International Journal of Health System and Disaster Management

: 2013  |  Volume : 1  |  Issue : 2  |  Page : 59--63

Metanarrative review: Current status and opportunities for public health research

Sanjeev Davey1, Anuradha Davey2, Jaivir Singh1,  
1 Department of Community Medicine, Muzaffarnagar Medical College and Hospital, Muzaffarnagar, Uttar Pradesh, India
2 Department of Community Medicine, Subharti Medical College, Meerut, Uttar Pradesh, India

Correspondence Address:
Sanjeev Davey
B-197, 3rd Floor, Prashant Vihar, Sector 14 Rohini, Delhi - 110 085


Metanarrative review (MNR) is a new way of doing systematic review (SR), for topics which are differently conceptualized and studied by different types of researchers in public health system research. The key aim of this paper is to explore current status and opportunities of MNRs for public health research. A SR on the key search word: «DQ»Metanarrative review for Public health research«DQ» was done from key indexed journals abstracting databases (PubMed, Cochrane, BioMed Central, and Google Scholar, etc.,) in all forms including e-journals till 31 st August 2013 since last 30 years. A total of 33 articles met the inclusion criteria, both types of studies showing its good role and no utility, were included. Major criteria of impact, effectiveness, and evaluation of MNR in health system research globally were taken in search. Studies from both developed and developing world were included including conferences data, research reports, and data from books, on role of MNR in health system research were taken (excluding thesis data) to draw final conclusions. MNR is a type of SR based on a MNR approach, suggested by Greenhalgh et al., (2005). It is a systematic«SQ» review rather than a traditional expert-driven literature review and it ensures a rigorous and extensive treatment of the literature in public health research. MNR has a great ability to show heterogeneous topic areas in public health system research by opening up the contrasting and complementary paths in which public health researchers have studied the same topic.

How to cite this article:
Davey S, Davey A, Singh J. Metanarrative review: Current status and opportunities for public health research.Int J Health Syst Disaster Manage 2013;1:59-63

How to cite this URL:
Davey S, Davey A, Singh J. Metanarrative review: Current status and opportunities for public health research. Int J Health Syst Disaster Manage [serial online] 2013 [cited 2022 Aug 12 ];1:59-63
Available from:

Full Text


In last 20 years, methods for reviewing the research literature in health have undergone a radical change. There are now many different methods available but with a confusing range of names. There are many approaches in systematic reviewing and each has a power and potential in differentsituations. [1] All public health researchers also know well about meta-analysis (MA), which focuses on contrasting and combining results from different studies, for purposes such as: a) identifying patterns among study results, b) sources of disagreement among those results and c) interesting relationships of multiple studies. [2] This is normally done by way of identification of a common measure of effect size, of which a weighted average is the output of a MA. MAs are usually an important component of a systematic review procedure as they can be done on several clinical trials of a medical treatment, to get a better understanding of how well the treatment works.

Review articles have now taken the form of a narrative review, in which a content expert can write on a field, condition, or treatment. Narrative reviews have many benefits such as a broad overview of relevant information probed by years of practical knowledge from an experienced author. So, a commonly used method to synthesize research in the context of systematic reviews that is emerging is of narrative synthesis, a defining characteristic of which is the adoption of a narrative summary of the findings of studies to the process of synthesis. [3],[4],[5],[6] Narrative synthesis basically it means how a quantitative research is synthesized? [7] Greenhalgh et al., (2005) metanarrative approach to synthesize evidence has been recently developed to inform complex policy-making questions by the formation of a multidisciplinary team. [7] This approach enable us to systematically review research and theoretical work within and across disciplines distilling not just the similarities and differences of perspectives within each tradition like sociology, psychology, health, geography but also across these, by identifying key dimensions of communities common to each tradition and to analyze how these can be compared. [7] Therefore, there is a need for researchers to be able to distinguish between these above methods and to select which method is the most appropriate to their situation. As this metanarrative approach is a new upcoming field, authors in this review have explored it as a possible new tool in public health research by critically analyzing and systematically reviewing the literature.


The key aim of this paper is to explore current status and opportunities of metanarrative reviews (MNRs) for public health research.

 Materials and Methods

A systematic review on key search word: "Meta-narrative review for Public health research " was done from main indexed journals abstracting databases, that is, i.e., PubMed, Cochrane, BioMed Central, and Google Scholar, and so on in all forms including e-journals till 31 st August 2013 since last 30 years.

Study designs

Previous systematic reviews and exploratory research studies on role of metanarrative review (MNR) in health system research were the main study designs which were incorporated in any language and of any size and to any extent in shaping the research.

Inclusion criteria

From 40 articles which were searched in above duration, 33 articles met the inclusion criteria, both types' studies on its good role and no utility were included on this review. Main criteria of impact, effectiveness, and evaluation of MNR in health system research globally were taken in search. Studies from both developed and developing world were included including conferences data, research reports, and data from books, on role of MNR in health system research were taken to draw final conclusions.

Exclusion criteria

Unpublished data from thesis were not taken for this review. This study is unique in its own kind as it involves systematic review of metanarrarative systematic review, as kind this kind of study has not been carried out previously in literature.


The results of this systematic review are summarized in [Table 1] given below to find the common themes and concepts emerging from this systematic review.{Table 1}


Public heath researcher has wide choices: Meta-analysis or systematic review

The Cochrane collaboration recommends the term "MA" to statistical methods of combining evidence, excluding ''research synthesis'' or ''evidence synthesis,'' like combining information from qualitative studies, for the systematic reviews. [8] MA forms part of a framework called estimation statistics which relies on effect sizes, confidence intervals, and precision planning to guide data analysis, and is an alternative to null hypothesis significance testing. A systematic review is a literature review focused on a research question that tries to identify, appraise, select, and synthesize all high-quality research evidence relevant to that question. An understanding of systematic reviews and how to implement them in practice is now becoming mandatory for all professionals involved in the delivery of health care.

Reasons for choosing a meta-analysis approach: Pros and cons

Decisions about the utility of an intervention or the validity of a hypothesis cannot be based on the results of a single study, because results typically vary from one study to the next. Rather, a mechanism is needed to synthesize data across studies. MA, approach applies objective formula, can be used with any number of studies.

But there are many problems with MA like: A MA of several small studies does not predict the results of a single large study. [9] Some feel that a weakness of the MA is that sources of bias are not controlled by the method: A good MA of badly designed studies can result in a bad statistics. [10] This would mean that only methodologically sound studies should be included in a MA, a practice called as ''best evidence synthesis. [10] Other meta-analysts include weaker studies and add a study level predictor variable that reflects the methodological quality of the studies to examine the effect of study quality on the effect size. [11] Others feel that it is a better approach is to preserve information about the variance in the study sample, casting as wide a net as possible, and that methodological selection criteria introduce unwanted subjectivity, defeating the purpose of the approach. [12]

Another pitfall is the reliance on the available corpus of published studies, which may create exaggerated outcomes due to publication bias, as studies which show negative results or insignificant results are less likely to be published. For any given research area, one cannot know how many studies have gone unreported. [13] This type of file drawer problem results in the distribution of effect sizes that are biased, skewed, or completely cut off, creating a serious base rate fallacy, in which the significance of the published studies is overestimated, as other studies were either not submitted for publication or were rejected. This should be seriously considered when interpreting the outcomes of a MA. [13],[14] This can be visualized with a funnel plot which is a scatter plot of sample size and effect sizes. If no publication bias is present, one would expect that there is no relation between sample size and effect size. [15]

Strengths and weaknesses of systematic reviews

Although systematic reviews of high-quality randomized controlled trials are crucial in evidence-based medicine. [16] Besides health interventions, systematic reviews concerns clinical tests, public health interventions, social interventions, adverse effects, and economic evaluations. [17],[18],[19] Systematic reviews are not limited to medicine and are quite common in other sciences where data are collected, published in the literature, and an assessment of methodological quality for a precisely defined subject would be very helpful. [20] Other fields where systematic reviews is used are: Psychology, nursing, dentistry, public-health, occupational therapy, speech therapy, physical therapy, educational-research, sociology, business-management, environmental-management, and conservation biology. [21]

Although systematic reviews are regarded as the strongest form of medical evidence, a review of 300 studies found that not all systematic reviews were equally reliable, and that their reporting could be improved by a universally agreed upon set of standards and guidelines. [20] Systematic reviews are now increasingly appearing in other fields, such as international development research. [22] Now, a number of donors in the UK like Department for International Development and AusAid are focusing attention and resources on testing the appropriateness of systematic reviews in assessing the impacts of development and humanitarian interventions. [22]

MNR: An approach knocking the doors of health system research

There is great confusion among researchers, journal editors, peer reviewers, and funders regarding a high quality MNR. MNRs are actually not ''linear'' reviews. It is a new review method that has been developed as a systematic way to synthesize diverse types of literature with a focus on identifying the ''storylines of research'' within and across disciplinary boundaries. This approach enables us to identify metanarratives of each discipline and to analyze the different ''discourses'' and languages of ''community.'' Some MNRs are not flagged in the title and/or they are inconsistently indexed, so they are difficult to locate in searches.

MNR: Current status and future horizon

We must appreciate the fact that the field of secondary research is growing fastly. MNR is a new way of doing systematic review, for topics which are differently conceptualized and studied by different types of researchers. It is a new method of doing qualitative and mixed-method systematic review and it is an upcoming method for evidence synthesis as we are getting more experience and methodological developments. [23] New approaches are now available to carry out mixed method literature reviews, which include qualitative and quantitative evidence, which can also identify the mechanisms by which the programs reach to their goal. [24],[25],[26] MNR can show heterogeneous topic areas by opening up the contrasting and complementary paths in which researchers have studied the same topic. This approach illuminates and clarifies a complex topic area while simultaneously highlighting the strengths and limitations of different research approaches in the topic. [27] Currently, we do not have previous publication standards for the reporting of MNRs, which has now been written by a Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) project. [23] In this RAMESES projects training materials and quality standards for MNRs are given. [28] The method of MNR was developed in 2005 in response to challenges which emerged in a review on diffusion of service level in healthcare innovations. [29] MNR certainly adds value to the synthesis o f heterogeneous bodies of literature, in which different groups of scientists have conceptualized and investigated the ''same'' problem in different ways and produced seemingly contradictory findings. [30] The summary and key features of this approach which are given in [Table 2] show that this technique can be useful for public health research, as found from many studies in literature. [30],[31],[32]{Table 2}

Methodology of meta-narrative review

Greenhalgh et al., 2005 synthesized research from a wide range of disciplines; their research questions were related to the diffusion of innovations in health service delivery and organization in this way they also identified a need to synthesize findings from research which contains many different theories arising from many different disciplines and study designs. [7]

A meta-narrative review: Asks following questions as per Greenhalgh et al., 2005 guidelines

(1) Which research traditions have considered this broad topic area?; (2) How has each tradition conceptualized the topic (for example, including assumptions about the nature of reality, preferred study designs and ways of knowing)?; (3) What theoretical approaches and methods did they use?; (4) What are the main empirical findings?; and (5) What insights can be drawn by combining and comparing findings from different traditions?'

Guiding principles of meta-narrative review

Currently it is based on six guiding principles given by Greenhalgh et al. [28],[29],[30],[31]

Principle of pragmatism: The reviewer must be guided by most useful topics to the intended audiencesPrinciple of pluralism: Using the established quality criteria appropriate to each, the topic must be seen from multiple angles and perspectives;Principle of historicity: Research traditions to unfolded over time, showing significant individual scientists, events, and discoveries;Principle of contestation: ''Conflicting data'' from different research traditions should be examined to generate better insightsPrinciple of reflexivity: Reviewers must continually reflect, individually and as a team, on the emerging findings;Principle of peer review: Emerging findings should ideally be presented to an external audience and their feedback must be used to guide further reflection and analysis.

Key phases in meta-narrative review

3 Important phases in a MNR are shown in text and flow diagram as found from many studies is as given below: [30],[31],[32],[33]

Planning phase: (a) Assemble a multidisciplinary research team (b) Outline the initial research question in a broad, open-ended format. (c) Agree outputs with funder or client. (d) Regular face-to-face review meetings including planned input from external peers the reviewSearch phase: (a) Initial search led by intuition, informal networking, and ''browsing,'' with a goal of mapping the diversity of perspectives and approaches. (b) Search for seminal conceptual papers. And (c) Search for empirical papers by electronic searching key databases, hand searching key journals and ''snowballing''Mapping phase: Identify (separately for each research tradition): (a) The key elements of the research paradigm (conceptual, theoretical, methodological, and instrumental); (b) The key actors and events; and (c) The prevailing language and imagery.

All these phases are summarized as a flow diagram in [Figure 1]. as given below:{Figure 1}


MNR is inspired by the work of Thomas Kuhn, on idea that science progresses in paradigms. MNR is used for a wide range of topics and questions, and it involves making judgments and inferences rather than checking against a technical checklist but problem may be, it is not possible to be prescriptive of what may be done in a review. A MA also getsbenefit from a detailed narrative review. The sense-making focus of MNRs means we need detailed data for reporting, in order to provide enough support for inferences and/or judgments to be made. A MNR can generate a large number of avenues which can be explored and explained, and because resources and timescale are limited, the expectation is that the review must be ''contained'' by progressively focusing both its breadth and depth. MNRs often see historically at how particular research traditions or epistemic traditions have unfolded over time and shaped the ''normal science'' of a topic area including public health system research. Narrative reviews such as MNR have been used for many purposes, but the problems such as narrative review can be subjective and becomes impossibly difficult when there are more than a few studies involved also needs caution while using this approach. So further research for example exploratory as well as more review/meta-analysis studies are still required in this upcoming field if we want to use this tool in public health research commonly in future.


1Potts HW. [Conference Presentation] Meta-narrative review. Presented at: 5 th ESRC Research Methods Festival, Oxford, UK; 2012. p. 1-25.
2Greenland S, O' Rourke K. Meta-analysis in Modern Epidemiology. In: Rothman KJ, Greenland S, Lash T, editors. 3 rd ed. Philadelphia: Lippincott Williams and Wilkins; 2008. p. 652-82.
3In: Cooper H, Hedges LV, editors. The Handbook of Research Synthesis. New York: Russell Sage Foundation; 1994a.
4Davis JW. 'Get fired up: A model for developing in-school 4-H programs', dissertation. Clemson: Clemson University; 1987.
5Higgins DJ, Altman D. Analysing and presenting results. In: Higgins J, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions 4.2.6 [Last updated Sept. 2006]; Section 8. Chichester: John Wiley and Sons, Ltd; 2006 pp. 1-5.
6Rodgers M, et al. Testing Methodological Guidance on the Conduct of Narrative Synthesis in Systematic Reviews [Effectiveness of Interventions to Promote Smoke Alarm Ownership and Function]. Vol 15. (Los Angeles, London, New Delhi and Singapore): SAGE Publications; 2009. p. 47-71.
7Barnett E-Page, Thomas J. Methods for the synthesis of qualitative research: A critical review [ ESRC]. [NCRM Working Paper Series Number (01/09)]. [Internet] c2013. Available from: [Last Updated 2013 Aug 31, Last cited on 2013 Aug 31].
8Cochrane-Glossaryat Cochrane Collaboration. [Internet] c2013. Available from: http://www.cochrane, org/glossary [Last updated 2013 July 31, Last cited 2013 July 31].
9LeLorier J, Grégoire G, Benhaddad A, Lapierre J, Derderian F. Discrepancies between meta-analyses and subsequent large randomized, controlled trials. N Engl J Med 1997;337:536-42.
10Slavin RE. Best-evidence synthesis: An alternative to meta-analytic and traditional reviews. Educational Researcher 1986;15:5-9.
11Hunter, Schmidt, Jackson, John E. Meta-analysis: Cumulating research findings across studies. Beverly Hills: Sage; 1982.
12Glass, McGaw, Smith. Meta-analysis in social research. Beverly Hills: Sage; 1981. Jun 01:1-279.
13Rosenthal R. "The "File Drawer Problem" and the Tolerance for Null Results". Psychol Bull 1979;86:638-41.
14Hunter, Schmidt JE, Frank L. Methods of meta-analysis: Correcting error and bias in research findings. Newbury Park: SAGE Publications; 1990.
15Light R.J. and Pillemer D.B. Summing up: The science of reviewing research. Cambridge: Harvard University Press; 1984. p. 1-191.
16"What is EBM?". Centre for Evidence Based Medicine. 2009. pp11-20 [Internetc2013]. Available from: [Last Updated 2013 Aug 31, Last cited on 2013 Aug 31].
17Systematic reviews: CRD's guidance for undertaking reviews in health care. York: University of York, Centre for Reviews and Dissemination; 2008. p. 1-294.
18Petticrew M, Roberts H. Systematic reviews in the social sciences. Wiley Blackwell; 2006. p. 1-324.
19Ader HJ, Gideon J. Mellenbergh; with contributions by David J. Hand. Methodological quality (chapter-3) in advising on research methods: A consultant's companion. Johannes van Kessel Publishing; 2008. p. 1-552.
20Moher D, Tetzlaff J, Tricco AC, Sampson M, Altman DG. Epidemiology and reporting characteristics of systematic reviews. PLoS Med 2007;4:e78.
21Environmental Evidence. [Internet] c2013. Available from: [Last Updated 2013 Jul 17, Last cited 2013 Jul 31].
22Hagen-Zanker, Duvendack J, Mallett M, Slater R, Carpenter R, Tromme S, et al. Making systematic reviews work for international development research. Overseas Development Institute; 2012 p. 1-4.
23Wong G, Greenhalgh T, Westhorp G, Buckingham J, Pawson R. RAMESES publication standards: Meta-narrative reviews. BMC Med 2013;11:20.
24Barnett-Page E, Thomas J. Methods for the synthesis of qualitative research: A critical review. BMC Med Res Methodol 2009;9:59.
25Gough D, Thomas J, Oliver S. Clarifying differences between review designs and methods. Syst Rev 2012;1:28.
26Sandelowski M, Voils CI, Leeman J, Crandell JL. Mapping the mixed methods-mixed research synthesis terrain. J Mix Method Res 2012;6:317-331.
27Mays N, Pope C, Popay J. Systematically reviewing qualitative and quantitative evidence to inform management and policy-making in the health field. J Health Serv Res Policy 2005;10 Suppl 1:6-20.
28Greenhalgh T, Wong G, Westhorp G, Pawson R. Protocol-realist and meta-narrative evidence synthesis: Evolving standards. BMC Med Res Methodol 2011;11:115.
29Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organisations: Systematic literature review and recommendations for future research. Milbank Q 2004;82:581-629.
30Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O, Peacock R. Story lines of research in diffusion of in novation: A meta- narrative approach to systematic review. Soc Sci 2005;61:417-30.
31Lewis MW, Grimes AJ. Meta-triangulation: Building theory from multiple paradigms. Acad Manage Rev 1999;24:672-90.
32Bertotti M, Jamal Farah, Harden Angela, Sheridan Kevin, Gail Barrow-Guevara, Lori Atim. Wellbeing and regeneration. project: A meta-narrative review of conceptualizations and meanings of 'community' within and across research traditions 2011 Mar-1-Oct-31.
33Juan Pablo Domecq Garces, Zhen Wang, Tarig A. Elraiyah, Mohammed Nabhan, Juan P. Brito Campana, et al. Eliciting patient perspective in patient-centered outcomes research: A meta narrative systematic review. Mayo Clinic: Rochester; 2012. p. 1-163.