High-quality obstetric delivery in a health facility reduces maternal and perinatal morbidity and mortality. This systematic review synthesizes qualitative evidence related to the facilitators and ...barriers to delivering at health facilities in low- and middle-income countries. We aim to provide a useful framework for better understanding how various factors influence the decision-making process and the ultimate location of delivery at a facility or elsewhere. We conducted a qualitative evidence synthesis using a thematic analysis. Searches were conducted in PubMed, CINAHL and gray literature databases. Study quality was evaluated using the CASP checklist. The confidence in the findings was assessed using the CERQual method. Thirty-four studies from 17 countries were included. Findings were organized under four broad themes: (1) perceptions of pregnancy and childbirth; (2) influence of sociocultural context and care experiences; (3) resource availability and access; (4) perceptions of quality of care. Key barriers to facility-based delivery include traditional and familial influences, distance to the facility, cost of delivery, and low perceived quality of care and fear of discrimination during facility-based delivery. The emphasis placed on increasing facility-based deliveries by public health entities has led women and their families to believe that childbirth has become medicalized and dehumanized. When faced with the prospect of facility birth, women in low- and middle-income countries may fear various undesirable procedures, and may prefer to deliver at home with a traditional birth attendant. Given the abundant reports of disrespectful and abusive obstetric care highlighted by this synthesis, future research should focus on achieving respectful, non-abusive, and high-quality obstetric care for all women. Funding for this project was provided by The United States Agency for International Development (USAID) and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization.
Labour companionship refers to support provided to a woman during labour and childbirth, and may be provided by a partner, family member, friend, doula or healthcare professional. A Cochrane ...systematic review of interventions by Bohren and colleagues, concluded that having a labour companion improves outcomes for women and babies. The presence of a labour companion is therefore regarded as an important aspect of improving quality of care during labour and childbirth; however implementation of the intervention is not universal. Implementation of labour companionship may be hampered by limited understanding of factors affecting successful implementation across contexts.
The objectives of the review were to describe and explore the perceptions and experiences of women, partners, community members, healthcare providers and administrators, and other key stakeholders regarding labour companionship; to identify factors affecting successful implementation and sustainability of labour companionship; and to explore how the findings of this review can enhance understanding of the related Cochrane systematic review of interventions.
We searched MEDLINE, CINAHL, and POPLINE K4Health databases for eligible studies from inception to 9 September 2018. There were no language, date or geographic restrictions.
We included studies that used qualitative methods for data collection and analysis; focused on women's, partners', family members', doulas', providers', or other relevant stakeholders' perceptions and experiences of labour companionship; and were from any type of health facility in any setting globally.
We used a thematic analysis approach for data extraction and synthesis, and assessed the confidence in the findings using the GRADE-CERQual approach. We used two approaches to integrate qualitative findings with the intervention review findings. We used a logic model to theorise links between elements of the intervention and health and well-being outcomes. We also used a matrix model to compare features of labour companionship identified as important in the qualitative evidence synthesis with the interventions included in the intervention review.
We found 51 studies (52 papers), mostly from high-income countries and mostly describing women's perspectives. We assessed our level of confidence in each finding using the GRADE-CERQual approach. We had high or moderate confidence in many of our findings. Where we only had low or very low confidence in a finding, we have indicated this.Labour companions supported women in four different ways. Companions gave informational support by providing information about childbirth, bridging communication gaps between health workers and women, and facilitating non-pharmacological pain relief. Companions were advocates, which means they spoke up in support of the woman. Companions provided practical support, including encouraging women to move around, providing massage, and holding her hand. Finally, companions gave emotional support, using praise and reassurance to help women feel in control and confident, and providing a continuous physical presence.Women who wanted a companion present during labour and childbirth needed this person to be compassionate and trustworthy. Companionship helped women to have a positive birth experience. Women without a companion could perceive this as a negative birth experience. Women had mixed perspectives about wanting to have a male partner present (low confidence). Generally, men who were labour companions felt that their presence made a positive impact on both themselves (low confidence) and on the relationship with their partner and baby (low confidence), although some felt anxious witnessing labour pain (low confidence). Some male partners felt that they were not well integrated into the care team or decision-making.Doulas often met with women before birth to build rapport and manage expectations. Women could develop close bonds with their doulas (low confidence). Foreign-born women in high-income settings may appreciate support from community-based doulas to receive culturally-competent care (low confidence).Factors affecting implementation included health workers and women not recognising the benefits of companionship, lack of space and privacy, and fearing increased risk of infection (low confidence). Changing policies to allow companionship and addressing gaps between policy and practice were thought to be important (low confidence). Some providers were resistant to or not well trained on how to use companions, and this could lead to conflict. Lay companions were often not integrated into antenatal care, which may cause frustration (low confidence).We compared our findings from this synthesis to the companionship programmes/approaches assessed in Bohren's review of effectiveness. We found that most of these programmes did not appear to address these key features of labour companionship.
We have high or moderate confidence in the evidence contributing to several of these review findings. Further research, especially in low- and middle-income settings and with different cadres of healthcare providers, could strengthen the evidence for low- or very low-confidence findings. Ahead of implementation of labour companionship, researchers and programmers should consider factors that may affect implementation, including training content and timing for providers, women and companions; physical structure of the labour ward; specifying clear roles for companions and providers; integration of companions; and measuring the impact of companionship on women's experiences of care. Implementation research or studies conducted on labour companionship should include a qualitative component to evaluate the process and context of implementation, in order to better interpret results and share findings across contexts.
Internalized homonegativity (IH) is an important variable affecting the wellbeing of lesbian, gay, and bisexual (LGB) persons. We included 201 studies in a systematic mapping review of IH. Most ...studies were conducted in North America and examined IH as a predictor of poor health. The primary focus of 14 studies was IH scale measurement, and, in total, these studies detailed nine distinct scales. Eighteen studies compared levels of IH in LGB populations, four described prevention programs, and one investigated IH using qualitative methods. Our review indicates that further research is needed, particularly qualitative research and ways to ameliorate IH.
The GRADE-CERQual ('Confidence in the Evidence from Reviews of Qualitative research') approach provides guidance for assessing how much confidence to place in findings from systematic reviews of ...qualitative research (or qualitative evidence syntheses). The approach has been developed to support the use of findings from qualitative evidence syntheses in decision-making, including guideline development and policy formulation. Confidence in the evidence from qualitative evidence syntheses is an assessment of the extent to which a review finding is a reasonable representation of the phenomenon of interest. CERQual provides a systematic and transparent framework for assessing confidence in individual review findings, based on consideration of four components: (1) methodological limitations, (2) coherence, (3) adequacy of data, and (4) relevance. A fifth component, dissemination (or publication) bias, may also be important and is being explored. As with the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach for effectiveness evidence, CERQual suggests summarising evidence in succinct, transparent, and informative Summary of Qualitative Findings tables. These tables are designed to communicate the review findings and the CERQual assessment of confidence in each finding. This article is the first of a seven-part series providing guidance on how to apply the CERQual approach. In this paper, we describe the rationale and conceptual basis for CERQual, the aims of the approach, how the approach was developed, and its main components. We also outline the purpose and structure of this series and discuss the growing role for qualitative evidence in decision-making. Papers 3, 4, 5, 6, and 7 in this series discuss each CERQual component, including the rationale for including the component in the approach, how the component is conceptualised, and how it should be assessed. Paper 2 discusses how to make an overall assessment of confidence in a review finding and how to create a Summary of Qualitative Findings table. The series is intended primarily for those undertaking qualitative evidence syntheses or using their findings in decision-making processes but is also relevant to guideline development agencies, primary qualitative researchers, and implementation scientists and practitioners.
Aim
To identify and assess available evidence from qualitative studies exploring experiences of individuals living with fetal alcohol spectrum disorders (FASD) or those living with a child with FASD, ...as well as experiences of interventions aimed at supporting individuals with FASD and their families.
Method
A systematic literature search was conducted in six electronic databases: PubMed, Embase, Cochrane Library, CINAHL, PsycINFO, and Scopus. Included studies were analysed using manifest content analysis. Methodological limitations and confidence in the evidence were assessed using a modified version of the Critical Appraisal Skills Programme and the Grading of Recommendations, Assessment, Development and Evaluation–Confidence in the Evidence from Reviews of Qualitative Research approach respectively.
Results
Findings from 18 studies show that individuals with FASD experience a variation of disabilities, ranging from somatic problems, high pain tolerance, destructive behaviour, hyperactivity, and aggressiveness, to social problems with friendship, school attendance, and maintenance of steady employment. Most studies reported parents’ experiences with FASD; parenting was viewed as a lifelong engagement and that the whole family is isolated and burdened because of FASD. People with FASD feel that their difficulties affect their daily life in a limiting way and make them feel different from others.
Interpretation
From the perspective of primarily parents, individuals with FASD and their parents face many different difficulties, for which they need societal support.
What this paper adds
Individuals with fetal alcohol spectrum disorders (FASD) feel their difficulties make them different from others.
Parents think of their parenting as a lifelong engagement.
There is a shortage of studies investigating experiences of children with FASD.
There is a shortage of studies investigating experiences of interventions given to individuals with FASD.
Resumen
Experiencias de vivir con trastornos del espectro alcoholico fetal: Una revision sistemática y una síntesis de datos cualitativos
Objetivo
Identificar y evaluar la evidencia disponible de estudios cualitativos que exploran las experiencias de individuos que viven con trastornos del espectro alcohólico fetal (TEAF) o de aquellos quienes viven con un niño con TEAF, así como experiencias de intervenciones que apuntan a apoyar individuos con TEAF y sus familias.
Método
Se realizó una búsqueda sistemática de literatura en seis bases de datos electrónicas: PubMed, Embase, biblioteca Cochrane, CINAHL, PsycINFO y Scopus. Los estudios incluidos fueron analizados utilizando análisis de contenido manifiesto. Se evaluaron las limitaciones metodológicas y la confiabilidad de la evidencia utilizando una versión modificada del Programa de Habilidades de Lectura Crítica (CASP) y la fuerza de Recomendación, Evaluación, Desarrollo y Evaluación (GRADE) – Confianza en la Evidencia de Revisiones de Investigación Cualitativa (CERQual), respectivamente.
Resultados
Hallazgos tomados de 18 estudios muestran que los individuos con TEAF experimentan una variedad de discapacidades, desde problemas somáticos, alta tolerancia al dolor, conductas destructivas, hiperactividad y agresividad, hasta problemas sociales con amistades, asistencia a la escuela, y mantenimiento de empleo estable. La mayoría de los estudios reportaron experiencias que los padres tenían con el TEAF; la paternidad fue vista como un compromiso de por vida y que toda la familia está aislada y con una pesada carga debido al TEAF. Personas con TEAF sienten que sus dificultades afectan sus vidas diarias de una manera limitada y les hace sentirse diferentes de los demás.
Interpretación
Desde la perspectiva primariamente de los padres los individuos con TEAF y sus padres deben enfrentarse a muchas dificultades para las cuales necesitan sostén de la sociedad.
Resumo
Experiências de viver com distúrbios do espectro da síndrome alcoólica fetal: uma revisão sistemática e síntese de dados qualitativos
Objetivo
Identificar e avaliar evidências disponíveis de estudos qualitativos que exploraram experiências de indivíduos com distúrbios do espectro da síndrome alcoólica fetal (DESAF) ou aqueles que vivem com uma criança com DESAF, bem como experiências de intervenções com o objetivo de apoiar indivíduos com DESAF e seus familiares.
Métodos
Uma busca sistemática foi conduzida em seis bases de dados eletrônicas: PubMed, Embase, Cochrane Library, CINAHL, PsycINFO e Scopus. Os estudos incluídos foram analisados utilizando a análise de conteúdo manifesto. As limitações metodológicas e a confiança na evidência foram avaliadas utilizando uma versão modificada do “Programa de de habilidades de avaliação crítica” e da abordagem da “Pontuação de recomendações, avaliação, desenvolvimento e confiança na avaliação da evidência de revisões de pesquisa qualitativa”, respectivamente.
Resultados
Os achados de 18 estudos mostraram que indivíduos com DESAF experimentam uma variedade de deficiências, que vão desde problemas somáticos, alta tolerância a dor, comportamento destrutivo, hiperatividade e agressividade, até problemas sociais com amizades, frequência escolar e manutenção de emprego estável. A maioria dos estudos relataram experiências dos pais de crianças com DESAF; a parentalidade foi vista como um compromisso pela vida toda e que toda a família é isolada e sobrecarregada por conta da DESAF. As pessoas com DESAF sentem que suas dificuldades afetam a vida diária de sua família de forma limitante a faz com que se sintam diferentes dos outros.
Interpretação
Da perspectiva dos pais, indivíduos com DESAF e seus familiares enfrentam muitas dificuldades para as quais precisam de suporte social.
What this paper adds
Individuals with fetal alcohol spectrum disorders (FASD) feel their difficulties make them different from others.
Parents think of their parenting as a lifelong engagement.
There is a shortage of studies investigating experiences of children with FASD.
There is a shortage of studies investigating experiences of interventions given to individuals with FASD.
This article is commented on by Autti‐Rämö on page 732 of this issue.
This article's has been translated into Spanish and Portuguese.
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The GRADE-CERQual (Grading of Recommendations Assessment, Development and Evaluation-Confidence in Evidence from Reviews of Qualitative research) approach has been developed by the GRADE 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. 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) relevance, (3) coherence and (4) adequacy of data. This paper is part of a series providing guidance on how to apply CERQual and focuses on CERQual's coherence component.
We developed the coherence component by searching the literature for definitions, gathering feedback from relevant research communities and developing consensus through project group meetings. We tested the CERQual coherence component within several qualitative evidence syntheses before agreeing on the current definition and principles for application.
When applying CERQual, we define coherence as how clear and cogent the fit is between the data from the primary studies and a review finding that synthesises that data. In this paper, we describe the coherence component and its rationale and offer guidance on how to assess coherence in the context of a review finding as part of the CERQual approach. This guidance outlines the information required to assess coherence, the steps that need to be taken to assess coherence and examples of coherence assessments.
This paper provides guidance for review authors and others on undertaking an assessment of coherence in the context of the CERQual approach. We suggest that threats to coherence may arise when the data supporting a review finding are contradictory, ambiguous or incomplete or where competing theories exist that could be used to synthesise the data. We expect the CERQual approach, and its individual components, to develop further as our experiences with the practical implementation of the approach increase.
This Campbell systematic review examines the effectiveness of interventions to reduce homelessness and increase residential stability for individuals who are homeless, or at risk of becoming ...homeless. Forty‐three studies were included in the review, 37 of which are from the USA.
Included interventions perform better than the usual services at reducing homelessness or improving housing stability in all comparisons. These interventions are:
High intensity case management
Housing First
Critical time intervention
Abstinence‐contingent housing
Non‐abstinence‐contingent housing with high intensity case management
Housing vouchers
Residential treatment
These interventions seem to have similar beneficial effects, so it is unclear which of these is best with respect to reducing homelessness and increasing housing stability.
Executive summary
Background
The United Nations Universal Declaration of Human Rights (Article 25) states that everyone has a right to housing. However, this right is far from being realized for many people worldwide. According to the United Nations High Commissioner for Refugees (UNHCR), there are approximately 100 million homeless people worldwide. The aim of this report is to contribute evidence to inform future decision making and practice for preventing and reducing homelessness.
Objectives
To identify, appraise and summarize the evidence on the effectiveness of housing programs and case management to improve housing stability and reduce homelessness among people who are homeless or at‐risk of becoming homeless.
Search methods
We conducted a systematic review in accordance with the Norwegian Knowledge Centre's handbook. We systematically searched for literature in relevant databases and conducted a grey literature search which was last updated in January 2016.
Selection criteria
Randomized controlled trials that included individuals who were already, or at‐risk of becoming, homeless were included if they examined the effectiveness of relevant interventions on homelessness or housing stability. There were no limitations regarding language, country or length of homelessness. Two reviewers screened 2,918 s and titles for inclusion. They read potentially relevant references in full, and included relevant studies in the review.
Data collection and analysis
We pooled the results and conducted meta‐analyses when possible. Our certainty in the primary outcomes was assessed using the Grading of Recommendations Assessment, Development, and Evaluation for effectiveness approach (GRADE).
Results
We included 43 relevant studies (described in 78 publications) that examined the effectiveness of housing programs and/or case management services on homelessness and/or housing stability. The results are summarized below. Briefly, we found that the included interventions performed better than the usual services in all comparisons. However, certainty in the findings varied from very low to moderate. Most of the studies were assessed as having high risk of bias due to poor reporting, lack of blinding, or poor randomization and/or allocation concealment of participants.
Case management
Case management is a process where clients are assigned case managers who assess, plan and facilitate access to health and social services necessary for the client's recovery. The intensity of these services can vary. One specific model is Critical time intervention, which is based on the same principles, but offered in three three‐month periods that decrease in intensity.
High intensity case management compared to usual services has generally more positive effects: It probably reduces the number of individuals who are homeless after 12‐18 months by almost half (RR=0.59, 95%CI=0.41 to 0.87)(moderate certainty evidence); It may increase the number of people living in stable housing after 12‐18 months and reduce the number of days an individual spends homeless (low certainty evidence), however; it may have no effect on the number of individuals who experience some homelessness during a two year period (low certainty evidence). When compared to low intensity case management, it may have little or no effect on time spent in stable housing (low certainty evidence).
Critical time intervention compared to usual services may 1) have no effect on the number of people who experience homelessness, 2) lead to fewer days spent homeless, 3) lead to more days spent not homeless and, 4) reduce the amount of time it takes to move from shelter to independent housing (low certainty evidence).
Abstinence‐contingent housing programs
Abstinence‐contingent housing is housing provided with the expectation that residents will remain sober. The results showed that abstinence‐contingent housing may lead to fewer days spent homeless, compared with usual services (low certainty evidence).
Non‐abstinence‐contingent housing programs
Non‐abstinence‐contingent housing is housing provided with no expectations regarding sobriety of residents. Housing First is the name of one specific non‐abstinence‐contingent housing program. When compared to usual servicesHousing Firstprobably reduces the number of days spent homeless (MD=‐62.5, 95%CI=‐86.86 to ‐38.14) and increases the number of days in stable housing (MD=110.1, 95%CI=93.05 to 127.15) (moderate certainty evidence). In addition, it may increase the number of people placed in permanent housing after 20 months (low certainty evidence).
Non‐abstinence‐contingent housing programs(not specified as Housing First) in combinationwith highintensity case management may reduce homelessness,compared to usual services (low certainty evidence). Group living arrangements may be better than individual apartments at reducing homelessness (low certainty evidence).
Housing vouchers with case management
Housing vouchers is a housing allowance given to certain groups of people who qualify. The results showed that it mayreduce homelessness and improve housing stability,compared with usual services or case management (low certainty evidence).
Residential treatment with case management
Residential treatment is a type of housing offered to clients who also need treatment for mental illness or substance abuse. We found that it mayreduce homelessness and improve housing stability, compared with usual services (low certainty evidence).
Authors’ conclusions
We found that a range of housing programs and case management interventions appear to reduce homelessness and improve housing stability, compared to usual services. The findings showed no indication of housing programs or case management resulting in poorer outcomes for homeless or at‐risk individuals than usual services.
Aside from a general need for better conducted and reported studies, there are specific gaps in the research. We identified research gaps concerning: 1)Disadvantaged youth; 2) Abstinence‐contingent housing with case management or day treatment; 3) Non‐abstinence contingent housing, specifically different living arrangements (group vs independent living); 4) Housing First compared to interventions other than usual services, and; 5) All interventions from contexts other than the USA.
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. 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.
We developed this guidance by examining the methods used by other GRADE approaches, gathering feedback from relevant research communities and developing consensus through project group meetings. We then piloted the guidance on several qualitative evidence syntheses before agreeing on the approach.
Confidence in the evidence is an assessment of the extent to which a review finding is a reasonable representation of the phenomenon of interest. Creating a summary of each review finding and deciding whether or not CERQual should be used are important steps prior to assessing confidence. Confidence should be assessed for each review finding individually, based on the judgements made for each of the four CERQual components. Four levels are used to describe the overall assessment of confidence: high, moderate, low or very low. The overall CERQual assessment for each review finding should be explained in a CERQual Evidence Profile and 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.
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