The lead reviewer (ZD) extracted all papers using data extraction forms previously tested and refined through a pilot study of four papers. All study details (including aim, participant details, methodology, method of data collection and analysis) were extracted into Microsoft Excel®version 14 (Microsoft
Corporation, Redmond, WA, USA) and checked by a second reviewer (PG). Extraction and analysis of study findings was undertaken by a group of coreviewers within the research team (ZD, PG, LK, CB, KM, KH) and followed steps 3–7 of the metaethnography process described by Noblit and Hare.94Despite being
numbered sequentially, these phases do not occur in a linear process.94
Step 3: reading the studies
The metaethnography process involved three levels of constructs, as described by Schutz137and
operationalised by Atkinset al.:96
1. first-order:participant quotes and participant observations, while recognising that in secondary analysis these represent the participants’views as selected by the study authors in evidencing their second-order constructs
2. second-order:study authors’themes/concepts and interpretations, also described by Noblit and Hare94
as‘metaphors’
3. third-order:our‘interpretations of interpretations of interpretations’(p. 35),94based on our analysis of
the first-order and second-order constructs extracted from the studies.
TABLE 7 Reasons for exclusion of full-text articles
Reason n Not LTC Not self-management intervention/support activity
Not male only/explicit gender comparison
Not qualitative data collection and analysis
✗ ✗ 1 ✗ 53 ✗ ✗ 30 ✗ ✗ 3 ✗ ✗ ✗ 2 ✗ 9 ✗ ✗ 4 ✗ 9 Totals 1 89 45 18 111
Each paper was read in full and copied verbatim into NVivo version 10 (QSR International, Warrington, UK) for line-by-line coding by the lead reviewer. Coding involved repeated reading and line-by-line categorising of first-order and second-order constructs, using participants’and authors’words wherever possible, and reading for possible third-order constructs.
Third-order constructs were developed by building second-order constructs into broader categories and themes in a framework which was revised iteratively using the hierarchical functions of the NVivo software (i.e. using‘parent’and‘child’nodes).
Rather than simply being a synthesis of the second-order constructs, third-order-constructs were derived inductively from the extracted data; this was an interpretive process that was not limited to interpretations offered by the original authors of included studies.
Coding by coreviewers (i.e. other members of the research team) was idiosyncratic but commonly involved working with printed papers, noting key‘metaphors’(themes, concepts and ideas) in the margins and highlighting first-order and second-order evidence that supported the coreviewers’interpretations. The lead
Records after duplicates removed
(n = 6330)
Excluded (n = 111)
Reasons (more than one may apply to each article) • Not LTC, n = 1
• Not self-management intervention or support activity, n = 89
• Not male only or lacking explicit gender comparison, n = 45
• Not qualitative data collection and analysis, n = 18
Excluded in initial title/abstract screen (n = 6181)
Included 58 that were unpublished (e.g. conference proceedings, theses), review articles, or linked quantitative or methodological papers that mentioned primary qualitative research
Studies and papers included in qualitative synthesis (n = 38 studies across 44 papers) Only 42 of the papers are captured in the previous boxes because an additional two were female only and sought separately
Additional studies identified (n = 4)
Studies and papers identified for inclusion through other sources (e.g. via reference checks and searching of published literature for unpublished records)
Not found or unprocessed (n = 0)
Full-text articles screened
(n = 149)
database searching
(n = 8450)
FIGURE 8 Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram for the qualitative review.
reviewer, ZD, met with each coreviewer to discuss/debrief coding decisions and ensure the credibility (i.e. the congruence of coding decisions with the original author interpretations) of the overall analytical process.
Step 4: determining how the studies are related
To offer a‘way in’to the synthesis, we adopted a similar approach to that of Campbellet al.:131initially
grouping studies by the broad categories of self-management intervention and support activity shown in
Table 6. Each coreviewer was allocated one or more category of studies to analyse. The lead reviewer then read each category of studies in the following order: face-to-face group support, online support, online information, information, psychological, lifestyle and‘various’; within this, she read the studies in
alphabetical order of first author rather than nominating‘key’papers. All included papers were analysed, rather than reading until saturation of concepts.
The lead reviewer and coreviewer independently completed matrices to report the second-order constructs and emerging third-order constructs for each paper (which for the lead reviewer were based on a more comprehensive line-by-line coding using NVivo). This facilitated the juxtaposing of metaphors and/or constructs alongside each other, leading to initial assumptions about relationships between studies.
Step 5: translating studies into one another
A defining element of metaethnography is the‘translation’of studies into each other, whereby metaphors, together with their inter-relationships, are compared across studies. Facilitated by discussions using the matrices of second- and third-order constructs, we translated studies firstly within types of support activity and then, secondly, across types.
The lead reviewer initially developed the constructs in relation to face-to-face support (the largest category of studies) and read other categories of studies with reference to this, using a constant comparison approach to identify and refine concepts. The‘models’function in NVivo was used to depict relationships between third-order constructs; this helped to develop the line-of-argument synthesis, which is
discussed next.
Step 6: synthesising translations
Studies can be synthesised in three ways:94
1. reciprocal translation, where the findings are directly comparable 2. refutational translation, where the findings are in opposition
3. a line-of-argument synthesis, where both similarities and contradictions are found and translations are encompassed in one overarching interpretation that aims to discover a whole among the set of parts, uncovering aspects that may be hidden in individual studies.
Because we found similarities and contradictions, we developed a line-of-argument synthesis (rather than reciprocal or refutational translation) that encompassed four key concepts, each of which was based around a set of third-order constructs.
Step 7: expressing the synthesis
The output of the synthesis, that is communicating our third-order concepts and overarching line-of- argument synthesis, is described by Noblit and Hare94as‘expressing the synthesis’(p. 29). They state that
‘the worth of any synthesis is in its comprehensibility to some audience’(p. 82),94emphasising the
importance of communicating the synthesis effectively, being mindful of the intended audience and using concepts and language that are meaningful (and understandable). We worked to make the synthesis comprehensible by discussion with coreviewers and, critically, through involvement of the patient and public involvement (PPI) group. The synthesis is presented inChapter 5and will also be expressed through other dissemination activities, for example the SELF-MAN symposium (www.self-man.com), mini-manuals and journal publications.
We undertook several steps to enhance the rigour of our analysis. Authors’themes and interpretations (second-order constructs) were independently extracted by two reviewers, each of whom additionally suggested their own interpretations of the study findings (third-order constructs).
We were influenced by a recent Health Technology Assessment metaethnography which found multiple reviewers offered‘broad similarities in interpretation, but differences of detail’(p. x).131We therefore
treated the lead reviewer’s analyses as the‘master copy’and compared these with the coreviewers’ extractions and interpretations. Peer debriefing meetings were held between the lead reviewer and each coreviewer to discuss matrices of second-order and third-order constructs which facilitated the consideration of alternative interpretations.
The third-order constructs and line-of-argument synthesis were further refined at a full-day meeting (January 2014) attended by the lead qualitative reviewer and wider team of five coreviewers involved in coding, extraction, analysis and interpretation (PG, KH, LK, KM, CB).
We identified the need to be reflexive about our interpretations and recognised potential sources of influence on our interpretations; for example, two reviewers (PG, KH) identified having a‘constructions of masculinity’lens, and we agreed to focus the line-of-argument synthesis on interpretations offered by authors of studies being synthesised, rather than framing our interpretations around constructions of masculinity. We considered it a strength that the six reviewers involved reflected a wide range of backgrounds and perspectives. Although PPI colleagues were not involved in the coding process, the line-of-argument synthesis and four key concepts were discussed with the PPI group to ensure credibility.