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. 2006 Oct;94(4):421-429, e205.

“Brimful of STARLITE”: toward standards for reporting literature searches

Andrew Booth 1
PMCID: PMC1629442  PMID: 17082834

Abstract

Context: Systematic reviews of qualitative research studies extend understanding of health care beyond effectiveness to acceptability and user views.

Objective: The paper surveys reports of qualitative systematic reviews and, by characterizing techniques used to identify articles for inclusion, proposes standards for reporting of literature searches.

Data Sources and Study Selection: A search of MEDLINE was performed for qualitative systematic reviews published from 1988 to December 2004, supported by searches of CINAHL, Web of Knowledge (including the Science and Social Sciences Citation Index), and the Cochrane Methodology Register, and Internet searches using the Copernic Agent Professional meta-search agent. Studies were included if they used techniques of qualitative synthesis in reviewing research studies in health care. Narrative reviews were excluded.

Data Extraction: Authors, year of publication, sampling strategy, databases, keywords, and other approaches used were extracted.

Data Synthesis: Sixty-four studies were identified, and forty-three met inclusion criteria for this review. A summary of searching methods was produced and used to construct the STARLITE mnemonic (sampling strategy, type of study, approaches, range of years, limits, inclusion and exclusions, terms used, electronic sources).

Conclusions: Considerable variation exists in search methods for qualitative systematic reviews. While diversity in methods is appropriate during the development of review methodology, major concerns remain about the absence of an accepted standard and the consequent poor quality of reporting.

Highlights

  • Systematic reviews of qualitative research studies are limited by poor quality reporting of search methods.

  • Standards for reporting literature searches must acknowledge the demands of both quantitative and qualitative systematic reviews.

  • The mnemonic STARLITE (sampling strategy, type of study, approaches, range of years, limits, inclusion and exclusions, terms used, electronic sources) may be used to convey the essential elements for reporting literature searches.

Implications

  • There is a pressing need to achieve international consensus about standards for reporting literature searches.

  • Further work needs to define the contents of each proposed element and the ways these elements are to be evaluated.

  • Librarians have a key role in defining standards for systematic reviews and their subsequent reporting.

BACKGROUND

Recent years have seen increasing recognition of the potential contribution of qualitative health research to informing health policy and clinical practice [1, 2]. Qualitative approaches allow the researcher to explore the richness and complexity of human experience in a given context [3]. In representing human experience, this type of research provides important information about such aspects as the appropriateness of care and the impact of illness. As such, it complements the role of quantitative research where the focus is often on improved understanding of the effectiveness of health care. Qualitative research may also give consumers “a voice in the decision-making process through the documentation of their experiences, preferences, and priorities” [2]. Specifically, in health technology assessment (HTA), a properly employed qualitative approach can provide “valuable information on the implementation and impact of health technologies on both health professionals and patients” [4]. In particular, the value of systematic reviews of qualitative research that synthesize the findings of multiple studies covering the same topic is being increasingly acknowledged.

Systematic reviews—in which evidence has been systematically identified from comprehensive searches of the published and unpublished literature, appraised for quality, and then synthesized to produce generalizable messages—have become a key tool in the development of an evidence base [5]. A qualitative systematic review, also referred to as a qualitative meta-synthesis, is a method for integrating or comparing the findings from qualitative studies [6]. The accumulated knowledge resulting from this process may lead to the development of a new theory, an overarching “narrative,” a wider generalization, or an “interpretative translation” [7]. Whereas a quantitative meta-synthesis, or meta-analysis, aims to pool the numerical results of individual quantitative studies, a qualitative meta-synthesis looks for “themes” or “constructs” that lie in or across individual qualitative studies. The goal of such a qualitative meta-synthesis is not aggregative in the sense of “adding studies together,” as with a meta-analysis. On the contrary, it is interpretative in broadening understanding of a particular phenomenon [8]. Within this broader category of “qualitative meta-synthesis,” the narrow term “meta-ethnography” [9] refers to the specific method of data synthesis that has been most widely adopted in the literature to date. For example, Paterson and colleagues have identified thirty-eight studies examining the firsthand experience of living with diabetes [10]. They have found that the prevailing metaphor was the concept of balance and specific subthemes identified across multiple studies included “knowing one's body,” “learning how to manage diabetes,” and “fostering supportive, collaborative relationships with others.”

Compared to systematic reviews of the quantitative research literature, qualitative systematic reviews in health care are a much more recent phenomenon. Whereas quantitative reviews are conducted according to such guidelines as the Cochrane Handbook [11] and the National Health Service (NHS) Centre for Reviews and Dissemination report number 4 [12], similar accepted principles for qualitative reviews are lacking [13]. The second edition of published NHS Centre for Reviews and Dissemination guidelines does cater superficially to qualitative research in the context of effectiveness research, but it is widely acknowledged that qualitative reviews may be used for a much broader range of purposes, which may or may not include the “typical” effectiveness question [12]. Included in a quantitative legacy that is being increasingly challenged by qualitative systematic reviewers are such acknowledged systematic review mechanisms as checklists [6, 14–16] and a hierarchy of evidence [17].

Notwithstanding considerable progress, vigorous debate exists as to whether it is appropriate to apply conventional systematic review techniques, developed primarily for quantitative systematic reviews and meta-analyses, to reviews of qualitative research [18]. Some commentators argue that it is more appropriate to develop and apply methods analogous to those used in conducting primary qualitative research, employing familiar techniques such as purposive sampling and theoretical saturation in preference to quantitative-centric review methods [19, 20]. Regardless of one's stance on such issues, applying such methods to qualitative research presents significant philosophical and practical challenges [21].

This comparative immaturity of methods for qualitative systematic reviews is mirrored in the specific context of the identification of studies. Whereas techniques for retrieval of quantitative study designs (such as randomized controlled trials) are relatively far advanced, it is only comparatively recently that attention has started to be focused on methods for identifying qualitative research studies [2, 22–24]. This deficiency is fittingly signaled by the fact that a chapter on searching for qualitative research has not yet been included in the international HTA community's otherwise impressively comprehensive E-text on Health Technology Assessment Information Resources [25].

This investigation has been conducted to accompany and inform methodological advances pursued via a UK Economic and Social Research Council (ESRC)– funded† project on approaches to synthesizing qualitative and quantitative research. This study aims to identify published examples of qualitative systematic reviews in health care published between 1988 and December 2004. It then seeks to characterize these reviews with regard to methods used for the sampling of studies for inclusion in each review and the search techniques used to identify such studies. In doing so, this study attempts to outline priorities for future development of the methods of qualitative systematic reviews, particularly with respect to standards for the identification and reporting of included studies.

The nature of the study question together with the resource limitations of an unfunded project mean that it is not possible to conduct a full systematic review of identified qualitative systematic reviews. The methodology used for this study is a systematic survey of the literature. It employs systematic searching methods to identify qualitative systematic reviews. However, it makes no attempt to deliver judgments on the quality of retrieved studies or to validate independently decisions about the inclusion or exclusion of retrieved studies. It may thus be considered an “epidemiological survey” in attempting to quantify the absence or presence of key characteristics of the literature.

METHODS

As indicated in the description of a qualitative systematic review above, a major issue for this systematic survey of the literature is the variation that exists with regard to the terminology used to describe qualitative systematic reviews. This variation applies to “false-negatives”; that is, reviews that use qualitative methods and yet are not identifiable by such terms as “qualitative systematic review,” “meta-ethnography,” or “meta-synthesis.” For example, this author was involved in one such study described simply as a “systematic review” [26]. However, it also applies to “false positives”; that is, to reviews that claim to be “qualitative systematic reviews” but simply use the term to differentiate from meta-analyses, that is, quantitative systematic reviews. For example, there are frequent instances of qualitative systematic reviews of randomized controlled trials. Such a situation is further compounded because few journals in which qualitative systematic reviews are published utilize structured abstracts. Such abstracts can help to clarify whether systematic searches have taken place and whether an established method of synthesis (such as Noblit and Hare's meta-ethnography [9]) has been employed.

A comprehensive search was undertaken of the social science, health, and information science literature using PubMed, MEDLINE, CINAHL, Web of Knowledge (including the Science and Social Sciences Citation Index), and the Cochrane Methodology Register. A sensitive search strategy was used combining the keywords “(qualitative review$) OR meta-ethnograph$ OR metaethnograph$ OR metasynthesis OR meta-synthesis OR (qualitative AND systematic review$).” Although the combination of “qualitative AND meta-analysis” appeared to yield some relevant hits, it greatly increased the retrieval of manifestly irrelevant records. A verification strategy, produced by searching for this combination and then using the Boolean “NOT” with the sensitive search strategy, revealed no unique relevant records (Figure 1). As it appeared that indexers were adding the index term “meta-analysis” to recognize the presence in the title or abstract of the term “meta-synthesis,” the final strategy as given was considered adequate.

Figure 1.

Figure 1

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Verification strategy

To be included, a study had to meet two criteria: the study, or at the very least a significant part of it, should have been a qualitative systematic review that reports search strategies and/or techniques, and it should have been conducted in a health care context. All decisions on inclusion were made by the author. In cases of doubt, reference was made to the full-text of the article in question. A list of potentially eligible and yet excluded studies was maintained to assist transparency. Citations to key qualitative methodological texts were followed up, and Related Articles features on MEDLINE and Web of Knowledge were also utilized. Searches of the Internet using the Copernic Agent Professional meta-search agent <http://www.copernic.com> were used to track down unpublished and gray literature. This software is particularly useful for systematic literature reviews, because it searches multiple search engines (including AlltheWeb, Alta Vista, Hotbot, Lycos, and Yahoo), saves the results in an “audit trail” on the searcher's computer, and allows manual weeding of results for inclusion or exclusion. Searches covered the period from 1988, when a key text on metasynthesis was published [9], to December 2004 and were restricted to English language, due to practical constraints. There were no other restrictions.

In excess of 400 articles passed an initial screening by title. Review of abstracts and text from those articles yielded 64 publications that met inclusion criteria. Published examples of meta-syntheses were obtained, and data regarding search methods were extracted into a matrix. A summary produced from this matrix is seen in Table 1. Key variables included authors, year of publication, the sampling strategy (including inclusion and exclusion criteria), and the search strategy (including databases, search terms used, and other searching approaches). The sampling strategy was defined as “comprehensive” if the search strategy attempted to retrieve all relevant studies in a topic area in a conventional systematic review manner, “purposive” if the search strategy followed an underlying rationale in only trying to find a subset of predefined studies, and “opportunistic” if a review worked with a convenience subset of already retrieved studies. For limits, where languages for inclusion were reported, studies were categorized according to whether the reviews covered “English only,” “other (specified) languages,” or “all languages” (i.e., no language restrictions). For ease of presentation, all other categories of data extraction are simply coded in Table 1 as “Yes” for item reported or “No” for item not reported. However, full details of strategies were recorded in a matrix constructed as a tool for data extraction. Data on the topic area were also recorded, although only methodological data were reported in this survey.

Table 1 Included studies with level of literature search reporting (n = 44)

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RESULTS

Overall, sixty-five studies were identified; of these, forty-four (68%) reported at least one of three elements (databases, keywords, other approaches) of their search methods (Table 1) [10, 21, 26–67]. The remaining twenty-one studies did not report any elements of their search strategies (Table 2; find online) [7, 28, 68–88]. Four of these referred to another publication for details of their methods. Of the remaining seventeen, twelve studies did not attempt to conduct a systematic search of the literature, four simply represented an analysis of papers previously produced by the authors, and the remaining one analyzed studies from a previous report. A median of five databases was used in each review (range 1 to 23). The largest number of databases was searched in studies that exclusively involved information professionals in the review process [26, 38].

Table 2 Other qualitative systematic reviews excluded for not reporting search methods

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Keywords (search terms used) were only reported in twenty-five studies. While no formal analysis of the quality of search strategies was undertaken, certain characteristics could be observed from the literature. There was little evidence for the use of techniques to maximize retrieval such as truncation or explosion of subject terms. Where search terms were reported, it was not usually clear whether they were free-text terms or approved subject headings. Studies did not typically present a sample search strategy, not even as an appendix, and thus it was difficult to observe whether Boolean operators had been employed correctly. In addition, it was unclear whether methodological terms had been used in addition to subject-specific terms to privilege qualitative studies (e.g., the term “qualitative”). Only nine of the studies reported keywords specifically to retrieve qualitative studies. No formal data were extracted on whether a librarian or information specialist was involved in the search process. However, very few studies acknowledged such a contribution in either the authorship or the acknowledgements, and, furthermore, most studies failed to report any such involvement in their methods sections.

The database most frequently mentioned was CINAHL (31 times). MEDLINE was mentioned thirty times, the PsycINFO/PsycLIT/Psychological Abstracts combination was mentioned twenty-five times, and Sociological Abstracts/SOCIOFILE (9 times) and ERIC (5 times) were also listed.

The most common supplementary strategies used alongside searching bibliographic databases were following up reference lists (17 times) and hand-searching (13 times). The most comprehensive report of the literature searching process itemized 23 databases, 10 Websites, and 6 other techniques and reported keywords [26].

Although this study focused on the methodological content of included studies, not their topical content, it was interesting to observe that the most common topics related to chronic disease and to women's health. This observation, which requires further empirical exploration, attests to the possibility that qualitative systematic reviews are being utilized as a facilitative method to provide a “collective voice” to disenfranchised groups [89].

In performing the data extraction, a necessary prelude to reporting the presence or absence of certain characteristics of literature-searching approaches in qualitative systematic reviews, the author has identified several features that might usefully form the basis for future reporting standards for literature searches for systematic reviews. These are briefly outlined below.

PROPOSED STANDARDS FOR REPORTING LITERATURE SEARCHES

The systematic review movement has already driven the development of standards to improve the quality of reporting of quantitative systematic reviews (e.g., QUOROM [90] and MOOSE [91]). Such standards make it easier for readers to assess the quality of such reviews and for researchers to replicate their methods [92]. To date, no standards have been published for reporting of literature searches, so critical to the successful conduct of systematic reviews.

Clearly, standards need to cover all stages of the systematic review process. Nevertheless, the case is particularly strong for focusing on the quality of reporting methods for identification of included studies, at least in the first instance. Reasons for this include the poor quality of reporting as observed by this survey, the impact of sampling decisions on the findings of qualitative reviews, and the fact that, once a question has been identified, decisions made at this stage determine the remainder of the review process. Table 3 encapsulates a proposed framework for reporting the quality of literature searches based on the empirical findings from this review and supported by the author's extensive experience conducting other forms of synthesis such as HTAs, guidelines, and quantitative systematic reviews. The elements to be included when reporting literature searching to allow a reader to assess the quality of a search and to replicate it, if necessary, are conveyed using the mnemonic STARLITE.

Table 3 Elements of the STARLITE mnemonic

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STARLITE constitutes not simply a memorable mnemonic but also serves as an acronym for Standards for Reporting Literature searches. Many of the above elements are already widely acknowledged as important in the recording of literature searches, although no formal standards exist. A notable addition, however, is the inclusion of “sampling strategy.” This addition is stimulated by the specific needs of qualitative systematic reviews, where an assumption of comprehensiveness cannot be made. It is possible for a qualitative systematic review to be explicit and systematic, while not aspiring to comprehensiveness, if it employs purposive sampling of the literature from certain disciplines or even from particular years. Indeed closer examination of many quantitative systematic reviews reveals that they create an illusion of “comprehensiveness,” when the reality is that the studies that they actually include are shaped by arbitrary decisions about search strategies dictated themselves by time and resource limitations.

The author intends, subject to agreement with colleagues in the international HTA community, this approach to form a framework for accepted standards for reporting of literature searches for HTAs and systematic reviews in general. An outline example of reporting for a qualitative systematic review using the STARLITE framework is provided (Table 4; find online). Within this framework, future work could concentrate on specifying how exactly the contents of each element should be reported and subsequently evaluated. The magnitude of the task ahead is emphasized by returning to the survey dataset and summarizing the presence or absence of the STARLITE elements (Table 5).

Table 4 Outline example of a report of a literature search structured according to STARLITE principles

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Table 5 Completeness of reporting (n = 44)

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DISCUSSION

This literature survey has sought to identify the presence and absence of prespecified characteristics in a body of literature believed to meet an operational definition of a “qualitative systematic review” in health care. It is recognized that use of a single reviewer for judgments on inclusion and exclusion of studies opens the possibility of bias. This limitation would indeed be serious if the reviewer had subsequently attempted to make value judgments on whether or not the literature searching methods are “adequate” or not. Such an approach would require the addition of several quality procedures such as the use of additional reviewers, a quality checklist, and assessment of inter-rater reliability. By retaining a descriptive, rather than evaluative, focus the author has been able to characterize a population of qualitative systematic review studies. This population does, of course, have the further potential to be extended further through more exhaustive search procedures such as hand-searching of key qualitative journals such as Qualitative Research and Qualitative Health Research.

Further work is required on assessing the quality of the reported search methods and evaluating their likely impact on the quality of the subsequent reviews. In this context, it is interesting to observe commencement of the Evaluating Health Technology Assessment Searches (EHTAS) research study to develop a quality assessment checklist for searches used in HTAs and systematic reviews. Finally, this survey has been independently examined in a wider study investigating the quality of reporting of the methods of all stages of the qualitative systematic review, not just the searching, and there are plans to use this data set in further methodological research.

The field of qualitative systematic review is still relatively immature, with no consensus yet on what constitutes such a review. This is illustrated by examples identified from the tables above; does searching only one database, synthesizing a small number of studies by a select group of authors, or identifying studies systematically but stopping short of synthesis rightly constitute a qualitative systematic review? Of course, each criterion exists on a continuum, rendering judgments on what should be included or excluded in this genre necessarily subjective. Ironically, this means that this survey, while possessing a measure of systematicity, falls short of the requirement to be easily reproducible.

CONCLUSION

Recent years have seen ongoing improvement in methods of conducting and reporting systematic reviews. While these two issues remain discrete stages of the review process, they are interconnected; one cannot automatically conclude that a poorly reported review has been badly conducted, but such poor reporting does mean that many of the intrinsic virtues of a systematic review are negated. For example, systematic reviews draw strength from the fact that they claim to be both explicit and reproducible. In 1987, Mulrow [93] highlighted the poor state of the medical review article. Over a decade later, in 1999, McAlister and colleagues [94] found that less than a quarter of published reviews described how evidence was identified, evaluated, or integrated.

Librarians have a key role in the further development of systematic review methods, particularly as they relate to retrieval of the evidence. This is true for both the conduct of the review itself and its subsequent reporting. Findings from this survey have the potential to inform the future work of groups of international information specialists, such as the Cochrane Collaboration Information Retrieval Methods Group [95], in developing standards for reporting literature searches to the benefit of both quantitative and qualitative systematic reviews. In the meantime, these findings are offered with the exhortation that authors and editors improve the quality of methods for identifying studies for inclusion in systematic reviews. It is hoped that this article, and its underpinning research, will stimulate improvements in conducting and reporting systematic reviews, both qualitative and quantitative.

Acknowledgments

The author thanks his collaborators on Economic and Social Research Council Research Methods Programme project number: H333250043 for providing the stimulus for this spin-off project, especially Mary Dixon-Woods who put the team together.

Footnotes

Supplemental electronic content is included with this paper on PubMed Central.

† Principal investigator: Mary Dixon-Woods, project ID H333250043.

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