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How to Write a Literature Review | Guide, Examples, & Templates

Published on January 2, 2023 by Shona McCombes . Revised on September 11, 2023.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research that you can later apply to your paper, thesis, or dissertation topic .

There are five key steps to writing a literature review:

• Search for relevant literature
• Evaluate sources
• Identify themes, debates, and gaps
• Outline the structure
• Write your literature review

A good literature review doesn’t just summarize sources—it analyzes, synthesizes , and critically evaluates to give a clear picture of the state of knowledge on the subject.

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Table of contents

What is the purpose of a literature review, examples of literature reviews, step 1 – search for relevant literature, step 2 – evaluate and select sources, step 3 – identify themes, debates, and gaps, step 4 – outline your literature review’s structure, step 5 – write your literature review, free lecture slides, other interesting articles, frequently asked questions, introduction.

• Quick Run-through
• Step 1 & 2

When you write a thesis , dissertation , or research paper , you will likely have to conduct a literature review to situate your research within existing knowledge. The literature review gives you a chance to:

• Demonstrate your familiarity with the topic and its scholarly context
• Develop a theoretical framework and methodology for your research
• Position your work in relation to other researchers and theorists
• Show how your research addresses a gap or contributes to a debate
• Evaluate the current state of research and demonstrate your knowledge of the scholarly debates around your topic.

Writing literature reviews is a particularly important skill if you want to apply for graduate school or pursue a career in research. We’ve written a step-by-step guide that you can follow below.

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Writing literature reviews can be quite challenging! A good starting point could be to look at some examples, depending on what kind of literature review you’d like to write.

• Example literature review #1: “Why Do People Migrate? A Review of the Theoretical Literature” ( Theoretical literature review about the development of economic migration theory from the 1950s to today.)
• Example literature review #2: “Literature review as a research methodology: An overview and guidelines” ( Methodological literature review about interdisciplinary knowledge acquisition and production.)
• Example literature review #3: “The Use of Technology in English Language Learning: A Literature Review” ( Thematic literature review about the effects of technology on language acquisition.)
• Example literature review #4: “Learners’ Listening Comprehension Difficulties in English Language Learning: A Literature Review” ( Chronological literature review about how the concept of listening skills has changed over time.)

You can also check out our templates with literature review examples and sample outlines at the links below.

Download Word doc Download Google doc

Before you begin searching for literature, you need a clearly defined topic .

If you are writing the literature review section of a dissertation or research paper, you will search for literature related to your research problem and questions .

Make a list of keywords

Start by creating a list of keywords related to your research question. Include each of the key concepts or variables you’re interested in, and list any synonyms and related terms. You can add to this list as you discover new keywords in the process of your literature search.

• Social media, Facebook, Instagram, Twitter, Snapchat, TikTok
• Body image, self-perception, self-esteem, mental health
• Generation Z, teenagers, adolescents, youth

Search for relevant sources

Use your keywords to begin searching for sources. Some useful databases to search for journals and articles include:

• Your university’s library catalogue
• Google Scholar
• Project Muse (humanities and social sciences)
• Medline (life sciences and biomedicine)
• EconLit (economics)
• Inspec (physics, engineering and computer science)

You can also use boolean operators to help narrow down your search.

Make sure to read the abstract to find out whether an article is relevant to your question. When you find a useful book or article, you can check the bibliography to find other relevant sources.

You likely won’t be able to read absolutely everything that has been written on your topic, so it will be necessary to evaluate which sources are most relevant to your research question.

For each publication, ask yourself:

• What question or problem is the author addressing?
• What are the key concepts and how are they defined?
• What are the key theories, models, and methods?
• Does the research use established frameworks or take an innovative approach?
• What are the results and conclusions of the study?
• How does the publication relate to other literature in the field? Does it confirm, add to, or challenge established knowledge?
• What are the strengths and weaknesses of the research?

Make sure the sources you use are credible , and make sure you read any landmark studies and major theories in your field of research.

You can use our template to summarize and evaluate sources you’re thinking about using. Click on either button below to download.

Take notes and cite your sources

As you read, you should also begin the writing process. Take notes that you can later incorporate into the text of your literature review.

It is important to keep track of your sources with citations to avoid plagiarism . It can be helpful to make an annotated bibliography , where you compile full citation information and write a paragraph of summary and analysis for each source. This helps you remember what you read and saves time later in the process.

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To begin organizing your literature review’s argument and structure, be sure you understand the connections and relationships between the sources you’ve read. Based on your reading and notes, you can look for:

• Trends and patterns (in theory, method or results): do certain approaches become more or less popular over time?
• Themes: what questions or concepts recur across the literature?
• Debates, conflicts and contradictions: where do sources disagree?
• Pivotal publications: are there any influential theories or studies that changed the direction of the field?
• Gaps: what is missing from the literature? Are there weaknesses that need to be addressed?

This step will help you work out the structure of your literature review and (if applicable) show how your own research will contribute to existing knowledge.

• Most research has focused on young women.
• There is an increasing interest in the visual aspects of social media.
• But there is still a lack of robust research on highly visual platforms like Instagram and Snapchat—this is a gap that you could address in your own research.

There are various approaches to organizing the body of a literature review. Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

The simplest approach is to trace the development of the topic over time. However, if you choose this strategy, be careful to avoid simply listing and summarizing sources in order.

Try to analyze patterns, turning points and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred.

If you have found some recurring central themes, you can organize your literature review into subsections that address different aspects of the topic.

For example, if you are reviewing literature about inequalities in migrant health outcomes, key themes might include healthcare policy, language barriers, cultural attitudes, legal status, and economic access.

Methodological

If you draw your sources from different disciplines or fields that use a variety of research methods , you might want to compare the results and conclusions that emerge from different approaches. For example:

• Look at what results have emerged in qualitative versus quantitative research
• Discuss how the topic has been approached by empirical versus theoretical scholarship
• Divide the literature into sociological, historical, and cultural sources

Theoretical

A literature review is often the foundation for a theoretical framework . You can use it to discuss various theories, models, and definitions of key concepts.

You might argue for the relevance of a specific theoretical approach, or combine various theoretical concepts to create a framework for your research.

Like any other academic text , your literature review should have an introduction , a main body, and a conclusion . What you include in each depends on the objective of your literature review.

The introduction should clearly establish the focus and purpose of the literature review.

Depending on the length of your literature review, you might want to divide the body into subsections. You can use a subheading for each theme, time period, or methodological approach.

As you write, you can follow these tips:

• Summarize and synthesize: give an overview of the main points of each source and combine them into a coherent whole
• Analyze and interpret: don’t just paraphrase other researchers — add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
• Critically evaluate: mention the strengths and weaknesses of your sources
• Write in well-structured paragraphs: use transition words and topic sentences to draw connections, comparisons and contrasts

In the conclusion, you should summarize the key findings you have taken from the literature and emphasize their significance.

When you’ve finished writing and revising your literature review, don’t forget to proofread thoroughly before submitting. Not a language expert? Check out Scribbr’s professional proofreading services !

This article has been adapted into lecture slides that you can use to teach your students about writing a literature review.

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

• Sampling methods
• Simple random sampling
• Stratified sampling
• Cluster sampling
• Likert scales
• Reproducibility

 Statistics

• Null hypothesis
• Statistical power
• Probability distribution
• Effect size
• Poisson distribution

Research bias

• Optimism bias
• Cognitive bias
• Implicit bias
• Hawthorne effect
• Anchoring bias
• Explicit bias

A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a thesis, dissertation , or research paper , in order to situate your work in relation to existing knowledge.

There are several reasons to conduct a literature review at the beginning of a research project:

• To familiarize yourself with the current state of knowledge on your topic
• To ensure that you’re not just repeating what others have already done
• To identify gaps in knowledge and unresolved problems that your research can address
• To develop your theoretical framework and methodology
• To provide an overview of the key findings and debates on the topic

Writing the literature review shows your reader how your work relates to existing research and what new insights it will contribute.

The literature review usually comes near the beginning of your thesis or dissertation . After the introduction , it grounds your research in a scholarly field and leads directly to your theoretical framework or methodology .

A literature review is a survey of credible sources on a topic, often used in dissertations , theses, and research papers . Literature reviews give an overview of knowledge on a subject, helping you identify relevant theories and methods, as well as gaps in existing research. Literature reviews are set up similarly to other  academic texts , with an introduction , a main body, and a conclusion .

An  annotated bibliography is a list of  source references that has a short description (called an annotation ) for each of the sources. It is often assigned as part of the research process for a  paper .  

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What is a Literature Review? How to Write It (with Examples)

A literature review is a critical analysis and synthesis of existing research on a particular topic. It provides an overview of the current state of knowledge, identifies gaps, and highlights key findings in the literature. 1 The purpose of a literature review is to situate your own research within the context of existing scholarship, demonstrating your understanding of the topic and showing how your work contributes to the ongoing conversation in the field. Learning how to write a literature review is a critical tool for successful research. Your ability to summarize and synthesize prior research pertaining to a certain topic demonstrates your grasp on the topic of study, and assists in the learning process. 

Table of Contents

• What is the purpose of literature review? 
• a. Habitat Loss and Species Extinction: 
• b. Range Shifts and Phenological Changes: 
• c. Ocean Acidification and Coral Reefs: 
• d. Adaptive Strategies and Conservation Efforts: 
• How to write a good literature review 
• Choose a Topic and Define the Research Question: 
• Decide on the Scope of Your Review: 
• Select Databases for Searches: 
• Conduct Searches and Keep Track: 
• Review the Literature: 
• Organize and Write Your Literature Review: 
• Frequently asked questions 

What is a literature review?

A well-conducted literature review demonstrates the researcher’s familiarity with the existing literature, establishes the context for their own research, and contributes to scholarly conversations on the topic. One of the purposes of a literature review is also to help researchers avoid duplicating previous work and ensure that their research is informed by and builds upon the existing body of knowledge.

What is the purpose of literature review?

A literature review serves several important purposes within academic and research contexts. Here are some key objectives and functions of a literature review: 2  

• Contextualizing the Research Problem: The literature review provides a background and context for the research problem under investigation. It helps to situate the study within the existing body of knowledge. 
• Identifying Gaps in Knowledge: By identifying gaps, contradictions, or areas requiring further research, the researcher can shape the research question and justify the significance of the study. This is crucial for ensuring that the new research contributes something novel to the field. 
• Understanding Theoretical and Conceptual Frameworks: Literature reviews help researchers gain an understanding of the theoretical and conceptual frameworks used in previous studies. This aids in the development of a theoretical framework for the current research. 
• Providing Methodological Insights: Another purpose of literature reviews is that it allows researchers to learn about the methodologies employed in previous studies. This can help in choosing appropriate research methods for the current study and avoiding pitfalls that others may have encountered. 
• Establishing Credibility: A well-conducted literature review demonstrates the researcher’s familiarity with existing scholarship, establishing their credibility and expertise in the field. It also helps in building a solid foundation for the new research. 
• Informing Hypotheses or Research Questions: The literature review guides the formulation of hypotheses or research questions by highlighting relevant findings and areas of uncertainty in existing literature. 

Literature review example

Let’s delve deeper with a literature review example: Let’s say your literature review is about the impact of climate change on biodiversity. You might format your literature review into sections such as the effects of climate change on habitat loss and species extinction, phenological changes, and marine biodiversity. Each section would then summarize and analyze relevant studies in those areas, highlighting key findings and identifying gaps in the research. The review would conclude by emphasizing the need for further research on specific aspects of the relationship between climate change and biodiversity. The following literature review template provides a glimpse into the recommended literature review structure and content, demonstrating how research findings are organized around specific themes within a broader topic. 

Literature Review on Climate Change Impacts on Biodiversity:

Climate change is a global phenomenon with far-reaching consequences, including significant impacts on biodiversity. This literature review synthesizes key findings from various studies: 

a. Habitat Loss and Species Extinction:

Climate change-induced alterations in temperature and precipitation patterns contribute to habitat loss, affecting numerous species (Thomas et al., 2004). The review discusses how these changes increase the risk of extinction, particularly for species with specific habitat requirements. 

b. Range Shifts and Phenological Changes:

Observations of range shifts and changes in the timing of biological events (phenology) are documented in response to changing climatic conditions (Parmesan & Yohe, 2003). These shifts affect ecosystems and may lead to mismatches between species and their resources. 

c. Ocean Acidification and Coral Reefs:

The review explores the impact of climate change on marine biodiversity, emphasizing ocean acidification’s threat to coral reefs (Hoegh-Guldberg et al., 2007). Changes in pH levels negatively affect coral calcification, disrupting the delicate balance of marine ecosystems. 

d. Adaptive Strategies and Conservation Efforts:

Recognizing the urgency of the situation, the literature review discusses various adaptive strategies adopted by species and conservation efforts aimed at mitigating the impacts of climate change on biodiversity (Hannah et al., 2007). It emphasizes the importance of interdisciplinary approaches for effective conservation planning. 

How to write a good literature review

Writing a literature review involves summarizing and synthesizing existing research on a particular topic. A good literature review format should include the following elements. 

Introduction: The introduction sets the stage for your literature review, providing context and introducing the main focus of your review. 

• Opening Statement: Begin with a general statement about the broader topic and its significance in the field. 
• Scope and Purpose: Clearly define the scope of your literature review. Explain the specific research question or objective you aim to address. 
• Organizational Framework: Briefly outline the structure of your literature review, indicating how you will categorize and discuss the existing research. 
• Significance of the Study: Highlight why your literature review is important and how it contributes to the understanding of the chosen topic. 
• Thesis Statement: Conclude the introduction with a concise thesis statement that outlines the main argument or perspective you will develop in the body of the literature review. 

Body: The body of the literature review is where you provide a comprehensive analysis of existing literature, grouping studies based on themes, methodologies, or other relevant criteria. 

• Organize by Theme or Concept: Group studies that share common themes, concepts, or methodologies. Discuss each theme or concept in detail, summarizing key findings and identifying gaps or areas of disagreement. 
• Critical Analysis: Evaluate the strengths and weaknesses of each study. Discuss the methodologies used, the quality of evidence, and the overall contribution of each work to the understanding of the topic. 
• Synthesis of Findings: Synthesize the information from different studies to highlight trends, patterns, or areas of consensus in the literature. 
• Identification of Gaps: Discuss any gaps or limitations in the existing research and explain how your review contributes to filling these gaps. 
• Transition between Sections: Provide smooth transitions between different themes or concepts to maintain the flow of your literature review. 

Conclusion: The conclusion of your literature review should summarize the main findings, highlight the contributions of the review, and suggest avenues for future research. 

• Summary of Key Findings: Recap the main findings from the literature and restate how they contribute to your research question or objective. 
• Contributions to the Field: Discuss the overall contribution of your literature review to the existing knowledge in the field. 
• Implications and Applications: Explore the practical implications of the findings and suggest how they might impact future research or practice. 
• Recommendations for Future Research: Identify areas that require further investigation and propose potential directions for future research in the field. 
• Final Thoughts: Conclude with a final reflection on the importance of your literature review and its relevance to the broader academic community. 

Conducting a literature review

Conducting a literature review is an essential step in research that involves reviewing and analyzing existing literature on a specific topic. It’s important to know how to do a literature review effectively, so here are the steps to follow: 1  

Choose a Topic and Define the Research Question:

• Select a topic that is relevant to your field of study. 
• Clearly define your research question or objective. Determine what specific aspect of the topic do you want to explore? 

Decide on the Scope of Your Review:

• Determine the timeframe for your literature review. Are you focusing on recent developments, or do you want a historical overview? 
• Consider the geographical scope. Is your review global, or are you focusing on a specific region? 
• Define the inclusion and exclusion criteria. What types of sources will you include? Are there specific types of studies or publications you will exclude? 

Select Databases for Searches:

• Identify relevant databases for your field. Examples include PubMed, IEEE Xplore, Scopus, Web of Science, and Google Scholar. 
• Consider searching in library catalogs, institutional repositories, and specialized databases related to your topic. 

Conduct Searches and Keep Track:

• Develop a systematic search strategy using keywords, Boolean operators (AND, OR, NOT), and other search techniques. 
• Record and document your search strategy for transparency and replicability. 
• Keep track of the articles, including publication details, abstracts, and links. Use citation management tools like EndNote, Zotero, or Mendeley to organize your references. 

Review the Literature:

• Evaluate the relevance and quality of each source. Consider the methodology, sample size, and results of studies. 
• Organize the literature by themes or key concepts. Identify patterns, trends, and gaps in the existing research. 
• Summarize key findings and arguments from each source. Compare and contrast different perspectives. 
• Identify areas where there is a consensus in the literature and where there are conflicting opinions. 
• Provide critical analysis and synthesis of the literature. What are the strengths and weaknesses of existing research? 

Organize and Write Your Literature Review:

• Literature review outline should be based on themes, chronological order, or methodological approaches. 
• Write a clear and coherent narrative that synthesizes the information gathered. 
• Use proper citations for each source and ensure consistency in your citation style (APA, MLA, Chicago, etc.). 
• Conclude your literature review by summarizing key findings, identifying gaps, and suggesting areas for future research. 

The literature review sample and detailed advice on writing and conducting a review will help you produce a well-structured report. But remember that a literature review is an ongoing process, and it may be necessary to revisit and update it as your research progresses. 

Frequently asked questions

A literature review is a critical and comprehensive analysis of existing literature (published and unpublished works) on a specific topic or research question and provides a synthesis of the current state of knowledge in a particular field. A well-conducted literature review is crucial for researchers to build upon existing knowledge, avoid duplication of efforts, and contribute to the advancement of their field. It also helps researchers situate their work within a broader context and facilitates the development of a sound theoretical and conceptual framework for their studies.

Literature review is a crucial component of research writing, providing a solid background for a research paper’s investigation. The aim is to keep professionals up to date by providing an understanding of ongoing developments within a specific field, including research methods, and experimental techniques used in that field, and present that knowledge in the form of a written report. Also, the depth and breadth of the literature review emphasizes the credibility of the scholar in his or her field.  

Before writing a literature review, it’s essential to undertake several preparatory steps to ensure that your review is well-researched, organized, and focused. This includes choosing a topic of general interest to you and doing exploratory research on that topic, writing an annotated bibliography, and noting major points, especially those that relate to the position you have taken on the topic. 

Literature reviews and academic research papers are essential components of scholarly work but serve different purposes within the academic realm. 3 A literature review aims to provide a foundation for understanding the current state of research on a particular topic, identify gaps or controversies, and lay the groundwork for future research. Therefore, it draws heavily from existing academic sources, including books, journal articles, and other scholarly publications. In contrast, an academic research paper aims to present new knowledge, contribute to the academic discourse, and advance the understanding of a specific research question. Therefore, it involves a mix of existing literature (in the introduction and literature review sections) and original data or findings obtained through research methods. 

Literature reviews are essential components of academic and research papers, and various strategies can be employed to conduct them effectively. If you want to know how to write a literature review for a research paper, here are four common approaches that are often used by researchers.  Chronological Review: This strategy involves organizing the literature based on the chronological order of publication. It helps to trace the development of a topic over time, showing how ideas, theories, and research have evolved.  Thematic Review: Thematic reviews focus on identifying and analyzing themes or topics that cut across different studies. Instead of organizing the literature chronologically, it is grouped by key themes or concepts, allowing for a comprehensive exploration of various aspects of the topic.  Methodological Review: This strategy involves organizing the literature based on the research methods employed in different studies. It helps to highlight the strengths and weaknesses of various methodologies and allows the reader to evaluate the reliability and validity of the research findings.  Theoretical Review: A theoretical review examines the literature based on the theoretical frameworks used in different studies. This approach helps to identify the key theories that have been applied to the topic and assess their contributions to the understanding of the subject.  It’s important to note that these strategies are not mutually exclusive, and a literature review may combine elements of more than one approach. The choice of strategy depends on the research question, the nature of the literature available, and the goals of the review. Additionally, other strategies, such as integrative reviews or systematic reviews, may be employed depending on the specific requirements of the research.

The literature review format can vary depending on the specific publication guidelines. However, there are some common elements and structures that are often followed. Here is a general guideline for the format of a literature review:  Introduction:   Provide an overview of the topic.  Define the scope and purpose of the literature review.  State the research question or objective.  Body:   Organize the literature by themes, concepts, or chronology.  Critically analyze and evaluate each source.  Discuss the strengths and weaknesses of the studies.  Highlight any methodological limitations or biases.  Identify patterns, connections, or contradictions in the existing research.  Conclusion:   Summarize the key points discussed in the literature review.  Highlight the research gap.  Address the research question or objective stated in the introduction.  Highlight the contributions of the review and suggest directions for future research.

Both annotated bibliographies and literature reviews involve the examination of scholarly sources. While annotated bibliographies focus on individual sources with brief annotations, literature reviews provide a more in-depth, integrated, and comprehensive analysis of existing literature on a specific topic. The key differences are as follows: 

References 

• Denney, A. S., & Tewksbury, R. (2013). How to write a literature review.  Journal of criminal justice education ,  24 (2), 218-234. 
• Pan, M. L. (2016).  Preparing literature reviews: Qualitative and quantitative approaches . Taylor & Francis. 
• Cantero, C. (2019). How to write a literature review.  San José State University Writing Center . 

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Writing a Literature Review

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

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

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

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

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

What are the parts of a lit review?

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

Introduction:

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

Conclusion:

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

How should I organize my lit review?

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

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

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

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

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

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

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

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

What Is A Literature Review?

A plain-language explainer (with examples).

By:  Derek Jansen (MBA) & Kerryn Warren (PhD) | June 2020 (Updated May 2023)

If you’re faced with writing a dissertation or thesis, chances are you’ve encountered the term “literature review” . If you’re on this page, you’re probably not 100% what the literature review is all about. The good news is that you’ve come to the right place.

Literature Review 101

• What (exactly) is a literature review
• What’s the purpose of the literature review chapter
• How to find high-quality resources
• How to structure your literature review chapter
• Example of an actual literature review

What is a literature review?

The word “literature review” can refer to two related things that are part of the broader literature review process. The first is the task of  reviewing the literature  – i.e. sourcing and reading through the existing research relating to your research topic. The second is the  actual chapter  that you write up in your dissertation, thesis or research project. Let’s look at each of them:

Reviewing the literature

The first step of any literature review is to hunt down and  read through the existing research  that’s relevant to your research topic. To do this, you’ll use a combination of tools (we’ll discuss some of these later) to find journal articles, books, ebooks, research reports, dissertations, theses and any other credible sources of information that relate to your topic. You’ll then  summarise and catalogue these  for easy reference when you write up your literature review chapter. 

The literature review chapter

The second step of the literature review is to write the actual literature review chapter (this is usually the second chapter in a typical dissertation or thesis structure ). At the simplest level, the literature review chapter is an  overview of the key literature  that’s relevant to your research topic. This chapter should provide a smooth-flowing discussion of what research has already been done, what is known, what is unknown and what is contested in relation to your research topic. So, you can think of it as an  integrated review of the state of knowledge  around your research topic. 

What’s the purpose of a literature review?

The literature review chapter has a few important functions within your dissertation, thesis or research project. Let’s take a look at these:

Purpose #1 – Demonstrate your topic knowledge

The first function of the literature review chapter is, quite simply, to show the reader (or marker) that you  know what you’re talking about . In other words, a good literature review chapter demonstrates that you’ve read the relevant existing research and understand what’s going on – who’s said what, what’s agreed upon, disagreed upon and so on. This needs to be  more than just a summary  of who said what – it needs to integrate the existing research to  show how it all fits together  and what’s missing (which leads us to purpose #2, next). 

Purpose #2 – Reveal the research gap that you’ll fill

The second function of the literature review chapter is to  show what’s currently missing  from the existing research, to lay the foundation for your own research topic. In other words, your literature review chapter needs to show that there are currently “missing pieces” in terms of the bigger puzzle, and that  your study will fill one of those research gaps . By doing this, you are showing that your research topic is original and will help contribute to the body of knowledge. In other words, the literature review helps justify your research topic.  

Purpose #3 – Lay the foundation for your conceptual framework

The third function of the literature review is to form the  basis for a conceptual framework . Not every research topic will necessarily have a conceptual framework, but if your topic does require one, it needs to be rooted in your literature review. 

For example, let’s say your research aims to identify the drivers of a certain outcome – the factors which contribute to burnout in office workers. In this case, you’d likely develop a conceptual framework which details the potential factors (e.g. long hours, excessive stress, etc), as well as the outcome (burnout). Those factors would need to emerge from the literature review chapter – they can’t just come from your gut! 

So, in this case, the literature review chapter would uncover each of the potential factors (based on previous studies about burnout), which would then be modelled into a framework. 

Purpose #4 – To inform your methodology

The fourth function of the literature review is to  inform the choice of methodology  for your own research. As we’ve  discussed on the Grad Coach blog , your choice of methodology will be heavily influenced by your research aims, objectives and questions . Given that you’ll be reviewing studies covering a topic close to yours, it makes sense that you could learn a lot from their (well-considered) methodologies.

So, when you’re reviewing the literature, you’ll need to  pay close attention to the research design , methodology and methods used in similar studies, and use these to inform your methodology. Quite often, you’ll be able to  “borrow” from previous studies . This is especially true for quantitative studies , as you can use previously tried and tested measures and scales. 

How do I find articles for my literature review?

Finding quality journal articles is essential to crafting a rock-solid literature review. As you probably already know, not all research is created equally, and so you need to make sure that your literature review is  built on credible research . 

We could write an entire post on how to find quality literature (actually, we have ), but a good starting point is Google Scholar . Google Scholar is essentially the academic equivalent of Google, using Google’s powerful search capabilities to find relevant journal articles and reports. It certainly doesn’t cover every possible resource, but it’s a very useful way to get started on your literature review journey, as it will very quickly give you a good indication of what the  most popular pieces of research  are in your field.

One downside of Google Scholar is that it’s merely a search engine – that is, it lists the articles, but oftentimes  it doesn’t host the articles . So you’ll often hit a paywall when clicking through to journal websites. 

Thankfully, your university should provide you with access to their library, so you can find the article titles using Google Scholar and then search for them by name in your university’s online library. Your university may also provide you with access to  ResearchGate , which is another great source for existing research. 

Remember, the correct search keywords will be super important to get the right information from the start. So, pay close attention to the keywords used in the journal articles you read and use those keywords to search for more articles. If you can’t find a spoon in the kitchen, you haven’t looked in the right drawer. 

Need a helping hand?

How should I structure my literature review?

Unfortunately, there’s no generic universal answer for this one. The structure of your literature review will depend largely on your topic area and your research aims and objectives.

You could potentially structure your literature review chapter according to theme, group, variables , chronologically or per concepts in your field of research. We explain the main approaches to structuring your literature review here . You can also download a copy of our free literature review template to help you establish an initial structure.

In general, it’s also a good idea to start wide (i.e. the big-picture-level) and then narrow down, ending your literature review close to your research questions . However, there’s no universal one “right way” to structure your literature review. The most important thing is not to discuss your sources one after the other like a list – as we touched on earlier, your literature review needs to synthesise the research , not summarise it .

Ultimately, you need to craft your literature review so that it conveys the most important information effectively – it needs to tell a logical story in a digestible way. It’s no use starting off with highly technical terms and then only explaining what these terms mean later. Always assume your reader is not a subject matter expert and hold their hand through a journe y of the literature while keeping the functions of the literature review chapter (which we discussed earlier) front of mind.

Example of a literature review

In the video below, we walk you through a high-quality literature review from a dissertation that earned full distinction. This will give you a clearer view of what a strong literature review looks like in practice and hopefully provide some inspiration for your own. 

Wrapping Up

In this post, we’ve (hopefully) answered the question, “ what is a literature review? “. We’ve also considered the purpose and functions of the literature review, as well as how to find literature and how to structure the literature review chapter. If you’re keen to learn more, check out the literature review section of the Grad Coach blog , as well as our detailed video post covering how to write a literature review . 

Psst… there’s more!

This post is an extract from our bestselling Udemy Course, Literature Review Bootcamp . If you want to work smart, you don't want to miss this .

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16 Comments

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• UConn Library
• Literature Review: The What, Why and How-to Guide
• Introduction

Literature Review: The What, Why and How-to Guide — Introduction

• Getting Started
• How to Pick a Topic
• Strategies to Find Sources
• Evaluating Sources & Lit. Reviews
• Tips for Writing Literature Reviews
• Writing Literature Review: Useful Sites
• Citation Resources
• Other Academic Writings

What are Literature Reviews?

So, what is a literature review? "A literature review is an account of what has been published on a topic by accredited scholars and researchers. In writing the literature review, your purpose is to convey to your reader what knowledge and ideas have been established on a topic, and what their strengths and weaknesses are. As a piece of writing, the literature review must be defined by a guiding concept (e.g., your research objective, the problem or issue you are discussing, or your argumentative thesis). It is not just a descriptive list of the material available, or a set of summaries." Taylor, D.  The literature review: A few tips on conducting it . University of Toronto Health Sciences Writing Centre.

Goals of Literature Reviews

What are the goals of creating a Literature Review?  A literature could be written to accomplish different aims:

• To develop a theory or evaluate an existing theory
• To summarize the historical or existing state of a research topic
• Identify a problem in a field of research 

Baumeister, R. F., & Leary, M. R. (1997). Writing narrative literature reviews .  Review of General Psychology , 1 (3), 311-320.

What kinds of sources require a Literature Review?

• A research paper assigned in a course
• A thesis or dissertation
• A grant proposal
• An article intended for publication in a journal

All these instances require you to collect what has been written about your research topic so that you can demonstrate how your own research sheds new light on the topic.

Types of Literature Reviews

What kinds of literature reviews are written?

Narrative review: The purpose of this type of review is to describe the current state of the research on a specific topic/research and to offer a critical analysis of the literature reviewed. Studies are grouped by research/theoretical categories, and themes and trends, strengths and weakness, and gaps are identified. The review ends with a conclusion section which summarizes the findings regarding the state of the research of the specific study, the gaps identify and if applicable, explains how the author's research will address gaps identify in the review and expand the knowledge on the topic reviewed.

• Example : Predictors and Outcomes of U.S. Quality Maternity Leave: A Review and Conceptual Framework:  10.1177/08948453211037398  

Systematic review : "The authors of a systematic review use a specific procedure to search the research literature, select the studies to include in their review, and critically evaluate the studies they find." (p. 139). Nelson, L. K. (2013). Research in Communication Sciences and Disorders . Plural Publishing.

• Example : The effect of leave policies on increasing fertility: a systematic review:  10.1057/s41599-022-01270-w

Meta-analysis : "Meta-analysis is a method of reviewing research findings in a quantitative fashion by transforming the data from individual studies into what is called an effect size and then pooling and analyzing this information. The basic goal in meta-analysis is to explain why different outcomes have occurred in different studies." (p. 197). Roberts, M. C., & Ilardi, S. S. (2003). Handbook of Research Methods in Clinical Psychology . Blackwell Publishing.

• Example : Employment Instability and Fertility in Europe: A Meta-Analysis:  10.1215/00703370-9164737

Meta-synthesis : "Qualitative meta-synthesis is a type of qualitative study that uses as data the findings from other qualitative studies linked by the same or related topic." (p.312). Zimmer, L. (2006). Qualitative meta-synthesis: A question of dialoguing with texts .  Journal of Advanced Nursing , 53 (3), 311-318.

• Example : Women’s perspectives on career successes and barriers: A qualitative meta-synthesis:  10.1177/05390184221113735

Literature Reviews in the Health Sciences

• UConn Health subject guide on systematic reviews Explanation of the different review types used in health sciences literature as well as tools to help you find the right review type
• << Previous: Getting Started
• Next: How to Pick a Topic >>
• Last Updated: Sep 21, 2022 2:16 PM
• URL: https://guides.lib.uconn.edu/literaturereview

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• What is a Literature Review? | Guide, Template, & Examples

What is a Literature Review? | Guide, Template, & Examples

Published on 22 February 2022 by Shona McCombes . Revised on 7 June 2022.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research.

There are five key steps to writing a literature review:

• Search for relevant literature
• Evaluate sources
• Identify themes, debates and gaps
• Outline the structure
• Write your literature review

A good literature review doesn’t just summarise sources – it analyses, synthesises, and critically evaluates to give a clear picture of the state of knowledge on the subject.

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Table of contents

Why write a literature review, examples of literature reviews, step 1: search for relevant literature, step 2: evaluate and select sources, step 3: identify themes, debates and gaps, step 4: outline your literature review’s structure, step 5: write your literature review, frequently asked questions about literature reviews, introduction.

• Quick Run-through
• Step 1 & 2

When you write a dissertation or thesis, you will have to conduct a literature review to situate your research within existing knowledge. The literature review gives you a chance to:

• Demonstrate your familiarity with the topic and scholarly context
• Develop a theoretical framework and methodology for your research
• Position yourself in relation to other researchers and theorists
• Show how your dissertation addresses a gap or contributes to a debate

You might also have to write a literature review as a stand-alone assignment. In this case, the purpose is to evaluate the current state of research and demonstrate your knowledge of scholarly debates around a topic.

The content will look slightly different in each case, but the process of conducting a literature review follows the same steps. We’ve written a step-by-step guide that you can follow below.

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Writing literature reviews can be quite challenging! A good starting point could be to look at some examples, depending on what kind of literature review you’d like to write.

• Example literature review #1: “Why Do People Migrate? A Review of the Theoretical Literature” ( Theoretical literature review about the development of economic migration theory from the 1950s to today.)
• Example literature review #2: “Literature review as a research methodology: An overview and guidelines” ( Methodological literature review about interdisciplinary knowledge acquisition and production.)
• Example literature review #3: “The Use of Technology in English Language Learning: A Literature Review” ( Thematic literature review about the effects of technology on language acquisition.)
• Example literature review #4: “Learners’ Listening Comprehension Difficulties in English Language Learning: A Literature Review” ( Chronological literature review about how the concept of listening skills has changed over time.)

You can also check out our templates with literature review examples and sample outlines at the links below.

Download Word doc Download Google doc

Before you begin searching for literature, you need a clearly defined topic .

If you are writing the literature review section of a dissertation or research paper, you will search for literature related to your research objectives and questions .

If you are writing a literature review as a stand-alone assignment, you will have to choose a focus and develop a central question to direct your search. Unlike a dissertation research question, this question has to be answerable without collecting original data. You should be able to answer it based only on a review of existing publications.

Make a list of keywords

Start by creating a list of keywords related to your research topic. Include each of the key concepts or variables you’re interested in, and list any synonyms and related terms. You can add to this list if you discover new keywords in the process of your literature search.

• Social media, Facebook, Instagram, Twitter, Snapchat, TikTok
• Body image, self-perception, self-esteem, mental health
• Generation Z, teenagers, adolescents, youth

Search for relevant sources

Use your keywords to begin searching for sources. Some databases to search for journals and articles include:

• Your university’s library catalogue
• Google Scholar
• Project Muse (humanities and social sciences)
• Medline (life sciences and biomedicine)
• EconLit (economics)
• Inspec (physics, engineering and computer science)

You can use boolean operators to help narrow down your search:

Read the abstract to find out whether an article is relevant to your question. When you find a useful book or article, you can check the bibliography to find other relevant sources.

To identify the most important publications on your topic, take note of recurring citations. If the same authors, books or articles keep appearing in your reading, make sure to seek them out.

You probably won’t be able to read absolutely everything that has been written on the topic – you’ll have to evaluate which sources are most relevant to your questions.

For each publication, ask yourself:

• What question or problem is the author addressing?
• What are the key concepts and how are they defined?
• What are the key theories, models and methods? Does the research use established frameworks or take an innovative approach?
• What are the results and conclusions of the study?
• How does the publication relate to other literature in the field? Does it confirm, add to, or challenge established knowledge?
• How does the publication contribute to your understanding of the topic? What are its key insights and arguments?
• What are the strengths and weaknesses of the research?

Make sure the sources you use are credible, and make sure you read any landmark studies and major theories in your field of research.

You can find out how many times an article has been cited on Google Scholar – a high citation count means the article has been influential in the field, and should certainly be included in your literature review.

The scope of your review will depend on your topic and discipline: in the sciences you usually only review recent literature, but in the humanities you might take a long historical perspective (for example, to trace how a concept has changed in meaning over time).

Remember that you can use our template to summarise and evaluate sources you’re thinking about using!

Take notes and cite your sources

As you read, you should also begin the writing process. Take notes that you can later incorporate into the text of your literature review.

It’s important to keep track of your sources with references to avoid plagiarism . It can be helpful to make an annotated bibliography, where you compile full reference information and write a paragraph of summary and analysis for each source. This helps you remember what you read and saves time later in the process.

You can use our free APA Reference Generator for quick, correct, consistent citations.

To begin organising your literature review’s argument and structure, you need to understand the connections and relationships between the sources you’ve read. Based on your reading and notes, you can look for:

• Trends and patterns (in theory, method or results): do certain approaches become more or less popular over time?
• Themes: what questions or concepts recur across the literature?
• Debates, conflicts and contradictions: where do sources disagree?
• Pivotal publications: are there any influential theories or studies that changed the direction of the field?
• Gaps: what is missing from the literature? Are there weaknesses that need to be addressed?

This step will help you work out the structure of your literature review and (if applicable) show how your own research will contribute to existing knowledge.

• Most research has focused on young women.
• There is an increasing interest in the visual aspects of social media.
• But there is still a lack of robust research on highly-visual platforms like Instagram and Snapchat – this is a gap that you could address in your own research.

There are various approaches to organising the body of a literature review. You should have a rough idea of your strategy before you start writing.

Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

The simplest approach is to trace the development of the topic over time. However, if you choose this strategy, be careful to avoid simply listing and summarising sources in order.

Try to analyse patterns, turning points and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred.

If you have found some recurring central themes, you can organise your literature review into subsections that address different aspects of the topic.

For example, if you are reviewing literature about inequalities in migrant health outcomes, key themes might include healthcare policy, language barriers, cultural attitudes, legal status, and economic access.

Methodological

If you draw your sources from different disciplines or fields that use a variety of research methods , you might want to compare the results and conclusions that emerge from different approaches. For example:

• Look at what results have emerged in qualitative versus quantitative research
• Discuss how the topic has been approached by empirical versus theoretical scholarship
• Divide the literature into sociological, historical, and cultural sources

Theoretical

A literature review is often the foundation for a theoretical framework . You can use it to discuss various theories, models, and definitions of key concepts.

You might argue for the relevance of a specific theoretical approach, or combine various theoretical concepts to create a framework for your research.

Like any other academic text, your literature review should have an introduction , a main body, and a conclusion . What you include in each depends on the objective of your literature review.

The introduction should clearly establish the focus and purpose of the literature review.

If you are writing the literature review as part of your dissertation or thesis, reiterate your central problem or research question and give a brief summary of the scholarly context. You can emphasise the timeliness of the topic (“many recent studies have focused on the problem of x”) or highlight a gap in the literature (“while there has been much research on x, few researchers have taken y into consideration”).

Depending on the length of your literature review, you might want to divide the body into subsections. You can use a subheading for each theme, time period, or methodological approach.

As you write, make sure to follow these tips:

• Summarise and synthesise: give an overview of the main points of each source and combine them into a coherent whole.
• Analyse and interpret: don’t just paraphrase other researchers – add your own interpretations, discussing the significance of findings in relation to the literature as a whole.
• Critically evaluate: mention the strengths and weaknesses of your sources.
• Write in well-structured paragraphs: use transitions and topic sentences to draw connections, comparisons and contrasts.

In the conclusion, you should summarise the key findings you have taken from the literature and emphasise their significance.

If the literature review is part of your dissertation or thesis, reiterate how your research addresses gaps and contributes new knowledge, or discuss how you have drawn on existing theories and methods to build a framework for your research. This can lead directly into your methodology section.

A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a dissertation , thesis, research paper , or proposal .

There are several reasons to conduct a literature review at the beginning of a research project:

• To familiarise yourself with the current state of knowledge on your topic
• To ensure that you’re not just repeating what others have already done
• To identify gaps in knowledge and unresolved problems that your research can address
• To develop your theoretical framework and methodology
• To provide an overview of the key findings and debates on the topic

Writing the literature review shows your reader how your work relates to existing research and what new insights it will contribute.

The literature review usually comes near the beginning of your  dissertation . After the introduction , it grounds your research in a scholarly field and leads directly to your theoretical framework or methodology .

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How To Write A Literature Review - A Complete Guide

Table of Contents

A literature review is much more than just another section in your research paper. It forms the very foundation of your research. It is a formal piece of writing where you analyze the existing theoretical framework, principles, and assumptions and use that as a base to shape your approach to the research question.

Curating and drafting a solid literature review section not only lends more credibility to your research paper but also makes your research tighter and better focused. But, writing literature reviews is a difficult task. It requires extensive reading, plus you have to consider market trends and technological and political changes, which tend to change in the blink of an eye.

Now streamline your literature review process with the help of SciSpace Copilot. With this AI research assistant, you can efficiently synthesize and analyze a vast amount of information, identify key themes and trends, and uncover gaps in the existing research. Get real-time explanations, summaries, and answers to your questions for the paper you're reviewing, making navigating and understanding the complex literature landscape easier.

In this comprehensive guide, we will explore everything from the definition of a literature review, its appropriate length, various types of literature reviews, and how to write one.

What is a literature review?

A literature review is a collation of survey, research, critical evaluation, and assessment of the existing literature in a preferred domain.

Eminent researcher and academic Arlene Fink, in her book Conducting Research Literature Reviews , defines it as the following:

“A literature review surveys books, scholarly articles, and any other sources relevant to a particular issue, area of research, or theory, and by so doing, provides a description, summary, and critical evaluation of these works in relation to the research problem being investigated.

Literature reviews are designed to provide an overview of sources you have explored while researching a particular topic, and to demonstrate to your readers how your research fits within a larger field of study.”

Simply put, a literature review can be defined as a critical discussion of relevant pre-existing research around your research question and carving out a definitive place for your study in the existing body of knowledge. Literature reviews can be presented in multiple ways: a section of an article, the whole research paper itself, or a chapter of your thesis.

A literature review does function as a summary of sources, but it also allows you to analyze further, interpret, and examine the stated theories, methods, viewpoints, and, of course, the gaps in the existing content.

As an author, you can discuss and interpret the research question and its various aspects and debate your adopted methods to support the claim.

What is the purpose of a literature review?

A literature review is meant to help your readers understand the relevance of your research question and where it fits within the existing body of knowledge. As a researcher, you should use it to set the context, build your argument, and establish the need for your study.

What is the importance of a literature review?

The literature review is a critical part of research papers because it helps you:

• Gain an in-depth understanding of your research question and the surrounding area
• Convey that you have a thorough understanding of your research area and are up-to-date with the latest changes and advancements
• Establish how your research is connected or builds on the existing body of knowledge and how it could contribute to further research
• Elaborate on the validity and suitability of your theoretical framework and research methodology
• Identify and highlight gaps and shortcomings in the existing body of knowledge and how things need to change
• Convey to readers how your study is different or how it contributes to the research area

How long should a literature review be?

Ideally, the literature review should take up 15%-40% of the total length of your manuscript. So, if you have a 10,000-word research paper, the minimum word count could be 1500.

Your literature review format depends heavily on the kind of manuscript you are writing — an entire chapter in case of doctoral theses, a part of the introductory section in a research article, to a full-fledged review article that examines the previously published research on a topic.

Another determining factor is the type of research you are doing. The literature review section tends to be longer for secondary research projects than primary research projects.

What are the different types of literature reviews?

All literature reviews are not the same. There are a variety of possible approaches that you can take. It all depends on the type of research you are pursuing.

Here are the different types of literature reviews:

Argumentative review

It is called an argumentative review when you carefully present literature that only supports or counters a specific argument or premise to establish a viewpoint.

Integrative review

It is a type of literature review focused on building a comprehensive understanding of a topic by combining available theoretical frameworks and empirical evidence.

Methodological review

This approach delves into the ''how'' and the ''what" of the research question —  you cannot look at the outcome in isolation; you should also review the methodology used.

Systematic review

This form consists of an overview of existing evidence pertinent to a clearly formulated research question, which uses pre-specified and standardized methods to identify and critically appraise relevant research and collect, report, and analyze data from the studies included in the review.

Meta-analysis review

Meta-analysis uses statistical methods to summarize the results of independent studies. By combining information from all relevant studies, meta-analysis can provide more precise estimates of the effects than those derived from the individual studies included within a review.

Historical review

Historical literature reviews focus on examining research throughout a period, often starting with the first time an issue, concept, theory, or phenomenon emerged in the literature, then tracing its evolution within the scholarship of a discipline. The purpose is to place research in a historical context to show familiarity with state-of-the-art developments and identify future research's likely directions.

Theoretical Review

This form aims to examine the corpus of theory accumulated regarding an issue, concept, theory, and phenomenon. The theoretical literature review helps to establish what theories exist, the relationships between them, the degree the existing approaches have been investigated, and to develop new hypotheses to be tested.

Scoping Review

The Scoping Review is often used at the beginning of an article, dissertation, or research proposal. It is conducted before the research to highlight gaps in the existing body of knowledge and explains why the project should be greenlit.

State-of-the-Art Review

The State-of-the-Art review is conducted periodically, focusing on the most recent research. It describes what is currently known, understood, or agreed upon regarding the research topic and highlights where there are still disagreements.

Can you use the first person in a literature review?

When writing literature reviews, you should avoid the usage of first-person pronouns. It means that instead of "I argue that" or "we argue that," the appropriate expression would be "this research paper argues that."

Do you need an abstract for a literature review?

Ideally, yes. It is always good to have a condensed summary that is self-contained and independent of the rest of your review. As for how to draft one, you can follow the same fundamental idea when preparing an abstract for a literature review. It should also include:

• The research topic and your motivation behind selecting it
• A one-sentence thesis statement
• An explanation of the kinds of literature featured in the review
• Summary of what you've learned
• Conclusions you drew from the literature you reviewed
• Potential implications and future scope for research

Here's an example of the abstract of a literature review

Is a literature review written in the past tense?

Yes, the literature review should ideally be written in the past tense. You should not use the present or future tense when writing one. The exceptions are when you have statements describing events that happened earlier than the literature you are reviewing or events that are currently occurring; then, you can use the past perfect or present perfect tenses.

How many sources for a literature review?

There are multiple approaches to deciding how many sources to include in a literature review section. The first approach would be to look level you are at as a researcher. For instance, a doctoral thesis might need 60+ sources. In contrast, you might only need to refer to 5-15 sources at the undergraduate level.

The second approach is based on the kind of literature review you are doing — whether it is merely a chapter of your paper or if it is a self-contained paper in itself. When it is just a chapter, sources should equal the total number of pages in your article's body. In the second scenario, you need at least three times as many sources as there are pages in your work.

Quick tips on how to write a literature review

To know how to write a literature review, you must clearly understand its impact and role in establishing your work as substantive research material.

You need to follow the below-mentioned steps, to write a literature review:

• Outline the purpose behind the literature review
• Search relevant literature
• Examine and assess the relevant resources
• Discover connections by drawing deep insights from the resources
• Structure planning to write a good literature review

1. Outline and identify the purpose of  a literature review

As a first step on how to write a literature review, you must know what the research question or topic is and what shape you want your literature review to take. Ensure you understand the research topic inside out, or else seek clarifications. You must be able to the answer below questions before you start:

• How many sources do I need to include?
• What kind of sources should I analyze?
• How much should I critically evaluate each source?
• Should I summarize, synthesize or offer a critique of the sources?
• Do I need to include any background information or definitions?

Additionally, you should know that the narrower your research topic is, the swifter it will be for you to restrict the number of sources to be analyzed.

2. Search relevant literature

Dig deeper into search engines to discover what has already been published around your chosen topic. Make sure you thoroughly go through appropriate reference sources like books, reports, journal articles, government docs, and web-based resources.

You must prepare a list of keywords and their different variations. You can start your search from any library’s catalog, provided you are an active member of that institution. The exact keywords can be extended to widen your research over other databases and academic search engines like:

• Google Scholar
• Microsoft Academic
• Science.gov

Besides, it is not advisable to go through every resource word by word. Alternatively, what you can do is you can start by reading the abstract and then decide whether that source is relevant to your research or not.

Additionally, you must spend surplus time assessing the quality and relevance of resources. It would help if you tried preparing a list of citations to ensure that there lies no repetition of authors, publications, or articles in the literature review.

3. Examine and assess the sources

It is nearly impossible for you to go through every detail in the research article. So rather than trying to fetch every detail, you have to analyze and decide which research sources resemble closest and appear relevant to your chosen domain.

While analyzing the sources, you should look to find out answers to questions like:

• What question or problem has the author been describing and debating?
• What is the definition of critical aspects?
• How well the theories, approach, and methodology have been explained?
• Whether the research theory used some conventional or new innovative approach?
• How relevant are the key findings of the work?
• In what ways does it relate to other sources on the same topic?
• What challenges does this research paper pose to the existing theory
• What are the possible contributions or benefits it adds to the subject domain?

Be always mindful that you refer only to credible and authentic resources. It would be best if you always take references from different publications to validate your theory.

Always keep track of important information or data you can present in your literature review right from the beginning. It will help steer your path from any threats of plagiarism and also make it easier to curate an annotated bibliography or reference section.

4. Discover connections

At this stage, you must start deciding on the argument and structure of your literature review. To accomplish this, you must discover and identify the relations and connections between various resources while drafting your abstract.

A few aspects that you should be aware of while writing a literature review include:

• Rise to prominence: Theories and methods that have gained reputation and supporters over time.
• Constant scrutiny: Concepts or theories that repeatedly went under examination.
• Contradictions and conflicts: Theories, both the supporting and the contradictory ones, for the research topic.
• Knowledge gaps: What exactly does it fail to address, and how to bridge them with further research?
• Influential resources: Significant research projects available that have been upheld as milestones or perhaps, something that can modify the current trends

Once you join the dots between various past research works, it will be easier for you to draw a conclusion and identify your contribution to the existing knowledge base.

5. Structure planning to write a good literature review

There exist different ways towards planning and executing the structure of a literature review. The format of a literature review varies and depends upon the length of the research.

Like any other research paper, the literature review format must contain three sections: introduction, body, and conclusion. The goals and objectives of the research question determine what goes inside these three sections.

Nevertheless, a good literature review can be structured according to the chronological, thematic, methodological, or theoretical framework approach.

Literature review samples

1. Standalone

2. As a section of a research paper

How SciSpace Discover makes literature review a breeze?

SciSpace Discover is a one-stop solution to do an effective literature search and get barrier-free access to scientific knowledge. It is an excellent repository where you can find millions of only peer-reviewed articles and full-text PDF files. Here’s more on how you can use it:

Find the right information

Find what you want quickly and easily with comprehensive search filters that let you narrow down papers according to PDF availability, year of publishing, document type, and affiliated institution. Moreover, you can sort the results based on the publishing date, citation count, and relevance.

Assess credibility of papers quickly

When doing the literature review, it is critical to establish the quality of your sources. They form the foundation of your research. SciSpace Discover helps you assess the quality of a source by providing an overview of its references, citations, and performance metrics.

Get the complete picture in no time

SciSpace Discover’s personalized suggestion engine helps you stay on course and get the complete picture of the topic from one place. Every time you visit an article page, it provides you links to related papers. Besides that, it helps you understand what’s trending, who are the top authors, and who are the leading publishers on a topic.

Make referring sources super easy

To ensure you don't lose track of your sources, you must start noting down your references when doing the literature review. SciSpace Discover makes this step effortless. Click the 'cite' button on an article page, and you will receive preloaded citation text in multiple styles — all you've to do is copy-paste it into your manuscript.

Final tips on how to write a literature review

A massive chunk of time and effort is required to write a good literature review. But, if you go about it systematically, you'll be able to save a ton of time and build a solid foundation for your research.

We hope this guide has helped you answer several key questions you have about writing literature reviews.

Would you like to explore SciSpace Discover and kick off your literature search right away? You can get started here .

Frequently Asked Questions (FAQs)

1. how to start a literature review.

• What questions do you want to answer?

• What sources do you need to answer these questions?

• What information do these sources contain?

• How can you use this information to answer your questions?

2. What to include in a literature review?

• A brief background of the problem or issue

• What has previously been done to address the problem or issue

• A description of what you will do in your project

• How this study will contribute to research on the subject

3. Why literature review is important?

The literature review is an important part of any research project because it allows the writer to look at previous studies on a topic and determine existing gaps in the literature, as well as what has already been done. It will also help them to choose the most appropriate method for their own study.

4. How to cite a literature review in APA format?

To cite a literature review in APA style, you need to provide the author's name, the title of the article, and the year of publication. For example: Patel, A. B., & Stokes, G. S. (2012). The relationship between personality and intelligence: A meta-analysis of longitudinal research. Personality and Individual Differences, 53(1), 16-21

5. What are the components of a literature review?

• A brief introduction to the topic, including its background and context. The introduction should also include a rationale for why the study is being conducted and what it will accomplish.

• A description of the methodologies used in the study. This can include information about data collection methods, sample size, and statistical analyses.

• A presentation of the findings in an organized format that helps readers follow along with the author's conclusions.

6. What are common errors in writing literature review?

• Not spending enough time to critically evaluate the relevance of resources, observations and conclusions.

• Totally relying on secondary data while ignoring primary data.

• Letting your personal bias seep into your interpretation of existing literature.

• No detailed explanation of the procedure to discover and identify an appropriate literature review.

7. What are the 5 C's of writing literature review?

• Cite - the sources you utilized and referenced in your research.

• Compare - existing arguments, hypotheses, methodologies, and conclusions found in the knowledge base.

• Contrast - the arguments, topics, methodologies, approaches, and disputes that may be found in the literature.

• Critique - the literature and describe the ideas and opinions you find more convincing and why.

• Connect - the various studies you reviewed in your research.

8. How many sources should a literature review have?

When it is just a chapter, sources should equal the total number of pages in your article's body. if it is a self-contained paper in itself, you need at least three times as many sources as there are pages in your work.

9. Can literature review have diagrams?

• To represent an abstract idea or concept

• To explain the steps of a process or procedure

• To help readers understand the relationships between different concepts

10. How old should sources be in a literature review?

Sources for a literature review should be as current as possible or not older than ten years. The only exception to this rule is if you are reviewing a historical topic and need to use older sources.

11. What are the types of literature review?

• Argumentative review

• Integrative review

• Methodological review

• Systematic review

• Meta-analysis review

• Historical review

• Theoretical review

• Scoping review

• State-of-the-Art review

12. Is a literature review mandatory?

Yes. Literature review is a mandatory part of any research project. It is a critical step in the process that allows you to establish the scope of your research, and provide a background for the rest of your work.

But before you go,

• Six Online Tools for Easy Literature Review
• Evaluating literature review: systematic vs. scoping reviews
• Systematic Approaches to a Successful Literature Review
• Writing Integrative Literature Reviews: Guidelines and Examples

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Literature Reviews

What this handout is about.

This handout will explain what literature reviews are and offer insights into the form and construction of literature reviews in the humanities, social sciences, and sciences.

Introduction

OK. You’ve got to write a literature review. You dust off a novel and a book of poetry, settle down in your chair, and get ready to issue a “thumbs up” or “thumbs down” as you leaf through the pages. “Literature review” done. Right?

Wrong! The “literature” of a literature review refers to any collection of materials on a topic, not necessarily the great literary texts of the world. “Literature” could be anything from a set of government pamphlets on British colonial methods in Africa to scholarly articles on the treatment of a torn ACL. And a review does not necessarily mean that your reader wants you to give your personal opinion on whether or not you liked these sources.

What is a literature review, then?

A literature review discusses published information in a particular subject area, and sometimes information in a particular subject area within a certain time period.

A literature review can be just a simple summary of the sources, but it usually has an organizational pattern and combines both summary and synthesis. A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information. It might give a new interpretation of old material or combine new with old interpretations. Or it might trace the intellectual progression of the field, including major debates. And depending on the situation, the literature review may evaluate the sources and advise the reader on the most pertinent or relevant.

But how is a literature review different from an academic research paper?

The main focus of an academic research paper is to develop a new argument, and a research paper is likely to contain a literature review as one of its parts. In a research paper, you use the literature as a foundation and as support for a new insight that you contribute. The focus of a literature review, however, is to summarize and synthesize the arguments and ideas of others without adding new contributions.

Why do we write literature reviews?

Literature reviews provide you with a handy guide to a particular topic. If you have limited time to conduct research, literature reviews can give you an overview or act as a stepping stone. For professionals, they are useful reports that keep them up to date with what is current in the field. For scholars, the depth and breadth of the literature review emphasizes the credibility of the writer in his or her field. Literature reviews also provide a solid background for a research paper’s investigation. Comprehensive knowledge of the literature of the field is essential to most research papers.

Who writes these things, anyway?

Literature reviews are written occasionally in the humanities, but mostly in the sciences and social sciences; in experiment and lab reports, they constitute a section of the paper. Sometimes a literature review is written as a paper in itself.

Let’s get to it! What should I do before writing the literature review?

If your assignment is not very specific, seek clarification from your instructor:

• Roughly how many sources should you include?
• What types of sources (books, journal articles, websites)?
• Should you summarize, synthesize, or critique your sources by discussing a common theme or issue?
• Should you evaluate your sources?
• Should you provide subheadings and other background information, such as definitions and/or a history?

Find models

Look for other literature reviews in your area of interest or in the discipline and read them to get a sense of the types of themes you might want to look for in your own research or ways to organize your final review. You can simply put the word “review” in your search engine along with your other topic terms to find articles of this type on the Internet or in an electronic database. The bibliography or reference section of sources you’ve already read are also excellent entry points into your own research.

Narrow your topic

There are hundreds or even thousands of articles and books on most areas of study. The narrower your topic, the easier it will be to limit the number of sources you need to read in order to get a good survey of the material. Your instructor will probably not expect you to read everything that’s out there on the topic, but you’ll make your job easier if you first limit your scope.

Keep in mind that UNC Libraries have research guides and to databases relevant to many fields of study. You can reach out to the subject librarian for a consultation: https://library.unc.edu/support/consultations/ .

And don’t forget to tap into your professor’s (or other professors’) knowledge in the field. Ask your professor questions such as: “If you had to read only one book from the 90’s on topic X, what would it be?” Questions such as this help you to find and determine quickly the most seminal pieces in the field.

Consider whether your sources are current

Some disciplines require that you use information that is as current as possible. In the sciences, for instance, treatments for medical problems are constantly changing according to the latest studies. Information even two years old could be obsolete. However, if you are writing a review in the humanities, history, or social sciences, a survey of the history of the literature may be what is needed, because what is important is how perspectives have changed through the years or within a certain time period. Try sorting through some other current bibliographies or literature reviews in the field to get a sense of what your discipline expects. You can also use this method to consider what is currently of interest to scholars in this field and what is not.

Strategies for writing the literature review

Find a focus.

A literature review, like a term paper, is usually organized around ideas, not the sources themselves as an annotated bibliography would be organized. This means that you will not just simply list your sources and go into detail about each one of them, one at a time. No. As you read widely but selectively in your topic area, consider instead what themes or issues connect your sources together. Do they present one or different solutions? Is there an aspect of the field that is missing? How well do they present the material and do they portray it according to an appropriate theory? Do they reveal a trend in the field? A raging debate? Pick one of these themes to focus the organization of your review.

Convey it to your reader

A literature review may not have a traditional thesis statement (one that makes an argument), but you do need to tell readers what to expect. Try writing a simple statement that lets the reader know what is your main organizing principle. Here are a couple of examples:

The current trend in treatment for congestive heart failure combines surgery and medicine. More and more cultural studies scholars are accepting popular media as a subject worthy of academic consideration.

Consider organization

You’ve got a focus, and you’ve stated it clearly and directly. Now what is the most effective way of presenting the information? What are the most important topics, subtopics, etc., that your review needs to include? And in what order should you present them? Develop an organization for your review at both a global and local level:

First, cover the basic categories

Just like most academic papers, literature reviews also must contain at least three basic elements: an introduction or background information section; the body of the review containing the discussion of sources; and, finally, a conclusion and/or recommendations section to end the paper. The following provides a brief description of the content of each:

• Introduction: Gives a quick idea of the topic of the literature review, such as the central theme or organizational pattern.
• Body: Contains your discussion of sources and is organized either chronologically, thematically, or methodologically (see below for more information on each).
• Conclusions/Recommendations: Discuss what you have drawn from reviewing literature so far. Where might the discussion proceed?

Organizing the body

Once you have the basic categories in place, then you must consider how you will present the sources themselves within the body of your paper. Create an organizational method to focus this section even further.

To help you come up with an overall organizational framework for your review, consider the following scenario:

You’ve decided to focus your literature review on materials dealing with sperm whales. This is because you’ve just finished reading Moby Dick, and you wonder if that whale’s portrayal is really real. You start with some articles about the physiology of sperm whales in biology journals written in the 1980’s. But these articles refer to some British biological studies performed on whales in the early 18th century. So you check those out. Then you look up a book written in 1968 with information on how sperm whales have been portrayed in other forms of art, such as in Alaskan poetry, in French painting, or on whale bone, as the whale hunters in the late 19th century used to do. This makes you wonder about American whaling methods during the time portrayed in Moby Dick, so you find some academic articles published in the last five years on how accurately Herman Melville portrayed the whaling scene in his novel.

Now consider some typical ways of organizing the sources into a review:

• Chronological: If your review follows the chronological method, you could write about the materials above according to when they were published. For instance, first you would talk about the British biological studies of the 18th century, then about Moby Dick, published in 1851, then the book on sperm whales in other art (1968), and finally the biology articles (1980s) and the recent articles on American whaling of the 19th century. But there is relatively no continuity among subjects here. And notice that even though the sources on sperm whales in other art and on American whaling are written recently, they are about other subjects/objects that were created much earlier. Thus, the review loses its chronological focus.
• By publication: Order your sources by publication chronology, then, only if the order demonstrates a more important trend. For instance, you could order a review of literature on biological studies of sperm whales if the progression revealed a change in dissection practices of the researchers who wrote and/or conducted the studies.
• By trend: A better way to organize the above sources chronologically is to examine the sources under another trend, such as the history of whaling. Then your review would have subsections according to eras within this period. For instance, the review might examine whaling from pre-1600-1699, 1700-1799, and 1800-1899. Under this method, you would combine the recent studies on American whaling in the 19th century with Moby Dick itself in the 1800-1899 category, even though the authors wrote a century apart.
• Thematic: Thematic reviews of literature are organized around a topic or issue, rather than the progression of time. However, progression of time may still be an important factor in a thematic review. For instance, the sperm whale review could focus on the development of the harpoon for whale hunting. While the study focuses on one topic, harpoon technology, it will still be organized chronologically. The only difference here between a “chronological” and a “thematic” approach is what is emphasized the most: the development of the harpoon or the harpoon technology.But more authentic thematic reviews tend to break away from chronological order. For instance, a thematic review of material on sperm whales might examine how they are portrayed as “evil” in cultural documents. The subsections might include how they are personified, how their proportions are exaggerated, and their behaviors misunderstood. A review organized in this manner would shift between time periods within each section according to the point made.
• Methodological: A methodological approach differs from the two above in that the focusing factor usually does not have to do with the content of the material. Instead, it focuses on the “methods” of the researcher or writer. For the sperm whale project, one methodological approach would be to look at cultural differences between the portrayal of whales in American, British, and French art work. Or the review might focus on the economic impact of whaling on a community. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed. Once you’ve decided on the organizational method for the body of the review, the sections you need to include in the paper should be easy to figure out. They should arise out of your organizational strategy. In other words, a chronological review would have subsections for each vital time period. A thematic review would have subtopics based upon factors that relate to the theme or issue.

Sometimes, though, you might need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you. Put in only what is necessary. Here are a few other sections you might want to consider:

• Current Situation: Information necessary to understand the topic or focus of the literature review.
• History: The chronological progression of the field, the literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.
• Methods and/or Standards: The criteria you used to select the sources in your literature review or the way in which you present your information. For instance, you might explain that your review includes only peer-reviewed articles and journals.

Questions for Further Research: What questions about the field has the review sparked? How will you further your research as a result of the review?

Begin composing

Once you’ve settled on a general pattern of organization, you’re ready to write each section. There are a few guidelines you should follow during the writing stage as well. Here is a sample paragraph from a literature review about sexism and language to illuminate the following discussion:

However, other studies have shown that even gender-neutral antecedents are more likely to produce masculine images than feminine ones (Gastil, 1990). Hamilton (1988) asked students to complete sentences that required them to fill in pronouns that agreed with gender-neutral antecedents such as “writer,” “pedestrian,” and “persons.” The students were asked to describe any image they had when writing the sentence. Hamilton found that people imagined 3.3 men to each woman in the masculine “generic” condition and 1.5 men per woman in the unbiased condition. Thus, while ambient sexism accounted for some of the masculine bias, sexist language amplified the effect. (Source: Erika Falk and Jordan Mills, “Why Sexist Language Affects Persuasion: The Role of Homophily, Intended Audience, and Offense,” Women and Language19:2).

Use evidence

In the example above, the writers refer to several other sources when making their point. A literature review in this sense is just like any other academic research paper. Your interpretation of the available sources must be backed up with evidence to show that what you are saying is valid.

Be selective

Select only the most important points in each source to highlight in the review. The type of information you choose to mention should relate directly to the review’s focus, whether it is thematic, methodological, or chronological.

Use quotes sparingly

Falk and Mills do not use any direct quotes. That is because the survey nature of the literature review does not allow for in-depth discussion or detailed quotes from the text. Some short quotes here and there are okay, though, if you want to emphasize a point, or if what the author said just cannot be rewritten in your own words. Notice that Falk and Mills do quote certain terms that were coined by the author, not common knowledge, or taken directly from the study. But if you find yourself wanting to put in more quotes, check with your instructor.

Summarize and synthesize

Remember to summarize and synthesize your sources within each paragraph as well as throughout the review. The authors here recapitulate important features of Hamilton’s study, but then synthesize it by rephrasing the study’s significance and relating it to their own work.

Keep your own voice

While the literature review presents others’ ideas, your voice (the writer’s) should remain front and center. Notice that Falk and Mills weave references to other sources into their own text, but they still maintain their own voice by starting and ending the paragraph with their own ideas and their own words. The sources support what Falk and Mills are saying.

Use caution when paraphrasing

When paraphrasing a source that is not your own, be sure to represent the author’s information or opinions accurately and in your own words. In the preceding example, Falk and Mills either directly refer in the text to the author of their source, such as Hamilton, or they provide ample notation in the text when the ideas they are mentioning are not their own, for example, Gastil’s. For more information, please see our handout on plagiarism .

Revise, revise, revise

Draft in hand? Now you’re ready to revise. Spending a lot of time revising is a wise idea, because your main objective is to present the material, not the argument. So check over your review again to make sure it follows the assignment and/or your outline. Then, just as you would for most other academic forms of writing, rewrite or rework the language of your review so that you’ve presented your information in the most concise manner possible. Be sure to use terminology familiar to your audience; get rid of unnecessary jargon or slang. Finally, double check that you’ve documented your sources and formatted the review appropriately for your discipline. For tips on the revising and editing process, see our handout on revising drafts .

Works consulted

We consulted these works while writing this handout. This is not a comprehensive list of resources on the handout’s topic, and we encourage you to do your own research to find additional publications. Please do not use this list as a model for the format of your own reference list, as it may not match the citation style you are using. For guidance on formatting citations, please see the UNC Libraries citation tutorial . We revise these tips periodically and welcome feedback.

Anson, Chris M., and Robert A. Schwegler. 2010. The Longman Handbook for Writers and Readers , 6th ed. New York: Longman.

Jones, Robert, Patrick Bizzaro, and Cynthia Selfe. 1997. The Harcourt Brace Guide to Writing in the Disciplines . New York: Harcourt Brace.

Lamb, Sandra E. 1998. How to Write It: A Complete Guide to Everything You’ll Ever Write . Berkeley: Ten Speed Press.

Rosen, Leonard J., and Laurence Behrens. 2003. The Allyn & Bacon Handbook , 5th ed. New York: Longman.

Troyka, Lynn Quittman, and Doug Hesse. 2016. Simon and Schuster Handbook for Writers , 11th ed. London: Pearson.

You may reproduce it for non-commercial use if you use the entire handout and attribute the source: The Writing Center, University of North Carolina at Chapel Hill

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A literature review surveys prior research published in books, scholarly articles, and any other sources relevant to a particular issue, area of research, or theory, and by so doing, provides a description, summary, and critical evaluation of these works in relation to the research problem being investigated. Literature reviews are designed to provide an overview of sources you have used in researching a particular topic and to demonstrate to your readers how your research fits within existing scholarship about the topic.

Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . Fourth edition. Thousand Oaks, CA: SAGE, 2014.

Importance of a Good Literature Review

A literature review may consist of simply a summary of key sources, but in the social sciences, a literature review usually has an organizational pattern and combines both summary and synthesis, often within specific conceptual categories . A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information in a way that informs how you are planning to investigate a research problem. The analytical features of a literature review might:

• Give a new interpretation of old material or combine new with old interpretations,
• Trace the intellectual progression of the field, including major debates,
• Depending on the situation, evaluate the sources and advise the reader on the most pertinent or relevant research, or
• Usually in the conclusion of a literature review, identify where gaps exist in how a problem has been researched to date.

Given this, the purpose of a literature review is to:

• Place each work in the context of its contribution to understanding the research problem being studied.
• Describe the relationship of each work to the others under consideration.
• Identify new ways to interpret prior research.
• Reveal any gaps that exist in the literature.
• Resolve conflicts amongst seemingly contradictory previous studies.
• Identify areas of prior scholarship to prevent duplication of effort.
• Point the way in fulfilling a need for additional research.
• Locate your own research within the context of existing literature [very important].

Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper. 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Jesson, Jill. Doing Your Literature Review: Traditional and Systematic Techniques . Los Angeles, CA: SAGE, 2011; Knopf, Jeffrey W. "Doing a Literature Review." PS: Political Science and Politics 39 (January 2006): 127-132; Ridley, Diana. The Literature Review: A Step-by-Step Guide for Students . 2nd ed. Los Angeles, CA: SAGE, 2012.

Types of Literature Reviews

It is important to think of knowledge in a given field as consisting of three layers. First, there are the primary studies that researchers conduct and publish. Second are the reviews of those studies that summarize and offer new interpretations built from and often extending beyond the primary studies. Third, there are the perceptions, conclusions, opinion, and interpretations that are shared informally among scholars that become part of the body of epistemological traditions within the field.

In composing a literature review, it is important to note that it is often this third layer of knowledge that is cited as "true" even though it often has only a loose relationship to the primary studies and secondary literature reviews. Given this, while literature reviews are designed to provide an overview and synthesis of pertinent sources you have explored, there are a number of approaches you could adopt depending upon the type of analysis underpinning your study.

Argumentative Review This form examines literature selectively in order to support or refute an argument, deeply embedded assumption, or philosophical problem already established in the literature. The purpose is to develop a body of literature that establishes a contrarian viewpoint. Given the value-laden nature of some social science research [e.g., educational reform; immigration control], argumentative approaches to analyzing the literature can be a legitimate and important form of discourse. However, note that they can also introduce problems of bias when they are used to make summary claims of the sort found in systematic reviews [see below].

Integrative Review Considered a form of research that reviews, critiques, and synthesizes representative literature on a topic in an integrated way such that new frameworks and perspectives on the topic are generated. The body of literature includes all studies that address related or identical hypotheses or research problems. A well-done integrative review meets the same standards as primary research in regard to clarity, rigor, and replication. This is the most common form of review in the social sciences.

Historical Review Few things rest in isolation from historical precedent. Historical literature reviews focus on examining research throughout a period of time, often starting with the first time an issue, concept, theory, phenomena emerged in the literature, then tracing its evolution within the scholarship of a discipline. The purpose is to place research in a historical context to show familiarity with state-of-the-art developments and to identify the likely directions for future research.

Methodological Review A review does not always focus on what someone said [findings], but how they came about saying what they say [method of analysis]. Reviewing methods of analysis provides a framework of understanding at different levels [i.e. those of theory, substantive fields, research approaches, and data collection and analysis techniques], how researchers draw upon a wide variety of knowledge ranging from the conceptual level to practical documents for use in fieldwork in the areas of ontological and epistemological consideration, quantitative and qualitative integration, sampling, interviewing, data collection, and data analysis. This approach helps highlight ethical issues which you should be aware of and consider as you go through your own study.

Systematic Review This form consists of an overview of existing evidence pertinent to a clearly formulated research question, which uses pre-specified and standardized methods to identify and critically appraise relevant research, and to collect, report, and analyze data from the studies that are included in the review. The goal is to deliberately document, critically evaluate, and summarize scientifically all of the research about a clearly defined research problem . Typically it focuses on a very specific empirical question, often posed in a cause-and-effect form, such as "To what extent does A contribute to B?" This type of literature review is primarily applied to examining prior research studies in clinical medicine and allied health fields, but it is increasingly being used in the social sciences.

Theoretical Review The purpose of this form is to examine the corpus of theory that has accumulated in regard to an issue, concept, theory, phenomena. The theoretical literature review helps to establish what theories already exist, the relationships between them, to what degree the existing theories have been investigated, and to develop new hypotheses to be tested. Often this form is used to help establish a lack of appropriate theories or reveal that current theories are inadequate for explaining new or emerging research problems. The unit of analysis can focus on a theoretical concept or a whole theory or framework.

NOTE : Most often the literature review will incorporate some combination of types. For example, a review that examines literature supporting or refuting an argument, assumption, or philosophical problem related to the research problem will also need to include writing supported by sources that establish the history of these arguments in the literature.

Baumeister, Roy F. and Mark R. Leary. "Writing Narrative Literature Reviews."  Review of General Psychology 1 (September 1997): 311-320; Mark R. Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Kennedy, Mary M. "Defining a Literature." Educational Researcher 36 (April 2007): 139-147; Petticrew, Mark and Helen Roberts. Systematic Reviews in the Social Sciences: A Practical Guide . Malden, MA: Blackwell Publishers, 2006; Torracro, Richard. "Writing Integrative Literature Reviews: Guidelines and Examples." Human Resource Development Review 4 (September 2005): 356-367; Rocco, Tonette S. and Maria S. Plakhotnik. "Literature Reviews, Conceptual Frameworks, and Theoretical Frameworks: Terms, Functions, and Distinctions." Human Ressource Development Review 8 (March 2008): 120-130; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016.

Structure and Writing Style

I.  Thinking About Your Literature Review

The structure of a literature review should include the following in support of understanding the research problem :

• An overview of the subject, issue, or theory under consideration, along with the objectives of the literature review,
• Division of works under review into themes or categories [e.g. works that support a particular position, those against, and those offering alternative approaches entirely],
• An explanation of how each work is similar to and how it varies from the others,
• Conclusions as to which pieces are best considered in their argument, are most convincing of their opinions, and make the greatest contribution to the understanding and development of their area of research.

The critical evaluation of each work should consider :

• Provenance -- what are the author's credentials? Are the author's arguments supported by evidence [e.g. primary historical material, case studies, narratives, statistics, recent scientific findings]?
• Methodology -- were the techniques used to identify, gather, and analyze the data appropriate to addressing the research problem? Was the sample size appropriate? Were the results effectively interpreted and reported?
• Objectivity -- is the author's perspective even-handed or prejudicial? Is contrary data considered or is certain pertinent information ignored to prove the author's point?
• Persuasiveness -- which of the author's theses are most convincing or least convincing?
• Validity -- are the author's arguments and conclusions convincing? Does the work ultimately contribute in any significant way to an understanding of the subject?

II.  Development of the Literature Review

Four Basic Stages of Writing 1.  Problem formulation -- which topic or field is being examined and what are its component issues? 2.  Literature search -- finding materials relevant to the subject being explored. 3.  Data evaluation -- determining which literature makes a significant contribution to the understanding of the topic. 4.  Analysis and interpretation -- discussing the findings and conclusions of pertinent literature.

Consider the following issues before writing the literature review: Clarify If your assignment is not specific about what form your literature review should take, seek clarification from your professor by asking these questions: 1.  Roughly how many sources would be appropriate to include? 2.  What types of sources should I review (books, journal articles, websites; scholarly versus popular sources)? 3.  Should I summarize, synthesize, or critique sources by discussing a common theme or issue? 4.  Should I evaluate the sources in any way beyond evaluating how they relate to understanding the research problem? 5.  Should I provide subheadings and other background information, such as definitions and/or a history? Find Models Use the exercise of reviewing the literature to examine how authors in your discipline or area of interest have composed their literature review sections. Read them to get a sense of the types of themes you might want to look for in your own research or to identify ways to organize your final review. The bibliography or reference section of sources you've already read, such as required readings in the course syllabus, are also excellent entry points into your own research. Narrow the Topic The narrower your topic, the easier it will be to limit the number of sources you need to read in order to obtain a good survey of relevant resources. Your professor will probably not expect you to read everything that's available about the topic, but you'll make the act of reviewing easier if you first limit scope of the research problem. A good strategy is to begin by searching the USC Libraries Catalog for recent books about the topic and review the table of contents for chapters that focuses on specific issues. You can also review the indexes of books to find references to specific issues that can serve as the focus of your research. For example, a book surveying the history of the Israeli-Palestinian conflict may include a chapter on the role Egypt has played in mediating the conflict, or look in the index for the pages where Egypt is mentioned in the text. Consider Whether Your Sources are Current Some disciplines require that you use information that is as current as possible. This is particularly true in disciplines in medicine and the sciences where research conducted becomes obsolete very quickly as new discoveries are made. However, when writing a review in the social sciences, a survey of the history of the literature may be required. In other words, a complete understanding the research problem requires you to deliberately examine how knowledge and perspectives have changed over time. Sort through other current bibliographies or literature reviews in the field to get a sense of what your discipline expects. You can also use this method to explore what is considered by scholars to be a "hot topic" and what is not.

III.  Ways to Organize Your Literature Review

Chronology of Events If your review follows the chronological method, you could write about the materials according to when they were published. This approach should only be followed if a clear path of research building on previous research can be identified and that these trends follow a clear chronological order of development. For example, a literature review that focuses on continuing research about the emergence of German economic power after the fall of the Soviet Union. By Publication Order your sources by publication chronology, then, only if the order demonstrates a more important trend. For instance, you could order a review of literature on environmental studies of brown fields if the progression revealed, for example, a change in the soil collection practices of the researchers who wrote and/or conducted the studies. Thematic [“conceptual categories”] A thematic literature review is the most common approach to summarizing prior research in the social and behavioral sciences. Thematic reviews are organized around a topic or issue, rather than the progression of time, although the progression of time may still be incorporated into a thematic review. For example, a review of the Internet’s impact on American presidential politics could focus on the development of online political satire. While the study focuses on one topic, the Internet’s impact on American presidential politics, it would still be organized chronologically reflecting technological developments in media. The difference in this example between a "chronological" and a "thematic" approach is what is emphasized the most: themes related to the role of the Internet in presidential politics. Note that more authentic thematic reviews tend to break away from chronological order. A review organized in this manner would shift between time periods within each section according to the point being made. Methodological A methodological approach focuses on the methods utilized by the researcher. For the Internet in American presidential politics project, one methodological approach would be to look at cultural differences between the portrayal of American presidents on American, British, and French websites. Or the review might focus on the fundraising impact of the Internet on a particular political party. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed.

Other Sections of Your Literature Review Once you've decided on the organizational method for your literature review, the sections you need to include in the paper should be easy to figure out because they arise from your organizational strategy. In other words, a chronological review would have subsections for each vital time period; a thematic review would have subtopics based upon factors that relate to the theme or issue. However, sometimes you may need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you. However, only include what is necessary for the reader to locate your study within the larger scholarship about the research problem.

Here are examples of other sections, usually in the form of a single paragraph, you may need to include depending on the type of review you write:

• Current Situation : Information necessary to understand the current topic or focus of the literature review.
• Sources Used : Describes the methods and resources [e.g., databases] you used to identify the literature you reviewed.
• History : The chronological progression of the field, the research literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.
• Selection Methods : Criteria you used to select (and perhaps exclude) sources in your literature review. For instance, you might explain that your review includes only peer-reviewed [i.e., scholarly] sources.
• Standards : Description of the way in which you present your information.
• Questions for Further Research : What questions about the field has the review sparked? How will you further your research as a result of the review?

IV.  Writing Your Literature Review

Once you've settled on how to organize your literature review, you're ready to write each section. When writing your review, keep in mind these issues.

Use Evidence A literature review section is, in this sense, just like any other academic research paper. Your interpretation of the available sources must be backed up with evidence [citations] that demonstrates that what you are saying is valid. Be Selective Select only the most important points in each source to highlight in the review. The type of information you choose to mention should relate directly to the research problem, whether it is thematic, methodological, or chronological. Related items that provide additional information, but that are not key to understanding the research problem, can be included in a list of further readings . Use Quotes Sparingly Some short quotes are appropriate if you want to emphasize a point, or if what an author stated cannot be easily paraphrased. Sometimes you may need to quote certain terminology that was coined by the author, is not common knowledge, or taken directly from the study. Do not use extensive quotes as a substitute for using your own words in reviewing the literature. Summarize and Synthesize Remember to summarize and synthesize your sources within each thematic paragraph as well as throughout the review. Recapitulate important features of a research study, but then synthesize it by rephrasing the study's significance and relating it to your own work and the work of others. Keep Your Own Voice While the literature review presents others' ideas, your voice [the writer's] should remain front and center. For example, weave references to other sources into what you are writing but maintain your own voice by starting and ending the paragraph with your own ideas and wording. Use Caution When Paraphrasing When paraphrasing a source that is not your own, be sure to represent the author's information or opinions accurately and in your own words. Even when paraphrasing an author’s work, you still must provide a citation to that work.

V.  Common Mistakes to Avoid

These are the most common mistakes made in reviewing social science research literature.

• Sources in your literature review do not clearly relate to the research problem;
• You do not take sufficient time to define and identify the most relevant sources to use in the literature review related to the research problem;
• Relies exclusively on secondary analytical sources rather than including relevant primary research studies or data;
• Uncritically accepts another researcher's findings and interpretations as valid, rather than examining critically all aspects of the research design and analysis;
• Does not describe the search procedures that were used in identifying the literature to review;
• Reports isolated statistical results rather than synthesizing them in chi-squared or meta-analytic methods; and,
• Only includes research that validates assumptions and does not consider contrary findings and alternative interpretations found in the literature.

Cook, Kathleen E. and Elise Murowchick. “Do Literature Review Skills Transfer from One Course to Another?” Psychology Learning and Teaching 13 (March 2014): 3-11; Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Jesson, Jill. Doing Your Literature Review: Traditional and Systematic Techniques . London: SAGE, 2011; Literature Review Handout. Online Writing Center. Liberty University; Literature Reviews. The Writing Center. University of North Carolina; Onwuegbuzie, Anthony J. and Rebecca Frels. Seven Steps to a Comprehensive Literature Review: A Multimodal and Cultural Approach . Los Angeles, CA: SAGE, 2016; Ridley, Diana. The Literature Review: A Step-by-Step Guide for Students . 2nd ed. Los Angeles, CA: SAGE, 2012; Randolph, Justus J. “A Guide to Writing the Dissertation Literature Review." Practical Assessment, Research, and Evaluation. vol. 14, June 2009; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016; Taylor, Dena. The Literature Review: A Few Tips On Conducting It. University College Writing Centre. University of Toronto; Writing a Literature Review. Academic Skills Centre. University of Canberra.

Writing Tip

Break Out of Your Disciplinary Box!

Thinking interdisciplinarily about a research problem can be a rewarding exercise in applying new ideas, theories, or concepts to an old problem. For example, what might cultural anthropologists say about the continuing conflict in the Middle East? In what ways might geographers view the need for better distribution of social service agencies in large cities than how social workers might study the issue? You don’t want to substitute a thorough review of core research literature in your discipline for studies conducted in other fields of study. However, particularly in the social sciences, thinking about research problems from multiple vectors is a key strategy for finding new solutions to a problem or gaining a new perspective. Consult with a librarian about identifying research databases in other disciplines; almost every field of study has at least one comprehensive database devoted to indexing its research literature.

Frodeman, Robert. The Oxford Handbook of Interdisciplinarity . New York: Oxford University Press, 2010.

Another Writing Tip

Don't Just Review for Content!

While conducting a review of the literature, maximize the time you devote to writing this part of your paper by thinking broadly about what you should be looking for and evaluating. Review not just what scholars are saying, but how are they saying it. Some questions to ask:

• How are they organizing their ideas?
• What methods have they used to study the problem?
• What theories have been used to explain, predict, or understand their research problem?
• What sources have they cited to support their conclusions?
• How have they used non-textual elements [e.g., charts, graphs, figures, etc.] to illustrate key points?

When you begin to write your literature review section, you'll be glad you dug deeper into how the research was designed and constructed because it establishes a means for developing more substantial analysis and interpretation of the research problem.

Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1 998.

Yet Another Writing Tip

When Do I Know I Can Stop Looking and Move On?

Here are several strategies you can utilize to assess whether you've thoroughly reviewed the literature:

• Look for repeating patterns in the research findings . If the same thing is being said, just by different people, then this likely demonstrates that the research problem has hit a conceptual dead end. At this point consider: Does your study extend current research?  Does it forge a new path? Or, does is merely add more of the same thing being said?
• Look at sources the authors cite to in their work . If you begin to see the same researchers cited again and again, then this is often an indication that no new ideas have been generated to address the research problem.
• Search Google Scholar to identify who has subsequently cited leading scholars already identified in your literature review [see next sub-tab]. This is called citation tracking and there are a number of sources that can help you identify who has cited whom, particularly scholars from outside of your discipline. Here again, if the same authors are being cited again and again, this may indicate no new literature has been written on the topic.

Onwuegbuzie, Anthony J. and Rebecca Frels. Seven Steps to a Comprehensive Literature Review: A Multimodal and Cultural Approach . Los Angeles, CA: Sage, 2016; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016.

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What is a literature review?

A literature review is an integrated analysis -- not just a summary-- of scholarly writings and other relevant evidence related directly to your research question.  That is, it represents a synthesis of the evidence that provides background information on your topic and shows a association between the evidence and your research question.

A literature review may be a stand alone work or the introduction to a larger research paper, depending on the assignment.  Rely heavily on the guidelines your instructor has given you.

Why is it important?

A literature review is important because it:

• Explains the background of research on a topic.
• Demonstrates why a topic is significant to a subject area.
• Discovers relationships between research studies/ideas.
• Identifies major themes, concepts, and researchers on a topic.
• Identifies critical gaps and points of disagreement.
• Discusses further research questions that logically come out of the previous studies.

APA7 Style resources

APA Style Blog - for those harder to find answers

1. Choose a topic. Define your research question.

Your literature review should be guided by your central research question.  The literature represents background and research developments related to a specific research question, interpreted and analyzed by you in a synthesized way.

• Make sure your research question is not too broad or too narrow.  Is it manageable?
• Begin writing down terms that are related to your question. These will be useful for searches later.
• If you have the opportunity, discuss your topic with your professor and your class mates.

2. Decide on the scope of your review

How many studies do you need to look at? How comprehensive should it be? How many years should it cover? 

• This may depend on your assignment.  How many sources does the assignment require?

3. Select the databases you will use to conduct your searches.

Make a list of the databases you will search. 

Where to find databases:

• use the tabs on this guide
• Find other databases in the Nursing Information Resources web page
• More on the Medical Library web page
• ... and more on the Yale University Library web page

4. Conduct your searches to find the evidence. Keep track of your searches.

• Use the key words in your question, as well as synonyms for those words, as terms in your search. Use the database tutorials for help.
• Save the searches in the databases. This saves time when you want to redo, or modify, the searches. It is also helpful to use as a guide is the searches are not finding any useful results.
• Review the abstracts of research studies carefully. This will save you time.
• Use the bibliographies and references of research studies you find to locate others.
• Check with your professor, or a subject expert in the field, if you are missing any key works in the field.
• Ask your librarian for help at any time.
• Use a citation manager, such as EndNote as the repository for your citations. See the EndNote tutorials for help.

Review the literature

Some questions to help you analyze the research:

• What was the research question of the study you are reviewing? What were the authors trying to discover?
• Was the research funded by a source that could influence the findings?
• What were the research methodologies? Analyze its literature review, the samples and variables used, the results, and the conclusions.
• Does the research seem to be complete? Could it have been conducted more soundly? What further questions does it raise?
• If there are conflicting studies, why do you think that is?
• How are the authors viewed in the field? Has this study been cited? If so, how has it been analyzed?

Tips: 

• Review the abstracts carefully.  
• Keep careful notes so that you may track your thought processes during the research process.
• Create a matrix of the studies for easy analysis, and synthesis, across all of the studies.
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Literature Review

• What is a Literature Review?
• What is NOT a Literature Review?
• Purposes of a Literature Review
• Types of Literature Reviews
• Literature Reviews vs. Systematic Reviews
• Systematic vs. Meta-Analysis

Literature Review  is a comprehensive survey of the works published in a particular field of study or line of research, usually over a specific period of time, in the form of an in-depth, critical bibliographic essay or annotated list in which attention is drawn to the most significant works.

Also, we can define a literature review as the collected body of scholarly works related to a topic:

• Summarizes and analyzes previous research relevant to a topic
• Includes scholarly books and articles published in academic journals
• Can be an specific scholarly paper or a section in a research paper

The objective of a Literature Review is to find previous published scholarly works relevant to an specific topic

• Help gather ideas or information
• Keep up to date in current trends and findings
• Help develop new questions

A literature review is important because it:

• Explains the background of research on a topic.
• Demonstrates why a topic is significant to a subject area.
• Helps focus your own research questions or problems
• Discovers relationships between research studies/ideas.
• Suggests unexplored ideas or populations
• Identifies major themes, concepts, and researchers on a topic.
• Tests assumptions; may help counter preconceived ideas and remove unconscious bias.
• Identifies critical gaps, points of disagreement, or potentially flawed methodology or theoretical approaches.
• Indicates potential directions for future research.

All content in this section is from Literature Review Research from Old Dominion University 

Keep in mind the following, a literature review is NOT:

Not an essay 

Not an annotated bibliography  in which you summarize each article that you have reviewed.  A literature review goes beyond basic summarizing to focus on the critical analysis of the reviewed works and their relationship to your research question.

Not a research paper   where you select resources to support one side of an issue versus another.  A lit review should explain and consider all sides of an argument in order to avoid bias, and areas of agreement and disagreement should be highlighted.

A literature review serves several purposes. For example, it

• provides thorough knowledge of previous studies; introduces seminal works.
• helps focus one’s own research topic.
• identifies a conceptual framework for one’s own research questions or problems; indicates potential directions for future research.
• suggests previously unused or underused methodologies, designs, quantitative and qualitative strategies.
• identifies gaps in previous studies; identifies flawed methodologies and/or theoretical approaches; avoids replication of mistakes.
• helps the researcher avoid repetition of earlier research.
• suggests unexplored populations.
• determines whether past studies agree or disagree; identifies controversy in the literature.
• tests assumptions; may help counter preconceived ideas and remove unconscious bias.

As Kennedy (2007) notes*, it is important to think of knowledge in a given field as consisting of three layers. First, there are the primary studies that researchers conduct and publish. Second are the reviews of those studies that summarize and offer new interpretations built from and often extending beyond the original studies. Third, there are the perceptions, conclusions, opinion, and interpretations that are shared informally that become part of the lore of field. In composing a literature review, it is important to note that it is often this third layer of knowledge that is cited as "true" even though it often has only a loose relationship to the primary studies and secondary literature reviews.

Given this, while literature reviews are designed to provide an overview and synthesis of pertinent sources you have explored, there are several approaches to how they can be done, depending upon the type of analysis underpinning your study. Listed below are definitions of types of literature reviews:

Argumentative Review      This form examines literature selectively in order to support or refute an argument, deeply imbedded assumption, or philosophical problem already established in the literature. The purpose is to develop a body of literature that establishes a contrarian viewpoint. Given the value-laden nature of some social science research [e.g., educational reform; immigration control], argumentative approaches to analyzing the literature can be a legitimate and important form of discourse. However, note that they can also introduce problems of bias when they are used to to make summary claims of the sort found in systematic reviews.

Integrative Review      Considered a form of research that reviews, critiques, and synthesizes representative literature on a topic in an integrated way such that new frameworks and perspectives on the topic are generated. The body of literature includes all studies that address related or identical hypotheses. A well-done integrative review meets the same standards as primary research in regard to clarity, rigor, and replication.

Historical Review      Few things rest in isolation from historical precedent. Historical reviews are focused on examining research throughout a period of time, often starting with the first time an issue, concept, theory, phenomena emerged in the literature, then tracing its evolution within the scholarship of a discipline. The purpose is to place research in a historical context to show familiarity with state-of-the-art developments and to identify the likely directions for future research.

Methodological Review      A review does not always focus on what someone said [content], but how they said it [method of analysis]. This approach provides a framework of understanding at different levels (i.e. those of theory, substantive fields, research approaches and data collection and analysis techniques), enables researchers to draw on a wide variety of knowledge ranging from the conceptual level to practical documents for use in fieldwork in the areas of ontological and epistemological consideration, quantitative and qualitative integration, sampling, interviewing, data collection and data analysis, and helps highlight many ethical issues which we should be aware of and consider as we go through our study.

Systematic Review      This form consists of an overview of existing evidence pertinent to a clearly formulated research question, which uses pre-specified and standardized methods to identify and critically appraise relevant research, and to collect, report, and analyse data from the studies that are included in the review. Typically it focuses on a very specific empirical question, often posed in a cause-and-effect form, such as "To what extent does A contribute to B?"

Theoretical Review      The purpose of this form is to concretely examine the corpus of theory that has accumulated in regard to an issue, concept, theory, phenomena. The theoretical literature review help establish what theories already exist, the relationships between them, to what degree the existing theories have been investigated, and to develop new hypotheses to be tested. Often this form is used to help establish a lack of appropriate theories or reveal that current theories are inadequate for explaining new or emerging research problems. The unit of analysis can focus on a theoretical concept or a whole theory or framework.

* Kennedy, Mary M. "Defining a Literature."  Educational Researcher  36 (April 2007): 139-147.

All content in this section is from The Literature Review created by Dr. Robert Larabee USC

Robinson, P. and Lowe, J. (2015),  Literature reviews vs systematic reviews.  Australian and New Zealand Journal of Public Health, 39: 103-103. doi: 10.1111/1753-6405.12393

What's in the name? The difference between a Systematic Review and a Literature Review, and why it matters . By Lynn Kysh from University of Southern California

Systematic review or meta-analysis?

A  systematic review  answers a defined research question by collecting and summarizing all empirical evidence that fits pre-specified eligibility criteria.

A  meta-analysis  is the use of statistical methods to summarize the results of these studies.

Systematic reviews, just like other research articles, can be of varying quality. They are a significant piece of work (the Centre for Reviews and Dissemination at York estimates that a team will take 9-24 months), and to be useful to other researchers and practitioners they should have:

• clearly stated objectives with pre-defined eligibility criteria for studies
• explicit, reproducible methodology
• a systematic search that attempts to identify all studies
• assessment of the validity of the findings of the included studies (e.g. risk of bias)
• systematic presentation, and synthesis, of the characteristics and findings of the included studies

Not all systematic reviews contain meta-analysis. 

Meta-analysis is the use of statistical methods to summarize the results of independent studies. By combining information from all relevant studies, meta-analysis can provide more precise estimates of the effects of health care than those derived from the individual studies included within a review.  More information on meta-analyses can be found in  Cochrane Handbook, Chapter 9 .

A meta-analysis goes beyond critique and integration and conducts secondary statistical analysis on the outcomes of similar studies.  It is a systematic review that uses quantitative methods to synthesize and summarize the results.

An advantage of a meta-analysis is the ability to be completely objective in evaluating research findings.  Not all topics, however, have sufficient research evidence to allow a meta-analysis to be conducted.  In that case, an integrative review is an appropriate strategy. 

Some of the content in this section is from Systematic reviews and meta-analyses: step by step guide created by Kate McAllister.

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Literature review.

• What is a Literature Review?
• What is Its Purpose?
• 1. Select a Topic
• 2. Set the Topic in Context
• 3. Types of Information Sources
• 4. Use Information Sources
• 5. Get the Information
• 6. Organize / Manage the Information
• 7. Position the Literature Review
• 8. Write the Literature Review

A literature review is a comprehensive summary of previous research on a topic. The literature review surveys scholarly articles, books, and other sources relevant to a particular area of research.  The review should enumerate, describe, summarize, objectively evaluate and clarify this previous research.  It should give a theoretical base for the research and help you (the author) determine the nature of your research.  The literature review acknowledges the work of previous researchers, and in so doing, assures the reader that your work has been well conceived.  It is assumed that by mentioning a previous work in the field of study, that the author has read, evaluated, and assimiliated that work into the work at hand.

A literature review creates a "landscape" for the reader, giving her or him a full understanding of the developments in the field.  This landscape informs the reader that the author has indeed assimilated all (or the vast majority of) previous, significant works in the field into her or his research. 

 "In writing the literature review, the purpose is to convey to the reader what knowledge and ideas have been established on a topic, and what their strengths and weaknesses are. The literature review must be defined by a guiding concept (eg. your research objective, the problem or issue you are discussing, or your argumentative thesis). It is not just a descriptive list of the material available, or a set of summaries.( http://www.writing.utoronto.ca/advice/specific-types-of-writing/literature-review )

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How to Write a Literature Review

Learn what a literature review is, where it is used, and the structure it should follow, including how to refer to studies and establish themes. We provides tips on writing a literature review, such as stating your research question, selecting key terms, and finding relevant literature on your topic.

Updated on May 17, 2023

A literature review is an overview of the existing literature on a particular topic. It provides a concise summary and critical analysis of existing publications. This justifies why the study was conducted. It also helps the reader understand the topic and see areas for future research. It can be part of a manuscript’s introduction section or a required part of an academic thesis. It can also be a standalone paper, such as a narrative review.

This article discusses what a literature review is when it’s part of a research paper. It provides strategies, tools, and tips for writing a good review.

What is a literature review, and where is it used?

A literature review is an organized summary of existing literature on a topic or research question. It’s used to help readers understand what has been done before related to the topic you’re writing on.

It shows how your study fits into the literature, why your study is needed, and what novel insights your study will bring to the literature.

In that sense, a literature review justifies your work and its potential impact. Literature reviews are also valuable for other researchers, as they can overview a specific topic.

A literature review is used in academic documents, including manuscripts, theses and dissertations, and in standalone papers such as systematic reviews and narrative reviews.

In a manuscript or dissertation, the literature review is presented as background information in the introduction section. Here, it summarizes prior research on the key concepts the paper focuses on, identifies gaps in the literature, and provides context for why the current study is needed. It focuses on summarizing articles that provide specific evidence relating to the topic of the larger manuscript and is very narrowly focused.

In contrast, a standalone literature review is a comprehensive and critical analysis of the existing research and literature on a specific topic. It synthesizes the current state of knowledge on the topic, identifies gaps, contradictions, and future directions for research. A literature review paper is typically longer, more comprehensive, and applies a study methodology.

What structure do literature reviews follow?

Literature reviews follow a logical structure, meaning every sentence logically leads to the next. They begin with a broad overview of the topic and then narrow down to specific research carried out on that topic in a way that builds on the previous information. Supporting studies are discussed one-by-one or they’re grouped by themes. They may or may not specifically indicate the authors by name. That depends on personal style and guidelines.

Referring to studies

For example, the literature review in Howden et al. (2018), reporting on a randomized controlled trial (RCT) on fitness and heart failure, first states the overall theme: sedentary aging’s association with worsening cardiovascular health. In concise sentences, it then lists the themes along with subscript numbers of the supporting literature, e.g., “...middle age is the strongest predictor of future heart failure.5–7”. No authors are named. This may be because of the referencing style (using numbers leading to the References list, unlike, for instance, APA, which uses last names), or it may be the authors’ preference.

Tramontano et al. (2021), on remote work , lists authors’ names along with the supporting research. In some cases, the names are in parentheses (per APA style) and in other cases, (e.g., ...Gonzales Vazquez and colleagues (2019) indicated...) the names represent the study. Again, it’s a combination of referencing style and authors’ preference.

Establish themes

As the literature review progresses, you synthesize the information from the articles. Articles are grouped together by theme or evidence (i.e., supporting or contrasting), with relevant citations giving support. Typically, findings are condensed and summarized concisely (i.e., in one or a couple of sentences).

For example, if you were exploring how processed food affects heart health, articles in the literature review might be grouped into categories such as heart health in general, processed foods, and the negative effects of processed foods on general heart health. You’d then summarize the key findings for each category with relevant citations.

As such, a literature review in a manuscript is not simply a chronological list of articles and their findings. Rather, it’s a report and analysis of the existing literature. It weaves a narrative that underpins your own study.

Writing your literature review

State your research question .

The first step to writing a good literature review is stating your research question.

If you’re writing a manuscript or dissertation, you likely already know what your research question is. Be sure it’s clearly presented at the end of the introductory paragraph so the reader immediately knows what the study will be about.

Select key terms

Next, identify several key words/terms/phrases that will be used to query your search for relevant literature.

For example, if your manuscript is about the effects of processed foods on heart health, you will want to use keywords such as “cardiovascular,” “processed foods,” and “heart disease” to retrieve relevant publications.

Find relevant literature on your topic

Most researchers have a specialty or a few specialties. Reading other studies should already be part of your day-to-day practice. So it’s very unusual to start a literature review from zero. You probably already have a folder full of PDFs (or, ideally, a reference manager full of well-organized articles in digital format).

For your current research, you’ll then add further literature in more specific and specialized areas. You’ll need to update your personal library. And you may find you lack sufficient publications in a certain area of research. Your literature review will address all these issues. Methods for diving in include databases, review articles, and asking colleagues and other researchers.

Online databases

Searching with databases often requires a combination of free and paid sources.

Google Scholar is probably the most commonly known search engine for academic literature because, well, it’s Google. Type titles, keywords, authors, or other entries to find papers on your topic of interest. You don’t need to create an account, but just because a publication is listed in Scholar doesn’t mean you can access the full text. Still, its powerful search features can help you rapidly narrow your search. You can then find publications in a database for which you have a subscription.

EBSCO and ProQuest are commonly available in universities’ online libraries, and databases like PubMed are comprehensive scientific collections. Some databases are open access, while others require a subscription to fully access the articles. Hopefully, you have access through your university or institution.

There are also publisher-managed search engines and databases like ScienceDirect or Scopus , as well as Wiley Online Library . These usually require a subscription.

Elicit is an AI-based search engine. Ask a research question and find relevant literature. It also suggests questions based on your input for better results. No account is needed.

Zendy is a search engine dedicated to open access journals. It’s accessible once you create an account.

Colleagues, fellow researchers

Asking your colleagues or fellow researchers in your field can be a great resource for finding additional studies. You can also look for highly cited papers in your field or search for articles from known experts in your field.

Other literature reviews, review articles, and reference lists

Previous review papers on your topic, introduction sections of articles (which contain their own literature reviews), are reference lists of papers are all great tools for finding additional articles. Look through the reference lists of previous prior review papers to locate other relevant articles.

With this approach, you’ll find yourself diving down one rabbit hole after another. And it can get overwhelming, so scan quickly, keep notes, and use a good reference manager (see below). After a while, you’ll start to see the same publications emerge. You’ll start to recognize the seminal pieces as well as highly specific studies on limited populations.

Software and reference managers

Apps like Connected Papers can help expand your collection and ensure you’re not missing any articles. With this tool, you can search for a work and then see it visualized through other articles it references, and that referenced it. It’s shown as a network of connected papers – fantastic for visual types.

Reference managers like EndNote and Mendeley are helpful tools for organizing your papers and adding citations to your manuscript. You can download them to your computer and easily search for the information you’ve read before, saving a lot of time in the writing process. While they both require creating an account, Mendeley is free. Paperpile is an excellent lighter-weight option.

Organize your sources

When you’ve compiled sufficient publications via your literature search, extract relevant information for your research question.

Identify themes

First, identify the most relevant papers for your research question. One good approach is to read the abstract and methods sections to understand the main findings.

Narrow down your list to articles that have a research question as similar as possible to yours. Then, group them by themes or evidence. For instance, group articles showing that processed foods lead to increased rates of heart disease in one section.

Include contradictory evidence to fully cover the scope of the topic. This will help you better organize the sections for your review later.

Define your key concepts

Every good review section begins with specific definitions of the concepts the paper will focus on. They should be defined in the abstract and introduction.

Write an outline

Write an outline with subheadings representing categories or themes your review will cover. Under each theme, enter a few references or key points that reflect what you want to convey to your reader in that section.

Organize the subheadings logically so that one idea flows into the next. Don’t jump back and forth between concepts. For example, if you’re establishing a common, evidence-supported definition of heart disease, focus only on that. Bringing in other diseases will confuse the reader. If you need to compare with other diseases, that’s probably cause for another subsection.

Review previous articles on your topic and check how the authors structured their introduction section to get ideas for your outline.

For longer reviews, you can use tables to present the literature and key themes more clearly for the reader. Tables are especially useful in dedicated review papers like narrative reviews.

Write your literature review

Following your outline, expand on your notes with sentences and paragraphs, including relevant citations (see the section above for examples of how these are typically written). Use clear and concise language. Make sure all your paragraphs have a dedicated topic sentence that reflects what the rest of the paragraph is about.

Start your review broadly, then use your prior research to narrow down to why your research question is needed. For example, define what heart disease is broadly, then narrow down to how specific processed foods can impact it and what still needs to be investigated (i.e., with your study).

Review your work

After finishing your first draft, revise and refine your work. Here are some key steps.

Refine your literature review

As you write, you may need to expand sections or include more evidence. Read over your review several times and determine if it’s conveying the information you want to get across clearly and adjust accordingly.

Omit unnecessary information

In scientific communication, less is more, so avoid making your review too long. Remove unnecessary information and avoid being too wordy. As a general rule, aim for just one idea per sentence and no more than around 15–20 words per sentence.

A credible citation (or citations) should support every assertion. But it can also get tempting to follow irrelevant paths that aren’t immediately relevant to the study you’re doing now.

Professional editing can also help you refine wordiness.

Check the logical structure

Check that each section in your review relates to the main research question. Check that every paragraph transitions smoothly to the next and that the ideas flow logically from one argument to the next. Ask yourself, “Does this idea directly relate to my next idea?” (and vice versa).

Also, check for consistency and completeness. Be sure you used the same wording for key concepts throughout your review and that you included all relevant evidence for your arguments.

Check for and remove/correct plagiarism

There are many ways to plagiarize , and some authors don’t even know when they’re doing it. It can be a critical mistake.

Journals use tools such as i Thenticate to detect plagiarism. And being caught plagiarizing can be a cause for a rapid rejection . Avoid plagiarizing by ensuring you cite the original source and don’t copy/paste text unless you use quotation marks. You can check for plagiarism using apps like Grammarly or Trinka , which can also help you improve your writing style and correct grammar mistakes.

Get outside perspectives

Ask a senior researcher or colleague to read your work and provide feedback or criticism. Ask junior researchers as well. Put your ego on the line for the good of rigorous science. Often, those with less experience may be able to see the more basic gaps in logic and clarity, as they bring a less honed and specialized perspective.

Check that you’ve included all references in the format required by the journal (e.g., APA, Vancouver, AMA). Use tools like Mendeley and EndNote to automatically generate a bibliography section based on the references you enter in your document. But do double-check what the software generates. It may be relying on incorrect metadata.

Good example of a literature review in a published article

Good literature reviews should be clear, concise, and informative. They should present enough information on the topic that you can understand the importance of the topic, the relevance of the literature included for the broader field, and what’s still missing from the literature (i.e., where further research is needed).

Here’s a good example:

Heart issues, sedentary lifestyle, exercise (from Howden et al. 2018)

Readable and well-structured, this review quickly highlights the negative relationship between a sedentary lifestyle and heart issues. It concisely reviews previous literature showing the relationship between exercise and heart health, so the reader understands why the study is needed.

Bonus: What’s the difference between a literature review and an annotated bibliography?

An annotated bibliography is a list of references with a brief summary of the results of that reference. It can also include your personal notes on the study and why it’s relevant to your study.

Especially for students, a literature review can be confused with an annotated bibliography. Both these devices detail existing studies. However, they perform quite different functions.

Annotated bibliographies are powerful when you’re writing a dissertation or any longer research piece, as they help you keep track of everything you’ve read and why it’s relevant. You may not publish it, but you can definitely use it when you write your literature review.

So, the key differences between an annotated bibliography are:

• An annotated bibliography is a list of references with no connection established among them, while a literature review is a narrative of all the studies.
• Annotated bibliographies are organized alphabetically by reference, whereas literature reviews are organized by themes or supporting or contrasting evidence. 
• Annotated bibliographies summarize (in a few sentences) each reference, while literature reviews place the publication in context along with other publications.

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Literature Reviews

Steps in the literature review process.

• What is a literature review?
• Define your research question
• Determine inclusion and exclusion criteria
• Choose databases and search
• Review Results
• Synthesize Results
• Analyze Results
• Librarian Support
• You may need to some exploratory searching of the literature to get a sense of scope, to determine whether you need to narrow or broaden your focus
• Identify databases that provide the most relevant sources, and identify relevant terms (controlled vocabularies) to add to your search strategy
• Finalize your research question
• Think about relevant dates, geographies (and languages), methods, and conflicting points of view
• Conduct searches in the published literature via the identified databases
• Check to see if this topic has been covered in other discipline's databases
• Examine the citations of on-point articles for keywords, authors, and previous research (via references) and cited reference searching.
• Save your search results in a citation management tool (such as Zotero, Mendeley or EndNote)
• De-duplicate your search results
• Make sure that you've found the seminal pieces -- they have been cited many times, and their work is considered foundational 
• Check with your professor or a librarian to make sure your search has been comprehensive
• Evaluate the strengths and weaknesses of individual sources and evaluate for bias, methodologies, and thoroughness
• Group your results in to an organizational structure that will support why your research needs to be done, or that provides the answer to your research question  
• Develop your conclusions
• Are there gaps in the literature?
• Where has significant research taken place, and who has done it?
• Is there consensus or debate on this topic?
• Which methodological approaches work best?
• For example: Background, Current Practices, Critics and Proponents, Where/How this study will fit in 
• Organize your citations and focus on your research question and pertinent studies
• Compile your bibliography

Note: The first four steps are the best points at which to contact a librarian. Your librarian can help you determine the best databases to use for your topic, assess scope, and formulate a search strategy.

Videos Tutorials about Literature Reviews

This 4.5 minute video from Academic Education Materials has a Creative Commons License and a British narrator.

Recommended Reading

• Last Updated: Oct 26, 2022 2:49 PM
• URL: https://guides.lib.utexas.edu/literaturereviews

What is a PHR? Definitions of Personal Health Record (PHR) Used in Literature—A Systematic Literature Review

• Conference paper
• First Online: 20 August 2020
• Cite this conference paper

• Jani Koskinen   ORCID: orcid.org/0000-0001-8325-9277 13 &
• Minna M. Rantanen   ORCID: orcid.org/0000-0001-8832-5616 13  

Part of the book series: Communications in Computer and Information Science ((CCIS,volume 1270))

Included in the following conference series:

• International Conference on Well-Being in the Information Society

512 Accesses

1 Citations

The purpose of this article is to clarify how term personal health record (PHR) is defined and used in literature. A systematic literature review was conducted to find out what are used as definitions for personal health record. We found and screened in total 1,781 articles published in years 2000–2017. Four databases chosen in review were ScienceDirect, IEEEXplore, Proguest and Pubmed. After criteria screening 1,234 articles were taken under further analysis. Most of the articles did not have any definition for term “personal health record” (n = 1,001; 81%). Only 233 (19%) articles included some kind of definition of the term. Few definitions were found that are constantly used in the field of medical informatics. However, those definitions are in contradiction between others and overall discourse in field. Thus, we need clear and systematic structure for different PHRs and proposal for hierarchy is presented in this article.

• Personal health record
• Terminology
• Categorisation

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Koskinen, J., Rantanen, M.M. (2020). What is a PHR? Definitions of Personal Health Record (PHR) Used in Literature—A Systematic Literature Review. In: Cacace, M., et al. Well-Being in the Information Society. Fruits of Respect. WIS 2020. Communications in Computer and Information Science, vol 1270. Springer, Cham. https://doi.org/10.1007/978-3-030-57847-3_2

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Trends in guideline implementation: an updated scoping review

• Sanne Peters   ORCID: orcid.org/0000-0001-6235-1752 1 , 2 ,
• Krithika Sukumar 3 ,
• Sophie Blanchard 4 ,
• Akilesh Ramasamy 5 ,
• Jennifer Malinowski 6 ,
• Pamela Ginex 7 ,
• Emily Senerth 8 ,
• Marleen Corremans 9 ,
• Zachary Munn 10 ,
• Tamara Kredo 11 ,
• Lucia Prieto Remon 12 ,
• Etienne Ngeh 13 , 14 ,
• Lisa Kalman 15 ,
• Samia Alhabib 16 ,
• Yasser Sami Amer 17 , 18 , 19 &
• Anna Gagliardi 3 , 20  

Implementation Science volume  17 , Article number:  50 ( 2022 ) Cite this article

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Guidelines aim to support evidence-informed practice but are inconsistently used without implementation strategies. Our prior scoping review revealed that guideline implementation interventions were not selected and tailored based on processes known to enhance guideline uptake and impact. The purpose of this study was to update the prior scoping review.

We searched MEDLINE, EMBASE, AMED, CINAHL, Scopus, and the Cochrane Database of Systematic Reviews for studies published from 2014 to January 2021 that evaluated guideline implementation interventions. We screened studies in triplicate and extracted data in duplicate. We reported study and intervention characteristics and studies that achieved impact with summary statistics.

We included 118 studies that implemented guidelines on 16 clinical topics. With regard to implementation planning, 21% of studies referred to theories or frameworks, 50% pre-identified implementation barriers, and 36% engaged stakeholders in selecting or tailoring interventions. Studies that employed frameworks ( n =25) most often used the theoretical domains framework (28%) or social cognitive theory (28%). Those that pre-identified barriers ( n =59) most often consulted literature (60%). Those that engaged stakeholders ( n =42) most often consulted healthcare professionals (79%). Common interventions included educating professionals about guidelines (44%) and information systems/technology (41%). Most studies employed multi-faceted interventions (75%). A total of 97 (82%) studies achieved impact (improvements in one or more reported outcomes) including 10 (40% of 25) studies that employed frameworks, 28 (47.45% of 59) studies that pre-identified barriers, 22 (52.38% of 42) studies that engaged stakeholders, and 21 (70% of 30) studies that employed single interventions.

Conclusions

Compared to our prior review, this review found that more studies used processes to select and tailor interventions, and a wider array of types of interventions across the Mazza taxonomy. Given that most studies achieved impact, this might reinforce the need for implementation planning. However, even studies that did not plan implementation achieved impact. Similarly, even single interventions achieved impact. Thus, a future systematic review based on this data is warranted to establish if the use of frameworks, barrier identification, stakeholder engagement, and multi-faceted interventions are associated with impact.

Trial registration

The protocol was registered with Open Science Framework ( https://osf.io/4nxpr ) and published in JBI Evidence Synthesis.

Peer Review reports

Contributions to the literature

By including guidelines on any clinical topic, this review of 118 studies published between 2014 and 2021 provides a comprehensive picture of implementation planning practices.

Compared to an earlier version, this updated review found that guidelines are implemented with a broader range of interventions types and that more interventions are selected and tailored based on frameworks, pre-identifying barriers, and stakeholder engagement.

However, even studies that did not employ these approaches achieved impact, raising important questions about their value that can only be answered through a future systematic review based on this data.

Clinical practice guidelines include recommendations that are based on the best available evidence and are intended to optimize patient care [ 1 , 2 ]. Given that guidelines support evidence-informed decision making and reduce practice variations, they are essential for planning, delivering, and improving high-quality health care [ 3 ]. However, policy and practice are not consistently informed by evidence-based clinical practice guidelines, which can lead to suboptimal care and inappropriate use of health care resources [ 4 , 5 , 6 , 7 ].

It is known that guideline implementation is a complex process that is often hindered by a variety of individual-, organisational-, and system-level barriers [ 8 , 9 , 10 , 11 ]. Common barriers identified across countries include, for example, limited knowledge of and negative attitudes toward existing guidelines, and lack of managers’ support for guideline implementation [ 12 , 13 ].

Despite many barriers, guideline implementation is increasingly recognized as a process crucial to improving healthcare quality. Existing reviews have focused on specific clinical disciplines such as nursing and occupational therapy [ 14 , 15 ], medical areas including cancer and venous thromboembolism prevention [ 16 , 17 ], barriers of guideline implementation [ 18 , 19 ], or specific topics such as the role of middle managers, nudge strategies, and de-implementation strategies [ 20 , 21 , 22 ].

Considerable knowledge is now available on how to optimize guideline implementation and uptake. Research shows that implementation interventions selected and tailored according to pre-identified barriers, theory, and/or stakeholder engagement can optimize guideline implementation and uptake [ 8 , 23 , 24 , 25 ]. For example, a Cochrane review by Baker et al. of 26 randomized controlled trials (RCTs) revealed that tailoring interventions to overcome barriers was more likely to improve professional practice compared to no intervention or dissemination of guidelines [ 23 ]. Flottorp et al. employed rigorous methods to compile and establish consensus on a framework of 57 barriers of guideline implementation organized in 7 broad categories that implementers can use to help identify barriers [ 8 ]. Kim et al. first synthesized published research, then interviewed international guideline developers to compile strategies for integrating patient preferences in guidelines, an approach shown to improve relevance and uptake of recommendations [ 24 ]. Gagliardi et al. conducted a series of studies that identified and then elaborated on the concept of guideline implementability, referring to content included in or with guidelines such as implementation instructions or tools that can help users to implement recommendations [ 25 ]. Squires et al. conducted a meta-review of 25 reviews demonstrating that single interventions were as capable as multifaceted interventions of achieving positive impact [ 26 ]. To examine if and how guidelines were implemented based on these principles, the Guidelines International Network Implementation Working Group published a scoping review in 2015 on trends in guideline implementation [ 27 ]. The review included 32 studies published between 2004 and 2013. Most included studies employed educational meetings or materials targeted at patients and/or healthcare professionals rather than a range of implementation interventions selected and tailored according to pre-identified barriers, theory, and/or stakeholder engagement, approaches proven to optimize guideline implementation and uptake [ 8 , 23 , 24 , 25 ]. The study also revealed inconsistent impact on patient and healthcare professional knowledge or behaviour, or clinical outcomes, possibly due to sub-optimal implementation. Moreover, the review included studies of guideline implementation in only four health topics (arthritis, diabetes, colorectal cancer, and heart failure), which resulted in few eligible studies and limited ability to identify trends in guideline implementation over time.

In the 8 years that have passed since literature searches were conducted for the 2015 scoping review, research continues to show that many patients do not access or experience guideline-recommended care. For example, 11 to 45% of American asthma specialists and primary care clinicians complied with asthma guidelines [ 28 ], 43 to 62% of 369,251 people from 20 countries achieved diabetes guideline targets [ 6 ], 44% of 30,113 Americans at high risk of hepatitis C virus received testing as per guidelines [ 29 ], and 36% of 414,851 Americans at 31 institutions did not receive recommended perioperative antibiotic prophylaxis [ 30 ]. Hence, further knowledge is needed to understand if guideline implementers are employing aforementioned strategies known to improve use of guidelines and realize associated benefits. The purpose of this study was to update and expand the 2015 scoping review [ 27 ]. The aim was to assess trends in guideline implementation, including the implementation strategies or interventions (hereafter, “interventions”) used, the implementation planning approaches employed for selecting and/or tailoring interventions, and the impact on patient or healthcare professional knowledge, behavior, or clinical outcomes.

The following research questions were investigated:

What approaches were used for implementation planning (i.e., pre-identified barriers, use of frameworks, or stakeholder engagement)?

What interventions have been used to implement guidelines in any healthcare context?

Do implementation planning approaches (pre-identify barriers, use of frameworks, stakeholder engagement) or multi-faceted interventions appear to lead to positive impact?

The scoping review methodological approach was guided by Arksey and O’Malley’s framework and the JBI Manual for Evidence Synthesis and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Review (PRISMA-ScR) recommendations [ 31 , 32 , 33 , 34 , 35 ], see supplementary file 1 for the completed PRISMA-ScR checklist. A detailed protocol of this scoping review was published in JBI Evidence Synthesis [ 36 ]. The authors are members of the Guidelines International Network Implementation Working Group. The purpose of a scoping review is to explore what data is available on a certain topic, as well as whether there is sufficient data available for a more robust systematic review.

Eligibility criteria

Supplementary file 2 details inclusion and exclusion criteria. In brief, studies were eligible if they evaluated the impact of guideline implementation interventions. Guidelines were defined as documents intended to optimize patient care that include recommendations informed by the best available evidence and an assessment of the benefits and harms of alternative care options [ 1 , 2 ]. In case studies reported a local guideline, the research team investigated whether these clearly reflected and referenced (inter)national guidelines or were developed according to recognized methods, such as a literature review of the available evidence. Guidelines were considered for inclusion where they target patients aged 18 or older (and/or family or carers) or clinicians (physicians, nurses, allied health) of any specialty. Studies were eligible if they were conducted in primary or secondary/tertiary (hospital inpatient, outpatient, emergency) healthcare settings and published in English, French, or German (languages that could be translated by members of the research team). All authors contributed to development of the eligibility criteria, and two reviewers (AG and SP) further refined criteria based on review of the first 100 search results.

Search strategy

The search strategy (supplementary file 3 ) was based on that used for the 2015 scoping review [ 27 ] and was updated based on input from the research team and a medical librarian, in accordance with Peer Review of Electronic Search Strategies (PRESS) criteria [ 37 ]. AG executed searches in MEDLINE, EMBASE, AMED (all Ovid), CINAHL (EBSCOhost), Scopus, and the Cochrane Database of Systematic Reviews. Articles published from 2014 to January 2021 were included to capture relevant studies published subsequent to the execution of searches for the 2015 scoping review [ 27 ].

Study selection

One researcher (AG) uploaded search results into Covidence (Veritas Health Innovation, Melbourne, Australia) to remove duplicates. To prepare for screening, all screeners reviewed the 2015 publication [ 27 ], updated screening criteria, and an Excel file in which AG annotated screening decisions for the first 100 search results. Titles and abstracts were independently screened by two reviewers (SP, SB, AR, JM, PG, ES, MC, ZM, or AG) against the eligibility criteria. Selected titles and abstracts were additionally screened by a third reviewer (AG or SP). Potentially relevant papers were retrieved and imported into Covidence. The full text of selected papers was assessed by two independent reviewers (AG and SP), who noted reasons for exclusion.

Data extraction and analysis

Data was extracted from included papers by one researcher (SP, SB, AR, JM, PG, ES, MC, ZM, TK, EN, LPR, LK, or AG) and verified by a second researcher (KS). KS discussed any uncertainties or discrepancies with a third independent reviewer (AG or SP). The data extraction template, based on that used in the 2015 review [ 27 ] and a few additional items added by the research team, included study characteristics, guideline topic, study objective(s), implementation planning approaches for selecting implementation interventions (including the underpinning theories and frameworks, tailoring to pre-identified barriers, stakeholder engagement, or co-design processes), characteristics of the intervention (target group, single versus multi-faceted, type, content, format, delivery mode, timing, and involved personnel), and impact of interventions. Guideline topics were categorized according to the ICD-11 for Mortality and Morbidity Statistics (ICD-11 MMS) version 02/2022 disease categories [ 38 ]. Theories and frameworks were grouped as per Nilsen’s literature review in Implementation Science [ 39 ]. Guideline implementation interventions were labeled according to the modified Mazza et al. taxonomy [ 40 ] that was expanded in the 2015 scoping review [ 27 ]. The taxonomy categorizes 51 interventions organized into five groups: professional, financial, organisational, structural changes, and regulatory [ 27 , 41 ]. We extracted outcomes as reported by the authors to understand the impact of the intervention employed on each study, where the impact referred to improvements on patient or healthcare professional cognitive (e.g., beliefs, knowledge), behavioral (e.g., prescribing, self-management), or clinical (e.g., physiological measures) outcomes. As noted above in Approach, one purpose of a scoping review is to describe literature on a given topic, and in so doing, identify whether a future systematic review involving complex statistical analyses is feasible. Therefore, we described impact according to three broad categories: positive impact—studies that achieved improvements in all outcomes reported; mixed impact—studies that achieved improvements in some but not all outcomes reported; and no impact—studies that did not achieve improvement in any reported outcomes. Included studies were not appraised for methodological quality or risk of bias as this is not customary for scoping reviews. However, we indirectly addressed study quality by assessing and reporting research design, use of models, theories or frameworks, and thoroughness by which interventions were described.

Data analysis included developing summary statistics and frequency counts. KS developed summary tables and SP used this information to do descriptive statistics in IBM SPSS statistics (version 28.0.1.0). To identify possible associations between implementation planning and impact/outcomes that could be evaluated in a future systematic review, we counted the number of studies that did or did not achieve improvement in reported outcomes.

Search results

The literature search resulted in 15,853 articles (Fig. 1 ). After removal of duplicates, 11,875 studies were not eligible and 384 were retrieved as potentially relevant. Of these, 208 articles were excluded by two additional reviewers because they did not meet the inclusion criteria. Of the 176 full-text articles acquired and screened, 58 were excluded due to a variety of reasons described in the PRISMA flow diagram, such as the absence of a formal guideline and the impact of the intervention not evaluated. As a result, 118 studies were eligible for review. Details of all included studies are available in supplementary file 4 , references [ 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 , 123 , 124 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 , 133 , 134 , 135 , 136 , 137 , 138 , 139 , 140 , 141 , 142 , 143 , 144 , 145 , 146 , 147 , 148 , 149 , 150 , 151 , 152 , 153 , 154 , 155 , 156 , 157 , 158 , 159 ].

PRISMA flow diagram of search results

Characteristics of included studies

The highest number of studies were conducted in the USA (44, 37.3%), followed by the Netherlands (12, 10.2%), Australia (11, 9.3%), the UK (8, 6.8%), and Canada (7, 5.9%). With respect to research design, most studies involved an RCT (39, 33.1%), (cross-sectional) pre- and post-design (31, 26.3%) or a cohort study (18, 15.3%). Regarding study objectives, the majority of the eligible studies were undertaken to promote compliance with existing guidelines for quality improvement (106, 89.8%). Twelve studies (10.2%) implemented a newly developed or updated guideline. The guidelines in the included studies addressed the following 16 clinical topics: Diseases of the circulatory system (25, 21.2%); neoplasms (12, 10.2%); endocrine, nutritional, or metabolic diseases (12, 10.2%); mental, behavioral, or neurodevelopmental disorders (9, 7.6%); diseases of the respiratory system (8, 6.8%); injury, poisoning, or certain other consequences of external causes (7, 5.9%); factors influencing health status or contact with health services (7, 5.9%); certain infectious or parasitic diseases (6, 5.1%); diseases of the musculoskeletal system or connective tissue (6, 5.1%); diseases of the genitourinary system (4, 3.4%); diseases of the nervous system (3, 2.5%); diseases of the digestive system (3, 2.5%); external causes of morbidity or mortality (2, 1.7%); diseases of the skin (1, 0.8%); pregnancy, childbirth, or the puerperium (1, 0.8%); and symptoms, signs, or clinical findings, not elsewhere classified (12, 10.2%).

Implementation planning approaches

Table 1 summarizes the number of studies that selected or tailored implementation interventions based on pre-identified barriers, the use of frameworks and/or employed stakeholder engagement.

Theories and frameworks

Of the 118 eligible studies, 25 (21.2%) of those employed a least one theory or framework, as described by Nilsen [ 39 ]. Seven studies (28%) used a “process model,” which can help to understand all specific steps involved in the process of translating research into practice. Ten studies (40%) employed a “determinant framework,” which can help to explore all barriers and enablers that influence implementation outcomes. Fifteen studies (60%) utilised a “classic theory,” which is a theory that originates from fields external to implementation science, such as psychology, but can be applied to provide understanding of aspects of implementation. Seven studies (28%) used an “implementation theory,” that has been developed by implementation researchers to help explore explanations of certain implementation aspects. Only one study (4%) employed an “evaluation framework,” which focuses on the evaluation of implementation outcomes. Of the 11 distinct theories and frameworks, most frequently used were the theoretical domains framework TDF (7, 28% of 25), to identify implementation barriers and enablers [ 48 , 68 , 70 , 74 , 85 , 105 , 132 ], and social cognitive theories (7, 28%), to provide understanding and explanation of aspects of implementation [ 61 , 62 , 86 , 93 , 114 , 135 , 155 ]. Seven (28% of 25) studies used more than one theory or framework. Besides the theories and frameworks as categorized by Nilsen [ 39 ], the Plan-Do-Study-Act (PDSA) cycle was used in 11 studies [ 42 , 45 , 51 , 55 , 65 , 90 , 94 , 103 , 114 , 140 , 143 ], the UK Medical Research Council framework for complex interventions [ 171 ] and a program logic model were both used in 1 study, respectively [ 93 ] and [ 118 ].

Pre-identified barriers and tailoring

Fifty-nine (50% of 118) studies identified one or more barriers. Most frequently, barriers were identified by the literature (33, 55.9% of 59), surveys (16, 27.1%), group discussions (11, 18.6%), and interviews (10, 16.9%). Twenty-three (39%) studies used more than one method to identify barriers. Seven (11.9%) studies identified barriers but did not specify how that was done. Of the 59 studies that pre-identified barriers, 38 (64.4% of 59) of those reported that they tailored their intervention to address the barriers. Of those, most did not report which method they used to map pre-identified barriers to implementation interventions, while 5 (13.2% of 38) studies referenced the Behaviour Change Wheel [ 170 ].

Stakeholder engagement

Stakeholder engagement was employed in 42 (35.6% of 118) studies. Most of the studies referred to co-designing components of their implementation interventions with professionals (33, 78.6% of 42). A smaller number of studies included engagement with patients (2, 4.8%) or with both professionals and patients (7, 16.7%). The majority of the stakeholder engagement sessions were based on group discussions (30, 71.4%). Ten studies (23.8%) did not specify the method that they used to engage stakeholders. In most studies, detailed information was lacking about the extent of stakeholder engagement and how the stakeholder engagement informed intervention selection or design. There were only 3 studies (7.1%) in which the intervention was entirely based on stakeholder engagement [ 84 , 131 , 150 ].

Various implementation planning approaches were used in complementary ways. Twelve of the included studies (10.2%) combined pre-identified barriers with tailoring of the intervention and stakeholder engagement [ 42 , 45 , 79 , 89 , 98 , 106 , 118 , 119 , 131 , 141 , 158 ]. Nine of the included studies (7.6%) employed a theory or framework, pre-identified barriers, and tailoring [ 48 , 56 , 62 , 67 , 68 , 70 , 86 , 114 , 134 ]. Eight studies entailed pre-identified barriers and stakeholder engagement [ 87 , 97 , 99 , 125 , 147 , 148 , 150 , 153 ]. One study included a theory or framework, pre-identified barriers, and stakeholder engagement [ 93 ], while another study incorporated a framework and stakeholder engagement [ 94 ]. Nine of the included studies (7.6%) used all implementation planning approaches in their study [ 52 , 58 , 85 , 103 , 105 , 132 , 137 , 151 , 152 ].

• Implementation interventions

Table 2 summarizes the implementation interventions used in included studies according to the modified Mazza et al. taxonomy [ 40 ]. The majority of the studies involved a multi-faceted (88, 74.6%) rather than a single (30, 25.4%) intervention. Multi-faceted interventions included a mean of 5 interventions (range 2 to 13). Overall, 40 of the 52 distinct interventions types were employed from the modified Mazza taxonomy of guideline implementation strategies. The most frequently used types of interventions were educating groups of professionals about guideline intent and benefits (52, 44.1%), information/communication technology (48, 40.7%), and providing feedback to professionals on compliance (40, 33.9%).

Impact on knowledge, behavior, and outcomes

The majority of studies (66, 55.9%) achieved positive impact, referring to improvements in all outcomes reported, and 31 (26.3%) studies achieved mixed impact, referring to improvement in some but not all outcomes reported. Overall, 97 (82.2%) studies achieved positive impact on one or more reported outcomes.

The most frequently reported impact was healthcare professionals’ behavior (e.g., medication prescribing) (60, 50.8%), see Table 3 . Twenty-nine studies (24.6%) targeted both patient/family and healthcare professional related outcomes.

The interventions did not report any iatrogenic effects or unintended consequences. Two studies reported negative effects on one of their secondary outcome measures [ 68 , 89 ].

Factors influencing impact

Implementation planning approaches and multi-faceted interventions do not appear to be possibly associated with positive impact (see Table 4 ), given that there is not a big difference in number of studies with overall positive impact versus mixed or no impact. Studied that used a theory or framework showed only slightly more frequently mixed or no change in study results (12.7%) in comparison to overall positive study impact (8.5%). The same can be said about pre-identified barriers, 26.3% of studies demonstrated mixed or no change, and 23.7% of studies had overall positive impact. The difference between overall positive study impact and mixed or no study impact is slightly bigger for tailoring intervention to pre-identified barriers (12.7 versus 19.5%). Stakeholder engagement revealed in about half of the studies overall positive impact (18.6 versus 16.9%). Single interventions seemed to lead more frequently to overall positive impact (17.8 versus 7.6%), while multi-faceted interventions revealed in about half of the studies overall positive impact (38.1 versus 36.4%).

This review included 118 studies published from 2014 to January 2021 that were largely conducted in high-income countries to improve compliance with existing guidelines or related outcomes across 16 broad disease categories. With respect to implementation planning approaches, 21% studies employed one or more of 11 distinct theories or frameworks, 50% pre-identified barriers using one or more approaches, and 36% reported engaging patients and/or professionals in planning processes. With respect to implementation interventions, a total of 40 intervention types were employed from among the 52 included in the modified Mazza taxonomy of guideline implementation strategies [ 40 ], most commonly educating professionals about guidelines (44%), information systems or technology (41%), and informing professionals of their compliance (34%). The majority of studies employed multi-faceted interventions (75%) with a range of 2 to 13 interventions. With respect to impact, 82% of studies achieved improvements in one or more reported outcomes, most often on professional behavior. Beneficial outcomes seemed to be achieved regardless of whether implementation planning was employed, the intervention was single versus multi-faceted, or type of intervention used. However, possible associations are not clear and a future systematic review is needed to more definitively establish that area.

In comparison with the first version of this review published in 2015 [ 27 ], this updated review included many more studies across a greater number of disease categories (32 studies in 2015 versus 118 in this review). The studies included in this review more often employed one or more implementation planning approaches compared with 19% that did so in our 2015 review [ 27 ]. Similar to the 2015 review, most studies in this review employed multi-faceted strategies. However, unlike the 2015 review in which most studies used educational meetings or material, studies in this review employed a broad range of types of interventions, and information technology and audit & feedback were nearly as common as educational interventions. Similar to the original review, this review found that most studies achieved positive impact, and this was not associated with the use of implementation planning approaches, type of intervention, or multi-faceted approaches.

Previous reviews on guideline implementation identified common implementation interventions or strategies, which included dissemination, education and training, social interaction, decision support systems, and standing orders [ 172 ]. A review by Chan et al. specifically focused on the impact of four types of interventions directed at professionals: reminders, educational outreach visits, audit & feedback and incentives, revealing largely positive impact achieved by educational outreach and audit & feedback, and mixed results for reminders and incentives [ 173 ]. In contrast to these studies, our review included many more studies and explored the full range of interventions or strategies that have been targeted to patients and/or healthcare professionals. Another added value of our review is that we included a variety of disease categories, while other reviews focused on strategies used to implement guidelines on specific topics, such as nursing guidelines [ 14 , 174 ]. Our review also included many more studies, namely 118, in comparison to other implementation-focused reviews, which included 41 to 69 studies [ 14 , 172 , 173 , 174 ].

Spoon et al. found in their systematic review that 43% of studies used barrier assessment to select and tailor interventions [ 174 ], which is in line with the 50% of included studies in our review. A systematic review by Cassidy et al. found that most studies combined educational meetings with educational materials, but did not assess how interventions were chosen or factors that influenced impact [ 14 ]. In contrast to previously published reviews, our review identified other factors thought to influence impact such as implementation planning approaches and multi-faceted interventions.

A notable finding of this review is that, compared to our 2015 review, more efforts to promote the use of guidelines are informed by implementation planning approaches including the use of theory or frameworks, pre-identification of barriers, and stakeholder engagement in implementation planning. This concurs with another scoping review that focused specifically on use of theory in guideline implementation planning, of 175 included studies, 47% employed theory, and of those, 76% used theory to inform surveys or interviews that identified barriers of guideline use as a preliminary step in implementation planning [ 12 ]. This could be attributed to the original Cochrane review that revealed the importance of tailoring interventions [ 175 ] and a worldwide trend in engaging stakeholders in both research and quality improvement [ 176 , 177 ]. This could also be attributed to decades of accumulated research on how to optimize guideline implementation, which has influenced the consciousness and practices of guideline implementers. Similarly, this review showed that the types of interventions employed have broadened beyond educational meetings and materials compared with our 2015 review. This is also likely a reflection of greater awareness of the need for implementation planning to select and tailor interventions that best match a given healthcare context [ 175 ], and knowledge of the fact that educational interventions generally have a small impact on professional behavior or outcomes [ 178 ]. Given that the vast majority of included studies achieved positive impact in one or more outcomes, this review reinforces the relevance and utility of these approaches for selecting and tailoring interventions, although publication bias could also be at play. Most implementation studies included in our review did not address the costs and economic impact of the interventions, which is an important consideration when informing policy planning decisions.

This review revealed, as have many other reviews [ 14 , 27 , 172 , 173 , 174 ], that most guideline implementers employed multi-faceted interventions. This continuing trend is remarkable because a 2014 meta-review by Squires et al. showed that single strategies were capable of achieving positive impact [ 26 ], as did our 2015 review [ 27 ] and this updated review. This belief may be perpetuated by reviews of studies that largely employed multi-faceted interventions, many of which achieved positive outcomes, and conclude that multi-faceted interventions are essential [ 179 ], and by the belief that interventions should address every barrier identified. However, outside of the context of funded research, most guideline developers possess few resources to implement guidelines, and the vast majority of guidelines are disseminated and not implemented, leading to low rates of compliance with guidelines, of which very few benefit from becoming the subject of implementation research. Thus, further research is needed to generate insight on how to prioritize barriers and corresponding interventions as a means of simplifying both implementation planning and implementation, ultimately making it easier and less costly for guideline implementers to promote uptake of their guidelines.

This review featured both strengths and limitations. With respect to strengths, we used rigorous scoping review methods including triplicate screening by international experts in guideline implementation and duplicate data extraction [ 31 , 32 , 33 , 34 , 37 ] and complied with reporting standards for scoping reviews [ 180 ] and for search strategies [ 37 ]. By including guidelines on any clinical topic, we expanded the breadth of the findings beyond our original 2015 scoping review [ 27 ] and reviews of guideline implementation by others [ 172 , 174 ]. We also included non-English language studies, those few were identified. With respect to limitations, as with most reviews, our search strategy may not have identified all relevant studies. Although we screened over 12,000 titles/abstracts, our eligibility criteria may have been overly stringent. Studies that achieved improvements in all reported study outcomes are not necessarily more meaningful than those studies that achieved improvements in only some, but not all, of the reported outcomes. We did not undertake complex statistical analyses to quantify study impact or identify determinants of the positive impact of interventions. However, this scoping review identified that sufficient literature is available to do so and we will undertake such analyses in a future systematic review. That systematic review will appraise the methodological quality of included studies, something not required of a scoping review. Additionally, given the lack of risk of bias assessment or a process to establish certainty in the synthesised results, the results of our analyses should be interpreted judiciously and be viewed as indicatory as opposed to confirmatory. The majority of studies were conducted in a few high-income countries so the findings may not be relevant to low- or middle-income countries.

This review of 118 studies found that more studies used processes to select and tailor interventions, and a wider array of types of interventions, in comparison to a similar review published in 2015. Given that most studies achieved impact, this might reinforce the need for implementation planning approaches, such as pre-identifying barriers, using theory or frameworks, tailoring interventions, and engaging stakeholders in co-design process. However, even studies that did not employ implementation planning approaches achieved impact. Similarly, both single versus multi-faceted interventions achieved impact. Thus, a future systematic review based on this data is warranted to establish if barrier identification, use of theory/frameworks, tailored interventions, stakeholder engagement, and multi-faceted interventions are associated with impact.

Availability of data and materials

All data is available in supplementary files.

Abbreviations

Systematic Reviews and Meta-Analyses Scoping Review

ICD-11 for Mortality and Morbidity Statistics

Theoretical domains framework

Plan Do Study Act

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Acknowledgements

Members of the Guidelines International Network reviewed this manuscript to further refine the interpretation of findings and enhance communication of the findings. The Guidelines International Network (GIN) is an international not-for-profit association of organizations and individuals involved in the development and use of clinical practice guidelines. GIN is a Scottish Charity, recognized under Scottish Charity Number SC034047. More information on the Network and its activities are available on its website: www.g-i-n.net . This paper/presentation reflects the views of its authors, and the Guidelines International Network is not liable for any use that may be made of the information contained therein.

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All authors (SP, KS, SB, AR, JM, PG, ES, MC, ZM, TK, LPR, EN, LK, SA, YSM, & AG) were involved in the design of the study. SP, SB, AR, JM, PG, ES, MC, ZM, and AG screened titles and abstracts. SP, KS, PG, TK, SB, JM, MC, ZM, EN, AR, LPR, ES, LK, and AG extracted data. SP and AG wrote the first draft of the manuscript and all authors approved the final version.

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Supplementary Information

Additional file 1..

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.

Additional file 2.

Eligibility criteria.

Additional file 3.

Search strategy.

Additional file 4. 

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Peters, S., Sukumar, K., Blanchard, S. et al. Trends in guideline implementation: an updated scoping review. Implementation Sci 17 , 50 (2022). https://doi.org/10.1186/s13012-022-01223-6

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Enhancing health and wellness by, for and with Indigenous youth in Canada: a scoping review

• Udoka Okpalauwaekwe 1 ,
• Clifford Ballantyne 2 ,
• Scott Tunison 3 &
• Vivian R. Ramsden 4  

BMC Public Health volume  22 , Article number:  1630 ( 2022 ) Cite this article

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Indigenous youth in Canada face profound health inequities which are shaped by the rippling effects of intergenerational trauma, caused by the historical and contemporary colonial policies that reinforce negative stereotypes regarding them. Moreover, wellness promotion strategies for these youth are replete with individualistic Western concepts that excludes avenues for them to access holistic practices grounded in their culture. Our scoping review explored strategies, approaches, and ways health and wellness can be enhanced by, for, and with Indigenous youth in Canada by identifying barriers/roadblocks and facilitators/strengths to enhancing wellness among Indigenous youth in Canada.

We applied a systematic approach to searching and critically reviewing peer-reviewed literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews [PRISMA-ScR] as a reporting guideline. Our search strategy focused on specific keywords and MeSH terms for three major areas: Indigenous youth, health, and Canada. We used these keywords, to systematically search the following electronic databases published in English between January 01, 2017, to May 22, 2021: Medline [Ovid], PubMed, ERIC, Web of Science, Scopus, and iportal. We also used hand-searching and snowballing methods to identify relevant articles. Data collected were analysed for contents and themes.

From an initial 1695 articles collated, 20 articles met inclusion criteria for this review. Key facilitators/strengths to enhancing health and wellness by, for, and with Indigenous youth that emerged from our review included: promoting culturally appropriate interventions to engage Indigenous youth; using strength-based approaches; reliance on the wisdom of community Elders; taking responsibility; and providing access to wellness supports. Key barriers/roadblocks included: lack of community support for wellness promotion activities among Indigenous youth; structural/organizational issues within Indigenous communities; discrimination and social exclusion; cultural illiteracy among youth; cultural discordance with mainstream health systems and services; and addictions and risky behaviours.

This scoping review extracted 20 relevant articles about ways to engage Indigenous youth in health and wellness enhancement. Our findings demonstrate the importance of promoting health by, and with Indigenous youth, by engaging them in activities reflexive of their cultural norms, rather than imposing control measures that are incompatible with their value systems.

Peer Review reports

Introduction

The term ‘Indigenous’ is internationally recognized to describe a distinct group of people that live within or are attached to geographically distinct ancestral territories [ 1 , 2 ]. In Canada, the term Indigenous is an inclusive term used to refer to the First Nations, Métis, and Inuit people, each of which has unique histories, cultural traditions, languages, and beliefs [ 3 , 4 , 5 ]. Indigenous peoples are the fastest-growing population in Canada, with a population estimated at 1.8 million, which is 5.1% of the Canadian population [ 6 , 7 ]. Within this population, 63% identify as First Nation, 33% as Métis, and 4% as Inuit [ 6 , 7 ]. Indigenous youth are the youngest population in Canada, with over 50% of Indigenous youth under 25 years [ 7 ]. Projections of Indigenous peoples in Canada have estimated a 33.3 to 78.7% increase in Indigenous populations, with the youth making up the largest proportion of the Indigenous population by 2041 [ 6 , 7 ].

Before European contact in North America, Indigenous peoples in Canada lived and thrived with their cultures, languages, and distinct ways of knowing [ 2 ]. However, Indigenous peoples in Canada rank lower in almost every health determinant when compared with non-Indigenous Canadians [ 8 , 9 , 10 ]. A report on health disparities in Saskatoon, Saskatchewan, described First Nations peoples to be “more likely to experience poor health outcomes in essentially every indicator possible” (page 27) [ 11 ]. This greater burden of ill health among Indigenous peoples in Canada has been attributed to systemic racism (associated with differences in power, resources, capacities, and opportunities) [ 9 , 10 , 12 , 13 ] and intergenerational trauma (stemming from the past and ongoing legacy of colonization such as experienced through the Indian residential and Day school systems, the Sixties Scoop, and the ongoing waves of Indigenous child and youth apprehensions seen in the foster and child care structures that remove Indigenous children from their family, community and traditional lands) [ 3 , 9 , 10 , 12 , 13 , 14 , 15 , 16 , 17 ]. These traumatic historical events, along with ongoing inequities, such as: socioeconomic and environmental dispossession; loss of language; disruption of ties to Indigenous families, community, land and cultural traditions; have been reported to exacerbate drastically and cumulatively the physical, mental, social and spiritual health of Indigenous peoples in Canada, creating “soul wounds” (3 p.208) that require interventions beyond the Westernized biomedical models of health and healing [ 3 , 9 , 10 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 ].

In the same way, Indigenous youth in Canada face some of the most profound health inequities when compared with non-Indigenous youth which can be further shaped by the rippling effects of intergenerational trauma caused by the historical and contemporary colonial policies that reinforce or legitimize negative stereotypes regarding Indigenous youth in Canada [ 2 , 10 , 14 , 20 , 22 , 23 , 24 , 25 , 26 , 27 ]. When compared with their non-Indigenous peers, Indigenous youth in Canada have been reported to be more likely to have higher rates of chronic conditions [e.g., diabetes, obesity, chronic respiratory diseases, heart diseases, etc.] [ 14 ], discrimination [ 28 , 29 ], youth incarceration and state care [ 12 , 20 , 30 ], poverty [ 31 ], homelessness [ 32 ], higher adverse mental health conditions [ 20 , 33 , 34 , 35 , 36 , 37 ], higher suicide rates [ 33 , 38 , 39 ], and lower overall life expectancies [ 24 , 40 , 41 , 42 ].

Indigenous peoples’ perception of health and wellness is shaped by their worldview and traditional knowledge [ 43 , 44 ]. While the Western concept of health broadly defines health as the state of complete physical, mental, social well-being, and not merely the absence of disease [ 45 ], Indigenous peoples understand health in a holistic way [ 26 ] that seeks balance between the physical, mental, emotional, and spiritual aspects of an Indigenous person in reciprocal relationships with their families, communities, the land, the environment, their ancestors, and future generations [ 46 , 47 , 48 ]. Unfortunately, this holistic concept of health and wellness opposes the individualistic and biomedically focused Western worldview of health, which is a dominant lens commonly used in health research, projects, and programs involving Indigenous communities [ 46 ]. This practice further perpetuates the legacy of colonization and excludes avenues for Indigenous communities to access holistic healing practices “grounded in their culture” [ 43 , 49 , 50 ]. For example, health research involving Indigenous peoples in Canada tends to focus on Indigenous health deficits and identified social determinants in the communities, more often and without proper representation [ 43 ]. Additionally, there is the imposition of research on rather than with youth [ 43 , 44 ]; and the failure to acknowledge Indigenous worldviews in research, to ensure in benefits them [ 43 ].

Authentically engaging with Indigenous youth has been cited by Indigenous scholars as one of the ways of achieving and enhancing wellness by, for, and with youth [ 51 , 52 ]. This is characterized by meaningful and sustained involvement of the youth in program planning, development, and decision-making to promote self-confidence and positive relationships [ 53 ]. Authentic engagement involves working with rather than on youth as research partners or program planning participants [ 54 ]. This shift to working with rather than on implies respect for the knowledge of the lived experiences of the youth involved [ 54 , 55 , 56 ] and is based on meaningful relationships built over time among all involved [ 53 , 57 , 58 ]. Research has shown that engaging youth (Indigenous or non-Indigenous) as partners in a project/program fosters a sense of belonging, self-determination, and self-actualization within their community; thus, enhancing community wellness [ 54 , 56 , 58 , 59 ].

This paper explores what is known in the peer-reviewed literature about strategies, approaches, and ways to engage Indigenous youth in health and wellness enhancement. Our main objective is to use information gathered from this review to inform youth engagement strategies, by considering the facilitators/strengths and barriers/roadblocks to enhancing wellness with Indigenous youth. We define facilitators in this context as factors that improve, enhance, strengthen, or motivate a journey to health, wellness, and self-determination. These are considered ‘strengths’ in the language of Indigenous peoples as they support equitable strength-based pathways towards reconciliation. Conversely, barriers are roadblocks, and demotivating factors or processes that limit and challenge Indigenous peoples’ access to achieving health and wellness. Our overarching research question was, in what ways can Indigenous youth enhance health and wellness for themselves, their family, and the Indigenous communities where they live?

Sub-questions included:

What factors do Indigenous youth in Canada identify as facilitators/strengths to enhancing health and wellness?

What factors do Indigenous youth in Canada identify as barriers/roadblocks to enhancing health and wellness?

Methodology and methods

Scoping reviews help provide an overview of the research available on a given area of interest where evidence is emerging [ 60 ]. While there are several accepted approaches to such reviews, this scoping review was undertaken using the Joanna Briggs Institute (JBI) Guideline for scoping reviews [ 61 ]. This approach was based on the Arksey and O’Malley methodological framework [ 62 ], which was further advanced by Levac et al. [ 60 ], and Peter et al. [ 61 ]. Our search strategy focused on primary sources that elucidated youth-driven, youth-led, or youth-engaged strategies carried out by, for, and with Indigenous youth to enhance health and wellness. We chose to explore all health programs and research inquiry that explore health challenges on the physical, mental, emotional, and spiritual aspects of an Indigenous person to encompass the definition of health and wellness as defined and understood from an Indigenous perspective. This scoping review is reported in accordance with the guidelines provided in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews (PRISMA-ScR) [ 63 ]. See Supplementary material file 1 for PRISMA-SCR checklist.

Protocol registration and reporting information

There was no pre-published or registered protocol before the commencement of this study.

Eligibility criteria

Types of studies.

A priori inclusion criteria for articles in this study included: 1] peer-reviewed journal articles reporting health and wellness programs, initiatives, and/or strategies among Indigenous youth in Canada, and 2] peer-reviewed journal articles published between January 01, 2017, to May 22, 2021. We chose a 5-year time frame to limit our findings to the most updated peer-reviewed literature which could provide implications for the growing body of work done in the field of Indigenous research among youth. Systematic reviews, meta-analyses, study protocols, opinion pieces, and narrative reviews were excluded.

Participants

Peer-reviewed studies involving Indigenous youth (First Nations, Métis, and Inuit) in Canada were eligible for inclusion. We considered the fluidity of definitions for youth by age range as literature sources generally defined youth in stages between adolescence to early adulthood [ 6 , 64 , 65 ]. In Canada, the Government of Canada uses several age brackets to identify youth depending on context, program, or policies in question. For example, Statistics Canada defines youth as between 15 to 29 years [ 6 ], Health Canada in the first State of Youth Report defined youth as between 12 to 30 years [ 65 ] when referring to statistical reports, and as between 13 to 36 years when referring to youth-led programs and policies [ 65 ]. However, for the purposes of this review we defined and referred to Indigenous youth or young people as between 10 to 24 years to be more representative of a broader definition of youth which is in keeping with Indigenous peoples’ worldviews, languages, and cultures and more representative of a broader definition of youth as offered by Sawyer et al. [ 64 ].

Information sources and search strategy

With the assistance of an Academic Reference Librarian, search terms were identified, which were categorized and combined into three conceptual MeSH terms that we adapted for the database-specific search strategy. These terms included: Indigenous youth (including synonyms and MeSH terms), health (including synonyms and MeSH terms) and Canada. Thus, studies were then identified for this scoping review by searching electronic databases and hand-searching reference lists of included articles.

Initially, the following databases (Medline (Ovid), PubMed, ERIC, Web of Science and Scopus) were used to identify relevant articles published between January 1, 2017, and April 30, 2021. This constituted our first search. We then carried out a second search (updated search) on May 22, 2021, using the same search queries on the same library databases; in addition, we included the University of Saskatchewan’s Indigenous Studies Portal (iPortal) [ 66 ] to ensure we had as many hits as possible for our search query on focused studies with Indigenous communities. To ensure exhaustiveness, we employed hand-searching techniques and snowballing methods to identify articles relevant to the research questions by reviewing reference lists of relevant articles that met the eligibility criteria. Following this, all the identified articles were collated in Endnote Reference Manager version X9.3 [ 67 ] and exported, after removing duplicates, into Distiller SR [ 68 ], a web-based systematic review and meta-analysis software. The syntax used on electronic databases and the University of Saskatchewan’s iPortal to identify potentially relevant articles for inclusion into this review study is outlined in Table  1 .

Selection of sources of evidence

Two iterative stages were employed to select sources of evidence for this review study. First, we created screening, coding, and data extraction forms using Distiller SR [ 68 ] for each stage. In the first stage, UO screened titles and abstracts of all articles using the following keywords: Indigenous youth; health; wellness; engagement and Canada. In the second stage, UO independently screened and reviewed the full-text articles (FTAs) of citations included from the first stage. The questions in Table  2 were used to screen the eligibility for inclusion of the article for data extraction. A second reviewer (ST) also independently reviewed and screened every 10th FTA citation from the first phase to check inter-rater reliability.

Data charting process and data items

Data were extracted using a pre-designed data extraction form on DistillerSR [ 68 ]. All extracted data were exported into Microsoft Excel [ 69 ] for data cleaning and analysis. The title fields used to extract data from included articles are shown in Table  3 .

Critical appraisal of individual sources of evidence

Conjointly, UO and CB appraised each article included considering characteristics and methodological quality using the JBI Critical Appraisal Tool for qualitative and quantitative studies [ 70 ]. The JBI Critical Appraisal Tool was designed to evaluate the rigour, trustworthiness, relevance, and potential for bias in study designs, conduct, and analysis [ 70 ]. Results on the critical appraisals are summarized in Supplementary material file  2 .

Synthesis of results

We categorized findings in this review as facilitators/strengths and barriers/roadblocks to enhancing wellness by, for, and with Indigenous youth, further describing how youth described wellness promotion. We met weekly via videoconference to discuss, review, and revisit our study evaluation protocol to ensure we adhered strictly to the scoping review guidelines.

As a result of our literature search, 1671 articles from five library databases and 24 articles through hand-search and snowball methods were identified. Of the 1695 articles, 253 were excluded as duplicates on EndNote vX9.3 using the ‘remove duplicates’ function on the software. Another 1227 articles were excluded following screening of title and abstracts on Distiller SR which we had fed with a series of screening questions (see Table 2 ) that were reviewed independently by two reviewers (UO and ST). Inter-rater reliability (Cohen’s kappa) calculated was 0.886, standard error = 0.147, p -value = 0.001. Where there were conflicts in article inclusion ratings, a third reviewer (CB), was brought in to discuss and provide a resolution. This left 215 articles for full-text article (FTA) screening. After reviewing 215 FTAs, a further 195 articles were excluded, leaving 20 articles for inclusion into the final review. Articles were excluded in the eligibility stage for the following reasons, 1) articles not focused on Indigenous youth or Indigenous communities, 2) articles not focused on Indigenous health and/or wellness, 3) articles not primarily focused in Canadian settings, 4) articles not written in English, 5) articles considered irrelevant or not applicable to addressing the research objectives or research questions of our study, 6) articles other than original research (i.e., we excluded review studies, opinion papers, and conference abstracts). A flowchart of article selection can be found in Fig.  1 .

PRISMA flowchart showing selection of articles for scoping review

Characteristics of sources of evidence

The general and methodological characteristics of all 20 included articles are summarized in Table  4 . Of these, one study was published in 2017, two in 2018, eleven in 2019, four in 2020 and two in 2021. Five (25%) studies that were included were set in the province of Ontario, four (20%) in the province of Saskatchewan, three (15%) in the Northwest Territories and two in the province of Alberta. Fifty percent (10/20) of the studies recruited or focused on Indigenous (First Nations, Métis, and Inuit) people as study participants, seven (35%) studies recruited or concentrated on First Nations peoples only, and three (15%), on Inuit peoples only. Sixteen (80%) articles were qualitative studies, three (15%) used mixed methods, and one (5%) was a quantitative study. Eleven (55%) studies used participatory research approaches (which included photovoice, community-based participatory research (CBPR) or participatory action research (PAR)) in their study designs, seven (35%) integrated Indigenous research methods (e.g., the two-eyed seeing approach) into their study design, and five (25%) studies used descriptive or inferential evaluation strategies in their study design. Interviews, focus-group discussions, and discussion circles were the most common data collection methodology used in 17 (85%) of the studies included. Youth were commonly engaged in non-cultural activities in twelve (60%) of the studies and employed a youth-adult co-led strategy in 16 (80%) of the included studies.

Results of individual sources of evidence

All included studies provided answers relevant to one or more of the research questions with the potential for changing practice and strategies for engagement. All the included studies explored, investigated, or evaluated issues addressing health and wellness among Indigenous youth in Canada. The age range of youth involved in included studies ranged between 11 to 24 years. All studies utilized fun and interactive strategies to engage youth in their respective studies with the outcomes aimed at promoting health, developing capacity in youth participants and engaging youth in collaborating on sustainable outcomes for and with their communities [ 5 , 8 , 40 , 44 , 57 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 ], save for one [ 16 ]. The summary of individual sources of evidence is described in Table  5 .

The key facilitators/strengths and barriers/roadblocks to enhancing health and wellness by, for, and with Indigenous youth that emerged from the included studies are described in Table  6 , in descending order of major themes for the frequency of citation by included articles per theme. The facilitators/strengths and barriers/roadblocks have also been categorized into sub-themes under five major themes for facilitators/strengths and six major themes for barriers/roadblocks. Health outcomes/programs examined by included studies included suicide prevention [ 40 ], mental health promotion [ 71 , 74 ], HIV prevention [ 75 ], wellness promotion through youth empowerment and cultural activism [5, 8, 16, 57, 72,,76, 77, 78,79, 80], social health [ 76 , 83 ], land-based healing and wellness [ 77 , 82 ], art-media based therapy and wellness [ 44 , 73 , 81 , 84 ]. An overview of the facilitators/strengths and barriers/roadblocks to enhancing health and wellness by, for, and with Indigenous youth is presented in Fig.  2 .

Summary of facilitators/strengths and barriers/roadblocks to enhancing wellness by, for and with Indigenous youth

Facilitators/strengths to enhancing health and wellness by, for, and with indigenous youth

Five major themes emerged and were identified as facilitators/strengths to enhancing health and wellness by, for, and with Indigenous youth in Canada. The most identified facilitator/strength of health and wellness among Indigenous youth in Canada, identified in 19 [95%] of the included studies, was the promotion of strength-based approaches to engaging with youth in the community [ 5 , 8 , 16 , 44 , 57 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 ]. A number of sub-themes also emerged from this major theme to include: peer-mentoring [ 5 , 8 , 44 , 57 , 71 , 73 , 74 , 75 , 76 , 79 , 80 , 81 , 82 , 83 , 84 ]; engaging youth in programs that developed and promoted self-determination, capacity building and empowerment [ 5 , 8 , 44 , 57 , 72 , 73 , 74 , 76 , 77 , 78 , 79 , 80 , 82 , 83 , 84 ]; building positive relationships and social connections with others, nature and the environment [ 5 , 8 , 44 , 57 , 72 , 73 , 76 , 77 , 79 , 80 , 81 , 82 , 83 , 84 ]; showing kindness to one another [ 5 , 16 , 44 , 57 , 77 , 79 , 80 , 81 , 83 ]; and engaging youth in cultural activities [ 57 , 76 , 82 , 83 ] that stimulate or encourage mutual learning, enhance critical consciousness and cause transformative change [ 5 , 8 , 75 , 76 , 79 , 81 ]. The next most common facilitator identified in 16 [80%] of included studies was enhancing cultural identity and connectedness through youth engagement in cultural activities [ 8 , 16 , 40 , 44 , 57 , 71 , 72 , 75 , 76 , 77 , 79 , 80 , 81 , 82 , 83 , 84 ]. Other facilitators included: reliance on the wisdom, skills, and teachings of community Elders, Traditional Knowledge Keepers and community leaders in the pursuit of health and wellness promotion with Indigenous youth [ 5 , 16 , 44 , 72 , 77 , 79 , 80 , 81 , 83 , 84 ]; taking responsibility for one’s journey to wellness [ 44 , 57 , 72 , 74 , 79 , 80 , 82 , 83 ]; and providing access to health services and other wellness supports (including traditional health services) for youth in Indigenous communities [ 76 , 78 ]. A summary of the facilitators/strengths is provided in Fig. 2 .

Barriers/roadblocks to enhancing health and wellness by, for, and with indigenous youth

Six major themes emerged and identified as barriers/roadblocks to enhancing health and wellness by, for and with Indigenous youth in Canada. The most identified barrier/roadblock to enhancing health and wellness identified in 55% (11/20) of the included articles was a lack of community support [including social, financial, and organizational support] for wellness promotion strategies among Indigenous youth [ 5 , 44 , 57 , 72 , 74 , 75 , 76 , 77 , 78 , 80 , 81 ]. Structural and organizational issues within Indigenous communities regarding wellness promotion strategies were identified as the second most common barrier/roadblock to enhancing wellness in 50% [10/20] of included studies [ 5 , 8 , 72 , 73 , 76 , 77 , 78 , 81 , 82 , 83 ]. These structural and organizational issues included: Indigenous community problems or concerns affecting the sustainability of instituted wellness programs/strategies [ 5 , 8 , 78 , 81 ]; dogmatism and debates about definitions regarding traditions of health among Indigenous communities [ 72 , 77 , 82 , 83 ]; social and structural instability within communities (e.g., leadership concerns) [ 8 , 76 , 83 ]; modest to low capacity of service providers (e.g. vendors, health service centers, social service centers, etc.) to meet the demands of communities [ 73 , 78 , 81 ]; and the misperception of a lack of control for self-governance in Indigenous communities [ 81 ]. Discrimination and social exclusion of Indigenous youth were also identified as a barrier/roadblock to enhancing wellness in eight (40%) studies included [ 5 , 8 , 44 , 57 , 74 , 76 , 80 , 83 ]. Forms of discrimination and social exclusion identified as subthemes included: Racism (e.g., personal, interpersonal, structural and systemic racism) [ 5 , 8 , 76 , 80 , 83 ]; low self-esteem and a low view of self-identity leading to self-deprecation and self-exclusion from engaging in youth activities [ 8 , 44 , 76 , 80 , 83 ]; mental health stigmatization [ 73 , 74 , 76 ]; lack of inclusivity of traditional Indigenous activities into Canadian teaching institutions [ 76 , 77 ]; and all forms of bullying, abuse and hunger [ 57 , 80 ]. Other barriers/roadblocks included: cultural illiteracy among Indigenous youth [ 44 , 57 , 73 , 74 , 75 , 83 , 84 ]; friction between Western and Traditional methods of promoting health and wellness [ 5 , 74 , 76 , 77 ]; and risky behaviours such as gang activity, substance use/abuse and addictions [ 44 , 57 , 75 , 76 , 80 ]. A summary of the barriers/roadblocks is provided in Fig. 2 .

Scoping reviews determine the extent, range, and quality of evidence on any chosen topic [ 60 , 61 , 62 , 63 ]. In addition, they can be used to map and describe what is known about an identified topic to identify existing gaps in the literature regarding the chosen topic [ 60 , 61 , 62 , 63 ]. In this scoping review, the peer-reviewed evidence regarding facilitators/strengths and barriers/roadblocks to enhancing health and wellness by, for and with Indigenous youth in Canada were mapped and synthesized. Key facilitators/strengths highlighted included: promoting culturally appropriate interventions [ 8 , 16 , 40 , 44 , 57 , 71 , 72 , 75 , 76 , 77 , 79 , 80 , 81 , 82 , 83 , 84 ] using strength-based approaches [ 5 , 8 , 16 , 44 , 57 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 ]. Key barriers to enhancing health and wellness by, for and with Indigenous youth identified in this review were the lack of community support for wellness promotion activities among Indigenous youth [ 5 , 44 , 57 , 72 , 74 , 75 , 76 , 77 , 78 , 80 , 81 ] and structural/organizational issues within Indigenous communities [ 5 , 8 , 72 , 73 , 76 , 77 , 78 , 81 , 82 , 83 ].

Strength-based approaches empower community members, academic researchers, and policymakers to effect community change while focusing on what has worked in the past and the community vision for success in the future [ 79 ]. This is contrasted with the common narrative in most studies exploring Indigenous health and wellness that focused on why and where the community has failed to thrive [ 79 ]. Promoting strength-based interventions by, for, and with Indigenous youth works in parallel with ensuring that health interventions are culturally appropriate [ 44 , 79 ] because Indigenous epistemologies or ways of knowing see reality as intricate processes of interdependent relationships between humans, nature, and the spirit world [ 44 , 77 ]. As such, wellness promotion in Indigenous communities should emphasize support for their traditional values such as respect, trust, non-judgement, and relationality, all of which support cultural revitalization [ 26 , 71 ].

Conversely, wellness promotion in Indigenous communities should disavow the use of Western-based epistemologies that embrace and emphasize control over risk factors and health [ 44 , 79 ]. The definition and perception of health and wellness by Indigenous peoples are starkly different from the Western perspective of health promotion [ 44 , 79 ] which was found in our study to be a barrier/roadblock to enhancing health and wellness by, for and with Indigenous youth [ 8 , 43 , 44 , 76 ]. Because of these contrasting and conflicting views on health and wellness, research carried out with Indigenous communities must be grounded in their culture. Elder Jim Dumont – a professor of Native Studies and a member of the Shawanaga First Nation on Eastern Georgian Bay, when describing the role of Indigenous culture in facilitating wellness among Indigenous peoples, defined Indigenous culture as a “ facilitator to spiritual expression” [ 85 p.11]. He described Indigenous culture as “an expression of the life-ways, the spiritual, psychological, social, and material practice of the Indigenous worldview, which attends to the whole person’s spiritual desire to live life to the fullest” [ 85 p.9]. This was the way of life for Indigenous peoples before colonization [ 2 ]. Back then, Indigenous peoples honoured and utilized traditional methods and practices connected to their respective unceded homelands to promote and sustain health and wellness by themselves within their respective communities [ 2 , 16 , 86 ]. These cultural practices provided and promoted health and wellness for the community, the peoples, the lands, and the environment [ 2 ].

Furthermore, Indigenous wellness promotion by, for and with Indigenous youth should go beyond making mainstream health promotion strategies more culturally appropriate. Indigenous wellness promotion should also invite youth as partners and co-researchers to authentically engage with the community, acknowledging their needs while working together with them to identify opportunities for change (which should include shared power and responsibilities in the relationship dynamic). This must be the fundamental principle for any work done by, for, or with Indigenous communities (i.e., authentic engagement) [ 54 , 55 , 59 ]. Authentic engagement is working and walking with rather than on communities [ 54 ] in a way that encourages respectful, compassionate, and genuine interest in the work undertaken by all partners involved [ 54 , 55 , 57 , 87 , 88 ]. In authentically engaging with Indigenous communities, emphasis should be placed on connecting with , rather than controlling, community members [ 44 , 89 ]. By doing so, enhances a community’s ability to answer their issues by identifying their community strengths and assets, considering opportunities for change, and co-creating meaningful solutions to mitigate them.

The Tri-Council Policy Statement (TCPS) on Ethical Conduct for Research involving Humans indicates in Chapter 9 that, where research involves First Nations, Métis, and Inuit peoples and their communities, they are to have a role in shaping and co-creating research that affects them; with respect being given to the autonomy of these communities and the individuals within them to decide to participate [ 90 ]. Our study showed that where youth were engaged as partners and co-researchers, promoted self-determination, capacity building and ultimately enhanced wellness [ 8 , 40 , 44 , 57 , 72 , 74 , 75 , 76 , 77 , 79 , 84 ].

From the outcomes of this review, youth were engaged as partners or co-researcher in 55% of the included articles using research approaches such as community-based participatory research [CBPR], photovoice, visual voice, participatory videography, performative arts, participatory narrative, and storytelling methods [ 8 , 40 , 44 , 57 , 72 , 74 , 75 , 76 , 77 , 79 , 84 ]. This review demonstrated that these methods helped foster an environment for transformative learning, reciprocal transfer of expertise, shared decision-making, and co-ownership of the research processes [ 8 , 40 , 44 , 57 , 72 , 74 , 75 , 76 , 77 , 79 , 84 ]. For example, Goodman et al. identified that through photovoice, youth identified how racism negatively influenced the types of social supports and relationships formed in their community, leading to improved access to mental health-promoting social programs [ 76 ]. Anang et al. reported that engaging Indigenous youth as co-researchers in exploring ways to promote suicide prevention revitalized awareness of their cultural identity, which was identified as a protective factor to youth suicide [ 40 ]. A group of First Nation girls involved in the Girl Power Program designed to build and foster empowerment using youth participatory action research approach indicated that working as co-researchers/co-creators in the program empowered them to find healing from wounded spirits, which helped enhance positive changes towards wellness through āhkamēyimowin (perseverance) [ 57 ]. Thus, we can conclude from our study that engaging youth as partners in research processes optimizes their personal experiences and gives them a voice which can stimulate action.

Engaging Indigenous youth in the co-creation of wellness strategies should also involve community Elders, Traditional Knowledge Keepers, and other Indigenous community leaders. This review demonstrated that reliance on the wisdom of Elders, Traditional Knowledge Keepers and Indigenous community leaders facilitated and enhanced wellness among Indigenous youth [ 5 , 16 , 44 , 72 , 77 , 79 , 80 , 81 , 83 , 84 , 91 ]. Elders, Traditional Knowledge Keepers, and Indigenous community leaders play a central role in increasing awareness related to the community’s histories, languages, knowledge, and ways of knowing [ 91 , 92 ]. For non-Indigenous researchers and allies, Elders and Traditional Knowledge Keepers can provide formal and informal teachings on: histories of the Indigenous community in question, their world views, languages in the community, arts, crafts and songs, value systems in the nation/community; knowledge of traditional plants and medicines; clan teachings in the nation/community; ceremonial knowledge or protocols; and understanding of wellness in the community that can increase cultural awareness and build Indigenous research competencies for non-Indigenous researchers and allies [ 91 , 92 , 93 ]. Hence, engaging Elders, Knowledge Keepers and Indigenous community leaders in youth wellness programs can provide an avenue for mutual learning, guiding non-Indigenous researchers/allies towards cultural appropriateness in co-developing youth-driven wellness strategies.

Practical implications

Overall, this review emphasized the importance of promoting wellness among Indigenous youth using ‘ culture as strength ’ rather than imposing control measures on Indigenous values. The historical experiences of Indigenous youth have revealed traumatic and distressful pasts propagated by the cumulative intergenerational impacts of colonization which evolved from Residential Schools, Day Schools, and the Sixties Scoop [ 15 , 16 , 33 , 94 , 95 ]. The 2015 Truth and Reconciliation Commission of Canada’s 96 Calls-to-Action stressed the need to decolonize mainstream health promotion strategies and embrace the promotion of self-determination in the use of and access to traditional knowledge, therapies, and healing practices Indigenous peoples [ 95 , 96 ]. This review provided a foundation for authentically engaging Indigenous youth in the co-creation of culturally appropriate wellness promotion strategies/programs driven and sustained by authentically engaged Indigenous youth in the community. Considering the number of qualitative studies we found in our review, a meta-synthesis of qualitative studies may guide future directions based on the findings in our study to further pursue to understand, appraise, summarize, and combine qualitative evidence to address the specific research questions particularly around the influences and experiences of cultural connectedness and wellness among Indigenous youth in Canada. Nonetheless, this review also contributes to the growing literature identifying strength-based approaches to enhancing health and wellness among Indigenous peoples in Canada.

Study limitations

This review aimed to provide an entire scope of all original studies published in peer-reviewed journals to allow for as broad a scope of literature synthesis as possible. However, this study is not without limitations. First, the search was limited to multiple library databases, including the University of Saskatchewan’s Indigenous Studies Portal (iPortal) [ 66 ]. Although this review produced many peer-reviewed and original studies, there is a potential that other relevant articles and reports were missed because we did not search the grey literature. Secondly, because this review was limited to peer-reviewed articles published in English, it is possible that potentially relevant studies in other languages were omitted. Moreover, the outcomes of this review are limited to the nature of the data reported in the articles included in the review. Additionally, we acknowledge the differences and nuances in Indigenous practices, values and culture which limits the generalizability of our review findings. Lastly, some of the studies in the scoping review utilized Indigenous study designs and methods that could not be appropriately evaluated using the JBI Critical Appraisal Tools [ 70 ].

This scoping review identified ways health and wellness can be enhanced by, for, and with Indigenous youth by identifying facilitators/strengths and barriers/roadblocks to enhancing health and wellness among Indigenous youth from identified studies published between January 1, 2017, and May 22, 2021. The outcomes of this review showed that promoting culturally based and appropriate interventions using strength-based approaches were key facilitators/strengths to enhancing health and wellness among Indigenous youth. Thus, the outcomes demonstrate the continued need to promote programs grounded in culture as a part of enhancing health and wellness while authentically engaging Indigenous youth in health and wellness strategies, interventions, and programs.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Abbreviations

Community-based participatory research

First Nations

Full-Text Articles

University of Saskatchewan’s Indigenous Studies Portal

Joanna Briggs Institute

Medical Subject Headings

Participatory action research

Preferred Reporting Items for Systematic Reviews and Meta Analyses

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews

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Acknowledgements

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Funding provided by the Saskatchewan Health Research Foundation (SHRF) and the Canadian Institute of Health Research (CIHR)/Saskatchewan Center for Patient-Oriented Research (SCPOR) as part of the SHRF Leader Award held by Dr. Ramsden.

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University of Saskatchewan, Saskatoon, Saskatchewan, S7N 0X1, Canada

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Okpalauwaekwe, U., Ballantyne, C., Tunison, S. et al. Enhancing health and wellness by, for and with Indigenous youth in Canada: a scoping review. BMC Public Health 22 , 1630 (2022). https://doi.org/10.1186/s12889-022-14047-2

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• v.8(3); 2016 Jul

The Literature Review: A Foundation for High-Quality Medical Education Research

a  These are subscription resources. Researchers should check with their librarian to determine their access rights.

Despite a surge in published scholarship in medical education 1 and rapid growth in journals that publish educational research, manuscript acceptance rates continue to fall. 2 Failure to conduct a thorough, accurate, and up-to-date literature review identifying an important problem and placing the study in context is consistently identified as one of the top reasons for rejection. 3 , 4 The purpose of this editorial is to provide a road map and practical recommendations for planning a literature review. By understanding the goals of a literature review and following a few basic processes, authors can enhance both the quality of their educational research and the likelihood of publication in the Journal of Graduate Medical Education ( JGME ) and in other journals.

The Literature Review Defined

In medical education, no organization has articulated a formal definition of a literature review for a research paper; thus, a literature review can take a number of forms. Depending on the type of article, target journal, and specific topic, these forms will vary in methodology, rigor, and depth. Several organizations have published guidelines for conducting an intensive literature search intended for formal systematic reviews, both broadly (eg, PRISMA) 5 and within medical education, 6 and there are excellent commentaries to guide authors of systematic reviews. 7 , 8

• A literature review forms the basis for high-quality medical education research and helps maximize relevance, originality, generalizability, and impact.
• A literature review provides context, informs methodology, maximizes innovation, avoids duplicative research, and ensures that professional standards are met.
• Literature reviews take time, are iterative, and should continue throughout the research process.
• Researchers should maximize the use of human resources (librarians, colleagues), search tools (databases/search engines), and existing literature (related articles).
• Keeping organized is critical.

Such work is outside the scope of this article, which focuses on literature reviews to inform reports of original medical education research. We define such a literature review as a synthetic review and summary of what is known and unknown regarding the topic of a scholarly body of work, including the current work's place within the existing knowledge . While this type of literature review may not require the intensive search processes mandated by systematic reviews, it merits a thoughtful and rigorous approach.

Purpose and Importance of the Literature Review

An understanding of the current literature is critical for all phases of a research study. Lingard 9 recently invoked the “journal-as-conversation” metaphor as a way of understanding how one's research fits into the larger medical education conversation. As she described it: “Imagine yourself joining a conversation at a social event. After you hang about eavesdropping to get the drift of what's being said (the conversational equivalent of the literature review), you join the conversation with a contribution that signals your shared interest in the topic, your knowledge of what's already been said, and your intention.” 9

The literature review helps any researcher “join the conversation” by providing context, informing methodology, identifying innovation, minimizing duplicative research, and ensuring that professional standards are met. Understanding the current literature also promotes scholarship, as proposed by Boyer, 10 by contributing to 5 of the 6 standards by which scholarly work should be evaluated. 11 Specifically, the review helps the researcher (1) articulate clear goals, (2) show evidence of adequate preparation, (3) select appropriate methods, (4) communicate relevant results, and (5) engage in reflective critique.

Failure to conduct a high-quality literature review is associated with several problems identified in the medical education literature, including studies that are repetitive, not grounded in theory, methodologically weak, and fail to expand knowledge beyond a single setting. 12 Indeed, medical education scholars complain that many studies repeat work already published and contribute little new knowledge—a likely cause of which is failure to conduct a proper literature review. 3 , 4

Likewise, studies that lack theoretical grounding or a conceptual framework make study design and interpretation difficult. 13 When theory is used in medical education studies, it is often invoked at a superficial level. As Norman 14 noted, when theory is used appropriately, it helps articulate variables that might be linked together and why, and it allows the researcher to make hypotheses and define a study's context and scope. Ultimately, a proper literature review is a first critical step toward identifying relevant conceptual frameworks.

Another problem is that many medical education studies are methodologically weak. 12 Good research requires trained investigators who can articulate relevant research questions, operationally define variables of interest, and choose the best method for specific research questions. Conducting a proper literature review helps both novice and experienced researchers select rigorous research methodologies.

Finally, many studies in medical education are “one-offs,” that is, single studies undertaken because the opportunity presented itself locally. Such studies frequently are not oriented toward progressive knowledge building and generalization to other settings. A firm grasp of the literature can encourage a programmatic approach to research.

Approaching the Literature Review

Considering these issues, journals have a responsibility to demand from authors a thoughtful synthesis of their study's position within the field, and it is the authors' responsibility to provide such a synthesis, based on a literature review. The aforementioned purposes of the literature review mandate that the review occurs throughout all phases of a study, from conception and design, to implementation and analysis, to manuscript preparation and submission.

Planning the literature review requires understanding of journal requirements, which vary greatly by journal ( table 1 ). Authors are advised to take note of common problems with reporting results of the literature review. Table 2 lists the most common problems that we have encountered as authors, reviewers, and editors.

Sample of Journals' Author Instructions for Literature Reviews Conducted as Part of Original Research Article a

Common Problem Areas for Reporting Literature Reviews in the Context of Scholarly Articles

Locating and Organizing the Literature

Three resources may facilitate identifying relevant literature: human resources, search tools, and related literature. As the process requires time, it is important to begin searching for literature early in the process (ie, the study design phase). Identifying and understanding relevant studies will increase the likelihood of designing a relevant, adaptable, generalizable, and novel study that is based on educational or learning theory and can maximize impact.

Human Resources

A medical librarian can help translate research interests into an effective search strategy, familiarize researchers with available information resources, provide information on organizing information, and introduce strategies for keeping current with emerging research. Often, librarians are also aware of research across their institutions and may be able to connect researchers with similar interests. Reaching out to colleagues for suggestions may help researchers quickly locate resources that would not otherwise be on their radar.

During this process, researchers will likely identify other researchers writing on aspects of their topic. Researchers should consider searching for the publications of these relevant researchers (see table 3 for search strategies). Additionally, institutional websites may include curriculum vitae of such relevant faculty with access to their entire publication record, including difficult to locate publications, such as book chapters, dissertations, and technical reports.

Strategies for Finding Related Researcher Publications in Databases and Search Engines

Search Tools and Related Literature

Researchers will locate the majority of needed information using databases and search engines. Excellent resources are available to guide researchers in the mechanics of literature searches. 15 , 16

Because medical education research draws on a variety of disciplines, researchers should include search tools with coverage beyond medicine (eg, psychology, nursing, education, and anthropology) and that cover several publication types, such as reports, standards, conference abstracts, and book chapters (see the box for several information resources). Many search tools include options for viewing citations of selected articles. Examining cited references provides additional articles for review and a sense of the influence of the selected article on its field.

Box Information Resources

• Web of Science a
• Education Resource Information Center (ERIC)
• Cumulative Index of Nursing & Allied Health (CINAHL) a
• Google Scholar

Once relevant articles are located, it is useful to mine those articles for additional citations. One strategy is to examine references of key articles, especially review articles, for relevant citations.

Getting Organized

As the aforementioned resources will likely provide a tremendous amount of information, organization is crucial. Researchers should determine which details are most important to their study (eg, participants, setting, methods, and outcomes) and generate a strategy for keeping those details organized and accessible. Increasingly, researchers utilize digital tools, such as Evernote, to capture such information, which enables accessibility across digital workspaces and search capabilities. Use of citation managers can also be helpful as they store citations and, in some cases, can generate bibliographies ( table 4 ).

Citation Managers

Knowing When to Say When

Researchers often ask how to know when they have located enough citations. Unfortunately, there is no magic or ideal number of citations to collect. One strategy for checking coverage of the literature is to inspect references of relevant articles. As researchers review references they will start noticing a repetition of the same articles with few new articles appearing. This can indicate that the researcher has covered the literature base on a particular topic.

Putting It All Together

In preparing to write a research paper, it is important to consider which citations to include and how they will inform the introduction and discussion sections. The “Instructions to Authors” for the targeted journal will often provide guidance on structuring the literature review (or introduction) and the number of total citations permitted for each article category. Reviewing articles of similar type published in the targeted journal can also provide guidance regarding structure and average lengths of the introduction and discussion sections.

When selecting references for the introduction consider those that illustrate core background theoretical and methodological concepts, as well as recent relevant studies. The introduction should be brief and present references not as a laundry list or narrative of available literature, but rather as a synthesized summary to provide context for the current study and to identify the gap in the literature that the study intends to fill. For the discussion, citations should be thoughtfully selected to compare and contrast the present study's findings with the current literature and to indicate how the present study moves the field forward.

To facilitate writing a literature review, journals are increasingly providing helpful features to guide authors. For example, the resources available through JGME include several articles on writing. 17 The journal Perspectives on Medical Education recently launched “The Writer's Craft,” which is intended to help medical educators improve their writing. Additionally, many institutions have writing centers that provide web-based materials on writing a literature review, and some even have writing coaches.

The literature review is a vital part of medical education research and should occur throughout the research process to help researchers design a strong study and effectively communicate study results and importance. To achieve these goals, researchers are advised to plan and execute the literature review carefully. The guidance in this editorial provides considerations and recommendations that may improve the quality of literature reviews.

• Open access
• Published: 24 August 2022

Identifying and understanding benefits associated with return-on-investment from large-scale healthcare Quality Improvement programmes: an integrative systematic literature review

• S’thembile Thusini 1 ,
• Maria Milenova 1 ,
• Noushig Nahabedian 2 ,
• Barbara Grey 2 ,
• Tayana Soukup 1 &
• Claire Henderson 1  

BMC Health Services Research volume  22 , Article number:  1083 ( 2022 ) Cite this article

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We previously developed a Quality Improvement (QI) Return-on-Investment (ROI) conceptual framework for large-scale healthcare QI programmes. We defined ROI as any monetary or non-monetary value or benefit derived from QI. We called the framework the QI-ROI conceptual framework. The current study describes the different categories of benefits covered by this framework and explores the relationships between these benefits.

We searched Medline, Embase, Global health, PsycInfo, EconLit, NHS EED, Web of Science, Google Scholar, organisational journals, and citations, using ROI or returns-on-investment concepts (e.g., cost–benefit, cost-effectiveness, value) combined with healthcare and QI. Our analysis was informed by Complexity Theory in view of the complexity of large QI programmes. We used Framework analysis to analyse the data using a preliminary ROI conceptual framework that was based on organisational obligations towards its stakeholders. Included articles discussed at least three organisational benefits towards these obligations, with at least one financial or patient benefit. We synthesized the different QI benefits discussed.

We retrieved 10 428 articles. One hundred and two (102) articles were selected for full text screening. Of these 34 were excluded and 68 included. Included articles were QI economic, effectiveness, process, and impact evaluations as well as conceptual literature. Based on these literatures, we reviewed and updated our QI-ROI conceptual framework from our first study. Our QI-ROI conceptual framework consists of four categories: 1) organisational performance, 2) organisational development, 3) external outcomes, and 4) unintended outcomes (positive and negative). We found that QI benefits are interlinked, and that ROI in large-scale QI is not merely an end-outcome; there are earlier benefits that matter to organisations that contribute to overall ROI. Organisations also found positive aspects of negative unintended consequences, such as learning from failed QI.

Discussion and conclusion

Our analysis indicated that the QI-ROI conceptual framework is made-up of multi-faceted and interconnected benefits from large-scale QI programmes. One or more of these may be desirable depending on each organisation’s goals and objectives, as well as stage of development. As such, it is possible for organisations to deduce incremental benefits or returns-on-investments throughout a programme lifecycle that are relevant and legitimate.

Peer Review reports

Introduction

Health services worldwide are faced with challenges to improve the safety and quality of care whilst managing rising healthcare costs [ 1 , 2 , 3 , 4 ]. One way to improve healthcare quality is through Quality Improvement (QI). QI is a systematic approach to improving healthcare quality as well as strengthening health systems and reducing costs [ 5 , 6 ]. QI uses sets of methods such as Lean and Plan-Do-Study-Act (PDSA) [ 7 ]. These methods often incorporate analysis, improvement or reconfiguring, and monitoring of systems. QI is guided by Implementation and Improvement Sciences in the targeted design of improvement strategies to maximise programmes’ success [ 8 ]. QI can be implemented as small projects or large programmes aimed at benefiting entire organisations or health systems [ 9 , 10 ]. Healthcare is a complex system as it involves connections, actions and interactions of multiple stakeholders and processes [ 11 ]. Therefore, QI in healthcare is a complex intervention. This complexity can be costly.

QI may require significant investment to implement and maintain [ 12 , 13 ]. QI implementers must therefore demonstrate its value to help leaders justify and account for their investment decisions [ 14 , 15 ]. QI outcomes are assessed through programme evaluations, comparative research, and economic evaluations such as Return on Investment (ROI). ROI is increasingly being recommended for evaluating or forecasting financial returns (making a business case) for healthcare programmes [ 16 , 17 ]. Originally from accounting and economics, ROI methods calculate a programme’s costs against its benefits [ 18 ]. All perceived programme benefits must be converted to money (monetised) and reported as a single ratio or percentage, e.g., ROI of 1:1 means a 100% profit was made [ 19 ]. A favourable ROI is where a positive estimation of a financial return from an investment can be made [ 19 , 20 ]. However, most healthcare benefits are not amenable to monetisation [ 20 ]. Additionally, healthcare QI programmes do not often make a profit or save costs [ 21 ]. This raises questions of ROI utility in QI programmes.

ROI was introduced into healthcare as a simple objective measure of a programme’s success [ 16 ]. However, in practice, ROI methodology has been found to be complicated and sophisticated [ 22 ]. ROI has also been found to misrepresent reality due to its inability to incorporate certain crucial programme outcomes that are valued in healthcare [ 23 ]. The concerns over ROI have resulted in various attempts to refashion it. Today, there are ROI methods that encourage detailing of non-monetisable qualitative benefits in some way in addition to monetised benefits [ 24 , 25 ]. However, these methods still prioritise monetisable benefits [ 19 , 20 ]. As such, some have referred to ROI as insincere and synthetic [ 24 , 26 ].

The suitability of ROI as a method for evaluating the value of QI in healthcare and other service industries has been contested for decades [ 23 , 27 , 28 , 29 , 30 , 31 , 32 ]. Within and outside healthcare, others have requested a ‘return to value’ rather a focus on financial outcomes [ 33 ] or renamed ROI as ROQ ‘return on quality’ where quality and not profit is favoured [ 34 ]. This hints at ROI being a concept. As a concept, ROI encapsulates mental abstractions of how costs and benefits are perceived [ 35 , 36 ]. Thus, the apparent lack of ROI acceptance in healthcare suggests a need to understand ROI as a concept of a return-on-investment. Understanding the meaning of concepts in research is deemed a crucial step in advancing scientific inquiry [ 36 ].

This report is the second part of a larger study on the concept and determinants of ROI from large-scale healthcare QI. The current and previous studies were to develop the ROI concept and a framework for understanding the ROI concept in the healthcare context. The third study will focus on the determinants. In the first part (under submission), we developed the QI-ROI concept by differentiating ROI from similar concepts. In that study, we found that patient outcomes were seen as of primary importance. In addition, several other organisational benefits including financial benefits were also seen as important. We concluded that ROI in healthcare QI represents any valued benefit. We translated this conceptualisation as follows: attaining a return-on-investment whatever that is, is valued and therefore of benefit, and any benefit is of value in and of itself. We then proposed a framework for analysis of return-on-investment from QI programmes. We called this a QI-ROI conceptual framework.

In the current study, we sought to deepen our understanding of the QI-ROI concept. Gelman and Kalish stated that “concepts correspond to categories of things in the real world and are embedded in larger knowledge structures…the building blocks of ideas” [ 35 ] (p. 298). Therefore, in the current study, we aimed to search for these building blocks of the QI-ROI concept. The objective was to further develop the QI-ROI framework by exploring the categories of goals and benefits that reflect ROI from large-scale QI programmes. In other words, what QI authors and experts would deem or have deemed a return-on-investment from QI programmes. This knowledge was then used to compile types of benefits that if achieved, represent the QI-ROI. We also explored if and how QI benefits are linked to each other. The linkages were crucial in gaining insights into how the complexity of healthcare as well as QI as a complex intervention may impact ROI evaluation.

Underpinning theory

Our wider research project on the ROI concept is informed and underpinned by Complexity Theory. We deemed this theory pertinent, given the multiple QI objectives of multiple healthcare stakeholders. Complexity Theory encompasses a group of theories from different disciplines that highlight the interdependent, interconnected, and interrelated nature of a system i.e., human and technological components of an organisation [ 11 , 37 , 38 ]. These components influence each other in unpredictable ways with emergent consequences [ 11 ]. Therefore, complexity may lead to uncertainties, benefits, and challenges that may impact ROI. Various tools can be used to study this complexity in QI programmes [ 8 , 39 , 40 ]. However, in this study, Complexity Theory was used only to highlight the complexity during our analysis rather than to study it. We will examine this complexity in detail in our next study on ROI determinants.

Review type

This paper is part of a larger Integrative Systematic Review on the ROI concept and its determinants from healthcare QI programmes. Our review is registered with PROSPERO, CRD42021236948. We have amended the protocol firstly to add additional authors as the complexity of the review called for more author perspectives. Secondly, we added the use of Framework analysis instead of Thematic analysis. A link to our PRISMA reporting checklist [ 25 ] is included in the supplementary files . We followed review guidance on Integrated Reviews by Whittemore and Knafl [ 41 ] and Conceptual Framework Development by Jabareen [ 42 ]. This led to 8 separate review stages. Stage 1; clarifying research question, involved background reading as is discussed in our protocol on PROSPERO. The remainder of the stages are reported here. Stages 2–3 involved searching and selecting literature. In stage 4 we assessed the quality of research studies, stages 5–8 are reported in the synthesis, analysis, and results sections below.

Search strategy

We searched Medline, Embase, Global health, PsycInfo, EconLit, NHS EED, Web of Science, Google, Google scholar, organisational journals, as well hand-searched citations. Search terms were from these three categories: (1) healthcare or health*, (2) ROI related economic evaluation terms (SROI, CBA, CEA, CUA), as well as terms value, benefit, and outcomes, and (3) QI, and its specific methods. Table 1 contains definitions of search terms. No language/date limits were set to enable us to note any changes in QI-ROI conceptualisation over time. The search ended on January 30 th , 2021. The search strategy is provided as Supplementary Table  1 .

Eligibility

During our initial search, many articles identified themselves as large-scale QI programmes. To focus our selection criteria, we developed a preliminary ROI conceptual framework (Fig.  1 ). This framework contained various needs and obligations of healthcare organisations [ 53 , 54 ], which we assumed to signal desired organisational outcomes. The Framework had four criteria: 1) organisational performance (patients and financial outcomes), 2) organisational capacity and capability, 3) external relations (e.g., accreditation), and 4) unintended consequences (positive/negative). Organisational performance is a marker of how well organisations perform on delivering value for its stakeholders [ 55 ]. Thus, in a way it includes external relations, e.g., population health. However, they have been isolated here to deduce some unique external outcomes and obligations towards external stakeholders. We then used this framework to decide on eligibility. We included literature on discussions and evaluations of large-scale QI programmes at all healthcare levels (primary, secondary, tertiary) globally.

Preliminary QI ROI conceptual framework

We included literature that mentioned at least three QI organisational goals or benefits, two of which had to be patient or financial outcomes. By doing this, we sought to isolate articles that discussed a wide range of QI outcomes, with patient and financial outcomes as basic organisational QI performance goals. In addition, articles had to mention use of at least one QI method and involvement of various stakeholders, in at least two organisational units. Altogether, this denoted a three-dimensional criteria: depth, breath, and complexity of programmes per organisation. Table 2 has Included/excluded article types.

Screening and selection of articles

Citations were downloaded onto Endnote, Clarivate [ 56 ] to compile a list of citations and remove duplicates. Rayyan software [ 57 ] was used to screen abstracts and full titles as per our search criteria. Screening and selection were performed by two independent reviewers, ST and MM. To refine our selection criteria, five articles were initially selected and discussed to clarify any uncertainties. The two reviewers then completed the screening and selection of the remaining articles independently: ST 100%, MM 5%. Overall agreement was over 90%. Disagreements were discussed and settled by ST and MM, as well as with co-author CH.

Data extraction

Data extraction was performed using words and phrases in the preliminary conceptual framework as well as outcomes in the review’s search terms. We searched for these from all parts of an article where QI benefits, outcomes, and goals may be discussed. This included the introduction, aims, objectives, results as well as discussion and conclusion. Articles were tabulated according to type of article, country, setting, programme type, and outcomes discussed. Data extraction file has been included as Supplementary Table 2 .

Quality assessment

For researchers of integrative reviews and conceptual development, quality assessment is optional as the quality of studies has little or no bearing on concept development [ 41 , 42 ]. As such, there was no intention to exclude articles based on their quality. However, to understand the scientific context in which QI benefits are discussed, we assessed all empirical studies using specific quality assessment and reporting tools. For reviews, we used Critical Appraisal Skills Programme (CASP) [ 58 ], for mixed methods, the Mixed Methods Appraisal Tool (MMAT) [ 59 ], for implementation studies; Standards for Reporting Implementation Studies (STaRI) [ 60 ]. For economic evaluations, the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) [ 61 ], and for QI, the Standards for QUality Improvement Reporting Excellence (SQUIRE) [ 62 ]. As these are different tools, there was no single criteria to judge collective study quality. We therefore assessed the number of appropriate items reported or addressed as per respective study’s tool. We assigned good if 80–100% items were addressed, moderate if 50–79% of items were addressed, and poor if less than 50%.

Data integration, synthesis, and analysis

We followed Framework Analysis [ 63 ], using guidance by Braun & Clarke [ 64 ] thematic analysis, and deductive-inductive hybrid analysis by Fereday & Muir-Cochrane [ 65 ]. This allowed us to identify data from our ROI preliminary conceptual framework as well as any emerging data related to ROI. During the synthesis we summarised findings from the integrated literature and compiled a table of themes, sub-themes, and related outcomes. In the analysis, we noted the complexity and relationships between these themes and outcomes.

The result was a developed QI-ROI framework that outlines the ROI concepts from our first study (e.g., efficiency, productivity, cost-management, cost-saving). Productivity is the quantity of outputs/returns (e.g., patients seen) per investment/input (e.g., staff). Efficiency is achieving those outputs from same or less inputs with least or no waste (e.g., in time, money, effort) [ 66 ]. Cost management are certain strategies used to manage cost [ 67 ]. Cost saving can be an outcome of efficiency, productivity, and cost-management. This initial QI-ROI framework was combined with the categories of QI benefits from the current study to form an extended QI-ROI framework.

A total of 10 428 articles were retrieved, 10 327 were excluded for various reason as shown in Fig.  2 . One hundred and two (102) articles were eligible, 34 were excluded and 68 included. Included articles were: Conceptual n  = 24, Quantitative studies n  = 19 , Qualitative studies n  = 3, Mixed-Methods studies n  = 8, Systematic Reviews n  = 8, Literature reviews n  = 2, Brief Reports n  = 4. Together, the articles represent 18 years of QI evaluation (2002–2020). Excluded articles were where programmes engaged a single department and/or discussed two or fewer QI outcomes/goals. Thirteen of these were collaboratives. There was one pre-print. A link to the excluded studies document is available in the supplementary files .

PRISMA flow chart

Article characteristics

Included articles covered different healthcare levels and disciplines. Primary care included public health, child and maternal health, and mental health. Secondary and tertiary healthcare included mental health, medical and surgical care, critical care, accident and emergency and acute care services, paediatrics and neonatal care, outpatients, pharmacy, and laboratories. One article covered both health and social care, and another article was about QI in a healthcare related charitable organisation. Articles were from these global regions: Africa, Asia, Europe, Australia, and Canada. The mostly represented regions were the US and the UK. Only 15 of 68 articles were economically focused. ROI was a specific subject of only four articles [ 68 , 69 , 70 , 71 ], and five authors discussed development of QI business cases [ 33 , 72 , 73 , 74 , 75 ]. One article discussed cost–benefit analysis from a qualitative perspective [ 76 ], there were two economic systematic reviews, and three economic evaluations. de la Perrelle et al. [ 77 ] also found this lack of economic evaluations in their systematic review. However some authors reported their implementation costs [ 78 , 79 , 80 ]. The summary of included studies can be found as Supplementary Table 3 .

Quality of studies

Thirty articles were not subject to quality assessment. These were conceptual articles, unsystematic literature reviews, and brief reports. Thirty-eight articles were subjected to quality assessment: 19 quantitative studies, three qualitative studies, eight mixed-methods studies, and eight systematic reviews. Of the 38 studies, 39% reported or addressed 80%-100% of all items required, 43% reported on 50%-79% of the data required, and 18% reported below 50% of items required by their respective reporting tool. The main areas of poor rigour were: ethics (29%), statistical analysis methods (75%), discussion and management of study limitations (42%). For some mixed methods studies (29%), integration of quantitative and qualitative data was unclear. In some cases, these issues may merely reflect poor reporting. However in the absence of data, poor rigour was assumed. Overall, the quality of the studies was summed-up as moderate. The quality assessment summary is provided as Supplementary Table 4 .

Data synthesis and analysis

Authors either directly studied QI outcomes, reported additional QI outcomes and benefits, and or discussed QI goals and missed opportunities. A number of papers reported financial savings or had savings as a goal [ 77 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 ]. Gandjour & Lauterbach [ 89 ] noted that cost-saving was more likely when improving an over-use or misuse problem. For example, an article reported cost-reduction from malpractice suits [ 74 ]. Financial benefits through QI were mostly internal to organisations, and a small number involved societies and healthcare funders [ 73 , 75 ].

There was a shared view that quality and patient safety should be more central to QI and investment goals than financial outcomes [ 72 , 88 , 90 , 91 , 92 , 93 , 94 , 95 ]. This view had not changed over time. Thus, QI goals were primarily improving patient outcomes through systems, structural, process, and behavioural improvements. This enabled improved efficiency and productivity. Efficiency and productivity enabled managers’ abilities to manage, minimise, or reduce costs, and eventually save costs [ 73 , 94 , 96 , 97 , 98 ]. Systems efficiency helped improve staff efficiency, effectiveness, productivity, and experience, which benefited patients [ 84 , 99 , 100 ]. Improved systems enabled improved organisational capacity, capability, and resilience [ 93 , 101 , 102 , 103 , 104 , 105 , 106 ].

Most authors highlighted that good quality and patient safety relied upon good staff outcomes and leadership. A few studies focused on some of these specific areas. Examples include Mery et al. [ 71 ] who studied QI programmes as an organisational capability and capacity development tool. Hatcher [ 83 ] studied QI as a staff safety promotion tool, Lavoie-Tremblay et al. [ 99 ] evaluated QI as a tool for team effectiveness. Furukawa et al. [ 107 ] and Heitmiller et al. [ 84 ] focused QI towards environment sustainability. MacVane [ 96 ] saw QI as a governance tool. Williams et al. [ 100 ] focused on both staff and patient outcomes. QI was also used to operationalise organisations’ strategies [ 93 , 108 ]. Staines et al. [ 108 ] found that a positive QI reputation allowed recruitment of a suitable CEO.

There was a general recognition that QI does not always achieve its intended goals. Additionally, some QI strategies were more successful than others [ 80 ]. Particularly, some literature reviews and empirical studies reported variable, mixed, or inconclusive results [ 86 , 109 , 110 , 111 , 112 , 113 , 114 , 115 ], even a decline in quality [ 99 ]. A few articles discussed negative unintended outcomes [ 81 , 100 , 104 , 110 , 112 , 114 , 116 , 117 , 118 , 119 ]. de la Perrelle et al. [ 77 ] noted this lack of reporting of negative findings in their review. They suspected this to be due to publication bias. Rationales for not achieving goals were given as implementation difficulties related to contextual and behavioural challenges [ 78 , 114 , 120 , 121 ].

Some authors noted that overall benefits accrued over time during phases of a programme’s implementation process [ 80 , 122 ]. Morganti et al. [ 123 ] noted different measures of QI success but suggested that spread of a programme was a measure of lasting success. Sustainability of outcomes was therefore also seen as an important achievement by most authors. This was supported by some of the literature which also indicated that successful QI built legacies mainly through spreading, embedding, and sustaining improvements [ 78 , 93 , 101 , 102 , 103 , 104 , 105 , 106 ]. This finding was confirmed by impact studies, extensive QI programme evaluations and discussions of overall QI impacts [ 69 , 85 , 87 , 93 , 103 , 104 , 105 , 106 , 108 , 115 , 116 , 119 , 121 , 124 , 125 , 126 ]. These literatures elaborated on QI goals, failures, and successes, as well as the lessons learnt. Authors suggested that lessons and cultural changes as a result of QI were essential to meeting patient safety needs [ 93 , 109 ]. Authors highlighted that ultimately, QI benefited a wide range of stakeholders at different levels in different ways.

Based on the findings, we compiled data into four overarching themes (Table 3 ). These themes aligned with our ROI preliminary framework; however, adjustments were made to reflect the findings. Organisational capacity and capability was renamed organisational development to acknowledge the broader organisational outcomes. This included all the outcomes that develop and improve organisations’ ability to fulfil their duties. Resilience and QI legacy were additional sub-themes under organisational development. External relations was renamed external outcomes to reflect the broad outcomes beyond relationships with regulators, communities, and other organisations. External outcomes were extended to include collaboration, societal and environmental outcomes, and incentives. Incentives included accreditation, awards, ranking, competitiveness, influence, power, and financial rewards.

Negative unintended outcomes include any negative impact resulting from a QI programme. These were external imposition, top-down distortions, duplication, high resource demands, loss of revenue, and loss of buy-in. Authors reported that at times external or managerial agendas were superimposed over other QI goals [ 108 , 116 , 127 , 128 ]. At times this caused duplication of processes (e.g., data collection) and or increased demand on already stretched services. In addition, successful QI can cause loss of funding as services become absolute [ 108 ]. Eventually different negative outcomes may cause staff or leaders to disengage from current or future QI.

Positive unintended outcomes were difficult to delineate as often programmes were geared towards patient outcomes but impacted other parts of an organisation in the process. However, as improvement strategies involved changing systems and human behaviours, improvement of these aspects must be intended. We therefore had this sub-theme only include new innovations and opportunities. The final overarching themes were named 1) organisational performance (two sub-themes), 2) organisational development (12 sub-themes), 3) external outcomes (five sub-themes), 4) unintended outcomes (two sub-themes).

Based on the themes, we updated our ROI preliminary conceptual framework to map the four overarching themes that represent QI-ROI (Fig.  3 ). The beneficial outcomes are presented under the headings “gains, benefits, returns”, whilst negative outcomes are presented as “losses, costs, investments”. These concepts are technically defined differently. They are used together here to denote their co-existence within QI programmes. For example, loss of revenue is a potential investment lost, high resource demands may require investment or incur costs, duplication is inefficient and costly, loss of buy-in is a costly setback. All will raise money spent or lost if not well managed or avoided. They may also affect organisational performance and development, as well as stakeholder engagement in future programmes. Thus, impacts are both monetary and non-monetary.

Updated preliminary ROI Conceptual Framework. Most QI goals and outcomes affect an organisation’s culture. The four overarching themes are connected and influence one another e.g., improved performance enabled attainment of external incentives. An overlap exists amongst these themes, e.g., collaboration was improved both internally (organisational development, and externally as an external QI benefit)

Authors also saw investments as both in monetary and non-monetary forms. These were viewed as both equally essential for patient safety and quality. Some of these investments were part of ongoing organisational strategies. Investments included staff time, recruitment and retention costs, training costs, patient engagement costs [ 68 , 69 , 77 , 95 , 108 , 113 , 114 , 116 ]. Some investments depended on the goodwill of the staff and patients and were seen as priceless [ 119 ]. Staines et al. [ 108 ] referred to two types of investments: “hard” infrastructure (e.g., technology) and “soft” infrastructure (e.g., awareness, commitment, and culture).

The literature also noted that QI outcomes are interlinked and interrelated, and as such QI-ROI may not be readily observable. Deducing ROI may require studying “cause-and-effect chains” [ 92 ] (p. 2) or an ROI chain; the link between events from a given investment to a given outcome. Sibthorpe et al. [ 113 ] saw this as important for understanding QI impacts and attracting QI investment. This can be done by tracking inputs, processes, outputs, and outcomes as much as possible throughout a programme. By doing this, the integrity of the ROI chain may be assessed by identifying areas where QI-ROI is created, lost, or influenced. This may then help maximise QI-ROI. However, tracking this chain in complex contexts may be a challenge.

The QI-ROI chain

In complex systems, programme inputs, processes, outputs are not a once-only event, occurring only at initial implementation. Outcomes of earlier inputs, outputs, and processes become inputs in the next phase and so forth until the final impact is achieved (end-ROI). It may therefore be helpful to recognise and celebrate earlier achievements [ 33 , 97 ]. Further, before a final impact is realised, a programme may act and interact with several variables. Due to this complexity, the linkages may resemble a web rather than a chain. The literature attested to the fact that QI impacts are unpredictable, and difficult to measure [ 33 , 113 , 119 ]. QI inputs may or may not be converted into active QI ingredients that will affect organisational change and improvement [ 80 ]. For example, if one of the strategies is to train staff; do they actually learn what is needed? The answer would depend on several internal and external determining factors [ 78 , 79 , 114 , 120 , 121 ]. Such factors may force adaptations, influence fidelity to strategies, sustainability, and decisions to proceed, de-implement or disinvest.

The ROI chain is illustrated here in Figs.  4 and 5 . Figure  4 demonstrates that the overall ROI results from changes in processes, structures, and systems. These may be visible through behavioural (human and systems), and technological improvements, before final impact and ROI can be detected. Two-tier order mechanisms are alluded to here; the first order mechanisms operationalise QI strategies and provide non-monetary ROI, whilst the second order mechanisms convert QI efforts into financial returns. A first order mechanisms may be for example increased staff proficiency leading staff development, whilst a second order may be improved productivity due to increased proficiency. Productivity may then help save costs.

QI-ROI Chain

Extended QI-ROI conceptual framework: phased format

In summary, different investments are made towards a QI programme and a change is propagated through changing and improving processes, behaviours, systems, and structures. Technical (e.g., skills) and social (e.g., culture) changes and improvements may be achieved. These changes and improvements can then lead to improved efficiency and productivity. Efficiency and productivity can then improve cost-management. Better cost-management and control can then lead to cost-reduction, cost-minimisation, cost-avoidance, cost-containment, and cost-saving. All these are outputs, immediate and intermediate outcomes that become mechanisms through which monetary ROI is achieved. Before then, the outputs present as non-monetary returns-on-investments either as enabled abilities (e.g., cost-management, cost-reduction, cost-minimisation, cost-avoidance, cost-containment), outputs or intermediate outcomes (e.g., improved behaviour, productivity, efficiency).

Non-monetary ROI can also be achieved through organisational development e.g., staff development and collaboration. Organisational development is the basis for safe healthcare systems and may lead to cost-saving, and hard cash ROI. Improvements in staff and process outcomes may improve culture, which may also improve patient and financial outcomes. Improvements in patient outcomes may lead to further benefits (e.g., incentives), and become an organisation’s legacy (culture, capacity and capabilities). This can help an organisation become more resilient and sustainable. QI culture and QI legacies are the basis from which future organisational development as well as patient and financial outcomes can be achieved.

Altogether, the QI outcomes contribute to higher goals such as organisational learning, transformation, financial stability, value-based healthcare, and high reliability [ 101 , 102 , 105 , 116 ]. Although intended goals and short-term outcomes may be achieved earlier, long-term sustainable impacts depend on successful implementation, embedding a QI safety culture, and developing legacies that support future improvement efforts. Whatever the end-outcome, lessons may be learnt, research, innovation and development may ensue, capacities and capabilities may improve. As Banke-Thomas et al. [ 68 ] stated, “ The application of (S)ROI … could be used to inform policy and practice such that the most cost-beneficial interventions are implemented to solve existing (public health) challenges” (p.10).

Figure  5 illustrates the updated QI-ROI conceptual framework in a phased format. This figure represents the current conceptualisation of QI-ROI based on our analysis of the healthcare QI evaluation literature. The processes described here are more complex but have been simplified for clarity. The figure contains the ROI-like concepts from our first study (e.g., efficiency, productivity, effectiveness, cost saving). These concepts are seen here as building blocks of financial ROI. However, some of these also form part of improvements in other organisational performance and developmental goals. Such improvements can be seen as non-monetary ROI which includes improved abilities, development, and overall improved outputs and outcomes. Together, these are the building blocks of the QI-ROI concept as indicated by the literature.

The aim of this part of the review was to further develop a framework for understanding the benefits that reflect the concept of ROI from large-scale healthcare QI programmes (the QI-ROI). We achieved this by reviewing different QI literatures on the goals and or benefits from QI programmes. The goals embody aspirations or QI-ROI as imagined, whilst the reported outcomes and benefits represent QI-ROI as experienced. Together, these form a concept of QI-ROI. We considered negative outcomes to be part of this conceptualisation as they may highlight perceptions of the absence of the QI-ROI. We grounded our theoretical assumptions on organisational needs, duties, and obligations as defined by organisations themselves as well as various internal and external stakeholders.

Our assumption was that at a minimum, a QI programme that delivers on any organisational needs and obligations, delivers a return-on-investment for healthcare organisations. The reviewed literature revealed numerous QI goals and outcomes. These included aspects of an organisation’s performance and development, as well as external and unintended QI outcomes. Through the Complexity Theory lens, we noted the different connections of these outcomes. This deepened our understanding of QI-ROI as a collection of interlinked QI benefits that occur incrementally throughout a programme’s lifecycle. These benefits include systems, processual, and structural improvements. Central to these, are sustainable improved patient outcomes.

Although QI effectiveness was not the focus of this review, it is related to QI-ROI. In-fact some view ROI as an overall measure of QI effectiveness [ 22 ]. Since the induction of QI into healthcare, a sizeable body of literature have questioned QI’s value and effectiveness [ 136 , 137 , 138 , 139 , 140 , 141 , 142 ]. Several factors have been found to determine QI’s success. These include aspects of organisations’ structures, systems, behaviours, cultures, and leadership [ 143 , 144 ]. The collection of benefits referred to in this review as QI-ROI largely contribute towards these QI effectiveness determinants [ 145 , 146 , 147 ]. Thus, improvement in these aspects must be of value for organisations. Further, achieving QI’s pre-defined goals (effectiveness) is not the end, but part of the journey towards QI-ROI. This is important to note as depending on the QI resources required, costs may increase, rendering QI value inversely related to its cost [ 21 , 148 , 149 ].

The insights into the building blocks of good quality healthcare are not new and inter-disciplinary health services research attest to this [ 150 , 151 , 152 , 153 ]. Wider health and social science as well as organisational literature have repeatedly pointed to the importance of improving staff capacities and capabilities, as well as experience [ 154 ]. A systematic review by Hall et al. [ 155 ], found that poor staff wellbeing and burnout are frequently associated with poor patient outcomes. Latino [ 156 ] argued that the intellectual capital of human beings is one of the greatest benefits not captured through financial outcomes. Implementation and Improvement Sciences have highlighted the importance of understanding contexts, interventions, and human behaviour and their influence on QI programme success and sustainability [ 39 , 40 ].

Effective leadership was a consistent patient safety pre-requisite in the Francis Mid-Staffordshire review [ 157 ]. The Francis review also highlighted negative cultures and failure to learn as contributing factors to poor quality care. Negative QI outcomes and failed attempts must be avoided, but they are part of learning safety cultures [ 158 ]. Patient engagement has also been found to be crucial in leaning and safety cultures [ 159 ]. A safety culture: one that prioritises safe care, is thus deemed foundational to efforts to improve quality and safety [ 158 , 160 , 161 , 162 , 163 , 164 ].

There are of-course other ways to improve healthcare, and organisations do invest in various programmes that specifically target some of the themes within our QI-ROI conceptual framework, for example leadership programmes [ 165 ]. Determining whether QI or other types of investments and programmes led to any specific improvement is known to be challenging [ 166 , 167 ]. As a result, claims of causality are not possible. Through Complexity Theory, QI-ROI can be viewed in terms of contribution or correlation to organisational outcomes rather than direct attribution [ 11 , 37 , 166 ]. Understanding of QI contribution to organisational outcomes may be achieved through methods such as contribution analysis and the action effect method [ 166 , 167 ]. These methods can help detect the type and level of QI contribution.

QI’s key contributions to healthcare improvement are evident in the reviewed literature, and external bodies such as the UK Care Quality Commission (CQC) attest to this. In 2018, 80% of Trusts rated “Outstanding” by the CQC had organisational improvement programmes [ 101 ]. As a result, QI was identified in the UK National Health Service (NHS) Long-term Plan as an approach for improving every aspect of how the NHS operates [ 168 ]. Further, organisations that have mature improvement cultures claim to have benefited in several of the QI-ROI conceptual framework’s dimensions [ 169 , 170 , 171 ]. Mature organisations indicate that, in addition to organisational development and performance, environmental and social impacts [ 172 ], reputation, [ 173 ], and resilience [ 174 ], are crucial organisational outcomes. QI programmes are now also used to engage with modern healthcare agendas like value-based healthcare and environmental sustainability [ 175 , 176 ]. In achieving such goals, QI programmes can be cost-effective without saving actual costs [ 177 ].

However, QI-ROI is not a one-time event. ROI may be created or lost at different stages of a programme [ 25 ]. In a complex healthcare programme, QI-ROI is iterative and dynamic with many determinants, some of them outside the control of QI implementers alone [ 13 , 39 , 167 ]. Additionally, QI may affect various levels of stakeholders from frontline, to societies, to policymakers differently. [ 13 , 39 , 167 ]. These levels interact with and influence each other [ 11 , 39 ]. As such, it is important to note the co-dependencies of QI outcomes when planning and evaluating QI. As Donabedian [ 178 ] stated; structures, processes and outcomes are mutually dependent. This means that it is important to take small wins with big wins through observing the QI-ROI chain [ 179 ]. Therefore, not only is the traditional ROI approach unreliable as a forecasting tool, as an evaluation tool, it is a distal and an incomplete marker of QI value.

Finally, large-scale programmes took many forms, some internal and some involving external collaborators. Collaborations have been recommended as a way to improve patient safety and experience, and save costs [ 180 , 181 ]. However, unless formally integrated, organisations run internal budgets, their performance assessed individually, and with own governance structures [ 14 , 182 , 183 , 184 ]. Notably, collaboratives appear to be geared towards health system-wide benefits and indirectly address organisational-level impacts [ 138 ]. Therefore, collaboratives may bring unique challenges as well as benefits. This may mean that different organisations at different developmental levels deduce different outcomes from the same QI programmes [ 102 , 146 ]. Research developments here will be valuable to improve understanding of QI-ROI, for example how and why collaboratives work (or not) [ 51 , 185 ]. Nonetheless, this review reveals largely shared QI goals and outcomes regardless of the type of large-scale programme.

Strengths and limitations

A strength of our review is that our theoretical assumptions were grounded on organisational needs, duties, and obligations as defined by organisations and external stakeholders. This step preceded the first study where we analysed different returns-on-investments concepts in healthcare QI. The current study sought to strengthen the first study’s QI-ROI conceptual framework by connecting the QI-ROI concept with categories of QI benefits as seen by healthcare QI stakeholders. Additionally, our review lens through complexity theory gave us a glimpse of the processes though which these QI-ROI building blocks independently or in concert may influence ROI. As such, our framework provides clues to its practical application.

A limitation of this review is that it was broad, encompassing various disciplines in various countries, reporting on different types of programmes. The review was meant to be an exploration of the QI field’s view of QI returns-on-investment. Researchers may wish to explore these in specific contexts, for example by studying particular “building blocks” of QI-ROI in a specific context or programme. Additionally, some of the literature is quite dated, however newer literature do suggest continuance of some trends and issues in QI-ROI and QI business case matters. Lastly, subjectivity in the synthesis and analysis cannot be ruled out as it is inherent in qualitative analyses [ 63 ].

Implications for research and practice

Economic evaluation of large-scale programmes are a new phenomenon, and research is needed to help identify the most suitable evaluation methods. This need is compounded by the fact that large-scale QI programmes come in many forms. It is important to assess QI’s contribution to organisational performance and development through suitable and innovative research methods such as realist reviews rather than seek a definitive causal link which may be imperceptible in complex large QI programmes. A study of collaboratives alone or in comparison to internal organisation-wide QI programmes may help explore the best ways to approach large-scale QI programmes to maximise ROI. In addition, a thorough study of the relationships of the QI-ROI determinants as well as QI benefits may help to understand why and how QI benefits influence one another. Lastly, guidance on how to weigh different QI benefits, and how to develop a standardisable yet flexible QI-ROI tools will be crucial for future research and practical application.

ROI in healthcare is a highly debated topic. This review is but one contribution to this ongoing debate. Our review suggests that in healthcare, ROI must reflect value-based healthcare principles, with value defined as patient and organisational benefits. We hope that by defining the ROI concept in this manner, links between wider large-scale QI benefits and organisational strategic intents will be highlighted. In doing this, leaders may be able to frame QI value, benefits and thus ROI in a useful way. This broader view is crucial if healthcare organisations and health systems are to continue investing in essential healthcare quality improvements. ROI is not a one-time event and may be created or lost at different stages of a programme. Further, many factors determine whether it can be deduced, many of them outside the control of QI implementers. Such factors must be taken into consideration in valuing healthcare QI.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Some data has been included in this published article as its supplementary information files.

Abbreviations

• Quality Improvement
• Return on Investment

Social Return on Investment

Return on Investment from healthcare nhquality improvement

Cost Effectiveness Analysis

Cost Utility Analysis

Cost Benefit Analysis

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Acknowledgements

The authors would like to Dr Kia-Chong Chua, King's College London, UK for his very insightful contribution to the process and analysis of the review.

This work is supported by the Economic and Social Research Council, grant number ES/P000703/1. 

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Two reviewers ST and MM worked independently under the guidance of senior co-author CH. MM reviewed 5% of articles from search to synthesis, and ST 100% of all stages. Agreement in the co-review stages was over 90%. ST completed the synthesis and analysis of the review. Any disagreements were discussed with NN, BG, TS, and CH. ST wrote the manuscript, compiled all the tables and figures in this manuscript. All authors advised, reviewed, and approved the development of this manuscript, its tables, and figures.

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S'thembile Thusini is a PhD student, with the Health Service and Population Research Dept, Institute of Psychiatry, Psychology and Neuroscience, King's College London.

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TS received funding from Cancer Alliance and Health Education England for training cancer multidisciplinary teams (MDTs) in assessment and quality improvement methods in the United Kingdom. TS received consultancy fees from Roche Diagnostics. The other authors declare that they have no competing interests. TS research is supported by the Welcome Trust (219425/Z/19/Z) and Diabetes UK (19/0006055).

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Additional file 1: supplementary table 1..

Example search strategy. Supplementary Table 2. Data extraction tool. Supplementary Table 3. Included studies. Supplementary Table 4. Summary of Quality assessment. Links Current study PRISMA Checklist. Search strategies. Data extraction tool. Excluded studies.

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Thusini, S., Milenova, M., Nahabedian, N. et al. Identifying and understanding benefits associated with return-on-investment from large-scale healthcare Quality Improvement programmes: an integrative systematic literature review. BMC Health Serv Res 22 , 1083 (2022). https://doi.org/10.1186/s12913-022-08171-3

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The use and impact of surveillance-based technology initiatives in inpatient and acute mental health settings: A systematic review

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Background: The use of surveillance technologies is becoming increasingly common in inpatient mental health settings, commonly justified as efforts to improve safety and cost-effectiveness. However, the use of these technologies has been questioned in light of limited research conducted and the sensitivities, ethical concerns and potential harms of surveillance. This systematic review aims to: 1) map how surveillance technologies have been employed in inpatient mental health settings, 2) identify any best practice guidance, 3) explore how they are experienced by patients, staff and carers, and 4) examine evidence regarding their impact. Methods: We searched five academic databases (Embase, MEDLINE, PsycInfo, PubMed and Scopus), one grey literature database (HMIC) and two pre-print servers (medRxiv and PsyArXiv) to identify relevant papers published up to 18/09/2023. We also conducted backwards and forwards citation tracking and contacted experts to identify relevant literature. Quality was assessed using the Mixed Methods Appraisal Tool. Data were synthesised using a narrative approach. Results: A total of 27 studies were identified as meeting the inclusion criteria. Included studies reported on CCTV/video monitoring (n = 13), Vision-Based Patient Monitoring and Management (VBPMM) (n = 6), Body Worn Cameras (BWCs) (n = 4), GPS electronic monitoring (n = 2) and wearable sensors (n = 2). Twelve papers (44.4%) were rated as low quality, five (18.5%) medium quality, and ten (37.0%) high quality. Five studies (18.5%) declared a conflict of interest. We identified minimal best practice guidance. Qualitative findings indicate that patient, staff and carer perceptions and experiences of surveillance technologies are mixed and complex. Quantitative findings regarding the impact of surveillance on outcomes such as self-harm, violence, aggression, care quality and cost-effectiveness were inconsistent or weak. Discussion: There is currently insufficient evidence to suggest that surveillance technologies in inpatient mental health settings are achieving the outcomes they are employed to achieve, such as improving safety and reducing costs. The studies were generally of low methodological quality, lacked lived experience involvement, and a substantial proportion (18.5%) declared conflicts of interest. Further independent coproduced research is needed to more comprehensively evaluate the impact of surveillance technologies in inpatient settings, including harms and benefits. If surveillance technologies are to be implemented, it will be important to engage all key stakeholders in the development of policies, procedures and best practice guidance to regulate their use, with a particular emphasis on prioritising the perspectives of patients.

Competing Interest Statement

AS and UF have undertaken and published research on BWCs. We have received no financial support from BWC or any other surveillance technology companies. All other authors declare no competing interests.

Clinical Protocols

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=463993

Funding Statement

This study is funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme (grant no. PR-PRU-0916-22003). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. ARG was supported by the Ramon y Cajal programme (RYC2022-038556-I), funded by the Spanish Ministry of Science, Innovation and Universities.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Data Availability

The template data extraction form is available in Supplementary 1. MMAT quality appraisal ratings for each included study are available in Supplementary 2. All data used is publicly available in the published papers included in this review.

View the discussion thread.

Supplementary Material

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The outlook for euro area financial stability remains fragile amid weak macro-financial conditions and heightened geopolitical risks.

Explore the latest sources of risk and vulnerabilities for the euro area financial system in detail by reading the full report.

We look at risks to euro area residential and commercial real estate markets in a turning property market cycle.

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The outlook for euro area financial stability remains fragile, as tighter financing conditions are increasingly transmitted to the real economy in an environment of weak growth, high inflation and heightened geopolitical risks.

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The Macroprudential Bulletin provides insight into our work in the field of macroprudential policy. The aim of the Macroprudential Bulletin is to raise awareness of macroprudential policy issues in the euro area and to foster broader discussion on key macroprudential issues.

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