A Walk Through Thematic Synthesis: A Worked Example Of Qualitative .

A walk through Thematic Synthesis:A worked example of qualitativeevidence synthesisCatherine HoughtonSchool of Nursing and MidwiferyEvidence Synthesis Ireland TrainerMay 2020

Overview About meAbout Evidence Synthesis IrelandAbout Qualitative Evidence SynthesisAbout Thematic SynthesisA worked example of thematic synthesis

About me Senior Lecturer in Nursing and Midwifery,NUIG Qualitative researcher Co-chair of QUESTS ESI trainer [On sabbatical]

Acknowledgements IIQMAtlas-tiEvidence Synthesis IrelandJenny McSharryNUI GalwayAlex Clark and Bailey Sousa

Building evidence synthesis knowledge,awareness and capacity on the island of Irelandwww.evidencesynthesisireland.ieemail: reland@EvidSynIRL CochraneIreland

KEY ACTIVITIES

About Qualitative Evidence SynthesisSYSTEMATICREVIEWQESQUALITATIVERESEARCH

A real meal deal question-led, protocol-driven study of abody of qualitative literature with a systematic approach tostudy selection, quality, and synthesis. While morequalitative systematic reviews are being done than ever,more are still needed. Relevant Scholarly conversations-where you stand andwhat your work adds! Get specific-what are the nuances of what is beingexperienced and by what population-avoid generic lifeexperience Foster creativity- the specifics require careful thought andcreativity Strategic sense- "I know my stuff"

Qualitative EvidenceSynthesisQualitative evidence synthesis is a process of scientificenquiry aimed at reviewing and rigorously integratingthe findings of qualitative research (Thorne et al. 2004,Sandelowski and Barroso 2007).A means of presenting the complexities of humanexperiences in a way that is recognisable to theevidence-based community (Thorne 2008).

subsuming the concepts from theprimary studies (Dixon-Woods et al. 2005) about retaining differences andenlightening complexities (Thorne et al. 2004)

The Family “a family of methodological approachesto developing new knowledge based onrigorous analysis of existing qualitativefindings” (Thorne at al. 2004, p.1343)

Qualitative Evidence Synthesis:Choosing a MethodologyResearch seAudience and purposeType of data

About thematic synthesis Thomas and HardenPragmaticUseful for integrating findings with intervention reviewsImportant to “go beyond” the primary studies (Thomas and Harden, 2008)3 Stages:line by line codinggeneration of descriptive themesgeneration of interpretive/analytical themes

A worked example of thematic synthesisTo explore potential participants’ views and experiences of therecruitment process for participation in trials. The specificobjectives were to: Describe potential participants’ perceptions and experiences of acceptingor declining to participate in trials Explore the barriers and facilitators to participating in trials Explore to what extent the barriers and facilitators identified wereaddressed by strategies to improve recruitment evaluated in a previouslypublished Cochrane review (Treweek 2018)

STAGES of QES Refining the questionSearchingScreeningData extractionAssessment of methodological limitationsSynthesisAssessment of confidenceReporting

FORMULATING THE QUESTIONBOOTH ET AL. (2016)SPICE Setting - Perspective- Interest, Phenomenon of –Comparison – Evaluation (Booth 2006)SPIDER Sample - Phenomenon of Interest – Design –Evaluation - Research type (Cooke et al. 2014).PICOC Population – Intervention – Comparison – Outcome –Context (Petticrew & Roberts 2006)CHIP Context of the particular study, How the study wasconducted, the Issues examined, and the People involved inthe study (Shaw 2010).

The Question: SPICE (Booth 2006)S – Setting: What is the context? Where is it being done?P – Perspective: Who are the users, potential users, orstakeholders of the service?I – Intervention/Phenomena of Interest: What is being done forthe users, potential users, or stakeholders?C – Comparison: What are the alternatives?E – Evaluation: What do we learn about the phenomena beingexplored or evaluated?

Searching for Qualitative Papers:Exhaustive vs PurposiveQualitative evidence synthesis aims“to find sufficient cases to explorepatterns and so are not necessarilyattempting to be exhaustive in theirsearching” (Booth,2011)

Searching for Qualitative Papers:Specific versus sensitiveSearch procedures should generallyprivilege specificity (retrieval of onlyrelevant items) over sensitivity (retrievalof all potential items) in recognition thatqualitative research is far less prevalentthan quantitative research and so subjectsearches that run withoutmethodological filters will contain ahigher proportion of irrelevant hits(Harris et al. 2017)

Search Methods# Search strings1 (participat* OR recruit* OR enrol* OR non-participat* OR nonparticipat*OR selection).ti ADJ8 (trial*).ti2 (participat* OR recruit* OR non-participat* OR nonparticipat*).ab ADJ8(trial*).ab3 (participat* OR recruit* OR non-participat* OR nonparticipat*).if ADJ8(trial*).if4 (1 OR 2 OR 3)5 (qualitative OR ethnograph* OR phenomenol* OR "grounded theory"OR hermeneutic* OR observation* OR "focus group" OR "focus groups"OR interview* OR "mixed method" OR "mixed methods" ORmultimethod OR "multi-method").ti,ab6 (experience* OR perceive* OR perception* OR attitude* OR barrier* ORfacilitat* OR challenge* OR opportunit* OR opinion* OR agree* ORaccept* OR refuse* OR refusal OR decline* OR decision* ORdecide*).ti,ab7 (control*).ti,ab AND (trial OR trials).ti,ab8 (random*).ti,ab9 (7 OR 8)10 (4 AND 5 AND 6 AND 9)

C:CompletenessWe will not include studies that are incomplete and do not fullydescribe the methods used within the qualitative component ofthe study (Partial records such as abstracts and short reports havealready been excluded).A: AccuracyAccuracy will be measured based on the clear inclusionof qualitative research question/objectives usingthe CASP screening questions: Was there a clear statement of the aims of the research? Is a qualitative methodology appropriate?R: Relevance The phenomenon of interest is the recruitment/decision toparticipate in trials. “Potential participants” are those with experience of accepting ordeclining invitations to participate in RCTs. Studies that focus more on the experience of participation intrials, or other elements of the trial process, will be excludedbased on reduced relevance to the purpose of this review We will exclude hypothetical trials as advocated inthe Treweek (2018) reviewT: TimelinessWe will only include studies from 2000 onwards as they are likelyto be more relevant than older studies.

DATA EXTRACTION Pertinent information-subgroup analysisPopulation and settingMethodsFindingsAssessment of methodologicallimitations(CASP) Other information(consider data management compatibility!)

Assessment of methodologicallimitations

Assessment of methodological limitations:Critical Appraisal Skills Programme (CASP) toolCommonly Used

Assessment of methodological limitations :CASP tool

Thematic synthesis The findings generated from thematic synthesisare particularly useful to policymakers andpractitioners (Booth 2016). This approach is suitable for synthesis whenthere are a larger number of studies included. 3 Stages:line by line codinggeneration of descriptive themesgeneration of analytical themes

Line by Line .

Descriptive themes

Analytical themes

Model

Assessment of confidence GRADE CERQual Examines individual review findings andappraises them in the context ofmethodological limitations, relevance,coherence, and adequacy of data (Lewin2018)

Assessment of confidence Methodological Limitation refers to the extent of limitations in thedesign or conduct of the primary studies- CASP Relevance is the extent to which the evidence from the primarystudies is applicable to the context specified in the review question.This may pertain to the relevancy of the population researched, thephenomenon of interest or the setting. Coherence refers to identifying patterns in the data across theprimary studies included in an evidence synthesis. Coherenceexplores whether the finding is well grounded in data and providesa convincing explanation for the patterns found in these dataReflexivity Adequacy of data is an overall determination of the degree ofrichness and quantity of data supporting a review finding-sensitivityanalysis

Summary of review findingExample QuoteStudies contributing to thereview findingCERQualassessment ofconfidence in theevidenceExplanation of CERQual assessmentCommunicate face-to-face:Trial information deliveredverbally during face to facecontact can be less confusingthan written trial details.“The communication withthe FP reassured somepatients more than theinformation sheet – theyhighly valued the personalinformation and discussionof the trial which madethem feel safe” (Authorquote, Bleidorn 2015)Barnes 2012, Moynihan 2012, ModerateBleidorn 2015, Oud-Rengerick confidence2015, Attwood 2016, Dellson2018Adequacyvery minor concernsRelevanceModerate concerns in one study (Dellson)CohesionMinor concernsmethodological limitationsminor concerns in two studiesCommunication skills arevital: The person deliveringthe trial information shouldhave good communicationskills, be approachable,trustworthy, personcentered and knowledgeablewith a good ability to addresspotential participants’queries. Consideration needsto be given to whether aclinician or a researcher isthe most appropriate personto provide the trialinformation.“He [recruiting doctor]was very calm throughoutthe whole process Itwas very much he talkedto me directly, veryclearly, concisely, didn’tmince his words, didn’tbeat around the bush. Justvery professional and veryclear on what he waswanting and what wasbeing said to m”(Participant quote, Sawyer2017).Chang 2004, Costenbader2007, Harrop 2006a, Madsen2007a, Madsen 2007b,Jackson 2010, Moynihan2012, Smyth 2012, Habersack2013, Oud-Rengerick 2015,Tarimo 2010 Bleidorn 2015,Ballantyne 2017, Sawyer2017High confidenceAdequacySome individual minor concerns but highnumber of studies included.RelevanceSome individual minor concerns but highnumber of studies included.CohesionMinor concernsMethodological limitationsModerate concerns in one study and minorconcerns in one studyWritten information shouldbe an adjunct: Written trialinformation is beneficial asan adjunct to verbalinformation and facilitatestime and space for reflectionwithout the added influenceof recruiters’ presence.“The letter is a goodHughes Morley 2016, Jackson2010, Sawyer 2017, Smythidea I mean if they signyou up you have to decide 2012,very quickly and you don’thave time to chew overthe information, so havinga letter makes sense, youcan sit and think about itand decide what to do”(Participant quote, HughesMorley 2016).ModerateconfidenceAdequacyvery minor concernsRelevanceMinor concernsCohesionMinor concernsMethodological limitationsMinor concerns in one study

Reporting

Lessons learned1.2.3.4.5.6.Read, read, readGather a great teamBe inductive, be analytical, be braveUse management software for transparencyEmbrace the “Q” of QESWrite, write, write

Thank youReferences available on requestFurther queries, please email:Catherine.houghton@nuigalway.ieLinks:Master Classarchive nar/archived-webinars.htmlIIQM blog: iiqm.wordpress.com

Thematic synthesis The findings generated from thematic synthesis are particularly useful to policymakers and practitioners (Booth 2016). This approach is suitable for synthesis when there are a larger number of studies included. 3 Stages: line by line coding generation of descriptive themes generation of analytical themes