Dr Kate Flemming Department of Health Sciences University of York, UK Meta-ethnography Dr Kate Flemming Department of Health Sciences University of York, UK kate.flemming@york.ac.uk

This is where it all began….. George Noblit R Dwight Hare

So what’s it about? ‘The meaning of meta-ethnography for us is as a form of synthesis for ethnographic or other interpretive studies’ p14 We use this term [meta-ethnography], in part, because of the analogy to meta-analysis. We share the goal of those proposing meta-analytic and integrative research reviews of “putting together” all the research available to us. p 25 (Noblit & Hare 1988)

This is about interpretive synthesis The original text does not deal with other parts of the systematic reviewing process such as: Search strategies Inclusion and exclusion criteria Quality appraisal

Meta-ethnography Most widely used method of qualitative synthesis reported (Hannes & Macaitis 2012) Enables a systematic and detailed understanding of how studies are related, through the comparison of findings within and across studies. These are coded and condensed into themes which ultimately provide an interpretation of the whole body of research(Noblit and Hare 1988) However from the interpretive perspective how this is done depends on the substance of the individual studies and how they relate to each other

The principle method of synthesis Is around the notion of ‘Translation’ Noblit & Hare describe this as ‘one case is like another except that…’ (p38) This is not dissimilar to constant comparison techniques

Family carers’ perceptions of their educational needs when providing end-of-life care Smoking in pregnancy: findings from a systematic review of qualitative studies of women who commence pregnancy as smokers

The Seven Steps of Meta-ethnography Getting started Noblit and Hare say this is ‘finding something that is worthy of a synthesis effort’ p26 Need to consider.... Is qualitative synthesis appropriate for the question you are asking? Is a synthesis on this topic needed?  What experience does the team need?

2. Deciding what is relevant Scope of searching: Does it need to be exhaustive? It depends on the purpose of the synthesis There is a tendency to undertake exhaustive searching. However searching can be pre-planned to be comprehensive or iterative ie ‘seek all available concepts until saturation is achieved’ (Tong et al 2012) Various qualitative filters can be used ‘qualitative’, ‘interviews’ & ‘findings’

2. Deciding what is relevant Other top tips: Clear inclusion and exclusion criteria can be helpful Use an information scientist if you can Track your key papers

Carers review: what we found 5507 papers found & 5440 were excluded After further sifting 67 papers were suitable for inclusion This was too many! We re-read the papers and included those that reported key concepts highly relevant to the study aims This left us with 35 papers reporting on 34 studies At the end of the synthesis process we re-read the papers not included and included any ‘absent concepts’

3. Reading the studies ‘Repeated re-reading of the accounts’ p28 During this stage you can also incorporate Quality appraisal Data extraction – possibly a two stage process

4. Determining how the studies are related Refers to how do you start to put the studies together ‘We think it makes sense to create a list of the key metaphors, phrases, ideas, and/or concepts in each account’ p28 ‘When we talk about the key metaphors of a study, we are referring to what others may call the themes, perspectives, organizers, and/or concepts revealed by qualitative studies’ p14 Then look at the relationship between them

5. Translating the studies into one another Studies may be related to each other in one of four ways: They can be about different things They can be about roughly similar things They can be studies that refute each other They can be studies that progressively build a line of argument Meta-ethnographic technique: No point in synthesising! Reciprocal translation Refutational synthesis Lines of argument synthesis

5. Translating the studies into one another Reciprocal translation analysis– in an iterative fashion one study is translated into another Refutational synthesis – studies amenable to general meta-ethnographic approach, but refutations are examined more closely Lines of argument synthesis – more about interpretation ‘what can we say about the whole based on the selective studies of the parts?’

5. Translating the studies into one another ‘Translations need to protect the particular, respect holism & enable comparison’ p28 ‘I found that I was judged as a disgusting, uneducated, gutter rat. I found this by the way people would look, question my motives, make comments on my parental ability etc.’ (Wiggington & Lee 2012, p9)

How does this look in practice? Flemming et al 2013

How does this look in practice? Flemming et al 2013

6. Synthesising translations Synthesis refers to making a whole into something more than the parts alone imply Translations as a set are one level of meta-ethnographic synthesis The translations can be compared with one another to determine of there are some that can encompass others This presents the second level of synthesis and is often presented as a line of argument

How this looks in practice Flemming et al 2013

7. Expressing the synthesis How do you go about telling people what you’ve done? Generally written for academic audiences Does this limit how you write up a meta-ethnography? I would argue yes – mainly from the problem of restrictions of word length in journals Suggested that play, art and music could all be relevant expressions!

Findings represented as diagrams Before pregnancy Being a smoker Through pregnancy Quitting and trying to quit Point of delivery Being a pregnant smoker Continuing to smoke The findings of the synthesis demonstrate how contexts constrain positive behaviour change: Smoking status

Questions?

Useful resources Karin Hannes and Craig Lockwood (eds) (2012) Synthesizing Qualitative Research: Choosing the Right Approach J Wiley – Blackwell Michael Saini & Aron Shlonsky (2012) Systematic Synthesis of Qualitative Research (Pocket Guides to Social Work Research Methods) OUP USA

References and Further Reading Britten N, Campbell R, Pope C. et al Using meta-ethnography to synthesise qualitative research: a worked example. J of Health Serv Res Policy 2002;7(4):209-21 Campbell R et al Evaluating meta-ethnography: a synthesis of qualitative research on lay experiences of diabetes and diabetes care. Social Science and Medicine 2003;56: 671-684 Cook A, Smith D, Booth A. Beyond PICO: The SPIDER tool for qualitative evidence synthesis. Qualitative Health Research 2012 22, DOI: 10.1177/1049732312452938 Dixon-Woods M, Agarwal S, Jones D, et al. Synthesising qualitative and quantitative evidence: a review of possible methods. J Health Serv Res Policy 2005;10(1):45-53 Flemming K. The use of morphine to treat cancer-related pain: A synthesis of quantitative and qualitative research. Journal of Pain and Symptom Management 2010; 39(1): 139-154 Flemming K & Briggs M. Electronic searching to locate qualitative research: evaluation of three strategies. J Adv Nurs 2007;57(1):95-100 Flemming K. The synthesis of qualitative research and evidence-based nursing. Evidence Based Nursing. 2007;10(3):68-71 Munro S.A. et al Patient adherence to tuberculosis treatment: A systematic review of qualitative research. PLOS Medicine 2007;4(7): 1230-1244 Noblit GW & Hare RD. Meta-ethnography: synthesizing qualitative studies. California. Sage Publications, 1988 Noyes J & Lewin S (2010) Supplemental Guidance on Selecting a Method of Qualitative Evidence Synthesis, and Integrating Qualitative Evidence with Cochrane Intervention Reviews. http://cqrmg.cochrane.org/supplemental-handbook-guidance Noyes J, Popay J. Directly observed therapy and tuberculosis: how can a systematic review of qualitative research contribute to improving services? A qualitative meta-synthesis. Journal of Advanced Nursing 2007; 57: 227-243. Pearson A Balancing the evidence: incorporating the synthesis of qualitative data into systematic reviews. JBI Reports 2004;2(2):45-64 Pope C & Mays N. Synthesising qualitative research. In Pope C & Mays N. (eds) Qualitative Research in Health Care (3rd edition). Oxford. Blackwell Publishing. 2006 Pope C, Mays N, & Popay J. Synthesizing Qualitative and Quantitative Health Evidence: A guide to methods. Maidenhead. Open University Press. 2007 Pound P. et al Resisting medicines: a synthesis of qualitative studies of medicine taking Social Science & Medicine 61 (2005) 133–155 Thomas J, Harden A, Oakley A. et al Integrating qualitative research with trials in systematic reviews. BMJ 2004;328:1010-2 Tong A, Sainsbury P, Craig JC. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health. 2007;19(6):349-357. Tong A, Flemming K, McInnes E et al Enhancing transparency in reporting the synthesis of qualitative research:ENTREQ. BMC Medical Research Methodology 2012; 12:181 http://www.biomedcentral.com/1471-2288/12/181