Qualitative Evidence Synthesis (QES):

Karin HannesCentre for Methodology of

Educational Research

Qualitative Evidence Synthesis: AgendaPART 1• Its context (and how I became triggered by QES)• How to formulate questions and search for qualitative insightsPART 2• Its popularity• Its role in systematic reviews (practical examples)• A list of developed approaches• A comparison of characteristics of two commonly used approachesPART 3• New developments

– Context specific versus multi-context reviews– Mixed methods reviews

CONTEXT AND STEPWISE APPROACHPART 1:

CONTEXT

Emma,Born the 6th of October 2010

CONTEXT

• Women who exercised did not lose significantly more weight than women in the usual care group.

• Women who took part in a diet or diet plus exercise programme, lost significantly more weight than women in the usual care.

• There was no difference in the magnitude of weight loss between diet and diet plus exercise group.

• The interventions seemed not to affect breastfeeding performance adversely.

CONTEXT

A recent study in the Journal of the America College of Nutritian found that those who ate cereals where lower in weight compared to those who ate meat and eggs or skipped breakfast.

CONTEXT

Logical, rational reasoning:

• IF a diet helps to loose weight after pregancy.• IF cereals have proven to work well as a diet.

• THEN the consumption of cereals will lead to weight loss after pregnancy!

• After having consumed cereals for several months……………..

• If it has proven itself to work for others…

• THEN WHY DOESN’T IT WORK FOR ME!

CONTEXT

What is evidence?• Evidence of ‘effectiveness’: the extent to which an intervention,

when used appropriately, achieves the intended effect.• Evidence of ‘feasibility’: the extent to which an intervention is

practical and practicable, whether or not an intervention is physically, culturally or financially practical or possible within a given context.

• Evidence of ‘appropriateness’ the extent to which an intervention fits with a situation, how an intervention relates to the context in which it is given.

• Evidence of ‘meaningfulness’: the extent to which an intervention is positively experienced by the population and relates to the personal experience, opinions, values, beliefs and interpretations of the population.

CONTEXT

Systematic ReviewsIF I am not interested in evidence of effectiveness,

BUT in feasibility, appropriateness, meaningfulness,…

Qualitative Evidence Synthesis:A process of summarizing qualitative research findings, either aggregative or interpretive, by comparing and analysing texts derived from multiple accounts of an event or situation as reported in basic qualitative research studies.

Explore questions such as • how do people experience illness?• why does an intervention work (or not), for whom and in what circumstances…? • what are the barriers and facilitators to accessing health care?• what impact do specific barriers and facilitators have on people, their experiences and

behavior?

CONTEXT

Systematic Reviews• Could I still use the methodology outlined for SR

to answer these questions? Could I use it in the same way?

1. Question formulation PICO becomes SPI(C)E2. Searching Sensitive (all-inclusive) versus Specific

(Selective)3. Critical appraisal Proponents versus Opponents4. Synthesis Variety of Approaches5. Recommendations Not always the goal, could be

building theory as well

CONTEXT

QES: Stepwise approachPICO becomes SPICE

I Intervention/(topic of) Interest: diet(C) Comparison: (training, placebo)

E Evaluation: Attitude, view, opinion on...

•Elements that hinder the diet•Impact of the diet on the general welbeing of the mother•Opinions on how to best integrate the diet in daily family life

P Perspective: Mothers in a post-natal situation

S Setting: Western SPI(C)E !

For some qualitative questions there isn’t an intervention to be evaluated.

QES: Stepwise approachSearching qualitative evidence: problems

• Little result from searching the major databases

– 30% database & handsearch– 50% ‘snowballing’– 24% personal contacts(Greenhalgh, 2005)

• Major problems:

– Bad indexing– Less developed and tested methodological filters

– MeSH-term: qualitative research • General rules:

– Use methodological filters– Examine references– Use the related article features in major databases– Search for citations (backword and forward)

QES: Stepwise approachSearching qualitative evidence: keywords

• Technique: focus group, interview, action research, content analysis, thematic analysis...

• Software: Nudist OR Nvivo OR Atlas-ti• Citations : Glaser and Strauss, Miles and

Huberman,...• Phenomenon: perceptions, attitudes, user

views, standpoints, viewpoints, experiences,...

• Methodology: ethnographic, phenomenologic,…• Type of data: stories, narratives, descriptions,

themes, exploration, findings (<--> results)

QES: Stepwise approachSearching qualitative evidence: INTERTASC

www.york.ac.uk/inst/crd/intertasc/index.htm

• nursing methodology research OR (qualitative OR ethnolog* OR ethnog* OR ethnomethodolog* OR emic OR etic OR phenomenolog*[Title/Abstract]) OR (hermeneutic* OR heidegger* OR husserl* OR colaizzi* OR giorgi* OR glaser OR strauss [title/abstract]) OR (kaam* OR manen OR participant observ* OR constant compar* [title/abstract]) OR (focus group* OR grounded theory OR "narrative analysis" OR lived experience* OR life experience* [title/abstract]) OR (theoretical sampl* OR purposive sampl* OR ricoeur OR spiegelberg* OR merleau [title/abstract]) OR (metasynthes* OR meta-synthes* OR metasummar* OR meta-summar* OR metastud* OR meta-stud* [title/abstract]) OR (maximum variation OR snowball [title/abstract]) OR (field stud* OR field note* OR fieldnote* OR field record* OR action research [title/abstract]) OR (thematic analys* OR content analy* OR unstructured categor* or structured categor* [title/abstract]) OR (participant observation* OR nonparticipant observation* OR non participant observation* [title/abstract]) OR (tape recording OR "tape record*" OR "video record*" OR "audio record*" OR taperecord* OR audiorecord* OR videotap* OR videorecord*)

http://www.library.ualberta.ca/subject/healthsciences/QualitativeFilters/index.cfm

Methodology

Citations/authors

Techniques

QES: Stepwise approachSearching qualitative evidence: debate

• We need a sensitive approach to searching that includes all potentially relevant studies.

• We need a search strategy that is specific and purposeful, including studies that are relevant to our synthesis. This might include working with a saturation point for inclusion.

• Related to the goal and/or approach of a particular study.

Searching: addressed in upcoming presentationNext step ‘critical appraisal’ addressed in upcoming presentation

PART 2: Qualitative Evidence Synthesis (QES) approaches

QES in the public health literatureThe role of QES (in SR)

A list of developed approachesComparing characteristics of different approaches

QES in the public health literature

Timetrend based on the reviews from:Dixon-Woods & colleagues (2007)Hannes & Macaitis (2011)

Quantitative

Accumulating

Strictly comparable

More power

Through data

Nature

Aim

Studies

Result

Synthesis

Meta-analysis

Evidence-synthesis

Qualitative

Make sense of data

Basic comparability

Added value in content

Through interpretation

The role of QES in SR: different aims

The role of QES in SR• Inform: reviews by using evidence from qualitative research to help

define and refine the question, and to ensure the review includes appropriate studies and addresses important outcomes (scoping review)

• Enhance: reviews by synthesizing evidence from qualitative research identified whilst looking for evidence of effectiveness (process and implementation issues).

• Extend: reviews by undertaking a search to specifically seek out evidence from qualitative studies to address questions directly related to the effectiveness review (mixed method or multilevel synthesis).

• Supplement: reviews by synthesizing qualitative evidence within a stand-alone, but complementary review to address questions on other than effectiveness (stand-alone or parallel synthesis).

Note:These should be distinguished from a narrative report of a quantitative SR. When individual studies cannot be pooled quantitatively (reason: heterogeneity), they may still have useful qualitative information to be shared with the reader.

Narrative synthesis because pooling is not possible? Rather not labelled as QES…

Example:Narrative report

Adding a bit won’t work.

The need: full SR of QR !

‘Mixed Method Approach’Children & Healthy Eating - EPPI-centre: eppi.ioe.ac.uk

Children’s Views TrialsRecommendation for interventions Good quality Other

Do not promote fruit and vegetables in the same way

None None

Brand fruit and vegetables as an ‘exciting’ or child-relevant product, as well as a ‘tasty’ one

5 5

Reduce health emphasis in messages to promote fruit and vegetables particularly those which concern future health

5 6

Example: Extending ReviewWhich interventions match recommendations derived from children’s views and experiences? Conclusion

Example: Supplementing review• Barroso J, Powell-Cope GM. Metasynthesis of Qualitative Research on Living

with HIV Infection. Qual Health Res vol 10, nr 3, 2000.:– Understand experience of adults living with HIV infection– 21 articles– Method: constant comparative analysis– Themes:

• Finding meaning in HIV: death, loss, surviving• Shattered meaning: fear, irreparable• Human connectedness: meaningfull relationships alienation, isolation• Focusing on the self: actions to enhance fysical and emotional health• Negociating care: active role• Dealing with stigma: personal, family, society

The role of QES in SR• Provide evidence on the subjective experience of those involved in

developing, delivering and receiving an intervention OR/AND

• Provide a research-based context for interpreting and explaining trial results

• How to achieve change (more effectively)?• How to improve interventions?• How to ‘fit’ subjective needs?• What other type of interventions might be needed?

OR/AND

• Reveal the extent to which effective interventions are actually adopted in policies and practice (what are barriers and bridges?)

OR/AND

• Contribute to the understanding of heterogeneity in outcomes

A list of developed approachesQES-approach DevelopedMeta-ethnography Noblit & Hare, 1988

Meta-summary Sandelowski & Barosso (2008)

Meta-study Paterson et al (2001)

Realist synthesis Pawson et al (2004)

Meta-narrative mapping Greenhalgh (2005)

Critical Interpretive Synthesis Dixon-Woods et al (2006)

Narrative Synthesis Popey et al (2006)

Textual narrative synthesis Lucas (2007)

Ecological triangulation Banning (unknown)

Framework synthesis Brunton et al (2006), Oliver et al (2008)

Meta-interpretation Weed (2005)

Meta-aggregation Joanna Briggs Institute (2001), Hannes and Lockwood (2010)

Bayesian meta-analysis Roberts et al (2002), Voils et al (2009)

Content analysis Evans and Fitzgerald (2002), Suikkala & Leino-Kilpi (2000)

Case Survey Yin & Heald (1975), Jensen & Rodgers (2001)

Qualitative Comparative analysis Cress & Snow (2000)

Thematic synthesis Thomas & Harden (2008)

Cross-case analysis Miles & Huberman (1994)

Grounded theory Finfgeld (1999) Kearney (2001), Eaves (2001)

… …

A list of developed approaches• MAKING SENSE OF THE

MYRIAD OF QUALITATIVE EVIDENCE SYNTHESIS METHODS

• No clear guidance about how to determine which of the existing synthesis methods best fits a particular purpose.

• possible considerations…

A list of developed approachesConsider Questions to be asked

The nature of the research •Will the synthesis method result in the expected and desired outcomes?•Is the method congruent with the goals of the synthesis project?•Does the primary research support the method?

The nature of the researcher •How tolerant is the researcher to the amount of structure and ambiguity that is inherent in the method?•Is his/her epistemological stance congruent with that of the synthesis method?

The nature of the research team •Is there the necessary mix of disciplinary, methodological, and other perspectives among the research team to enact this method?• Is the expertise needed for this method (e.g., statistical analysis, theoretical) available?

Resource requirements •How much personnel, time and effort are required for this method?•Is there adequate funding to support expenses incurred in implementing this method?

Paterson, B. (2011). Introducing Qualitative Evidence Synthesis. In Hannes, K., & Lockwood, C. (eds.). Qualitative Ev. Synthesis: choosing the right approach. Wiley-Blackwell, UK.

Qualitative Evidence Synthesis approachesDecision to conduct a qualitative evidence

synthesis

To aggregate / summarise / integrate qualitative data to address specific questions in relation to a Cochrane

intervention review

To interpret synthesised qualitative evidence and

develop explanatory theory or models

Primarily to integrate and interpret qualitative and quantitative evidence

within a single approach or integrated model

Can be used to develop explanatory theory

Purpose of the additional qualitative synthesis

Thematic analysis without theory generationMeta-aggregation

Realist reviewEPPI approach (thematic)Narrative synthesis

Meta-ethnographyThematic analysis with theory generationGrounded theory

ProductExplanatory theory, analytical or

conceptual framework or interpretative framework/ mechanism

Product Aggregated findings from source papers

Comparing characteristics of different approaches (developed for synthesis)Meta-ethnography Meta-aggregation

Purpose Seek and reveal similarities and differences, achieving a degree of innovation

To aggregate findings of included studies and aid decision making

Epistemology Idealism Realism

Quality Assessment Not discussed, relevance argument Required, using standardized critical appraisal instrument

Synthesis Refutational and reciprocal translation, line of argument synthesis

Aggregation of findings into categories and of categories into synthesized findings

Outcome Higher order interpretation of findings, theory

Standardised chart informing practice and policy

PART 3: Revent developments

Context-specific versus multi-context reviewsMixed methods reviews

Context-specific versus multi-context syntheses

Quantitative Review Qualitative Review

Context-specific versus multi-context reviewsMulti-context reviews

Exhaustive searchLittle access to or knowledge of local databases

and experts

Targets a broad audience (but no-one in particular)Findings may be too general

Risk of downplaying important local characteristicsContext may get lost

Potential low level of acceptance in end-users

Wide ranging in scopeAbility to cross compare different settings

Works for topics were little heterogeneity between settings is expected

Findings are more likely transferable to a broad range of settings

Context-specific reviewsSelective search

(related to context)Access to and knowledge of local databases

and experts

Only relevant to the ‘happy few’.Findings are less likely transferable to

other settings

Targeted audienceHighly relevant to practice and policyMaintains integrity with the context

reported in original studiesFindings may induce a higher level of

acceptance in the end-users

Context-specific versus multi-context reviews

• Context-specific syntheses do well in responding to the needs and policies of a targeted setting.

• Multi-context syntheses assist in building a cumulative knowledge base and are an excellent choice when little heterogeneity is expected.

• Integrating the best of both– Umbrella reviews, in which insights in a particular phenomenon

generated from different settings could be summarized.– Transcontextual adaptation, which means modifying insights in such a

way that they become relevant and reply to the needs and policies of a targeted setting.

QES: conclusion

• If you wish to embark in the field of qualitative evidence synthesis you will soon realise that

– There are no fixed standards– There is no general consensus (and will there ever be one?)– You shall have to travel slowly,– By your own means (but the CQRM-group can help),– On small and potentially difficult roads…

• BE PREPARED FOR A POTENTIAL DELAY!