Introduction to qualitative evidence synthesis - Variants and application

To explore factors influencing the implementation of a nursing care delivery model in a hospital setting. A qualitative evidence synthesis with a thematic synthesis was conducted. The search string consisted of four 'cluster topics': (1) nursing, (2) care delivery models, (3) hospital setting, (4) qualitative and mixed methods designs. Four electronic databases were searched from January 2000 until July 2024: MEDLINE (PubMed interface), Embase (embase.com interface), CINAHL (EBSCOhost interface) and Web of Science. A thematic synthesis was conducted consisting of the following steps; the 'line-by-line' coding of the text, the development and allocation of 'descriptive themes' and the generation of 'analytical themes'. In total, 3976 references were screened, of which 25 were included in the qualitative evidence synthesis. Eight analytical themes were generated that influence the implementation of a nursing care delivery model in a hospital setting: shared understanding of the care delivery model, ownership of the change, scope of practice and role clarity, collaboration, communication, responsibility, a double-loop process and aggregated recommendations. The themes were categorised on four different levels: vision, process, interactional factors and contextual factors. The eight themes identified in this qualitative evidence synthesis showed that during the implementation of a nursing care delivery model, a clear implementation strategy is often missing. It is advised that future implementation processes have a clear guide and goal. The analytical themes can guide the future implementation of a new nursing care delivery model in a hospital setting. This review can support nurses, researchers, hospital management and policymakers when implementing organisational alternatives to reorganise nursing care in a hospital setting. The qualitative evidence synthesis was reported according to the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) statement. No patient or public contribution.

There is limited understanding of which factors most influence take-up of DRR behaviour in the general population. This evidence gap may limit the effectiveness of DRR implementation and, hence, impede translation of increasing evidence for DRR1 into real-world public health benefits.Reviews of quantitative studies have identified poor knowledge and persistence of myths about ageing2,3 as important. However, these findings are limited by the scope of included questionnaires.Qualitative literature reporting the perspectives of the general public offers an opportunity to increase this understanding. Qualitative studies can examine poorly understood phenomena in greater depth and with fewer a priori assumptions. Qualitative evidence synthesis (QES) is increasingly recognised as valuable, particularly in relation to complex interventions like DRR.We will present a QES regarding the perspectives of dementia- free members of the general public towards DRR. Searches indicate that no QES for this topic currently exists.Systematic searches of Medline, PsycINFO, Embase and CINAHL for studies published since 1995 that have used qualitative methods to explore DRR perspectives in the general public were undertaken, supplemented by hand searches of included studies’ reference lists. Following independent screening by two reviewers, 41 publications based on 37 individual studies meeting inclusion criteria have been identified.Data will be analysed using thematic synthesis, as outlined by Thomas and Harden (2008)4 and recommended for QES regarding complex health interventions5. ‘Line-by-line’ inductive coding and development of descriptive themes across studies will produce a summary of the perspectives of the general public for DRR. A conceptual framework explaining the relationships between key themes and considering the implications for implementation will be proposed.The Critical Appraisal Skills Programme (CASP) tool will be used to appraise included studies. Rather than imposing an arbitrary quality cut-off point for inclusion, sensitivity analyses will be used to examine the influence of lower quality studies on review findings. Finally, the Confidence in the Evidence from Qualitative Reviews (CERQual) approach will facilitate assessment of confidence in review findings to aid future use. Data extraction is ongoing.Findings from this synthesis will support better targeted quantitative examination of DRR implementation determinants and more strategic intervention design. 1.World Health Organisation. Risk reduction of cognitive decline and dementia: WHO guidelines. World Health Organisation. 2019. Geneva. Licence CC BY-NC-SA 3.0 IGO2.Cahill, S., Pierce, M., Werner, P., Darley, A., Bobersky, A. A systematic review of the public’s knowledge and understanding of Alzheimer’s disease and dementia. Alz Dis Assoc Disord. 2015; 29:255-2753.Cations, M., Radisic, G., Crotty, M., Laver, K.E. What does the general public understand about prevention and treatment of dementia? A systematic review of population-based surveys. PLoS One. 2018, 13(4):e01960854.Thomas, J. and Harden, A. (2008). Methods for the thematic synthesis of qualitative research in systematic reviews, BMC Medical Research Methodology. 2008 July; 8:45. doi 10.1186/1471-2288-8-455.Noyes, J., Booth, A., Cargo, M., et al. (2018). Cochrane Qualitative and Implementation Methods Group guidance series – paper 1: introduction. J of Clin Epidemiol. 2018; 97:35-38

Background Inflammatory bowel disease is a chronic condition of the bowel which is known to be very challenging for patients especially during times of active disease or flare ups of their symptoms. Those affected have to adapt their lives to the chronic nature of their condition. The aim of this review was to synthesise qualitative evidence on the perceptions and experiences of those living with inflammatory bowel disease on nursing care received in all health care settings and identify barriers and facilitators for optimal nursing care. Qualitative evidence synthesis guided by Thomas & Harden’s (2008) method of thematic synthesis was used. Methods A systematic search was carried out in CINAHL, Embase, Medline, Cochrane and Google Scholar using combinations of key words. Searches were imported into Covidence which is an online software product used for systematic reviews. Title and abstract screening and full text screening were carried out to screen for eligible papers. Included studies were critically appraised using Critical Appraisal Support Programme (CASP) and thematic synthesis of the data was conducted. Eleven studies were included in the synthesis. Results From the thematic synthesis of the included studies three analytical themes were developed; 1) Meaningful care for patients, 2) Accessible support and information 3) “A constant” for people with IBD. Conclusion This review demonstrated the positive and negative experiences of patients with inflammatory bowel disease on the nursing care they received. It raises key issues for patients which can be addressed by nursing when caring for patients. The results will inform nursing on what is important to patients and how their healthcare needs can be met in all settings. This review will also support evidence for nurses to obtain resources and improve patient care.

Background: Children and young people with life-limiting conditions and their families need physical and emotional support to manage the challenges of their lives. There is a lack of synthesised qualitative research about how music therapy is experienced by children, young people and their families supported by paediatric palliative care services. Aim: To systematically identify and synthesise qualitative research on experiences of music therapy in paediatric palliative care from stakeholder perspectives. Design: A Qualitative Evidence Synthesis was conducted using Thematic Synthesis. The review protocol was registered in PROSPERO (registration number: CRD42021251025). Data sources: Searches were conducted with no dates imposed via the electronic databases PsycINFO, MEDLINE, EMBASE, AMED and CINAHL in April 2021 and updated in April 2022. Studies were appraised for quality using the Critical Appraisal Skills Programme tool (CASP). Results: A total of 148 studies were found, 5 studies met the eligibility criteria reporting the experiences of 14 mothers, 24 family members and 4 staff members in paediatric palliative care. There were five overarching themes: emotional and physical reprieve, opportunity for normalised experiences, thriving despite life limited condition, enhance family wellbeing and therapeutic relationship central to outcomes. Conclusion: Music therapy provides unique benefits for this paediatric population particularly in supporting child and family wellbeing. The therapeutic relationship, interpersonal skills of the therapist and experience in paediatric palliative care are perceived as central to these positive outcomes.

Introduction:The growth of the evidence-based policy movement sought to determine how to better assess and incorporate qualitative evidence in clinical practice and policy development. The question engendered was not whether qualitative research is valuable but how researchers can enhance its rigor. From this discussion arose over one hundred appraisal tools for the quality appraisal process of qualitative studies. For those without a deep familiarity with the qualitative research paradigm, navigating through the breadth of tools to find the most suitable tool for the task is a cumbersome process. This presentation will review the descriptive characteristics of available quality appraisal tools for assessing the quality of primary qualitative studies in qualitative evidence syntheses (QES). This presentation will also offer a critical discussion on the use of reflexivity as a de facto quality criterion, and how methodological reporting may influence the application of quality criteria in QES.Methods:We conducted a systematic search to identify quality appraisal tools of qualitative research designed for use in QES. This search built upon the work of Santiago-Delefosse and colleagues by extending their search to 2016.Results:We identified eight appraisal tools intended for use in the quality appraisal process of a QES. We provide a description of the structure, content, objectives, and philosophies of tools followed by considerations concerning their historical antecedents, common patterns regarding structure, content, and purpose, and the implications of these patterns on the QES process.Conclusions:Quality appraisal of qualitative research is an important step in QES, and there have been a proliferation of tools for this purpose. By providing an overview of available tools detailing their intent and strengths, this presentation will assist those engaging in QES to choose an appropriate tool for their work.

IntroductionResearch on research is key to enhancing efficacy in trial methodology. Clinical trials involving women during pregnancy and childbirth are limited, with a paucity of data guiding evidence-based practice. Following a prioritisation exercise that highlighted the top-ten unanswered recruitment questions, this qualitative evidence synthesis was designed specifically to focus on the barriers and enablers for clinicians/healthcare professionals in helping conduct randomised trials within the context of recruitment during pregnancy and childbirth.MethodsThe synthesis was undertaken using Thomas and Harden’s three stage thematic synthesis method and reported following the ENTREQ guidelines. Using a pre-determined SPIDER strategy, we conducted a comprehensive search of databases; Pubmed, CINAHL, PsycINFO, EMBASE, and grey searches for records until January 2019. We included all reports of qualitative data on recruiter’s experiences, perceptions, views of recruiting women during pregnancy and childbirth to clinical trials. Altogether 13,401 records were screened, resulting in 31 full-text reviews, of which five were eligible for inclusion. Quality was appraised using CASP. Data were extracted onto a specifically defined form. We used thematic synthesis to identify descriptive and analytical themes, and to interpret and generate theory. Confidence was assessed using GRADE-CERQual. The review protocol is publicly available (OSF https://osf.io/g4dt9/).ResultsFive papers (representing four individual studies) from two different countries were included. All studies focused on the experiences of trial recruiters in the maternity setting. We identified four analytical themes; Recruitment through a clinician’s lens, Recruiters judgement on acceptability, From protocol to recruiters lived experience, Framing recruitment in context. These were linked by an overarching theme combining beliefs and power.ConclusionThe overarching theme combining beliefs and power links the experiences and perceptions of recruiters. This synthesis shows a gap between the trial design study protocol and the recruiter’s lived experience. Strategies such as collaborative trial design, mitigating gatekeeping behaviours, and training may support recruiters in their endeavour.

Qualitative evidence syntheses (QES) have increased in prominence and profile over the last decade as a discrete set of methodologies to undertake systematic reviews of primary qualitative research in health and social care and in education. The findings from a qualitative evidence synthesis can enable a richer interpretation of a particular phenomenon, set of circumstances, or experiences than single primary qualitative research studies can achieve. Qualitative evidence synthesis methods were developed in response to an increasing demand from health and social professionals, policy makers, guideline developers and educationalists for review evidence that goes beyond “what works” afforded by systematic reviews of effectiveness. The increasing interest in the synthesis of qualitative research has led to methodological developments documented across a plethora of texts and journal articles. This “State of the Method” paper aims to bring together these methodological developments in one place, contextualizing advances in methods with exemplars to support readers in making choices in approach to a synthesis and aid understanding. The paper clarifies what a “qualitative evidence synthesis” is and explores its role, purpose and development. It details the kind of questions a QES can explore, the processes associated with a QES, including the methods for synthesis. The rational and methods for integrating a QES with systematic reviews of effectiveness are also detailed. Finally approaches reporting and recognition of what a “good” or rigorous QES look like are provided.

Children and young people with diabetes (CYPD) from socio-economically deprived and/or ethnic minority groups tend to have poorer glucose control and greater risk of diabetes-related complications. In this systematic review of qualitative evidence (qualitative evidence synthesis, QES), we aimed to explore the experiences and views of clinical encounters in diabetes care from the perspectives of CYPD and their family/carers from underserved communities and healthcare professionals in diabetes care. We searched 6 databases to March 2022 with extensive search terms, and used a thematic synthesis following methods of Thomas and Harden. We identified 7 studies and described 11 descriptive themes based on primary and secondary constructs. From these, three "analytical themes" were developed. (1) "Alienation of CYPD" relates to their social identity and interaction with peers, family and health service practitioners in the context of diabetes self- and family/carer management and is impacted by communication in the clinical encounter. (2) "Empowerment of CYPD and family/carers" explores families' understanding of risks and consequences of diabetes and taking responsibility for self- and family/carer management in the context of their socio-cultural background. (3) "Integration of diabetes (into self and family)" focuses on the ability to integrate diabetes self-management into the daily lives of CYPD and family/carers beyond the clinical consultation. The analytical themes are interdependent and provide a conceptual framework from which to explore and strengthen the therapeutic alliance in clinical encounters and to foster greater concordance with treatment plans. Communicating the biomedical aspects of managing diabetes in the clinical encounter is important, but should be balanced with addressing socio-emotional factors important to CYPD and family/carers.

Perinatal healthcare systems, services and research are shaped by cisheteronormative assumptions, i.e. that families involve one woman who carries a pregnancy and one man who is a non-carrying partner; furthermore, assuming that conception has usually resulted from sexual intercourse, with both parties providing gametes. These assumptions obscure and sometimes exacerbate LGBTQ+ people's experiences and needs. This evidence synthesis aimed to identify and bring together the experiences of LGBTQ+ people who have faced pregnancy or baby loss; collectively perinatal loss. A qualitative evidence synthesis was conducted using systematic methods. Relevant databases were systematically searched using predefined search terms, and complimented by citation chaining. Eligibility was restricted to empirical qualitative studies published in English, unrestricted by participants' relationship to the loss (i.e. physically pregnant or not - sometimes respectively described as gestational/birthing or non-gestational/non-birthing parent), type of perinatal loss (e.g. miscarriage, stillbirth), time since loss, setting, publication date, or type of qualitative methodology. Study selection followed a multi-stage screening process. Thematic synthesis was used to analyse and interpret patterns of meaning across included studies. Seven studies met the eligibility criteria, reported across 10 papers. All seven were conducted in the Global North (including North America, Australia, and Europe). Thematic synthesis generated one overarching theme - enduring hope and loss - which captured the layers of loss experienced by LGBTQ+ people. This included the complexity of loss, and the loss commonly not being felt as an isolated incident, but rather part of a longer process. The three connected themes were: 1. Investment, which included the effort of navigating cisheteronormative systems, frequently after investing time, finances and emotions in assisted conception. 2. Support in relation to loss, highlighting the challenges of accessing support while being marginalised, excluded, or feeling invisible and, at times, unsafe as an LGBTQ+ family. 3. Meaning-making, in the immediate experience of loss, the aftermath of loss and the care received, and the time beyond. Cisheteronormative systems and interactions have potential to amplify loss and contribute to feelings of disenfranchisement amongst LGBTQ+ people. Further research is needed to evaluate support provided, inclusive of implications for subsequent reproductive choices.

Systematic reviews of qualitative research (‘qualitative evidence syntheses’) are increasingly popular and represent a potentially important source of information about people’s views, needs and experiences. Since 2013, Cochrane has published qualitative evidence syntheses, and the Cochrane Effective Practice and Organisation of Care group has been involved in the majority of these reviews. But more guidance is needed on how to prepare these reviews in an environment that is more familiar with reviews of quantitative research. In this paper, we describe and reflect on how Cochrane qualitative evidence syntheses differ from reviews of intervention effectiveness and how these differences have influenced the guidance developed by the EPOC group. In particular, we discuss how it has been important to display to end users, firstly, that qualitative evidence syntheses are carried out with rigour and transparency, and secondly, that these quality standards need to reflect qualitative research traditions. We also discuss lessons that reviews of effectiveness might learn from qualitative research.

The synthesis of qualitative research, particularly meta-ethnography, has become well established in health research. Qualitative evidence synthesis can help address a number of problems including insufficient appreciation of the value of qualitative research. If primary qualitative research can contribute to the transformation of health services by engaging with the views and experiences of those receiving and providing healthcare, then qualitative evidence synthesis can take this to a higher conceptual level by providing a more coherent understanding of the real lives of people receiving healthcare. In this chapter, I review five seminal meta-ethnographies by exploring how the products of these syntheses make original and potentially transformative contributions to healthcare. These syntheses contributed a series of new concepts and lines of argument. The concepts include lay testing; identity threat and stigma; and managing illness as a struggle. By helping to redress the epistemic injustices of testimonial injustice and hermeneutic injustice, which are endemic in healthcare, qualitative evidence synthesis can support more person-centred practice. Qualitative evidence synthesis can give credence and authority to patients’ perspectives. If synthesis authors make the effort to communicate their findings to the public, this may help to change communication in healthcare settings.

Background: The demand for long-term residential care for people with dementia is, especially for those in the moderate to severe stages, increasing. However, dementia care services within long-term care (LTC) settings remain underdeveloped in low- and middle-income countries (LMICs). Objectives: This qualitative evidence synthesis aimed to explore LTC staff's experiences of taking care of people with dementia in LTC facilities in LMICs. Methods: A comprehensive literature search was conducted of six databases in January 2023 and updated in August 2024 for qualitative studies of LTC staff's experience of caring for people with dementia. Thematic synthesis was utilised for data synthesis, and NVivo facilitated this process. Results: 8,565 studies were screened, and 11 articles were included in this review. The studies included were conducted in Brazil (n = 2), China (n = 5), India (n = 1), Iran (n = 1), Malaysia (n = 1) and South Africa (n = 1) between 2012 and 2024. An overarching theme was identified: We are an island: underdeveloped dementia care within the LTC settings in LMICs, and the following categories identified as (1) the development of care provided for people living with dementia within care home settings is in its infancy; (2) the positive and effective coping strategies that may help embrace a brighter future of dementia care; (3) the deficiencies in caregiving approaches that contributed to poor-quality care for people living with dementia. Conclusions: The development of dementia care services within LTC in LMICs is still in its early stages. The main concern is the lack of available support and training for care staff and their insufficient dementia knowledge and care competencies. We hope that this review will help to increase attention to this significant issue of long-term institutional care for people with dementia in LMICs and that further research could investigate and enhance potential improvements in the practical implementation of long-term residential dementia care.

BackgroundCoeliac disease is a chronic autoimmune condition associated with intestinal and extraintestinal symptoms. Coeliac Disease is managed through strict adherence to a gluten-free diet, which, though usually effective, is challenging to maintain. This review synthesised qualitative research on the psychosocial experiences of adults living with coeliac disease.MethodsKeyword searches were conducted of the academic databases CINAHL, EMBASE, MEDLINE, PsychINFO, SCOPUS and Web of Science for articles published (2005–2021), followed by forward and backward searches. Thematic synthesis of included articles was carried out on sections reporting findings or results, discussion, conclusions, and supporting data. The inductive thematic synthesis identified descriptive and analytical themes from the included studies.ResultsOf 1284 records identified, 17 articles from 15 original studies were included in the thematic synthesis. The majority of studies were from Europe (76%), with the remainder from North America and Australia. Data represented 371 adults with coeliac disease (72% female; 17–85 years old, diagnosed < 1–42 years ago) across eight countries. Findings identified six analytical themes relating to the psychosocial experience of coeliac disease: ‘Living with ongoing risk’; ‘Losing more than gluten’; ‘A changed identity’; ‘A changed relationship with food’; ‘The gluten-free diet creates a multifaceted burden’; and ‘Learning how to live well with Coeliac Disease’.ConclusionsCoeliac disease changes adults’ psychosocial experiences. Adaptation involves ongoing learning, and development of psychological acceptance facilitates adjustment. Increased public education about coeliac disease may reduce stigma and risk. Psychosocial assessment and support could improve quality of life post-diagnosis.

In sub-Saharan Africa, accessing HIV testing services is a significant challenge for men who have sex with men (MSM) and transgender women (TGW). In this qualitative evidence synthesis, our aim is to understand social and structural barriers and how they hinder MSM’s and TGW’s access to HIV testing services in sub-Saharan African countries. We searched four selective databases (PubMed, Web of Science and CINAHL complemented with Google Scholar) for qualitative studies, published in English between January 2005 and December 2023, generated 1507 articles, of which 22 were included. Thematic synthesis was conducted for data synthesis. This led to five barriers that hinder HIV test uptake among MSM and TGW, which included: non-availability of tailored HIV testing services, stigma, lack of trust among service providers, sexual and physical violence, and criminalization of same sex relationship. To navigate these social and structural barriers and cope with fears of discrimination and criminalization, MSM and TGW engaged into riskier behaviors, including avoiding HIV testing, non-disclosure, or relying on informal or alternative sources of HIV testing. Decriminalization of same-sex relationship and peer-led HIV testing services were noted to address structural barriers, including stigma and poor access, and subsequently increase the participation in HIV testing services.

To identify and summarise health workers' views on the use of audit as a method to improve the quality of maternal and newborn healthcare in low- and middle-income countries (LMICs). We conducted a qualitative evidence synthesis. PubMed, CINAHL and Global Health databases were searched using keywords, synonyms and MeSH headings for 'audit', 'views' and 'health workers' to find papers that used qualitative methods to explore health workers' views on audit in LMICs. Titles and abstracts were then screened for inclusion. The remaining full-text papers were then screened. The final included papers were quality assessed using the Critical Appraisal Skills Programme tool for qualitative research. Data on audit type and health workers' perceptions were extracted and analysed using thematic synthesis. Nineteen papers were included in the review, most from sub-Saharan Africa. Health workers generally held favourable views of audit and expressed dedication to the process. Similarly, they described positive experiences conducting audit. The main barriers to implementing audit were the presence of a blame culture, inadequate training and the lack of time and resources to conduct audit. Health workers' motivation and dedication to the audit process helped to overcome such barriers. Health workers are dedicated to the process of audit, but must be supported with training, leadership and adequate resources to use it. Decision-makers and technical partners supporting audit should focus on improving audit training and finding ways to conduct audit without requiring too much staff time.