Editorial Note: Dr Natalie Leon is a Specialist Scientist  at the Health Systems Research Unit, at the South African Medical Research Council. In this piece, Natalie describes what Qualitative Evidence Synthesis is, why it is important and how it is used in real-life settings in informing and guiding decisions. The piece also describes how DSBS is involved in building QES research capacity both locally and internationally.

 

Background

Evidence synthesis (ES) is a research method where there is a systematic approach to the review of individual research papers on a topic area, to present the most comprehensive and up-to-date knowledge available on that topic. Qualitative evidence synthesis (QES) is when the systematic reviewing approach focuses on only reviewing evidence from qualitative research papers on a topic. This article provides an overview of what QES is, how it is used in real-life settings. It also describes how the Division of Social and Behavioural Sciences (DSBS) is producing QES products and building local and international QES research capacity. 

What is QES For and Why Do We Need It?

Policymakers, politicians, health managers, practitioners, and researchers are increasingly pressured to demonstrate that the best available evidence informs their work and practices. Policymakers may want to know how best to implement a new programme, or to improve an existing programmes, like for child vaccinations. They would like to get evidence from research on the question of “What are the implementation barriers and facilitators for successful child vaccination programmes?” However, it is often hard to get accessible, good quality, relevant evidence on a topic. There is often an overload of individual research papers on any one topic, it can be difficult to tell the quality of the research, and findings from single research studies are unlikely to give a full answer. Evidence synthesis (also referred to as knowledge synthesis) is one approach to this problem. It aims to provide a comprehensive, robust, and transparent approach to reviewing and summarising the best available evidence, using systematic review methods. QES for policy-informed decision-making is an opportunity to narrow the gap between research and practice by providing decision-makers with more comprehensive, robust, relevant and accessible evidence.  

There is a long history of evidence synthesis on clinical questions, such as what medicines work best for the treatment of diseases. This relies on synthesising quantitative evidence from studies about the effectiveness of medicines. For example, treatment of different types of cancers will be guided by evidence that was synthesised from quantitative, experimental studies on the effectiveness of different types of cancer medicines. 

In the last two decades, however, policy makers have become increasingly interested in evidence that can go beyond questions of effectiveness of medicines, to help with improving the implementation of various health programmes. For example, although we know vaccinations prevent a range of diseases, vaccination programmes are not always reaching as many people as needed, and World Health Organisation (WHO) policy makers would like to have evidence how to strengthen the implementation of vaccination programmes across the globe. This is the kind of complex health system question where qualitative evidence synthesis can help to provide answers. See Box 1 for further examples of the type of research questions that can QES usually address. For instance, a QES research question can explore the barriers and facilitators to implementation of vaccination programmes across the world, from the perspective of the health care managers and personnel. Another QES question could be to explore the same issue, but from the perspective of parents and caregivers who are meant to use the vaccination services. Such information can then be used to inform local or international guidelines about the important implementation factors to consider when trying to improve the effectiveness of your vaccination immunisation programmes. 

Members of DSBS, together with colleagues from the South African Medical Research Council (SAMRC), have been part of QES research commissioned by the WHO, to inform international policy guidance. These included QES research that was used to inform WHO guidelines on effective implementation of lay health workers, safer home-based abortion care, and the implementation factors to consider for effective use of mobile phone-based (digital) health services. We are involved in ongoing QES research on patient and care giver perspectives on childhood vaccinations, on the relatively new HPV vaccination for adolescents, as well as on provider perspectives on the integration of various services at a primary health care level. 

Qualitative Evidence Methods and Capacity Building

The value of using qualitative evidence for policy making is gaining international recognition. The first Symposium on using qualitative evidence to inform decisions for the Sustainable Development Goals took place in 2019 in Brazil. The conference explored how qualitative evidence can broaden and humanise decision and policy-making processes locally and globally and highlighted the use of qualitative evidence synthesis in policy and practice in the areas of health, education, and social welfare. 

To conduct QES research, two equally important sets of skills are needed: skills in conducting qualitative research, and skills in conducting systematic review research. Methods for QES research are like those used for synthesis of quantitative evidence, but there are a few differences that make it more suitable to the nature of qualitative knowledge generation.  As shown in Box 1, the research steps require a systematic and transparent approach to how data sources as searched, how it is screened for eligibility, and how it is analysed and presented as findings.  There are also methods for assessing the level of confidence in the evidence for each of the review findings, known as the GRADE-CERQual approach (like the GRADE approach in quantitative reviews).  This confidence in evidence assessment is particularly helpful for decision-makers who then have additional information to help weight the value of evidence for their policymaking.

Members of DSBS and their SAMRC colleagues have not only been commissioned authors of QES research projects, but they have also gained international recognition as QES trainers, building global and local capacity among health social scientists. This has been done through a series of invited international workshops in South Africa (2016), the UK (2018), Brazil (2019), and China (2019). In December 2019, we also conducted a 3-day QES workshop in DSBS at UCT with social scientists from across South Africa. 

Conclusion

QES is a research method that is increasingly used to contribute more comprehensive, robust and relevant evidence for local and global policies and guidelines.  QES provides a new area for social scientists to apply their qualitative research skills and combine this with new skills in evidence synthesis research.

Box 1: Qualitative Evidence Synthesis (QES) Research Questions and Methods Research Questions Common QES topics include questions on: What are the underlying barriers and facilitators to effective implementation of an intervention? What factors shape how people experience and perceive a health condition? What factors shape how people experience and perceive a medical treatment? What are the factors that can help us understand the reasons of why a health intervention works, or not? What's the best way to implement an intervention in our local context? Research Methods QES research methods include the following steps: Developing a clear research question for the systematic review Designing a search strategy to find all the relevant studies Determining inclusion/exclusion criteria in terms of which studies will be selected and analysed Quality appraisal of included primary studies, to assess how much weight the studies might eventually contribute to the findings Data extraction and analysis of the selected studies Data synthesis to identify the main findings in relation to your research questions, and presenting this in an accessible 'Summary of qualitative Findings' table Methods for assessing the level of confidence to place in each of the findings. This is known as the GRADE-CERQual approach, which can help guide decision-makers in how much weight to lend to each finding. This certainty of evidence assessment is particularly helpful for decision-makers who then have additional information to help weight the evidence, against other decision-making criteria in their policy-making and practice.

 

Author Biography

Dr Natalie Leon is a Specialist Scientist  at the Health Systems Research Unit, at the South African Medical Research Council. Her research interest is in process evaluation of complex health system interventions and qualitative evidence synthesis approaches, to inform policy and management decision-making. Natalie is a co-investigator on the UCT iALARM and BRIDGES projects, and has expertise in health systems research in a variety of topics, including qualitative evidence synthesis, digital health, HIV and TB Cascade, gendered health inequities, and health information systems.

Email: Natalie.Leon@mrc.ac.za