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Methods for the synthesis of qualitative research: a critical review
Elaine Barnett-Page* and James Thomas

Address: Evidence for Policy and Practice Information and Co-ordinating (EPPI-) Centre, Social Science Research Unit, 18 Woburn Square, London
WC1H 0NS, UK
Email: Elaine Barnett-Page* - [email protected]; James Thomas - [email protected]
* Corresponding author

Published: 11 August 2009 Received: 9 March 2009

Accepted: 11 August 2009
BMC Medical Research Methodology 2009, 9:59 doi:10.1186/1471-2288-9-59
This article is available from: http://www.biomedcentral.com/1471-2288/9/59
© 2009 Barnett-Page and Thomas; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Background: In recent years, a growing number of methods for synthesising qualitative research
have emerged, particularly in relation to health-related research. There is a need for both
researchers and commissioners to be able to distinguish between these methods and to select
which method is the most appropriate to their situation.
Discussion: A number of methodological and conceptual links between these methods were
identified and explored, while contrasting epistemological positions explained differences in
approaches to issues such as quality assessment and extent of iteration. Methods broadly fall into
'realist' or 'idealist' epistemologies, which partly accounts for these differences.
Summary: Methods for qualitative synthesis vary across a range of dimensions. Commissioners
of qualitative syntheses might wish to consider the kind of product they want and select their
method – or type of method – accordingly.

Background method that is fit for their purpose. It also represents an

The range of different methods for synthesising qualita- attempt to guide the reader through some of the varied
tive research has been growing over recent years [1,2], terminology to spring up around qualitative synthesis.
alongside an increasing interest in qualitative synthesis to Other helpful reviews of synthesis methods have been
inform health-related policy and practice [3]. While the undertaken in recent years with slightly different foci to
terms 'meta-analysis' (a statistical method to combine the this paper. Two recent studies have focused on describing
results of primary studies), or sometimes 'narrative syn- and critiquing methods for the integration of qualitative
thesis', are frequently used to describe how quantitative research with quantitative [4,5] rather than exclusively
research is synthesised, far more terms are used to describe examining the detail and rationale of methods for the syn-
the synthesis of qualitative research. This profusion of thesis of qualitative research. Two other significant pieces
terms can mask some of the basic similarities in approach of work give practical advice for conducting the synthesis
that the different methods share, and also lead to some of qualitative research, but do not discuss the full range of
confusion regarding which method is most appropriate in methods available [6,7]. We begin our Discussion by out-
a given situation. This paper does not argue that the vari- lining each method of synthesis in turn, before comparing
ous nomenclatures are unnecessary, but rather seeks to and contrasting characteristics of these different methods
draw together and review the full range of methods of syn- across a range of dimensions. Readers who are more
thesis available to assist future reviewers in selecting a familiar with the synthesis methods described here may

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prefer to turn straight to the 'dimensions of difference' tively' (p204). The former would involve looking to see
analysis in the second part of the Discussion. whether the same concept, theory etc exists in different
studies; the latter would involve the construction of a big-
Discussion ger picture or theory (i.e. LOA synthesis). They also talk
Overview of synthesis methods about comparing or integrating imported concepts (e.g.
Meta-ethnography from other disciplines) as well as those evolved 'in vivo'.
In their seminal work of 1988, Noblit and Hare proposed
meta-ethnography as an alternative to meta-analysis [8]. Grounded theory
They cited Strike and Posner's [9] definition of synthesis Kearney [16], Eaves [17] and Finfgeld [18] have all
as an activity in which separate parts are brought together adapted grounded theory to formulate a method of syn-
to form a 'whole'; this construction of the whole is essen- thesis. Key methods and assumptions of grounded theory,
tially characterised by some degree of innovation, so that as originally formulated and subsequently refined by Gla-
the result is greater than the sum of its parts. They also ser and Strauss [19] and Strauss and Corbin [20,21],
borrowed from Turner's theory of social explanation [10], include: simultaneous phases of data collection and anal-
a key tenet of which was building 'comparative under- ysis; an inductive approach to analysis, allowing the the-
standing' [[8], p22] rather than aggregating data. ory to emerge from the data; the use of the constant
comparison method; the use of theoretical sampling to
To Noblit and Hare, synthesis provided an answer to the reach theoretical saturation; and the generation of new
question of 'how to "put together" written interpretive theory. Eaves cited grounded theorists Charmaz [22] and
accounts' [[8], p7], where mere integration would not be Chesler [23], as well as Strauss and Corbin [20], as
appropriate. Noblit and Hare's early work synthesised informing her approach to synthesis.
research from the field of education.
Glaser and Strauss [19] foresaw a time when a substantive
Three different methods of synthesis are used in meta-eth- body of grounded research should be pushed towards a
nography. One involves the 'translation' of concepts from higher, more abstract level. As a piece of methodological
individual studies into one another, thereby evolving work, Eaves undertook her own synthesis of the synthesis
overarching concepts or metaphors. Noblit and Hare methods used by these authors to produce her own clear
called this process reciprocal translational analysis (RTA). and explicit guide to synthesis in grounded formal theory.
Refutational synthesis involves exploring and explaining Kearney stated that 'grounded formal theory', as she
contradictions between individual studies. Lines-of-argu- termed this method of synthesis, 'is suited to study of phe-
ment (LOA) synthesis involves building up a picture of the nomena involving processes of contextualized under-
whole (i.e. culture, organisation etc) from studies of its standing and action' [[24], p180] and, as such, is
parts. The authors conceptualised this latter approach as a particularly applicable to nurses' research interests.
type of grounded theorising.
As Kearney suggested, the examples examined here were
Britten et al [11] and Campbell et al [12] have both con- largely dominated by research in nursing. Eaves synthe-
ducted evaluations of meta-ethnography and claim to sised studies on care-giving in rural African-American
have succeeded, by using this method, in producing theo- families for elderly stroke survivors; Finfgeld on courage
ries with greater explanatory power than could be among individuals with long-term health problems; Kear-
achieved in a narrative literature review. While both these ney on women's experiences of domestic violence.
evaluations used small numbers of studies, more recently
Pound et al [13] conducted both an RTA and an LOA syn- Kearney explicitly chose 'grounded formal theory' because
thesis using a much larger number of studies (37) on it matches 'like' with 'like': that is, it applies the same
resisting medicines. These studies demonstrate that meta- methods that have been used to generate the original
ethnography has evolved since Noblit and Hare first intro- grounded theories included in the synthesis – produced
duced it. Campbell et al claim to have applied the method by constant comparison and theoretical sampling – to
successfully to non-ethnographical studies. Based on their generate a higher-level grounded theory. The wish to
reading of Schutz [14], Britten et al have developed both match 'like' with 'like' is also implicit in Eaves' paper. This
second and third order constructs in their synthesis distinguishes grounded formal theory from more recent
(Noblit and Hare briefly allude to the possibility of a 'sec- applications of meta-ethnography, which have sought to
ond level of synthesis' [[8], p28] but do not demonstrate include qualitative research using diverse methodological
or further develop the idea). approaches [12].

In a more recent development, Sandelowski & Barroso Thematic Synthesis

[15] write of adapting RTA by using it to 'integrate findings Thomas and Harden [25] have developed an approach to
interpretively, as opposed to comparing them interpre- synthesis which they term 'thematic synthesis'. This com-

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bines and adapts approaches from both meta-ethnogra- Zhao [29], drawing on Ritzer's work [30], outlined three
phy and grounded theory. The method was developed out components of analysis, which they proposed should be
of a need to conduct reviews that addressed questions undertaken prior to synthesis. These are meta-data-analy-
relating to intervention need, appropriateness and accept- sis (the analysis of findings), meta-method (the analysis
ability – as well as those relating to effectiveness – without of methods) and meta-theory (the analysis of theory).
compromising on key principles developed in systematic Collectively, these three elements of analysis, culminating
reviews. They applied thematic synthesis in a review of the in synthesis, make up the practice of 'meta-study'. Pater-
barriers to, and facilitators of, healthy eating amongst son et al pointed out that the different components of
children. analysis may be conducted concurrently.

Free codes of findings are organised into 'descriptive' Paterson et al argued that primary research is a construc-
themes, which are then further interpreted to yield 'analyt- tion; secondary research is therefore a construction of a
ical' themes. This approach shares characteristics with construction. There is need for an approach that recog-
later adaptations of meta-ethnography, in that the analyt- nises this, and that also recognises research to be a prod-
ical themes are comparable to 'third order interpretations' uct of its social, historical and ideological context. Such an
and that the development of descriptive and analytical approach would be useful in accounting for differences in
themes using coding invoke reciprocal 'translation'. It also research findings. For Paterson et al, there is no such thing
shares much with grounded theory, in that the approach as 'absolute truth'.
is inductive and themes are developed using a 'constant
comparison' method. A novel aspect of their approach is Meta-study was developed to study the experiences of
the use of computer software to code the results of adults living with a chronic illness. Meta-data-analysis was
included studies line-by-line, thus borrowing another conceived of by Paterson et al in similar terms to Noblit
technique from methods usually used to analyse primary and Hare's meta-ethnography (see above), in that it is
research. essentially interpretive and seeks to reveal similarities and
discrepancies among accounts of a particular phenome-
Textual Narrative Synthesis non. Meta-method involves the examination of the meth-
Textual narrative synthesis is an approach which arranges odologies of the individual studies under review. Part of
studies into more homogenous groups. Lucas et al [26] the process of meta-method is to consider different
comment that it has proved useful in synthesising evi- aspects of methodology such as sampling, data collection,
dence of different types (qualitative, quantitative, eco- research design etc, similar to procedures others have
nomic etc). Typically, study characteristics, context, called 'critical appraisal' (CASP [31]). However, Paterson
quality and findings are reported on according to a stand- et al take their critique to a deeper level by establishing the
ard format and similarities and differences are compared underlying assumptions of the methodologies used and
across studies. Structured summaries may also be devel- the relationship between research outcomes and methods
oped, elaborating on and putting into context the used. Meta-theory involves scrutiny of the philosophical
extracted data [27]. and theoretical assumptions of the included research
papers; this includes looking at the wider context in which
Lucas et al [26] compared thematic synthesis with textual new theory is generated. Paterson et al described meta-
narrative synthesis. They found that 'thematic synthesis synthesis as a process which creates a new interpretation
holds most potential for hypothesis generation' whereas which accounts for the results of all three elements of
textual narrative synthesis is more likely to make transpar- analysis. The process of synthesis is iterative and reflexive
ent heterogeneity between studies (as does meta-ethnog- and the authors were unwilling to oversimplify the proc-
raphy, with refutational synthesis) and issues of quality ess by 'codifying' procedures for bringing all three compo-
appraisal. This is possibly because textual narrative syn- nents of analysis together.
thesis makes clearer the context and characteristics of each
study, while the thematic approach organises data accord- Meta-narrative
ing to themes. However, Lucas et al found that textual nar- Greenhalgh et al [32]'s meta-narrative approach to syn-
rative synthesis is 'less good at identifying commonality' thesis arose out of the need to synthesise evidence to
(p2); the authors do not make explicit why this should be, inform complex policy-making questions and was
although it may be that organising according to themes, as assisted by the formation of a multi-disciplinary team.
the thematic approach does, is comparatively more suc- Their approach to review was informed by Thomas Kuhn's
cessful in revealing commonality. The Structure of Scientific Revolutions [33], in which he pro-
posed that knowledge is produced within particular para-
Meta-study digms which have their own assumptions about theory,
Paterson et al [28] have evolved a multi-faceted approach about what is a legitimate object of study, about what are
to synthesis, which they call 'meta-study'. The sociologist legitimate research questions and about what constitutes

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a finding. Paradigms also tend to develop through time to just the synthesis component. It involves an iterative
according to a particular set of stages, central to which is approach to refining the research question and searching
the stage of 'normal science', in which the particular and selecting from the literature (using theoretical sam-
standards of the paradigm are largely unchallenged and pling) and defining and applying codes and categories. It
seen to be self-evident. As Greenhalgh et al pointed out, also has a particular approach to appraising quality, using
Kuhn saw paradigms as largely incommensurable: 'that is, relevance – i.e. likely contribution to theory development
an empirical discovery made using one set of concepts, – rather than methodological characteristics as a means of
theories, methods and instruments cannot be satisfacto- determining the 'quality' of individual papers [35]. The
rily explained through a different paradigmatic lens' [[32], authors also stress, as a defining characteristic, critical
p419]. interpretive synthesis's critical approach to the literature
in terms of deconstructing research traditions or theoreti-
Greenhalgh et al synthesised research from a wide range cal assumptions as a means of contextualising findings.
of disciplines; their research question related to the diffu-
sion of innovations in health service delivery and organi- Dixon-Woods et al rejected reciprocal translational analy-
sation. They thus identified a need to synthesise findings sis (RTA) as this produced 'only a summary in terms that
from research which contains many different theories aris- have already been used in the literature' [[34], p5], which
ing from many different disciplines and study designs. was seen as less helpful when dealing with a large and
diverse body of literature. Instead, Dixon-Woods et al
Based on Kuhn's work, Greenhalgh et al proposed that, adopted a lines-of-argument (LOA) synthesis, in which –
across different paradigms, there were multiple – and rejecting the difference between first, second and third
potentially mutually contradictory – ways of understand- order constructs – they instead developed 'synthetic con-
ing the concept at the heart of their review, namely the dif- structs' which were then linked with constructs arising
fusion of innovation. Bearing this in mind, the reviewers directly from the literature.
deliberately chose to select key papers from a number of
different research 'paradigms' or 'traditions', both within The influence of grounded theory can be seen in particular
and beyond healthcare, guided by their multidisciplinary in critical interpretive synthesis's inductive approach to
research team. They took as their unit of analysis the formulating the review question and to developing cate-
'unfolding "storyline" of a research tradition over time' gories and concepts, rejecting a 'stage' approach to system-
[[32], p417) and sought to understand diffusion of inno- atic reviewing, and in selecting papers using theoretical
vation as it was conceptualised in each of these traditions. sampling. Dixon-Woods et al also claim that critical inter-
Key features of each tradition were mapped: historical pretive synthesis is distinct in its 'explicit orientation
roots, scope, theoretical basis; research questions asked towards theory generation' [[34], p9].
and methods/instruments used; main empirical findings;
historical development of the body of knowledge (how Ecological Triangulation
have earlier findings led to later findings); and strengths Jim Banning is the author of 'ecological triangulation' or
and limitations of the tradition. The results of this exercise 'ecological sentence synthesis', applying this method to
led to maps of 13 'meta-narratives' in total, from which the evidence for what works for youth with disabilities. He
seven key dimensions, or themes, were identified and dis- borrows from Webb et al [36] and Denzin [37] the con-
tilled for the synthesis phase of the review. cept of triangulation, in which phenomena are studied
from a variety of vantage points. His rationale is that
Critical Interpretive Synthesis building an 'evidence base' of effectiveness requires the
Dixon-Woods et al [34] developed their own approach to synthesis of cumulative, multi-faceted evidence in order
synthesising multi-disciplinary and multi-method evi- to find out 'what intervention works for what kind of out-
dence, termed 'critical interpretive synthesis', while comes for what kind of persons under what kind of con-
researching access to healthcare by vulnerable groups. ditions' [[38], p1].
Critical interpretive synthesis is an adaptation of meta-
ethnography, as well as borrowing techniques from Ecological triangulation unpicks the mutually interde-
grounded theory. The authors stated that they needed to pendent relationships between behaviour, persons and
adapt traditional meta-ethnographic methods for synthe- environments. The method requires that, for data extrac-
sis, since these had never been applied to quantitative as tion and synthesis, 'ecological sentences' are formulated
well as qualitative data, nor had they been applied to a following the pattern: 'With this intervention, these out-
substantial body of data (in this case, 119 papers). comes occur with these population foci and within these
grades (ages), with these genders ... and these ethnicities
Dixon-Woods et al presented critical interpretive synthesis in these settings' [[39], p1].
as an approach to the whole process of review, rather than

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Framework Synthesis mined and the higher the frequency of a particular find-
Brunton et al [40] and Oliver et al [41] have applied a ing, the greater its validity. The authors even discuss the
'framework synthesis' approach in their reviews. Frame- calculation of 'effect sizes' for qualitative findings. Quali-
work synthesis is based on framework analysis, which was tative metasummaries can be undertaken as an end in
outlined by Pope, Ziebland and Mays [42], and draws themselves or may serve as a basis for a further synthesis.
upon the work of Ritchie and Spencer [43] and Miles and
Huberman [44]. Its rationale is that qualitative research Dimensions of difference
produces large amounts of textual data in the form of tran- Having outlined the range of methods identified, we now
scripts, observational fieldnotes etc. The sheer wealth of turn to an examination of how they compare with one
information poses a challenge for rigorous analysis. another. It is clear that they have come from many differ-
Framework synthesis offers a highly structured approach ent contexts and have different approaches to understand-
to organising and analysing data (e.g. indexing using ing knowledge, but what do these differences mean in
numerical codes, rearranging data into charts etc). practice? Our framework for this analysis is shown in
Additional file 1: dimensions of difference [48]. We have
Brunton et al applied the approach to a review of chil- examined the epistemology of each of the methods and
dren's, young people's and parents' views of walking and found that, to some extent, this explains the need for dif-
cycling; Oliver et al to an analysis of public involvement ferent methods and their various approaches to synthesis.
in health services research. Framework synthesis is distinct
from the other methods outlined here in that it utilises an Epistemology
a priori 'framework' – informed by background material The first dimension that we will consider is that of the
and team discussions – to extract and synthesise findings. researchers' epistemological assumptions. Spencer et al
As such, it is largely a deductive approach although, in [49] outline a range of epistemological positions, which
addition to topics identified by the framework, new topics might be organised into a spectrum as follows:
may be developed and incorporated as they emerge from
the data. The synthetic product can be expressed in the Subjective idealism: there is no shared reality independ-
form of a chart for each key dimension identified, which ent of multiple alternative human constructions
may be used to map the nature and range of the concept
under study and find associations between themes and Objective idealism: there is a world of collectively
exceptions to these [40]. shared understandings

'Fledgling' approaches Critical realism: knowledge of reality is mediated by

There are three other approaches to synthesis which have our perceptions and beliefs
not yet been widely used. One is an approach using con-
tent analysis [45,46] in which text is condensed into fewer Scientific realism: it is possible for knowledge to
content-related categories. Another is 'meta-interpreta- approximate closely an external reality
tion' [47], featuring the following: an ideographic rather
than pre-determined approach to the development of Naïve realism: reality exists independently of human
exclusion criteria; a focus on meaning in context; interpre- constructions and can be known directly [49,45,46].
tations as raw data for synthesis (although this feature
doesn't distinguish it from other synthesis methods); an Thus, at one end of the spectrum we have a highly con-
iterative approach to the theoretical sampling of studies structivist view of knowledge and, at the other, an unprob-
for synthesis; and a transparent audit trail demonstrating lematized 'direct window onto the world' view.
the trustworthiness of the synthesis.
Nearly all of positions along this spectrum are represented
In addition to the synthesis methods discussed above, in the range of methodological approaches to synthesis
Sandelowski and Barroso propose a method they call covered in this paper. The originators of meta-narrative
'qualitative metasummary' [15]. It is mentioned here as a synthesis, critical interpretive synthesis and meta-study all
new and original approach to handling a collection of articulate what might be termed a 'subjective idealist'
qualitative studies but is qualitatively different to the approach to knowledge. Paterson et al [28] state that
other methods described here since it is aggregative; that meta-study shies away from creating 'grand theories'
is, findings are accumulated and summarised rather than within the health or social sciences and assume that no
'transformed'. Metasummary is a way of producing a single objective reality will be found. Primary studies, they
'map' of the contents of qualitative studies and – accord- argue, are themselves constructions; meta-synthesis, then,
ing to Sandelowski and Barroso – 'reflect [s] a quantitative 'deals with constructions of constructions' (p7). Green-
logic' [[15], p151]. The frequency of each finding is deter- halgh et al [32] also view knowledge as a product of its

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disciplinary paradigm and use this to explain conflicting ecological triangulation is adopted) and that interven-
findings: again, the authors neither seek, nor expect to tions can and should be modelled according to the prod-
find, one final, non-contestable answer to their research ucts of its syntheses.
question. Critical interpretive synthesis is similar in seek-
ing to place literature within its context, to question its While pigeonholing different methods into specific epis-
assumptions and to produce a theoretical model of a phe- temological positions is a problematic process, we do sug-
nomenon which – because highly interpretive – may not gest that the contrasting epistemologies of different
be reproducible by different research teams at alternative researchers is one way of explaining why we have – and
points in time [[34], p11]. need – different methods for synthesis.

Methods used to synthesise grounded theory studies in Iteration

order to produce a higher level of grounded theory [24] Variation in terms of the extent of iteration during the
appear to be informed by 'objective idealism', as does review process is another key dimension. All synthesis
meta-ethnography. Kearney argues for the near-universal methods include some iteration but the degree varies.
applicability of a 'ready-to-wear' theory across contexts Meta-ethnography, grounded theory and thematic synthe-
and populations. This approach is clearly distinct from sis all include iteration at the synthesis stage; both frame-
one which recognises multiple realities. The emphasis is work synthesis and critical interpretive synthesis involve
on examining commonalities amongst, rather than dis- iterative literature searching – in the case of critical inter-
crepancies between, accounts. This emphasis is similarly pretive synthesis, it is not clear whether iteration occurs
apparent in most meta-ethnographies, which are con- during the rest of the review process. Meta-narrative also
ducted either according to Noblit and Hare's 'reciprocal involves iteration at every stage. Banning does not men-
translational analysis' technique or to their 'lines-of-argu- tion iteration in outlining ecological triangulation and
ment' technique and which seek to provide a 'whole' neither do Lucas or Thomas and Harden for thematic nar-
which has a greater explanatory power. Although Noblit rative synthesis.
and Hare also propose 'refutational synthesis', in which
contradictory findings might be explored, there are few It seems that the more idealist the approach, the greater
examples of this having been undertaken in practice, and the extent of iteration. This might be because a large
the aim of the method appears to be to explain and degree of iteration does not sit well with a more 'positivist'
explore differences due to context, rather than multiple ideal of procedural objectivity; in particular, the notion
realities. that the robustness of the synthetic product depends in
part on the reviewers stating up front in a protocol their
Despite an assumption of a reality which is perhaps less searching strategies, inclusion/exclusion criteria etc, and
contestable than those of meta-narrative synthesis, critical being seen not to alter these at a later stage.
interpretive synthesis and meta-study, both grounded for-
mal theory and meta-ethnography place a great deal of Quality assessment
emphasis on the interpretive nature of their methods. This Another dimension along which we can look at different
still supposes a degree of constructivism. Although less synthesis methods is that of quality assessment. When the
explicit about how their methods are informed, it seems approaches to the assessment of the quality of studies
that both thematic synthesis and framework synthesis – retrieved for review are examined, there is again a wide
while also involving some interpretation of data – share methodological variation. It might be expected that the
an even less problematized view of reality and a greater further towards the 'realism' end of the epistemological
assumption that their synthetic products are reproducible spectrum a method of synthesis falls, the greater the
and correspond to a shared reality. This is also implicit in emphasis on quality assessment. In fact, this is only par-
the fact that such products are designed directly to inform tially the case.
policy and practice, a characteristic shared by ecological
triangulation. Notably, ecological triangulation, accord- Framework synthesis, thematic narrative synthesis and
ing to Banning, can be either realist or idealist. Banning thematic synthesis – methods which might be classified as
argues that the interpretation of triangulation can either sharing a 'critical realist' approach – all have highly speci-
be one in which multiple viewpoints converge on a point fied approaches to quality assessment. The review in
to produce confirming evidence (i.e. one definitive which framework synthesis was developed applied ten
answer to the research question) or an idealist one, in quality criteria: two on quality and reporting of sampling
which the complexity of multiple viewpoints is repre- methods, four to the quality of the description of the sam-
sented. Thus, although ecological triangulation views real- ple in the study, two to the reliability and validity of the
ity as complex, the approach assumes that it can be tools used to collect data and one on whether studies used
approximately knowable (at least when the realist view of appropriate methods for helping people to express their

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views. Studies which did not meet a certain number of tent and utility of findings rather than methodology in
quality criteria were excluded from contributing to find- order to establish quality. While earlier forms of meta-
ings. Similarly, in the example review for thematic synthe- study included only studies which demonstrated 'episte-
sis, 12 criteria were applied: five related to reporting aims, mological soundness', in its most recent form [51] this
context, rationale, methods and findings; four relating to method has sought to include all relevant studies, exclud-
reliability and validity; and three relating to the appropri- ing only those deemed not to be 'qualitative' research.
ateness of methods for ensuring that findings were rooted Critical interpretive synthesis also conforms to what we
in participants' own perspectives. Studies which were might expect of its approach to quality assessment: quality
deemed to have significant flaws were excluded and sensi- of research is judged as the extent to which it informs the-
tivity analyses were used to assess the possible impact of ory. The threshold of inclusion is informed by expertise
study quality on the review's findings. Thomas and and instinct rather than being articulated a priori.
Harden's use of thematic narrative synthesis similarly
applied quality criteria and developed criteria additional In terms of quality assessment, it might be important to
to those they found in the literature on quality assess- consider the academic context in which these various
ment, relating to the extent to which people's views and methods of synthesis developed. The reason why thematic
perspectives had been privileged by researchers. It is worth synthesis, framework synthesis and ecological triangula-
noting not only that these methods apply quality criteria tion have such highly specified approaches to quality
but that they are explicit about what they are: assessing assessment may be that each of these was developed for a
quality is a key component in the review process for both particular task, i.e. to conduct a multi-method review in
of these methods. Likewise, Banning – the originator of which randomised controlled trials (RCTs) were included.
ecological triangulation – sees quality assessment as The concept of quality assessment in relation to RCTs is
important and adapts the Design and Implementation much less contested and there is general agreement on cri-
Assessment Device (DIAD) Version 0.3 (a quality assess- teria against which quality should be judged.
ment tool for quantitative research) for use when apprais-
ing qualitative studies [50]. Again, Banning writes of Problematizing the literature
excluding studies deemed to be of poor quality. Critical interpretive synthesis, the meta-narrative
approach and the meta-theory element of meta-study all
Greenhalgh et al's meta-narrative review [32] modified a share some common ground in that their review and syn-
range of existing quality assessment tools to evaluate stud- thesis processes include examining all aspects of the con-
ies according to validity and robustness of methods; sam- text in which knowledge is produced. In conducting a
ple size and power; and validity of conclusions. The review on access to healthcare by vulnerable groups, criti-
authors imply, but are not explicit, that this process cal interpretive synthesis sought to question 'the ways in
formed the basis for the exclusion of some studies. which the literature had constructed the problematics of
Although not quite so clear about quality assessment access, the nature of the assumptions on which it drew,
methods as framework and thematic synthesis, it might be and what has influenced its choice of proposed solutions'
argued that meta-narrative synthesis shows a greater com- [[34], p6]. Although not claiming to have been directly
mitment to the concept that research can and should be influenced by Greenhalgh et al's meta-narrative approach,
assessed for quality than either meta-ethnography or Dixon-Woods et al do cite it as sharing similar character-
grounded formal theory. The originators of meta-ethnog- istics in the sense that it critiques the literature it reviews.
raphy, Noblit and Hare [8], originally discussed quality in
terms of quality of metaphor, while more recent use of Meta-study uses meta-theory to describe and deconstruct
this method has used amended versions of CASP (the the theories that shape a body of research and to assess its
Critical Appraisal Skills Programme tool, [31]), yet has quality. One aspect of this process is to examine the his-
only referred to studies being excluded on the basis of lack torical evolution of each theory and to put it in its socio-
of relevance or because they weren't 'qualitative' studies political context, which invites direct comparison with
[8]. In grounded theory, quality assessment is only dis- meta-narrative synthesis. Greenhalgh et al put a similar
cussed in terms of a 'personal note' being made on the emphasis on placing research findings within their social
context, quality and usefulness of each study. However, and historical context, often as a means of seeking to
contrary to expectation, meta-narrative synthesis lies at explain heterogeneity of findings. In addition, meta-nar-
the extreme end of the idealism/realism spectrum – as a rative shares with critical interpretive synthesis an iterative
subjective idealist approach – while meta-ethnography approach to searching and selecting from the literature.
and grounded theory are classified as objective idealist
approaches. Framework synthesis, thematic synthesis, textual narrative
synthesis, meta-ethnography and grounded theory do not
Finally, meta-study and critical interpretive synthesis – share the same approach to problematizing the literature
two more subjective idealist approaches – look to the con- as critical interpretive synthesis, meta-study and meta-nar-

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rative. In part, this may be explained by the extent to All of these methods, then, look within the studies to
which studies included in the synthesis represented a explain differences. Other methods look beyond the study
broad range of approaches or methodologies. This, in itself to the context in which it was produced. Critical
turn, may reflect the broadness of the review question and interpretive synthesis and meta-study look at differences
the extent to which the concepts contained within the in theory or in socio-economic context. Critical interpre-
question are pre-defined within the literature. In the case tive synthesis, like meta-narrative, also explores epistemo-
of both the critical interpretive synthesis and meta-narra- logical orientation. Meta-narrative is unique in
tive reviews, terminology was elastic and/or the question concerning itself with disciplinary paradigm (i.e. the story
formed iteratively. Similarly, both reviews placed great of the discipline as it progresses). It is also distinctive in
emphasis on employing multi-disciplinary research that it treats conflicting findings as 'higher order data'
teams. Approaches which do not critique the literature in [[32], p420], so that the main emphasis of the synthesis
the same way tend to have more narrowly-focused ques- appears to be on examining and explaining contradictions
tions. They also tend to include a more limited range of in the literature.
studies: grounded theory synthesis includes grounded
theory studies, meta-ethnography (in its original form, as Going 'beyond' the primary studies
applied by Noblit and Hare) ethnographies. The thematic Synthesis is sometimes defined as a process resulting in a
synthesis incorporated studies based on only a narrow product, a 'whole', which is more than the sum of its parts.
range of qualitative methodologies (interviews and focus However, the methods reviewed here vary in the extent to
groups) which were informed by a similarly narrow range which they attempt to 'go beyond' the primary studies and
of epistemological assumptions. It may be that the transform the data. Some methods – textual narrative syn-
authors of such syntheses saw no need for including such thesis, ecological triangulation and framework synthesis –
a critique in their review process. focus on describing and summarising their primary data
(often in a highly structured and detailed way) and trans-
Similarities and differences between primary studies lating the studies into one another. Others – meta-ethnog-
Most methods of synthesis are applicable to heterogene- raphy, grounded theory, thematic synthesis, meta-study,
ous data (i.e. studies which use contrasting methodolo- meta-narrative and critical interpretive synthesis – seek to
gies) apart from early meta-ethnography and synthesis push beyond the original data to a fresh interpretation of
informed by grounded theory. All methods of synthesis the phenomena under review. A key feature of thematic
state that, at some level, studies are compared; many are synthesis is its clear differentiation between these two
not so explicit about how this is done, though some are. stages.
Meta-ethnography is one of the most explicit: it describes
the act of 'translation' where terms and concepts which Different methods have different mechanisms for going
have resonance with one another are subsumed into beyond the primary studies, although some are more
'higher order constructs'. Grounded theory, as represented explicit than others about what these entail. Meta-ethnog-
by Eaves [17], is undertaken according to a long list of raphy proposes a 'Line of Argument' (LOA) synthesis in
steps and sub-steps, includes the production of generali- which an interpretation is constructed to both link and
zations about concepts/categories, which comes from explain a set of parts. Critical interpretive synthesis based
classifying these categories. In meta-narrative synthesis, its synthesis methods on those of meta-ethnography,
comparable studies are grouped together at the appraisal developing an LOA using what the authors term 'synthetic
phase of review. constructs' (akin to 'third order constructs' in meta-eth-
nography) to create a 'synthesising argument'. Dixon-
Perhaps more interesting are the ways in which differ- Woods et al claim that this is an advance on Britten et al's
ences between studies are explored. Those methods with a methods, in that they reject the difference between first,
greater emphasis on critical appraisal may tend (although second and third order constructs.
this is not always made explicit) to use differences in
method to explain differences in finding. Meta-ethnogra- Meta-narrative, as outlined above, focuses on conflicting
phy proposes 'refutational synthesis' to explain differ- findings and constructs theories to explain these in terms
ences, although there are few examples of this in the of differing paradigms. Meta study derives questions from
literature. Some synthesis methods – for example, the- each of its three components to which it subjects the data-
matic synthesis – look at other characteristics of the stud- set and inductively generates a number of theoretical
ies under review, whether types of participants and their claims in relation to it. According to Eaves' model of
context vary, and whether this can explain differences in grounded theory [17], mini-theories are integrated to pro-
perspective. duce an explanatory framework. In ecological triangula-
tion, the 'axial' codes – or second level codes evolved from

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the initial deductive open codes – are used to produce seems clear that, while similar in some respects, there are
Banning's 'ecological sentence' [39]. genuine differences in approach to the synthesis of what
is essentially textual data. To some extent, these differ-
The synthetic product ences can be explained by the epistemological assump-
In overviewing and comparing different qualitative syn- tions that underpin each method. Our methods split into
thesis methods, the ultimate question relates to the utility two broad camps: the idealist and the realist (see Table 1
of the synthetic product: what is it for? It is clear that some for a summary). Idealist approaches generally tend to
methods of synthesis – namely, thematic synthesis, tex- have a more iterative approach to searching (and the
tual narrative synthesis, framework synthesis and ecologi- review process), have less a priori quality assessment pro-
cal triangulation – view themselves as producing an cedures and are more inclined to problematize the litera-
output that is directly applicable to policy makers and ture. Realist approaches are characterised by a more linear
designers of interventions. The example of framework approach to searching and review, have clearer and more
synthesis examined here (on children's, young people's well-developed approaches to quality assessment, and do
and parents' views of walking and cycling) involved policy not problematize the literature.
makers and practitioners in directing the focus of the syn-
thesis and used the themes derived from the synthesis to Mapping the relationships between methods
infer what kind of interventions might be most effective in What is interesting is the relationship between these
encouraging walking and cycling. Likewise, the products methods of synthesis, the conceptual links between them,
of the thematic synthesis took the form of practical recom- and the extent to which the originators cite – or, in some
mendations for interventions (e.g. 'do not promote fruit cases, don't cite – one another. Some methods directly
and vegetables in the same way in the same intervention'). build on others – framework synthesis builds on frame-
The extent to which policy makers and practitioners are work analysis, for example, while grounded theory and
involved in informing either synthesis or recommenda- constant comparative analysis build on grounded theory.
tion is less clear from the documents published on ecolog- Others further develop existing methods – meta-study,
ical triangulation, but the aim certainly is to directly critical interpretive synthesis and meta-narrative all adapt
inform practice. aspects of meta-ethnography, while also importing con-
cepts from other theorists (critical interpretive synthesis
The outputs of synthesis methods which have a more con- also adapts grounded theory techniques).
structivist orientation – meta-study, meta-narrative, meta-
ethnography, grounded theory, critical interpretive syn- Some methods share a clear conceptual link, without
thesis – tend to look rather different. They are generally directly citing one another: for example, the analytical
more complex and conceptual, sometimes operating on themes developed during thematic synthesis are compara-
the symbolic or metaphorical level, and requiring a fur- ble to the third order interpretations of meta-ethnogra-
ther process of interpretation by policy makers and practi- phy. The meta-theory aspect of meta-study is echoed in
tioners in order for them to inform practice. This is not to both meta-narrative synthesis and critical interpretive syn-
say, however, that they are not useful for practice, more thesis (see 'Problematizing the literature, above); how-
that they are doing different work. However, it may be ever, the originators of critical interpretive synthesis only
that, in the absence of further interpretation, they are refer to the originators of meta-study in relation to their
more useful for informing other researchers and theoreti- use of sampling techniques.
cians.
Summary
Looking across dimensions While methods for qualitative synthesis have many simi-
After examining the dimensions of difference of our larities, there are clear differences in approach between
included methods, what picture ultimately emerges? It
Table 1: Summary table

Idealist Realist

Searching Iterative Linear

Quality assessment Less clear, less a priori; quality of content rather than method Clear and a priori
Problematizing the literature Yes No
Question Explore Answer
Heterogeneity Lots Little
Synthetic product Complex Clear for policy makers and practitioners

N.B.: In terms of the above dimensions, it is generally a question of degree rather than of absolute distinctions.

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them, many of which can be explained by taking account 3. Mays N, Pope C, Popay J: Systematically reviewing qualitative
and quantitative evidence to inform management and pol-
of a given method's epistemology. icy-making in the health field. J Health Serv Res Pol 2005,
10(Suppl 1):6-20.
However, within the two broad idealist/realist categories, 4. Dixon-Woods M, Bonas S, Booth A, Jones DR, Miller T, Shaw RL,
Smith J, Sutton A, Young B: How can systematic reviews incor-
any differences between methods in terms of outputs porate qualitative research? A critical perspective. Qual Res
appear to be small. 2006, 6:27-44.
5. Pope C, Mays N, Popay J: Synthesizing Qualitative and Quantitative
Health Evidence: a Guide to Methods Maidenhead: Open University
Since many systematic reviews are designed to inform pol- Press; 2007.
icy and practice, it is important to select a method – or 6. Thorne S, Jenson L, Kearney MH, Noblit G, Sandelowski M: Qualita-
tive metasynthesis: reflections on methodological orienta-
type of method – that will produce the kind of conclu- tion and ideological agenda. Qual Health Res 2004, 14:1342-1365.
sions needed. However, it is acknowledged that this is not 7. Centre for Reviews and Dissemination: Systematic Reviews. CRD's Guid-
always simple or even possible to achieve in practice. ance for Undertaking Reviews in Health Care York: CRD; 2008.
8. Noblit GW, Hare RD: Meta-Ethnography: Synthesizing Qualitative Stud-
ies London: Sage; 1988.
The approaches that result in more easily translatable 9. Strike K, Posner G: Types of synthesis and their criteria. In
Knowledge Structure and Use Edited by: Ward S, Reed L. Philadelphia:
messages for policy-makers and practitioners may appear Temple University Press; 1983.
to be more attractive than the others; but we do need to 10. Turner S: Sociological Explanation as Translation New York: Cambridge
take account lessons from the more idealist end of the University Press; 1980.
11. Britten N, Campbell R, Pope C, Donovan J, Morgan M, Pill R: Using
spectrum, that some perspectives are not universal. meta-ethnography to synthesis qualitative research: a
worked example. J Health Serv Res 2002, 7:209-15.
12. Campbell R, Pound P, Pope C, Britten N, Pill R, Morgan M, Donovan
Competing interests J: Evaluating meta-ethnography: a synthesis of qualitative
The authors declare that they have no competing interests. research on lay experiences of diabetes and diabetes care.
Soc Sci Med 2003, 65:671-84.
13. Pound P, Britten N, Morgan M, Yardley L, Pope C, Daker-White G,
Authors' contributions Campbell R: Resisting medicines: a synthesis of qualitative
Both authors made substantial contributions, with EBP studies of medicine taking. Soc Sci Med 2005, 61:133-155.
taking a lead on writing and JT on the analytical frame- 14. Schutz A: Collected Paper Volume 1. The Hague: Martinus Nijhoff; 1962.
15. Sandelowski M, Barroso J: Handbook for Synthesizing Qualitative
work. Both authors read and approved the final manu- Research New York: Springer Publishing Company; 2007.
script. 16. Kearney MH: Enduring love: a grounded formal theory of
women's experience of domestic violence. Research Nurs
Health 2001, 24:270-82.
Additional material 17. Eaves YD: A synthesis technique for grounded theory data
analysis. J Adv Nurs 2001, 35:654-63.
18. Finfgeld D: Courage as a process of pushing beyond the strug-
Additional file 1 gle. Qual Health Res 1999, 9:803-814.
19. Glaser BG, Strauss AL: The Discovery of Grounded Theory: Strategies for
Dimensions of difference. Ranging from subjective idealism through Qualitative Research New York: Aldine De Gruyter; 1967.
objective idealism and critical realism to scientific realism to naïve realism 20. Strauss AL, Corbin J: Basics of Qualitative Research: Grounded Theory
Click here for file Procedures and Techniques Newbury Park, CA: Sage; 1990.
[http://www.biomedcentral.com/content/supplementary/1471- 21. Strauss AL, Corbin J: Basics of Qualitative Research: Techniques and Pro-
2288-9-59-S1.doc] cedures for Developing Grounded Theory Thousand Oaks, CA: Sage;
1998.
22. Charmaz K: The grounded theory method: an explication and
interpretation. In Contemporary Field Research: A Collection of Read-
ings Edited by: Emerson RM. Waveland Press: Prospect Heights, IL;
1983:109-126.
Acknowledgements 23. Chesler MA: Professionals' Views of the Dangers of Self-Help Groups:
The authors would like to acknowledge the helpful contributions of the fol- Explicating a Grounded Theoretical Approach [Michigan]: Department of
lowing in commenting on earlier drafts of this paper: David Gough, Sandy Sociology, University of Michigan, Ann Arbour Centre for Research
on Social Organisation, Working Paper Series; 1987.
Oliver, Angela Harden, Mary Dixon-Woods, Trisha Greenhalgh and Bar- 24. Kearney MH: Ready-to-wear: discovering grounded formal
bara L. Paterson. We would also like to thank the peer reviewers: Helen J theory. Res Nurs Health 1988, 21:179-186.
Smith, Rosaline Barbour and Mark Rodgers for their helpful reviews. The 25. Thomas J, Harden A: Methods for the thematic synthesis of
methodological development was supported by the Department of Health qualitative research in systematic reviews. BMC Med Res Meth
2008, 8:45.
(England) and the ESRC through the Methods for Research Synthesis Node
26. Lucas PJ, Arai L, Baird , Law C, Roberts HM: Worked examples of
of the National Centre for Research Methods (NCRM). An earlier draft of alternative methods for the synthesis of qualitative and
this paper currently appears as a working paper on the National Centre for quantitative research in systematic reviews. BMC Med Res
Research Methods' website http://www.ncrm.ac.uk/. Meth 2007, 7(4):.
27. Harden A, Garcia J, Oliver S, Rees R, Shepherd J, Brunton G, Oakley
A: Applying systematic review methods to studies of people's
References views: an example from public health research. J Epidemiol
1. Dixon-Woods M, Agarwhal S, Jones D, Young B, Sutton A: Synthe- Community H 2004, 58:794-800.
sising qualitative and quantitative evidence: a review of pos- 28. Paterson BL, Thorne SE, Canam C, Jillings C: Meta-Study of Qualitative
sible methods. J Health Serv Res Pol 2005, 10(1):45-53b. Health Research. A Practical Guide to Meta-Analysis and Meta-Synthesis
2. Barbour RS, Barbour M: Evaluating and synthesizing qualitative Thousand Oaks, CA: Sage Publications; 2001.
research: the need to develop a distinctive approach. J Eval 29. Zhao S: Metatheory, metamethod, meta-data-analysis: what,
Clin Pract 2003, 9(2):179-186. why and how? Sociol Perspect 1991, 34:377-390.

Page 10 of 11
(page number not for citation purposes)
BMC Medical Research Methodology 2009, 9:59 http://www.biomedcentral.com/1471-2288/9/59

30. Ritzer G: Metatheorizing in Sociology Lexington, MA: Lexington Books;

1991.
31. CASP (Critical Appraisal Skills Programme) [http://
www.phru.nhs.uk/Pages/PHD/CASP.htm]. date unknown
32. Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O, Peacock
R: Storylines of research in diffusion of innovation: a meta-
narrative approach to systematic review. Soc Sci Med 2005,
61:417-30.
33. Kuhn TS: The Structure of Scientific Revolutions Chicago: University of
Chicago Press; 1962.
34. Dixon-Woods M, Cavers D, Agarwal S, Annandale E, Arthur A, Har-
vey J, Hsu R, Katbamna S, Olsen R, Smith L, Riley R, Sutton AJ: Con-
ducting a critical interpretive synthesis of the literature on
access to healthcare by vulnerable groups. BMC Med Res Meth
2006, 6(35):.
35. Gough D: Weight of evidence: a framework for the appraisal
of the quality and relevance of evidence. In Applied and Practice-
based Research Volume 22. Issue 2 Edited by: Furlong J, Oancea A. Spe-
cial Edition of Research Papers in Education; 2007:213-228.
36. Webb EJ, Campbell DT, Schwartz RD, Sechrest L: Unobtrusive Meas-
ures Chicago: Rand McNally; 1966.
37. Denzin NK: The Research Act: a Theoretical Introduction to Sociological
Methods New York: McGraw-Hill; 1978.
38. Banning J: Ecological Triangulation [http://mycahs.colostate.edu/
James.H.Banning/PDFs/Ecological%20Triangualtion.pdf].
39. Banning J: Ecological Sentence Synthesis [http://mycahs.colostate.edu/
James.H.Banning/PDFs/Ecological%20Sentence%20Synthesis.pdf].
40. Brunton G, Oliver S, Oliver K, Lorenc T: A Synthesis of Research
Addressing Children's, Young People's and Parents' Views of Walking and
Cycling for Transport London: EPPI-Centre, Social Science Research
Unit, Institute of Education, University of London; 2006.
41. Oliver S, Rees R, Clarke-Jones L, Milne R, Oakley A, Gabbay J, Stein
K, Buchanan P, Gyte G: A multidimensional conceptual frame-
work for analysing public involvement in health services
research. Health Expect 2008, 11:72-84.
42. Pope C, Ziebland S, Mays N: Qualitative research in health care:
analysing qualitative data. BMJ 2000, 320:114-116.
43. Ritchie J, Spencer L: Qualitative data analysis for applied policy
research. In Analysing Qualitative Data Edited by: Bryman A, Burgess
R. London: Routledge; 1993:173-194.
44. Miles M, Huberman A: Qualitative Data Analysis London: Sage; 1984.
45. Evans D, Fitzgerald M: Reasons for physically restraining
patients and residents: a systematic review and content anal-
ysis. Int J Nurs Stud 2002, 39:739-743.
46. Suikkala A, Leino-Kilpi H: Nursing student-patient relationships:
a review of the literature from 1984–1998. J Adv Nurs 2000,
33:42-50.
47. Weed M: 'Meta-interpretation': a method for the interpretive
synthesis of qualitative research. Forum: Qual Soc Res 2005, 6:Art
37.
48. Gough D, Thomas J: Dimensions of difference in systematic
reviews. [http://www.ncrm.ac.uk/RMF2008/festival/programme/
sys1].
49. Spencer L, Ritchie J, Lewis J, Dillon L: Quality in Qualitative Evaluation:
a Framework for Assessing Research Evidence London: Government
Chief Social Researcher's Office; 2003.
50. Banning J: Design and Implementation Assessment Device
(DIAD) Version 0.3: A response from a qualitative perspec-
tive. [http://mycahs.colostate.edu/James.H.Banning/PDFs/
Design%20and%20Implementation%20Assessment%20Device.pdf].
51. Paterson BL: Coming out as ill: understanding self-disclosure Publish with Bio Med Central and every
in chronic illness from a meta-synthesis of qualitative
research. In Reviewing Research Evidence for Nursing Practice Edited scientist can read your work free of charge
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