Use of qualitative methods in published health services and management research: a 10-year review

Recommendations and quality criteria to improve the early diagnosis of primary biliary cholangitis

OBJECTIVE

The study aimed to establish recommendations and quality criteria to enhance the healthcare process of PBC.

PATIENTS AND METHODS

It was conducted using qualitative techniques, preceded by a literature review. A consensus conference involving five specialists in the field was held, followed by a Delphi process developed in two waves, in which 30 specialist physicians in family and community medicine, digestive system and internal medicine were invited to participate.

RESULTS

Seven recommendations and 15 sets of quality criteria, indicators and standards were obtained. Those with the highest consensus were «Know the impact on the patient's quality of life. Consider their point of view and agree on recommendations and care» and «Evaluate possible fibrosis at the time of diagnosis and during PBC follow-up, assessing the evolution of factors associated with poor disease prognosis: noninvasive fibrosis (elastography > 2.1 kPa/year), GGT, ALP and bilirubin annually», respectively.

CONCLUSIONS

The implementation of the consensus recommendations and criteria would provide better patient care. The need for multidisciplinary follow-up and an increased role of primary care is emphasized.

Using qualitative free-text data to investigate the lived experience of the COVID-19 pandemic for a large cohort of Australians with different multiple sclerosis related disability levels

BACKGROUND

No large-scale qualitative studies have investigated the lived experience of people living with multiple sclerosis (PwMS) during the pandemic according to their disability level. We used qualitative research methods to investigate the lived experience of a large cohort of Australians living with differing multiple sclerosis (MS)-related disability levels during the COVID-19 pandemic. We also provided useful contextualisation to existing quantitative work.

METHODS

This was a retrospective survey-based mixed-methods cohort study. A quality-of-life study was conducted within the Australian MS Longitudinal Study during the pandemic. Disability severity was calculated using the Patient Determined Disease Steps. Qualitative free-text data regarding COVID-19 impacts was collected/analysed for word frequency and also thematically (inductively/deductively using sophisticated grounded theory) using NVivo software. We also triangulated word frequency with emerging themes.

RESULTS

N=509 PwMS participated providing n=22 530 words of COVID-19-specific data. Disability severity could be calculated for n=501 PwMS. The word 'working' was important for PwMS with no disability, and 'support' and 'isolation' for higher disability levels. For PwMS with milder disability, thematic analysis established that multitasking increased stress levels, particularly if working from home (WFH) and home-schooling children. If not multitasking, WFH was beneficial for managing fatigue. PwMS with severe disability raised increased social isolation as a concern including prepandemic isolation.

CONCLUSIONS

We found negative impacts of multitasking and social isolation for PwMS during the pandemic. WFH was identified as beneficial for some. We recommend targeted resourcing decisions for PwMS in future pandemics including child-care relief and interventions to reduce social isolation and suggest that these could be incorporated into some form of advanced care planning. As the nature of work changes postpandemic, we also recommend a detailed investigation of WFH for PwMS including providing tailored employment assistance.

'Do we need doulas…?' - Perspectives of maternity care managers on the role of doulas in Poland

AIM

The purpose of this study was to analyse perinatal care managers' perspectives on the role of doulas in Poland and to consider how managers' perspectives might affect the opportunities for doulas to practice in individual hospitals.

DESIGN

This is a qualitative descriptive study.

METHOD

The total of 17 hospitals was selected for the study. Semi-structured interviews were conducted with 11 manager staff members.

RESULTS

Three groups of facilities were identified: '0' (n = 6) - refused to give interviews, 'A' (n = 8) - marginal experience in working with doulas, and 'B' (n = 3) - regular experience in working with doulas. The hospitals from Group A showed indifference towards working with doulas. Group B declared a positive attitude towards such cooperation. Attitudes towards doulas vary among executives and are related to the frequency of doula-assisted births. Our results indicate factors that may influence the attitude of medical staff towards doulas and which may contribute to improve future initiatives meant to facilitate collaboration between midwives and doulas.

PATIENT OR PUBLIC CONTRIBUTION

This study explored the lived experiences of perinatal care managers.

Knowledge, Attitude, and Practice of Qualitative Research Among Health Sciences Faculty

Background The importance of qualitative research in health sciences is rising. Qualitative research needs more attention from healthcare practitioners. Hence, some questions in the healthcare field may only be answered through qualitative research methodologies. In this study, we aimed to assess the knowledge, practice, and attitude among health sciences faculty about qualitative research. Methodology This cross-sectional study was conducted at King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS). A convenient sampling technique was used to collect data from health sciences faculty participants. Participants were included from five different colleges, i.e., College of Medicine, Applied Health Sciences, Nursing, Pharmacy, and College of Dentistry. A 20-question, self-made questionnaire was given to each participant. The questionnaire had five attitude questions, 10 knowledge questions, and five practice questions. Results A total of 236 participants completed the study questionnaire. The majority of the study participants (198, 84%) had an overall poor knowledge of qualitative research methodologies. Most participants (214, 91%) agreed that qualitative research is important in health sciences. More than half of the participants had never attended a qualitative methods workshop (140, 59%). About three-quarters of the participants (175, 74%) had never participated in a qualitative research project. Conclusions The overall knowledge and practice of qualitative research methodologies were poor among KSAU-HS health sciences faculty while they had a good attitude toward its importance in health sciences.

Understanding what changes adults in a smoking cessation study believe they need to make to quit smoking: A qualitative analysis of pre- and post-quit perceptions

OBJECTIVE

Most individuals who try to quit smoking will not succeed even if they use evidence-based treatment. Qualitative methods can help identify cessation treatments' limitations and suggest adaptations to increase treatment success.

METHOD

Rapid qualitative analysis was conducted on data from 125 adults who smoked daily (48% female; 44% White) and participated in a smoking cessation trial and completed qualitative interviews 2 weeks prequit, reporting on changes they needed to make to quit, and 100 adults (50% female; 49% White) who completed a second interview 2 weeks postquit, reporting changes they had made.

RESULTS

The anticipated changes reported prequit (in order of frequency) were as follows: identify smoking triggers (without a coping plan), focus on benefits of quitting, reduce exposure to others smoking, make other health changes, reduce exposure to nonsocial smoking cues, and reduce alcohol consumption. Many participants were unable to identify specific changes that would aid their cessation success. Changes reported postquit included the following: use the 4 D strategies (delay, drink water, deep breathing, distract), reduce exposure to nonsocial smoking cues, focus on benefits of quitting, change daily routine, make other health changes, reduce exposure to others smoking, and get support from loved ones. Most changes reported postquit were consistent with clinical practice guidelines; however, use of cessation medication was the least reported theme.

CONCLUSION

Prior to quitting, over a third of participants were unable to identify changes to increase cessation success. Those who could focus on triggers and cues for smoking. Postquit, participants reported using cessation strategies encouraged during study cessation counseling. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A systematic review of the qualitative literature on barriers to high-quality prenatal and postpartum care among low-income women

OBJECTIVE

To examine the qualitative literature on low-income women's perspectives on the barriers to high quality prenatal and postpartum care.

DATA SOURCES AND STUDY SETTING

We performed searches in PubMed, Web of Science, Embase, SocIndex, and CINAHL for peer-reviewed studies published between 1990 to 2021.

STUDY DESIGN

Systematic review of qualitative studies with participants who were currently pregnant or had delivered within the past two years and identified as low-income at delivery.

DATA COLLECTION / EXTRACTION METHODS

Two reviewers independently assessed studies for inclusion, evaluated study quality, and extracted information on study design and themes.

PRINCIPLE FINDINGS

We identified 34 studies that met inclusion criteria, including 23 focused on prenatal care, 6 on postpartum care, and 5 on both. The most frequently mentioned barriers to prenatal and postpartum care were structural. These included delays in gaining pregnancy-related Medicaid coverage, challenges finding providers who would accept Medicaid, lack of provider continuity, transportation and childcare hurdles, and legal system concerns. Individual-level factors, such as lack of awareness of pregnancy, denial of pregnancy, limited support, conflicting priorities, and indifference to pregnancy also interfered with timely use of prenatal and postpartum care. For those who accessed care, experiences of dismissal, discrimination, and disrespect related to race, insurance status, age, substance use, and language were common.

CONCLUSIONS

Over a period of 30 years, qualitative studies have identified consistent structural and individual barriers to high-quality prenatal and postpartum care. Medicaid policy changes including expanding presumptive eligibility, increased reimbursement rates for pregnancy services, payment for birth doula support, and extension of postpartum coverage may help overcome these challenges.

A Review on The Theories of Adoption Telemedicine in Middle Ease : Toward Building Iraqi Telemedicine

Telemedicine is the use of modern telecommunications and information technologies for the provision of clinical care to individuals at a distance, and transmission of information to provide that care. Recent advances in information technology and biomedicine increased significantly the technical feasibility, clinical feasibility and affordability enabled collaborative of telemedicine and medical service delivery. Health organizations around the world are becoming more interested in the acquisition and implementation the telemedicine technology to improve or expand existing services and patient care. The ultimate success of telemedicine in an organization requires the adoption of adequate care both technological and managerial issues. This study examined theadoption theories,the key management problem facing many health care organizations which interested in or currently evaluating telemedicine . this research models targeted the technology adoption and empirically evaluated in a study of the investigation involving more public health agencies and criticize the theories.Several research and management implications that emerged from the study results are discussed.

A systematic scoping review of published qualitative research pertaining to the field of perioperative anesthesiology

Purpose

Qualitative research (QR) take advantage of a wide range of methods and theoretical frameworks to explore people’s beliefs, perspectives, experiences, and behaviours and has been applied to many areas of healthcare. The aim of this review was to explore how QR has contributed to the field of perioperative anesthesiology.

Source

We performed a systematic scoping review of published QR studies pertaining to the field of perioperative anesthesiology in three databases (CINAHL, Pubmed, and Embase), published between January 2000 and June 2018. We extracted data regarding publication and researchers’ characteristics, main study objectives, and methodological details. Descriptive statistics were generated for each data extraction category.

Principal findings

A total of 107 articles fulfilled our inclusion criteria. We identified 13 main research topics addressed by the included studies. Topics such as “patient safety,” “barriers to evidence-base medicine,” “patient experiences under local/regional anesthesia,” “training in practice,” “experiences of care,” and “implementation of changes in clinical practice” were commonly tackled. Others, such as “interprofessional communication”, “work environment,” and “patients’/healthcare professionals’ interactions” were less common. Qualitative research was often poorly reported and methodological details were frequently missing.

Conclusion

Qualitative research has been used to explore an array of issues in perioperative anesthesiology. Some areas may benefit from further primary research, such as interprofessional communication or patient-centred care, while other areas may deserve a detailed systematic knowledge synthesis. We identified suboptimal reporting of qualitative methods and their link to study findings. Increased attention to quality criteria and reporting standards in QR is called for.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12630-021-02106-y.

Burnout and Leadership Style in Behavioral Health Care: a Literature Review

Burnout among behavioral health care providers and employees is associated with poor patient and provider outcomes. Leadership style has generally been identified as a means of reducing burnout, yet it is unclear whether some leadership styles are more effective than others at mitigating burnout. Additionally, behavioral health care is provided in a variety of contexts and a leadership style employed in one context may not be effective in another. The purpose of this paper was to review the literature on leadership style and burnout in behavioral health care contexts to identify the different leadership styles and contexts in which the relationship between the two constructs was studied. Studies were categorized based on the leadership style, study design, research methods, and study context. Findings of this review provide insights into potential approaches to prevent employee burnout and its attending costs, as well as ways to improve future research in this critical area.

Application of Mixed Methods in Health Services Management Research: A Systematic Review

Mixed methods research (MMR) is versatile, pragmatic, and adaptable to constraints and opportunities during a research process. Although MMR has gain popularity in health services management research, little is known about how the research approach has been used and the quality of research. We conducted a systematic review of 198 MMR articles published in selected U.S.-based and international health services management journals from 2000 through 2018 to examine the extent of MMR application and scientific rigor. Results showed limited, yet increasing, use of MMR and a high degree of correspondence between MMR designs and study purposes. However, most articles did not clearly justify using MMR designs and the reporting of method details and research integration were inadequate in a significant portion of publications. We propose a checklist to assist the preparation and review of MMR manuscripts. Additional implications and recommendations to improve transparency, rigor, and quality in MMR are discussed.

Ethnography and user-centered design to inform context-driven implementation

Despite pervasive findings pointing to its inextricable role in intervention implementation, context remains poorly understood in implementation science. Existing approaches for describing context (e.g., surveys, interviews) may be narrow in scope or superficial in their elicitation of contextual data. Thus, in-depth and multilevel approaches are needed to meaningfully describe the contexts into which interventions will be implemented. Moreover, many studies assess context without subsequently using contextual information to enhance implementation. To be useful for improving implementation, though, methods are needed to apply contextual information during implementation. In the case example presented in this paper, we embedded an ethnographic assessment of context within a user-centered design approach to describe implementation context and apply that information to promote implementation. We developed a patient-reported outcome measure-based clinical intervention to assess and address the pervasive unmet needs of young adults with cancer: the Needs Assessment & Service Bridge (NA-SB). In this paper, we describe the user-centered design process that we used to anticipate context modifications needed to deliver NA-SB and implementation strategies needed to facilitate its implementation. Our ethnographic contextual inquiry yielded a rich understanding of local implementation context and contextual variation across potential scale-up contexts. Other methods from user-centered design (i.e., translation tables and a design team prototyping workshop) allowed us to translate that information into specifications for NA-SB delivery and a plan for implementation. Embedding ethnographic methods within a user-centered design approach can help us to tailor interventions and implementation strategies to their contexts of use to promote implementation.

Application of Andersen's behavioural model of health services use: a scoping review with a focus on qualitative health services research

INTRODUCTION

Qualitative methods have become integral in health services research, and Andersen's behavioural model of health services use (BMHSU) is one of the most commonly employed models of health service utilisation. The model focuses on three core factors to explain healthcare utilisation: predisposing, enabling and need factors. A recent overview of the application of the BMHSU is lacking, particularly regarding its application in qualitative research. Therefore, we provide (1) a descriptive overview of the application of the BMHSU in health services research in general and (2) a qualitative synthesis on the (un)suitability of the model in qualitative health services research.

METHODS

We searched five databases from March to April 2019, and in April 2020. For inclusion, each study had to focus on individuals ≥18 years of age and to cite the BMHSU, a modified version of the model, or the three core factors that constitute the model, regardless of study design, or publication type. We used MS Excel to perform descriptive statistics, and applied MAXQDA 2020 as part of a qualitative content analysis.

RESULTS

From a total of 6319 results, we identified 1879 publications dealing with the BMSHU. The main methodological approach was quantitative (89%). More than half of the studies are based on the BMHSU from 1995. 77 studies employed a qualitative design, the BMHSU was applied to justify the theoretical background (62%), structure the data collection (40%) and perform data coding (78%). Various publications highlight the usefulness of the BMHSU for qualitative data, while others criticise the model for several reasons (eg, its lack of cultural or psychosocial factors).

CONCLUSIONS

The application of different and older models of healthcare utilisation hinders comparative health services research. Future research should consider quantitative or qualitative study designs and account for the most current and comprehensive model of the BMHSU.

Harmonizing evidence-based practice, implementation context, and implementation strategies with user-centered design: a case example in young adult cancer care

BACKGROUND

Attempting to implement evidence-based practices in contexts for which they are not well suited may compromise their fidelity and effectiveness or burden users (e.g., patients, providers, healthcare organizations) with elaborate strategies intended to force implementation. To improve the fit between evidence-based practices and contexts, implementation science experts have called for methods for adapting evidence-based practices and contexts and tailoring implementation strategies; yet, methods for considering the dynamic interplay among evidence-based practices, contexts, and implementation strategies remain lacking. We argue that harmonizing the three can be facilitated by user-centered design, an iterative and highly stakeholder-engaged set of principles and methods.

METHODS

This paper presents a case example in which we used a three-phase user-centered design process to design and plan to implement a care coordination intervention for young adults with cancer. Specifically, we used usability testing to redesign and augment an existing patient-reported outcome measure that served as the basis for our intervention to optimize its usability and usefulness, ethnographic contextual inquiry to prepare the context (i.e., a comprehensive cancer center) to promote receptivity to implementation, and iterative prototyping workshops with a multidisciplinary design team to design the care coordination intervention and anticipate implementation strategies needed to enhance contextual fit.

RESULTS

Our user-centered design process resulted in the Young Adult Needs Assessment and Service Bridge (NA-SB), including a patient-reported outcome measure and a collection of referral pathways that are triggered by the needs young adults report, as well as implementation guidance. By ensuring NA-SB directly responded to features of users and context, we designed NA-SB for implementation, potentially minimizing the strategies needed to address misalignment that may have otherwise existed. Furthermore, we designed NA-SB for scale-up; by engaging users from other cancer programs across the country to identify points of contextual variation which would require flexibility in delivery, we created a tool intended to accommodate diverse contexts.

CONCLUSIONS

User-centered design can help maximize usability and usefulness when designing evidence-based practices, preparing contexts, and informing implementation strategies-in effect, harmonizing evidence-based practices, contexts, and implementation strategies to promote implementation and effectiveness.

Context counts: a qualitative study exploring the interplay between context and implementation success

PURPOSE

Implementing change in healthcare is difficult to accomplish due to the unpredictability associated with challenging the status quo. Adapting the intervention/practice/program being implemented to better fit the complex context is an important aspect of implementation success. Despite the acknowledged influence of context, the concept continues to receive insufficient attention at the team-level within implementation research. Using two heterogeneous multidisciplinary healthcare teams as implementation case studies, this study evaluates the interplay between context and implementation and highlights the ways in which context influences the introduction of a collective leadership intervention in routine practice.

DESIGN/METHODOLOGY/APPROACH

The multiple case study design adopted, employed a triangulation of qualitative research methods which involved observation (Case A = 16 h, Case B = 15 h) and interview data (Case A = 13 participants, Case B = 12 participants). Using an inductive approach, an in-depth thematic analysis of the data outlined the relationship between team-level contextual factors and implementation success.

FINDINGS

Themes are presented under the headings: (1) adapting to the everyday realities, a key determinant for implementation success and (2) implementation stimulating change in context. The findings demonstrate a dynamic relationship between context and implementation. The challenges of engaging busy healthcare professionals emphasised that mapping the contextual complexity of a site and adapting implementation accordingly is essential to enhance the likelihood of successful implementation. However, implementation also altered the surrounding context, stimulating changes within both teams.

ORIGINALITY/VALUE

By exposing the reciprocal relationship between team-level contextual factors and implementation, this research supports the improved design of implementation strategies through better understanding the interplay and mutual evolution of evidence-based healthcare interventions within different contexts.

Pain Standards for Accredited Healthcare Organizations (ACDON Project): A Mixed Methods Study

Up to 50% of cancer patients and up to 90% of those in terminal stages experience pain associated with disease progression, poor quality of life, and social impact on caregivers. This study aimed to establish standards for the accreditation of oncological pain management in healthcare organizations. A mixed methods approach was used. First, a pragmatic literature review was conducted. Second, consensus between professionals and patients was reached using the Nominal Group and Delphi technique in a step that involved anesthesiologists, oncologists, family physicians, nurses, psychologists, patient representatives, and caregivers. Third, eight hospitals participated in a pilot assessment of the level of fulfillment of each standard. A total of 37 standards were extracted. The Nominal Group produced additional standards, of which 60 were included in Questionnaire 0 that was used in the Delphi Technique. Two Delphi voting rounds were performed to reach a high level of consensus, and involved 64 and 62 participants with response rates of 90% and 87%, respectively. Finally, 39 standards for the management of cancer pain were agreed upon. In the self-evaluation, the average range of compliance was between 56.4% and 100%. The consensus standards of the ACDON Project might improve the monitoring of cancer pain management. These standards satisfied the demands of professionals and patients and could be used for the accreditation of approaches in cancer pain management.

Cross-sectional analysis of bibliometrics and altmetrics: comparing the impact of qualitative and quantitative articles in the British Medical Journal

OBJECTIVES

In comparison to quantitative research, the impact of qualitative articles in the medical literature has been questioned by the BMJ; to explore this, we compared the impact of quantitative and qualitative articles published in BMJ.

DESIGN

Cross-sectional survey.

SETTING

Articles published in the BMJ between 2007 and 2017.

MAIN OUTCOME MEASURES

Bibliometric and altmetric measures of research impact were collected using Web of Science, Google Scholar, Scopus, Plum Analytics and ProQuest Altmetric. Bibliometric measures consisted of citation numbers, field weighted citation impact and citation percentile. Altmetric measures consisted of article usage, captures, mentions, readers, altmetric attention score and score percentile. Scores were compared using the Wilcoxon Rank-sum test.

RESULTS

We screened a total of 7777 articles and identified 42 qualitative articles. Each qualitative article was matched to 3 quantitative articles published during the same year (126 quantitative articles). Citation numbers were not statistically different between the two research types; the median number of citations (google scholar) per quantitative article was 62 (IQR 38-111) versus 58 (IQR 36-85) per qualitative article (p=0.47). Using Plum Analytics, qualitative articles were found to have a significantly higher usage, with a median of 984 (IQR 581-1351) versus 379 (IQR 177-763) for quantitative (p<0.001). The Altmetric Attention Score was higher for quantitative articles at 16 (IQR 7-37) versus qualitative articles at 9 (IQR 5-23, p=0.05), as was the Altmetric Score percentile 93 (IQR 87-96) versus 88 (IQR 76-95; p=0.02).

CONCLUSION

Qualitative and quantitative articles published in the BMJ between 2007 and 2017 both have a high impact. No article type was consistently superior in terms of bibliometric or altmetric measures, suggesting that type of article is not the major driver of impact.

Beyond exploratory: a tailored framework for designing and assessing qualitative health research

The objective of this commentary is to develop a framework for assessing the rigour of qualitative approaches that identifies and distinguishes between the diverse objectives of qualitative health research, guided by a narrative review of the published literature on qualitative guidelines and standards from peer-reviewed journals and national funding organisations that support health services research, patient-centered outcomes research and other applied health research fields. In this framework, we identify and distinguish three objectives of qualitative studies in applied health research: exploratory, descriptive and comparative. For each objective, we propose methodological standards that may be used to assess and improve rigour across all study phases-from design to reporting. Similar to hierarchies of quality of evidence within quantitative studies, we argue that standards for qualitative rigour differ, appropriately, for studies with different objectives and should be evaluated as such. Distinguishing between different objectives of qualitative health research improves the ability to appreciate variation in qualitative studies and to develop appropriate evaluations of the rigour and success of qualitative studies in meeting their stated objectives. Researchers, funders and journal editors should consider how further developing and adopting the framework for assessing qualitative rigour outlined here may advance the rigour and potential impact of this important mode of inquiry.

Challenges and facilitators for health practitioners and academics engaging in collaborative research and publication: A systematic review / Herausforderungen und Förderfaktoren für gemeinsame Forschung und wissenschaftliche Publikation von Angehörigen verschiedener Gesundheitsberufe aus Praxis und Forschung: ein systematischer Review

Introduction

While academics are frequently engaged in research activities and subsequent dissemination of results through publication, all too often they occur without health practitioner involvement. While there are contemporary expectations that health practitioners will be active contributors to their discipline’s body of knowledge, many find it difficult to prioritise research involvement given the demands of direct patient care. With this awareness as a central focus, we undertook a literature review to identify the challenges and facilitators that impact on health practitioners and academics working collaboratively on research and publishing their findings in peer-reviewed journals.

Methods

A configurative systematic review was performed with six electronic databases (Proquest, CINAHL, Medline, ScienceDirect, ERIC, SocINDEX) searched for studies from the disciplines of nursing, social work, allied health professions, health management, psychology and sociology. Manual searches were also undertaken to minimise the risk of missed studies. A rigorous search and retrieval process identified 20 relevant studies for inclusion in the review. The studies were first critically appraised then summarised. These steps were followed by thematic synthesis of the findings of the reviewed studies.

Results

Challenges and facilitators to health practitioners and academics working collaboratively on research activities were found to be related to the interplay between practitioners, academics, educational and health institutions and professional demands. The interplay of these factors emerged as complex.

Conclusion

Strategies have been recommended that may encourage active partnerships between institutions, health practitioners and academics enabling greater research collaborations and subsequent increased publication of their combined achievements.

A qualitative investigation of the health economic impacts of bariatric surgery for obesity and implications for improved practice in health economics

Obesity is an economic problem. Bariatric surgery is cost-effective for severe and resistant obesity. Most economic evaluations of bariatric surgery use administrative data and narrowly defined direct medical costs in their quantitative analyses. Demand far outstrips supply for bariatric surgery. Further allocation of health care resources to bariatric surgery (particularly public) could be stimulated by new health economic evidence that supports the provision of bariatric surgery. We postulated that qualitative research methods would elicit important health economic dimensions of bariatric surgery that would typically be omitted from the current economic evaluation framework, nor be reported and therefore not considered by policymakers with sufficient priority. We listened to patients: Focus group data were analysed thematically with software assistance. Key themes were identified inductively through a dialogue between the qualitative data and pre-existing economic theory (perspective, externalities, and emotional capital). We identified the concept of emotional capital where participants described life-changing desires to be productive and participate in their communities postoperatively. After self-funding bariatric surgery, some participants experienced financial distress. We recommend a mixed-methods approach to the economic evaluation of bariatric surgery. This could be operationalised in health economic model conceptualisation and construction, through to the separate reporting of qualitative results to supplement quantitative results.

Changes in Quality of Life Among Enrollees in Hennepin Health: A Medicaid Expansion ACO

Despite limited program evaluations of Medicaid accountable care organizations (ACOs), no studies have examined if cost-saving goals negatively affect quality of life and health care experiences of low-income enrollees. The Hennepin Health ACO uses an integrated care model to address the physical, behavioral, and social needs of Medicaid expansion enrollees. As part of a larger evaluation, we conducted semistructured interviews with 35 primary care using Hennepin Health members enrolled for 2 or more years. Using fuzzy set qualitative comparative analysis, we assessed enrollee complexity and use of the care model and improvements in quality of life. We found improved quality of life was consistently associated with strong bonds to primary care, consistent mental health care, and support from extended care team members. Comprehensive, integrated care models within ACOs may improve quality of life for low-income Medicaid enrollees through coordinated primary and mental health care.

Do not do in COPD: consensus statement on overuse

Background

To identify practices that do not add value, cause harm, or subject patients with chronic obstructive pulmonary disease (COPD) to a level of risk that outweighs possible benefits (overuse).

Methods

A qualitative approach was applied. First, a multidisciplinary group of healthcare professionals used the Metaplan technique to draft and rank a list of overused procedures as well as self-care practices in patients with stable and exacerbated COPD. Second, in successive consensus-building rounds, description files were created for each "do not do" (DND) recommendation, consisting of a definition, description, quality of supporting evidence for the recommendation, and the indicator used to measure the degree of overuse. The consensus group comprised 6 pulmonologists, 2 general practitioners, 1 nurse, and 1 physiotherapist.

Results

In total, 16 DND recommendations were made for patients with COPD: 6 for stable COPD, 6 for exacerbated COPD, and 4 concerning self-care.

Conclusion

Overuse poses a risk for patients and jeopardizes care quality. These 16 DND recommendations for COPD will lower care risks and improve disease management, facilitate communication between physicians and patients, and bolster patient ability to provide self-care.

Housing First and harm reduction: a rapid review and document analysis of the US and Canadian open-access literature

BACKGROUND

Housing First is an evidence-based practice intended to serve chronically homeless individuals with co-occurring serious mental illness and substance use disorders. Despite housing active substance users, harm reduction is an often-overlooked element during the Housing First implementation process in real-world settings. In this paper, we explore the representation of the Housing First model within the open-access scholarly literature as a potential contributing factor for this oversight.

METHODS

We conducted a rapid review of the US and Canadian open-access Housing First literature. We followed a document analysis approach, to form an interpretation of the articles' content related to our primary research questions.

RESULTS

A total of 55 articles on Housing First were included in the final analysis. Only 21 of these articles (38.1%) included explicit mention of harm reduction. Of the 34 articles that did not discuss harm reduction, 22 provided a description of the Housing First model indicating it does not require abstinence from substance use; however, descriptions did not all clearly indicate abstinence was not required beyond program entry. Additional Housing First descriptions focused on the low-barrier entry criteria and/or the intervention's client-centeredness.

CONCLUSIONS

Our review demonstrated a lack of both explicit mention and informed discussion of harm reduction in the Housing First literature, which is likely contributing to the Housing First research-practice gap to some degree. Future Housing First literature should accurately explain the role of harm reduction when discussing it in the context of Housing First programming, and public agencies promoting Housing First uptake should provide resources for proper implementation and monitor program fidelity to prevent model drift.

Aging and orthopedics: how a lifespan development model can inform practice and research

Orthopedic surgical care, like all health care today, is in flux owing to an aging population and to chronic medical conditions leading to an increased number of people with illnesses that need to be managed over the lifespan. The result is an ongoing shift from curing acute illnesses to the management and care of chronic illness and conditions. Theoretical models that provide a useful and feasible vision for the future of health care and health care research are needed. This review discusses how the lifespan development model used in some disciplines within the behavioural sciences can be seen as an extension of the biopsychosocial model. We posit that the lifespan development model provides useful perspectives for both orthopedic care and research. We present key concepts and recommendations, and we discuss how the lifespan development model can contribute to new and evolving perspectives on orthopedic outcomes and to new directions for research. We also offer practical guidelines on how to implement the model in orthopedic practice.

The Importance Of Integrating Narrative Into Health Care Decision Making

When making health care decisions, patients and consumers use data but also gather stories from family and friends. When advising patients, clinicians consult the medical evidence but also use professional judgment. These stories and judgments, as well as other forms of narrative, shape decision making but remain poorly understood. Furthermore, qualitative research methods to examine narrative are rarely included in health science research. We illustrate how narratives shape decision making and explain why it is difficult but necessary to integrate qualitative research on narrative into the health sciences. We draw on social-scientific insights on rigorous qualitative research and our ongoing studies of decision making by patients with cancer, and we describe new tools and approaches that link qualitative research findings with the predominantly quantitative health science scholarship. Finally, we highlight the benefits of more fully integrating qualitative research and narrative analysis into the medical evidence base and into evidence-based medical practice.

Disentangling the concept of "the complex older patient" in general practice: a qualitative study

BACKGROUND

The rising life expectancy in the developed world leads to an increase in the number of older patients and the complexity of their complaints in general practice. Although interventions and support for general practitioners are available, implementation lags. Knowledge on what determines a complex older patient, the problems of which general practitioners encounter and the situations they actually need support for, is necessary for better implementation.

METHODS

To provide support to general practitioners in their struggle with complex older patients, the aim of this research was to disentangle the concept of the complex older patient in general practice. A qualitative approach was used consisting of 15 semi-structured interviews with general practitioners. The general practitioner was asked to prepare a case of a complex older patient out of their own practice that could be discussed during the interview. Transcripts of the interview were analysed using inductive thematic analysis.

RESULTS

Analysis of the interviews resulted in twelve themes that could be categorised into five factors that contribute to the complexity of cases of older patients. The five factors are: not being in charge, different views on necessary care, encountering the boundaries of medicine, limits to providing social care, ill-equipped.

CONCLUSION

The factors that were found imply that a better organisational structure for elderly care and consulting elderly care physicians could support general practitioners in providing care for older complex patients. Furthermore, understanding the current concept of patient autonomy seems unjustified in cases of complex older patients.

How do doctors and nurses manage delirium in intensive care units? A qualitative study using focus groups

OBJECTIVES

The aim of this study was to explore the experiences of doctors and nurses caring for patients with delirium in the intensive care unit (ICU) and to describe the process of delirium management.

SETTING

This study was performed in 5 ICUs located within 4 hospitals in Madrid (Spain).

PARTICIPANTS

Purposeful sampling was performed which included (1) doctors and nurses working in ICUs, (2) with >1 year experience in the ICU and (3) clinical experience with delirium. 38 professionals participated (19 doctors, 19 nurses), including 22 women and 16 men. The total mean age was 39 years.

DESIGN

A qualitative study using focus groups.

METHODS

7 focus groups were held to collect data: 3 nurse focus groups, 3 doctor focus groups and 1 mixed focus group. Each group comprised 6-10 participants. A semistructured questions guide was used. Thematic analysis methods were used to analyse the data.

RESULTS

3 themes were identified: (1) the professional perspective on delirium; (2) implementing pharmacological and non-pharmacological treatment for delirium and (3) work organisation in the ICU. The professionals regarded patients with delirium with uncertainty, and felt they were often underdiagnosed and poorly managed. Doctors displayed discrepancies regarding pharmacological prescriptions and decision-making. The choice of medication was determined by experience. Nurses felt that, for many doctors, delirium was not considered a matter of urgency in the ICU. Nurses encountered difficulties when applying verbal restraint, managing sleep disorders and providing early mobilisation. The lack of a delirium protocol generates conflicts regarding what type of care management to apply, especially during the night shift. A degree of group pressure exists which, in turn, influences the decision-making process and patient care.

CONCLUSIONS

Patients with delirium represent complex cases, requiring the implementation of specific protocols. These results serve to improve the process of care in patients with delirium.

The perceptions of medical researchers on qualitative methodologies

We aimed to verify doctor's perception of the qualitative research method, via a qualitative study of interviews with questions on the academic profile of doctors and on the methodology. We interviewed 42 professionals, of which 18 had experience with the qualitative method and 24 with the quantitative method. The results showed that knowledge on the qualitative method was virtually nil among "quantitative researchers", who did not value qualitative research, although some of those realized that it would be important to be more accepting in clinical practice. Others only considered the method as subsidiary to quantitative. The majority considered qualitative methods as lacking academic structure, taking too long to conduct empirical studies, and being difficult to publish. All of them criticized the misuse of the method, and the "quantitatives" pointed out the problem of being unable to reproduce. We concluded that widening the use of the qualitative method by doctors requires investment from the beginning of the academic career and participation in qualitative research projects.

A Longitudinal Study of State Strategies and Policies to Accelerate Evidence-Based Practices in the Context of Systems Transformation

OBJECTIVE

To profile state agency efforts to promote implementation of three evidence-based practices (EBPs): screening and brief intervention (SBIRT), psychosocial interventions, and medication-assisted treatment (MAT).

DATA SOURCES/STUDY SETTING

Primary data collected from representatives of 50 states and the District of Columbia's Single State Authorities from 2007 to 2009.

STUDY DESIGN/DATA COLLECTION

The study used mixed methods, in-depth, semistructured interviews and quantitative surveys. Interviews assessed state and provider strategies to accelerate implementation of EBPs.

PRINCIPAL FINDINGS

Statewide implementation of psychosocial interventions and MAT increased significantly over 3 years. In the first two assessments, states that contracted directly with providers were more likely to link use of EBPs to reimbursement, and states with indirect contract, through counties and other entities, increased recommendations, and some requirements for provision of specific EBPs. The number of states using legislation as a policy lever to promote EBPs was unchanged.

CONCLUSIONS

Health care reform and implementation of parity in coverage increases access to treatment for alcohol and drug use. Science-based substance abuse treatment will become even more crucial as payers seek consistent quality of care. This study provides baseline data on service delivery, contracting, and financing as state agencies and treatment providers prepare for implementation of the Affordable Care Act.

The main characteristics of qualitative studies carried out by doctors in Brazil: a literature review

This paper explores the possibilities of the nutrition-sensitive agriculture approach in the context of the programs and actions towards promoting food and nutrition sovereignty and security in Brazil. To analyze the links between nutrition and agriculture, this paper presents the conceptual framework related to food and nutrition security, and stresses the correlations among concepts, institutional structures and program design in Brazil. Dominant models of food production and consumption are scrutinized in the light of these relationships. This paper also highlights differences amongst different ways to promote nutrition-sensitive agriculture through food-acquisition programs from family farmers, experiences in agro-ecology and bio-fortification programs. In the closing remarks, the paper draws some lessons learned from the Brazilian experience that highlight the advantages of family farming and rapid food production, distribution and consumption cycles in order to promote access to an affordable, diversified and more adequate diet in nutritional terms.

Notions of quality and standards for qualitative research reporting

The utility of qualitative research findings in the health sciences has been the subject of considerable debate, particularly with the advent of qualitative systematic reviews in recent years. There has been a significant investment in the production of guidance to improve the reporting of quantitative research; however, comparatively little time has been spent on developing the same for qualitative research reporting. This paper sets out to examine the possibility of developing a framework for refereed journals to utilize when guiding authors on how to report the results of qualitative studies in the hope that this will improve the quality of reports and subsequently their inclusion in qualitative syntheses and guidelines to inform practice at the point of care.

Navigating Care Transitions

As reforms push for improved integration across the care continuum, managers and policy makers are increasingly concerned about care transitions, such as during shift changes or when moving patients between units or institutions. The authors examined transitions from an emergency department to inpatient units through a 2-year ethnographic study of an academic medical center. Data include 48 semistructured interviews with doctors and administrators and 349 hr of observations of doctors. The authors show that organizational design poses challenges to doctors attempting between-unit care transitions, including heavy reliance on technology, separation of responsibility and control, and misalignment of routines and temporal rhythms. Each challenge threatened doctors’ awareness of the current state of other units and processes. To recover awareness, doctors engaged in time-consuming workarounds. Improved awareness will likely require a mix of interventions, including standardized protocols, work redesign, advanced information technologies specifically designed to enhance awareness, and high-reliability practices, such as safety organizing.

Barriers and facilitators to evidence-based blood pressure control in community practice

INTRODUCTION

The Electronic Communications and Home Blood Pressure Monitoring trial (e-BP) demonstrated that team care incorporating a pharmacist to manage hypertension using secure E-mail with patients resulted in almost twice the rate of blood pressure (BP) control compared with usual care. To translate e-BP into community practices, we sought to identify contextual barriers and facilitators to implementation.

METHODS

Interviews were conducted with medical providers, staff, pharmacists, and patients associated with community-based primary care clinics whose physician leaders had expressed interest in implementing e-BP. Transcripts were analyzed using qualitative template analysis, incorporating codes derived from the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Barriers included incorporating an unfamiliar pharmacist into the health care team, lack of information technology resources, and provider resistance to using a single BP management protocol. Facilitators included the intervention's perceived potential to improve quality of care, empower patients, and save staff time. Sustainability of the intervention emerged as an overarching theme.

CONCLUSION

A qualitative approach to planning for translation is recommended to gain an understanding of contexts and to collaborate to adapt interventions through iterative, bidirectional information gathering. Interviewees affirmed that web pharmacist care offers small primary care practices a means to expand their workforce and provide patient-centered care. Reproducing e-BP in these practices will be challenging, but our interviewees expressed eagerness to try and were optimistic that a tailored intervention could succeed.

Recognition as a patient-centered medical home: fundamental or incidental?

PURPOSE

Little is known about reasons why a medical group would seek recognition as a patient-centered medical home (PCMH). We examined the motivations for seeking recognition in one group and assessed why the group allowed recognition to lapse 3 years later.

METHODS

As part of a larger mixed methods case study, we conducted 38 key informant interviews with executives, clinicians, and front-line staff. Interviews were conducted according to a guide that evolved during the project and were audio-recorded and fully transcribed. Transcripts were analyzed and thematically coded.

RESULTS

PCMH principles were consistent with the organization's culture and mission, which valued innovation and putting patients first. Motivations for implementing specific PCMH components varied; some components were seen as part of the organization's patient-centered culture, whereas others helped the practice compete in its local market. Informants consistently reported that National Committee for Quality Assurance recognition arose incidentally because of a 1-time incentive from a local group of large employers and because the organization decided to allocate some organizational resources to respond to the complex reporting requirements for about one-half of its clinics.

CONCLUSIONS

Becoming patient centered and seeking recognition as such ran along separate but parallel tracks within this organization. As the Affordable Care Act continues to focus attention on primary care redesign, this apparent disconnect should be borne in mind.

A 'year in the life' of health services research in oncology

Oncology health services research (HSR) is a broad, multidimensional field. Current areas of research foci may be informative. We searched Medline for oncology HSR papers published in English in a single year (2009). Abstracted data related to access, quality, cost, health/wellbeing, place on the cancer continuum and study design. Among 1113 papers, the most commonly studied HSR domain was quality-of-care (65%). Within the care continuum, 'treatment' received the greatest attention (37%), and 'prevention' the least (5%). More specifically, treatment-related quality-of-care was most often studied (23%). Breast cancer was the most common site focus (28%). Most studies were descriptive (75%), retrospective (35%) or cross-sectional (35%). These findings might inform the decisions of researchers or policy makers seeking to improve cancer health services delivery.

Writing usable qualitative health research findings

Scholars in diverse health-related disciplines and specialty fields of practice routinely promote qualitative research as an essential component of intervention and implementation programs of research and of a comprehensive evidence base for practice. Remarkably little attention, however, has been paid to the most important element of qualitative studies--the findings in reports of those studies--and specifically to enhancing the accessibility and utilization value of these findings for diverse audiences of users. The findings in reports of qualitative health research are too often difficult to understand and even to find owing to the way they are presented. A basic strategy for enhancing the presentation of these findings is to translate them into thematic statements, which can then in turn be translated into the language of intervention and implementation. Writers of qualitative health research reports might consider these strategies better to showcase the significance and actionability of findings to a wider audience.

Why do some parents refuse consent for lumbar puncture on their child? A qualitative study

OBJECTIVE

Qualitative analysis of the attitudes, beliefs, and perceptions of parents who refuse consent for lumbar puncture (LP) on their child.

METHODS

We performed prospective, semistructured, face-to-face interviews with 24 families declining consent for LP in their child (aged between 1 month and 10 years of age), in 2 hospitals, over a 1-year period in the United Arab Emirates. The questionnaire included open-ended questions to allow parents to discuss their beliefs, concerns, and expectations. Content analysis of the transcripts was performed on how parents experienced the issue: their behavior, perceptions, and beliefs, as well as their opinions on what might have made them consent. Identified themes resulting from that analysis were labeled and coded before reducing them into categories and generating a Pareto chart.

RESULTS

Seven (29%) families were unfamiliar with LP indications and 3 had the impression that LP was also therapeutic. The emerged themes were fear of complications by 18 (75%), perception that LP was unnecessary by 5 (21%), and distrust of the motives behind the request for consent. Fear of paralysis and conviction that LP is unnecessary encompassed 80% of the causes for refusal. Eleven families (46%) stated that nothing would have made them consent, and 10 (42%) would agree only if the child looked unwell or deteriorated. CONCLUSIONS A better understanding of parents' perceptions, beliefs, and fears will help develop appropriate solutions to their refusal of LP consent.

"I'm satisfied … but": clients' and families' contingent responses about home care

Home care service organizations need a means of gaining useful feedback about satisfaction with care from clients and their families. Interviews were conducted with 82 older adult clients and 52 family members about their satisfaction with home care. A subgroup of participants (n = 39) provided "contingent" satisfaction responses. Contingent responses reflect the duality of perceptions that clients and families convey about services. Three themes emerged as critical to understanding these types of responses: adept versus inept staff, predictable versus precarious scheduling, and responsive versus restrictive care plans. Understanding the reasons for contingent responses could help home care agencies to target quality improvement initiatives for individual clients and families.

Young smokers' views of genetic susceptibility testing for lung cancer risk: minding unintended consequences

Assessment of smokers' responses to individualized feedback of genetic susceptibility has shown little or no influence on smoking cessation outcomes. One explanation is that smokers may be having unintended responses that undermine the feedback's motivational impact (e.g., fatalism or downplaying risk). In preparation for a large randomized trial with college smokers, we conducted a qualitative pilot study to explore smokers' motives for genetic testing and how these motives might influence interpretation of genetic risk feedback.Prior to reviewing informational materials describing a test for the glutathione S-transferase M1 gene, 33 college smokers (18 to 21 years) participated in a 30 minute, semi-structured, open-ended interview regarding their attitudes on health risks, genetic testing in general, genetic testing for lung cancer risk, and informational needs regarding genetics and genetic testing for lung cancer risk.Two central themes emerged from analysis of the interviews: general impressions of genetic testing and perceived value of genetic testing. Prominent in the second theme was the finding that genetic risk feedback may be unsuccessful in motivating quitting a) due to skepticism about genetic tests, b) participants dismissing genetic feedback as personally irrelevant, and c) participants receiving low risk results justifying continued smoking in light of public health messages that "it's never too late to quit". These findings require careful consideration among health professionals looking to genetic risk feedback as a vehicle to motivate disease prevention or behavior change.

Paucity of qualitative research in general medical and health services and policy research journals: analysis of publication rates

BACKGROUND

Qualitative research has the potential to inform and improve health care decisions but a study based on one year of publications suggests that it is not published in prominent health care journals. A more detailed, longitudinal analysis of its availability is needed. The purpose of this study was to identify, count and compare the number of qualitative and non-qualitative research studies published in high impact health care journals, and explore trends in these data over the last decade.

METHODS

A bibliometric approach was used to identify and quantify qualitative articles published in 20 top general medical and health services and policy research journals from 1999 to 2008. Eligible journals were selected based on performance in four different ranking systems reported in the 2008 ISI Journal Citation Reports. Qualitative and non-qualitative research published in these journals were identified by searching MEDLINE, and validated by hand-searching tables of contents for four journals.

RESULTS

The total number of qualitative research articles published during 1999 to 2008 in ten general medical journals ranged from 0 to 41, and in ten health services and policy research journals from 0 to 39. Over this period the percentage of empirical research articles that were qualitative ranged from 0% to 0.6% for the general medical journals, and 0% to 6.4% for the health services and policy research journals.

CONCLUSIONS

This analysis suggests that qualitative research it is rarely published in high impact general medical and health services and policy research journals. The factors that contribute to this persistent marginalization need to be better understood.

Qualitative methods in health services and management research: pockets of excellence and progress, but still a long way to go

The 10-year systematic review of published health services and management research by Weiner et al. (2011) chronicles the contributions of qualitative methods, highlights areas of substantial progress, and identifies areas in need of more progress. This article (Devers, 2011) discusses possible reasons for lack of progress in some areas--related to the under-supply of well-trained qualitative researchers and more tangible demand for their research--and mechanisms for future improvement. To ensure a robust health services research toolbox, the field must take additional steps to provide stronger education and training in qualitative methods and more funding and publication opportunities. Given the rapidly changing health care system post the passage of national health reform and the chalresearch issues associated with it, the health services research and management field will not meet its future challenges with quantitative methods alone or with a half-empty toolbox.