Evaluating meta-ethnography: systematic analysis and synthesis of qualitative research.

BACKGROUND: Methods for reviewing and synthesising findings from quantitative research studies in health care are well established. Although there is recognition of the need for qualitative research to be brought into the evidence base, there is no consensus about how this should be done and the methods for synthesising qualitative research are at a relatively early stage of development. OBJECTIVE: To evaluate meta-ethnography as a method for synthesising qualitative research studies in health and health care. METHODS: Two full syntheses of qualitative research studies were conducted between April 2002 and September 2004 using meta-ethnography: (1) studies of medicine-taking and (2) studies exploring patients' experiences of living with rheumatoid arthritis. Potentially relevant studies identified in multiple literature searches conducted in July and August 2002 (electronically and by hand) were appraised using a modified version of the Critical Appraisal Skills Programme questions for understanding qualitative research. Candidate papers were excluded on grounds of lack of relevance to the aims of the synthesis or because the work failed to employ qualitative methods of data collection and analysis. RESULTS: Thirty-eight studies were entered into the medicine-taking synthesis, one of which did not contribute to the final synthesis. The synthesis revealed a general caution about taking medicine, and that the practice of lay testing of medicines was widespread. People were found to take their medicine passively or actively or to reject it outright. Some, in particular clinical areas, were coerced into taking it. Those who actively accepted their medicine often modified the regimen prescribed by a doctor, without the doctor's knowledge. The synthesis concluded that people often do not take their medicines as prescribed because of concern about the medicines themselves. 'Resistance' emerged from the synthesis as a concept that best encapsulated the lay response to prescribed medicines. It was suggested that a policy focus should be on the problems associated with the medicines themselves and on evaluating the effectiveness of alternative treatments that some people use in preference to prescribed medicines. The synthesis of studies of lay experiences of living with rheumatoid arthritis began with 29 papers. Four could not be synthesised, leaving 25 papers (describing 22 studies) contributing to the final synthesis. Most of the papers were concerned with the everyday experience of living with rheumatoid arthritis. This synthesis did not produce significant new insights, probably because the early papers in the area were substantial and theoretically rich, and later papers were mostly confirmatory. In both topic areas, only a minority of the studies included in the syntheses were found to have referenced each other, suggesting that unnecessary replication had occurred. LIMITATIONS: We only evaluated meta-ethnography as a method for synthesising qualitative research, but there are other methods being employed. Further research is required to investigate how different methods of qualitative synthesis influence the outcome of the synthesis. CONCLUSIONS: Meta-ethnography is an effective method for synthesising qualitative research. The process of reciprocally translating the findings from each individual study into those from all the other studies in the synthesis, if applied rigorously, ensures that qualitative data can be combined. Following this essential process, the synthesis can then be expressed as a 'line of argument' that can be presented as text and in summary tables and diagrams or models. Meta-ethnography can produce significant new insights, but not all meta-ethnographic syntheses do so. Instead, some will identify fields in which saturation has been reached and in which no theoretical development has taken place for some time. Both outcomes are helpful in either moving research forward or avoiding wasted resources. Meta-ethnography is a highly interpretative method requiring considerable immersion in the individual studies to achieve a synthesis. It places substantial demands upon the synthesiser and requires a high degree of qualitative research skill. Meta-ethnography has great potential as a method of synthesis in qualitative health technology assessment but it is still evolving and cannot, at present, be regarded as a standardised approach capable of application in a routinised way. FUNDING: Funding for this study was provided by the Health Technology Assessment programme of the National Institute for Health Research.

Exploring users' experiences of accessing out-of-hours primary medical care services.

BACKGROUND: Since 2000, out-of-hours primary medical care services in the UK have undergone major changes in the organisation and delivery of services in response to recommendations by the Carson Review and more recently, through the new General Medical Services Contract (GMS2). People calling their general practice in the evening or at weekends are redirected to the out-of-hours service which may offer telephone advice, a home visit or a visit to a treatment centre. Little is known about users' experiences under the new arrangements. AIM: To explore users' experiences of out-of-hours primary medical care. DESIGN OF STUDY: A qualitative study employing focus groups and telephone interviews. SETTING: Three out-of-hours primary medical care service providers in England. METHODS: Focus groups and telephone interviews were conducted with 27 recent users of out-of-hours services. RESULTS: Key areas of concern included the urgency with which cases are handled, and delays when waiting for a call back or home visit. Users felt that providers were reluctant to do home visits. The service was regarded as under-resourced and frequently misused. Many expressed anxiety about calling, feeling unsure about how appropriate their call was and many were uncertain about how the service operated. CONCLUSIONS: Service users need clear information on how current out-of-hours services operate and how it should be used. Problems with triaging need to be addressed, users should be kept informed of any delays, and care needs to be taken to ensure that the new arrangements do not alienate older people or individuals with complex health needs.

A critical review of the concept of patient motivation in the literature on physical rehabilitation.

Rehabilitation professionals have long suspected that a patient's motivation plays an important role in determining the outcome of therapy, despite the lack of a clear definition of the phenomenon. The fact that such a subjective concept is commonly used by clinicians prompted this investigation into the range and nature of professional understandings of patient motivation. The literature dealing with physical rehabilitation and motivation was reviewed and was found to fall into three broad groups. One group of mainly clinical articles conceives of motivation as an internal 'personality trait' of the individual patient, and explains the nature and causes of motivation purely in terms of internal dispositions. Another body of literature considers motivation to be a quality which is affected by social factors, and stresses the importance of awareness of such factors in explaining motivation. The third approach considers social factors in combination with personality or clinical characteristics. It is argued that the personality-based approach facilitates moralising in the therapeutic encounter, a problem which is both highlighted and critiqued by the methodology which emphasises the importance of social factors. The practical implications of the relative merits of these different theories of motivation are considered.

How useful are non-random comparisons of outcomes and quality of care in purchasing hospital stroke services?

We performed a prospective observational study using a stroke register, case-note review and survey of carers with 6 months of follow-up in two adjacent health districts in East London. District 1 was a teaching district and had no special stroke service; District 2 had a comprehensive stroke service comprising stroke unit, review of all stroke admissions and community follow-up. Three hundred and sixty-one consecutive patients with stroke admitted to hospital and 103 carers were surveyed at 6 months from admission using the Royal College of Physicians (London) Stroke Audit standards. We also assessed mortality, disability, perceived health, mood, and satisfaction with services 6 months after stroke, carer mood, perceived health and satisfaction with services. The standard of care was below that set by the Royal College of Physicians of London in both districts and there were no significant differences between the districts in age-standardized mortality at 1 and 6 months, Barthel score, extended ADL score, Geriatric Depression score, Nottingham Health Profile score and patient satisfaction with services at 6 months. Carer outcomes did not differ between districts. Service costs, particularly costs of rehabilitation services, were much lower in District 2. A comprehensive district stroke service was not associated with major differences in patient outcomes or standards of care. This may have been because the non-random nature of the comparison meant that the patients differed in other ways than in the nature of treatment. Caution is needed when using these techniques in making purchasing decisions.