Using qualitative comparative analysis (QCA) in systematic reviews of complex interventions: a worked example

BACKGROUND

Systematic reviews that address policy and practice questions in relation to complex interventions frequently need not only to assess the efficacy of a given intervention but to identify which intervention - and which intervention components - might be most effective in particular situations. Here, intervention replication is rare, and commonly used synthesis methods are less useful when the focus of analysis is the identification of those components of an intervention that are critical to its success.

METHODS

Having identified initial theories of change in a previous analysis, we explore the potential of qualitative comparative analysis (QCA) to assist with complex syntheses through a worked example. Developed originally in the area of political science and historical sociology, a QCA aims to identify those configurations of participant, intervention and contextual characteristics that may be associated with a given outcome. Analysing studies in these terms facilitates the identification of necessary and sufficient conditions for the outcome to be obtained. Since QCA is predicated on the assumption that multiple pathways might lead to the same outcome and does not assume a linear additive model in terms of changes to a particular condition (that is, it can cope with 'tipping points' in complex interventions), it appears not to suffer from some of the limitations of the statistical methods often used in meta-analysis.

RESULTS

The worked example shows how the QCA reveals that our initial theories of change were unable to distinguish between 'effective' and 'highly effective' interventions. Through the iterative QCA process, other intervention characteristics are identified that better explain the observed results.

CONCLUSIONS

QCA is a promising alternative (or adjunct), particularly to the standard fall-back of a 'narrative synthesis' when a quantitative synthesis is impossible, and should be considered when reviews are broad and heterogeneity is significant. There are very few examples of its use with systematic review data at present, and further methodological work is needed to establish optimal conditions for its use and to document process, practice, and reporting standards.

Comparing universal Lynch syndrome tumor-screening programs to evaluate associations between implementation strategies and patient follow-through

PURPOSE

Universal tumor screening (UTS) for all colorectal cancer patients can improve the identification of Lynch syndrome, the most common cause of hereditary colorectal cancer. This multiple-case study explored how variability in UTS procedures influenced patient follow-through (PF) with germ-line testing after a screen-positive result.

METHODS

Data were obtained through Web-based surveys and telephone interviews with institutional informants. Institutions were categorized as Low-PF (≤10% underwent germ-line testing), Medium-PF (11-40%), or High-PF (>40%). To identify implementation procedures (i.e., conditions) unique to High-PF institutions, qualitative comparative analysis was performed.

RESULTS

Twenty-one informants from 15 institutions completed surveys and/or interviews. Conditions present among all five High-PF institutions included the following: (i) disclosure of screen-positive results to patients by genetic counselors; and (ii) genetic counselors either facilitate physician referrals to genetics professionals or eliminate the need for referrals. Although both of these High-PF conditions were present among two Medium-PF institutions, automatic reflex testing was lacking and difficulty contacting screen-positive patients was a barrier. The three remaining Medium-PF and five Low-PF institutions lacked the conditions found in High-PF institutions.

CONCLUSION

METHODS for streamlining UTS procedures, incorporating a high level of involvement of genetic counselors in tracking and communication of results and in reducing barriers to patient contact, are reviewed within a broader discussion on maximizing the effectiveness and public health impact of UTS.

Using qualitative evidence on patients' views to help understand variation in effectiveness of complex interventions: a qualitative comparative analysis

BACKGROUND

Complex healthcare interventions consist of multiple components which may vary in trials conducted in different populations and contexts. Pooling evidence from trials in a systematic review is challenging because it is unclear which components are needed for effectiveness. The potential is recognised for using recipients' views to explore why some complex interventions are effective and others are not. Methods to maximise this potential are poorly developed.

METHODS

We used a novel approach to explore how patients' views may explain the disparity in effectiveness of complex interventions. We used qualitative comparative analysis to explore agreement between qualitative syntheses of data on patients' views and evidence from trialed interventions to increase adherence to treatments. We first populated data matrices to reflect whether the content of each trialed intervention could be matched with suggestions arising from patients' views. We then used qualitative comparative analysis software to identify, by a process of elimination, the smallest number of configurations (patterns) of components that corresponded with patients' suggestions and accounted for whether each intervention was effective or ineffective.

RESULTS

We found suggestions by patients were poorly represented in interventions. Qualitative comparative analysis identified particular combinations of components corresponding with patients' suggestions and with whether an intervention was effective or ineffective. Six patterns were identified for an effective and four for an ineffective intervention. Two types of patterns arose for the effective interventions, one being didactic (providing clear information or instruction) and the other interactive (focusing on personal risk factors).

CONCLUSIONS

Our analysis highlights how data on patients' views has the potential to identify key components across trials of complex interventions or inform the content of new interventions to be trialed.

Weight management programmes: Re-analysis of a systematic review to identify pathways to effectiveness

Background

Previous systematic reviews of weight management programmes (WMPs) have not been able to account for heterogeneity of effectiveness within programmes using top‐down behavioural change taxonomies. This could be due to overlapping causal pathways to effectiveness (or lack of effectiveness) in these complex interventions. Qualitative comparative analysis (QCA) can help identify these overlapping pathways.

Methods

Using trials of adult WMPs with dietary and physical activity components identified from a previous systematic review, we selected the 10 most and 10 least effective interventions by amount of weight loss at 12 months compared to minimal treatment. Using intervention components suggested by synthesis of studies of programme user views, we labelled interventions as to the presence of these components and, using qualitative comparative analysis, developed pathways of component combinations that created the conditions sufficient for interventions to be most effective and least effective.

Results

Informed by the synthesis of views studies, we constructed 3 truth tables relating to quality of the user‐provider relationship; perceived high need for guidance from providers; and quality of the relationship between peers in weight management programmes. We found effective interventions were characterized by opportunities to develop supportive relationships with providers or peers, directive provider‐led goal setting and components perceived to foster self‐regulation.

Conclusions

Although QCA is an inductive method, this innovative approach has enabled the identification of potentially critical aspects of WMPs, such as the nature of relationships within them, which were previously not considered to be as important as more concrete content such as dietary focus.

I'm Not Good for Anything and That's Why I'm Stressed: Analysis of the Effect of Self-Efficacy and Emotional Intelligence on Student Stress Using SEM and QCA

Stress negatively affects the well-being and the quality of life of the society. Specifically in the academic context, it is relevant to analyze its levels due to its impact on performance and learning. There are factors that affect the said stress including, among others, self-efficacy, and emotional intelligence. The purpose of this study is to analyze how emotional intelligence and perceived self-efficacy affect student stress. In order to show this influence, two complementary methodologies are implemented: the structural equation models (SEMs) and the comparative qualitative analysis (QCA). A total of 477 students (85% of women) from a private University of Valencia participated in the study, with ages ranging from 18 to 53 years old (M = 21.57, SD = 3.68). The assessment instruments used were as follows: Emotional Intelligence Scale (TMMS-24) to measure emotional intelligence; General Self-Efficacy Scale (GSS) to measure self-efficacy; and Perceived Stress Scale (PSS) to measure stress. The results in the SEM endorse the hypotheses that emotional clarity and self-efficacy are negatively related to stress and positively related to emotional attention (EA), explaining 25% of the variance. The QCA results show that none of the variables is a necessary condition for inducing stress. Nevertheless, different combinations of these variables are sufficient conditions to explain 35% of the high stress levels. The most important combination over high stress levels seems to be the interaction between high levels of EA and low levels of self-efficacy. Regarding the low levels of perceived stress, there are sufficient conditions to explain 50% of them. Mainly, the most important interaction is between low levels of self-efficacy and low levels of EA. The comparison of both methodologies enables the broadening of new horizons at the methodological level applicable to different contexts.

Using qualitative comparative analysis and theory of change to unravel the effects of a mental health intervention on service utilisation in Nepal

Background

The integration of mental health services into primary care is essential to improve the coverage of mental health services in low resource settings, but the evaluation of this remains challenging. We used a programme’s Theory of Change (ToC) as a conceptual framework to determine what combination(s) of conditions at facility and community level influenced the mental health service utilisation as a result of a district mental healthcare plan (MHCP) implemented in Chitwan, Nepal. In addition, we show how qualitative comparative analysis can be used to provide an integrated analysis of data from a ToC.

Methods

We conducted a longitudinal case study of 10 health facilities where the MHCP was implemented. We collected data from all facilities at baseline (October to December 2013) and quarterly following the implementation of the intervention (March 2014 to November 2016). The data were analysed using pooled qualitative comparative analysis in fsQCA V.2.5.

Results

The following conditions were necessary for high mental health service utilisation: presence of basic and advanced psychosocial care, evidence-based identification and treatment guidelines (WHO mhGAP), referral to tertiary services and the presence of trained female community health volunteers. Two additional combinations of conditions were also identified as sufficient for a high mental health service utilisation: high medication supply, trained facility staff and either the use of a community informant detection tool or having a larger proportion of the community attend community awareness activities.

Conclusions

Both supply-side interventions (formalised approaches to health worker detection and treatment, training of health workers, supervision) and demand-side interventions (community awareness and case finding) are important to integrate mental health in primary care. ToC can be used to provide an integrated analysis of data from a ToC, therefore helping to shed light on the black box of complex multilevel interventions.

Organizational Factors Affect Safety-Net Hospitals' Breast Cancer Treatment Rates

OBJECTIVE

To identify key organizational approaches associated with underuse of breast cancer care.

SETTING

Nine New York City area safety-net hospitals.

STUDY DESIGN

Mixed qualitative-quantitative, cross-sectional cohort.

METHODS

We used qualitative comparative analysis (QCA) of key stakeholder interviews, defined organizational "conditions," calibrated conditions, and identified solution pathways. We defined underuse as no radiation after lumpectomy in women <75 years or mastectomy in women with ≥4 positive nodes, or no systemic therapy in women with tumors ≥1 cm. We used hierarchical models to assess organizational and patient factors' impact on underuse.

PRINCIPAL FINDINGS

Underuse varied by hospital (8-29 percent). QCA found lower underuse sites designated individuals to track and follow-up no-shows; shared clinical information during handoffs; had fully integrated electronic medical records enabling transfer of responsibility across specialties; had strong system support; allocated resources to cancer clinics; had a patient-centered culture paying close organizational attention to clinic patients. High underuse sites lacked these characteristics. Multivariate modeling found that hospitals with strong approaches to follow-up had low underuse rates (RR = 0.28; 0.08-0.95); individual patient characteristics were not significant.

CONCLUSIONS

At safety-net hospitals, underuse of needed cancer therapies is associated with organizational approaches to track and follow-up treatment. Findings provide varying approaches to safety nets to improve cancer care delivery.

Emotional Intelligence, Empathy, Self-Esteem, and Life Satisfaction in Spanish Adolescents: Regression vs. QCA Models

Adolescence is a complex period, in which the individual is subject to profound emotional, physical, and psychological changes. Healthy development during adolescence is crucial for future positive development; self-esteem and life satisfaction are fundamental. The importance of sociodemographic variables (sex and age), empathy, and emotional intelligence (EI) on self-esteem and life satisfaction was studied, comparing complementary methodologies, regression models, and fuzzy-set qualitative comparative analysis (fsQCA) models. This is a cross-sectional design in a convenience sample of 991 adolescents (528 females, 53.3%; aged between 12 and 19 years; M = 14.01, SD = 1.40) from Spanish schools. Data were collected using the Rosenberg Self-Esteem Scale (RSES), the Satisfaction With Life Scale (SWLS), the Basic Empathy Scale (BES), and Trait Meta-Mood Scale (TMMS)24. The results of the regression models suggest that cognitive empathy, emotional clarity, and emotional repair are the main predictor variables for self-esteem. Meanwhile, the results of the fsQCA suggest that being older and low levels of cognitive empathy, emotional clarity, and emotional repair predict higher levels of self-esteem. On the other hand, life satisfaction in regression models is significantly predicted by the emotional clarity and emotional repair dimensions of the TMMS24 and self-esteem. Meanwhile, in the prediction of life satisfaction, the results of the fsQCA suggest that the most important interactions were high emotional clarity, emotional repair, and low self-esteem. As research has already shown, promoting empathy and EI leads to higher levels of self-esteem and life satisfaction.

Understanding Why Nurse Practitioner (NP) and Physician Assistant (PA) Productivity Varies Across Community Health Centers (CHCs): A Comparative Qualitative Analysis

This study asks how much and why the productivity of advanced practice clinicians (APCs; nurse practitioners and physician assistants) varies across community health centers (CHCs), as measured in their marginal contribution to overall patient visits. We found APCs in the 90th percentile CHCs provide about 1,840 adjusted-visits per year, whereas APCs in the 10th percentile CHCs provide about 978 adjusted-visits per year. We interviewed leadership at 14 high APC and 16 low APC productivity CHCs to elicit organizational conditions that could explain the difference. Using content analysis and then qualitative comparative analysis, we found several important conditions were more common among high productivity CHCs, including scheduling APCs and physicians for the same number of visits, parity in terms of any financial incentives, and formal education programs for new APCs during onboarding/transition to practice.

Psychosocial Factors and Chronic Illness as Predictors for Anxiety and Depression in Adolescence

Adolescence is a challenging time when emotional difficulties often arise. Self-esteem, good relationships with peers, and emotional competences can buffer the effects of these difficulties. The difficulties can be even greater when coupled with the presence of a chronic physical illness (CD). Our goal is to analyze psychosocial factors and CD as predictors for anxiety and depression. It was compared the results of structural equation models (SEM) with models based on qualitative comparative analysis (QCA) to analyze the possible influence of these variables on levels of anxiety-depression in adolescents with and without CD. The sample consisted of 681 adolescents, between 12 and 16 years old (M = 13.94, SD = 1.32). 61.50% were girls and 13.40% (n = 222) presented a CD (mainly pneumo-allergic and endocrine). They were evaluated by the Hospital Anxiety and Depression Scale, the Self-esteem Questionnaire, the Emotional Competences Questionnaire and the Strengths and Difficulties Questionnaire. The results obtained by SEM show that low self-esteem, problems with peers and low emotional competencies predict anxiety in 41% of the variance and depression in 72%. The results obtained by QCA show that the different combinations of these variables explain between 24 and 61% of low levels of anxiety and depression and 47–55% of high levels. Our data show how the presence of a CD, low self-esteem, problems with peers and problems in emotional skills play a fundamental role in explaining levels of anxiety and depression. These aspects will help provide increased resources for emotional adjustment in the educational context, facilitating the transitions to be made by adolescents.

Pathways to mental health improvement in a community-led area-based empowerment initiative: evidence from the Big Local 'Communities in Control' study, England

BACKGROUND

Area-based initiatives that include a focus on community empowerment are increasingly being seen as potentially an important way of improving health and reducing inequalities. However, there is little empirical evidence on the pathways between communities having more control and health outcomes.

PURPOSE

To identify pathways to health improvement in a community-led area-based community empowerment initiative.

METHODS

Longitudinal data on mental health, community control, area belonging, satisfaction, social cohesion and safety were collected over two time points, 6 months apart from 48 participants engaged in the Big Local programme, England. Qualitative comparative analysis (QCA) was used to explore pathways to health improvement.

RESULTS

There was no clear single pathway that led to mental health improvement but positive changes in 'neighbourhood belonging' featured in 4/5 health improvement configurations. Further, where respondents experienced no improvement in key social participation/control factors, they experienced no health improvement.

CONCLUSION

This study demonstrates a potential pathway between an improvement in 'neighbourhood belonging' and improved mental health outcomes in a community empowerment initiative. Increasing neighbourhood belonging could be a key target for mental health improvement interventions.

Developing and testing intervention theory by incorporating a views synthesis into a qualitative comparative analysis of intervention effectiveness

Qualitative comparative analysis (QCA) was originally developed as a tool for cross-national comparisons in macrosociology, but its use in evaluation and evidence synthesis of complex interventions is rapidly developing. QCA is theory-driven and relies on Boolean logic to identify pathways to an outcome (eg, is the intervention effective or not?). We use the example of two linked systematic reviews on weight management programs (WMPs) for adults-one focusing on user views (a "views synthesis") and one focusing on the effectiveness of WMPs incorporating dietary and physical activity-to demonstrate how a synthesis of user views can supply a working theory to structure a QCA. We discuss how a views synthesis is especially apt to supply this working theory because user views can (a) represent a "middle-range theory" of the intervention; (b) bring a participatory, democratic perspective; and (c) provide an idiographic understanding of how the intervention works that external taxonomies may not be able to furnish. We then discuss the practical role that the views synthesis played in our QCA examining pathways to effectiveness: (a) by suggesting specific intervention features and sharpening the focus on the most salient features to be examined, (b) by supporting interpretation of findings, and (c) by bounding data analysis to prevent data dredging.

Pathways to Medical Home Recognition: A Qualitative Comparative Analysis of the PCMH Transformation Process

OBJECTIVE

To understand the process of practice transformation by identifying pathways for attaining patient-centered medical home (PCMH) recognition.

DATA SOURCES/STUDY SETTING

The CMS Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration was designed to help FQHCs achieve NCQA Level 3 PCMH recognition and improve patient outcomes. We used a stratified random sample of 20 (out of 503) participating sites for this analysis.

STUDY DESIGN

We developed a conceptual model of structural, cultural, and implementation factors affecting PCMH transformation based on literature and initial qualitative interview themes. We then used conventional cross-case analysis, followed by qualitative comparative analysis (QCA), a cross-case method based on Boolean logic algorithms, to systematically identify pathways (i.e., combinations of factors) associated with attaining-or not attaining-Level 3 recognition.

DATA COLLECTION METHODS

Site-level indicators were derived from semistructured interviews with site leaders at two points in time (mid- and late-implementation) and administrative data collected prior to and during the demonstration period.

PRINCIPAL FINDINGS

The QCA results identified five distinct pathways to attaining PCMH recognition and four distinct pathways to not attaining recognition by the end of the demonstration. Across these pathways, one condition (change leader capacity) was common to all pathways for attaining recognition, and another (previous improvement or recognition experience) was absent in all pathways for not attaining recognition. In general, sites could compensate for deficiencies in one factor with capacity in others, but they needed a threshold of strengths in cultural and implementation factors to attain PCMH recognition.

CONCLUSIONS

Future efforts at primary care transformation should take into account multiple pathways sites may pursue. Sites should be assessed on key cultural and implementation factors, in addition to structural components, in order to differentiate interventions and technical assistance.

Innovation Model of China's High-End Equipment Industry: Do Social Capital and Dynamic Capabilities Matter for the COVID-19 Crisis?

This paper explores the different model combinations of enterprise innovation in China based on the roles of social capital and dynamic capabilities. We implement Qualitative Comparative Analysis to understand the non-linear asymmetric relationships better. We use the data of 44 Listed Companies in China's high-end equipment manufacturing industry and find that three innovation models (the market-oriented independent innovation, government-supported technological innovation and industry-supported learning innovation models) are valid. Social capital, dynamic capabilities, and intra-industry networks are the main determinants of these innovation models. We also discuss the implications of these innovation dynamics on Chinese enterprises as a way to sustain the economy's high-quality development, including during the era of the COVID-19 pandemic crisis.

Assessing the impact of household participation on satisfaction and safe design in humanitarian shelter projects

Participation has long been considered important for post-disaster recovery. Establishing what constitutes participation in post-disaster shelter projects, however, has remained elusive, and the links between different types of participation and shelter programme outcomes are not well understood. Furthermore, recent case studies suggest that misguided participation strategies may be to blame for failures. This study analysed 19 shelter projects implemented in the Philippines following Typhoon Haiyan in November 2013 to identify the forms of participation employed. Using fuzzy-set qualitative comparative analysis, it assessed how household participation in the planning, design, and construction phases of shelter reconstruction led to outcomes of household satisfaction and safe shelter design. Participation was operationalised via eight central project tasks, revealing that the involvement of households in the early planning stages of projects and in construction activities were important for satisfaction and design outcomes, whereas engagement during the design phase of projects had little impact on the selected outcomes.

Fuzzy-set qualitative comparative analysis of implementation outcomes in an integrated mental healthcare trial in South Africa

BACKGROUND

Integrating mental health services into primary healthcare platforms is an established health systems strategy in low-to-middle-income countries. In South Africa, this was pursued through the Programme for Improving Mental Health Care (PRIME), a multi-country initiative that relied on task-sharing as a principle implementation strategy. Towards better describing the implementation processes, qualitative comparative analysis was adopted to explore causal pathways in the intervention.

OBJECTIVE

This study aimed to explore factors that could have influenced key outcomes of an integrated mental healthcare intervention in South Africa.

METHODS

Drawing from an embedded multiple case study design, the analysis used qualitative comparative analysis. Focusing on nine PHC clinics in the Dr Kenneth Kaunda District as cases, with depression reduction scores set as outcome measures, trial data variables were modelled in a hypothetical causal process. A fuzzy-set qualitative comparative analysis was performed by 1) developing the research questions, 2) developing the fuzzy set, 3) testing necessity and 4) testing sufficiency. These steps were undertaken collaboratively among the research team.

RESULTS

The data were calibrated during several meetings among team members to gain a degree of consensus. Necessity analyses suggested that none of the causal conditions exceeded the threshold of necessity and triviality, and confirmed the inclusion of relevant variables in line with the proposed models. Sufficiency analyses produced two configurations, which were subjected to standard and specific analyses. Ultimately, the results suggested that none of the causal conditions were necessary for a reduction in depression scores to occur, while programme fidelity was identified as a sufficient condition for a reduction in scores to occur.

CONCLUSIONS

The study highlights the importance of understanding implementation pathways to enable better integration of mental health services within primary healthcare in low-to-middle-income settings. It underlines the importance of programme fidelity in achieving the goals of implementation.

The Transition of Cities towards Innovations in Mobility: Searching for a Global Perspective

The growing concentration of the population in urban areas presents great challenges for sustainability. Within this process, mobility emerges as one of the main generators of externalities that hinder the achievement of the Sustainable Development Goals. The transition of cities towards innovations in sustainable mobility requires progress in different dimensions, whose interaction requires research. Likewise, it is necessary to establish whether the experiences developed between cities with different contexts can be extrapolated. Therefore, the purpose of this study was to identify how the conditions that determine a city’s readiness to implement urban mobility innovations could be combined. For this, qualitative comparative analysis was applied to a model developed using the multi-level perspective, analyzing 60 cities from different geographical areas and with a different gross domestic product per capita. The R package Set Methods was used. The explanation of the readiness of cities to implement mobility innovations is different to the explanation of the readiness negation. While readiness is explained by two solutions, in which only regime elements appear, the negation of readiness is explained by five possible solutions, showing the interaction between the landscape and regimen elements and enacting the negation of innovations as a necessary condition. The cluster analysis shows us that the results can be extrapolated between cities with different contexts.

Implementation of e-Mental Health Interventions for Informal Caregivers of Adults With Chronic Diseases: Mixed Methods Systematic Review With a Qualitative Comparative Analysis and Thematic Synthesis

BACKGROUND

Informal caregivers commonly experience mental health difficulties related to their caregiving role. e-Mental health interventions provide mental health support in a format that may be more accessible to informal caregivers. However, e-mental health interventions are seldom implemented in real-world practice.

OBJECTIVE

This mixed methods systematic review aimed to examine factors associated with the effectiveness and implementation of e-mental health interventions for informal caregivers of adults with chronic diseases. To achieve this aim, two approaches were adopted: combinations of implementation and intervention characteristics sufficient for intervention effectiveness were explored using qualitative comparative analysis, and barriers to and facilitators of implementation of e-mental health interventions for informal caregivers were explored using thematic synthesis.

METHODS

We identified relevant studies published from January 1, 2007, to July 6, 2022, by systematically searching 6 electronic databases and various secondary search strategies. Included studies reported on the effectiveness or implementation of e-mental health interventions for informal caregivers of adults with cancer, chronic obstructive pulmonary disease, dementia, diabetes, heart disease, or stroke. Randomized controlled trials reporting on caregivers' mental health outcomes were included in a crisp-set qualitative comparative analysis. We assessed randomized controlled trials for bias using the Risk of Bias 2.0 tool, and we assessed how pragmatic or explanatory their trial design was using the Pragmatic Explanatory Continuum Indicator Summary 2 tool. Studies of any design reporting on implementation were included in a thematic synthesis using the Consolidated Framework for Implementation Research to identify barriers to and facilitators of implementation.

RESULTS

Overall, 53 reports, representing 29 interventions, were included in the review. Most interventions (27/29, 93%) focused on informal cancer or dementia caregivers. In total, 14 reports were included in the qualitative comparative analysis, exploring conditions including the presence of peer or professional support and key persuasive design features. Low consistency and coverage prevented the determination of condition sets sufficient for intervention effectiveness. Overall, 44 reports were included in the thematic synthesis, and 152 barriers and facilitators were identified, with the majority related to the intervention and individual characteristic domains of the Consolidated Framework for Implementation Research. Implementation barriers and facilitators in the inner setting (eg, organizational culture) and outer setting (eg, external policies and resources) domains were largely unexplored.

CONCLUSIONS

e-Mental health interventions for informal caregivers tend to be well-designed, with several barriers to and facilitators of implementation identified related to the intervention and individual user characteristics. Future work should focus on exploring the views of stakeholders involved in implementation to determine barriers to and facilitators of implementing e-mental health interventions for informal caregivers, focusing on inner and outer setting barriers and facilitators.

TRIAL REGISTRATION

PROSPERO (International Prospective Register of Systematic Reviews) CRD42020155727; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020155727.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2019-035406.

Configurational Paths to Higher Efficiency in County Hospital: Evidence From Qualitative Comparative Analysis

Background

The efficient operation of county-level medical institutions is a significant guarantee in constructing Chinese rural tertiary care service networks. However, it is still unclear how to increase the efficiency of county hospitals under the interaction of multiple factors. In this study, 35 county general hospitals in China were selected to explore the configuration paths of county hospitals' high and poor efficiency status under the Environment-Structure-Behavior (ESB) framework and provide evidence-based recommendations for measures to enhance its efficiency.

Methods

Data envelopment analysis with the bootstrapping procedure was used to estimate the technical efficiency value of case hospitals. A fuzzy-set qualitative comparative analysis approach was carried out to explore the configuration of conditions to the efficiency status.

Results

Antecedent configurations affecting the efficiency status of county hospitals were identified based on the ESB analytical framework. Three high-efficiency configuration paths can be summarized as structural optimization, capacity enhancement, and government support. Another three types of paths, namely insufficient capacity, aggressive expansion, and poor decision-making, will lead to inefficient configurations.

Conclusion

Qualitative comparative analysis is necessary when exploring complex causality. The efficiency situation of county hospitals results from a combination of influencing factors instead of the effect of a single one. There is no solitary configuration for high efficiency that applies to all healthcare units. Any measures aimed at efficiency promotion should be discussed within the framework of a case-specific analysis.

Identifying conditions for a third dose intention of COVID-19 vaccination in college students: A fuzzy-set qualitative comparative analysis

Background

During the pandemic, a third dose of the COVID-19 vaccine effectively reduces the proportion of severe cases in those infected, but vaccine hesitancy impedes this reasonable prevention method. Epidemic control in China is being tested due to the large population base, especially in crowded places like college campuses. This study aimed to explore the configuration paths of psychological antecedents for college students to receive a third COVID-19 vaccine.

Methods

An anonymous cross-sectional survey was carried out in five universities in Wuhan using convenience sampling. A long version of the 5C 7-point Likert scale was used to measure college students' intention and psychological antecedents on the third dose of the COVID-19 vaccine. A fuzzy-set Qualitative Comparative Analysis (QCA) approach was performed to explore the configuration of conditions to the vaccination willingness.

Results

31.67% of respondents surveyed did not receive their third dose of the COVID-19 vaccine. The score of intention to get the vaccine for college students who did not receive the booster vaccine was 4.93 (±1.68). Average scores of 5.19 (±1.24), 4.35 (±1.75), 4.02 (±1.45), 5.84 (±1.23), and 4.61(±1.32) were reported for confidence, complacency, constraints, calculation, and collective responsibility in them. QCA showed high confidence and collective responsibility playing a central role in third dose vaccination intention. Meanwhile, low confidence and collective responsibility are the core conditions of low vaccination willingness.

Conclusion

Eliminating vaccine hesitancy necessitates focusing on the psychological antecedents of vaccination intentions to identify critical targets for policy and interventions. This study identified trust and collective responsibility are core elements of the psychological antecedents of college students' intention to receive the booster vaccine for COVID-19. To achieve herd immunity as soon as possible, health administration and campus can start with vaccine confidence-building and collective responsibility cultivation to take appropriate actions and measures to improve coverage of the booster vaccination.

Complex Pathways to Transfer: A Qualitative Comparative Analysis of the Transition From Community College to 4-Year University

Many community college students express a desire to transfer to a 4-year institution, but few achieve that goal. In this article, we examine what conditions lead to successful student transfer and which serve as barriers. Drawing on data from a longitudinal qualitative study of 61 transfer-intending students in Texas and using qualitative comparative analysis, we investigate the student-level conditions and experiences that contribute to successful or unsuccessful transfer to a 4-year institution. We find that there is no single condition that can predict success. Instead, we describe how factors such as social capital, students' family background, and advising supports interact with one another to determine student success or failure in the transfer process. We identify specific pathways to transfer, with implications for policies and programs that can help bolster students in the face of potential barriers. We provide suggestions for policy, practice, and future research.

What Drives the Food Safety Certification: A Qualitative Comparative Analysis of Food Companies in China

Food safety is related to health and quality of life. Therefore, the social responsibility of the food industry to ensure food safety has received increasing attention. Influencing factors and mechanisms of participation in food safety certification are important issues in this field. Existing studies on factors affecting food safety certification mainly focus on the impact of a single or few factors. In this study, listed Chinese food companies were selected, and the fuzzy set qualitative comparative analysis method was utilized to explore the matching mode of various factors to encourage companies to obtain food safety certification. The following results were obtained. (1) State-owned companies tend to achieve food safety certification. (2) Companies with high media attention are inclined to achieve food safety certification. (3) In state-owned companies, when the company size is small, a higher degree of food safety concern in the mission statement can encourage the company to achieve food safety certification, and when the company size is large, higher media attention can encourage the company to achieve food safety certification. (4) In non-state-owned companies, when food safety concerns are highlighted in the mission statement and media attention is relatively high, the company will gain food safety certification. This study provides new perspectives on food safety-related research and suggestions for government and the public sector to supervise food safety issues in enterprises.

The digital transformation of management consulting companies: a qualitative comparative analysis of Romanian industry

Digital transformation affects all industries. This study targets how management consulting companies address this phenomenon. Based on a survey of 30 Romanian management consulting companies and a qualitative comparative analysis, we model the relationship between management consulting companies’ current context (customers’ industries, internal and external triggers for digital transformation), the current state of digital transformation, and expected digital transformation. By considering managerial expectations importance in future decisions, and contingency theory for explaining the links between context, current state and expected digital transformation, different paths concerning digital transformation are identified at Romanian management consulting companies. For some of them, the combination of internal and external triggers and the existence of previous digital transformation activities led to increases in the recognized importance of digital transformation in future business models and to newer business services (digital strategy). For others, which do not have powerful external triggers, digital transformation is associated with internal efficiency–related triggers, and it targets only improvements in existing business models due to technology adoption (technology strategy). A small number of management consulting companies do not expect digital transformation to have a large impact on their future business model, because of either the lack of external triggers to do so or the absence of previous digital transformation activities. This research demonstrates the contingency and evolutionary nature of the digital transformation process, in which specific combinations between internal and external triggers can explain the expectations of management consulting companies’ managers about digital transformation.

Prioritizing Equity: Exploring Conditions Impacting Community Coalition Efforts

Purpose: There is a critical push toward addressing equity in health care. Community coalitions are uniquely situated to heed this call by tackling issues of equity and well-being that are the most relevant for their local context. This article analyzes internal and external contextual factors that may affect coalitions' prioritization of equity.

Methods: Data were collected from 18 coalitions participating in a national, U.S.-based initiative aimed at strengthening community coalition work through the principles of equity and inclusion. A hybrid qualitative–quantitative method (qualitative comparative analysis [QCA]) was conducted using the direct method of calibration and fuzzy set QCA and to obtain casual sufficiency results.

Results: Coalitions located in states that did not expand Medicaid after the Affordable Care Act were most likely to prioritize equity, as were coalitions who were both working with marginalized populations and had low organizational readiness for the initiative. However, only one case demonstrated the latter causal solution; the former accounts for greater coverage of the outcome.

Conclusion: This study illustrates the use of QCA for evaluation and underscores the critical role of contextual factors for affecting meaningful community-level change. Coalitions are willing and able to prioritize tackling health inequities across settings, but those in settings with low state-level support may be more likely to emphasize inequities in their work.

Family and Community Approaches to Intimate Partner Violence: Restorative Programs in the United States

Now is the time to rethink reliance on legal intervention to end intimate partner violence (IPV). Arrest, incarceration, and family separation have fallen disproportionately on people who are Black or Brown, impoverished, or immigrant, lesbian, gay, bisexual, transgender and queer (LGBTQ). Restorative approaches bring together the persons harmed, persons causing harm, their family or community networks, or combinations of these stakeholders. Based on a U.S. national study, this article examines: What influences programs to adopt a restorative approach to ending IPV? How do programs safeguard their original vision for social change? What principles guide the programs in carrying out their work in safe and productive ways?