Focusing the question Janet Harris Cochrane Qualitative Research Methods Group ESQUIRE Qualitative Systematic Review Workshop University of Sheffield 6 September 2011

Aims for this session Overview of question types in qualitative systematic reviewing Formulating a qualitative question: a worked example Over to you!

Question types Informing questions Enhancing questions Extending questions Supplementing questions

Informing questions are used during development of an effectiveness question The effectiveness PICO is used as a starting point The qualitative questions scope the background information for each element of the PICO The information produced Provides clarity on the scope of the Question, helping to refine the Population, Intervention, Comparison and Outcomes for the effectiveness question Provides useful information for developing Inclusion/Exclusion Criteria Starting point for development of search Strategy

Informing questions: Example P: Women aged 45 or over I: Written invitation to cervical screening C: Written invitation plus follow up reminder O: Attendance at screening When reviewing search results, we ask: Are there factors, identified from a qualitative background search, that affect the formulation of the question? -Socioeconomic group -Level of education -Ethnicity -Can you think of other factors?

Enhancing questions use the results of related studies to add to interpretation of review results They identify qualitative studies that are closely linked to the studies included in the effectiveness review Either embedded within included trials, that explain how the process of conducting the study and other factors may have affected results Or ‘sibling studies’) that were conducted alongside included trials Or independently conducted similar qualitative

Enhancing questions P: In women eligible for breast cancer screening, what are attitudes toward I: A written invitation to cervical screening [C: A written invitation plus follow up reminder] [O: In terms of influencing their decision to attend for screening] Qualitative data embedded within randomised trials explores acceptability of written invitations (process evaluation) A qualitative study of patient satisfaction with the cervical screening service is conducted alongside the trial Qualitative studies exploring patient satisfaction with invitations to cervical screening are located for the similar populations (P), interventions (I)

Extending questions are used to explore specific issues arising from the review findings These issues are usually noted in the Discussion and Authors’ Conclusions section of an effectiveness review The qualitative data can be used to retrospectively review issues with the population, intervention, comparison, and/or outcomes They help to explain effects/results of the effectiveness review in terms of external validity

Extending questions: Example Ide ntify issues identified in review Bonfill et al issues noted in the Discussion and Authors’ Conclusions section: Information complimenting attendance for screening was missing in the great majority of studies Participation probably depends on the women’s satisfaction but no data was included in any of the studies Further reviews comparing the effective interventions and studies that include women’s satisfaction and equity issues are needed.

Extending question: Example Question: What is women’s satisfaction with invitations to screening? Search on broad screening terms for studies not directly related to the review Identify factors that influence satisfaction Ask if there are preferences for variations in the intervention Consider whether these factors or preferences cut across different populations/settings Use findings to explain effects/results of the effectiveness review in terms of external validity e.g. What how can information from the review and extending question help me to modify invitations to local screening services?

Supplementing questions explore aspects that are not about effectiveness These questions aim to place effectiveness in the broader context of lived experience May be used to develop theory or refine theory related to an effectiveness intervention

Supplementing question: Example 1 What are womens’ attitudes toward breast cancer screening and treatment? The question moves beyond invitations to the wider context of whether women Believe breast cancer is a risk for them Think screening does any good, or just creates anxiety Think that treatment for breast cancer makes a difference Have cultural values or religious beliefs that represent barriers to screening and treatment

Supplementing questions can be formulated In response to a specific review In response to a topic e.g. Screening In response to a more general issue that affects people’s attitudes toward health e.g. education, faith etc

Supplementing question: Example 2 What are patients’ experiences of taking medication? Pound et al, 2005 Resisting medicines: A synthesis of qualitative studies of medicine taking Worried about harm, dependence, masking other symptoms Significant impact on identity, posed problems in terms of disclosure and stigma Modified regimens – symptomatic or strategic medicine taking, or adjusting doses to minimise unwanted consequences Desire to minimise the intake, echoed in some peoples’ use of non- pharmacological treatments to either supplant or supplement Few discussed regimen changes with their doctors. ‘We conclude that the main reason why people do not take their medicines as prescribed is not because of failings in patients, doctors or systems, but because of concerns about the medicines.’

A structure for formulated questions Cochrane Reviews use PATIENT-INTERVENTION- COMPARISON-OUTCOME (PICO) structure Within qualitative evidence syntheses the following may be more appropriate: SETTING PERSPECTIVE INTERVENTION/INTEREST COMPARISON EVALUATION

Let us consider SPICE S Setting – Where? In what context? P Perspective – For who? I Intervention (Phenomenon of Interest)– What? C Comparison – What else? E Evaluation – How well? What result?

Time for some practice! You have been commissioned to look at whether peer support helps people to self-manage chronic condition such as rheumatoid arthritis, multiple sclerosis, and asthma. What type of qualitative question(s) can you formulate? Informing Enhancing Extending Supplementing

More practice... Read the summary handout of Lewin et al (2010)