1. Focusing the question Janet Harris
Cochrane Qualitative & Implementation Research Methods Group
ESQUIRE Qualitative Systematic Review Workshop 2015

2. Session aims
To provide examples of question formulation for qualitative and mixed methods reviews
To identify the issues and challenges in formulating different types of review questions

3. What are qualitative research questions?
What are people’s experiences of the intervention?
What outcomes or aspects of the intervention do they value and why?
Why do interventions work (or not work)? For whom, in what circumstances? At what point in time?
How does the surrounding context hinder or promote implementation of a programme, service or treatment?
How can a particular intervention be adapted for large scale roll out? (Roen 2006)

4. What are the aims of using qualitative research in reviews?
Reviews using qualitative research, or integrating qualitative and quantitative research are conducted in order to:
Inform the development of a review protocol
Explain relative effectiveness or variations in effectiveness of an intervention
Produce an explanatory theory, conceptual model, or interpretive framework

5. 1) Asking qualitative questions to develop a review protocol
First: what is a review protocol?
Helps to plan the review and anticipate problems
Encourages comment and review
Aids transparency and audit
Can be prescriptive or allow for iteration

6. Elements of a review protocol
Contents
Title
Background
Review question/objectives
Inclusion and exclusion criteria
Search strategy
Screening
Quality assessment
Coding and data extraction
Synthesis methods
Conflicts of interest
Describes problem and need for review, directly linked to review questions
Decisions on what to include and exclude are decided after scoping available research
Decisions on how to assess quality are based on types of studies found during scoping, and types of synthesis that can be done based on existing studies

7. Framing background questions
The aim of background questions is to collect general information about an issue, a phenomenon, an intervention
Background questions are useful when
Little is known about a subject
Different members of the team have different levels of knowledge
The problem is being framed in different ways
Those who are commissioning the review have information needs that may not match what has been researched

8. Caught between a rock and a hard place
Deciding the review focus and scope
Rock and a hard place is derived from the original adage which means to be under significant pressure and/or stuck between two very obnoxious decisions which both have equally unpleasant outcomes.
Although there are multifarious theories as to how the saying came about, the most common is that it arose from an economic crisis in the USA. The two complications being unemployment and underpaid wages, the figurative ‘rock’ and ‘hard place’.
Information needs of policymakers
Existing research
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9. Background question examples
Little is known:
Involving patients and the wider community in diabetes research
Different problem frames:
Do social support interventions to reduce hospital admissions
Unrealistic information needs:
Factors influencing the effectiveness of community-based malnutrition programmes versus hospital-based programmes

10. Background question format
Problem
Root question: W5H
Who?
What?
Where?
When?
Why?
How?

11. Background question example 1
Problem:
Lack of involvement in designing diabetes interventions may produce inappropriate interventions
Root question: W5H
Who has involved patients and communities in diabetes research?
What sort of involvement has been used?
Where: in which countries?
When: At what stage(s) of designing and conducting the research was involvement used?
Why was involvement used – what were the benefits?
How were people involved?

12. Background question example 2
Problem: Frail elderly people
Lack social support to manage conditions
Represent over 50% of avoidable hospital admissions
Root question: W5H
Who provides social support for self management?
What sort of support is needed/provided?
Where can support be accessed?
When is support provided?
Why?
How is social support related to a reduction in avoidable admissions?

13. Background question: Your turn
Problem: Pick a problem in your group (2 minutes)
Root question: Lets develop together
Who?
What?
Where?
When?
Why?
How?

14. Defining the scope of your review
Background questions are one way to define/negotiate the scope of your review
The scope may also be defined by the type of review
For example, reviews aiming to explain the effectiveness of an intervention could take issues in the original intervention review as a starting point

15. 2) Question formulation to explain effectiveness of an intervention
Read Glenton et al 2013
Why is a qualitative review being conducted?
What is the phenomenon of interest for the qualitative review?
Can you formulate a qualitative review question?
Let’s look at several question formulation tools

16. Question formulation tool for qualitative evidence synthesis
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?
(Booth 2006)

17. Question formulation for health management
E Expectation—what does the search requester want the information for (the original ‘I’s)?
C Client Group.
L Location.
I Impact—what is the change in the service, if any, which is being looked for? What would constitute success? How is this being measured?
P Professionals.
S Service—for which service are you looking for information? For example, outpatient services, nurse-led clinics, intermediate care.
(Wildridge & Bell 2002)

18. Developing qualitative questions for intervention reviews
Qualitative research should be considered if
Your review question is about a complex intervention
More information is needed on the components of an intervention – what are various elements of the intervention how do they work together?
Information is needed on the surrounding context – the setting, the environment, that may influence the relative success of the intervention
Information is needed on why the intervention works or doesn’t work in different settings, for different populations

19. Systematic review questions and approaches to conceptualizing interventions
Systematic Reviews of Complex Multicomponent Health Care Interventions [Internet].
Guise JM, Chang C, Viswanathan M, et al.
Rockville (MD): Agency for Healthcare Research and Quality (US); 2014 Mar. [Accessed 19 August 2014]

20. 3) Qualitative questions for reviews that produce models or theories
When the aim is to
identify components of an intervention, or intervention types, or processes of implementation
map different definitions or dimensions of a concept
produce an explanation for how and why something works

21. Examples of questions to develop models and theories
What are the elements in a causal pathway between advice interventions and health outcomes? (Allmark et al, 2013)
How does community based peer support impact on understanding of existing health information and use of health information and health services to improve health and reduce health inequalities? (Harris et al 2015)

22. Aim of the review: Producing a logic model or framework
The question aims to
identify types of interventions
Types of outcomes from the intervention
Relationships between them
The model can be used to build hypotheses, and/or decide the focus of a review based on amount of evidence

24. Aim of the review: Producing explanatory theory
The question aims to identify concepts and constructs in primary studies that contribute to building an explanation for a phenomenon
What is peer support?
What is community-based peer support?
How is support related to health inequalities?

25. Question formulation exercise
Can you formulate a review question that aims to develop a logic model or theory?

26. References
Allmark, P., Baxter, S., Goyder, E., Guillaume, L. and Crofton-Martin, G. (2013) Assessing the health benefits of advice services: using research evidence and logic model methods to explore complex pathways. Health & Social Care in the Community, 21 (1) I
Booth, A. (2006). Clear and present questions: Formulating questions for evidence based practice. Library Hi Tech, 24(3), doi: /
Guise JM, Chang C, Viswanathan M, et al. Systematic Reviews of Complex Multicomponent Health Care Interventions [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2014 Mar. [Accessed 19 August 2014]
Harris J, Springett J, Croot L, Booth A, Campbell F, Thompson J, et al.Can community-based peer support promote health literacy and reduce inequalities? A realist review. Public Health Res 2015;3(3)
Wildrige V & Bell L. How CLIP became ECLIPSE: a mnemonic to assist in searching for health policy/management information; HILJ 2002, 19 (2) DOI: