Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series

How human factors affect escalation of care: a protocol for a qualitative evidence synthesis of studies

INTRODUCTION

Failure to rescue is defined as mortality after complications during hospital care. Incidence ranges 10.9%-13.3% and several national reports such as National Confidential Enquiry into Patient Outcomes and Death and National Institute of Clinical Excellence CG 50 highlight failure to rescue as a significant problem for safe patient care.To avoid failure to rescue events, there must be successful escalation of care. Studies indicate that human factors such as situational awareness, team working, communication and a culture promoting safety contribute to avoidance of failure to rescue events. Understanding human factors is essential to developing work systems that mitigate barriers and facilitate prompt escalation of care. This qualitative evidence synthesis will identify and synthesise what is known about the human factors that affect escalation of care.

METHODS AND ANALYSIS

We will search MEDLINE (Ovid), EMBASE (Ovid) and CINAHL, between database inception and 2018, for studies describing human factors affecting failure to rescue and/or care escalation. A search strategy was developed by two researchers and a medical librarian. Only studies exploring in-hospital (ward) populations using qualitative data collection methods will be included. Screening will be conducted by two researchers. We are likely to undertake a thematic synthesis, using the Thomas and Harden framework. Selected studies will be assessed for quality, rigour and limitations. Two researchers will extract and thematically synthesise codes using a piloted data extraction tool to develop analytical themes.

ETHICS AND DISSEMINATION

The qualitative evidence synthesis will use available published literature and no ethical approval is required. This synthesis will be limited by the quality of studies, rigour and reproducibility of study findings. Results will be published in a peer-reviewed journal, publicised at conferences and on social media.

PROSPERO REGISTRATION NUMBER

CRD42018104745.

Synthesising evidence on patient portals: a protocol for an umbrella review

INTRODUCTION

Over the last two decades, patient portals have emerged as a noticeable eHealth strategy. To date, research on patient portals has been rapidly increasing. Our umbrella review aims to provide a meta-level synthesis to make sense of the evidence on patient portals from published systematic reviews (SRs).

METHODS

We will employ a modified version of the Joanna Briggs Institute umbrella review method. The search strategy encompasses multiple databases. The inclusion criterion is specific to SRs focused on patient portal. Patients or public were not involved in this work.

ANALYSIS

Two researchers will independently screen titles/abstracts and then full-text articles against the inclusion/exclusion criteria. Methodological quality of included reviews will be assessed and data will be extracted from the final selection of reviews. These reviews will be categorised into quantitative, qualitative and/or mixed-synthesis groups based on information about the design of primary studies provided in the reviews. Correspondingly, we will create quantitative, qualitative and/or mixed-synthesis Excel data-extraction tables. Within each table, data will be extracted with the reference to primary studies as reported in the reviews, and will be synthesised into themes and then a smaller number of findings/outcomes. Modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Confidence in the Evidence from Reviews of Qualitative research (CERQual) tools will be applied to assess the strength of evidence at the level of each finding/outcome. The output of our umbrella review will consist of summary of findings tables and evidence profile tables. A narrative meta-level synthesis will be provided. We will use the clinical adoption meta-model as an organising framework.

ETHICS AND DISSEMINATION

As an outcome of this review, we will create a guidance and roadmap to be used in a future Delphi study to gather feedback from Canadian eHealth stakeholders. We will also present at conferences and publish the final report. The umbrella review does not require ethical approval.

PROSPERO REGISTRATION NUMBER

CRD42018096657.

Methods Assessing Sociocultural Aspects of Health Technologies: Results of a Literature Review

Objectives

Social and cultural aspects are rarely assessed in health technology assessments (HTA), despite being part of most HTA definitions. One hypothesis for the reason why they are hardly considered in HTA is that we lack relevant assessment methods. Accordingly, this review aims at providing an overview of methodological approaches to address social and cultural aspects related to health technologies in HTA.

Methods

We conducted a comprehensive literature search by searching fourteen databases and a hand-search of two pertinent journals. Additionally, we sent a query to all member agencies of the International Network of Agencies for Health Technology Assessment (INAHTA) asking them for methods they use to assess social and cultural aspects.

Results

A total of 125 publications met our inclusion criteria. We grouped the methodological approaches into checklists for experts, literature reviews, stakeholder participatory approaches, primary data collection methods, and combinations of methodological approaches.

Conclusions

There is a wide variety of methods available for assessing social and cultural aspects of health technologies, some of which have been applied in HTA. The presented overview of the different approaches and their merits can facilitate the assessment of these aspects, and improve the knowledge regarding (potential) success and failure of the implementation of a health technology.

Perspectives of people with aphasia post-stroke towards personal recovery and living successfully: A systematic review and thematic synthesis

BACKGROUND

There is increased focus on supporting people with chronic conditions to live well via person-centred, integrated care. There is a growing body of qualitative literature examining the insider perspectives of people with post-stroke aphasia (PWA) on topics relating to personal recovery and living successfully (PR-LS). To date no synthesis has been conducted examining both internal and external, structural influences on living well. In this study, we aimed to advance theoretical understanding of how best to promote and support PR-LS by integrating the perspectives of PWA on a wide range of topics relating to PR-LS. This is essential for planning and delivering quality care.

METHODS AND FINDINGS

We conducted a systematic review, following PRISMA guidelines, and thematic synthesis. Following a search of 7 electronic databases, 31 articles were included and critically appraised using predetermined criteria. Inductive and iterative analysis generated 5 analytical themes about promoting PR-LS. Aphasia occurs in the context of a wider social network that provides valued support and social companionship and has its own need for formal support. PWA want to make a positive contribution to society. The participation of PWA is facilitated by enabling environments and opportunities. PWA benefit from access to a flexible, responsive, life-relevant range of services in the long-term post-stroke. Accessible information and collaborative interactions with aphasia-aware healthcare professionals empower PWA to take charge of their condition and to navigate the health system.

CONCLUSION

The findings highlight the need to consider wider attitudinal and structural influences on living well. PR-LS are promoted via responsive, long-term support for PWA, friends and family, and opportunities to participate autonomously and contribute to the community. Shortcomings in the quality of the existing evidence base must be addressed in future studies to ensure that PWA are meaningfully included in research and service development initiatives.

SYSTEMATIC REVIEW REGISTRATION

International Prospective Register of Systematic Reviews PROSPERO 2017: CRD42017056110.

Associations of Patient and Staff Outcomes With Inpatient Unit Designs Incorporating Decentralized Caregiver Workstations: A Systematic Review of Empirical Evidence

OBJECTIVES:

This systematic literature review synthesizes and assesses quality of research addressing associations of patient and staff outcomes with inpatient unit designs incorporating decentralized caregiver workstations.

BACKGROUND:

A current hospital design trend is to include decentralized caregiver workstations on inpatient units. A review of literature addressing decentralized unit design is needed.

METHODS:

The systematic review methodology was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Database searches were conducted for studies published in peer-reviewed journals through October 2017. Included were empirical studies associating patient and/or staff outcomes and unit design with decentralized caregiver workstations. Individual studies were evaluated for quality using established methods, and Grading of Recommendations Assessment, Development and Evaluation (GRADE) and GRADE-Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) guided rigorous inspection of evidence quality and strength for quantitative outcomes and qualitative findings, respectively.

RESULTS:

The search yielded 1,096 records with 36 full-text articles examined and 12 articles included in the final review. This work was dominated by studies with limited analyses. Staff outcomes have been most widely studied, especially collaboration/communication and walking. Overall, studies exploring decentralized nursing as a design intervention have produced limited results for both staff and patient outcomes. Strength of evidence of the current literature with quantitative methods as a whole was rated very low quality.

CONCLUSIONS:

Although varying degrees of caregiver workstation decentralization in inpatient units are now common, the literature addressing the impacts of such designs is of very low quality and shows inconsistency in associated outcomes. Rigorous, well-designed studies with consistently defined design and outcome measures are needed for greater confidence in determining any effects of decentralized unit design.

Perceptions and experiences of labour companionship: a qualitative evidence synthesis

BACKGROUND

Labour companionship refers to support provided to a woman during labour and childbirth, and may be provided by a partner, family member, friend, doula or healthcare professional. A Cochrane systematic review of interventions by Bohren and colleagues, concluded that having a labour companion improves outcomes for women and babies. The presence of a labour companion is therefore regarded as an important aspect of improving quality of care during labour and childbirth; however implementation of the intervention is not universal. Implementation of labour companionship may be hampered by limited understanding of factors affecting successful implementation across contexts.

OBJECTIVES

The objectives of the review were to describe and explore the perceptions and experiences of women, partners, community members, healthcare providers and administrators, and other key stakeholders regarding labour companionship; to identify factors affecting successful implementation and sustainability of labour companionship; and to explore how the findings of this review can enhance understanding of the related Cochrane systematic review of interventions.

SEARCH METHODS

We searched MEDLINE, CINAHL, and POPLINE K4Health databases for eligible studies from inception to 9 September 2018. There were no language, date or geographic restrictions.

SELECTION CRITERIA

We included studies that used qualitative methods for data collection and analysis; focused on women's, partners', family members', doulas', providers', or other relevant stakeholders' perceptions and experiences of labour companionship; and were from any type of health facility in any setting globally.

DATA COLLECTION AND ANALYSIS

We used a thematic analysis approach for data extraction and synthesis, and assessed the confidence in the findings using the GRADE-CERQual approach. We used two approaches to integrate qualitative findings with the intervention review findings. We used a logic model to theorise links between elements of the intervention and health and well-being outcomes. We also used a matrix model to compare features of labour companionship identified as important in the qualitative evidence synthesis with the interventions included in the intervention review.

MAIN RESULTS

We found 51 studies (52 papers), mostly from high-income countries and mostly describing women's perspectives. We assessed our level of confidence in each finding using the GRADE-CERQual approach. We had high or moderate confidence in many of our findings. Where we only had low or very low confidence in a finding, we have indicated this.Labour companions supported women in four different ways. Companions gave informational support by providing information about childbirth, bridging communication gaps between health workers and women, and facilitating non-pharmacological pain relief. Companions were advocates, which means they spoke up in support of the woman. Companions provided practical support, including encouraging women to move around, providing massage, and holding her hand. Finally, companions gave emotional support, using praise and reassurance to help women feel in control and confident, and providing a continuous physical presence.Women who wanted a companion present during labour and childbirth needed this person to be compassionate and trustworthy. Companionship helped women to have a positive birth experience. Women without a companion could perceive this as a negative birth experience. Women had mixed perspectives about wanting to have a male partner present (low confidence). Generally, men who were labour companions felt that their presence made a positive impact on both themselves (low confidence) and on the relationship with their partner and baby (low confidence), although some felt anxious witnessing labour pain (low confidence). Some male partners felt that they were not well integrated into the care team or decision-making.Doulas often met with women before birth to build rapport and manage expectations. Women could develop close bonds with their doulas (low confidence). Foreign-born women in high-income settings may appreciate support from community-based doulas to receive culturally-competent care (low confidence).Factors affecting implementation included health workers and women not recognising the benefits of companionship, lack of space and privacy, and fearing increased risk of infection (low confidence). Changing policies to allow companionship and addressing gaps between policy and practice were thought to be important (low confidence). Some providers were resistant to or not well trained on how to use companions, and this could lead to conflict. Lay companions were often not integrated into antenatal care, which may cause frustration (low confidence).We compared our findings from this synthesis to the companionship programmes/approaches assessed in Bohren's review of effectiveness. We found that most of these programmes did not appear to address these key features of labour companionship.

AUTHORS' CONCLUSIONS

We have high or moderate confidence in the evidence contributing to several of these review findings. Further research, especially in low- and middle-income settings and with different cadres of healthcare providers, could strengthen the evidence for low- or very low-confidence findings. Ahead of implementation of labour companionship, researchers and programmers should consider factors that may affect implementation, including training content and timing for providers, women and companions; physical structure of the labour ward; specifying clear roles for companions and providers; integration of companions; and measuring the impact of companionship on women's experiences of care. Implementation research or studies conducted on labour companionship should include a qualitative component to evaluate the process and context of implementation, in order to better interpret results and share findings across contexts.

Crossing cultural divides: A qualitative systematic review of factors influencing the provision of healthcare related to female genital mutilation from the perspective of health professionals

INTRODUCTION

As a result of global migration, health professionals in destination countries are increasingly being called upon to provide care for women and girls who have experienced female genital mutilation/cutting (FGM/C). There is considerable evidence to suggest that their care experiences are sub-optimal. This systematic review sought to illuminate possible reasons for this by exploring the views, experiences, barriers and facilitators to providing FGM-related healthcare in high income countries, from health professionals' perspectives.

METHODS

Sixteen electronic databases/resources were searched from inception to December 2017, supplemented by reference list searching and suggestions from experts. Inclusion criteria were: qualitative studies (including grey literature) of any design, any cadre of health worker, from OECD countries, of any date and any language. Two reviewers undertook screening, selection, quality appraisal and data extraction using tools from the Joanna Briggs Institute (JBI). Synthesis involved an inductive thematic approach to identify descriptive themes and interpret these into higher order analytical constructs. Confidence in the review findings was assessed using GRADE-CERQual. The review protocol was registered with PROSPERO (CRD420150300042015).

RESULTS

Thirty papers (representing 28 distinct studies) from nine different countries were included. The majority of studies focused on maternity contexts. No studies specifically examined health professionals' role in FGM/C prevention/safeguarding. There were 20 descriptive themes summarised into six analytical themes that highlighted factors perceived to influence care: knowledge and training, communication, cultural (mis)understandings, identification of FGM/C, clinical management practices and service configuration. Together, these inter-linked themes illuminate the ways in which confidence, communication and competence at provider level and the existence and enactment of pathways, protocols and specialist support at service/system level facilitate or hinder care.

CONCLUSIONS

FGM/C is a complex and culturally shaped phenomenon. In order to work effectively across cultural divides, there is a need for provider training, clear guidelines, care pathways and specialist FGM/C centres to support mainstream services.

A methodological systematic review of meta-ethnography conduct to articulate the complex analytical phases

BACKGROUND

Decision making in health and social care requires robust syntheses of both quantitative and qualitative evidence. Meta-ethnography is a seven-phase methodology for synthesising qualitative studies. Developed in 1988 by sociologists in education Noblit and Hare, meta-ethnography has evolved since its inception; it is now widely used in healthcare research and is gaining popularity in education research. The aim of this article is to provide up-to-date, in-depth guidance on conducting the complex analytic synthesis phases 4 to 6 of meta-ethnography through analysis of the latest methodological evidence.

METHODS

We report findings from a methodological systematic review conducted from 2015 to 2016. Fourteen databases and five other online resources were searched. Expansive searches were also conducted resulting in inclusion of 57 publications on meta-ethnography conduct and reporting from a range of academic disciplines published from 1988 to 2016.

RESULTS

Current guidance on applying meta-ethnography originates from a small group of researchers using the methodology in a health context. We identified that researchers have operationalised the analysis and synthesis methods of meta-ethnography - determining how studies are related (phase 4), translating studies into one another (phase 5), synthesising translations (phase 6) and line of argument synthesis - to suit their own syntheses resulting in variation in methods and their application. Empirical research is required to compare the impact of different methods of translation and synthesis. Some methods are potentially better at preserving links with the context and meaning of primary studies, a key principle of meta-ethnography. A meta-ethnography can and should include reciprocal and refutational translation and line of argument synthesis, rather than only one of these, to maximise the impact of its outputs.

CONCLUSION

The current work is the first to articulate and differentiate the methodological variations and their application for different purposes and represents a significant advance in the understanding of the methodological application of meta-ethnography.

Factors that influence parents' and informal caregivers' acceptance of routine childhood vaccination: a qualitative evidence synthesis

This is a protocol for a Cochrane Review (Qualitative). The objectives are as follows:

Identify, appraise and synthesise qualitative studies exploring: parents’ and informal caregivers’ views, experiences, or decision‐making regarding routine childhood vaccination; or the factors influencing acceptance of routine childhood vaccination arising from parents’ and informal caregivers’ accounts. Develop a conceptual understanding of what and how different factors influence parental acceptance of routine childhood vaccination. Explore how the findings of this review can enhance our understanding of the related intervention reviews (Saeterdal 2014 ; Oyo‐Ita 2016 ; Jacobson 2018 ; Kaufman 2018 ).

Living life precariously with rheumatoid arthritis - a mega-ethnography of nine qualitative evidence syntheses

Background

Rheumatoid arthritis is an autoimmune disease that causes joint inflammation. It affects around 400,000 people in the UK and 1 million adults in the USA. Given the appropriate treatment, many can have relatively few symptoms. It is therefore important to understand what it is like to live with rheumatoid arthritis and gain insight into peoples’ decisions about utilising healthcare. The aims of this study were: (1) to bring together qualitative evidence syntheses that explore patients’ experience of living with rheumatoid arthritis and (2) develop a conceptual understanding of what it is like to live with rheumatoid arthritis.

Methods

We used the methods of mega-ethnography. The innovation of mega-ethnography is to use conceptual findings from qualitative evidence syntheses as primary data. We searched four bibliographic databases from inception until September 2018 to identify qualitative evidence syntheses that explored patients’ experience of rheumatoid arthritis.

Results

We identified 373 qualitative evidence syntheses, removed 179 duplicates and screened 194 full text studies. We identified 42 qualitative evidence syntheses that explored the experience of pain or arthritis and 9 of these explored the experience of rheumatoid arthritis. We abstracted ideas into 10 conceptual categories: (1) rheumatoid arthritis is in control of my body (2) rheumatoid arthritis alters reciprocity; (3) rheumatoid arthritis is an emotional challenge; (4) rheumatoid arthritis disrupts my present and future self; (5) the challenge of balancing personal and work life; (6) I am trying to make sense of what is happening; (7) rheumatoid arthritis is variable and unpredictable; (8) rheumatoid arthritis is invisible; (9) I need a positive experience of healthcare, and (10) I need to reframe the situation. We developed a conceptual model underpinned by living life precariously with rheumatoid arthritis.

Conclusions

This is the second mega-ethnography, or synthesis of qualitative evidence syntheses using the methods of meta-ethnography. Future research should consider the proliferation of qualitative evidence synthesis in order to avoid duplication of research effort. Our model for rheumatoid arthritis has some important clinical implications that might be transferable to other musculoskeletal conditions.

Electronic supplementary material

The online version of this article (10.1186/s41927-018-0049-0) contains supplementary material, which is available to authorized users.

A systematic review of ethnic minority women's experiences of perinatal mental health conditions and services in Europe

Background

Women from ethnic minority groups are at greater risk of developing mental health problems. Poor perinatal mental health impacts on maternal morbidity and mortality and can have a devastating impact on child and family wellbeing. It is important to ensure that services are designed to meet the unique needs of women from diverse backgrounds.

Aim

The aim of the review was to explore ethnic minority women's experiences of perinatal mental ill health, help-seeking and perinatal mental health services in Europe.

Data sources

Searches included CINAHL, Maternity and Infant Care, MEDLINE and PsycINFO with no language or date restrictions. Additional literature was identified by searching reference lists of relevant studies.

Design

This was a mixed method systematic review. Study selection, appraisal and data extraction were conducted by two researchers independently. A convergent approach was adopted for the analysis and the data were synthesised thematically.

Results

The 15 eligible studies included women from a range of minority ethnic backgrounds and were all undertaken in the United Kingdom (UK). Seven overarching themes were identified; awareness and beliefs about mental health, isolation and seeking support, influence of culture, symptoms and coping strategies, accessing mental health services, experiences of mental health services and what women want.

Conclusion

Lack of awareness about mental ill health, cultural expectations, ongoing stigma, culturally insensitive and fragmented health services and interactions with culturally incompetent and dismissive health providers all impact on ethnic minority women's ability to receive adequate perinatal mental health support in the UK. Future research should focus on in-depth exploration of the experiences of these women across multiple European settings and interventions to reduce health inequalities among vulnerable mothers and families affected by perinatal mental ill health.

Considerations of complexity in rating certainty of evidence in systematic reviews: a primer on using the GRADE approach in global health

Public health interventions and health technologies are commonly described as 'complex', as they involve multiple interacting components and outcomes, and their effects are largely influenced by contextual interactions and system-level processes. Systematic reviewers and guideline developers evaluating the effects of these complex interventions and technologies report difficulties in using existing methods and frameworks, such as the Grading of Recommendations Assessment, Development and Evaluation (GRADE). As part of a special series of papers on implications of complexity in the WHO guideline development, this paper serves as a primer on how to consider sources of complexity when using the GRADE approach to rate certainty of evidence. Relevant sources of complexity in systematic reviews, health technology assessments and guidelines of public health are outlined and mapped onto the reported difficulties in rating the estimates of the effect of these interventions. Recommendations on how to address these difficulties are further outlined, and the need for an integrated use of GRADE from the beginning of the review or guideline development is emphasised. The content of this paper is informed by the existing GRADE guidance, an ongoing research project on considering sources of complexity when applying the GRADE approach to rate certainty of evidence in systematic reviews and the review authors' own experiences with using GRADE.

The WHO-INTEGRATE evidence to decision framework version 1.0: integrating WHO norms and values and a complexity perspective

INTRODUCTION

Evidence-to-decision (EtD) frameworks intend to ensure that all criteria of relevance to a health decision are systematically considered. This paper, part of a series commissioned by the WHO, reports on the development of an EtD framework that is rooted in WHO norms and values, reflective of the changing global health landscape, and suitable for a range of interventions and complexity features. We also sought to assess the value of this framework to decision-makers at global and national levels, and to facilitate uptake through suggestions on how to prioritise criteria and methods to collect evidence.

METHODS

In an iterative, principles-based approach, we developed the framework structure from WHO norms and values. Preliminary criteria were derived from key documents and supplemented with comprehensive subcriteria obtained through an overview of systematic reviews of criteria employed in health decision-making. We assessed to what extent the framework can accommodate features of complexity, and conducted key informant interviews among WHO guideline developers. Suggestions on methods were drawn from the literature and expert consultation.

RESULTS

The new WHO-INTEGRATE (INTEGRATe Evidence) framework comprises six substantive criteria-balance of health benefits and harms, human rights and sociocultural acceptability, health equity, equality and non-discrimination, societal implications, financial and economic considerations, and feasibility and health system considerations-and the meta-criterion quality of evidence. It is intended to facilitate a structured process of reflection and discussion in a problem-specific and context-specific manner from the start of a guideline development or other health decision-making process. For each criterion, the framework offers a definition, subcriteria and example questions; it also suggests relevant primary research and evidence synthesis methods and approaches to assessing quality of evidence.

CONCLUSION

The framework is deliberately labelled version 1.0. We expect further modifications based on focus group discussions in four countries, example applications and input across concerned disciplines.

Qualitative evidence synthesis for complex interventions and guideline development: clarification of the purpose, designs and relevant methods

This paper is one of a series exploring the implications of complexity for systematic reviews and guideline development, commissioned by the WHO. The paper specifically explores the role of qualitative evidence synthesis. Qualitative evidence synthesis is the broad term for the group of methods used to undertake systematic reviews of qualitative research evidence. As an approach, qualitative evidence synthesis is increasingly recognised as having a key role to play in addressing questions relating to intervention or system complexity, and guideline development processes. This is due to the unique role qualitative research can play in establishing the relative importance of outcomes, the acceptability, fidelity and reach of interventions, their feasibility in different settings and potential consequences on equity across populations. This paper outlines the purpose of qualitative evidence synthesis, provides detail of how qualitative evidence syntheses can help establish understanding and explanation of the complexity that can occur in relation to both interventions and systems, and how qualitative evidence syntheses can contribute to evidence to decision frameworks. It provides guidance for the choice of qualitative evidence synthesis methods in the context of guideline development for complex interventions, giving 'real life' examples of where this has occurred. Information to support decision-making around choice qualitative evidence synthesis methods in the context of guideline development is provided. Approaches for reporting qualitative evidence syntheses are discussed alongside mechanisms for assessing confidence in the findings of a review.

Viewpoints of adolescents with overweight and obesity attending lifestyle obesity treatment interventions: a qualitative systematic review

BACKGROUND

Current UK guidance recommends that adolescents with obesity attend a family-based multi-component obesity intervention. However, these programmes suffer from low recruitment and high rates of attrition. Understanding the views of adolescents is necessary for developing future interventions. The aim of this systematic review was to synthesize and explore the views of adolescents who have attended an obesity intervention.

METHODS

Published literature was identified by searching six databases. Studies of adolescents (12-17 years) who attended an obesity intervention were examined. Only studies that collected and analysed data qualitatively were included. Full texts were analysed using thematic synthesis.

RESULTS

Twenty-eight studies were included. Thirty-five analytical themes were developed that were broadly divided into seven domains. Key themes included ensuring adolescents receive a 'tailored intervention' that involves 'active engagement'. Support from professionals, family and peers were valued highly. Adolescents expressed 'prior fears of attending interventions' and wanted 'longer term support'. 'Enjoyment of sport and physical activity' was evident, and adolescents were strongly motivated by improving body image and social desirability.

DISCUSSION

Considering the views of adolescents attending obesity interventions may help to inform policy makers in the development of future interventions. This may lead to an improvement in recruitment and attrition rates.

Associations between sex work laws and sex workers' health: A systematic review and meta-analysis of quantitative and qualitative studies

BACKGROUND

Sex workers are at disproportionate risk of violence and sexual and emotional ill health, harms that have been linked to the criminalisation of sex work. We synthesised evidence on the extent to which sex work laws and policing practices affect sex workers' safety, health, and access to services, and the pathways through which these effects occur.

METHODS AND FINDINGS

We searched bibliographic databases between 1 January 1990 and 9 May 2018 for qualitative and quantitative research involving sex workers of all genders and terms relating to legislation, police, and health. We operationalised categories of lawful and unlawful police repression of sex workers or their clients, including criminal and administrative penalties. We included quantitative studies that measured associations between policing and outcomes of violence, health, and access to services, and qualitative studies that explored related pathways. We conducted a meta-analysis to estimate the average effect of experiencing sexual/physical violence, HIV or sexually transmitted infections (STIs), and condomless sex, among individuals exposed to repressive policing compared to those unexposed. Qualitative studies were synthesised iteratively, inductively, and thematically. We reviewed 40 quantitative and 94 qualitative studies. Repressive policing of sex workers was associated with increased risk of sexual/physical violence from clients or other parties (odds ratio [OR] 2.99, 95% CI 1.96-4.57), HIV/STI (OR 1.87, 95% CI 1.60-2.19), and condomless sex (OR 1.42, 95% CI 1.03-1.94). The qualitative synthesis identified diverse forms of police violence and abuses of power, including arbitrary arrest, bribery and extortion, physical and sexual violence, failure to provide access to justice, and forced HIV testing. It showed that in contexts of criminalisation, the threat and enactment of police harassment and arrest of sex workers or their clients displaced sex workers into isolated work locations, disrupting peer support networks and service access, and limiting risk reduction opportunities. It discouraged sex workers from carrying condoms and exacerbated existing inequalities experienced by transgender, migrant, and drug-using sex workers. Evidence from decriminalised settings suggests that sex workers in these settings have greater negotiating power with clients and better access to justice. Quantitative findings were limited by high heterogeneity in the meta-analysis for some outcomes and insufficient data to conduct meta-analyses for others, as well as variable sample size and study quality. Few studies reported whether arrest was related to sex work or another offence, limiting our ability to assess the associations between sex work criminalisation and outcomes relative to other penalties or abuses of police power, and all studies were observational, prohibiting any causal inference. Few studies included trans- and cisgender male sex workers, and little evidence related to emotional health and access to healthcare beyond HIV/STI testing.

CONCLUSIONS

Together, the qualitative and quantitative evidence demonstrate the extensive harms associated with criminalisation of sex work, including laws and enforcement targeting the sale and purchase of sex, and activities relating to sex work organisation. There is an urgent need to reform sex-work-related laws and institutional practices so as to reduce harms and barriers to the realisation of health.

What influences women's movement and the use of different positions during labour and birth: a systematic review protocol

BACKGROUND

Women want to give birth in a safe and supportive environment where they are free to move and adopt different positions. Moving freely and using different positions in labour results in a range of physical and psychological benefits for women. However, many women report that they are restricted from moving freely during labour and birth and it is important to understand the factors that are influencing this.

METHODS

A mixed-methods systematic review will be undertaken. Qualitative, quantitative and mixed-methods primary empirical studies will be identified by systematically searching seven electronic databases using a search strategy that includes medical subject headings (MeSH) and keywords to cover synonyms and related terms. In addition, reference-tracking will be undertaken, and expert researchers will be contacted to locate relevant studies. Two reviewers will be involved in the assessment of the studies against eligibility criteria, formal quality appraisal and data extraction. A results-based convergent synthesis will be undertaken, using narrative synthesis if the quantitative data are too heterogeneous for meta-analysis, meta-ethnography for the synthesis of the qualitative data and the production of a line of argument synthesis. Finally, confidence in the findings will be formally assessed and conclusions drawn.

DISCUSSION

The findings of this review will allow researchers, practitioners and policy makers to better understand the factors influencing women's movement and the use of different positions during labour and birth. This will inform future research and the development of maternity services designed to implement best-evidence concerning movement and positioning during labour and birth into clinical practice.

SYSTEMATIC REVIEW REGISTRATION

In accordance with the PRISMA-P guidelines (Moher et al. Syst Rev 4:1, 2015), the systematic review protocol was registered with the International Prospective Register of Systematic reviews (PROSPERO) on July 17, 2018 (CRD42018103354).

Appraising Qualitative Research for Evidence Syntheses: A Compendium of Quality Appraisal Tools

As the movement toward evidence-based health policy continues to emphasize the importance of including patient and public perspectives, syntheses of qualitative health research are becoming more common. In response to the focus on independent assessments of rigor in these knowledge products, over 100 appraisal tools for assessing the quality of qualitative research have been developed. The variety of appraisal tools exhibit diverse methods and purposes, reflecting the lack of consensus as to what constitutes appropriate quality criteria for qualitative research. It is a daunting task for those without deep familiarity of the field to choose the best appraisal tool for their purpose. This article provides a description of the structure, content, and objectives of existing appraisal tools for those wanting to evaluate primary qualitative research for a qualitative evidence synthesis. We then discuss common features of appraisal tools and examine their implications for evidence synthesis.

Improving trial recruitment processes: how qualitative methodologies can be used to address the top 10 research priorities identified within the PRioRiTy study

How can we improve recruitment to trials? In their recently published paper, Healy et al. outline the top 10 prioritised questions for trial recruitment research identified by the PRioRiTy study. The challenge now is for researchers to answer these questions; but how best can these be answered? In this commentary, we illustrate how qualitative research can be utilised to generate in-depth insight into trial recruitment issues, either as a stand-alone methodology, or through a mixed-methods approach. Consideration is given to how different forms of qualitative research can be used to address these priorities and to help researchers set out an agenda to optimise its value.

Understanding women's, caregivers', and providers' experiences with home-based records: A systematic review of qualitative studies

Mothers, caregivers, and healthcare providers in 163 countries have used paper and electronic home-based records (HBRs) to facilitate primary care visit. These standardized records have the potential to empower women, improve the quality of care for mothers and children and reduce health inequities. This review examines experiences of women, caregivers and providers with home-based records for maternal and child health and seeks to explore the feasibility, acceptability, affordability and equity of these interventions. We systematically searched MEDLINE, MEDLINE In-Process, MEDLINE Ahead of Print, Embase, CINAHL, ERIC, and PsycINFO for articles that were published between January 1992 and December 2017. We used the CASP checklist to assess study quality, a framework analysis to support synthesis, and GRADE-CERQual to assess the confidence in the key findings. Of 7,904 citations, 19 studies met our inclusion criteria. In these studies, mothers, caregivers and children shared HBR experiences in relation to maternal and child health which facilitated the monitoring of immunisations and child growth and development. Participants' reports of HBRs acting as a point of commonality between patient and provider offer an explanation for their perceptions of improved communication and patient-centered care, and enhanced engagement and empowerment during pregnancy and childcare. Healthcare providers and nurses reported that the home-based record increased their feeling of connection with their patients. Although there were concerns around electronic records and confidentiality, there were no specific concerns reported for paper records. Mothers and other caregivers see home based records as having a pivotal role in facilitating primary care visits and enhancing healthcare for their families. The records' potential could be limited by users concerns over confidentiality of electronic home-based records, or shortcomings in their design. Health systems should seize the opportunity HBRs provide in empowering women, especially in the contexts of lower literacy levels and weak health care delivery systems.

Prevalence of and reasons for women's, family members', and health professionals' preferences for cesarean section in China: A mixed-methods systematic review

BACKGROUND

China has witnessed a rapid increase of cesarean section (CS) rates in recent years. Several non-clinical factors have been cited as contributing to this trend including maternal request and perceived convenience. We aimed to assess preferences for mode of delivery and reasons for preferences for CS in China to inform the development of future interventions to mitigate unnecessary CSs, which are those performed in the absence of medical indications.

METHODS AND FINDINGS

We conducted a mixed-methods systematic review and included longitudinal, cross-sectional, and qualitative studies in mainland China, Hong Kong, and Taiwan that investigated preferences for mode of delivery among women and family members and health professionals, and the reasons underlying such preferences. We searched MEDLINE/PubMed, Embase, CINAHL, POPLINE, PsycINFO, Global Health Library, and one Chinese database (CNKI) using a combination of the key terms 'caesarean section', 'preference', 'choice', 'knowledge', 'attitude', 'culture', 'non-clinical factors', and 'health professionals-patient relations' between 1990 and 2018 without language restriction. Meta-analysis of quantitative studies and meta-synthesis of qualitative studies were applied. We included 66 studies in this analysis: 47 quantitative and 19 qualitative. For the index pregnancy, the pooled proportions of preference for CS reported by women in longitudinal studies were 14% in early or middle pregnancy (95% CI 12%-17%) and 21% in late pregnancy (95% CI 15%-26%). In cross-sectional studies, the proportions were 17% in early or middle pregnancy (95% CI 14%-20%), 22% in late pregnancy (95% CI 18%-25%), and 30% postpartum (95% CI 19%-40%). Women's preferences for CS were found to rise as pregnancy progressed (preference change across longitudinal studies: mean difference 7%, 95% CI 1%-13%). One longitudinal study reported that the preference for CS among women's partners increased from 8% in late pregnancy to 17% in the immediate postpartum period. In addition, 18 quantitative studies revealed that some pregnant women, ranging from 4% to 34%, did not have a straightforward preference for a mode of delivery, even in late pregnancy. The qualitative meta-synthesis found that women's perceptions of CS as preferable were based on prioritising the baby's and woman's health and appeared to intensify through interactions with the health system. Women valued the convenience of bypassing labour because of fear of pain, antagonistic relations with providers, and beliefs of deteriorating quality of care during labour and vaginal birth, fostering the feeling that CS was the safest option. Health professionals' preference for CS was influenced by financial drivers and malpractice fears. This review has some limitations, including high heterogeneity (despite subgroup and sensitivity analysis) in the quantitative analysis, and the potential for over-reporting of women's preferences for CS in the qualitative synthesis (due to some included studies only including women who requested CS).

CONCLUSIONS

Despite a minority of women expressing a preference for CS, individual, health system, and socio-cultural factors converge, contributing to a high CS rate in mainland China, Hong Kong, and Taiwan. In order to reduce unnecessary CSs, interventions need to address all these non-clinical factors and concerns.

SYSTEMATIC REVIEW REGISTRY

Prospero CRD42016036596.

Are we entering a new era for qualitative research? Using qualitative evidence to support guidance and guideline development by the World Health Organization

Qualitative approaches are one of several methodologies utilised within the social sciences. New developments within qualitative methods are widening the opportunities for using qualitative evidence to inform health policy and systems decisions. In this commentary, we discuss how, in our work with the World Health Organization (WHO), we have explored ways of broadening the types of evidence used to develop evidence-informed guidance for health systems.Health systems decisions are commonly informed by evidence on the effectiveness of health system interventions. However, decision makers and other stakeholders also typically have additional questions, including how different stakeholders value different outcomes, the acceptability and feasibility of different interventions and the impacts of these interventions on equity and human rights. Evidence from qualitative research can help address these questions, and a number of WHO guidelines are now using qualitative evidence in this way. This growing use of qualitative evidence to inform decision making has been facilitated by recent methodological developments, including robust methods for qualitative evidence syntheses and approaches for assessing how much confidence to place in findings from such syntheses. For research evidence to contribute optimally to improving and sustaining the performance of health systems, it needs to be transferred easily between different elements of what has been termed the 'evidence ecosystem'. This ecosystem includes primary and secondary evidence producers, guidance developers and those implementing and evaluating interventions to strengthen health systems. We argue that most of the elements of an ecosystem for qualitative evidence are now in place - an important milestone that suggests that we are entering a new era for qualitative research. However, a number of challenges and constraints remain. These include how to build stronger links between the communities involved in the different parts of the qualitative evidence ecosystem and the need to strengthen capacity, particularly in low and middle income countries, to produce and utilise qualitative evidence and decision products informed by such evidence. We invite others who want to support the wider use of qualitative evidence in decision processes to look for opportunities in their settings to put this into practice.

Exploring the relationship between sanitation and mental and social well-being: A systematic review and qualitative synthesis

The WHO defines health not as the absence of disease but as a "state of complete physical, mental, and social well-being." To date, public health research on sanitation has focused mainly on the impact of sanitation on infectious diseases and related sequelae, such as diarrhea and malnutrition. This review focuses on the mental and social well-being implications of sanitation. We systematically searched leading databases to identify eligible studies. Qualitative studies were assessed using a 17-point checklist adapted from existing tools, while quantitative studies were assessed using the Liverpool Quality Appraisal Tool. We followed a best-fit framework synthesis approach using six a priori well-being dimensions (privacy, shame, anxiety, fear, assault, and safety), which were examined using line-by-line coding. Two additional dimensions (dignity and embarrassment) inductively emerged during coding for a total of eight well-being outcomes. We then synthesized coded text for each dimension into descriptive themes using thematic analysis. For quantitative studies, we extracted any measures of association between sanitation and well-being. We identified 50 eligible studies covering a variety of populations and sanitation contexts but many studies were conducted in India (N = 14) and many examined the sanitation experience for women and girls (N = 19). Our synthesis results in a preliminary conceptual model in which privacy and safety, including assault, are root well-being dimensions. When people perceive or experience a lack of privacy or safety during open defecation or when using sanitation infrastructure, this can negatively influence their mental and social well-being. We found that perceptions and experiences of privacy and safety are influenced by contextual and individual factors, such as location of sanitation facilities and user's gender identity, respectively. Privacy and safety require thorough examination when developing sanitation interventions and policy to ensure a positive influence on the user's mental and social well-being.

Values and preferences of men for undergoing prostate-specific antigen screening for prostate cancer: a systematic review

OBJECTIVES

To investigate men's values and preferences regarding prostate-specific antigen (PSA)-based screening for prostate cancer.

DESIGN

Systematic review.

DATA SOURCES

We searched MEDLINE, EMBASE, PsycINFO and grey literature up to 2 September 2017.

ELIGIBILITY CRITERIA

Primary studies of men's values and preferences regarding the benefits and harms of PSA screening.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed risk of bias with a modified version of a risk of bias tool for values and preferences studies, the International Patient Decision Aid Standards instrument V.3 and the Cochrane Collaboration risk of bias tool.

RESULTS

We identified 4172 unique citations, of which 11 studies proved eligible. Five studies investigated PSA screening using a direct choice study design, whereas six used decisions aids displaying patient-important outcomes. The direct choice studies used different methodologies and varied considerably in the reporting of outcomes. Two studies suggested that men were willing to forego screening with a small benefit in prostate cancer mortality if it would decrease the likelihood of unnecessary treatment or biopsies. In contrast, one study reported that men were willing to accept a substantial overdiagnosis to reduce their risk of prostate cancer mortality. Among the six studies involving decision aids, willingness to undergo screening varied substantially from 37% when displaying a hypothetical reduction in mortality of 10 per 1000 men, to 44% when displaying a reduction in mortality of 7 per 1000. We found no studies that specifically investigated whether values and preferences differed among men with family history, of African descent or with lower socioeconomic levels.

CONCLUSION

The variability of men's values and preferences reflect that the decision to screen is highly preference sensitive. Our review highlights the need for shared decision making in men considering prostate cancer screening.

TRIAL REGISTRATION NUMBER

CRD42018095585.

A systematic review of community Leg Clubs for patients with chronic leg ulcers

Aim

Appraise the evidence on the outcomes of Leg Clubs on ulcer healing, psychosocial outcomes, patient safety, cost and experiences of Leg Club members.

Background

The Leg Club is a community-based social model of care in 30 UK locations and nine overseas for treating patients with chronic leg wounds. However, its cumulative effectiveness has not been reviewed to-date.

Methods

Systematic review of primary research relating to the impact and quality of care of Leg Clubs treating patients with leg ulcers. Six electronic databases were systematically searched using the MeSH term ‘leg ulcer’, including other representative terms, in combination with ‘Leg Club’. The quality of individual studies was assessed using appraisal tools. The confidence in the quantitative evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation (GRADE); and the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) assessed the quality of qualitative findings.

Findings

A total of 17 relevant publications were identified. Out of the 17 articles, four publications represent findings from randomised controlled trial (RCT). Thus, evidence from 14 independent studies involving at least 532 participants were included in the synthesis of this review. The quality of the evidence varied across the different outcomes and were mostly low or of very low quality. Findings from one underpowered RCT from Australia reporting on clinical, patient-reported outcomes and economic outcomes were evaluated as moderate quality. Studies indicate that the Leg Club model has a positive impact on ulcer healing and recurrence, mood, sleep, quality of life and pain. Moreover, only three studies assessed wound infections and reported no infections had occurred during treatment at the Leg Clubs. Economic evaluations find Leg Clubs to be probably more cost-effective than usual care. Both patients and nurses projected positive views about the Leg Clubs, with particular emphasis on improved social interactions and delivery of patient-centred care.

Applying GRADE-CERQual to qualitative evidence synthesis findings-paper 6: how to assess relevance of the data

BACKGROUND

The GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research) approach has been developed by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group. The approach has been developed to support the use of findings from qualitative evidence syntheses in decision-making, including guideline development and policy formulation. CERQual includes four components for assessing how much confidence to place in findings from reviews of qualitative research (also referred to as qualitative evidence syntheses): (1) methodological limitations, (2) coherence, (3) adequacy of data and (4) relevance. This paper is part of a series providing guidance on how to apply CERQual and focuses on CERQual's relevance component.

METHODS

We developed the relevance component by searching the literature for definitions, gathering feedback from relevant research communities and developing consensus through project group meetings. We tested the CERQual relevance component within several qualitative evidence syntheses before agreeing on the current definition and principles for application.

RESULTS

When applying CERQual, we define relevance as the extent to which the body of data from the primary studies supporting a review finding is applicable to the context (perspective or population, phenomenon of interest, setting) specified in the review question. In this paper, we describe the relevance component and its rationale and offer guidance on how to assess relevance in the context of a review finding. This guidance outlines the information required to assess relevance, the steps that need to be taken to assess relevance and examples of relevance assessments.

CONCLUSIONS

This paper provides guidance for review authors and others on undertaking an assessment of relevance in the context of the CERQual approach. Assessing the relevance component requires consideration of potentially important contextual factors at an early stage in the review process. We expect the CERQual approach, and its individual components, to develop further as our experiences with the practical implementation of the approach increase.

Applying GRADE-CERQual to qualitative evidence synthesis findings-paper 4: how to assess coherence

BACKGROUND

The GRADE-CERQual (Grading of Recommendations Assessment, Development and Evaluation-Confidence in Evidence from Reviews of Qualitative research) approach has been developed by the GRADE working group. The approach has been developed to support the use of findings from qualitative evidence syntheses in decision-making, including guideline development and policy formulation. CERQual includes four components for assessing how much confidence to place in findings from reviews of qualitative research (also referred to as qualitative evidence syntheses): (1) methodological limitations, (2) relevance, (3) coherence and (4) adequacy of data. This paper is part of a series providing guidance on how to apply CERQual and focuses on CERQual's coherence component.

METHODS

We developed the coherence component by searching the literature for definitions, gathering feedback from relevant research communities and developing consensus through project group meetings. We tested the CERQual coherence component within several qualitative evidence syntheses before agreeing on the current definition and principles for application.

RESULTS

When applying CERQual, we define coherence as how clear and cogent the fit is between the data from the primary studies and a review finding that synthesises that data. In this paper, we describe the coherence component and its rationale and offer guidance on how to assess coherence in the context of a review finding as part of the CERQual approach. This guidance outlines the information required to assess coherence, the steps that need to be taken to assess coherence and examples of coherence assessments.

CONCLUSIONS

This paper provides guidance for review authors and others on undertaking an assessment of coherence in the context of the CERQual approach. We suggest that threats to coherence may arise when the data supporting a review finding are contradictory, ambiguous or incomplete or where competing theories exist that could be used to synthesise the data. We expect the CERQual approach, and its individual components, to develop further as our experiences with the practical implementation of the approach increase.

Applying GRADE-CERQual to qualitative evidence synthesis findings-paper 3: how to assess methodological limitations

BACKGROUND

The GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research) approach has been developed by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group. The approach has been developed to support the use of findings from qualitative evidence syntheses in decision-making, including guideline development and policy formulation. CERQual includes four components for assessing how much confidence to place in findings from reviews of qualitative research (also referred to as qualitative evidence syntheses): (1) methodological limitations, (2) coherence, (3) adequacy of data and (4) relevance. This paper is part of a series providing guidance on how to apply CERQual and focuses on CERQual's methodological limitations component.

METHODS

We developed the methodological limitations component by searching the literature for definitions, gathering feedback from relevant research communities and developing consensus through project group meetings. We tested the CERQual methodological limitations component within several qualitative evidence syntheses before agreeing on the current definition and principles for application.

RESULTS

When applying CERQual, we define methodological limitations as the extent to which there are concerns about the design or conduct of the primary studies that contributed evidence to an individual review finding. In this paper, we describe the methodological limitations component and its rationale and offer guidance on how to assess methodological limitations of a review finding as part of the CERQual approach. This guidance outlines the information required to assess methodological limitations component, the steps that need to be taken to assess methodological limitations of data contributing to a review finding and examples of methodological limitation assessments.

CONCLUSIONS

This paper provides guidance for review authors and others on undertaking an assessment of methodological limitations in the context of the CERQual approach. More work is needed to determine which criteria critical appraisal tools should include when assessing methodological limitations. We currently recommend that whichever tool is used, review authors provide a transparent description of their assessments of methodological limitations in a review finding. We expect the CERQual approach and its individual components to develop further as our experiences with the practical implementation of the approach increase.

Applying GRADE-CERQual to qualitative evidence synthesis findings-paper 2: how to make an overall CERQual assessment of confidence and create a Summary of Qualitative Findings table

BACKGROUND

The GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research) approach has been developed by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group. The approach has been developed to support the use of findings from qualitative evidence syntheses in decision making, including guideline development and policy formulation. CERQual includes four components for assessing how much confidence to place in findings from reviews of qualitative research (also referred to as qualitative evidence syntheses): (1) methodological limitations, (2) coherence, (3) adequacy of data and (4) relevance. This paper is part of a series providing guidance on how to apply CERQual and focuses on making an overall assessment of confidence in a review finding and creating a CERQual Evidence Profile and a CERQual Summary of Qualitative Findings table.

METHODS

We developed this guidance by examining the methods used by other GRADE approaches, gathering feedback from relevant research communities and developing consensus through project group meetings. We then piloted the guidance on several qualitative evidence syntheses before agreeing on the approach.

RESULTS

Confidence in the evidence is an assessment of the extent to which a review finding is a reasonable representation of the phenomenon of interest. Creating a summary of each review finding and deciding whether or not CERQual should be used are important steps prior to assessing confidence. Confidence should be assessed for each review finding individually, based on the judgements made for each of the four CERQual components. Four levels are used to describe the overall assessment of confidence: high, moderate, low or very low. The overall CERQual assessment for each review finding should be explained in a CERQual Evidence Profile and Summary of Qualitative Findings table.

CONCLUSIONS

Structuring and summarising review findings, assessing confidence in those findings using CERQual and creating a CERQual Evidence Profile and Summary of Qualitative Findings table should be essential components of undertaking qualitative evidence syntheses. This paper describes the end point of a CERQual assessment and should be read in conjunction with the other papers in the series that provide information on assessing individual CERQual components.

Applying GRADE-CERQual to qualitative evidence synthesis findings-paper 7: understanding the potential impacts of dissemination bias

BACKGROUND

The GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research) approach has been developed by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group. The approach has been developed to support the use of findings from qualitative evidence syntheses in decision-making, including guideline development and policy formulation. CERQual includes four components for assessing how much confidence to place in findings from reviews of qualitative research (also referred to as qualitative evidence syntheses): (1) methodological limitations, (2) coherence, (3) adequacy of data and (4) relevance. This paper is part of a series providing guidance on how to apply CERQual and focuses on a probable fifth component, dissemination bias. Given its exploratory nature, we are not yet able to provide guidance on applying this potential component of the CERQual approach. Instead, we focus on how dissemination bias might be conceptualised in the context of qualitative research and the potential impact dissemination bias might have on an overall assessment of confidence in a review finding. We also set out a proposed research agenda in this area.

METHODS

We developed this paper by gathering feedback from relevant research communities, searching MEDLINE and Web of Science to identify and characterise the existing literature discussing or assessing dissemination bias in qualitative research and its wider implications, developing consensus through project group meetings, and conducting an online survey of the extent, awareness and perceptions of dissemination bias in qualitative research.

RESULTS

We have defined dissemination bias in qualitative research as a systematic distortion of the phenomenon of interest due to selective dissemination of studies or individual study findings. Dissemination bias is important for qualitative evidence syntheses as the selective dissemination of qualitative studies and/or study findings may distort our understanding of the phenomena that these syntheses aim to explore and thereby undermine our confidence in these findings. Dissemination bias has been extensively examined in the context of randomised controlled trials and systematic reviews of such studies. The effects of potential dissemination bias are formally considered, as publication bias, within the GRADE approach. However, the issue has received almost no attention in the context of qualitative research. Because of very limited understanding of dissemination bias and its potential impact on review findings in the context of qualitative evidence syntheses, this component is currently not included in the GRADE-CERQual approach.

CONCLUSIONS

Further research is needed to establish the extent and impacts of dissemination bias in qualitative research and the extent to which dissemination bias needs to be taken into account when we assess how much confidence we have in findings from qualitative evidence syntheses.

Applying GRADE-CERQual to qualitative evidence synthesis findings-paper 5: how to assess adequacy of data

BACKGROUND

The GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research) approach has been developed by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) working group. The approach has been developed to support the use of findings from qualitative evidence syntheses in decision-making, including guideline development and policy formulation. CERQual includes four components for assessing how much confidence to place in findings from reviews of qualitative research (also referred to as qualitative evidence syntheses): (1) methodological limitations; (2) coherence; (3) adequacy of data; and (4) relevance. This paper is part of a series providing guidance on how to apply CERQual and focuses on CERQual's adequacy of data component.

METHODS

We developed the adequacy of data component by searching the literature for definitions, gathering feedback from relevant research communities and developing consensus through project group meetings. We tested the CERQual adequacy of data component within several qualitative evidence syntheses before agreeing on the current definition and principles for application.

RESULTS

When applying CERQual, we define adequacy of data as an overall determination of the degree of richness and the quantity of data supporting a review finding. In this paper, we describe the adequacy component and its rationale and offer guidance on how to assess data adequacy in the context of a review finding as part of the CERQual approach. This guidance outlines the information required to assess data adequacy, the steps that need to be taken to assess data adequacy, and examples of adequacy assessments.

CONCLUSIONS

This paper provides guidance for review authors and others on undertaking an assessment of adequacy in the context of the CERQual approach. We approach assessments of data adequacy in terms of the richness and quantity of the data supporting each review finding, but do not offer fixed rules regarding what constitutes sufficiently rich data or an adequate quantity of data. Instead, we recommend that this assessment is made in relation to the nature of the finding. We expect the CERQual approach, and its individual components, to develop further as our experiences with the practical implementation of the approach increase.

Factors that influence the provision of intrapartum and postnatal care by skilled birth attendants in low- and middle-income countries: a qualitative evidence synthesis

BACKGROUND

In many low- and middle-income countries women are encouraged to give birth in clinics and hospitals so that they can receive care from skilled birth attendants. A skilled birth attendant (SBA) is a health worker such as a midwife, doctor, or nurse who is trained to manage normal pregnancy and childbirth. (S)he is also trained to identify, manage, and refer any health problems that arise for mother and baby. The skills, attitudes and behaviour of SBAs, and the extent to which they work in an enabling working environment, impact on the quality of care provided. If any of these factors are missing, mothers and babies are likely to receive suboptimal care.

OBJECTIVES

To explore the views, experiences, and behaviours of skilled birth attendants and those who support them; to identify factors that influence the delivery of intrapartum and postnatal care in low- and middle-income countries; and to explore the extent to which these factors were reflected in intervention studies.

SEARCH METHODS

Our search strategies specified key and free text terms related to the perinatal period, and the health provider, and included methodological filters for qualitative evidence syntheses and for low- and middle-income countries. We searched MEDLINE, OvidSP (searched 21 November 2016), Embase, OvidSP (searched 28 November 2016), PsycINFO, OvidSP (searched 30 November 2016), POPLINE, K4Health (searched 30 November 2016), CINAHL, EBSCOhost (searched 30 November 2016), ProQuest Dissertations and Theses (searched 15 August 2013), Web of Science (searched 1 December 2016), World Health Organization Reproductive Health Library (searched 16 August 2013), and World Health Organization Global Health Library for WHO databases (searched 1 December 2016).

SELECTION CRITERIA

We included qualitative studies that focused on the views, experiences, and behaviours of SBAs and those who work with them as part of the team. We included studies from all levels of health care in low- and middle-income countries.

DATA COLLECTION AND ANALYSIS

One review author extracted data and assessed study quality, and another review author checked the data. We synthesised data using the best fit framework synthesis approach and assessed confidence in the evidence using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. We used a matrix approach to explore whether the factors identified by health workers in our synthesis as important for providing maternity care were reflected in the interventions evaluated in the studies in a related intervention review.

MAIN RESULTS

We included 31 studies that explored the views and experiences of different types of SBAs, including doctors, midwives, nurses, auxiliary nurses and their managers. The included studies took place in Africa, Asia, and Latin America.Our synthesis pointed to a number of factors affecting SBAs' provision of quality care. The following factors were based on evidence assessed as of moderate to high confidence. Skilled birth attendants reported that they were not always given sufficient training during their education or after they had begun clinical work. Also, inadequate staffing of facilities could increase the workloads of skilled birth attendants, make it difficult to provide supervision and result in mothers being offered poorer care. In addition, SBAs did not always believe that their salaries and benefits reflected their tasks and responsibilities and the personal risks they undertook. Together with poor living and working conditions, these issues were seen to increase stress and to negatively affect family life. Some SBAs also felt that managers lacked capacity and skills, and felt unsupported when their workplace concerns were not addressed.Possible causes of staff shortages in facilities included problems with hiring and assigning health workers to facilities where they were needed; lack of funding; poor management and bureaucratic systems; and low salaries. Skilled birth attendants and their managers suggested factors that could help recruit, keep, and motivate health workers, and improve the quality of care; these included good-quality housing, allowances for extra work, paid vacations, continuing education, appropriate assessments of their work, and rewards.Skilled birth attendants' ability to provide quality care was also limited by a lack of equipment, supplies, and drugs; blood and the infrastructure to manage blood transfusions; electricity and water supplies; and adequate space and amenities on maternity wards. These factors were seen to reduce SBAs' morale, increase their workload and infection risk, and make them less efficient in their work. A lack of transport sometimes made it difficult for SBAs to refer women on to higher levels of care. In addition, women's negative perceptions of the health system could make them reluctant to accept referral.We identified some other factors that also may have affected the quality of care, which were based on findings assessed as of low or very low confidence. Poor teamwork and lack of trust and collaboration between health workers appeared to negatively influence care. In contrast, good collaboration and teamwork appeared to increase skilled birth attendants' motivation, their decision-making abilities, and the quality of care. Skilled birth attendants' workloads and staff shortages influenced their interactions with mothers. In addition, poor communication undermined trust between skilled birth attendants and mothers.

AUTHORS' CONCLUSIONS

Many factors influence the care that SBAs are able to provide to mothers during childbirth. These include access to training and supervision; staff numbers and workloads; salaries and living conditions; and access to well-equipped, well-organised healthcare facilities with water, electricity, and transport. Other factors that may play a role include the existence of teamwork and of trust, collaboration, and communication between health workers and with mothers. Skilled birth attendants reported many problems tied to all of these factors.