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Research methods and reporting
Rapid reviews methods series: guidance on rapid qualitative evidence synthesis
  1. Andrew Booth1,2,
  2. Isolde Sommer3,4,
  3. Jane Noyes2,5,
  4. Catherine Houghton2,6,
  5. Fiona Campbell1,7
  6. The Cochrane Rapid Reviews Methods Group and Cochrane Qualitative and Implementation Methods Group (CQIMG)
  1. 1EnSyGN Sheffield Evidence Synthesis Group, University of Sheffield, Sheffield, UK
  2. 2Cochrane Qualitative and Implementation Methods Group (CQIMG), London, UK
  3. 3Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems, Krems, Austria
  4. 4Cochrane Rapid Reviews Group & Cochrane Austria, Krems, Austria
  5. 5Bangor University, Bangor, UK
  6. 6University of Galway, Galway, Ireland
  7. 7University of Newcastle upon Tyne, Newcastle upon Tyne, UK
  1. Correspondence to Professor Andrew Booth, Univ Sheffield, Sheffield, UK; a.booth{at}sheffield.ac.uk

Abstract

This paper forms part of a series of methodological guidance from the Cochrane Rapid Reviews Methods Group and addresses rapid qualitative evidence syntheses (QESs), which use modified systematic, transparent and reproducible methodsu to accelerate the synthesis of qualitative evidence when faced with resource constraints. This guidance covers the review process as it relates to synthesis of qualitative research. ‘Rapid’ or ‘resource-constrained’ QES require use of templates and targeted knowledge user involvement. Clear definition of perspectives and decisions on indirect evidence, sampling and use of existing QES help in targeting eligibility criteria. Involvement of an information specialist, especially in prioritising databases, targeting grey literature and planning supplemental searches, can prove invaluable. Use of templates and frameworks in study selection and data extraction can be accompanied by quality assurance procedures targeting areas of likely weakness. Current Cochrane guidance informs selection of tools for quality assessment and of synthesis method. Thematic and framework synthesis facilitate efficient synthesis of large numbers of studies or plentiful data. Finally, judicious use of Grading of Recommendations Assessment, Development and Evaluation approach for assessing the Confidence of Evidence from Reviews of Qualitative research assessments and of software as appropriate help to achieve a timely and useful review product.

  • Systematic Reviews as Topic
  • Patient Care

Data availability statement

No data are available. Not applicable. All data is from published articles.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjebm-2023-112620

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Rapid Qualitative Evidence Synthesis (QES) is a relatively recent innovation in evidence synthesis and few published examples currently exists.

    • Guidance for authoring a rapid QES is scattered and requires compilation and summary.

    WHAT THIS STUDY ADDS

    • This paper represents the first attempt to compile current guidance, illustrated by the experience of several international review teams.

    • We identify features of rapid QES methods that could be accelerated or abbreviated and where methods resemble those for conventional QESs.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • This paper offers guidance for researchers when conducting a rapid QES and informs commissioners of research and policy-makers what to expect when commissioning such a review.

    Introduction

    This paper forms part of a series from the Cochrane Rapid Reviews Methods Group providing methodological guidance for rapid reviews. While other papers in the series1–4 focus on generic considerations, we aim to provide in-depth recommendations specific to a resource-constrained (or rapid) qualitative evidence synthesis (rQES).5 This paper is accompanied by recommended resources (online supplemental appendix A) and an elaboration with practical considerations (online supplemental appendix B).

    Supplemental material

    The role of qualitative evidence in decision-making is increasingly recognised.6 This, in turn, has led to appreciation of the value of qualitative evidence syntheses (QESs) that summarise findings across multiple contexts.7 Recognition of the need for such syntheses to be available at the time most useful to decision-making has, in turn, driven demand for rapid qualitative evidence syntheses.8 The breadth of potential rQES mirrors the versatility of QES in general (from focused questions to broad overviews) and outputs range from descriptive thematic maps through to theory-informed syntheses (see table 1).

    View this table:
    Table 1

    Glossary of important terms (alphabetically)

    As with other resource-constrained reviews, no one size fits all. A team should start by specifying the phenomenon of interest, the review question,9 the perspectives to be included9 and the sample to be determined and selected.10 Subsequently, the team must finalise the appropriate choice of synthesis.11 Above all, the review team should consider the intended knowledge users,3 including requirements of the funder.

    An rQES team, in particular, cannot afford any extra time or resource requirements that might arise from either a misunderstanding of the review question, an unclear picture of user requirements or an inappropriate choice of methods. The team seeks to align the review question and the requirements of the knowledge user with available time and resources. They also need to ensure that the choice of data and choice of synthesis are appropriate to the intended ‘knowledge claims’ (epistemology) made by the rQES.11 This involves the team asking ‘what types of data are meaningful for this review question?’, ‘what types of data are trustworthy?’ and ‘is the favoured synthesis method appropriate for this type of data?’.12 This paper aims to help rQES teams to choose methods that best fit their project while understanding the limitations of those choices. Our recommendations derive from current QES guidance,5 evidence on modified QES methods,8 13 and practical experience.14 15

    This paper presents an overview of considerations and recommendations as described in table 2. Supplemental materials including additional resources details of our recommendations and practical examples are provided in online supplemental appendices A and B.

    View this table:
    Table 2

    Recommendations for resource-constrained qualitative evidence synthesis (rQES)

    Setting the review question and topic refinement

    Rapid reviews summarise information from multiple research studies to produce evidence for ‘the public, researchers, policymakers and funders in a systematic, resource-efficient manner’.16 Involvement of knowledge users is critical.3 Given time constraints, individual knowledge users could be asked only to feedback on very specific decisions and tasks or on selective sections of the protocol. Specifically, whenever a QES is abbreviated or accelerated, a team should ensure that the review question is agreed by a minimum number of knowledge users with expertise or experience that reflects all the important review perspectives and with authority to approve the final version2 5 11 (table 2, item R1).

    Involvement of topic experts can ensure that the rQES is responsive to need.14 17 One Cochrane rQES saved considerable time by agreeing the review topic within a single meeting and one-phase iteration.9 Decisions on topics to be omitted are also informed by a knowledge of existing QESs.17

    An information specialist can help to manage the quantity and quality of available evidence by setting conceptual boundaries and logistic limits. A structured question format, such as Setting-Perspective-Interest, phenomenon of-Comparison-Evaluation or Population-Interest, phenomenon of-Context helps in communicating the scope and, subsequently, in operationalising study selection.9 18

    Scoping (of review parameters) and mapping (of key types of evidence and likely richness of data) helps when planning the review.5 19 The option to choose purposive sampling over comprehensive sampling approaches, as offered by standard QES, may be particularly helpful in the context of a rapid QES.8 Once a team knows the approximate number and distribution of studies, perhaps mapping them against country, age, ethnicity, etc), they can decide whether or not to use purposive sampling.12 An rQES for the WHO combined purposive with variation sampling. Sampling in two stages started by reducing the initial number of studies to a more manageable sampling frame and then sampling approximately a third of the remaining studies from within the sampling frame.20

    Sampling may target richer studies and/or privilege diversity.8 21 A rich qualitative study typically illustrates findings with verbatim extracts from transcripts from interviews or textual responses from questionnaires. Rich studies are often found in specialist qualitative research or social science journals. In contrast, less rich studies may itemise themes with an occasional indicative text extract and tend to summarise findings. In clinical or biomedical journals less rich findings may be placed within a single table or box.

    No rule exists on an optimal number of studies; too many studies makes it challenging to ‘maintain insight’,22 too few does not sustain rigorous analysis.23 Guidance on sampling is available from the forthcoming Cochrane-Campbell QES Handbook.

    A review team can use templates to fast-track writing of a protocol. The protocol should always be publicly available (table 2, item R2).24 25 Formal registration may require that the team has not commenced data extraction but should be considered if it does not compromise the rQES timeframe. Time pressures may require that methods are left suitably flexible to allow well-justified changes to be made as a detailed picture of the studies and data emerge.26 The first Cochrane rQES drew heavily on text from a joint protocol/review template previously produced within Cochrane.24

    Setting eligibility criteria

    An rQES team may need to limit the number of perspectives, focusing on those most important for decision-making5 9 27 (table 2, item R3). Beyond the patients/clients each additional perspective (eg, family members, health professionals, other professionals, etc) multiplies the additional effort involved.

    A rapid QES may require strict date and setting restrictions17 and language restrictions that accommodate the specific requirements of the review. Specifically, the team should consider whether changes in context over time or substantive differences between geographical regions could be used to justify a narrower date range or a limited coverage of countries and/or languages. The team should also decide if ‘indirect evidence’ is to substitute for the absence of direct evidence. An rQES typically focuses on direct evidence, except when only indirect evidence is available28 (table 2, item R4). Decisions on relevance are challenging—precautions for swine influenza may inform precautions for bird influenza.28 A smoking ban may operate similarly to seat belt legislation, etc. A review team should identify where such shared mechanisms might operate.28 An rQES team must also decide whether to use frameworks or models to focus the review. Theories may be unearthed within the topic search or be already known to team members, fro example, Theory of Planned Behaviour.29

    Options for managing the quantity and quality of studies and data emerge during the scoping (see above). In summary, the review team should consider privileging rich qualitative studies2; consider a stepwise approach to inclusion of qualitative data and explore the possibility of sampling (table 2, item R5). For example, where data is plentiful an rQES may be limited to qualitative research and/or to mixed methods studies. Where data is less plentiful then surveys or other qualitative data sources may need to be included. Where plentiful reviews already exist, a team may decide to conduct a review of reviews5 by including multiple QES within a mega-synthesis28 29 (table 2, item R6).

    Searching

    Searching for QES merits its own guidance,21–23 30 this section reinforces important considerations from guidance specific to qualitative research. Generic guidance for rapid reviews in this series broadly applies to rapid QESs.1

    In addition to journal articles, by far the most plentiful source, qualitative research is found in book chapters, theses and in published and unpublished reports.21 Searches to support an rQES can (a) limit the number of databases searched, deliberately selecting databases from diverse disciplines, (b) use abbreviated study filters to retrieve qualitative designs and (c) employ high yield complementary methods (eg, reference checking, citation searching and Related Articles features). An information specialist (eg, librarian) should be involved in prioritising sources and search methods (table 2, item R7).11 14

    According to empirical evidence optimal database combinations include Scopus plus CINAHL or Scopus plus ProQuest Dissertations and Theses Global (two-database combinations) and Scopus plus CINAHL plus ProQuest Dissertations and Theses Global (three-database combination) with both choices retrieving between 89% and 92% of relevant studies.30

    If resources allow, searches should include one or two specialised databases (table 2, item R8) from different disciplines or contexts21 (eg, social science databases, specialist discipline databases or regional or institutional repositories). Even when resources are limited, the information specialist should factor in time for peer review of at least one search strategy (table 2, item R9).31 Searches for ‘grey literature’ should selectively target appropriate types of grey literature (such as theses or process evaluations) and supplemental searches, including citation chaining or Related Articles features (table 2, item R10).32 The first Cochrane rQES reported that searching reference lists of key papers yielded an extra 30 candidate papers for review. However, the team documented exclusion of grey literature as a limitation of their review.15

    Study selection

    Consistency in study selection is achieved by using templates, by gaining a shared team understanding of the audience and purpose, and by ongoing communication within, and beyond, the team.2 33 Individuals may work in parallel on the same task, as in the first Cochrane rQES, or follow a ‘segmented’ approach where each reviewer is allocated a different task.14 The use of machine learning in the specific context of rQES remains experimental. However, the possibility of developing qualitative study classifiers comparable to those for randomised controlled trials offers an achievable aspiration.34

    Title and abstract screening

    The entire screening team should use pre-prepared, pretested title and abstract templates to limit the scale of piloting, calibration and testing (table 2, item R11).1 14 The first Cochrane rQES team double-screened titles and abstracts within Covidence review software.14 Disagreements were resolved with reference to a third reviewer achieving a shared understanding of the eligibility criteria and enhancing familiarity with target studies and insight from data.14 The team should target and prioritise identified risks of either over-zealous inclusion or over-exclusion specific to each rQES (table 2, item R12).14 The team should maximise opportunities to capture divergent views and perspectives within study findings.35

    Full-text screening

    Full-text screening similarly benefits from using a pre-prepared pretested standardised template where possible1 14 (table 2, item R11). If a single reviewer undertakes full-text screening,8 the team should identify likely risks to trustworthiness of findings and focus quality control procedures (eg, use of additional reviewers and percentages for double screening) on specific threats14 (table 2, item R13). The Cochrane rQES team opted for double screening to assist their immersion within the topic.14

    Data extraction

    Data extraction of descriptive/contextual data may be facilitated by review management software (eg, EPPI-Reviewer) or home-made approaches using Google Forms, or other survey software.36 Where extraction of qualitative findings requires line-by-line coding with multiple iterations of the data then a qualitative data management analysis package, such as QSR NVivo, reaps dividends.36 The team must decide if, collectively, they favour extracting data to a template or coding direct within an electronic version of an article.

    Quality control must be fit for purpose but not excessive. Published examples typically use a single reviewer for data extraction8 with use of two independent reviewers being the exception. The team could limit data extraction to minimal essential items. They may also consider re-using descriptive details and findings previously extracted within previous well-conducted QES (table 2, item R14). A pre-existing framework, where readily identified, may help to structure the data extraction template.15 37 The same framework may be used to present the findings. Some organisations may specify a preferred framework, such as an evidence-to-decision-making framework.38

    Assessment of methodological limitations

    The QES community assess ‘methodological limitations’ rather than use ‘risk of bias’ terminology. An rQES team should pick an approach appropriate to their specific review. For example, a thematic map may not require assessment of individual studies—a brief statement of the generic limitations of the set of studies may be sufficient. However, for any synthesis that underpins practice recommendations39 assessment of included studies is integral to the credibility of findings. In any decision-making context that involves recommendations or guidelines, an assessment of methodological limitations is mandatory.40 41

    Each review team should work with knowledge users to determine a review-specific approach to quality assessment.27 While ‘traffic lights’, similar to the outputs from the Cochrane Risk of Bias tool, may facilitate rapid interpretation, accompanying textual notes are invaluable in highlighting specific areas for concern. In particular, the rQES team should demonstrate that they are aware (a) that research designs for qualitative research seek to elicit divergent views, rather than control for variation; (b) that, for qualitative research, the selection of the sample is far more informative than the size of the sample; and (c) that researchers from primary research, and equally reviewers for the qualitative synthesis, need to be thoughtful and reflexive about their possible influences on interpretation of either the primary data or the synthesised findings.

    Selection of checklist

    Numerous scales and checklists exist for assessing the quality of qualitative studies. In the absence of validated risk of bias tools for qualitative studies, the team should choose a tool according to Cochrane Qualitative and Implementation Methods Group (CQIMG) guidance together with expediency (according to ease of use, prior familiarity, etc) (table 2, item R15).41 In comparison to the Critical Appraisal Skills Programme checklist which was never designed for use in synthesis,42 the Cochrane qualitative tool is similarly easy to use and was designed for QES use. Work is underway to identify an assessment process that is compatible with QESs that support decision-making.41 For now the choice of a checklist remains determined by interim Cochrane guidance and, beyond this, by personal preference and experience. For an rQES a team could use a single reviewer to assess methodological limitations, with verification of judgements (and support statements) by a second reviewer (table 2, item R16).

    Synthesis

    The CQIMG endorses three types of synthesis; thematic synthesis, framework synthesis and meta-ethnography (box 1).43 44 Rapid QES favour descriptive thematic synthesis45 or framework synthesis,46 47 except when theory generation (meta-ethnography48 49 or analytical thematic synthesis) is a priority (table 2, item R17).

    Box 1

    Choosing a method for rapid qualitative synthesis

    Thematic synthesis: first choice method for rQES.45 For example, in their rapid QES Crooks and colleagues44 used a thematic synthesis to understand the experiences of both academic and lived experience coresearchers within palliative and end of life research.45

    Framework synthesis: alternative where a suitable framework can be speedily identified.46 For example, Bright and colleagues46 considered ‘best-fit framework synthesis’ as appropriate for mapping study findings to an ‘a priori framework of dimensions measured by prenatal maternal anxiety tools’ within their ‘streamlined and time-limited evidence review’.47

    Less commonly, an adapted meta-ethnographical approach was used for an implementation model of social distancing where supportive data (29 studies) was plentiful.48 However, this QES demonstrates several features that subsequently challenge its original identification as ‘rapid’.49

    Abbrevations: QES, qualitative evidence synthesis; rQES, resource-constrained qualitative evidence synthesis.

    The team should consider whether a conceptual model, theory or framework offers a rapid way for organising, coding, interpreting and presenting findings (table 2, item R18). If the extracted data appears rich enough to sustain further interpretation, data from a thematic or framework synthesis can subsequently be explored within a subsequent meta-ethnography.43 However, this requires a team with substantial interpretative expertise.11

    Assessments of confidence in the evidence4 are central to any rQES that seeks to support decision-making and the QES-specific Grading of Recommendations Assessment, Development and Evaluation approach for assessing the Confidence of Evidence from Reviews of Qualitative research (GRADE-CERQual) approach is designed to assess confidence in qualitative evidence.50 This can be performed by a single reviewer, confirmed by a second reviewer.26 Additional reviewers could verify all, or a sample of, assessments. For a rapid assessment a team must prioritise findings, using objective criteria; a WHO rQES focused only on the three ‘highly synthesised findings’.20 The team could consider reusing GRADE-CERQual assessments from published QESs if findings are relevant and of demonstrable high quality (table 2, item R19).50 No rapid approach to full application of GRADE-CERQual currently exists.

    Reporting and record management

    Little is written on optimal use of technology.8 A rapid review is not a good time to learn review management software or qualitative analysis management software. Using such software for all general QES processes (table 2, item R20), and then harnessing these skills and tools when specifically under resource pressures, is a sounder strategy. Good file labelling and folder management and a ‘develop once, re-use multi-times’ approach facilitates resource savings.

    Reporting requirements include the meta-ethnography reporting guidance (eMERGe)51 and the Enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) statement.52 An rQES should describe limitations and their implications for confidence in the evidence even more thoroughly than a regular QES; detailing the consequences of fast-tracking, streamlining or of omitting processes all together.8 Time spent documenting reflexivity is similarly important.27 If QES methodology is to remain credible rapid approaches must be applied with insight and documented with circumspection.53 54 (56)

    Data availability statement

    No data are available. Not applicable. All data is from published articles.

    Ethics statements

    Patient consent for publication

    Ethics approval

    Not applicable.

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    Supplementary materials

    • Supplementary Data

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    Footnotes

    • Correction notice Since this paper first published, updates have been made to the left hand column of table 2.

    • Contributors All authors (AB, IS, JN, CH, FC) have made substantial contributions to the conception and design of the guidance document. AB led on drafting the work and revising it critically for important intellectual content. All other authors (IS, JN, CH, FC) contributed to revisions of the document. All authors (AB, IS, JN, CH, FC) have given final approval of the version to be published. As members of the Cochrane Qualitative and Implementation Methods Group and/or the Cochrane Rapid Reviews Methods Group all authors (AB, IS, JN, CH, FC) agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests AB is co-convenor of the Cochrane Qualitative and Implementation Methods Group. In the last 36 months, he received royalties from Systematic Approaches To a Successful Literature Review (Sage 3rd edition), honoraria from the Agency for Healthcare Research and Quality, and travel support from the WHO. JN is lead convenor of the Cochrane Qualitative and Implementation Methods Group. In the last 36 months, she has received honoraria from the Agency for Healthcare Research and Quality and travel support from the WHO. CH is co-convenor of the Cochrane Qualitative and Implementation Methods Group.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; internally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.