Ginny Brunton

Integrating qualitative research with trials in systematic reviews

An example review from public health shows how integration is possible and some potential benefits The value of including data from different types of studies in systematic reviews of health interventions is increasingly recognised. A recent editorial accepted that qualitative research should be included in systematic reviews, but pointed to a “daunting array of theoretical and practical problems.”1 This article presents an approach to combining qualitative and quantitative research in a systematic review. We describe how we used this approach in a systematic review of interventions to promote healthy eating among children, full details of which are available.2 The review question was: “What is known about the barriers to, and facilitators of, healthy eating among children aged 4-10 years?” The specific focus of the review was fruit and vegetable intake. We searched for two types of research: controlled trials (randomised or non-randomised) that examined interventions to promote healthy eating and studies that examined childrens perspectives and understandings (views studies), often by using qualitative research methods—for example, in-depth interviews and focus groups. ![][1] But will she eat her greens? Credit: PAUL DARRAH/REX We used conventional systematic review methods: sensitive searching, systematic screening, and independent quality assessment. These methods found 33 trials and eight qualitative studies that met our prespecified inclusion criteria. We assessed studies for quality and reliability according to standards for their specific study types; they were then synthesised individually by using methods appropriate to the study. We conducted a meta-analysis with the data extracted from trials, used qualitative methods to synthesise the textual data extracted from the qualitative studies, and then integrated the findings from the qualitative synthesis with those from the meta-analysis. This gave us one review with three syntheses (fig 1). Fig 1 Stages of the review We maintained the key principles of avoiding bias and maximising … [1]: /embed/graphic-1.gif

Applying systematic review methods to studies of people's views: an example from public health research

Methods for systematic reviews are well developed for trials, but not for non-experimental or qualitative research. This paper describes the methods developed for reviewing research on people’s perspectives and experiences (“views” studies) alongside trials within a series of reviews on young people’s mental health, physical activity, and healthy eating. Reports of views studies were difficult to locate; could not easily be classified as “qualitative” or “quantitative”; and often failed to meet seven basic methodological reporting standards used in a newly developed quality assessment tool. Synthesising views studies required the adaptation of qualitative analysis techniques. The benefits of bringing together views studies in a systematic way included gaining a greater breadth of perspectives and a deeper understanding of public health issues from the point of view of those targeted by interventions. A systematic approach also aided reflection on study methods that may distort, misrepresent, or fail to pick up people’s views. This methodology is likely to create greater opportunities for people’s own perspectives and experiences to inform policies to promote their health.

Teenage pregnancy and social disadvantage: systematic review integrating controlled trials and qualitative studies

Objectives To determine the impact on teenage pregnancy of interventions that address the social disadvantage associated with early parenthood and to assess the appropriateness of such interventions for young people in the United Kingdom. Design Systematic review, including a statistical meta-analysis of controlled trials on interventions for early parenthood and a thematic synthesis of qualitative studies that investigated the views on early parenthood of young people living in the UK. Data sources 12 electronic bibliographic databases, five key journals, reference lists of relevant studies, study authors, and experts in the field. Review methods Two independent reviewers assessed the methodological quality of studies and abstracted data. Results Ten controlled trials and five qualitative studies were included. Controlled trials evaluated either early childhood interventions or youth development programmes. The overall pooled effect size showed that teenage pregnancy rates were 39% lower among individuals receiving an intervention than in those receiving standard practice or no intervention (relative risk 0.61; 95% confidence interval 0.48 to 0.77). Three main themes associated with early parenthood emerged from the qualitative studies: dislike of school; poor material circumstances and unhappy childhood; and low expectations for the future. Comparison of these factors related to teenage pregnancy with the content of the programmes used in the controlled trials indicated that both early childhood interventions and youth development programmes are appropriate strategies for reducing unintended teenage pregnancies. The programmes aim to promote engagement with school through learning support, ameliorate unhappy childhood through guidance and social support, and raise aspirations through career development and work experience. However, none of these approaches directly tackles all the societal, community, and family level factors that influence young people’s routes to early parenthood. Conclusions A small but reliable evidence base supports the effectiveness and appropriateness of early childhood interventions and youth development programmes for reducing unintended teenage pregnancy. Combining the findings from both controlled trials and qualitative studies provides a strong evidence base for informing effective public policy.

An Emerging Framework for Including Different Types of Evidence in Systematic Reviews for Public Policy

Evidence-informed policy and practice call on research addressing a broad range of research questions: evaluating the need for, and development, implementation, acceptability and effectiveness of interventions. Synthesizing this evidence requires methods that integrate the findings from diverse study designs. This article reports the development of a new model of research synthesis for this purpose. On completion of a series of substantive reviews, methodological reflections addressed: the interrelationship between review questions, relevant theory and values within the review process; methodological similarities and differences with more conventional reviews of effectiveness; the added value in terms of conclusions and specific recommendations; and the relevance to public policy.

Attitudes to walking and cycling among children, young people and parents: a systematic review

Background: Promoting walking and cycling as a part of everyday activity is seen as a strategy for tackling obesity and chronic disease. Policy needs to be based on evidence about people’s views of walking and cycling as well as effects of interventions. Methods: Studies of the views of children, young people and parents about walking and cycling were searched for systematically, and a framework analysis applied. The findings were synthesised and compared with the findings of an effectiveness review of interventions for encouraging walking and cycling as an alternative to motorised transport. Results: The synthesis of views described a culture of car use, fed by a fear and dislike of local environments and parental responses that emphasised children’s safety at the expense of developing their independence, despite children expressing responsible attitudes towards transport choices. Comparison with effectiveness literature found that most evaluated interventions targeted only the public’s fear and dislike of local environments. Conclusion: Interventions need to address pedestrian and cyclist safety, perceptions of risk, and parental norms regarding children’s independence.

Evaluating the effectiveness of public health interventions: the role and activities of the Cochrane Collaboration

Public health decision makers, funders, practitioners, and the public are increasingly interested in the evidence that underpins public health decision making. Decisions in public health cover a vast range of activities. With the ever increasing global volume of primary research, knowledge and changes in thinking and approaches, quality systematic reviews of all the available research that is relevant to a particular practice or policy decision are an efficient way to synthesise and utilise research efforts. The Cochrane Collaboration includes an organised entity that aims to increase the quality and quantity of public health systematic reviews, through a range of activities. This paper aims to provide a glossary of the terms and activities related to public health and the Cochrane Collaboration.

The effectiveness of community engagement in public health interventions for disadvantaged groups: a meta-analysis

BackgroundInequalities in health are acknowledged in many developed countries, whereby disadvantaged groups systematically suffer from worse health outcomes such as lower life expectancy than non-disadvantaged groups. Engaging members of disadvantaged communities in public health initiatives has been suggested as a way to reduce health inequities. This systematic review was conducted to evaluate the effectiveness of public health interventions that engage the community on a range of health outcomes across diverse health issues.MethodsWe searched the following sources for systematic reviews of public health interventions: Cochrane CDSR and CENTRAL, Campbell Library, DARE, NIHR HTA programme website, HTA database, and DoPHER. Through the identified reviews, we collated a database of primary studies that appeared to be relevant, and screened the full-text documents of those primary studies against our inclusion criteria. In parallel, we searched the NHS EED and TRoPHI databases for additional primary studies. For the purposes of these analyses, study design was limited to randomised and non-randomised controlled trials. Only interventions conducted in OECD countries and published since 1990 were included. We conducted a random effects meta-analysis of health behaviour, health consequences, self-efficacy, and social support outcomes, and a narrative summary of community outcomes. We tested a range of moderator variables, with a particular emphasis on the model of community engagement used as a potential moderator of intervention effectiveness.ResultsOf the 9,467 primary studies scanned, we identified 131 for inclusion in the meta-analysis. The overall effect size for health behaviour outcomes is d = .33 (95% CI .26, .40). The interventions were also effective in increasing health consequences (d = .16, 95% CI .06, .27); health behaviour self-efficacy (d = .41, 95% CI .16, .65) and perceived social support (d = .41, 95% CI .23, .65). Although the type of community engagement was not a significant moderator of effect, we identified some trends across studies.ConclusionsThere is solid evidence that community engagement interventions have a positive impact on a range of health outcomes across various conditions. There is insufficient evidence to determine whether one particular model of community engagement is more effective than any other.

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

BackgroundSystematic 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.MethodsHaving 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.ResultsThe 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.ConclusionsQCA 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.

Interventions addressing the social determinants of teenage pregnancy

Purpose – The limited evidence of effectiveness of existing teenage pregnancy strategies which focus on sex education, together with growing evidence that factors such as poor school ethos, disaffection, truancy, poor employment prospects and low expectations are associated with teenage pregnancy, has increased interest in interventions which target these “wider” social determinants. This paper aims to identify promising interventions and priorities for future research and to make recommendations for policy and practice in the UK. Design/methodology/approach – This paper discusses the evidence regarding the potential of interventions which target determinants of teenage pregnancy relating to school disaffection and low expectations, drawing on recent systematic reviews and trials to consider future directions for research, policy and practice. Findings – High-quality research evidence illustrates the potential of two approaches to address determinants of teenage pregnancy relating to disaffection and low expectations. These are school-ethos interventions, which aim to facilitate a positive and inclusive school-ethos, strengthen school relationships and reduce disaffection; and targeted, intensive youth work interventions, which aim to promote positive expectations, vocational readiness and self-esteem through vocational and life-skills education, volunteering and work experience. Practical implications – Two forms of intervention which address key social determinants of teenage pregnancy – school-ethos interventions and targeted youth work interventions – require more attention from researchers and policy-makers. Originality/value – This paper calls for a shift in the research and policy agenda. In addition to interventions that aim to address proximal, individual factors, such as sexual health-related knowledge, there should be a more complementary focus on socio-environmental as well as targeted individual-focused interventions aiming to address the wider social determinants of teenage pregnancy.

Psychosocial Predictors, Assessment, and Outcomes of Cosmetic Procedures: A Systematic Rapid Evidence Assessment

BackgroundRecent breast implant complications led to a UK government policy review of the evidence concerning cosmetic interventions. We synthesised cosmetic intervention research evidence covering psychosocial factors associated with requesting procedures and psychological outcomes, effects of procedures on psychological outcomes, preintervention assessments for identifying those at risk, alternative therapy effectiveness, and issues in achieving informed consent.MethodsUndertaking a systematic rapid evidence assessment, six databases and three journals were searched. Included studies were systematic reviews or primary studies of participants requesting cosmetic procedures; published 2002–2012; containing either psychological or psychosocial measures, a psychological outcome, or evaluation of informed consent. Reviewers independently assessed study eligibility, extracted data, and assessed quality, undertaking narrative synthesis.ResultsMethodological quality of the included 13 systematic reviews and 179 primary studies was low, with wide variation in psychosocial measures. Findings suggest several psychosocial factors (e.g., intimate partner violence) may be associated with requesting cosmetic surgery. Multiple factors (e.g., unrealistic expectations) may predict poor psychological outcomes. Current psychological screening tools focus predominantly on body dysmorphic disorder (BDD) symptoms. Psychological and pharmacological interventions are effective alternative BDD treatments. Patients and doctors bring different needs to informed consent discussions, inconsistently matched to those required by professional ethics, litigation risk, and facilitating profit.ConclusionsSystematically reviewing this literature for UK policy has highlighted that some groups may be at risk of poor post-cosmetic procedure outcomes. Practitioners and patients must explore reasons for seeking cosmetic procedures and discuss all potential results and alternative solutions. Future research should employ more robust methodologies to identify effects in those at risk, led by consensus on a core set of psychological outcomes.Level of Evidence IIIThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.