Abstract
In 2007, the journal Qualitative Research published a review on qualitative evidence syntheses conducted between 1988 and 2004. It reported on the lack of explicit detail regarding methods for searching, appraisal and synthesis, and a lack of emerging consensus on these issues. We present an update of this review for the period 2005–8. Not only has the amount of published qualitative evidence syntheses doubled, but authors have also become more transparent about their searching and critical appraisal procedures. Nevertheless, for the synthesis component of the qualitative reviews, a black box remains between what people claim to use as a synthesis approach and what is actually done in practice. A detailed evaluation of how well authors master their chosen approach could provide important information for developers of particular methods, who seem to succeed in playing the game according to the rules. Clear methodological instructions need to be developed to assist others in applying these synthesis methods.
Background
In 2007, the journal Qualitative Research published a review from Dixon-Woods et al. (2007) on published reports of qualitative evidence syntheses (QES). The authors identified 42 studies for the period between 1988 and 2004. Since 2004, methodologists have invested in developing new methods for QES. Several variants of existing methods have been reported. Recently published approaches include textual narrative synthesis, focusing on heterogeneity between included studies (Lucas et al., 2007), critical interpretive synthesis adapted from the frequently used meta-ethnographic approach to synthesis (Dixon-Woods et al., 2006), qualitative meta-summary designed to aggregate (rather than to interpret) findings of original studies (Sandelowski et al., 2007) and thematic analysis formally introduced by Thomas and Harden (2008). The Cochrane Qualitative Research Methods Group develops and supports methodological work on the inclusion in systematic reviews of evidence from research using qualitative methods, and disseminates this work within and beyond the Collaboration’s Review Groups. The methods group conveners recently produced a chapter in the Cochrane Handbook of systematic reviews of effectiveness (Noyes et al., 2007). Online published subchapters include information on how to use qualitative research to develop robust effectiveness questions for Cochrane Systematic Reviews, how to search for and critically appraise qualitative research, and how to extract and synthesize findings from qualitative research (Cochrane Qualitative Research Methods Group, 2009). QES have gained significant recognition in the field of health care, both as a standalone product or as a scientific contribution able to inform, extend, enhance or supplement systematic reviews of effectiveness. They are now promoted through international organizations such as the Cochrane and Campbell Collaboration (Hannes et al., 2007), the Evidence for Policy and Practice Information and Coordinating Centre (Oliver et al., 2005) and the Joanna Briggs Institute (Pearson et al., 2007). This article presents an update of the review from Dixon-Woods et al. (2007) for the period 2005–8. It aims to identify newly developed methods and also seeks to reveal how authors have conducted the basic steps in their review; search strategies, critical appraisal exercises, and syntheses. Major differences in the practical application of these steps between the range of reviews are discussed. In addition, we aim to evaluate the popularity of QES in the scientific research community by developing a time trend on the number of syntheses published over the last 20 years (1988–2008).
Method
Search strategy and inclusion criteria
We used the comprehensive search strategy developed by Booth (2006) and utilised by Dixon-Woods et al. (2007), as well as the inclusion criteria presented in their methods section, to be able to make valid statements on the comparison between both reviews. We considered articles published in the English language, in a peer reviewed journal, conducted within the field of health care and reporting a synthesis of qualitative research. We also included papers with a methodological focus; for example, the presentation of a new method, if they reported on the findings of a particular research project. Qualitative, narrative reviews from quantitative studies or summaries that were not explicit about their method for synthesis were excluded. In addition, we excluded reviews with a topical focus on concepts or definitions used in health care or health care research.
Screening
Our database search revealed a total of 4765 potentially eligible studies (including duplicates between databases) (Figure 1). A total of 364 titles passed an initial title screening from KH (Karin Hannes). With a reference and related article search we identified a further 18 studies. Abstracts from 394 articles were screened for inclusion and exclusion criteria. Articles for which both authors agreed they warranted inclusion were ordered and reviewed. Articles for which there was doubt as to their appropriateness were also ordered for further examination. A full-text version was retrieved for 203 abstracts. A detailed analysis identified 82 articles that satisfied our inclusion criteria. Disagreements were solved by discussion. The majority of the excluded papers (n = 121) were quantitative and theoretical reviews, or did not qualify as a review. Twenty-one per cent did not label their method of synthesis or was rather descriptive in the methods section. Other papers were excluded for topical reasons (not in health care) or because they presented primary research. Some were exclusively methodological in focus or included only one qualitative study in the synthesis. The list of studies excluded following a full reading may be obtained from the authors. Both authors agreed upon the final selection of articles.
Search strategy
Data extraction
Findings from the included papers were extracted by KH and then verified, confirmed or disconfirmed by KM (Kirsten Macaitis). Disagreements were solved by discussion. Four characteristics were studied for detailed content and relevance: (1) methods for searching, (2) number of included studies, (3) methods for critical appraisal, and (4) methods for synthesis (Table 1). For the first characteristic we described the databases and additional information resources that the authors used to retrieve their studies, whether or not the keywords used for searching were specified and whether or not the QES were comprehensive in terms of languages and dates. The second column lists the number of papers included in a particular synthesis. The third and fourth columns respectively describe the critical appraisal tool or evaluation framework used and the evidence synthesis approach opted for by the authors. Studies using a mixed method approach were eligible for inclusion provided it was possible to extract findings derived from the original qualitative research reports. Although in many cases the presentation of the synthesis method was fairly descriptive, no major inconsistencies were found between both reviewers in the data extraction phase.
Characteristics of published QES
The reference of all the articles included is presented in the appendix.** References to appraisal instruments and methods of synthesis listed in the table can be found in the original research papers.
Findings
Between January 2005 and December 2008, 82 qualitative evidence syntheses were identified within the field of health care (Table 1), in addition to the 42 published QES previously identified by Dixon-Woods and colleagues (2007). Within the span of four years the amount of QES has doubled (Figure 2). The first QES was detected in 1994 (Jensen and Allen, 1994). It was not until 1997 that additional QES were found in public health literature. Since then, the number of QES has steadily increased. This indicates a growing interest of researchers to conduct this type of synthesis and it appears that the peak of interest has not yet been reached. There is a small drop in published QES in 2004 and 2008. We doubt that this is related to a decrease in interest for QES. Dixon-Woods and colleagues (2007) performed a search in the year 2005. The papers included in the present study were derived from a search conducted in mid-2009. We expect databases to have a considerable delay in indexing their articles, which will most likely explain the drops in numbers. It is anticipated that the number of QES will continue to rise beyond the year 2008. In what follows, we compare the characteristics of this particular update with those from the original review (Dixon-Woods et al., 2007). The main findings are presented in Table 2.
Timetrend number of qualitative evidence syntheses – 20 years
Comparison of original review and update for main characteristics
Characteristics of the papers
The majority of the papers are still published in journals targeted toward nurses. With almost 16 per cent of the QES published, the Journal of Advanced Nursing dethrones the journal Qualitative Health Research, which scored exceptionally well in the previous review. Other popular journals include those targeted to paediatrics and psychiatrics/psychologists. High impact medical journals such as the Lancet have recently started to publish QES and a variety of medical journals have shown an interest for this approach to synthesis. Most authors have only contributed one QES to the field of health care. A minority of four authors published two or more QES. The main reason to conduct a QES seems to be topical and closely related to the core research programmes of the reviewers. There has been a significant increase in authors labelling their article as a systematic review compared to what has been reported in the original review from Dixon-Woods and colleagues (2007). The term meta-synthesis is also very popular, with 35 per cent of the authors using it in the title of their article. Three authors present their final product as a comprehensive or integrative review, using quantitative, qualitative and/or mixed method studies in their summary (one in the original review), a label that will most likely increase in popularity given the number of authors interested in portraying results of different basic research designs. Only one author used meta-analysis in the title (none in the previous review), which is jargon related to the conduct of quantitative reviews. The number of original articles included in a synthesis ranged from two to 113. In the original review the range was three to 292.
Methods for searching
Of all papers only five did not describe the databases they had searched (15 in the original review). Medline is still the most popular database with 76 hits in 84 papers, followed by CINAHL (n = 70) and Psychinfo/Psychlit (n = 51). Embase scores significantly lower with 39 hits, which is most likely explained by the fact that it is extremely expensive to have access to this information source. Other popular databases with more than 10 hits include Sociological Abstracts (n = 16), Web of Science/(Soc)Science Citation Index (n = 18) and ERIC (n = 11). More than 40 different databases have been mentioned in the context of QES reviews, some of them giving access to grey literature, such as Digital Dissertations, SIGLE, Proquest and Digital Abstracts. A small proportion of the databases are local or topic specific search engines. Some authors refer to an interface rather than a particular database; for example, OVID or EBSCO, making it difficult to evaluate in which information source they have retrieved their articles. Supplementary search strategies most commonly used were reference or citation searching. More than half of the QES had used this strategy, which is considerably more than the number reported in Dixon-Wood et al.’s review (2007). Other popular search strategies include hand searching journals (n = 28), contacting experts or authors (n = 16) or searching the web (n = 8). Some authors also mentioned personal correspondence, related paper options in existing databases, email discussion lists, footnote chasing, or searching conference abstracts, etc. More authors chose to specify their search terms; however, the level of detail provided varied between authors. Some authors did not report their key terms and referred to another paper that described the procedure in detail; a standard set of key terms developed by other scholars in the field or stated that details could be retrieved from the authors. Notably, only 10 per cent of the papers were comprehensive for language and 30 per cent reported having searched without limits on the dates of publication of original research articles. Most authors restrict their language to English, in rare cases elaborated to the languages spoken in the home country from the authors. About 18 per cent of the authors provided no details on the date range they had been searching. The amount of authors lacking clarity on the language of the included papers is even higher.
Methods of appraisal
Twenty-three papers did not describe a critical appraisal exercise as part of their evidence synthesis. Only five papers explicitly pleaded against the quality assessment of papers or provided a valid reason for not conducting a quality appraisal. Compared to the review conducted by Dixon-Woods and colleagues (2007) more authors seem to be convinced of the relevance or added value of critically appraising the methodological quality of studies to be included. However, the criteria used varied between detailed descriptions of relevant items in existing or modified checklists to a set of broad criteria evaluating, for example, the rich description of data, the credibility or relevance of the original study. One team used an overall judgement approach to critical appraisal (Smith et al., 2005). Five reviewers have opted for a self-developed assessment instrument and three explicitly stated having used previously developed checklists to create one of their own. Two others mentioned a critical appraisal exercise, but did not specify their tool. Most reviewers used existing instruments or frameworks, among them the popular Critical Appraisal Skills Program (CASP)-instrument (n = 18). Other popular checklist or frameworks are the Mays and Pope criteria (n = 6), the Popay criteria (n = 6) and the criteria developed by the Joanna Briggs Institute (n = 4). At least 24 different assessment tools have been identified in the context of this review. A substantial amount of authors provided readers with explicit numbers and reasons for exclusion (n = 28). Thirty-nine per cent of the authors claiming to have used an appraisal instrument or framework failed to describe the exact number of excluded papers or reasons for exclusion.
Methods of synthesis
In the majority of the papers meta-ethnography or a technique based on the principles of Noblit and Hare (1988) was used as the method for synthesis. One paper used critical interpretive synthesis and linked this approach to meta-ethnography. Thematic analysis appeared to be a popular approach as well. Twenty papers opted for this approach; a large increase from the previous review, where thematic analysis was not utilised in any papers. Thematic analysis seems to have many shapes and forms and its lack of explicitness about procedures and aims has been identified before (Dixon-Woods et al., 2005). Recent attempts to describe this synthesis technique in detail and develop software products that can assist reviewers in accurately applying it will most likely have contributed to its growing popularity (Thomas and Harden, 2008). Some authors referred to narrative synthesis as their synthesis method (n = 8). Some used it as an umbrella term under which they fitted e.g. a thematic analysis. Other methods of synthesis included meta-study developed by Paterson and colleagues (2001) (n = 3), content analysis (n = 5), the meta-aggregative approach from the Joanna Briggs Institute (n = 4, not used in the previous review) and grounded theory (n = 2). Two authors indicated having used a deductive approach, but did not specify this any further. Another two referred to the framework developed by Ritchie and Spencer (1994). Yu et al. (2008) based a synthesis on the transactional model of stress. Eight authors mentioned meta-synthesis as their approach. Some referenced methodologists such as Paterson et al. (2001), while others refer to existing techniques such as critical interpretive synthesis, meta-ethnography or meta-aggregation. Most worrisome is that these references are often used alongside each other, while they are considered different techniques of which the basic principles may even contradict each other (e.g. the interpretive versus the aggregative spectrum). For most cases it was unclear what exactly had been executed in the synthesis exercise. Most authors using the meta-ethnographic approach succeed in copying an accurate description of Noblit and Hares’ (1988) principles in the methods section. They failed, however, to comply with the methodology in conducting or presenting their synthesis. Only 11 out of 25 review teams that labelled their synthesis as a meta-ethnography presented a model or visually displayed theory on the phenomenon of interest or were explicit on their line of argument and/or second and third order constructs in the findings sections. Authors reporting on methods of synthesis based on the format of basic qualitative research principles, such as grounded theory and thematic analysis, seem to better adhere to the basic principles of their approach.
Discussion
Notable changes compared to the original review
The number of published QES has increased during the last two decades and there are some important changes in their characteristics when compared with the review conducted by Dixon-Woods and colleagues (2007).
Searching
Considerably more authors provide clear details on the databases and other information sources searched. Supplementary search strategies have gained popularity and more authors reveal the specific key-terms that have been used to retrieve original studies. This clearly adds to the transparency of the procedures used by authors of QES, which is a positive evolution. It was noticed that many authors opted for a sensitive search strategy, comparable to what is portrayed as the standard quantitative reviews. There is general agreement on the need for search strategies aiming to identify qualitative research to be systematic and explicit. However, in recent debate the need for comprehensive, exhaustive searches in qualitative research is questioned. Theoretical and purposive sampling might be a feasible alternative as long as the ‘picture’ from the studies that have been retrieved incorporate all likely insights. Much remains to be done on when and how these contrasting sampling philosophies are to be used appropriately (Noyes et al., 2008).
Critical appraisal
More review teams seem to be convinced of the relevance or added value of critically appraising the methodological quality of studies to be included. Half of those using an appraisal instrument or framework succeed in providing numbers and reasons for exclusion. It shows that authors have begun to consider quality appraisal as an important procedural step that can have an impact on the final result of a synthesis. As a consequence, it becomes more important to shift the academic debate from whether or not to appraise to what criteria to use for an assessment of methodological quality, particularly because the criteria used to assess the quality of studies differ substantially between authors, ranging from very broad criteria aiming to familiarize the reviewers with the studies to explicit checklists leading to in- or ex-clusion of papers. Authors should be stimulated to give more thought to their choice of instrument. Hannes et al. (2010) recently compared three online available critical appraisal instruments and found that the most frequently used CASP-tool does not score particularly well in evaluating the intrinsic methodological quality of an original study when compared with other instruments, such as the Evaluation Tool for Qualitative Studies (ETQS) and the Joanna Briggs critical appraisal instrument. The CASP-tool gives a good indication of what should be reported in a qualitative report, but barely addresses theoretical and interpretive validity.
Synthesis methods
The description of the synthesis approach was a weak issue in many reviews. There appears to be a black box between what people claim to use as a synthesis approach and what is actually done in practice, which was also one on the conclusions of Dixon-Woods and colleagues (2007) in their review. The developers of a particular method for synthesis, or those who have pioneered it in the field, are the ones succeeding in playing the game according to the rules set out in the basic books and articles that promote a particular synthesis strategy. However, the methods are not always accurately applied. One example is the presentation of the results section in papers using a meta-aggregative approach. This approach has primarily been developed to produce lines of actions to inform decision-making processes (Hannes and Lockwood, 2011). The two papers in which one of the developers of the methodology was involved as a co-author clearly presented recommendations for practice and policy (Pearson et al., 2006; Rhodes et al., 2006). Other authors that adopted the meta-aggregative approach presented their findings completely different; for example, as a theory (Briggs and Flemming, 2007). Only a fraction of the users of meta-ethnography presented the synthesis as a line of argument, using first-, second- and third-order constructs. This is, however, a central characteristic of the meta-ethnographic approach (Noblit and Hare, 1988). It indicates that the boundaries between methods of synthesis have become blurred in scientific literature.
Mixing methods
Many authors seem to adapt to the different phases identified in quantitative systematic reviews. This is most likely to reach an acceptance stage with potential adopters. Some reviewers have mixed elements from conventional quantitative reviews with elements from QES approaches, often with little attention for the specific set of standards of a particular method. Although it is possible to use different designs in a single study, reviewers need to be knowledgeable about the various approaches and aware of the consequences of mixing and matching.
Strengths and limitations of this review
In adopting the procedure outlined in the original review from Dixon-Woods and colleagues (2007), some of the limitations they have discussed apply to our update as well. Limiting the search to papers published in peer-reviewed journals will most likely have decreased the number of QES included. In addition, the QES in Table 1 present only a small fraction of the number of syntheses that have originally been retrieved in the search. Although the inclusion criteria have facilitated the selection process, there has been considerable debate between both reviewers. First, there is a very thin line between what counts as a health care topic and what does not. Reviews that addressed policy or educational topics were excluded, as well as reviews that were closer to social welfare than health care. Second, many of the excluded papers presented a systematic and transparent approach of the searching, appraisal and extraction phase in their systematic review, but lacked a clear description of the method used to synthesize data or summarized information in a fairly descriptive way, choosing, for example, tables to include details of the individual studies in a matrix or using a pre-developed coding sheet for data extraction, without synthesizing in more depth. Papers that explicitly stated they could not consider anything else but a narrative or descriptive synthesis for their research were included. We believe that many of the excluded reviews could be considered high quality; however, for the purpose of our review we needed information on their particular approach. Many of the mixed methods or comprehensive reviews were also excluded because their qualitative synthesis method was not described.
We did not systematically evaluate whether there was an acceptable degree of methodological congruence between the chosen synthesis approach and what had been conducted by the authors (Sandelowski et al., 1997). As a consequence, studies that misrepresented their synthesis method – for example, a content analysis wrongly presented as a narrative analysis – were included in the review. Considerable incongruence was noticed while conducting the review. However, to address this issue properly the development of a compendium outlining the specific characteristics of each particular synthesis approach would be necessary, which is beyond the scope of this review.
Although mixed-method studies were considered in the original review, it was not quite clear from its summary table how many of them were identified, since the category ‘number of papers’ did not outline the proportion of quantitative studies potentially included. We refined this category by including information on the number of qualitative studies in the total amount of original studies considered in the synthesis. About 20 per cent of the syntheses in our update were mixed. We expect this number to increase. It would be worthwhile to evaluate a potential change in the time trend in future updates of this review.
Conclusion
The number of researchers engaged in the further development of methods for QES is rapidly increasing. The time trend shows that the interest in QES has certainly grown since the publication of the first review from Dixon-Woods and colleagues (2007). This is not surprising since QES enable reviewers to answer different kinds of questions, refine conclusions and act as a scoping exercise for conventional systematic reviews. Our review revealed some shifts in the characteristics from published QES, particularly those related to searching and critical appraisal. These processes have become much more transparent and repeatable. The synthesis part, however, would benefit from clear instructions on the basic methodological and philosophical underpinnings on the approach as well as on the purpose it serves, to prevent authors from choosing the wrong approach or having to modify an approach to fit their particular goals. We are not convinced that additional methods need to be developed at this point in time. The research community would benefit more from specific guidance from those who have developed a particular method. Pitfalls and suggestions for improvement will probably surface best by putting the methods in practice as intended. These particular issues also draw attention to the importance of guidelines on how particular methods for QES should be reported.
Footnotes
Appendix
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Acknowledgements
We would like to thank the Joanna Briggs Institute for the visiting scholarship that has led to the publication of this update. A special thanks to Alan Pearson, Anthea Court, Zoe Jordan and Craig Lockwood is also extended for their continuous support and encouragement.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Biographical notes
Karin Hannes, PhD, is Doctor-Assistant at the Centre for Methodology of Educational Research, KU Leuven, Belgium. She has a background in andragogics and medical-social sciences and teaches research methodology to undergraduates. She is co-convener of the Cochrane Qualitative Research Methods Group and the Campbell Process and Implementation Methods Group and specializes in qualitative evidence synthesis.
Kirsten Macaitis, MSc, is Research Associate at the National Institute of Labour Studies, Flinders University, South Australia, and has worked on projects regarding precarious housing and employment, and the impact of minimum wages on the low paid. She has a background in sociology and is an experienced researcher in the areas of culture, religion, work, and health. She has expert research skills in both qualitative and quantitative methodologies.