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Qualitative research: literature review .

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Exploring the literature review 

Literature review model: 6 steps.

literature review process

Adapted from The Literature Review , Machi & McEvoy (2009, p. 13).

Your Literature Review

Step 2: search, boolean search strategies, search limiters, ★ ebsco & google drive.

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1. Select a Topic

"All research begins with curiosity" (Machi & McEvoy, 2009, p. 14)

Selection of a topic, and fully defined research interest and question, is supervised (and approved) by your professor. Tips for crafting your topic include:

  • Be specific. Take time to define your interest.
  • Topic Focus. Fully describe and sufficiently narrow the focus for research.
  • Academic Discipline. Learn more about your area of research & refine the scope.
  • Avoid Bias. Be aware of bias that you (as a researcher) may have.
  • Document your research. Use Google Docs to track your research process.
  • Research apps. Consider using Evernote or Zotero to track your research.

Consider Purpose

What will your topic and research address?

In The Literature Review: A Step-by-Step Guide for Students , Ridley presents that literature reviews serve several purposes (2008, p. 16-17).  Included are the following points:

  • Historical background for the research;
  • Overview of current field provided by "contemporary debates, issues, and questions;"
  • Theories and concepts related to your research;
  • Introduce "relevant terminology" - or academic language - being used it the field;
  • Connect to existing research - does your work "extend or challenge [this] or address a gap;" 
  • Provide "supporting evidence for a practical problem or issue" that your research addresses.

★ Schedule a research appointment

At this point in your literature review, take time to meet with a librarian. Why? Understanding the subject terminology used in databases can be challenging. Archer Librarians can help you structure a search, preparing you for step two. How? Contact a librarian directly or use the online form to schedule an appointment. Details are provided in the adjacent Schedule an Appointment box.

2. Search the Literature

Collect & Select Data: Preview, select, and organize

AU Library is your go-to resource for this step in your literature review process. The literature search will include books and ebooks, scholarly and practitioner journals, theses and dissertations, and indexes. You may also choose to include web sites, blogs, open access resources, and newspapers. This library guide provides access to resources needed to complete a literature review.

Books & eBooks: Archer Library & OhioLINK

Databases: scholarly & practitioner journals.

Review the Library Databases tab on this library guide, it provides links to recommended databases for Education & Psychology, Business, and General & Social Sciences.

Expand your journal search; a complete listing of available AU Library and OhioLINK databases is available on the Databases  A to Z list . Search the database by subject, type, name, or do use the search box for a general title search. The A to Z list also includes open access resources and select internet sites.

Databases: Theses & Dissertations

Review the Library Databases tab on this guide, it includes Theses & Dissertation resources. AU library also has AU student authored theses and dissertations available in print, search the library catalog for these titles.

Did you know? If you are looking for particular chapters within a dissertation that is not fully available online, it is possible to submit an ILL article request . Do this instead of requesting the entire dissertation.

Newspapers:  Databases & Internet

Consider current literature in your academic field. AU Library's database collection includes The Chronicle of Higher Education and The Wall Street Journal .  The Internet Resources tab in this guide provides links to newspapers and online journals such as Inside Higher Ed , COABE Journal , and Education Week .

Database

Search Strategies & Boolean Operators

There are three basic boolean operators:  AND, OR, and NOT.

Used with your search terms, boolean operators will either expand or limit results. What purpose do they serve? They help to define the relationship between your search terms. For example, using the operator AND will combine the terms expanding the search. When searching some databases, and Google, the operator AND may be implied.

Overview of boolean terms

About the example: Boolean searches were conducted on November 4, 2019; result numbers may vary at a later date. No additional database limiters were set to further narrow search returns.

Database Search Limiters

Database strategies for targeted search results.

Most databases include limiters, or additional parameters, you may use to strategically focus search results.  EBSCO databases, such as Education Research Complete & Academic Search Complete provide options to:

  • Limit results to full text;
  • Limit results to scholarly journals, and reference available;
  • Select results source type to journals, magazines, conference papers, reviews, and newspapers
  • Publication date

Keep in mind that these tools are defined as limiters for a reason; adding them to a search will limit the number of results returned.  This can be a double-edged sword.  How? 

  • If limiting results to full-text only, you may miss an important piece of research that could change the direction of your research. Interlibrary loan is available to students, free of charge. Request articles that are not available in full-text; they will be sent to you via email.
  • If narrowing publication date, you may eliminate significant historical - or recent - research conducted on your topic.
  • Limiting resource type to a specific type of material may cause bias in the research results.

Use limiters with care. When starting a search, consider opting out of limiters until the initial literature screening is complete. The second or third time through your research may be the ideal time to focus on specific time periods or material (scholarly vs newspaper).

★ Truncating Search Terms

Expanding your search term at the root.

Truncating is often referred to as 'wildcard' searching. Databases may have their own specific wildcard elements however, the most commonly used are the asterisk (*) or question mark (?).  When used within your search. they will expand returned results.

Asterisk (*) Wildcard

Using the asterisk wildcard will return varied spellings of the truncated word. In the following example, the search term education was truncated after the letter "t."

Explore these database help pages for additional information on crafting search terms.

  • EBSCO Connect: Searching with Wildcards and Truncation Symbols
  • EBSCO Connect: Searching with Boolean Operators
  • EBSCO Connect: EBSCOhost Search Tips
  • EBSCO Connect: Basic Searching with EBSCO
  • ProQuest Help: Search Tips
  • ERIC: How does ERIC search work?

★ EBSCO Databases & Google Drive

Tips for saving research directly to Google drive.

Researching in an EBSCO database?

It is possible to save articles (PDF and HTML) and abstracts in EBSCOhost databases directly to Google drive. Select the Google Drive icon, authenticate using a Google account, and an EBSCO folder will be created in your account. This is a great option for managing your research. If documenting your research in a Google Doc, consider linking the information to actual articles saved in drive.

EBSCO Databases & Google Drive

EBSCOHost Databases & Google Drive: Managing your Research

This video features an overview of how to use Google Drive with EBSCO databases to help manage your research. It presents information for connecting an active Google account to EBSCO and steps needed to provide permission for EBSCO to manage a folder in Drive.

About the Video:  Closed captioning is available, select CC from the video menu.  If you need to review a specific area on the video, view on YouTube and expand the video description for access to topic time stamps.  A video transcript is provided below.

  • EBSCOhost Databases & Google Scholar

Defining Literature Review

What is a literature review.

A definition from the Online Dictionary for Library and Information Sciences .

A literature review is "a comprehensive survey of the works published in a particular field of study or line of research, usually over a specific period of time, in the form of an in-depth, critical bibliographic essay or annotated list in which attention is drawn to the most significant works" (Reitz, 2014). 

A systemic review is "a literature review focused on a specific research question, which uses explicit methods to minimize bias in the identification, appraisal, selection, and synthesis of all the high-quality evidence pertinent to the question" (Reitz, 2014).

Recommended Reading

Cover Art

About this page

EBSCO Connect [Discovery and Search]. (2022). Searching with boolean operators. Retrieved May, 3, 2022 from https://connect.ebsco.com/s/?language=en_US

EBSCO Connect [Discover and Search]. (2022). Searching with wildcards and truncation symbols. Retrieved May 3, 2022; https://connect.ebsco.com/s/?language=en_US

Machi, L.A. & McEvoy, B.T. (2009). The literature review . Thousand Oaks, CA: Corwin Press: 

Reitz, J.M. (2014). Online dictionary for library and information science. ABC-CLIO, Libraries Unlimited . Retrieved from https://www.abc-clio.com/ODLIS/odlis_A.aspx

Ridley, D. (2008). The literature review: A step-by-step guide for students . Thousand Oaks, CA: Sage Publications, Inc.

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Methodology

  • What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

Published on June 19, 2020 by Pritha Bhandari . Revised on June 22, 2023.

Qualitative research involves collecting and analyzing non-numerical data (e.g., text, video, or audio) to understand concepts, opinions, or experiences. It can be used to gather in-depth insights into a problem or generate new ideas for research.

Qualitative research is the opposite of quantitative research , which involves collecting and analyzing numerical data for statistical analysis.

Qualitative research is commonly used in the humanities and social sciences, in subjects such as anthropology, sociology, education, health sciences, history, etc.

  • How does social media shape body image in teenagers?
  • How do children and adults interpret healthy eating in the UK?
  • What factors influence employee retention in a large organization?
  • How is anxiety experienced around the world?
  • How can teachers integrate social issues into science curriculums?

Table of contents

Approaches to qualitative research, qualitative research methods, qualitative data analysis, advantages of qualitative research, disadvantages of qualitative research, other interesting articles, frequently asked questions about qualitative research.

Qualitative research is used to understand how people experience the world. While there are many approaches to qualitative research, they tend to be flexible and focus on retaining rich meaning when interpreting data.

Common approaches include grounded theory, ethnography , action research , phenomenological research, and narrative research. They share some similarities, but emphasize different aims and perspectives.

Note that qualitative research is at risk for certain research biases including the Hawthorne effect , observer bias , recall bias , and social desirability bias . While not always totally avoidable, awareness of potential biases as you collect and analyze your data can prevent them from impacting your work too much.

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Each of the research approaches involve using one or more data collection methods . These are some of the most common qualitative methods:

  • Observations: recording what you have seen, heard, or encountered in detailed field notes.
  • Interviews:  personally asking people questions in one-on-one conversations.
  • Focus groups: asking questions and generating discussion among a group of people.
  • Surveys : distributing questionnaires with open-ended questions.
  • Secondary research: collecting existing data in the form of texts, images, audio or video recordings, etc.
  • You take field notes with observations and reflect on your own experiences of the company culture.
  • You distribute open-ended surveys to employees across all the company’s offices by email to find out if the culture varies across locations.
  • You conduct in-depth interviews with employees in your office to learn about their experiences and perspectives in greater detail.

Qualitative researchers often consider themselves “instruments” in research because all observations, interpretations and analyses are filtered through their own personal lens.

For this reason, when writing up your methodology for qualitative research, it’s important to reflect on your approach and to thoroughly explain the choices you made in collecting and analyzing the data.

Qualitative data can take the form of texts, photos, videos and audio. For example, you might be working with interview transcripts, survey responses, fieldnotes, or recordings from natural settings.

Most types of qualitative data analysis share the same five steps:

  • Prepare and organize your data. This may mean transcribing interviews or typing up fieldnotes.
  • Review and explore your data. Examine the data for patterns or repeated ideas that emerge.
  • Develop a data coding system. Based on your initial ideas, establish a set of codes that you can apply to categorize your data.
  • Assign codes to the data. For example, in qualitative survey analysis, this may mean going through each participant’s responses and tagging them with codes in a spreadsheet. As you go through your data, you can create new codes to add to your system if necessary.
  • Identify recurring themes. Link codes together into cohesive, overarching themes.

There are several specific approaches to analyzing qualitative data. Although these methods share similar processes, they emphasize different concepts.

Qualitative research often tries to preserve the voice and perspective of participants and can be adjusted as new research questions arise. Qualitative research is good for:

  • Flexibility

The data collection and analysis process can be adapted as new ideas or patterns emerge. They are not rigidly decided beforehand.

  • Natural settings

Data collection occurs in real-world contexts or in naturalistic ways.

  • Meaningful insights

Detailed descriptions of people’s experiences, feelings and perceptions can be used in designing, testing or improving systems or products.

  • Generation of new ideas

Open-ended responses mean that researchers can uncover novel problems or opportunities that they wouldn’t have thought of otherwise.

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Researchers must consider practical and theoretical limitations in analyzing and interpreting their data. Qualitative research suffers from:

  • Unreliability

The real-world setting often makes qualitative research unreliable because of uncontrolled factors that affect the data.

  • Subjectivity

Due to the researcher’s primary role in analyzing and interpreting data, qualitative research cannot be replicated . The researcher decides what is important and what is irrelevant in data analysis, so interpretations of the same data can vary greatly.

  • Limited generalizability

Small samples are often used to gather detailed data about specific contexts. Despite rigorous analysis procedures, it is difficult to draw generalizable conclusions because the data may be biased and unrepresentative of the wider population .

  • Labor-intensive

Although software can be used to manage and record large amounts of text, data analysis often has to be checked or performed manually.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

  • Chi square goodness of fit test
  • Degrees of freedom
  • Null hypothesis
  • Discourse analysis
  • Control groups
  • Mixed methods research
  • Non-probability sampling
  • Quantitative research
  • Inclusion and exclusion criteria

Research bias

  • Rosenthal effect
  • Implicit bias
  • Cognitive bias
  • Selection bias
  • Negativity bias
  • Status quo bias

Quantitative research deals with numbers and statistics, while qualitative research deals with words and meanings.

Quantitative methods allow you to systematically measure variables and test hypotheses . Qualitative methods allow you to explore concepts and experiences in more detail.

There are five common approaches to qualitative research :

  • Grounded theory involves collecting data in order to develop new theories.
  • Ethnography involves immersing yourself in a group or organization to understand its culture.
  • Narrative research involves interpreting stories to understand how people make sense of their experiences and perceptions.
  • Phenomenological research involves investigating phenomena through people’s lived experiences.
  • Action research links theory and practice in several cycles to drive innovative changes.

Data collection is the systematic process by which observations or measurements are gathered in research. It is used in many different contexts by academics, governments, businesses, and other organizations.

There are various approaches to qualitative data analysis , but they all share five steps in common:

  • Prepare and organize your data.
  • Review and explore your data.
  • Develop a data coding system.
  • Assign codes to the data.
  • Identify recurring themes.

The specifics of each step depend on the focus of the analysis. Some common approaches include textual analysis , thematic analysis , and discourse analysis .

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Writing a Literature Review

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A literature review is a document or section of a document that collects key sources on a topic and discusses those sources in conversation with each other (also called synthesis ). The lit review is an important genre in many disciplines, not just literature (i.e., the study of works of literature such as novels and plays). When we say “literature review” or refer to “the literature,” we are talking about the research ( scholarship ) in a given field. You will often see the terms “the research,” “the scholarship,” and “the literature” used mostly interchangeably.

Where, when, and why would I write a lit review?

There are a number of different situations where you might write a literature review, each with slightly different expectations; different disciplines, too, have field-specific expectations for what a literature review is and does. For instance, in the humanities, authors might include more overt argumentation and interpretation of source material in their literature reviews, whereas in the sciences, authors are more likely to report study designs and results in their literature reviews; these differences reflect these disciplines’ purposes and conventions in scholarship. You should always look at examples from your own discipline and talk to professors or mentors in your field to be sure you understand your discipline’s conventions, for literature reviews as well as for any other genre.

A literature review can be a part of a research paper or scholarly article, usually falling after the introduction and before the research methods sections. In these cases, the lit review just needs to cover scholarship that is important to the issue you are writing about; sometimes it will also cover key sources that informed your research methodology.

Lit reviews can also be standalone pieces, either as assignments in a class or as publications. In a class, a lit review may be assigned to help students familiarize themselves with a topic and with scholarship in their field, get an idea of the other researchers working on the topic they’re interested in, find gaps in existing research in order to propose new projects, and/or develop a theoretical framework and methodology for later research. As a publication, a lit review usually is meant to help make other scholars’ lives easier by collecting and summarizing, synthesizing, and analyzing existing research on a topic. This can be especially helpful for students or scholars getting into a new research area, or for directing an entire community of scholars toward questions that have not yet been answered.

What are the parts of a lit review?

Most lit reviews use a basic introduction-body-conclusion structure; if your lit review is part of a larger paper, the introduction and conclusion pieces may be just a few sentences while you focus most of your attention on the body. If your lit review is a standalone piece, the introduction and conclusion take up more space and give you a place to discuss your goals, research methods, and conclusions separately from where you discuss the literature itself.

Introduction:

  • An introductory paragraph that explains what your working topic and thesis is
  • A forecast of key topics or texts that will appear in the review
  • Potentially, a description of how you found sources and how you analyzed them for inclusion and discussion in the review (more often found in published, standalone literature reviews than in lit review sections in an article or research paper)
  • Summarize and synthesize: Give an overview of the main points of each source and combine them into a coherent whole
  • Analyze and interpret: Don’t just paraphrase other researchers – add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
  • Critically Evaluate: Mention the strengths and weaknesses of your sources
  • Write in well-structured paragraphs: Use transition words and topic sentence to draw connections, comparisons, and contrasts.

Conclusion:

  • Summarize the key findings you have taken from the literature and emphasize their significance
  • Connect it back to your primary research question

How should I organize my lit review?

Lit reviews can take many different organizational patterns depending on what you are trying to accomplish with the review. Here are some examples:

  • Chronological : The simplest approach is to trace the development of the topic over time, which helps familiarize the audience with the topic (for instance if you are introducing something that is not commonly known in your field). If you choose this strategy, be careful to avoid simply listing and summarizing sources in order. Try to analyze the patterns, turning points, and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred (as mentioned previously, this may not be appropriate in your discipline — check with a teacher or mentor if you’re unsure).
  • Thematic : If you have found some recurring central themes that you will continue working with throughout your piece, you can organize your literature review into subsections that address different aspects of the topic. For example, if you are reviewing literature about women and religion, key themes can include the role of women in churches and the religious attitude towards women.
  • Qualitative versus quantitative research
  • Empirical versus theoretical scholarship
  • Divide the research by sociological, historical, or cultural sources
  • Theoretical : In many humanities articles, the literature review is the foundation for the theoretical framework. You can use it to discuss various theories, models, and definitions of key concepts. You can argue for the relevance of a specific theoretical approach or combine various theorical concepts to create a framework for your research.

What are some strategies or tips I can use while writing my lit review?

Any lit review is only as good as the research it discusses; make sure your sources are well-chosen and your research is thorough. Don’t be afraid to do more research if you discover a new thread as you’re writing. More info on the research process is available in our "Conducting Research" resources .

As you’re doing your research, create an annotated bibliography ( see our page on the this type of document ). Much of the information used in an annotated bibliography can be used also in a literature review, so you’ll be not only partially drafting your lit review as you research, but also developing your sense of the larger conversation going on among scholars, professionals, and any other stakeholders in your topic.

Usually you will need to synthesize research rather than just summarizing it. This means drawing connections between sources to create a picture of the scholarly conversation on a topic over time. Many student writers struggle to synthesize because they feel they don’t have anything to add to the scholars they are citing; here are some strategies to help you:

  • It often helps to remember that the point of these kinds of syntheses is to show your readers how you understand your research, to help them read the rest of your paper.
  • Writing teachers often say synthesis is like hosting a dinner party: imagine all your sources are together in a room, discussing your topic. What are they saying to each other?
  • Look at the in-text citations in each paragraph. Are you citing just one source for each paragraph? This usually indicates summary only. When you have multiple sources cited in a paragraph, you are more likely to be synthesizing them (not always, but often
  • Read more about synthesis here.

The most interesting literature reviews are often written as arguments (again, as mentioned at the beginning of the page, this is discipline-specific and doesn’t work for all situations). Often, the literature review is where you can establish your research as filling a particular gap or as relevant in a particular way. You have some chance to do this in your introduction in an article, but the literature review section gives a more extended opportunity to establish the conversation in the way you would like your readers to see it. You can choose the intellectual lineage you would like to be part of and whose definitions matter most to your thinking (mostly humanities-specific, but this goes for sciences as well). In addressing these points, you argue for your place in the conversation, which tends to make the lit review more compelling than a simple reporting of other sources.

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Encyclopedia of Evidence in Pharmaceutical Public Health and Health Services Research in Pharmacy pp 1–15 Cite as

Methodological Approaches to Literature Review

  • Dennis Thomas 2 ,
  • Elida Zairina 3 &
  • Johnson George 4  
  • Living reference work entry
  • First Online: 09 May 2023

335 Accesses

The literature review can serve various functions in the contexts of education and research. It aids in identifying knowledge gaps, informing research methodology, and developing a theoretical framework during the planning stages of a research study or project, as well as reporting of review findings in the context of the existing literature. This chapter discusses the methodological approaches to conducting a literature review and offers an overview of different types of reviews. There are various types of reviews, including narrative reviews, scoping reviews, and systematic reviews with reporting strategies such as meta-analysis and meta-synthesis. Review authors should consider the scope of the literature review when selecting a type and method. Being focused is essential for a successful review; however, this must be balanced against the relevance of the review to a broad audience.

  • Literature review
  • Systematic review
  • Meta-analysis
  • Scoping review
  • Research methodology

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Thomas, D., Zairina, E., George, J. (2023). Methodological Approaches to Literature Review. In: Encyclopedia of Evidence in Pharmaceutical Public Health and Health Services Research in Pharmacy. Springer, Cham. https://doi.org/10.1007/978-3-030-50247-8_57-1

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Qualitative researchers TEND to:

Researchers using qualitative methods tend to:

  • t hink that social sciences cannot be well-studied with the same methods as natural or physical sciences
  • feel that human behavior is context-specific; therefore, behavior must be studied holistically, in situ, rather than being manipulated
  • employ an 'insider's' perspective; research tends to be personal and thereby more subjective.
  • do interviews, focus groups, field research, case studies, and conversational or content analysis.

reasons to make a qualitative study; From https://www.editage.com/insights/qualitative-quantitative-or-mixed-methods-a-quick-guide-to-choose-the-right-design-for-your-research?refer-type=infographics

Image from https://www.editage.com/insights/qualitative-quantitative-or-mixed-methods-a-quick-guide-to-choose-the-right-design-for-your-research?refer-type=infographics

Qualitative Research (an operational definition)

Qualitative Research: an operational description

Purpose : explain; gain insight and understanding of phenomena through intensive collection and study of narrative data

Approach: inductive; value-laden/subjective; holistic, process-oriented

Hypotheses: tentative, evolving; based on the particular study

Lit. Review: limited; may not be exhaustive

Setting: naturalistic, when and as much as possible

Sampling : for the purpose; not necessarily representative; for in-depth understanding

Measurement: narrative; ongoing

Design and Method: flexible, specified only generally; based on non-intervention, minimal disturbance, such as historical, ethnographic, or case studies

Data Collection: document collection, participant observation, informal interviews, field notes

Data Analysis: raw data is words/ ongoing; involves synthesis

Data Interpretation: tentative, reviewed on ongoing basis, speculative

  • Qualitative research with more structure and less subjectivity
  • Increased application of both strategies to the same study ("mixed methods")
  • Evidence-based practice emphasized in more fields (nursing, social work, education, and others).

Some Other Guidelines

  • Guide for formatting Graphs and Tables
  • Critical Appraisal Checklist for an Article On Qualitative Research

Quantitative researchers TEND to:

Researchers using quantitative methods tend to:

  • think that both natural and social sciences strive to explain phenomena with confirmable theories derived from testable assumptions
  • attempt to reduce social reality to variables, in the same way as with physical reality
  • try to tightly control the variable(s) in question to see how the others are influenced.
  • Do experiments, have control groups, use blind or double-blind studies; use measures or instruments.

reasons to do a quantitative study. From https://www.editage.com/insights/qualitative-quantitative-or-mixed-methods-a-quick-guide-to-choose-the-right-design-for-your-research?refer-type=infographics

Quantitative Research (an operational definition)

Quantitative research: an operational description

Purpose: explain, predict or control phenomena through focused collection and analysis of numberical data

Approach: deductive; tries to be value-free/has objectives/ is outcome-oriented

Hypotheses : Specific, testable, and stated prior to study

Lit. Review: extensive; may significantly influence a particular study

Setting: controlled to the degree possible

Sampling: uses largest manageable random/randomized sample, to allow generalization of results to larger populations

Measurement: standardized, numberical; "at the end"

Design and Method: Strongly structured, specified in detail in advance; involves intervention, manipulation and control groups; descriptive, correlational, experimental

Data Collection: via instruments, surveys, experiments, semi-structured formal interviews, tests or questionnaires

Data Analysis: raw data is numbers; at end of study, usually statistical

Data Interpretation: formulated at end of study; stated as a degree of certainty

This page on qualitative and quantitative research has been adapted and expanded from a handout by Suzy Westenkirchner. Used with permission.

Images from https://www.editage.com/insights/qualitative-quantitative-or-mixed-methods-a-quick-guide-to-choose-the-right-design-for-your-research?refer-type=infographics.

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Reproduced from Grant, M. J. and Booth, A. (2009), A typology of reviews: an analysis of 14 review types and associated methodologies. Health Information & Libraries Journal, 26: 91–108. doi:10.1111/j.1471-1842.2009.00848.x

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A Guide to Writing a Qualitative Systematic Review Protocol to Enhance Evidence-Based Practice in Nursing and Health Care

Affiliations.

  • 1 PhD candidate, School of Nursing and Midwifey, Monash University, and Clinical Nurse Specialist, Adult and Pediatric Intensive Care Unit, Monash Health, Melbourne, Victoria, Australia.
  • 2 Lecturer, School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia.
  • 3 Senior Lecturer, School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia.
  • PMID: 26790142
  • DOI: 10.1111/wvn.12134

Background: The qualitative systematic review is a rapidly developing area of nursing research. In order to present trustworthy, high-quality recommendations, such reviews should be based on a review protocol to minimize bias and enhance transparency and reproducibility. Although there are a number of resources available to guide researchers in developing a quantitative review protocol, very few resources exist for qualitative reviews.

Aims: To guide researchers through the process of developing a qualitative systematic review protocol, using an example review question.

Methodology: The key elements required in a systematic review protocol are discussed, with a focus on application to qualitative reviews: Development of a research question; formulation of key search terms and strategies; designing a multistage review process; critical appraisal of qualitative literature; development of data extraction techniques; and data synthesis. The paper highlights important considerations during the protocol development process, and uses a previously developed review question as a working example.

Implications for research: This paper will assist novice researchers in developing a qualitative systematic review protocol. By providing a worked example of a protocol, the paper encourages the development of review protocols, enhancing the trustworthiness and value of the completed qualitative systematic review findings.

Linking evidence to action: Qualitative systematic reviews should be based on well planned, peer reviewed protocols to enhance the trustworthiness of results and thus their usefulness in clinical practice. Protocols should outline, in detail, the processes which will be used to undertake the review, including key search terms, inclusion and exclusion criteria, and the methods used for critical appraisal, data extraction and data analysis to facilitate transparency of the review process. Additionally, journals should encourage and support the publication of review protocols, and should require reference to a protocol prior to publication of the review results.

Keywords: guidelines; meta synthesis; qualitative; systematic review protocol.

© 2016 Sigma Theta Tau International.

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Quantitative and qualitative data can be collected using various methods. It is important to use a data collection method to help answer your research question(s).

Many data collection methods can be either qualitative or quantitative. For example, in surveys, observational studies or case studies, your data can be represented as numbers (e.g., using rating scales or counting frequencies) or as words (e.g., with open-ended questions or descriptions of what you observe).

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Galdas P, Darwin Z, Fell J, et al. A systematic review and metaethnography to identify how effective, cost-effective, accessible and acceptable self-management support interventions are for men with long-term conditions (SELF-MAN). Southampton (UK): NIHR Journals Library; 2015 Aug. (Health Services and Delivery Research, No. 3.34.)

Cover of A systematic review and metaethnography to identify how effective, cost-effective, accessible and acceptable self-management support interventions are for men with long-term conditions (SELF-MAN)

A systematic review and metaethnography to identify how effective, cost-effective, accessible and acceptable self-management support interventions are for men with long-term conditions (SELF-MAN).

Chapter 3 qualitative review methods.

The objective of the qualitative metaethnography was to systematically identify experiences of, and perceptions of, interventions or specific activities aimed at supporting or promoting self-management of LTCs among men of differing age, ethnicity and socioeconomic background.

A summary of the methods used in the metaethnography is provided in Appendix 3 , using the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) reporting standards for qualitative evidence synthesis, developed by Tong et al. 93

The evidence synthesis was conducted using a metaethnography approach originally described by Noblit and Hare. 94 This approach was chosen because of its emphasis on conceptual development and generating new insights (i.e. being interpretive rather than integrative 94 ) and because it is compatible with synthesising all types of qualitative research. 95

Metaethnography involves seven stages: getting started, deciding what is relevant, reading the studies, determining how studies are related to each other, translating studies into each other, synthesising translations and expressing the synthesis; 94 these seven, often overlapping, stages are depicted in Figure 7 .

Seven steps of metaethnography.

  • Step 1: getting started

The first stage involved identifying a ‘worthy’ research question and one that could be addressed through qualitative evidence synthesis. 94 This stage took place in developing the original funding application for the current review and its justification is presented in Chapter 1 .

  • Step 2: deciding what is relevant

The second stage, ‘deciding what is relevant’, was viewed as comprising the search strategy, inclusion criteria and quality appraisal, consistent with the experiences of Atkins et al. 96 These are presented next, before steps 3–7 are described in the section Data extraction strategy and data analysis .

  • Search methods

Search strategy

A comprehensive electronic search strategy ( Appendix 4 ) was developed in liaison with information specialists. It sought to identify all available studies, rather than using purposive sampling to identify all available concepts. Five electronic databases were searched in July 2013 [Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, MEDLINE, PsycINFO and Social Science Citation Index].

Because of challenges with methodological indexing of qualitative research, 97 the electronic search was complemented by checking reference lists, and using an adapted strategy published elsewhere 98 that includes ‘thesaurus terms’ (keywords indexed in electronic databases, e.g. ‘Qualitative Research’), ‘free text terms’ (commonly used research methodology terms searched for in the titles, abstracts and keywords) and ‘broad-based terms’ (i.e. the broad free-text terms ‘qualitative’, ‘findings’ and ‘interview$’ and the thesaurus term ‘Interviews’). Terms relating to gender were combined with other terms to narrow the search and increase the precision of the strategy (e.g. ‘men’, ‘male’, ‘masculine$’, ‘gender’, ‘sex difference$’, ‘sex factors’).

Study selection: study screening methods and inclusion criteria

Records were initially screened by one reviewer (ZD) on the basis of the title and abstract. Decisions were recorded in EndNote X7.0.2 (Thomson Reuters, CA, USA), a reference management database. All articles identified as potentially eligible for inclusion were obtained in full. Attempts were made to identify and obtain published findings for unpublished literature that was otherwise eligible, for example doctoral theses or conference proceedings.

The full-text literature was screened independently by two reviewers (ZD and PG) using the inclusion criteria listed in Table 5 . Studies that explored the experiences of men alone, or included a clear and explicit comparison between men and women, were included. Studies which focused on self-management experiences of people with LTCs more generally (i.e. did not consider experiences of, or perceptions of, a self-management support intervention or activity) were excluded. The approach to screening was inclusive; for example, studies where the qualitative findings were limited (e.g. Iredale et al. , 99 Ramachandra et al. , 100 Smith et al. 101 ) and mixed-sex studies with limited findings on gender comparisons (e.g. Barlow et al. 102 , 103 ) were retained in case they contributed to the synthesis.

TABLE 5

Screening criteria: qualitative

  • Classification of self-management interventions and support activities in the qualitative evidence synthesis

The original study protocol sought to code self-management interventions and support activities using the most up-to-date version of the taxonomy of BCT. 104 – 106 As in the quantitative review (see Chapter 2 , Coding interventions for analysis ), we found that the level of detail reported on self-management interventions or activities in the qualitative literature was limited in detail, precision and consistency, making coding with the BCT taxonomy unfeasible.

Most of the qualitative literature did not focus on behaviour change per se or seek to address men’s views and experiences of behaviour change techniques; for example, some papers were concerned with the dynamics of social support groups, or the use of other self-management support and information. The BCT taxonomy is applicable to only studies that are judged as targeting behaviour change; we were therefore limited to ‘lifestyle’ and ‘psychological’ studies. Only a minority of the studies ( n  = 13) provided sufficient information on interventions to allow even rudimentary coding with the BCT taxonomy, and these are presented in Appendix 5 . Issues around application of the BCT taxonomy are returned to in the discussion chapter (see Chapter 6 ).

The lack of detail reported in the qualitative literature also made it unfeasible to classify interventions using the system developed for the quantitative review. Whereas the quantitative review concerned trials of specific interventions, approximately half of the studies in the qualitative review 99 , 101 , 107 – 130 included more than one intervention or activity (e.g. ‘any cancer support group’).

We therefore developed a broad system for classifying interventions and support activities that offered a pragmatic way to group studies and make the analysis process more manageable. The categories are shown in Table 6 .

TABLE 6

Categories and descriptions of self-management interventions and support activities in the qualitative evidence synthesis

  • Quality assessment strategy

The purpose of quality appraisal in the review was to provide descriptive information on the quality of the included studies rather than as a basis for inclusion. We considered that studies of weaker quality either would not contribute or would contribute only minimally to the final synthesis. 94 , 131 We therefore chose not to use design-specific appraisal tools (which the original protocol stated we would) because we placed emphasis on conceptual contribution, which did not require a detailed design-specific appraisal of methodological quality. With that in mind, we used the Critical Appraisal Skills Programme (CASP) tool. 132

The CASP tool comprises 10 checklist-style questions (see Appendix 6 ) for assessing the quality of various domains (including aims, design, methods, data analysis, interpretation, findings and value of the research). Because of the checklist nature of the CASP tool, we developed some additional questions informed by other metaethnography studies 96 , 131 that enabled us to extract and record more detailed narrative summaries of the main strengths, limitations and concerns of each study (see Appendix 7 ).

The CASP tool was used in the light of the experiences reported by other researchers who recommended that, despite rather low inter-rater agreement, such an approach ‘encourag[es] the reviewers to read the papers carefully and systematically, and serves as a reminder to treat the papers as data for the synthesis’ (p. 44). 131

Its focus is on procedural aspects of the conduct of the research rather than the insights offered. 133 The quality appraisal (which focused on methodological quality) did not form part of the inclusion criteria because, as recognised by Campbell et al. , 131 it is conceptual quality that is most important for evidence synthesis and it is the process of synthesis that judges the ‘worth’ of studies, with conceptually limited studies making a limited contribution. 94 Additionally, it is acknowledged that agreement is often slight, with low reproducibility. 131 , 133 Appraisal was conducted by two reviewers independently (ZD and PG), with discrepancies resolved through discussion.

Search outcome

The electronic search strategy identified 6330 unique references. Screening based on title and abstract identified 149 papers for full-text screening. Dual screening of these full-text articles identified 34 studies (reported in 38 papers) to be included in the review. Reasons for excluding the remaining 111 articles are shown in Table 7 .

TABLE 7

Reasons for exclusion of full-text articles

Inter-rater agreement on the decision to include was 88.6%. The majority of disagreements ( n  = 17) concerned the definition of self-management intervention or activity. Having discussed the 17 disagreements, we agreed that five studies on which there was disagreement would be included. 100 , 103 , 110 , 116 , 134

An additional four studies were identified through reference checks and efforts to locate published literature linked to unpublished work identified through the electronic search. 111 , 112 , 135 , 136 An additional two papers (women only), although individually ineligible, were located as ‘linked papers’ for two of the original 34 studies, 114 , 120 giving a total of 38 studies (reported in 44 papers), as shown in Figure 8 .

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram for the qualitative review.

  • Data extraction strategy and data analysis

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. 94 Despite 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 Schutz 137 and operationalised by Atkins et al. : 96

  • 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
  • second-order: study authors’ themes/concepts and interpretations, also described by Noblit and Hare 94 as ‘metaphors’
  • third-order: our ‘interpretations of interpretations of interpretations’ (p. 35), 94 based on our analysis of the first-order and second-order constructs extracted from the studies.

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 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 Campbell et al. : 131 initially 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

  • reciprocal translation, where the findings are directly comparable
  • refutational translation, where the findings are in opposition
  • 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 Hare 94 as ‘expressing the synthesis’ (p. 29). They state that ‘the worth of any synthesis is in its comprehensibility to some audience’ (p. 82), 94 emphasising 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 in Chapter 5 and 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). 131 We 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.

  • Public and patient involvement

The SELF-MAN research team worked with a specially constituted public and patient advisory group comprising men living with one or more LTCs who were involved in either running or attending a LTC support group in the north of England. Members were recruited via the research team’s existing networks. Stakeholders’ support groups were all condition-specific – arthritis ( n  = 1), diabetes ( n  = 1), heart failure ( n  = 2) and Parkinson’s disease ( n  = 1) – although some men lived with multiple LTCs. All stakeholders attended a welcome meeting prior to the commencement of the study to prepare them for the involvement in the research, and were provided with ongoing support and guidance by the chief investigator throughout the research process. Members were reimbursed for travel, expenses and time throughout the duration of the project (in line with current INVOLVE recommendations 138 ).

The overarching aims of PPI in the project were, first, to help ensure that the review findings spoke to the self-management needs and priorities of men with LTCs, and, second, to ensure the development of appropriate outputs that would have benefit and relevance for service users. A recognised limitation of our group was that stakeholder representation was drawn from face-to-face group-based support interventions.

The stakeholder group met on three half-days over the course of the 12-month project. On each occasion, the group provided positive affirmation that the project was being conducted in accordance with its stated objectives. In the first two meetings, the group offered feedback and advice to the investigative team on preliminary and emerging analysis of the qualitative data throughout the research process: specifically, the development of third-order constructs and the line-of-argument synthesis. Responding to their input, we made revisions to some of our interpretations, particularly in relation to the importance of physical aspects of environments in which interventions took place. The group’s input also highlighted the need for future research to address depression as a common and often overlooked comorbidity in men (see Chapter 7 , Recommendations for future research ), and that they welcomed recommendations for sustainability of support groups and improving communication within groups. When considering the key outcomes to be assessed in the quantitative review, stakeholders also recommended that emphasis should be placed on quality-of-life outcome measures when considering whether or not a self-management support intervention is effective.

In the final meeting, the stakeholder group provided detailed recommendations for the content of the Self-Manual: Man’s Guide to Better Self-Management of Long Term Conditions (not yet available). It advised that the guide should be rephrased from ‘how to’ self-manage to ‘how to better ’ self-manage because men may view themselves as already self-managing and therefore not identify with the former.

Six or seven stakeholders attended each meeting. The female partner of one of the men attended and contributed to discussions at each meeting. Members of the group each received reimbursement of travel expenses and a £150 honorarium for each meeting they attended. In the final meeting, the stakeholders provided feedback on their involvement in the research process overall, focusing on what was done well and what could be improved. Feedback indicated that most stakeholders had a positive experience, particularly valuing the opportunity to have their ‘voices heard’ and make a potential impact on future service delivery. Recommendations for improvements mostly centred on ensuring prompt reimbursement of expenses incurred in attending the meetings.

Included under terms of UK Non-commercial Government License .

  • Cite this Page Galdas P, Darwin Z, Fell J, et al. A systematic review and metaethnography to identify how effective, cost-effective, accessible and acceptable self-management support interventions are for men with long-term conditions (SELF-MAN). Southampton (UK): NIHR Journals Library; 2015 Aug. (Health Services and Delivery Research, No. 3.34.) Chapter 3, Qualitative review methods.
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  • Published: 11 October 2016

Reviewing the research methods literature: principles and strategies illustrated by a systematic overview of sampling in qualitative research

  • Stephen J. Gentles 1 , 4 ,
  • Cathy Charles 1 ,
  • David B. Nicholas 2 ,
  • Jenny Ploeg 3 &
  • K. Ann McKibbon 1  

Systematic Reviews volume  5 , Article number:  172 ( 2016 ) Cite this article

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Overviews of methods are potentially useful means to increase clarity and enhance collective understanding of specific methods topics that may be characterized by ambiguity, inconsistency, or a lack of comprehensiveness. This type of review represents a distinct literature synthesis method, although to date, its methodology remains relatively undeveloped despite several aspects that demand unique review procedures. The purpose of this paper is to initiate discussion about what a rigorous systematic approach to reviews of methods, referred to here as systematic methods overviews , might look like by providing tentative suggestions for approaching specific challenges likely to be encountered. The guidance offered here was derived from experience conducting a systematic methods overview on the topic of sampling in qualitative research.

The guidance is organized into several principles that highlight specific objectives for this type of review given the common challenges that must be overcome to achieve them. Optional strategies for achieving each principle are also proposed, along with discussion of how they were successfully implemented in the overview on sampling. We describe seven paired principles and strategies that address the following aspects: delimiting the initial set of publications to consider, searching beyond standard bibliographic databases, searching without the availability of relevant metadata, selecting publications on purposeful conceptual grounds, defining concepts and other information to abstract iteratively, accounting for inconsistent terminology used to describe specific methods topics, and generating rigorous verifiable analytic interpretations. Since a broad aim in systematic methods overviews is to describe and interpret the relevant literature in qualitative terms, we suggest that iterative decision making at various stages of the review process, and a rigorous qualitative approach to analysis are necessary features of this review type.

Conclusions

We believe that the principles and strategies provided here will be useful to anyone choosing to undertake a systematic methods overview. This paper represents an initial effort to promote high quality critical evaluations of the literature regarding problematic methods topics, which have the potential to promote clearer, shared understandings, and accelerate advances in research methods. Further work is warranted to develop more definitive guidance.

Peer Review reports

While reviews of methods are not new, they represent a distinct review type whose methodology remains relatively under-addressed in the literature despite the clear implications for unique review procedures. One of few examples to describe it is a chapter containing reflections of two contributing authors in a book of 21 reviews on methodological topics compiled for the British National Health Service, Health Technology Assessment Program [ 1 ]. Notable is their observation of how the differences between the methods reviews and conventional quantitative systematic reviews, specifically attributable to their varying content and purpose, have implications for defining what qualifies as systematic. While the authors describe general aspects of “systematicity” (including rigorous application of a methodical search, abstraction, and analysis), they also describe a high degree of variation within the category of methods reviews itself and so offer little in the way of concrete guidance. In this paper, we present tentative concrete guidance, in the form of a preliminary set of proposed principles and optional strategies, for a rigorous systematic approach to reviewing and evaluating the literature on quantitative or qualitative methods topics. For purposes of this article, we have used the term systematic methods overview to emphasize the notion of a systematic approach to such reviews.

The conventional focus of rigorous literature reviews (i.e., review types for which systematic methods have been codified, including the various approaches to quantitative systematic reviews [ 2 – 4 ], and the numerous forms of qualitative and mixed methods literature synthesis [ 5 – 10 ]) is to synthesize empirical research findings from multiple studies. By contrast, the focus of overviews of methods, including the systematic approach we advocate, is to synthesize guidance on methods topics. The literature consulted for such reviews may include the methods literature, methods-relevant sections of empirical research reports, or both. Thus, this paper adds to previous work published in this journal—namely, recent preliminary guidance for conducting reviews of theory [ 11 ]—that has extended the application of systematic review methods to novel review types that are concerned with subject matter other than empirical research findings.

Published examples of methods overviews illustrate the varying objectives they can have. One objective is to establish methodological standards for appraisal purposes. For example, reviews of existing quality appraisal standards have been used to propose universal standards for appraising the quality of primary qualitative research [ 12 ] or evaluating qualitative research reports [ 13 ]. A second objective is to survey the methods-relevant sections of empirical research reports to establish current practices on methods use and reporting practices, which Moher and colleagues [ 14 ] recommend as a means for establishing the needs to be addressed in reporting guidelines (see, for example [ 15 , 16 ]). A third objective for a methods review is to offer clarity and enhance collective understanding regarding a specific methods topic that may be characterized by ambiguity, inconsistency, or a lack of comprehensiveness within the available methods literature. An example of this is a overview whose objective was to review the inconsistent definitions of intention-to-treat analysis (the methodologically preferred approach to analyze randomized controlled trial data) that have been offered in the methods literature and propose a solution for improving conceptual clarity [ 17 ]. Such reviews are warranted because students and researchers who must learn or apply research methods typically lack the time to systematically search, retrieve, review, and compare the available literature to develop a thorough and critical sense of the varied approaches regarding certain controversial or ambiguous methods topics.

While systematic methods overviews , as a review type, include both reviews of the methods literature and reviews of methods-relevant sections from empirical study reports, the guidance provided here is primarily applicable to reviews of the methods literature since it was derived from the experience of conducting such a review [ 18 ], described below. To our knowledge, there are no well-developed proposals on how to rigorously conduct such reviews. Such guidance would have the potential to improve the thoroughness and credibility of critical evaluations of the methods literature, which could increase their utility as a tool for generating understandings that advance research methods, both qualitative and quantitative. Our aim in this paper is thus to initiate discussion about what might constitute a rigorous approach to systematic methods overviews. While we hope to promote rigor in the conduct of systematic methods overviews wherever possible, we do not wish to suggest that all methods overviews need be conducted to the same standard. Rather, we believe that the level of rigor may need to be tailored pragmatically to the specific review objectives, which may not always justify the resource requirements of an intensive review process.

The example systematic methods overview on sampling in qualitative research

The principles and strategies we propose in this paper are derived from experience conducting a systematic methods overview on the topic of sampling in qualitative research [ 18 ]. The main objective of that methods overview was to bring clarity and deeper understanding of the prominent concepts related to sampling in qualitative research (purposeful sampling strategies, saturation, etc.). Specifically, we interpreted the available guidance, commenting on areas lacking clarity, consistency, or comprehensiveness (without proposing any recommendations on how to do sampling). This was achieved by a comparative and critical analysis of publications representing the most influential (i.e., highly cited) guidance across several methodological traditions in qualitative research.

The specific methods and procedures for the overview on sampling [ 18 ] from which our proposals are derived were developed both after soliciting initial input from local experts in qualitative research and an expert health librarian (KAM) and through ongoing careful deliberation throughout the review process. To summarize, in that review, we employed a transparent and rigorous approach to search the methods literature, selected publications for inclusion according to a purposeful and iterative process, abstracted textual data using structured abstraction forms, and analyzed (synthesized) the data using a systematic multi-step approach featuring abstraction of text, summary of information in matrices, and analytic comparisons.

For this article, we reflected on both the problems and challenges encountered at different stages of the review and our means for selecting justifiable procedures to deal with them. Several principles were then derived by considering the generic nature of these problems, while the generalizable aspects of the procedures used to address them formed the basis of optional strategies. Further details of the specific methods and procedures used in the overview on qualitative sampling are provided below to illustrate both the types of objectives and challenges that reviewers will likely need to consider and our approach to implementing each of the principles and strategies.

Organization of the guidance into principles and strategies

For the purposes of this article, principles are general statements outlining what we propose are important aims or considerations within a particular review process, given the unique objectives or challenges to be overcome with this type of review. These statements follow the general format, “considering the objective or challenge of X, we propose Y to be an important aim or consideration.” Strategies are optional and flexible approaches for implementing the previous principle outlined. Thus, generic challenges give rise to principles, which in turn give rise to strategies.

We organize the principles and strategies below into three sections corresponding to processes characteristic of most systematic literature synthesis approaches: literature identification and selection ; data abstraction from the publications selected for inclusion; and analysis , including critical appraisal and synthesis of the abstracted data. Within each section, we also describe the specific methodological decisions and procedures used in the overview on sampling in qualitative research [ 18 ] to illustrate how the principles and strategies for each review process were applied and implemented in a specific case. We expect this guidance and accompanying illustrations will be useful for anyone considering engaging in a methods overview, particularly those who may be familiar with conventional systematic review methods but may not yet appreciate some of the challenges specific to reviewing the methods literature.

Results and discussion

Literature identification and selection.

The identification and selection process includes search and retrieval of publications and the development and application of inclusion and exclusion criteria to select the publications that will be abstracted and analyzed in the final review. Literature identification and selection for overviews of the methods literature is challenging and potentially more resource-intensive than for most reviews of empirical research. This is true for several reasons that we describe below, alongside discussion of the potential solutions. Additionally, we suggest in this section how the selection procedures can be chosen to match the specific analytic approach used in methods overviews.

Delimiting a manageable set of publications

One aspect of methods overviews that can make identification and selection challenging is the fact that the universe of literature containing potentially relevant information regarding most methods-related topics is expansive and often unmanageably so. Reviewers are faced with two large categories of literature: the methods literature , where the possible publication types include journal articles, books, and book chapters; and the methods-relevant sections of empirical study reports , where the possible publication types include journal articles, monographs, books, theses, and conference proceedings. In our systematic overview of sampling in qualitative research, exhaustively searching (including retrieval and first-pass screening) all publication types across both categories of literature for information on a single methods-related topic was too burdensome to be feasible. The following proposed principle follows from the need to delimit a manageable set of literature for the review.

Principle #1:

Considering the broad universe of potentially relevant literature, we propose that an important objective early in the identification and selection stage is to delimit a manageable set of methods-relevant publications in accordance with the objectives of the methods overview.

Strategy #1:

To limit the set of methods-relevant publications that must be managed in the selection process, reviewers have the option to initially review only the methods literature, and exclude the methods-relevant sections of empirical study reports, provided this aligns with the review’s particular objectives.

We propose that reviewers are justified in choosing to select only the methods literature when the objective is to map out the range of recognized concepts relevant to a methods topic, to summarize the most authoritative or influential definitions or meanings for methods-related concepts, or to demonstrate a problematic lack of clarity regarding a widely established methods-related concept and potentially make recommendations for a preferred approach to the methods topic in question. For example, in the case of the methods overview on sampling [ 18 ], the primary aim was to define areas lacking in clarity for multiple widely established sampling-related topics. In the review on intention-to-treat in the context of missing outcome data [ 17 ], the authors identified a lack of clarity based on multiple inconsistent definitions in the literature and went on to recommend separating the issue of how to handle missing outcome data from the issue of whether an intention-to-treat analysis can be claimed.

In contrast to strategy #1, it may be appropriate to select the methods-relevant sections of empirical study reports when the objective is to illustrate how a methods concept is operationalized in research practice or reported by authors. For example, one could review all the publications in 2 years’ worth of issues of five high-impact field-related journals to answer questions about how researchers describe implementing a particular method or approach, or to quantify how consistently they define or report using it. Such reviews are often used to highlight gaps in the reporting practices regarding specific methods, which may be used to justify items to address in reporting guidelines (for example, [ 14 – 16 ]).

It is worth recognizing that other authors have advocated broader positions regarding the scope of literature to be considered in a review, expanding on our perspective. Suri [ 10 ] (who, like us, emphasizes how different sampling strategies are suitable for different literature synthesis objectives) has, for example, described a two-stage literature sampling procedure (pp. 96–97). First, reviewers use an initial approach to conduct a broad overview of the field—for reviews of methods topics, this would entail an initial review of the research methods literature. This is followed by a second more focused stage in which practical examples are purposefully selected—for methods reviews, this would involve sampling the empirical literature to illustrate key themes and variations. While this approach is seductive in its capacity to generate more in depth and interpretive analytic findings, some reviewers may consider it too resource-intensive to include the second step no matter how selective the purposeful sampling. In the overview on sampling where we stopped after the first stage [ 18 ], we discussed our selective focus on the methods literature as a limitation that left opportunities for further analysis of the literature. We explicitly recommended, for example, that theoretical sampling was a topic for which a future review of the methods sections of empirical reports was justified to answer specific questions identified in the primary review.

Ultimately, reviewers must make pragmatic decisions that balance resource considerations, combined with informed predictions about the depth and complexity of literature available on their topic, with the stated objectives of their review. The remaining principles and strategies apply primarily to overviews that include the methods literature, although some aspects may be relevant to reviews that include empirical study reports.

Searching beyond standard bibliographic databases

An important reality affecting identification and selection in overviews of the methods literature is the increased likelihood for relevant publications to be located in sources other than journal articles (which is usually not the case for overviews of empirical research, where journal articles generally represent the primary publication type). In the overview on sampling [ 18 ], out of 41 full-text publications retrieved and reviewed, only 4 were journal articles, while 37 were books or book chapters. Since many books and book chapters did not exist electronically, their full text had to be physically retrieved in hardcopy, while 11 publications were retrievable only through interlibrary loan or purchase request. The tasks associated with such retrieval are substantially more time-consuming than electronic retrieval. Since a substantial proportion of methods-related guidance may be located in publication types that are less comprehensively indexed in standard bibliographic databases, identification and retrieval thus become complicated processes.

Principle #2:

Considering that important sources of methods guidance can be located in non-journal publication types (e.g., books, book chapters) that tend to be poorly indexed in standard bibliographic databases, it is important to consider alternative search methods for identifying relevant publications to be further screened for inclusion.

Strategy #2:

To identify books, book chapters, and other non-journal publication types not thoroughly indexed in standard bibliographic databases, reviewers may choose to consult one or more of the following less standard sources: Google Scholar, publisher web sites, or expert opinion.

In the case of the overview on sampling in qualitative research [ 18 ], Google Scholar had two advantages over other standard bibliographic databases: it indexes and returns records of books and book chapters likely to contain guidance on qualitative research methods topics; and it has been validated as providing higher citation counts than ISI Web of Science (a producer of numerous bibliographic databases accessible through institutional subscription) for several non-biomedical disciplines including the social sciences where qualitative research methods are prominently used [ 19 – 21 ]. While we identified numerous useful publications by consulting experts, the author publication lists generated through Google Scholar searches were uniquely useful to identify more recent editions of methods books identified by experts.

Searching without relevant metadata

Determining what publications to select for inclusion in the overview on sampling [ 18 ] could only rarely be accomplished by reviewing the publication’s metadata. This was because for the many books and other non-journal type publications we identified as possibly relevant, the potential content of interest would be located in only a subsection of the publication. In this common scenario for reviews of the methods literature (as opposed to methods overviews that include empirical study reports), reviewers will often be unable to employ standard title, abstract, and keyword database searching or screening as a means for selecting publications.

Principle #3:

Considering that the presence of information about the topic of interest may not be indicated in the metadata for books and similar publication types, it is important to consider other means of identifying potentially useful publications for further screening.

Strategy #3:

One approach to identifying potentially useful books and similar publication types is to consider what classes of such publications (e.g., all methods manuals for a certain research approach) are likely to contain relevant content, then identify, retrieve, and review the full text of corresponding publications to determine whether they contain information on the topic of interest.

In the example of the overview on sampling in qualitative research [ 18 ], the topic of interest (sampling) was one of numerous topics covered in the general qualitative research methods manuals. Consequently, examples from this class of publications first had to be identified for retrieval according to non-keyword-dependent criteria. Thus, all methods manuals within the three research traditions reviewed (grounded theory, phenomenology, and case study) that might contain discussion of sampling were sought through Google Scholar and expert opinion, their full text obtained, and hand-searched for relevant content to determine eligibility. We used tables of contents and index sections of books to aid this hand searching.

Purposefully selecting literature on conceptual grounds

A final consideration in methods overviews relates to the type of analysis used to generate the review findings. Unlike quantitative systematic reviews where reviewers aim for accurate or unbiased quantitative estimates—something that requires identifying and selecting the literature exhaustively to obtain all relevant data available (i.e., a complete sample)—in methods overviews, reviewers must describe and interpret the relevant literature in qualitative terms to achieve review objectives. In other words, the aim in methods overviews is to seek coverage of the qualitative concepts relevant to the methods topic at hand. For example, in the overview of sampling in qualitative research [ 18 ], achieving review objectives entailed providing conceptual coverage of eight sampling-related topics that emerged as key domains. The following principle recognizes that literature sampling should therefore support generating qualitative conceptual data as the input to analysis.

Principle #4:

Since the analytic findings of a systematic methods overview are generated through qualitative description and interpretation of the literature on a specified topic, selection of the literature should be guided by a purposeful strategy designed to achieve adequate conceptual coverage (i.e., representing an appropriate degree of variation in relevant ideas) of the topic according to objectives of the review.

Strategy #4:

One strategy for choosing the purposeful approach to use in selecting the literature according to the review objectives is to consider whether those objectives imply exploring concepts either at a broad overview level, in which case combining maximum variation selection with a strategy that limits yield (e.g., critical case, politically important, or sampling for influence—described below) may be appropriate; or in depth, in which case purposeful approaches aimed at revealing innovative cases will likely be necessary.

In the methods overview on sampling, the implied scope was broad since we set out to review publications on sampling across three divergent qualitative research traditions—grounded theory, phenomenology, and case study—to facilitate making informative conceptual comparisons. Such an approach would be analogous to maximum variation sampling.

At the same time, the purpose of that review was to critically interrogate the clarity, consistency, and comprehensiveness of literature from these traditions that was “most likely to have widely influenced students’ and researchers’ ideas about sampling” (p. 1774) [ 18 ]. In other words, we explicitly set out to review and critique the most established and influential (and therefore dominant) literature, since this represents a common basis of knowledge among students and researchers seeking understanding or practical guidance on sampling in qualitative research. To achieve this objective, we purposefully sampled publications according to the criterion of influence , which we operationalized as how often an author or publication has been referenced in print or informal discourse. This second sampling approach also limited the literature we needed to consider within our broad scope review to a manageable amount.

To operationalize this strategy of sampling for influence , we sought to identify both the most influential authors within a qualitative research tradition (all of whose citations were subsequently screened) and the most influential publications on the topic of interest by non-influential authors. This involved a flexible approach that combined multiple indicators of influence to avoid the dilemma that any single indicator might provide inadequate coverage. These indicators included bibliometric data (h-index for author influence [ 22 ]; number of cites for publication influence), expert opinion, and cross-references in the literature (i.e., snowball sampling). As a final selection criterion, a publication was included only if it made an original contribution in terms of novel guidance regarding sampling or a related concept; thus, purely secondary sources were excluded. Publish or Perish software (Anne-Wil Harzing; available at http://www.harzing.com/resources/publish-or-perish ) was used to generate bibliometric data via the Google Scholar database. Figure  1 illustrates how identification and selection in the methods overview on sampling was a multi-faceted and iterative process. The authors selected as influential, and the publications selected for inclusion or exclusion are listed in Additional file 1 (Matrices 1, 2a, 2b).

Literature identification and selection process used in the methods overview on sampling [ 18 ]

In summary, the strategies of seeking maximum variation and sampling for influence were employed in the sampling overview to meet the specific review objectives described. Reviewers will need to consider the full range of purposeful literature sampling approaches at their disposal in deciding what best matches the specific aims of their own reviews. Suri [ 10 ] has recently retooled Patton’s well-known typology of purposeful sampling strategies (originally intended for primary research) for application to literature synthesis, providing a useful resource in this respect.

Data abstraction

The purpose of data abstraction in rigorous literature reviews is to locate and record all data relevant to the topic of interest from the full text of included publications, making them available for subsequent analysis. Conventionally, a data abstraction form—consisting of numerous distinct conceptually defined fields to which corresponding information from the source publication is recorded—is developed and employed. There are several challenges, however, to the processes of developing the abstraction form and abstracting the data itself when conducting methods overviews, which we address here. Some of these problems and their solutions may be familiar to those who have conducted qualitative literature syntheses, which are similarly conceptual.

Iteratively defining conceptual information to abstract

In the overview on sampling [ 18 ], while we surveyed multiple sources beforehand to develop a list of concepts relevant for abstraction (e.g., purposeful sampling strategies, saturation, sample size), there was no way for us to anticipate some concepts prior to encountering them in the review process. Indeed, in many cases, reviewers are unable to determine the complete set of methods-related concepts that will be the focus of the final review a priori without having systematically reviewed the publications to be included. Thus, defining what information to abstract beforehand may not be feasible.

Principle #5:

Considering the potential impracticality of defining a complete set of relevant methods-related concepts from a body of literature one has not yet systematically read, selecting and defining fields for data abstraction must often be undertaken iteratively. Thus, concepts to be abstracted can be expected to grow and change as data abstraction proceeds.

Strategy #5:

Reviewers can develop an initial form or set of concepts for abstraction purposes according to standard methods (e.g., incorporating expert feedback, pilot testing) and remain attentive to the need to iteratively revise it as concepts are added or modified during the review. Reviewers should document revisions and return to re-abstract data from previously abstracted publications as the new data requirements are determined.

In the sampling overview [ 18 ], we developed and maintained the abstraction form in Microsoft Word. We derived the initial set of abstraction fields from our own knowledge of relevant sampling-related concepts, consultation with local experts, and reviewing a pilot sample of publications. Since the publications in this review included a large proportion of books, the abstraction process often began by flagging the broad sections within a publication containing topic-relevant information for detailed review to identify text to abstract. When reviewing flagged text, the reviewer occasionally encountered an unanticipated concept significant enough to warrant being added as a new field to the abstraction form. For example, a field was added to capture how authors described the timing of sampling decisions, whether before (a priori) or after (ongoing) starting data collection, or whether this was unclear. In these cases, we systematically documented the modification to the form and returned to previously abstracted publications to abstract any information that might be relevant to the new field.

The logic of this strategy is analogous to the logic used in a form of research synthesis called best fit framework synthesis (BFFS) [ 23 – 25 ]. In that method, reviewers initially code evidence using an a priori framework they have selected. When evidence cannot be accommodated by the selected framework, reviewers then develop new themes or concepts from which they construct a new expanded framework. Both the strategy proposed and the BFFS approach to research synthesis are notable for their rigorous and transparent means to adapt a final set of concepts to the content under review.

Accounting for inconsistent terminology

An important complication affecting the abstraction process in methods overviews is that the language used by authors to describe methods-related concepts can easily vary across publications. For example, authors from different qualitative research traditions often use different terms for similar methods-related concepts. Furthermore, as we found in the sampling overview [ 18 ], there may be cases where no identifiable term, phrase, or label for a methods-related concept is used at all, and a description of it is given instead. This can make searching the text for relevant concepts based on keywords unreliable.

Principle #6:

Since accepted terms may not be used consistently to refer to methods concepts, it is necessary to rely on the definitions for concepts, rather than keywords, to identify relevant information in the publication to abstract.

Strategy #6:

An effective means to systematically identify relevant information is to develop and iteratively adjust written definitions for key concepts (corresponding to abstraction fields) that are consistent with and as inclusive of as much of the literature reviewed as possible. Reviewers then seek information that matches these definitions (rather than keywords) when scanning a publication for relevant data to abstract.

In the abstraction process for the sampling overview [ 18 ], we noted the several concepts of interest to the review for which abstraction by keyword was particularly problematic due to inconsistent terminology across publications: sampling , purposeful sampling , sampling strategy , and saturation (for examples, see Additional file 1 , Matrices 3a, 3b, 4). We iteratively developed definitions for these concepts by abstracting text from publications that either provided an explicit definition or from which an implicit definition could be derived, which was recorded in fields dedicated to the concept’s definition. Using a method of constant comparison, we used text from definition fields to inform and modify a centrally maintained definition of the corresponding concept to optimize its fit and inclusiveness with the literature reviewed. Table  1 shows, as an example, the final definition constructed in this way for one of the central concepts of the review, qualitative sampling .

We applied iteratively developed definitions when making decisions about what specific text to abstract for an existing field, which allowed us to abstract concept-relevant data even if no recognized keyword was used. For example, this was the case for the sampling-related concept, saturation , where the relevant text available for abstraction in one publication [ 26 ]—“to continue to collect data until nothing new was being observed or recorded, no matter how long that takes”—was not accompanied by any term or label whatsoever.

This comparative analytic strategy (and our approach to analysis more broadly as described in strategy #7, below) is analogous to the process of reciprocal translation —a technique first introduced for meta-ethnography by Noblit and Hare [ 27 ] that has since been recognized as a common element in a variety of qualitative metasynthesis approaches [ 28 ]. Reciprocal translation, taken broadly, involves making sense of a study’s findings in terms of the findings of the other studies included in the review. In practice, it has been operationalized in different ways. Melendez-Torres and colleagues developed a typology from their review of the metasynthesis literature, describing four overlapping categories of specific operations undertaken in reciprocal translation: visual representation, key paper integration, data reduction and thematic extraction, and line-by-line coding [ 28 ]. The approaches suggested in both strategies #6 and #7, with their emphasis on constant comparison, appear to fall within the line-by-line coding category.

Generating credible and verifiable analytic interpretations

The analysis in a systematic methods overview must support its more general objective, which we suggested above is often to offer clarity and enhance collective understanding regarding a chosen methods topic. In our experience, this involves describing and interpreting the relevant literature in qualitative terms. Furthermore, any interpretative analysis required may entail reaching different levels of abstraction, depending on the more specific objectives of the review. For example, in the overview on sampling [ 18 ], we aimed to produce a comparative analysis of how multiple sampling-related topics were treated differently within and among different qualitative research traditions. To promote credibility of the review, however, not only should one seek a qualitative analytic approach that facilitates reaching varying levels of abstraction but that approach must also ensure that abstract interpretations are supported and justified by the source data and not solely the product of the analyst’s speculative thinking.

Principle #7:

Considering the qualitative nature of the analysis required in systematic methods overviews, it is important to select an analytic method whose interpretations can be verified as being consistent with the literature selected, regardless of the level of abstraction reached.

Strategy #7:

We suggest employing the constant comparative method of analysis [ 29 ] because it supports developing and verifying analytic links to the source data throughout progressively interpretive or abstract levels. In applying this approach, we advise a rigorous approach, documenting how supportive quotes or references to the original texts are carried forward in the successive steps of analysis to allow for easy verification.

The analytic approach used in the methods overview on sampling [ 18 ] comprised four explicit steps, progressing in level of abstraction—data abstraction, matrices, narrative summaries, and final analytic conclusions (Fig.  2 ). While we have positioned data abstraction as the second stage of the generic review process (prior to Analysis), above, we also considered it as an initial step of analysis in the sampling overview for several reasons. First, it involved a process of constant comparisons and iterative decision-making about the fields to add or define during development and modification of the abstraction form, through which we established the range of concepts to be addressed in the review. At the same time, abstraction involved continuous analytic decisions about what textual quotes (ranging in size from short phrases to numerous paragraphs) to record in the fields thus created. This constant comparative process was analogous to open coding in which textual data from publications was compared to conceptual fields (equivalent to codes) or to other instances of data previously abstracted when constructing definitions to optimize their fit with the overall literature as described in strategy #6. Finally, in the data abstraction step, we also recorded our first interpretive thoughts in dedicated fields, providing initial material for the more abstract analytic steps.

Summary of progressive steps of analysis used in the methods overview on sampling [ 18 ]

In the second step of the analysis, we constructed topic-specific matrices , or tables, by copying relevant quotes from abstraction forms into the appropriate cells of matrices (for the complete set of analytic matrices developed in the sampling review, see Additional file 1 (matrices 3 to 10)). Each matrix ranged from one to five pages; row headings, nested three-deep, identified the methodological tradition, author, and publication, respectively; and column headings identified the concepts, which corresponded to abstraction fields. Matrices thus allowed us to make further comparisons across methodological traditions, and between authors within a tradition. In the third step of analysis, we recorded our comparative observations as narrative summaries , in which we used illustrative quotes more sparingly. In the final step, we developed analytic conclusions based on the narrative summaries about the sampling-related concepts within each methodological tradition for which clarity, consistency, or comprehensiveness of the available guidance appeared to be lacking. Higher levels of analysis thus built logically from the lower levels, enabling us to easily verify analytic conclusions by tracing the support for claims by comparing the original text of publications reviewed.

Integrative versus interpretive methods overviews

The analytic product of systematic methods overviews is comparable to qualitative evidence syntheses, since both involve describing and interpreting the relevant literature in qualitative terms. Most qualitative synthesis approaches strive to produce new conceptual understandings that vary in level of interpretation. Dixon-Woods and colleagues [ 30 ] elaborate on a useful distinction, originating from Noblit and Hare [ 27 ], between integrative and interpretive reviews. Integrative reviews focus on summarizing available primary data and involve using largely secure and well defined concepts to do so; definitions are used from an early stage to specify categories for abstraction (or coding) of data, which in turn supports their aggregation; they do not seek as their primary focus to develop or specify new concepts, although they may achieve some theoretical or interpretive functions. For interpretive reviews, meanwhile, the main focus is to develop new concepts and theories that integrate them, with the implication that the concepts developed become fully defined towards the end of the analysis. These two forms are not completely distinct, and “every integrative synthesis will include elements of interpretation, and every interpretive synthesis will include elements of aggregation of data” [ 30 ].

The example methods overview on sampling [ 18 ] could be classified as predominantly integrative because its primary goal was to aggregate influential authors’ ideas on sampling-related concepts; there were also, however, elements of interpretive synthesis since it aimed to develop new ideas about where clarity in guidance on certain sampling-related topics is lacking, and definitions for some concepts were flexible and not fixed until late in the review. We suggest that most systematic methods overviews will be classifiable as predominantly integrative (aggregative). Nevertheless, more highly interpretive methods overviews are also quite possible—for example, when the review objective is to provide a highly critical analysis for the purpose of generating new methodological guidance. In such cases, reviewers may need to sample more deeply (see strategy #4), specifically by selecting empirical research reports (i.e., to go beyond dominant or influential ideas in the methods literature) that are likely to feature innovations or instructive lessons in employing a given method.

In this paper, we have outlined tentative guidance in the form of seven principles and strategies on how to conduct systematic methods overviews, a review type in which methods-relevant literature is systematically analyzed with the aim of offering clarity and enhancing collective understanding regarding a specific methods topic. Our proposals include strategies for delimiting the set of publications to consider, searching beyond standard bibliographic databases, searching without the availability of relevant metadata, selecting publications on purposeful conceptual grounds, defining concepts and other information to abstract iteratively, accounting for inconsistent terminology, and generating credible and verifiable analytic interpretations. We hope the suggestions proposed will be useful to others undertaking reviews on methods topics in future.

As far as we are aware, this is the first published source of concrete guidance for conducting this type of review. It is important to note that our primary objective was to initiate methodological discussion by stimulating reflection on what rigorous methods for this type of review should look like, leaving the development of more complete guidance to future work. While derived from the experience of reviewing a single qualitative methods topic, we believe the principles and strategies provided are generalizable to overviews of both qualitative and quantitative methods topics alike. However, it is expected that additional challenges and insights for conducting such reviews have yet to be defined. Thus, we propose that next steps for developing more definitive guidance should involve an attempt to collect and integrate other reviewers’ perspectives and experiences in conducting systematic methods overviews on a broad range of qualitative and quantitative methods topics. Formalized guidance and standards would improve the quality of future methods overviews, something we believe has important implications for advancing qualitative and quantitative methodology. When undertaken to a high standard, rigorous critical evaluations of the available methods guidance have significant potential to make implicit controversies explicit, and improve the clarity and precision of our understandings of problematic qualitative or quantitative methods issues.

A review process central to most types of rigorous reviews of empirical studies, which we did not explicitly address in a separate review step above, is quality appraisal . The reason we have not treated this as a separate step stems from the different objectives of the primary publications included in overviews of the methods literature (i.e., providing methodological guidance) compared to the primary publications included in the other established review types (i.e., reporting findings from single empirical studies). This is not to say that appraising quality of the methods literature is not an important concern for systematic methods overviews. Rather, appraisal is much more integral to (and difficult to separate from) the analysis step, in which we advocate appraising clarity, consistency, and comprehensiveness—the quality appraisal criteria that we suggest are appropriate for the methods literature. As a second important difference regarding appraisal, we currently advocate appraising the aforementioned aspects at the level of the literature in aggregate rather than at the level of individual publications. One reason for this is that methods guidance from individual publications generally builds on previous literature, and thus we feel that ahistorical judgments about comprehensiveness of single publications lack relevance and utility. Additionally, while different methods authors may express themselves less clearly than others, their guidance can nonetheless be highly influential and useful, and should therefore not be downgraded or ignored based on considerations of clarity—which raises questions about the alternative uses that quality appraisals of individual publications might have. Finally, legitimate variability in the perspectives that methods authors wish to emphasize, and the levels of generality at which they write about methods, makes critiquing individual publications based on the criterion of clarity a complex and potentially problematic endeavor that is beyond the scope of this paper to address. By appraising the current state of the literature at a holistic level, reviewers stand to identify important gaps in understanding that represent valuable opportunities for further methodological development.

To summarize, the principles and strategies provided here may be useful to those seeking to undertake their own systematic methods overview. Additional work is needed, however, to establish guidance that is comprehensive by comparing the experiences from conducting a variety of methods overviews on a range of methods topics. Efforts that further advance standards for systematic methods overviews have the potential to promote high-quality critical evaluations that produce conceptually clear and unified understandings of problematic methods topics, thereby accelerating the advance of research methodology.

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The systematic methods overview used as a worked example in this article (Gentles SJ, Charles C, Ploeg J, McKibbon KA: Sampling in qualitative research: insights from an overview of the methods literature. The Qual Rep 2015, 20(11):1772-1789) is available from http://nsuworks.nova.edu/tqr/vol20/iss11/5 .

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SJG wrote the first draft of this article, with CC contributing to drafting. All authors contributed to revising the manuscript. All authors except CC (deceased) approved the final draft. SJG, CC, KAB, and JP were involved in developing methods for the systematic methods overview on sampling.

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Gentles, S.J., Charles, C., Nicholas, D.B. et al. Reviewing the research methods literature: principles and strategies illustrated by a systematic overview of sampling in qualitative research. Syst Rev 5 , 172 (2016). https://doi.org/10.1186/s13643-016-0343-0

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The effectiveness, implementation, and experiences of peer support approaches for mental health: a systematic umbrella review

  • Ruth E. Cooper 1   na1 ,
  • Katherine R. K. Saunders 1   na1 ,
  • Anna Greenburgh 2 ,
  • Prisha Shah 6 ,
  • Rebecca Appleton 2 ,
  • Karen Machin 6 ,
  • Tamar Jeynes 6 ,
  • Phoebe Barnett 2 , 3 , 4 ,
  • Sophie M. Allan 2 , 5 ,
  • Jessica Griffiths 1 ,
  • Ruth Stuart 1 ,
  • Lizzie Mitchell 6 ,
  • Beverley Chipp 6 ,
  • Stephen Jeffreys 6 ,
  • Brynmor Lloyd-Evans 2 ,
  • Alan Simpson 1 , 7 &
  • Sonia Johnson 2 , 8  

BMC Medicine volume  22 , Article number:  72 ( 2024 ) Cite this article

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Peer support for mental health is recommended across international policy guidance and provision. Our systematic umbrella review summarises evidence on the effectiveness, implementation, and experiences of paid peer support approaches for mental health.

We searched MEDLINE, EMBASE, PsycINFO, The Campbell Collaboration, and The Cochrane Database of Systematic Reviews (2012–2022) for reviews of paid peer support interventions for mental health. The AMSTAR2 assessed quality. Results were synthesised narratively, with implementation reported using the CFIR (Consolidated Framework for Implementation Research). The protocol was registered with PROSPERO (registration number: CRD42022362099).

We included 35 reviews (426 primary studies, n  = 95–40,927 participants): systematic reviews with ( n  = 13) or without ( n  = 13) meta-analysis, or with qualitative synthesis ( n  = 3), scoping reviews ( n  = 6). Most reviews were low or critically low (97%) quality, one review was high quality. Effectiveness was investigated in 23 reviews. Results were mixed; there was some evidence from meta-analyses that peer support may improve depression symptoms (particularly perinatal depression), self-efficacy, and recovery. Factors promoting successful implementation, investigated in 9 reviews, included adequate training and supervision, a recovery-oriented workplace, strong leadership, and a supportive and trusting workplace culture with effective collaboration. Barriers included lack of time, resources and funding, and lack of recognised peer support worker (PSW) certification. Experiences of peer support were explored in 11 reviews, with 3 overarching themes: (i) what the PSW role can bring, including recovery and improved wellbeing for service users and PSWs; (ii) confusion over the PSW role, including role ambiguity and unclear boundaries; and (iii) organisational challenges and impact, including low pay, negative non-peer staff attitudes, and lack of support and training.

Conclusions

Peer support may be effective at improving some clinical outcomes, self-efficacy, and recovery. Certain populations, e.g. perinatal populations, may especially benefit from peer support. Potential strategies to successfully implement PSWs include co-production, clearly defined PSW roles, a receptive hierarchical structure and staff, appropriate PSW and staff training with clinical and/or peer supervision alongside safeguarding. Services could benefit from clear, coproduced, setting specific implementation guidelines for PSW. PSW roles tend to be poorly defined and associations between PSW intervention content and impacts need further investigation. Future research should reflect the priorities of providers/service users involved in peer support.

Peer Review reports

Peer support in mental health care is a recovery-orientated approach delivered by individuals who have lived experience of mental health difficulties (as service users, carers, parents or supporters). Peer support workers (PSWs) are employed to draw on these experiences to support mental health service users or carers of people with mental health conditions [ 1 , 2 ]. As such, PSWs are uniquely positioned to facilitate recovery through empathic engagement with service users and their support networks. The success of peer support is thought to be based in the sharing of lived experiences and mental health knowledge and through interpersonal connection [ 3 , 4 ]. Across diagnoses, peer support may promote recovery through the modelling of coping strategies, and by providing hope and an example of recovery to those dealing with mental health difficulties [ 5 ].

Peer support has been utilised across various populations and types of service, for example in services for early intervention in psychosis [ 6 ], for people with co-occurring substance abuse and mental health difficulties [ 7 ], and in community interventions to reduce mental health inpatient admissions [ 8 ]. The format of peer support varies across services, for example it may involve one-to-one or group sessions, online or face-to-face delivery, unstructured open-ended conversations or more structured manualised support, or activities such as walking groups [ 9 , 10 ]. Peer support may be delivered by trained peer support staff or on a more ad hoc basis among peers [ 11 ]. Peer support for mental health takes place within mental health services in both statutory and voluntary sector settings [ 11 ]. Although PSWs may be paid or unpaid [ 6 , 12 ], paid roles have become increasingly available in mental health care settings [ 13 ]. Professionalising PSW roles as paid demonstrates the value of the role and appropriately rewards work done, should ensure formal training, supervision and management, and may help to clarify the boundaries of the role [ 14 ].

Service user networks and researchers in relevant fields have strongly advocated for provision of peer support [ 14 , 15 ], and peer support is now recognised and recommended across international mental health policy guidance, reflecting an increased understanding of the value of embedding lived experience support in formal mental health services [ 16 , 17 , 18 , 19 , 20 ]. In the UK, peer support is currently being expanded in the NHS [ 16 ].

There have been many reviews of the peer support literature separately evaluating the efficacy, implementation, and experiences of peer support from a variety of different perspectives (e.g. [ 21 , 22 , 23 , 24 ]). Given the numerous and sometimes inconclusive results from existing reviews on this topic, our research group, the NIHR Mental Health Policy Research Unit, agreed with policy makers in England to conduct an umbrella review of peer support to provide clinicians, policy makers and researchers with an overall assessment on the evidence available, comparing results between reviews, while taking the quality of these reviews into account [ 25 , 26 ]. The aim of this systematic umbrella review is to collate, synthesise and summarise the available evidence from published reviews to address the following research questions:

What is the effectiveness (e.g. clinical, social, functional) and cost-effectiveness of paid peer support approaches for mental health?

What influences the implementation of peer support approaches for mental health?

What are the experiences of peer support approaches for mental health (e.g. of acceptability) from the perspective of PSWs, healthcare practitioners, service users, carers?

This umbrella review was conducted by the NIHR Mental Health Policy Research Unit (MHPRU), based at King’s College London and University College London, which delivers evidence to inform government and NHS policy in England, agreeing a programme of rapid research with policymakers.

Study design and protocol

We conducted a systematic umbrella review following guidance from Fusar-Poli et al. [ 27 ] and Cochrane [ 28 ]. The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (see Additional file 1 : Appendix 1 for the PRISMA checklist) [ 29 ]. The protocol was registered with PROSPERO (registration number: CRD42022362099) [ 30 ]. One amendment was made to the protocol after registration. We amended the ‘intervention’ section to state that reviews were excluded if the majority of interventions did not meet eligibility criteria, e.g. because we found that reviews often included paid and unpaid peer support interventions and did not report results separately.

Lived experience researcher involvement

Members of the MHPRU Lived Experience Working Group (LEWG), who collectively have substantial experience of delivering or receiving peer support, contributed extensively to this review, including protocol development, study selection, data extraction, quality appraisal, data synthesis, drafting the manuscript and lived experience commentary, and attending working group meetings.

Eligibility criteria

The eligibility criteria are detailed in full in the protocol [ 30 ]. In summary, we included:

Study designs : Published, peer-reviewed systematic, scoping or realist reviews which synthesised quantitative or qualitative data (narratively or formally using, e.g. a meta-analysis or meta-synthesis) that examined outcomes or experiences relevant to our research questions.

Intervention : We defined peer support as ‘involving a person who has lived experience of mental health condition(s), or caring for those with mental health conditions, being employed to use and draw on their experiences and empathy to support service users who have mental health conditions or carers or parents of people with mental health conditions.’ Eligible peer support approaches were paid, meaning that the PSW was paid for their work, and delivered face-to-face or remotely, for people with mental health conditions or for carers of people with mental health conditions, across any mental healthcare settings. Peer support approaches were ineligible if the PSWs were not in a dedicated peer support role, if they were primarily for physical health, or automated (i.e. peer support ‘bots’ or avatars). We excluded reviews where over 50% of primary studies in the review did not meet eligibility criteria, e.g. if the majority of people delivering the interventions were unpaid.

Population : Children, young people and adults with a mental health condition (including substance use disorders), carers, paid PSWs and mental healthcare practitioners working alongside PSWs. We excluded service users with a primary diagnosis of an organic mental disorder (e.g. dementia), neurodevelopmental disorders, acquired cognitive impairment and adjustment disorders.

Outcome measures : Included reviews reported outcomes or data on at least one of the following peer support related outcomes that addressed our research questions: (i) clinical outcomes, (ii) economic or cost-effectiveness, (iii) recovery outcomes, e.g. hope, empowerment, goal-attainment, quality of life, (iv) social outcomes, (v) implementation outcomes and barriers and facilitators to implementation, (vi) experiences of delivering, receiving or working alongside peer support and (vii) theories of what works for whom in peer support.

Information sources and search strategy

We combined terms for peer support, reviews and mental health conditions using Boolean operators (AND, OR). We searched the following databases: MEDLINE, EMBASE, PsycINFO, The Campbell Collaboration and The Cochrane Database of Systematic Reviews (see Additional file 1 : Appendix 2 for full search strategy). Searches were run from January 2012 to November 2022 as these reviews will include primary research published before 2012 [ 31 ]. There was no time limit for the primary papers in the included reviews. We had no language restrictions.

Selection process

Reviewers (KS, RC, JG, RS, RA, KM, PS, SA) screened titles and abstracts, and subsequently full texts. To ensure consistent application of eligibility criteria all reviewers initially independently screened the same ten titles and abstracts and discussed inclusion/exclusion. The remaining titles and abstracts were then screened. Records were double screened blind by two reviewers at both the title and abstract (94% agreement) and full text (86% agreement) stages. All disagreements were resolved through discussion with the study team.

Data extraction

Data extraction was completed in Microsoft Excel by the review team (RC, KS, KM, PS, JG, RS, PB, RA). The data used in the paper were checked by another member of the review team. The extracted data included basic information about reviews (e.g. number of included studies, number of participants, review type, aim/objectives), basic information about primary studies (e.g. references, designs), search strategy (e.g. databases searched, eligibility criteria), population (e.g. gender, age), peer support approach (e.g. peer support type and description), type of comparator, additional information (e.g. quality appraisal methods, review author conclusions), primary and secondary outcomes of systematic review or qualitative results.

Quality appraisal of included reviews

The quality of included reviews was independently assessed by reviewers (RC, KS, KM, PS, JG, RS, PB, RA) using the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews), a 16-point tool for assessment of the methodological quality of systematic reviews [ 32 ]. We adapted the AMSTAR 2 to apply for scoping reviews and systematic reviews of qualitative data (described in full in Additional file 1 : Appendix 3). The following questions were adapted: (1) PICO criteria, (2) Protocol requirements, (8) Detail of included studies, (9) Risk of Bias requirement. Two reviewers (KS, AG) 100% double-scored reviews blind with any outstanding disagreements resolved through discussion between AG, KS, and RC. Overall ratings for each study were calculated according to guidance [ 32 ], based on 7 critical domains and 6 non-critical domains within the AMSTAR 2 tool. Studies with no or one non-critical weakness and no critical flaws were rated as high quality. Studies with more than one non-critical weakness and no critical weaknesses were rated as moderate quality. Studies with one critical flaw irrespective of non-critical weaknesses were rated as low quality, and those with more than one critical flaw irrespective of non-critical weaknesses were rated as critically low quality. The AMSTAR 2 guidance [ 32 ] states that reviews of critically low quality should not be relied on for comprehensive and accurate summaries of the literature.

Synthesis methods

Rq 1: what is the effectiveness (e.g. clinical, social, functional) and cost-effectiveness of paid peer support approaches for mental health.

Data were tabulated and summarised narratively by two researchers (KS, AG); effectiveness meta-analysis data calculated from two or more studies were tabulated separately from non-meta-analysis effectiveness outcomes. Review outcomes were similar, but not similar enough to combine meaningfully in a meta-analysis. Effect sizes (with 95% CIs and p -values) were reported along with I 2 statistic (with 95% CIs, p -values, χ 2 , and degrees of freedom) where available. We did not tabulate data for subgroup analyses.

RQ 2: What influences the implementation of peer support approaches for mental health?

Outcomes were tabulated according to the main domains in the Consolidated Framework for Implementation Research (CFIR) [ 33 ]. The CFIR provides a comprehensive framework, composed of 5 domains, associated with the effective implementation of interventions [ 33 ]. The 5 domains are as follows: Innovation (the ‘thing’ being implemented); Outer setting (the setting in which the inner setting exists, e.g. hospital system); Inner setting (the setting in which the innovation is implemented, e.g. hospital); Individuals (the roles and characteristics of individuals); Implementation process (the activities and strategies used to implement the innovation) [ 33 ]. Synthesis was conducted using a collaborative process involving one member of the study team (RA) and one lived experience researcher (PS).

RQ 3: What are the experiences of peer support approaches for mental health (e.g. of acceptability) from the perspective of PSWs, healthcare practitioners, service users and carers?

Experiences were synthesised narratively, by three researchers, including two lived experience researchers (TJ, KM, RC) [ 34 ]. Themes from reviews which were identified as addressing research question 3 were extracted and similar themes across the reviews were grouped together. Each group was accounted for using an existing theme from one or more of the reviews or if this was not possible a new theme was developed. Three overarching themes were identified through iterative scrutiny of the data and discussion between TJ, KM, and RC. A summary of the common themes across the reviews, grouped under the three overarching themes, was then developed, including highlighting contrasting findings.

Study selection

The search strategy identified 777 references to be screened (a further 2 papers were identified through other methods); 93 full text articles were assessed for eligibility with 57 excluded (see Additional file 1 : Appendix 4 for reasons for exclusion). Thirty-five reviews (reported in 36 papers) were included (see Fig.  1 ).

figure 1

PRISMA flow diagram [ 29 ]

Characteristics of included reviews

Review characteristics are detailed in Table  1 . Of the 35 included reviews, 13 were systematic reviews with meta-analyses, 13 were systematic reviews without meta-analyses, 3 were systematic reviews with a qualitative synthesis and 6 were scoping reviews. The individual reviews included between 95 and 40,927 participants; 6 reviews did not report the number of participants. For reviews where the population were service users, almost all were categorised as adults with mental health problems. Thirteen reviews specified that participants had severe mental illness (SMI) diagnoses [ 1 , 21 , 22 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ], six reviews explicitly included studies with participants accessing mental health services [ 22 , 37 , 38 , 43 , 45 ] [ 46 ], three reviews were conducted in perinatal populations [ 47 , 48 , 49 ], three reviews included participants with any/common mental health conditions [ 50 , 51 , 52 ], four reviews included participants with substance use disorders [ 1 , 38 , 53 , 54 ], two reviews included participants with eating disorders [ 55 , 56 ], one included people experiencing suicidality [ 57 ] and one included articles on peer support for crisis management [ 58 ]. The samples in the remaining reviews were PSWs and various stakeholders (e.g. non-peer staff, service users) [ 23 , 24 , 34 , 59 , 60 , 61 , 62 , 63 , 64 ]. Most reviews included interventions involving any form of peer support, individual, group or combined, although three reviews looked at group peer support alone [ 35 , 43 , 49 ], and three reviews looked at individual peer support alone [ 1 , 40 , 45 ]. Reviews looked at peer support delivered in-person, online or over the phone, and surveyed a range of approaches including both structured and unstructured peer support (see Table  1 ). The reviews included 426 primary studies. We assessed study overlap; most primary studies ( n  = 300) were only included in one review; however, many primary studies were included twice ( n  = 72), three times ( n  = 18) to a maximum of nine times ( n  = 1) (see Additional file 1 : Appendix 5 for overlapping studies). Only 1 review reported that people with lived experience were involved in the review [ 57 ]. Only 2 reviews assessed certainty of evidence (using GRADE) [ 21 , 22 ].

Most reviews were appraised as low or critically low (97%) quality and one review was appraised as high quality. The most common weaknesses were in critical domains concerning registering protocols before commencement of the review (21 studies), justification of excluding individual studies (28 studies) and considering risk of bias when interpreting results (13 studies). Reviews without meta-analyses were not scored in the critical domains assessing meta-analytical method or publication bias. There were 13 studies with meta-analyses assessed in these two domains: two of these exhibited one critical weakness and two exhibited two critical weaknesses. As scoping reviews are intended to provide overviews of existing literature regardless of risk of bias [ 65 ], scoping reviews were not scored in the critical domain concerning risk of bias assessment techniques (see Additional file 1 : Appendix 3 for adjustments to quality appraisal for scoping and qualitative reviews). Of the 29 reviews that were eligible to be scored in this domain, 10 exhibited a critical weakness. The review eliciting high confidence was a Cochrane review [ 21 ]. No reviews were rated as moderate. AMSTAR 2 ratings are detailed in Table  1 and in full in Additional file 1 : Appendix 3.

Results of synthesis

Rq1: what is the effectiveness (e.g. clinical, social, functional) and cost-effectiveness of paid peer support approaches for mental health.

Effectiveness outcomes were reported in 23 reviews (66% of total). A wide variety of clinical, recovery and psychosocial effectiveness outcomes were reported across both meta-analysis [ 21 , 22 , 37 , 40 , 41 , 42 , 43 , 44 , 45 , 47 , 48 , 51 , 52 ] and narrative results [ 1 , 21 , 22 , 35 , 36 , 37 , 38 , 40 , 41 , 42 , 43 , 44 , 48 , 50 , 51 , 53 , 54 , 56 , 57 , 58 , 60 ]. Comparator groups also varied across the primary studies included in the reviews, including Treatment as Usual (TaU), active controls (e.g. a comparable standard treatment) and waitlist control groups.

All outcomes except for one (family or carer use of formal community support services; [ 44 ]) were service user outcomes, rather than carer, staff or PSW outcomes. Outcomes from systematic reviews with meta-analysis are reported in Tables  2 , 3 and 4 . Effectiveness results from reviews not including meta-analysis are summarised at the end of this section and reported in full in Additional file 1 : Appendix 6. Evidence was heterogenous across all outcomes and reviews, with many analyses reporting no effect. In the meta-analysis results, there was often notable heterogeneity. There was limited data on cost and cost-effectiveness, but the evidence available from three systematic reviews without meta-analyses (See Additional file 1 : Appendix 6) suggested that peer support interventions were low cost and cost-saving [ 38 , 48 , 50 ].

Results from meta-analyses

Clinical outcomes.

For depression outcomes, evidence from two reviews with meta-analyses suggested that peer support is effective in improving perinatal depression [ 47 , 48 ]. Three reviews of peer support for adults and adolescents with mental health problems including those with SMI diagnoses reported no effect on depression post-intervention [ 22 , 35 , 43 ], where two of these reviews looked at group-based peer support alone [ 35 , 43 ]. Two of these reviews reported follow-up results; one review of group peer support for adults with any mental health condition continued to find no effect at 3–6 months follow-up [ 35 ], while the other involving adults with SMI reported improvements in depression and anxiety at 6 months follow-up, despite reporting no effect at post-intervention [ 22 ]. One review [ 52 ] measured clinical recovery in adults with any mental health diagnosis, reporting improvements post-intervention and at 6–9-month follow-up, but no improvement at 12–18-month follow-up.

Most evidence regarding mental health symptom severity among adults and adolescents with mental health diagnoses or who were using mental health services suggested no effect [ 22 , 35 , 41 , 42 , 43 , 44 ], other than for perinatal depression as previously summarised. One review [ 40 ] of individual peer support for adults with primarily SMI diagnoses reported improvements in symptom severity, while another involving adults with SMI [ 44 ] reported symptom improvements following family-led peer support, but no improvement following individual-led peer support. Results for service use varied depending on the measure, for example, peer support was associated with reduced risk of hospitalisation [ 44 ], including after a follow-up period [ 45 ], but no effect was found regarding length of stay [ 41 , 42 ].

All reviews providing meta-analytic evidence relevant to this question were rated low or critically low quality, except from one high-quality review [ 21 ] which found no effect of peer support on patient activation between 1 and 6 months follow-up (a person’s perceived ability to manage their illness and their approach to healthcare) in adults with schizophrenia diagnoses or similar SMI.

Recovery outcomes

Of the seven reviews with meta-analyses reporting data on overall self-reported recovery, five reported improvements in recovery in adults with mental health diagnoses including SMI [ 22 , 35 , 40 , 44 , 45 ]. Two studies found effects for individual peer support interventions alone [ 40 , 45 ], and one reported an effect for group-based peer support alone [ 35 ]. Only two reviews reported no effect [ 21 , 43 ], where one included studies of adults with SMI in both individual and group-based peer support [ 21 ], and the other involved studies with adults and adolescents with any mental health problem in group-based peer support alone [ 43 ].

Three reviews reported follow-up data showing continued improvements for adults with mental health diagnoses including SMI at follow-ups of 6 months [ 22 ], 3–6 months [ 35 ] and 12–18 months [ 45 ], the former and the latter reviewing individual and group peer support, and the second focussing on group peer support alone. One further review reported no improvements at medium-term follow-up (1–6 months) [ 21 ]. One review of adults with any mental health diagnosis identified improvements in personal recovery post-intervention, but not at 6–9 or 12–18 months follow-up, and found no improvements in functional recovery post-intervention or at 12–18 months follow-up, but did report improvements at 6–9 months follow-up [ 52 ].

All reviews providing meta-analytic evidence for these outcomes were rated as critically low or low quality, except for one [ 21 ] which was rated high quality. Based on evidence from three studies, this latter review [ 21 ] found no effect of peer support on recovery in the medium term for adults with schizophrenia diagnoses or similar SMI.

Psychosocial outcomes

Evidence regarding hope or hopefulness was mixed. Four reviews with meta-analyses suggested that peer support resulted in improvements in adults with SMI [ 22 , 37 , 40 , 44 ], where one of these studies looked at individual peer support alone [ 40 ] and the rest included both individual and group peer support. However, three reviews of studies including SMI and mixed mental health diagnoses samples reported no effect [ 21 , 35 , 43 ], where two of these reviews focussed on group-based peer support alone [ 35 , 43 ]. One study [ 22 ] followed up adults with SMI and those using secondary MH services at 3–6 months and found continued improvements in hope. However, another review investigating longer-term outcomes (over 6 months) in adults with SMI found no effect [ 21 ].

Improvements in empowerment were evidenced by two reviews with meta-analyses [ 40 , 51 ] of studies involving adults with any mental health diagnosis including SMI. No effects were reported in four reviews [ 22 , 35 , 43 , 44 ]. One of the meta-analyses finding positive effects of peer support on empowerment looked at individual peer support alone [ 40 ], whereas two of the meta-analyses with no effect solely involved group-based peer support [ 35 , 43 ]. Three studies reported follow-up data. Two showed improvements at 6 months in adults with SMI [ 22 ] and at 6–12 months follow-up among adults using mental health services with any diagnoses [ 45 ]. The other showed no improvements from group-based peer support only in adults with mental health diagnoses including SMI between 3 weeks and 6 months follow-up [ 35 ].

Quality of life reportedly improved in two reviews with meta-analyses [ 37 , 44 ] of studies involving adults with SMI, while there was no evidence of improvement in one other with an SMI sample [ 22 ]. The two studies which reported follow-up data continued to find no effect [ 22 , 45 ].

There were improvements in self-efficacy in adults with any mental health problem in all three reviews with meta-analyses reporting this outcome [ 43 , 44 , 51 ]. Decreases in self-stigma and stigma-related stress in adults and adolescents with any mental health problem were found by one review with meta-analysis of group-based peer support [ 43 ]. There was no evidence for peer support improving satisfaction with care [ 22 , 41 , 42 , 44 , 45 ] or relational outcomes (including social support and network) and building relationships (both personally and with staff) [ 41 , 42 , 44 , 45 ].

All reviews providing meta-analytic evidence for these outcomes were rated as critically low or low quality, except one high-quality review [ 21 ] which found no effect of peer support on hope in adults with schizophrenia diagnoses or similar SMI in the medium or long term.

Summary of results from systematic reviews without meta-analysis

Effectiveness results from systematic reviews without meta-analyses are tabulated in full in Additional file 1 : Appendix 6. These reviews presented mixed results pertaining to clinical outcomes including depression, anxiety, eating disorder pathology, and psychosis. However, two scoping reviews reported evidence of peer support in improving suicidal ideation [ 57 , 58 ]. Evidence was deemed inconclusive regarding the impact of peer support on indicators of service use, where three reviews failed to find evidence for peer support [ 21 , 22 , 41 , 42 ], three reported mixed results [ 1 , 38 , 54 ], and one found evidence for improvements associated with peer support [ 36 ]. More consistent evidence was found indicating peer support improves recovery outcomes [ 1 , 36 , 38 , 40 , 44 , 53 ]. For most psychosocial outcomes, systematic reviews presented mixed evidence, for example different effects were found by one high-quality review for empowerment, hope and self-efficacy, depending on what measures were used [ 21 ]. Despite mixed effects being reported overall for the impact of peer support on satisfaction with care, one review cited some possible associated moderating factors such as the number of conversations had between peer supporter and recipient [ 48 ]. Evidence was marginally less mixed for relational outcomes, such as strength of interpersonal relationships and sense of community, as the majority (three) of relevant reviews found evidence in support of peer support [ 21 , 38 , 58 ], although one review found this did not persist long term [ 21 ].

Implementation was investigated in nine reviews [ 23 , 24 , 36 , 39 , 46 , 50 , 55 , 59 , 62 ]. Table 5 shows an overview of implementation outcomes by CFIR domain [ 33 ]. All reviews relevant to this research question were rated as critically low quality based on the adapted AMSTAR 2 rating scale (see Additional file 1 : Appendix 3).

Studies reported generally high acceptability and feasibility of PSW-led interventions [ 36 , 39 , 46 , 50 ]. When planning a peer-led service, co-producing the design of peer support provision with the community and stakeholders was found to be key [ 59 ].

Outer setting

The existence of national policy and funding provisions for employing and retaining PSWs facilitated PSW-led care [ 39 , 46 , 59 ], as did integration of interventions within existing healthcare systems [ 50 ]. However, barriers included power hierarchies [ 39 ], difficulties incorporating PSWs in medical mental health care models [ 24 , 39 , 46 ], interference of work with welfare benefits [ 62 ] and a lack of recognised PSW certification [ 62 ].

Inner setting

A workplace culture emphasising recovery-orientated practice [ 24 , 59 ], and organisational openness and readiness to employ PSWs [ 39 ], was important. Facilitators included strong leadership and support at the highest level [ 46 ], and flexible and understanding employers, especially in times of crisis [ 59 ]. A key facilitator was a supportive, accepting and trusting workplace culture where PSWs occupy a central position and fit in well with other staff members [ 24 ]. A trusting culture allowed the management of risk in a psychologically safe space [ 59 ]; effective communication and collaboration between PSWs and other workers facilitated this [ 24 ], while stigmatising staff attitudes were a barrier [ 62 ]. It was easier to implement PSWs in a more collaborative and less hierarchical service [ 59 ]. There were practical facilitators and barriers for PSWs also, such as access to desk space or administrative data [ 24 , 46 ], time restraints, high caseloads [ 23 , 24 ] and insufficient funding for PSW role [ 24 , 50 ].

Individuals

The professionalisation and legitimisation of the PSW role was seen as important, with associated performance standards and/or a code of ethics [ 24 ] which was linked to rigorous recruitment practices, ensuring parity in the recruitment of PSWs and other staff [ 46 ]. A further facilitator was high levels of competency among peer-counsellors when delivering interventions and having relevant skills and knowledge, e.g. mental health conditions [ 50 ]. PSWs were often required to have recovered from their mental health difficulties [ 55 ] and be able to use their coping skills and resilience to avoid potential negative impacts on their wellbeing [ 24 ]. PSWs reported a conflicted sense of identity between being a ‘peer’ with experience of mental health problems and a ‘professional’ as a barrier to their work [ 62 ]. The use of champions and implementation leaders to drive the set up and maintenance of PSW interventions was reported as a facilitator [ 46 ], as was staff willingness and ability to work with PSWs and accept them as part of the service [ 24 ].

Implementation process

Studies emphasised the importance of comprehensive training for PSWs delivered both prior to starting work and on an ongoing basis, alongside regular clinical supervision [ 24 , 46 , 50 , 55 ] supporting the management of any problems encountered [ 59 ]. PSW roles should be clearly defined [ 24 , 62 ] and training should also be delivered to other members of staff to help them work effectively with PSWs [ 46 ]. Establishing sustainable models of cost and supervision from the outset was key for the longevity of PSW [ 50 ].

Experiences of both the benefits and challenges of peer support were reported in 11 reviews [ 23 , 34 , 39 , 42 , 46 , 49 , 55 , 60 , 61 , 63 , 64 ] from a range of perspectives: PSWs [ 23 , 34 , 39 , 55 , 61 ], service users [ 39 , 55 , 61 ], non-peer staff [ 61 ], peer support group members [ 49 ], and mixed samples which consisted of combinations of PSWs, service users, non-peer staff, carers, mental health organisations, policy makers and peer programme developers [ 23 , 39 , 42 , 46 , 55 , 60 , 61 , 63 , 64 ]. In one review, it was unclear whose perspective was being presented [ 46 ], although this review only contributed to one theme. All reviews providing evidence for this research question were rated as critically low quality based on the adapted AMSTAR 2 rating scale (see Additional file 1 : Appendix 3). We identified 3 overarching themes: (i) what the PSW role can bring, (ii) confusion over the PSW role and (iii) organisational challenges and impact. Table 6 gives an overview of the overarching themes and subthemes (with more detail in Additional file 1 : Appendix 7). The following provides an overview of each overarching theme from the perspective of the different samples (i.e. PSWs, service users, mixed samples).

What the PSW role can bring

Perspective of psws.

PSWs experienced improved wellness and recovery from working in the role, reporting increased self-esteem, personal growth, and social networks [ 23 , 34 , 55 , 61 ]. They benefited in a variety of ways, e.g. the role provided a route back into employment, improving functioning and social inclusion, and allowed them to learn more about their own mental health [ 23 , 34 ]. PSWs also reported increased self-acceptance as they no longer had to hide their mental health issues [ 34 ]. The role was therefore often reported to be mutually beneficial for PSWs and service users [ 34 , 55 ]. PSWs felt it was important that they were role models for service users, being ‘the evidence of recovery’ [ 34 ]. However, working as a PSW could also have a negative impact on the PSWs’ wellbeing and recovery [ 23 , 34 ]. Reasons for this included the role reminding them of their mental health condition and the ‘sick’ label staying with them [ 23 ].

Perspective of service users

For service users, PSWs could be role models, giving them hope of recovery [ 39 , 55 , 61 ]. PSW support normalised and de-medicalised service user experiences [ 55 ]. Lack of judgement from PSWs reduced feelings of self-stigma for service users [ 55 ]. Service users felt empowered by and valued gaining experiential knowledge from PSWs, perceiving them to be more insightful than non-peer staff, and trusting their services [ 39 ]. Service users also built rapport more easily with PSWs than non-peer staff, feeling they were more approachable and had greater empathy than non-peer staff [ 39 , 61 ]. However, some service users reported that PSWs are not role models and found it challenging to view them as professionals or fully trust their knowledge, due to their lack of training and concerns about their mental health history [ 39 , 61 ].

Perspective of non-peer staff

From working with PSWs, non-peer staff developed increased empathy towards service users and a belief in recovery [ 61 ].

Perspective of peer support group members

Forming relationships in peer support groups and having their experiences validated by others was valuable for recovery [ 49 ]. However, group members could feel isolated when other members’ experiences contrasted with their own [ 49 ].

Perspective of mixed samples

PSWs were perceived to be role models, providing valuable support to service users and giving them hope of recovery [ 60 , 64 ]. Working as a PSW could enable service users to find a role in the community, beyond the identity of being a ‘patient’ [ 61 ]. PSWs could build trust-based pathways to function as a bridge between service users and non-peer staff [ 64 ]. Within teams, working with PSWs could improve recovery-oriented care and PSWs carried out various roles, such as providing psychosocial support, advocating for service users, providing insights based on their lived experiences [ 64 ]. For mental health organisations, PSW roles decreased stigma towards mental health problems and set a positive example [ 61 ]. However, there were fears that the PSWs’ mental health condition could impact the provided support, such as increased PSW absenteeism which could increase non-peer staff caseloads and concerns that service users’ and PSWs’ could experience distress due to exposure to difficult (‘triggering’) content [ 42 , 55 , 60 ]. PSWs experienced pressure due to the perception that they were pioneers, leading to expectations, e.g. failure could reduce future PSW opportunities [ 64 ]. There was also concern that PSWs lacked mental health knowledge, beyond their own experience [ 64 ].

Confusion over the PSW role

A lack of clarity about the PSW job description led PSWs to feel the role was undervalued and tokenistic and meant they felt confused in their role. This impacted their perception of competence which affected their recovery and led to uncertainty in their responsibilities with service users [ 23 , 34 ]. PSWs also found the transition from service user to PSW and knowing where to draw the line between friend and service provider to be challenging [ 23 , 61 ]. Linked to this, their dual identity as a service user and provider could be a source of stress. For example, it meant they could closely connect with service users who had similar difficulties to their own, but this could also be triggering and lead to a recurrence of the PSWs’ own mental health issues [ 34 ]. PSWs expressed varying views on disclosing their recovery story [ 34 , 39 ]. For some, sharing elements of their story was linked to their own personal recovery [ 34 ]. However, other PSWs felt fearful of disclosure, e.g. they were concerned about being labelled ‘mentally ill’ and service users not trusting them [ 39 ].

A lack of clarity on the PSW role could lead service users to view the role as informal, leading to negative perceptions of the PSW services. Perceptions of tokenism of peer support could lead to the content of the PSW intervention ‘feeling irrelevant’ [ 39 ].

PSWs and non-peer staff found the PSW role to be ambiguous, e.g. the role was not clearly defined [ 63 ] and job descriptions were ‘vague’ [ 64 ]. Although this gave flexibility to define the role [ 64 ], it also led to challenges. Some PSWs felt they were expected to develop the role over time and received insufficient training, which hampered service delivery and could result in perceptions that PSWs were tokenistic [ 42 , 63 , 64 ]. Uncertainty about the role also led to a lack of support from non-peer staff [ 63 ]. Relatedly, there was confusion for PSWs over when/with whom to disclose their lived experience [ 63 , 64 ]. Some PSWs felt vulnerable and were reluctant to disclose, but disclosure could build trust with service users, enabled PSWs to be recovery role models, and could educate non-peer staff on alternative views [ 63 , 64 ]. Disclosure was also felt to require discretion when fitting with professional relationships. However, ‘professionalisation’ of PSWs may not challenge the existing boundaries (e.g. traditional hospital-based boundaries which could make it difficult for the sharing of lived experience to be valuable), when challenging these boundaries could change culture [ 63 , 64 ]. The transition for PSWs from patient to staff was challenging, e.g. non-peer staff were concerned about the PSW becoming unwell, making PSWs feel like they are being treated like patients [ 63 , 64 ]. There were issues around boundaries, including whether PSWs should relate to service users as friends or service users [ 63 ].

Organisational challenges and impact

PSWs experienced a lack of support and training for their role, potentially related to unclear job descriptions, and insufficient supervision [ 23 , 34 ]. This meant that PSWs struggled to develop the skills for their roles, including to work with service users with more complex needs than their own experiences [ 23 ]. Although there were some contrasting views, PSWs were concerned that they received low pay which made them feel that they were not valued, and they perceived themselves to be ‘cheap labour’ [ 23 , 34 , 61 ]. Some PSWs felt accepted in their teams however others experienced negative and rejecting non-peer staff attitudes [ 23 , 34 , 61 ]. For example, PSWs reported not being invited to social events and being treated like patients [ 61 ]. Consequently, some PSWs felt excluded, that their roles were tokenistic and experienced self-stigma [ 23 , 34 ]. PSWs as part of the newer recovery model reported challenges around integrating into traditional treatment models, e.g. where doctors spent the least time with service users but held the majority of power and decision making for service users. PSWs were expected to contest the traditional treatment model in support of a recovery focus, e.g. by their presence or in some cases being openly challenging, and this clash between old and new treatment models could lead to friction [ 23 ].

There was a fear that ‘cheap labour’ provided by PSWs may lead to fewer non-peer staff positions [ 61 ].

PSWs often received low pay, which led to role dissatisfaction for PSWs, suggesting the job was tokenistic or the role was unclear [ 63 , 64 ]. One reason for low pay was due to PSWs not requiring certification (i.e. specific qualifications, which e.g. a social worker would require) [ 63 ]. Some PSWs were positive about certification but others felt it could conflict with the grassroots ethos of peer support. However, there was the view that lived experience was not solely sufficient to work in interprofessional teams [ 64 ]. Despite this, supervision and support were often not offered to PSWs leading to risks [ 60 , 64 ].

There were challenges in PSW relationships with non-peer staff which could lead to a lack of support and hostility from non-peer staff. Non-peer staff felt threatened that they may be replaced by PSWs [ 64 ], were uneasy about working with people they previously treated [ 46 ], were concerned about the effectiveness of peer support [ 39 ], and felt expectations to support PSWs, increasing their workload [ 42 ]. This undermined the role of PSWs, e.g. they were subsequently given fewer responsibilities [ 39 ]. For PSWs, they wanted to challenge stigma by taking on more responsibility but high, varying workloads could jeopardise relationships with non-peer staff and team hierarchies hindered their ability to challenge clinically dominant ways of thinking [ 64 ].

A final theme was the perception that service users should be able to choose among PSWs as service providers [ 60 ].

Summary of key findings

An overview and summary of the key findings for each research question is presented in Table  7 .

Key findings

Our umbrella review of 35 reviews explored the effectiveness, implementation and experiences of peer support for mental health.

Effectiveness was reported in 23 reviews. Many reviews reporting effectiveness data reported no effect of peer support on a range of outcomes, mirroring the findings from other reviews [ 9 , 66 ] including those focusing on other types of peer support (e.g. online peer support for young people) [ 67 ]. However, there was consistent evidence from meta-analyses that peer support may improve the clinical outcomes of perinatal depression and risk of hospitalisation of adults with severe mental illness, as well as recovery outcomes, and self-efficacy and stigma-related outcomes. Mixed meta-analytic results were found for the clinical outcomes of overall psychiatric symptoms in adults with SMI, psychosis symptoms, length of hospital stay and patient activation, and for psychosocial outcomes such as hope, empowerment, and quality of life. There was no meta-analytic evidence for improvements in relational support. Evidence from systematic reviews without meta-analysis similarly gave a mixed picture regarding psychosocial and clinical outcomes, but indicated more consistent evidence that peer support has a positive impact on recovery, suicidal ideation, and, to some degree, satisfaction with care.

Many possible sources of heterogeneity across the included reviews could contribute to the mixed findings in this study, such as low-quality methodologies, differences in the populations included, and poor specification of peer support roles or the content of interventions delivered. One important potential contributor to our mixed results is that the primary studies contributing to the included reviews often varied in the type of control groups they considered, for example studies with treatment as usual, active controls and waitlist controls were often reviewed within the same paper. As such, it was not possible to determine whether peer support is effective in comparison to certain types of care provision but not others. In a similar vein, we could not perform subgroup analysis to determine whether specific forms of peer support are more effective on certain populations as most reviews with meta-analyses involved a combination of different formats and a range of participant groups. Nevertheless, there was some indication that differences in the format of peer support may impact its effectiveness on empowerment, as the two meta-analyses involving individual peer support alone found a positive effect on empowerment, but the two looking at group-based peer support alone did not. However, further research is needed to adequately address such questions.

Although this overview of quantitative evidence does not give unequivocal support for peer support on a variety of outcomes, the mixed results must be understood not only in the context of heterogeneity of the quantitative research conducted thus far, but with regard to the qualitative evidence documenting strong support for this intervention (as discussed in more detail below). Given that the implementation of peer support in mental health services is still relatively rare and highly variable, many of the trials conducted thus far may have tested peer support in environments where it is not fully embedded in the organisation and culture. Indeed, peer support may have positive impacts on the operation of mental health services that have not been measured as quantitative outcomes in existing trials—such as a stronger culture of person-centred care. More consistent quantitative results demonstrating the benefit of peer support may increasingly emerge as it becomes better integrated in the mental health care system.

We identified several factors reported to be important for the successful implementation of peer support, which were summarised and structured using the CFIR. These factors included adequate training and supervision for PSWs, a recovery-oriented workplace structure, strong leadership and a supportive and trusting workplace culture with effective collaboration between PSWs and non-peer staff. Barriers to peer support being implemented effectively included a lack of time, resources, and appropriate funding, and a lack of recognised PSW certification. Policy, research and campaign groups have advocated implementation approaches in line with these findings, for example, ImROC (implementing Recovery through Organisational Change) [ 14 , 68 ], who support peer support implementation globally and international competence frameworks from New Zealand [ 69 , 70 ], outline recovery focus as a core principle of peer support and emphasise the importance of training and ongoing professional development; peer support practice guidelines in the USA outline the importance of and give guidelines for supervision [ 71 ]. Formalised career pathways for PSWs [ 72 ] may help to address some of the identified barriers to effective implementation of peer support work, although these are still early in their development [ 68 ].

Experiences of peer support were from a range of perspectives (e.g. PSWs, service users, non-peer staff) and were organised under three main themes. The benefits of peer support for PSWs, service users and non-peer staff were expressed in many reviews; however, there were also conflicting and challenging experiences of the role. The mental health experience of PSWs was viewed as valuable, but also subject to some stigmatising views. For PSWs, the role could improve their personal wellness and recovery, providing a route back into employment and improving functioning, and provide service users with role models of recovery. The reciprocal benefits of peer support have also been highlighted as an advantage of peer support in resources developed by NHS England [ 19 ]. However, PSWs reported the ‘sick’ label stayed with them in the role, with non-peer staff at times concerned that PSWs mental health would impact their work, and some service users reported that they found it challenging to trust PSWs knowledge due to their lack of training and mental health history. A key experience, which became the core of our second theme, was the ambiguity of the PSW job description, including lack of clarity over boundaries with service users and when to disclose PSWs’ personal experiences. This ambiguity meant that the role was flexible, but also led to the perception that it was tokenistic and left PSWs feeling confused which impacted their own recovery. IMROC recommend the prioritisation of clear roles when implementing peer support [ 68 ]. Professional accreditation can counter the view of peer support as tokenistic, e.g. the UK Peer Support Competence Framework outlined by the Royal College of Psychiatrists [ 73 ] and the Canadian Peer support Accreditation and Certification, a national standard endorsing peer support work as a valuable career, developed in 2017 by PSWs themselves [ 74 ]. The final theme ‘organisational challenges and impact’ included experiences such as PSWs receiving inadequate support, training and supervision, and receiving low pay, leaving them feeling undervalued. Some non-peer staff attitudes were also a reported issue; while some PSWs felt accepted within teams, others experienced negative and rejecting non-peer staff attitudes, such as being treated as patients and not being invited to staff social events. Organisations should prepare, structurally and culturally, for the introduction of PSWs in order to ensure PSW wellbeing and reduce the risk of absences due to sickness [ 68 , 75 ].

Strengths and limitations

We conducted a comprehensive search of several relevant databases and identified a large number of reviews for inclusion, providing the first detailed summary of review findings relating to effectiveness, implementation and experiences of peer support. We also had consistent involvement of researchers with lived experience of mental health and peer support delivery and receipt throughout the design, data screening and extraction, analysis and synthesis, and manuscript drafting for this paper, which allowed lived experience priorities and experiences to guide our approaches to data and our decision making throughout.

We aimed to focus our review on paid peer support; however, this information was underreported in the reviews, and even when reported, interventions were often grouped with peer support interventions that did not fully meet our eligibility criteria (e.g. were unpaid). We also synthesised data from studies where payment status of PSWs was ambiguous, i.e. not reported. This limits our ability to draw firm conclusions around paid peer support specifically, as a significant portion of the data synthesised was from studies investigating unpaid or voluntary peer support. Another limitation was the lack of involvement of people with lived experience in the included reviews, with involvement reported in only one review [ 57 ]. Given the service user-led origins of peer support, future reviews should ensure involvement of people with lived experience. This is addressed in more detail later in this paper. Most included reviews were appraised by the AMSTAR 2 as low or critically low (97%) quality with only one review appraised as high quality. Although the low quality of reviews is a limitation, we aimed to report an overview of all current evidence for peer support to inform policy makers and healthcare practitioners, therefore to maximise the evidence base, we synthesised the reviews scored as ‘critically low quality’. Our ratings are also in line with a prior umbrella review of peer support which rated 87% of reviews as critically low quality and the remainder as low quality, but reported outcomes from all reviews [ 66 ].

Beyond the aforementioned limitations regarding variation in studies within each review, there is also a loss of granular detail through the umbrella review process of summarising data across reviews, which themselves contain many studies which have been summarised. The person-centred nature of peer support may mean that there are meaningful outcomes for the service user which are not easily captured in standard outcome measurement tools or recognised as clinically significant. Variation in peer support roles across studies may have contributed to the contradictions in our findings for RQ3, e.g. the challenges around PSW roles being ambiguous, but also the reported benefits of a flexible role.

A strength of our review was our broad inclusion criteria, for example, for qualitative data on experiences of peer support we reported data from the perspectives of service users, non-peer staff and PSWs. Though some data was reported separately by role, there were studies where experiences were reported together, and these perspectives were difficult to disentangle. Finally, we did not conduct a formal meta-synthesis of the qualitative experiences data; therefore, some detail may have been missed.

Implications for practice

Peer support may be effective at improving some clinical outcomes, self-efficacy and recovery outcomes for some people and could augment the standard service range. Certain groups may benefit from peer support more than others; evidence was strongest for depression outcomes within perinatal populations, but extremely variable for other populations. Peer support may differ in effectiveness depending on population needs and characteristics. PSWs need adequate pay, clear role descriptions and guidelines (e.g. about boundaries and disclosure), ongoing training and supervision, and opportunities for progression. Attitudes about peer support held by non-peer staff may significantly support or impede the implementation and experience of PSWs, and non-peer staff may require training about PSW roles and how to work collaboratively with PSWs. Culture, hierarchical structure and staff acceptability of peer support impact implementation and experience of peer support—structural and cultural change may be required for peer support to succeed, e.g. ensuring a recovery-oriented care model is operating in the service.

Implications for policy

Successful implementation of PSWs in healthcare settings is likely to require a coproduction approach with clearly defined PSW roles, a receptive hierarchical structure and staff, strong leadership and appropriate training (for PSWs and staff) with clinical and/or peer supervision alongside safeguarding. Issues relating to cost, lack of time and lack of resources are key considerations for service providers aiming to implement PSW that is sustained and effective within services. Additionally, Services could benefit from clear, coproduced guidelines, outlining the steps that are most likely to lead to successful PSW implementation.

Implications for research

Future primary and secondary research could usefully explore the differences in efficacy, implementation and experiences in paid PSW over time as it becomes more established; an important distinction as there are likely to be differences in these outcomes as the role of PSW develops. Such studies could consider using more personalised outcome measures such as goal-based outcome measurement [ 76 ]. Current PSW roles are still poorly defined and PSW content, including PSW variations (such as whether PSWs should deliver structured or more loosely structured, informal interventions, or whether interventions should vary according to need and context), need further exploration. Realist investigations around what works for whom, how and in which contexts would uncover more fine-grained detail on the specific contexts and mechanisms that explain these differences. Very few reviews included in this umbrella review reported lived experience researcher leadership or involvement in the undertaking of the study. It is imperative for future research in this area to appropriately reflect the priorities of those who are directly involved in PSW, either as providers or as service users. As the number of PSWs increases and more formalised roles are created, positive impact may not be restricted to outcomes of those supported by PSWs, but also to the functioning of services at an organisational level [ 68 ]. Further research is needed to evaluate how teams function with and without PSWs in order to understand how they may impact experiences through changes at a system level [ 68 ].

Our umbrella review has summarised data from 35 reviews on the effectiveness, implementation, and experiences of peer support for mental health. Although we attempted to focus solely on paid peer support, this detail was often not reported in the reviews. While data on effectiveness was mixed, there was some evidence of improvements on outcomes including depression, particularly perinatal depression, self-efficacy, and recovery, illustrating the potential benefits of wider PSW implementation across mental health services. Good implementation of peer support depends on co-design with people with lived experience, clear job descriptions, a recovery-oriented workplace culture, strong leadership, appropriate training for PSWs and staff , and supervision for PSWs. However due to limited information on cost or cost-effectiveness, we are unable to draw conclusions around resources required to implement PSWs. Experiences of peer support were from a range of perspectives. Peer support was mutually beneficial for PSWs’ and service users’ wellbeing and recovery and PSWs became role models. However, at times PSW roles were ambiguous, this meant that the role was flexible but could also lead to confusion which could impact PSWs own recovery. Potential strategies to successfully implement peer support include that the PSW roles should be clear, PSWs should be appropriately trained and paid, as well as supported and supervised within a trusting and accepting workplace structure and culture that advocates for a recovery-oriented model of care.

Lived experience commentary, written by LM and KM

This study provides a useful summary of the available research on peer support. By providing an overarching review of 35 reviews including 426 available studies, the paper brings together the knowledge on a topic of growing importance and understanding of the experiences, effectiveness, and implementation of peer support. However, this evidence is limited to ‘paid peer support workers’ included in data from academic literature of systematic reviews.

The nature of an umbrella review means that the systematic reviews themselves are synthesised, limiting our ability to look at specific details in the primary studies, for example to look for evidence of lived experience involvement or co-authorship or demographics of participants. The papers within the review are likely to have originated from traditionally funded research enquiries, and an umbrella review potentially magnifies academic or clinical perspectives over user voices and interests. While this is a frustration in any mental-health-related topic, this is particularly concerning in relation to peer support, with its origins in our user-led history.

The roots in user-led peer support are also overlooked when limiting the studies to paid peer support work. Although they might use the same language of mutuality and reciprocity, the two feel different. We are hesitant to suggest that we would prefer the skills and expertise of our supporters to be voluntary and unpaid; we strongly believe their expertise should be valued and funded. But there is something magical about informal peer support which can be lost when it is over-policed in bureaucratic cultures. Additionally, with studies included in the review dating back to 1979, we question how relevant these studies are in informing England’s evolving peer support landscape.

A crucial area of future research is exploring what type of peer support works best for whom and in what circumstances, and how we can deliver this. Furthermore, we need to better understand how NHS cultures can be supported to value the expertise that originates in our lived experience, including the marginalised experiences which have been disproportionately represented in mental health services.

Availability of data and materials

The data used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

A MeaSurement Tool to Assess systematic Reviews

Consolidated Framework for Implementation Research

Implementing Recovery through Organisational Change

Lived Experience Working Group

Population, Intervention, Comparator group, Outcome

Peer support worker

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Acknowledgements

This work is supported by the NIHR UCLH BRC.

This study is funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

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Ruth E. Cooper and Katherine R. K. Saunders are joint first-authors.

Authors and Affiliations

NIHR Mental Health Policy Research Unit, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK

Ruth E. Cooper, Katherine R. K. Saunders, Jessica Griffiths, Ruth Stuart & Alan Simpson

NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK

Anna Greenburgh, Rebecca Appleton, Phoebe Barnett, Sophie M. Allan, Brynmor Lloyd-Evans & Sonia Johnson

Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK

Phoebe Barnett

National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK

University of East Anglia, Norwich, UK

Sophie M. Allan

MHPRU Lived Experience Working Group, London, UK

Prisha Shah, Karen Machin, Tamar Jeynes, Lizzie Mitchell, Beverley Chipp & Stephen Jeffreys

Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, London, UK

Alan Simpson

Camden and Islington NHS Foundation Trust, London, UK

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All authors (RC, KS, AG, PS, RA, KM, TJ, PB, SA, JG, RS, LM, BC, SJ, BLE, AS, SJ) substantially contributed to the conception or design of this study. Data acquisition was undertaken by: KS, RC, JG, RS, RA, KM, PS, SA, PB. The data were synthesised and interpreted by: KS, AG, RA, PS, KM, TJ, and RC. KS and RC led on drafting the manuscript with input and/or editing by all other authors (AG, PS, RA, KM, TJ, PB, SA, JG, RS, LM, BC, SJ, BLE, AS, SJ). All authors (RC, KS, AG, PS, RA, KM, TJ, PB, SA, JG, RS, LM, BC, SJ, BLE, AS, SJ) read and approved the final manuscript.

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Additional file 1: appendix 1..

Prisma checklist [ 29 ]. Appendix 2. Full search strategy. Appendix 3. AMSTAR2 ratings. Appendix 4. Excluded studies following full text screening, with reasons. Appendix 5. Study overlap. Appendix 6. Effectiveness of peer support outcomes: results for non-meta-analysis results. Appendix 7. Experiences of peer support (detailed themes).

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Cooper, R.E., Saunders, K.R.K., Greenburgh, A. et al. The effectiveness, implementation, and experiences of peer support approaches for mental health: a systematic umbrella review. BMC Med 22 , 72 (2024). https://doi.org/10.1186/s12916-024-03260-y

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qualitative methods literature review

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Health and medical experience of migrant workers: qualitative meta-synthesis

  • Hyun-Jin Cho 1 ,
  • Kyoungrim Kang 2 &
  • Kyo-Yeon Park 1  

Archives of Public Health volume  82 , Article number:  27 ( 2024 ) Cite this article

Metrics details

Migrant workers in Korea are contributing to economic development by resolving labour shortages due to the increase in the ageing population, and they have become necessary and important in the Korean economy. However, long working hours, poor working conditions, and cultural differences can cause migrant workers to experience disadvantages in using health and medical services. Therefore, this study aimed to understand and analyse the health and medical service experience of migrant workers in Korea by reviewing previous studies in order to improve their health and access to medical services.

The qualitative meta-synthesis method suggested by Thomas and Harden was used. The key question for searching the literature is ‘What is the status of the use of health and medical service by migrant workers in Korea and the attributes that affect them?' Five electronic databases (RISS, KCI, KISS, Science ON, and KMbase) were searched for Korean literature published in academic journals until 6 November 2022 using a combination of “migrant worker or foreign worker or foreign labourer or migrant” and “medical or health” in Korean.

A total of nine studies out of 1,006 were included in the review after methodological quality assessment using the Critical Appraisal Skills Program (CASP). The results of studies were synthesised into three themes and ten sub-themes: ‘Personal factors’ of personal health beliefs and the financial burden of healthcare costs; ‘Cultural factors’ of cultural differences in the lifestyle, cultural differences in the healthcare environment, and traditional medicine in the country; and ‘Socio-institutional factors’ of poor and difficult working environment, insufficient information about medical institutions, policies with a lack of practical applicability, systems of healthcare institutions, and healthcare services usage.

Conclusions

This study identified the experiences of migrant workers in using health and medical care services. The results of this study can be used as a basis for improving the health of migrant workers and access to healthcare services. Based on the results of this study, it is necessary to improve the health management ability of migrant workers by developing a health management platform that can support Korean medical information and provide professional and accurate self-health management information.

Peer Review reports

The number of foreigners staying in Korea has been on a steady rise despite a brief decline due to COVID-19. Since 2022, the increasing trend has recovered again, with about 2.35 million foreigners staying in Korea as of April 2023, of which about 470,000 were employed either regularly or temporarily [ 1 ]. Migrant workers are mainly engaged in labour-intensive jobs such as agriculture, manufacturing, construction, and domestic care, which benefit both countries of origin and migrant countries and contribute to economic growth [ 2 ]. Migrant workers have become essential manpower in Korean agriculture and industrial fields while solving labour shortages in the low-wage 3D industry in Korea’s labour market, which is currently ageing, highly educated, and high-wage [ 3 , 4 ].

However, migrant workers have health problems or health risks due to changes in the living environment and cultural differences [ 5 ], and long working hours and poor working conditions cause disadvantages in using health and medical services [ 4 ]. According to the “Foreign Workers Survey” conducted by the Korea Institute for Health and Social Affairs in 2020 [ 6 ], 72% of the participants said they had been sick over the past year, and 17.9% did not receive hospital treatment even when they were unbearably sick or injured. In addition, the majority of migrant workers reported that their health conditions deteriorated after migration [ 7 ]. As the influx of migrant workers in Korea continues to increase, the demand for medical support for migrant workers is also increasing, but access to healthcare is not easy due to social, administrative, and cultural factors [ 8 ].

The World Health Organisation (WHO) charter stated that “enjoying the highest level of health that can be achieved without distinction of race, religion, political beliefs, economic or social conditions is everyone’s basic right” [ 9 ]. As migration becomes more common, the right to health of migrant workers is a basic right that applies to everyone [ 10 ], and more social attention is required for a healthy life and healthy labour [ 11 ]. In addition, as Korean health promotion policies are strengthened [ 12 ], it is necessary to pay attention to prevention and promotion for the health of migrant workers, and to increase access to practical medical services [ 11 ].

To keep up with this trend, there were researched policy-related studies on the health of migrant workers [ 10 , 13 , 14 ], the actual condition of using health information of migrant workers [ 15 ], and studies related to the health status and medical service use of migrant workers [ 16 , 17 , 18 ]. In this way, efforts are being made to understand the health status, healthcare status, and the status of medical service use of migrant workers in detail and to understand the meaning of participants’ experiences in depth through exploratory research on migrant workers’ health and medical experiences and perceptions [ 4 , 19 , 20 ].

The study attempts to comprehensively understand the status of health management and medical service use experienced by migrant workers through qualitative meta-synthesis [ 21 ] based on previous studies that explored the health and medical experiences of migrant workers. In addition, it aims to seek ways to improve the health of migrant workers in Korea and access to health and medical services by deriving and reinterpreting common core concepts from individual studies through synthesis.

The purpose of this study is to comprehensively examine qualitative research related to the healthcare and healthcare service experience of migrant workers in Korea. By understanding and analysing the health management status and healthcare service experiences of migrant workers in Korea, meaningful topics can be synthesised and interpreted, and it is intended to provide fundamental data to improve the health of migrant workers in Korea and access to healthcare services.

Study design

This study is a qualitative meta-synthesis study conducted to synthesise research on the healthcare and healthcare service experiences of migrant workers in Korea.

Key questions

The key questions for searching the literature are “What is the status of health and medical service use of migrant workers in Korea? " and “What are the attributes that affect their health and medical service use?”

Literature search, collection and selection process

Literature search.

This study reviewed only academic papers among Korean literature that studied the healthcare and healthcare service experiences of migrant workers. Authors used five electronic databases to search for all literature corresponding to related subject words without restrictions on the year of publication as a study published in academic journals until November 6, 2022. For the literature search, five Korean databases were searched: Research Information Sharing Service (RISS), Korea Citation Index Quotation Index (KCI), Korean Studies Information Service System (KISS), Science ON, and Korean Medical Paper Database (KMbase). These databases are the most used databases in Korea. We searched for only studies written in Korean to gain a deeper understanding of the meaning of the participants’ statements in qualitative research. To increase the sensitivity of literature search, Google Scholar was searched academic publications to comprehensively include. In addition, additional literature was searched by reviewing the reference lists of the studies obtained through the database search. The main keywords in the databases were searched in Korean. The search terms were the study subjects “migrant worker” OR “foreign worker” OR “foreign labourer”, and to minimise papers that may be omitted from the subjects, “migrant” was additionally searched according to the librarian’s advice, and the study subject “medical” OR “health.” Our detailed search strategy is provided in Additional file 1 .

Inclusion criteria and limitations

The inclusion criteria were (1) studies on migrant workers in Korea, (2) studies published in academic journals, (3) studies on health and medical experiences, and (4) adult migrant workers. Whereas the exclusion criteria were (1) quantitative studies, (2) conference presentations, abstracts only, dissertations and reports, (3) studies published in languages other than Korean.

Literature collection and selection

Studies were collected using electronic databases, and the collected literature was managed using EndNote X9.3.1 (compatible with EndNote 20), a bibliographical management program. The literature selection for the review was performed according to the reporting guidelines recommended by PRISMA 2020 Statement. The literature selection process was carried out by two researchers (HJC, KYP) independently.

The literature search yielded 1,006 studies, including 402 from RISS, 255 from KCI, 188 from KISS, 109 from Science On, and 52 from KMbase. Using EndNote, 424 duplicate papers were identified and removed. For the remaining 582 articles, titles and abstracts were reviewed according to the inclusion and exclusion criteria, and 571 studies that did not fit the study purpose were excluded. After an in-depth review of the full texts of the selected 11 studies, this study excluded one study that did not specify the health-related experience of the study participants, and one conference presentation. Consequently, nine studies were selected for the systematic review and have been identified in full text. Three researchers (KK, HJC, KYP) independently performed the literature selection process to ensure the validity and reliability of the results. During this process, researchers addressed disagreements by reviewing the manuscript through a research meeting and adjusting until an agreement was reached. The literature excluded in the selection stages was recorded and the document selection process was described using the 2020 PRISMA systematic review flow chart (Fig.  1 ).

figure 1

The study selection process using PRISMA 2020

Quality assessment

The quality evaluation of the literature was performed using Critical Appraisal Skills Program (CASP) tool [ 22 ]. The CASP qualitative research checklist is commonly used to assess qualitative research in meta-synthesis studies [ 23 , 24 ]. This checklist is a tool for evaluating the reliability, integrity, and rigour of the literature. The CASP checklist consists of ten questions in three sections: ‘Are the results of the study valid?‘, ‘What are the results?‘, and ‘Will the results help locally?‘. The quality appraisal tool includes clear statements of aims, appropriateness of qualitative methodology, appropriateness of research design, appropriateness of recruitment strategy, data collection, the relationship between researcher and participants, ethical issues, rigour in data analysis, clear statement of findings, and value of the research. Most questions require ‘yes/no or can’t tell’ response. The higher the score on the CASP, the more systematic the qualitative research is conducted, scores were presented as the percentage of questions [ 25 ]. Two researchers (HJC, KYP) independently evaluated a quality of the literature, and if there was a disagreement during the quality evaluation process of the literature, three researchers (KK, HJC, KYP) resolved disagreements through discussions and consensus. The CASP evaluation results of nine studies were more than 80% (Table  1 ).

Data extraction

By analysing the characteristics of the literature included in this study, data were extracted by authors, publication years, study purpose, characteristics of participants, study methodology, data collection methods, and major results (Table  1 ). Data extraction was carried out independently by two researchers (HJC, KYP), and if opinions disagreed during the data extraction process, three researchers (KK, HJC, KYP) reached an agreement through discussion.

Data synthesis

The thematic synthesis method of Thomas and Harden [ 21 ] was used to synthesise the data of the selected literature, and it was analysed in three steps: the coding of text ‘line-by-line’, the development of ‘descriptive themes’, and the generation of ‘analytical themes’ [ 21 ]. This approach was chosen as it could address key questions, with the aim of providing information to improve the health of migrant workers. It has also been used commonly in qualitative meta-synthesis studies [ 26 , 27 , 28 , 29 , 30 ].

The first step: It extracted and coded meaningful sentences and phrases while repeatedly reading statements or study results of study participants in nine articles.

The second step: While discussing the similarities and differences in the coded data, similar codes were categorised into descriptive sub-themes.

The third step: Analytic themes were created to provide clarified meaning around the list of sub-themes.

If there was a disagreement between researchers, it was resolved through discussion in the process of analysis and synthesis.

Characteristics of the included literature

A total of nine studies [ 4 , 5 , 19 , 20 , 31 , 32 , 33 , 34 , 35 ] were included in this review. The included literature was published between 2013 and 2022, and the total number of study participants recruited were 133. The methods of data collection were two focus group interviews [ 4 , 31 ], three in-depth interviews [ 19 , 20 , 35 ], one participant observation and in-depth interviews [ 32 ], one participant observation and focus group interviews [ 33 ], one literature review and in-depth interviews [ 34 ], and one meeting minutes and focus group interviews [ 5 ]. In addition, the methods of data analysis were two grounded theories [ 19 , 20 ], one directed content analysis [ 31 ], one ethnography [ 32 ], one life history analysis [ 33 ], one deductive content analysis [ 4 ], one narrative analysis [ 5 ], one triangulation [ 34 ], and one thematic analysis [ 35 ].

Meta-synthesise

As a result of synthesising research on the healthcare and healthcare service experience of migrant workers in Korea, the following three themes were derived: (1) personal factors, (2) cultural factors, (3) social institutional factors (Table  2 ). Because migrant workers prioritise work before health, they choose work despite poor working conditions, and suffer from physical and mental health problems due to hard work, changes in living environment, and cultural differences, but they bore the pain by force or reduce the pain in their own way after self-diagnosis because of a society that restricts access to medical services. They used healthcare services centred on medical support projects or free clinics, but they did not reveal that they were sick even when they were sick, and repeated the vicious cycle of threatening their health with a work-centred life pattern to show that their body is a productive labour force.

Personal factors

Personal health beliefs.

Migrant workers immigrated to Korea to find jobs for making money. He entered poor working conditions to find a job in Korea, and showed an addiction to investing his body and time with the idea that it would be over if he failed to work due to the currency value several times higher than his home country [ 33 ]. Migrant workers should not be sick to take responsibility for the living expenses of their families in their home country, and even if they were sick, it was difficult to pay for medical expenses and receive treatment [ 32 ]. Migrant workers overworked their bodies with constant labour to show that their bodies were a productive labour force, revealing physical pain was difficult to reveal diseases because it meant they had to quit work, and continued labour by connecting the cause of the disease to ageing or underlying diseases [ 33 ]. In the process of enduring hard labour by dismissing migrant labour in Korea as temporary labour to make a lot of money and return home [ 33 ], they were difficult to take care of their health even if there were signs of health problems because they have been pushed out of their priorities in life [ 19 ]. Migrant workers delayed taking care of their health by comforting themselves with the fact that they could work despite physical or psychological pain [ 33 ], or they hoped that their family or time would solve their health problem because they could not solve it themselves [ 19 ]. Some migrant workers have health belief that make them reluctant to use hospital due to distrust of western medicine, which become a threat to their health [ 4 ].

Financial burden of medical expenses

Migrant workers were financially burdened with medical and insurance costs, and they were unable to actively use medical services, such as giving up treatment when hospital costs such as examination or surgery were high [ 4 , 20 , 31 , 32 ]. Especially, unregistered migrant workers gave up the use of medical services due to their low ability to pay for health insurance due to an environment where they had no visas and low wages [ 20 ]. If it was possible that support from friendly medical staff and medical expense support groups, healthcare services could be revisited, but few organisations provide full medical expenses, so it was difficult to solve high treatment costs such as large surgery alone [ 20 ].

Cultural factors

Cultural differences in living conditions.

Migrant workers were at risk of exposure to various diseases due to stress and long hours of work under a different weather, food, and language from their home countries [ 19 , 32 ]. Migrant workers consumed a lot of sugar such as cakes, resulting in type 2 diabetes, and their bodies were ruined by junk food and high-calorie food-oriented eating habits [ 34 ]. In the case of married migrant women, physical health problems were experienced due to the food culture of their in-laws different from their home countries, and hard work instead of their husbands with physical and economic difficulties in foreign country [ 19 ]. In the case of married migrant female workers, it was invisible that postpartum depression, loneliness, and homesickness, so they could not ask for help, and they also developed diseases by enduring health abnormalities due to lack of Korean language skills [ 19 ]. In some cases, medical staff forced Muslim women to take off hijab even though they did not interfere with the examination [ 20 ], and the conflict felt by migrant workers due to cultural differences did not end up as an inconvenience, but as a health threat [ 5 ]. It also had difficulty choosing appropriate medical institutions or using medical services as language barriers regardless of gender [ 4 , 20 , 32 , 34 ].

Cultural differences in medical environment

The experience of using medical services different from the home country made it reluctant to reuse medical services, and cultural differences in the medical environment acted as a factor that threatened the health of migrant workers [ 5 ]. Migrant workers felt psychological burdens and difficulties in the process of using general hospitals in Korea due to their experiences in using medical services different from their home countries. They felt anxious about treatment due to a lack of understanding of the detailed divisions of the Korean medical community and confusion arising from institutional differences, and confidence in hospitals decreased [ 5 ]. Unlike in their home country, migrant workers felt frustrated because they did not know the causes and treatment methods of their health problems, as well as the types and effects of medicines due to the unilateral doctor’s treatment method [ 31 ], the lack of explanations about medicines at pharmacies, and felt like discriminated against [ 5 ]. They also asked for a prescription of drugs or fluids that worked in their home country, but they felt humiliated when their doctor refused or advised them to stop taking the medicine they had taken previously taken [ 5 ]. In addition, traditional first aid methods vary from country to country, which also became a conflict factor in the process of interaction with Korean doctors, making them hesitant to reuse medical services [ 5 ]. Migrant workers had restrictions on the use of healthcare services due to much greater psychological stress due to limitations of language communication disorders and cultural differences in the use of medical services [ 5 ].

Folk remedies in one’s country

Migrant workers purchased and took health supplements through their acquaintances or used folk remedies such as moxibustion treatment [ 20 , 33 ], and used them for emergency treatments experienced in the cultural environment of their home country [ 5 ]. When they were sick, they took drugs brought from their home country after self-diagnosis [ 33 ], received help from religious institutions or religious leaders, and found a shaman due to unknown symptoms [ 4 ]. They also exercised such as stretching, hiking, and cycling [ 20 ].

Social institutional factors

Poor and hard-working conditions.

It was difficult for migrant workers to use hospitals on weekdays because they were concerned that employers would negatively view the use of medical institutions in migrant workers mainly working in difficult jobs with poor working conditions [ 4 , 20 , 31 , 32 ]. As a result, since most symptoms were tolerated and preventive medical services were not available [ 4 ], even if there was a health problem, it had become a factor that threatens the health of migrant workers because they cannot respond properly. Public hospitals and private medical support organisations that can provide medical support are concentrated in Seoul [ 34 ], so geographical access to medical services was low. When employed, they experienced psychological burdens and stress due to discrimination caused by being limited to jobs avoided by Koreans, distrust of migrant workers, tension that cannot be free to eat or rest due to walking on eggshells around their boss, and job insecurity [ 31 ]. In particular, unregistered migrant workers experienced emotional pain, psychological atrophy, disability caused by industrial accidents, depression and despair, employers’ distrust of physical pain, and inappropriate follow-up measures as illegal residents [ 33 ]. Migrant workers were tired of mental stress from long-term labour, and physically felt pain in their limbs, neck, thyroid gland, abdomen, and kidneys [ 20 ]. Female migrant workers experienced physical burdens and the risk of musculoskeletal diseases due to the act of hugging children while working as a housekeeper and restaurant employee, repeated handling of heavy tableware, long standing or uncomfortable posture, repeated use of hands and wrists, long working hours, and lack of rest [ 31 , 33 ].

Insufficient information about medical institutions

Migrant workers were not aware of information probably related to the use of medical services such as medical expenses, medical departments, examination status, and use procedures because there was no place to obtain information on medical institutions [ 4 , 20 , 31 , 34 ]. Even if there was health insurance, they were not aware of how to use it or benefits, and they were not aware of emergency medical services or free medical services, so there was a limit to the use of health medical services [ 4 ]. Migrant workers obtained health information through family, friends, acquaintances, employers, and migrant communities [ 4 , 33 ], but in the case of communities and communal groups, uncertain information was supplied with commercial medical information, and the necessary information was not well provided [ 4 , 34 ]. Migrant workers also obtained health information through TV or the Internet [ 19 , 31 ]. Migrant workers use medical services based on their own description on disease condition or symptoms rather than expert diagnosis or advice, so they often rely on personal information from acquaintances when choosing a medical institution [ 4 ].

Policies with a lack of practical applicability

- Industrial accident.

In the case of unregistered migrant workers, it was rare to treat for diseases or accidents caused by industrial accidents when using medical institutions, and they rarely received health check-ups or supported medical expenses at work [ 20 ]. In the event of an industrial accident, compensation can be applied for, but in the process to deal with industrial accidents, employers were fined for hiring unregistered migrants, and unregistered migrants could be forcibly repatriated for illegal stay, making it almost impossible to deal with industrial accidents [ 20 ]. In addition, there was an institutional loophole in which migrant workers could not apply for industrial accidents at all when they first entered the country and start working [ 34 ]. In the case of female migrant workers, they usually worked at small business offices or private homes that did not have industrial accident insurance, and their physical pain was not visible because it was a chronic disease that was not included in industrial accident [ 33 ].

- Health insurance policy.

Migrant workers were very passive in signing up for health insurance, considering migrant labour as a short-term temporary labour [ 33 ], and the requirements for joining medical insurance should be confirmed residency for more than three months, and for migrant workers who are unfamiliar with life in Korea, the differential medical welfare system according to their status of residence felt discriminatory and became a factor threatening their health [ 5 ]. In the case of medical insurance, not only unregistered migrant workers, but also migrant workers employed in occupations such as nursing labour, domestic labour, and farms were excluded [ 33 ].

- COVID-19 disinfection policy.

Korea’s quarantine policies during the pandemic of infectious diseases such as COVID-19 had a more negative impact on migrants’ use of medical services and were fatal to unregistered migrants [ 35 ]. As the medical support project for migrants was suspended, it became difficult to receive medical expenses as well as disease treatment, and the increase in hate discrimination against migrants during the COVID-19 pandemic also reduced access to medical services [ 35 ]. The continuity of healthcare deteriorated as hospitals were reluctant or refused to visit migrants, and hospitals were delayed even if they were sick [ 35 ]. The quarantine policy due to COVID-19 has blocked the continuity of medical care in the early detection and treatment of migrants and the management of chronic diseases, acting as a factor that threatens the health of migrants [ 35 ].

Medical institution’s system

Migrant workers had difficulties in using medical services due to the lack of medical institutions that could interpret [ 4 , 19 ]. In the process of using medical services, if the migrant worker did not communicate well with the medical staff, the medical staff became annoyed, discriminated against, or refused treatment [ 20 ]. As a result, emotional accessibility was lowered, which made it difficult to use medical services [ 4 ]. Unregistered migrants felt uncomfortable and anxious about filling out documents related to personal information when using medical services and were reluctant to reuse medical services because they had been denied access to public health centres or other medical institutions because they did not have a visa [ 20 ].

Use of healthcare services

Migrant workers mainly used free clinics for migrants, clinics near workplaces, and health centres [ 19 , 20 , 31 ]. Migrant workers used free clinics for migrants due to economic burden [ 32 ], or health centres or cultural centres that provided free examinations and treatment [ 19 ]. It was difficult to get medical treatment during weekday working hours, so they visited a health centre on Sunday due to the burden of treatment costs [ 32 ] or were treated under someone else’s name to receive medical insurance benefits [ 19 ]. Migrant workers want to receive Western treatment, but have used low-cost oriental medicine, or purchased non-prescription drugs at pharmacies [ 4 , 20 ]. Migrant workers want to receive Western treatment, but have used low-cost oriental medicine, or purchased non-prescription drugs at pharmacies [ 4 , 20 ]. Most of them also did not use the dentist clinic with high-cost burden due to the large number of non-benefit treatments [ 20 ]. In the case of unregistered migrants, they received simple medical treatment at the free clinic of the support centre and, in the worst case, they planned treatment in their home country, where they could benefit from health insurance [ 20 ]. Migrant workers who had economic support, were able to communicate in the language, or met friendly medical staff were optimistic about using medical services. On the other hand, migrant workers gave up using medical services, endured pain, and thought about returning to their home countries if they had experiences of not receiving economic support, language communication difficulties, and treatment being rejected by medical staff [ 20 ].

This study aimed at enhancing the well-being of migrant workers in Korea and increasing their access to healthcare and medical services by performing qualitative meta-synthesis related to the health and medical experience of migrant workers in Korea. Nine studies [ 4 , 5 , 19 , 20 , 31 , 32 , 33 , 34 , 35 ] were included in the final analysis of this reviews in this study, the healthcare and medical service experiences of migrant workers in Korea were examined systematically. Through the integration of these studies, three main themes and ten sub-themes were derived, namely: ‘personal factors,’ ‘cultural factors,’ and ‘social and institutional factors.’

The first theme, ‘Personal factors’, was derived into three sub-themes: ‘individual health beliefs’ and ‘economic burden of medical expenses.’ Migrant workers moved for the purpose of earning money, so they prioritise work over health. According to the study of Lee [ 33 ], migrant workers’ postponement of healthcare while overworking themselves in voluntary labour was described as “self-rule based on economic principles.” Even if the purpose of migration is to gain economic benefits through labour, migrant workers need to take a long-term perspective and shift their mindset of health priorities so that their bodies can be maintained as a productive workforce. Therefore, it is necessary to periodically implement preventive programs or education on healthcare for migrant workers so that distrust of Western medicine or false health beliefs can be changed. Migrant workers also were unable to receive medical treatment on time due to economic burdens, and it is necessary to provide various medical services by expanding professional free medical services.

‘Cultural factors’ are factors that face from differences from other environments while leaving the home country, regardless of the country of migration. For example, migrant workers, who had low sugar intake in their home countries, ate a lot of sugar such as cakes that could be easily encountered in Korea, and suffered from chronic diseases such as diabetes [ 34 ], and not only they were unfamiliar with Korean food culture, but also they were experienced health problems [ 34 ] due to a diet focused on cheap and convenient junk food or high-calorie food [ 36 ]. Since this dietary problem is the factor of threat that can be prevented through food and health education, providing rest and health education to migrant workers through game-based health workshops at the corporate level will effectively eliminate this factor and greatly enhance motivation for healthcare. Differences in eating habits as well as different medical service systems from their home countries are cultural factors that confuse migrant workers. It will be possible to increase the accessibility of Korean medical services by providing basic knowledge to migrant workers who are confused by the medical service system that is different from their home country by explaining detailed areas of Korean medical service [ 5 ]. Recently, Korea is changing into a multicultural society due to the influx of migrant workers to fill the labour shortage and the increase in international marriage, so it is necessary to improve multicultural acceptance to understand and recognise members of different cultures [ 37 ]. In line with the social trend, medical staff need to provide an appropriate explanation of the treatment process of the disease with an understanding of migrant workers [ 20 ], and culture nursing education should be provided for medical staff so that nursing in consideration of culture can be conducted [ 38 ].

In the context of ‘social and institutional factors,’ the poor working environment serves as a fundamental cause of health problems among migrant workers, and it is difficult to use medical institutions without improvement in the working environment where they can freely use medical institutions even if health and medical services are improved and expanded [ 20 , 34 ]. As a result, it is important to create a social atmosphere that guarantees the basic rights of migrant workers, and it is also essential to reduce psychological burdens and stress through cooperative relationships among co-workers rather than maintaining the employer-employee relationship. Moreover, migrant workers had limited access to medical services due to lack of information on medical institutions. To solve this difficulty, it is important to utilise a community for information sharing [ 34 ], and it is necessary to provide information on medical institutions by guiding institutions and organisations that provide free medical treatment upon arrival. On the other hand, although industrial accident compensation insurance, health insurance systems, and COVID-19 quarantine policies were not applied discriminatively to migrant workers, the social system experienced in a foreign country acted as a factor limiting migrant workers’ use of medical services. These systems also were not consistently applied to migrant workers due to unfamiliar foreign policies, which in turn restricts their access to medical services. Local governments where many migrants live proposed measures to support health and medical services to supplement these policy problems. For example, the study of Shin and Choi [ 34 ] were proposed the centres would offer free professional support across various departments tailored to the needs and scale of the migrants, or ‘Health Card’ was created to use a certain amount of insurance in a way that does not expose the identity for undocumented migrant workers within the local government. Migrant workers did not communicate well with medical staff due to language barriers, and as a result, unfriendly medical staff and refusal of treatment had become a factor that threatens the health of migrant workers. To solve this problem, the study of Shin and Choi [ 34 ] was suggested that migrants who can use Korean well for smooth communication could be trained as activists or interpreters to help migrants use medical services. Additionally, it is crucial to develop hospital information and educational materials in multiple languages, enabling nurses to provide care and to establish dedicated departments catering to foreigners, thereby streamlining the treatment process for migrant workers [ 38 ].

This study examined the health and medical experiences of migrant workers based in the preceding literature. When faced with physical and psychological distress, their initial response often involved enduring the discomfort and waiting for a natural recovery, while seeking health-related information through various ways, including family, acquaintances, communities, and the Internet. These behaviours led to ways such as self-diagnosis based on inaccurate information, taking health supplements or medications, using folk remedies such as moxibustion, using first aid methods of home country, exercising, or seeking out shamans. They try to use medical services after their symptoms or pain worsens, but due to financial burden, they mainly use free clinics, public health centres, and oriental medicine clinics. This pattern of healthcare coping results in the disease getting worse due to missing the appropriate treatment period. To break this pattern of healthcare coping, it needs to be provided that accurate information about disease symptoms. For this, it is important to develop a healthcare program or platform for migrant workers to enable self-health management. It also can improve migrant workers’ ability to cope with health problems that providing professional and accurate information, such as information about Korean medical institutions or disease-related information. Especially, simple and repetitive health information can be provided easily, quickly and accurately at the right time by using an easily accessible platform such as a chatbot.

Studies have been examined to determine the status of migrant workers’ healthcare or use of medical services and their health and medical care experiences, but these results have not been integrated. This study has significance in that it provides comprehensive and integrated data on the health and medical experiences of migrant workers by applying a qualitative meta-synthesis method to study that qualitatively analysed the health and medical experiences of migrant workers in Korea from various perspectives. It is also meaningful in that it provided basic data for the development of health management platforms and policy activation to improve the health of migrant workers in Korea and access to health and medical services. However, this study is limited in that it was unable to analyse in detail from each perspective, even though the study participants had diverse perspectives, including not only migrant workers but also medical staff, volunteers, and public officials. In addition, studies included in the qualitative meta-synthesis were examined from the perspective of female migrant workers, so there are limitations in comparing them with the health and medical experiences of male migrant workers. Accordingly, follow-up qualitative studies on the health and medical experiences of male migrant workers will be needed. This study may have a publication bias by reviewing only studies written in Korean to understand in depth the meaning of the statements made by the participants in individual studies. However, we tried to reduce publication bias by performing a quality assessment of the literature, searching for various synonyms in Korean approved databases, and adding grey literature and manual searches. Nevertheless, this study only reviewed studies of migrant workers in Korea to integrate the health and healthcare service experiences, so it may not be applicable to other countries with different socio-cultural backgrounds. It is suggested that future studies integrate the health and healthcare service experiences of migrant workers in other countries and compare them with Korea.

This study conducted qualitative meta-synthesis based on exploratory studies related to the health and medical experiences of migrant workers in Korea to comprehensively understand the healthcare and healthcare service experience of migrant workers in Korea. The final nine studies were integrated, as a result, personal factors such as individual health beliefs and economic burdens on medical expenses, cultural factors such as cultural differences between living and medical environments, private therapy in the home country, and social and institutional factors such as poor and hard-working conditions, insufficient information about medical institutions, policies with a lack of practical applicability, the system of medical institutions, and social and medical service use. Through this, it was confirmed that the health management status of migrant workers and their experience in using medical services. The results of this study could be used as basic data for improving the health of migrant workers in Korea and improving accessibility to healthcare services in the future. Based on the results of this study, it is suggested to develop a health management platform that can provide Korean medical information to migrant workers and provide professional and accurate self-health management information to improve their health management skills and increase the use of healthcare services.

Data availability

The datasets generated during and/or analysed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

World Health Organization

Research Information Sharing Service

Korea Citation Index Quotation Index

Korean Studies Information Service System

Korean Medical database

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

Critical Appraisal Skills Program

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This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) (No. NRF-2021R1G1A1095715).

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Cho, HJ., Kang, K. & Park, KY. Health and medical experience of migrant workers: qualitative meta-synthesis. Arch Public Health 82 , 27 (2024). https://doi.org/10.1186/s13690-024-01254-z

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    Mixed studies review/mixed methods review: Refers to any combination of methods where one significant component is a literature review (usually systematic). Within a review context, it refers to a combination of review approaches, for example, combining quantitative with qualitative research or outcome with process studies.

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    In other words, a qualitative synthesis might be used to explore the findings of a prior quantitative synthesis or vice versa [16, 17]. An example of a predominantly aggregative sub-review followed by a configuring sub-review is the EPPI-Centre's mixed methods review of barriers to healthy eating . A sub-review on the effectiveness of public ...

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