Objective
Considerable time and resources are allocated to carry out qualitative research. The purpose of our study was to evaluate the availability of qualitative research on women’s health screening and assess its influence on screening practice guidelines in the United States, Canada, and the United Kingdom.
Study Design
Medline, CINHAL, and WEB of Science databases were used to identify the availability of qualitative research conducted in the past 15 years on 3 different women’s health screening topics: cervical cancer screening, breast cancer screening, and prenatal first-trimester screening. Key national practice guidelines on women’s health screening were selected using the National Guideline Clearinghouse web site. Bibliometric analysis was used to determine the frequency of qualitative references cited in the guidelines.
Results
A total of 272 qualitative research papers on women’s health screening was identified: 109 on cervical cancer screening, 104 on breast cancer screening, and 59 on prenatal first-trimester screening. The qualitative studies focused on health care provider perspectives as well as ethical, ethnographic, psychological, and social issues surrounding screening. Fifteen national clinical practice guidelines on women’s health screening were identified. A total of 943 references was cited, only 2 of which comprised of qualitative research cited by only 1 clinical practice guideline.
Conclusion
Although there is considerable qualitative research that has been carried out on women’s health screening, its incorporation into clinical practice guidelines is minimal. Further exploration of the disconnect between the two is important for enhancing knowledge translation of qualitative research within clinical practice.
A considerable amount of resources both financial and human are dedicated to qualitative research on a yearly basis. Experts in the field of qualitative research describe their data as “findings about experiences lived, behaviors, emotions, organizational functioning, social movements, cultural phenomenon, and interactions between nations.”
A scan of the existing literature on women’s health reveals a variety of topics addressed in qualitative research: barriers to accessing health services, determinants of health, psychological factors, quality of care, women’s views and experiences, gender equity, socioeconomic disparity, and cultural values.
Clinical practice guidelines (CPGs) have emerged as a new and important tool used in evidence-based medicine. They are systematically designed recommendations for clinicians regarding the care of patients with specific conditions. All available evidence on the topic is gathered, and the information is evaluated and synthesized into practical documents that help guide clinicians in their decision making. Contrary to other tools used in clinical medicine, CPGs are supposed to provide greater emphasis on the clinical context by considering qualitative data more profoundly. Whether CPGs incorporate qualitative research conducted in the medical field is uncertain.
The purpose of our study was to assess whether CPGs on women’s health screening take into consideration qualitative evidence generated on this topic. We measured the availability and use of qualitative evidence in CPGs on breast cancer screening, cervical cancer screening, and prenatal first-trimester screening in the United States, Canada, and the United Kingdom.
Materials and Methods
To determine the use of qualitative evidence in CPGs, we undertook 2 searches. First, we conducted a search for qualitative literature on breast cancer screening, cervical cancer screening, and prenatal first-trimester screening using the following databases independently: Medline, CINHAL, and WEB of Science. Articles published in the last 15 years (January 1997 through November 2012) that contained the following search key words in any part of the text were selected. The search key words for breast cancer screening were: cancer screening and breast neoplasm, and qualitative studies; cancer screening and cervix neoplasms and qualitative studies for cervical cancer screening; and prenatal diagnosis and qualitative research for prenatal first-trimester screening.
All searches were limited to human subjects and to the English language. Two independent reviewers scanned the titles and abstracts of the identified articles to determine inclusion using criteria listed in Table 1 . The abstract and main text of the selected articles were reviewed and categorized according to 1 of the following qualitative themes: ethics, psychology, society, ethnography, health provider perspectives, and other. Ethical themes explored the ethical implications of screening and implementing screening programs. Psychological themes dealt with behaviours, attitudes, and decision-making processes associated with screening. Social themes explored barriers to screening, education, promotion, determinants of health, and social roles related to screening. Ethnographic themes were defined as the studies exploring cultural and religious aspects of screening. Health provider perspectives were defined as opinions of, or interactions between, health care practitioners and their patients. Other refers to articles that combined more than 1 of the themes cited in the previous text.
| Data and analysis type used in the qualitative studies |
| Semistructured or open-ended interviews |
| Focus groups |
| Case studies |
| Ethnographic studies |
| Participant observation |
| Printed materials |
| Media sources |
| Analysis of content, discourse, narrative or ethnography |
It was specified whether the selected articles belonged to a core clinical journal, included in the Abridged Index Medicus (AIM) as published by the US National Library of Medicine.
The second step of our study was to identify key national CPGs. We used the National Guideline Clearinghouse web site to identify CPGs by doing key word searches of 3 screening topics: breast cancer, cervical cancer, and prenatal first-trimester screening, published by medical organizations in the United States, Canada, and the United Kingdom.
The latest and most up-to-date versions of the guidelines on each screening topic were chosen to be reviewed. Guidelines published by independent organizations, for which inclusion into larger national guidelines or task forces was identified, were not individually included for review, but the more inclusive guidelines were selected. For example, the CPG by American College of Obstetricians and Gynecologists (ACOG), Invasive Prenatal Testing for Aneuploidy (2007), was included in a more recently updated guideline, the US Preventive Task Force (USPTF) Recommendation Statement Screening for Cervical Cancer (2012) ; therefore, the latter was included for review.
The listed references cited in the guidelines were examined individually by 1 reviewer, who screened the abstract and text (if necessary) for qualitative content using the criteria listed in Table 2 . This study is a review of the literature and does not require ethics approval.
| Inclusion criteria |
| Studies considered 1 of these screening areas: |
| Breast cancer |
| Cervical cancer |
| Prenatal first trimester |
| Studies were conducted in an empirical qualitative manner as defined in Table 1 |
| Studies were conducted between January 1997 and November 2012 (past 15 years) |
| Studies were conducted in the English language |
| Exclusion criteria |
| Studies were not original research (ie, editorials; opinions, or letters) |
| Studies with qualitative data analyzed quantitatively |
| Study content was irrelevant to screening in 1 of the 3 previously mentioned areas |
Results
A total of 109 qualitative articles was identified relating to cervical cancer screening, 104 articles relating to breast cancer screening, and 59 articles relating to prenatal first-trimester screening. The articles were categorized according to the themes listed in Table 3 . The majority of qualitative articles pertaining to cervical and breast cancer screening dealt with ethnographic themes, whereas most articles on prenatal screening addressed the psychological impacts of screening. Only 1 of the identified articles was published in a core clinical journal, with a focus on community health worker training on breast cancer screening in Southeast Asia.
| Variable | Cervical cancer screening | Breast cancer screening | Prenatal screening |
|---|---|---|---|
| Total number of qualitative articles | 109 | 104 | 59 |
| Qualitative themes | |||
| Ethnographic | 66 | 61 | 8 |
| Health provider perspectives | 11 | 12 | 10 |
| Ethical | 0 | 3 | 9 |
| Psychological | 16 | 14 | 23 |
| Social | 14 | 11 | 7 |
| Other | 2 | 3 | 2 |
| Core clinical journals | 0 | 1 | 0 |
Table 4 lists the selected CPGs and their total number of listed references including the number of qualitative research references. A total of 15 national CPGs were reviewed, 5 in each screening category, providing a total of 943 references. Only 2 of the 943 references reviewed consisted of qualitative research (0.2%), both of which were cited in 1 of the 15 reviewed CPGs. The CPG that included the 2 qualitative references was derived from the National Health Service–Royal College of Obstetricians and Gynecologists collaboration on antenatal care and discussed the qualitative research evidence in a separate section as well as defined the word, qualitative, in the glossary of terms.
| Clinical practice guideline title and year of publication | Number of references | Number of qualitative references |
|---|---|---|
| Prenatal screening | ||
| SOGC-CCMG joint CPG on prenatal screening for aneuploidy singleton pregnancy, 2011 | 106 | 0 |
| SOGC-CCMG joint CPG on prenatal screening for aneuploidy in twin pregnancy, 2011 | 91 | 0 |
| ACMG CPF on fetal aneuploidy and neural tube defects, 2009 | 30 | 0 |
| ACOG CPG on screening for fetal chromosomal abnormalities, 2007 | 43 | 0 |
| NHS-RCOG CPG on antenatal care, section 9, screening for fetal anomalies, 2008 | 79 | 2 |
| Cervical cancer screening | ||
| Health Canada, programmatic guidelines for screening for cancer of the cervix in Canada, 1999 | 39 | 0 |
| SOGC Canadian consensus guidelines on HPV, section 5, 2007 | 46 | 0 |
| ACS/ASCP/ASCCP guidelines for the preventing and early detection of cervical cancer, 2012 | 158 | 0 |
| USPTF recommendation statement screening for cervical cancer, 2012 | 46 | 0 |
| NHS guidelines for the NHS cervical screening program, second Edition, screening section, 2010 | 46 | 0 |
| Breast cancer screening | ||
| CTFPHC, recommendations on screening for breast cancer in average-risk women aged 40-74 years, 2011 | 47 | 0 |
| ACOG CPG on breast cancer screening, 2011 | 54 | 0 |
| ACR breast screening with imaging recommendations, 2010 | 82 | 0 |
| USPTF screening for breast cancer recommendation statement, 2009 | 32 | 0 |
| NHS clinical guidelines for breast cancer screening assessment, third ed, endorsed by the RCR, 2010 | 44 | 0 |
| Total | 943 | 2 |
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