March 2016


Confidence in the Evidence from Reviews of Qualitative Research 

CERQual at the European Commission Initiative on Breast Cancer

On December 11th 2015, Ӧzge Tunçalp, member of the CERQual Coordinating Group, gave a presentation entitled: “Incorporating qualitative research into guideline development: the way forward” at the European Commission Initiative on Breast Cancer in Baveno, Italy. The meeting was attended by clinicians, researchers and policymakers focusing on improving breast cancer screening, diagnosis and care in Europe. The presentation was well received, followed with an interactive Q&A as the group is working on updating the current guidance in Europe.

To see the presentation CLICK HERE. More about the meeting and the agenda can be found HERE.

CERQual: A Blog from the Field

Joseph D. Tucker, UNC Project-China
Qualitative evidence synthesis can serve as a powerful tool for evaluating research, drawing together evidence from multiple primary studies and providing an evidence base for policy.  However, the tools, purpose, and inferences made from qualitative data are different from those made from quantitative data.  Inferences made from multiple qualitative studies should be guided by standard techniques that have been developed (Table 1).
A qualitative evidence synthesis brings together primary (quotes from individuals who were interviewed) and secondary (interpretations of interviews) data to address a specific research question.  The early stages of a systematic review of qualitative studies are similar to a systematic review of quantitative studies of effectiveness in terms of developing a specific research question, seeking guidance from Cochrane and other normative groups, and identifying appropriate search algorithms.  The middle stages of a meta-synthesis use qualitative methods to combine data from individual studies.  There are also standard approaches for summarizing the certainty of evidence which are analogous to the GRADE approach. 
This is where CERQual can be an extremely useful approach.  The CERQual approach helped our research team in three ways.  First, it allowed us to present a larger amount of qualitative data in a cohesive, standardized way.  Second, given the fact that the approach emerged out of the work of GRADE and Cochrane, policymakers familiar with the GRADE system find it easy to interpret CERQual assessments. Third, the CERQual approach is designed specifically for qualitative research and thus the methods and tools that support the CERQual approach are familiar to qualitative researchers. As a result, using CERQual was seamless and relatively straightforward.  Our team benefited from attending a one-day workshop in Oslo and from discussing the project with members of the CERQual coordinating group.      
We used the CERQual approach as part of a series of qualitative evidence syntheses to inform guidelines for the World Health Organization’s HIV Department.  

Table 1.  Standard techniques used in quantitative meta-analysis compared to qualitative meta-synthesis.
Standard techniques/stages Quantitative Evidence Review Qualitative Evidence Review
Review design Cochrane Community (link here) Cochrane Qualitative and Implementation Methods Group (link here)
Study registration PROSPERO (details here) PROSPERO (details here)
Data pooling methodology Statistical methods Qualitative methods
Study quality assessment Dependent on study designs included in the review Several tools available and used before, including the CASP tool1
Study checklist PRISMA2 ENTREQ3
Summarizing strength of evidence GRADE approach4 (details here) CERQual approach (details here)

1.    Critical Appraisal Skills Programme. Qualitative Appraisal Checklist for Qualitative Research. 2006. (accessed January 25 2015).
2.    Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS medicine 2009; 6(7): e1000100.
3.    Tong A, Flemming K, McInnes E, Oliver S, Craig J. Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC medical research methodology 2012; 12: 181.
4.    Atkins D, Best D, Briss PA, et al. Grading quality of evidence and strength of recommendations. Bmj 2004; 328(7454): 1490.

Recent CERQual Publications

Lewin et al. 2015 – Using qualitative evidence in decision making for health and social interventions: An approach to assess confidence in findings from qualitative evidence syntheses

Colvin et al. 2015 - Confidence in the Evidence from Reviews of Qualitative research (CERQual): Development and Future Directions of a Novel Approach

Downe et al. 2015 - What matters to women: a systematic scoping review to identify the processes and outcomes of antenatal care provision that are important to healthy pregnant women
We are also thankful to members of the CERQual Project Group and other colleagues publishing summaries of the CERQual approach in SPANISH and CHINESE.

Progress on series of papers providing guidance on applying CERQual

Work is progressing on completing the series of seven papers providing guidance on how to apply the CERQual approach. These papers follow on from the more conceptual paper published in 2015.

GRADE-CERQual Project Group members are now invited to give feedback on the five core papers in the series before they are submitted to a journal for consideration. These papers cover the following topics: (1) Making an overall CERQual assessment and creating a Summary of Qualitative Findings table; (2) Assessing methodological limitations; (3) Assessing coherence; (4) Assessing adequacy; (5) Assessing relevance. The introductory paper and a paper on dissemination bias in qualitative research are being written by the CERQual coordinating team only. For each paper, we have created a Google form for feedback. You can access these forms here:

1. Introduction paper
2. Overall assessment of confidence and Summary of qualitative findings table
3. Methodological limitations assessment
4. Coherence assessment
5. Adequacy assessment
6. Relevance assessment
7. Dissemination Bias

The five draft papers are available for download here.

Please submit your feedback by 8 April through the Google form.
At this stage, we are interested in comments on structure and content only. Individuals who make substantive contributions to one or more papers and who meet the ICMJE criteria will be added to a group authorship list for the relevant paper/s (‘and the CERQual Project Group’), in alphabetical order. Please note that the draft papers are not for further distribution at this stage.

The Middle East’s First GRADE-CERQual training workshop
January is not the start of a new year in Iran (it actually happens late in March), and weekends are Thursday and Friday. Hence Saturday was perhaps a good working day in Iran to discuss the GRADE-CERQual approach! Professor Arash Rashidian, a member of CERQual’s Coordinating Group, conducted an introductory workshop on CERQual in Tehran on 2 January 2016.

It was hosted by the School of Public Health and the Knowledge Utilization Research Center of the Tehran University of Medical Sciences. There were about 40 participants, of which over ten were academic staff (from five different universities) and the rest post-graduate students of different disciplines. This was the first CERQual workshop to be held in a Middle Eastern country.  The participants had a wide range of expertise in the conduct of qualitative research and systematic reviews in different clinical, nursing, public health and health system fields. The GRADE-CERQual approach was well received with lots of interest raised in applying the approach. We look forward to CERQual being used more widely in Iran!

[1] Andrew Booth, Arash Rashidian, Benedicte Carlsen, Chris Colvin, Claire Glenton, Heather Munthe-Kaas, Jane Noyes, Megan Wainwright, Meghan Bohren, Ruth Garside, Simon Lewin. Özge Tuncalp could not make it because of overlapping engagements.