meta synthesis literature review

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Qualitative Meta-synthesis

• Qualitative Research Synthesis
• Framework Synthesis - Best-fit Framework Synthesis
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" Qualitative meta-synthesis is an intentional and coherent approach to analyzing data across qualitative studies. It is a process that enables researchers to identify a specific research question and then search for, select, appraise, summarize, and combine qualitative evidence to address the research question" (Erwin et al, 2011).

Further Reading/Resources

Erwin, E. J., Brotherson, M. J., & Summers, J. A. (2011). Understanding qualitative metasynthesis: Issues and opportunities in early childhood intervention research. Journal of Early Intervention , 33 (3), 186-200 . Full Text Finlayson, K. W., & Dixon, A. (2008). Qualitative meta-synthesis: a guide for the novice. Nurse researcher , 15 (2). Full Text Finfgeld-Connett, D. (2018). A guide to qualitative meta-synthesis . New York, NY, USA:: Routledge. Catalogue Link  

Douglas, S. N., Jensen, E. J., & West, P. (2022). Barriers and Benefits Experienced by Caregivers Seeking Medical Care for Their Children with Autism Spectrum Disorders: a Qualitative Meta-synthesis. Review Journal of Autism and Developmental Disorders , 1-13. Full Text

References Erwin, E. J., Brotherson, M. J., & Summers, J. A. (2011). Understanding qualitative metasynthesis: Issues and opportunities in early childhood intervention research. Journal of Early Intervention , 33 (3), 186-200 . Full Text

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What Is Meta Synthesis In Literature Review

Imagine a regular literature review as a jigsaw puzzle, piecing together individual studies to form a picture. Meta-synthesis is like zooming out, taking those same puzzle pieces and creating a stunning mosaic, uncovering deeper patterns and insights that transcend individual studies.

Table of Contents

This blog will guide you on what is a meta synthesis literature review, its processes and types. Let’s explore deeper. 

What Is A Meta Synthesis?

A simple meta-synthesis definition is:

Meta-synthesis represents a sophisticated and systematic approach to distilling knowledge from many primary studies. Unlike traditional literature reviews that summarize individual studies, meta-synthesis involves integrating and synthesizing data from diverse sources. It is a systematic process that goes beyond the surface, extracting meaningful insights by analyzing, comparing, and synthesizing findings from multiple studies.

Importance Of Meta Synthesis Literature Review

The importance of meta synthesis literature review cannot be overstated. As the volume of research papers grows exponentially, the need for methodologies to make sense of this vast sea of information becomes increasingly evident. Meta-synthesis emerges as a beacon in this context, offering a structured and systematic way to navigate the existing literature’s complexities.

• Holistic Perspective: Meta-synthesis enables researchers to move beyond the isolated perspectives of individual studies, fostering a holistic understanding of a particular research question or topic. It provides a panoramic view that transcends the limitations of singular viewpoints.
• Identifying Patterns and Trends: By synthesizing data from multiple studies, meta-synthesis allows for identifying patterns, trends, or recurring themes within the existing literature. This process can unveil hidden insights that may not be apparent when examining studies in isolation.
• Addressing Research Gaps: One of the key contributions of meta-synthesis is its ability to bridge gaps in the existing literature. By systematically integrating findings, researchers can identify areas where knowledge is lacking or conflicting, paving the way for more targeted and informed future research.
• Advancing Knowledge: Through the synthesis of diverse perspectives, meta-synthesis has the potential to generate new knowledge, theories, or conceptual frameworks. It serves as a catalyst for intellectual advancement, pushing the boundaries of understanding within a given field.

Understanding Meta Synthesis Literature Review

Meta-synthesis goes beyond the traditional literature review by employing a systematic and integrative approach to analyze and interpret findings from multiple primary studies. It plays a crucial role in research paper format by offering a more thorough understanding of a specific phenomenon or research question. Meta-synthesis involves synthesizing qualitative, quantitative, or mixed-methods data to generate new insights, patterns, or theories that may not be apparent when looking at individual studies in isolation.

The primary role of meta synthesis literature review is to bridge gaps between various studies, reconcile conflicting findings, and provide a more holistic perspective on a research topic. It allows researchers to move beyond the surface-level understanding provided by individual studies and identify overarching themes, patterns, or relationships within the existing literature. Meta-synthesis is particularly valuable in fields where research findings are diverse or fragmented, offering a way to distill and integrate knowledge effectively.

Difference Between Traditional Literature Review And Meta Synthesis

The Process Of Meta-Synthesis

The process of meta-synthesis involves a systematic journey through distinct phases, each contributing to the comprehensive understanding and synthesis of existing literature. 

Step 1: Identifying Primary Studies

The first step in the meta synthesis literature review process is meticulously identifying relevant primary studies. This involves conducting a comprehensive and systematic literature search, often using databases, academic journals, and other scholarly sources. Researchers employ specific inclusion and exclusion criteria to ensure the selected studies align with the research question or topic of interest.

Key considerations during this phase include the relevance of study designs, publication dates, and the quality of the research. The goal is to cast a wide net, capturing diverse perspectives and insights on the chosen subject.

Step 2: Data Extraction And Synthesis

Once the pool of primary studies is identified, the next phase involves the extraction and synthesis of data. Researchers systematically collect relevant information from each study, including key findings, methodologies, and contextual details. This data extraction process is often guided by a predetermined set of criteria, ensuring consistency and reliability.

The synthesis aspect comes into play as researchers analyze the extracted data, looking for commonalities, differences, and patterns across the studies. This synthesis may involve categorizing information, grouping similar findings, or identifying overarching themes. The goal is to transform individual pieces of data into a cohesive and integrated body of knowledge.

Step 3: Analysis And Interpretation

With the synthesized data in hand, the analysis and interpretation phase begins. Researchers critically examine the collective findings, seeking to understand the literature’s relationships, contradictions, or gaps. This analytical process may involve statistical methods, thematic analysis, or other qualitative and quantitative approaches, depending on the nature of the synthesized data.

Interpretation is a crucial element, requiring researchers to go beyond the surface-level observations and delve into the deeper implications of the synthesized information. This phase aims to draw meaningful conclusions, offer insights into the research question, and contribute to the development of a better understanding of the subject.

Key Components And Steps

• Define Research Question: Clearly articulate the thesis statement or topic that will guide the meta-synthesis process.
• Literature Search: Conduct a systematic and exhaustive search for relevant primary studies using databases, academic journals, and other scholarly sources.
• Screening and Selection: Apply inclusion and exclusion criteria to screen and select studies that align with the research question.
• Data Extraction: Extract pertinent information from selected studies, including key findings, methodologies, and contextual details.
• Data Synthesis: Systematically analyze and synthesize the extracted data, looking for common themes, patterns, or relationships.
• Quality Assessment: Evaluate the quality and rigour of each included study to ensure the validity and reliability of the synthesized findings.
• Analysis and Interpretation: Apply appropriate analytical methods to interpret the synthesized data and draw meaningful conclusions.
• Report Writing: Communicate the results of the meta-synthesis in a clear and organized manner, highlighting key findings and their implications.

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Types Of Meta-Synthesis

Meta-synthesis is a versatile research methodology that can be tailored to different types of data and research questions. Understanding the various meta synthesis literature review approaches is essential for researchers seeking to employ this method effectively.

Qualitative Meta-Synthesis

Qualitative meta-synthesis focuses on synthesizing findings from qualitative studies. It involves systematically analyzing and integrating data gathered through methods such as interviews, observations, or content analysis. The goal is to uncover common themes, patterns, or conceptual frameworks that emerge across a range of qualitative studies.

The process of qualitative meta synthesis includes: 

• Data Extraction: Extracting qualitative data from primary studies.
• Coding and Categorization: Coding and categorizing data to identify recurring themes.
• Synthesis: Integrating and interpreting qualitative findings to derive overarching insights.
• Report Writing: Communicating synthesized qualitative data coherently and comprehensively.

Quantitative Meta-Synthesis

Quantitative meta-synthesis, often called meta-analysis, focuses on synthesizing numerical data from multiple quantitative studies. This approach involves statistical methods to analyze and combine quantitative findings, such as effect sizes or outcome measures. The aim is to provide a quantitative summary that goes beyond the results of individual studies.

The process of quantitative meta synthesis literature review includes:

• Data Extraction: Extracting quantitative data, including statistical results, from primary studies.
• Statistical Analysis: Using statistical methods (e.g., meta-regression, pooling effect sizes) to synthesize numerical data.
• Interpretation: Interpreting the combined quantitative results to draw overarching conclusions.
• Report Writing: Presenting the meta-synthesized quantitative data in a format that facilitates understanding and application.

Mixed-Methods Meta-Synthesis

Mixed-methods meta-synthesis combines qualitative and quantitative approaches to understand a research question comprehensively. This type of meta-synthesis recognizes the value of both types of data and aims to integrate them to offer a more holistic perspective. 

Researchers employing mixed-methods meta-synthesis may analyze and synthesize qualitative and quantitative data separately before integrating the findings. Here is the process of mixed-methods meta synthesis.

• Separate Analysis: Independently analyze and synthesize qualitative and quantitative data.
• Integration: Integrating findings from both analyses to derive comprehensive insights.
• Synthesis: Creating a cohesive narrative that captures the synergies between qualitative and quantitative perspectives.
• Report Writing: Presenting integrated findings clearly and coherently, emphasizing the complementary nature of the two types of data.

Comparative Analysis

Comparative analysis in meta-synthesis involves systematically comparing and contrasting findings across different studies. This type of meta-synthesis is not restricted to a specific methodological approach but focuses on exploring variations, similarities, or differences in outcomes, methodologies, or contexts across selected studies.

The process of comparative analysis is: 

• Identification of Comparisons: Identifying key elements for comparison across primary studies.
• Data Extraction: Extracting relevant data for each identified comparison.
• Analysis: Systematically comparing and contrasting data to identify patterns or trends.
• Synthesis: Synthesizing the comparative findings to draw overarching conclusions.
• Report Writing: Communicating the comparative analysis results in a format that highlights key similarities and differences.

Advantages And Challenges Of Meta-Synthesis

Meta-synthesis, as a powerful research methodology, presents researchers with unique advantages and challenges. A better understanding of both aspects is essential for those considering or conducting meta-synthesis.

Advantages In Research Integration

Comprehensive Insights: Meta-synthesis allows researchers to go beyond the confines of individual studies, providing a comprehensive view of a particular research question or topic. By synthesizing findings from multiple sources like newspapers and journals, it facilitates a more holistic understanding.

• Identification of Patterns: The systematic analysis and integration of data enable the identification of patterns, trends, or recurring themes across various studies. This contributes to the development of overarching concepts or theories that may not be evident when examining studies in isolation.
• Bridging Gaps in Knowledge: Meta-synthesis is effective in addressing gaps in existing literature. By bringing together diverse perspectives, it helps researchers identify areas where knowledge is lacking or where conflicting findings may necessitate further investigation.
• Enhanced Generalizability: The aggregation of findings from different studies can enhance the generalizability of results. This is particularly valuable in fields where individual studies may have limited sample sizes or specific contextual constraints.
• Facilitating Evidence-Based Practice: Meta-synthesis contributes to evidence-based practice by providing a robust foundation for decision-making in various fields, from healthcare to education. Synthesized findings offer a more informed basis for policy development and implementation.

Challenges In Conducting Meta-Synthesis

• Heterogeneity of Studies: One of the primary challenges is dealing with the heterogeneity of studies, including variations in methodologies, participant characteristics, and outcome measures. Integrating diverse data sets requires careful consideration and methodological rigour.
• Quality Assessment: Assessing the quality of primary studies poses a challenge, especially when dealing with diverse research designs. Determining the reliability and validity of studies becomes crucial in ensuring the robustness of the meta-synthesis findings.
• Time-Consuming Process: Conducting meta-synthesis is a time-consuming process, from the exhaustive literature search to the detailed analysis and synthesis of data. Researchers need to allocate sufficient time and resources to execute the methodology effectively.
• Limited Availability of Data: In some cases, data availability may be limited, either due to sparse research on a specific topic or restrictions in accessing certain types of information. This limitation can impact the depth and breadth of the meta-synthesis.
• Potential for Publication Bias: There is a risk of publication bias, where studies with positive or statistically significant results are more likely to be published. This bias can skew the synthesis of findings and affect the overall validity of the meta-synthesis.

Examples Of Meta-Synthesis In Literature Review

Meta-synthesis is a part of a thesis or dissertation that has been widely applied across various disciplines, contributing to a deeper understanding of complex research questions. The following examples highlight how meta-synthesis has been employed successfully in literature reviews.

Mental Health Interventions: Meta-synthesis has been utilized to explore the effectiveness of various mental health interventions. Researchers identified common themes by synthesizing findings from qualitative studies on different interventions, facilitating the development of more holistic and patient-centred mental health approaches.

Educational Practices: In education, meta-synthesis has been employed to analyze and integrate research on diverse teaching practices. This has resulted in identifying effective pedagogical strategies and developing evidence-based recommendations for improving educational outcomes.

Impact On Advancing Knowledge

• Understanding Chronic Diseases: Meta-synthesis has played a pivotal role in advancing knowledge about chronic diseases such as diabetes or cardiovascular conditions. By synthesizing qualitative and quantitative studies, researchers have identified key factors influencing disease progression, treatment effectiveness, and patient outcomes.
• Cross-Cultural Perspectives: In cross-cultural studies, meta-synthesis has been instrumental in integrating research from various cultural contexts. This has led to a more nuanced understanding of how cultural factors impact health behaviours, mental health, and overall well-being.

Practical Applications in Various Fields:

• Evidence-Based Healthcare Practices: Meta-synthesis has been widely applied in healthcare to inform evidence-based practices. By synthesizing data from multiple studies, healthcare professionals can make more informed decisions about treatment strategies, interventions, and patient care.
• Public Policy Development: In public policy, meta-synthesis has been utilized to inform decision-making processes. Policymakers can develop more effective and targeted interventions by synthesizing research on social issues, economic factors, and public health outcomes.

Tips For Conducting Effective Meta-Synthesis

Here are some additional tips and tricks to help you conduct an effective meta synthesis. 

• Clearly articulate the criteria for including or excluding studies. This ensures that the selected studies align with the research question and contribute to a meaningful synthesis.
• Conduct a thorough and systematic literature search using multiple databases. This helps identify a broad range of relevant studies for potential inclusion.
• Transparently report the decisions made during the meta-synthesis process. Documenting methodological choices, such as the choice of synthesis method or criteria for study inclusion, enhances the replicability and credibility of the research.
• Adhere to established reporting standards for meta-synthesis. This ensures a standardized and comprehensive presentation of methods and findings, aiding in the clear communication of the research.
• Collaborate with researchers from different disciplines to bring diverse perspectives to the meta-synthesis process. Interdisciplinary collaboration can enhance the depth and breadth of the synthesis.
• Subjecting the meta-synthesis process to peer review provides an external evaluation of the methodology and findings. Peer feedback can help identify potential biases, strengthen the research design, and enhance the overall quality of the meta-synthesis.

Frequently Asked Questions

What is a meta synthesis.

Meta-synthesis is a research method that systematically analyzes and integrates findings from multiple studies, transcending individual perspectives. It aims to distill common themes, patterns, or insights, providing a comprehensive understanding of a specific research question or topic.

What is a meta synthesis study?

A meta-synthesis study is a research approach that systematically reviews, analyzes, and synthesizes findings from multiple individual studies. It aims to generate new insights, patterns, or theories by integrating diverse perspectives on a specific research topic or question.

What is meta synthesis in research?

Meta-synthesis in research is a systematic process of analyzing and integrating findings from multiple studies on a specific topic. It goes beyond summarization, aiming to uncover common themes, patterns, or relationships, providing a holistic understanding that transcends individual study outcomes.

What is meta synthesis qualitative research?

Meta-synthesis in qualitative research involves systematically analyzing and synthesizing findings from multiple qualitative studies. It seeks to uncover overarching themes, patterns, or concepts, providing a comprehensive and interpretive understanding of the phenomenon under investigation.

Are systematic reviews always meta synthesis?

No, systematic reviews are not always meta-synthesis. While both involve a systematic approach to reviewing literature, systematic reviews may summarize findings without integrating them, while meta-synthesis aims explicitly to analyze and synthesize data from multiple studies to generate new insights.

How develop a strategy for meta-synthesis?

Develop a strategy for meta-synthesis by defining a clear research question, establishing rigorous inclusion criteria, conducting a systematic literature search, extracting relevant data, employing appropriate synthesis methods, addressing biases, and transparently reporting the process and findings.

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• How It Works

Systematic Reviews & Other Review Types

• What is a Systematic Review?
• What is a Scoping Review?
• What is a literature review?
• What is a Rapid Review?
• What is a Mixed Methods Review?
• What is a Network Meta-Analysis?
• What is an Overview of Reviews?

What is a Meta-Syntheses?

• What is an Integrative Review?
• What is a Diagnostic Test Accuracy Review?
• What is a Living Systematic Review?

A meta-synthesis brings together qualitative data to form a new interpretation of the research field.  It helps to generate new theories or an explanatory theory of why the intervention works or not.  It creates a hypothesis for future testing or comparison with trial outcomes.

Meta-syntheses are best designed t o re-interpret meaning across many qualitative studies.

(S. Atkins et al (2008)

Meta-Syntheses Resources:

• What makes a good systematic review and metaanalysis?
• Protocol-developing meta-ethnography reporting guidelines (eMERGe)
• Conducting a meta-ethnography
• Cochrane Qualitative & Implementation Methods Group
• Emerge Project

How a Meta-Syntheses differs from a Systematic Review

Timeframe:  12 months or less. 

Question: " A clearly formulated question helps to set boundaries for the scope and depth of a meta-ethnography" (Atkins S.)

Sources and searches:  Not as exhaustive as a systematic review, unless the question requires exhaustive searching.  Can search within a particular setting.  Search specifically for qualitative studies if possible (be careful with search filters).  Search may rely more heavily on inclusion and exclusion criteria.

Selection:  Different screening process--includes repeated reading of articles to connect and record concepts or themes. 

Appraisal:  Focus is on the translation of studies and then systematically compared or 'translated' within and across studies while retaining the structure of the relationships between central concepts/themes and includes a 'thematic analysis'.

Synthesis: Qualitative Differs from a Meta-Analysis (Quantitative)   "The goal is  not  aggregative  in the sense of 'adding studies together' as with a meta-analysis.  On the contrary,  it is interpretative in broadening understanding of a particular phenomenon." (Source: Grant et al (2009))

There are 3 types of synthesis that may be used.  A second level of synthesis is possible.

• Reciprocal Translation: Concepts in one study can incorporate those of another.
• Refutational Translation: Concepts in different studies contradict one another.
• Line of Argument Synthesis: Studies identify different aspects of the topic that can be drawn together in a new interpretation.

(France EF, Ring N  et al 1988)

Limitations of a Meta-Syntheses

• Only appropriate for high-quality qualitative studies
• Can only accommodate a limited number of primary studies
• Choice of a meta-ethnography may not be confirmed until pool of evidence known
• Requires significant methodological skill and experience with qualitative methods
• May take time to engage with the evidence and develop theory
• Requires further interpretation by policy makers and practitioners

Source: M. Petticrew et al (2013) and Li T. et al (2001)

Other names for a Meta-Syntheses

Meta-synthesis, Meta-ethnography, Qualitative Evidence Synthesis, Qualitative Meta-Synthesis, Meta narrative review (related)

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• Last Updated: Mar 13, 2024 4:27 PM
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Metasynthesis: issues of empirical and theoretical context

• Open access
• Published: 06 September 2022
• Volume 57 , pages 3339–3361, ( 2023 )

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• Julius Sim   ORCID: orcid.org/0000-0002-1816-1676 1 &
• Anne Marit Mengshoel   ORCID: orcid.org/0000-0003-1800-4440 2  

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Metasynthesis is an approach to synthesizing primary qualitative research, and may take either an aggregative or an interpretive approach. In either case, the resulting synthesis inevitably occurs at a remove from both the empirical and the theoretical contexts of the original research. We argue that seeking to retain these contexts in the synthesis poses specific challenges. Thus, the empirical context of an original study and the individuality of participants’ first-order accounts will be incompletely and selectively represented in a published study, and will be further out of reach at the level of synthesis. Syntheses should therefore be faithful to, but not seek to reproduce, the empirical context of the primary studies. As regards theoretical context, accommodating the concepts and the broader theoretical frameworks of primary studies may require potentially divergent philosophical assumptions to be reconciled with each other and with the theoretical standpoint of the synthesist. Selecting studies where these assumptions are compatible, at the level of both theory and methodology, may lessen this challenge. Some metasyntheses seek to integrate not just concepts but also theories (metatheorizing), but here the challenges of philosophical and theoretical compatibility are more acute, and the means of achieving such integration appear to be underdeveloped.

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Analysis and Synthesis

Meta-analysis, complexity, and heterogeneity: a qualitative interview study of researchers’ methodological values and practices

Meta-analysis and the science of research synthesis

Avoid common mistakes on your manuscript.

1 Introduction

Metasynthesis is an increasingly popular means of synthesizing qualitative research findings, with the aim of achieving insights of greater scope, generalizability, conceptual development or practical usefulness than can be attained in any individual primary study (Campbell et al. 2003 ; Thorne et al. 2004 ; Malterud 2019 ).

Several different methods of synthesis exist under the umbrella heading of metasynthesis: meta-ethnography, thematic synthesis, critical interpretive synthesis, metastudy, and various others (Barnett-Page and Thomas 2009 ; Booth et al. 2016 ; Saini and Shlonsky 2012 ). Footnote 1 However, underlying these different methods are two broad approaches: aggregative synthesis and interpretive synthesis (Paterson 2012 ; Malterud 2019 ). In aggregative metasynthesis—exemplified by methods such as meta-aggregation (Hannes and Lockwood 2011 ) and metasummary (Sandelowski and Barroso 2007 )—the concern is to generate a largely descriptive mapping and categorization of findings in a comprehensive range of relevant primary qualitative studies, looking for patterns and commonalities. The concepts utilized in an aggregative synthesis are assumed to be ‘largely secure and well specified’ (Dixon-Woods et al. 2005 : p. 46), and the meaning of such concepts is therefore not normally the analytical focus of the synthesis. Instead, the focus is often a practical or instrumental concern, such as developing or evaluating healthcare interventions through what are referred to as ‘lines of action’ (Hannes and Lockwood 2011 ). In contrast, interpretive synthesis is exemplified by methods such as meta-ethnography (Noblit and Hare 1988 ) and grounded formal theory (Kearney 1998 , 2001a ), and conducts the synthesis at a higher level of abstraction. It consists of a conceptual or theoretical process in which new insights are developed, rather than a descriptive account of the phenomenon of interest (Dixon-Woods et al. 2005 ), and is not so directly oriented to issues of practice or policy. Footnote 2 Broadly, interpretive synthesis reflects Strike and Posner’s ( 1983 : p. 346) view of synthesis as ‘conceptual innovation’, which they define as ‘the invention or employment of concepts not found in the parts as means of creating the whole’, and as involving ‘a reconceiving of the assumptions under which the research was done’ (p. 359).

In both approaches, the primary qualitative studies and subsequent metasyntheses move progressively away from the original empirical data, and this is represented by different levels of construct. Research participants frame their accounts in what Schutz ( 1963 ) calls first-order constructs. When subsequently analysed by the researcher, these are transformed into second-order constructs: ‘constructs of the constructs made by the actors on the social scene’ (Schutz 1963 : p. 242). Development or elaboration of interpretations or theory by the study authors will accordingly be in terms of these second-order constructs. In the process of synthesis, these second-order constructs are, by extension, transposed into third-order constructs. This process of synthesis therefore takes place at a remove both from the empirical context of the data collection in the original studies and from the higher-order interpretation of these data by the authors of these studies. Footnote 3

An important issue, therefore, is how the empirical and the conceptual or theoretical contexts of primary qualitative studies are taken account of or preserved in the process of synthesis. Footnote 4 We will explore this question by focusing on the different types and levels of interpretation, in relation to both data and theory, that occur between the original data and a synthesis and discuss these issues in relation to different approaches to metasynthesis.

2 The issue of empirical context

Major and Savin-Baden ( 2010 : p. 15) claim that metasynthesis can preserve the empirical detail of the original studies: ‘Through retaining some of the dense description of the original data, the broader picture provides some detail that conveys the experiences of the original participants.’ Weed ( 2008 : p. 22) argues that because ‘the move from the specific to the generic will result in the loss of some individual differentiations… the synthesis method should be constructed to allow for as much detail of individual cases to be carried as far through the synthesis as is possible.’ However, Sandelowski and Barroso ( 2007 : p. 18) take a rather different view, arguing that although interpretive metasyntheses are ‘faithful to the findings in each report’, they provide ‘interpretive transformations far removed from these findings,’ and Suri and Clarke ( 2009 : p. 406) similarly maintain that in a synthesis ‘some of the rich contextual information found available in reports of primary research [will] be sacrificed.’ This perspective poses a potential challenge to any view of metasynthesis that sees it as a means of representing the empirical world, and we will argue that this is a persuasive challenge.

During data collection, researchers in primary studies have access to participants’ accounts in full and also to the specific social context in which these accounts were obtained, particularly if the data analyst had also collected the data at first hand. Some parts of these accounts are directly accessible to the reader of a report through illustrative quotations and other information (e.g. details of participants’ demographic or other biographical characteristics and their social circumstances) may provide further context. Data may also provide information on the broader social, community or institutional context in which the study was set. This contextual detail contributes to providing a ‘thick description’ of a social phenomenon. Based on a distinction drawn by Ryle ( 1971 ), Geertz ( 1973 ) described a thick description as one that goes beyond a purely factual or descriptive account of what people have said or done and seeks to express the underlying meaning and motivation of these words and actions, and the social context in which they occurred. A similar notion of the dependence of meaning on context is expressed by Mishler ( 1979 : p. 2):

We rely on context to understand the behavior and speech of others and to ensure that our own behavior is understood, implicitly grounding out interpretations of motives and intentions in context.

However, this sense of descriptive richness is not available in its entirety to the synthesist or other reader of a primary qualitative study, as the data presented in a report are inevitably selective and the reader does not have first-hand familiarity with the context in which they were collected. Similarly, whilst the primary researcher may endeavour to preserve the individuality of participants’ accounts, some of this individuality will inevitably be lost—particularly in a broadly thematic approach to analysis, if less so in a more narrative approach. If, as Atkins et al. ( 2008 : p. 7) claim, ‘the intention of a synthesis is to retain the rich context of the data’, this may be hard to achieve. A further issue, identified by Thorne et al. ( 2002 : p. 445–446), is that the primary data quoted by authors may encourage a distorted interpretation by virtue of having been chosen to present the most ‘graphic, vivid and touching examples to bring the ideas alive to their readers’, or may have been derived from ‘only one or two particularly articulate and colorful participants.’ Moreover, not all of the findings of a qualitative study are necessarily contained within the quoted data ; they may be conveyed indirectly in the researchers’ textual account of what was heard or seen. There are therefore difficulties in retaining empirical context at the level of primary studies, even before questions of synthesis are addressed.

Descriptions of metasynthesis commonly describe it in terms of a summary or integration of the findings of primary qualitative studies rather than a secondary analysis of the original data (e.g. Zhao 1991 ; Zimmer 2006 ; Sandelowski and Barroso 2007 ; Finfgeld-Connett 2018 ). Nonetheless, the original data do appear to feature in various ways in some forms of metasynthesis. The method of meta-aggregative synthesis developed by the Joanna Briggs Institute makes use of the original data to assess the rigour of the findings extracted from these studies, which are designated in the Institute’s manual, in rather stark terms, as either ‘unequivocal’, ‘credible’ or ‘unsupported’ according to the adequacy of these data (Lockwood et al. 2020 ). Here, the data within the original studies are not proposed as the subject matter on which the synthesis should operate, but as a means of validating the findings of these studies by demonstrating their origins (Pearson et al. 2011 ). To this extent, the empirical context of the primary studies plays a confirmatory role, rather than being the material on which the synthesis is conducted.

Other approaches to metasynthesis appear to give the original data quoted in the primary studies a more central role in the analysis. Major and Savin-Baden ( 2010 : p. 50) argue that the primary research reports used in a qualitative synthesis should ‘contain qualitative data rather than summaries of themes’ and that the data thereby used in the synthesis should take the form of ‘thick quotations/descriptions from the primary data set.’ They further note (2010: p. 54) that the number of reports included in the synthesis should ‘provide sufficient original data for analysis.’ Similarly, Finfgeld-Connett ( 2010 ) suggests that focusing on direct quotations from research reports serves to offset the removal of the synthesis from the original data. Many metasyntheses (e.g. Smith et al. 2005 ; Lindahl and Lindblad 2011 ; Uhrenfeldt et al. 2013 ; Fegran et al. 2014 ; Honein-AbouHaidar et al. 2016 ; Holt et al. 2017 ; Kersey et al. 2022 ) use quotations from participants in the primary studies in direct support of their interpretations. Holt et al. ( 2017 ) go further, however, and seem to base their own synthesis predominantly on extracted quotations from such studies. In a similar way, Smit et al. centre their synthesis of experiences of breast cancer on the quoted data in the primary studies before focusing on the authors’ analyses of these data and complain that ‘it was challenging to code studies without referring to the original authors’ interpretations of the respective quotation’ (Smit et al. 2019 : 242). Thomas and Harden ( 2008 ) do not draw a firm distinction between the original data and the researchers’ findings in the original studies and use both in their method of thematic synthesis, which incorporates the principles embodied in thematic analysis of primary qualitative data (Braun and Clarke 2022 ). Pilkington et al. ( 2020 ) also use both data and findings in their meta-ethnography but distinguish these in terms of the analysis of first- and second-order constructs, respectively.

Using data presented in the primary studies as an element within the synthesis does not, however, take us very far in terms of capturing the original empirical context, given the selective availability of such data and lack of first-hand contact with the context of data collection suggested earlier. Moreover, a synthesis that is centred on the data quoted by the authors of research reports risks mistaking the function of quotations in qualitative research reports. This function is more one of exemplifying the meanings that underlie the data, than of expressing such meanings; data that are suitable for the purpose of illustration are not necessarily optimal for the purpose of interpretation. It is reasonable to insist that meaning should be grounded in the data, but unless one adopts a strongly realist stance this does not imply that meaning is wholly contained within the data, as it derives in part from other elements in the process of analysis that are at a higher level of abstraction. As Paley ( 2017 : p. 116, original emphasis) puts it:

Meaning is not a property of anything. It is not resident in the text… Meaning is what the analyst brings to the data; it is not in the data, awaiting discovery… Meaning only arrives when a theory is applied to the phenomenon concerned, and an inference is made on that basis.

Accordingly, the greater the reliance on the original data in the studies included in the synthesis, the more the synthesis will fail to capture the insights drawn by the authors of these studies. What will result is not so much a synthesis as a re-analysis of these data, as occurs in secondary qualitative data analysis (Heaton 2008 ).

Furthermore, as metasynthesis seeks to provide a greater degree of conceptual abstraction (in its interpretive form) or a summary or mapping of findings (in its aggregative form), this logically necessitates a distancing from the specific empirical detail in the primary studies. For Zimmer ( 2006 : p. 315), this raises a concern:

The theorizing engaged in by the synthesist removes the findings of the constituent studies from the richness of the primary description and its intended impact. This raises the question of as to [sic] whether this abstracting process in qualitative meta-synthesis actually violates the tenets of the interpretive paradigm within which the constituent studies are philosophically situated.

Similarly, Paterson et al. ( 2001 : p. 15) identify as a limitation of metasynthesis that it ‘decontextualizes data, removing them from the emotional and physical context within which they were originally constructed.’ If the process of interpretation is seen as lying at the level of the rich empirical detail and thick description provided by primary qualitative studies, these are valid concerns. However, if we consider what occurs during a metasynthesis, the interpretation that takes place is at a higher and more abstract level, and we should not expect this empirical richness to be carried through. Here, interpretation is not in terms of understanding the detail of specific first-person accounts but has to do with a higher-order form of interpretation that we expect to be conceptually, rather than empirically, rich—at least in interpretive, if less so in aggregative, metasyntheses. So it is to more conceptual issues that we now turn.

3 The issue of theoretical context

3.1 concepts and theories.

It is important initially to define and distinguish concepts and theories and the way in which they indicate different levels of abstraction. In broad terms, a concept is an abstract description of some feature or property of what we perceive or experience in the world around us. Whilst phenomena in the empirical world are observable, concepts, by virtue of their abstract nature, are not directly observable but are inferred from, or applied to, these phenomena. They thereby provide a mental image of, or give a meaning to, such phenomena, and help us to move from describing to understanding the world. Concepts are regarded by Goertz ( 2006 : p. 5) as ‘ontological’, insofar as they are ‘about the fundamental constitutive elements of a phenomenon.’ They also relate most strongly to the essential, rather than the superficial or ‘accidental’, properties of things in the world (Goertz 2006 ). Footnote 5

The extension of a concept is the class of observable phenomena to which it applies, whilst the intension of a concept refers to the properties that a phenomenon must possess to lie within the concept’s extension (Salmon 1963 ). The intension of a concept thereby defines its meaning (Sartori 2009a ), and this meaning depends upon some sort of implicit or explicit theoretical stance—whether this is a set of initial theoretical assumptions or a more fully developed theory—such that a concept with the same name may have different meanings in different theories (e.g. ‘conflict’ may have a different meaning in a particular psychological theory from its meaning within a theory in political science, just as ‘culture’ will differ in its meaning between anthropological and organizational theory). Equally, in some instances a concept may have a similar meaning in different theories; for example, within different theories of attitude formation, the concept of an ‘attitude’ may be similar, even though theoretical accounts of how attitudes are formed are distinct (Maio and Haddock 2010 ).

Theories are therefore framed in terms of concepts but lie at a further level of abstraction. They contain statements as to the interrelationships between such concepts, in terms of theoretical propositions that make up the theory as a whole (Hoyle et al. 2002 ). Maxwell ( 2013 ) suggests that a single proposition linking two concepts could constitute a theory, but theories are commonly more complex than this and consist of an interlinked series of such propositions within an explanatory framework. Importantly, Bulmer ( 1984 : p. 43) points out:

Concepts in themselves are not theories. They are categories for the organisation of ideas and observations. In order to form an explanatory theory, concepts must be interrelated… Concepts, then, mediate between theory and data.

It follows that whilst concepts refer to some sort of theoretical context, reference to one or more concepts does not in itself constitute a theory unless these concepts are set in certain relationships. This process of examining, developing and interrelating concepts may be regarded as theorizing , with theory as the end product (Swedberg 2012 , 2016 ).

Theories can be seen as existing within a particular paradigm . Developed by Kuhn ( 1970 ), this term refers to a set of philosophical assumptions about the nature of the world (ontology) and how we can appropriately gain knowledge or understanding about it (epistemology). Blaikie and Priest ( 2017 ) describe, as examples, the neo-positivist, interpretive, and critical realist paradigms. As each paradigm will make different philosophical assumptions, Kuhn ( 1970 ) saw them as incommensurable; even if paradigms are not wholly incompatible in this way, they will nonetheless each contain certain philosophical assumptions that cannot be reconciled with those of another paradigm.

3.2 Concepts, theories and metasynthesis

The second-order constructs within which data analysis is framed in primary qualitative studies provide a conceptual context for the insights developed by the authors of these studies. Even if a study is not set explicitly in a theoretical context, the analysis that occurs within it will draw upon what we have referred to as an implicit theoretical stance; for example, through a decision to code this sentence rather than that, or to code it in the same or a different way in relation to another sentence. Moreover, even before any clearly defined theoretical concepts have been identified, what Blumer ( 1954 : p. 7) calls sensitizing concepts will provide ‘a general sense of reference and guidance in approaching empirical instances.’ For Seale ( 1999 : p. 26), knowledge is always ‘mediated by pre-existing ideas and values, whether this is acknowledged by researchers or not.’ These ideas and values do not mean that a specific theory must always predate any attempt to collect data; this would seem to deny the possibility of theory-building research, restricting the role of research to elaborating, refining or testing a pre-existing theory. Rather, it says that the researcher must take a perspective that embodies certain conceptual or theoretical assumptions, reflecting the particular paradigm within which he or she is working. Footnote 6

So, a theoretical context of some type exists in a primary study, even if only at an implicit or underdeveloped level to guide data collection, but in what way should it be—and indeed, need it be—accommodated within the metasynthesis?

3.3 Interpretation at the level of the synthesis

As we have argued earlier, analysis within metasynthesis should take as its raw material the second-order constructs identified in the primary studies. It may, for example, take the form of a thematic synthesis (Thomas and Harden 2008 ), or the sorting of coded data into an a priori structure within framework synthesis (Oliver et al. 2008 ), or the processes of reciprocal and refutational translation conducted in meta-ethnography (Noblit and Hare 1988 ). As we have noted, these constructs from the original studies will represent certain theoretical frames of reference, either explicit or implicit, and these may be quite diverse.

The synthesist faces the task of accommodating, or at least taking account of, the theoretical frameworks of individual primary studies, and this is challenging given that, in terms of their underlying paradigms, these frameworks may make different fundamental assumptions at the level of ontology and epistemology, even when applied to ostensibly much the same phenomenon. For example, observational studies have seen doctor-patient encounters from the perspective of ethnomethodology (Heath 1981 ; Peräkylä 1998 ), or as a process of negotiation within the interactionist tradition (Strong 1979 ; Madden and Sim 2016 ), or as a forum in which more macrosociological notions of capitalist ideology and class relationships are reproduced (Waitzkin 1979 ). The insights derived within such studies will reflect, and be expressed in terms of, the theory within which they are set, the philosophical assumptions that underlie these theories, and the methodologies grounded in such theories (Fig.  1 ).

The relationship between philosophical, theoretical and methodological elements in research. The logical progression from theory to data analysis is not wholly unidirectional, as theory may be generated from data through processes of induction or abduction

One strategy that can be adopted at the level of synthesis is simply to consider each primary study, one by one, in the light of its underlying theoretical context, but then put these theoretical considerations largely aside when moving into the process of synthesis, dealing with these second-order constructs at a largely descriptive level—as if they were summaries of the data in the original studies rather than conceptual accounts that give them some theoretical meaning. For example, the theme of ‘stigma’ might be drawn from a previous study of mental illness (Marcussen et al. 2019 ) without taking full account of the theory of identity (Burke and Stets 2009 ) in which this study was set, or the concepts of ‘rule’ and ‘ritual’ might be drawn from Strong’s ( 1979 ) study of paediatric clinics without reference to the theory of frame analysis (Goffman 1975 ) that underlies it. Similarly, ‘coping’ might be identified in a study of lung cancer (Harrop et al. 2017 ) without full regard to the associated theory of sense of coherence (Antonovsky 1979 ). Whilst in this way the manifest meanings of insights from primary studies may be sorted or coalesced in terms of their variation and commonality, the theoretical context of these insights is largely left behind. The end result will treat the findings of primary studies more at a descriptive than at a conceptual level and will not develop a theoretical understanding.

The extent to which this is a concern will depend upon the approach that is taken to metasynthesis. For example, metasummary has been described as ‘a quantitatively oriented aggregation of qualitative findings that are themselves topical or thematic summaries or surveys of data’ (Sandelowski and Barroso 2007 : p. 151). These metasummaries are specifically contrasted with more interpretive forms of metasynthesis and represent ‘integrations that are approximately equal to the sum of the parts, or the sum of findings across reports in a target domain of research’ (Thorne et al. 2004 : p. 1358). As the intention is to produce a descriptive—rather than a conceptual or theoretical—account of findings from primary studies, the synthesis may proceed without engaging fully, or perhaps even at all, with the theoretical frameworks of these studies or with the paradigmatic assumptions that underly them. An approach such as metasummary will make certain philosophical assumptions of its own—it is likely, for example, to adopt a realist rather than an idealist ontology—but it may be argued that it is not thereby committed to analysing or assimilating the philosophical frameworks of the primary studies included in the synthesis.

If we return to another aggregative method of synthesis—meta-aggregation—this can be seen as rejecting more explicitly the notion of an ontological or epistemological foundation by virtue of adopting the perspective of pragmatism (Hannes and Lockwood 2011 ). This approach contests the more established view that methods must be grounded firmly in a particular philosophical paradigm. Instead of arguing, in a more-or-less deductive line of reasoning, that a certain ontological position as to what constitutes reality will lead inevitably to a particular epistemological stance on how one can learn about this reality, which in turn will dictate certain methodological choices, as was outlined in Fig.  1 , pragmatism adopts a less foundationalist approach. For pragmatism, what matters is not whether the methods that one uses have a coherent philosophical grounding, but whether they are conducive to practical conclusions (Morgan 2014 ): in particular, certain actions or interventions. In this way, the understanding that is sought is instrumental rather than theoretical, and any notion of reconceptualizing the original studies is specifically avoided (Lockwood et al. 2015 ).

Accordingly, reflecting this pragmatic concern with action within a meta-aggregative approach, Hannes and Lockwood ( 2011 : p. 1638) argue that ‘[c]hoosing one explanation over another… is similar to stating that the chosen one is expected to be better than another in producing an anticipated or desired outcome’ and that ‘[u]nlike theoretical predictions, declamatory statements do not indicate a hypothetical explanation for the insights emerging from the synthesis as a whole.’ Similarly, they say of meta-aggregation that it ‘does not seek to re-interpret as some other methods of qualitative synthesis do’ (Hannes and Lockwood 2011 : p. 1637).

The implication of pragmatism here is that dealing with underlying epistemological and theoretical issues is not a concern simply because the aim of meta-aggregation is not to produce an interpretive or theoretical explanation but to generate practical ‘lines of action.’ Reconciling any differences in the underlying philosophical or theoretical frameworks of primary studies is therefore not an issue for this type of synthesis. Footnote 7

3.4 Engaging with theoretical context

If, however, the purpose of a metasynthesis is to develop an interpretive or theoretical account of a phenomenon, rather than a more descriptive representation of a body of qualitative research, the problem of theoretical context is less easily settled. One approach would be to point to Major and Savin-Baden’s ( 2010 ) suggestion that the synthesist should select studies that lie within the same methodological tradition, which will secure a large degree of similarity in their underlying philosophical assumptions. For example, studies employing in-depth interviews and exploring or developing a phenomenological theory are likely, in both respects, to be grounded in an idealist, rather than realist, ontology and in an interpretive, rather than neo-positivist, epistemology. The similar philosophical underpinning of such studies is therefore likely to give rise to both theoretical and methodological compatibility at the level of synthesis.

An alternative approach is to suggest that differing methodological frameworks are not problematic but are in fact beneficial to the synthesis. Thus, pointing to the differing theoretical frameworks and research methods used by primary investigators, Finfgeld-Connett ( 2018 : p. 56) claims that ‘[t]hese factors alone help to ensure a thorough and unbiased examination of a research topic’, and argues elsewhere ( 2014 : p. 348–9):

First… combining findings from different epistemological perspectives represents a form of triangulation and enhances validity… Second, qualitative findings, regardless of their epistemological origins, constitute evidence-based results that have the potential to add to qualitative systematic reviews. Ignoring selected findings solely due to their epistemological origins seems entirely contrary to the goal of knowledge development and theory generation, especially when the meaning and context of the original findings are preserved.

The appeal to triangulation is not, however, entirely germane, as theoretical triangulation (Denzin 2009 ) is more to do with choosing two or more theoretical frameworks that are appropriate to interpret a particular body of data, rather than a strategy that can be used to reconcile epistemological differences in such frameworks (Blaikie 1991 ; Sim and Sharp 1998 ). Finfgeld-Connett’s second argument seems to suggest that the meanings from individual studies can be synthesized without regard to questions of epistemology; but this assumes, rather than demonstrates, that one can separate the meaning of findings from their underlying philosophical assumptions, which is the question at issue.

Others confront the challenge of epistemology more directly. For example, Jensen and Allen ( 1996 : p. 558) argue that ‘the differing views of reality underpinning [various qualitative] approaches lead to the generation of substantively different kinds of knowledge’, and Estabrooks et al. ( 1994 : p. 506) contend that bringing together studies that use different research approaches makes theory development difficult because of ‘major differences in the epistemological foundations’ that may exist between methods. The extent to which such differences are troublesome will depend on how dissimilar the underlying assumptions are. On this basis Schreiber et al. ( 1997 ) suggest, for example, that a grounded theory study may be brought together more readily with an ethnographic study than with one centred in phenomenology. Similarly, Zimmer ( 2006 ) uses the same comparison of phenomenology and grounded theory to suggest that differences in focus (narrow and descriptively detailed in the former case and broader and more conceptual in the latter case) may present difficulties in combining studies. Footnote 8 Consequently, seeking some form of theoretical uniformity within the studies that are synthesized will lessen the difficulty of reconciling differing theoretical contexts.

3.5 Metasynthesis as developing concepts and constructing theory

Rather than seek to assimilate and reconcile within a synthesis the conceptual and theoretical context of the primary studies, some approaches to metasynthesis take a different approach. In framework synthesis—based on the method of framework analysis used in primary qualitative research (Ritchie and Spencer 1994 )—the conceptual or theoretical framework for the synthesis is largely determined a priori (Carroll et al. 2011 , 2013 ). Findings in the studies reviewed are mapped to themes derived from this pre-existing conceptual framework, with the possibility of some additional themes suggested more inductively by these studies. A prior theoretical framework is thereby applied to the process of synthesis rather than being derived from it.

Other approaches take a more fully inductive approach and seek to generate new concepts and theories. Such approaches have been characterized by Schreiber et al. ( 1997 ) as involving either theory explication or theory building . Theory explication, despite its name, is not directly related to theories, but has to do with a process of reconceptualization, whereby a particular concept within primary studies is refined or elaborated through a process of deconstruction and reconstruction. Finfgeld’s ( 1999 ) study of the concept of courage provides an example. By analysing her own and others’ previous studies, Finfgeld sought to deconstruct and reconstruct courage as a concept in the context of chronic illness. In the process of theory explication, we might appeal to ‘metaconcepts’: higher-level concepts that help us make sense of the nature and function of lower-level concepts (Sartori 2009b ).

Theory building goes somewhat further than theory explication, as it seeks to create new theory in the way exemplified by grounded theory (Schreiber et al. 1997 ). Although not framed in terms of theory construction, the seminal method of meta-ethnography (Noblit and Hare 1988 ) started the movement in the direction of theory-building metasynthesis. Meta-ethnography follows the inductive principles of grounded theory in relation to the ‘lines of argument’ that are constructed towards the conclusion of the synthesis. Adopting the notion of translation described by Turner ( 1980 ), findings from primary studies are translated into each other in the form of metaphors that capture the conceptual and interpretive essence of these findings, rather than simply their manifest meaning. These metaphors ‘achieve both abstraction and complexity, and create translations that preserve the relations between concepts’ (Noblit and Hare 1988 : p. 37). A synthesis of insights from these studies is therefore produced through these lines of argument and generates conceptual interpretations that are not reducible to those of an individual constituent study in the synthesis (Campbell et al. 2003 ). For example, Malpass et al. ( 2009 ) develop a novel interpretation of antidepressant use through lines of argument derived from a synthesis of sixteen original studies. Patients’ experiences of antidepressants were analysed in terms of both a decision-making and a meaning-making process, leading correspondingly to the theoretical notions of a ‘medication career’ and a ‘moral career.’

Noblit ( 2018 ) emphasizes that meta-ethnography is not about synthesizing themes or concepts, which he associates with a more aggregative analysis, but about synthesizing the broader interpretations, or ‘storylines’, in the primary studies. Also, as noted above, Noblit and Hare ( 1988 ) described their inductive method of synthesis as taking place more at the level of interpretation than of theory. Footnote 9 To this extent, meta-ethnography moves away from the emphasis on theory-building originally developed within grounded theory (Glaser and Strauss 1967 ) and firmly maintained within Glaser’s ( 1992 ) perspective on the method. However, in their adaptation of the principles of meta-ethnography within what they describe as critical interpretive synthesis, Dixon-Woods et al. ( 2006 : p. 2) describe the aim of their method as the ‘generation of theory with strong explanatory power.’ Footnote 10

3.6 Grounded formal theory and metatheory

The methods of theory explication and theory building outlined in the previous section synthesize concepts and interpretations derived from previous studies, but they do not synthesize theories, in terms of how we have defined these earlier. Instead, these concepts are integrated within a new theory constructed within the synthesis, such that theory is the end-product, rather than the raw material, of the process. Two approaches go further in terms of synthesizing theories per se.

The first of these is Kearney’s ( 1998 , 2001a ) account of a form of synthesis—grounded formal theory—whereby substantive grounded theories embodied in original studies are synthesized into a higher-level formal theory with a greater degree of abstraction and generality. This is achieved by applying the standard methods of grounded theory—such as theoretical sampling, category formation, constant comparison and theoretical saturation (Glaser and Strauss 1967 )—to the theoretical insights in the original grounded theory studies. Kearney’s ( 2001b ) synthesis of studies of domestic violence illustrates some key aspects of this method. The 16 studies included in the synthesis had all adopted a theory-building approach and used constant comparative methods characteristic of grounded theory, and similar methods were used at the level of the synthesis, indicating how this approach ‘applies like methods to like materials’ (Kearney 2001b : p. 271). In articulating the synthesis, Kearney has recourse not only to the findings in the original studies but also to some of the data quoted. This notion of grounding insights in the data is in line with the principles of grounded theory, but it also suggests that the process of grounded formal theory relies not just on a synthesis of theoretical insights within the original studies but also on constructing theory de novo from data within these studies. Footnote 11 Hence, Kearney ( 2001b : p. 279) describes her analysis as: ‘the consolidation of conceptual components from different studies and the bringing together of a broad spectrum of data in support of this analysis.’

The second approach to theory integration is based on the idea of metatheory. Ritzer ( 1990 ) describes three types of metatheorizing, each of which takes existing theory as its subject matter. Footnote 12 The first of these focuses on the study of theory in order to develop a fuller understanding of its nature and function. The second, which Ritzer ( 1990 : p. 4) terms ‘metatheorizing as a prelude to theory development’, seeks to develop new theory; Anchin ( 2008 : p. 804–805) captures this function as a ‘scaffolding for integrating more specific theories that conceptually and empirically map different aspects of the phenomenon under study.’ The third type has to do with establishing an overarching perspective that encompasses some or all of existing theory in an area. Footnote 13 Whilst a number of writers on metatheory (e.g. Wallace 1992 ) concern themselves principally with the first approach—which may be seen as a prerequisite for the other approaches (Weinstein and Weinstein 1992 ) —of particular relevance here are the second and third approaches. Paterson et al. ( 2001 : p. 117) see metatheory as encompassing both of these functions:

Meta-theory creates the context in which the implications of a range of theoretical approaches that have influenced the body of knowledge can be considered and evaluated. In addition, new theoretical alternatives that might account for a more comprehensive, accurate or credible interpretation of the phenomenon can be synthesized.

Within the field of qualitative synthesis, metatheory—alongside metamethod (the study, evaluation and codification of research methods) and meta-data-analysis (the analysis of findings from previous studies, essentially equivalent to the approaches that we have hitherto referred to under the broad heading of metasynthesis)—has been incorporated in what has been referred to as ‘metastudy’ (Zhao 1991 ). In their own account of metastudy, Paterson et al. ( 2001 ) use the term ‘metasynthesis’ in a specific sense to refer to the integration of the processes of metatheory, metamethod and meta-data-analysis; metasynthesis here is ‘the creation of a new interpretation of a phenomenon that accounts for the data, method, and theory by which the phenomenon has been studied by others’ (Paterson et al. 2001 : p. 13); see Fig.  2 . In this way, not just the findings of primary studies are analysed, but also their theoretical and methodological bases and assumptions. Footnote 14 Hence, metastudy can be regarded as a synthesis of studies, not just of findings (Thorne et al. 2004 ).

Elements within metastudy; adapted from Zhao ( 1991 ) and Paterson et al. ( 2001 )

The ways in which metatheorizing and its place in the wider process of metastudy have been interpreted and represented in the literature are varied. For example, in their metastudy of childhood illness, Nicholas et al. ( 2006 ) focus on metamethod and meta-data-analysis, but do not explain how they addressed metatheory. Jefferies et al. ( 2010 ) describe their synthesis of research on nursing documentation as a metastudy but focus just on the findings of the included studies, without the other elements of metastudy described by Zhao ( 1991 ) and Paterson et al. ( 2001 ), thereby suggesting a different interpretation of the term. Watkins et al. ( 2010 ) address all three elements of metastudy in their synthesis of research on mental health in Black men, but the emphasis in their metatheory on the grounded theory perspective in the studies reviewed suggests an interpretation of metatheory focused more on methodology than on substantive theory. Similarly, Smit et al. ( 2019 ) describe as metatheory an assessment of the confidence—in terms of relevance, coherence and adequacy—that can be placed in the findings of their review, with no real reference to the evaluation of theory in the studies they reviewed. In addition, many studies centre their metatheory on evaluating the theories used in the primary studies, rather than on synthesizing them (Howard et al. 2007 ; Edwards et al. 2009 ; Lee et al. 2015 ; Ronkainen et al. 2016 ; Holt et al. 2017 ; Thurlings and den Brok 2017 ; Kersey et al. 2022 ). Finally, in Honein-AbouHaidar et al.’s ( 2016 ) metastudy of studies of colorectal cancer screening, an explanatory framework is developed in the metasynthesis stage of the metastudy, but it is unclear to what extent this is derived from the process of metatheory as opposed to that of meta-data-analysis.

However, a recent study that moves closer to the synthesis of theories through a process of metatheorizing is Al-Sahan et al.’s ( 2020 ) study of psychosocial responses to loss of bodily parts. Through a search of the literature, the authors found 89 relevant ‘primary’ theories, and within these 586 constructs were identified through a process of deconstruction of the primary theories. These constructs were, in turn, organized into seven construct categories, which were organized into five pre-existing ‘dominant’ theories (communication, developmental regulation, emotion, resource, and social cognition) with which these construct categories were associated. A similar approach is taken in a synthesis of research on mental toughness by Anthony et al. ( 2016 ), who relate the findings in the studies reviewed to a prior bioecological model of human development (Bronfenbrenner and Morris 2006 ). However, the process of synthesis in these examples takes the form not so much of an integration of primary theories as a deconstruction of these theories and a subsequent mapping of theoretical constructs to a smaller number of broader, established theories.

A somewhat different approach is taken by Pound and Campbell ( 2015 ), based on a view of metatheorizing proposed by Turner ( 1990 : p. 38) that emphasizes the generation of ‘theories that are more parsimonious, abstract and useful in explain how the social universe operates.’ In synthesizing a number of sociological theories on risk taking, they analyse each theory to identify its core theoretical propositions (e.g. propositions relating to Becker’s ( 1963 ) notion of the deviant career) and render these more abstract, with the result that they are less bound to a particular substantive or historical context. These propositions are then tabulated in terms of their similarities and dissimilarities, a process that they liken somewhat to reciprocal and refutational translation in meta-ethnography. Based on an analysis of such convergence or divergence, these propositions are integrated within a new, ‘more robust’ theory that brings additional theoretical insight, which by further analogy with meta-ethnography is likened to the construction of a line of argument (Pound and Campbell 2015 ). This approach brings us considerably closer to an integrated theory.

In summary, the theoretical context of primary qualitative studies can be handled within metasynthesis in various ways. In the first instance, it can be largely set aside, as within meta-aggregation. In more interpretive syntheses, a particular concept in the primary studies can be reinterpreted and reconceptualized: Schreiber et al.’s ( 1997 ) notion of theory explication. Moving closer to the level of theory, interpretations in primary studies can be brought together to form lines of argument (in meta-ethnography) or to build theory (critical interpretive synthesis). Finally, an attempt can be made to synthesize existing theories themselves through grounded formal theory or metatheorizing.

4 Overall reflections

We have examined the ways in which, and the extent to which, the empirical and theoretical contexts of primary research can be preserved or accounted for in the process of metasynthesis. Regarding the first of these, we have argued that it is the insights derived from these data, not the data per se, that are the appropriate subject matter of a metasynthesis. Although primary data quoted in a study may inform an understanding of the way in which the authors of a study developed and named certain codes or themes in their analysis, this does not imply that data should themselves be the material on which the synthesist conducts his or her analysis.

It would be wrong, however, to see this loss of empirical context as an inadequacy. If metasynthesis—particularly in its interpretive rather than its aggregative variety—is about drawing broader conceptual or theoretical insights from primary studies, some loss of contact with this empirical context is inevitable, and even desirable, and to describe this as a limitation of metasynthesis (Nicholas et al. 2006 ) or as contrary to the interpretive paradigm (Zimmer 2006 ) may be misleading. In this connection, Richards ( 1998 : p. 320) maintains that the ‘making and using of theory (in any area of inquiry) requires distance from the data… we should get (though not necessarily stay) close to our data.’ In a similar but more instrumental vein, Gewurtz et al. ( 2008 : p. 302) suggest that within metasynthesis ‘some distance from the lived-experience might be a necessary sacrifice in order to develop deeper insights and understanding, and to make findings from qualitative research and phenomena more accessible and relevant to practice.’ Concerns about a loss of the empirical context of the primary studies may therefore be ill-founded insofar as they misunderstand the higher-level analysis that occurs within a metasynthesis. The ‘richness’ achieved through a metasynthesis lies not in a representation of first-person accounts of the empirical world but in the insights that are derived from primary qualitative studies. It is debatable, therefore, to what extent an interpretive synthesis is realistically able ‘to remain attentive to the identities of individual participants and to respect their individual voices’ (Major and Savin-Baden 2011 : p. 657). At the same time, however, in the search for these higher-order insights, the empirical world should not be made invisible; Kearney ( 2001a : p. 243) argues that the theory developed through a synthesis should not be ‘so abstract that its terms seem to float over the realities of illness experience.’

Of relevance here is the distinction between descriptive, interpretive, and theoretical validity (Maxwell 1992 ). Descriptive validity, as Maxwell describes it, refers to the simple accuracy of what researchers report from their data collection, separate from any inference of meaning. Interpretive validity relates to a more emic notion of participants’ meanings and perspectives as expressed in the accounts they give. These accounts are ‘grounded in the language of the people studied and rely as much as possible on their own words and concepts’ (Maxwell 1992 : p. 289). In contrast, theoretical validity ‘goes beyond concrete description and interpretation and explicitly addresses the theoretical constructions that the researcher brings to, or develops during, the study’ (Maxwell 1992 : p. 291). Each of these types of validity can be seen as a precondition for the next one. As Sandelowski ( 2006 ) indicates, in metasynthesis interpretive validity, and thereby theoretical validity, depend upon how the synthesist deals with the primary authors’ interpretations, not the first-person accounts of research participants, which are out of reach of the synthesist. Accordingly, descriptive validity is not within the control of the synthesist but lies in the hands of the primary researcher. So the empirical context of the original studies can and should be reflected in, but cannot be reproduced in, the synthesis.

Issues regarding the handling of concepts and theory in metasynthesis are perhaps more complex. Aggregative approaches to metasynthesis—such as metasummary (Sandelowski and Barroso 2007 ) and meta-aggregation (Pearson et al. 2011 )—engage with primary studies largely at a descriptive rather than a conceptual level and often seek insights that are related to practical rather than theoretical concerns. Conceptual and theoretical issues are therefore not problematized within this approach and Strike and Posner’s ( 1983 : p. 359) notion of ‘reconceptualizing the assumptions’ of the original research is largely absent. In more interpretive models of metasynthesis, insights are derived at a more conceptual level, and if some account is not taken of the philosophical or theoretical standpoints underlying the primary studies, a conceptually thin synthesis will result. Unless a pragmatist stance is adopted, a fuller engagement with theory does, however, bring the challenge of reconciling philosophical or theoretical frameworks that may be in some measure discrepant (Suri 2013 ). Clearly, to the extent that studies chosen for synthesis come from similar, or philosophically compatible, traditions, this difficulty will be lessened (Jensen and Allen 1996 ; Major and Savin-Baden 2010 ).

With regard to concepts described or developed within previous studies, the process of theory explication described by Schreiber et al. (1989) allows these concepts to be integrated and refined, as in Finfgeld’s ( 1999 ) analysis of courage described earlier. Moving from the level of concepts that of theory, several interpretive approaches within metasynthesis seek to build new theory—or in the case of meta-ethnography, to construct higher-order interpretations—from the original studies. These syntheses often follow the principles of grounded theory, which is not, nor indeed seeks to be, premised on assimilating or integrating previously articulated theory, and to that extent this is a coherent approach. Other syntheses do, however, engage directly with the substantive content of extant theories through the processes of grounded formal theory or metatheorizing. Grounded formal theory, by applying ‘like methods to like materials’ (Kearney 2001b : p. 271), avoids some of the difficulties associated with synthesizing studies that adopt divergent philosophical or theoretical standpoints, though this has the likely consequence that only a subset of the primary research on a particular phenomenon can be included in the synthesis. In this respect, metatheorizing is potentially broader in scope. However, the metatheory produced is often an analysis and evaluation of these theories, such that metatheorizing more commonly produces a critical juxtapositioning, rather than an integration, of these theories. This juxtapositioning—essentially the third of Ritzer’s ( 1990 ) functions of metatheory—allows a range of different theories to be mapped and analysed, and the heterogeneity, or even incompatibility, of these theories might be the focus of such analysis. Indeed, Something similar to this forms part of the meta-narrative synthesis described by Greenhalgh et al. ( 2005 ), where the focus is on examining and comparing the different, and often incommensurable, traditions or perspectives that underlie empirical work in an area.

However, the form of metatheory that seeks some form of integration of theories poses a greater challenge:

If we gather and combine the insights of multiple theories, can we be sure that they share the same understanding of the world and how our concepts relate to it (the ontological question) and/or our ability to gather and accumulate knowledge of it (the epistemological question)? (Cairney 2013 : p. 2)

This reflects Byrnes’ ( 1992 ) argument that the extent to which theories can coherently be combined depends on the degree to which they share what he calls metatheoretical belief systems. These systems represent three core assumptions underlying a theory, which relate broadly to: i) the phenomena that it is appropriate to examine, ii) issues of ontology, and ii) issues of epistemology. Combining theories therefore requires compatibility at the level of their fundamental philosophical assumptions. For some, this would set very strict limits on theory integration across different paradigms (Burrell and Morgan 1979 ; Jackson and Carter 1991 ). In contrast, Sibeon ( 2004 ) argues for ‘ontological flexibility’ in his defence of theory synthesis and opposes a strong notion of incommensurability, even in respect of ‘mutually opposed schools of thought’ (p. 29). He argues that:

synthesis and theoretical integration… is perfectly legitimate providing that the integration, where it combines otherwise unaligned or mutually exclusive concepts, does not contradict itself through failure to re-work the cluster of imported conceptualizations so as to make them compatible (p. 30).

This quotation does, however, indicate that some degree of theoretical compatibility is necessary. Hence, Pound and Campbell ( 2015 ) focused specifically on sociological theories of risk-taking, and warn, notwithstanding Sibeon’s view, that their approach to metatheorizing might meet problems of incommensurability if conducted across disciplines. They further note a difficulty in synthesizing all of the theories that they identified by virtue of their differing breadth—specifically, Durkheim’s ( 1897 ) work on suicide was found difficult to integrate with other more focused theories.

A further challenge lies in assimilating the philosophical framework represented in individual studies within the framework within which the synthesis itself is set. Therefore, for interpretive metasyntheses at least, as well as being compatible with each other, the studies chosen for review also have to be compatible with the philosophical and theoretical stance of the synthesist.

5 Conclusion

We have argued that metasynthesis should not be seen as some form of secondary data analysis. It is not the function of metasynthesis to reproduce the rich detail of the empirical world sought in primary studies, but to analyse the broader interpretations into which this detail is transformed. Data from original studies may be used illustratively, but not as the material on which the synthesis operates, given the selective and incomplete nature of these data. Loss of contact with the empirical context in which the primary data collection occurred is therefore not a shortcoming of metasynthesis, but a reflection of the higher-order interpretation that the synthesis involves.

Regarding more conceptual and theoretical concerns, aggregative methods of metasynthesis circumvent problematic issues by positioning themselves at a largely descriptive level of analysis and avoiding any process of reconceptualization. However, accommodating the conceptual frameworks utilized in primary studies is more challenging for interpretive metasynthesis—though if underlying philosophical assumptions, and theories based upon them, are broadly compatible, this difficulty is lessened.

The account of metastudy given by Paterson et al. ( 2001 ) provides a means of bringing together not only the theoretical context but also methodological characteristics with the findings of primary studies. The process of metatheorizing within this approach can provide a form of critical juxtapositioning of different theoretical frameworks, and of methodological approaches, and thereby illuminate the interpretations developed within the synthesis. To date, however, a comprehensive account is lacking of the extent to which theories can be integrated within a metasynthesis and the way in which this might be done, though a degree of similarity in the scope and philosophical underpinnings of these theories appears to be crucial.

In terms of research practice, those engaging in metasynthesis should acknowledge that seeking to preserve in a full sense the empirical context of the original qualitative studies is neither possible nor necessary. Additionally, unless perhaps a purely aggregative synthesis is proposed, due regard should be given to differences, and possible incompatibilities, in the theoretical and philosophical frameworks that may underlie the studies included in the metasynthesis, and the synthesis should be constructed in the light of these. The way in which not just theoretical concepts but theories themselves might be synthesized is a potentially fruitful area for further methodological development.

Data availability

Not applicable.

Some commentators use metasynthesis to refer to a particular approach to synthesis, rather than as an umbrella term as we do, and some favour ‘qualitative evidence synthesis’ as the generic description (Booth et al. 2016 ). Finfgeld ( 2003 ), Sandelowski and Barroso ( 2007 ), Thorne ( 2017 ) and Bergdahl ( 2019 ) propose that the term metasynthesis should be reserved for syntheses with a strong interpretive orientation, whereas in contrast, Major and Savin-Baden ( 2010 ) associate it with an aggregative approach. Paterson et al. ( 2001 ) use the term in a specific sense within their account of metastudy, to be considered in due course. See Britten et al. ( 2017 ) for a discussion of nomenclature.

Although methods such as meta-aggregation are described by some of its proponents as interpretive (Pearson et al. 2005 , 2011 ; Lockwood & Pearson, 2013 ), they do not involve the type of (re)conceptualizing, and the view of knowledge as socially constructed, that broadly characterize the interpretive tradition in social science. This somewhat thin version of interpretation is reflected in the claim by its adherents that meta-aggregation does not seek to re-interpret the findings of primary studies (Hannes and Lockwood 2011 ; Pearson et al. 2011 ).

Toye and colleagues ( 2017 , 2019 ) have recently described a synthesis of syntheses, which they term ‘mega-ethnography’. They note that this type of synthesis introduces fourth-order constructs – the interpretations of the interpretations presented in the extant meta-ethnographies being synthesized. This additional remove from the context of the original studies suggests that the challenges identified in this paper will, a fortiori , be magnified in mega-ethnography.

We are not referring to the empirical context as a component of the data that may be synthesized in the review process, in the way discussed by Booth et al. ( 2019 ) in relation to complex interventions. Rather, we are thinking of empirical context in terms of framing the meanings that are conveyed in the findings of primary qualitative studies.

Concepts are sometimes referred to as constructs. It is not straightforward to draw a clear distinction between the two terms. However, Kerlinger ( 1986 ) suggests that constructs are concepts that have been specifically invented or adopted for a particular scientific purpose; in this way, they may differ from concepts that have a more general meaning outside a discipline. The term construct may also be used when referring to the way in which, or the levels at which, concepts are created or negotiated, such as in Schutz’s ( 1963 ) use of the term noted earlier, or in relation to the idea of social constructionism (Burr 2015 ). It is also a term preferred in the context of psychometrics (Nunnally & Bernstein 1994 ).

In this connection, note that in the context of describing grounded theory as a method of constructing theory, Glaser and Strauss ( 1967 : p. 3) are clear that ‘the researcher does not approach reality as a tabula rasa . He must have a perspective that will help him see relevant data and abstract significant categories from his scrutiny of the data.’ Similarly, Glaser ( 1978 ) argues that a prior sense of ‘theoretical sensitivity’ is required in order to generate a substantive theory from data, and more recently Swedberg ( 2012 : p. 8) notes that ‘for successful theorizing in social science, you need to be thoroughly grounded in the core ideas of social science.’.

In addition to Hannes and Lockwood’s ( 2011 ) proposal of pragmatism as the philosophical foundation of meta-aggregation, Lockwood and Pearson ( 2013 ) argue for a form of transcendental phenomenology as the basis of this form of aggregation, whilst associating a more hermeneutic form of phenomenology with meta-ethnography. Whilst the transcendental versus interpretive distinction makes sense here, the basis for the appeal to phenomenology is less clear in their account.

In contrast, Florczak ( 2018 : p. 223) sees no such problem in the meta-aggregative approach, which in her view ‘allows for data from different paradigms of thought to be synthesized, which means that findings from phenomenological studies can be mixed with data from grounded theory or other research methods as long as the voice of the participant is heard.’ Her own position, in contrast, is that ‘[l]oosening the findings from particular paradigmatic perspectives strips them of their context and renders the synthesis meaningless.’

More explicit links with the notion of theory have, however, been made recently within grounded theory (Noblit 2018 ; Urrieta and Noblit 2018 ).

Doyle ( 2003 ) describes an approach to meta-ethnography in which several ‘external’ theories are applied to the process of synthesis, suggesting a less inductive process than that originally described by Noblit and Hare ( 1988 ).

Here, Kearney applies the idea of theoretical saturation: ‘The fewer the complete substantive theories, the greater the need for re-interpretation of original data by the formal theorist and the lower the theoretical saturation of the findings. The greater the number of substantive theories to work with, the higher the level of formal theory that can be achieved and the more saturated and transferable will be to the product of analysis’ (Kearney 2001a : p. 237).

The theories on which metatheory characteristically operates are what Merton ( 1968 ) called theories of the middle range. These are substantive theories that seek to explain specific, delimited aspects of social life, rather than more abstract, general theories that lie further from empirical reality.

As an extension of Ritzer’s first formulation, Colomy ( 1991 ) identifies an addition function of metatheory: that of adjudicating between different theoretical traditions.

In a similar way, critical interpretive synthesis (Dixon-Woods et al. 2006 ) extends beyond the findings of primary studies to a critical analysis of their theoretical and methodological contexts.

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Sim, J., Mengshoel, A.M. Metasynthesis: issues of empirical and theoretical context. Qual Quant 57 , 3339–3361 (2023). https://doi.org/10.1007/s11135-022-01502-w

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Metasynthesis: An Original Method to Synthesize Qualitative Literature in Psychiatry

Affiliations.

• 1 AP-HP, Cochin Hospital, Maison de Solenn, Paris, France.
• 2 Université Paris Descartes, Sorbonne Paris Cité, Paris, France.
• 3 CESP, Faculté de médecine, Université Paris-Sud, Faculté de médecine, Université de Versailles Saint-Quentin-en-Yvelines (UVSQ), INSERM, Université Paris-Saclay, Villejuif, France.
• 4 Service Universitaire de Psychiatrie de l'Adolescent, Centre Hospitalier Argenteuil, Argenteuil, France.
• 5 ECSTRA Team, UMR-1153, INSERM, Paris Diderot University, Sorbonne Paris Cité, Paris, France.
• 6 Université Paris-Sud, Paris, France.
• PMID: 29249996
• PMCID: PMC5716974
• DOI: 10.3389/fpsyt.2017.00269

Background: Metasynthesis-the systematic review and integration of findings from qualitative studies-is an emerging technique in medical research that can use many different methods. Nevertheless, the method must be appropriate to the specific scientific field in which it is used. The objective is to describe the steps of a metasynthesis method adapted from Thematic Synthesis and phenomenology to fit the particularities of psychiatric research.

Method: We detail each step of the method used in a metasynthesis published in 2015 on adolescent and young adults suicidal behaviors. We provide clarifications in several methodological points using the latest literature on metasyntheses. The method is described in six steps: define the research question and the inclusion criteria, select the studies, assess their quality, extract and present the formal data, analyze the data, and express the synthesis.

Conclusion: Metasyntheses offer an appropriate balance between an objective framework, a rigorously scientific approach to data analysis and the necessary contribution of the researcher's subjectivity in the construction of the final work. They propose a third level of comprehension and interpretation that brings original insights, improve the global understanding in psychiatry, and propose immediate therapeutic implications. They should be included in the psychiatric common research toolkit to become better recognized by clinicians and mental health professionals.

Keywords: metaethnography; metasynthesis; psychiatry; qualitative evidence synthesis; qualitative research; suicide.

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Distribution in time for articles…

Distribution in time for articles included in the metasynthesis.

Flowchart of the metasynthesis steps.

Flowchart for selecting studies from…

Flowchart for selecting studies from Ref. (22).

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A Guide to Qualitative Meta-synthesis

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Theory-generating meta-synthesis methods stem from the qualitative research paradigm, especially grounded theory. Systematic and rigorous methods are used to identify topically related research reports that provide qualitative findings for analysis. The subsequent analysis of the data goes beyond merely reorganizing and recategorizing research findings. Newly synthesized concepts are developed, and the dynamic relationships among them are fully articulated. The validity of the resultant theory is ensured based on theoretical, methodological, and researcher triangulation; unbiased data collection and sampling strategies; inductive-deductive data analysis and synthesis strategies; and continuous reflexivity.

Meta-synthesis-generated theories are highly important in environments where the use of normalized algorithms, guidelines, and protocols are on the rise. The types of theories discussed in this book will help service providers customize standardized tools so that the most effective evidence-based, yet individualized, interventions can be implemented.

TABLE OF CONTENTS

Chapter 1 | 12  pages, introduction to theory-generating meta-synthesis research, chapter 2 | 5  pages, research purpose, topic, questions, and hypotheses, chapter 3 | 13  pages, data collection and sampling, chapter 4 | 31  pages, data extraction, analysis, and theory generation, chapter 5 | 9  pages, writing up the results, chapter 6 | 6  pages, looking ahead.

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• Research article
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• Published: 10 July 2008

Methods for the thematic synthesis of qualitative research in systematic reviews

• James Thomas 1 &
• Angela Harden 1  

BMC Medical Research Methodology volume  8 , Article number:  45 ( 2008 ) Cite this article

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There is a growing recognition of the value of synthesising qualitative research in the evidence base in order to facilitate effective and appropriate health care. In response to this, methods for undertaking these syntheses are currently being developed. Thematic analysis is a method that is often used to analyse data in primary qualitative research. This paper reports on the use of this type of analysis in systematic reviews to bring together and integrate the findings of multiple qualitative studies.

We describe thematic synthesis, outline several steps for its conduct and illustrate the process and outcome of this approach using a completed review of health promotion research. Thematic synthesis has three stages: the coding of text 'line-by-line'; the development of 'descriptive themes'; and the generation of 'analytical themes'. While the development of descriptive themes remains 'close' to the primary studies, the analytical themes represent a stage of interpretation whereby the reviewers 'go beyond' the primary studies and generate new interpretive constructs, explanations or hypotheses. The use of computer software can facilitate this method of synthesis; detailed guidance is given on how this can be achieved.

We used thematic synthesis to combine the studies of children's views and identified key themes to explore in the intervention studies. Most interventions were based in school and often combined learning about health benefits with 'hands-on' experience. The studies of children's views suggested that fruit and vegetables should be treated in different ways, and that messages should not focus on health warnings. Interventions that were in line with these suggestions tended to be more effective. Thematic synthesis enabled us to stay 'close' to the results of the primary studies, synthesising them in a transparent way, and facilitating the explicit production of new concepts and hypotheses.

We compare thematic synthesis to other methods for the synthesis of qualitative research, discussing issues of context and rigour. Thematic synthesis is presented as a tried and tested method that preserves an explicit and transparent link between conclusions and the text of primary studies; as such it preserves principles that have traditionally been important to systematic reviewing.

Peer Review reports

The systematic review is an important technology for the evidence-informed policy and practice movement, which aims to bring research closer to decision-making [ 1 , 2 ]. This type of review uses rigorous and explicit methods to bring together the results of primary research in order to provide reliable answers to particular questions [ 3 – 6 ]. The picture that is presented aims to be distorted neither by biases in the review process nor by biases in the primary research which the review contains [ 7 – 10 ]. Systematic review methods are well-developed for certain types of research, such as randomised controlled trials (RCTs). Methods for reviewing qualitative research in a systematic way are still emerging, and there is much ongoing development and debate [ 11 – 14 ].

In this paper we present one approach to the synthesis of findings of qualitative research, which we have called 'thematic synthesis'. We have developed and applied these methods within several systematic reviews that address questions about people's perspectives and experiences [ 15 – 18 ]. The context for this methodological development is a programme of work in health promotion and public health (HP & PH), mostly funded by the English Department of Health, at the EPPI-Centre, in the Social Science Research Unit at the Institute of Education, University of London in the UK. Early systematic reviews at the EPPI-Centre addressed the question 'what works?' and contained research testing the effects of interventions. However, policy makers and other review users also posed questions about intervention need, appropriateness and acceptability, and factors influencing intervention implementation. To address these questions, our reviews began to include a wider range of research, including research often described as 'qualitative'. We began to focus, in particular, on research that aimed to understand the health issue in question from the experiences and point of view of the groups of people targeted by HP&PH interventions (We use the term 'qualitative' research cautiously because it encompasses a multitude of research methods at the same time as an assumed range of epistemological positions. In practice it is often difficult to classify research as being either 'qualitative' or 'quantitative' as much research contains aspects of both [ 19 – 22 ]. Because the term is in common use, however, we will employ it in this paper).

When we started the work for our first series of reviews which included qualitative research in 1999 [ 23 – 26 ], there was very little published material that described methods for synthesising this type of research. We therefore experimented with a variety of techniques borrowed from standard systematic review methods and methods for analysing primary qualitative research [ 15 ]. In later reviews, we were able to refine these methods and began to apply thematic analysis in a more explicit way. The methods for thematic synthesis described in this paper have so far been used explicitly in three systematic reviews [ 16 – 18 ].

The review used as an example in this paper

To illustrate the steps involved in a thematic synthesis we draw on a review of the barriers to, and facilitators of, healthy eating amongst children aged four to 10 years old [ 17 ]. The review was commissioned by the Department of Health, England to inform policy about how to encourage children to eat healthily in the light of recent surveys highlighting that British children are eating less than half the recommended five portions of fruit and vegetables per day. While we focus on the aspects of the review that relate to qualitative studies, the review was broader than this and combined answering traditional questions of effectiveness, through reviewing controlled trials, with questions relating to children's views of healthy eating, which were answered using qualitative studies. The qualitative studies were synthesised using 'thematic synthesis' – the subject of this paper. We compared the effectiveness of interventions which appeared to be in line with recommendations from the thematic synthesis with those that did not. This enabled us to see whether the understandings we had gained from the children's views helped us to explain differences in the effectiveness of different interventions: the thematic synthesis had enabled us to generate hypotheses which could be tested against the findings of the quantitative studies – hypotheses that we could not have generated without the thematic synthesis. The methods of this part of the review are published in Thomas et al . [ 27 ] and are discussed further in Harden and Thomas [ 21 ].

Qualitative research and systematic reviews

The act of seeking to synthesise qualitative research means stepping into more complex and contested territory than is the case when only RCTs are included in a review. First, methods are much less developed in this area, with fewer completed reviews available from which to learn, and second, the whole enterprise of synthesising qualitative research is itself hotly debated. Qualitative research, it is often proposed, is not generalisable and is specific to a particular context, time and group of participants. Thus, in bringing such research together, reviewers are open to the charge that they de-contextualise findings and wrongly assume that these are commensurable [ 11 , 13 ]. These are serious concerns which it is not the purpose of this paper to contest. We note, however, that a strong case has been made for qualitative research to be valued for the potential it has to inform policy and practice [ 11 , 28 – 30 ]. In our experience, users of reviews are interested in the answers that only qualitative research can provide, but are not able to handle the deluge of data that would result if they tried to locate, read and interpret all the relevant research themselves. Thus, if we acknowledge the unique importance of qualitative research, we need also to recognise that methods are required to bring its findings together for a wide audience – at the same time as preserving and respecting its essential context and complexity.

The earliest published work that we know of that deals with methods for synthesising qualitative research was written in 1988 by Noblit and Hare [ 31 ]. This book describes the way that ethnographic research might be synthesised, but the method has been shown to be applicable to qualitative research beyond ethnography [ 32 , 11 ]. As well as meta-ethnography, other methods have been developed more recently, including 'meta-study' [ 33 ], 'critical interpretive synthesis' [ 34 ] and 'metasynthesis' [ 13 ].

Many of the newer methods being developed have much in common with meta-ethnography, as originally described by Noblit and Hare, and often state explicitly that they are drawing on this work. In essence, this method involves identifying key concepts from studies and translating them into one another. The term 'translating' in this context refers to the process of taking concepts from one study and recognising the same concepts in another study, though they may not be expressed using identical words. Explanations or theories associated with these concepts are also extracted and a 'line of argument' may be developed, pulling corroborating concepts together and, crucially, going beyond the content of the original studies (though 'refutational' concepts might not be amenable to this process). Some have claimed that this notion of 'going beyond' the primary studies is a critical component of synthesis, and is what distinguishes it from the types of summaries of findings that typify traditional literature reviews [e.g. [ 32 ], p209]. In the words of Margarete Sandelowski, "metasyntheses are integrations that are more than the sum of parts, in that they offer novel interpretations of findings. These interpretations will not be found in any one research report but, rather, are inferences derived from taking all of the reports in a sample as a whole" [[ 14 ], p1358].

Thematic analysis has been identified as one of a range of potential methods for research synthesis alongside meta-ethnography and 'metasynthesis', though precisely what the method involves is unclear, and there are few examples of it being used for synthesising research [ 35 ]. We have adopted the term 'thematic synthesis', as we translated methods for the analysis of primary research – often termed 'thematic' – for use in systematic reviews [ 36 – 38 ]. As Boyatzis [[ 36 ], p4] has observed, thematic analysis is "not another qualitative method but a process that can be used with most, if not all, qualitative methods..." . Our approach concurs with this conceptualisation of thematic analysis, since the method we employed draws on other established methods but uses techniques commonly described as 'thematic analysis' in order to formalise the identification and development of themes.

We now move to a description of the methods we used in our example systematic review. While this paper has the traditional structure for reporting the results of a research project, the detailed methods (e.g. precise terms we used for searching) and results are available online. This paper identifies the particular issues that relate especially to reviewing qualitative research systematically and then to describing the activity of thematic synthesis in detail.

When searching for studies for inclusion in a 'traditional' statistical meta-analysis, the aim of searching is to locate all relevant studies. Failing to do this can undermine the statistical models that underpin the analysis and bias the results. However, Doyle [[ 39 ], p326] states that, "like meta-analysis, meta-ethnography utilizes multiple empirical studies but, unlike meta-analysis, the sample is purposive rather than exhaustive because the purpose is interpretive explanation and not prediction" . This suggests that it may not be necessary to locate every available study because, for example, the results of a conceptual synthesis will not change if ten rather than five studies contain the same concept, but will depend on the range of concepts found in the studies, their context, and whether they are in agreement or not. Thus, principles such as aiming for 'conceptual saturation' might be more appropriate when planning a search strategy for qualitative research, although it is not yet clear how these principles can be applied in practice. Similarly, other principles from primary qualitative research methods may also be 'borrowed' such as deliberately seeking studies which might act as negative cases, aiming for maximum variability and, in essence, designing the resulting set of studies to be heterogeneous, in some ways, instead of achieving the homogeneity that is often the aim in statistical meta-analyses.

However you look, qualitative research is difficult to find [ 40 – 42 ]. In our review, it was not possible to rely on simple electronic searches of databases. We needed to search extensively in 'grey' literature, ask authors of relevant papers if they knew of more studies, and look especially for book chapters, and we spent a lot of effort screening titles and abstracts by hand and looking through journals manually. In this sense, while we were not driven by the statistical imperative of locating every relevant study, when it actually came down to searching, we found that there was very little difference in the methods we had to use to find qualitative studies compared to the methods we use when searching for studies for inclusion in a meta-analysis.

Quality assessment

Assessing the quality of qualitative research has attracted much debate and there is little consensus regarding how quality should be assessed, who should assess quality, and, indeed, whether quality can or should be assessed in relation to 'qualitative' research at all [ 43 , 22 , 44 , 45 ]. We take the view that the quality of qualitative research should be assessed to avoid drawing unreliable conclusions. However, since there is little empirical evidence on which to base decisions for excluding studies based on quality assessment, we took the approach in this review to use 'sensitivity analyses' (described below) to assess the possible impact of study quality on the review's findings.

In our example review we assessed our studies according to 12 criteria, which were derived from existing sets of criteria proposed for assessing the quality of qualitative research [ 46 – 49 ], principles of good practice for conducting social research with children [ 50 ], and whether studies employed appropriate methods for addressing our review questions. The 12 criteria covered three main quality issues. Five related to the quality of the reporting of a study's aims, context, rationale, methods and findings (e.g. was there an adequate description of the sample used and the methods for how the sample was selected and recruited?). A further four criteria related to the sufficiency of the strategies employed to establish the reliability and validity of data collection tools and methods of analysis, and hence the validity of the findings. The final three criteria related to the assessment of the appropriateness of the study methods for ensuring that findings about the barriers to, and facilitators of, healthy eating were rooted in children's own perspectives (e.g. were data collection methods appropriate for helping children to express their views?).

Extracting data from studies

One issue which is difficult to deal with when synthesising 'qualitative' studies is 'what counts as data' or 'findings'? This problem is easily addressed when a statistical meta-analysis is being conducted: the numeric results of RCTs – for example, the mean difference in outcome between the intervention and control – are taken from published reports and are entered into the software package being used to calculate the pooled effect size [ 3 , 51 ].

Deciding what to abstract from the published report of a 'qualitative' study is much more difficult. Campbell et al . [ 11 ] extracted what they called the 'key concepts' from the qualitative studies they found about patients' experiences of diabetes and diabetes care. However, finding the key concepts in 'qualitative' research is not always straightforward either. As Sandelowski and Barroso [ 52 ] discovered, identifying the findings in qualitative research can be complicated by varied reporting styles or the misrepresentation of data as findings (as for example when data are used to 'let participants speak for themselves'). Sandelowski and Barroso [ 53 ] have argued that the findings of qualitative (and, indeed, all empirical) research are distinct from the data upon which they are based, the methods used to derive them, externally sourced data, and researchers' conclusions and implications.

In our example review, while it was relatively easy to identify 'data' in the studies – usually in the form of quotations from the children themselves – it was often difficult to identify key concepts or succinct summaries of findings, especially for studies that had undertaken relatively simple analyses and had not gone much further than describing and summarising what the children had said. To resolve this problem we took study findings to be all of the text labelled as 'results' or 'findings' in study reports – though we also found 'findings' in the abstracts which were not always reported in the same way in the text. Study reports ranged in size from a few pages to full final project reports. We entered all the results of the studies verbatim into QSR's NVivo software for qualitative data analysis. Where we had the documents in electronic form this process was straightforward even for large amounts of text. When electronic versions were not available, the results sections were either re-typed or scanned in using a flat-bed or pen scanner. (We have since adapted our own reviewing system, 'EPPI-Reviewer' [ 54 ], to handle this type of synthesis and the screenshots below show this software.)

Detailed methods for thematic synthesis

The synthesis took the form of three stages which overlapped to some degree: the free line-by-line coding of the findings of primary studies; the organisation of these 'free codes' into related areas to construct 'descriptive' themes; and the development of 'analytical' themes.

Stages one and two: coding text and developing descriptive themes

In our children and healthy eating review, we originally planned to extract and synthesise study findings according to our review questions regarding the barriers to, and facilitators of, healthy eating amongst children. It soon became apparent, however, that few study findings addressed these questions directly and it appeared that we were in danger of ending up with an empty synthesis. We were also concerned about imposing the a priori framework implied by our review questions onto study findings without allowing for the possibility that a different or modified framework may be a better fit. We therefore temporarily put our review questions to one side and started from the study findings themselves to conduct an thematic analysis.

There were eight relevant qualitative studies examining children's views of healthy eating. We entered the verbatim findings of these studies into our database. Three reviewers then independently coded each line of text according to its meaning and content. Figure 1 illustrates this line-by-line coding using our specialist reviewing software, EPPI-Reviewer, which includes a component designed to support thematic synthesis. The text which was taken from the report of the primary study is on the left and codes were created inductively to capture the meaning and content of each sentence. Codes could be structured, either in a tree form (as shown in the figure) or as 'free' codes – without a hierarchical structure.

line-by-line coding in EPPI-Reviewer.

The use of line-by-line coding enabled us to undertake what has been described as one of the key tasks in the synthesis of qualitative research: the translation of concepts from one study to another [ 32 , 55 ]. However, this process may not be regarded as a simple one of translation. As we coded each new study we added to our 'bank' of codes and developed new ones when necessary. As well as translating concepts between studies, we had already begun the process of synthesis (For another account of this process, see Doyle [[ 39 ], p331]). Every sentence had at least one code applied, and most were categorised using several codes (e.g. 'children prefer fruit to vegetables' or 'why eat healthily?'). Before completing this stage of the synthesis, we also examined all the text which had a given code applied to check consistency of interpretation and to see whether additional levels of coding were needed. (In grounded theory this is termed 'axial' coding; see Fisher [ 55 ] for further discussion of the application of axial coding in research synthesis.) This process created a total of 36 initial codes. For example, some of the text we coded as "bad food = nice, good food = awful" from one study [ 56 ] were:

'All the things that are bad for you are nice and all the things that are good for you are awful.' (Boys, year 6) [[ 56 ], p74]

'All adverts for healthy stuff go on about healthy things. The adverts for unhealthy things tell you how nice they taste.' [[ 56 ], p75]

Some children reported throwing away foods they knew had been put in because they were 'good for you' and only ate the crisps and chocolate . [[ 56 ], p75]

Reviewers looked for similarities and differences between the codes in order to start grouping them into a hierarchical tree structure. New codes were created to capture the meaning of groups of initial codes. This process resulted in a tree structure with several layers to organize a total of 12 descriptive themes (Figure 2 ). For example, the first layer divided the 12 themes into whether they were concerned with children's understandings of healthy eating or influences on children's food choice. The above example, about children's preferences for food, was placed in both areas, since the findings related both to children's reactions to the foods they were given, and to how they behaved when given the choice over what foods they might eat. A draft summary of the findings across the studies organized by the 12 descriptive themes was then written by one of the review authors. Two other review authors commented on this draft and a final version was agreed.

relationships between descriptive themes.

Stage three: generating analytical themes

Up until this point, we had produced a synthesis which kept very close to the original findings of the included studies. The findings of each study had been combined into a whole via a listing of themes which described children's perspectives on healthy eating. However, we did not yet have a synthesis product that addressed directly the concerns of our review – regarding how to promote healthy eating, in particular fruit and vegetable intake, amongst children. Neither had we 'gone beyond' the findings of the primary studies and generated additional concepts, understandings or hypotheses. As noted earlier, the idea or step of 'going beyond' the content of the original studies has been identified by some as the defining characteristic of synthesis [ 32 , 14 ].

This stage of a qualitative synthesis is the most difficult to describe and is, potentially, the most controversial, since it is dependent on the judgement and insights of the reviewers. The equivalent stage in meta-ethnography is the development of 'third order interpretations' which go beyond the content of original studies [ 32 , 11 ]. In our example, the step of 'going beyond' the content of the original studies was achieved by using the descriptive themes that emerged from our inductive analysis of study findings to answer the review questions we had temporarily put to one side. Reviewers inferred barriers and facilitators from the views children were expressing about healthy eating or food in general, captured by the descriptive themes, and then considered the implications of children's views for intervention development. Each reviewer first did this independently and then as a group. Through this discussion more abstract or analytical themes began to emerge. The barriers and facilitators and implications for intervention development were examined again in light of these themes and changes made as necessary. This cyclical process was repeated until the new themes were sufficiently abstract to describe and/or explain all of our initial descriptive themes, our inferred barriers and facilitators and implications for intervention development.

For example, five of the 12 descriptive themes concerned the influences on children's choice of foods (food preferences, perceptions of health benefits, knowledge behaviour gap, roles and responsibilities, non-influencing factors). From these, reviewers inferred several barriers and implications for intervention development. Children identified readily that taste was the major concern for them when selecting food and that health was either a secondary factor or, in some cases, a reason for rejecting food. Children also felt that buying healthy food was not a legitimate use of their pocket money, which they would use to buy sweets that could be enjoyed with friends. These perspectives indicated to us that branding fruit and vegetables as a 'tasty' rather than 'healthy' might be more effective in increasing consumption. As one child noted astutely, 'All adverts for healthy stuff go on about healthy things. The adverts for unhealthy things tell you how nice they taste.' [[ 56 ], p75]. We captured this line of argument in the analytical theme entitled 'Children do not see it as their role to be interested in health'. Altogether, this process resulted in the generation of six analytical themes which were associated with ten recommendations for interventions.

Six main issues emerged from the studies of children's views: (1) children do not see it as their role to be interested in health; (2) children do not see messages about future health as personally relevant or credible; (3) fruit, vegetables and confectionery have very different meanings for children; (4) children actively seek ways to exercise their own choices with regard to food; (5) children value eating as a social occasion; and (6) children see the contradiction between what is promoted in theory and what adults provide in practice. The review found that most interventions were based in school (though frequently with parental involvement) and often combined learning about the health benefits of fruit and vegetables with 'hands-on' experience in the form of food preparation and taste-testing. Interventions targeted at people with particular risk factors worked better than others, and multi-component interventions that combined the promotion of physical activity with healthy eating did not work as well as those that only concentrated on healthy eating. The studies of children's views suggested that fruit and vegetables should be treated in different ways in interventions, and that messages should not focus on health warnings. Interventions that were in line with these suggestions tended to be more effective than those which were not.

Context and rigour in thematic synthesis

The process of translation, through the development of descriptive and analytical themes, can be carried out in a rigorous way that facilitates transparency of reporting. Since we aim to produce a synthesis that both generates 'abstract and formal theories' that are nevertheless 'empirically faithful to the cases from which they were developed' [[ 53 ], p1371], we see the explicit recording of the development of themes as being central to the method. The use of software as described can facilitate this by allowing reviewers to examine the contribution made to their findings by individual studies, groups of studies, or sub-populations within studies.

Some may argue against the synthesis of qualitative research on the grounds that the findings of individual studies are de-contextualised and that concepts identified in one setting are not applicable to others [ 32 ]. However, the act of synthesis could be viewed as similar to the role of a research user when reading a piece of qualitative research and deciding how useful it is to their own situation. In the case of synthesis, reviewers translate themes and concepts from one situation to another and can always be checking that each transfer is valid and whether there are any reasons that understandings gained in one context might not be transferred to another. We attempted to preserve context by providing structured summaries of each study detailing aims, methods and methodological quality, and setting and sample. This meant that readers of our review were able to judge for themselves whether or not the contexts of the studies the review contained were similar to their own. In the synthesis we also checked whether the emerging findings really were transferable across different study contexts. For example, we tried throughout the synthesis to distinguish between participants (e.g. boys and girls) where the primary research had made an appropriate distinction. We then looked to see whether some of our synthesis findings could be attributed to a particular group of children or setting. In the event, we did not find any themes that belonged to a specific group, but another outcome of this process was a realisation that the contextual information given in the reports of studies was very restricted indeed. It was therefore difficult to make the best use of context in our synthesis.

In checking that we were not translating concepts into situations where they did not belong, we were following a principle that others have followed when using synthesis methods to build grounded formal theory: that of grounding a text in the context in which it was constructed. As Margaret Kearney has noted "the conditions under which data were collected, analysis was done, findings were found, and products were written for each contributing report should be taken into consideration in developing a more generalized and abstract model" [[ 14 ], p1353]. Britten et al . [ 32 ] suggest that it may be important to make a deliberate attempt to include studies conducted across diverse settings to achieve the higher level of abstraction that is aimed for in a meta-ethnography.

Study quality and sensitivity analyses

We assessed the 'quality' of our studies with regard to the degree to which they represented the views of their participants. In doing this, we were locating the concept of 'quality' within the context of the purpose of our review – children's views – and not necessarily the context of the primary studies themselves. Our 'hierarchy of evidence', therefore, did not prioritise the research design of studies but emphasised the ability of the studies to answer our review question. A traditional systematic review of controlled trials would contain a quality assessment stage, the purpose of which is to exclude studies that do not provide a reliable answer to the review question. However, given that there were no accepted – or empirically tested – methods for excluding qualitative studies from syntheses on the basis of their quality [ 57 , 12 , 58 ], we included all studies regardless of their quality.

Nevertheless, our studies did differ according to the quality criteria they were assessed against and it was important that we considered this in some way. In systematic reviews of trials, 'sensitivity analyses' – analyses which test the effect on the synthesis of including and excluding findings from studies of differing quality – are often carried out. Dixon-Woods et al . [ 12 ] suggest that assessing the feasibility and worth of conducting sensitivity analyses within syntheses of qualitative research should be an important focus of synthesis methods work. After our thematic synthesis was complete, we examined the relative contributions of studies to our final analytic themes and recommendations for interventions. We found that the poorer quality studies contributed comparatively little to the synthesis and did not contain many unique themes; the better studies, on the other hand, appeared to have more developed analyses and contributed most to the synthesis.

This paper has discussed the rationale for reviewing and synthesising qualitative research in a systematic way and has outlined one specific approach for doing this: thematic synthesis. While it is not the only method which might be used – and we have discussed some of the other options available – we present it here as a tested technique that has worked in the systematic reviews in which it has been employed.

We have observed that one of the key tasks in the synthesis of qualitative research is the translation of concepts between studies. While the activity of translating concepts is usually undertaken in the few syntheses of qualitative research that exist, there are few examples that specify the detail of how this translation is actually carried out. The example above shows how we achieved the translation of concepts across studies through the use of line-by-line coding, the organisation of these codes into descriptive themes, and the generation of analytical themes through the application of a higher level theoretical framework. This paper therefore also demonstrates how the methods and process of a thematic synthesis can be written up in a transparent way.

This paper goes some way to addressing concerns regarding the use of thematic analysis in research synthesis raised by Dixon-Woods and colleagues who argue that the approach can lack transparency due to a failure to distinguish between 'data-driven' or 'theory-driven' approaches. Moreover they suggest that, "if thematic analysis is limited to summarising themes reported in primary studies, it offers little by way of theoretical structure within which to develop higher order thematic categories..." [[ 35 ], p47]. Part of the problem, they observe, is that the precise methods of thematic synthesis are unclear. Our approach contains a clear separation between the 'data-driven' descriptive themes and the 'theory-driven' analytical themes and demonstrates how the review questions provided a theoretical structure within which it became possible to develop higher order thematic categories.

The theme of 'going beyond' the content of the primary studies was discussed earlier. Citing Strike and Posner [ 59 ], Campbell et al . [[ 11 ], p672] also suggest that 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" . This was certainly true of the example given in this paper. We used a series of questions, derived from the main topic of our review, to focus an examination of our descriptive themes and we do not find our recommendations for interventions contained in the findings of the primary studies: these were new propositions generated by the reviewers in the light of the synthesis. The method also demonstrates that it is possible to synthesise without conceptual innovation. The initial synthesis, involving the translation of concepts between studies, was necessary in order for conceptual innovation to begin. One could argue that the conceptual innovation, in this case, was only necessary because the primary studies did not address our review question directly. In situations in which the primary studies are concerned directly with the review question, it may not be necessary to go beyond the contents of the original studies in order to produce a satisfactory synthesis (see, for example, Marston and King, [ 60 ]). Conceptually, our analytical themes are similar to the ultimate product of meta-ethnographies: third order interpretations [ 11 ], since both are explicit mechanisms for going beyond the content of the primary studies and presenting this in a transparent way. The main difference between them lies in their purposes. Third order interpretations bring together the implications of translating studies into one another in their own terms, whereas analytical themes are the result of interrogating a descriptive synthesis by placing it within an external theoretical framework (our review question and sub-questions). It may be, therefore, that analytical themes are more appropriate when a specific review question is being addressed (as often occurs when informing policy and practice), and third order interpretations should be used when a body of literature is being explored in and of itself, with broader, or emergent, review questions.

This paper is a contribution to the current developmental work taking place in understanding how best to bring together the findings of qualitative research to inform policy and practice. It is by no means the only method on offer but, by drawing on methods and principles from qualitative primary research, it benefits from the years of methodological development that underpins the research it seeks to synthesise.

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Acknowledgements

The authors would like to thank Elaine Barnett-Page for her assistance in producing the draft paper, and David Gough, Ann Oakley and Sandy Oliver for their helpful comments. The review used an example in this paper was funded by the Department of Health (England). The methodological development was supported by Department of Health (England) and the ESRC through the Methods for Research Synthesis Node of the National Centre for Research Methods. In addition, Angela Harden held a senior research fellowship funded by the Department of Health (England) December 2003 – November 2007. The views expressed in this paper are those of the authors and are not necessarily those of the funding bodies.

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Thomas, J., Harden, A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol 8 , 45 (2008). https://doi.org/10.1186/1471-2288-8-45

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Definition : "Systematic reviews of diagnostic test accuracy provide a summary of test performance based on all available evidence, evaluate the quality of published studies, and account for variation in findings between studies." JBI Reviewers Handbook

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When to use : When there is an abundance and a diversity of research, as a first step to a systematic review, or to identify gaps in a topic area.

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Definition : A meta-ethnography brings together qualitative data to form a new interpretation of the research field.  It helps to build new theories and is not to be confused with a meta-analysis which tests a hypothesis using quantitative data.  It primarily generates theory such as program theory, implementation theory, or an explanatory theory of why the intervention works or not; hypothesis for future testing or comparison with trial outcomes.

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• Conducting a meta-ethnography of qualitative literature: lessons learnt.
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When to use : For multidisciplinary topics or topics with a body of literature that includes quantitative, qualitative, and mixed methods studies, to determine not only the effects of interventions but also their appropriateness, to identify research gaps, to provide an explanation for possible heterogeneity between trials, to answer multiple questions in one systematic review.

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When to use : For conditions with multiple interventions, where there are many combinations of direct or indirect interactions, to make treatment estimates for an entire treatment network instead of scanning each individual pair-wise comparison, to give the "full picture" to clinicians, potential to more explicitly "rank" treatments using summary outputs

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Treatment Outcomes With Licensed and Unlicensed Stimulant Doses for Adults With Attention-Deficit/Hyperactivity Disorder : A Systematic Review and Meta-Analysis

• 1 Department of Psychiatry, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, Brazil
• 2 Division of Child & Adolescent Psychiatry, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), Los Angeles, California
• 3 Child Study Center, Yale University School of Medicine, New Haven, Connecticut
• 4 Department of Psychiatry, University of Oxford, Oxford, United Kingdom
• 5 Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom
• 6 Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, United Kingdom
• 7 Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/ School of Public Health, Kyoto, Japan
• 8 Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
• 9 Center for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, United Kingdom
• 10 Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, United Kingdom
• 11 Solent NHS Trust, Southampton, United Kingdom
• 12 Department of Child and Adolescent Psychiatry, NYU Grossman School of Medicine, New York, New York
• 13 Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, United Kingdom

Question   Are unlicensed doses of stimulants associated with positive treatment outcomes in adults with attention-deficit/hyperactivity disorder (ADHD)?

Findings   In this systematic review and meta-analysis of group averages, unlicensed doses of stimulants were associated with small, possibly nonclinically meaningful, additional reductions of ADHD symptoms and increased risk of treatment discontinuation due to adverse events in comparison with licensed doses of these medications.

Meaning   Based on averages from available placebo-controlled randomized clinical trials, unlicensed doses of stimulants may not have positive risk benefits for adults with ADHD and practitioners should generally consider unlicensed doses cautiously.

Importance   Stimulants (methylphenidate and amphetamines) are often prescribed at unlicensed doses for adults with attention-deficit/hyperactivity disorder (ADHD). Whether dose escalation beyond US Food and Drug Administration recommendations is associated with positive risk benefits is unclear.

Objective   To investigate the impact, based on averages, of stimulant doses on treatment outcomes in adults with ADHD and to determine, based on averages, whether unlicensed doses are associated with positive risk benefits compared with licensed doses.

Data Sources   Twelve databases, including published (PubMed, Cochrane Library, Embase, Web of Sciences) and unpublished (ClinicalTrials.gov) literature, up to February 22, 2023, without language restrictions.

Study Selection   Two researchers independently screened records to identify double-blinded randomized clinical trials of stimulants against placebo in adults (18 years and older) with ADHD.

Data Extraction and Synthesis   Aggregate data were extracted and synthesized in random-effects dose-response meta-analyses and network meta-analyses.

Main Outcome Measures   Change in ADHD symptoms and discontinuations due to adverse events.

Results   A total of 47 randomized clinical trials (7714 participants; mean age, 35 (SD, 11) years; 4204 male [56%]) were included. For methylphenidate, dose-response curves indicated additional reductions of symptoms with increments in doses, but the gains were progressively smaller and accompanied by continued additional risk of adverse events dropouts. Network meta-analyses showed that unlicensed doses were associated with greater reductions of symptoms compared with licensed doses (standardized mean difference [SMD], −0.23; 95% CI, −0.44 to −0.02; very low certainty of evidence), but the additional gain was small and accompanied by increased risk of adverse event dropouts (odds ratio, 2.02; 95% CI, 1.19-3.43; moderate certainty of evidence). For amphetamines, the dose-response curve approached a plateau and increments in doses did not indicate additional reductions of symptoms, but there were continued increments in the risk of adverse event dropouts. Network meta-analysis did not identify differences between unlicensed and licensed doses for reductions of symptoms (SMD, −0.08; 95% CI, −0.24 to 0.08; very low certainty of evidence).

Conclusions and Relevance   Based on group averages, unlicensed doses of stimulants may not have positive risk benefits compared with licensed doses for adults with ADHD. In general, practitioners should consider unlicensed doses cautiously. Practitioners may trial unlicensed doses if needed and tolerated but should be aware that there may not be large gains in the response to the medication with those further increments in dose. However, the findings are averages and will not generalize to every patient.

Read More About

Farhat LC , Flores JM , Avila-Quintero VJ, et al. Treatment Outcomes With Licensed and Unlicensed Stimulant Doses for Adults With Attention-Deficit/Hyperactivity Disorder : A Systematic Review and Meta-Analysis . JAMA Psychiatry. 2024;81(2):157–166. doi:10.1001/jamapsychiatry.2023.3985

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A meta-synthesis study of literature review and systematic review published in nurse prescribing

Azar darvishpour.

1. PhD Candidate, Department of Medical-Surgical Nursing, Faculty of Nursing and Midwifery, Iran University of Medical Science, Tehran, Iran & Social Determinants of Health (SDH) Research Center, School of Nursing and Midwifery, Guilan University of Medical Sciences (GUMS), Guilan, Iran. ri.ca.smug@ruophsivrad

Soodabeh Joolaee

2. Associate Professor of Nursing, Center for Nursing Care Research, Department of Nursing Management, Faculty of Nursing and Midwifery, Iran University of Medical Science, Tehran, Iran. moc.oohay@seealooj

Mohammad Ali Cheraghi

3. Associate Professor, Department of critical Nursing, Faculty of Nursing and Midwifery, Tehran University of Medical Science, Tehran, Iran. moc.oohay@0002ilaihgareh

Background: Prescribing represents a new aspect of practice for nurses. To make qualitative results more accessible to clinicians, researchers, and policy makers, individuals are urged to synthesize findings from related studies. Therefore this study aimed to aggregate and interpret existing literature review and systematic studies to obtain new insights on nurse prescription.

Methods: This was a qualitative meta synthesis study using Walsh and Downe process. In order to obtain data all Digital National Library of Medicine's databases, search engines and several related sites were used. Full texts with "review and nurs* prescri* " words in the title or abstract in English language and published without any time limitation were considered. After eliminating duplicate and irrelevant studies, 11 texts were selected. Data analysis was conducted using qualitative content analysis. Multiple codes were compared based on the differences and similarities and divided to the categories and themes.

Results: The results from the meta synthesis of the 11 studies revealed 8 themes namely: leading countries in prescribing, views, features, infrastructures, benefits, disadvantages, facilitators and barriers of nursing prescription that are discussed in this article. The results led to a schematic model.

Conclusion: Despite the positive view on nurse prescribing, there are still issues such as legal, administrative, weak research and educational deficiencies in academic preparation of nurses that needs more effort in these areas and requires further research.

Introduction

Many countries have introduced non-medical prescription to improve efficiency and access to medication, particularly where access to doctors can be difficult ( 1 ). The number of countries where nurses are legally permitted to prescribe medication has grown considerably over the last two decades ( 2 ). Now in many countries (Australia, USA, UK, Canada, Ireland, etc) specific groups of nurses are allowed to prescribe various drugs ( 3 ).

In fact, in countries with a well-developed education system for nurses, opportunities exist for nurses to obtain advanced practice training and graduate education; in the US, Canada and the United Kingdom. For example, a nurse practitioner typically defined as a registered nurse who is educated to function in an advanced clinical role and prescribing is one aspect of this advanced clinical role ( 4 ).

The benefits of non-medical prescribing have been consistently reported in the literature ( 1 ). Improved speed and convenience of access to medicines have been consistently reported as key benefits of non-medical prescription by patients and health professionals ( 1 ).

According to this, the World Health Organization (WHO) in the fifth meeting of the regional advisory panel in the Eastern Mediterranean nursing convention (Islamabad, Pakistan, 2001) recommended that it required nurses as first-line health care providers to be empowered and prepared to prescribe properly ( 5 ). However, nurses in many countries still do not have the authority to prescribe medication. The introduction of major policy initiatives, such as nurse prescribing, requires high level of discussion and policy development to ensure successful implementation ( 6 ). Accordingly, each country can utilize international experiences to minimize their inevitable losses and damages. It can give new insight regarding the different aspects and necessity of implementation of nurse drug prescribing in leading countries. A significant number of review studies have been conducted related to nurse prescribing ( 2 , 7 - 16 ). Each of these studies has contributed to our understanding of nurse prescribing, but to both advance knowledge and policy making for its implementation, knowledge synthesis across multiple studies is required. To make qualitative results more accessible to clinicians, researchers, and policymakers, individuals are urged to synthesize findings from related studies ( 17 ). Thus the purpose of this study was to aggregate and interpret existing literature review and systematic review studies to obtain new insights on nurse prescribing drugs, and to present a schematic model of nurse prescribing that can be a useful framework for its implementation. According to the purpose of the study, the following questions were considered in literature reviews:

• - What is the overall view on nurse prescribing?
• - What are the positive and negative outcomes of nurse prescribing?
• - What are the barriers and facilitators for its implementation?

Qualitative Meta synthesis method was applied to conduct this study. The purpose of the Meta synthesis is to dig below the surface of what is currently understood regarding a phenomenon, to emerge with the kernel of a new truth, a better kind of understanding of something ( 18 ). Metasynthesis, a systematic synthesis of findings across qualitative studies, seeks to generate new interpretations for which there is a consensus within a particular field of study ( 19 ). A qualitative meta synthesis integrates individual qualitative studies by bringing together and breaking down the findings (themes, metaphors, or categorizations) of individual studies, elucidating the key features, and combining these findings into a transformed whole –a single description of the findings that authentically represents all of the cases ( 20 ).

The meta synthesis process employed in this study followed that done by Walsh and Downe (2005) ( 21 ). Walsh and Downe developed and proposed a seven-step approach for the qualitative meta-synthesis: ( 1 ) framing a meta-synthesis exercise, ( 2 ) locating relevant papers, ( 3 ) deciding what to include, ( 4 ) appraising studies, ( 5 ) comparing and contrasting exercise, ( 6 ) reciprocating translation, and ( 7 ) synthesizing translation ( 21 ).

Search strategy included all of the following databases, search interfaces and journals of INLM (Integrated Digital National Library of Medicine) from August 14, 2012 to December week 4 2012: EBSCO host (CINAHL), EBSCO host (Medline), Ovid SP (MEDLINE(R)), Cochran Library, Scopus, Web of science, Elsevier, Emelard, JAMA Journals, Wiley, Oxford Journals, Springer and Thieme Journals and few related sites (World Health Organization (www.who.int), websites for health professionals ( http://www.nurse-prescriber.co . uk), Google Scholar (scholar.google.com) and http://journals.cambridge.org/action/ search).

The inclusion, exclusion criteria and appropriate data sources were identified. The inclusion criteria included: all studies without time restriction that contain search terms (review and nurs* prescri*) in the title or abstract, with published full text in English. The review studies that had a search strategy were included but review studies of experts' opinion and without a search strategy were excluded from the meta synthesis.

One researcher screened all titles and abstracts and two other researchers during supervising the process of study, screened full texts as relevant to the purpose of study. Quality assessment and data extraction was carried out by three researchers.

The qualities of included papers were appraised using AMSTAR tool (Assessment of Multiple Systematic Reviews consists of 11 items) ( 22 ) and CASP tool (Critical Appraisal Skills Program for Review articles with 10 items) ( 23 ). Studies were awarded a score between 0 and 11 for AMSTAR and 0-10 for CASP tool. Studies rated as low, medium, and high quality.

The electronic search yielded 5829 results in which. 49 were duplicated and 5739 had no relevant to the research objectives and therefore excluded. This reduced the number of texts to 41. The full texts of the remaining 41articles were reviewed and a further 30 put aside and not reviewed (i.e. book review). Finally, 11 studies were selected, reviewed and included in this study ( 2 , 7 - 16 ). Figure 1 shows summary of the selection process for articles used in the study. Table 1 illustrates search strategy of Ovid SP (MEDLINE(R))

The flowchart for the search and selection process

4 of these 11 review articles were considered as systematic review and 7 literature review. Systematic review articles were evaluated by means of AMSTAR in which three were strong (score of 0.8) and one moderate (score of 0.51 to 0.79). Review articles with CASP (Critical Appraisal Skills Program) tool were tested that three were evaluated as "strong" (score more than 0.8) and 4 "moderate" articles (score of 0.51 to 0.79).

All 11 studies that met the inclusion criteria were read line by line several times in order to get the intended message of the content as well as an accurate impression of the context. The results and conclusions of studies were considered as “meaning units” and coded, integrated, synthesized and categorized. Multiple codes based on the differences and similarities compared and divided into category and themes. The results of meta synthesis revealed 8 themes namely: Leading countries in prescribing, Views, Features, Infrastructures, Benefits, Disadvantages, Facilitators and Barriers. Examples illustrating these themes can be found in Tables 1 , ​ ,2 2 and ​ and3. 3 . These themes are described bellow.

Further research is needed to provide a picture for investigated concept. The results were lead to a schematic model ( Fig. 2 ). This model of nurse prescribing can help policymakers to identify areas for attention.

Schematic model of nurse prescribing medicine

Leading countries in prescription drug

The results showed that four studies in this meta synthesis focused on the leading countries in prescription drug ( 2 , 13 - 15 ).

Bhanbhro et al (2011) found that the majority of studies about nurse prescribing were undertaken in the UK with only one from USA, Canada, Botswana and Zimbabwe each ( 15 ). In addition, Kroezen et al (2011) showed that seven Western European and Anglo-Saxon countries (Australia, Canada, Ireland, New Zealand, Sweden, the UK and the USA) had implemented nurse prescribing medicines. Netherlands and Spain were in the process of introducing nurse prescribing drug policies ( 2 ).

Views relating to nurse prescribing

Nine studies indicated the views (doctors, nurses, and patients) related to nurse prescriber ( 8 - 16 ). All of these studies have reported positive views on nurse. For example Latter and Courtenay (2004) stated: “The review highlights that nurse prescribing has generally been evaluated positively to date” ( 10 ).

Also Van Ruth et al (2008) mentioned "The effects of nurse prescribing seem positive, although the high risk of bias in the studies means they must be regarded with caution" ( 12 ).

In addition, Bhanbhro et al. (2011) reported that non-medical prescribing was widely accepted and viewed positively by patients and professionals ( 15 ).

Only two studies noted indirectly negative views of physicians on the nurse practitioners prescribing medicine as follows:

"Nurses and pharmacists were positive about supplementary prescribing (SP) but the medical profession were more critical and lacked awareness/ understanding, according to the identified literature" ( 11 ).

Also Creedon, et al (2009) quoted Wilhelmsson and Foldeivi (2003) that the Swedish GPs had lacked knowledge on the training of nurse prescribers, which could account for their negative views on nurse prescribing ( 13 ).

However, these negative views can be a barrier that should be given particular importance to the implementation of nurse prescriber.

Results showed that seven authors came up with the issue of Features of nurse prescribing ( 2 , 7 , 10 , 12 - 14 , 16 ).This issue consists of 4 category (Prescribing patterns, Areas of nurse prescribing, Confidence in prescribing and Quality and safety of practice) that emerged in this study. Table 2 shows summary of emerged cods and categories of this issue.

The findings showed the most important feature of nurse prescribing was long consultation results of Horrocks et al (2002) and Van Ruth et al (2008) studies. These studies noted that longer consultations lead to better quality of care and increase patient satisfaction and improve patient-centered care as the main goal of health care system ( 7 , 12 ).

Eight studies ( 7 - 10 , 12 - 14 , 16 ) investigated benefits of nurse prescribing. These benefits were categorized as: benefits for health system, patients, and nurses. Benefits for health system consists of better care delivery, acquiring patients satisfaction, reduction in number of required personnel, effectiveness and potentially reduction in costs.

There were some benefits for patients including convenience, easier access to drugs and care, receive better care, health promotion, earlier treatment, reduce in waiting time for medication, safety, satisfaction of care, improvement in compliance with medications, prevention of relapses, closeness and proximity of patients to health care providers, make sense of the nurses concerns expressed by patients and reduction in the number of journeys some carers had to make. And benefits for nurses included reduction in workload, time saving, professional autonomy, professional development, satisfaction of role, increasing clinical competence, better use of nurses' skills and experience, recognition abilities, capabilities and expertise of nurses, better accountability, enhance the effective monitoring and reporting of adverse drug reactions, improve communication between the professional health care team. In addition, the evidence showed that nurse prescribing was also useful for physicians and other health care professionals. Jabareen (2008) quoted Crossman (2006) that Nurse prescribing allows GPs to take on more complex cases ( 27 ). Also Bowskill (2009) quoted Jordan, Knight and Pointon (2004) and Jones et al (2007) that nurse prescribing was a useful means for reducing professional distance, enabling nurse prescribers to work more closely with medical colleagues ( 28 ).

Disadvantages

Two studies ( 9 , 16 ) mentioned disadvantages of nurse prescribing. Harris (2004) stated this Disadvantage as follows: "Most of nurses felt that there was additional work associated with record keeping and administration" ( 9 ). Price et al (2012) has quoted the disadvantage as "safety concerns" including: working outside the parameters of Patient Group Directions (PGD), poor record keeping and the development of PGD that failed to comply with legal requirements ( 16 ).

Infrastructures

In total, the meta synthesis showed that three authors investigated the infrastructures of nurse prescribing ( 2 , 10 , 15 ). Most other studies were not relevant to the main study question. This issue covered three categories (legal status, educational and organizational conditions).

Only one study stated the legal restrictions as follows: "All Western-European and Anglo-Saxon countries that have realized or initiated nurse prescribing have imposed legal restrictions on which categories of nurses can prescribe medicines" ( 2 ).

Two studies ( 2 , 15 ) addressed organizational conditions as illustrated in the following comment:

"The gradual growth over time of legislative authority and in the numbers of non-medical prescribers, particularly nurses, in some countries suggests that the acceptability of nonmedical prescribing is based on the perceived value to the health care system as a whole ( 15 ) and "It is nonetheless clear that most countries operate some sort of mandatory registration system in which nurse prescribers have to be registered before they are allowed to prescribe" ( 2 ).

One study ( 2 ) which focused on educational conditions stated: "nurses are required to successfully complete a prescribing course before they are allowed to start prescribing and one of the most important requirements for nurses internationally to enter prescribing programs is sufficient clinical experience" and also: "nurses must have three - five years of clinical experience in their own field of practice, before they are eligible for endorsements as a nurse practitioner and hence for prescribing medicines".

The results indicated barriers to nurse prescribing categories included: legal limitations, executive factors, educational deficiencies, research weaknesses, humanistic factors such as concerns about the adequacy of pharmacologic knowledge and unaware of physicians about nurse prescribing education ( Table 3 ).

Facilitators

The results of the meta synthesis indicated the facilitators of nurse prescribing such as training and educational preparations, managerial factor for support mechanisms and competency assessment, organizational factors to aware physicians and other staff about nurse prescribing. Table 4 shows summary of facilitators in nurse prescribing implementation identified by the meta-synthesis.

As the results show in Schematic model ( Fig. 2 ), barriers and facilitators are directly in contact with infrastructures. In fact, with structural reforming, the barriers will be eliminated and the implementation of the nurse prescribing will be facilitated.

Our analysis showed different aspects of nurse prescribing that can help other countries act on its implementation with greater recognition.

The first theme "the leading countries in prescribing" depicted that the implementation of nurse prescribing in UK was higher than other countries. Nurse drug prescribing in the UK has grown significantly over the last decade and it is well established as a mainstream qualification ( 29 ).

Despite this fact that nurse prescribing has had well growth in European and American countries, but unfortunately, there is no evidence to indicate its implementation in Asian countries. This may be attributed due to diverse policy of health care system, cultural, economical, political and social conditions dominated in these countries that the nurses. Hence, despite the useful information derived from leading countries, the health policy makers should consider their context for nurse prescribing implementation.

This issue can also be looked at the other side that may be nurses are prescribing in these countries now, but it has not been published in online articles. As the Miles et al (2006) mentioned detailed information about the specific nature of nurse prescribing in low-resource settings was generally lacking in the literature ( 30 ).

The theme "Views"(second theme) indicated the views of different stakeholders (doctors, nurses, and patients) on nurse prescribing. Although all reviews studies reported positive views regarding nurse prescribing but negative views of physicians was reported which may be due to lack of knowledge on the training of nurse prescribers. Health professions have often specific knowledge in their field and do not have sufficient awareness about other professions. This may cause resistance to implementation of such activities that have overlap with their areas of functions. However, the health policy makers should pay special attention to this issue in their strategic planning and provide proper context for professional's familiarity with other fields. For instance it is recommended some of nursing courses be taught by physicians. In this way, doctors may become more familiar with the content of nursing courses and also nurses learn better interaction with physicians.

Another theme in our findings was" features of nurse prescribing". One of the features of nurse prescribing noted in studies was longer consultations of nurse prescribers than physicians that can lead patient-centered care as a main goal of health care system. This feature is a unique characteristic of nursing that is affected by holistic perspective toward patient. Based on the Irajpour et al (2012) study, more problems raise when some professionals treat patients as medical cases only worth studying rather than a human who needs health services ( 31 ). Thus nurse prescribing with their holistic view may probably face fewer problems.

"Benefits" and "disadvantages" were the two other themes emerged in our study.

These results showed in contrast to the considerable benefits of nurse prescribing, there are a few disadvantages that can be corrected by managerial planning. Each of identified benefits is enough important to support the development of nurse prescribing in all countries. These benefits are likely to be extended if nurse practitioners are able to prescribe ( 32 ). Here's a point worth mentioning that these reviews despite the many benefits of nurse prescribing have not addressed cost-benefit and cost- effectiveness of nurse prescribing. In other words, there are very few published evaluations about the clinical outcomes and cost effectiveness of nurse prescribing, particularly in direct comparison with doctors, the traditional prescribers of medication ( 30 ).

For example it is mentioned in Venning et al (2000) study that clinical care and health service costs of nurse practitioners and general practitioners were similar. However, they concluded if nurse practitioners were able to maintain the benefits while reducing their return consultation rate or shortening consultation times, they could be more cost effective than general practitioners ( 33 ). Another possible explanation for cost- effectiveness of nurse prescribing may be the view of hospitals in the past which considered nurses as cheap labor and believed they “owned” nurses. Today, many hospitals hold the same view ( 34 ). Thus with a simple count it may be concluded that the nurse prescribing is both cost-benefit and cost-effectiveness. However more information is needed about the cost-benefit and cost-effectiveness of nurse prescribing that point to the need for further research.

Another theme in this meta-synthesis was infrastructures. Although the main issues for implementation of nurse prescribing (legal status, educational and organizational conditions) have been expressed in studies, but there is no available evidence regarding the cultural and political context that strongly affect on the entire topic of nurse prescribing. Importance of this issue is stated in Mills et al study (2oo6) who mentioned some of issues may be somewhat irrelevant when it comes to politically and economically unstable environments ( 30 ).

Thus it seems that one of the priorities of nurse prescribing implementation is providing cultural and political context. However these factors can affect as the barriers in nurse prescribing implementation because they can influence on views of policy makers and managers. Then their views can impact on strategic planning, implementation, and supportive structure or even on interaction of medical team colleagues.

The results identified a broad range of barriers and facilitators (Theme 7 and 8). These factors should be inferred as guides for policymakers to implementation of the nurse prescribing. Also the results revealed there are still issues such as legal, administrative, weak research and educational deficiencies in leading countries which needs for more effort to be made in these areas. Based on this review lack of confidence in applied pharmacology and therapeutics is an issue categorized in human factors as the barrier of nurse drug prescription. Conversely, self-confidence is a facilitator in nurse prescribing. On the other hand, delegating authority and enhancing self-confidence of nurses can help them to apply their knowledge in practice ( 35 ).

Miles et al (2oo6) expressed there are key elements of success in developing mechanisms for nurse prescribing such as strong political, support of nursing and academic programs to educate. ( 30 ). However, one of the problems highlighted with training programs is that many academic nursing education programs are not always feasible, affordable or attainable, particularly in rural areas ( 30 ). Support mechanisms are other important issues that are addressed in this meta synthesis. For providing this the nurse managers can play an important role. This support can undertake any facilitating activity, such as providing facilities, means and equipment, information, education, rewards and even some symbolic behaviors that nurses perceive to be facilitating ( 35 ). Also the support that physicians give in terms of ongoing training and supervision is important key in nurse prescribing ( 36 ).

Considering the findings of this study, it seems that nursing prescribing is positive experience and other countries can introduce its implementation without serious concern. In this metasynthesis, the most important factors identified including providing valuable information for nurse managers and policy makers. However, the results revealed there are still issues such as legal, administrative, weak research and educational deficiencies in leading countries that needs more effort in these areas. Appropriate training and support mechanisms are needed in order to facilitate implementation of nurse prescribing. In spite of the useful information that has been obtained from the study of the leading countries, cultural and social factors of each country are also of great importance. Hence health policy makers should identify barriers and facilitators within their own context and use this information to promote health system.

Ethical Considerations

Although the ethical issues were minimal in this study since no human subjects were involved, the researchers still had an ethical responsibility arising from this study. In order to fulfill this, the researchers considered the ethical responsibility as follows:

• Commitment to respecting moral rights of authors and no forging parts or all of the results (data making‏)
• Intentional manipulation of data or analyzes (falsification), or reporting methods not used by the researchers

Recommendations for future research

There are little evidences reporting the economic and financial outcomes of non-medical prescribing. It is therefore recommended that future studies explore cost-benefit and cost-effectiveness of nurse prescribing.

Considering the importance of the cultural context of health systems in implementation of programs, policymakers must recognize this within their own context. It is suggested that next research should be on understanding of infrastructures and existing context of nurse prescribing in each country.

There is also a need for more theory-based research on nurse prescribing. Future research should address this.

Limitations

Limitations of this synthesis include the exclusion of unpublished and in progress reviews and systematic reviews.

Acknowledgements

This study is part of a PhD thesis financially supported by Tehran University of Medical Sciences (Grant Number: 1929).

Conflict of Interest

No conflict of interest associated with this work.

Cite this article as: Darvishpour A, Joolaee S, Cheraghi M.A. A meta-synthesis study of literature review and systematic review published in nurse prescribing. Med J Islam Repub Iran 2014 (22 July). Vol. 28:77.

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• http://orcid.org/0000-0002-5210-1538 Elisa Pineda 1 , 2 ,
• Jemima Stockton 3 ,
• Shaun Scholes 3 ,
• Camille Lassale 4 , 5 and
• Jennifer S Mindell 3
• 1 The George Institute for Global Health UK , Imperial College London , London , UK
• 2 School of Public Health , Imperial College London , London , UK
• 3 Research Department of Epidemiology and Public Health , University College London , London , UK
• 4 Barcelona Institute for Global Health (ISGlobal) , Barcelona , Spain
• 5 CIBER Physiopathology of Obesity and Nutrition (CIBEROBN) , Carlos III Health Institute (ISCIII) , Madrid , Spain
• Correspondence to Dr Elisa Pineda; e.pineda{at}imperial.ac.uk

Background Obesity is influenced by a complex, multifaceted system of determinants, including the food environment. Governments need evidence to act on improving the food environment. The aim of this study was to review the evidence from spatial environmental analyses and to conduct the first series of meta-analyses to assess the impact of the retail food environment on obesity.

Methods We performed a systematic review and random-effects meta-analyses, focusing on geographical–statistical methods to assess the associations between food outlet availability and obesity. We searched OvidSP-Medline, Scielo, Scopus and Google Scholar databases up to January 2022. The search terms included spatial analysis, obesity and the retail food environment. Effect sizes were pooled by random-effects meta-analyses separately according to food outlet type and geographical and statistical measures.

Findings Of the 4118 retrieved papers, we included 103 studies. Density (n=52, 50%) and linear and logistic regressions (n=68, 66%) were the main measures used to assess the association of the food environment with obesity. Multilevel or autocorrelation analyses were used in 35 (34%) studies. Fast-food outlet proximity was positively and significantly associated with obesity (OR: 1.15, 95% CI: 1.02 to 1.30, p=0.02). Fresh fruit and vegetable outlet density and supermarket proximity were inversely associated with obesity (OR: 0.93, 95% CI: 0.90 to 0.96, p<0.001; OR: 0.90, 95% CI: 0.82 to 0.98, p=0.02). No significant associations were found for restaurants, convenience stores or any of the body mass index measures.

Conclusions Food outlets which sell mostly unhealthy and ultra-processed foods were associated with higher levels of obesity, while fruit and vegetable availability and supermarket accessibility, which enable healthier food access, were related to lower levels of obesity. The regulation of food outlets through zoning laws may not be enough to tackle the burden of obesity. Regulations that focus on increasing the availability of healthy food within stores and ensure overall healthy food environments require further attention.

PROSPERO registration number CRD42018111652.

• Malnutrition

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:  https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/bmjnph-2023-000663

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WHAT IS ALREADY KNOWN ON THIS TOPIC

The food environment is a recognised key determinant for the prevention of obesity and other diet-related non-communicable diseases (NCDs). Multiple studies have identified inconsistent findings regarding the association between elements of the retail food environment and obesity. Variability in geographical and analytical methods has been pointed out as a potential cause for these discrepancies.

WHAT THIS STUDY ADDS

This systematic literature review and meta-analyses consolidates all the evidence and effect sizes to determine which elements of the retail food environment have the greatest impact on obesity. It stratigically considers elements of the retail food environment, along with geographical and statistical methods to provide increased statistical power, accuracy, and a comprehensive summary of findings regarding the association of the food environment with obesity.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

The evidence generated from this systematic review and meta-analyses can serve as a foundational tool for policymakers and researchers in developing programmes and interventions for the prevention of obesity and other diet-related NCDs. This study offers a quantitative and visual guide for identifying the retail food environment elements that require greater focus in strategies aimed at tackling obesity.

Introduction

The retail food environment and obesity.

Obesity, a critical risk factor for non-communicable diseases (NCDs), is prevalent in countries across all income levels, including low-, middle- and high-income nations. 1 2 Its prevalence is shaped by a complex array of determinants, notably the retail food environment and advertising landscapes. 3 Modern food environments are marked by the widespread availability and promotion of energy-dense, nutrient-poor foods. 4 For instance, the increase in food retailers has contributed to a significant rise in calorie availability, facilitating greater access to a wide array of food choices. 5 To combat structural overconsumption and curb the obesity epidemic, policy interventions must be enacted, even in the face of commercial interests. However, the specific influence of food environments on obesity, as distinct from individual behaviour, remains poorly defined. 6 7 There is a scarcity of evidence identifying the exact elements of food environments that contribute to obesity and could be targeted for change. 3 4 8 This review aims to enhance understanding of the analytical methods required to dissect the various components of the modern retail food environment in relation to obesity and to assess the impact of retail food environments on obesity levels.

Analysing the retail food environment

Spatial analysis, leveraging Geographic Information Systems (GIS), has become instrumental in exploring the interplay between the environment and health outcomes. It particularly aids in investigating the food environment by mapping the locations of food stores, examining their spatial distribution and assessing their impact on obesity and population health. This approach enables the study of how the proximity and density of food outlets relative to residential areas influence access to healthy versus unhealthy food options, thereby identifying key environmental factors and protective measures against obesity through spatial patterns. 9–12

Previous literature reviews

Previous literature reviews on the relationship between the retail food environment and obesity have underscored methodological issues that may affect the analysis and interpretation of how food environments influence health and dietary outcomes. There is a recognised need for precise, comprehensive evaluations, including standardised and validated measurement techniques and diverse approaches to assessing the retail food environment, as current methods exhibit considerable variability. 12–14 Essential aspects of retail food environment research involve confirming the location and type of food outlets through store audits (ground truthing), 13 considering the confounding effects of socioeconomic status 14 15 and using longitudinal studies to observe changes in the retail food environment and dietary choices over time. 15 16

Despite numerous studies investigating the retail food environment’s impact on obesity, systematic reviews and meta-analyses are scarce. 17–20 Previous analyses have often been restricted to specific regions or populations, with limited attention to the methodologies for measuring the retail food environment. 17–20 This paper undertakes a systematic review and meta-analyses to synthesise available evidence on the retail food environment’s role in obesity and diet-related NCDs, aiming to pinpoint elements that could be targeted by policy interventions. Furthermore, it critically assesses the methodological strategies used to study the global impact of the retail food environment on obesity.

Obesity and the food environment

The food environment encompasses physical, economic, political and sociocultural factors affecting dietary choices. 21 Glanz et al. ’s 22 model suggests that dietary intake is shaped by policy, environment, individual and behavioural factors. This includes the community nutrition environment (types of food stores, locations, and availability), which in this study we refer to as the 'retail food environment'; organisational settings (neighbourhood, school, workplace); and consumer aspects (food availability, placement, pricing, promotions, nutrition labelling). Key attributes defining the food environment are geographical access, availability, affordability and advertising. 23–25 While various factors contribute to obesity, environmental and policy measures can significantly improve the food environment, leading to widespread dietary changes and reduced obesity and disease rates. 26

We performed a systematic review and meta-analyses to assess the association of the retail food environment with adult obesity and to evaluate the geographical and statistical methods used. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed ( online supplemental figure S1 ). Search results were screened by two reviewers for eligibility. The review was registered in PROSPERO as CRD42018111652.

Supplemental material

Literature search strategy.

We conducted a literature search on 31 January 2022, spanning papers published from 1946 onwards, to identify studies focusing on the impact of the retail food environment on obesity through spatial analysis. Using OvidSP-Medline, Scopus and Google Scholar databases, we structured the search around three primary themes: the retail food environment, obesity and spatial analysis. Initially, each theme was explored individually, and subsequently, we employed the ‘AND’ operator to search them concurrently. Using the Population, Intervention, Control, Outcome (PICO) framework ( online supplemental table S1 ) for eligibility assessment, 27 we considered publications examining the influence of the retail food environment on adult obesity or body mass index (BMI) for inclusion in our systematic literature review and meta-analyses.

Our literature search strategy involved MeSH words, Boolean search terms and proximity searching characters ($, *, W, #) on Medline (OvidSP, 1946–current: 31 January 2022). The terms covered diverse aspects such as buffer, chain, convenience, density variations (denoted by densit*), desert, distance, eating habits (indicated by eat$), environmental factors, farmers’ markets, fast food, geography, geolocation, geospatial analysis, GIS (geographic information systems), global, grocery stores, increase, index, location, markets, access, provision, proximity, restaurants, retail, spatial considerations, stores, supermarkets, supply, BMI (body mass index), body mass, nutrition, obesity, overweight, positional factors, weight gain and overeating. Additionally, the search extended to Scopus and Google Scholar using the query “(ALL (obesity) AND ALL (food environment OR convenience store OR food retail) AND ALL (GIS OR spatial analysis OR geographic information systems))” as of 31 January 2022.

Risk of bias and quality assessment criteria

Risk of bias and quality were evaluated using a weighted quality score derived from the Cochrane risk-of-bias tool, the systematic review data collection procedures from The Guide to Community Preventive Services 28 and the food environment quality assessment by Williams et al . 29 Nine criteria were assessed: population representativeness, outcome validity, exposure representativeness, exposure source, retail food environment assessment method, physical activity assessment, study design, statistical methods and data temporality. Studies received one point for each criterion met ( online supplemental table S2 ).

Spatial and statistical methods and study design appraisal

Study design, statistical methods and models were explored and assessed according to their consideration of spatial clustering, 30 and according to their inclusion of confounders.

Meta-analysis

We performed random-effect meta-analyses to explore the link between the retail food environment and obesity, analysing data from various outlets including fast-food restaurants, convenience stores, supermarkets and farmers’ markets. We evaluated the retail food environment using density, proximity and the Retail Food Environment Index (RFEI)—the ratio of unhealthy to healthy food outlets. Our analyses focused on ORs for categorical outcomes and beta-coefficients (β) for continuous variables, combining similar measures for meta-analyses. We assessed the impact of the retail food environment on adult BMI (β) and obesity prevalence (ORs), selecting the most relevant estimate from studies providing multiple results to ensure observations remained independent. Only models adjusted for confounders were included. For comparability, we considered data within 1 mile buffers or equivalent, representing walkable distances. In longitudinal studies, the most recent data were used. When results were stratified by sex and socioeconomic position (SEP), we chose observations based on the largest sample size or prioritised women and low-income groups if sizes were equal. We reported effect sizes and 95% CIs for each study, using Stata V.16.0 for all statistical analyses. 31

We retrieved 4118 studies, and after applying inclusion and exclusion criteria, retained 103 articles yielding 526 data points ( online supplemental figure S1 ). These were categorised by statistical measure, geographical measure and food outlet type, with 437 data points used in meta-analyses and meta-regression. The analysis covered 16 countries, with 90% of the studies from high-income countries: 1 from Africa, 5 each from Asia, Latin America and Australia, 14 from Europe and 74 from North America, spanning from 2004 to 2021, predominantly between 2011 and 2017 (n=54, 52%) ( online supplemental table S3 ).

In terms of retail food environment measures, 52 (50%) studies evaluated density, 21 (20%) proximity, 3 (3%) both, 4 (4%) the RFEI or variants and 15 (15%) other measures like ratio and diversity. Most studies (n=77, 75%) assessed one geographical measure, 20 (19%) evaluated two and six (6%) assessed up to three. From the 526 data points that were extracted from all studies, fast-food outlets were the most examined (n=166, 32%), followed by supermarkets (n=102, 19%), restaurants (n=101, 19%) and convenience stores (n=61, 12%), fresh fruit and vegetable stores (n=17, 3%), grocery stores (n=14, 3%), specialty stores (n=8, 2%), supercentres (n=5, 1%), and farmers’ markets (n=4, 1%). A majority of the studies, 61% (n=63), accounted for walkability or physical activity as a confounder ( online supplemental table S4 ).

Associations varied by geographical area, underscoring the need for representative geographical selection. For example, Fan et al 32 found different associations between restaurants and obesity for men at the census tract level and for women at the block level. However, 64% (n=66) of studies did not perform ground truthing or verify retail food environment data ( online supplemental table S4 ).

Statistical and geographical methods

Of the studies analysed, 68 (66%) applied linear or logistic regression, while 35 (34%) used multilevel modelling or methods accounting for spatial factors and clustering ( online supplemental table S3 ). In terms of data sources for food outlet locations, 39 (38%) used government databases, 27 (26%) commercial databases, 14 (14%) conducted ground truthing, 23 (22%) employed various methods and 1 (1%) did not disclose their source. Among the studies employing multilevel modelling or spatial considerations, 26 (74%) identified positive correlations between the presence of food retailers selling foods high in fat, sugar and salt (HFSS) and obesity rates ( online supplemental table S3 ).

Study design

Of the 89 cross-sectional studies analysed, 59 (66%) discovered a correlation between obesity and food retailers specialising in unhealthy foods and beverages, such as convenience stores and fast-food outlets. Among the 14 longitudinal studies, half revealed a significant link between the presence of unhealthy food outlets and obesity (refer to online supplemental tables S3 and S4 for detailed findings).

Quality and bias assessment of studies

The mean quality score of the studies was low, at 4 out of 9 points, with the highest being 7. 33 34 Key limitations included the reliance on cross-sectional designs, the failure to account for clustering or to apply spatial methods in 30 (29%) studies, reliance on self-reported height and weight data in 34 (33%) studies and the use of inappropriate statistical methods in 43 (42%) studies ( online supplemental table S5 ). Studies deemed to have a high risk of bias were excluded from the meta-analyses.

In the meta-analyses conducted, significant heterogeneity was observed across the studies, stemming from variations in statistical methods, study designs, stratification by gender and ethnicity, geographical measures of the retail food environment, classifications of food outlets and the definitions used to measure or define obesity, thereby limiting the robustness of the pooled analyses. Despite these variances, the majority of the studies used BMI, derived from measured height and weight, as a primary indicator, reporting it either as a continuous variable (kg/m 2 ) or in categorical terms (overweight or obesity). However, there was a notable scarcity of studies disaggregating outcome data by critical demographic factors such as age group, gender, ethnicity or SEP, which is pivotal considering the diverse exposure to retail food environments experienced by these groups. 35 Results of the meta-analyses are presented below by measure of the retail food environment (ie, density and proximity) and statistical measures (ORs and Beta-coefficients─in the supplemental material).

The findings revealed that the density of fast-food outlets did not significantly influence obesity rates (OR: 1.01, 95% CI: 0.99 to 1.04, p=0.18), in contrast to proximity to fast-food outlets, which showed a significant association with obesity (OR: 1.15, 95% CI: 1.02 to 1.30, p=0.02) ( figure 1 ). Restaurant density’s correlation with obesity was marginally significant (OR: 0.92, 95% CI: 0.85 to 1.00, p=0.05), yet the literature lacked sufficient data to evaluate the impact of restaurant proximity ( figure 2 ). No significant relationship was identified between the density of convenience stores and obesity (OR: 1.02, 95% CI: 0.95 to 1.10, p=0.64), and a similar non-significant trend was observed for proximity to convenience stores (OR: 1.04, 95% CI: 0.97 to 1.11, p=0.31) ( figure 3 ).

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Fast-food outlet density and proximity and its association with obesity. REML, Restricted Maximum Likelihood.

Restaurant density and its association with obesity. REML, Restricted Maximum Likelihood.

Convenience store density and proximity and its association with obesity. REML, Restricted Maximum Likelihood.

Furthermore, supermarket density did not show a significant relationship with obesity (OR: 0.98, 95% CI: 0.92 to 1.05, p=0.53), whereas a significant inverse relationship was evident between supermarket proximity and obesity (OR: 0.90, 95% CI: 0.82 to 0.98, p=0.02) ( figure 4 ). An inverse association was also noted between the density of fresh fruit and vegetable stores and obesity (OR: 0.93, 95% CI: 0.90 to 0.96, p<0.001) ( figure 5 ), though data were insufficient to assess the impact of proximity to these outlets. The RFEI did not reveal any significant associations with obesity (OR: 1.00, 95% CI: 0.99 to 1.01, p=0.99) ( figure 6 ), and BMI as a continuous variable showed no association with any type of food outlet, indicating a nuanced and complex relationship between the retail food environment and obesity ( online supplemental figures S2–S7 ).

Supermarket density and proximity and its association with obesity. REML, Restricted Maximum Likelihood.

Fruit and vegetable store density and its association with obesity. REML, Restricted Maximum Likelihood.

Retail Food Environment Index (RFEI) and its association with obesity. REML, Restricted Maximum Likelihood.

The results of our systematic review and meta-analyses indicate a nuanced relationship between the retail food environment and obesity. Results for the association between the retail food environment and obesity varied significantly by type of food outlet, statistical measure and geographical measure. However, the pooled effect sizes show that proximity of fast-food outlets was associated with a higher risk of obesity, while proximity of supermarkets and fresh fruit and vegetable stores was associated with a lower risk of obesity.

Previous research highlights the crucial role of fruit and vegetable availability and affordability in fostering healthy eating habits and preventing obesity and chronic diseases. 36 Conversely, fast-food outlets predominantly offer ultra-processed foods—industrially processed items rich in fat, salt and/or sugar—whose consumption is associated with increased risks of obesity and chronic conditions. 37

The observed phenomenon can be attributed to the ease of access to different types of food outlets and their impact on dietary choices. Fast-food outlets, often closer to residential areas or on the pathways from school or the office to home, provide convenient access to high-calorie, processed foods, which can contribute to higher obesity rates among nearby residents. 14 Conversely, supermarkets, which are sometimes located further from residential areas, offer a broader range of healthier food options. When supermarkets are closer, it encourages the purchase and consumption of healthier foods, potentially reducing obesity risk. 38 This highlights the significant role of the retail food environment accessibility in influencing dietary behaviours and obesity prevalence.

In addition, socioeconomic area level may play a critical role in this context by influencing both access to and choices within the retail food environment. 39 Individuals living in lower socioeconomic areas may have more limited access to supermarkets offering a variety of healthy options due to cost or proximity, leading to a reliance on closer, often less expensive fast-food outlets. 39 This disparity can result in dietary patterns that contribute to higher obesity rates in these populations, underscoring the need for targeted interventions to improve access to healthy food options across all socioeconomic groups.

Importantly, while geographical measures such as proximity and density provide insights into the retail food environment or built food environment, they do not capture the complexities within food outlets that influence consumer choices. The 'in-store food environment', encompassing product placement, promotion strategies and food layout, plays a pivotal role in shaping dietary habits. Studies have demonstrated that strategic placement of healthy food options at eye level or in prominent store locations can significantly influence consumer purchases towards healthier choices. 40–43

A comprehensive approach, addressing both the proximity of various food outlet types and the intricate details of the in-store food environment, is essential for devising effective public health interventions aimed at reducing obesity. Future research and policy efforts should consider these dimensions of the food environment to develop more nuanced and impactful strategies for obesity prevention.

The UK is a pioneer in regulating the food environment, having introduced legislation to restrict the promotion and placement of HFSS foods within retail settings, both online and physical. 44 This legislation targets the influence of food retailers on consumer choices, particularly aiming to reduce the impact of price promotions on children’s food preferences by limiting promotions and strategic placement of HFSS products. This is a crucial step in promoting healthier eating habits and combating obesity and related health issues.

Additionally, in high-income countries, zoning powers allow local authorities to regulate food outlets’ location, and healthy food carts have been effectively deployed in urban areas to increase access to nutritious food. 18

Studies on the food environment can inform the creation of improved land use and public health policies, mitigating the negative effects of local food and nutrition environments on population health 45 Effective obesity reduction efforts should include policies or regulations to limit the availability of low-quality food in neighbourhoods, schools and other sensitive areas. However, the relationship between food outlets and obesity has shown inconsistent results, underscoring the need for solid evidence to guide government actions on enhancing the food environment.

This research significantly advances the evidence 18–20 by integrating a systematic review with meta-analyses to explore the retail food environment’s influence on obesity and BMI. This dual approach, not previously used for this topic, integrates geographical and statistical analyses and offers a comprehensive analysis of the relationship between food outlet types, BMI and obesity. Furthermore, this study is distinct as it includes analyses that employ spatial methodologies to explore the retail food environment’s components and their correlation with obesity, providing a comprehensive evidence base for policy formulation aimed at enhancing public health.

Implications for policymakers and urban planners

The observed association between fast-food outlet proximity and increased obesity risk emphasises the need for zoning regulations to manage their density in residential areas, schools and communal spaces. This strategic intervention becomes crucial in mitigating the obesity crisis. Our study discerns variations in associations among different food outlet types. While proximity of fast-food outlets correlates positively with obesity, proximity of supermarkets and fresh produce stores demonstrates an inverse relationship. Urban planners can influence health outcomes by strategically placing health-promoting outlets in residential areas, aligning with the concept of fostering a ‘healthy food environment’.

Beyond reaffirming existing knowledge, our study introduces novel insights into nuanced relationships between specific food outlets and obesity risk. Policymakers and urban planners can leverage this information to refine existing zoning laws based on prevalent food outlet types.

Our analysis also reveals a gap in the assessment of in-store food environments. Policymakers should focus on internal dynamics, implementing regulations targeting the arrangement and promotion of food items within stores to encourage healthier choices. Moreover, they should engage with town planners, health professionals and community representatives to develop comprehensive strategies. Collaborative efforts can lead to urban spaces that limit the impact of detrimental food outlets and food choices while promoting health and well-being. This aligns with the broader goal of fostering healthier communities, emphasising the importance of continued research and dialogue between academia and policymakers.

Strengths and limitations

This study’s primary strength lies in its comprehensive systematic search strategy, which involved querying multiple databases, imposing no publication date restrictions and conducting searches in two languages. Additionally, it uniquely explored and assessed geographical measures and statistical methods within a systematic literature review context and conducted a risk-of-bias assessment to objectively evaluate the reviewed literature.

By incorporating spatial analysis, this study addressed gaps in previous literature by elucidating the impact of food outlets’ geographical distribution on obesity rates. This approach enabled the identification of spatial patterns and correlations potentially overlooked in traditional epidemiological studies, thereby providing insight into the obesogenic environment.

Spatial analysis also enhanced the meta-analyses by facilitating the integration and comparison of findings from studies across different geographical scales and settings, thereby bolstering the robustness of our conclusions. This rigour in methodology supported evidence synthesis, offering a detailed overview of the retail food environment’s role in obesity.

Through a detailed spatial analysis, our study not only corroborates the significance of geographical factors in obesity prevalence but also underscores the need for targeted public health interventions. By pinpointing areas with high concentrations of unhealthy food outlets relative to healthy ones, policymakers and urban planners can devise more effective strategies aimed at improving the food environment and, subsequently, public health.

However, the study has limitations. The review focused on obesity in the adult population because of the diverse reviews already focused on children, and because of the important role that adults play in food outlet selection within a family setting. Focusing on adult populations is critical for chronic disease prevention and successful ageing. Only studies based on neighbourhood, rural or urban environments were considered. Studies that did not include an objective measure of obesity such as BMI via measured height and weight were excluded. However, many studies that used BMI and other measures of diet and obesity were considered. The identified exposures, measures and outcomes included in this study were the most reported in the literature. Although this may exclude other important obesity-related outcomes (eg, adiposity, fat mass, diet), focusing on BMI and obesity allowed a wider comparison between studies and could facilitate translation into policies and actions to regulate and improve the food environment.

Despite significant methodological diversity among the studies reviewed, the literature consistently identifies the food environment as a crucial factor in preventing obesity. Regions characterised by abundant fast-food outlets, limited supermarket access and scarce fresh fruit and vegetable stores tend to have higher obesity rates. While regulating access to healthier food options is necessary, it may not suffice to combat obesity on its own. Comprehensive strategies are also needed, including regulation of the in-store availability of unhealthy foods and the promotion of a food environment that supports healthy and affordable diets.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

Acknowledgments.

The authors wish to acknowledge Dr Clare Llewelyn and Professor Eric Brunner for their guidance and support on this study.

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Supplementary materials

Supplementary data.

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• Data supplement 1

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Contributors EP designed the study, collected and analysed the data, drafted the manuscript, and was responsible for the overall content as the guarantor. JS, SS, CL and JSM drafted and revised the draft and provided statistical advice.

Funding This study was funded by CONACYT, the National Council on Science and Technology in Mexico.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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