Synthesising qualitative findingsAn interpretive perspective

Janet Harris K U Leuven QES Workshop 4 – 6 June 2012

Acknowledgements

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

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)

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)

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

Mapping qualitative synthesis methods

Meta-narrative

CIS* Meta-study Meta-ethnography

Grounded theory

Thematic synthesis

Textual narrative synthesis

Framework synthesis

Ecological triangulation

Subjective idealism

Subjective idealism

Subjective idealism

Objective idealism

Objective idealism

Critical realism

Critical realism

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

Type of question Extent of iteration

Quality assessment Going beyond primary studies Problematizing the literature

The synthetic product

Idealist Realist

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)

Approaches to qualitative evidence synthesis

Noyes & Lewin, 2010 http://cqrmg.cochrane.org/supplemental-handbook-guidance

Interpretive approaches

Extent of iteration

Meta-narrative

CIS Meta-study Meta-ethnography

Grounded theory

Thematic synthesis

Textual narrative synthesis

Framework synthesis

Ecological triangulation

Subjective idealism

Subjective idealism

Subjective idealism

Objective idealism

Objective idealism

Critical realism

Critical realism

Critical realism

Scientific realism

Iteration throughout

Iteration at searching

Iteration at synthesis

Iteration at synthesis

Iteration at synthesis

Iteration not mentioned

Iteration at searching

Iteration not mentioned

Idealist Realist

Approaches to inclusion

Meta-narrative

CIS Meta-study Meta-ethnography

Grounded theory

Thematic synthesis

Textual narrative synthesis

Framework synthesis

Ecological triangulation

Subjective idealism

Subjective idealism

Subjective idealism

Objective idealism

Objective idealism

Critical realism

Critical realism

Critical realism

Scientific realism

Quality is important in terms of the end product - information to inform policy makers

Multi-method review which includes RCTs

Multi-method review which includes RCTs

Multi-method review which includes RCTs

Idealist Realist

Less emphasis on quality; more emphasis on utility and relevance

Specific approaches to quality assessment

Context surrounding knowledge production

Meta-narrative

CIS Meta-study Meta-ethnography

Grounded theory

Thematic synthesis

Textual narrative synthesis

Framework synthesis

Ecological triangulation

Subjective idealism

Subjective idealism

Subjective idealism

Objective idealism

Objective idealism

Critical realism

Critical realism

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

Synthesis typologies

Integrative and interpretive

(e.g. Dixon-Woods et al. 2004; Noblit and Hare, 1988)

Aggregation and configuration

(e.g. Sandelowski, forthcoming)

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 findingConcentration of findings in any one

studyThe 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

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.

19 43%

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.

15 31%

3. Children were important sources of physical, practical, emotional, and social support, and unconditional love to their mothers, buffering the negative effects of HIV.

7 18%

*Adapted from Sandelowski M, Barroso J (2003) Creating metasummaries of qualitative findings Nursing Research 52: 226-233

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

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.

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 1st and 2nd order concepts.

Translating studies into one another

Meta-ethnographic synthesisAdapted from Britten et al., 2002

CONCEPTS described in primary studies

Second order interpretations

Third order interpretations

Adherence/compliance:correct and routine medicine takingSelf regulation: problematic adherence; leaving off drugsAversion: eg dislike of taking drugs; harmful side effectsAlternative coping strategies:eg Traditional remedies, self-help

a)Patients conduct cost-benefit analyses: weigh up risks vs benefitsb) 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 legitimateh) Fear of sanctions and guilt produce selective disclosure

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

Grounded theory synthesis steps

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.

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?