R E S E A R C H A R T I C L E Open Access
Meta-ethnography in healthcare research: a
guide to using a meta-ethnographic
approach for literature synthesis
, Rebecca Lawton
, Maria Panagioti
and Judith Johnson
Background: Qualitative synthesis approaches are increasingly used in healthcare research. One of the most
commonly utilised approaches is meta-ethnography. This is a systematic approach which synthesises data from
multiple studies to enable new insights into patients’and healthcare professionals’experiences and perspectives.
Meta-ethnographies can provide important theoretical and conceptual contributions and generate evidence for
healthcare practice and policy. However, there is currently a lack of clarity and guidance surrounding the data
synthesis stages and process.
Method: This paper aimed to outline a step-by-step method for conducting a meta-ethnography with illustrative
Results: A practical step-by-step guide for conducting meta-ethnography based on the original seven steps as
developed by Noblit & Hare (Meta-ethnography: Synthesizing qualitative studies.,1998) is presented. The stages
include getting started, deciding what is relevant to the initial interest, reading the studies, determining how the
studies are related, translating the studies into one another, synthesising the translations and expressing the
We have incorporated adaptations and developments from recent publications. Annotations based on a previous
meta-ethnography are provided. These are particularly detailed for stages 4–6, as these are often described as
being the most challenging to conduct, but with the most limited amount of guidance available.
Conclusion: Meta-ethnographic synthesis is an important and increasingly used tool in healthcare research, which
can be used to inform policy and practice. The guide presented clarifies how the stages and processes involved in
conducting a meta-synthesis can be operationalised.
Keywords: Meta-ethnography, Research methods, Qualitative synthesis, Qualitative health research
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* Correspondence: firstname.lastname@example.org
University of Leeds, Leeds LS2 9JT, UK
Bradford Institute for Health Research, Bradford BD9 6RJ, UK
Full list of author information is available at the end of the article
Sattar et al. BMC Health Services Research (2021) 21:50
The range of different methods for synthesising qualita-
tive research has grown in recent years . There are
now a number of different qualitative synthesis methods
including qualitative meta-synthesis, narrative synthesis,
thematic synthesis, interpretative synthesis, grounded
theory and meta-ethnography. A qualitative synthesis is
defined as ‘any methodology whereby study findings are
systematically interpreted through a series of expert
judgements to represent the meaning of the collected
work’.. In a qualitative synthesis the findings of quali-
tative studies are pooled . The use of some types of
qualitative syntheses allow for the inclusion of mixed-
methods and quantitative research studies alongside
qualitative studies. A qualitative synthesis approach can
be used to examine the available literature, and review
and integrate the primary research studies related to a
specific question or phenomenon, to reveal deeper in-
sights or explanations that would not be possible from a
single study . The various qualitative synthesis ap-
proaches mentioned above differ in their purposes,
philosophical traditions and whether they primarily ag-
gregate or re-interpret the study findings [4,5]. Meta-
ethnography is an inductive, interpretative approach
upon which most interpretative qualitative synthesis
methods are based  and is the most commonly uti-
lised qualitative synthesis approach in healthcare re-
Meta-ethnography is particularly suited to developing
conceptual models and theories . This method of
qualitative synthesis is often chosen over alternative ap-
proaches as it is more suitable for the development of
analytical rather than descriptive findings . A meta-
ethnography differs from other qualitative synthesis ap-
proaches as the reviewer re-interprets the conceptual
data (themes, concepts or metaphors) created by the au-
thors of the primary study whilst taking into account the
primary data (participant quotes) using a unique transla-
tion synthesis method in order to transcend the findings
of individual study accounts and create higher order
themes [10,11]. Meta-ethnographic reviews offer greater
description of methods and higher order interpretation
compared to conventional narrative literature reviews
. In health sciences, meta-ethnographies can be used
to generate evidence for healthcare and policy . A
meta-ethnographic synthesis approach is suitable when
researchers are interested in conceptual or theoretical
understandings of a particular phenomenon. Unlike
some qualitative synthesis approaches which allow the
inclusion of mixed-methods design studies (such as the-
matic synthesis and interpretative synthesis), a meta-
ethnographic approach enables only the inclusion of
qualitative studies. A meta-ethnography can include
multiple study designs, whereas other approaches such
as grounded theory require only the inclusion of similar
study approaches .
Although meta-ethnography is a widely used qualitative
literature synthesis method within healthcare research, it
is poorly demarcated and there is a lack of clarity sur-
rounding the description of the data analysis process. A
number of reviews have used this approach [15–20]but
do not provide a fully rigorous description of the stages in-
volved in the analysis process. Given the value of qualita-
tive meta-synthesis in integrating the findings from
multiple studies into a higher conceptual level, it is im-
portant to provide detailed guidance on each of the steps
involved in conducting a meta-ethnography. This paper
aims to fill this gap by outlining a step-by-step method for
conducting meta-ethnography. We describe our interpret-
ation of each of the seven steps outlined by Noblit & Hare
 who first proposed this approach. We also incorpor-
ate adaptations and developments by recent researchers
 and provide annotations where applicable to assist in
describing the stages involved.
The worked example we are using is a published
meta-ethnography (reference and author names omitted
for author anonymity during peer review). Where applic-
able, illustrative examples from this review are provided
alongside the each phase to demonstrate the process.
Within a meta-ethnographic synthesis, the process of
translation is key and unique. It is defined as ‘comparing
the metaphors and concepts in one account with the
metaphors and concepts in others’. A meta-
ethnography should involve a reciprocal and refutational
translation, where possible combined with a line of argu-
ment synthesis [22,23]. Reciprocal translation occurs
when concepts in one study can incorporate those of an-
other , whereas a refutational translation explains
and explores differences, exceptions, incongruities and
inconsistencies [1,22,24]. Reviewers often overlook
refutational translation [24,25]; however studies may re-
fute each other [26,27] or concepts within studies may
refute one another [27,28]. Therefore it may be possible
to conduct both a reciprocal and refutational translation
. A line of argument synthesis is not an alternative
to conducting a translation but is viewed as the next
stage of analysis . A line of argument synthesis is the
translation of accounts that interpret different aspects of
the same phenomenon under study, which results in
producing a whole that is greater than the sum of its in-
dividual parts [10,15]. Although Noblit & Hare  de-
scribe meta-ethnography as a seven step process, it is
important to acknowledge that this process is iterative
and the phases are not discrete but may overlap and run
in parallel . A meta-ethnography reporting tool,
eMERGE has very recently been developed, and provides
a framework for reviewers to follow when reporting the
important aspects of a meta-ethnography .
Sattar et al. BMC Health Services Research (2021) 21:50 Page 2 of 13
In order to identify relevant literature to inform the
present guide, we searched for articles which described
an evaluation or discussed methodological issues in con-
ducting a meta-ethnography or provided guidance for
reporting a meta-ethnography. We then scanned the ref-
erence lists of relevant articles to identify further rele-
vant literature. We also drew on the results from two
recent systematic reviews [23,29]. As such, while the
searches conducted for the present article were not sys-
tematic, the guide reflects recent methodological recom-
mendations in the wider methodological literature. All
relevant articles were read and recommendations were
noted; where any disagreement between authors of pa-
pers was apparent, guidance which was based on system-
atic reviews of the evidence rather than individual
reflections was prioritised.
Doing a meta-ethnographic synthesis: a step-by-step
guide with illustrated examples
Phase 1: getting started
The initial stage requires the authors to identify an area
of interest . The reviewers need to consider if a syn-
thesis of the topic is required and whether a qualitative
synthesis and the meta-ethnographic approach fits with
the research question . E.g. A meta-ethnographic
synthesis approach is suitable when researchers are in-
terested in conceptual or theoretical understandings of a
particular phenomenon. It is also important to deter-
mine whether there is a large and growing body of quali-
tative research in this area, and whether synthesizing
qualitative findings can contribute valuable knowledge
to the existing literature . As proposed by Campbell
and colleagues , we emphasize, that at this stage, it is
important to establish a team of researchers who have
different approaches, opinions and the key skills to con-
duct the meta-ethnography, as this will add rigour to the
We were interested in the disclosure of adverse events
within healthcare; specifically in the perceptions and ex-
periences of patients and healthcare professionals relat-
ing to these events. We were aware of the large and
growing body of qualitative research in this area. Our
searches revealed that there was no qualitative synthesis
specific to the experiences of adverse event disclosure.
We believed that synthesizing the views, attitudes and
experiences of both groups (patients and healthcare pro-
fessionals) would enable us to understand what patients
require from the disclosure conversation and what
healthcare professionals currently offer. Our motivation
for synthesizing the body of qualitative evidence was to
inform future disclosure interventions which were
acceptable to patients and practical for healthcare pro-
fessionals to deliver. Synthesizing qualitative findings
can make valuable knowledge accessible to healthcare
professionals and policy makers .
Phase 2: deciding what is relevant to the initial interest
Once you have chosen your topic of interest, phase 2 in-
volves the following steps: a) defining the focus of the
synthesis, b) selecting studies for inclusion in the synthe-
sis and locating relevant studies, c) developing inclusion
and exclusion criteria and d) quality assessment of the
included studies .
2a. Defining the focus of the synthesis An important
decision involves deciding whether to include all the
studies within your chosen area of interest. It is neces-
sary to find a balance between a review which has a
broad scope, and a focus which will yield a manageable
number of studies. The scope of a meta-ethnography is
more restricted compared to other qualitative narrative
reviews. This is due to the avoidance of making gross
generalisations across disparate fields [10,26]. There is
currently no agreement to how many studies should be
included in the synthesis. Some researchers argue that
synthesizing a large number of studies may interfere
with the ability to produce a useful interpretative output
and could result in an aggregative synthesis . Synthe-
sizing too few studies can result in underdeveloped the-
ories/concepts [24,28]. A large number of studies have
varied from 40  to over 100 . The volume of
data, rather than just the number of studies is important
and team size and resources will affect the ability to
manage this data . It is recognised that focusing on a
particular aspect of your chosen topic interest and ex-
cluding certain aspects may result in some papers being
overlooked. However it is important to make this choice
to ensure that you have manageable number of studies
Our systematic review question focused on ‘The views
and experiences of patients and healthcare professionals
on the disclosure of adverse events’.We focused on stud-
ies which examined the views and experiences of pa-
tients (and/or family members, members of the general
public) and healthcare professionals. We found that
qualitative research in the area of adverse event disclos-
ure was limited. As this was an under-researched area,
we were able to include all the available qualitative stud-
ies in this research area (enabling us to include both pa-
tients’and healthcare professionals’views on adverse
Phase 2b: locating relevant studies The second im-
portant step involves locating potentially relevant
Sattar et al. BMC Health Services Research (2021) 21:50 Page 3 of 13
qualitative studies by conducting a systematic search of
the literature. In order to conduct a systematic search, a
well-constructed and comprehensive search strategy
needs to be developed. Qualitative searches can yield a
large number of search results, which can be daunting
and time consuming to screen. One of the ways to make
your search strategy more specific is through the use of
qualitative search filters. Empirically tested search filters
for qualitative studies have been developed [33–35].
However it is possible that some of the potentially rele-
vant studies may be missed when using such filters. De-
cisions regarding your search strategy and screening
depend on your aims and resources available. We advise
the use of a librarian for reaching decisions on the con-
tent of searches. Multiple databases are utilised to locate
relevant articles and this can be further supplemented by
hand searching. This is important as it can locate rele-
vant articles which are not indexed or inaccurately
indexed, and minimises the risk of missing relevant stud-
Some argue that a more purposive sampling approach
may be more appropriate [36,37], which aims to provide
a holistic interpretation of a phenomenon, where the ex-
tent of searching is driven by the need to reach theoret-
ical saturation rather than to identify all eligible studies
[24,38]. Detailed information on purposive sampling
technique is available [24,28]. Also, to avoid the poten-
tial problem of having too few descriptively or
conceptually-rich studies, knowledge-building and
theory-generating systematic reviewers can conduct ex-
pansive searches of the literature . We do not de-
scribe here how to conduct a systematic search of the
literature, however there are a number of papers which
describe this process [39–41].
We searched five electronic databases, and our search
strategy included a combination of the three major con-
cepts (disclosure, safety incident and experience). We
also supplemented the database searches by hand
searching relevant journals and reference lists. We chose
not to apply qualitative filters in order to capture all the
possible relevant articles.
Phase 2c: decisions to include studies A number of
factors should be considered when deciding whether to
include or exclude studies from the synthesis. An im-
portant consideration is the expertise of the review au-
thors and the time available to complete the review .
Reviewers should consider the likelihood of excluding
valuable insights on the basis of quality, and the contri-
bution of these studies to the development and inter-
pretation of findings. Would excluding such studies
affect the coherence of qualitative synthesized findings?
. Also, an important consideration is the nature of
the primary data which is available to synthesise . In-
cluding predominantly thin descriptive data can be prob-
lematic as it is difficult to further interpret data which
lacks depth . Conceptually rich data which is ex-
planatory, or rich descriptive data which provides suffi-
cient detail to be further developed is suitable for meta-
ethnography. Therefore selecting studies based on this
suitability is one of the approaches reviewers should
consider. Further discussion on decisions to include
studies is available .
Phase 2d: quality appraisal There is a lack of agree-
ment surrounding the use of quality appraisal for quali-
tative studies . Some researchers argue there are
difficulties with quality appraisal as some aspects of quali-
tative research are difficult to appraise and therefore de-
pend on subjective judgement . Although this debate
continues, we argue that at least some quality appraisal of
studies needs to be considered to give an indication of the
credibility of the included studies. Critically appraising the
studies and assigning numerical scores to indicate level of
quality is also useful as it can be used as a way to order
the studies for analysis. Previous published qualitative re-
views have either used the highest scoring paper as the
‘index study’ or have arranged all the papers in
chronological order by date, and used the most recently
published paper as the ‘index study’. One of the limi-
tations is of assigning numerical scores using CASP and
the use the highest scoring as an index study is that it fo-
cuses on the methodological rather than conceptual
strength. Other reviewers have chosen a ‘conceptually
rich’index account [43,44] however it is unclear how this
‘conceptually rich’index account should be selected. The
different ways of ordering study accounts has yet to be
formally empirically compared and there is no guidance
for reviewers . However the order could affect the syn-
thesis output [11,12,24,45]. There are different perspec-
tives to the use of tools in the quality assessment of
qualitative research . Some recommend the exclusion
of studies based on a low-quality assessment and others
refute this view and suggest that such tools may not truly
assess the meaningfulness and potential impact of qualita-
tive findings . However, we believe that these check-
lists can equip novice qualitative researchers with the
resources to evaluate qualitative research efficiently.
Two common and widely used quality assessment
tools are the Critical Appraisal Skills Programme (CASP)
and the Qualitative Assessment and Review Instrument
(JBI-QARI). The Critical Appraisal Skills Checklist
(CASP) provides detailed instructions and decision rules
on how to interpret the criteria . This checklist con-
tains a number of questions which help the reviewer to
assess the rigour, credibility and relevance of each study
[49–52]. All studies are critically appraised and each
Sattar et al. BMC Health Services Research (2021) 21:50 Page 4 of 13
study is assigned a numerical score out of ten, where a
higher score is correlated to a higher quality . The
two studies ranked with the highest scores are used as
index studies, and can be used as the first studies from
which concepts are translated into other studies and
therefore shaping the analysis . Similarly, the Quali-
tative Assessment and Review Instrument (JBI-QARI) is
a 10 item checklist which assesses the methodological
quality of a study, and determines the extent to which a
study has addressed the possibility of bias in its design,
conduct and analysis . Some researchers provide
guidelines for determining and excluding studies which
have major methodological flaws . However, it can
be argued that excluding studies based on quality criteria
may result in the exclusion of insightful studies.
GRADE-CERQual is a recently developed approach
which provides guidance for assessing how much confi-
dence to place in findings from systematic reviews of
qualitative research . The application of GRADE-
CERQual can be helpful for appraising the overall qual-
ity of the qualitative synthesis  but a quality appraisal
of primary studies is required before applying the
We used the CASP checklist to assess the quality of
included studies. We chose to use the CASP as it propa-
gates a systematic process through which the strengths
and weaknesses of a research study can be identified
. The CASP guidelines are easy to follow, especially
for novice researchers . We made a decision in ad-
vance not to exclude studies with low quality scores. We
believed that although some authors may have failed to
describe the methods in sufficient detail for us to deter-
mine that quality criteria had been met, lack of reporting
did not necessarily mean it was poorly conducted re-
search . We did however use the quality rating of
the studies in our synthesis approach. The study ranked
with the highest score was used as the ‘index study’and
was the first study from which concepts were translated
into other studies and therefore shaping the analysis
Phase 3: Reading the studies
It is during this phase where the synthesis process be-
gins. First, this involves repeatedly reading the included
studies and familiarising yourself with the key concepts
and metaphors. It is important at this stage to become
as familiar as possible with the content and detail of the
included studies. A concept is defined as ‘having some
analytical or conceptual power, unlike more descriptive
themes . It is important to acknowledge that reading
the studies is not a discrete phase; reading occurs
throughout the synthesis process. The notion of first,
second order and third order constructs  are useful
in distinguishing the ‘data’of the meta-ethnography
which are defined in Table 1below.
Once you have read through the chosen studies, the
next step involves extracting the ‘raw data’from the
studies for the synthesis. The raw data for a meta-
ethnographic synthesis are the first and second order
constructs [29,31]. The data needs to be extracted from
each of the studies, which can be done by using a stan-
dardised data extraction form . Alternative ways to
extract data include creating a list of metaphors and
themes  or coding concepts in Nvivo; a software
programme for the analysis of qualitative data . The
data should be extracted verbatim, so there is no risk of
losing important data  and to preserve the original
terminology used by the primary authors. However,
some authors of a previous meta-ethnography chose to
record summaries of primary author interpretations due
to the large number of studies included in their synthesis
. However, one of the drawbacks of recording such
summaries is that there is the risk of potentially losing
It is essential at this stage to extract information on
study characteristics for each study, using a separate data
extraction form as it provides context for interpretations
and explanation of each study . This includes infor-
mation on study sample, data collection methods, data
analysis methods, study outcomes and study
We have provided an example of a data extraction
table we used to extract the raw data (Fig. 1).
Phase 4: determining how the studies are related
During this stage, the relationships between the key con-
cepts from the different papers need to be considered. A
concept is described as a ‘meaningful idea that develops
by comparing particular instances’[29,45]. It is also im-
portant that concepts explain and do not only describe
Table 1 Key terms in a meta-ethnography
Primary authors Refers to the authors of the original primary qualitative studies
Reviewers/team members Refers to the individuals conducting the meta-ethnography
First order constructs Represent the primary data reported in each paper (participant quotations).
Second order constructs The primary authors’interpretations of the primary data (metaphorical themes or concepts).
Third order constructs The reviewers higher order interpretations developed from a tertiary analysis of the first and second order constructs.
Sattar et al. BMC Health Services Research (2021) 21:50 Page 5 of 13
the data [29,45] as one of the aims of qualitative analysis
is to develop concepts which help to understand an ex-
perience and not just describe it . In order to consider
the relationship between concepts from the different stud-
ies, you are required to look across the studies for com-
mon and recurring concepts. This can be done by creating
a list of the themes . These are then juxtaposed against
each other to examine the relationships between the key
concepts and metaphors these themes reflect and to iden-
tify common and recurring concepts. From this list, the
themes from the different studies are then clustered into
relevant categories, where we grouped common concepts
from studies according to the common underlying
metaphors, an approach which has previously been used
[12,31,59]. During this phase it is essential to examine
the contextual data about each study. This includes set-
tings, aims and focuses. These newly formed categories
are labelled using terminology which encompasses all the
relevant concepts they contain. This phase is likely to be
iterative, and clusters may be revised through discussions
within the review team of how they are related and by
making reference to the original text.
Fig. 1 Example of a data extraction table
Fig. 2 List of key metaphors/concepts from each study
Sattar et al. BMC Health Services Research (2021) 21:50 Page 6 of 13
Other authors have used diagrams [11,32] or coding
using qualitative analysis software . The use of lists
or tables in phase 4 is useful when synthesising a small
number of studies, however such an approach would be
unwieldy when there are hundreds of concepts, whereas
coding in NVivo is efficient . However, the recording
of links between concepts within primary studies may be
difficult when using NVivo .
During this phase, for our review we created a list of
the themes from each paper (Fig. 2) listed under each
study name. As we had included both healthcare profes-
sional and patient studies, we also labelled whether the
study had included patients, healthcare professionals or
The next step involved reducing the themes from the
different studies into relevant categories (Fig. 3).
It is important to note that the category labels you
create during this phase are not the higher third
order constructs, but are descriptive labels. The third
order constructs are developed within the next two
phases. However, the data within each category forms
the basis of reciprocal translation or refutational syn-
thesis in the next stages. This approach can work well
when you have a manageable number of studies, how-
ever this can prove to be challenging when you have
a larger number of studies. In previous meta-
ethnographies where a large number of studies have
been included, a thematic analysis of themes was car-
ried out instead .
Phase 5: translating the studies into one another
The original method of meta-ethnography suggests that
this phase involves ‘comparing the metaphors and con-
cepts in one account with the metaphors and concepts
in others’. However, despite a number of meta-
ethnographies being conducted, it is unclear how this
should be done and how this phase of the analysis
should be recorded. To address this lack of clarity, we
will now outline below one way in which this can be
done. During this phase, each concept from each paper
is compared with all the other papers to check for the
presence or absence of commonality. Doing this high-
lights the similarities and differences between the con-
cepts and metaphors and allows the researcher to
organise them into further conceptual categories, which
results in the development of the higher third order
This phase is approached by arranging the studies ei-
ther chronologically  from the highest scoring paper
to the lowest scoring paper (where the scores are gener-
ated during the quality appraisal process . Arranging
the studies chronologically is advised when you are in-
cluding a large number of papers over a large time span
[12,29]. The order in which studies are compared may
influence the synthesis, as earlier papers will have a
strong influence on the subsequent development of ideas
. The reviewer first starts by summarising the
themes and concepts from paper 1. Summarising in-
volves comparing and contrasting the concepts taking
into account study contexts. They then summarise the
Fig. 3 Reducing themes into relevant categories
Sattar et al. BMC Health Services Research (2021) 21:50 Page 7 of 13
themes and concepts from paper 2, commenting first on
what is similar with paper 1 and then what paper 2 may
add to paper 1 or where its findings diverge from paper
1[12,29]. Next, paper 3 is summarised, considering
what is similar to papers 1 and 2, and then noting any
areas of divergence and anything that paper 3 adds to
the knowledge offered in papers 1 and 2. This process
continues until you have synthesised all the papers and
produces a synthesis of the primary author interpreta-
tions (see Fig. 4) which are useful in aiding with the de-
velopment of the third order constructs in the next
Examining the key concepts within and across the
studies is similar to the method of constant comparison
. During this phase, it is important to refer back to
the table of study characteristics you recorded earlier,
(country, sample, recruitment method, gender, publica-
tion date etc.) to use as a context for the comparisons
 as well the full papers. This process can also be sup-
ported by creating a translations table, as this is a useful
way to display this level of synthesis  (see Fig. 5for
an example of a translations table). Maintaining a per-
sonal journal during this phase of the analysis can help
to ensure that the researcher is aware of their position
from a theoretical point of view . Discussing the key
concepts and their meanings with team members can re-
sult in collaborative interpretations.
We conducted two separate syntheses; one for the
views of patients and one for healthcare professionals,
and conducted a line of argument synthesis of all the in-
cluded studies, therefore we found it useful to have two
separate translation tables; one for each group. Part of
the translation table for healthcare professionals is
shown in Fig. 5(see example of table below).
Phase 6: Synthesising the translations
This phase is described by as‘making the whole
into something more than the parts alone imply’. How-
ever, similar to Phase 5, there has been no clear guid-
ance on how to carry out this phase. During this phase,
the studies are now viewed as a ‘whole’with the aim of
developing a framework [29,31]. When writing about
how the studies are related, reviewers can present this in
a narrative and/or diagrammatic form . Phase 6 can
be broken down into the following two stages; (a) recip-
rocal and refutational synthesis and (b) line of argument
(A) Reciprocal and refutational synthesis This stage of
the synthesis involves deciding whether the studies are
sufficiently similar in their focus to allow for a reciprocal
translation synthesis. Alternatively, the studies may re-
fute each other in which case a refutational synthesis is
conducted. It is possible to conduct both types of syn-
thesis to discuss similar accounts (reciprocal translation
synthesis) and also explore any contradictions between
the studies (refutational synthesis) . Generally, recip-
rocal translation syntheses are conducted more fre-
quently in reviews than refutational syntheses and
guidance on how to conduct a refutational synthesis is
currently limited . Below we first discuss how to
carry out a reciprocal translation and then describe the
way a refutational synthesis can be conducted. Referring
to the translations table of data developed in the stages
above allows reviewers to establish the relationship
Fig. 4 Primary data synthesis of the primary author interpretations
Sattar et al. BMC Health Services Research (2021) 21:50 Page 8 of 13
Fig. 5 Example of a translations table
Sattar et al. BMC Health Services Research (2021) 21:50 Page 9 of 13
between the studies and consider how to approach a re-
ciprocal and refutational synthesis.
It is during this phase where the shared themes across
the studies are summarised by juxtaposing the first and
second order constructs. This leads to the generation of
new concepts which provide a fuller account of the given
phenomenon and resolve any contradictions . These
are known as the original third order constructs developed
by the review authors and provide a new understanding of
the phenomena . To put briefly, this can be achieved
by reading the primary data synthesis (Fig. 4)alongside
the translations table (Fig. 5) and drawing out the main
points to form the reciprocal translations and therefore
developing the third order constructs. It is important to
constantly check the summary and third order constructs
you are developing against the translations table to ensure
it is consistent with the original data.
There are limited published examples of refutational
synthesis [25,45] as reviewers often focus on reciprocal
translations . Also reviewers may conduct a refuta-
tional synthesis, but not label it as such . There are
two published examples of refutational synthesis [43,64].
This is not surprising given the lack of guidance available
on how to conduct a refutational synthesis. The purpose
of a refutational synthesis is to explore and explain the dif-
ferences, exceptions, incongruities and inconsistencies in
concepts across the studies [1,24]. Refutational synthesis
focuses on identifying, understanding and reconciling the
contradictions, rather than developing concepts around
the similarities. Similar to reciprocal translation, reviewers
are required to refer back to the primary data synthesis
and translations table in order to develop third order con-
structs. The contradictions between the concepts across
the studies may be explained by differences in participants,
settings or study design. During this phase, it is helpful to
refer back to the study characteristics table as this can
help provide context for interpretations and explanations
. It has been suggested that a refutational translation
can be approached by placing two refutational concepts at
either end of a continuum and proceed by analysing the
differences between the concepts [22,28]. In order to ex-
press the refutational findings, a narrative can be created
so that the findings ‘are placed into context’.
(B) A lines of argument synthesis A lines of argument
synthesis can then be created from the third order con-
structs, which involves ‘making a whole into something
more than the parts alone imply’(known as higher order
interpretations) . A lines of argument synthesis
means that there is an ‘interpretation of the relationship
between the themes, which further emphasises a key
concept that may be hidden within individual studies in
order to discover the whole from a set of parts’. This
is classed as a further higher level of interpretative synthe-
sis, and provides scope for developing new insights.
A lines of argument synthesis is achieved by constant
comparison of the concepts and developing a ‘grounded
theory that puts the similarities and differences between
the studies into interpretative order’. Practically, re-
viewers can approach this phase by reading through the
reciprocal translations and noting down the similarities
and differences between each of the third-order con-
structs. These notes can then be used to construct inter-
pretations of how each third order construct relates to
the others in the analysis. These relationships can then
be represented using a diagram to aid understanding.
Each of the reviewers can carry out this stage independ-
ently, and merge their findings as a team to produce the
final line of argument synthesis. Diagrams can be used
to develop the line of argument synthesis and it is sug-
gested that discussions between team members are vital
to this process [29,30]. A lines of argument synthesis
can be a useful way to bring together and explain the
perspectives of two or more different groups and inter-
preting the relationship between the themes. This is par-
ticularly relevant for research in healthcare, where often
the views of one or more groups are examined on a
phenomenon (e.g. patients and healthcare professionals).
An example of a line of argument synthesis from the
worked example is presented in Fig. 6.
We conducted separate reciprocal translations for the
first- and second-order constructs relating to patients
and healthcare professionals, resulting in third order
constructs which related to solely either patients or pro-
fessionals. Therefore, the synthesis process for our re-
view consisted of three steps- (1) reciprocal translations
of the patient studies to understand patients’views and
experiences of disclosure, (2) reciprocal translations of
the healthcare professional studies to explore healthcare
professionals views and experiences on disclosure and
(3) a line of argument synthesis which contributed to
the identification of both the key elements of an ideal
disclosure desired by patients and the facilitators for
healthcare professionals which can increase the likeli-
hood of this taking place. We initially considered a refu-
tational translation instead of a line-of-argument
synthesis, but it was apparent during the synthesis that
the concepts from the patient and healthcare profes-
sional studies were not contradictory in nature; rather
they described alternate perspectives of the same
phenomenon. Therefore we believed a line of argument
synthesis was the most appropriate for the aim of our
synthesis. During this stage of the analysis, we found it
helpful to place all the third order constructs in a table
to enable visual comparison (see Table 2).
Sattar et al. BMC Health Services Research (2021) 21:50 Page 10 of 13
The third order constructs should be theoretically rich.
In our synthesis, although we found that the data we
were dealing with was descriptive, it was rich descriptive
data. This therefore provided us with sufficient detail to
further interpret this and develop third order constructs
. The third order constructs we developed reflected
the data we were dealing with, but allowed us to produce
higher levels of analysis. Reviewers should take caution
when dealing descriptive data. They need determine
whether it is ‘thin descriptive data’which could be prob-
lematic to further interpret due to lack of depth, or ‘rich
descriptive data’which can provide sufficient detail to be
further interpreted .
Phase 7: expressing the synthesis
Reviewers should follow the eMERGE reporting guid-
ance when writing up the synthesis  and the PRIS
MA guidelines may be used alongside this if systematic
searches are conducted as many journals may require a
PRISMA diagram . In addition to these standard
reporting methods as described by the eMERGE guid-
ance  the final phase can be broken down into the
following three stages; (a) summary of findings, (b)
strengths, limitations & reflexivity and (c) recommenda-
tions and conclusions (refer to  where this phase is
described in further detail).
Meta-ethnography is an evolving approach to synthesis-
ing qualitative research and is being increasingly used in
healthcare research . A meta-ethnographic approach
offers a greater description of methods and higher-order
interpretation (an overarching explanation of a
phenomenon that goes beyond what the study parts
alone imply), compared to a conventional narrative lit-
erature review . The use of this approach can assist
in generating evidence for healthcare staff, researchers
and policy-makers. Although this approach is being used
by numerous reviewers, transparency on how each of
the stages should be conducted is still poor and there is
a lack of clarity surrounding the exact stages reviewers
utilise to reach their final synthesis . The ultimate
aim of qualitative research synthesis in healthcare is to
contribute towards improvements in patient care and
experience, as well as improving the processes for
healthcare professionals involved . In order for a
meta-ethnography syntheses to be considered to be of
high quality and useful, the meta-ethnographic approach
needs to be rigorous and consistent. Therefore, a clear
understanding of the steps included in a meta-
ethnography is vital to produce a synthesis which is
rigorous and comprehensive. Poorly reported methods
of meta-ethnography can also make it challenging, par-
ticularly for early career qualitative researchers to con-
duct this synthesis. Therefore, we have provided a
practical step-by-step guide to assist reviewers with con-
ducting a meta-ethnographic synthesis of qualitative re-
search. High quality qualitative research synthesis should
not end with the final write up and further research
needs to focus on how the impact of qualitative research
can be maximised to improve healthcare.
Like any other method, the meta-ethnographic ap-
proach is not without its limitations. Within a meta-
ethnography, although reviewers provide a synthesis, this
Fig. 6 Example of a line of argument synthesis developed
Table 2 Examples of third order constructs
Third order constructs:
Patient studies (views on
Third order constructs:
Healthcare professional studies
(views on disclosure process)
Third order constructs: Healthcare
professional studies (barriers to disclosure)
Need for information Sometimes economical with the truth Difficulty of disclosure in a blame culture
Importance of sincere regret Owning up without saying ‘I’m sorry’Avoidance of litigation
Promise of improvement To tell or to not tell?
-When anxiety may cause unnecessary anxiety
-Outcome determines disclosure
Disclosure is a learned skill
Sattar et al. BMC Health Services Research (2021) 21:50 Page 11 of 13
is only one interpretation and as qualitative synthesis is
subjective, several alternative interpretations are likely to
be possible . The subjective nature of a meta-
ethnography may also affect the representativeness of
the synthesis findings. To develop this guide, we
searched for articles in a number of ways which is de-
scribed in detail in the methods section. However, as a
systematic literature search was not conducted to iden-
tify articles for the development of this guide, there is
the potential that this may have resulted in the exclusion
of some articles. Whilst we have provided guidance on
how to conduct a meta-ethnographic synthesis, it is im-
portant to note that this is a flexible guide, which re-
searchers can utilise and adapt the stages, according to
their own research questions and the phenomenon
under study. Some of the steps and challenges described
in this guide hold true for systematic reviews in general.
However, this guide aimed to offer practical step-by-step
guidance on how to conduct meta-ethnography for even
those researchers who may not be experienced in con-
ducting systematic reviews as well as being unfamiliar
with a meta-ethnographic approach. This guide was de-
veloped to assist with conducting a meta-ethnography
within healthcare research. Although this guide would
be potentially useful beyond healthcare research, there
might be additional challenges and considerations in
other research fields which may not be fully captured in
There was previously a lack of step-by-step guide to
meta-ethnography conduct. In this paper, we have filled
this gap by providing a practical step-by-step guide for
conducting meta-ethnography based on the original
seven steps as developed by Noblit & Hare . We
have incorporated adaptations and developments by re-
cent publications and we provide detailed annotations,
particularly for stages 4–6 which are often described as
being the most challenging to conduct, yet the least
amount of guidance is provided for conducting these
stages. We have described each stage in relation to one
of the previous meta-ethnographies we have conducted
to aid understanding, and allows the reader to follow on
from one step to the next easily.
This report is independent research funded by the National Institute for
Health Research, Yorkshire and Humber Applied Research Collaborations. The
views expressed in this publication are those of the author(s) and not
necessarily those of the NHS, the National Institute for Health Research or
the Department of Health and Social Care.
RS, RL and JJ originated the idea for this guide to conducting a meta-
ethnography. RS, RL and JJ conducted the original meta-ethnography from
which annotations and examples are based on within this manuscript. All
authors contributed to the development of the method, and read and
approved the final manuscript. RS drafted the first version of this manuscript.
RS, RL, JJ and MP made significant contributions to the ideas developed and
presented in this manuscript.
is a PhD student (MSc, BSc Honours) based in the School of Psychology
at the University of Leeds and Bradford Institute for Health Research. RL
(PhD, BA) is a Professor in Psychology of healthcare, based at the University
of Leeds and Bradford Institute for Health Research. MP
(PhD, MSc, BSc
Honours) is a senior research fellow based at the Centre for Primary Care,
(PhD, BSc Honours) is a clinical psychologist based at the
University of Leeds and Bradford Institute for Health Research.
This research was funded by NIHR CLAHRC Yorkshire and Humber.
Availability of data and materials
The datasets used and/or analysed during the current study are available
from the corresponding author on reasonable request.
Ethics approval and consent to participate
Consent for publication
The authors declare that they have no competing interests.
University of Leeds, Leeds LS2 9JT, UK.
Bradford Institute for Health
Research, Bradford BD9 6RJ, UK.
National Institute of Health Research for
Primary Care Research, Manchester Academic Health Science Centre,
University of Manchester, Manchester M13 9PL, UK.
Received: 10 June 2020 Accepted: 26 December 2020
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