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Improving the content validity of the mixed methods appraisal tool: a modified e-Delphi study
Open accessAbstract
OBJECTIVE: The mixed methods appraisal tool (MMAT) was developed for critically appraising different study designs. This study aimed to improve the content validity of three of the five categories of studies in the MMAT by identifying relevant methodological criteria for appraising the quality of qualitative, survey, and mixed methods studies. STUDY DESIGN AND SETTING: First, we performed a literature review to identify critical appraisal tools and extract methodological criteria. Second, we conducted a two-round modified e-Delphi technique. We asked three method-specific panels of experts to rate the relevance of each criterion on a five-point Likert scale. RESULTS: A total of 383 criteria were extracted from 18 critical appraisal tools and a literature review on the quality of mixed methods studies, and 60 were retained. In the first and second rounds of the e-Delphi, 73 and 56 experts participated, respectively. Consensus was reached for six qualitative criteria, eight survey criteria, and seven mixed methods criteria. These results led to modifications of eight of the 11 MMAT (version 2011) criteria. Specifically, we reformulated two criteria, replaced four, and removed two. Moreover, we added six new criteria. CONCLUSION: Results of this study led to improve the content validity of this tool, revise it, and propose a new version (MMAT version 2018).
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“As a result, this review employed Hong et al.’s [75] Mixed Methods Appraisal Tool (MMAT), as the instrument provides reviewers with a single tool to assess quantitative, qualitative and mixed methods research, and has shown improved content validity over recent years [76].”
From The Mental Health of Elite-Level Coaches: A Systematic Scoping Review (2024) · cites this paper as [76]
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MethodMonitoring of high-risk children in health services: A geospatial mixed-methods study
Shibukawa, B. M. C., Uema, R. T. B., de Oliveira, N. N., de Oliveira, R. R., dos Santos, J. L. G., & Higarashi, I. H. (2022) · Revista Latino-Americana de Enfermagem · doi:10.1590/1518-8345.5806.3777 · Cited by 4
Stíobhairt, A., Staunton, D., & Guérin, S. (2023) · Mental Health Review Journal · doi:10.1108/mhrj-02-2022-0009 · Cited by 4
Coombes, J., Holland, A. J. A., Ryder, C., Finlay, S. M., Hunter, K., Bennett‐Brook, K., Orcher, P., Scarcella, M., Briscoe, K., Forbes, D., et al. (2023) · BMC Health Services Research · doi:10.1186/s12913-023-09567-5 · Cited by 4
Valdiviezo‐Oña, J., Toscano-Molina, L., Chávez, J. F., Criollo, J. E. H., & Paz, C. (2023) · Advances in Mental Health · doi:10.1080/18387357.2023.2235030 · Cited by 4
“This tool allows for the evaluation of the most common methodologies and designs with speci fi c criteria for qualitative, quantitative randomised controlled trials, quantitative non-randomised, quantitative descriptive, and mixed methods studies (Hong et al., 2019).”
Rabie, A. H., & Hakami, A. (2023) · Global Journal of Health Science · doi:10.5539/gjhs.v15n9p1 · Cited by 4
“An important step in systematic reviews is to critically assess the selected studies for their credibility, validity and reliability (Hong et al., 2019).”
BackgroundMethodPlay as a Stress-Coping Method Among Children in Light of the COVID-19 Pandemic: A Review
Raudenská, J., Gumančík, J., Raudenský, M., Pasqualucci, A., Tamayo, M. A. N., Varrassi, G., & Javůrková, A. (2023) · Cureus · doi:10.7759/cureus.43550 · Cited by 6
Content Validity-Based Evaluation Criteria System for Siting Wind-Solar Plants
Sachit, M. S., Shafri, H. Z. M., Abdullah, A. F., Rafie, A. S. M., & Hanoon, S. K. (2024) · Iraqi Journal of Science · doi:10.24996/ijs.2024.65.1.44 · Cited by 4
“The Delphi technique, used to converge the opinions of a group of experts, was followed over several rounds to collect ratings [42].”
MethodDzinamarira, T., Kuupiel, D., & Mashamba-Thompson, T. P. (2020) · Systematic Reviews · doi:10.1186/s13643-019-1266-3 · Cited by 4
Gopalani, S. V., Sedani, A. E., Janitz, A. E., Clifton, S. C., Stoner, J. A., Peck, J. D., Comiford, A. L., Salvatore, A. L., & Campbell, J. E. (2020) · BMJ Open · doi:10.1136/bmjopen-2019-035658 · Cited by 4
Miao, M., Power, E., Rietdijk, R., Brunner, M., & Togher, L. (2021) · Digital Health · doi:10.1177/20552076211035988 · Cited by 4
Hurst, L., Kirwan, M., Christie, V., Cross, C., Baylis, S., White, L., & Gwynne, K. G. (2024) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph21030290 · Cited by 5
Gill, J., Jones, A., Price, K., Goodison, E., & Tyson, P. J. (2024) · Journal of Child and Adolescent Psychiatric Nursing · doi:10.1111/jcap.12459 · Cited by 2
Gaskin, J., Li, W. W., van Eijk, L., & Sarnyai, Z. (2025) · Police Practice and Research · doi:10.1080/15614263.2025.2506647 · Cited by 8
“The second stage of selection involved the methodological appraisal of the full text of each included article utilising the Mixed Methods Appraisal Tool (MMAT) Version 18 (Hong et al., 2019).”
Esquisábel‐Soteras, B., Olano‐Lizarraga, M., Pardavila‐Belio, M. I., & Vázquez‐Calatayud, M. (2025) · Nurse Education in Practice · doi:10.1016/j.nepr.2025.104537 · Cited by 5
Exploring the trauma experiences of people working in homelessness: mixed-methods systematic review
Camp, B., Elahi, A., Waqas, A., & Weatherhead, S. (2025) · BMJ Open · doi:10.1136/bmjopen-2024-087270 · Cited by 3
“⇒ The use of the Mixed Methods Appraisal Tool for quality appraisal and GRADE-CERQual for assessing confidence in qualitative findings strengthened the methodological rigour.”
InfluentialBisen, R., & Ganvir, S. (2025) · Cureus · doi:10.7759/cureus.98440 · Cited by 3
Oganesova, Z., MacLaughlin, H. L., McCafferty, K., Potthoff, S., Greenwood, S. A., Vickerstaff, V., Batterham, R. L., Afuwape, S. A., Motallebzadeh, R., & Brown, A. C. (2025) · EClinicalMedicine · doi:10.1016/j.eclinm.2025.103649 · Cited by 4
Psychosocial aspects of release in youth and developing athletes: A systematic review
McGlinchey, T. R., Wood, N. S., Saward, C., Healy, L. C., & Sarkar, M. (2025) · Journal of Sports Sciences · doi:10.1080/02640414.2025.2604953 · Cited by 3
“The quality of each included study was assessed using the mixed methods appraisal tool (MMAT; Hong et al., 2019).”
Impact of Vulvodynia on the Quality of Life of Women: A Rapid Review
Escajadillo, M. F. C., Córdoba, M. G. D. Q., Ramon, M., Gómez‐Cantarino, S., Romero-Arana, A., & Arroyo-Bello, E. (2025) · Journal of Clinical Medicine · doi:10.3390/jcm15010070 · Cited by 3
“The evaluation of methodological quality and risk of bias, performed using the Mixed Methods Appraisal Tool (MMAT, version 2018) [15], revealed that the overall quality of the included studies was satisfactory.”
Osei, E. P., Campos, S., & Martyn-Nemeth, P. A. (2025) · The Science of Diabetes Self-Management and Care · doi:10.1177/26350106251397917 · Cited by 3
Kınık, Ç., & Küçükali, A. S. (2025) · Uluslararası Davranış Sürdürülebilirlik ve Yönetim Dergisi · doi:10.71444/jobesam.1734513 · Cited by 3
Wearable Technologies in School Physical Education: A Systematic Review of Pedagogical Implications
Zhao, Z., & Su, Y. (2026) · Physical Education Theory and Methodology · doi:10.17309/tmfv.2026.1.07 · Cited by 7
“Using MMAT adds methodological transparency and rigour to this review (Hong et al., 2019).”
Troop, P., Keam, B., Mullen, C., & Odhiambo, J. N. (2026) · PLoS ONE · doi:10.1371/journal.pone.0340307 · Cited by 3
Hastuti, D., -, A., & Zubaidah, Z. (2026) · Frontiers in Pediatrics · doi:10.3389/fped.2026.1730571 · Cited by 3
Barriers and Enablers to Seeking Eye Care Among the Adult Indian Population: A Systematic Review
Yelagondula, V. K., Marmamula, S., Subramanian, A., & Lawrenson, J. G. (2026) · Ophthalmic and Physiological Optics · doi:10.1007/s44402-026-00027-1 · Cited by 3
Cooper, C., Sala, L. L., Patlamazoglou, L., Patrick, P., Sabo, A., Rajaram, G., & Robinson, J. (2026) · Computers in Human Behavior Reports · doi:10.1016/j.chbr.2026.101067 · Cited by 4
Sustainable Anesthesia: A Scoping Review of Carbon Reduction Strategies
Moser, A. J., Hammer, S., König, A., Bornemann‐Cimenti, H., Heuschneider, L., & Lang-Illievich, K. (2026) · Anesthesia & Analgesia · doi:10.1213/ane.0000000000008046 · Cited by 3
Arab, R. A. E., Moosa, O. A. A., Almagharbeh, W. T., Abuadas, F. H. A., Abdalla, N., Abdrbo, A. A., & Hassanein, S. E. (2026) · Journal of Medical Systems · doi:10.1007/s10916-026-02400-6 · Cited by 3
“…synthesis of the primary evidence base; undertaking methodological and model-readiness appraisal using Mixed Methods Appraisal Tool (MMAT) [15, 16 ] and PROBAST + AI [ 17], where applicable; and deriving practice-oriented recommendations from direct assessment of trial conduct, external…”
Prevalencia de miopía, hipermetropía y astigmatismo en México: Una revisión sistemática
Ortiz, M. I., Campuzano-Revilla, G. P., Muñoz‐Pérez, V. M., & Cuevas‐Suárez, C. E. (2022) · Educación y Salud Boletín Científico Instituto de Ciencias de la Salud Universidad Autónoma del Estado de Hidalgo · doi:10.29057/icsa.v10i20.8591 · Cited by 3
“Evaluación de la calidad metodológica La evaluación de la calidad se realizó mediante la herramienta Mix Methods Appraisal Tool (MMAT).(14) Los estudios se analizaron en los siguientes dominios: preguntas de investigación claras, recolección de datos adecuada, estrategias de muestreo relevantes, muestras representativ…”
BackgroundNursing practices on sexual health for people with neurological disorders: A narrative review
Lefebvre, S., Cousin, L., Bourmaleau, J., Rohé, S., Devictor, J., Martin, P., & Jović, L. (2024) · Journal of Clinical Nursing · doi:10.1111/jocn.17318 · Cited by 3
Nhlabatsi, M. L., van Teijlingen, E., & Hundley, V. A. (2024) · African Journal of Health Sciences · doi:10.4314/ajhs.v36i5.2 · Cited by 3
“These appraisal tools provided a structural framework for assessing the rigour of selected studies (53, 54).”
MethodLi, J. Q., Sun, T., Zuo, J. T., Yao, X., Cai, L. N., Zheng, H. Y., & Ye, X. H. (2024) · Journal of Advanced Nursing · doi:10.1111/jan.16384 · Cited by 4
Metadata
- Authors
- Hong, Q. N., Pluye, P., Fàbregues, S., Bartlett, G., Boardman, F., Cargo, M., Dagenais, P., Gagnon, M.-P., Griffiths, F., Nicolau, B., O’Cathain, A., Rousseau, M.-C., & Vedel, I.
- Affiliations
- McGill University (CA)
- Universitat Oberta de Catalunya (ES)
- University of Warwick (GB)
- University of Canberra (AU)
- Université de Sherbrooke (CA)
- Université Laval (CA)
- University of Sheffield (GB)
- Institut National de la Recherche Scientifique (CA)
- Corresponding author
- Pluye, Pierre
- ORCID
- Venue
- Journal of Clinical Epidemiology
- Publisher
- Elsevier BV
- Published
- 2019-07
- Volume
- 111
- Pages
- 49-59.e1
- ISSN
- 0895-4356 (ISSN-L)
- OpenAlex
- W2924322406
- Cited by
- 1,082
- References
- 50
- Citations by year
- 2026: 205 · 2025: 178 · 2024: 190 · 2023: 174 · 2022: 163 · 2021: 110 · 2020: 57 · 2019: 5
- FWCI
- 168.24
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Journal of Clinical Epidemiology (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- The Oberta in Open Access (Universitat Oberta de Catalunya) (publishedVersion, cc-by-nc-nd)
- White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
- HAL (submittedVersion, cc-by-nc-nd)
- eScholarship@McGill (McGill) (submittedVersion)
- EspaceINRS (National Institute for Scientific Research (Canada)) (submittedVersion)
- RECERCAT (Consorci de Serveis Universitaris de Catalunya) (submittedVersion, cc-by-nc-nd)
- Warwick Research Archive Portal (University of Warwick) (submittedVersion)
- Topics
- Social Sciences › Sociology and Political Science › Delphi Technique in Research
- Social Sciences › Decision Sciences › Statistics, Probability and Uncertainty › Meta-analysis and systematic reviews
- Health Sciences › Nursing › Research and Theory › Health Education and Validation
- Keywords
- Mixed Methods Appraisal Tool, content validity, critical appraisal, methodological quality criteria, qualitative research, survey research, mixed methods, e-Delphi, expert consensus
- MeSH terms
- Systematic Reviews as Topic, Delphi Technique, Research Design, Reproducibility of Results
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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