Toward a metasynthesis of qualitative findings on motherhood in HIV-positive women

A guiding framework to maximise the power of the arts in medical education: a systematic review and metasynthesis

CONTEXT

A rich literature describes many innovative uses of the arts in professional education. However, arts-based teaching tends to be idiosyncratic, depending on the interests and enthusiasm of individual teachers, rather than on strategic design decisions. An overarching framework is needed to guide implementation of arts-based teaching in medical education. The objective of this study was to review and synthesise the literature on arts-based education and provide a conceptual model to guide design, evaluation and research of the use of the arts in medical education.

METHODS

A systematic literature review using the PubMed and ERIC databases. Search terms included humanism, art, music, literature, teaching, education, learning processes, pedagogy and curriculum. We selected empirical studies and conceptual articles about the use of creative arts, imagery and symbolism in the context of professional education. Data synthesis involved a qualitative content analysis of 49 included articles, identifying themes related to educational characteristics, processes and outcomes in arts-based education.

RESULTS

Four common themes were identified describing (i) unique qualities of the arts that promote learning, (ii) particular ways learners engage with art, (iii) documented short- and long-term learning outcomes arising from arts-based teaching and (iv) specific pedagogical considerations for using the arts to teach in professional education contexts.

CONCLUSIONS

The arts have unique qualities that can help create novel ways to engage learners. These novel ways of engagement can foster learners' ability to discover and create new meanings about a variety of topics, which in turn can lead to better medical practice. At each of these steps, specific actions by the teacher can enhance the potential for learners to move to the next step. The process can be enhanced when learners participate in the context of a group, and the group itself can undergo transformative change. Future work should focus on using this model to guide process design and outcome measurement in arts-based education.

Testing HIV positive in pregnancy: A phenomenological study of women's experiences

OBJECTIVE

globally women receive HIV testing in pregnancy; however, limited information is available on their experiences of this potentially life-changing event. This study aims to explore women's experiences of receiving a positive HIV test result following antenatal screening.

DESIGN

a qualitative, phenomenological approach.

SETTING

two public National Health Service (NHS) hospitals and HIV support organisations.

PARTICIPANTS

a purposive sampling strategy was used. Thirteen black African women with a positive HIV result, in England, participated.

METHODS

data were collected using in-depth semi-structured interviews. An interpretive phenomenological approach to data analysis was used.

FINDINGS

the emergent phenomenon was transition and transformation of 'being,' as women accepted HIV as part of their lives. Paired themes support the phenomenon: shock and disbelief; anger and turmoil; stigma and confidentiality issues; acceptance and resilience. Women had extreme reactions to their positive HIV diagnosis, compounded by the cultural belief that they would die. Initial disbelief of the unexpected result developed into sadness at the loss of their old self. Turmoil was evident, as women considered termination of pregnancy, self-harm and suicide. Women felt isolated from others and relationship breakdowns often occurred. Most reported the pervasiveness of stigma, and how this was managed alongside living with HIV. Coping strategies included keeping HIV 'secret' and making their child(ren) the prime focus of life. Growing resilience was apparent with time.

KEY CONCLUSIONS

this study gives midwives unique understanding of the complexities and major implications for women who tested positive for HIV. Women's experiences resonated with processes of bereavement, providing useful insight into a transitional and transformational period, during which appropriate support can be targeted.

IMPLICATIONS

midwives are crucial in improving the experience of women when they test HIV positive and to do this they need to be appropriately trained. Midwives need to acknowledge the social and psychological impact of HIV and pathways should be developed to support early referral for appropriate support.

Using Sandelowski and Barroso's Meta-Synthesis Method in Advancing Qualitative Evidence

The purpose of this article was to iteratively account for and discuss the handling of methodological challenges in two qualitative research syntheses concerning patients' experiences of hospital transition. We applied Sandelowski and Barroso's guidelines for synthesizing qualitative research, and to our knowledge, this is the first time researchers discuss their methodological steps. In the process, we identified a need for prolonged discussions to determine mutual understandings of the methodology. We discussed how to identify the appropriate qualitative research literature and how to best conduct exhaustive literature searches on our target phenomena. Another finding concerned our status as third-order interpreters of participants' experiences and what this meant for synthesizing the primary findings. Finally, we discussed whether our studies could be classified as metasummaries or metasyntheses. Although we have some concerns regarding the applicability of the methodology, we conclude that following Sandelowski and Barroso's guidelines contributed to valid syntheses of our studies.

Navigating in an unpredictable daily life: a metasynthesis on children's experiences living with a parent with severe mental illness

A large group of individuals suffering from mental illness are parents living with their children. These children are invisible in the health care even though at risk for illhealth. The aim of this metasynthesis was to advance knowledge of how children of parents with mental illness experience their lives, thus contributing to the evidence of this phenomenon. The metasynthesis is following Sandelowski and Barroso's guidelines. Literature searches covering the years 2000 to 2013 resulted in 22 reports which were synthesised into the theme 'navigating in an unpredictable everyday life' and the metaphor compass. Children of parents with mental illness irrespective of age are responsible, loving and worrying children who want to do everything to help and support. Children feel shame when the parent behaves differently, and they conceal their family life being afraid of stigmatisation and bullying. When their parent becomes ill, they distance to protect themselves. The children cope through information, knowledge, frankness and trustful relationships. These children need support from healthcare services because they subjugate own needs in favour of the parental needs, they should be encouraged to talk about their family situation, and especially, young children should to be child-like, playing and seeing friends.

Taking culture seriously in biomedical HIV prevention trials: a meta-synthesis of qualitative studies

A substantial gap exists between widespread acknowledgement of the importance of incorporating cultural sensitivity in biomedical HIV prevention trials and empirical evidence to guide the operationalization of cultural sensitivity in these trials. We conducted a systematic literature search and qualitative meta-synthesis to explore how culture is conceptualized and operationalized in global biomedical HIV prevention trials. Across 29 studies, the majority (n = 17) were conducted in resource-limited settings. We identified four overarching themes: (1) semantic cultural sensitivity - challenges in communicating scientific terminology into local vernaculars; (2) instrumental cultural sensitivity - understanding historical experiences to guide tailoring of trial activities; (3) budgetary, logistical, and personnel implications of operationalizing cultural sensitivity; and (4) culture as an asset. Future investigations should address how sociocultural considerations are operationalized across the spectrum of trial preparedness, implementation, and dissemination in particular sociocultural contexts, including intervention studies and evaluations of the effectiveness of methods used to operationalize culturally sensitive practices.

Type 2 diabetes patients' and providers' differing perspectives on medication nonadherence: a qualitative meta-synthesis

BACKGROUND

Poor adherence to medication regimens increases adverse outcomes for patients with Type 2 diabetes. Improving medication adherence is a growing priority for clinicians and health care systems. We examine the differences between patient and provider understandings of barriers to medication adherence for Type 2 diabetes patients.

METHODS

We searched systematically for empirical qualitative studies on the topic of barriers to medication adherence among Type 2 diabetes patients published between 2002-2013; 86 empirical qualitative studies qualified for inclusion. Following qualitative meta-synthesis methods, we coded and analyzed thematically the findings from studies, integrating and comparing findings across studies to yield a synthetic interpretation and new insights from this body of research.

RESULTS

We identify 7 categories of barriers: (1) emotional experiences as positive and negative motivators to adherence, (2) intentional non-compliance, (3) patient-provider relationship and communication, (4) information and knowledge, (5) medication administration, (6) social and cultural beliefs, and (7) financial issues. Patients and providers express different understandings of what patients require to improve adherence. Health beliefs, life context and lay understandings all inform patients' accounts. They describe barriers in terms of difficulties adapting medication regimens to their lifestyles and daily routines. In contrast, providers' understandings of patients poor medication adherence behaviors focus on patients' presumed needs for more information about the physiological and biomedical aspect of diabetes.

CONCLUSIONS

This study highlights key discrepancies between patients' and providers' understandings of barriers to medication adherence. These misunderstandings span the many cultural and care contexts represented by 86 qualitative studies. Counseling and interventions aimed at improving medication adherence among Type 2 diabetes might become more effective through better integration of the patient's perspective and values concerning adherence difficulties and solutions.

A systematic review and metasynthesis of barriers and facilitators to negotiating consistent condom use among sex workers in Asia

Female sex work accounts for about 15% of the global HIV burden in women. Asia is the region with the second highest attributable fraction of the HIV epidemic after sub-Saharan Africa. This review synthesises studies that depict the barriers and facilitators encountered by sex workers in Asia when negotiating consistent condom use. A total of 18 studies published between January 1989 and May 2015 were included in the review. Data were extracted, critically appraised and analysed using a thematic analysis approach. Individual-level factors related to sex workers' knowledge, perception and power, as well as interpersonal-level factors that encompassed dynamics with clients and peer-related factors, presented as both barriers and facilitators to sex workers' condom negotiation process. In addition, the structural environment of sex work, access to resources, poverty, stigma, the legal environment and the role of media were also identified as factors in influencing the condom negotiation process of sex workers. A multisectoral interventional approach that addresses the multilevel barriers encountered by sex workers in condom negotiation is needed. Awareness of safe-sex practice should be collectively enhanced among sex workers, clients and brothel managers.

Life changes in women infected with HIV by their husbands: an interpretive phenomenological study

HIV transmission from husbands to wives in stable marital relationships has increased. Our study explored women's perspectives on their life changes after being infected with HIV by their husbands. The interpretive phenomenological approach guided the study. Cambodian women (n = 15) who self-identified their infections as coming from their husbands participated in two in-depth interviews. The participants underwent significant changes in interpersonal and intimate relationships with their spouses, reporting that their partners became more devoted husbands and agreed to follow safer sex practices within the marriage. However, families suffered from hunger and poverty due to the parents' physical weaknesses. Both the husbands' changed behavior and their children gave these women the strength to not only go on with their life routines, but also to report that life was better than before the HIV diagnosis. These results inform health policies and programs targeting families where HIV affects both spouses.

Parents' experiences of caring for a child with autism spectrum disorder

Autism spectrum disorder (ASD) is a developmental disorder involving abnormal communication, repetitive and restrictive interests, and impaired social functioning. ASD can have a profound impact on family life, including the roles and responsibilities that parents assume. In this metasynthesis, we explore the experiences of parents who care for a child with ASD. We undertook a thematic synthesis to integrate qualitative evidence, searching 10 electronic databases and reviewing 4,148 abstracts. We selected 31 articles for inclusion (involving 160 fathers and 425 mothers) and examined the articles using a constant comparative approach. We identified six themes: prediagnosis, diagnosis, family life adjustment, navigating the system, parental empowerment, and moving forward. Our findings can inform the development of programs and services for families, provide insight for health care workers who advocate on behalf of parents, and provide valuable information to parents, particularly those of children newly diagnosed with ASD.

Living with breast cancer-related lymphedema: a synthesis of qualitative research

PURPOSE/OBJECTIVES

To describe the experience of female patients living with breast cancer-related lymphedema (BCRL) to gain a comprehensive understanding of this experience. The review is designed as a qualitative meta-synthesis.

DATA SOURCES

Electronic searches were conducted in MEDLINE®, CINAHL®, EMBASE, PsycINFO, and Social Sciences Citation Index. Articles were included where researchers used qualitative research methods and when a comprehensive description of methods and the study's findings were provided.

DATA SYNTHESIS

From 2,185 references, 13 articles were included. A total of 94 author and participant aggregations were extracted, qualitatively assessed, and assigned to one of 14 categories. Four themes relating to the experience of living with BCRL were identified: experience of everyday life, energy sapping, personal empowerment, and contribution of others.

CONCLUSIONS

Requirements of living with BCRL may only be influenced to a limited extent by the women themselves. They struggle with their situation, appearance, and the concomitant uncertainties. They feel strengthened where they succeed in developing a helpful view of their situation and where support structures are available to them.

IMPLICATIONS FOR NURSING

Professionals can employ this meta-synthesis by contextualizing it as part of a process of critical reflection on their own endeavors to meet the requirements of women living with BCRL.

Creating an eLearning resource to improve knowledge and understanding of pregnancy in the context of HIV infection

Patient narratives have much to teach healthcare professionals about the experience of living with a chronic condition. While the biomedical narrative of HIV treatment is hugely encouraging, the narrative of living with HIV continues to be overshadowed by a persuasive perception of stigma. This paper presents how we sought to translate the evidence from a qualitative study of the perspectives of HIV affected pregnant women and expectant fathers on the care they received, from the pre conception to post natal period, into educational material for maternity care practice. Narrative scripts were written based on the original research interviews, with care taken to reflect the key themes from the research. We explore the way in which the qualitative findings bring to life patient and partner experiences and what it means for nurses, midwives and doctors to be prepared to care for couples affected by HIV. In so doing, we challenge the inequity between the dominance of biomedical knowledge over understanding the patient experience in the preparation of health professionals to care for HIV affected women and men who are having a baby or seeking to have a baby.

Illness-related emotional experiences of patients living with incurable lung cancer: a qualitative metasynthesis

BACKGROUND

Living with incurable lung cancer often drastically changes the patients' lives physically, socially, psychologically, and spiritually. The emotional experiences of patients with incurable lung cancer have been studied with a qualitative approach, but the findings are yet to be synthesized.

OBJECTIVE

The objective of this study was to synthesize interpreted knowledge on the illness-related emotional experiences of patients with incurable lung cancer.

METHODS

A qualitative metasynthesis was carried out to integrate the findings from 10 qualitative studies conducted between 1995 and 2011. The studies were critically appraised according to the method defined by Sandelowski and Barroso, and the findings were extracted, edited, and abstracted. The concept "loss" was imported as a method to synthesize the findings.

RESULTS

Eight themes of emotional experiences emerged: "guilt, blame, shame, and stigmatization," "hope and despair," "loneliness," "changing in self-image and self-worth," "uselessness and dependency," "uncertainty and worries," "anxiety and fear," and "loss." The loss experiences were categorized as unrecognized and clear losses.

CONCLUSION

This study supports that patients with incurable lung cancer undergo illness-related emotions that can be identified as losses. Further studies are required to determine the best way for nurses to implement emotional care.

IMPLICATIONS FOR PRACTICE

Nurses play an important role in the acknowledgement of unrecognized and clear losses while caring for patients with incurable lung cancer.

[Permanent education in health: a review]

OBJECTIVE

To undertake a meta-synthesis of the literature on the main concepts and practices related to permanent education in health.

METHODS

A bibliographical search was conducted for original articles in the PubMed, Web of Science, LILACS, IBECS and SciELO databases, using the following search terms: "public health professional education", "permanent education", "continuing education", "permanent education health". Of the 590 articles identified, after applying inclusion and exclusion criteria, 48 were selected for further analysis, grouped according to the criteria of key elements, and then underwent meta-synthesis.

RESULTS

The 48 original publications were classified according to four thematic units of key elements: 1) concepts, 2) strategies and difficulties, 3) public policies and 4) educational institutions. Three main conceptions of permanent education in health were found: problem-focused and team work, directly related to continuing education and education that takes place throughout life. The main strategies for executing permanent education in health are discussion, maintaining an open space for permanent education , and permanent education clusters. The most limiting factor is mainly related to directly or indirect management. Another highlight is the requirement for implementation and maintenance of public policies, and the availability of financial and human resources. The educational institutions need to combine education and service aiming to form critical-reflexive graduates.

CONCLUSIONS

The coordination between health and education is based as much on the actions of health services as on management and educational institutions. Thus, it becomes a challenge to implement the teaching-learning processes that are supported by critical-reflexive actions. It is necessary to carry out proposals for permanent education in health involving the participation of health professionals, teachers and educational institutions.

OBJECTIVE

To undertake a meta-synthesis of the literature on the main concepts and practices related to permanent education in health.

METHODS

A bibliographical search was conducted for original articles in the PubMed, Web of Science, LILACS, IBECS and SciELO databases, using the following search terms: "public health professional education", "permanent education", "continuing education", "permanent education health". Of the 590 articles identified, after applying inclusion and exclusion criteria, 48 were selected for further analysis, grouped according to the criteria of key elements, and then underwent meta-synthesis.

RESULTS

The 48 original publications were classified according to four thematic units of key elements: 1) concepts, 2) strategies and difficulties, 3) public policies and 4) educational institutions. Three main conceptions of permanent education in health were found: problem-focused and team work, directly related to continuing education and education that takes place throughout life. The main strategies for executing permanent education in health are discussion, maintaining an open space for permanent education, and permanent education clusters. The most limiting factor is mainly related to directly or indirect management. Another highlight is the requirement for implementation and maintenance of public policies, and the availability of financial and human resources. The educational institutions need to combine education and service aiming to form critical-reflexive graduates.

CONCLUSIONS

The coordination between health and education is based as much on the actions of health services as on management and educational institutions. Thus, it becomes a challenge to implement the teaching-learning processes that are supported by critical-reflexive actions. It is necessary to carry out proposals for permanent education in health involving the participation of health professionals, teachers and educational institutions.

Renegotiating environments to achieve participation: A metasynthesis of qualitative chronic disease research

BACKGROUND

Qualitative studies describe environmental influences on participation in adults with chronic disease, but translating these findings into practice can be difficult.

PURPOSE

This study sought to synthesize qualitative research findings regarding the influence of environmental factors on participation among adults with chronic disease.

METHODS

Searching revealed 31 I articles that describe the link between environment and participation for adults with osteoarthritis, rheumatoid arthritis, diabetes mellitus, heart disease, cancer, chronic obstructive pulmonary disease, and/or depression. Study findings were analyzed using metasynthesis methods to identify themes.

FINDINGS

For adults with chronic disease, renegotiating their environments and occupations to achieve, maintain, or rework their participation involves understanding support processes, being ordinary and able, navigating systems, and navigating physical environments.

IMPLICATIONS

Key areas that occupational therapy interventions can target are facilitating constructive collaboration between client and support person, fostering connections with others, recognizing cultural pressure to be ordinary and able, and advocating for supportive policy and practice.

The psychological experiences of adult heart transplant recipients: a systematic review and meta-summary of qualitative findings

BACKGROUND

Psychosocial factors and physical health are associated with increased psychological distress post-heart transplant. Integrating findings from qualitative studies could highlight mechanisms for how these factors contribute to psychological well-being, thus aiding the development of interventions.

OBJECTIVE

To integrate qualitative findings regarding adult heart transplant recipients experiences, such as their emotions, perceptions and attitudes.

METHODS

A systematic review and meta-summary were conducted. Data from seven studies were categorized into 16 abstracted findings.

RESULTS

The most prominent finding across the studies related to recipients' perceptions of the importance of social support. Other prominent findings related to factors that promoted psychological well-being, such as faith, optimism and sense of control.

CONCLUSIONS

Psychological well-being may be improved by enhancing perceived control over health and daily life, promoting an optimistic outlook by facilitating access to social support from other heart transplant recipients and ensuring post-transplant recipient-caregiver partnerships adequately support the transition back to independence.

A case study of maternal response to the implied antepartum diagnosis of inevitable labor dystocia

Two pregnant women, one obese and one of extremely small stature, received antepartum recommendations from their health care providers to schedule cesarean births. In response, both women sought providers who would support their desire to attempt vaginal birth. The women's perspectives on their birth experiences along with the pertinent medical record data from their pregnancies and births provide a reminder about the inherent normalcy of birth amid the current culture of interventive obstetrical practices.

Quality of Life and Emotional Distress among HIV-Positive Women during Transition to Motherhood

The purpose of this preliminary study was to describe the quality of life (QOL) and emotional distress during pregnancy and early postpartum, and to examine the ability of psychopathological symptoms to predict QOL at early postpartum.Asample of 75 pregnant women (31 HIV-positive and 44 HIV-negative) was assessed during the second trimester of pregnancy and two to four days postpartum. QOL was assessed with the WHOQOL-Bref. The emotional distress was assessed with the Brief Symptom Inventory, and with the Emotional Assessment Scale. Seropositive women reported increased negative emotional reactivity and lower scores in social relationships and overall QOL during pregnancy than HIV-negative women. Both HIV-positive and HIV-negative women reported better QOL after the birth of their child, when compared with the pregnancy period. Among HIV-positive women, lower anxiety and depressive symptoms during pregnancy were, respectively, significant predictors of better psychological QOL and overall QOL at early postpartum. Less intense somatic symptoms predicted better physical QOL. Longitudinal assessment of QOL and emotional status may provide potentially useful information for tailoring psychological interventions in the maternity care of HIV-infected women, during their transition to motherhood.

Understanding the health and social care needs of people living with IBD: a meta-synthesis of the evidence

AIM

To undertake a metasynthesis of qualitative studies to understand the health and social needs of people living with inflammatory bowel disease (IBD).

METHODS

A systematic search strategy identified qualitative studies exploring the phenomenon of living with inflammatory bowel disease. Databases included MEDLINE, PsychInfo, EMBASE, CINAHL and the British Nursing Index via the OVID platform. Qualitative search filters were adapted from Hedges database (http://www.urmc.rochester.edu/hslt/miner/digital_library/tip_sheets/Cinahl_eb_filters.pdf). Qualitative empirical studies exploring the health and social needs of people living with inflammatory bowel disease were selected. Study eligibility and data extraction were independently completed using the Critical Appraisal Skills Programme for qualitative studies. The studies were analysed and synthesised using metasynthesis methodology. The themes from the studies allowed for common translations into a new interpretation of the impact of living with inflammatory bowel disease.

RESULTS

Of 1395 studies, six published studies and one unpublished thesis fulfilled the inclusion criteria. First iteration of synthesis identified 16 themes, 2nd iteration synthesised these into three main 2nd order constructs: "detained by the disease"; "living in a world of disease" and "wrestling with life". "Detained by the disease" is the fear of incontinence, the behaviour the patients display due to the fear, and the impact this has on the individual, such as social isolation and missing out on life events. All of these serve to "pull" the patient back from normal living. "Living in a world of disease" is the long term effects of living with a long term condition and the fear of these effects. "Wrestling with life" is the continued fight to thrive, the "push" to continue normal living.

CONCLUSION

The metasynthesis provides a comprehensive representation of living with IBD. The unmistakeable burden of incontinence is exposed and its ongoing effects are demonstrated. The combined overall impact of living with IBD is the tension these patients live with: "Pushed and pulled: a compromised life", people living with IBD experience a constant conflict throughout their lives, they push to be normal but IBD pulls them back. The impact of the fear of incontinence and behaviour of the individual as a result, requires further qualitative enquiry.

'Every pregnant woman needs a midwife'--the experiences of HIV affected women in maternity care

TITLE

'Every pregnant woman needs a midwife'-the experiences of HIV affected women in Northern Ireland.

OBJECTIVE

to explore HIV positive women's experiences of pregnancy and maternity care, with a focus on their interactions with midwives.

DESIGN

a prospective qualitative study.

SETTING

regional HIV unit in Northern Ireland.

PARTICIPANTS

22 interviews were conducted with 10 women at different stages of their reproductive trajectories.

FINDINGS

the pervasive presence of HIV related stigma threatened the women's experience of pregnancy and care. The key staff attributes that facilitated a positive experience were knowledge and experience, empathy and understanding of their unique needs and continuity of care.

KEY CONCLUSIONS

pregnancy in the context of HIV, whilst offering a much needed sense of normality, also increases woman's sense of anxiety and vulnerability and therefore the need for supportive interventions that affirm normality is intensified. A maternity team approach, with a focus on providing 'balanced care' could meet all of the woman and child's medical needs, whilst also emphasising the normalcy of pregnancy.

The significance of breastfeeding to incarcerated pregnant women: an exploratory study

BACKGROUND

Breastfeeding rates of incarcerated women in the United States are unknown but are likely to be low. Little is known about the breastfeeding views and experiences of incarcerated women. This exploratory study examined the breastfeeding knowledge, beliefs, and experiences of pregnant women incarcerated in New York City jails.

METHODS

Semistructured interviews were conducted with 20 pregnant women in a New York City jail. Research methods were inspired by grounded theory.

RESULTS

Three main themes emerged from women's collective stories about wanting to breastfeed and the challenges that they experienced. First, incarceration removes women from their familiar social and cultural context, which creates uncertainty in their breastfeeding plans. Second, incarceration and the separation from their high-risk lifestyle makes women want a new start in motherhood. Third, being pregnant and planning to breastfeed represent a new start in motherhood and give women the opportunity to redefine their maternal identity and roles.

CONCLUSIONS

Breastfeeding is valued by incarcerated pregnant women and has the potential to contribute to their psychosocial well-being and self-worth as a mother. Understanding the breastfeeding experiences and views of women at high risk for poor pregnancy outcomes and inadequate newborn childcare during periods of incarceration in local jails is important for guiding breastfeeding promotion activities in this transient and vulnerable population. Implications from the findings will be useful to correctional facilities and community providers in planning more definitive studies in similar incarcerated populations. (BIRTH 39:2 June 2012).

What lies behind the wish to hasten death? A systematic review and meta-ethnography from the perspective of patients

Background

There is a need for an in-depth approach to the meaning of the wish to hasten death (WTHD). This study aims to understand the experience of patients with serious or incurable illness who express such a wish.

Methods and Findings

Systematic review and meta-ethnography of qualitative studies from the patient's perspective. Studies were identified through six databases (ISI, PubMed, PsycINFO, CINAHL, CUIDEN and the Cochrane Register of Controlled Trials), together with citation searches and consultation with experts. Finally, seven studies reporting the experiences of 155 patients were included. The seven-stage Noblit and Hare approach was applied, using reciprocal translation and line-of-argument synthesis. Six main themes emerged giving meaning to the WTHD: WTHD in response to physical/psychological/spiritual suffering, loss of self, fear of dying, the desire to live but not in this way, WTHD as a way of ending suffering, and WTHD as a kind of control over one's life (‘having an ace up one's sleeve just in case’). An explanatory model was developed which showed the WTHD to be a reactive phenomenon: a response to multidimensional suffering, rather than only one aspect of the despair that may accompany this suffering. According to this model the factors that lead to the emergence of WTHD are total suffering, loss of self and fear, which together produce an overwhelming emotional distress that generates the WTHD as a way out, i.e. to cease living in this way and to put an end to suffering while maintaining some control over the situation.

Conclusions

The expression of the WTHD in these patients is a response to overwhelming emotional distress and has different meanings, which do not necessarily imply a genuine wish to hasten one's death. These meanings, which have a causal relationship to the phenomenon, should be taken into account when drawing up care plans.

Clients' relational conceptions of conjoint couple and family therapy quality: a grounded formal theory

Based upon a qualitative metasynthesis of 49 articles centered on clients' experiences of their conjoint couple and family therapy, the investigators constructed a grounded formal theory of Clients' Relational Conceptions of Conjoint Couple and Family Therapy Quality. The theory suggests from pretherapy conceptions to posttherapy reflections, clients' perceptions of conjoint couple and family therapy quality appear to consist of clients' constructed meanings regarding a series of interrelated relationships between clients and their therapists and therapy environments, between clients and themselves, between clients and other family members, and between process and outcome both inside and outside therapy. Within and across these relationships, clients appear to focus on expectations, connections, balance, and change when evaluating the quality of their clinical experiences. Based upon this theory, the investigators recommend that researchers continue to explore this clinical phenomenon and that therapists regularly seek clients' conceptions of quality in therapy.

Reproductive attitudes and behaviors in people with sickle cell disease or sickle cell trait: a qualitative interpretive meta-synthesis

Sickle cell disease (SCD) is a serious and life threatening disorder. The literature on informed reproductive decisions among people with SCD is limited, suggesting that there is a lack of awareness about SCD and Sickle cell trait status (SCT) among high-risk populations. The purpose of this qualitative interpretive meta-synthesis (QIMS) is to examine the reproductive attitudes and behaviors in people with SCD or SCT to create effective genetic counseling programs to inform reproductive decision making. Three studies were included in the QIMS for a total sample of 79 participants. The majority of the sample was African American, ages 16 to 63. Other demographic characteristics of the study populations and data collection methods used in these studies varied. Seven themes on reproductive attitudes and behaviors among people with SCD or SCT emerged: lack of awareness or education about SCD and SCT; men who deny having SCT; attitudes toward learning one's SCT status; rationales for learning a partner's SCT status prior to commencing a relationship; valuing relationships over SCD risk; learning one's own and partner's SCT status; and the consequences of not asking about partners' SCT status. Implications for prevention programming involving improved education and awareness about the disease and reproduction are discussed.

Environmental factors that influence communication for patients with a communication disability in acute hospital stroke units: a qualitative metasynthesis

OBJECTIVE

To develop a taxonomy of the environmental factors that influence communication between patients with communication disabilities and their health care providers in hospital stroke units.

DATA SOURCES

We conducted a metasynthesis of 3 qualitative studies conducted by our research team on the environmental factors that influence communication between patients and health care providers in hospital stroke units.

STUDY SELECTION

These studies identified environmental factors which influence communication from the perspectives of 10 patients with communication disabilities, 10 health care providers, and by direct observation of 65 patients interacting with health care providers.

DATA EXTRACTION

The findings of each study formed the data for the metasynthesis.

DATA SYNTHESIS

The findings of the qualitative studies were analyzed and then synthesized using reciprocal translation. The environmental factors were grouped into 11 higher order categories and 2 overall themes. The themes were (1) health care providers (knowledge, skills, attitude, experience, characteristics) and (2) stroke unit structure and processes (patient opportunities to communicate, family, use of communication aids and equipment, opportunities to learn, policies and procedures, physical environment).

CONCLUSIONS

Acute stroke inpatients with communication disabilities need knowledgeable and skilled health care providers to communicate as effectively as possible. However, there are many environmental barriers and facilitators at the level of stroke unit structures and processes that also impact on the ability of health care providers to communicate with patients. Interventions to improve the communicative accessibility of stroke units need to focus on health care providers and on the processes that govern the unit.

A meta-study of qualitative research examining stressor appraisals and coping among adolescents in sport

The main aim of this study was to create an integrated theoretical perspective of the qualitative adolescent sport stressor appraisal and coping literature. A secondary aim was to critique theoretical and methodological issues in the extant literature. Following database searches, 20 studies were retained for analysis. Meta-data, meta-theory, and meta-method analyses were conducted followed by a final meta-synthesis of findings. Analyses produced four themes: contextual and dynamic stressor appraisals, contextual and dynamic coping, coping resources and processes of acquisition, and social networks as assets and liabilities. Findings highlight the need for precise use of theory in the study of coping. Finally, while several data collection methods have been used, there is scope for greater methodological diversity to advance our understanding of coping among adolescent athletes.

Towards a family-centered approach to HIV treatment and care for HIV-exposed children, their mothers and their families in poorly resourced settings

This article provides a summary of emerging psychosocial evidence relevant to the success of comprehensive family-centered approaches to HIV prevention, treatment, care and support programs in poorly resourced settings. This report synthesizes current evidence on maternal, paternal and family experiences of HIV prevention, diagnosis, treatment, adherence and disclosure, with special focus on HIV-infected mothers and HIV-exposed children. Taking a developmental approach, we explore the current challenges and opportunities towards a family-centered approach within the continuum of HIV treatment and care, beginning in pregnancy and following the course of childhood. The discussion is limited to early and middle childhood and excludes discussion of special issues emergent in adolescence, which would warrant discussion outside the scope of this article. Attention is drawn to the complexity of problems arising within the family context and the need for improvements in the integration of aspects of treatment, care and support. While this article focuses on examples from sub-Saharan Africa, the lessons learnt and future challenges outlined are applicable to most low- and middle-income countries, and to poorly resourced contexts in higher-income countries.

Family members' experiences of everyday life when a child is dependent on a ventilator: a metasynthesis study

Children using mechanical ventilation for survival represent a small, but growing, vulnerable population in society. The aim of this study was to describe the existing qualitative research that examined family members' experiences when a child is dependent on ventilator at home. A metasynthesis is an interpretative integration of qualitative research findings based on a systematic literature search. Twelve original research reports focusing on the life situation of ventilator- and technology-dependent children and their families published between 1998 and 2006 were selected as data. Themes from the metasynthesis included experiences of the ill child, siblings, and parents and the meaning of space and place. These findings provide an understanding of the family members' experiences when a child is dependent on a ventilator for survival. Recommendations for future research with this population of families include a greater focus on professional support systems and family strengths and the use of longitudinal research methods using observation and interviews.

Weighing distress: decision-making surrounding management of the pregnancy experience among HIV-infected Thai women

The researchers conducted this grounded theory study in order to describe the decision making surrounding management of the pregnancy experience of 38 pregnant, HIV-infected Thai women. Data were collected using in-depth interviews and an open-ended questionnaire, and they were analyzed using constant comparative analysis. We found that "weighing distress" was the core category of the decision-making process. The supporting categories were being ambivalent about continuing the pregnancy, exploring alternative options, and selecting the appropriate choice. Health care providers should encourage family members to participate and be involved in the women's decision-making processes.

A meta-synthesis of qualitative research into needs and experiences of significant others to critically ill or injured patients

AIMS AND OBJECTIVES

This study aimed to describe the significant others' experiences and needs when a person is critically ill or injured in an acute care setting.

BACKGROUND

Being a significant other to a hospitalised critically ill or injured patient is a heavily distressing life event. Addressing significant others' needs adequately has been shown to be essential to mitigate the psychological consequences of such distressing events.

DESIGN

A systematic review of qualitative research.

METHODS

Meta-ethnographic synthesis was used for analysis.

RESULTS

The key findings are described in five major themes: uncertainty and emotional 'roller coaster'; information--balancing hope and reality; to guard and to protect the loved one; alliance with caregivers--crucial support; and social network--support and disequilibrium.

CONCLUSIONS

The study can provide a broader understanding of the significant others' situation. They are facing an overwhelming and emotionally challenging situation and need to be seen and heard.

RELEVANCE TO CLINICAL PRACTICE

The results point towards the nurses' key position in handling the needs of the significant others. This kind of description might be helpful in taking on this delicate task and might also serve as a body of knowledge to influence clinical practice guidelines and nursing interventions in this field.

The essence of healing from sexual violence: a qualitative metasynthesis

A qualitative metasynthesis was conducted to identify the essence of healing from sexual violence, as described by adults who experienced it as children or as adults. Based on the findings of 51 reports, four domains of healing were identified: (a) managing memories, (b) relating to important others, (c) seeking safety, and (c) reevaluating self. The ways of healing within each domain reflected opposing responses. The dialectical process identified for each of the four domains include, respectively: (a) calling forth memories, (b) regulating relationships with others, (c) constructing an "as-safe-as-possible" lifeworld, and (d) restoring a sense of self. These complex processes resulted in a new reality for the participants that was based on a greater sense of agency and provided a more satisfying life course.

Experiencing cancer in old age: a qualitative systematic review

Our purpose in this study was to find, report, and interpret the results of qualitative studies which investigated the experiences of older people living with cancer. We conducted systematic literature searches, identified and extracted the findings from 11 studies, and analyzed them systematically. We interpreted the findings to suggest that living with cancer in old age is to live in a perpetual state of ambiguity. The experience is characterized by a sense of disintegration, diminished identity, suffering, and social retraction. These experiences are balanced by sources of comfort and strength found within the self and among diverse relationships. The results of our study illuminate the complex, multidimensional character of living with cancer in old age. They show that older people living with cancer are resilient as well as vulnerable. We argue for changes in attitudes and behavior that will enable health care professionals to foster older peoples' resilience.

Methodological issues and challenges in data collection and analysis of qualitative meta-synthesis

Qualitative meta-synthesis is an emerging method for synthesis of findings of qualitative studies. Based on a qualitative meta-synthesis study on the lived experiences of immigrant Asian nurses working in Western countries (Xu, 2007), this paper discusses several methodological issues and challenges encountered during the data collection and analysis processes and strategies used to resolve them. These issues and challenges include, but are not limited to: adequacy of qualifying studies and inclusion criteria; availability and accessibility of qualified studies; publication bias; quality versus quantity of primary studies; studies containing both quantitative and qualitative data; studies based on identical samples; separation of relevant data for analysis; and validity of synthesis findings. The strategies used (or desired) to resolve these issues and challenges were illustrated with exemplars from the published meta-synthesis study. This paper argues and concludes that: (a) the quality of qualified available studies is more essential for a qualitative meta-synthesis study and the quality versus quantity issue must be dealt with in context and perspective; (b) creativity and flexibility consistent with the principles and spirit of qualitative inquiry is required in resolving these issues; and (c) working within multiple constraints, the meta-synthesist frequently has to settle with less than ideal solutions during the research process in the real world.

Revisão sistemática de literatura e metassíntese qualitativa: considerações sobre sua aplicação na pesquisa em enfermagem

Trata-se de uma reflexão sobre a condução de metassíntese qualitativa, que aborda características da revisão bibliográfica sistemática, como uma tendência emergente da necessidade de reunir dados para a tomada de decisão em saúde, comparando as diversas modalidades de revisão, metanálise e metassíntese. Aborda também a pesquisa qualitativa, suas definições, variedade de disciplinas, métodos e peculiaridades, destacando a vasta produção em pesquisa qualitativa no âmbito da enfermagem, e a necessidade de dar visibilidade e impacto aos seus resultados, visando a sua aplicação na prática. Apresenta a definição de metassíntese qualitativa e suas características, discutindo aspectos relacionados à complexidade da metodologia e à sua condução prática. Conclui que a metassíntese qualitativa pode ser uma ferramenta a ser pesquisada no âmbito da Enfermagem, aperfeiçoando a metodologia e validando-a, através da inclusão da grande produção de pesquisa qualitativa com aspectos importantes do ofício de cuidar e ser cuidado.

Development and psychometric assessment of a multidimensional measure of internalized HIV stigma in a sample of HIV-positive adults

There is a need for a psychometrically sound measure of the stigma experienced by diverse persons living with HIV/AIDS (PLHA). The goal of this study was to develop and evaluate a multidimentional measure of internalized HIV stigma that captures stigma related to treatment and other aspects of the disease among sociodemographically diverse PLHA. We developed a 28-item measure of internalized HIV stigma composed of four scales based on previous qualitative work. Internal consistency reliability estimates in a sample of 202 PLHA was 0.93 for the overall measure, and exceeded 0.85 for three of the four stigma scales. Items discriminated well across scales, and correlations of the scales with shame, social support, and mental health supported construct validity. This measure should prove useful to investigators examining in the role of stigma in HIV treatment and health outcomes, and evaluating interventions designed to mitigate the impacts of stigma on PLHA.

Mothers' experiences of having a preterm infant in the neonatal care unit: a meta-synthesis

Neonatal nurses today are challenged not only to provide the best possible developmental care for a preterm infant but also to help the mother through an uncertain motherhood toward a feeling of being a real mother for her preterm baby. An increasing interest in mothers' experiences of having a preterm baby is seen. A meta-synthesis of 14 qualitative research studies on mothers' experiences of having a preterm baby in the neonatal intensive care unit, published from 2000 onward, was conducted. Noblit and Hare's methodological approach was used. The meta-synthesis revealed five metaphors that captured the mothers' experiences. These metaphors centered on reciprocal relationships that consisted of mother-baby relationship ("from their baby to my baby"), maternal development (a striving to be a real normal mother), the turbulent neonatal environment (from foreground to background), maternal caregiving and role reclaiming strategies (from silent vigilance to advocacy), and mother-nurse relationship (from continuously answering questions through chatting to sharing of knowledge). Implications of the meta-synthesis for neonatal nursing are addressed.

HIV-related stigma among people with HIV and their families: a qualitative analysis

We examined the interconnectedness of stigma experiences in families living with HIV, from the perspective of multiple family members. Semi-structured interviews were conducted with 33 families (33 parents with HIV, 27 children under age 18, 19 adult children, and 15 caregivers). Parents were drawn from the HIV Cost and Services Utilization Study, a representative sample of people in care for HIV in US. All of the families recounted experiences with stigma, including 100% of mothers, 88% of fathers, 52% of children, 79% of adult children, and 60% of caregivers. About 97% of families described discrimination fears, 79% of families experienced actual discrimination, and 10% of uninfected family members experienced stigma from association with the parent with HIV. Interpersonal discrimination seemed to stem from fears of contagion. Findings indicate a need for interventions to reduce HIV stigma in the general public and to help families cope with stigma.

Qualitative perspectives in translational research

The rapid uptake of qualitative approaches in translational research can be best understood in the context of recent innovations in health services research, as well as an overarching concern with improving the quality of health care. Qualitative approaches highlight the human dimension in health care by foregrounding the perceptions, experiences, and behaviors of both consumers and providers of care. As such, these methods are particularly useful for addressing the complex issues related to improving health care quality and implementing system change. This overview traces a brief history of the factors contributing to the recent and rapid growth of qualitative methods in health research in general and translational research in particular; describes the varieties of qualitative approaches employed in this research; and illustrates the utility of these approaches for variable identification, instrument development, description/explanation of patient/provider perceptions and behaviors, individual/organizational change, and theory refinement.

Parenting programmes: a systematic review and synthesis of qualitative research

BACKGROUND

Parenting programmes are at the heart of intervention strategies for parents of children with emotional and behaviour problems. Systematic reviews and meta-analyses of randomized controlled trials have indicated that such programmes can improve many aspects of family life. However, there is currently a dearth of information concerning what it is that makes parenting programmes meaningful and helpful to parents. The aim of this paper was to examine parents' experience and perceptions of parenting programmes using the meta-ethnographic method, in order to sensitize policymakers and practitioners to the key factors that parents perceive to be of value.

METHODS

Systematic searches of a number of electronic databases were undertaken using key search terms. Critical appraisal of included studies was conducted using standardized criteria, and the reports were synthesized using meta-ethnographic methods.

RESULTS

Six reports were purposefully selected and critically appraised independently by two reviewers. Two were excluded. Based on the remaining four papers, five key concepts were identified as important when planning and delivering parenting programmes. A lines-of-argument synthesis was developed which suggests that the acquisition of knowledge, skills and understanding, together with feelings of acceptance and support from other parents in the parenting group, enabled parents to regain control and feel more able to cope. This led to a reduction in feelings of guilt and social isolation, increased empathy with their children and confidence in dealing with their behaviour.

CONCLUSION

This evaluation provides an indication of the components that parents perceive to be necessary in the provision of parenting programmes, independent of the particular type of programme being provided. It may therefore aid policymakers in decisions about which programmes to provide.

Breast cancer diagnosis and its treatment affecting the self: a meta-synthesis

There has been a great deal of qualitative research conducted that has examined the impact of breast cancer on the Self, however, there has been little effort to analyze these findings from a meta-perspective. This study sought to fill this gap by conducting a meta-synthesis of the qualitative research on breast cancer and its treatments affecting the Self. Meta-method and meta-synthesis techniques were used to integrate findings across 30 qualitative research reports conducted between 1990 and 2003 with a total of 795 women, from several different countries.The fusions identified from this meta-synthesis revealed 4 aspects of the Self affected by the diagnosis of breast cancer and its treatment: awareness of their own mortality, living with an uncertain certainty, attachment validation, and redefinition of Self. These findings were validated through use of a comparison study. The women adapt to being a breast cancer patient; redefining their lives and their self. This study highlights the existential process that women of many cultures move through as they incorporate the meaning of breast cancer into their lives. Nurses who are aware of these processes are better able to link women with resources to help them in their adaptation to living with breast cancer.