1. Dr Kate Flemming Department of Health Sciences University of York, UK
Meta-ethnography
Dr Kate Flemming
Department of Health Sciences
University of York, UK

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

18. How does this look in practice?
Flemming et al 2013

19. How does this look in practice?
Flemming et al 2013

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

22. How this looks in practice
Flemming et al 2013

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

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

25. Questions?

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

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