RESEARCH Open Access

Improving reporting of meta-ethnography:the eMERGe reporting guidanceEmma F. France1,17*, Maggie Cunningham1,17, Nicola Ring2, Isabelle Uny1, Edward A. S. Duncan1,17,Ruth G. Jepson3, Margaret Maxwell1,17, Rachel J. Roberts1,17, Ruth L. Turley4, Andrew Booth6, Nicky Britten7,Kate Flemming8, Ian Gallagher9, Ruth Garside7, Karin Hannes10, Simon Lewin11,12, George W. Noblit13,Catherine Pope14, James Thomas15, Meredith Vanstone16, Gina M. A. Higginbottom18 and Jane Noyes5

Abstract

Aims: The aim of this study was to provide guidance to improve the completeness and clarity of meta-ethnographyreporting.

Background: Evidence-based policy and practice require robust evidence syntheses which can further understandingof people’s experiences and associated social processes. Meta-ethnography is a rigorous seven-phase qualitativeevidence synthesis methodology, developed by Noblit and Hare. Meta-ethnography is used widely in health research,but reporting is often poor quality and this discourages trust in and use of its findings. Meta-ethnography reportingguidance is needed to improve reporting quality.

Design: The eMERGe study used a rigorous mixed-methods design and evidence-based methods to develop thenovel reporting guidance and explanatory notes.

Methods: The study, conducted from 2015 to 2017, comprised of: (1) a methodological systematic review of guidancefor meta-ethnography conduct and reporting; (2) a review and audit of published meta-ethnographies to identifygood practice principles; (3) international, multidisciplinary consensus-building processes to agree guidance content;(4) innovative development of the guidance and explanatory notes.

Findings: Recommendations and good practice for all seven phases of meta-ethnography conduct and reportingwere newly identified leading to 19 reporting criteria and accompanying detailed guidance.

Conclusion: The bespoke eMERGe Reporting Guidance, which incorporates new methodological developments andadvances the methodology, can help researchers to report the important aspects of meta-ethnography. Use of theguidance should raise reporting quality. Better reporting could make assessments of confidence in the findings morerobust and increase use of meta-ethnography outputs to improve practice, policy, and service user outcomes in healthand other fields. This is the first tailored reporting guideline for meta-ethnography. This article is being simultaneouslypublished in the following journals: Journal of Advanced Nursing, Psycho-oncology, Review of Education, and BMC MedicalResearch Methodology.

Keywords: Guideline, Meta-ethnography, Nursing, Publication standards, Qualitative evidence synthesis, Qualitativeresearch, Reporting, Research design, Systematic review

* Correspondence: emma.france@stir.ac.uk1University of Stirling, Stirling, UK17NMAHP Research Unit, Unit 13 Scion House, Stirling University InnovationPark, Stirling FK9 4NF, UKFull list of author information is available at the end of the article

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

France et al. BMC Medical Research Methodology (2019) 19:25 https://doi.org/10.1186/s12874-018-0600-0

Why is this research or review needed?

� No bespoke reporting guidance exists formeta-ethnography, one of the most commonly usedyet often poorly reported, methodologies for qualitativeevidence synthesis which could contribute robustevidence for policy and practice.

� Existing generic guidance for reporting qualitativeevidence syntheses pays insufficient attention toreporting the complex synthesis processes ofmeta-ethnography—tailored guidance should improvereporting and could improve quality of conduct.

� Better reporting of meta-ethnographies will likelyhave greater impact on understanding of specificphenomena of interest which will subsequentlyinform intervention development and changes inpolicy and practice.

What are the key findings?

� Recommendations, guidance, and good practice forconducting and/or reporting all seven phases of ameta-ethnography were identified for the first time,along with uncertainties and evidence gaps regardinggood practices.

� Nineteen reporting criteria were developed includingdetailed guidance on Phases 3–6: approach toreading/extracting data; processes for/ outcome ofrelating studies; processes for/ outcome oftranslation and synthesizing translations.

� The analysis and interpretation of methodologicalevidence and novel development work underpinningthis new tailored reporting guidance advancesmeta-ethnography methodology, for example, toincorporate good practice in translation andsynthesis.

How should the findings be used to influencepolicy/practice/research/education?

� Use of the guidance by researchers, peer-reviewers,and journal editors to ensure complete and transparentreporting of meta-ethnographies will ensure theirfindings are optimized for use in policy and practice.

� The guidance can be used to inform the designand conduct of meta-ethnographies because of theunderpinning rigorous, comprehensive analysis,interpretation, and synthesis of the latestmethodological evidence.

IntroductionEvidence-based decision-making for health services, pol-icies, and programmes requires qualitative and quantitativeresearch; this is recognized by leading evidence-producing

organisations including Cochrane, the Campbell Collabor-ation, and the World Health Organization [1, 2]. To makesense of large volumes of research, robust syntheses of alltypes of research are needed [1]. Syntheses of qualitativestudies, such as meta-ethnographies, can be used todevelop theory about how a service, policy, strategy, orintervention works and how people experience these[3]; provide evidence of the acceptability, feasibility,and appropriateness of interventions or services [4–8];convey people’s experiences of, for example, illness [9, 10];and inform the development, implementation, and evalu-ation of complex interventions [11, 12].

What is meta-ethnography?Meta-ethnography is a seven phase, theory-based [13] andpotentially theory-generating, interpretive methodologyfor qualitative evidence synthesis developed by sociologistsNoblit and Hare [14] in the field of education. Meta-eth-nography aims to produce novel interpretations that tran-scend individual study findings, rather than aggregatefindings [15]. Meta-ethnography involves systematicallycomparing conceptual data from primary qualitativestudies to identify and develop new overarching concepts,theories, and models. It was designed to preserve theoriginal meanings and contexts of study concepts [9, 14].The originators of meta-ethnography developed a dis-

tinctive analytic synthesis process of “translation” and“synthesis of translations” [14], underpinned by thetheory of social comparison [13], which involves analysingthe conceptual data, for example, concepts, themes,developed by authors of primary studies.

Why is reporting guidance neededMeta-ethnography is a distinct, complex and increasinglycommon and influential qualitative methodology. It is themost widely used qualitative evidence synthesis method-ology in health and social care research [16–18] and isincreasingly used by other academic disciplines [2].Many other qualitative evidence synthesis methodologiesand methods are based on or influenced by it [2, 19, 20].A methodological evaluation of the effectiveness of meta-ethnography for synthesizing qualitative studies in healthand health care concluded that meta-ethnography canlead to important new conceptual understandings ofhealth care issues [9] and high quality meta-ethnographieshave informed clinical guidelines [21, 22]. However, thequality of reporting in published meta-ethnographiesvaries and is often poor despite methodological advances[9, 17, 23–25]. Adequate quality in reporting is one ofseveral prerequisites to assessing confidence in meta-ethnography findings that could inform evidence-basedpolicy and practice, for instance, in health and socialcare [26].

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Reporting guidance is commonly used in health andsocial care research and can raise publication standards[27]. For systematic reviews and meta-analyses of quan-titative studies, the most commonly used guidance isPreferred Reporting Items for Systematic Reviews andMeta-Analyses (PRISMA) [28]. For reviews of qualitativestudies, the most commonly used one is the generic2012 ENTREQ (Enhancing transparency in reporting thesynthesis of qualitative research) statement [29]. Qualitativeevidence synthesis methodologies differ greatly; therefore,unique reporting guidance for metanarrative reviewswas recently developed [30]. There is currently no guidanceon reporting the complex synthesis process of meta-eth-nography. Such guidance should improve the transparencyand completeness of reporting and thus maximize the abil-ity of meta-ethnographies to contribute robust evidence tohealth, social care, and other disciplines, such as educa-tion. Although meta-ethnography continues to evolve,reporting guidance is needed currently for this complexmethodology.

MethodsThe methods used to develop the eMERGe meta-ethnog-raphy reporting guidance followed a rigorous approachconsistent with, but exceeding, good practice recommen-dations [31] and were published in a protocol [32]. The re-search questions were:

1. What are the existing recommendations andguidance for conducting and reporting each processin a meta-ethnography and why? (Stage 1)

2. What good practice principles can we identify inmeta-ethnography conduct and reporting to informrecommendations and guidance? (Stage 2)

3. From the good practice principles, what standardscan we develop in meta-ethnography conduct andreporting to inform recommendations and guidance?(Stage 2)

4. What is the consensus of experts and otherstakeholders on key standards and domains forreporting meta-ethnography in an abstract andmain report/publication? (Stages 3 & 4).

Details of the methods are given in supplementary FileS1 (Additional file 1). Guidance development was con-ducted by the grant project team (the first 10 authors), inconsultation with the one of the two originators ofmeta-ethnography, George Noblit and supported by amultidisciplinary project advisory group of national andinternational academics, policy experts, nonacademic usersof syntheses such as clinical guideline developers and layadvisors, who had an active role in the development of theguidance and whose contributions were central through-out the project (the 11 authors from A. B. onwards were

advisory group members). Guidance development tookplace over a 2-year period from 2015 to 2017 and com-prised four stages, outlined in Fig 1:

1. Identification of potential reporting standards toinclude in the guidance;

2. Development and application of potential standardsto published meta-ethnographies;

3. Consensus on guidance content;4. Development of reporting criteria for the guidance

and explanatory notes.

Stage 1. Identification of standardsStage 1 was conducted by the grant project teamwho undertook a systematic review (PROSPEROCRD42015024709) of relevant methodological andreporting guidance on meta-ethnographies to identifypotential reporting standards [32]. From this review, weidentified 138 recommendations for meta-ethnographystandards on reporting from 57 included publications (seesupplementary File S2) (Additional file 2).

Stage 2. Development and application of the standardsThe grant project team reviewed 29 published meta-ethnographies (see supplementary File S3) (Additional file 3)from various academic disciplines and interviewed nonaca-demic end users of meta-ethnographies to identify goodpractice principles and recommendations which we thendeveloped into an audit tool of 109 measurable provisionalstandards. The 29 meta-ethnographies were chosen by aca-demic experts who were asked to justify why they consid-ered them seminal (i.e., they had influenced or significantlyadvanced thinking and/or were of central importance inthe field of meta-ethnography) or relatively poorly re-ported, or meta-ethnographies were identified as poorlyreported from published reviews. The team applied theprovisional standards to a purposive sample of 40 pub-lished health and social care-related meta-ethnographies(selected from 571 identified through comprehensivesystematic searches to give variation in, for example,journal, academic discipline, topic, number of includedstudies and of authors—supplementary File S1 gives fullsampling details) (Additional file 1) in a retrospectiveaudit to determine the extent to which the standardswere met (“not at all”, “in part” or “in full”) and to iden-tify ways the standards could be refined.

Stage 3. Consensus on guidance contentFrom the results of Stage 2, the project team reviewedand refined the 109 provisional standards by clarifyingambiguous wording, merging duplicative standards, andcombining standards on similar processes to create 53items which were discussed in an online workshop andtested in Delphi consensus studies [33] with academic and

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nonacademic potential end users. Two parallel, onlineDelphi consensus studies with identical questions wereconducted: one Delphi for international experts in qualita-tive methods (comprising editors or researchers with priormeta-ethnography/qualitative evidence synthesis experience)and one for professional/academic and lay people (potentialend-users of meta-ethnographies). Sixty-two people (39experts and 23 professional/lay people) completed allthree rounds of the Delphi. Four items failed to reachconsensus in both Delphi studies and so were excludedfrom the final guidance (these were the abstract shouldideally differentiate between reported findings of theprimary studies and of the synthesis; state the qualitativeresearch expertise of reviewers; state in which orderprimary study accounts had data extracted from them; statethe order in which studies were translated/synthesized).Participants reached consensus that 49 of 53 items shouldbe included in the guidance, too many for usable reportingguidance; therefore, further steps were undertaken tocondense these items into fewer reporting criteria.

Stage 4. Development of the guidanceTo develop the final reporting criteria for the guidance,a project advisory group meeting was convened whichhad 26 attendees including expert academics, otherprofessionals, and lay members. The group discussed andagreed the structure of the guidance and the accompany-ing explanatory notes. Following this meeting, the grantproject team agreed which Delphi items should be mergedto create usable guidance. The project advisory groupthen commented on the readability and usability of theguidance. Members of the grant project team then furtherrefined the guidance and explanatory notes. The finalguidance and explanatory notes were checked against theDelphi items to ensure content and meaning had beenpreserved throughout this iterative process. Members ofthe project advisory group and project team reviewed andagreed the final guidance table and explanatory notes.Supplementary File S1 gives details of the methods whichalso appear in a published protocol [32] and funder’sreport [34] (Additional file 1).

Fig 1 Guidance development flowchart

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How to use the guidanceThe eMERGe reporting guidance is designed for use byresearchers conducting a meta-ethnography (referred tothroughout as “reviewers”: the term “reviewers” for peoplewho conduct and report meta-ethnographies was thepreferred term identified from the eMERGe Delphi studiesin line with the increasing use of systematic review meth-odology for qualitative evidence syntheses), peer reviewers,journal editors, and end-users of meta-ethnographiesincluding policy makers and practitioners. The eMERGeguidance also provides a helpful structure for anyonecontemplating or conducting a meta-ethnography. Whilethe guidance was developed for meta-ethnography, someof the reporting criteria, such as those relating to stating areview question and reporting literature search and selec-tion strategies, might also be applicable to other forms ofqualitative evidence synthesis and thus overlap with thegeneric ENTREQ guidance for reporting a wide range ofqualitative evidence syntheses [29]. In contrast to eMERGe,ENTREQ does not provide guidance regarding reporting ofthe complex analytic synthesis processes (Phases 4–6) in ameta-ethnography and did not follow good practice guid-ance for developing a reporting guideline [31], for example,it was not designed with the consensus of a wider commu-nity of experts [34, 35].The eMERGe guidance consists of three parts:

1. Part 1: Table of reporting criteria that are commonto all meta-ethnographies,

2. Part 2: Detailed explanatory notes on how to applythe common reporting criteria includingsupplementary detail of findings for phases 3–6 (seesupplementary information Table S4) (Additionalfile 4),

3. Part 3: Extensions for reporting steps and processeswhich are not common to every meta-ethnography.

Readers should refer to and use all three parts of theguidance. Parts 1 and 2 of the eMERGe reporting guidanceare organized by the seven phases of meta-ethnography.Suggestions are provided in the grey cells of the tablein Part 1 for where specific reporting criteria could bereported under journal article section headings. Whereappropriate, reviewers should also consider additionalrelevant guidance for reporting other common qualita-tive evidence synthesis steps and processes, such assearches for evidence. See for example, the “STARLITE”guidance [36] and PRISMA [28] for reporting literaturesearches (refer to the EQUATOR Network for a compre-hensive database of up-to-date reporting guidance https://www.equator-network.org/). Part 3 covers eMERGe exten-sions for format and content of the meta-ethnographyoutput (for example, of an abstract); assessment of meth-odological strengths and limitations of included primary

studies; and using the GRADE CERQual approach toassess confidence in findings from qualitative evidencesyntheses [1, 26].Users of this guidance should note that meta-ethnography

is an iterative process and although the guidance is pre-sented by meta-ethnography phases, we are not advocatinga linear approach to meta-ethnography conduct. Fur-thermore, those conducting meta-ethnographies mayneed to be creative and adapt the methodology to theirspecific research/review question [37].

Part 1: Guidance table (see Table 1)

Part 2: Explanatory notesPHASE 1—Selecting meta-ethnography and getting started

Reporting criterion 1—Rationale and context for themeta-ethnography Consider whether a meta-ethnographyof this topic is needed [38–40], for example, is there anexisting meta-ethnography on the topic and if so, provide areason for updating it [41] and describe the gap in researchor knowledge to be filled by the meta-ethnography. Thisshould include reviewers describing the availability of quali-tative data which potentially could be synthesized and thecontext of the meta-ethnography, for instance, the political,cultural, social, policy, or other relevant contexts; any fund-ing sources for the meta-ethnography; and the timescalesfor the meta-ethnography conduct. Reviewers should con-sider referring to frameworks which provide guidance onhow to specify context, such as Noyes et al. [1].

Reporting criterion 2—Aim(s) of the meta-ethnographyThe intention of meta-ethnography is to produce a newconfiguration/interpretation, a new model, conceptualframework, or theory, although ultimately this might notbe possible, for instance, if no conceptual innovation hadoccurred since an early, conceptually rich primary studyaccount [9, 42, 43]. The aim(s) of the meta-ethnographyshould be explicitly stated and should be compatible withsuch intentions. The aim may be refined after reading theliterature and examining the available data [9, 24, 44–46].If the initial aim(s) is (are) changed during Phases 1 and 2,give details of any refinements made.

Reporting criterion 3—Focus of the meta-ethnographyThe review question(s) should be explicitly stated and becongruent with the intention of meta-ethnography. If,during later phases, the initial review question(s) orobjective(s) needed to be refined, give details of any refine-ments. A well-defined review question, specifying a precisefocus, can lead to a more efficient synthesis and moreuseful output [42, 45, 46], for instance, by contributingto clear study inclusion criteria for Phase 2.

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Reporting criterion 4—Rationale for using meta-ethnography Many qualitative evidence synthesis method-ologies and methods exist [44]. Unlike meta-ethnography,some of these are aggregative (e.g., thematic analysis, JoannaBriggs Institute methods), combine qualitative and quantita-tive data (e.g., critical interpretive synthesis, metanarrative,metastudy, metasummary, realist synthesis), or have a realistepistemology (e.g., thematic synthesis, framework synthesis)[3, 20, 44]. The rationale should be given for why meta-eth-nography was chosen as the most appropriate metetal.hodology for conducting an interpretive synthesis [40].If reviewers made adaptations or modifications to Noblitand Hare’s [14] methodology or methods, state whymeta-ethnography was still considered the most appro-priate methodology and describe all adaptations andmodifications made.

Table 1 The eMERGe meta-ethnography reporting guidance

No. Criteria Headings Reporting Criteria

Phase 1—Selecting meta-ethnography and getting started

Introduction

1 Rationale and context forthe meta-ethnography

Describe the gap in research orknowledge to be filled by themeta-ethnography, and the widercontext of the meta-ethnography

2 Aim(s) of themeta-ethnography

Describe the meta-ethnography aim(s)

3 Focus of themeta-ethnography

Describe the meta-ethnography reviewquestion(s) (or objectives)

4 Rationale for usingmeta-ethnography

Explain why meta-ethnography wasconsidered the most appropriatequalitative synthesis methodology

Phase 2—Deciding what is relevant

Methods

5 Search strategy Describe the rationale for the literaturesearch strategy

6 Search processes Describe how the literature searchingwas carried out and by whom

7 Selecting primary studies Describe the process of studyscreening and selection, and who wasinvolved

Findings

8 Outcome of studyselection

Describe the results of study searchesand screening

Phase 3—Reading included studies

Methods

9 Reading and dataextraction approach

Describe the reading and dataextraction method and processes

Findings

10 Presenting characteristicsof included studies

Describe characteristics of the includedstudies

Phase 4—Determining how studies are related

Methods

11 Process for determininghow studies are related

Describe the methods and processesfor determining how the includedstudies are related:- Which aspects of studies werecompared

AND- How the studies were compared

Findings

12 Outcome of relatingstudies

Describe how studies relate to eachother

Phase 5—Translating studies into one another

Methods

13 Process of translatingstudies

Describe the methods of translation:- Describe steps taken to preserve thecontext and meaning of therelationships between concepts withinand across studies- Describe how thereciprocal and refutational translationswere conducted- Describe howpotential alternative interpretations or

Table 1 The eMERGe meta-ethnography reporting guidance(Continued)

No. Criteria Headings Reporting Criteria

explanations were considered in thetranslations

Findings

14 Outcome of translation Describe the interpretive findings ofthe translation.

Phase 6—Synthesizing translations

Methods

15 Synthesis process Describe the methods used to developoverarching concepts (“synthesisedtranslations”)Describe how potentialalternative interpretations orexplanations were considered in thesynthesis

Findings

16 Outcome of synthesisprocess

Describe the new theory, conceptualframework, model, configuration, orinterpretation of data developed fromthe synthesis

Phase 7—Expressing the synthesis

Discussion

17 Summary of findings Summarize the main interpretivefindings of the translation andsynthesis and compare them toexisting literature

18 Strengths, limitations, andreflexivity

Reflect on and describe the strengthsand limitations of the synthesis:- Methodological aspects—for example,describe how the synthesis findingswere influenced by the nature of the included studies and how themeta-ethnography was conducted.- Reflexivity—for example, the impactof the research team on thesynthesis findings

19 Recommendations andconclusions

Describe the implications of thesynthesis

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PHASE 2—Deciding what is relevant

Reporting criterion 5—Search strategy Explain howthe search strategy was informed by the research aim(s),question, or objectives and the meta-ethnography’s purpose[46, 47]. Reviewers should provide a rationale for whetherthe approach to searching was comprehensive (searchstrategies sought all available studies), purposeful (e.g.,searching sought all available concepts until theoreticalsaturation was achieved), or a combination of approaches.Purposeful searches may be suited for theory-generatingsyntheses [46, 47]. In addition, provide a rationale for theselection of bibliographic databases and other sourcesof literature; when searching was stopped if purposefulsearches were used; and any search limiters (restrictionsto the searches) such as the years covered, geography,language, and so on.

Reporting criterion 6—Search processes Describe andprovide a rationale for how the literature searching wasconducted, following appropriate guidance for reportingqualitative literature searches, for example, STARLITE[36], some journals may also require use of PRISMA [28].

Reporting criterion 7—Selecting primary studiesDescribe the screening method, such as by title, abstract,and/or full text review and identify who was involved instudy selection. Specify the inclusion and exclusion criteriafor study selection, for example, in terms of population,language, year limits, type of publication, study type, meth-odology, epistemology, country, setting, type of qualitativedata, methods, conceptual richness of data, and so on.Also, describe any sampling decisions for study selection—were all relevant studies included or a purposive ortheoretical sample of studies [46, 48]?

Reporting criterion 8—Outcome of study selectionProvide details on the number of primary studies assessedfor eligibility and included in the meta-ethnography. Givereasons for exclusion, for example, for comprehensivesearches provide numbers of studies screened indicatedin a figure/flowchart; for purposeful searching describereasons for study exclusion and inclusion based onmodifications to the review question and/or contributionto theory development.Outcome of study selection can be presented as a pri-

mary study flow diagram or narrative—reviewers shouldnote publication requirements—many journals require aPRISMA type flow diagram [28]. If comprehensive literaturesearches were conducted, reviewers should follow appropri-ate reporting guidance formats, such as PRISMA [28] andSTARLITE [36]. If publication requirements preventfull reporting, reviewers should state where readers can

access these data in full, for example, on a project website,in online files.

PHASE 3—Reading included studies

Reporting criterion 9—Reading and data extractionapproach This is the phase where the clearest divergencecan start to be seen from other types of qualitative evidencesyntheses. As described in the original meta-ethnographytext:“… we think it is best to identify this phase as the repeated

reading of the accounts and the noting of interpretativemetaphors. Meta-ethnography is the synthesis of texts; thisrequires extensive attention to the details in the accountsand what they tell you about your substantive concerns.”([14], p. 28).Reviewers should describe:

1. the process and strategy for reading includedstudies to indicate how close (critical) reading wasachieved and who was involved in reading studies.

2. the strategy for extracting or recording data fromincluded studies and state who was involved in this,whether processes were conducted independentlyby reviewers and whether data were checked foraccuracy and if so, how.

3. the process for identifying and recording concepts,themes, and metaphors from the primary studies[25]. Indicate whether data were extracted fromacross the full primary study (desirable), or specificsections only, for example, findings (notrecommended because conceptual data may appearthroughout the account and the primary studycontext could be lost [37, 40]). Clarify whichkind(s) of primary study findings were extracted,such as participant quotes and/or conceptsdeveloped by authors of primary studies (sometimescalled first- and second-order constructs, respectively;[23]) so that readers can follow reviewers’ conceptdevelopment.

Examples of how data extraction has been done include:create a list of metaphors and themes [9], create a grid ortable of concepts [43, 49, 50], or code concepts in a soft-ware programme for the analysis of qualitative data suchas QSR NVivo [40].Reviewers should state what they mean by the termin-

ology they have used for the units of synthesis, for example,metaphor, concept, theme.

Reporting criterion 10—Presenting characteristics ofincluded studies Provide a detailed description in narra-tive and/or table or other diagrammatic format of includedstudies and their study characteristics (such as year of

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publication, population, number of participants, data collec-tion, methodology, analysis, research questions, studyfunder) [40, 49]. If publication requirements prevent fullreporting, state where readers can access these data infull, for example, a project website, online files.In addition, provide key contextual information about

the primary studies and comment on their relevance tothe context(s) specified in the meta-ethnography reviewquestion [42, 51, 52]. Context of included primary studiescan influence the analysis process [42], for example,primary study accounts published after a certain datemay reflect a change in health policy/practice such asthe introduction of a smoking ban in enclosed publicplaces. If two or more included primary study accounts,for example, papers, were derived from the same primarystudy, this should be made explicit. Contextual informationshould include details about the primary study participants(such as their gender, age, socioeconomic status, ethnicity,and so on); the setting such as a geographical setting (acountry, region, city) or organisation (hospital, school,company, community); and key political, historical, andcultural factors of relevance, for instance, the introductionof a major international guideline, which affected clinicalcare, preceded publication of included studies. If suchcontextual information is not available in the primarystudy accounts, reviewers should make this clear to readers(Table 1).

PHASE 4—Determining how studies are related

Reporting criterion 11—Process for determining howstudies are related Reviewers should describe whichaspects of the primary studies were compared and why,to determine how they are related, bearing in mind theaim of their meta-ethnography. Aspects could include:(i) research design, such as the: study aims; contexts;type of studies; theoretical approach/paradigm; partici-pant characteristics, for example, their gender, ethnicity,culture, or age; study focus, for example, a health orsocial issue, long-term conditions, other diseases, or caresettings; (ii) findings—the meaning of the concepts,metaphors, and/or themes [14]; the overarching storylineor explanation of a phenomenon from the primary studyaccounts [37] and (iii) other contextual factors, such asthe time period, for instance, whether findings of primarystudy accounts differed because they were conducted indifferent time contexts. In addition, reviewers shoulddescribe how the studies were compared, that is, themethods and process of comparison. There is a widevariety of methods for comparing studies; examples ofhow Phase 4 has been reported include: Campbell et al.[24]; Atkins et al. [42]; Malpass et al. [43]; Beck [53];Britten and Pope [49]; Erasmus [50].

Reporting criterion 12—Outcome of relating studiesDescribe how primary studies relate: (i) to each other;(ii) to the review question; and (iii) to the prespecifiedaspects of context which were considered important, forexample, do they relate reciprocally and/or refutationally,or do they explore different aspects of the topic understudy [9, 14, 25, 42, 43, 49, 50, 53]? When reviewers arereporting how studies are related they should also report“disconfirming cases” [4, 51] that is, where one or morefindings (e.g., metaphors or concepts) from a study differfrom those of other studies for reasons that may beexplained by differences in participants, settings, or studydesign. Reviewers can describe how studies were relatedin narrative, tabular, and/or diagrammatic form.

PHASE 5—Translating studies into one another

Reporting criterion 13—Process of translating studiesThere is a variety of ways to conduct translation; therefore,reviewers should state their understanding and workingdefinitions of reciprocal and refutational translation.Examples of approaches to translation identified by oursystematic review are: Atkins et al. [42], Campbell et al. [9],Garside [54], Toye et al. [40], and Doyle [55]. Examples ofrefutational translation include Garside [54] and Wikbergand Bondas [56].Reviewers should also:

1. state who was involved in translation;2. describe how meaning was translated from one

study into another, for instance, by reporting one ormore examples of how this was done;

3. describe how relationships between concepts withinand across studies, were preserved in thetranslation, such as by drawing concept maps toshow relationships between concepts [43, 57] (grids,tables, and other visual diagrams could also be used);

4. describe how the contexts of the primary studies werepreserved in the process of translation, for example,were subgroups of studies translated according to acommon health condition or time-period [9]?

5. clearly indicate whose interpretation is beingpresented [25]—that of the research participants,study authors, or reviewers (sometimes called first-,second-, and third-order constructs, respectively) [23];

6. describe how potential alternative interpretations orexplanations were considered in the translation.

Refutational translation is often overlooked [4, 51]; itspurpose is to explain differences and to explore and explainexceptions, incongruities, and inconsistencies [47, 58].An entire study could refute another study [49, 59] orconcepts/metaphors within studies could refute oneanother [45, 49, 59], in which case it may be possible to

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do both reciprocal and refutational translation in ameta-ethnography rather than one or the other. Reviewersshould identify disconfirming cases that could inform orhave an impact on translation and, subsequently, synthesis.Some argue that synthesizing a large number of studies

might result in a superficial synthesis that loses its“groundedness” in the studies [9]; too few studies mightresult in underdeveloped theory/concepts [40, 45]. Thereis no consensus over what constitutes too few or too manystudies; perceptions of a “large” number of studies variesfrom over 40 [9] to over 100 [51]. The volume of data willalso depend on the richness and length of those accountsand team size will affect the ability to manage the data. Ifa large volume of data were synthesized, reviewers shouldexplicitly describe how translation was achieved given thisvolume, for example, did they translate studies in smallerclusters to preserve conceptual richness and/or staygrounded in the data?

Reporting criterion 14—Outcome of translationDescribe the interpretive findings of the reciprocal trans-lation and refutational translation—including how eachprimary study contributed to the translation [47] anddescribe alternative interpretations/explanations. Clearlydocument from which concepts in primary studies, thereviewers’ concepts are derived [47]. Reviewers need todifferentiate between concepts derived from the partici-pants of primary study accounts (sometimes called firstorder constructs) and those derived by the authors ofthe primary study accounts (sometimes called second-orderconstructs). An example of how this has been reported isBritten et al. [23] and a clear table describing the differentlevels of constructs can be found in Malpass et al. [43].Descriptions of the study concepts and reviewers’ conceptsand their interrelationships can be provided in table, dia-grammatic or narrative form, with additional informationin supplementary files. When quotes are used, reviewersshould state their origin—primary study participants,primary study authors, or the reviewers’ own analysisnotes. If any study was reported in more than onepaper/account, describe how this was dealt with.

PHASE 6—Synthesizing translations

Reporting criterion 15—Synthesis process There aretwo aspects of Phase 6: synthesizing translations and lineof argument synthesis. The synthesized translations(concepts) represent the reviewers’ interpretation of thetranslations and are referred to in Britten et al. [23] asthird-order constructs.A line of argument synthesis aims to provide a fresh

interpretation; it goes further than translation and putsany similarities and dissimilarities into a new interpretivecontext [14]. George Noblit [37] has more recently

further defined a line of argument as the new “storyline”or overarching explanation of a phenomenon. Reviewersshould describe the methods used to develop synthesizedtranslations and how the line of argument synthesis wasconducted. If line of argument synthesis was not con-ducted, state why not. In addition, describe:

(1) how many and which studies were synthesized.Sometimes studies are excluded in Phases 5 and 6(for instance, because they lack conceptual depth),so the number of synthesized studies may differfrom the number of studies meeting reviewinclusion criteria.

(2) who was involved in the synthesis and explain howsynthesis findings have been considered fromalternative perspectives (for example, from differentacademic disciplines) [42, 54, 59].

(3) how reviewers remained grounded with primarystudy data and avoided losing conceptual richnessduring synthesis, particularly if a large amount ofdata were synthesized. (See the discussion onvolume of data to be synthesized in Phase 5).

Reporting criterion 16—Outcome of synthesis processDescribe the interpretive findings of the synthesis oftranslations, the line of argument synthesis and any newmodel, conceptual framework or theory developed in anarrative, grid, table and/or visually, for instance, as anillustration, diagram or film. Any of these may be con-sidered to be a synthesis product and a single synthesismay have more than one product. Reviewers shouldshow the inter-relationships between the data from theprimary studies and the reviewers’ new interpretations.If development of a new theory, conceptual framework,or model was not possible, state why not.Describe the context where the new theory, model, or

framework applies, or not, based on the characteristicsof included primary studies. For example, the newtheory may have been based solely on studies of young,white women, or studies conducted in countries withprivate health care, or the included studies may be olderand/or predate a significant development in the field.

PHASE 7—Expressing the synthesis

Reporting criterion 17—Summary of findings Relatethe main interpretive findings to the synthesis objec-tive(s), review question(s), focus, and intended audience(s)[9, 14, 42, 59, 60]. Compare the concept, model, or the-ory generated in the synthesis to the existing literature,such as research and policy publications. Reviewers shouldconsider the possible influence of findings from other au-thors (both from primary study accounts and the wider lit-erature) on their own conclusions [4].

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Reporting criterion 18—Strengths, limitations, andreflexivity Consideration of methodological and otherstrengths and limitations and how they may influencethe final interpretation is a key to meta-ethnographyreporting. Reviewers should reflect on and describe theeffect of these on the synthesis process and outcomesbecause they may affect the credibility and trustworthiness(in other fields, this is referred to as validity and reliability)of the synthesis findings.Strengths and limitations of: (i) the included primary

studies; and (ii) how the meta-ethnography was conductedshould be described. The latter are infrequently reportedin published meta-ethnographies. Reviewers should com-ment on how these aspects may have influenced or limitedthe synthesis findings:

1. the characteristics, content and context of theprimary studies, such as the temporal context, typeof participant, cultural factors, study design.

2. the conduct of the synthesis. Considerationsinclude, but are not restricted to: the order inwhich studies were synthesized [25, 54], the impactof study selection and sampling, the number ofincluded studies/ volume of data (may affect depthof analysis), the context of the synthesis, and anymodifications made to Noblit and Hare’s [14]original methodology.

Reflexivity—critically reflecting on the context ofknowledge construction, especially the effect of theresearcher on the research process—should include com-ment on how the reviewers influenced the interpretiveprocess and synthesis findings [61], for example:

1. the reviewers’ background, perspectives, andexperience, such as, but not limited to,epistemological position(s), professional position(s)held, academic discipline, organisation(s), orprofessional bodies represented [51];

2. if the reviewers have a specific view, stance, orpersonal interest, for example, the reviewer’sviewpoint on access to abortion care for a reviewabout women’s reproductive health care services.

3. any influence of the funder of the meta-ethnography;4. any conflicts of interests of the reviewers, that is,

any factor, for example, financial, political, ororganizational, which might influence thejudgement of the reviewers when conducting theinterpretation and synthesis.

5. how each reviewer was involved and how theircontribution to literature searching and screening,reading of studies, data extraction, translation, andsynthesis may have influenced the interpretiveprocess [40, 42, 54, 59].

Reporting criterion 19—Recommendations and con-clusions Describe the implications of the synthesis find-ings for policy, practice, and/or theory. Policy and practiceimplicet al.ations were particularly important to eMERGenonacademic and lay project advisors. Identify any areaswhere further primary or secondary research is needed.

Part 3: ExtensionsThe first three extensions for reporting steps and processesthat are not common to every meta-ethnography areavailable as supplementary material to this paper (seeAdditional file 5).

DiscussionThe eMERGe guidance is intended to increase transpar-ency and completeness of reporting, making it easier fordiverse stakeholders to judge the trustworthiness andcredibility of meta-ethnographies and also intended tomake the findings more usable and useful to informservices and interventions, such as in health, socialcare, and education. The development of this guidanceused methods following, but exceeding, good practicein developing reporting guidance [31] incorporatingsystematic literature reviews; consensus methods; andconsultation with one of the two originators of meta-ethnography, George Noblit. The team believe that theguidance is unusual among current reporting guidancein the extent to which it has involved lay people in allaspects of the development [32].This guidance is not intended as a detailed guide in

how to conduct a meta-ethnography—some such publi-cations exist (e.g., [9, 41–43, 49]) and others from theeMERGe project are in preparation (see http://emerge-project.org/publications/). The guidance is designed toraise the reporting quality of meta-ethnographies andthus to assist those writing, reviewing, updating, andusing meta-ethnographies in making judgements aboutquality of meta-ethnography conduct and output. Itmight also help users of qualitative evidence syntheses torecognize other forms of qualitative evidence synthesismislabelled as a meta-ethnography, a common occurrence[25]. The guidance does, however, advance the methodologythrough its comprehensive analysis, interpretation and syn-thesis of methodological publications on meta-ethnography,published since Noblit and Hare’s original monograph,which underpin the reporting criteria and explanatory notes.Some might argue that the guidance is overly pre-

scriptive and detracts from the original purposes ofmeta-ethnography and, indeed, qualitative research. Itis our view and that of others [62] who conducting ameta-ethnography involves creative, interpretive, qualita-tive analysis methods; however, a creative and interpretiveapproach should not preclude describing clearly how theresearch was conducted and some guidance is required to

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avoid misuse or mislabelling of the methods [15] and pooror misleading reporting. In this guidance, definitions andrequirements have not been imposed arbitrarily, unneces-sarily, or where consensus is lacking. Meta-ethnographyhas been described as an advanced qualitative researchmethodology [9, 38, 40] probably reflecting its complexityas a methodology. Training materials to accompany thisguidance including video clips and slides (available fromhttp://emergeproject.org/resources) have been developedas part of the eMERGe project.This guidance has been designed to have the flexibility

to be applied to diverse reporting formats with differingpublication requirements (for example, journal articles,reports, book chapters) and this explains why some stan-dards, which apply only to certain formats, are includedas “extensions” to the guidance. Publication require-ments can limit manuscript length; therefore, reviewersmight need to provide some data in an alternative for-mat, such as online, to achieve full reporting.Methodological developments in meta-ethnography and

in relevant qualitative evidence synthesis methodologygenerally will continue to occur. This guidance was cre-ated with an eye to accommodating these future develop-ments which will be monitored through our discussionlist: www.jiscmail.ac.uk/META-ETHNOGRAPHY. Futureresearch will investigate the impact of the eMERGereporting guidance, for example, by updating our earliersystematic review of meta-ethnography reporting practices[25], with a view to updating the guidance and we regardthis guidance as one baseline from which to track the evo-lution of meta-ethnography.

ConclusionThis guidance has been developed following a rigorous ap-proach in line with and exceeding good practice in creatingreporting guidance. It is intended to improve the clarity andcompleteness of reporting of meta-ethnographies to facilitateuse of their findings to inform the design and delivery of ser-vices and interventions in health, social care, and otherfields. Qualitative data are essential for conveying people’s(e.g., patients, carers, clinicians) experiences and understand-ing social processes and it is important that they contributeto the evidence base. Meta-ethnography is an evolving quali-tative evidence synthesis methodology with huge potentialto contribute evidence for policy and practice. In future,changes to the guidance might be required to encompassmethodological advances and accommodate changes identi-fied after evaluation of the impact of the guidance.

Additional files

Additional file 1: File S1. Supplementary information: the eMERGeproject research design & methods. (DOCX 184 kb)

Additional file 2: File S2. Supplementary information: A. 57publications included in the systematic review for ‘Stage1 Identificationof Standards’and B. Publications contributing to development ofreporting criteria. (DOCX 299 kb)

Additional file 3: File S3. Supplementary information: the sample of 29published meta-ethnographies analysed in ‘Stage 2 Development andApplication of Standards’. (DOCX 27 kb)

Additional file 4: Table S4. Supplementary information: explanatorynotes for Phases 3-6 to accompany Part 2 of the guidance. (DOCX 88 kb)

Additional file 5: Part 3: eMERGe Reporting Guidance - Extensions.(DOCX 48 kb)

AcknowledgementsWe warmly thank the members of our project advisory group: Geoff Allan,Marjory Barton, Ian Gallagher, Anne Ward, Lorna Neill, Gordon Snedden,Veronica Saunders (lay members), Andrew Booth, Nicky Britten, RonaCampbell, Margaret Cargo, Kate Flemming, Ruth Garside, Claire Glenton,Karin Hannes, Angela Harden, Gina Higginbottom, Christine Johnstone,Simon Lewin, George W. Noblit, Sandy Oliver, Cathy Pope, Karen Ritchie,James Thomas, Meredith Vanstone, and Geoff Wong (academic, otherexperts, and professional end-users); and Sheena Blair, independent chair ofthe advisory group; Kevin Swingler, Steve Boulton, the participants in theDelphi, and our funder the National Institute of Health Research (NIHR).

FundingThis study was funded by an NIHR Health Service and Delivery ResearchHS&DR grant (13/114/60). The views and opinions expressed therein arethose of the authors and do not necessarily reflect those of the HS&DRProgramme, NIHR, NHS, or the Department of Health.The systematic reviews were undertaken with the support of NIHR HealthService and Delivery Research HS&DR grant, Grant/Award Number: 13/114/60;DECIPHer, a UKCRC Public Health Research Centre of Excellence: British HeartFoundation; Cancer Research UK; Economic and Social Research Council, Grant/Award Number: RES-590-28-0005; Medical Research Council; Welsh Govern-ment; Wellcome Trust, Grant/Award Number: WT087640MA, under the auspicesof the UK Clinical Research Collaboration, is gratefully acknowledged.

Supporting informationAdditional supporting information may be found online at https://osf.io/nmf7v/.

Authors’ contributionsAll authors have agreed on the final version and meet at least one of thefollowing criteria (recommended by the ICMJE*): substantial contributions toconception and design, acquisition of data, or analysis and interpretation ofdata; drafting the article or revising it critically for important intellectualcontent. All authors read and approved the final manuscript. *http://www.icmje.org/recommendations/.

Competing interestsCatherine Pope is an author of the book Pope C, Mays N, Popay J. Synthesizingqualitative and quantitative health evidence: a guide to methods. Buckingham:Open University Press 2007 which discusses meta-ethnography; she receivesroyalties from this. Jane Noyes is a Journal of Advanced Nursing Editor. She wasrecused from the Journal of Advanced Nursing management of this paper. Noconflict of interest has been declared by the remaining author(s).

Publisher’s NoteThis article is being simultaneously published in the Journal of AdvancedNursing, Psycho-oncology, Review of Education, and BMC Medical ResearchMethodology. The article followed a double-blind peer-review model managedby the Journal of Advanced Nursing, and the editors from each of the journalsin question consolidated on the decision process.

Author details1University of Stirling, Stirling, UK. 2Edinburgh Napier University, Edinburgh,UK. 3University of Edinburgh, Edinburgh, UK. 4Cardiff University, Cardiff, UK.5Bangor University, Bangor, UK. 6University of Sheffield, Sheffield, UK.7University of Exeter Medical School, Exeter, UK. 8Department of HealthSciences, University of York, York, UK. 9eMERGe project, Stirling, UK.

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10University of Leuven, Leuven, Belgium. 11Global Health Unit NorwegianInstitute of Public Health and Health Systems Research Unit, Oslo, Norway.12South African Medical Research Council, Capetown, South Africa.13University of North Carolina at Chapel Hill, Chapel Hill, USA. 14University ofSouthampton, Southampton, UK. 15EPPI-Centre Institute of Education,London, UK. 16McMaster University, Hamilton, ON, Canada. 17NMAHPResearch Unit, Unit 13 Scion House, Stirling University Innovation Park,Stirling FK9 4NF, UK. 18School of Health Sciences & Centre for EvidenceBased Health Care, The University of Nottingham, Nottingham, UK.

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