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We used thematic synthesis [27]. Our procedure took place in four stages: designing the research, that is, defining the question, subjects, types of studies to include, and the protocol; the search for and selection of articles; and the analysis itself, in two separate stages, first a descriptive portion in which we determined and compared themes, and then an interpretive stage in which we constructed a descriptive schema of the phenomenon, original proposals that we then examined from the perspectives of theory, the literature, clinical practice, and care [25,27]. These steps increase both the possibilities for generalisation and the strength of these generalisations. [28] Our method is consistent with the ENTREQ statements [29]. (S1 Table) Here are the six steps of our method: Definition of the research question (summarised in the aims and objectives);Identification and selection of studies;Quality assessment of the selected studies;Analysis of the papers, identification of themes, and translation of the themes across studies;Generating analytical themes and structuring the synthesisWriting the synthesis.
We conducted a systematic search for qualitative studies specifically devoted to suicidal behaviours in young people (step 2). The QUALIGRAMH working group (Qualitative Group for Research in Adolescent Mental Health, INSERM U 669, Maison des Adolescents, Hôpital Cochin, Paris), composed of specialists in qualitative research and disorders of young people, defined the study criteria. The papers were selected only if they met the following criteria: Used solely qualitative methodology.Specifically concerned suicidal behaviours in adolescents and young adults (referred to hereafter as youth or young people).Interviewed: - Young people who were suicidal, or who had attempted suicide in their youth, or- Parents of these youth, or- Medical professionals who provide care to suicidal youth.Were published in English or French between 1990 and May, 2014 (the period covering most of the qualitative articles about suicide).Finally the following studies were excluded: Studies using quantitative or mixed methodologies;Studies in the general population exploring prevention of suicide or social representations of suicide in adolescents and young adults;Studies concerning solely deliberate self-harm or non-suicidal self-injury.The study was conducted from January to May 2014. An initial search identified a selection of papers, from which we collected keywords. Based on this selection as well as on existing literature reviews about suicide [30–32], the research group drew up a list of keywords, a mix of free-text terms and thesaurus terms related to suicidal behaviours, youth, and qualitative research [33,34] and compiled a list of databases indexing qualitative studies in the fields of medicine, sociology, and psychology [25,35]. We performed our search on July 1, 2013 (and updated it on May 31, 2014) (Table 1 and S2 Table).
Table data removed from full text. Table identifier and caption: 10.1371/journal.pone.0127359.t001 Web searches—January 1, 1990 to July 1, 2013 (updated on May 31, 2014). In all, we obtained 1804 references, 1403 of which remained after removal of duplicates (Fig 1). Two authors (JL and MO) screened all titles and abstracts, according to the relevance of their theme and methodology. If the abstract was not sufficient, the full text was read. Disagreements were resolved during working group meetings. For example, we initially included all studies concerning deliberate self-harm or non-suicidal self-injury in our selection. After discussions and literature review [3], we decided to exclude all these papers because we do not think that the issues of suicide and self-harm are identical: the question of death is posed differently for these two groups of subjects. Another issue was whether or not to include mixed studies, given that the best way of dealing with mixed methods remains unclear [25]. After consulting these papers, we concluded that they did not contribute to our thematic framework and decided to exclude them from the analysis. Full texts of potentially relevant papers were then examined, and a second selection was performed (the papers excluded at this point and the reasons for their exclusion are listed in S1 File). After removal of studies that did not meet the criteria defined above, 42 papers remained. Scanning the reference lists for more potentially relevant papers provided 2 more papers. In all, the review finally included 44 studies, around 2.5% of the papers screened. This rate is consistent with the findings of other such meta-syntheses [25,33,34].
Figure data removed from full text. Figure identifier and caption: 10.1371/journal.pone.0127359.g001 Flowchart for selecting studies. The evaluation of quality (step 3) is necessary to enable discussion of the studies and to ascertain the value and integrity of the data used. The working group chose a tool widely used for medical meta-syntheses, the Critical Appraisal Skills Programme (CASP) [32,36]. Two researchers (JL and MO) independently performed the evaluation, and the working group reached a consensus about it. Table 2 summarises the quality evaluation criteria.
Table data removed from full text. Table identifier and caption: 10.1371/journal.pone.0127359.t002 Evaluation of the quality of the studies according to the Critical Appraisal Skill Programme (CASP). 1 Number of studies.
We followed the procedure described by Thomas and Harden (2008) to analyse the data [27]. The analysis (step 4) included a careful reading of the titles, abstracts, and complete papers as well as repeated rereadings. One researcher (JL) extracted the formal characteristics of the studies, while he and two others (ARL and MO) independently extracted and analysed the data, which were then compared during meetings. We used thematic analysis to develop categories inductively from the first-order themes identified in these studies. Afterwards, the translation work involved comparing themes across papers to match themes from one paper with those from another and ensure that each key theme captured similar themes from different papers. Finally, we ordered these translation results into a framework containing three superordinate themes (step 5). This step is more interpretive, since the group decided to organize the themes through a more conceptual line of argument. The last step consisted in expressing the synthesis in a useful form (step 6). This process led not to a summary of the different studies included, but to an interpretation of the papers, described in the discussion. Research meetings were held regularly to discuss the results obtained. The triangulation of sources—meta-synthesis does this by definition—and the triangulation of reviewers made possible a high level of rigour in the results [37,38].
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