Qualitative Evidence Synthesis (QES) for Guidelines: Paper 2 - Using qualitative evidence synthesis findings to inform evidence-to-decision frameworks and recommendations

Mexican Clinical Practice Guidelines for Adult Overweight and Obesity Management

PURPOSE

To develop Mexico's first methodologically rigorous clinical practice guideline for the management of adult overweight and obesity. The target audiences are interdisciplinary healthcare professionals across healthcare systems who are the first point of contact for patients with obesity in Mexico, patients, and health system decision makers.

RECENT FINDINGS

A review of recent international obesity clinical practice guidelines and an expert consensus process identified: i) common recommendations appropriate for implementation in Mexico and ii) knowledge gaps requiring the formulation of new recommendations. In all, 20 new recommendations and 20 good practice statements were developed using the GRADE Evidence-to-Decision Framework and expert consensus. Overweight and obesity negatively impact the health and well-being of individuals and populations in Mexico. This guideline aims to establish a new evidence-based, patient-centered, non-stigmatizing, and practical treatment and management framework, based on the fundamental principles of chronic disease prevention and management.

Evaluating the impact of the global evidence, local adaptation (GELA) project for enhancing evidence-informed guideline recommendations for newborn and young child health in three African countries: a mixed-methods protocol

BACKGROUND

Poverty-related diseases (PRD) remain amongst the leading causes of death in children under-5 years in sub-Saharan Africa (SSA). Clinical practice guidelines (CPGs) based on the best available evidence are key to strengthening health systems and helping to enhance equitable health access for children under five. However, the CPG development process is complex and resource-intensive, with substantial scope for improving the process in SSA, which is the goal of the Global Evidence, Local Adaptation (GELA) project. The impact of research on PRD will be maximized through enhancing researchers and decision makers' capacity to use global research to develop locally relevant CPGs in the field of newborn and child health. The project will be implemented in three SSA countries, Malawi, South Africa and Nigeria, over a 3-year period. This research protocol is for the monitoring and evaluation work package of the project. The aim of this work package is to monitor the various GELA project activities and evaluate the influence these may have on evidence-informed decision-making and guideline adaptation capacities and processes. The specific project activities we will monitor include (1) our ongoing engagement with local stakeholders, (2) their capacity needs and development, (3) their understanding and use of evidence from reviews of qualitative research and, (4) their overall views and experiences of the project.

METHODS

We will use a longitudinal, mixed-methods study design, informed by an overarching project Theory of Change. A series of interconnected qualitative and quantitative data collections methods will be used, including knowledge translation tracking sheets and case studies, capacity assessment online surveys, user testing and in-depth interviews, and non-participant observations of project activities. Participants will comprise of project staff, members of the CPG panels and steering committees in Malawi, South Africa and Nigeria, as well as other local stakeholders in these three African countries.

DISCUSSION

Ongoing monitoring and evaluation will help ensure the relationship between researchers and stakeholders is supported from the project start. This can facilitate achievement of common goals and enable researchers in South Africa, Malawi and Nigeria to make adjustments to project activities to maximize stakeholder engagement and research utilization. Ethical approval has been provided by South African Medical Research Council Human Research Ethics Committee (EC015-7/2022); The College of Medicine Research and Ethics Committee, Malawi (P.07/22/3687); National Health Research Ethics Committee of Nigeria (01/01/2007).

The social lives of point-of-care tests in low- and middle-income countries: a meta-ethnography

Point-of-care tests (POCTs) have become technological solutions for many global health challenges. This meta-ethnography examines what has been learned about the 'social lives' of POCTs from in-depth qualitative research, highlighting key social considerations for policymakers, funders, developers and users in the design, development and deployment of POCTs. We screened qualitative research examining POCTs in low- and middle-income countries and selected 13 papers for synthesis. The findings illuminate five value-based logics-technological autonomy, care, scalability, rapidity and certainty-shaping global health innovation ecosystems and their entanglement with health systems. Our meta-ethnography suggests that POCTs never achieve the technological autonomy often anticipated during design and development processes. Instead, they are both embedded in and constitutive of the dynamic relationships that make up health systems in practice. POCTs are often imagined as caring commodities; however, in use, notions of care inscribed in these devices are constantly negotiated and transformed in relation to multiple understandings of care. POCTs promise to standardize care across scale, yet our analysis indicates nonstandard processes, diagnoses and treatment pathways as essential to 'fluid technologies' rather than dangerous aberrations. The rapidity of POCTs is constructed and negotiated within multiple distinct temporal registers, and POCTs operate as temporal objects that can either speed up or slow down experiences of diagnosis and innovation. Finally, while often valued as epistemic tools that can dispel diagnostic uncertainty, these papers demonstrate that POCTs contribute to new forms of uncertainty. Together, these papers point to knowledge practices as multiple, and POCTs as contributing to, rather than reducing, this multiplicity. The values embedded in POCTs are fluid and contested, with important implications for the kind of care these tools can deliver. These findings can contribute to more reflexive approaches to global health innovation, which take into account limitations of established global health logics, and recognize the socio-technical complexity of health systems.

Tools for assessing the methodological limitations of a QES-a short note

The increasing prevalence and application of qualitative evidence syntheses (QES) in decision-making processes underscore the need for robust tools to assess the methodological limitations of a completed QES. This commentary discusses the limitations of three existing tools and presents the authors' efforts to address this gap. Through a simple comparative analysis, the three tools are examined in terms of their coverage of essential topic areas. The examination finds that existing assessment tools lack comprehensive coverage, clarity, and grounding in qualitative research principles. The authors advocate for the development of a new collaboratively developed evidence-based tool rooted in qualitative methodology and best practice methods. The conclusion emphasizes the necessity of a tool that can provide a comprehensive judgement on the methodological limitations of a QES, addressing the needs of end-users, and ultimately enhancing the trustworthiness of QES findings in decision-making processes.

Use of qualitative research in World Health Organisation guidelines: a document analysis

BACKGROUND

Guidelines depend on effect estimates, usually derived from randomised controlled trials, to inform their decisions. Qualitative research evidence may improve decisions made but where in the process and the methods to do this have not been so clearly established. We sought to describe and appraise how qualitative research has been used to inform World Heath Organization guidance since 2020.

METHODS

We conducted a document analysis of WHO guidelines from 2020 to 2022. We purposely sampled guidelines on the topics of maternal and newborn health (MANH) and infectious diseases, as most of the qualitative synthesis to date has been conducted on these topics, likely representing the 'best case' scenario. We searched the in-built repository feature of the WHO website and used standardised search terms to identify qualitative reporting. Using deductive frameworks, we described how qualitative evidence was used to inform guidelines and appraised the standards of this use.

RESULTS

Of the 29 guidelines, over half used qualitative research to help guide decisions (18/29). A total of 8 of these used qualitative research to inform the guideline scope, all 18 to inform recommendations, and 1 to inform implementation considerations. All guidelines drew on qualitative evidence syntheses (QES), and five further supplemented this with primary qualitative research. Qualitative findings reported in guidelines were typically descriptive, identifying people's perception of the benefits and harms of interventions or logistical barriers and facilitators to programme success. No guideline provided transparent reporting of how qualitative research was interpreted and weighed used alongside other evidence when informing decisions, and only one guideline reported the inclusion of qualitative methods experts on the panel. Only a few guidelines contextualised their recommendations by indicating which populations and settings qualitative findings could be applied.

CONCLUSIONS

Qualitative research frequently informed WHO guideline decisions particularly in the field of MANH. However, the process often lacked transparency. We identified unmet potential in informing implementation considerations and contextualisation of the recommendations. Use in these areas needs further methods development.

Community views on active case finding for tuberculosis in low- and middle-income countries: a qualitative evidence synthesis

BACKGROUND

Active case finding (ACF) refers to the systematic identification of people with tuberculosis in communities and amongst populations who do not present to health facilities, through approaches such as door-to-door screening or contact tracing. ACF may improve access to tuberculosis diagnosis and treatment for the poor and for people remote from diagnostic and treatment facilities. As a result, ACF may also reduce onward transmission. However, there is a need to understand how these programmes are experienced by communities in order to design appropriate services.

OBJECTIVES

To synthesize community views on tuberculosis active case finding (ACF) programmes in low- and middle-income countries.

SEARCH METHODS

We searched MEDLINE, Embase, and eight other databases up to 22 June 2023, together with reference checking, citation searching, and contact with study authors to identify additional studies. We did not include grey literature.

SELECTION CRITERIA

This review synthesized qualitative research and mixed-methods studies with separate qualitative data. Eligible studies explored community experiences, perceptions, or attitudes towards ACF programmes for tuberculosis in any endemic low- or middle-income country, with no time restrictions.

DATA COLLECTION AND ANALYSIS

Due to the large volume of studies identified, we chose to sample studies that had 'thick' description and that investigated key subgroups of children and refugees. We followed standard Cochrane methods for study description and appraisal of methodological limitations. We conducted thematic synthesis and developed codes inductively using ATLAS.ti software. We examined codes for underlying ideas, connections, and interpretations and, from this, generated analytical themes. We assessed the confidence in the findings using the GRADE-CERQual approach, and produced a conceptual model to display how the different findings interact.

MAIN RESULTS

We included 45 studies in this synthesis, and sampled 20. The studies covered a broad range of World Health Organization (WHO) regions (Africa, South-East Asia, Eastern Mediterranean, and the Americas) and explored the views and experiences of community members, community health workers, and clinical staff in low- and middle-income countries endemic for tuberculosis. The following five themes emerged. • ACF improves access to diagnosis for many, but does little to help communities on the edge. Tuberculosis ACF and contact tracing improve access to health services for people with worse health and fewer resources (High confidence). ACF helps to find this population, exposed to deprived living conditions, but is not sensitive to additional dimensions of their plight (High confidence) and out-of-pocket costs necessary to continue care (High confidence). Finally, migration and difficult geography further reduce communities' access to ACF (High confidence). • People are afraid of diagnosis and its impact. Some community members find screening frightening. It exposes them to discrimination along distinct pathways (isolation from their families and wider community, lost employment and housing). HIV stigma compounds tuberculosis stigma and heightens vulnerability to discrimination along these same pathways (High confidence). Consequently, community members may refuse to participate in screening, contact tracing, and treatment (High confidence). In addition, people with tuberculosis reported their emotional turmoil upon diagnosis, as they anticipated intense treatment regimens and the prospect of living with a serious illness (High confidence). • Screening is undermined by weak health infrastructure. In many settings, a lack of resources results in weak services in competition with other disease control programmes (Moderate confidence). In this context of low investment, people face repeated tests and clinic visits, wasted time, and fraught social interaction with health providers (Moderate confidence). ACF can create expectations for follow-up health care that it cannot deliver (High confidence). Finally, community education improves awareness of tuberculosis in some settings, but lack of full information impacts community members, parents, and health workers, and sometimes leads to harm for children (High confidence). • Health workers are an undervalued but important part of ACF. ACF can feel difficult for health workers in the context of a poorly resourced health system and with people who may not wish to be identified. In addition, the evidence suggests health workers are poorly protected against tuberculosis and fear they or their families might become infected (Moderate confidence). However, they appear to be central to programme success, as the humanity they offer often acts as a driving force for retaining people with tuberculosis in care (Moderate confidence). • Local leadership is necessary but not sufficient for ensuring appropriate programmes. Local leadership creates an intrinsic motivation for communities to value health services (High confidence). However, local leadership cannot guarantee the success of ACF and contact tracing programmes. It is important to balance professional authority with local knowledge and rapport (High confidence).

AUTHORS' CONCLUSIONS

Tuberculosis active case finding (ACF) and contact tracing bring a diagnostic service to people who may otherwise not receive it, such as those who are well or without symptoms and those who are sick but who have fewer resources and live further from health facilities. However, capturing these 'missing cases' may in itself be insufficient without appropriate health system strengthening to retain people in care. People who receive a tuberculosis diagnosis must contend with a complex and unsustainable cascade of care, and this affects their perception of ACF and their decision to engage with it.

Assessing unConventional Evidence (ACE) tool: development and content of a tool to assess the strengths and limitations of 'unconventional' source materials

BACKGROUND

When deciding whether to implement an intervention, decision-makers typically have questions on feasibility and acceptability and on factors affecting implementation. Descriptions of programme implementation and of policies and systems are rich sources of information for these questions. However, this information is often not based on empirical data collected using explicit methods. To use the information in unconventional source materials in syntheses or other decision support products, we need methods of assessing their strengths and limitations. This paper describes the development and content of the Assessing unConventional Evidence (ACE) tool, a new tool to assess the strengths and limitations of these sources.

METHODS

We developed the ACE tool in four stages: first, we examined existing tools to identify potentially relevant assessment criteria. Second, we drew on these criteria and team discussions to create a first draft of the tool. Third, we obtained feedback on the draft from potential users and methodologists, and through piloting the tool in evidence syntheses. Finally, we used this feedback to iteratively refine the assessment criteria and to improve our guidance for undertaking the assessment.

RESULTS

The tool is made up of 11 criteria including the purpose and context of the source; the completeness of the information presented; and the extent to which evidence is provided to support the findings made. Users are asked to indicate whether each of the criteria have been addressed. On the basis of their judgements for each criterion, users then make an overall assessment of the limitations of the source, ranging from no or very minor concerns to serious concerns. These assessments can then facilitate appropriate use of the evidence in decision support products.

CONCLUSIONS

Through focussing on unconventional source materials, the ACE tool fills an important gap in the range of tools for assessing the strengths and limitations of policy-relevant evidence and supporting evidence-informed decision-making.

Rapid molecular tests for tuberculosis and tuberculosis drug resistance: a qualitative evidence synthesis of recipient and provider views

BACKGROUND

Programmes that introduce rapid molecular tests for tuberculosis and tuberculosis drug resistance aim to bring tests closer to the community, and thereby cut delay in diagnosis, ensure early treatment, and improve health outcomes, as well as overcome problems with poor laboratory infrastructure and inadequately trained personnel. Yet, diagnostic technologies only have an impact if they are put to use in a correct and timely manner. Views of the intended beneficiaries are important in uptake of diagnostics, and their effective use also depends on those implementing testing programmes, including providers, laboratory professionals, and staff in health ministries. Otherwise, there is a risk these technologies will not fit their intended use and setting, cannot be made to work and scale up, and are not used by, or not accessible to, those in need.

OBJECTIVES

To synthesize end-user and professional user perspectives and experiences with low-complexity nucleic acid amplification tests (NAATs) for detection of tuberculosis and tuberculosis drug resistance; and to identify implications for effective implementation and health equity.

SEARCH METHODS

We searched MEDLINE, Embase, CINAHL, PsycInfo and Science Citation Index Expanded databases for eligible studies from 1 January 2007 up to 20 October 2021. We limited all searches to 2007 onward because the development of Xpert MTB/RIF, the first rapid molecular test in this review, was completed in 2009.

SELECTION CRITERIA

We included studies that used qualitative methods for data collection and analysis, and were focused on perspectives and experiences of users and potential users of low-complexity NAATs to diagnose tuberculosis and drug-resistant tuberculosis. NAATs included Xpert MTB/RIF, Xpert MTB/RIF Ultra, Xpert MTB/XDR, and the Truenat assays. Users were people with presumptive or confirmed tuberculosis and drug-resistant tuberculosis (including multidrug-resistant (MDR-TB)) and their caregivers, healthcare providers, laboratory technicians and managers, and programme officers and staff; and were from any type of health facility and setting globally. MDR-TB is tuberculosis caused by resistance to at least rifampicin and isoniazid, the two most effective first-line drugs used to treat tuberculosis.

DATA COLLECTION AND ANALYSIS

We used a thematic analysis approach for data extraction and synthesis, and assessed confidence in the findings using GRADE CERQual approach. We developed a conceptual framework to illustrate how the findings relate.

MAIN RESULTS

We found 32 studies. All studies were conducted in low- and middle-income countries. Twenty-seven studies were conducted in high-tuberculosis burden countries and 21 studies in high-MDR-TB burden countries. Only one study was from an Eastern European country. While the studies covered a diverse use of low-complexity NAATs, in only a minority of studies was it used as the initial diagnostic test for all people with presumptive tuberculosis. We identified 18 review findings and grouped them into three overarching categories. Critical aspects users value People with tuberculosis valued reaching diagnostic closure with an accurate diagnosis, avoiding diagnostic delays, and keeping diagnostic-associated cost low. Similarly, healthcare providers valued aspects of accuracy and the resulting confidence in low-complexity NAAT results, rapid turnaround times, and keeping cost to people seeking a diagnosis low. In addition, providers valued diversity of sample types (for example, gastric aspirate specimens and stool in children) and drug resistance information. Laboratory professionals appreciated the improved ease of use, ergonomics, and biosafety of low-complexity NAATs compared to sputum microscopy, and increased staff satisfaction. Challenges reported to realizing those values People with tuberculosis and healthcare workers were reluctant to test for tuberculosis (including MDR-TB) due to fears, stigma, or cost concerns. Thus, low-complexity NAAT testing is not implemented with sufficient support or discretion to overcome barriers that are common to other approaches to testing for tuberculosis. Delays were reported at many steps of the diagnostic pathway owing to poor sample quality; difficulties with transporting specimens; lack of sufficient resources; maintenance of low-complexity NAATs; increased workload; inefficient work and patient flows; over-reliance on low-complexity NAAT results in lieu of clinical judgement; and lack of data-driven and inclusive implementation processes. These challenges were reported to lead to underutilization.  Concerns for access and equity The reported concerns included sustainable funding and maintenance and equitable use of resources to access low-complexity NAATs, as well as conflicts of interest between donors and people implementing the tests. Also, lengthy diagnostic delays, underutilization of low-complexity NAATs, lack of tuberculosis diagnostic facilities in the community, and too many eligibility restrictions hampered access to prompt and accurate testing and treatment. This was particularly the case for vulnerable groups, such as children, people with MDR-TB, or people with limited ability to pay. We had high confidence in most of our findings.

AUTHORS' CONCLUSIONS

Low-complexity diagnostics have been presented as a solution to overcome deficiencies in laboratory infrastructure and lack of skilled professionals. This review indicates this is misleading. The lack of infrastructure and human resources undermine the added value new diagnostics of low complexity have for recipients and providers. We had high confidence in the evidence contributing to these review findings. Implementation of new diagnostic technologies, like those considered in this review, will need to tackle the challenges identified in this review including weak infrastructure and systems, and insufficient data on ground level realities prior and during implementation, as well as problems of conflicts of interest in order to ensure equitable use of resources.

Qualitative evidence syntheses of attitudes and preferences to inform guidelines on infant feeding in the context of Ebola Virus Disease (EVD) transmission risk

Background

Breast-feeding holds considerable potential to reduce infant mortality. Feeding choices, already complex, take on additional complexity against a backdrop of the risk of transmissible Ebola Virus. This review describes the factors that influence infant feeding and attitudes of pregnant women, mothers, family members and health practitioners, policy makers and providers (midwives) concerning infant feeding when there is a risk of Mother-to-Child (MTC) transmission of Ebola Virus Disease (EVD).

Methodology

A systematic review of qualitative studies identified through rigorous searches of thirteen online databases and additional citation searches of included studies was undertaken. Search terms included breast-feeding, breast-feeding, infant feeding; Ebola; and qualitative, interview(s) and findings. Independent extraction of data by two reviewers using predefined extraction forms. Studies were assessed using the CASP Qualitative checklist.

Principal findings

5219 references were screened. 38 references related specifically to Ebola, and five papers met the inclusion criteria with data gathered from two settings: Guinea and Sierra Leone. The EVD outbreak had a significant impact on beliefs, attitudes, and resources to support infant feeding practices negatively affecting the nutritional status of children. The evidence from these studies highlight the need for guidance and appropriate psychosocial support need to be available to mothers who display symptoms and become infected and to front-line staff who are giving advice. Communities need to be engaged because stigma and fear may hinder uptake of appropriate interventions. The EVD outbreak caused multi-level system disruption akin to that seen following a natural disaster, meaning that logistics and coordination are critical and need adequate resourcing. Food production and distribution, and malnutrition screening are also disrupted and thereby compounding compromised nutritional status. The limited number of relevant studies highlights the need for further primary research, particularly in translation of messages to local settings.

Conclusions

An EVD outbreak causes multi-level disruption that negatively impacts infant feeding and child care practices. Negative impacts have multiple causes and successful planning for Ebola outbreaks requires that nutrition of infants and young children is a priority. Lessons from the Ebola pandemic have wider applicability to other pandemic contexts including Covid-19.

An Ebola outbreak has been likened to a natural disaster in its devastating impact on child health and nutritional status. The ease of transmission of a disease with a 50% mortality rate for those once infected raises particular challenges for breast-feeding women. This systematic review explored the attitudes and preferences of pregnant women, mothers, family members, health practitioners and policy makers concerning infant feeding during an Ebola epidemic as documented in qualitative studies. Participants reported confusion and inconsistent guidance regarding breast-feeding practice, together with difficulties in conveying recommendations to separate mothers infected with Ebola from their breast-feeding infants. Disruption impacted on access to supplementary and complementary feeds, health systems monitoring child growth and support to child health. Widespread distrust and suspicion of health professionals hindered health care provision. Wider family assumed roles in feeding and caring for young children, within the context of reduced access to nutritious foods and supplementary feeds. The work of humanitarian agencies, while valuable, lacked coordination. Planning for an Ebola outbreak requires advance preparation of health messaging for mothers and caregivers, coordinated provision of complementary feeds and support for families who assume caring responsibilities. Strategies to ensure linked up working between government and humanitarian agencies are essential.

Perspectives into the experience of successful, substantial long-term weight-loss maintenance: a systematic review

Purpose: In light of the increasing prevalence of overweight and obesity, understanding the experiences, strategies and challenges encountered when trying to achieve substantial, sustainable weight loss is an important area to investigate. We systematically evaluated qualitative studies focusing on the accounts of individuals who have achieved sustained weight loss to create a comprehensive picture of the experience of sustainable weight loss.

Methods: Included studies were peer-reviewed studies that qualitatively assessed the views and experiences of adults who previously had or currently have overweight or obesity who successfully lost weight and who subsequently maintained or regained weight. The evidence was systematically synthesized, which enabled the formulation of clear themes and recommendations.

Results: The 15 chosen studies included the accounts of 294 individuals. We found that continuous monitoring and goal setting, driven by sustained motivation and encouraging experiences, while resisting ever present challenges and enduring discouraging experience encapsulates the experience of sustained, substantial weight loss.

Conclusions: This review aims to provide a comprehensive understanding of the experiences, strategies and challenges encountered when trying to achieve substantial, sustained weight loss. Additional research taking into account findings from this review and others of its kind will enhance the formulation of treatment protocols.

Patients' experiences of delirium: A systematic review and meta-summary of qualitative research

AIMS

The purpose of this systematic review and meta-summary was the aggregation of the empirical qualitative literature on patients' experiences of delirium in order to support the development and implementation of patient-oriented delirium management and to guide future research.

DESIGN

We conducted a systematic literature review of qualitative research published between January 1980 and June 2019.

DATA SOURCES

In June 2019, we searched in Medline, CINAHL, SSCI and PsycInfo to identify relevant reports. In addition, we conducted searches in three dissertation databases (BASE, DART and ProQuest) and Google Scholar.

REVIEW METHODS

We used methods developed by Sandelowski and Barroso to construct a meta-summary of the findings by extracting them from the reports, abstracting them into meta- findings and calculating their manifest interstudy frequency effect sizes.

RESULTS

Out of the 742 identified records, 24 reports based on delirium experience accounts of 483 patients met our criteria and were included. One thousand ninety-seven findings were extracted from these reports and abstracted into 92 meta-findings. These were grouped to the five emerging themes 'perception', 'emotions', 'interaction with others', 'dealing with delirium' and 'influence on further life'.

CONCLUSION

Delirium is commonly perceived as an overall distressing condition, which can accompany and influence patients even after hospital discharge.

IMPACT

This systematic review and meta-summary is the most comprehensive aggregation of qualitative research of the patient delirium experience to date. It allows us to better understand, extract meaning from, and weigh the qualitative findings in their context by calculating their manifest frequency effect sizes. This can be used to support the development and implementation of delirium management concepts.

Systematic review of the methodological literature for integrating qualitative evidence syntheses into health guideline development

Guidelines produced by local, national and international bodies underpin clinical practice and healthcare services worldwide. For guidelines to be based on the best available evidence, it is critical that syntheses of both qualitative and quantitative evidence are used to inform decision-making. As methods for qualitative evidence syntheses (QES) develop, they are increasingly able to inform health guideline production. However, the process whereby this form of evidence is considered and incorporated tends to be unclear. This systematic review synthesized existing guidance concerning the use of QES in guideline development. Sources published in English that described or prescribed methods for incorporating QES into evidence-based health guidelines were eligible for inclusion. Seventeen relevant papers were identified. The literature indicates that there is a reasonable consensus about many stages of conducting a QES to inform guideline development. Areas needing further exploration include: the way that committees engage with QES; the usefulness of different QES methodologies; and understanding of how expert committees use evidence. Methods for producing QES for guideline committees tend to be similar to quantitative systematic review methods in terms of searching, quality appraisal, systematic management of data, and presentation of results. While this allows transparency and accountability, it could be argued that it is less "true" to the principles of being led by the data, which are fundamental to most qualitative research. Understanding the process of using QES to produce guidelines is critical to determining their validity and applicability, and to ensure that healthcare provision is based on the best available evidence.

Patients' attitudes and experiences of transition from paediatric to adult healthcare in rheumatology: a qualitative systematic review

OBJECTIVES

We aimed to describe patients' attitudes and experiences of transition from paediatric to adult healthcare in rheumatology to inform patient-centred transitional care programmes.

METHODS

We searched MEDLINE, EMBASE, PsycINFO and CINAHL to August 2019 and used thematic synthesis to analyse the findings.

RESULTS

From 26 studies involving 451 people with juvenile-onset rheumatic conditions we identified six themes: a sense of belonging (comfort in familiarity, connectedness in shared experiences, reassurance in being with others of a similar age, desire for normality and acceptance); preparedness for sudden changes (confidence through guided introductions to the adult environment, rapport from continuity of care, security in a reliable point of contact, minimizing lifestyle disruptions); abandonment and fear of the unknown (abrupt and forced independence, ill-equipped to hand over medical information, shocked by meeting adults with visible damage and disability, vulnerability in the loss of privacy); anonymous and dismissed in adult care (deprived of human focus, sterile and uninviting environment, disregard of debilitating pain and fatigue); quest for autonomy (controlled and patronized in the paediatric environment, liberated from the authority of others, freedom to communicate openly); and tensions in parental involvement (overshadowed by parental presence, guilt of excluding parents, reluctant withdrawal of parental support).

CONCLUSION

Young people feel dismissed, abandoned, ill-prepared and out of control during transition. However, successful transition can be supported by preparing for changes, creating a sense of belonging and negotiating parental involvement and autonomy. Incorporating patient-identified priorities into transitional services may improve satisfaction and outcomes in young people with juvenile-onset rheumatic conditions.

Qualitative Evidence Synthesis (QES) for Guidelines: Paper 3 - Using qualitative evidence syntheses to develop implementation considerations and inform implementation processes

BACKGROUND

This is the third in a series of three papers describing the use of qualitative evidence syntheses (QES) to inform the development of clinical and health systems guidelines. WHO has recognised the need to improve its guideline methodology to ensure that decision-making processes are transparent and evidence based, and that the resulting recommendations are relevant and applicable to end users. In addition to the standard data on effectiveness, WHO guidelines increasingly use evidence derived from QES to provide information on acceptability and feasibility and to develop important implementation considerations.

METHODS

WHO convened a group drawn from the technical teams involved in formulating recent (2010-2018) guidelines employing QES. Using a pragmatic and iterative approach that included feedback from WHO staff and other stakeholders, the group reflected on, discussed and identified key methods and research implications from designing QES and using the resulting findings in guideline development. As members of WHO guideline technical teams, our aim in this paper is to explore how we have used findings from QES to develop implementation considerations for these guidelines.

RESULTS

For each guideline, in addition to using systematic reviews of effectiveness, the technical teams used QES to gather evidence of the acceptability and feasibility of interventions and, in some cases, equity issues and the value people place on different outcomes. This evidence was synthesised using standardised processes. The teams then used the QES to identify implementation considerations combined with other sources of information and input from experts.

CONCLUSIONS

QES were useful sources of information for implementation considerations. However, several issues for further development remain, including whether researchers should use existing health systems frameworks when developing implementation considerations; whether researchers should take confidence in the evidence into account when developing implementation considerations; whether qualitative evidence that reveals implementation challenges should lead guideline panels to make conditional recommendations or only point to implementation considerations; and whether guideline users find it helpful to have challenges pointed out to them or whether they also need solutions. Finally, we need to explore how QES findings can be incorporated into derivative products to aid implementation.

Qualitative Evidence Synthesis (QES) for Guidelines: Paper 1 - Using qualitative evidence synthesis to inform guideline scope and develop qualitative findings statements

BACKGROUND

WHO has recognised the need to ensure that guideline processes are transparent and evidence based, and that the resulting recommendations are relevant and applicable. Along with decision-making criteria that require findings from effectiveness reviews, WHO is increasingly using evidence derived from qualitative evidence syntheses (QES) to inform the values, acceptability, equity and feasibility implications of its recommendations. This is the first in a series of three papers examining the use of QES in developing clinical and health systems guidelines.

METHODS

WHO convened a group of methodologists involved in developing recent (2010-2018) guidelines that were informed by QES. Using a pragmatic and iterative approach that included feedback from WHO staff and other stakeholders, the group reflected on, discussed and identified key methods and research implications from designing QES and using the resulting findings in guideline development. Our aim in this paper is to (1) describe and discuss how the findings of QES can inform the scope of a guideline and (2) develop findings for key guideline decision-making criteria.

RESULTS

QES resulted in the addition of new outcomes that are directly relevant to service users, a stronger evidence base for decisions about how much effective interventions and related outcomes are valued by stakeholders in a range of contexts, and a more complete database of summary evidence for guideline panels to consider, linked to decisions about values, acceptability, feasibility and equity.

CONCLUSIONS

Rigorously conducted QES can be a powerful means of improving the relevance of guidelines, and of ensuring that the concerns of stakeholders, at all levels of the healthcare system and from a wide range of settings, are taken into account at all stages of the process.