thematic synthesis of the literature

• Research article
• Open access
• Published: 10 July 2008

Methods for the thematic synthesis of qualitative research in systematic reviews

• James Thomas 1 &
• Angela Harden 1  

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

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

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

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

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

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

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

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

The review used as an example in this paper

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

Qualitative research and systematic reviews

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

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

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

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

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

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

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

Quality assessment

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

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

Extracting data from studies

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

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

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

Detailed methods for thematic synthesis

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

Stages one and two: coding text and developing descriptive themes

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

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

line-by-line coding in EPPI-Reviewer.

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

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

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

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

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

relationships between descriptive themes.

Stage three: generating analytical themes

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

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

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

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

Context and rigour in thematic synthesis

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

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

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

Study quality and sensitivity analyses

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

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

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

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

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

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

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

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Acknowledgements

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

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

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Barnett-Page, E., & Thomas, J. (2009). Methods for the synthesis of qualitative research: a critical review. BMC medical research methodology , 9 (1), 1-11. Full Text Thomas, J., & Harden, A. (2008). Methods for the thematic synthesis of qualitative research in systematic reviews. BMC medical research methodology , 8 (1), 1-10. Full Text  

Caskurlu, S., Richardson, J. C., Maeda, Y., & Kozan, K. (2021). The qualitative evidence behind the factors impacting online learning experiences as informed by the community of inquiry framework: A thematic synthesis. Computers & Education , 165 , 104111. Full Text

References Nicholson, E., Murphy, T., Larkin, P., Normand, C., & Guerin, S. (2016). Protocol for a thematic synthesis to identify key themes and messages from a palliative care research network. BMC research notes , 9 (1), 1-5. Full Text

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Protocol for a systematic review and thematic synthesis of patient experiences of central venous access devices in anti-cancer treatment

• Caoimhe Ryan   ORCID: orcid.org/0000-0001-7279-563X 1 ,
• Hannah Hesselgreaves 2 ,
• Olivia Wu 1 ,
• Jim Paul 3 ,
• Judith Dixon-Hughes 3 &
• Jonathan G. Moss 4  

Systematic Reviews volume  7 , Article number:  61 ( 2018 ) Cite this article

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Three types of central venous access devices (CVADs)—peripherally inserted central catheters (PICCs), skin-tunnelled central catheters (Hickman-type devices), and implantable chest wall Ports (Ports)—are routinely used in the intravenous administration of anti-cancer treatment. These devices avoid the need for peripheral cannulation and allow for home delivery of treatment. Assessments of these devices have tended to focus on medical and economic factors, but there is increased interest in the importance of patient experiences and perspectives in this area. The aim of this systematic review is to synthesise existing research regarding patient experiences of these CVADs to help clinicians guide, prepare, and support patients receiving CVADs for the administration of anti-cancer treatment.

A systematic search of MEDLINE, Embase, and CINAHL research databases will be carried out along with a supplementary reference list search. This review will include quantitative, qualitative, and mixed methods studies published in peer-review journals, reporting some aspect(s) of patient experiences or perspectives regarding the use of PICC, Hickman, or Port CVADs for the administration of anti-cancer drugs. The methodological quality and risk of bias of included papers will be assessed using the Mixed Methods Appraisal Tool (MMAT). Relevant outcome data will be extracted from included studies and analysed using a thematic synthesis approach.

The results section of the review will comprise thematic synthesis of quantitative studies, thematic synthesis of qualitative studies, and the aggregation of the two. Results will aim to offer an account of current understandings of patient experiences and perspective regarding PICC, Hickman-type, and Port devices in the context of anti-cancer treatment. Confidence in cumulative evidence will be assessed using the Confidence in the Evidence from Reviews of Qualitative research (CERQual) approach.

Systematic review registration

This systematic review protocol is registered with the International Prospective Register of Systematic Reviews (PROSPERO). Registration number: CRD42017065851 . This protocol was prepared using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols checklist (PRISMA-P) (Shamseer et al., BMJ 349: 2015).

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Three types of central venous access devices (CVADs) are routinely used in the intravenous administration of anti-cancer treatment: peripherally inserted central catheters (PICCs), skin-tunnelled central catheters (Hickman-type devices), and implantable chest wall Ports (Ports).

All three deliver the drug into the superior vena cava, which drains directly into the right atrium of the heart. PICC lines are inserted into a peripheral vein in the arm. The end of the line remains outside the body, emerging from a point usually above the elbow. Hickman-type devices are inserted into a central vein in the neck or upper chest. The end of the line is tunnelled under the skin to emerge from the chest, where it sits outside the body. Chest wall Ports constitute a closed-system that is fully implanted in the body with no external lines. Vascular access is via needle puncture.

The main benefit of the devices is that they avoid the need for peripheral cannulation which relies on peripheral arm veins that easily become occluded. Moreover, peripheral cannulation usually involves repeated needle insertions which patients tend to find unpleasant, even painful and distressing [ 1 ]. They also allow for home delivery of treatment via portable chemotherapy infusion pump.

Patient-centred approaches in the area of vascular access exist but are limited. Published reports on the use of vascular access devices in the context of anti-cancer treatment have tended to focus on medical and economic factors such as cost, maintenance, infection, and other complications [ 2 , 3 ], with much less attention given to patient experiences and perspectives. It is therefore difficult to gain a clear picture of how patients experience PICC, Hickman, and Port devices [ 4 ]. Developing a better understanding of these experiences would offer important insight into the roles these devices play in patients’ quality of life and in the burden of treatment. Moreover, a comparison of the effects and experiences of these different devices would be important in guiding device selection where more than one device is clinically suitable.

To our knowledge no systematic review has previously been carried out on this topic. The present review will draw together existing approaches to recording and assessing patient experiences of these CVADs in order to produce a coherent understanding of such experiences. This will help clinicians guide, prepare, and support patients receiving CVADs for the administration of anti-cancer treatment.

The aim of this review is to synthesise existing literature that investigates patient experiences with PICC, Hickman-type, and Port devices in the context of anti-cancer treatment.

This review will address the following questions: What are patients’ experiences and perspectives regarding the three different central venous access devices implanted for delivering long-term anti-cancer treatment: peripherally inserted central catheters (PICC), Hickman-type tunnelled catheters, and totally implanted chest wall Ports? What effect (if any) do these CVADs have on patients’ quality of life in the context of anti-cancer treatment, and what aspects of each device are important in this respect? To what extent is it possible to compare and contrast patient experiences of different CVADs? What are the limitations of the existing literature, and what additional research is needed?

Eligibility criteria

This review will include empirical studies published in peer-review journals meeting review-specific eligibility criteria. These criteria were developed in line with the existing search tools PICO (Population, Intervention, Comparison, Outcome) [ 5 ] and SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type) [ 6 ]. PICO is typically used in systematic reviews of quantitative research, answering clinical questions. SPIDER was adapted from the former for use in systematic reviews of qualitative and mixed method research. As our review will comprise quantitative, qualitative, and mixed methods studies, our eligibility criteria include elements from both.

As the use of PICCs and chest wall Ports in cancer treatment was not well established until the 1990s and involved a learning curve of several years, this review will consider only studies published from the year 1997 onward.

Participant population

Studies will be eligible for inclusion where participants are adult or paediatric patients (or parents/guardians of paediatric patients) diagnosed with any type of cancer including solid malignancy and haematologic malignancy, who have received PICC, Hickman-type or chest wall Port CVADs for the primary purpose of the administration of anti-cancer drugs.

Intervention

Included studies will involve the implantation (via any technique) of any of the following venous access devices for the long-term administration of any anti-cancer treatment: (i) peripherally inserted central catheters (PICC), (ii) subcutaneously tunnelled central catheters (Hickman-type device), and (iii) implantable chest wall Ports (Port).

Comparator/control

Studies will not be included or excluded on the basis of comparator. Where relevant and appropriate, comparisons between devices or other forms of venous access in the administration of anti-cancer treatment will be considered in analysis.

The review will include empirical studies using quantitative and/or qualitative analytic methods. It will exclude non-empirical studies but will not limit inclusion based on study design. Studies that report outcomes regarding CVADs but do not report or discuss any patient experience will also be excluded, as will studies that do not provide sufficient detail for a thematic synthesis—i.e. studies that do not contribute to themes or where data cannot be themed.

This review will include studies conducted in oncology settings such as hospitals, and clinics, or related contexts including home-treatment, patient care facilities, or patient groups/organisations.

Evaluation/outcomes

Finally, to be eligible for inclusion study, participants must have completed a measure (e.g. questionnaire, survey) or provided an account (e.g. interview, focus group) of some aspect of their own experience with or perspectives on CVADs or in the case of paediatric patients, where parents/guardians similarly report on some aspect of their own and their children’s experiences and perspectives (please see ‘ Outcomes and Prioritisation ’ section, below, for explanations of these outcomes).

Information sources

A systematic search strategy will be used to search MEDLINE, Embase, and CINAHL research databases. A further important component of our search strategy, especially for the purposes of identifying relevant qualitative research, involves forward and backward citation tracking of publications meeting the inclusion criteria, via Web of Science and Google Scholar. In addition, experts including authors of key papers will be contacted to minimise the likelihood of overlooking key sources.

Search strategy

Search terms will target three key domains: (i) central venous access devices, (ii) patient population, and (iii) patient experiences. Search terms for Hickman and Port devices and for cancer and chemotherapy will be adapted from an existing systematic review comparing the clinical effectiveness of these devices [ 7 ]. The search strategy has been constructed with advice and guidance from an information scientist. An example of search terms and strategy is provided in Appendix .

Data management

Details of all searches will be recorded. Search results will be downloaded to EndNote desktop software. Studies sourced through supplemental hand searching will be recorded and imported into EndNote.

Selection process

Duplicate publications will be removed. The titles and abstracts of all remaining publications will be assessed against inclusion criteria. Those not meeting these criteria will be excluded. All titles and abstracts identified at this stage will also be screened independently by a second reviewer. Disparities will be resolved through discussion or in consultation with a third party. Full texts of the remaining publications will be obtained for further review. Reasons for further exclusions at this stage will be documented. The selection process, including search results and reasons for exclusion at each stage of screening, will be recorded and represented in a PRISMA flow diagram (Additional file  1 )[ 8 ].

Data collection process

Data extraction will be performed by one reviewer using a data extraction form developed by the researchers for the purposes of this review. This form will be refined by the reviewer until the data extraction is complete, to ensure the appropriateness and usefulness of all fields.

For all studies, descriptive data will be extracted regarding type(s) of vascular access device included in the study, patient population, sample size, stated research aims, study context, study design, methodology, reason for measurement of patient experience, and timing of measurement (in relation to device placement).

For quantitative studies, outcome data including descriptive and inferential statistics will be extracted for measures of patient experiences or perspectives regarding CVADs. Details of measurement instruments will also be recorded. The purpose of qualitative synthesis is to ‘go beyond’ primary studies. This means the data to be extracted from the qualitative studies comprises the analyses and interpretations of the study authors including all themes, categories, theories, models, and similar. Therefore, all material labelled as results or findings by the authors as well as subsequent discussions and conclusions relating to CVADs will be extracted in full [ 9 ].

Outcomes and prioritisation

The primary outcomes of interest will be any aspect of patients’ (or parent/guardians’) self-reported experiences or perspectives relating to PICC, Hickman, or Port devices. The data to be collected will include quantitative and qualitative materials, i.e. survey or questionnaire data, qualitative themes, and participant quotations.

For our present purposes, ‘patient perspectives’ will include opinions, attitudes, and evaluations (including acceptance and satisfaction). Patient experiences will include emotions, physical sensations (e.g. pain, discomfort), psychological factors (e.g. stress, mood), and pragmatic factors (e.g. routine activities).

Our analyses will prioritise any of the above as they relate to device acceptance or preference or to patient wellbeing or quality of life. Secondary prioritisation will be given to any of the above as they relate to device placement (insertion).

Risk of bias in individual studies

Critical appraisal of methodological quality and risk of bias of included papers will be undertaken independently by two reviewers according to the Mixed Methods Appraisal Tool (MMAT) developed by Pluye and colleagues [ 10 ] for the appraisal of qualitative, quantitative, and mixed methods research. Following these guidelines, the reviewers will assess for all included studies whether (i) there are clear research questions and (ii) the data collected address the research question. The following assessments will then be made, depending on study type:

Qualitative studies

The reviewers will assess the appropriateness of data sources and analytical processes, the study’s consideration of context/setting, and the study’s consideration of researchers’ influence.

Randomised controlled trials

The reviewers will assess the study’s descriptions of randomisation and allocation concealment, the completeness of outcome data, and the level of drop-out rates.

Nonrandomised quantitative studies

The reviewers will assess the study’s minimisation of selection bias, use of appropriate measurement instruments, use of comparable groups across study conditions, and the completeness of outcome data.

Descriptive cross-sectional quantitative studies

The reviewers will assess the appropriateness of the study’s sampling strategy and the representativeness of the sample, use of appropriate measurement instruments, and acceptability of response rate.

Data analysis and synthesis

Data will be analysed using a narrative approach, specifically thematic synthesis. Our analysis will comprise three phases. The first phase will be a thematic synthesis of the patient experience and perspective data extracted from the quantitative studies selected for inclusion in our review. We use inclusive definitions of patient experience and perspectives in this review. Our search strategy therefore includes a range of broad search terms relating to these phenomena. In addition, to our knowledge, there are no validated or standardised measures relating to patient experiences of CVADs in common usage. For instance, one such measure recently developed in France (specific to Port devices) [ 11 ] has to date been used in a single pilot study [ 12 ]. Consequently, we anticipate significant heterogeneity with regard to quantitative outcomes, and these data will not be quantitatively synthesised. The second phase of analysis will be a thematic synthesis of the qualitative studies selected for inclusion. The final third stage will be an aggregation of both sets of analysis. In the interests of transparency, detailed accounts of each stage of analysis will be recorded. The second phase of analysis will be a thematic synthesis of the patient experience and perspective data extracted from qualitative studies selected for inclusion. The final third stage will be an aggregation of both sets of analysis. In the interests of transparency, detailed accounts of each stage of analysis will be recorded.

Analytic method

Thematic synthesis is an adaptation for the purpose of secondary data synthesis of ‘thematic analysis’ and provides a set of established methods and techniques for the identification and development of analytic themes in primary research data [ 9 ]. Thematic synthesis was selected for the purposes of this review for a several reasons [ 13 ]. First, it is well suited to our present objective of aggregating existing evidence and identifying patterns within data. Second, whilst it is most commonly associated with the synthesis of qualitative research outcomes, thematic synthesis is also used for the synthesis of quantitative research outcomes, particularly where there is heterogeneity in outcome variables and measurements. Finally, the process of thematic synthesis offers good transparency and outcomes are accessible.

Thematic synthesis involves three stages of analysis (all three stages will be applied to all included quantitative studies and repeated for all included qualitative studies). First, the data—here, those pertaining to patient experiences and perspectives—are coded. A coding frame will be developed comprising codes derived from the data. Coding will be carried out by the first reviewer and checked by a second reviewer. Disparities or discrepancies in coding will be resolved through discussion or in consultation with a third party if necessary; the coding frame will be adjusted accordingly.

In the second stage of analysis, similarities between codes will be identified. Codes will be grouped into ‘descriptive themes’ that capture and describe patterns in the data across studies. Each theme will be entered as columns into a table, and coded data from each study will illustrate the themes in rows, to facilitate comparison within and between studies, as part of the constant comparison analytic process [ 14 , 15 ]. Memos will be used as part of the analysis process and may be included in the summary table where clarity may be required about the interpretation of a piece of evidence [ 16 ]. The aim of this table is to demonstrate themes with illustrative data and capture similarities and differences within the data where possible—that is, to show how themes are generated but also show divergence of findings in each theme, where it applies.

The third stage of thematic synthesis will involve the development of analytic themes. The purpose of this phase of analysis is to ‘go beyond’ the primary reported data by synthesising findings across studies and interpreting their meaning in relation to our review research questions. This will comprise the narrative component of our analysis, which will provide narrative descriptions of each theme.

Once thematic synthesis has been completed for quantitative studies and for qualitative studies, a final phase of analysis will compare both sets of results, and the three central venous access devices included in the review. This process will aggregate results, providing an overall account of current understandings of patient experiences and perspectives of CVADs in the context of anti-cancer treatment.

Confidence in cumulative evidence

Confidence in discrete review findings will be assessed using the recently developed Confidence in the Evidence from Reviews of Qualitative research (CERQual) approach [ 17 ]. Assessment of confidence in a given review finding involves evaluating how likely it is that the finding represents a real phenomenon, i.e. genuine patient experiences of CVADs. This assessment will be based upon an evaluation of the following: (i) methodological limitations of the primary studies contributing to the finding, (ii) the relevance of the primary contributing studies with regard to the objectives of the systematic review, (iii) the coherence of the finding, and (iv) the adequacy of data supporting the finding.

For the purposes of this study, these evaluations will be conducted as follows:

Methodological limitations of contributing studies: With reference to our prior critical appraisal of methodological quality of these studies (see above), we will evaluate the extent to which the primary studies contributing to the finding are generally of good methodological quality.

Relevance of contributing studies: We will evaluate the extent to which the primary studies contributing to the finding are similar in context and aims/objectives to the present review. For instance, studies carried out with the primary aim of investigating some aspect of patients’ experiences of CVADs in the context of cancer treatment will be considered highly relevant. Those in which findings relating to patient experiences of CVADs are secondary or incidental to an alternative aim will be considered to be of low relevance.

Coherence of finding: We will assess the extent to which the finding offers a credible explanation for the patterns it describes (e.g. tendencies, relationships between relevant factors). This will involve assessing the consistency or inconsistency of the pattern across various research contexts represented by studies included in the review and the ability of the finding to account for notable variations across contexts. Findings will be judged to be of low coherence if they describe inconsistent or contradictory patterns and where inconsistencies are unexplained.

Adequacy of supporting data: We will assess the extent to which a given finding is supported by substantial evidence defined both in terms of number of studies contributing to a given study and the quantitative robustness or qualitative richness (i.e. fullness and depth) of the data provided by these studies.

The above evaluations will necessarily entail subjective judgements and will therefore be carried out by two reviewers working in collaboration. A summary table will list for each review finding—primary contributing studies, evaluations of the above four domains, an overall confidence rating (high, moderate, low, or very low), and an explanation of the rating judgement.

The results section of the review will summarise the findings of (i) the thematic synthesis of quantitative studies, (ii) the thematic synthesis of qualitative studies, and (iii) the aggregation (comparison and juxtaposition) of both sets of findings.

The results will offer an account of current understandings of patient experiences and perspective regarding PICC, Hickman-type, and Port devices in the context of anti-cancer treatment. They will explore the extent to which and/or the ways in which these devices affect patients’ quality of life. Comparisons between experiences of different devices, or between especially positive and negative experiences, will be explored as appropriate and similarities and differences discussed and tabulated, if the data lend themselves to this. Not all relevant comparisons can be identified in advance, so other comparisons may become important. Finally, the results of this review will consider the gaps in the existing literature and of ways in which existing data can be used to support patients.

Abbreviations

Confidence in the Evidence from Reviews of Qualitative research

Central venous access device

Mixed Methods Appraisal Tool for the appraisal of qualitative, quantitative, and mixed methods research

Peripherally inserted central catheter

Framework for the development of systematic literature searches. Acronym derived from key aspects of empirical studies: Population, Intervention, Comparison, Outcome

Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols

Adaptation of PICO for the development of systematic searches of qualitative literature. Acronym derived from key aspects of empirical studies: Sample, Phenomenon of Interest, Design, Evaluation

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Caoimhe Ryan & Olivia Wu

School of Medical Education, Newcastle University, Newcastle upon Tyne, UK

Hannah Hesselgreaves

Institute of Cancer Sciences, University of Glasgow, Glasgow, UK

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Contributions

CR drafted this manuscript. HH contributed to the design of the protocol and provided input across all sections. OW provided guidance during the initial development of this protocol and offered comments on full drafts of the protocol. JDH was consulted during the development of the protocol and provided comments on full drafts. JP was consulted during the development of the protocol and provided comments on full drafts. JM offered expertise regarding limitations by year for the systematic review described as well as comments on full drafts of the protocol. All authors read and approved the final manuscript.

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Additional file

Additional file 1:.

PRISMA-P checklist. (DOCX 35 kb)

Ovid MEDLINE(R) via Ovid 1946 to Week 2 2017

exp Vascular Access Devices/

Catheterization, Central Venous/

(central venous adj5 (catheter* or access)).tw.

percutaneous catheter*.tw.

(venous adj5 (catheter* or access)).tw.

vascular access.tw.

hickman*.tw.

((perhiperally adj5 catheter*) or PICC*).tw.

(implant* adj5 catheter*).tw.

(venous adj5 Port*).tw.

(Portacath* or Port-a-cath*).tw.

(implant* adj5 Port*).tw.

(implant* adj5 reservoir*).tw.

(subcutaneous* adj5 Port*).tw.

(tunnel* adj5 catheter*).tw.

exp Neoplasms/

chemotherapy.tw.

(tumor* or tumour*).tw.

cancer*.tw.

malignan*.tw.

oncolog*.tw.

exp Patient Satisfaction/

(patient* adj5 experience*).tw.

(patient* adj5 perspective*).tw.

(patient* adj5 view*).tw.

(patient* adj5 attitude*).tw.

(patient* adj5 opinion*).tw.

(patient* adj5 satisf*).tw.

(patient* adj5 accept*).tw.

(patient* adj5 evaluat*).tw.

(patient* adj5 assess*).tw.

(patient* adj5 choice*).tw.

(patient* adj5 decision*).tw.

(patient* adj5 prefer*).tw.

(patient* adj5 (questionnaire* or survey*)).tw.

16 and 23 and 38

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Ryan, C., Hesselgreaves, H., Wu, O. et al. Protocol for a systematic review and thematic synthesis of patient experiences of central venous access devices in anti-cancer treatment. Syst Rev 7 , 61 (2018). https://doi.org/10.1186/s13643-018-0721-x

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Meta-thematic synthesis of research on early childhood coding education: A comprehensive review

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The growing significance of coding in 21st-century early childhood education extends beyond technical proficiency, encompassing cognitive development, problem-solving, and creativity. Coding is being integrated globally into educational curricula to prepare students for the digital era. This research examines coding’s potential impact on cognitive and socio-emotional development and emphasizes the need for evidence-based analysis. A meta-thematic analysis synthesizes qualitative data from various studies in a study on coding’s effects on preschool children’s cognitive and socio-emotional development. It focuses on two themes: cognitive contributions and socio-emotional contributions. Thirteen suitable studies were identified from 942 visualized using the PRISMA flow diagram. Coding education enhances cognitive and socio-emotional skills in preschoolers, with implications for curriculum integration. In summary, coding’s holistic benefits in early childhood education are explored, and a meta-thematic analysis investigates its influence on cognitive and socio-emotional domains in preschoolers, emphasizing the need for rigorous evidence-based research.

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1 Introduction

Technological developments require new generations to acquire specific skills (P21). As technology has become an integral part of our lives, understanding basic computing structures and applications has become essential knowledge required in the 21st century (Czerkawski, 2015 , October). Therefore, it is widely recognized that digital literacy is essential in today’s information society (Barendsen & Stoker, 2013 ). Beyond digital literacy, coding, which refers to using languages that enable computing, is increasingly recognized as a new literacy (Bers, 2020 ; Burke et al., 2016 ; Vee, 2013 ).

When Papert ( 1980 ) developed LOGO, the first programming language to support children’s mathematical skills, he firmly believed that it influenced children’s thinking and led them to think, build, and design in new ways (Papert, 1980 , 2000 , 2005 ). Interest in Papert’s views, which draw attention to the basic concepts of computer science, has increased. This interest has led to the need to enable individuals to take an active and creative role in the use of new cognitive skills and technologies, such as code literacy, and the promotion of programming skills in the early years as essential educational support (Muñoz-Repiso & González, 2019 ). Lin and Weintrop ( 2021 ) stated that computing and the technologies it enables are reshaping the world, and they emphasized that every aspect of our lives is influenced by technology, from how we work and learn to how we play and socialize. Given this increasing presence in our lives, providing opportunities and tools to help people understand how technologies work and train them to control them is becoming an increasing focus of computer education efforts.

Coding is being promoted as a new literacy for all students at all levels of education, including very young children, and is seen as a necessity of the 21st century (Bers, 2019 ; Lye & Koh, 2014 ). For this reason, in recent years, efforts to teach coding and computational thinking, the basic concepts of computer science, in early years and to integrate them into educational processes have increased. These efforts have also accelerated classroom practices and research in this field. However, the studies focus on children’s coding and computational thinking skills (Macrides et al., 2022 ; Papadakis et al., 2016 ; Popat & Starkey, 2019 ). However, Papert ( 1980 ) stated that children’s building using technology and writing code is a new way of thinking for children and that children develop many skills while writing code. For this reason, it is necessary to examine and support the effects of coding on children’s developmental areas in preschool.

Coding is defined as an essential 21st-century skill and literacy that affects all areas of life (Bers et al., 2019 ; McLennan, 2018 ; Monteiro et al., 2021 ; Vee, 2013 ), which is defined as the process of writing the correct syntaxes in a ruleful and sequential manner using command sets and developing applications in order to solve problems, provide human-computer interaction, and enable computers to perform a specific task (Bers et al., 2019 ; Demirer & Sak, 2016 ; Fesakis & Serafeim, 2009 ; Kalelioğlu et al., 2016; Li et al., 2020; McLennan, 2018 ; Vorderman, 2019 ; Wing, 2006 ). Coding is the process of developing systematic ways to solve problems by creating algorithms, which are a set of instructions used to describe each step to perform a specific task or solve a problem (Campell & Walsh, 2017; Ching et al., 2018 ; Lee & Junoh, 2019 ; Lee & Björklund Larsen, 2019 ; McLennan, 2017 ; Vorderman, 2017). The thinking style in coding is seen as the process of numerical thinking, solving problems using algorithms and developing a logical approach, analyzing and organizing data, dividing problems into small and manageable parts, transforming them into specific algorithms, and transforming and organizing them into programming languages (Arabacıoğlu et al., 2007 ; Bers et al., 2019 ; Futschek, 2006 ; Futschek & Moschitz, 2011 ; Gibson, 2012 ; Li et al., 2020; Sullivan et al., 2017 ; Van-Roy & Haridi ( 2004 ).

2.1 Coding in preschool

Coding, a new form of literacy, has become a fundamental tool for reading and interpreting data and communicating with others in a digital society, providing an opportunity to connect children with technology. Thus, coding goes beyond algorithmic thinking and offers children a symbolic language to read and write (Bers, 2018a , 2018b; Mclennan, 2017 ). Despite different conceptual approaches, coding, which is seen not only as a set of technical skills but also as a social and cultural issue involving different fields of knowledge, basically involves thinking like a computer scientist (Grover & Pea, 2018 ), creating and collaborating (Kafai & Burke, 2014 ), and using computing languages, which are especially important for future generations (Monteiro et al., 2021 ). Bers ( 2019 ) argues that, similar to natural languages, children should be introduced to and familiarized with these new artificial languages from an early age. Monteiro et al. ( 2021 ) emphasize that this artificial language should develop children’s perceptual, expressive, and creative skills and lay a strong foundation for developing critical and functional competencies. They also cite understanding “artificial languages” used to create digital structures and transformations as a fundamental skill. In this context, Rushkoff ( 2010 ) states that being able to use the language of computers is emerging as an inevitable skill that allows us to participate fully and effectively in the digital reality that surrounds us. González ( 2015 ) and Bers ( 2019 ) state that individuals will join the new world as code literate when they can read and write in the language of computers and other machines and think numerically.

The literature emphasizes that coding as literacy in preschool education enables the development of personal and social skills that enable children to express, share, and create using computer science languages, ways of thinking, and creativity (Bers, 2020 ; Grover & Pea, 2018 ; Kafai & Burke, 2014 ; Monteiro et al., 2021 ; Resnick & Rusk, 2020 ; Vee, 2013 ). Coding is increasingly recognized as a new literacy that should be encouraged at the right age (Monteiro et al., 2021 ). In recent years, countries and scholars have emphasized the importance and necessity for children to develop the fundamental understandings, skills, and thinking approaches emerging in computer science, such as coding, programming, and computational thinking (García-Valcárcel et al., 2017; Liu et al., 2017 ; Webb et al., 2017 ; Wilson et al., 2010 ). Education stakeholders have begun to emphasize that coding, like mathematics and literacy, is essential for everyone. On January 17, 2018, the European Commission presented a new “Digital Education Action Plan” for Europe to help educational institutions and education systems better adapt individuals to live and work in an era of rapid digital change (Bocconi et al., 2018 ; Webb et al., 2017 ; Wilson et al., 2010 ). The European Commission has also taken an active role in this regard and started to promote coding as today’s literacy (Moreno-León et al., 2015 ).

When the studies on coding skills are examined, it is emphasized that coding provides children with an essential skill necessary for participation in the digital society and contributes to developing all children into computational participants (Kafai & Burke ( 2014 ). In addition, while coding develops children’s critical and creative thinking skills, it also supports their computational competencies (Grover & Pea, 2013 ). The coding process develops problem-solving, reasoning, acquisition of mathematical concepts, meta-cognitive skills (Akyol-Altun, 2018 ; Baytak & Land, 2011 ; Clements & Nastasi, 1999; Çiftçi & Bildiren, 2019; Fessakis et al., 2013 ). (Israel et al., 2015 ; Lai & Yang (2011) Lambert & Guiffre, 2009 ; Sengupta et al., 2013 ); creative thinking skills (Kim, Chunk, & Yu (2013). As Papert ( 1980 ), one of the pioneers of computer science education, emphasized, coding can be generalized for children’s lifelong learning and development, giving them a valuable intellectual structure. In the last decade, numerous research and policy initiatives have focused on the conceptual and technical aspects of introducing coding to young children and the cognitive and social aspects underlying this trend (Monteiro et al.)

Studies on coding in early childhood show that intensive efforts are being made to teach coding skills to children in their early years. It is seen that there have been significant developments in areas such as how to teach coding, instructional approaches, and the assessment of these skills. However, it is necessary to reveal how children and educators conceptualize coding in early childhood and their views on its contribution to development.

When studies on coding skills are examined, coding provides a fundamental skill necessary for participation in the digital society and significantly contributes to children’s developmental areas. According to Papert ( 1980 ), one of the pioneers of computer science education, coding can be generalized for children’s lifelong learning and development. It can equip them with a valuable intellectual structure. In the last decade, numerous research and policy initiatives have focused on the conceptual and technical aspects of introducing coding to young children and the cognitive and social aspects underlying this trend (Monteiro et al.).

2.2 The effect of coding on development

Many countries have incorporated coding education into school curricula (Heintz et al., 2016 ; Hsu, 2019 ). The United States, 16 European countries (Austria, Bulgaria, Czech Republic, Denmark, Estonia, France, Hungary, Ireland, Israel, Lithuania, Malta, Malta, Spain, Poland, Portugal, Slovakia, and the United Kingdom), as well as New Zealand, Australia, Singapore, and Nordic countries have integrated coding into the curriculum at the national, regional, or local level (Bers 2018b; Bocconi et al., 2018 ; Digital News Asia, 2015 ; European Schoolnet, 2015 ). This effort has made coding a new focus of instructional processes starting from early childhood (Bers, 2018a , 2018b; Barron et al., 2011 ; Bers, 2018; CSTA, 2020 ; Grover & Pea, 2013 ; ISTE, 2019 ; NAEYC, 2012 ; US Department of Education, 2010 ; K-12 CSframework, https://k12cs.org/ ).

In recent years, the widespread use of innovative coding platforms, especially screenless programmable robots, has made it possible to integrate coding into early childhood education (Su et al., 2023 ), but classroom applications have not gained momentum. However, Macrides et al. ( 2022 ) and Papadakis et al. ( 2016 ) revealed that these studies were primarily aimed at supporting coding and IS skills. Popat and Starkey ( 2019 ) stated that the revival of coding in the school curriculum promises to prepare students for the future beyond just learning to code. In their review, Popat and Starkey ( 2019 ) found that various other educational outcomes, such as problem-solving, critical thinking, social skills, self-management, and academic skills, can also be learned through teaching coding.

2.3 Effects on cognitive development

There is still a limited understanding of the effects of learning to code on the cognitive development of young children. Although more studies are needed in this area (Relkin et al., 2021 ), studies prove the positive effects of coding on children’s cognitive attitudes, knowledge, and skills (Bers et al., 2014 ; Çiftci & Bildiren, 2020 ; Sullivan & Bers, 2016 ). Coding contributes to developing these skills involving analysis, problem-solving, concept development, transforming problems into specific algorithms and programming languages (García- Peñalvo et al., 2016 ), and spatial reasoning and logic (NAEYC, 2012 ). García- Peñalvo et al. (2016) argued that since children develop their thinking skills through language, learning to use a programming language involving logical sequencing, abstraction, and problem-solving also supports their analytical thinking skills. In a rapidly changing digital society, coding is thought to be useful for children to develop computational thinking skills (Bers et al., 2014 ; Chou, 2020 ), mathematical thinking (Goldenberg & Carter, 2021 ), problem-solving, critical thinking, and higher order thinking (Ackermann, 2001 ; Bers et al., 2002 ; Bers, 2010 ; Bers & Horn, 2010 ; Clements & Gullo, 1984 ; Clements & Meredith, 1993 ; Kazakoff & Bers, 2012 ; Lee et al., 2013 ; Popat & Starkey, 2019 ; Portelance et al., 2016 ; Strawhacker et al., 2015 ).

Coding helps develop cognitive abilities such as systematic thinking, problem-solving, relationships between events, and creative thinking (Fesakis & Serafeim, 2009 ). For this reason, studies are showing that coding practices contribute significantly to children’s cognitive development (Grover & Pea, 2013 ; Kazakoff & Bers, 2012 ; Kazakoff et al., 2013 ; Papadakis et al., 2016 ). Recent studies on this subject have examined cognitive development (Flannery et al., 2013), sequencing skills (Caballero-Gonzalez et al., 2019; Kazakoff et al., 2013 ; Kazakoff & Bers, 2014 ), problem-solving skills (Akyol-Altun, 2018 ; Bers et al., 2014 ; Fessakis et al., 2013 ; Koç, 2019; Saxena et al., 2020 ), executive functions (Di Lieto et al., 2017 ), creativity (Flannery & Bers, 2013; Resnick, 2006 ; Siper-Kabadayı, 2019 ; Sullivan & Bers, 2017, 2019 ; Wang et al., 2011 ), and computational thinking (Batı, 2022; Bers et al., 2014 ; Bers et al., 2019 ; Caballero-Gonzalez et al., 2019; Kalogiannakis & Papadakis, 2017 ; Kazakoff et al., 2013 ; Papadakis et al., 2016 ), and visuospatial skills (Bers et al., 2014 ; Flannery et al., 2013).

2.4 Effect on social-emotional development

Bers ( 2020 ), who sees coding as another language and a new literacy and presents its general framework, refers to coding as “expressive symbolic systems” and “computational thinking tools.” However, she emphasizes that focusing only on information processing ignores the symbolic language aspect of coding, an expressive tool and that a language can be a language when it has a social and a mental side. Moreover, she emphasizes that coding as literacy should include not only thinking like a natural language but also expression and communication or social interaction, which involves doing, creating, and bringing into being. Bers ( 2008 ) states that coding, like writing, is a tool for human expression and emphasizes that in this process, children seek new ways of thinking and expressing new ideas and develop new thinking, feeling, and communication skills through this impressive process.

Coding provides the necessary motivation for children to learn programming in more detail and supports their emotional aspects by enabling them to transform ideas into products (Heikkilä, 2020 ; Toh et al., 2016 ). Machines have become a part of our lives, and we communicate with them just as we do with other individuals. For this reason, García- Peñalvo et al. (2016) stated that coding enables children to collaborate better with machines.

Fox and Farmer ( 2011 ) state that children not only manipulate objects and learn rules while creating concrete products through coding but also write codes, build artifacts in virtual environments, and review, share, and revise them. For this reason, it is emphasized that coding activities allow students to cooperate with their peers and provide highly sustainable participation in problem-solving and reasoning (Fox & Farmer, 2011 ). Studies have found that computers can act as a catalyst for social interaction in early childhood education classrooms (Clements, 1999 ) and that children have twice as much social interaction in front of computers as in other activities (Svensson, 2000 ) and speak twice as many words as in non-technology-related activities (New & Cochran, 2007 ). Coding education, whether provided through block-based applications or robotic tools and activities, can improve children’s peer collaboration, communication, and social relations (Bers et al., 2019 ; Lee et al., 2013 , 2017 ; Sullivan & Bers, 2018 ; Wartella & Jennings, 2000 ), social development and socially oriented development (Bers, 2012 ; Caballero-Gonzalez et al., 2019; Critten et al., 2022 ; Fessakis et al., 2013 ; Flannery et al., 2013; Pugnali et al., 2017 ; Strawhacker & Bers, 2015 ) and self-regulation skills (Kazakoff, 2014 ).

The findings of this study provide evidence that coding contributes to some children’s developmental areas. In addition, the opinions and perceptions of the participants regarding coding are also seen as a factor that will contribute to the field. The views of children who receive coding education and teachers who work with children on the effects of coding on development are considered necessary to guide the studies conducted in this field and the practices and curricula to be developed.

2.5 Review studies on coding

Many systematic analysis studies have been conducted on coding at the K-12 level. Lye and Koh ( 2014 ), who conducted one of these studies, revealed that empirical studies on early childhood are lacking. However, since Lye and Koh ( 2014 ) drew attention to the deficiency in the field of early childhood, it is seen that studies in this field have increased rapidly. With this increase, the studies conducted in this field have started to be analyzed. There are a limited number of review studies conducted for preschool children. Papadakis et al. ( 2016 ) present a literature review including 18 studies on how the ScratchJr application affects children’s CT, coding, and general literacy skills in preschool. The study emphasized that ScratchJr seems to be a helpful application that positively affects children’s IT and coding skills. Popat and Starkey ( 2019 ) included 11 studies in their review study to analyze the educational outcomes of children learning coding at school. Of these studies, only one was on the problem-solving skills of 5-6-year-old children. Other studies are primarily studies for primary school children. Popat and Starkey ( 2019 ) stated that the studies show that students can learn coding and that they can learn several other educational outcomes (such as mathematical problem-solving, critical thinking, social skills, self-management, and academic skills) through coding instruction.

Sulistyaningtyas et al. ( 2021 , September) reviewed 9 studies on coding for early childhood children between 2015 and 2020. This review includes two main objectives: coding practices in early childhood and the impact of coding on early childhood development. In the study, unplugged and plugged activities were used in early childhood, and Children’s planning and inhibition skills in communication, collaboration, and creativity were stated as learning outcomes. Macrides et al. ( 2022 ) analyzed the studies on programming in early childhood education. This review study analyzed 34 studies for children aged 3–8 years. Of these studies, 5 were conducted with children over 6. These findings show that there has been a significant increase in studies on preschool children in recent years. The intervention programs examined in these studies primarily focus on teaching coding (11 studies) and IT skills (11 studies), with limited attention given to supporting children’s overall development. Among the studies targeting developmental areas, the emphasis is mainly on cognitive aspects, particularly problem-solving and creativity. Zurnacı and Turan ( 2022 ) reported that, in Turkey, there were 30 studies on preschool coding, consisting of 11 qualitative, 11 quantitative, and 4 mixed-methods studies. These studies predominantly address coding and IT skills but also address academic, cognitive, language, and social skills.

Su et al. ( 2023 ) reviewed 20 studies on early childhood coding curricula published in 2012–2021. In this study, educational practices for children were examined in depth. In this review, how the curricula in educational practices for children are designed, which coding platforms or applications are used, what pedagogical approaches are used, research methods, and findings obtained from these studies were examined in depth. In recent years, educational approaches to support preschool children’s coding skills have increased, and robotics, Web 2.0 tools, and web-based applications have been developed to support children’s coding skills. These studies have revealed that children can acquire coding skills early on. However, it is essential to examine how coding skills contribute to children’s other developmental areas and to develop research and applications in this field. This review of coding has contributed significantly to the current state of the art in this field, as well as the needs and future research. Resnick and Rusk ( 2020 ) note that over the past decade, they have seen that it is possible to extend coding experiences to millions of children worldwide. At the same time, they emphasize that there are extraordinary challenges, that coding has been introduced in ways that undermine its potential and promise in many places, and that educational strategies and pedagogies to introduce coding must be carefully discussed. For this reason, in addition to the quantitative data on coding, it is thought that knowing how teachers and children interpret coding can shed light on similar future studies. For this reason, this study aims to shed light on future studies by comprehensively examining qualitative studies on preschool children and the effects of coding on children’s developmental areas in these studies.

3 Methodology

3.1 research model.

This research endeavors to ascertain the impact of coding instruction on preschool-aged children’s cognitive and socio-emotional development. The primary objective of this investigation is to undertake a systematic analysis of qualitative primary data, discerning recurring themes and topics elucidating the effects of coding education on children’s development. This analytical process culminates in synthesizing these identified themes and topics, ultimately facilitating the derivation of comprehensive conclusions. In the context of this research, the meta-thematic analysis approach is recurrently utilized to meticulously dissect the primary qualitative data (Thomas & Harden, 2008 ). Specifically, this study adopts a meta-thematic framework to synthesize qualitative studies concerning preschool children and their engagement with coding education. Within the purview of the meta-thematic analysis, three overarching themes are meticulously examined:

Theme 1: “What are the cognitive ramifications of incorporating coding education in preschool settings?”

Theme 2: “What are the socio-emotional implications stemming from integrating coding education in preschool contexts?”

Theme 3: “ What are the comparisons of theses data and research articles data ?”

These themes provide the structural foundation for the comprehensive investigation into the multifaceted impacts of coding education on preschool-aged children’s cognitive and socio-emotional development.

3.2 Studies included in the study

In this study, studies on coding education at the preschool education level were investigated within the scope of meta-thematic analysis. The criteria for the inclusion of the study in the meta-thematic analysis were determined as follows:

Being at the level of preschool education (0–6 years),

Aiming to measure the effects and limitations of coding education on students’ cognitive, emotional, and social context,

Scientifically qualified and sufficient,

Including direct participant views,

Being an experimental study,

Being a thesis or article,

The studies were selected according to these criteria.

In the study, seven databases, including “Science Direct-SD,” “Taylor and Francis-TF,” “Higher Education Council Thesis Center (YokTez-YT),” “Dergipark,” “ProQuest-PQ,” ERIC-E,” and “Web of Science-WOS,” were utilized. The databases were searched with the keywords “preschool coding,” “early childhood coding,” “computer-free coding,” “preschool programming,” and “early childhood programming.”

The articles and theses searched in the database were selected based on the above criteria. At the end of this study, 942 studies had been reached. Based on the criteria at the end of the evaluation, 13 articles were included in the meta-thematic analysis. The number of included and excluded studies in the meta-thematic analysis is presented in Fig.  1 using the PRISMA flow diagram (Moher et al., 2009 ).

Flow diagram of the studies included in the meta-thematic analysis

According to the criteria presented in the PRISMA flow diagram in Fig.  1 and 942 studies examining the research topic were reached. Based on the evaluation according to the research criteria, some studies were eliminated by not being included in the meta-thematic analysis. Two of the studies scanned in the databases were eliminated due to duplication. Another 653 studies were eliminated from the remaining studies due to irrelevant topics. Of the remaining 287 studies, 182 studies were eliminated because they were not suitable for the primary purpose as a result of abstract screening. Of the remaining 105 studies, 88 were eliminated due to qualitative evaluation. Of these studies, 62 were eliminated because there was no qualitative interview data, and 26 were eliminated because there was no experimental study. Among the remaining 17 studies, as a result of the research conducted at the level of the findings, it was determined that the data of four studies needed to be sufficient and appropriate in terms of content and were eliminated. Thus, 13 studies were reached as a result of the screening. This study is limited to 13 studies accessed during the meta-thematic analysis process and included in the analysis. Although this situation is considered a limitation of the study, it follows the nature of meta-thematic studies (Batdı, 2017 , 2019 ).

The reasons for not including the studies that were not included in the meta-thematic analysis are shown in Table  1 . Accordingly, 942 studies were collected from 7 databases, and 929 were eliminated for the reasons shown in Table  1 . 13 studies were included in the meta-thematic analysis.

General information on the articles and the theses used in this study is given in Table  2 below.

The provided sources offer a diverse range of perspectives and insights on the integration of coding into education. Despite this diversity, the common thread across all sources is their emphasis on the importance and benefits of integrating coding into educational settings. They highlight how this integration can address various challenges educators face, such as teaching abstract concepts, fostering creativity, and enhancing problem-solving skills among students. Moreover, the sources underscore the significance of providing resources and support for educators to incorporate coding into their teaching practices effectively. However, differences emerge in the themes explored and the depth of analysis offered. For instance, some sources delve into the practical challenges educators face in implementing coding activities (E1, SD), while others focus on the pedagogical benefits and implications of such integration (WOS, PQ). Overall, while the sources vary in their approach and emphasis, they collectively advocate for integrating coding as a valuable tool for enhancing education and preparing students for the demands of the digital age.

The codes obtained in the meta-thematic analysis related to coding education in preschool were grouped under three themes. In this context, the titles “Contributions of coding education in preschool to the cognitive domain,” “Contributions of coding education in preschool to a social-emotional domain,” and “Comparision of theses data and research articles data” were accepted as themes.

In the current study, the theme created by the researcher related to the research topic and the codes that make up the theme were discussed separately and presented with the findings. At the same time, in interpreting the findings, the sources from which the codes were referenced were directly quoted and supported by the presentation of the themes and codes.

4.1 Contributions of coding education in preschool to the cognitive domain

In the meta-thematic analysis, the sub-problem of the research, “Contributions of coding education in preschool to the cognitive domain,” was taken as a theme. Participant opinions were analyzed in the studies, and codes were created regarding their statements. Codes were created for features such as coding education in preschool, developing students’ intelligence, developing cognitive skills, and reinforcing what is learned.

Contributions of coding education in preschool to the cognitive domain

As a result of the meta-thematic analysis, three sub-categories and ten codes were reached under the theme “Contributions of Coding Education in Preschool to Cognitive Domain.” These codes are shown in Fig.  2 ; Table  3 with the frequency and percentage values. Two experts (academicians) from the field of educational sciences worked on the codes and grouped them into three sub-themes.

The skills development sub-category covers the skills that students are expected to develop, especially those widely referred to as 21st-century skills. During the coding process, it was observed that students especially developed these skills. The codes in the learning enhancement sub-category cover the skills that need to be acquired in daily life and learning towards the permanent learning process. In this case, it is an essential skill that emerges in the final learning process. Interdisciplinary contribution is an important dimension in education that is becoming increasingly important today. In this study, it emerged as a sub-dimension, albeit a very small one.

Table  3 shows that the codes are grouped around three sub-categories. Among these sub-categories, skills development has the highest rate, with 75.3%. Learning enhancement is the sub-category with the second highest rate of 23.6%. Interdisciplinary contribution is the sub-category with the lowest rate of 1.1%. In this context, it can be said that coding education develops skills in preschool children in general.

These codes belong to the skills development sub-category. The contribution of coding education in the cognitive dimension was to develop problem-solving skills with 26.4% and directing (commanding) skills with 24.7%. This skill can also be expressed as a computational thinking skill. This code emerged from the statements about students giving commands to the robot or computer and directing it. In the thesis coded YT3-p.73, the statement “ Then it would be like this. First, I program it to turn silently, then play a birthday song, and then turn it off .” “ It is to teach ways to tell tools such as computers and phones what to do. ” In the article coded E3-p.10, the statement “ I need to stick the arrows in the right direction and take this character to dinner by following the path… ” can be shown as an example.

The code for problem-solving skills was found 47 times in the studies. Some of the statements referenced in this code are “ I believe that it will contribute to the development of children’s abilities in areas such as thinking skills, logic development, problem-solving, etc .” in the article coded E2- p.753. In the thesis coded YT2-p.55, the statement “ It is an approach that provides problem-solving, creativity and analytical thinking skills. ” can be given as examples.

For the code related to the development of creativity: in the thesis coded YT6-p.117, the statement “ They did not have difficulty in applying the new rule as before, they created new rules themselves and turned this situation into a new game ” in the thesis coded YT1-p.68, the statement “ We adjust those things when we press it, it does the coding we want, it does the coding according to our imagination .” and in the article coded PQ-p.304, the statement “ It develops creative thinking and improves cooperative learning. It was collaborative training because we carried out the activities in two groups.”

These codes serve as crucial indicators of the impact of coding education on cognitive dimensions, showcasing its role in enhancing problem-solving skills, directing abilities (such as computational thinking), and fostering creativity among students. They are supported by specific statements and instances extracted from the qualitative research studies, demonstrating real-world applications and observations.

These codes belong to the learning enhancement sub-category. The references related to the code of transferring to daily life: in the thesis coded YT4-s.119, the statement “ There were touches about life-related to the general program. In other words, you always tried to associate it with life rather than sitting down and doing fashion mode robotics training…” and in the thesis coded YT3-p.76, the statement “ They reach places that we cannot reach… For example, lifting large items… ” can be given as examples.

Regarding the effective learning code: In the article coded E1-p.63, the statement “ Taking some concepts through disconnected activities that they already had some experience with and using them to apply them with technology helped them respond quickly and understand better .” can be given as an example.

Codes related to permanent learning: In the thesis coded YT6-p.115, statements “ They did not forget the order of events in the story. Each child made small changes in the story for his/her next friend, and the other child had no difficulty remembering or practicing .” Regarding the code of facilitating learning: In the thesis coded YT4- p.120, the statement “…They had much difficulty in the activities we did about graphics. At the end of the training process, they were able to do such activities much more easily. ” can be given as an example. Regarding the statement in which the code for being comprehensive was revealed: In the article PT4- p.119, the statement “ The activities in the implemented education program were very comprehensive and numerous. Turkish language, art, science, mathematics, drama, play, etc. activities in the preschool program were all included, . .” can be given as an example.

These codes collectively illustrate how coding education transcends theoretical learning, promoting practical application in daily life, improving learning efficacy, supporting long-term knowledge retention, enhancing skill mastery, and contributing to a comprehensive educational experience across different subject areas.

These codes belong to the interdisciplinary contribution sub-category. For the code of contributing to different disciplines: in the article coded PQ-p.311, the statement “ For example, I can use it in animals, colors, shapes, internal organs, and mathematics activities. ” can be given as an example. Regarding the code for the development of intelligence and manual skills: in the article coded E2-p.755, the statement “ I think it was beneficial for the development of intelligence. Being careful helped a lot in the development of manual skills. I also believe using the materials will improve the sensory organs .” can be shown as an example.

These codes emphasize the broad spectrum of benefits associated with coding education. They show how coding contributes to diverse subject areas and is pivotal in enhancing cognitive abilities, fostering manual dexterity, and potentially improving sensory perception through materials and hands-on experiences.

4.2 Contributions of coding education in preschool to the social-emotional domain

In the meta-thematic analysis, the sub-problem of the study, “ Contributions of coding education in preschool to the social-emotional domain ,” was taken as a theme. The participants’ opinions in the articles and theses obtained from the research were examined, and codes were created regarding their statements. Codes such as motivating, fun, and cooperative learning were created for coding education in preschool. As a result of the meta-thematic analysis, eight codes were found under the theme “Contributions of coding education in preschool to a social-emotional domain.” These codes are given in Fig.  3 . In addition, Table  4 below shows the frequency and percentage values of the codes.

Contributions of coding education in preschool to the social-emotional domain”

As a result of the meta-thematic analysis, two sub-categories and eight codes were reached under the theme “Contributions of Coding Education in Preschool to Social-Emotional Domain.” These codes are shown in Fig.  3 ; Table  4 with the frequency and percentage values. Two experts (academicians) from the field of educational sciences worked on the codes and grouped them into two sub-themes.

These sub-categories encompass crucial facets of comprehensive growth. Social and behavioral development entails the acquisition of proficiencies indispensable for efficacious engagement, collaboration, and adjustment in diverse social contexts. Personal development and empowerment concentrate on individual advancement, nurturing resilience, self-assurance, and self-governance to empower individuals to navigate life with certitude. In unison, these categories epitomize manifold dimensions of human maturation and skill enhancement.

Table  4 shows that the codes are grouped around two sub-categories. Social and behavioral development has the highest rate among these sub-categories, with 76.5%. Personal development and empowerment is the sub-category with the second highest rate of 23.5%. In this context, it can be said that coding education develops social-emotional aspects in preschool children in general.

These codes belong to the social and behavioral development sub-category. The code with the highest percentage value was the code of being fun, with 25.9%. Codes related to being fun: In the thesis coded YT6-p.118, the statement “ They had much fun in the game of reaching the nest through obstacles. They put the obstacles in different places and continued to play. ” and in the article coded PQ-p.309, the statement “ It should be included in the school curriculum. It provides cognitive thinking as it both entertains and provides problem-solving skills and even cooperation… ” can be given as an example.

The codes related to supporting cooperative learning and communication can be referenced as follows: “ In the field of social-emotional development, the fact that children look for solutions together, communicate and help each other during programming activities supports the development of collaborative attitude in children .” in the thesis coded YT2- p.64 and “… The fact that group activities were given much space and the groups were mixed strengthened their communication .” the thesis coded YT4- p.120 can be given as examples. Regarding the curiosity code: In the thesis coded YT5- p.78, the statement “ I want to place the cubes immediately for my character to move. ” can be exemplified.

These codes underscore how coding endeavors impart technical proficiencies and yield considerable benefits towards cultivating intangible skills, such as collaboration, proficient communication, and inherent drive and intellectual inquisitiveness, among students.

These codes belong to the personal development and empowerment sub-category. In the present study, 9.9% was found for the code of increasing motivation. The statement “ They were also eager to put the blocks together to create different dances .” In the articles WOS- p.341 and SD- p.142, the statement “… KIBO was an extraordinary source of motivation for our students” can be cited as examples. About the code related to gaining responsibility: In the article SD- p.141, the statement “…Progress was made in supporting values such as respect for a partner and their ideas, the ability to wait, the development of responsibility and autonomy, and the care of materials… ”. Regarding the code for increasing self-confidence: In the article PT2- p.64, the statement “… Learning new things makes children feel good and increases their self-confidence. They express that they are happy after the activity. ” can be given as an example. Referring to the codes related to providing focus: In the article coded E2- p.754, the statement “ The application contributed to the development of children in areas such as cooperation, sharing, focusing and attention… ” can be exemplified.

These codes highlight how coding education transcends technical skills, fostering personal growth by enhancing motivation, instilling a sense of responsibility, boosting self-confidence, and refining essential behavioral attributes like focus and attention.

4.3 Comparision of theses data and research articles data

When the studies are classified as theses and articles and analyzed in terms of similarities and differences, similarities and differences in Target Age Group, Learning Focus, Main Tools, Activities, Benefits, Challenges, Educational Impact, and Teacher Involvement are given in the table in detail (Table 5 ).

The data of research articles delves into the educational application of robotics and coding activities, primarily aimed at young children in preschool and early elementary school. The emphasis is on hands-on learning experiences integrating technology tools such as KIBO and Bee-Bot into the classroom environment. These tools are designed to introduce children to foundational concepts of programming and computational thinking playfully and interactively.

One of the key observations from the research articles’ data is the positive impact of these activities on various aspects of child development. Through engaging with robotics and coding, students demonstrate enhanced teamwork by collaborating with peers to solve problems and complete tasks. The iterative nature of these activities encourages perseverance and determination as students persist in their efforts to achieve success, boosting their confidence along the way.

Teachers and researchers also note the benefits of using structured materials, such as wooden blocks, in conjunction with technology tools. These materials provide tangible, hands-on experiences that help students develop spatial reasoning, problem-solving, and fine motor skills. Moreover, using concrete materials ensures that learning activities are accessible and engaging for all students, regardless of their prior experience or background knowledge.

However, integrating robotics and coding into the curriculum presents its own set of challenges. Educators highlight the importance of starting with unplugged, concrete activities to build foundational understanding before introducing technology-based tools. They also stress the need for adequate teacher training and resources to support effective implementation, particularly in designing developmentally appropriate activities and scaffolding learning experiences to meet the diverse needs of students.

In summary, the data from the research articles underscores the potential of robotics and coding activities to foster critical thinking, collaboration, and creativity among young learners. By providing hands-on experiences with technology tools, educators can help students develop essential skills for success in the digital age while promoting a positive attitude towards learning and exploration. However, achieving these goals requires careful planning, ongoing support, and a commitment to inclusive and equitable education for all students.

Theses data centers around educational activities promoting active participation, problem-solving skills, and curriculum integration. Teachers engage students in diverse activities that target various learning outcomes, including motor skills and cognitive development. These activities are adaptable for different age groups and subjects, allowing for flexibility in implementation.

Teachers reflect on the effectiveness of these activities, considering factors such as student engagement, comprehension, and skill acquisition. While the specific nature of the activities is not detailed, they likely involve hands-on experiences, group collaboration, and exploration of different concepts.

Overall, theses’ data highlight the importance of engaging students in interactive and multidimensional learning experiences that cater to their developmental needs and enhance their understanding of various subjects.

5 Discussion

The fact that computer science is seen as a skill that all individuals should acquire in the early years has increased interest in coding. In addition, innovative coding platforms such as screenless programmable robotics, which have increased in importance in recent years to support 21st-century skills and STEM skills, have increasingly entered children’s early years (Macrides et al., 2022 ). This growing interest in the necessity of coding has increased the efforts of countries to integrate coding into their educational curricula. This increase has also accelerated research in this field. The view that coding is not only about teaching computer science concepts to children but also about skills and literacy has started to gain importance. The view that coding is a skill that provides children with a new perspective, way of thinking, and behavior has been emphasized. However, Popat and Starkey ( 2019 ) and Su et al. ( 2023 ) emphasize that recent studies on coding in early childhood have mainly focused on children’s coding or computational thinking. Su et al. ( 2023 ) pointed out that there are limited studies on the effects of coding on development and that studies should be conducted in this field. Therefore, in this study, qualitative studies on coding were examined to reveal the effects of coding on development. This study has analyzed qualitative studies, considering that they will contribute significantly to this emerging field by examining the work done in this area, what needs to be done in the future, and what kinds of gaps exist.

The meta-thematic analysis aimed to answer the primary research question: “What are the contributions of coding in early childhood education to the cognitive domain?” The findings indicate opinions that coding contributes to directive (command-giving) skills, problem-solving abilities, and fostering creativity. Cognitive-weighted learning outcomes such as transferring knowledge to daily life, effective and lasting learning, and facilitating learning have been highlighted, emphasizing their contributions to various disciplines. Quantitative studies have demonstrated that coding affects sequencing (Kazakoff & Bers, 2012 ; Kazakoff et al., 2013 ; Muñoz-Repiso & Caballero-González, 2019), problem-solving (Akyol-Altun, 2018 ; Bers et al., 2014 ; Çiftci & Bildiren, 2020 ; Fessakis et al., 2013 ), and executive functions (Di Lieto et al., 2017 ). Furthermore, coding and robotics education have significantly supported early mathematical reasoning skills in children (Blanchard et al., 2010 ; Caballero-Gonzalez et al., 2019; Di Lieto et al., 2017 ; Flannery et al., 2013; Kazakoff et al., 2013 ). Canbeldek and Işıkoğlu (2023) observed that coding and robotics education programs positively affected preschool children’s cognitive development, language skills, and creativity. Mısırlı and Komis (2014) found that their implemented program supported the development of mathematical concepts such as sequencing and repetition, algorithmic thinking, measurement, and spatial orientation in children.

Popat and Starkey ( 2019 ) highlighted those researchers mentioned that the inclusion of coding in school curricula provides a range of learning outcomes applicable beyond computer science. Meanwhile, Su et al. ( 2023 ) reviewed studies on coding in early childhood and emphasized that it is a new field focusing on imparting coding skills. The authors suggested evaluating the effects of coding curriculum on holistic learning outcomes in early childhood, such as school readiness skills (e.g., literacy, numeracy, spatial, and social skills). They emphasized the need to assess more critical child developmental outcomes like language, self-regulation, and metacognitive skills to understand the impact of coding curriculum. Zurnacı and Turan ( 2022 ) reviewed studies on coding in preschool education in Turkey, revealing that the most addressed topic was cognitive skills such as problem-solving abilities (in 7 studies), attention, sequencing, and analysis. The findings of this study also demonstrate an emphasis on the limited skills of cognitive development as a multidimensional process related to coding.

The study sought to address the question of “What are the contributions of using coding in early childhood education to the socio-emotional domain?” as the second sub-problem of the research. The study’s findings indicated that coding contributes to the socio-emotional domain by enhancing enjoyment, increasing motivation, fostering collaborative learning, improving communication skills, promoting personal development, empowering through increased motivation for responsibility, enhancing self-confidence, and facilitating focus. Bers ( 2008 , 2012 ), who studies coding in early childhood, states that children should be motivated while using technology and that working in a social and collaborative environment should support social and emotional skills along with these skills. Based on the positive youth development approach, he developed the PTG approach in programs and applications to be developed for children and applied this approach to his applications. In unplugged and block-based applications, he has drawn the framework of learning environments where children can be motivated while coding and develop their social skills by working collaboratively. He presented a road map to change the perspectives that technology negatively affects children’s social and emotional development and to support these areas of development.

Similar studies, like the results of this study, also indicate that coding supports socio-emotional development. Applications focused on coding demonstrate support for children’s peer collaboration, communication, and social relationships (Bers et al., 2019 ; Caballero-Gonzalez et al., 2019; Critten et al., 2022 ; Fessakis et al., 2013 ; Flannery et al., 2013; Lee et al., 2013 ; Sullivan & Bers, 2016 ; Pugnali et al., 2017 ). Studies have shown that coding supports children’s self-regulation skills (Canbeldek and Işıkoğlu, 2023; Di Lieto et al., 2017 ; Kazakoff, 2014 ). Heikkilä ( 2020 ) observed that robotics applications supporting coding generated significant interest in children, increased their patience and enthusiasm, and reduced gender-biased perspectives.

The study sought to address the question of “What are the comparisons of theses data and research articles data?” as the third sub-problem of the research. Theses data, which focus on LEGO-based education, primarily target elementary and middle school students, offering activities that foster creativity, problem-solving, and engineering skills. Students build structures, mechanisms, and robots using LEGO bricks, motors, and sensors. This approach benefits learners by developing their spatial reasoning and engineering abilities, although it can present challenges in the complexity of designs and motor programming. Teachers in this context typically serve as facilitators, guiding students through exploration and experimentation.

In contrast, the data of research articles revolves around robotics and coding education for preschool and early elementary school students. It emphasizes computational thinking, coding skills, and teamwork, often using tools like KIBO and Bee-Bot. Students participate in sequencing, programming, and interactive storytelling, which promote collaboration, critical thinking, and fine motor skills. However, integrating technology and ensuring age-appropriateness can be significant challenges for educators in this domain. Teachers play a more active role in designing activities and scaffolding learning experiences to suit the developmental needs of young learners.

While both topics aim to enhance students’ learning experiences and skills development, their target age groups, learning focuses, main tools, and teacher involvement differ. LEGO-based education leans towards older students and emphasizes hands-on building and engineering, while robotics and coding education cater to younger learners and prioritize computational thinking and programming skills. Despite these variances, both approaches contribute to fostering creativity, problem-solving, and critical thinking skills essential for success in the 21st century.

Due to the nature of meta-thematic research (Batdı, 2019 ), the data used in this study consisted only of articles and theses that presented experimental studies and direct participant views. Therefore, the comparison of articles and thesis studies was limited to these articles. A more detailed comparison is recommended to contribute to the field.

Reviews conducted on coding in early childhood (Lye & Koh, 2014 ; Macrides et al., 2022 ; Papadakis et al., 2016 ; Su et al., 2023 ) have revealed significant findings. These studies have indicated that intervention programs primarily focus on children’s coding and computational thinking skills, with a limited number examining their impact on developmental domains. The present study, however, has demonstrated an understanding of coding’s influence on cognitive and socio-emotional development. Furthermore, a significant finding of this study indicates a focus on a few foundational skills within cognitive and socio-emotional development through coding.

Previous review studies have contributed significantly to coding practices, approaches, methods, techniques, materials, and assessments used in these interventions. They have also outlined a framework for studies centered around coding. Additionally, it is believed that identifying views, thoughts, and trends in the field will provide substantial contributions from practitioners or researchers regarding their perspectives on coding, ultimately strengthening and enhancing studies.

This study suggests a trend indicating that coding contributes to cognitive and socio-emotional domains. However, coding is proposed to support various cognitive and socio-emotional development aspects. It is essential to empirically validate and confirm these views concerning the impacts of coding on development through empirical studies.

Data availability

The data used to support the findings of this study are available from the corresponding author upon request.

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Başaran, M., Metin, Ş. & Vural, Ö.F. Meta-thematic synthesis of research on early childhood coding education: A comprehensive review. Educ Inf Technol (2024). https://doi.org/10.1007/s10639-024-12675-2

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Older people's perspectives on participation in physical activity: a systematic review and thematic synthesis of qualitative literature

Affiliations.

• 1 The George Institute for Global Health, The University of Sydney, Sydney, New South Wales, Australia.
• 2 School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.
• 3 Faculty of Health Science, The University of Sydney, Sydney, New South Wales, Australia.
• 4 Pain Management Research Institute, University of Sydney at Royal North Shore Hospital, Sydney, New South Wales, Australia Departamento de Fisioterapia, Faculdade de Ciências e Tecnologia, UNESP-Univ Estadual Paulista, Presidente Prudente, São Paulo, Brazil.
• PMID: 25586911
• DOI: 10.1136/bjsports-2014-094015

Background: Physical inactivity accounts for 9% of all deaths worldwide and is among the top 10 risk factors for global disease burden. Nearly half of people aged over 60 years are inactive. Efforts to identify which factors influence physical activity behaviour are needed.

Objective: To identify and synthesise the range of barriers and facilitators to physical activity participation.

Methods: Systematic review of qualitative studies on the perspectives of physical activity among people aged 60 years and over. MEDLINE, EMBASE, CINAHL, PsychINFO and AMED were searched. Independent raters assessed comprehensiveness of reporting of included studies. Thematic synthesis was used to analyse the data.

Results: From 132 studies involving 5987 participants, we identified six major themes: social influences (valuing interaction with peers, social awkwardness, encouragement from others, dependence on professional instruction); physical limitations (pain or discomfort, concerns about falling, comorbidities); competing priorities; access difficulties (environmental barriers, affordability); personal benefits of physical activity (strength, balance and flexibility, self-confidence, independence, improved health and mental well-being); and motivation and beliefs (apathy, irrelevance and inefficacy, maintaining habits).

Conclusions: Some older people still believe that physical activity is unnecessary or even potentially harmful. Others recognise the benefits of physical activity, but report a range of barriers to physical activity participation. Strategies to enhance physical activity participation among older people should include (1) raising awareness of the benefits and minimise the perceived risks of physical activity and (2) improving the environmental and financial access to physical activity opportunities.

Keywords: Aging; Elderly people; Exercise; Physical activity.

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• Systematic Review
• Aged, 80 and over
• Anxiety / psychology
• Attitude to Health*
• Costs and Cost Analysis
• Environment Design
• Exercise / psychology*
• Interpersonal Relations
• Leisure Activities / psychology
• Middle Aged
• Muscle Strength / physiology
• Sedentary Behavior
• Self Concept
• Walking / psychology

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Langlois ÉV, Daniels K, Akl EA, editors. Evidence Synthesis for Health Policy and Systems: A Methods Guide. Geneva: World Health Organization; 2018 Oct 8.

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KAREN DANIELS .

• Health systems are sensitive to political, economic and social factors that occur locally, nationally and internationally.
• Context is determined by situational factors, structural factors, cultural factors and international or exogenous factors.
• Implementation and context are highly interconnected, with implementation of evidence-based interventions always taking place within a given context, which in turn influences how the implementation takes place.
• Contextual information is fundamental for policy planning and development, but is often stripped away in systematic reviews.
• Reporting rich contextual information in primary studies helps to enrich the usefulness of subsequent systematic reviews.

4.1. INTRODUCTION

This chapter introduces the notion of context and its relationship to health policies and systems. It then considers how context may be taken into account in systematic reviews and evidence syntheses of health policy and systems research (HPSR) questions. The issue of context is closely related to the methods described in both Chapter 3 and the methods commentary on realist reviews, elsewhere in this volume; it is also fundamental to reviews of complex health interventions, as described and discussed in Chapter 5 .

4.2. THE IMPACT OF CONTEXT ON HEALTH POLICY AND SYSTEMS INTERVENTIONS

• Situational factors, transient or impermanent occurrences, such as a flood, which may lead to an increase in waterborne disease and thus bring attention to issues of sanitation.
• Structural factors, elements that are relatively unchanging or slow to change, such as a country’s political system or its level of inequity, which can determine the extent to which residents depend on public health. High levels of wealth or poverty are likely to also affect a country’s disease profile and other characteristics.
• Cultural factors, including pervasive belief systems, such as beliefs about women, hierarchy and ethnicity, which can shape local policies. For example, in some countries where the dominant religion does not favour abortion, this is mirrored in health policies that do not favour women’s right to access abortion services either.
• International or exogenous factors, whereby nation states, although independent, may also be subject to interdependencies. For example, if one country has managed to control a particular infectious disease (such as malaria), it may be concerned that a neighbouring country has not done the same, and therefore may seek to influence how its neighbour manages the disease.

One of the major contemporary changes facing health systems is the shift in focus from the Millennium Development Goals to the Sustainable Development Goals. Although the decision to adopt the Sustainable Development Goals was made at the United Nations, within the global context, and national governments have agreed to these goals, it is health systems managers at the front line of health care delivery, operating within their local contexts, who will have to adapt their services to reflect this shift within the global context ( 7 ). To take another example, the World Health Organization has responsibility for population health around the globe, that is, the global health system. As such, one of its functions is to set policies and develop guidelines to be used by countries across the globe, in an effort to ensure the highest attainable level of health for all people ( 8 ). These policies and guidelines, which are agreed to as being of global good, or good for the global health system, are then taken up by national governments, which ensure that they are implemented by health workers at the front line of delivery of care.

This context sensitivity contributes to the diversity of varied health systems, and also to their complexity ( 6 , 9 ). Another contributor to diversity is the fact that health systems are path dependent, that is, they are products of historical processes that have shaped them. For example, if a country has a colonial past, then its health system will be shaped by that past, and it may continue to organize services in the same manner as during the colonial period ( 10 ). Health systems are also social institutions, in that they are both a product of the society in which they occur and an influence on that society ( 6 , 11 , 12 ). The values and principles held by the society are likely to be reflected in the health system; for example, if a society values social equity, it may have a health system that favours universal access to health care ( 2 , 6 , 11 ).

Health systems activity takes place at different levels: the macro level (global and national health systems), the meso level (local or district health system) and the micro level (individual health facilities up to the patient–provider interface) ( Figure 4.1 ) ( 13 – 15 ).

The different levels of health systems.

In Europe in particular, reference is also made to a supranational level, because the legal and policy environment created by the European Union affects the health policy environment of European member states ( 16 , 17 ). The specificities, roles and functions of each of these levels are also sensitive to context ( 6 ) and may “vary quite substantially between countries, depending on the type and level of decentralization and autonomy of regions, provinces, or districts” ( 2 ). At the micro level, there are further sublevel divisions, in that health service delivery can take place within communities and at primary health care facilities, as well as at secondary and tertiary care hospitals. Each of these sublevels of front-line service delivery can be seen as a context, with its own systems and contextual interactions. The immediate environment of health services delivery is also sometimes referred to as the setting, although the term “setting” is often used interchangeably with the word “context”. The difference between setting and context is described in Box 4.1 .

Reviews of health policy and systems research questions need to take context into account to enhance the relevance and usability of the research outputs.

BOX 4.1 DISTINGUISHING CONTEXT AND SETTING

The literature is not always clear on the difference between context and setting, with some authors using the terms interchangeably, and others distinguishing the two. The following definitions by Pfadenhauer and colleagues ( 14 , 18 ) are appealing:

Context is ‘‘conceptualized as a set of characteristics and circumstances that consist of active and unique factors that surround the implementation. As such it is not a backdrop for implementation but interacts, influences, modifies and facilitates or constrains the intervention and its implementation. Context is usually considered in relation to an intervention or object, with which it actively interacts. A boundary between the concepts of context and setting is discernible: setting refers to the physical, specific location in which the intervention is put into practice. Context is much more versatile, embracing not only the setting but also roles, interactions and relationships’’ ( 18 ).

Setting ‘‘usually has a narrower focus. It often refers to the place where an intervention is delivered (e.g. primary care setting) or the circumstances of an intervention (e.g. low-income setting)’’ ( 14 ).

4.3. IMPLEMENTING HPSR EVIDENCE IN CONTEXT

Implementation of evidence-based interventions is the process of bringing into use practices that have been proven effective through research evaluation. This process occurs within health systems, and thus is also sensitive to the health policy and systems context in which the implementation occurs ( 14 , 18 , 19 ). Pfadenhauer and colleagues have explored the relationship between implementation and context, arguing that these are highly interconnected, with implementation of evidence-based interventions always taking place within a given context, which influences how the implementation takes place ( 14 ). Tomoaia-Cotisel and colleagues support this argument ( 15 ), further claiming that understanding context is important to the replication of research, because contextual knowledge is important to interpreting and applying the findings. In addition, before the findings can be applied, the evidence-based intervention needs to be adapted for the context in which it will be implemented. Therefore, the adapters need information about the original context or contexts in which the intervention was research-tested, so as to determine what changes might be needed for the intervention to work in the new context. To think about this more practically, imagine an intervention that works when tested in a research study in rural northern Sweden, where, although people are living remotely, they have good infrastructural access. Now imagine trying to implement that same intervention in rural Sudan, where access to resources and infrastructure is really poor. Or, to use a less extreme example, consider implementing the same intervention in rural northern Sweden and rural Alaska, where the environmental conditions may be similar, but the health systems (of Sweden and the United States, respectively) have vast differences. Thus, interventions that work in one context cannot simply be transported to another context, without some consideration and potential adaptation. This consideration is made easier when researchers offer details about the original context and setting in which the intervention was tested.

4.4. ADDRESSING THE CHALLENGE OF CONTEXT TO SYSTEMATIC REVIEWS OF HEALTH POLICY AND SYSTEMS INTERVENTIONS

The field of HPSR seeks to inform policy and implementation through evidence (hence the need for policy relevance), as outlined in Chapter 1 . However, traditional systematic reviews examining the effectiveness of interventions have been criticized for being too reductionist and for not taking context into account ( 15 , 20 – 22 ). These limitations present a challenge in performing systematic reviews of HPSR questions because contextual information is fundamental for policy planning and development, for instance, in assisting decision-makers to decide whether certain policy options are applicable to their context and setting ( 23 – 25 ). Greenhalgh has argued that in these traditional systematic reviews, the “technical process of stripping away all but the bare bones of a focused experimental question removes what practitioners and policymakers most need to engage with: the messy context in which people get ill, seek health care (or not), receive and take treatment (or not), and change their behaviour (or not)” ( 20 ). Key to these criticisms is that after stripping away the context, the researchers can only say whether an intervention works or not; they cannot explain why this is, why the intervention works or not ( 18 , 26 , 27 ). Systematic reviews that strip away context may be perceived as lacking relevance to policy- and decision-makers seeking information that will help them adapt the interventions reviewed to their local context ( 15 , 21 , 28 ). The lack of contextual relevance is, in turn, offered as a potential explanation for why policy- and decision-makers may not routinely use systematic reviews as part of their decision-making process ( 28 , 29 ).

A closer examination of context is recommended, because the context in which an intervention takes place will act as a mediator in the success or failure of the intervention; therefore, policy- and decision-makers need to know why a given intervention works in one place yet may fail in another ( 15 , 18 , 20 , 22 , 26 , 27 ). Thus, reviews of HPSR questions need to take context into account to enhance the relevance and usability of the research outputs. But review authors cannot do this on their own. A clearer description of context in reviews is reliant on a clearer description of context in primary studies (see Box 4.2 ).

4.5. METHODS PAPER

Box 4.2 a plea for context-rich primary studies to support context-rich systematic reviews and evidence synthesis.

The challenge of including context starts at the level of primary studies. If systematic reviewers are to take context into account, they need primary studies that do the same. Evidence synthesis becomes difficult when the primary studies included in the syntheses do not offer sufficient contextual information ( 15 ). Reporting rich contextual information in primary studies helps to enrich the usefulness of systematic reviews ( 15 ). This can enable these reviews to include an understanding of contextual factors that will, in turn, allow decision-makers to transfer knowledge gained from interventions implemented and evaluated in one context to the implementation of such interventions in other contexts ( 15 ).

Glenton, Lewin & Scheel struggled to find qualitative studies conducted alongside experimental trials, despite actively searching for them ( 30 ). This team had conducted an effectiveness review in which the results were promising but heterogeneous. Thus, they sought qualitative studies that had been conducted alongside the included trials, with the aim of using this contextual information to help explain the heterogeneity. Yet they found that 83% of the included trials either had no linked qualitative studies, or the qualitative studies that did exist were not accessible. Ultimately, they were able to access corresponding qualitative studies for only 17% of the included trials, and even then they found that the descriptions of the methods and the qualitative results were often sparse. They therefore concluded that qualitative studies conducted alongside trials hold some promise for explaining heterogeneity, by offering insight into the trial intervention context, but that too few of these studies are being conducted for their full promise to be realized.

In response to the poor reporting of context in primary studies, Tomoaia-Cotisel and colleagues developed a tool for the researchers with whom they were working, to be used in collecting contextual information in primary studies using quantitative, qualitative and mixed-methods designs ( 15 ). This tool is based on their experience of collecting contextual information across 14 research teams. When publishing their findings, each of the 14 teams added the contextual information that they had collected, as appendices to the main article. Investigators performing primary studies would be well advised to consider using a tool such as that developed by Tomoaia-Cotisel and colleagues, or developing their own tool. The use of such tools could improve the richness of their recording of the context in which their study took place, and in which the intervention that they are evaluating was implemented. Furthermore, reporting guidelines for journal articles have been extended to encourage authors of primary quantitative studies to report context in more detail. Enhanced reporting on context in evidence syntheses is therefore contingent on the authors of primary studies expanding on their context reporting.

Pfadenhauer LM, Gerhardus A, Mozygemba K, Lysdahl KB, Booth A, Hofmann B, et al. Making sense of complexity in context and implementation: the Context and Implementation of Complex Interventions (CICI) framework. Implement Sci. 2017;12:21. doi: 10.1186/s13012-017-0552-5 [ PMC free article : PMC5312531 ] [ PubMed : 28202031 ] [ CrossRef ] ( 19 ).

Attention to context in systematic reviews is further discussed in Chapter 3 , concerning methods; Chapter 5 , concerning reviews of complex interventions; and the methods commentary on realist reviews. In particular, Chapter 3 introduces the concepts of quantitative, qualitative and mixed-methods reviews. The CICI framework could be considered a companion to any of these review types, including qualitative reviews, although the latter tend to be inherently more context-focused than quantitative reviews. In quantitative reviews in particular, reviewers could consider using the CICI framework to inform a narrative reporting of the information on context that has been extracted from primary studies, so as to shed further light on the synthesis of quantitative outcomes.

4.6. SYSTEMATIC REVIEWS TAKING CONTEXT INTO ACCOUNT: EXAMPLES

Review example.

Liu and colleagues ( 31 ) explicitly set out to take context into account in their systematic review exploring interventions to attract and retain health workers in underserved rural areas. In exploring the literature, they found that studies and reviews of interventions presented contradictory evidence, yielding a complex picture of the effectiveness of the interventions. In response, the review authors recognized that these interventions had been developed and implemented in various contexts through different processes, and they felt that this heterogeneity might explain the variation in intervention effectiveness. Thus, they set out to conduct a review that would take this variation into account, with the objective of identifying contextual factors that policy-makers should consider when they design and implement interventions. Context was therefore taken into account in the design of the search terms, the study selection, and the collection and analysis of data. Using this approach, the authors were able to offer review findings that addressed contextual factors at the macro, meso and micro levels of the health systems. These factors included the fiscal capacity of a country or organization, decentralization of the health system and legislative processes. In making these contextual factors explicit, the review authors enhanced policy-makers’ ability to consider how the intervention might work in their own contexts.

Liu X, Dou L, Zhang H, Sun Y, Yuan B. Analysis of context factors in compulsory and incentive strategies for improving attraction and retention of health workers in rural and remote areas: a systematic review. Hum Resour Health. 2015;13:61. doi: 10.1186/s12960-015-0059-6 [ PMC free article : PMC4508764 ] [ PubMed : 26194003 ] [ CrossRef ] ( 31 ).

Review protocol example

Like Liu and colleagues ( 31 ), Belrhiti and colleagues ( 32 ) have embarked upon an HPSR systematic review that explicitly takes context into account. These authors very specifically focus on the meso level of the health system, by exploring interventions to improve district health systems management and leadership. In their protocol ( 32 ), they explain how exploring the effectiveness of such interventions is a primary objective of the review, whereas exploring contextual factors that enable or constrain the interventions is a secondary objective. This secondary objective is justified by the authors’ understanding of the interventions as multifaceted and complex in nature, and their observation that the interventions are “implemented in social systems characterized by human agency, uncertainty, and unpredictability” ( 32 ). The authors therefore begin by using a logic model (see Chapter 5 in this Methods Guide, on performing reviews of complex interventions, in particular section 5.5 ) to illuminate key contextual issues that may affect the interventions. The authors also describe how they will use “best fit” framework synthesis (described in more detail in Box 4.3 ) to analyse organizational policies and procedures, to allow them to interpret what is happening in specific contexts. They propose using this framework for the qualitative studies included in the review. These authors therefore acknowledge context in the overall focus of their review, in their inclusion criteria and in the analytical process of the review.

Belrhiti Z, Booth A, Marchal B, Verstraeten R. To what extent do site-based training, mentoring, and operational research improve district health system management and leadership in low- and middle-income countries: a systematic review protocol. Syst Rev. 2016;5:70. doi: 10.1186/s13643-016-0239-z [ PMC free article : PMC4847191 ] [ PubMed : 27116915 ] [ CrossRef ] ( 32 ).

The “best fit” framework mentioned above may be unfamiliar to some readers. Although Belrhiti and colleagues use the framework, they do not offer a detailed explanation of it. Box 4.3 includes a description of this framework, along with the antecedent thematic and framework synthesis approaches for comparison. These approaches are best considered in relation to the literature on qualitative methods, introduced in Chapter 3 .

BOX 4.3 THREE APPROACHES TO ANALYSIS IN SYSTEMATIC REVIEWS OF QUALITATIVE STUDIES

Analysis within reviews of qualitative studies (also known as qualitative evidence synthesis) follows the same principles as analysis of data in primary studies. Such analysis can be either inductive (whereby themes, codes and categories emerge from the data) or deductive (whereby themes, codes and categories are chosen a priori, before the analysis starts).

Thematic synthesis ( 33 , 34 )

Thematic synthesis involves analysing data from primary qualitative studies in an inductive manner, the approach commonly used for many primary studies. Using this approach, reviewers code the primary studies (sometimes just the results section, but often the discussion and conclusions too), line by line, as if coding a transcript of an interview or field notes from a qualitative observation. This coding can then lead to the development of descriptive themes (analysis at the manifest or superficial level) and analytic themes (when the reviewers go deeper, trying to identify patterns, relations and explanations in the data, thus analysing at the latent level). This approach is appropriate when the reviewers are doing an exploratory study, wanting to see what emerges from the data, and when they hold no prior assumptions about what they might find in relation to the review question. Although this approach can lead to a rich and nuanced analysis, the downside is that exploring the data in depth can take a very long time. However, in HPSR, when working with policy-makers who are seeking quick answers to prespecified questions and challenges, reviewers may not have the luxury of the time required by such an approach. Another challenge with this approach, as with thematic analysis of qualitative primary studies, is that the process of arriving at codes, themes and categories is often intuitive, with many of the links and explanations being made in the researcher’s or the reviewer’s mind, rendering transparency of the process hard to achieve.

Framework synthesis ( 34 , 35 )

Framework synthesis of qualitative studies follows the same principles as framework analysis of primary studies, whereby a deductive approach is used to analyse data from primary studies included in systematic reviews. With this approach, a tentative framework of themes or concepts is identified in advance. This up-front framework could be developed through the reviewers’ own understanding of the issue being reviewed, it could be developed from the literature on the subject, or it could be developed in conjunction with the requesters of the review (such as policy-makers, health systems managers or health policy lobbyists). As is often the case in reviews of HPSR questions, the requesters of the review are likely to have a predefined set of questions and issues that they would like to have addressed. Using the predefined framework, the reviewers can ensure that they actively seek out data to answer those questions. Having a predefined framework that is developed in collaboration with the review requesters can also be more transparent than trying to explain how themes have emerged from the data. The predefined framework is also useful for combining data from multiple study types, because data about the same issue can be grouped under the same predefined theme and then compared from there. One of the dangers of this approach is that reviewers may become attached to their predefined themes or categories and may be unwilling to consider data that do not fit within this framework. Those data could easily be lost, with the attendant risk that contradictory data or new insights become “buried”, even if there was no attempt to hide the data.

“Best fit” framework synthesis ( 35 – 37 )

“Best fit” framework synthesis combines thematic and framework synthesis, using both a deductive and an inductive approach to analyses. With this approach, the authors begin by systematically searching the literature for a theory or framework that would best align with their research question. In their search, they explicitly take context into account. For example, as described in section 4.6 of this chapter, Belrhiti and colleagues ( 32 ) are using the “best fit” approach to answer the question “To what extent do site-based training, mentoring and operational research improve district health system management and leadership in low- and middle-income countries (LMICs)?” Their question contains both interventions – site-based training, mentoring and operational research – and two levels of settings – district health systems and LMICs. Therefore, in their approach, they will look for explanatory theories and frameworks related both to the interventions and to how these interventions operate in the identified settings (this concept could also be incorporated into a logic model; see Chapter 5 on performing reviews of complex interventions, in particular section 5.5 ). The authors will also simultaneously search for primary studies that meet the intervention and setting criteria. They will then develop a tentative framework, based on the “best fit” of what they find in the literature, and as they analyse the context-sensitive primary studies, they will fit the data from these studies into the predefined framework. However, the originators of the “best fit” approach recognized that it would be unlikely for all of the data from the primary studies to fit within such a predefined framework; they furthermore recognized that the “best fit” theories that reviewers find are likely to be generic and not context specific ( 36 , 37 ). Thus, using this approach, reviewers will also code data from the context-specific primary studies inductively, looking at what new themes and categories emerge. These new themes and categories will then be compared and translated into the predefined framework, bringing context-specific data and insights to what might originally have been a generic framework. From there, the reviewers can develop a new, higher-level framework that brings together the predefined theory and framework with the intervention and context-specific data. Thus, Belrhiti and colleagues ( 32 ), as well as the originators of the approach, suggest that this approach is context sensitive. However, the originators argue that this approach can only be used where predefined theories or frameworks exist. In instances where the reviewers have little advance knowledge about the topic, a more inductive approach remains preferable.

Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;8:45. doi: 10.1186/1471-2288-8-45 [ PMC free article : PMC2478656 ] [ PubMed : 18616818 ] [ CrossRef ] ( 33 ). Gough D, Oliver S, Thomas J. An introduction to systematic reviews. Los Angeles (CA): Sage Publications; 2012 ( 34 ). Dixon-Woods M. Using framework-based synthesis for conducting reviews of qualitative studies. BMC Med. 2011;9:39. doi: 10.1186/1741-7015-9-39 [ PMC free article : PMC3095548 ] [ PubMed : 21492447 ] [ CrossRef ] ( 35 ). Carroll C, Booth A, Leaviss J, Rick J. “Best fit” framework synthesis: refining the method. BMC Med Res Methodol. 2013;13:37. doi: 10.1186/1471-2288-13-37 [ PMC free article : PMC3618126 ] [ PubMed : 23497061 ] [ CrossRef ] ( 36 ). Carroll C, Booth A, Cooper K. A worked example of “best fit” framework synthesis: a systematic review of views concerning the taking of some potential chemopreventive agents. BMC Med Res Methodol. 2011;11:29. doi: 10.1186/1471-2288-11-29 [ PMC free article : PMC3068987 ] [ PubMed : 21410933 ] [ CrossRef ] ( 37 ).

4.7. CONCLUSION

Contextually rich systematic reviews and evidence synthesis may better support health policy and systems decision-makers, as they consider how to apply the evidence for implementation in their settings. Contemporary developments in evidence synthesis methods can enable reviewers to produce such contextually rich reports. Production of such reviews is supported even further when reviewers are able to extract contextually rich data from the primary studies included the final systematic reviews.

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• Cite this Page DANIELS KAREN. UNDERSTANDING CONTEXT IN REVIEWS AND SYNTHESES OF HEALTH POLICY AND SYSTEMS RESEARCH. In: Langlois ÉV, Daniels K, Akl EA, editors. Evidence Synthesis for Health Policy and Systems: A Methods Guide. Geneva: World Health Organization; 2018 Oct 8. 4.
• PDF version of this title (3.8M)

In this Page

• INTRODUCTION
• THE IMPACT OF CONTEXT ON HEALTH POLICY AND SYSTEMS INTERVENTIONS
• IMPLEMENTING HPSR EVIDENCE IN CONTEXT
• ADDRESSING THE CHALLENGE OF CONTEXT TO SYSTEMATIC REVIEWS OF HEALTH POLICY AND SYSTEMS INTERVENTIONS
• METHODS PAPER
• SYSTEMATIC REVIEWS TAKING CONTEXT INTO ACCOUNT: EXAMPLES

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REVIEW article

This article is part of the research topic.

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

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

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

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

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

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

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

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

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

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Synthesis and Making Connections for Strong Analysis

by acburton | Apr 25, 2024 | Resources for Students , Writing Resources

If Russian Dolls Aren’t For You, Here Are a Few Other Ways to Think About Synthesis

‘Joining the Conversation’: When we perform synthesis in our writing and engage with making connections, we are joining a wider conversation. We are seeing what has already been said about the topic, seeking out what these many perspectives and viewpoints have in common and/or how they differ, and then interpreting these relationships to form our own input to the conversation. We must directly engage with our sources to draw insightful conclusions and share what we think as a result. ‘Building the Bridge’: Synthesis is building the bridge between your sources for the reader. To synthesize or make connections, we must figure out how we get from one source to the other. In other words, we cannot present our sources in isolation (this wouldn’t help create any new meaning). Instead, we need to build the bridge between source A and source B so that our readers can understand what the two, together, suggest about our understanding of a topic. Then, we build a bridge from this new understanding to source C and source D, and so on.

Start Synthesizing

So you want to synthesize information? To start, review the existing literature on your selected topic. When searching for resources, aim to collect a number from various authors, subjects, and settings to broaden your understanding of the material – giving yourself more information to consider in the next stage. Ultimately, you’ll want to find the main idea presented in each source, as well as how the author supports or argues against it, as well as why.

• Compare and Contrast

Compare and contrast the main idea found in each source reviewed. What does each perspective have in common? What are their differences? Begin to consider how these sources  ‘fit together’ (or, in other words, build the bridge!). During this stage, you may find that some of your collected resources don’t have as much depth or go into as much detail as you’d like. That’s okay, but you’ll want to consider what effect this might have on your ability to draw a meaningful conclusion once synthesized with other source material.

• Ask, What’s the Significance?

By evaluating the quality and significance of each source, you can begin to consider its relevance within the context of your research or in relation to your topic. How does the relationship of one source to another further your understanding of the topic you are focusing on? What is the larger impact of what is being said or argued?

• Infer the Relationship and Draw Conclusions

By this point, you have gone through the existing literature surrounding your subject and compared/contrasted it, finding the main idea of each, as well as their intended purpose, possible criticisms, strengths, and weaknesses. Finally, you have related these ideas to your own research. Although you may have found that your sources agree or disagree on minor (or major) key details, it is the writer’s job to seek the relationship between these sources, put them in conversation together, and draw meaning through analysis. In some cases, you’ll be asked to offer your own perspective or argumentation. Consider, how might you add to the existing conversation?

Synthesis is all about meaningful connections, it is not summarizing sources side by side. Before you make larger claims about a topic, make sure you build those bridges between the sources you found through research. Nestle them together. Move beyond summary. Then, you can create an interesting and compelling argument. For additional help, make an appointment with the Writing Center!

Works Cited

Kourakos, Evanthia J. “The Matryoshka-Doll Effect.”  Medium , Azure’s Whereabouts, 22 Apr. 2016,  medium.com/azure-s- whereabouts/the-matryoshka- doll-effect-be9d2760d2e2 .Acces sed 25 Apr. 2024.

“Libguides: English Research: Synthesizing Information.”  Synthesizing Information – English Research – LibGuides at Aultman Health Sciences Library ,  aultman.libguides.com/c.php?g= 545558&p=7711993 . Accessed 25 Apr. 2024.