1. Focusing the question Janet Harris Cochrane Qualitative Research Methods Group ESQUIRE Qualitative Systematic Review Workshop University of Sheffield 2 September 2013

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. Reflect What are the drivers for producing a review?

4. What is the aim of the review? Reviews using qualitative research, or integrating qualitative and quantitative research are conducted in order to: Inform an intervention review (Scoping review) Explain relative effectiveness or variations in effectiveness Produce an explanatory theory, conceptual model, or interpretive framework

5. Decision to conduct a qualitative evidence synthesis To interpret synthesised qualitative evidence and develop explanatory theory or models Purpose of the additional qualitative synthesis or Choice of Synthesis (Adapted from Noyes & Lewin, 2011) To aggregate/ summarise/ integrate qualitative data to address questions in relation to a specific intervention review Primarily to integrate and interpret qualitative and quantitative evidence within a single approach or integrated model. Can be used to develop explanatory theory. Thematic analysis without theory generation Meta-aggregation, meta- synthesis Meta-summary Product: Aggregated findings from source papers Meta- ethnography Grounded theory Thematic analysis with theory generation Framework synthesis Realist Review EPPI Approach Matrix Method Narrative Synthesis Bayesian Synthesis Critical Interpretive synthesis Product: Explanatory theory, analytical or conceptual framework or interpretative framework/mechanism Best fit synthesis

6. Using the PICOT question format In quantitative effectiveness reviews Population Intervention Comparison Outcome Time (point or period)

7. Using PICOT for client experiences P: Specific Client group or subgroup I: Client views on the effectiveness and acceptability of given interventions C: Client preferences for different treatment options, including the option of foregoing treatment O: Client views on what constitutes a desired, appropriate or acceptable outcome (NICE, 2013)

8. 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. http://www.ncbi.nlm.nih.gov/books/NBK194844/ [Accessed 19 August 2014]Agency for Healthcare Research and Quality (US) http://www.ncbi.nlm.nih.gov/books/NBK194844/

9. Review questions are (implictly or explicitly) based on our view of the problem Describe a problem in health or social care What is a possible solution? Example: High rates of CVD in low incomce communities related to high rates of smoking

10. Developing 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

11. Types of qualitative questions for intervention reviews Qualitative questions can be formulated to explore characteristics of P: are there important differences in Population that might influence effectiveness? I: is the Intervention delivered in different ways? C: is the Comparator delivered in different ways? O: do the Outcomes reflect the values of the Population and are they directly related to the Intervention?

12. Example Liu JJ, Davidson E, Bhopal RS, White M, Johnson MRD, Netto G, et al. Adapting health promotion interventions to meet the needs of ethnic minority groups: mixed-methods evidence synthesis. Health Technol Assess 2012;16(44).

13. Aim: Producing conceptual models When the aim is to clarify a concept that is being used in research The question aims to map different definitions and understandings of the concept

14. Conceptual synthesis: an example Need for review: The concept of patient-centredness is become a central feature of an increasing amount of research There is a danger of parallel and linear knowledge developing about person-centredness across different nursing specialities Few studies integrate perspectives on the concept Authors mix up their terminology in a way that does not advance conceptual clarity e.g. ‘person centred’, patient-centred, relationship-centred

15. Conceptual synthesis aims and question Aim: to develop a shared understanding of the concept of person-centredness Review question: Can secondary analysis of separate research studies, that did not have patient-centredness as the phenomenon of interest, inform our understanding of the concept? (McCormack et al, 2010)

16. Aim of the review: Producing explanatory theory When the aim is to produce theory, the question aims to identify concepts and constructs in primary studies that contribute to building an explanation for a phenomenon

17. Realist review (O’Campo et al, 2011) Need for the review: ‘Research is growing, including several systematic reviews. ‘ ‘Previous reviews have been equivocal in terms of locating strong evidence to recommend universal screening in health care settings’ ‘There remains a lack of understanding about the determinants of successes and failures in the implementation of screening programs’ ‘Previous reviews have failed to acknowledge the variation in contexts for screening and have often combined results from disparate settings, which may blur the evidence for whether or not screening programs are successful.’

18. Realist review question ‘We undertook a synthesis of existing studies to re-evaluate the evidence on program mechanisms of intimate partner violence (IPV) universal screening and disclosure within a health care context by addressing how, for whom, and in what circumstances these programs work.’ (O’Campo et al, 2011) Why and how are universal intimate partner violence (IPV) screening programs in health care settings effective?

19. Question formulation exercise For each topic, consider: What is the aim of the review? To compile data to inform an intervention review To gain a greater understanding of context and how it influences the intervention To produce an explanatory theory or conceptual model Can you formulate a review question for each topic?

20. Question 1 AF is an independent risk factor for stroke conferring a risk five times that of matched controls. Hence, stroke risk reduction with antithrombotic therapy is a crucial component of AF management. Guidelines recommend life-long oral-anticoagulation (OAC) therapy for patients with one or more risk factors for stroke. However, such therapy remains underutilised. Very little is known about patients’ understanding of AF and OAC treatment. What we do know is that patients with AF report poorer quality of life compared to the general population and greater levels of anxiety. There is a need to consolidate existing evidence

21. Question 2 Tuberculosis (TB) is a major contributor to the global burden of disease and has received considerable attention in recent years, particularly in low- and middle-income countries where it is closely associated with HIV/AIDS. Poor adherence to treatment is common despite various interventions aimed at improving treatment completion. Lack of a comprehensive and holistic understanding of barriers to and facilitators of, treatment adherence is currently a major obstacle to finding effective solutions.

22. Question 3 Our Cochrane review of school feeding programmes in disadvantaged children found significant positive effects The included trials were conducted in varying social contexts, educational systems, by staff with different backgrounds and cultural beliefs Simply knowing that feeding programmes work is not enough for policymakers to decide on the type of intervention that should be implemented.

23. Question 4 Directly observed therapy is part of a package of interventions to improve tuberculosis treatment and adherence. A Cochrane systematic review of trials showed an absence of evidence for or against directly observed therapy compared with people treating themselves. We decided to undertake a systematic review of qualitative research focusing on lay experiences and perceptions of TB treatment to consider whether findings from these studies could help explain the results of the RCTs and contribute in any other way to the development of policy for the treatment of TB.

24. 1.OAC: patients’ experiences of OAC? Meta-synthesis (Xuereb et al, 2011) 2.School feeding programmes: What are the aspects that determine success and failure of school feeding in various situations? Realist synthesis (Krisjansson et al, 2007) 3.Adherence to tuberculosis treatment: The aim of this systematic review of qualitative studies was to understand the factors considered important by patients, caregivers and health care providers in contributing to TB medication adherence. Meta ethnography (Munro et al, 2007) 4.Adherence to DOT: What are the lay experiences and perceptions of TB treatment? Can they explain the absence of any evidence for or against DOT compared with people treating themselves at home? Meta synthesis (Noyes & Popay, 2007 )

25. 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. http://www.ncbi.nlm.nih.gov/books/NBK194844/ [Accessed 19 August 2014] National Institute for Health and Clinical Excellence (March 2012) The guidelines manual. London: National Institute for Health and Clinical Excellence. Available from: www.nice.org.uk O’Campo et al, 2011 Why and how are universal intimate partner violence (IPV) screening programs in health care settings effective?