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• Volume 25, Issue 1
• Critical appraisal of qualitative research: necessity, partialities and the issue of bias
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• http://orcid.org/0000-0001-5660-8224 Veronika Williams ,
• Anne-Marie Boylan ,
• http://orcid.org/0000-0003-4597-1276 David Nunan
• Nuffield Department of Primary Care Health Sciences , University of Oxford, Radcliffe Observatory Quarter , Oxford , UK
• Correspondence to Dr Veronika Williams, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; veronika.williams{at}phc.ox.ac.uk

https://doi.org/10.1136/bmjebm-2018-111132

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• qualitative research

Introduction

Qualitative evidence allows researchers to analyse human experience and provides useful exploratory insights into experiential matters and meaning, often explaining the ‘how’ and ‘why’. As we have argued previously 1 , qualitative research has an important place within evidence-based healthcare, contributing to among other things policy on patient safety, 2 prescribing, 3 4 and understanding chronic illness. 5 Equally, it offers additional insight into quantitative studies, explaining contextual factors surrounding a successful intervention or why an intervention might have ‘failed’ or ‘succeeded’ where effect sizes cannot. It is for these reasons that the MRC strongly recommends including qualitative evaluations when developing and evaluating complex interventions. 6

Critical appraisal of qualitative research

Is it necessary.

Although the importance of qualitative research to improve health services and care is now increasingly widely supported (discussed in paper 1), the role of appraising the quality of qualitative health research is still debated. 8 10 Despite a large body of literature focusing on appraisal and rigour, 9 11–15 often referred to as ‘trustworthiness’ 16 in qualitative research, there remains debate about how to —and even whether to—critically appraise qualitative research. 8–10 17–19 However, if we are to make a case for qualitative research as integral to evidence-based healthcare, then any argument to omit a crucial element of evidence-based practice is difficult to justify. That being said, simply applying the standards of rigour used to appraise studies based on the positivist paradigm (Positivism depends on quantifiable observations to test hypotheses and assumes that the researcher is independent of the study. Research situated within a positivist paradigm isbased purely on facts and consider the world to be external and objective and is concerned with validity, reliability and generalisability as measures of rigour.) would be misplaced given the different epistemological underpinnings of the two types of data.

Given its scope and its place within health research, the robust and systematic appraisal of qualitative research to assess its trustworthiness is as paramount to its implementation in clinical practice as any other type of research. It is important to appraise different qualitative studies in relation to the specific methodology used because the methodological approach is linked to the ‘outcome’ of the research (eg, theory development, phenomenological understandings and credibility of findings). Moreover, appraisal needs to go beyond merely describing the specific details of the methods used (eg, how data were collected and analysed), with additional focus needed on the overarching research design and its appropriateness in accordance with the study remit and objectives.

Poorly conducted qualitative research has been described as ‘worthless, becomes fiction and loses its utility’. 20 However, without a deep understanding of concepts of quality in qualitative research or at least an appropriate means to assess its quality, good qualitative research also risks being dismissed, particularly in the context of evidence-based healthcare where end users may not be well versed in this paradigm.

How is appraisal currently performed?

Appraising the quality of qualitative research is not a new concept—there are a number of published appraisal tools, frameworks and checklists in existence. 21–23  An important and often overlooked point is the confusion between tools designed for appraising methodological quality and reporting guidelines designed to assess the quality of methods reporting. An example is the Consolidate Criteria for Reporting Qualitative Research (COREQ) 24 checklist, which was designed to provide standards for authors when reporting qualitative research but is often mistaken for a methods appraisal tool. 10

Broadly speaking there are two types of critical appraisal approaches for qualitative research: checklists and frameworks. Checklists have often been criticised for confusing quality in qualitative research with ‘technical fixes’ 21 25 , resulting in the erroneous prioritisation of particular aspects of methodological processes over others (eg, multiple coding and triangulation). It could be argued that a checklist approach adopts the positivist paradigm, where the focus is on objectively assessing ‘quality’ where the assumptions is that the researcher is independent of the research conducted. This may result in the application of quantitative understandings of bias in order to judge aspects of recruitment, sampling, data collection and analysis in qualitative research papers. One of the most widely used appraisal tools is the Critical Appraisal Skills Programme (CASP) 26 and along with the JBI QARI (Joanna Briggs Institute Qualitative Assessment and Assessment Instrument) 27 presents examples which tend to mimic the quantitative approach to appraisal. The CASP qualitative tool follows that of other CASP appraisal tools for quantitative research designs developed in the 1990s. The similarities are therefore unsurprising given the status of qualitative research at that time.

Frameworks focus on the overarching concepts of quality in qualitative research, including transparency, reflexivity, dependability and transferability (see box 1 ). 11–13 15 16 20 28 However, unless the reader is familiar with these concepts—their meaning and impact, and how to interpret them—they will have difficulty applying them when critically appraising a paper.

The main issue concerning currently available checklist and framework appraisal methods is that they take a broad brush approach to ‘qualitative’ research as whole, with few, if any, sufficiently differentiating between the different methodological approaches (eg, Grounded Theory, Interpretative Phenomenology, Discourse Analysis) nor different methods of data collection (interviewing, focus groups and observations). In this sense, it is akin to taking the entire field of ‘quantitative’ study designs and applying a single method or tool for their quality appraisal. In the case of qualitative research, checklists, therefore, offer only a blunt and arguably ineffective tool and potentially promote an incomplete understanding of good ‘quality’ in qualitative research. Likewise, current framework methods do not take into account how concepts differ in their application across the variety of qualitative approaches and, like checklists, they also do not differentiate between different qualitative methodologies.

On the need for specific appraisal tools

Current approaches to the appraisal of the methodological rigour of the differing types of qualitative research converge towards checklists or frameworks. More importantly, the current tools do not explicitly acknowledge the prejudices that may be present in the different types of qualitative research.

Concepts of rigour or trustworthiness within qualitative research 31

Transferability: the extent to which the presented study allows readers to make connections between the study’s data and wider community settings, ie, transfer conceptual findings to other contexts.

Credibility: extent to which a research account is believable and appropriate, particularly in relation to the stories told by participants and the interpretations made by the researcher.

Reflexivity: refers to the researchers’ engagement of continuous examination and explanation of how they have influenced a research project from choosing a research question to sampling, data collection, analysis and interpretation of data.

Transparency: making explicit the whole research process from sampling strategies, data collection to analysis. The rationale for decisions made is as important as the decisions themselves.

However, we often talk about these concepts in general terms, and it might be helpful to give some explicit examples of how the ‘technical processes’ affect these, for example, partialities related to:

Selection: recruiting participants via gatekeepers, such as healthcare professionals or clinicians, who may select them based on whether they believe them to be ‘good’ participants for interviews/focus groups.

Data collection: poor interview guide with closed questions which encourage yes/no answers and/leading questions.

Reflexivity and transparency: where researchers may focus their analysis on preconceived ideas rather than ground their analysis in the data and do not reflect on the impact of this in a transparent way.

The lack of tailored, method-specific appraisal tools has potentially contributed to the poor uptake and use of qualitative research for informing evidence-based decision making. To improve this situation, we propose the need for more robust quality appraisal tools that explicitly encompass both the core design aspects of all qualitative research (sampling/data collection/analysis) but also considered the specific partialities that can be presented with different methodological approaches. Such tools might draw on the strengths of current frameworks and checklists while providing users with sufficient understanding of concepts of rigour in relation to the different types of qualitative methods. We provide an outline of such tools in the third and final paper in this series.

As qualitative research becomes ever more embedded in health science research, and in order for that research to have better impact on healthcare decisions, we need to rethink critical appraisal and develop tools that allow differentiated evaluations of the myriad of qualitative methodological approaches rather than continuing to treat qualitative research as a single unified approach.

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• ↵ The Joanna Briggs Institute . JBI QARI Critical appraisal checklist for interpretive & critical research . Adelaide : The Joanna Briggs Institute , 2014 .
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Contributors VW and DN: conceived the idea for this article. VW: wrote the first draft. AMB and DN: contributed to the final draft. All authors approve the submitted article.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Correction notice This article has been updated since its original publication to include a new reference (reference 1.)

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Criteria for Good Qualitative Research: A Comprehensive Review

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• Open access
• Published: 18 September 2021
• Volume 31 , pages 679–689, ( 2022 )

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• Drishti Yadav   ORCID: orcid.org/0000-0002-2974-0323 1  

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This review aims to synthesize a published set of evaluative criteria for good qualitative research. The aim is to shed light on existing standards for assessing the rigor of qualitative research encompassing a range of epistemological and ontological standpoints. Using a systematic search strategy, published journal articles that deliberate criteria for rigorous research were identified. Then, references of relevant articles were surveyed to find noteworthy, distinct, and well-defined pointers to good qualitative research. This review presents an investigative assessment of the pivotal features in qualitative research that can permit the readers to pass judgment on its quality and to condemn it as good research when objectively and adequately utilized. Overall, this review underlines the crux of qualitative research and accentuates the necessity to evaluate such research by the very tenets of its being. It also offers some prospects and recommendations to improve the quality of qualitative research. Based on the findings of this review, it is concluded that quality criteria are the aftereffect of socio-institutional procedures and existing paradigmatic conducts. Owing to the paradigmatic diversity of qualitative research, a single and specific set of quality criteria is neither feasible nor anticipated. Since qualitative research is not a cohesive discipline, researchers need to educate and familiarize themselves with applicable norms and decisive factors to evaluate qualitative research from within its theoretical and methodological framework of origin.

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Good Qualitative Research: Opening up the Debate

Beyond qualitative/quantitative structuralism: the positivist qualitative research and the paradigmatic disclaimer.

What is Qualitative in Research

Avoid common mistakes on your manuscript.

Introduction

“… It is important to regularly dialogue about what makes for good qualitative research” (Tracy, 2010 , p. 837)

To decide what represents good qualitative research is highly debatable. There are numerous methods that are contained within qualitative research and that are established on diverse philosophical perspectives. Bryman et al., ( 2008 , p. 262) suggest that “It is widely assumed that whereas quality criteria for quantitative research are well‐known and widely agreed, this is not the case for qualitative research.” Hence, the question “how to evaluate the quality of qualitative research” has been continuously debated. There are many areas of science and technology wherein these debates on the assessment of qualitative research have taken place. Examples include various areas of psychology: general psychology (Madill et al., 2000 ); counseling psychology (Morrow, 2005 ); and clinical psychology (Barker & Pistrang, 2005 ), and other disciplines of social sciences: social policy (Bryman et al., 2008 ); health research (Sparkes, 2001 ); business and management research (Johnson et al., 2006 ); information systems (Klein & Myers, 1999 ); and environmental studies (Reid & Gough, 2000 ). In the literature, these debates are enthused by the impression that the blanket application of criteria for good qualitative research developed around the positivist paradigm is improper. Such debates are based on the wide range of philosophical backgrounds within which qualitative research is conducted (e.g., Sandberg, 2000 ; Schwandt, 1996 ). The existence of methodological diversity led to the formulation of different sets of criteria applicable to qualitative research.

Among qualitative researchers, the dilemma of governing the measures to assess the quality of research is not a new phenomenon, especially when the virtuous triad of objectivity, reliability, and validity (Spencer et al., 2004 ) are not adequate. Occasionally, the criteria of quantitative research are used to evaluate qualitative research (Cohen & Crabtree, 2008 ; Lather, 2004 ). Indeed, Howe ( 2004 ) claims that the prevailing paradigm in educational research is scientifically based experimental research. Hypotheses and conjectures about the preeminence of quantitative research can weaken the worth and usefulness of qualitative research by neglecting the prominence of harmonizing match for purpose on research paradigm, the epistemological stance of the researcher, and the choice of methodology. Researchers have been reprimanded concerning this in “paradigmatic controversies, contradictions, and emerging confluences” (Lincoln & Guba, 2000 ).

In general, qualitative research tends to come from a very different paradigmatic stance and intrinsically demands distinctive and out-of-the-ordinary criteria for evaluating good research and varieties of research contributions that can be made. This review attempts to present a series of evaluative criteria for qualitative researchers, arguing that their choice of criteria needs to be compatible with the unique nature of the research in question (its methodology, aims, and assumptions). This review aims to assist researchers in identifying some of the indispensable features or markers of high-quality qualitative research. In a nutshell, the purpose of this systematic literature review is to analyze the existing knowledge on high-quality qualitative research and to verify the existence of research studies dealing with the critical assessment of qualitative research based on the concept of diverse paradigmatic stances. Contrary to the existing reviews, this review also suggests some critical directions to follow to improve the quality of qualitative research in different epistemological and ontological perspectives. This review is also intended to provide guidelines for the acceleration of future developments and dialogues among qualitative researchers in the context of assessing the qualitative research.

The rest of this review article is structured in the following fashion: Sect.  Methods describes the method followed for performing this review. Section Criteria for Evaluating Qualitative Studies provides a comprehensive description of the criteria for evaluating qualitative studies. This section is followed by a summary of the strategies to improve the quality of qualitative research in Sect.  Improving Quality: Strategies . Section  How to Assess the Quality of the Research Findings? provides details on how to assess the quality of the research findings. After that, some of the quality checklists (as tools to evaluate quality) are discussed in Sect.  Quality Checklists: Tools for Assessing the Quality . At last, the review ends with the concluding remarks presented in Sect.  Conclusions, Future Directions and Outlook . Some prospects in qualitative research for enhancing its quality and usefulness in the social and techno-scientific research community are also presented in Sect.  Conclusions, Future Directions and Outlook .

For this review, a comprehensive literature search was performed from many databases using generic search terms such as Qualitative Research , Criteria , etc . The following databases were chosen for the literature search based on the high number of results: IEEE Explore, ScienceDirect, PubMed, Google Scholar, and Web of Science. The following keywords (and their combinations using Boolean connectives OR/AND) were adopted for the literature search: qualitative research, criteria, quality, assessment, and validity. The synonyms for these keywords were collected and arranged in a logical structure (see Table 1 ). All publications in journals and conference proceedings later than 1950 till 2021 were considered for the search. Other articles extracted from the references of the papers identified in the electronic search were also included. A large number of publications on qualitative research were retrieved during the initial screening. Hence, to include the searches with the main focus on criteria for good qualitative research, an inclusion criterion was utilized in the search string.

From the selected databases, the search retrieved a total of 765 publications. Then, the duplicate records were removed. After that, based on the title and abstract, the remaining 426 publications were screened for their relevance by using the following inclusion and exclusion criteria (see Table 2 ). Publications focusing on evaluation criteria for good qualitative research were included, whereas those works which delivered theoretical concepts on qualitative research were excluded. Based on the screening and eligibility, 45 research articles were identified that offered explicit criteria for evaluating the quality of qualitative research and were found to be relevant to this review.

Figure  1 illustrates the complete review process in the form of PRISMA flow diagram. PRISMA, i.e., “preferred reporting items for systematic reviews and meta-analyses” is employed in systematic reviews to refine the quality of reporting.

PRISMA flow diagram illustrating the search and inclusion process. N represents the number of records

Criteria for Evaluating Qualitative Studies

Fundamental criteria: general research quality.

Various researchers have put forward criteria for evaluating qualitative research, which have been summarized in Table 3 . Also, the criteria outlined in Table 4 effectively deliver the various approaches to evaluate and assess the quality of qualitative work. The entries in Table 4 are based on Tracy’s “Eight big‐tent criteria for excellent qualitative research” (Tracy, 2010 ). Tracy argues that high-quality qualitative work should formulate criteria focusing on the worthiness, relevance, timeliness, significance, morality, and practicality of the research topic, and the ethical stance of the research itself. Researchers have also suggested a series of questions as guiding principles to assess the quality of a qualitative study (Mays & Pope, 2020 ). Nassaji ( 2020 ) argues that good qualitative research should be robust, well informed, and thoroughly documented.

Qualitative Research: Interpretive Paradigms

All qualitative researchers follow highly abstract principles which bring together beliefs about ontology, epistemology, and methodology. These beliefs govern how the researcher perceives and acts. The net, which encompasses the researcher’s epistemological, ontological, and methodological premises, is referred to as a paradigm, or an interpretive structure, a “Basic set of beliefs that guides action” (Guba, 1990 ). Four major interpretive paradigms structure the qualitative research: positivist and postpositivist, constructivist interpretive, critical (Marxist, emancipatory), and feminist poststructural. The complexity of these four abstract paradigms increases at the level of concrete, specific interpretive communities. Table 5 presents these paradigms and their assumptions, including their criteria for evaluating research, and the typical form that an interpretive or theoretical statement assumes in each paradigm. Moreover, for evaluating qualitative research, quantitative conceptualizations of reliability and validity are proven to be incompatible (Horsburgh, 2003 ). In addition, a series of questions have been put forward in the literature to assist a reviewer (who is proficient in qualitative methods) for meticulous assessment and endorsement of qualitative research (Morse, 2003 ). Hammersley ( 2007 ) also suggests that guiding principles for qualitative research are advantageous, but methodological pluralism should not be simply acknowledged for all qualitative approaches. Seale ( 1999 ) also points out the significance of methodological cognizance in research studies.

Table 5 reflects that criteria for assessing the quality of qualitative research are the aftermath of socio-institutional practices and existing paradigmatic standpoints. Owing to the paradigmatic diversity of qualitative research, a single set of quality criteria is neither possible nor desirable. Hence, the researchers must be reflexive about the criteria they use in the various roles they play within their research community.

Improving Quality: Strategies

Another critical question is “How can the qualitative researchers ensure that the abovementioned quality criteria can be met?” Lincoln and Guba ( 1986 ) delineated several strategies to intensify each criteria of trustworthiness. Other researchers (Merriam & Tisdell, 2016 ; Shenton, 2004 ) also presented such strategies. A brief description of these strategies is shown in Table 6 .

It is worth mentioning that generalizability is also an integral part of qualitative research (Hays & McKibben, 2021 ). In general, the guiding principle pertaining to generalizability speaks about inducing and comprehending knowledge to synthesize interpretive components of an underlying context. Table 7 summarizes the main metasynthesis steps required to ascertain generalizability in qualitative research.

Figure  2 reflects the crucial components of a conceptual framework and their contribution to decisions regarding research design, implementation, and applications of results to future thinking, study, and practice (Johnson et al., 2020 ). The synergy and interrelationship of these components signifies their role to different stances of a qualitative research study.

Essential elements of a conceptual framework

In a nutshell, to assess the rationale of a study, its conceptual framework and research question(s), quality criteria must take account of the following: lucid context for the problem statement in the introduction; well-articulated research problems and questions; precise conceptual framework; distinct research purpose; and clear presentation and investigation of the paradigms. These criteria would expedite the quality of qualitative research.

How to Assess the Quality of the Research Findings?

The inclusion of quotes or similar research data enhances the confirmability in the write-up of the findings. The use of expressions (for instance, “80% of all respondents agreed that” or “only one of the interviewees mentioned that”) may also quantify qualitative findings (Stenfors et al., 2020 ). On the other hand, the persuasive reason for “why this may not help in intensifying the research” has also been provided (Monrouxe & Rees, 2020 ). Further, the Discussion and Conclusion sections of an article also prove robust markers of high-quality qualitative research, as elucidated in Table 8 .

Quality Checklists: Tools for Assessing the Quality

Numerous checklists are available to speed up the assessment of the quality of qualitative research. However, if used uncritically and recklessly concerning the research context, these checklists may be counterproductive. I recommend that such lists and guiding principles may assist in pinpointing the markers of high-quality qualitative research. However, considering enormous variations in the authors’ theoretical and philosophical contexts, I would emphasize that high dependability on such checklists may say little about whether the findings can be applied in your setting. A combination of such checklists might be appropriate for novice researchers. Some of these checklists are listed below:

The most commonly used framework is Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007 ). This framework is recommended by some journals to be followed by the authors during article submission.

Standards for Reporting Qualitative Research (SRQR) is another checklist that has been created particularly for medical education (O’Brien et al., 2014 ).

Also, Tracy ( 2010 ) and Critical Appraisal Skills Programme (CASP, 2021 ) offer criteria for qualitative research relevant across methods and approaches.

Further, researchers have also outlined different criteria as hallmarks of high-quality qualitative research. For instance, the “Road Trip Checklist” (Epp & Otnes, 2021 ) provides a quick reference to specific questions to address different elements of high-quality qualitative research.

Conclusions, Future Directions, and Outlook

This work presents a broad review of the criteria for good qualitative research. In addition, this article presents an exploratory analysis of the essential elements in qualitative research that can enable the readers of qualitative work to judge it as good research when objectively and adequately utilized. In this review, some of the essential markers that indicate high-quality qualitative research have been highlighted. I scope them narrowly to achieve rigor in qualitative research and note that they do not completely cover the broader considerations necessary for high-quality research. This review points out that a universal and versatile one-size-fits-all guideline for evaluating the quality of qualitative research does not exist. In other words, this review also emphasizes the non-existence of a set of common guidelines among qualitative researchers. In unison, this review reinforces that each qualitative approach should be treated uniquely on account of its own distinctive features for different epistemological and disciplinary positions. Owing to the sensitivity of the worth of qualitative research towards the specific context and the type of paradigmatic stance, researchers should themselves analyze what approaches can be and must be tailored to ensemble the distinct characteristics of the phenomenon under investigation. Although this article does not assert to put forward a magic bullet and to provide a one-stop solution for dealing with dilemmas about how, why, or whether to evaluate the “goodness” of qualitative research, it offers a platform to assist the researchers in improving their qualitative studies. This work provides an assembly of concerns to reflect on, a series of questions to ask, and multiple sets of criteria to look at, when attempting to determine the quality of qualitative research. Overall, this review underlines the crux of qualitative research and accentuates the need to evaluate such research by the very tenets of its being. Bringing together the vital arguments and delineating the requirements that good qualitative research should satisfy, this review strives to equip the researchers as well as reviewers to make well-versed judgment about the worth and significance of the qualitative research under scrutiny. In a nutshell, a comprehensive portrayal of the research process (from the context of research to the research objectives, research questions and design, speculative foundations, and from approaches of collecting data to analyzing the results, to deriving inferences) frequently proliferates the quality of a qualitative research.

Prospects : A Road Ahead for Qualitative Research

Irrefutably, qualitative research is a vivacious and evolving discipline wherein different epistemological and disciplinary positions have their own characteristics and importance. In addition, not surprisingly, owing to the sprouting and varied features of qualitative research, no consensus has been pulled off till date. Researchers have reflected various concerns and proposed several recommendations for editors and reviewers on conducting reviews of critical qualitative research (Levitt et al., 2021 ; McGinley et al., 2021 ). Following are some prospects and a few recommendations put forward towards the maturation of qualitative research and its quality evaluation:

In general, most of the manuscript and grant reviewers are not qualitative experts. Hence, it is more likely that they would prefer to adopt a broad set of criteria. However, researchers and reviewers need to keep in mind that it is inappropriate to utilize the same approaches and conducts among all qualitative research. Therefore, future work needs to focus on educating researchers and reviewers about the criteria to evaluate qualitative research from within the suitable theoretical and methodological context.

There is an urgent need to refurbish and augment critical assessment of some well-known and widely accepted tools (including checklists such as COREQ, SRQR) to interrogate their applicability on different aspects (along with their epistemological ramifications).

Efforts should be made towards creating more space for creativity, experimentation, and a dialogue between the diverse traditions of qualitative research. This would potentially help to avoid the enforcement of one's own set of quality criteria on the work carried out by others.

Moreover, journal reviewers need to be aware of various methodological practices and philosophical debates.

It is pivotal to highlight the expressions and considerations of qualitative researchers and bring them into a more open and transparent dialogue about assessing qualitative research in techno-scientific, academic, sociocultural, and political rooms.

Frequent debates on the use of evaluative criteria are required to solve some potentially resolved issues (including the applicability of a single set of criteria in multi-disciplinary aspects). Such debates would not only benefit the group of qualitative researchers themselves, but primarily assist in augmenting the well-being and vivacity of the entire discipline.

To conclude, I speculate that the criteria, and my perspective, may transfer to other methods, approaches, and contexts. I hope that they spark dialog and debate – about criteria for excellent qualitative research and the underpinnings of the discipline more broadly – and, therefore, help improve the quality of a qualitative study. Further, I anticipate that this review will assist the researchers to contemplate on the quality of their own research, to substantiate research design and help the reviewers to review qualitative research for journals. On a final note, I pinpoint the need to formulate a framework (encompassing the prerequisites of a qualitative study) by the cohesive efforts of qualitative researchers of different disciplines with different theoretic-paradigmatic origins. I believe that tailoring such a framework (of guiding principles) paves the way for qualitative researchers to consolidate the status of qualitative research in the wide-ranging open science debate. Dialogue on this issue across different approaches is crucial for the impending prospects of socio-techno-educational research.

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Yadav, D. Criteria for Good Qualitative Research: A Comprehensive Review. Asia-Pacific Edu Res 31 , 679–689 (2022). https://doi.org/10.1007/s40299-021-00619-0

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Critically appraising qualitative research

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• Ayelet Kuper , assistant professor 1 ,
• Lorelei Lingard , associate professor 2 ,
• Wendy Levinson , Sir John and Lady Eaton professor and chair 3
• 1 Department of Medicine, Sunnybrook Health Sciences Centre, and Wilson Centre for Research in Education, University of Toronto, 2075 Bayview Avenue, Room HG 08, Toronto, ON, Canada M4N 3M5
• 2 Department of Paediatrics and Wilson Centre for Research in Education, University of Toronto and SickKids Learning Institute; BMO Financial Group Professor in Health Professions Education Research, University Health Network, 200 Elizabeth Street, Eaton South 1-565, Toronto
• 3 Department of Medicine, Sunnybrook Health Sciences Centre
• Correspondence to: A Kuper ayelet94{at}post.harvard.edu

Six key questions will help readers to assess qualitative research

Summary points

Appraising qualitative research is different from appraising quantitative research

Qualitative research papers should show appropriate sampling, data collection, and data analysis

Transferability of qualitative research depends on context and may be enhanced by using theory

Ethics in qualitative research goes beyond review boards’ requirements to involve complex issues of confidentiality, reflexivity, and power

Over the past decade, readers of medical journals have gained skills in critically appraising studies to determine whether the results can be trusted and applied to their own practice settings. Criteria have been designed to assess studies that use quantitative methods, and these are now in common use.

In this article we offer guidance for readers on how to assess a study that uses qualitative research methods by providing six key questions to ask when reading qualitative research (box 1). However, the thorough assessment of qualitative research is an interpretive act and requires informed reflective thought rather than the simple application of a scoring system.

Box 1 Key questions to ask when reading qualitative research studies

Was the sample used in the study appropriate to its research question, were the data collected appropriately, were the data analysed appropriately, can i transfer the results of this study to my own setting, does the study adequately address potential ethical issues, including reflexivity.

Overall: is what the researchers did clear?

One of the critical decisions in a qualitative study is whom or what to include in the sample—whom to interview, whom to observe, what texts to analyse. An understanding that qualitative research is based in experience and in the construction of meaning, combined with the specific research question, should guide the sampling process. For example, a study of the experience of survivors of domestic violence that examined their reasons for not seeking help from healthcare providers might focus on interviewing a sample of such survivors (rather than, for example, healthcare providers, social services workers, or academics in the field). The sample should be broad enough to capture the many facets of a phenomenon, and limitations to the sample should be clearly justified. Since the answers to questions of experience and meaning also relate to people’s social affiliations (culture, religion, socioeconomic group, profession, etc), it is also important that the researcher acknowledges these contexts in the selection of a study sample.

In contrast with quantitative approaches, qualitative studies do not usually have predetermined sample sizes. Sampling stops when a thorough understanding of the phenomenon under study has been reached, an end point that is often called saturation. Researchers consider samples to be saturated when encounters (interviews, observations, etc) with new participants no longer elicit trends or themes not already raised by previous participants. Thus, to sample to saturation, data analysis has to happen while new data are still being collected. Multiple sampling methods may be used to broaden the understanding achieved in a study (box 2). These sampling issues should be clearly articulated in the methods section.

Box 2 Qualitative sampling methods for interviews and focus groups 9

Examples are for a hypothetical study of financial concerns among adult patients with chronic renal failure receiving ongoing haemodialysis in a single hospital outpatient unit.

Typical case sampling —sampling the most ordinary, usual cases of a phenomenon

The sample would include patients likely to have had typical experiences for that haemodialysis unit and patients who fit the profile of patients in the unit for factors found on literature review. Other typical cases could be found via snowball sampling (see below)

Deviant case sampling —sampling the most extreme cases of a phenomenon

The sample would include patients likely to have had different experiences of relevant aspects of haemodialysis. For example, if most patients in the unit are 60-70 years old and recently began haemodialysis for diabetic nephropathy, researchers might sample the unmarried university student in his 20s on haemodialysis since childhood, the 32 year old woman with lupus who is now trying to get pregnant, and the 90 year old who newly started haemodialysis due to an adverse reaction to radio-opaque contrast dye. Other deviant cases could be found via theoretical and/or snowball sampling (see below)

Critical case sampling —sampling cases that are predicted (based on theoretical models or previous research) to be especially information-rich and thus particularly illuminating

The nature of this sample depends on previous research. For example, if research showed that marital status was a major determinant of financial concerns for haemodialysis patients, then critical cases might include patients whose marital status changed while on haemodialysis

Maximum-variation sampling —sampling as wide a range of perspectives as possible to capture the broadest set of information and experiences)

The sample would include typical, deviant, and critical cases (as above), plus any other perspectives identified

Confirming-disconfirming sampling —Sampling both individuals or texts whose perspectives are likely to confirm the researcher’s developing understanding of the phenomenon under study and those whose perspectives are likely to challenge that understanding

The sample would include patients whose experiences would likely either confirm or disconfirm what the researchers had already learnt (from other patients) about financial concerns among patients in the haemodialysis unit. This could be accomplished via theoretical and/or snowball sampling (see below)

Snowball sampling —sampling participants found by asking current participants in a study to recommend others whose experiences would be relevant to the study

Current participants could be asked to provide the names of others in the unit who they thought, when asked about financial concerns, would either share their views (confirming), disagree with their views (disconfirming), have views typical of patients on their unit (typical cases), or have views different from most other patients on their unit (deviant cases)

Theoretical sampling —sampling individuals or texts whom the researchers predict (based on theoretical models or previous research) would add new perspectives to those already represented in the sample

Researchers could use their understanding of known issues for haemodialysis patients that would, in theory, relate to financial concerns to ensure that the relevant perspectives were represented in the study. For example, if, as the research progressed, it turned out that none of the patients in the sample had had to change or leave a job in order to accommodate haemodialysis scheduling, the researchers might (based on previous research) choose to intentionally sample patients who had left their jobs because of the time commitment of haemodialysis (but who could not do peritoneal dialysis) and others who had switched to jobs with more flexible scheduling because of their need for haemodialysis

It is important that a qualitative study carefully describes the methods used in collecting data. The appropriateness of the method(s) selected to use for the specific research question should be justified, ideally with reference to the research literature. It should be clear that methods were used systematically and in an organised manner. Attention should be paid to specific methodological challenges such as the Hawthorne effect, 1 whereby the presence of an observer may influence participants’ behaviours. By using a technique called thick description, qualitative studies often aim to include enough contextual information to provide readers with a sense of what it was like to have been in the research setting.

Another technique that is often used is triangulation, with which a researcher uses multiple methods or perspectives to help produce a more comprehensive set of findings. A study can triangulate data, using different sources of data to examine a phenomenon in different contexts (for example, interviewing palliative patients who are at home, those who are in acute care hospitals, and those who are in specialist palliative care units); it can also triangulate methods, collecting different types of data (for example, interviews, focus groups, observations) to increase insight into a phenomenon.

Another common technique is the use of an iterative process, whereby concurrent data analysis is used to inform data collection. For example, concurrent analysis of an interview study about lack of adherence to medications among a particular social group might show that early participants seem to be dismissive of the efforts of their local pharmacists; the interview script might then be changed to include an exploration of this phenomenon. The iterative process constitutes a distinctive qualitative tradition, in contrast to the tradition of stable processes and measures in quantitative studies. Iterations should be explicit and justified with reference to the research question and sampling techniques so that the reader understands how data collection shaped the resulting insights.

Qualitative studies should include a clear description of a systematic form of data analysis. Many legitimate analytical approaches exist; regardless of which is used, the study should report what was done, how, and by whom. If an iterative process was used, it should be clearly delineated. If more than one researcher analysed the data (which depends on the methodology used) it should be clear how differences between analyses were negotiated. Many studies make reference to a technique called member checking, wherein the researcher shows all or part of the study’s findings to participants to determine if they are in accord with their experiences. 2 Studies may also describe an audit trail, which might include researchers’ analysis notes, minutes of researchers’ meetings, and other materials that could be used to follow the research process.

The contextual nature of qualitative research means that careful thought must be given to the potential transferability of its results to other sociocultural settings. Though the study should discuss the extent of the findings’ resonance with the published literature, 3 much of the onus of assessing transferability is left to readers, who must decide if the setting of the study is sufficiently similar for its results to be transferable to their own context. In doing so, the reader looks for resonance—the extent that research findings have meaning for the reader.

Transferability may be helped by the study’s discussion of how its results advance theoretical understandings that are relevant to multiple situations. For example, a study of patients’ preferences in palliative care may contribute to theories of ethics and humanity in medicine, thus suggesting relevance to other clinical situations such as the informed consent exchange before treatment. We have explained elsewhere in this series the importance of theory in qualitative research, and there are many who believe that a key indicator of quality in qualitative research is its contribution to advancing theoretical understanding as well as useful knowledge. This debate continues in the literature, 4 but from a pragmatic perspective most qualitative studies in health professions journals emphasise results that relate to practice; theoretical discussions tend to be published elsewhere.

Reflexivity is particularly important within the qualitative paradigm. Reflexivity refers to recognition of the influence a researcher brings to the research process. It highlights potential power relationships between the researcher and research participants that might shape the data being collected, particularly when the researcher is a healthcare professional or educator and the participant is a patient, client, or student. 5 It also acknowledges how a researcher’s gender, ethnic background, profession, and social status influence the choices made within the study, such as the research question itself and the methods of data collection. 6 7

Research articles written in the qualitative paradigm should show evidence both of reflexive practice and of consideration of other relevant ethical issues. Ethics in qualitative research should extend beyond prescriptive guidelines and research ethics boards into a thorough exploration of the ethical consequences of collecting personal experiences and opening those experiences to public scrutiny (a detailed discussion of this problem within a research report may, however, be limited by the practicalities of word count limitations). 8 Issues of confidentiality and anonymity can become quite complex when data constitute personal reports of experience or perception; the need to minimise harm may involve not only protection from external scrutiny but also mechanisms to mitigate potential distress to participants from sharing their personal stories.

In conclusion: is what the researchers did clear?

The qualitative paradigm includes a wide range of theoretical and methodological options, and qualitative studies must include clear descriptions of how they were conducted, including the selection of the study sample, the data collection methods, and the analysis process. The list of key questions for beginning readers to ask when reading qualitative research articles (see box 1) is intended not as a finite checklist, but rather as a beginner’s guide to a complex topic. Critical appraisal of particular qualitative articles may differ according to the theories and methodologies used, and achieving a nuanced understanding in this area is fairly complex.

Further reading

Crabtree F, Miller WL, eds. Doing qualitative research . 2nd ed. Thousand Oaks, CA: Sage, 1999.

Denzin NK, Lincoln YS, eds. Handbook of qualitative research . 2nd ed. Thousand Oaks, CA: Sage, 2000.

Finlay L, Ballinger C, eds. Qualitative research for allied health professionals: challenging choices . Chichester: Wiley, 2006.

Flick U. An introduction to qualitative research . 2nd ed. London: Sage, 2002.

Green J, Thorogood N. Qualitative methods for health research . London: Sage, 2004.

Lingard L, Kennedy TJ. Qualitative research in medical education . Edinburgh: Association for the Study of Medical Education, 2007.

Mauthner M, Birch M, Jessop J, Miller T, eds. Ethics in Qualitative Research . Thousand Oaks, CA: Sage, 2002.

Seale C. The quality of qualitative research . London: Sage, 1999.

Silverman D. Doing qualitative research . Thousand Oaks, CA: Sage, 2000.

Journal articles

Greenhalgh T. How to read a paper: papers that go beyond numbers. BMJ 1997;315:740-3.

Mays N, Pope C. Qualitative research: Rigour and qualitative research. BMJ 1995;311:109-12.

Mays N, Pope C. Qualitative research in health care: assessing quality in qualitative research. BMJ 2000;320:50-2.

Popay J, Rogers A, Williams G. Rationale and standards for the systematic review of qualitative literature in health services research. Qual Health Res 1998;8:341-51.

Internet resources

National Health Service Public Health Resource Unit. Critical appraisal skills programme: qualitative research appraisal tool . 2006. www.phru.nhs.uk/Doc_Links/Qualitative%20Appraisal%20Tool.pdf

Cite this as: BMJ 2008;337:a1035

• Related to doi: , 10.1136/bmj.a288
• doi: , 10.1136/bmj.39602.690162.47
• doi: , 10.1136/bmj.a1020
• doi: , 10.1136/bmj.a879
• doi: 10.1136/bmj.a949

This is the last in a series of six articles that aim to help readers to critically appraise the increasing number of qualitative research articles in clinical journals. The series editors are Ayelet Kuper and Scott Reeves.

For a definition of general terms relating to qualitative research, see the first article in this series.

Contributors: AK wrote the first draft of the article and collated comments for subsequent iterations. LL and WL made substantial contributions to the structure and content, provided examples, and gave feedback on successive drafts. AK is the guarantor.

Funding: None.

Competing interests: None declared.

Provenance and peer review: Commissioned; externally peer reviewed.

• ↵ Holden JD. Hawthorne effects and research into professional practice. J Evaluation Clin Pract 2001 ; 7 : 65 -70. OpenUrl CrossRef PubMed Web of Science
• ↵ Hammersley M, Atkinson P. Ethnography: principles in practice . 2nd ed. London: Routledge, 1995 .
• ↵ Silverman D. Doing qualitative research . Thousand Oaks, CA: Sage, 2000 .
• ↵ Mays N, Pope C. Qualitative research in health care: assessing quality in qualitative research. BMJ 2000 ; 320 : 50 -2. OpenUrl FREE Full Text
• ↵ Lingard L, Kennedy TJ. Qualitative research in medical education . Edinburgh: Association for the Study of Medical Education, 2007 .
• ↵ Seale C. The quality of qualitative research . London: Sage, 1999 .
• ↵ Wallerstein N. Power between evaluator and community: research relationships within New Mexico’s healthier communities. Soc Sci Med 1999 ; 49 : 39 -54. OpenUrl CrossRef PubMed Web of Science
• ↵ Mauthner M, Birch M, Jessop J, Miller T, eds. Ethics in qualitative research . Thousand Oaks, CA: Sage, 2002 .
• ↵ Kuzel AJ. Sampling in qualitative inquiry. In: Crabtree F, Miller WL, eds. Doing qualitative research . 2nd ed. Thousand Oaks, CA: Sage, 1999 :33-45.

Qualitative Research

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Rapid Techniques in Qualitative Research: A Critical Review of the Literature

Affiliations.

• 1 University College London, London, United Kingdom.
• 2 Rapid Research Evaluation and Appraisal Lab, London, United Kingdom.
• 3 Australian National University, Canberra, Australia.
• PMID: 32667277
• DOI: 10.1177/1049732320921835

Qualitative researchers are under increasing time demands to rapidly collect, analyze, and disseminate the results of their findings. Adaptations to qualitative methods may be required to enable the use of timely and relevant qualitative data across multiple disciplinary settings. The aim of this review is to briefly explore the ways in which data collection and analysis methods have been adapted in qualitative research to deal with short study timeframes. We carried out a two-phased systematic review of the literature and determined there were six primary reasons why rapid techniques were used: (a) reduce time, (b) reduce cost, (c) increase the amount of collected data, (d) improve efficiency, (e) improve accuracy, and (f) obtain a closer approximation to the narrated realities of research participants. In addition, we analyzed the characteristics of the articles, how traditional methods were adapted and evaluated, the benefits and limitations of using rapid techniques, and future recommendations.

Keywords: adaptation; coping; enduring; methodology; qualitative; research design; systematic literature review.

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9 Critical Approaches to Qualitative Research

Kum-Kum Bhavnani, Department of Sociology, University of California at Santa Barbara

Peter Chua, Department of Sociology, San José State University

Dana Collins, Department of Sociology, California State University, Fullerton

• Published: 04 August 2014
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This chapter reflects on critical strategies in qualitative research. It examines the meanings and debates associated with the term “critical,” in particular, contrasting liberal and dialectical notions and practices in relation to social analysis and qualitative research. The chapter also explores how critical social research may be synonymous with critical ethnography in relation to issues of power, positionality, representation, and the production of situated knowledges. It uses Bhavnani’s framework to draw on Dana Collins’ research as a specific case to suggest how the notion of the “critical” relates to ethnographic research practices: ensuring feminist and queer accountability, resisting reinscription, and integrating lived experience.

Qualitative research is now ubiquitous and fairly well-respected throughout the human sciences. That Oxford University Press is producing this much-needed volume is further testament to that notion, and one which we applaud. However, although there are different approaches to conducting qualitative research, what is often not addressed are the philosophical notions underlying such research. And that is where the “critical” enters. Indeed, “critical,” used as an adjective and applied, within the academy, to methods of research is also a familiar phrase. The question is, therefore: what does “critical” mean, and how might it be translated such that present and future researchers could draw on some of its fundamentals as they plan their research studies in relation to progressive political activism?

The popularity of critical research is not predictable. Although the 1960s and early 1970s did offer a number of publications that engaged with critical research traditions (e.g., Gouldner, 1970 ), and the 1990s also led to a resurgence of interest in this area (e.g., Harvey, 1990 ; Thomas, 1993 ), it is now two decades since explicit discussions of critical research have been widely discussed within the social sciences (see Smith, 1999 ; Madison, 2012 , as exceptions).

In this chapter, we first outline meanings associated with “critical.” We then suggest that the narratives of critical ethnography are best suited for an overview chapter such as this. We consider critical ethnography to be virtually synonymous with critical social research as we discuss it in this chapter. In the final section of our chapter, we discuss Dana Collins’ specific research studies to suggest how her approach embraces the notion of “critical” ( Collins, 2005 ; 2007 ; 2009 ).

The “Critical” in Critical Approaches

“Critical” is used in many ways. In everyday use, the term can refer, among other definitions, to an assessment that points out flaws and mistakes (“a critical approach to the design”), or to being close to a crisis (“a critical illness”). On the positive side, it can refer to a close reading (“a critical assessment of Rosa Luxembourg’s writings”) or as being essential (“critical for effective educational strategies”). A final definition is that the word can be used to either denote considerable praise (“the playwright’s work was critically acclaimed”) or to indicate a particular turning point (“this is a critical time to vote”). It is this last definition that is closest to our approach as we reflect on “critical” in the context of qualitative research. That is, drawing from the writings of Marx, the Frankfurt School, and others (see Delanty, 2005 ; Marx, 1845/1976 ; Strydom, 2011 ), we suggest that critical approaches to qualitative methods do not signify only a particular way of thinking about the methods we use in our research studies, but that “critical approaches” also signify a turning point in how we think about the conduct of research across the human sciences, including its dialectical relations to the progressive and systematic transformation of social relations and social institutions.

The most straightforward notion of “critical” in this context is that it refers to (at the least) or insists (at its strongest) that research—and all ways by which knowledge is created—is firmly grounded within an understanding of social structures (social inequalities), power relationships (power inequalities), and the agency of human beings (an engagement with the fact that human beings actively think about their worlds). Critical approaches are most frequently associated with Marxist, feminist, and antiracist, indigenous, and Third World perspectives. At its most succinct, therefore, we argue that “critical” in this context refers to issues of epistemology, power, micropolitics, and resistance.

What does this mean, both theoretically and for how we conduct our research? Most would agree that whereas qualitative research does not, by definition, insist on a nonpositivist way of examining the social world, for critical approaches to be truly critical, an antipositivist approach is the sine qua non of critical research. Furthermore, it is evident as we survey critical empirical research that issues of reflexive and subjective techniques in data collection and the researcher’s relationship with research subjects also frame both the practices and the theories associated with research.

The following section begins by drawing attention to developments and debates involving the more restricted use the term critical as related to Marxism and then explores the ramifications for varying attempts to conduct critical qualitative research.

The Critical Debates

Karl Marx, Friedrich Engels, and their contemporaries (see Engels, 1877/1969 ; Harvey, 1996 ; Lenin, 1915/1977 ; Mao, 1990 ; Ollman, 2003 ) developed dialectical materialist notions of critique and “critical” that were substantively different from prior notions. They incorporated these dialectical materialist notions to develop Marxist theories and politics.

Dialectical materialism refers to an outlook on reality that emphasizes the importance of process and change that are inherent to things (such as objects, phenomena, and situations), as well as of the importance of human practices in making change. Significantly, human struggle over existing conditions and contradictions in things creates not only new conditions, but also new contradictions. This outlook serves as an analytical tool over idealist and old-fashioned materialist worldviews and as a source of strength for exploited peoples in their struggle against ruling elites and classes. It emphasizes that correct ideas, knowledge, and theoretical abstractions are established initially, and perhaps inevitably, through practice.

Dialectical materialism may be used to examine two aspects of the research process and the production of academic knowledge. The first aspect involves the writing process as it is carried out among multiple authors. At the drafting phase, the authors craft their distinct ideas into textual form. Contradictions in ideas are bound to exist in the draft. In doing revisions, some contradictions may become intensified and remain unresolved, yet, most frequently (and hopefully!), many are addressed in the form of clearer, more solid, and coherent arguments, thus resolving the earlier contradictions in the text. Yet, new struggles and contradictions emerge. The synthesis of ideas and argument in the final manuscript may again, however, engage in new struggles with the prevailing arguments being discussed.

The second aspect involves the relationship and interaction between the researcher and the interviewee. As their relationship begins, contradictions and differences usually exist between them, for instance, in terms of their prior experiences and knowledge, their material interests in the research project, and their communication skills in being persuasive and forging consent. The struggle of these initial contradictions could result in new conditions and contradictions. For example, this could lead to

the establishment of quality rapport between them, allowing the interview to be completed while the researcher maintains control over the situation;

the abrupt end of the interview due to the interviewee refusing and asserting her or his right to comply with the interview process; or

an explicit set of negotiations that address the unevenness in power relations between them, along with an invitation for both to be part of the research team and to collaborate in the collection and analysis of data and in the forging of new theories and knowledges.

In the first possibility, the prevailing power relations in interviews remain but shift to beneath the surface of the relationship, under the guise of “rapport.” In the second possibility, power relations in the interview process and initial contradictions are heightened, resulting in new conditions and contradictions that the researcher and research participant have to address, jointly and singly. In the third possibility, the research subject is transformed into a researcher as well, and the relationship between the two is transformed into a more active co-learning and co-teaching relationship. Still, new conflicts and contradictions may emerge as the research process continues to unfold. 1 In short, dialectical materialism stresses the analysis of change in the essence (1), practice (2), and struggle (3). Such analyses are at the root of how change may be imagined within the practices of social research.

Dialectical materialism, which forms the basis of the concept of “critical,” emphasizes the need to engage with power, inequality, and social relations in the arenas of the social, political, economic, cultural, and ideological. Based on this status, it is argued that an analysis of societies and ways of life demands a more comprehensive approach, one that does not view society and social institutions merely as a singular unit of analysis but rather as ones that are replete with history. Dialectical materialism directs its criticism against prevailing views or hegemonies, and, within the context of academic endeavors, engages in debates against positivism and neo-Kantian forms of social inquiry. It is this basis of “critical” that defines it in the context of research as a deep questioning of science, objectivity, and rationality. Thus, the meaning of the term “critical,” based on the idea of “critique,” emerges from the practice and application of dialectical materialism.

Historical materialism emerges from and is based on dialectical materialism. That is, any application of the dialectic to material realities is historical materialism. For example, any study of human society, its history, its development, and its process of change demands a dialectical approach rooted in historical materialism. This involves delving deeper into past and present social phenomena to thereby determine how people change the essence of social phenomena, and, simultaneously, transform their contradictions.

Dialectical materialism regards positivism as a crude and naïve endeavor to seek knowledge and explain phenomena and as one that assumes it is the task of social researchers to determine the laws of social relationships by relying solely on observations (i.e., by assuming there is a primacy of external conditions and actions). In addition, positivism separates the subject (the seemingly unbiased, detached observer) and object (the phenomenon/a under consideration) of study. Dialectical materialism overcomes the shortcomings of positivism by offering a holistic understanding of (a) the essence of phenomena; (b) the processes of internal changes, the handling of contradictions, and the development of knowledge; (c) the unity of the subject and object in the making of correct ideas; and (d) the role of practice and politics in knowledge creation.

Dialectical materialism directs its criticism against dominant standpoints. These standpoints can offer a simplistic form of idealism and philosophical materialism. Within the context of academic endeavors, the methods of dialectical materialism engage in debates against positivism and neo-Kantian forms of social inquiry. This approach challenges assertions that science, objectivity, and rationality are the sine qua non of research and that skepticism and liberalism are the only appropriate analytical positionings by which a research project can be defined as “critical.”

For instance, Auguste Comte and Emile Durkheim, in developing sociological positivism, argued for a new science to study society, one that adopted the methods of the natural sciences, such as skeptical empiricism and the practices of induction. In adopting these methods, approaches relying on early positivism sought to craft knowledge based on seemingly affirmative verification rather than being based on judgmental evaluation and transformative distinctions.

Positivism and dialectical materialism were both developed in response to Kantian and idealist philosophy. In the context of the European Enlightenment, in the late 1700s, Immanuel Kant inaugurated the philosophy of critique. Positivism challenged Kant’s philosophy of critique as the basis for the theory of knowledge.

Kant developed his notion of critique to highlight the workings of human reason and judgment, to illuminate its limitations, and to consolidate its application in order to secure a stable foundation for morality, religion, and metaphysical concerns. Politically, Kantian philosophy provided justification for both a traditionalism derived from earlier periods and a liberalism developed during the ascendance of the Enlightenment.

Kant sought to settle philosophical disputes between a narrow notion of empiricism (that relies on pure observation, perception, and experience as the basis for knowledge) and a narrow notion of rationalism (that relies on pure reason and concepts as the basis for knowledge). He argued that the essence (termed “thing-in-itself”) is unknowable, countering David Hume’s skeptical empiricism, and he was convinced that there is no knowledge outside of innate conceptual categories. For Kant, “concepts without perceptions are empty; perceptions without concepts are blind” (1781/1965, pp. A 51/B 75).

The method of dialectical materialism challenges Kant’s idealism for (what is claimed to be) its faulty assertion that correct ideas and knowing about the “thing-in-itself” can only emerge from innate conceptual categories, ones that are universal and transcendental. In Kantian philosophy, there is no reality (out there) to be known. Rather, it is the experience of reality itself that provides for human reason and consciousness.

Dialectical materialism overcomes Kant’s idealism with its recognition of the existence of concrete phenomena, outside and independent of human reason. Dialectical materialism stresses that social reality and concrete phenomena reflect on and determine the content of human consciousness (and also, we would argue, vice versa). Dialectical materialism also emphasizes the role of practice and politics in knowledge development, instead of merely centering the primacy of ideas and the meanings of objects.

In sum, the core debate against positivism centers on the practices of science. Dialectical materialism regards positivist approaches as crude and naïve endeavors that seek to determine unchangeable laws of nature, rely solely on observations and “sense experience” of phenomena as the basis for knowledge, highlight the primacy of external conditions and actions to explain phenomena, and separate the subject from the object of study. That is, dialectical materialism views positivism as a form of mechanical, as distinct from historical, materialism.

This abridged account of dialectical materialism and the critiques it offers of Kantian idealism and sociological positivism can allow for the formation of a preliminary set of criteria for what may constitute the “critical.” We argue that qualitative research may be critical if it makes clear conceptually and analytically:

The essence and root cause of any social phenomena (e.g., youth and politics);

The relationship between the essence of the social phenomena under consideration to the general social totality (such as how youth and their views of politics are related to wider systems within society, such as education, age, exploitation);

The contradictions within this social phenomenon (such as how young people are expressing their discontent),

and, therefore,

How to conduct more reflexive practices that interrelate data generation, data analysis, and political engagement that challenge existing relations of power.

Contemporary debates between neo-Kantian idealists and dialectical materialists have often been friendly regarding the direction for carving out what is meant by a critical project in qualitative social research. These debates bring to the fore issues of politics, ethics, research design, and the collection and analysis of data. They have also prompted a variety of ways in which “critical” may be used in relation to qualitative research. For the purposes of this chapter, we suggest four substantial ways in which “critical” is used in the context of qualitative research: (a) critical as a form of liberalism, (b) critical as a counterdisciplinary perspective, (c) critical as an expansion of politics, and (d) critical as a professionalized research endeavor and perspective.

Critical as a form of Kantian liberalism is one of the more conventional uses of the term in qualitative research. This use of critical is generally contrasted against the dogmatism of positivist approaches within social scientific research. Yet, to use critical in this way means that we embrace a liberalism that ends up promoting idealism in outlook and pluralism in practice. That is, Kantian liberalism presents itself as a “critical” and novel analysis by combining eclectic ideas and theories while not making known its political stand and its material interests. As a result, it supports prevailing modes of thinking that emphasize abstraction over concrete reality, and it succumbs to relativistist and pragmatist practices in research, such as “anything goes” in collecting data. In terms of methods, this use of “critical” promotes looseness and leniency in ethics and data collection and analysis, often without a structured accountability to the many constituencies that underlie all social research. Furthermore, the use of, for example, phrases such as “critical spaces,” when applied to social research, may be better understood as a celebration of method above theory and meta-theory and an engagement with some (of the often rather) excessive approaches to reflexivity and meta-reflexivity. In sum, this understanding of “critical” lacks appropriate structures of ethics and accountability and often tends to reject dialectic materialism.

The second use of “critical” in regards to qualitative research proposes a more analytical disagreement with conventional scholarly disciplines and, in so doing, seeks to take up counterdisciplinary positions ( Burawoy, 1998 ; 2003 ; Carroll, 2004 ; Smith, 2007 ). There are two main strands in this use of “critical.” One strand argues that “critical” is a means of exposing the weaknesses of conventional academic disciplines such as anthropology, political science, psychology, and sociology. At the same time, this strand maintains the viability of these core social science disciplines. For instance, academic feminists have continually highlighted the masculinist and heterosexist bias in what is considered top-tier scholarship and the need for these disciplines to be more inclusive in terms of perspectives and methodological techniques (e.g., Fonow & Cook, 1991 ; Harding, 1991 ; Ray, 2006 ). Yet such an approach may not inevitably focus on the fundamental problems, such as a neglect of the study of power inequalities (e.g., Boserup 1970 ; and see examples in Reinharz & Davidman, 1992 ). This second strand seeks to carve out interdisciplinary and multidisciplinary fields such as women studies, cultural studies, and area studies to overcome the paradigmatic and fundamental crises within core disciplines ( Bhavnani, Foran, & Kurian, 2003 ; March, 1995 ; Mohanty, 2003 ). Many of these interdisciplinary and multidisciplinary fields have often been more historical and qualitative in their approaches, seeking to go beyond positivist limitations and present a more nuanced and thorough analysis. However, even these multi-, inter-, and antidisciplinary fields have an uneven impact on dominant and conventional knowledge.

Moreover, both strands have not been able to overcome the increasing corporatization and neoliberalization of academic institutions. This issue addresses the increasing restructuring of public education into a private domain, one that relies on privatized practices and funding of both teaching and research. The neoliberalization of the academy is found in the ties of academic research to corporate grants, individualized career advancement, excessive publishing demands and citation indices, and the use of outsourcing for transcription, interviewing, online education, and private research spaces that are “rented” by public institutions, to name a few. These neoliberal conditions of research usually push out those critical researchers who attempt to avoid such exploitative avenues for research, writing, and collaboration. This use of “critical,” however, does expose that critical research is taking shape within contemporary processes of neoliberalism and the increasing privatization of the academy ( Giroux, 2009 ; Greenwood, 2012 ; Pavlidis, 2012 ).

The third and less familiar approach is to view “critical” as invigorating politics through the practices of feminist, antiracist, and participatory action research. This approach, for example, highlights the importance of analyzing power in research, as in terms of the conduct of inquiry, in political usefulness, and in affecting relations of power and material relations. Yet this view of “critical” is dogmatic because this approach demands that every research study meet all criteria of criticality comprehensively and perfectly.

A final use of “critical” emerges from the many scholarly and professionalized approaches that engage with the politics of academic knowledge construction while making visible the limits of positivism. “Critical” is used here as a means to focus primarily on revitalizing scholarship and research endeavors. However, we argue that even this use of “critical” ossifies the separation of the making of specialized knowledge from an active engagement to transform social life. Such a separation is antithetical to dialectical materialism. Often, this fourth form of the term “critical” is based on the logics of the Frankfurt School of critical theory (such as that of Adorno [1973] , Habermas [1985] , and Marcuse [1968] ) and other Western neo-Marxisms (from Lukacs [1971] and Gramsci [1971] to Negri [1999] ). Critical ethnographers and other critical social researchers, drawing from this tradition, often develop public intellectual persona by writing and talking about politics through scholarly and popular forms of publishing and speaking presentations and are even seen to take part in political mobilizations. Yet they can also shy away from infusing their research with a deep engagement in political processes outside the academy.

Later in this chapter, we discuss how to avoid some of the pitfalls of these four types of “critical,” but suffice it to say, in short, that it is the politics and the explicit situatedness of research projects that can permit research to remain “critical.”

Is Critical Ethnography the Same as Critical Research?

George Marcus (1998) argues that the ethnographer is a midwife who, through words, gives birth to what is happening in the lives of the oppressed. Beverley Skeggs (1994) has proposed that ethnography is, in itself, “a theory of the research process,” and Asad (1973) offered the now-classic critique of anthropology as the colonial encounter. However, although many approaches to and definitions of ethnography abound, it is the case that they all agree on one aspect: namely, that ethnographies offer an “insider’s” perspective on the social phenomena under consideration. It is often suggested that the best ethnographies, whether defined as critical or not, offer detailed descriptions of how people see, and inhabit, their social worlds and cultures (e.g., Behar, 1993 ; Ho, 2009 ; Kondo, 1990 ; Zinn, 1979 ).

It is evident from our argument so far that we do not think of ethnographic approaches to knowledge construction as being, in and of themselves, critical. This is because an ethnographic study, although not in opposition to critical ethnography or to critical research in general, has practices rooted in social anthropology. Therefore, its assumptions are often in line with anthropological assumptions (see Harvey [1990] for a recounting of some of these assumptions). Concepts such as “insider” versus “outsider,” “going native,” “gaining access,” and even conceptualizations of a homogenized and/or exoticized “field” that is out there ready to be examined by research remain as significant lenses of methodological conceptualization in much ethnographic research.

Despite, or perhaps because of, the move to reflexivity in ethnographic research, there remain enduring assumptions about best practices. As a result, a certain fetishization of research methods transpires, one that is often epitomized as reflexivity. In this instance, ethnographic and qualitative research become an ideal set of practices for extracting information. In sum, “best research practices,” as ways to extract information, reproduce core power dynamics of racism, gender, class, imperialism, and heteronormativity, which, in turn, reproduce the oppressive dynamics of noncritical qualitative research.

Furthermore, when presenting research merely as reflexive research, it is the case that the researcher can lose sight of the broader social structural and historical materialist context. In addition, a static notion of reflexivity can lead to the researcher not looking outward to assess the wider interconnections among the micropolitics of the research. That is, reflexivity is a dialectic among the researcher, the research process, and the analysis ( Jordan & Yeomans, 1995 ), but it is often presented simply as a series of apparently unchangeable/essential facets of the researcher. Our final point is that for theory to be critical in the development of research paradigms, it has to explicitly engage with lived experiences and cultures for, without that engagement, it remains as formalism (see, e.g., the work of Guenther [2009] and Kang [2010] as examples of critical qualitative research). We are very much in tune with Hesse-Biber and Leavy, who have suggested that (grounded) theory building is a “dynamic dance routine” in which “there is no one right dance, no set routine to follow. One must be open to discovery” (2006, p. 76).

An example of the limitation of conventionally reflexive research is in the area of lesbian and gay research methods that focus on the experiences of gay men and lesbians conducting qualitative research. It also offers a commentary on the role that non-normative sexuality plays in social research. By looking inward (see the earlier comment on “reflexivity”), these methodological frameworks focus on the researcher’s and participants’ lesbian/gay identifications. In so doing, this can fabricate a shared social structural positionality with research participants who have been labeled “gay” or “lesbian.” Such an approach to reflexivity overlooks the fabricated nature of positionalities and ignores the sometimes more significant divisions between researchers and participants that are expressed along the lines of race, class, gender, and nationality. Reflexivity is used only as a way to forge a connection for the exchange of information. A grave mistake is made in this rush to force similarity along the lines of how people practice non-normative sexualities ( Lewin & Leap, 1996 ; for a more successful engagement with queer intersectionality in research, see Browne & Nash, 2010 ).

The point to be made is that critical researchers should not merely ask “how does this knowledge engage with social structure?” Critical researchers, when contemplating the question “What is this?” as they set up and analyze their research, could also ask, “What could this be?” ( Carspecken, 1996 ; Degiuli, 2007 ; Denzin, 2001 ; Noblit, Flores, & Murillo, 2004 , all cited in Degiuli, 2007 ). Perhaps, borrowing from Karen O’Reilly’s thoughts on critical ethnography, one may think of critical research as “an approach that is overtly political and critical, exposing inequalities in an effort to effect change” ( Reilly, 2009 , p. 51). That is, in order for qualitative research to be critical, it must be grounded in the material relationships of history, as may be seen in the work of Carruyo (2011) , Chua (2001 ; 2006 ; 2007 ; 2012 ), Collins (2005 ; 2007 ; 2009 ), Lodhia (2010) , and Talcott (2010) .

Quantz (1992) , in his discussion of critical ethnography, suggests that five aspects are central to the discussion of critical research/ethnography: knowledge, values, society, history, and culture. So far in this chapter, we have discussed knowledge and its production, values/reflexivity and qualitative research/ethnography, society and unequal social relationships, and history as a method of historical and dialectical materialism in order to better understand social and institutional structures. What we have not discussed, however, is the notion of culture, nor, indeed, the predicament of culture ( Clifford, 1998 ): “Culture is an ongoing political struggle around the meaning given to actions of people located within unbounded asymmetrical power relations” ( Quantz, 1992 , p. 483).

Quantz elaborates by stating that culture develops as people struggle together to name their experiences (see Comaroff & Comaroff, 2012 , for a sophisticated and elegant discussion of this thinking). For example, one key task of critical research is to tease out how disempowerment is achieved, undermined, or resisted. That is, the job of the researcher is to see how the disempowerment—economic, political, cultural—of subordinated groups manifests itself within culture, and, indeed, whether the subordinated groups even recognize their disempowerment. For example, “the hand that rocks the cradle rules the world” is one example of how the material disempowerment of many groups of women is presented, in fact, as a strength of women, and yet it takes the gaze away from seeing the subordination of women by ostensibly emphasizing women’s hidden social power.

It is critical qualitative research that has to simultaneously analyze how our research can identify processes and expressions of disempowerment and can then lead to a restructuring of these relationships of disempowerment. At times, critical social researchers engage in long-term projects that involve policy advocacy and community solidarity to link community-driven research with social empowerment and community change (see Bonacich, 1998 ; Bonacich & Wilson, 2008 ; Hondagneu-Sotelo, 2007 ; Stoecker, 2012 ).

The key point is that critical qualitative research parts company with positivistic approaches because it is argued that positivism is only able to offer a superficial set of findings. Critical qualitative research hones research concepts, practices, and analyses into finer points of reference so that societal relationships may be not only understood, but also so that social power inequalities can be undermined. In short, critical social research has a Foucauldian notion of power at its very core and may thus be thought of as offering insights into people’s lived experiences ( Williams, 1976 ) as they negotiate asymmetrical societal power relations (see e.g., Novelli, 2006 ).

The Practices of Critical Qualitative Research

Within our current era of enduring global inequalities, what could constitute a truly critical approach to qualitative research? More than twenty years ago, in “Tracing the Contours” ( Bhavnani, 1993 ), it was argued that if all knowledge is historically contingent and, therefore, that the processes of knowledge production are situated, then this must apply to all research practices as well. 2 This argument was based on Haraway’s (1988) idea that the particularities of knowledge production do not lie in the characteristics of individuals. Rather, knowledge production is “about communities, not about isolated individuals” (p. 590). Building on this, Haraway discussed the significance of partiality and its relationship to objectivity. She suggested that it is the researcher’s knowledge of her own “limited location” that creates objectivity. In other words, knowing the limitations of one’s structural position as a researcher contributes to objective research because there is no objectivity that is omniscient, one from which all can be revealed (Haraway discusses this as the “god trick,” which is like “seeing everything from nowhere,” p. 582).

It is from Haraway’s insights that we develop our argument that situated knowledges are not synonymous with the static reflexivity we describe earlier. This is because, in this latter scenario, the researcher implies that all research knowledge is based on and derives from an individual’s personal historical and biographical perspectives. That is, researchers note their racial/ethnic identity, sex/gender, sexuality, age, class, and ability (i.e., biographical aspects of themselves), which are presented as essential and unchanging factors and that determine the knowledge created by the research. This has also been called “absolute relativism” ( Bhavnani, 1993 ) or “extreme relativism” ( Alcoff & Potter, 1993 ).

We suggest that the three elements central to research being “critical” are partiality, positionality, and accountability. Partiality leads to critical research interrogating prevailing representations as the research is conducted, and this builds on difference. Positionality is not about being reflexive, but about understanding the sociohistorical/political context from which research is created and thus engages with the micropolitics of a research endeavor. Accountability makes it evident that there are many constituencies to which all academic researchers are accountable—for example, their discipline, intellectual integrity, their institution and academic colleagues, the idea of rigorous scientific research, and academic freedom in research—as well as being accountable to the people with whom the research is being conducted. It is accountability that leads to a critical research project interrogating how the lived experiences and cultures of the research participants are inscribed within the research (see Stoecker, 2012 ).

What might the necessary elements be for ensuring that our research practices retain the criticality we have discussed earlier? We offer four possibilities that could form a filter through which one could decide if research is critical, using our definition of the term. First, all critical qualitative researchers should interrogate the history of ethnographic research that has led to the systematic domination of the poor; working classes; ethnic, racialized, sexual Others; women; and colonized peoples. That is, critical qualitative researchers must begin research with an understanding of how previous research, including their own, may continue to play a part in the subordination of peoples around the world, for example, by reinscribing them into predictable and stereotypical roles. Second, critical qualitative researchers should work to develop a consciousness of what might constitute critical research practices—without fetishizing methods—that challenge the system of domination often present in social research. Third, researchers who embrace critical qualitative approaches must develop comfort with the notion that they are conducting research with a purpose; that is, researchers grapple with and comprehend that critical research demands that they engage with the idea that they conduct research into research inequalities in order to undo these inequalities. Finally, critical qualitative researchers comprehend that their level of comfort can extend into the idea that research does not simply capture social realities; rather, the critical research approach is generative of narratives and knowledges. Once this last idea is accepted—namely, that knowledge is created in a research project and not merely captured—it is then a comparatively straightforward task to see the need for a researcher’s accountability for the narratives and knowledges he or she ultimately produces. In so doing, it is possible to recognize that all representations have a life of their own outside of any intentions and that representations can contribute to histories of oppression and subordination.

We propose that it is the actual practice of research, and, perhaps, even the idea of researcher as witness ( Fernandes, 2003 ), and not a notion of “best practices,” that keeps the politics of research at the center of the work we do. This includes insights into the redistribution of power, representation, and knowledge production. We suggest that critical research is work that shifts research away from the production of knowledge for knowledge’s sake and edges or nudges it toward a more transformative vision of social justice (see Burawoy, 1998 ; Choudry, 2011 ; D’Souza, 2009 ; Hussey, 2012 ; Hunter, Emerald, & Martin, 2013 ).

Thoughts from the Field

Here, based on Collins’s fieldwork, we highlight a set of critical methodological lessons that became prominent while she was conducting her field research in Malate, in the city of Manila, the Philippines, currently a tourist destination but once famous as a sex district. We define her work as a critical research practice.

Since 1999, Dana Collins has conducted urban ethnographic work in Malate, exploring gay men’s production of urban sexual place. She has been interested in the role of “desire” in urban renewal, and, in particular, how informal sexual laborers (whom she terms “gay hospitality workers,” a nomenclature drawn from their own understandings of their labor and lives) use “desire” to forge their place in a gentrifying district that is also displacing them. This displacement has involved analyzing urban tourism development, city-directed urban renewal, and gay-led gentrification, as well as informal sexual labor.

The research has involved her precarious immersion in an urban sexual field. She undertook participant observation of gay night life in the streets, as well as in private business establishments, and conducted in-depth and in-field interviews with gay business owners, city officials, conservationists, gay tourists, and gay-identified sexual laborers. In addition, she drew on insights from visual sociology and also completed extensive archival work and oral history interviewing. In all of this, she explored the collective memories of Malate as a freeing urban sexual space.

There exist multiple and shifting positionalities of power, knowledge, exchange, and resistance in her research. For one, she points out that she occupies multiple social locations as a white, lesbian-identified feminist ethnographer from a US university, one who forges complicated relationships with urban sexual space, sex workers, and both gay Filipino men and gay tourists.

A critical research practice at heart involves the shifting of epistemological foundations of social science research by addressing core questions of how we know what we know, how power shapes the practices of research, how we can better integrate research participants and communities as central producers of knowledge in our research, and how we can better conceptualize the relationship between the research we do and the social justice we are working toward in this world. 3 Such questions function as a call to action for critical researchers not only to examine the power relations present in research, but to generate new ways of researching that can confront the realities of racism, gender and class oppression, imperialism, and homophobia. This is about not only becoming better researchers, but also about seeking ways to shift the very paradigm of qualitative research and ensuring its service to social change. We have learned to use these questions as a central and ongoing part of the research we do.

Feminist and Queer Accountability to the Micropolitics of the Field

One of the primary tenets of critical qualitative research is that researchers must work with a wider understanding and application of the politics of research. For Kum-Kum Bhavnani (1993) , this means that one needs to be accountable to the micropolitics of research because such accountability destabilizes the tendency to conduct and present research from a transcendent position—the “all knowing” ethnographer, the “outsider” going in to understand the point of view of “insiders,” the attempt to (avoid) “go(ing) native,” and the researcher who aims to “gain access” at all costs and in the interests of furthering research. Micropolitics is not only the axis of inequality that shapes contemporary field relations; it is also the historical materialist relationship that constitutes the field and informs the basis of critical qualitative research. Micropolitics therefore is a critical framework that questions the essentializing and power-laden perceptions of research spaces and people because it encourages both a reflexive inquiry into the limited locations of research, and it involves the more critical practice of the researcher turning outward, to comprehend what Bhavnani calls the “interconnections” among researcher, research participants, and the social structural spaces of “the field.”

Micropolitics illuminates how all research is conducted from the limited locations of gender, race, class, sexual identification, and nationality, as well as illuminating the interconnections among all of these locations. This is not a simplistic reflexive practice of taking a moment in research to account for one’s positionality and then moving on to conduct normative field work; Bhavnani has been critical of such moments of inward inspection that lack substantial accountability to the wider micropolitics of the field. Rather, this move requires an ongoing interrogation of the limited locations of research that show how knowledge is not transcendent. Furthermore, when used reflexively, limited locations offer a more critical framework from which to practice research.

Micropolitics encouraged Collins’ attention to the limited location of a global feminist ethnographer doing research on gay male urban sexual space in Manila. For one, she moved among different positionalities throughout her research—of woman, queer-identified, white, US academic, tourist, ate (Tagalog term for older sister)—and none of these positions was either a transcendent or more authentic standpoint from which to conduct ethnographic work. So, for instance, as a white tourist, she moved easily among the gentrifying gay spaces because these spaces were increasingly designed to encourage her movement around Malate. This limited location showed the increasing establishment of white consumer space, which encouraged the movement of consumers like herself yet dissuaded the movement of the informal sexual laborers with whom she was also spending time—the gay hosts. Her limited location as a white woman researcher from a major US university meant that gay hosts sometimes shared their spaces and meanings of urban gay life with her, yet many times those particular spaces and dialogues were closed—she was not allowed into the many public sexual spaces (parks and avenues for cruising and sex late at night), yet gay hosts treated her as an audience for their many romantic stories about the boyfriends they met in the neighborhood.

Hosts emphasized that they gained much from hosting foreigners in terms of friendship, love, desire, and cultural capital. Yet they monitored the information they shared because she remained to them a US researcher who wielded the power of representation over their lives, despite her closeness with a group of five gay hosts. Hence, gay hosts often chose to remain silent about their difficult memories of sex work or any information that could frame them as one-dimensional “money boys,” as distinct from the “gay”-identified Filipino men who migrated to Malate to take part in a gay urban community.

Micropolitics challenges the authenticity of any one positionality over another; it was Collins’ movement among all of them, as well as her ongoing consideration of their social structural places, that provided her with a more critical orientation to the research. She suggests that she was not essentially a better “positioned” researcher to study “gay” life in Manila because she too is gay. Rather she found that differences of race, class, gender, and nationality tended to serve as more enduring, limited locations that influenced relationships within this research and that required ongoing critical reflexive engagement.

We want to add that a queer micropolitics of the field also offers critical insight into how identities are not stagnant but rather can be fabricated and performative during the research process. This moves researchers away from an essentialist take on their standpoint because an essentialist mind-set can lead to a search for the authentic insider and outsider. It can also lead to an essentialist social positionality that is more conducive for researching. Queer micropolitics show that research is made up of a collection of productive relations and identities. So, for example, her lesbian identification did not create a more authentic connection with gay hosts in Manila; rather, she often fabricated a shared “gay” positionality. This was a performance that served as a point of departure for her many conversations, from which she could proceed to share meanings of what it meant to be “gay” in the Manila and the United States.

Some of the productive relations that arise in research are the continuum of intimacies that develop while doing research. So, like feminists before her, she chose to develop close friendships with hosts where they genuinely loved (in a familial way) as they spoke of love. While learning about gay life in Malate, she stroked egos, offered advice, cried over broken hearts and life struggles, and built and maintained familial relations. Queer micropolitics shows, however, the limitations of such intimacies because intimacy does not equal similarity—the differing social locations of class, race, gender, and nationality meant that the experiences of urban gay life varied immensely. Thus, building such intimacies across these differences requires both the recognition and respect for boundaries that hosts constructed. She had to learn to see and know that when hosts became quiet and pulled away these were acts of self-preservation as well as acts of defiance against the many misrepresentations of their lives that had taken shape in academic research and journalistic renderings of their place in “exotic” sex districts.

A queer micropolitics also shows how research is an embodied practice: researchers are gendered, racialized, classed, and sexualized in the field. This became most apparent as she walked alone at night in the “field” and developed a keen awareness of the deeply gendered aspects of Malate’s urban spaces. For one, her embodiment was a peculiar presence because women in Manila do not walk alone at night. This includes women sex workers who publicly congregate in groups or with clients and escorts; otherwise, they are subject to police harassment. Hence, her very movement in the field as a sole woman felt like a transgression into masculine urban space because her feminine body was treated as “out-of-place” in the public spaces of the streets at night—she was flirted with, name called, followed, and sexually handled as she walked to gay bars for her research. As much as her queer location afforded her an understanding of how gender is a discursive production on the body, replete with the possibility of her being able to transcend and destabilize the gendered body as a biological “reality,” she confronted the discomfort of being read as a real woman in what became predominantly men’s spaces at night.

Yet this gendered embodiment, in part, shaped her knowledge of the district as she developed quick and knowledgeable movement through the streets, a queer micropolitical reading of urban space that arose out of this limited gender location. She was aware of the spacing of blocks, the alleys, the street lighting, and the time of night when crowds spilled out from the bars and onto the streets, allowing her to realize that a socially vibrant street life actually facilitated her movement. This queer micropolitical reading of urban space showed how both researchers and research participants do not simply exist in a neutral way in city space; rather, gender leads to our use and misuse of urban space. She has juxtaposed her experience with those of research participants in her study. The latter spoke at length about their exploratory and liberatory experiences of urban space, replete with their access to masculine sexual spaces—parks for cruising and sex, city blocks for meeting clients or picking up male sex workers, and alleys, movie theaters, and mall bathrooms for anonymous sex.

This queer micropolitical read of Malate’s gentrified space showed how very different was her access to the newly opening bars, restaurants, cafés, and lifestyle stores. Her whiteness signaled assumptions of her class location and positioned her as part of the international presence that this gentrifying space was targeting and whose movement among establishments was encouraged. She received free entry, free drinks, exceptional hospitality, and invitations to private parties, and her movements were closely monitored as she entered and exited establishments for the sake of “protecting a foreign tourist from street harassment” (interview with bar owner).

Overall, she experienced whiteness and class as equally embodied because these locations signaled her power as a “legitimate” consumer, allowing access to urban consumer sites and a privileged movement among gentrified spaces. This embodied experience of gentrified space differed from that of her gay hosts, who were often denied access to these establishments for being Filipino, young, working class, gay, and interested in foreigners. Contrarily, their bodies were constructed as a “threat” to urban renewal in the district.

Resisting Reinscription

Critical qualitative research is also concerned with the politics of representation in research. This requires a hard look at the implicit imperialisms of ethnographic work, including the tendency to go in and get out with abundant factual information, as well as the lasting impact of objectificatory research practices on fields of study. Such practices are evident in the now global rhetoric about the so-called Third World prostitute, who in both academic and journalistic renderings tends to be sensationalized and sexually Othered. This rendering is part of a long history of exoticization that has denied subjectivity and rendered invisible the lived experiences of sexual laborers around the world.

Such failed representations are part of what Kum-Kum Bhavnani (1993) has called “reinscription”—the tendency in research to freeze research participants and sites in time and space, thus rendering them both exotic and silenced. Reinscription denies agency to research participants and renders invisible the dynamic lived experiences of those same research participants. Doing research in both postcolonial and sexual spaces means that researchers must grapple with how our research participates in histories of reinscription—we both enter into and potentially contribute to a field that has been already “examined,” overstudied, and often exoticized. Thus, a critical qualitative approach is one that begins with a thorough understanding of these histories of representation so that we are not entering fields naïvely, as spaces only of exploration. Rather, we enter with knowledge of how the field has already been constituted for us through reinscription. A critical orientation has a core objective of understanding how our representations of research at all levels of the research process could contribute to exoticization by reinscribing participants and sites.

The issue of reinscription became particularly apparent when Dana Collins interviewed gay hosts and grappled with what appeared to be their elaboration of a contradictory picture of their sexual labor, as well as of their lives. In short, hosts tended to “lie,” remain silent, embellish “truths,” and articulate contradictory allusions to their life and labor in Malate. When Collins began her interviewing, she held the implicit objective of obtaining the “truth” about hosts’ lives, which she believed resided in “what they do” in the tourism industry. She was concerned with the “facts” about their lives, even though gay hosts were more likely to express their desire—desire for relations with foreigners, desire to migrate to a “gay” urban district, desire for rewarding work, and desire for community and social change. She struggled with many uncertainties about the discussions: how could they hold a range of “jobs” and attend school, yet spend most of their days and nights in Malate? How could they understand gay tourists as both boyfriends and clients? Why resist the label “sex worker” yet refer to themselves as “working boys” and claim to have “clients?” She struggled to make sense of the meanings that hosts offered even as she simultaneously felt misled concerning the “real” relations of hospitality.

Interviewing hosts about sexualized labor—as a way to produce a representation of sex work—did not facilitate the flow of candid information; hosts later expressed their view that sex work and their lives were already “overstudied.” Many researchers had previously descended on Malate to study sex work, and the district was a prime location for the outreach of HIV/AIDS organizations, some of which had breached the confidence of the gay host community. In short, Dana mistakenly started her research without the knowledge of Malate as a hyperrepresented field, and her research risked reinscribing gay hosts’ lives within that field as static and unchanging.

Importantly, those gay hosts who resisted becoming the “good research subjects” who give accurate and bountiful information, prompted a radical shift in her research framework. They told her stories about their imagined social lives, which encouraged her to rethink her commitment to researching sex work because the transformation of the discourses offered another view of the district, their work, and lives, one that offered a more visionary perspective. She began to focus less on “misinformation” and instead followed how hosts framed their lives. She treated these framings as social imaginings in which Malate features prominently in their understandings of gay identity, community, belonging, and change. In short, their social imaginings functioned as counternarratives to reinscription and offered their lived experience of urban gay place. Such imaginations expressed hope, fear, critique, and desire—in short, they present a utopic vision of identity, community, and urban change.

Integrating Lived Experience

Finally, critical qualitative research is a call to study lived experience, which is a messy, contradictory realm, but a deeply important one if we as critical researchers are truly interested in working against a history of research that has silenced those “under study” (see Weis & Fine, 2012 ). Paying attention to lived experience allows us to better engage with the contradictions mentioned earlier because lived experience is about understanding the meanings that research participants choose to share with researchers, and it is also about respecting their silences. As Kum-Kum Bhavnani (1993) has argued, silences can be as eloquent as words. Finally, integrating lived experience can take a critical qualitative project further because lived experience allows researchers to explore the epistemological relationship of the meanings and imaginings offered by research participants and to be explicit about the project of knowledge production. In other words, a central guiding question of critical qualitative research is how can research participants speak and shape epistemology, rather than solely being spoken about or being the subjects of epistemology?

Collins used hosts’ social imaginings as an epistemological contribution because their imaginings showed how hosts draw from experiences of urban gay community to articulate their desires for change, despite their simultaneous experiences of inequality and exclusion. We read social imaginings as a subjective rendering of urban place—the hosts’ social imaginings expressed their history, identity, subversive uses of urban space, and, ultimately, the symbolic reconstitution of that urban space. In this way, hosts were refiguring transnational urban space by writing themselves and their labor back into the district’s meaning, even as the global forces of tourism and urban renewal threatened to displace them.

In conclusion, we seek to highlight how critical research insists on the interplay of reflexivity, process, and practice. In particular, we encourage critical researchers to be mindful of the multiple meanings and usages of the term “critical” so that we can make more explicit our political interests and stand within our disciplines, the academy, our community, and the world. We offer dialectical materialism as a distinct mode of critical analysis that emphasizes an analysis of change in essence, practice, and struggle. We also suggest that, for researchers to be critical in their research, they should strive to take up research questions and projects that study change, contradictions, struggle, and practice in order to counter dominant interests and advance the well-being of the world’s majority. We should strive to build new research relationships—such as overcoming the faulty divides between researchers and research participants and by promoting systems of community accountability—that dialectically fuse research, political activism, and progressive social change.

Furthermore, we suggest that critical research can agitate against the homogeneity of ethnographic representation, allowing for the realities of people’s lives to come into view. Critical researchers recognize the contested fields of research; yet this requires our critical engagement with the research process, as a reflexive, empathetic, collective, self-altering, socially transformative, and embedded exercise in knowledge production. Therefore, critical research can resist imperialist research practices that are disembodied and that assume a singular social positioning. We use an imperative here to say that we must conduct research as embodied subjects who shift between multiple and limited locations. We also have to find more ways to remain accountable to our communities of research as a way to undo implicit imperialisms in social research. Critical research can work against the remnants of an objectivist and truth-seeking method that supports prevailing interests, classes, and groups while embracing research from social locations that offer situated knowledges and the possibility for greater shared understandings. Finally, critical research can engage the micropolitics of research and foreground the need for the accountability of researchers to resist reproducing epistemic violence.

This last is an idealist imagining of what should happen. However, a number of research projects have approximated closely to these goals.

Parts of our argument have appeared in some of our earlier work (e.g., Bhavnani & Talcott, 2011 ; Collins, 2009 ; 2002 ; Chua, 2001 ).

Although we, as the chapter’s three authors, do not usually use “we” in our writing as a general pronoun, it is the most direct way to offer our insights in this section.

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• v.84(1); 2020 Jan

A Review of the Quality Indicators of Rigor in Qualitative Research

Jessica l. johnson.

a William Carey University School of Pharmacy, Biloxi, Mississippi

Donna Adkins

Sheila chauvin.

b Louisiana State University, School of Medicine, New Orleans, Louisiana

Attributes of rigor and quality and suggested best practices for qualitative research design as they relate to the steps of designing, conducting, and reporting qualitative research in health professions educational scholarship are presented. A research question must be clear and focused and supported by a strong conceptual framework, both of which contribute to the selection of appropriate research methods that enhance trustworthiness and minimize researcher bias inherent in qualitative methodologies. Qualitative data collection and analyses are often modified through an iterative approach to answering the research question. Researcher reflexivity, essentially a researcher’s insight into their own biases and rationale for decision-making as the study progresses, is critical to rigor. This article reviews common standards of rigor, quality scholarship criteria, and best practices for qualitative research from design through dissemination.

INTRODUCTION

Within the past 20 years, qualitative research in health professions education has increased significantly, both in practice and publication. Today, one can pick up most any issue of a wide variety of health professions education journals and find at least one article that includes some type of qualitative research, whether a full study or the inclusion of a qualitative component within a quantitative or mixed methods study. Simultaneously, there have been recurrent calls for enhancing rigor and quality in qualitative research.

As members of the academic community, we share responsibility for ensuring rigor in qualitative research, whether as researchers who design and implement, manuscript reviewers who critique, colleagues who discuss and learn from each other, or scholarly teachers who draw upon results to enhance and innovate education. Therefore, the purpose of this article is to summarize standards of rigor and suggested best practices for designing, conducting, and reporting high-quality qualitative research. To begin, Denzin and Lincoln’s definition of qualitative research, a long-standing cornerstone in the field, provides a useful foundation for summarizing quality standards and best practices:

Qualitative research involves the studied use and collection of a variety of empirical materials – case study; personal experience; introspection; life story; interview; artifacts; cultural texts and productions; observational, historical, interactional, and visual texts – that describe the routine and problematic moments and meanings in individual lives. Accordingly, qualitative researchers deploy a wide range of interconnected interpretative practices, hoping always to get a better understanding of the subject matter at hand. It is understood, however, that each practice makes the world visible in a different way. Hence there is frequently a commitment to using more than one interpretative practice in any study. 1

In recent years, multiple publications have synthesized quality criteria and recommendations for use by researchers and peer reviewers alike, often in the form of checklists. 2-6 Some authors have raised concerns about the use of such checklists and adherence to strict, universal criteria because they do not afford sufficient flexibility to accommodate the diverse approaches and multiple interpretive practices often represented in qualitative studies. 7-11 They argue that a strict focus on using checklists of specific technical criteria may stifle the diversity and multiplicity of practices that are so much a part of achieving quality and rigor within the qualitative paradigm. As an alternative, some of these authors have published best practice guidelines for use by researchers and peer reviewers to achieve and assess methodological rigor and research quality. 12,13

Some journals within the field of health professions education have also established best practice guidance, as opposed to strict criteria or a checklist, for qualitative research. These have been disseminated as guiding questions or evaluation categories. In 2015, Academic Medicine produced an expanded second edition of a researcher/author manual that includes specific criteria with extensive explanations and examples. 14 Still others have disseminated best practice guidelines through a series of methodological articles within journal publications. 2

In this article, attributes of rigor and quality and suggested best practices are presented as they relate to the steps of designing, conducting, and reporting qualitative research in a step-wise approach.

BEST PRACTICES: STEP-WISE APPROACH

Step 1: identifying a research topic.

Identifying and developing a research topic is comprised of two major tasks: formulating a research question, and developing a conceptual framework to support the study. Formulating a research question is often stimulated by real-life observations, experiences, or events in the researcher’s local setting that reflect a perplexing problem begging for systematic inquiry. The research question begins as a problem statement or set of propositions that describe the relationship among certain concepts, behaviors, or experiences. Agee 15 and others 16,17 note that initial questions are usually too broad in focus and too vague regarding the specific context of the study to be answerable and researchable. Creswell reminds us that initial qualitative research questions guide inquiry, but they often change as the author’s understanding of the issue develops throughout the study. 16 Developing and refining a primary research question focused on both the phenomena of interest and the context in which it is situated is essential to research rigor and quality.

Glassick, Huber, and Maeroff identified six criteria applicable to assessing the quality of scholarship. 18,19 Now commonly referred to as the Glassick Criteria ( Table 1 ), these critical attributes outline the essential elements of any scholarly approach and serve as a general research framework for developing research questions and designing studies. The first two criteria, clear purpose and adequate preparation, are directly related to formulating effective research questions and a strong conceptual framework.

Glassick’s Criteria for Assessing the Quality of Scholarship of a Research Study 18

Generating and refining a qualitative research question requires thorough, systematic, and iterative review of the literature, and the use of those results to establish a clear context and foundation for the question and study design. Using an iterative approach, relevant concepts, principles, theories or models, and prior evidence are identified to establish what is known, and more importantly, what is not known. The iterative process contributes to forming a better research question, the criteria for which can be abbreviated by the acronym FINER, ie, f easible, i nteresting, n ovel, e thical, and r elevant, that is answerable and researchable, in terms of research focus, context specificity, and the availability of time, logistics, and resources to carry out the study. Developing a FINER research question is critical to study rigor and quality and should not be rushed, as all other aspects of research design depend on the focus and clarity of the research question(s) guiding the study. 15 Agee provides clear and worthwhile additional guidance for developing qualitative research questions. 15

Reflexivity, the idea that a researcher’s preconceptions and biases can influence decisions and actions throughout qualitative research activities, is a critical aspect of rigor even at the earliest stages of the study. A researcher’s background, beliefs, and experiences may affect any aspect of the research from choosing which specific question to investigate through determining how to present the results. Therefore, even at this early stage, the potential effect of researcher bias and any ethical considerations should be acknowledged and addressed. That is, how will the question’s influence on study design affect participants’ lives, position the researcher in relationship with others, or require specific methods for addressing potential areas of research bias and ethical considerations?

A conceptual framework is then actively constructed to provide a logical and convincing argument for the research. The framework defines and justifies the research question, the methodology selected to answer that question, and the perspectives from which interpretation of results and conclusions will be made. 5,6,20 Developing a well-integrated conceptual framework is essential to establishing a research topic based upon a thorough and integrated review of relevant literature (addressing Glassick criteria #1 and #2: clear purpose and adequate preparation). Key concepts, principles, assumptions, best practices, and theories are identified, defined, and integrated in ways that clearly demonstrate the problem statement and corresponding research question are answerable, researchable, and important to advancing thinking and practice.

Ringsted, Hodges, and Sherpbier describe three essential parts to an effective conceptual framework: theories and/or concepts and principles relevant to the phenomenon of interest; what is known and unknown from prior work, observations, and examples; and the researcher’s observations, ideas, and suppositions regarding the research problem statement and question. 21 Lingard describes four types of unknowns to pursue during literature review: what no one knows; what is not yet well understood; what controversy or conflicting results, understandings, or perspectives exist; and what are unproven assumptions. 22 In qualitative research, these unknowns are critical to achieving a well-developed conceptual framework and a corresponding rigorous study design.

Recent contributions from Ravitch and colleagues present best practices in developing frameworks for conceptual and methodological coherence within a study design, regardless of the research approach. 23,24 Their recommendations and arguments are highly relevant to qualitative research. Figure 1 reflects the primary components of a conceptual framework adapted from Ravitch and Carl 23 and how all components contribute to decisions regarding research design, implementation, and applications of results to future thinking, study, and practice. Notice that each element of the framework interacts with and influences other elements in a dynamic and interactive process from the beginning to the end of a research project. The intersecting bidirectional arrows represent direct relationships between elements as they relate to specific aspects of a qualitative research study.

Adaptation of Ravitch and Carl’s Components of a Conceptual Framework 23

Maxwell also provides useful guidance for developing an effective conceptual framework specific to the qualitative research paradigm. 17 The 2015 second edition of the Review Criteria for Research Manuscripts 14 and work by Ravitch and colleagues 23,24 provide specific guidance for applying the conceptual framework to each stage of the research process to enhance rigor and quality. Quality criteria for assessing a study’s problem statement, conceptual framework, and research question include the following: introduction builds a logical case and provides context for the problem statement; problem statement is clear and well-articulated; conceptual framework is explicit and justified; research purpose and/or question is clearly stated; and constructs being investigated are clearly identified and presented. 14,24,25 As best practice guidelines, these criteria facilitate quality and rigor while providing sufficient flexibility in how each is achieved and demonstrated.

While a conceptual framework is important to rigor in qualitative research, Huberman and Miles caution qualitative researchers about developing and using a framework to the extent that it influences qualitative design deductively because this would violate the very principles of induction that define the qualitative research paradigm. 25 Our profession’s recent emphasis on a holistic admissions process for pharmacy students provides a reasonable example of inductive and deductive reasoning and their respective applications in qualitative and quantitative research studies. Principles of inductive reasoning are applied when a qualitative research study examines a representative group of competent pharmacy professionals to generate a theory about essential cognitive and affective skills for patient-centered care. Deductive reasoning could then be applied to design a hypothesis-driven prospective study that compares the outcomes of two cohorts of students, one group admitted using traditional criteria and one admitted based on a holistic admissions process revised to value the affective skills of applicants. Essentially, the qualitative researcher must carefully generate a conceptual framework that guides the research question and study design without allowing the conceptual framework to become so rigid as to dictate a testable hypothesis, which is the founding principle of deductive reasoning. 26

Step 2: Qualitative Study Design

The development of a strong conceptual framework facilitates selection of appropriate study methods to minimize the bias inherent in qualitative studies and help readers to trust the research and the researcher (see Glassick criteria #3 in Table 1 ). Although researchers can employ great flexibility in the selection of study methods, inclusion of best practice methods for assuring the rigor and trustworthiness of results is critical to study design. Lincoln and Guba outline four criteria for establishing the overall trustworthiness of qualitative research results: credibility, the researcher ensures and imparts to the reader supporting evidence that the results accurately represent what was studied; transferability, the researcher provides detailed contextual information such that readers can determine whether the results are applicable to their or other situations; dependability, the researcher describes the study process in sufficient detail that the work could be repeated; confirmability, the researcher ensures and communicates to the reader that the results are based on and reflective of the information gathered from the participants and not the interpretations or bias of the researcher. 27

Specific best practice methods used in the sampling and data collection processes to increase the rigor and trustworthiness of qualitative research include: clear rationale for sampling design decisions, determination of data saturation, ethics in research design, member checking, prolonged engagement with and persistent observation of study participants, and triangulation of data sources. 28

Qualitative research is focused on making sense of lived, observed phenomenon in a specific context with specifically selected individuals, rather than attempting to generalize from sample to population. Therefore, sampling design in qualitative research is not random but defined purposively to include the most appropriate participants in the most appropriate context for answering the research question. Qualitative researchers recognize that certain participants are more likely to be “rich” with data or insight than others, and therefore, more relevant and useful in achieving the research purpose and answering the question at hand. The conceptual framework contributes directly to determining sample definitions, size, and recruitment of participants. A typical best practice is purposive sampling methods, and when appropriate, convenience sampling may be justified. 29

Purposive sampling reflects intentional selection of research participants to optimize data sources for answering the research question. For example, the research question may be best answered by persons who have particular experience (critical case sampling) or certain expertise (key informant sampling). Similarly, additional participants may be referred for participation by active participants (snowball sampling) or may be selected to represent either similar or opposing viewpoints (confirming or disconfirming samples). Again, the process of developing and using a strong conceptual framework to guide and justify methodological decisions, in this case defining and establishing the study sample, is critical to rigor and quality. 30 Convenience sampling, using the most accessible research participants, is the least rigorous approach to defining a study sample and may result in low accuracy, poor representativeness, low credibility, and lack of transferability of study results.

Qualitative studies typically reflect designs in which data collection and analysis are done concurrently, with results of ongoing analysis informing continuing data collection. Determination of a final sample size is largely based on having sufficient opportunity to collect relevant data until new information is no longer emerging from data collection, new coding is not feasible, and/or no new themes are emerging; that is, reaching data saturation , a common standard of rigor for data collection in qualitative studies . Thus, accurately predicting a sample size during the planning phases of qualitative research can be challenging. 30 Care should be taken that sufficient quantity (think thick description) and quality (think rich description) of data have been collected prior to concluding that data saturation has been achieved. A poor decision regarding sample size is a direct consequence of sampling strategy and quality of data generated, which leaves the researcher unable to fully answer the research question in sufficient depth. 30

Though data saturation is probably the most common terminology used to describe the achievement of sufficient sample size, it does not apply to all study designs. For example, one could argue that in some approaches to qualitative research, data collection could continue infinitely if the event continues infinitely. In education, we often anecdotally observe variations in the personality and structure of a class of students, and as generations of students continue to evolve with time, so too would the data generated from observing each successive class. In such situations, data saturation might never be achieved. Conversely, the number of participants available for inclusion in a sample may be small and some risk of not reaching data saturation may be unavoidable. Thus, the idea of fully achieving data saturation may be unrealistic when applied to some populations or research questions. In other instances, attrition and factors related to time and resources may contribute to not reaching data saturation within the limits of the study. By being transparent in the process and reporting of results when saturation may not have been possible, the resulting data may still contribute to the field and to further inquiry. Replication of the study using other samples and conducting additional types of follow-up studies are other options for better understanding the research phenomenon at hand. 31

In addition to defining the sample and selecting participants, other considerations related to sampling bias may impact the quantity and quality of data generated and therefore the quality of the study result. These include: methods of recruiting, procedures for informed consent, timing of the interviews in relation to experience or emotion, procedures for ensuring participant anonymity/confidentiality, interview setting, and methods of recording/transcribing the data. Any of these factors could potentially change the nature of the relationship between the researcher and the study participants and influence the trustworthiness of data collected or the study result. Thus, ongoing application of previously mentioned researcher reflexivity is critical to the rigor of the study and quality of sampling. 29,30

Common qualitative data collection methods used in health professions education include interview, direct observation methods, and textual/document analysis. Given the unique and often highly sensitive nature of data being collected by the researcher, trustworthiness is an essential component of the researcher-participant relationship. Ethical conduct refers to how moral principles and values are part of the research process. Participants’ perceptions of ethical conduct are fundamental to a relationship likely to generate high quality data. During each step of the research process, care must be taken to protect the confidentiality of participants and shield them from harm relating to issues of respect and dignity. Researchers must be respectful of the participants’ contributions and quotes, and results must be reported truthfully and honestly. 8

Interview methods range from highly structured to increase dependability or completely open-ended to allow for interviewers to clarify a participant’s response for increased credibility and confirmability. Regardless, interview protocols and structure are often modified or refined, based on concurrent data collection and analysis processes to support or refute preliminary interpretations and refine focus and continuing inquiry. Researcher reflexivity, or acknowledgement of researcher bias, is absolutely critical to the credibility and trustworthiness of data collection and analysis in such study designs. 32

Interviews should be recorded and transcribed verbatim prior to coding and analysis. 28 Member checking, a common standard of rigor, is a practice to increase study credibility and confirmability that involves asking a research subject to verify the transcription of an interview. 1,16,28 The research subject is asked to verify the completeness and accuracy of an interview transcript to ensure the transcript truthfully reflects the meaning and intent of the subject’s contribution.

Prolonged engagement involves the researcher gaining familiarity and understanding of the culture and context surrounding the persons or situations being studied. This strategy supports reflexivity, allowing the researcher to determine how they themselves may be a source of bias during the data collection process by altering the nature of how individuals behave or interact with others in the presence of the researcher. Facial expressions, spoken language, body language, style of dress, age, race, gender, social status, culture, and the researcher’s relationship with the participants may potentially influence either participants’ responses or how the researcher interprets those responses. 33 “Fitting in” by demonstrating an appreciation and understanding of the cultural norms of the population being studied potentially allows the researcher to obtain more open and honest responses from participants. However, if the research participants or topic are too familiar or personal, this may also influence data collection or analysis and interpretation of the results. 33 The possible applications of this section to faculty research with student participants in the context of pharmacy education are obvious, and researcher reflexivity is critical to rigor.

Some researchers using observational methods adopt a strategy of direct field observation, while others play partial or full participant roles in the activity being observed. In both observation scenarios, it is impossible to separate the researcher from the environment, and researcher reflexivity is essential. The pros and cons of observation approach, relative to the research question and study purpose, should be evaluated by the researcher, and the justification for the observational strategy selected should be made clear. 34 Regardless of the researcher’s degree of visibility to the study participants, persistent observation of the targeted sample is critical to the confirmability standard and to achieving data saturation. That is, study conclusions must be clearly grounded in persistent phenomena witnessed during the study, rather than on a fluke event. 28

Researchers acknowledge that observational methodologies are limited by the reality that the researcher carries a bias in determining what is observed, what is recorded, how it is recorded, and how it is transcribed for analysis. A study’s conceptual framework is critical to achieving rigor and quality and provides guidance in developing predetermined notions or plans for what to observe, how to record, and how to minimize the influence of potential bias. 34 Researcher notes should be recorded as soon as possible after the observation event to optimize accuracy. The more detailed and complete the notes, the more accurate and useful they can be in data analysis or in auditing processes for enhancing rigor in the interpretation phase of the study. 34

Triangulation is among the common standards of rigor applied within the qualitative research paradigm. Data triangulation is used to identify convergence of data obtained through multiple data sources and methods (eg, observation field notes and interview transcripts) to avoid or minimize error or bias and optimize accuracy in data collection and analysis processes. 33,35,36

Again, researcher practice in reflexivity throughout research processes is integral to rigor in study design and implementation. Researchers must demonstrate attention to appropriate methods and reflective critique, which are represented in both core elements of the conceptual framework ( Figure 1 ) and Glassick criteria ( Table 1 ). In so doing, the researcher will be well-prepared to justify sampling design and data collection decisions to manuscript reviewers and, ultimately, readers.

Step 3: Data Analysis

In many qualitative studies, data collection runs concurrently with data analysis. Specific standards of rigor are commonly used to ensure trustworthiness and integrity within the data analysis process, including use of computer software, peer review, audit trail, triangulation, and negative case analysis.

Management and analyses of qualitative data from written text, observational field notes, and interview transcriptions may be accomplished using manual methods or the assistance of computer software applications for coding and analysis. When managing very large data sets or complex study designs, computer software can be very helpful to assist researchers in coding, sorting, organizing, and weighting data elements. Software applications can facilitate ease in calculating semi-quantitative descriptive statistics, such as counts of specific events, that can be used as evidence that the researcher’s analysis is based on a representative majority of data collected ( inclusivism ) rather than focusing on selected rarities ( anecdotalism ). Using software to code data can also make it easier to identify deviant cases, detect coding errors, and estimate interrater reliability among multiple coders. 37 While such software helps to manage data, the actual analyses and interpretation still reside with the researcher.

Peer review, another common standard of rigor, is a process by which researchers invite an independent third-party researcher to analyze a detailed audit trail maintained by the study author. The audit trail methodically describes the step-by-step processes and decision-making throughout the study. Review of this audit trail occurs prior to manuscript development and enhances study confirmability. 1,16 The peer reviewer offers a critique of the study methods and validation of the conclusions drawn by the author as a thorough check on researcher bias.

Triangulation also plays a role in data analysis, as the term can also be used to describe how multiple sources of data can be used to confirm or refute interpretation, assertions, themes, and study conclusions. If a theme or theory can be arrived at and validated using multiple sources of data, the result of the study has greater credibility and confirmability. 16,33,36 Should any competing or controversial theories emerge during data collection or analysis, it is vital to the credibility and trustworthiness of the study that the author disclose and explore those negative cases. Negative case analysis refers to actively seeking out and scrutinizing data that do not fit or support the researcher’s interpretation of the data. 16

The use of best practices applying to data collection and data analysis facilitates the full examination of data relative to the study purpose and research question and helps to prevent premature closure of the study. Rather than stopping at the initial identification of literal, first-level assertion statements and themes, authors must progress to interpreting how results relate to, revise, or expand the conceptual framework, or offer an improved theory or model for explaining the study phenomenon of interest. Closing the loop on data collection is critical and is achieved when thorough and valid analysis can be linked back to the conceptual framework, as addressed in the next section.

Step 4: Drawing Valid Conclusions

Lingard and Kennedy 38 succinctly state that the purpose of qualitative research is to deepen one’s understanding of specific perspectives, observations, experiences, or events evidenced through the behaviors or products of individuals and groups as they are situated in specific contexts or circumstances. Conclusions generated from study results should enhance the conceptual framework, or contribute to a new theory or model development, and are most often situated within the discussion and conclusion sections of a manuscript.

The discussion section should include interpretation of the results and recommendations for practice. Interpretations should go beyond first-level results or literal description of observed behaviors, patterns, and themes from analysis. The author’s challenge is to provide a complete and thorough examination and explanation of how specific results relate to each other, contribute to answering the research question, and achieve the primary purpose of the research endeavor. The discussion should “close the loop” by integrating study results and analysis with the original conceptual framework. The discussion section should also provide a parsimonious narrative or graphical explanation and interpretation of study results that enhances understanding of the targeted phenomena.

The conclusion section should provide an overall picture or synopsis of the study, including its important and unique contributions to the field from the perspective of both conceptual and practical significance. The conclusion should also include personal and theoretical perspectives and future directions for research. Together, the discussion and conclusion should include responses to the larger questions of the study’s contributions, such as: So what? Why do these results matter? What next?

The strength of conclusions is dependent upon the extent to which standards of rigor and best practices were demonstrated in design, data collection, data analysis, and interpretation, as described in previous sections of this article. 4,12,17,23,24 Quality and rigor expectations for drawing valid conclusions and generating new theories are reflected in the following essential features of rigor and quality, which include: “Close the loop” to clearly link research questions, study design, data collection and analysis, and interpretation of results. Reflect effective integration of the study results with the conceptual framework and explain results in ways that relate, support, elaborate, and/or challenge conclusions of prior scholarship. Descriptions of new or enhanced frameworks or models are clear and effectively grounded in the study results and conclusions. Practical or theoretical implications are effectively discussed, including guidance for future studies. Limitations and issues of reflexivity and ethics are clearly and explicitly described, including references to actions taken to address these areas. 3,4,12,14

Step 5: Reporting Research Results

Key to quality reporting of qualitative research results are clarity, organization, completeness, accuracy, and conciseness in communicating the results to the reader of the research manuscript. O’Brien and others 4 proposed a standardized framework specifically for reporting qualitative studies known as the Standards for Reporting Qualitative Research (SRQR, Table 2 ). This framework provides detailed explanations of what should be reported in each of 21 sections of a qualitative research manuscript. While the SRQR does not explicitly mention a conceptual framework, the descriptions and table footnote clarification for the introduction and problem statement reflect the essential elements and focus of a conceptual framework. Ultimately, readers of published work determine levels of credibility, trustworthiness, and the like. A manuscript reviewer, the first reader of a study report, has the responsibility and privilege of providing critique and guidance to authors regarding achievement of quality criteria, execution and reporting of standards of rigor, and the extent to which meaningful contributions to thinking and practice in the field are presented. 13,39

An Adaptation of the 21 Elements of O’Brien and Colleagues’ Standards for Reporting Qualitative Research (SRQR) 4

Authors must avoid language heavy with connotations or adjectives that insert the researcher’s opinion into the database or manuscript. 14,40 The researcher should be as neutral and objective as possible in interpreting data and in presenting results. Thick and rich descriptions, where robust descriptive language is used to provide sufficient contextual information, enable the reader to determine credibility, transferability, dependability, and confirmability .

The process of demonstrating the credibility of research is rooted in honest and transparent reporting of how biases and other possible confounders were identified and addressed throughout study processes. Such reporting, first described within the study’s conceptual framework, should be revisited in reporting the work. Confounders may include the researcher’s training and previous experiences, personal connections to the background theory, access to the study population, and funding sources. These elements and processes are best represented in Glassick’s criteria for effective presentation and reflective critique ( Table 1 , criteria 5 and 6). Transferability is communicated, in part, through description of sampling factors such as: geographical location of the study, number and characteristics of participants, and the timeframe of data collection and analysis. 40 Such descriptions also contribute to the credibility of the results and readers’ determination of transfer to their and other contexts. To ensure dependability, the research method must be reported in detail such that the reader can determine proper research practices have been followed and that future researchers can repeat the study. 40 The confirmability of the results is influenced by reducing or at a minimum explaining any researcher influence on the result by applying and meeting standards of rigor such as member checking, triangulation, and peer review. 29,33

In qualitative studies, the researcher is often the primary instrument for data collection. Any researcher biases not adequately addressed or errors in judgement can affect the quality of data and subsequent research results. 33 Thus, due to the creative interpretative and contextually bound nature of qualitative studies, the application of standards of rigor and adherence to systematic processes well-documented in an audit trail are essential. The application of rigor and quality criteria extend beyond the researcher and are also important to effective peer review processes within a study and for scholarly dissemination. The goal of rigor in qualitative research can be described as ensuring that the research design, method, and conclusions are explicit, public, replicable, open to critique, and free of bias. 41 Rigor in the research process and results are achieved when each element of study methodology is systematic and transparent through complete, methodical, and accurate reporting. 33 Beginning the study with a well-developed conceptual framework and active use of both researcher reflexivity and rigorous peer review during study implementation can drive both study rigor and quality.

As the number of published qualitative studies in health professions educational research increases, it is important for our community of health care educators to keep in mind the unique aspects of rigor in qualitative studies presented here. Qualitative researchers should select and apply any of the above referenced study methods and research practices, as appropriate to the research question, to achieve rigor and quality. As in any research paradigm, the goal of quality and rigor in qualitative research is to minimize the risk of bias and maximize the accuracy and credibility of research results. Rigor is best achieved through thoughtful and deliberate planning, diligent and ongoing application of researcher reflexivity, and honest communication between the researcher and the audience regarding the study and its results.

REVIEW article

This article is part of the research topic.

Vol II: Person-Centred Rehabilitation – Theory, Practice and Research

Hope as experienced by people with acquired brain injury in a rehabilitationor recovery process: A qualitative systematic review and thematic synthesis Provisionally Accepted

• 1 Aalborg University, Denmark
• 2 Municipality of Copenhagen, Denmark

The final, formatted version of the article will be published soon.

Background: There has been an increasing interest in the concept of hope within the field of brain injury rehabilitation. Existing reviews have nevertheless focused on stroke, leaving out the broad populationgroup of people with acquired brain injury (ABI). Furthermore a just as majority of the included studies in those reviews excluded the subgroup of people with communication difficulties, thus primarily giving voice to a select group of people with ABI. Methods: A qualitative systematic review was conducted with the purpose of systematically reviewing and thematically synthesise findings about hope as experienced by adultspeople with ABI in a rehabilitation or recovery process. The search strategy included peer-reviewed qualitative studies published after 2000 in English or Scandinavian languages. Searches of EBSCO databases incorporating CINAHL, MEDLINE, and PsycINFO were conducted together with SocINDEX, Social Work Abstracts, Eric and Web of Science. Ten qualitative studies were included, and the Critical Appraisal Skills Program (CASP) was used for assessing the quality and relevance of the ten studies. Qualitative findings were synthesized using Thomas and Harden's methodology. data were analysed based on methods for thematic synthesis by Thomas and Harden. Results: Through a thematic synthesis eleven subthemes were identifiedemerged relating to experiences of hope. These were grouped into four analytical themes: (1) Hope a two folded phenomenon; (2) Time and temporality; (3) Progress, goals and visibility and (4) The alliance. Conclusion: This review has shown that even though hope has both a positive and negative side to it, it is necessary as a driving force for people with ABI in terms of supporting them to keep going and not give up. Rehabilitation professionals are advised to embrace the ambiguity of hope, customizing the support of hope to each person with ABI. Attention is needed on how to make progress visible for persons with ABI during their rehabilitation process just as rehabilitation professionals should acknowledge the alliance with the person with ABI as a core component of rehabilitation. This requires a focus on professionals' communication skills if hope promoting relationships between professionals and persons with ABI are to be achieved.

Keywords: hope, acquired brain injury, Rehabilitation, Recovery, literature review, qualitative studies, thematic synthesis

Received: 26 Jan 2024; Accepted: 26 Apr 2024.

Copyright: © 2024 Højgaard Nejst and Glintborg. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: PhD. Camilla Højgaard Nejst, Aalborg University, Aalborg, Denmark

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• Published: 11 August 2009

Methods for the synthesis of qualitative research: a critical review

• Elaine Barnett-Page 1 &
• James Thomas 1  

BMC Medical Research Methodology volume  9 , Article number:  59 ( 2009 ) Cite this article

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In recent years, a growing number of methods for synthesising qualitative research have emerged, particularly in relation to health-related research. There is a need for both researchers and commissioners to be able to distinguish between these methods and to select which method is the most appropriate to their situation.

A number of methodological and conceptual links between these methods were identified and explored, while contrasting epistemological positions explained differences in approaches to issues such as quality assessment and extent of iteration. Methods broadly fall into 'realist' or 'idealist' epistemologies, which partly accounts for these differences.

Methods for qualitative synthesis vary across a range of dimensions. Commissioners of qualitative syntheses might wish to consider the kind of product they want and select their method – or type of method – accordingly.

Peer Review reports

The range of different methods for synthesising qualitative research has been growing over recent years [ 1 , 2 ], alongside an increasing interest in qualitative synthesis to inform health-related policy and practice [ 3 ]. While the terms 'meta-analysis' (a statistical method to combine the results of primary studies), or sometimes 'narrative synthesis', are frequently used to describe how quantitative research is synthesised, far more terms are used to describe the synthesis of qualitative research. This profusion of terms can mask some of the basic similarities in approach that the different methods share, and also lead to some confusion regarding which method is most appropriate in a given situation. This paper does not argue that the various nomenclatures are unnecessary, but rather seeks to draw together and review the full range of methods of synthesis available to assist future reviewers in selecting a method that is fit for their purpose. It also represents an attempt to guide the reader through some of the varied terminology to spring up around qualitative synthesis. Other helpful reviews of synthesis methods have been undertaken in recent years with slightly different foci to this paper. Two recent studies have focused on describing and critiquing methods for the integration of qualitative research with quantitative [ 4 , 5 ] rather than exclusively examining the detail and rationale of methods for the synthesis of qualitative research. Two other significant pieces of work give practical advice for conducting the synthesis of qualitative research, but do not discuss the full range of methods available [ 6 , 7 ]. We begin our Discussion by outlining each method of synthesis in turn, before comparing and contrasting characteristics of these different methods across a range of dimensions. Readers who are more familiar with the synthesis methods described here may prefer to turn straight to the 'dimensions of difference' analysis in the second part of the Discussion.

Overview of synthesis methods

Meta-ethnography.

In their seminal work of 1988, Noblit and Hare proposed meta-ethnography as an alternative to meta-analysis [ 8 ]. They cited Strike and Posner's [ 9 ] definition of synthesis as an activity in which separate parts are brought together to form a 'whole'; this construction of the whole is essentially characterised by some degree of innovation, so that the result is greater than the sum of its parts. They also borrowed from Turner's theory of social explanation [ 10 ], a key tenet of which was building 'comparative understanding' [[ 8 ], p22] rather than aggregating data.

To Noblit and Hare, synthesis provided an answer to the question of 'how to "put together" written interpretive accounts' [[ 8 ], p7], where mere integration would not be appropriate. Noblit and Hare's early work synthesised research from the field of education.

Three different methods of synthesis are used in meta-ethnography. One involves the 'translation' of concepts from individual studies into one another, thereby evolving overarching concepts or metaphors. Noblit and Hare called this process reciprocal translational analysis (RTA). Refutational synthesis involves exploring and explaining contradictions between individual studies. Lines-of-argument (LOA) synthesis involves building up a picture of the whole (i.e. culture, organisation etc) from studies of its parts. The authors conceptualised this latter approach as a type of grounded theorising.

Britten et al [ 11 ] and Campbell et al [ 12 ] have both conducted evaluations of meta-ethnography and claim to have succeeded, by using this method, in producing theories with greater explanatory power than could be achieved in a narrative literature review. While both these evaluations used small numbers of studies, more recently Pound et al [ 13 ] conducted both an RTA and an LOA synthesis using a much larger number of studies (37) on resisting medicines. These studies demonstrate that meta-ethnography has evolved since Noblit and Hare first introduced it. Campbell et al claim to have applied the method successfully to non-ethnographical studies. Based on their reading of Schutz [ 14 ], Britten et al have developed both second and third order constructs in their synthesis (Noblit and Hare briefly allude to the possibility of a 'second level of synthesis' [[ 8 ], p28] but do not demonstrate or further develop the idea).

In a more recent development, Sandelowski & Barroso [ 15 ] write of adapting RTA by using it to ' integrate findings interpretively, as opposed to comparing them interpretively' (p204). The former would involve looking to see whether the same concept, theory etc exists in different studies; the latter would involve the construction of a bigger picture or theory (i.e. LOA synthesis). They also talk about comparing or integrating imported concepts (e.g. from other disciplines) as well as those evolved 'in vivo'.

Grounded theory

Kearney [ 16 ], Eaves [ 17 ] and Finfgeld [ 18 ] have all adapted grounded theory to formulate a method of synthesis. Key methods and assumptions of grounded theory, as originally formulated and subsequently refined by Glaser and Strauss [ 19 ] and Strauss and Corbin [ 20 , 21 ], include: simultaneous phases of data collection and analysis; an inductive approach to analysis, allowing the theory to emerge from the data; the use of the constant comparison method; the use of theoretical sampling to reach theoretical saturation; and the generation of new theory. Eaves cited grounded theorists Charmaz [ 22 ] and Chesler [ 23 ], as well as Strauss and Corbin [ 20 ], as informing her approach to synthesis.

Glaser and Strauss [ 19 ] foresaw a time when a substantive body of grounded research should be pushed towards a higher, more abstract level. As a piece of methodological work, Eaves undertook her own synthesis of the synthesis methods used by these authors to produce her own clear and explicit guide to synthesis in grounded formal theory. Kearney stated that 'grounded formal theory', as she termed this method of synthesis, 'is suited to study of phenomena involving processes of contextualized understanding and action' [[ 24 ], p180] and, as such, is particularly applicable to nurses' research interests.

As Kearney suggested, the examples examined here were largely dominated by research in nursing. Eaves synthesised studies on care-giving in rural African-American families for elderly stroke survivors; Finfgeld on courage among individuals with long-term health problems; Kearney on women's experiences of domestic violence.

Kearney explicitly chose 'grounded formal theory' because it matches 'like' with 'like': that is, it applies the same methods that have been used to generate the original grounded theories included in the synthesis – produced by constant comparison and theoretical sampling – to generate a higher-level grounded theory. The wish to match 'like' with 'like' is also implicit in Eaves' paper. This distinguishes grounded formal theory from more recent applications of meta-ethnography, which have sought to include qualitative research using diverse methodological approaches [ 12 ].

• Thematic Synthesis

Thomas and Harden [ 25 ] have developed an approach to synthesis which they term 'thematic synthesis'. This combines and adapts approaches from both meta-ethnography and grounded theory. The method was developed out of a need to conduct reviews that addressed questions relating to intervention need, appropriateness and acceptability – as well as those relating to effectiveness – without compromising on key principles developed in systematic reviews. They applied thematic synthesis in a review of the barriers to, and facilitators of, healthy eating amongst children.

Free codes of findings are organised into 'descriptive' themes, which are then further interpreted to yield 'analytical' themes. This approach shares characteristics with later adaptations of meta-ethnography, in that the analytical themes are comparable to 'third order interpretations' and that the development of descriptive and analytical themes using coding invoke reciprocal 'translation'. It also shares much with grounded theory, in that the approach is inductive and themes are developed using a 'constant comparison' method. A novel aspect of their approach is the use of computer software to code the results of included studies line-by-line, thus borrowing another technique from methods usually used to analyse primary research.

Textual Narrative Synthesis

Textual narrative synthesis is an approach which arranges studies into more homogenous groups. Lucas et al [ 26 ] comment that it has proved useful in synthesising evidence of different types (qualitative, quantitative, economic etc). Typically, study characteristics, context, quality and findings are reported on according to a standard format and similarities and differences are compared across studies. Structured summaries may also be developed, elaborating on and putting into context the extracted data [ 27 ].

Lucas et al [ 26 ] compared thematic synthesis with textual narrative synthesis. They found that 'thematic synthesis holds most potential for hypothesis generation' whereas textual narrative synthesis is more likely to make transparent heterogeneity between studies (as does meta-ethnography, with refutational synthesis) and issues of quality appraisal. This is possibly because textual narrative synthesis makes clearer the context and characteristics of each study, while the thematic approach organises data according to themes. However, Lucas et al found that textual narrative synthesis is 'less good at identifying commonality' (p2); the authors do not make explicit why this should be, although it may be that organising according to themes, as the thematic approach does, is comparatively more successful in revealing commonality.

Paterson et al [ 28 ] have evolved a multi-faceted approach to synthesis, which they call 'meta-study'. The sociologist Zhao [ 29 ], drawing on Ritzer's work [ 30 ], outlined three components of analysis, which they proposed should be undertaken prior to synthesis. These are meta-data-analysis (the analysis of findings), meta-method (the analysis of methods) and meta-theory (the analysis of theory). Collectively, these three elements of analysis, culminating in synthesis, make up the practice of 'meta-study'. Paterson et al pointed out that the different components of analysis may be conducted concurrently.

Paterson et al argued that primary research is a construction; secondary research is therefore a construction of a construction. There is need for an approach that recognises this, and that also recognises research to be a product of its social, historical and ideological context. Such an approach would be useful in accounting for differences in research findings. For Paterson et al, there is no such thing as 'absolute truth'.

Meta-study was developed to study the experiences of adults living with a chronic illness. Meta-data-analysis was conceived of by Paterson et al in similar terms to Noblit and Hare's meta-ethnography (see above), in that it is essentially interpretive and seeks to reveal similarities and discrepancies among accounts of a particular phenomenon. Meta-method involves the examination of the methodologies of the individual studies under review. Part of the process of meta-method is to consider different aspects of methodology such as sampling, data collection, research design etc, similar to procedures others have called 'critical appraisal' (CASP [ 31 ]). However, Paterson et al take their critique to a deeper level by establishing the underlying assumptions of the methodologies used and the relationship between research outcomes and methods used. Meta-theory involves scrutiny of the philosophical and theoretical assumptions of the included research papers; this includes looking at the wider context in which new theory is generated. Paterson et al described meta-synthesis as a process which creates a new interpretation which accounts for the results of all three elements of analysis. The process of synthesis is iterative and reflexive and the authors were unwilling to oversimplify the process by 'codifying' procedures for bringing all three components of analysis together.

Meta-narrative

Greenhalgh et al [ 32 ]'s meta-narrative approach to synthesis arose out of the need to synthesise evidence to inform complex policy-making questions and was assisted by the formation of a multi-disciplinary team. Their approach to review was informed by Thomas Kuhn's The Structure of Scientific Revolutions [ 33 ], in which he proposed that knowledge is produced within particular paradigms which have their own assumptions about theory, about what is a legitimate object of study, about what are legitimate research questions and about what constitutes a finding. Paradigms also tend to develop through time according to a particular set of stages, central to which is the stage of 'normal science', in which the particular standards of the paradigm are largely unchallenged and seen to be self-evident. As Greenhalgh et al pointed out, Kuhn saw paradigms as largely incommensurable: 'that is, an empirical discovery made using one set of concepts, theories, methods and instruments cannot be satisfactorily explained through a different paradigmatic lens' [[ 32 ], p419].

Greenhalgh et al synthesised research from a wide range of disciplines; their research question related to the diffusion of innovations in health service delivery and organisation. They thus identified a need to synthesise findings from research which contains many different theories arising from many different disciplines and study designs.

Based on Kuhn's work, Greenhalgh et al proposed that, across different paradigms, there were multiple – and potentially mutually contradictory – ways of understanding the concept at the heart of their review, namely the diffusion of innovation. Bearing this in mind, the reviewers deliberately chose to select key papers from a number of different research 'paradigms' or 'traditions', both within and beyond healthcare, guided by their multidisciplinary research team. They took as their unit of analysis the 'unfolding "storyline" of a research tradition over time' [[ 32 ], p417) and sought to understand diffusion of innovation as it was conceptualised in each of these traditions. Key features of each tradition were mapped: historical roots, scope, theoretical basis; research questions asked and methods/instruments used; main empirical findings; historical development of the body of knowledge (how have earlier findings led to later findings); and strengths and limitations of the tradition. The results of this exercise led to maps of 13 'meta-narratives' in total, from which seven key dimensions, or themes, were identified and distilled for the synthesis phase of the review.

Critical Interpretive Synthesis

Dixon-Woods et al [ 34 ] developed their own approach to synthesising multi-disciplinary and multi-method evidence, termed 'critical interpretive synthesis', while researching access to healthcare by vulnerable groups. Critical interpretive synthesis is an adaptation of meta-ethnography, as well as borrowing techniques from grounded theory. The authors stated that they needed to adapt traditional meta-ethnographic methods for synthesis, since these had never been applied to quantitative as well as qualitative data, nor had they been applied to a substantial body of data (in this case, 119 papers).

Dixon-Woods et al presented critical interpretive synthesis as an approach to the whole process of review, rather than to just the synthesis component. It involves an iterative approach to refining the research question and searching and selecting from the literature (using theoretical sampling) and defining and applying codes and categories. It also has a particular approach to appraising quality, using relevance – i.e. likely contribution to theory development – rather than methodological characteristics as a means of determining the 'quality' of individual papers [ 35 ]. The authors also stress, as a defining characteristic, critical interpretive synthesis's critical approach to the literature in terms of deconstructing research traditions or theoretical assumptions as a means of contextualising findings.

Dixon-Woods et al rejected reciprocal translational analysis (RTA) as this produced 'only a summary in terms that have already been used in the literature' [[ 34 ], p5], which was seen as less helpful when dealing with a large and diverse body of literature. Instead, Dixon-Woods et al adopted a lines-of-argument (LOA) synthesis, in which – rejecting the difference between first, second and third order constructs – they instead developed 'synthetic constructs' which were then linked with constructs arising directly from the literature.

The influence of grounded theory can be seen in particular in critical interpretive synthesis's inductive approach to formulating the review question and to developing categories and concepts, rejecting a 'stage' approach to systematic reviewing, and in selecting papers using theoretical sampling. Dixon-Woods et al also claim that critical interpretive synthesis is distinct in its 'explicit orientation towards theory generation' [[ 34 ], p9].

Ecological Triangulation

Jim Banning is the author of 'ecological triangulation' or 'ecological sentence synthesis', applying this method to the evidence for what works for youth with disabilities. He borrows from Webb et al [ 36 ] and Denzin [ 37 ] the concept of triangulation, in which phenomena are studied from a variety of vantage points. His rationale is that building an 'evidence base' of effectiveness requires the synthesis of cumulative, multi-faceted evidence in order to find out 'what intervention works for what kind of outcomes for what kind of persons under what kind of conditions' [[ 38 ], p1].

Ecological triangulation unpicks the mutually interdependent relationships between behaviour, persons and environments. The method requires that, for data extraction and synthesis, 'ecological sentences' are formulated following the pattern: 'With this intervention, these outcomes occur with these population foci and within these grades (ages), with these genders ... and these ethnicities in these settings' [[ 39 ], p1].

Framework Synthesis

Brunton et al [ 40 ] and Oliver et al [ 41 ] have applied a 'framework synthesis' approach in their reviews. Framework synthesis is based on framework analysis, which was outlined by Pope, Ziebland and Mays [ 42 ], and draws upon the work of Ritchie and Spencer [ 43 ] and Miles and Huberman [ 44 ]. Its rationale is that qualitative research produces large amounts of textual data in the form of transcripts, observational fieldnotes etc. The sheer wealth of information poses a challenge for rigorous analysis. Framework synthesis offers a highly structured approach to organising and analysing data (e.g. indexing using numerical codes, rearranging data into charts etc).

Brunton et al applied the approach to a review of children's, young people's and parents' views of walking and cycling; Oliver et al to an analysis of public involvement in health services research. Framework synthesis is distinct from the other methods outlined here in that it utilises an a priori 'framework' – informed by background material and team discussions – to extract and synthesise findings. As such, it is largely a deductive approach although, in addition to topics identified by the framework, new topics may be developed and incorporated as they emerge from the data. The synthetic product can be expressed in the form of a chart for each key dimension identified, which may be used to map the nature and range of the concept under study and find associations between themes and exceptions to these [ 40 ].

'Fledgling' approaches

There are three other approaches to synthesis which have not yet been widely used. One is an approach using content analysis [ 45 , 46 ] in which text is condensed into fewer content-related categories. Another is 'meta-interpretation' [ 47 ], featuring the following: an ideographic rather than pre-determined approach to the development of exclusion criteria; a focus on meaning in context; interpretations as raw data for synthesis (although this feature doesn't distinguish it from other synthesis methods); an iterative approach to the theoretical sampling of studies for synthesis; and a transparent audit trail demonstrating the trustworthiness of the synthesis.

In addition to the synthesis methods discussed above, Sandelowski and Barroso propose a method they call 'qualitative metasummary' [ 15 ]. It is mentioned here as a new and original approach to handling a collection of qualitative studies but is qualitatively different to the other methods described here since it is aggregative; that is, findings are accumulated and summarised rather than 'transformed'. Metasummary is a way of producing a 'map' of the contents of qualitative studies and – according to Sandelowski and Barroso – 'reflect [s] a quantitative logic' [[ 15 ], p151]. The frequency of each finding is determined and the higher the frequency of a particular finding, the greater its validity. The authors even discuss the calculation of 'effect sizes' for qualitative findings. Qualitative metasummaries can be undertaken as an end in themselves or may serve as a basis for a further synthesis.

Dimensions of difference

Having outlined the range of methods identified, we now turn to an examination of how they compare with one another. It is clear that they have come from many different contexts and have different approaches to understanding knowledge, but what do these differences mean in practice? Our framework for this analysis is shown in Additional file 1 : dimensions of difference [ 48 ]. We have examined the epistemology of each of the methods and found that, to some extent, this explains the need for different methods and their various approaches to synthesis.

Epistemology

The first dimension that we will consider is that of the researchers' epistemological assumptions. Spencer et al [ 49 ] outline a range of epistemological positions, which might be organised into a spectrum as follows:

Subjective idealism : there is no shared reality independent of multiple alternative human constructions

Objective idealism : there is a world of collectively shared understandings

Critical realism : knowledge of reality is mediated by our perceptions and beliefs

Scientific realism : it is possible for knowledge to approximate closely an external reality

Naïve realism : reality exists independently of human constructions and can be known directly [ 49 , 45 , 46 ].

Thus, at one end of the spectrum we have a highly constructivist view of knowledge and, at the other, an unproblematized 'direct window onto the world' view.

Nearly all of positions along this spectrum are represented in the range of methodological approaches to synthesis covered in this paper. The originators of meta-narrative synthesis, critical interpretive synthesis and meta-study all articulate what might be termed a 'subjective idealist' approach to knowledge. Paterson et al [ 28 ] state that meta-study shies away from creating 'grand theories' within the health or social sciences and assume that no single objective reality will be found. Primary studies, they argue, are themselves constructions; meta-synthesis, then, 'deals with constructions of constructions' (p7). Greenhalgh et al [ 32 ] also view knowledge as a product of its disciplinary paradigm and use this to explain conflicting findings: again, the authors neither seek, nor expect to find, one final, non-contestable answer to their research question. Critical interpretive synthesis is similar in seeking to place literature within its context, to question its assumptions and to produce a theoretical model of a phenomenon which – because highly interpretive – may not be reproducible by different research teams at alternative points in time [[ 34 ], p11].

Methods used to synthesise grounded theory studies in order to produce a higher level of grounded theory [ 24 ] appear to be informed by 'objective idealism', as does meta-ethnography. Kearney argues for the near-universal applicability of a 'ready-to-wear' theory across contexts and populations. This approach is clearly distinct from one which recognises multiple realities. The emphasis is on examining commonalities amongst, rather than discrepancies between, accounts. This emphasis is similarly apparent in most meta-ethnographies, which are conducted either according to Noblit and Hare's 'reciprocal translational analysis' technique or to their 'lines-of-argument' technique and which seek to provide a 'whole' which has a greater explanatory power. Although Noblit and Hare also propose 'refutational synthesis', in which contradictory findings might be explored, there are few examples of this having been undertaken in practice, and the aim of the method appears to be to explain and explore differences due to context, rather than multiple realities.

Despite an assumption of a reality which is perhaps less contestable than those of meta-narrative synthesis, critical interpretive synthesis and meta-study, both grounded formal theory and meta-ethnography place a great deal of emphasis on the interpretive nature of their methods. This still supposes a degree of constructivism. Although less explicit about how their methods are informed, it seems that both thematic synthesis and framework synthesis – while also involving some interpretation of data – share an even less problematized view of reality and a greater assumption that their synthetic products are reproducible and correspond to a shared reality. This is also implicit in the fact that such products are designed directly to inform policy and practice, a characteristic shared by ecological triangulation. Notably, ecological triangulation, according to Banning, can be either realist or idealist. Banning argues that the interpretation of triangulation can either be one in which multiple viewpoints converge on a point to produce confirming evidence (i.e. one definitive answer to the research question) or an idealist one, in which the complexity of multiple viewpoints is represented. Thus, although ecological triangulation views reality as complex, the approach assumes that it can be approximately knowable (at least when the realist view of ecological triangulation is adopted) and that interventions can and should be modelled according to the products of its syntheses.

While pigeonholing different methods into specific epistemological positions is a problematic process, we do suggest that the contrasting epistemologies of different researchers is one way of explaining why we have – and need – different methods for synthesis.

Variation in terms of the extent of iteration during the review process is another key dimension. All synthesis methods include some iteration but the degree varies. Meta-ethnography, grounded theory and thematic synthesis all include iteration at the synthesis stage; both framework synthesis and critical interpretive synthesis involve iterative literature searching – in the case of critical interpretive synthesis, it is not clear whether iteration occurs during the rest of the review process. Meta-narrative also involves iteration at every stage. Banning does not mention iteration in outlining ecological triangulation and neither do Lucas or Thomas and Harden for thematic narrative synthesis.

It seems that the more idealist the approach, the greater the extent of iteration. This might be because a large degree of iteration does not sit well with a more 'positivist' ideal of procedural objectivity; in particular, the notion that the robustness of the synthetic product depends in part on the reviewers stating up front in a protocol their searching strategies, inclusion/exclusion criteria etc, and being seen not to alter these at a later stage.

Quality assessment

Another dimension along which we can look at different synthesis methods is that of quality assessment. When the approaches to the assessment of the quality of studies retrieved for review are examined, there is again a wide methodological variation. It might be expected that the further towards the 'realism' end of the epistemological spectrum a method of synthesis falls, the greater the emphasis on quality assessment. In fact, this is only partially the case.

Framework synthesis, thematic narrative synthesis and thematic synthesis – methods which might be classified as sharing a 'critical realist' approach – all have highly specified approaches to quality assessment. The review in which framework synthesis was developed applied ten quality criteria: two on quality and reporting of sampling methods, four to the quality of the description of the sample in the study, two to the reliability and validity of the tools used to collect data and one on whether studies used appropriate methods for helping people to express their views. Studies which did not meet a certain number of quality criteria were excluded from contributing to findings. Similarly, in the example review for thematic synthesis, 12 criteria were applied: five related to reporting aims, context, rationale, methods and findings; four relating to reliability and validity; and three relating to the appropriateness of methods for ensuring that findings were rooted in participants' own perspectives. Studies which were deemed to have significant flaws were excluded and sensitivity analyses were used to assess the possible impact of study quality on the review's findings. Thomas and Harden's use of thematic narrative synthesis similarly applied quality criteria and developed criteria additional to those they found in the literature on quality assessment, relating to the extent to which people's views and perspectives had been privileged by researchers. It is worth noting not only that these methods apply quality criteria but that they are explicit about what they are: assessing quality is a key component in the review process for both of these methods. Likewise, Banning – the originator of ecological triangulation – sees quality assessment as important and adapts the Design and Implementation Assessment Device (DIAD) Version 0.3 (a quality assessment tool for quantitative research) for use when appraising qualitative studies [ 50 ]. Again, Banning writes of excluding studies deemed to be of poor quality.

Greenhalgh et al's meta-narrative review [ 32 ] modified a range of existing quality assessment tools to evaluate studies according to validity and robustness of methods; sample size and power; and validity of conclusions. The authors imply, but are not explicit, that this process formed the basis for the exclusion of some studies. Although not quite so clear about quality assessment methods as framework and thematic synthesis, it might be argued that meta-narrative synthesis shows a greater commitment to the concept that research can and should be assessed for quality than either meta-ethnography or grounded formal theory. The originators of meta-ethnography, Noblit and Hare [ 8 ], originally discussed quality in terms of quality of metaphor, while more recent use of this method has used amended versions of CASP (the Critical Appraisal Skills Programme tool, [ 31 ]), yet has only referred to studies being excluded on the basis of lack of relevance or because they weren't 'qualitative' studies [ 8 ]. In grounded theory, quality assessment is only discussed in terms of a 'personal note' being made on the context, quality and usefulness of each study. However, contrary to expectation, meta-narrative synthesis lies at the extreme end of the idealism/realism spectrum – as a subjective idealist approach – while meta-ethnography and grounded theory are classified as objective idealist approaches.

Finally, meta-study and critical interpretive synthesis – two more subjective idealist approaches – look to the content and utility of findings rather than methodology in order to establish quality. While earlier forms of meta-study included only studies which demonstrated 'epistemological soundness', in its most recent form [ 51 ] this method has sought to include all relevant studies, excluding only those deemed not to be 'qualitative' research. Critical interpretive synthesis also conforms to what we might expect of its approach to quality assessment: quality of research is judged as the extent to which it informs theory. The threshold of inclusion is informed by expertise and instinct rather than being articulated a priori.

In terms of quality assessment, it might be important to consider the academic context in which these various methods of synthesis developed. The reason why thematic synthesis, framework synthesis and ecological triangulation have such highly specified approaches to quality assessment may be that each of these was developed for a particular task, i.e. to conduct a multi-method review in which randomised controlled trials (RCTs) were included. The concept of quality assessment in relation to RCTs is much less contested and there is general agreement on criteria against which quality should be judged.

Problematizing the literature

Critical interpretive synthesis, the meta-narrative approach and the meta-theory element of meta-study all share some common ground in that their review and synthesis processes include examining all aspects of the context in which knowledge is produced. In conducting a review on access to healthcare by vulnerable groups, critical interpretive synthesis sought to question 'the ways in which the literature had constructed the problematics of access, the nature of the assumptions on which it drew, and what has influenced its choice of proposed solutions' [[ 34 ], p6]. Although not claiming to have been directly influenced by Greenhalgh et al's meta-narrative approach, Dixon-Woods et al do cite it as sharing similar characteristics in the sense that it critiques the literature it reviews.

Meta-study uses meta-theory to describe and deconstruct the theories that shape a body of research and to assess its quality. One aspect of this process is to examine the historical evolution of each theory and to put it in its socio-political context, which invites direct comparison with meta-narrative synthesis. Greenhalgh et al put a similar emphasis on placing research findings within their social and historical context, often as a means of seeking to explain heterogeneity of findings. In addition, meta-narrative shares with critical interpretive synthesis an iterative approach to searching and selecting from the literature.

Framework synthesis, thematic synthesis, textual narrative synthesis, meta-ethnography and grounded theory do not share the same approach to problematizing the literature as critical interpretive synthesis, meta-study and meta-narrative. In part, this may be explained by the extent to which studies included in the synthesis represented a broad range of approaches or methodologies. This, in turn, may reflect the broadness of the review question and the extent to which the concepts contained within the question are pre-defined within the literature. In the case of both the critical interpretive synthesis and meta-narrative reviews, terminology was elastic and/or the question formed iteratively. Similarly, both reviews placed great emphasis on employing multi-disciplinary research teams. Approaches which do not critique the literature in the same way tend to have more narrowly-focused questions. They also tend to include a more limited range of studies: grounded theory synthesis includes grounded theory studies, meta-ethnography (in its original form, as applied by Noblit and Hare) ethnographies. The thematic synthesis incorporated studies based on only a narrow range of qualitative methodologies (interviews and focus groups) which were informed by a similarly narrow range of epistemological assumptions. It may be that the authors of such syntheses saw no need for including such a critique in their review process.

Similarities and differences between primary studies

Most methods of synthesis are applicable to heterogeneous data (i.e. studies which use contrasting methodologies) apart from early meta-ethnography and synthesis informed by grounded theory. All methods of synthesis state that, at some level, studies are compared; many are not so explicit about how this is done, though some are. Meta-ethnography is one of the most explicit: it describes the act of 'translation' where terms and concepts which have resonance with one another are subsumed into 'higher order constructs'. Grounded theory, as represented by Eaves [ 17 ], is undertaken according to a long list of steps and sub-steps, includes the production of generalizations about concepts/categories, which comes from classifying these categories. In meta-narrative synthesis, comparable studies are grouped together at the appraisal phase of review.

Perhaps more interesting are the ways in which differences between studies are explored. Those methods with a greater emphasis on critical appraisal may tend (although this is not always made explicit) to use differences in method to explain differences in finding. Meta-ethnography proposes 'refutational synthesis' to explain differences, although there are few examples of this in the literature. Some synthesis methods – for example, thematic synthesis – look at other characteristics of the studies under review, whether types of participants and their context vary, and whether this can explain differences in perspective.

All of these methods, then, look within the studies to explain differences. Other methods look beyond the study itself to the context in which it was produced. Critical interpretive synthesis and meta-study look at differences in theory or in socio-economic context. Critical interpretive synthesis, like meta-narrative, also explores epistemological orientation. Meta-narrative is unique in concerning itself with disciplinary paradigm (i.e. the story of the discipline as it progresses). It is also distinctive in that it treats conflicting findings as 'higher order data' [[ 32 ], p420], so that the main emphasis of the synthesis appears to be on examining and explaining contradictions in the literature.

Going 'beyond' the primary studies

Synthesis is sometimes defined as a process resulting in a product, a 'whole', which is more than the sum of its parts. However, the methods reviewed here vary in the extent to which they attempt to 'go beyond' the primary studies and transform the data. Some methods – textual narrative synthesis, ecological triangulation and framework synthesis – focus on describing and summarising their primary data (often in a highly structured and detailed way) and translating the studies into one another. Others – meta-ethnography, grounded theory, thematic synthesis, meta-study, meta-narrative and critical interpretive synthesis – seek to push beyond the original data to a fresh interpretation of the phenomena under review. A key feature of thematic synthesis is its clear differentiation between these two stages.

Different methods have different mechanisms for going beyond the primary studies, although some are more explicit than others about what these entail. Meta-ethnography proposes a 'Line of Argument' (LOA) synthesis in which an interpretation is constructed to both link and explain a set of parts. Critical interpretive synthesis based its synthesis methods on those of meta-ethnography, developing an LOA using what the authors term 'synthetic constructs' (akin to 'third order constructs' in meta-ethnography) to create a 'synthesising argument'. Dixon-Woods et al claim that this is an advance on Britten et al's methods, in that they reject the difference between first, second and third order constructs.

Meta-narrative, as outlined above, focuses on conflicting findings and constructs theories to explain these in terms of differing paradigms. Meta study derives questions from each of its three components to which it subjects the dataset and inductively generates a number of theoretical claims in relation to it. According to Eaves' model of grounded theory [ 17 ], mini-theories are integrated to produce an explanatory framework. In ecological triangulation, the 'axial' codes – or second level codes evolved from the initial deductive open codes – are used to produce Banning's 'ecological sentence' [ 39 ].

The synthetic product

In overviewing and comparing different qualitative synthesis methods, the ultimate question relates to the utility of the synthetic product: what is it for? It is clear that some methods of synthesis – namely, thematic synthesis, textual narrative synthesis, framework synthesis and ecological triangulation – view themselves as producing an output that is directly applicable to policy makers and designers of interventions. The example of framework synthesis examined here (on children's, young people's and parents' views of walking and cycling) involved policy makers and practitioners in directing the focus of the synthesis and used the themes derived from the synthesis to infer what kind of interventions might be most effective in encouraging walking and cycling. Likewise, the products of the thematic synthesis took the form of practical recommendations for interventions (e.g. 'do not promote fruit and vegetables in the same way in the same intervention'). The extent to which policy makers and practitioners are involved in informing either synthesis or recommendation is less clear from the documents published on ecological triangulation, but the aim certainly is to directly inform practice.

The outputs of synthesis methods which have a more constructivist orientation – meta-study, meta-narrative, meta-ethnography, grounded theory, critical interpretive synthesis – tend to look rather different. They are generally more complex and conceptual, sometimes operating on the symbolic or metaphorical level, and requiring a further process of interpretation by policy makers and practitioners in order for them to inform practice. This is not to say, however, that they are not useful for practice, more that they are doing different work. However, it may be that, in the absence of further interpretation, they are more useful for informing other researchers and theoreticians.

Looking across dimensions

After examining the dimensions of difference of our included methods, what picture ultimately emerges? It seems clear that, while similar in some respects, there are genuine differences in approach to the synthesis of what is essentially textual data. To some extent, these differences can be explained by the epistemological assumptions that underpin each method. Our methods split into two broad camps: the idealist and the realist (see Table 1 for a summary). Idealist approaches generally tend to have a more iterative approach to searching (and the review process), have less a priori quality assessment procedures and are more inclined to problematize the literature. Realist approaches are characterised by a more linear approach to searching and review, have clearer and more well-developed approaches to quality assessment, and do not problematize the literature.

Mapping the relationships between methods

What is interesting is the relationship between these methods of synthesis, the conceptual links between them, and the extent to which the originators cite – or, in some cases, don't cite – one another. Some methods directly build on others – framework synthesis builds on framework analysis, for example, while grounded theory and constant comparative analysis build on grounded theory. Others further develop existing methods – meta-study, critical interpretive synthesis and meta-narrative all adapt aspects of meta-ethnography, while also importing concepts from other theorists (critical interpretive synthesis also adapts grounded theory techniques).

Some methods share a clear conceptual link, without directly citing one another: for example, the analytical themes developed during thematic synthesis are comparable to the third order interpretations of meta-ethnography. The meta-theory aspect of meta-study is echoed in both meta-narrative synthesis and critical interpretive synthesis (see 'Problematizing the literature, above); however, the originators of critical interpretive synthesis only refer to the originators of meta-study in relation to their use of sampling techniques.

While methods for qualitative synthesis have many similarities, there are clear differences in approach between them, many of which can be explained by taking account of a given method's epistemology.

However, within the two broad idealist/realist categories, any differences between methods in terms of outputs appear to be small.

Since many systematic reviews are designed to inform policy and practice, it is important to select a method – or type of method – that will produce the kind of conclusions needed. However, it is acknowledged that this is not always simple or even possible to achieve in practice.

The approaches that result in more easily translatable messages for policy-makers and practitioners may appear to be more attractive than the others; but we do need to take account lessons from the more idealist end of the spectrum, that some perspectives are not universal.

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Acknowledgements

The authors would like to acknowledge the helpful contributions of the following in commenting on earlier drafts of this paper: David Gough, Sandy Oliver, Angela Harden, Mary Dixon-Woods, Trisha Greenhalgh and Barbara L. Paterson. We would also like to thank the peer reviewers: Helen J Smith, Rosaline Barbour and Mark Rodgers for their helpful reviews. The methodological development was supported by the Department of Health (England) and the ESRC through the Methods for Research Synthesis Node of the National Centre for Research Methods (NCRM). An earlier draft of this paper currently appears as a working paper on the National Centre for Research Methods' website http://www.ncrm.ac.uk/ .

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Barnett-Page, E., Thomas, J. Methods for the synthesis of qualitative research: a critical review. BMC Med Res Methodol 9 , 59 (2009). https://doi.org/10.1186/1471-2288-9-59

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