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Makar Vorobyov
Makar Vorobyov

Making Paper ? Part 2


The GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research) approach has been developed by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group. The approach has been developed to support the use of findings from qualitative evidence syntheses in decision making, including guideline development and policy formulation.




Making Paper – part 2



CERQual includes four components for assessing how much confidence to place in findings from reviews of qualitative research (also referred to as qualitative evidence syntheses): (1) methodological limitations, (2) coherence, (3) adequacy of data and (4) relevance. This paper is part of a series providing guidance on how to apply CERQual and focuses on making an overall assessment of confidence in a review finding and creating a CERQual Evidence Profile and a CERQual Summary of Qualitative Findings table.


Structuring and summarising review findings, assessing confidence in those findings using CERQual and creating a CERQual Evidence Profile and Summary of Qualitative Findings table should be essential components of undertaking qualitative evidence syntheses. This paper describes the end point of a CERQual assessment and should be read in conjunction with the other papers in the series that provide information on assessing individual CERQual components.


GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative Research) is an approach for assessing how much confidence to place in review findings from systematic reviews of qualitative research or qualitative evidence syntheses (QES). The approach is being developed by the GRADE-CERQual Project Group, a subgroup of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group. The importance of assessing confidence in qualitative evidence is discussed in the first paper in this series [1].


GRADE-CERQual includes four components for assessing how much confidence to place in review findings: (1) the methodological limitations of the individual qualitative studies contributing to a review finding, (2) the coherence of the review finding, (3) the adequacy of data supporting a review finding and (4) the relevance of the data from the primary studies supporting a review finding to the context (perspective or population, phenomenon of interest and/or setting) specified in the review question. Making an overall assessment of confidence in a review finding involves moving from the judgements made for each CERQual component to a final assessment. The overall assessment of confidence in a review finding takes into account the concerns identified in relation to each of the four components and, in our experience, is an iterative process that benefits from discussion among the review team or those making the CERQual assessment (when this is being done for an existing synthesis).


The aim of this paper, the second in this series (Fig. 1), is to describe and discuss the process for making an overall assessment of confidence in a review finding and to outline how to create a CERQual Evidence Profile and a Summary of Qualitative Findings table. A key part of communicating an overall CERQual assessment is providing an explanation for the confidence assessment, based on the concerns identified in relation to each component. The review team therefore needs to create a Summary of Qualitative Findings table to display a summary of each review finding, the CERQual assessment of confidence in that finding and the explanation for that assessment.


In this paper, we discuss the following processes: firstly, moving from a review finding to a summary of a review finding; secondly, determining the review findings to which CERQual should be applied; thirdly, making an overall CERQual assessment of confidence in each individual review finding; and, finally, creating a CERQual Evidence Profile and a Summary of Qualitative Findings (SoQF) table. Papers 3, 4, 5 and 6 in the series describe how to assess each CERQual component (i.e. methodological limitations [5], coherence [6], adequacy [7], and relevance [8]). These component papers are closely related to this paper on making an overall CERQual assessment of confidence and creating a Summary of Qualitative Findings table. We have placed this paper before the four CERQual component papers as we think that it will be helpful for readers to understand how the component assessments will be used before discussing the details of how to apply each component. Key definitions are provided in Additional file 1.


The initial stages of the process for developing CERQual, which started in 2010, are outlined elsewhere [3]. Since then, we have used a number of methods to further refine the definitions of each component and the principles for application of the overall approach. We used a pragmatic approach to develop the methods for making an overall CERQual assessment of confidence and creating a Summary of Qualitative Findings table. We examined the methods used by other GRADE approaches, talked to experts in the field of qualitative evidence synthesis, developed consensus through multiple face-to-face CERQual project group meetings and teleconferences, and gained feedback from ongoing engagement with the qualitative evidence synthesis community. We presented an early version of the CERQual approach in 2015 to a group of methodologists, researchers and end users with experience in qualitative research, GRADE or guideline development. We further refined the approach through training workshops, seminars and presentations during which we actively sought, collated and shared feedback; by facilitating discussions of individual CERQual components within relevant organisations; through applying the approach within diverse qualitative evidence syntheses [9,10,11,12,13,14,15,16,17,18,19]; and through supporting other teams in using CERQual [20, 21]. As far as possible, we used a consensus approach in these processes. We also gathered feedback from CERQual users through an online feedback form and through short individual discussions with members of the review teams. The methods used to develop CERQual are described in more detail in the first paper in this series [1].


Our intention is that CERQual can be applied to the full range of types and levels of review findings. For example, a qualitative evidence synthesis may include review findings ranging from more descriptive or aggregative to more interpretive or configuring [4], as well as from more narrow (for example, in relation to a specific health care setting) to more broad (for example, cutting across several different kinds of social care settings). In general, the review team would assess all review findings emerging from a QES, but there may be circumstances in which this is not feasible or appropriate. For instance, some of the findings from a QES may be particularly relevant to a decision making process and the review team may therefore choose to apply CERQual to those findings only.


There are important reasons why it may be useful to apply CERQual to as many of the review findings as possible. Firstly, it is easier to undertake a CERQual assessment as part of the process of developing review findings, when the necessary data are easily accessible. Secondly, it is not always possible to predict which findings may be useful for a decision. Applying CERQual to all review findings means that individual review findings can be more quickly integrated into decision making processes. Where the review team decides not to apply CERQual to all review findings, a justification for this should be provided.


We recommend that CERQual assessments for each review finding should be made through discussion between at least two members of the review team. This is preferable to use by a single review author as it offers an opportunity to discuss judgments within the review team, may assist members of the review team in clearly describing the rationale behind each assessment and can be a helpful part of the iterative and reflexive process of formulating review findings. Because CERQual assessments are judgements, there is likely to be variation across assessors. In such cases, a strength of CERQual is that it provides a system that guides assessors through the key components of this assessment and an approach to reporting that promotes transparency and an explicit record of the judgements involved [22]. We therefore anticipate that the CERQual approach will improve reliability in comparison to intuitive judgments [23].


While the focus of this paper is on the application of CERQual by the review team, a CERQual assessment can, in principle, be applied to review findings from well-conducted qualitative evidence syntheses undertaken by others. In this case, sufficient time should be devoted to gaining a full understanding of how the synthesis has been conducted and presented before applying CERQual. Initial guidance for applying CERQual to a synthesis done by another team is provided in Additional file 3. Our limited experience to date suggests that applying CERQual to a synthesis done by another team is likely to be a challenging and time-consuming process, in part, because creating a Summary of Qualitative Findings is an interpretive process.


This paper provides broad guidance on how to approach a CERQual assessment. Detailed guidance on factors that may lead the review team to have concerns about a particular component is provided in the papers discussing each component [5,6,7,8].


CERQual is intended to be applied to all review findings reported in a synthesis. It is preferable for all review findings to be reported in the SoQF table regardless of their level of confidence. However, as determined by the requirements of particular audiences, review teams may decide to include only the highest priority review findings in a SoQF table in the main text of the review and to include the remaining findings in a supplementary SoQF table. It may also be useful to include the Evidence Profile as a supplementary table. The following types of review findings should generally be included in the main SoQF table: review findings that relate most closely to the review question; review findings relevant to the decision making process for which the synthesis was commissioned; review findings that are more novel or are unexpected given the current level of knowledge; and review findings that are more likely to affect practice or policy.


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