Methods of Synthesising Qualitative Evidence

Methods of Synthesising Qualitative Research Studies for Health Technology Assessment Nicola Ring & Ruth Jepson School of Nursing, Midwifery and Health, University of Stirling. Karen Ritchie Healthcare Improvement Scotland

Qualitative synthesis can: Enable reviewers/policy makers to: • understand the personal perspective • identify patient/carer needs & preferences for new technologies/service models Assist in HTA decision-making by: • helping assess effectiveness & appropriateness of interventions • providing insight into heterogeneity of trial outcomes

But …… ...its potential is yet to be fully realised.

Many areas of debate, e.g. •should qualitative studies be synthesised? • if so, which way is best, given that various methods exist? Many practical challenges, e.g. •searching, identifying and quality assessing relevant studies •confusing & daunting terminology

Narrative synthesis Metaethnography

Narrative summary

Meta-summary

Meta-study Meta-method

MetaInterpretation

Metasynthesis

Metareview

Meta-data analysis

Results Eight distinct methods identified: 1. meta-ethnography 2. thematic synthesis 3. meta-study 4. meta-summary 5. critical interpretive synthesis 6. grounded theory synthesis 7. meta-interpretation 8. qualitative cross-case analysis Research-led, Practice-driven, People-focussed

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Review of Qualitative Syntheses* We identified 107 reviews using 8 main synthesis methods Most useful/used: Meta-ethnography & Thematic synthesis Useful/used: Meta-study & Meta-summary Less well used: Critical interpretive synthesis, Grounded theory synthesis, Meta-interpretation, Qualitative cross-case analysis. *Int J Technol Assess Health Care, 27:4 (2011), 384–390.

Meta-ethnography • At least 63 published reviews identified • Leading method of qualitative synthesis • Original Noblit & Hare principles are frequently adapted/modified • Reviews on wide range of topics: • Disease/clinical conditions e.g. diabetes • Health services/technologies e.g. medicines • Other health/social care e.g. nurse education.

The 7 Steps of Meta-ethnography: 1. Getting started (the search) 2. Confirming initial interest (literature screening) 3. Reading studies and extracting data 4. Determining how studies are related (identifying common themes and concepts)

5. Translating studies (checking first and second order concepts and themes against each other) 6. Synthesising translations (creating new third order constructs, providing fresh insight within a ‘line of argument’) 7. Expressing the synthesis (e.g. report writing). (Noblit & Hare 1988)

Thematic synthesis • At least 15 published reviews identified • Useful in integrating qualitative research with quantitative findings • Reviews on wide range of topics: • Health services/technologies e.g. clinical decision-making, experiences of acute care (n=10) • Disease/clinical conditions e.g. understanding cancer risk, teenage pregnancy (n=5)

Thematic synthesis • Developed by the EPPI Centre for health promotion reviews • Provides a framework for integrating quantitative and qualitative research. • Steps include: – free coding of text ‘line-by-line’ from primary studies – organisation and development of ‘descriptive themes’ from within the relevant texts – generation of ‘analytical themes’

Thomas & Harden 2008

Integrating syntheses of qualitative and quantitative studies using a thematic approach Research Question

Synthesis of quantitative studies

Thematic synthesis of qualitative studies

Cross-study synthesis

Matrix juxtaposing themes against interventions Example Recommendation for intervention from children's views Do not promote fruit and vegetables in the same way Reduce health emphasis in messages to promote fruit and vegetables, particularly those which concern future health

Trials Good quality Other 0 0

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6 (Thomas et al 2004)

Understanding interventions using qualitative synthesis: an example Asthma action plans (AP): • In trials these improve clinical outcomes BUT • Internationally these are under-used • Working since 2006 to investigate barriers/ facilitators to use: – Trial based SR (Ring et al 2007) – Meta ethnography of views of patients/carer and professionals (Ring et al 2011) – Final step: integrate both sets of findings.

Integrating quantitative & qualitative synthesis findings • Meta-ethnography used to generate a model of AP implementation from perspective of patients/carers/professionals. • ‘Tested’ elements (e.g. partnership) in this model against RCT interventions to see if components within them. • Elements in implementation model contained in RCT interventions but underacknowledged in delivery & outcomes. 13

Conclusions Syntheses of qualitative research studies: • increasingly being used • give new insight into health conditions, health service delivery & interventions from personal perspective • different methods exist but most useful/common are meta ethnography & thematic synthesis • can contribute to HTA as standalone process or through integration with quantitative synthesis findings • potential yet to be fully realised in HTA process.

References Dixon-Woods M, Booth A, Sutton AJ. (2007) Synthesizing qualitative research: A review of published reports. Qualitative Research 7:375-422. Downie S. (2008) Meta-synthesis: a guide to knitting smoke. Evidence Based Midwifery 6(1):4-8. Harden A. et al. (2009) Teenage pregnancy and social disadvantage: systematic review integrating controlled trials and qualitative studies. British Medical Journal 339:b4254. Noblit GW, Hare RD. (1988) Meta-ethnography: synthesising qualitative studies. London: Sage. Ring N. et al. (2007) Promoting the use of Personal Asthma Action Plans: a systematic review. Primary Care Respiratory Journal 16(5):271-83. Ring N. et al. (2011) Understanding what helps or hinders asthma action plan use: a systematic review and synthesis of the qualitative literature. Patient Education and Counselling 85: e131-e143. Ring N, Jepson R, Ritchie K. (2011) Methods of synthesising qualitative research studies for health technology assessment. International Journal of Technology Assessment in Healthcare. 27(4) 384390. Ring N., Ritchie K, Mandava L, Jepson R. (2011) A guide to synthesising qualitative research for researchers undertaking health technology assessment and systematic reviews. NHS Quality Improvement Scotland and University of Stirling, Edinburgh. ISBN: 1 84404 917 5 Thomas J. et al. (2004) Integrating qualitative research with trials in systematic reviews. British Medical Journal 328:1010-12. Thomas J, Harden A. (2008) Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Medical Research Methods. 8:45. Iceberg picture from: www.tv.com . Asthma Action Plan from Asthma UK website.