amount of assistance was received from their family members and from the social
workers of the shelter where they live (41%, n = 79). A total of 14% (n = 27) of the respondents
thought that their overall health was ‘very good’, 65% (n = 125) of the respondents were of the
opinion that it was ‘good’, 18% (n = 35) of the respondents thought it was ‘poor,’ and 3% (n = 5) of
the respondents believed that their overall health was ‘very poor’.

The Test of Equal Proportions was used to test the hypothesis. The users of shelters who are
helped by social workers in 87% (n = 26) of cases evaluate their health as ‘good’ or ‘very good.’ On
the other hand, only 73% (n = 24) of the users of shelters, who are helped by family members
when in need of a visit to a physician, evaluate their health as ‘good’ or ‘very good.’ However, the
difference in proportion is not significant (p-value = 0.2919). Despite the fact that a statistically signifi-
cant relationship has not been demonstrated, the results of the qualitative research illustrate that
social support is perceived as an important factor in the use of health care services. ‘When it’s
needed… I mean that they accompany you to the doctors, otherwise I wouldn’t go to that doctor
on my own… if you need it, they will support you’ (CP 10). ‘I needed to be accompanied because
I was completely weak and didn’t feel like going anywhere, so I needed accompaniment’ (CP 6).

H3: There is a relationship between the length of stay in temporary accommodation and the use of health care
services.

The average length of stay on the street was 8.5 months for respondents, the average length of stay
in a hostel was 12.6 months, and the average length of stay in a shelter was 16 months (to illustrate
the data, 57% (n = 109), of the respondents stayed in a shelter for the first time, and 38% (n = 73) of
the respondents stayed in a shelter repeatedly). The Wilcoxon rank sum test was used to compare the
length of stay in temporary accommodation between different groups of respondents who said they
were using (or not using) health care services. Differences in the length of stay in the street (p-value =
0.2403), hostel (p-value = 0.7608) or in the shelter (p-value = 0.2134) did not prove to be statistically
significant. For homeless people who do not use any health care services, a median length of stay in
temporary housing was a total of 38 months and those who responded that they were using health
care services had a median length of stay of 18.75 months in temporary housing. Therefore, the
results at the threshold of statistical significance (p-value = 0.0714) show that the length of stay in
temporary housing is higher in people who do not use health care services. The above-mentioned
result of the quantitative survey is illustrated by the statement of one of the communication partners
in the qualitative part of the research:

I’ve been homeless for four years now… one has poor quality food because doesn’t have money… sometimes
you sleep outdoors, with mould and bed bugs in a homeless shelter but the longer you live in such environment,
the more you get used to it and the harder it is for you to go to the doctor. You are ashamed too… and plus, you

704 K. GLUMBÍKOVÁ ET AL.

have other worries, you worry where to sleep… trying to secure some certainty… just that health is secondary
… (CP 17).

H4: There is a relationship between the severity of physical difficulties and the use of health care services.

14% (n = 25) of the respondents stated that their physical condition was ‘very good,’ 63% (n = 115) of
the respondents reported that their physical condition was ‘good,’ 19% (n = 34) of the respondents
thought it was ‘poor,’ and 4% (n = 8) of the respondents called their condition ‘very poor.’

To show the statistical significance of the relationship between the severity of physical difficulties
and the use of health care services, the exact Fisher’s test was used (p-value = 0.0015). As part of our
further data processing, we ranked a cluster of values ‘very good-good’ as ‘good physical health’ and
‘poor-very poor’ as ‘poor physical health’ and compared them with each other. The results show in
only 63% (n = 85) of cases that people with good physical health seek the help of a physician.
People who evaluate their health as poor claim to seek medical help in 93% (n = 39) of cases. The
difference is huge and very statistically significant (p-value = 0.0152). The results also show that
men tend to seek help from physicians less frequently (the difference between the clusters of
men and women is 56% (n = 27) versus 90.9% (n = 20)), but the difference is also significant in
case of men (p-value = 0.0058). The results of the quantitative survey are illustrated by the statements
of the communication partners from the qualitative part of the research. They show that when a
serious health problem arises, the doctor’s visit is necessary and sometimes is also a question of
life and death: ‘When it’s serious, you just go to see a doctor. For example, I’ve had serious problems
with my heart… you have no choice then… ’ (CP 22). ‘I had pneumonia… they thought I was gonna
die, I had it in cold print that I was gonna die… it wasn’t about choosing anymore whether to go or
not to go to see a doctor… ’ (CP 29).

H5: There is a relationship between the quality of health care services and their use.

The shelter users who have evaluated a physician’s attitude to homeless people as good or rather
good visit physicians in 75% (n = 111) of cases, compared with 52% (n = 12) of those who have eval-
uated a physician’s attitude as bad or rather bad. This difference is significant (p-value = 0.04). Simi-
larly, if we ask directly whether a physician’s attitude affects their willingness to go and see a
physician, then clients who claimed that the physician’s attitude affected them positively actually
go to doctors more often (in 79% cases, n = 27), and vice versa, clients who claimed that the phys-
ician’s attitude affected them negatively go to doctors in 63% cases (n = 21). The difference is
smaller than in the first comparison and is not statistically significant (p-value = 0.49).

We examined the quality of health care services in each respondent group, namely the group of
respondents that considered the distance to a doctor’s office to be an important factor of the doctor’s
visit as well as the group of respondents that considered money the most important factor.

Given the implicit importance, that is, the connection between evaluation of health care services
and attendance, the most important factor appears to be the physician’s attitude (the difference is
75% of attendance (n = 111) vs. 52% of attendance (n = 12)). If, on the contrary, we consider the expli-
cit importance declared by clients, the most important factor is money (the difference is 90% of
attendance (n = 37) vs. 52% of attendance (n = 14)).

Several communication partners in the qualitative part of the research described their negative
experiences with physicians who showed an oppressive attitude toward the homeless.

Well, I’ll tell you that when I did everything, the doctors did their best to help me… now, some doctors… I’ll tell
you directly when you’re at the rock bottom, collecting social benefits, some doctors behave horribly. You’re just a
waste of time for them, which is terrible. I have experienced it a few times. (CP 6).

Discussion of the research results and implications for social work

The research results show, also as part of the reflection of the research limitations presented in its
methodology, that there is a relationship between mental health and the use of health care services.

EUROPEAN JOURNAL OF SOCIAL WORK 705

The results show that people with a bad mental state are less likely to use health care services. The
implications for social work therefore include:

The use of social work methods with regard to the comorbidity of a disease with an
emphasis on mental health

In homeless shelter practice, there is a need to purposefully and specifically develop methods of
social work that promote mental health and fulfil the requirement for the need for the multidimen-
sional support of homeless people. This need, according to Hwang, Kirst, et al. (2009), arises due to
the complexity of the needs resulting from interdependence and multiplication of the problems of
this target group, including health related problems. One of the methods that can address the com-
plexity of the needs and the comorbidity of disease is case management. According to Walsch and
Holton (2008), case management makes it possible to provide people with complex problems with
services in a timely and appropriate manner.

In this context, it may be interesting to note that 60% of the respondents answered that nobody
was there for them. In this context, it should be mentioned that a number of researches considered
the existence of social support in the use of health care services as crucial (see, e.g. Constantino et al.,
2005; Hwang et al., 2009). The implication for social work therefore includes:

The importance of social support and accompaniment in supporting the use of healthcare

Social support has proven to be an important factor supporting the use of health care services. The
level of this support intended for shelter residents is rather low and needs to be systematically devel-
oped. Wright and Tompkins (2006) draw attention to the importance of peer accompaniment in the
area of health care for homeless people. One of the successful practices is the activity of the Grounds-
well organisation in London, which set up the ‘Homeless Health Peer Advocacy.’ It is a programme
focused on accompanying homeless people to health care facilities. The accompanying people are
volunteers who have experience with homelessness themselves. The provided assistance helps over-
come personal, systemic, and practical barriers to access to health care.

The results, therefore, show that homeless people who do not use health care services have spent,
on average, a longer period of time in temporary accommodation (see also Baggett et al., 2010). The
result corresponds with the results of the qualitative part of the research, where the communication
partners themselves stated that after a certain period of homelessness health ceases to be a priority
and is replaced by survival as the main priority. A long-term stay ‘on the street’ or in different forms of
temporary housing was linked by communication partners to negative emotional distress aroused by
insecurities about accommodation, fear of security and the necessity to provide basic life needs. The
implication for social work therefore includes:

The need for rapid reintegration into housing

The need for housing stabilisation as a prerequisite for improving the health situation is also empha-
sised by research of the Housing First model, which according to Busch-Geertsema (2013) is based
on the principle of normalisation of living conditions, individualisation of support and transition
from support focused on a place to a more individualised support. The Housing First addresses
what homeless people identify as their first priority, which is housing (Stefanic & Tsemberis,
2007). According to Fitzpatrick-Lewis, the provision of permanent housing leads to a reduction in
substance abuse and to the increased use of health care services (see also Larimer et al., 2009)
as well as to improvement of the quality of mental health (Smith, 2005). However, the data collected
from the research also show that 64% of the respondents are unemployed. In this context, it seems
necessary to direct the support provided under Housing First, not only on the area of health but also

706 K. GLUMBÍKOVÁ ET AL.

on the job acquisition that could subsequently be an important factor in maintaining housing after
the programme’s end.

The results also show that there is a dependence between the severity of physical health problems
and the use of health services (see also Beijer et al., 2012). Homeless people who rated their health as
worse / more serious used health care services more often. In relation to the data from the qualitative
research part, it would be worthwhile to discover which types of health care services are used by
homeless people, given that communication partners in the qualitative research have reported
that they were particularly emergency care services. Communication partners have also stated
that they only used such services when their health problems became more urgent or more
serious. It seems that the preventive use of health care services is rather lower in the case of
shelter users (see Kushel, Perry, Bangsberg, Clark, & Moss, 2002). The preventive use of health care
services is rather absent; therefore social work with shelter residents should focus on promoting
health prevention.

The research participants perceived the seeking of medical help as a significant barrier and held an
oppressive view of physicians when the physicians associated these individuals with a situation of
homelessness; see also Martins (2008), Lyon-Callo (2000) a Laberge (2000). The implication for
social work therefore includes:

Changes in the medicalisation meta-narrative of homelessness through anti-oppressive
social work

The need for an anti-oppressive approach is related to the prevailing medicalisation meta-narrative of
homelessness based on a socially shared view of homeless people as weak, lazy, handicapped, and
prone to psychological and social problems (Swick, 2005), thus ignoring the multidimensional con-
ditionality of homelessness.

The above stated is also related to another instrument of anti-oppressive social work, which is
advocacy in the sense of defending the rights of recipients of social work. In the broader sense, it
means the promotion of rights of whole disadvantaged groups when compared with the general
public. In the narrower sense, it means the promotion of rights of specific people at different
system levels (Dominelli, 2010). Through this instrument, the right to housing for homeless people,
the right to a provision of intelligible information from the authorities, or the right to dignified
and respectable treatment in health care facilities can be defended.

Conclusion

The article aims at finding out about the relationship between the selected (health) characteristics of
the shelter residents and their impact on the use of health care services. Based on these research
results, we have formulated implications for the practice of social work with homeless people. The
methods of social work used in working with homeless people should respect the multidimension-
ality of the needs of this target group of clients, develop and support social support resources beyond
the context of social services, strive for rapid reintegration into permanent housing, and mitigate
oppressive mechanisms to which homeless people are exposed by society.

Notes

1. In the Czech Republic, a shelter is described in the Act No. 108/2006 on Social Services, Section 57 as follows:
‘Shelters provide temporary residential services to persons in an unfavourable social situation associated with
a loss of housing.’ The law on social services for shelters lays down the following basic (mandatory) activities:
‘(a) the provision of food or assistance in catering, (b) accommodation, (c) assistance in the application of the
rights, legitimate interests and in obtaining clarity in personal affairs.’ The law on social services (No. 108/2006)
further provides that ‘the provision of social services in shelters shall be made by payment… ’ The stay in a
shelter is limited, most often for a period of one year.

EUROPEAN JOURNAL OF SOCIAL WORK 707

2. SEEWOLF-Studie (Seelische Erkrankungsrate in den Einrichtungen der Wohnungslosenhilfe im Großraum
München).

3. The questions used ranged from yes/no questions, for example: Do you take medications prescribed to you by
your doctor? through multiple-choice questions, for example: What are the health care facilities you visit?
(select one or more options) Options: general practitioner, ophthalmologist, emergency room, dentist, gynaecol-
ogist, psychiatrist, dermatologist, pulmonary doctor, ear-nose-throat; other (please specify), to questions where
the respondents were asked to choose the degree of their agreement on the scale, for example: How do you
rate your physical health? Scale: Very good – Good – Bad – Very bad.

4. There was no mention of the name of the person or the shelter where the survey took place in the questionnaire.
In the final research report, the data are presented only as data summarised for the target group as a whole; data
related to individual respondents is not stated in any outputs. The data presented in this form does not help to
identify a particular person. Recordings of the qualitative interviews have been transcribed and then deleted in a
way that even the voice of the respondent has not been stored. Any data leading to identification of the com-
munication partner, third party, or organisation has been anonymised.

5. The researchers informed the participants the acquired information would not be passed to a third party outside
the research team (primarily to the shelter staff). They also stated that they have a reporting obligation in case the
participant would report very serious facts, such as grievous body harm to a third person.

6. The author presents an overview of the Czech Republic norms and requirements for ethics approval.

Acknowledgements

This research was partially supported by the NPU II Project LQ1602 ‘IT4Innovations excellence in science’ provided by the
MŠMT of Czech Republic.

Disclosure statement

No potential conflict of interest was reported by the authors.

Funding

This research was partially supported by the NPU II Project LQ1602 ‘IT4Innovations excellence in science’ provided by the
Ministerstvo Školství, Mládeže a Tělovýchovy (MŠMT) of Czech Republic.

Notes on contributors

Kateřina Glumbíková is an assistant professor at the Faculty of Social Studies at the University of Ostrava. In her disser-
tation thesis she dealt with the topis of reintegration of single mothers living in shelters into permanent forms of living.
Her research interest focuses on reflexivity in social work with families and relationship-based approach in social work
with families.

Alice Gojová is an associate professor at the Faculty of Social Studies at the University of Ostrava. In teaching and research
she is interested in the topic of community social work and social work with families.

Michal Burda is a junior researcher at the Institute for Research and Applications of Fuzzy Modeling, University of Ostrava,
Czech Republic. He obtained his Ph.D. degree in computer science and applied mathematics from VSB-Technical Univer-
sity in Ostrava. His research interests focus on data mining, fuzzy logic in expert systems and statistics.

Pavel Rusnok received amasters degree from the Czech Technical University (CTU) in mathematical engineering in 2008.
Now he is assistant researcher at Institute for Research and Applications of Fuzzy Modeling at Ostrava University, where
he is finishing his PhD in applied mathematics. His research interests include fuzzy logic, statistics, data mining and
machine learning.

Radka Poláková is an employee of the University of Ostrava. Her research is focused on algorithms for global optimis-
ation (especially differential evolution) and started in 2008. She was also a member of Biostatistics centre on the univer-
sity. She is placed on the second and third rank with an optimisation algorithm on the Black Box Optimization
Competition organised as part of Genetic and Evolutionary Computation conference in 2016 and 2018, respectively.
Her algorithm won a part for constrained problems of optimisation competition held on CEC2017 world congress in
San Sebastian. Her h-index on Scopus equals to 8.

708 K. GLUMBÍKOVÁ ET AL.

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710 K. GLUMBÍKOVÁ ET AL.

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Abstract

Introduction
Theoretical foundation
Health status of the homeless shelter population
The use of health care services by shelter residents
Methodology of the research
Results
Discussion of the research results and implications for social work
The use of social work methods with regard to the comorbidity of a disease with an emphasis on mental health
The importance of social support and accompaniment in supporting the use of healthcare
The need for rapid reintegration into housing
Changes in the medicalisation meta-narrative of homelessness through anti-oppressive social work
Conclusion
Notes
Acknowledgements
Disclosure statement
Notes on contributors
References

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