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Table 1 Meta-ethnography steps according to Noblit and Hare[15]

From: Individualised medicine from the perspectives of patients using complementarytherapies: a meta-ethnography approach

1 Getting started “Getting started” meant to define theobjective or interest of the synthesis and the wordingof the research question [2].
2 Deciding what is relevant to the initial interest Sixty-seven databases, including medical, social science,psychology, nutrition and complementary medicinedatabases (i.e., API-on, CAMbase, CAM-QUEST, CINAHL,Cochrane Library, DIMDI, GREENPILOT, Heclinet, MedPilot,PubMed, Psyndex, PsynINFO, Sinbad, Somed), were searchedfor the Boolean terms “complementary andalternative medicine” OR “CAM” OR“complementary medicine” OR“alternative medicine” OR qualitativeresearch” OR “qualitative studies” OR“interviews” OR “[exploratory ORgrounded theory OR content analysis OR focus groups ORethnography]” OR “reasons” OR“[concepts OR patient expectations OR motivationOR attitude to health OR patient communication OR healthknowledge OR patient acceptance of health care ORpatient participation OR physician-patient relations ORprofessional-patient relations]”. The selection ofthese terms followed predetermined inclusion criteriaand included qualitative research articles in Englishand German about reasons for CAM use from a patientperspective; all articles used in this analysis werepublished between 1980 and 2011. Exclusion criteria werequalitative studies with therapists, perspectives ofteaching personnel, review and theory papers andarticles devoted to study design and secondary analysis.A detailed description of the literature search andappraisal of the meta-ethnography will be publishedseparately and is also mentioned in Additional file1.
3 Reading the studies The studies were reviewed multiple times, while thefindings of the individual qualitative studies werecollected with extensive attention paid to the detailsin the articles and the key themes from each articlewere determined. Two members of the research teamextracted the themes of the individual qualitativestudies concerning patients’ reasons for CAM usageand transferred them into a spreadsheet program asprimary themes with their related explanations. Thespreadsheet’s columns contained the originalauthors and the key primary themes of reasons ofpatients seeking CAM, and the rows displayed the mainexplanations of the key themes or citations of thepatients. Key themes were juxtaposed, with the mostimportant interpretations of the authors focusing onconcepts of individualised medicine (mostly in thediscussion section of each article) in the last column;our team worked diligently to always keep in mind theresearch question, which was the expectation of patientsrelated to individualised medicine. After the extractionof key themes with reasons of patients for CAM, thespreadsheet data and personal notes were discussed inregular meetings. This discussion revealed no importantdifferences in the extracted data. The consolidatedspreadsheet data were finally discussed with the entireresearch team.
4 Determining how the studies are related For the syntheses, we had to determine how the individualstudies were related. According to Noblit and Hare, themetaphors, concepts or constructs used for this purposecan be either (1) directly comparable as“reciprocal” translations; (2) stand inrelative opposition to each other and are essentially“refutational”; or (3) present a“line-of-argument” rather than a reciprocalor refutational translation [15]. Here, “reciprocal” means thatthe studies can be combined such that one study can bepresented in terms of another. “Reciprocaltranslation” involves uniting ideas and conceptsfrom the original studies through a process of comparingacross the studies. “Refutational” meansthat the studies can be set against one another suchthat the grounds for one study’s refutation ofanother become visible. A “line-of-argument”synthesis ties the studies to one another and informshow the individual studies go beyond one another. At theend of this phase, the team assumed that the studies hadre-occurring themes and that a“line-of-argument” analysis could beperformed.
5 Translating the studies Translation in a meta-ethnography such as ours meanscomparing the metaphors and concepts in one article withthe metaphors in others. We first arranged all paperschronologically and according to main indications.Thereafter, we compared the key themes from paper onewith paper two, and the syntheses of these two paperswith paper three, and so on. The translation respectedthe individual meaning and maintained the centralmetaphors in relation to the studies’ other keymetaphors. We translated our key themes across allarticles in order to determine secondary key themes. Allsecondary key themes contributed reasoning behind whypatients turn toward CAM. To perform the translation,the research team members worked with grids or handcards. The relationship between the studies wasindicated by drawing arrows, lines and bubbles or byclustering the hand cards. The emerging secondary keythemes were transferred into the head line of aspreadsheet named “secondary key themes,”and the applicable explanations were entered in the rowsbelow, the themes were juxtaposed with theauthors’ main secondary interpretations from thediscussion section of each article. We made analyticaland reflexive notes during the translation to beprepared for the research group discussions.
6 Synthesizing translations The secondary key themes of the reciprocal translationwere brought together by synthesizing them, startingfrom the identified secondary key themes and matchingthem with their respective patients’ quotations ofthe primary studies. This process involved furtherre-readings of the original studies. The findings fromthe translation and the resulting spreadsheet data withsecondary themes, explanations, interpretations andsubthemes provided the foundation for a third orderanalysis. In this phase it was possible tore-conceptualize the findings, generating a newinterpretation of the secondary-order themes. Eachmember of the research team independently developed anoverarching mind-map and his or her own synthesis modelthat linked together the translated secondary key themesand authors’ interpretations. These models weremerged and discussed. In this phase we also used handcards to pick apart the original explanations of theauthors and subsequently put them together again inclusters. The clusters were compared to each other andclassified, resulting in our new third-order conceptswith dimensions and subthemes. This process was quitesimilar to standard primary qualitative research interms of subjectivity of interpretation, and can becompared to a grounded theory approach that puts thesimilarities between studies into an interpretive orderaccording to Noblit and Hare a “line ofargument”. The line of argument synthesis involvedbuilding up a picture of the whole from studies of itsparts. Our interpretation aimed to develop a model toexplain the overall concepts of patients aboutindividualised medicine.
7 Expressing the synthesis According to Noblit and Hare, the synthesis is mostlyexpressed in written words or in another presentableform [15]. We created a diagrammatic model and use thisfor publication and poster presentations to express thesynthesis. Quotations were used for validation.