Helen Smith

Conducting a meta-ethnography of qualitative literature: lessons learnt.

BackgroundQualitative synthesis has become more commonplace in recent years. Meta-ethnography is one of several methods for synthesising qualitative research and is being used increasingly within health care research. However, many aspects of the steps in the process remain ill-defined.DiscussionWe utilized the seven stages of the synthesis process to synthesise qualitative research on adherence to tuberculosis treatment. In this paper we discuss the methodological and practical challenges faced; of particular note are the methods used in our synthesis, the additional steps that we found useful in clarifying the process, and the key methodological challenges encountered in implementing the meta-ethnographic approach.The challenges included shaping an appropriate question for the synthesis; identifying relevant studies; assessing the quality of the studies; and synthesising findings across a very large number of primary studies from different contexts and research traditions. We offer suggestions that may assist in undertaking meta-ethnographies in the future.SummaryMeta-ethnography is a useful method for synthesising qualitative research and for developing models that interpret findings across multiple studies. Despite its growing use in health research, further research is needed to address the wide range of methodological and epistemological questions raised by the approach.

Understanding careseeking for child illness in sub-Saharan Africa: A systematic review and conceptual framework based on qualitative research of household recognition and response to child diarrhoea, pneumonia and malaria

Diarrhoea, pneumonia and malaria are the largest contributors to childhood mortality in sub-Saharan Africa. While supply side efforts to deliver effective and affordable interventions are being scaled up, ensuring timely and appropriate use by caregivers remains a challenge. This systematic review synthesises qualitative evidence on the factors that underpin household recognition and response to child diarrhoea, pneumonia and malaria in sub-Saharan Africa. For this review, we searched six electronic databases, hand searched 12 journals from 1980 to 2010 using key search terms, and solicited expert review. We identified 5104 possible studies and included 112. Study quality was appraised using the Critical Appraisal Skills Program (CASP) tool. We followed a meta-ethnographic approach to synthesise findings according to three main themes: how households understand these illnesses, how social relationships affect recognition and response, and how households act to prevent and treat these illnesses. We synthesise these findings into a conceptual model for understanding household pathways to care and decision making. Factors that influence household careseeking include: cultural beliefs and illness perceptions; perceived illness severity and efficacy of treatment; rural location, gender, household income and cost of treatment. Several studies also emphasise the importance of experimentation, previous experience with health services and habit in shaping household choices. Moving beyond well-known barriers to careseeking and linear models of pathways to care, the review suggests that treatment decision making is a dynamic process characterised by uncertainty and debate, experimentation with multiple and simultaneous treatments, and shifting interpretations of the illness and treatment options, with household decision making hinging on social negotiations with a broad variety of actors and influenced by control over financial resources. The review concludes with research recommendations for tackling remaining gaps in knowledge.

Evidence-based obstetrics in four hospitals in China: An observational study to explore clinical practice, women's preferences and provider's views

BackgroundEvidence-based obstetric care is widely promoted in developing countries, but the success of implementation is not known. Using selected childbirth care procedures in four hospitals in Shanghai, we compared practice against evidence-based information, and explored user and provider views about each procedure.MethodsObservational study. Using the Cochrane Library, we identified six procedures that should be avoided as routine and two that should be encouraged. Procedure rate determined by exit interviews with women, verified using hospital notes. Views of women and providers explored with in depth interviews.The study sites were three hospitals in Shanghai and one in neighbouring province of Jiangsu. 150 women at each centre for procedure rate, and 48 in-depth interviews with women and providers.ResultsVaginal births were 50% (303/599) of the total. Of the six practices where evidence suggests they should be avoided as routine, three were performed with rates above 70%: pubic shaving (3 hospitals), rectal examination (3 hospitals), and episiotomy (3 hospitals). Most women delivered lying down, pain relief was rarely given, and only in the urban district hospital did women routinely have a companion. Most women wanted support or companionship during labour and to be given pain relief; but current practice is insufficient to meet womens needs.ConclusionObstetric practice is not following best available evidence in the hospitals studied. There is a need to adjust hospital policy to support the use of interventions proven to be of benefit to women during childbirth, and develop approaches that ensure clinical practice changes.

Access to electronic health knowledge in five countries in Africa: A descriptive study.

BackgroundAccess to medical literature in developing countries is helped by open access publishing and initiatives to allow free access to subscription only journals. The effectiveness of these initiatives in Africa has not been assessed. This study describes awareness, reported use and factors influencing use of on-line medical literature via free access initiatives.MethodsDescriptive study in four teaching hospitals in Cameroon, Nigeria, Tanzania and Uganda plus one externally funded research institution in The Gambia. Survey with postgraduate doctors and research scientists to determine Internet access patterns, reported awareness of on-line medical information and free access initiatives; semi structured interviews with a sub-sample of survey participants to explore factors influencing use.ResultsIn the four African teaching hospitals, 70% of the 305 postgraduate doctors reported textbooks as their main source of information; 66% had used the Internet for health information in the last week. In two hospitals, Internet cafés were the main Internet access point. For researchers at the externally-funded research institution, electronic resources were their main source, and almost all had used the Internet in the last week. Across all 333 respondents, 90% had heard of PubMed, 78% of BMJ on line, 49% the Cochrane Library, 47% HINARI, and 19% BioMedCentral. HINARI use correlates with accessing the Internet on computers located in institutions. Qualitative data suggested there are difficulties logging into HINARI and that sometimes it is librarians that limit access to passwords.ConclusionText books remain an important resource for postgraduate doctors in training. Internet use is common, but awareness of free-access initiatives is limited. HINARI and other initiatives could be more effective with strong institutional endorsement and management to promote and ensure access.

Language and rigour in qualitative research: Problems and principles in analyzing data collected in Mandarin

In collaborative qualitative research in Asia, data are usually collected in the national language, and this poses challenges for analysis. Translation of transcripts to a language common to the whole research team is time consuming and expensive; meaning can easily be lost in translation; and validity of the data may be compromised in this process. We draw on several published examples from public health research conducted in mainland China, to highlight how language can influence rigour in the qualitative research process; for each problem we suggest potential solutions based on the methods used in one of our research projects in China.Problems we have encountered include obtaining sufficient depth and detail in qualitative data; deciding on language for data collection; managing data collected in Mandarin; and the influence of language on interpreting meaning.We have suggested methods for overcoming problems associated with collecting, analysing, and interpreting qualitative data in a local language, that we think help maintain analytical openness in collaborative qualitative research. We developed these methods specifically in research conducted in Mandarin in mainland China; but they need further testing in other countries with data collected in other languages. Examples from other researchers are needed.

Patient medical costs for tuberculosis treatment and impact on adherence in China: a systematic review

BackgroundCharging for tuberculosis (TB) treatment could reduce completion rates, particularly in the poor. We identified and synthesised studies that measure costs of TB treatment, estimates of adherence and the potential impact of charging on treatment completion in China.MethodsInclusion criteria were primary research studies, including surveys and studies using qualitative methods, conducted in mainland China. We searched MEDLINE, PUBMED, EMBASE, Science Direct, HEED, CNKI to June 2010; and web pages of relevant Chinese and international organisations. Cost estimates were extracted, transformed, and expressed in absolute values and as a percentage of household income.ResultsLow income patients, defined at household or district level, pay a total of US

Fostering children affected by AIDS in Richards Bay, South Africa: a qualitative study of grandparents' experiences

149 to 724 (RMB 1241 to 5228) for medical costs for a treatment course; as a percentage of annual household income, estimates range from 42% to 119%. One national survey showed 73% of TB patients at the time of the survey had interrupted or suspended treatment, and estimates from 9 smaller more recent studies showed that the proportion of patients at the time of the survey who had run out of drugs or were not taking them ranged from 3 to 25%. Synthesis of surveys and qualitative research indicate that cost is the most cited reason for default.ConclusionsDespite a policy of free drug treatment for TB in China, health services charge all income groups, and costs are high. Adherence measured in cross sectional surveys is often low, and the cumulative failure to adhere is likely to be much higher. These findings may be relevant to those concerned with the development and spread of multi-drug resistant TB. New strategies need to take this into account and ensure patient adherence.

Promoting childbirth companions in South Africa: a randomised pilot study

Grandparents are increasingly becoming the primary carers of children orphaned by the HIV epidemic in South Africa. Traditional family roles are being reversed as aging family members take responsibility for the physical and psychosocial needs of children. This study uses qualitative research to explore the experiences of grandparents fostering children orphaned by AIDS in Richards Bay, KwaZulu-Natal Province, South Africa. The idea was born after a local HIV support organisation (Richards Bay Family Care) observed a trend within their organisation of grandparents increasingly becoming foster parents for orphans. An exploratory study was conducted in the organisations three target areas (two rural villages and urban Richards Bay); the ultimate aim was to explore options for improving financial and emotional support for this group. The qualitative research methods included: four focus group discussions with foster-carers and community leaders (including two pocket-chart voting exercises); 12 in-depth interviews with grandparent foster-carers; and ten key-informant interviews, mostly with staff who provide support services. Data analysis was by thematic framework. The needs of the grandparent fostercarers varied: the rural participants were essentially concerned with meeting childrens basic needs (housing, food and education), while those in urban areas more often felt pressure to provide emotional and psychological support for orphans. In both groups, women were at the forefront of foster care. Important problems identified by the grandparents were child discipline and a feeling of disharmony in the intergenerational relationship. Government foster care grants were identified as a regular source of income for especially the rural foster-carers. The findings may help programme managers better understand the differences in the needs of urban and rural foster parents. The experiences of grandparents as carers of orphans affected by HIV or AIDS are unique considering their age, frailty and poverty status. More research is needed on the role played by men in fostering children orphaned by AIDS.

Promoting contraceptive use among unmarried female migrants in one factory in Shanghai: a pilot workplace intervention.

AbstractBackgroundMost women delivering in South African State Maternity Hospitals do not have a childbirth companion; in addition, the quality of care could be better, and at times women are treated inhumanely. We piloted a multi-faceted intervention to encourage uptake of childbirth companions in state hospitals, and hypothesised that lay carers would improve the behaviour of health professionals.MethodsWe conducted a pilot randomised controlled trial of an intervention to promote childbirth companions in hospital deliveries. We promoted evidence-based information for maternity staff at 10 hospitals through access to the World Health Organization Reproductive Health Library (RHL), computer hardware and training to all ten hospitals. We surveyed 200 women at each site, measuring companionship, and indicators of good obstetric practice and humanity of care. Five hospitals were then randomly allocated to receive an educational intervention to promote childbirth companions, and we surveyed all hospitals again at eight months through a repeat survey of postnatal women. Changes in median values between intervention and control hospitals were examined.ResultsAt baseline, the majority of hospitals did not allow a companion, or access to food or fluids. A third of women were given an episiotomy. Some women were shouted at (17.7%, N = 2085), and a few reported being slapped or struck (4.3%, N = 2080). Despite an initial positive response from staff to the childbirth companion intervention, we detected no difference between intervention and control hospitals in relation to whether a companion was allowed by nursing staff, good obstetric practice or humanity of care.ConclusionThe quality and humanity of care in these state hospitals needs to improve. Introducing childbirth companions was more difficult than we anticipated, particularly in under-resourced health care systems with frequent staff changes. We were unable to determine whether the presence of a lay carer impacted on the humanity of care provided by health professionals. Trial registration: Current Controlled Trials ISRCTN33728802

World Health Organization guideline development: an evaluation.

BackgroundIn urban China, more single women are becoming pregnant and resorting to induced abortion, despite the wide availability of temporary methods of contraception. We developed and piloted a workplace-based intervention to promote contraceptive use in unmarried female migrants working in privately owned factories.MethodsQuasi-experimental design. In consultation with clients, we developed a workplace based intervention to promote contraception use in unmarried female migrants in a privately owned factory. We then implemented this in one factory, using a controlled before-and-after design. The intervention included lectures, bespoke information leaflets, and support to the factory doctors in providing a contraceptive service.Results598 women participated: most were under 25, migrants to the city, with high school education. Twenty percent were lost when staff were made redundant, and implementation was logistically complicated. All women attended the initial lecture, and just over half the second lecture. Most reported reading the educational material provided (73%), but very few women reported using the free family planning services offered at the factory clinic (5%) or the Family Planning Institute (3%). At baseline, 90% (N = 539) stated that contraceptives were required if having sex before marriage; of those reporting sex in the last three months, the majority reporting using contraceptives (78%, 62/79) but condom use was low (44%, 35/79).Qualitative data showed that the reading material seemed to be popular and young women expressed a need for more specific reproductive health information, particularly on HIV/AIDS. Women wanted services with some privacy and anonymity, and views on the factory service were mixed.ConclusionImplementing a complex intervention with a hard to reach population through a factory in China, using a quasi-experimental design, is not easy. Further research should focus on the specific needs and service preferences of this population and these should be considered in any policy reform so that contraceptive use may be encouraged among young urban migrant workers.