Focusing the question

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

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Reflect

• What are the drivers for producing a review?

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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

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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.
Meta-ethnography Grounded theory Thematic
analysis with theory generation
Framework synthesis
Realist Review EPPI Approach Matrix
Method Narrative Synthesis Bayesian
Synthesis Critical Interpretive synthesis
Thematic analysis without theory
generation Meta-aggregation, meta-synthesis Meta-s
ummary
Best fit synthesis
Product Aggregated findings from source papers
Product Explanatory theory, analytical or
conceptual framework or interpretative
framework/mechanism
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Using the PICOT question format

• In quantitative effectiveness reviews
• Population
• Intervention
• Comparison
• Outcome
• Time (point or period)

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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)

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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/NBK194
844/ Accessed 19 August 2014
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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

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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 doesnt work in different settings, for
  different populations

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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?

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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 201216(44).

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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

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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

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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)

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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

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Realist review (OCampo 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.

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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. (OCampo et
  al, 2011)
• Why and how are universal intimate partner
  violence (IPV) screening programs in health care
  settings effective?

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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?

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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-anticoagulatio
  n (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

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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.

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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.

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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.

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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)

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• 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
• OCampo et al, 2011 Why and how are universal
  intimate partner violence (IPV) screening
  programs in health care settings effective?