1. Synthesising qualitative findings An interpretive perspective Janet Harris K U Leuven QES Workshop 4 – 6 June 2012

2. Acknowledgements  These power points build on the materials presented by Angela Harden in the systematic review workshop at K U Leuven, 6 th to 8 th May 2011

3. What is synthesis? ‘The process or result of building up separate elements, especially ideas, into a connected whole, especially a theory or system’ (Oxford English Dictionary)

4. What is synthesis? “..the product of activity where some set of parts is combined or integrated into a whole…..[synthesis] involves some degree of conceptual innovation, or employment of concepts not found in the characterisation of the parts and a means of creating the whole” Strike and Posner (1983)

5. Synthesis starts with an epistemological assumption  Subjective idealism: there is no shared reality independent of multiple alternative human constructions  Objective idealism: there is a world of collectively shared understandings  Critical realism: knowledge of reality is mediated by our perceptions and beliefs  Scientific realism: it is possible for knowledge to approximate closely an external reality Spencer et al, 2003

6. Mapping qualitative synthesis methods Meta- narrative CIS*Meta-studyMeta- ethnography Grounded theory Thematic synthesis Textual narrative synthesis Framework synthesis Ecological triangulation Subjective idealism Objective idealism Critical realism Scientific realism *Critical interpretive synthesis Barnett-Page and Thomas (2009) Idealist Realist Discrepancy preserves complexity of multiple views Convergence on a definite answer Commonalities across accounts produce greater explanatory power

7.  Type of question  Extent of iteration  Quality assessment  Going beyond primary studies  Problematizing the literature  The synthetic product Idealist Realist

8. The review method is related to the aim of the review and the literature that exists  A synthesis can aim to:  Bring together separate findings into an interpretive explanation that is greater than the sum of the parts (Meta ethnography)  Produce theories or models that are based on phenomena involving processes of contextualised understanding and action (Grounded theory)  Review need for an intervention, it’s appropriateness, acceptability and effectiveness (Thematic analysis)  Enable exploration of study heterogeneity by context, characteristics and findings (Textual narrative synthesis)  Look at how social, historical and ideological contexts influence the knowledge that is produced (Meta-study)  Bring together research of widely different designs and paradigms (Meta-narrative)

9. Approaches to qualitative evidence synthesis Noyes & Lewin, 2010 http://cqrmg.cochrane.org/supplemental-handbook-guidance Interpretive approaches

10. Extent of iteration Meta- narrative CISMeta-studyMeta- ethnography Grounded theory Thematic synthesis Textual narrative synthesis Framework synthesis Ecological triangulation Subjective idealism Objective idealism Critical realism Scientific realism Iteration throughout Iteration at searching Iteration at synthesis Iteration not mentioned Iteration at searching Iteration not mentioned Idealist Realist

11. Approaches to inclusion Meta- narrative CISMeta-studyMeta- ethnography Grounded theory Thematic synthesis Textual narrative synthesis Framework synthesis Ecological triangulation Subjective idealism Objective idealism Critical realism Scientific realism Quality is important in terms of the end product - information to inform policy makers Multi- method review which includes RCTs Idealist Realist Less emphasis on quality; more emphasis on utility and relevance Specific approaches to quality assessment

12. Context surrounding knowledge production Meta- narrative CISMeta-studyMeta- ethnography Grounded theory Thematic synthesis Textual narrative synthesis Framework synthesis Ecological triangulation Subjective idealism Objective idealism Critical realism Scientific realism Idealist Realist Examine the context in which the knowledge was produced (social, political, historical) De-contextualised because phenomenon has an accepted definition in the literature

13. Synthesis typologies  Integrative and interpretive (e.g. Dixon- Woods et al. 2004; Noblit and Hare, 1988)  Aggregation and configuration (e.g. Sandelowski, forthcoming)

14. A review of research about the experiences of motherhood for women with HIV*  45 studies  800 abstracted findings  Reduced to 93  Aggregation: effect sizes calculated for each finding  Concentration of findings in any one study  The frequency with which each of the 93 abstracted findings occurred *Sandelowski M, Barroso J (2003) Creating metasummaries of qualitative findings Nursing Research 52: 226-233

15. Frequency effect sizes for first 3 findings* Abstracted findings (n=93)No. of studies Effect size 1. Children were the main reasons to live, fight, get off drugs, care for oneself, and avoid risky behaviors. 1943% 2. Whether their children were in or out of their care or custody, being a mother was central to women’s lives: a source of self-esteem, strength, normalcy, inspiration, pride, hope, joy, sense of well-being, & sense of self as a whole woman. 1531% 3. Children were important sources of physical, practical, emotional, and social support, and unconditional love to their mothers, buffering the negative effects of HIV. 718% *Adapted from Sandelowski M, Barroso J (2003) Creating metasummaries of qualitative findings Nursing Research 52: 226-233

16. An ‘interpretive’ synthesis method: meta-ethnography  Similar methods to those employed in the primary research it contains.  Products: new interpretive constructions, ‘translating the studies into one another’  Transferring ideas, concepts and metaphors across studies;  Data: interpretations and explanations of original authors;  Looking for reciprocal and refutational studies and lines of argument;  Role of quality and sampling varies.  Exact methods vary amongst the small number of studies reported so far e.g. Britten N, Campbell R, Pope C, Donovan J, Morgan M, Pill R (2002) Using meta ethnography to synthesise qualitative research: a worked example. J Health Serv Res Policy 7(4):209-215

17. This review was about…  Research question: How do the perceived meanings of medicines affect patients’ medicine taking behaviour and communication with health professionals?  Was not concerned with searching or assessing quality – it is an example of a method of synthesis.

18. Steps taken in the synthesis  The researchers looked across the papers for common and recurring concepts.  Used Schutz’s notion of ‘first- and second- order constructs.  First order: everyday understandings of ordinary people  Second order: constructs of the social sciences  ‘Third order interpretations’ were derived from a ‘line of argument’ based on 1 st and 2 nd order concepts.

19. Translating studies into one another

20. Meta-ethnographic synthesis Adapted from Britten et al., 2002 CONCEPTS described in primary studies Second order interpretations Third order interpretations Adherence/compliance:correct and routine medicine taking Self regulation: problematic adherence; leaving off drugs Aversion: eg dislike of taking drugs; harmful side effects Alternative coping strategies:eg Traditional remedies, self-help a)Patients conduct cost- benefit analyses: weigh up risks vs benefits b) Medicine taking influenced by cultural meanings and resources c)Self regulation includes the use of alternative coping strategies Sanctions: Drs talk severely about need to take tablets regularly; coercion from significant others, fear of coercion d) Self regulation is… inhibited by… the threat of social and professional sanctions e) Self regulation flourishes if sanctions are not severe Selective disclosure: patients don’t tell Dr of altered doses; manage info to psychiatrists f) Patients may not articulate views which they do not perceive as medically legitimated g) Alternative coping strategies are not seen by patients as medically legitimate h) Fear of sanctions and guilt produce selective disclosure

21. Grounded theory synthesis  Developed by Eaves (2001) by combining steps used by grounded theorists Charmaz, Strauss & Corbin, Chesler)  Used with the aim of developing a substantive theory or model to explain a phenomenon  Starts with In-vivo codes: chunks of text containing the informant’s own words SO  Relies upon articles containing thick descriptions for theory-building

22. Grounded theory synthesis steps

23. Applying the synthesis approach of GT analysis to research data: a model of rural African American family caregiving for elderly stroke survivors. Eaves, 1997 in Eaves 2001.

24. Which approach should you use?  What is the aim of the review?  What sort of literature already exists?  How well defined are the concepts in the literature?  How contested are the concepts? Is there a variation in paradigms or definitions or conceptualisations?  What sort of expertise and resources do you have in your review team?