structure of a literature review for an article

Purdue Online Writing Lab Purdue OWL® College of Liberal Arts

Writing a Literature Review

Welcome to the Purdue OWL

This page is brought to you by the OWL at Purdue University. When printing this page, you must include the entire legal notice.

Copyright ©1995-2018 by The Writing Lab & The OWL at Purdue and Purdue University. All rights reserved. This material may not be published, reproduced, broadcast, rewritten, or redistributed without permission. Use of this site constitutes acceptance of our terms and conditions of fair use.

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.

Have a language expert improve your writing

Run a free plagiarism check in 10 minutes, generate accurate citations for free.

• Knowledge Base

Methodology

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

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.

Instantly correct all language mistakes in your text

Upload your document to correct all your mistakes in minutes

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.

Here's why students love Scribbr's proofreading services

Discover proofreading & editing

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.

Receive feedback on language, structure, and formatting

Professional editors proofread and edit your paper by focusing on:

• Academic style
• Vague sentences
• Style consistency

See an example

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.

Scribbr slides are free to use, customize, and distribute for educational purposes.

Open Google Slides Download PowerPoint

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 .  

Cite this Scribbr article

If you want to cite this source, you can copy and paste the citation or click the “Cite this Scribbr article” button to automatically add the citation to our free Citation Generator.

McCombes, S. (2023, September 11). How to Write a Literature Review | Guide, Examples, & Templates. Scribbr. Retrieved April 2, 2024, from https://www.scribbr.com/dissertation/literature-review/

Is this article helpful?

Shona McCombes

Other students also liked, what is a theoretical framework | guide to organizing, what is a research methodology | steps & tips, how to write a research proposal | examples & templates, what is your plagiarism score.

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

Make a Gift

How To Write An A-Grade Literature Review

3 straightforward steps (with examples) + free template.

By: Derek Jansen (MBA) | Expert Reviewed By: Dr. Eunice Rautenbach | October 2019

Quality research is about building onto the existing work of others , “standing on the shoulders of giants”, as Newton put it. The literature review chapter of your dissertation, thesis or research project is where you synthesise this prior work and lay the theoretical foundation for your own research.

Long story short, this chapter is a pretty big deal, which is why you want to make sure you get it right . In this post, I’ll show you exactly how to write a literature review in three straightforward steps, so you can conquer this vital chapter (the smart way).

Overview: The Literature Review Process

• Understanding the “ why “
• Finding the relevant literature
• Cataloguing and synthesising the information
• Outlining & writing up your literature review
• Example of a literature review

But first, the “why”…

Before we unpack how to write the literature review chapter, we’ve got to look at the why . To put it bluntly, if you don’t understand the function and purpose of the literature review process, there’s no way you can pull it off well. So, what exactly is the purpose of the literature review?

Well, there are (at least) four core functions:

• For you to gain an understanding (and demonstrate this understanding) of where the research is at currently, what the key arguments and disagreements are.
• For you to identify the gap(s) in the literature and then use this as justification for your own research topic.
• To help you build a conceptual framework for empirical testing (if applicable to your research topic).
• To inform your methodological choices and help you source tried and tested questionnaires (for interviews ) and measurement instruments (for surveys ).

Most students understand the first point but don’t give any thought to the rest. To get the most from the literature review process, you must keep all four points front of mind as you review the literature (more on this shortly), or you’ll land up with a wonky foundation.

Okay – with the why out the way, let’s move on to the how . As mentioned above, writing your literature review is a process, which I’ll break down into three steps:

• Finding the most suitable literature
• Understanding , distilling and organising the literature
• Planning and writing up your literature review chapter

Importantly, you must complete steps one and two before you start writing up your chapter. I know it’s very tempting, but don’t try to kill two birds with one stone and write as you read. You’ll invariably end up wasting huge amounts of time re-writing and re-shaping, or you’ll just land up with a disjointed, hard-to-digest mess . Instead, you need to read first and distil the information, then plan and execute the writing.

Step 1: Find the relevant literature

Naturally, the first step in the literature review journey is to hunt down the existing research that’s relevant to your topic. While you probably already have a decent base of this from your research proposal , you need to expand on this substantially in the dissertation or thesis itself.

Essentially, you need to be looking for any existing literature that potentially helps you answer your research question (or develop it, if that’s not yet pinned down). There are numerous ways to find relevant literature, but I’ll cover my top four tactics here. I’d suggest combining all four methods to ensure that nothing slips past you:

Method 1 – Google Scholar Scrubbing

Google’s academic search engine, Google Scholar , is a great starting point as it provides a good high-level view of the relevant journal articles for whatever keyword you throw at it. Most valuably, it tells you how many times each article has been cited, which gives you an idea of how credible (or at least, popular) it is. Some articles will be free to access, while others will require an account, which brings us to the next method.

Method 2 – University Database Scrounging

Generally, universities provide students with access to an online library, which provides access to many (but not all) of the major journals.

So, if you find an article using Google Scholar that requires paid access (which is quite likely), search for that article in your university’s database – if it’s listed there, you’ll have access. Note that, generally, the search engine capabilities of these databases are poor, so make sure you search for the exact article name, or you might not find it.

Method 3 – Journal Article Snowballing

At the end of every academic journal article, you’ll find a list of references. As with any academic writing, these references are the building blocks of the article, so if the article is relevant to your topic, there’s a good chance a portion of the referenced works will be too. Do a quick scan of the titles and see what seems relevant, then search for the relevant ones in your university’s database.

Method 4 – Dissertation Scavenging

Similar to Method 3 above, you can leverage other students’ dissertations. All you have to do is skim through literature review chapters of existing dissertations related to your topic and you’ll find a gold mine of potential literature. Usually, your university will provide you with access to previous students’ dissertations, but you can also find a much larger selection in the following databases:

• Open Access Theses & Dissertations
• Stanford SearchWorks

Keep in mind that dissertations and theses are not as academically sound as published, peer-reviewed journal articles (because they’re written by students, not professionals), so be sure to check the credibility of any sources you find using this method. You can do this by assessing the citation count of any given article in Google Scholar. If you need help with assessing the credibility of any article, or with finding relevant research in general, you can chat with one of our Research Specialists .

Alright – with a good base of literature firmly under your belt, it’s time to move onto the next step.

Need a helping hand?

Step 2: Log, catalogue and synthesise

Once you’ve built a little treasure trove of articles, it’s time to get reading and start digesting the information – what does it all mean?

While I present steps one and two (hunting and digesting) as sequential, in reality, it’s more of a back-and-forth tango – you’ll read a little , then have an idea, spot a new citation, or a new potential variable, and then go back to searching for articles. This is perfectly natural – through the reading process, your thoughts will develop , new avenues might crop up, and directional adjustments might arise. This is, after all, one of the main purposes of the literature review process (i.e. to familiarise yourself with the current state of research in your field).

As you’re working through your treasure chest, it’s essential that you simultaneously start organising the information. There are three aspects to this:

• Logging reference information
• Building an organised catalogue
• Distilling and synthesising the information

I’ll discuss each of these below:

2.1 – Log the reference information

As you read each article, you should add it to your reference management software. I usually recommend Mendeley for this purpose (see the Mendeley 101 video below), but you can use whichever software you’re comfortable with. Most importantly, make sure you load EVERY article you read into your reference manager, even if it doesn’t seem very relevant at the time.

2.2 – Build an organised catalogue

In the beginning, you might feel confident that you can remember who said what, where, and what their main arguments were. Trust me, you won’t. If you do a thorough review of the relevant literature (as you must!), you’re going to read many, many articles, and it’s simply impossible to remember who said what, when, and in what context . Also, without the bird’s eye view that a catalogue provides, you’ll miss connections between various articles, and have no view of how the research developed over time. Simply put, it’s essential to build your own catalogue of the literature.

I would suggest using Excel to build your catalogue, as it allows you to run filters, colour code and sort – all very useful when your list grows large (which it will). How you lay your spreadsheet out is up to you, but I’d suggest you have the following columns (at minimum):

• Author, date, title – Start with three columns containing this core information. This will make it easy for you to search for titles with certain words, order research by date, or group by author.
• Categories or keywords – You can either create multiple columns, one for each category/theme and then tick the relevant categories, or you can have one column with keywords.
• Key arguments/points – Use this column to succinctly convey the essence of the article, the key arguments and implications thereof for your research.
• Context – Note the socioeconomic context in which the research was undertaken. For example, US-based, respondents aged 25-35, lower- income, etc. This will be useful for making an argument about gaps in the research.
• Methodology – Note which methodology was used and why. Also, note any issues you feel arise due to the methodology. Again, you can use this to make an argument about gaps in the research.
• Quotations – Note down any quoteworthy lines you feel might be useful later.
• Notes – Make notes about anything not already covered. For example, linkages to or disagreements with other theories, questions raised but unanswered, shortcomings or limitations, and so forth.

If you’d like, you can try out our free catalog template here (see screenshot below).

2.3 – Digest and synthesise

Most importantly, as you work through the literature and build your catalogue, you need to synthesise all the information in your own mind – how does it all fit together? Look for links between the various articles and try to develop a bigger picture view of the state of the research. Some important questions to ask yourself are:

• What answers does the existing research provide to my own research questions ?
• Which points do the researchers agree (and disagree) on?
• How has the research developed over time?
• Where do the gaps in the current research lie?

To help you develop a big-picture view and synthesise all the information, you might find mind mapping software such as Freemind useful. Alternatively, if you’re a fan of physical note-taking, investing in a large whiteboard might work for you.

Step 3: Outline and write it up!

Once you’re satisfied that you have digested and distilled all the relevant literature in your mind, it’s time to put pen to paper (or rather, fingers to keyboard). There are two steps here – outlining and writing:

3.1 – Draw up your outline

Having spent so much time reading, it might be tempting to just start writing up without a clear structure in mind. However, it’s critically important to decide on your structure and develop a detailed outline before you write anything. Your literature review chapter needs to present a clear, logical and an easy to follow narrative – and that requires some planning. Don’t try to wing it!

Naturally, you won’t always follow the plan to the letter, but without a detailed outline, you’re more than likely going to end up with a disjointed pile of waffle , and then you’re going to spend a far greater amount of time re-writing, hacking and patching. The adage, “measure twice, cut once” is very suitable here.

In terms of structure, the first decision you’ll have to make is whether you’ll lay out your review thematically (into themes) or chronologically (by date/period). The right choice depends on your topic, research objectives and research questions, which we discuss in this article .

Once that’s decided, you need to draw up an outline of your entire chapter in bullet point format. Try to get as detailed as possible, so that you know exactly what you’ll cover where, how each section will connect to the next, and how your entire argument will develop throughout the chapter. Also, at this stage, it’s a good idea to allocate rough word count limits for each section, so that you can identify word count problems before you’ve spent weeks or months writing!

PS – check out our free literature review chapter template…

3.2 – Get writing

With a detailed outline at your side, it’s time to start writing up (finally!). At this stage, it’s common to feel a bit of writer’s block and find yourself procrastinating under the pressure of finally having to put something on paper. To help with this, remember that the objective of the first draft is not perfection – it’s simply to get your thoughts out of your head and onto paper, after which you can refine them. The structure might change a little, the word count allocations might shift and shuffle, and you might add or remove a section – that’s all okay. Don’t worry about all this on your first draft – just get your thoughts down on paper.

Once you’ve got a full first draft (however rough it may be), step away from it for a day or two (longer if you can) and then come back at it with fresh eyes. Pay particular attention to the flow and narrative – does it fall fit together and flow from one section to another smoothly? Now’s the time to try to improve the linkage from each section to the next, tighten up the writing to be more concise, trim down word count and sand it down into a more digestible read.

Once you’ve done that, give your writing to a friend or colleague who is not a subject matter expert and ask them if they understand the overall discussion. The best way to assess this is to ask them to explain the chapter back to you. This technique will give you a strong indication of which points were clearly communicated and which weren’t. If you’re working with Grad Coach, this is a good time to have your Research Specialist review your chapter.

Finally, tighten it up and send it off to your supervisor for comment. Some might argue that you should be sending your work to your supervisor sooner than this (indeed your university might formally require this), but in my experience, supervisors are extremely short on time (and often patience), so, the more refined your chapter is, the less time they’ll waste on addressing basic issues (which you know about already) and the more time they’ll spend on valuable feedback that will increase your mark-earning potential.

Literature Review Example

In the video below, we unpack an actual literature review so that you can see how all the core components come together in reality.

Let’s Recap

In this post, we’ve covered how to research and write up a high-quality literature review chapter. Let’s do a quick recap of the key takeaways:

• It is essential to understand the WHY of the literature review before you read or write anything. Make sure you understand the 4 core functions of the process.
• The first step is to hunt down the relevant literature . You can do this using Google Scholar, your university database, the snowballing technique and by reviewing other dissertations and theses.
• Next, you need to log all the articles in your reference manager , build your own catalogue of literature and synthesise all the research.
• Following that, you need to develop a detailed outline of your entire chapter – the more detail the better. Don’t start writing without a clear outline (on paper, not in your head!)
• Write up your first draft in rough form – don’t aim for perfection. Remember, done beats perfect.
• Refine your second draft and get a layman’s perspective on it . Then tighten it up and submit it to your supervisor.

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 .

You Might Also Like:

38 Comments

Thank you very much. This page is an eye opener and easy to comprehend.

This is awesome!

I wish I come across GradCoach earlier enough.

But all the same I’ll make use of this opportunity to the fullest.

Thank you for this good job.

Keep it up!

You’re welcome, Yinka. Thank you for the kind words. All the best writing your literature review.

Thank you for a very useful literature review session. Although I am doing most of the steps…it being my first masters an Mphil is a self study and one not sure you are on the right track. I have an amazing supervisor but one also knows they are super busy. So not wanting to bother on the minutae. Thank you.

You’re most welcome, Renee. Good luck with your literature review 🙂

This has been really helpful. Will make full use of it. 🙂

Thank you Gradcoach.

Really agreed. Admirable effort

thank you for this beautiful well explained recap.

Thank you so much for your guide of video and other instructions for the dissertation writing.

It is instrumental. It encouraged me to write a dissertation now.

Thank you the video was great – from someone that knows nothing thankyou

an amazing and very constructive way of presetting a topic, very useful, thanks for the effort,

It is timely

It is very good video of guidance for writing a research proposal and a dissertation. Since I have been watching and reading instructions, I have started my research proposal to write. I appreciate to Mr Jansen hugely.

I learn a lot from your videos. Very comprehensive and detailed.

Thank you for sharing your knowledge. As a research student, you learn better with your learning tips in research

I was really stuck in reading and gathering information but after watching these things are cleared thanks, it is so helpful.

Really helpful, Thank you for the effort in showing such information

This is super helpful thank you very much.

Thank you for this whole literature writing review.You have simplified the process.

I’m so glad I found GradCoach. Excellent information, Clear explanation, and Easy to follow, Many thanks Derek!

You’re welcome, Maithe. Good luck writing your literature review 🙂

Thank you Coach, you have greatly enriched and improved my knowledge

Great piece, so enriching and it is going to help me a great lot in my project and thesis, thanks so much

This is THE BEST site for ANYONE doing a masters or doctorate! Thank you for the sound advice and templates. You rock!

Thanks, Stephanie 🙂

This is mind blowing, the detailed explanation and simplicity is perfect.

I am doing two papers on my final year thesis, and I must stay I feel very confident to face both headlong after reading this article.

thank you so much.

if anyone is to get a paper done on time and in the best way possible, GRADCOACH is certainly the go to area!

This is very good video which is well explained with detailed explanation

Thank you excellent piece of work and great mentoring

Thanks, it was useful

Thank you very much. the video and the information were very helpful.

Good morning scholar. I’m delighted coming to know you even before the commencement of my dissertation which hopefully is expected in not more than six months from now. I would love to engage my study under your guidance from the beginning to the end. I love to know how to do good job

Thank you so much Derek for such useful information on writing up a good literature review. I am at a stage where I need to start writing my one. My proposal was accepted late last year but I honestly did not know where to start

Like the name of your YouTube implies you are GRAD (great,resource person, about dissertation). In short you are smart enough in coaching research work.

This is a very well thought out webpage. Very informative and a great read.

Very timely.

I appreciate.

Very comprehensive and eye opener for me as beginner in postgraduate study. Well explained and easy to understand. Appreciate and good reference in guiding me in my research journey. Thank you

Thank you. I requested to download the free literature review template, however, your website wouldn’t allow me to complete the request or complete a download. May I request that you email me the free template? Thank you.

Submit a Comment Cancel reply

Your email address will not be published. Required fields are marked *

Save my name, email, and website in this browser for the next time I comment.

• Print Friendly

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• CAREER FEATURE
• 04 December 2020
• Correction 09 December 2020

How to write a superb literature review

Andy Tay is a freelance writer based in Singapore.

You can also search for this author in PubMed   Google Scholar

Literature reviews are important resources for scientists. They provide historical context for a field while offering opinions on its future trajectory. Creating them can provide inspiration for one’s own research, as well as some practice in writing. But few scientists are trained in how to write a review — or in what constitutes an excellent one. Even picking the appropriate software to use can be an involved decision (see ‘Tools and techniques’). So Nature asked editors and working scientists with well-cited reviews for their tips.

Access options

Access Nature and 54 other Nature Portfolio journals

Get Nature+, our best-value online-access subscription

24,99 € / 30 days

cancel any time

Subscribe to this journal

Receive 51 print issues and online access

185,98 € per year

only 3,65 € per issue

Rent or buy this article

Prices vary by article type

Prices may be subject to local taxes which are calculated during checkout

doi: https://doi.org/10.1038/d41586-020-03422-x

Interviews have been edited for length and clarity.

Updates & Corrections

Correction 09 December 2020 : An earlier version of the tables in this article included some incorrect details about the programs Zotero, Endnote and Manubot. These have now been corrected.

Hsing, I.-M., Xu, Y. & Zhao, W. Electroanalysis 19 , 755–768 (2007).

Article   Google Scholar  

Ledesma, H. A. et al. Nature Nanotechnol. 14 , 645–657 (2019).

Article   PubMed   Google Scholar  

Brahlek, M., Koirala, N., Bansal, N. & Oh, S. Solid State Commun. 215–216 , 54–62 (2015).

Choi, Y. & Lee, S. Y. Nature Rev. Chem . https://doi.org/10.1038/s41570-020-00221-w (2020).

Download references

Related Articles

• Research management

Africa’s postdoc workforce is on the rise — but at what cost?

Career Feature 02 APR 24

Impact factors are outdated, but new research assessments still fail scientists

World View 02 APR 24

How scientists are making the most of Reddit

Career Feature 01 APR 24

Adopt universal standards for study adaptation to boost health, education and social-science research

Correspondence 02 APR 24

How can we make PhD training fit for the modern world? Broaden its philosophical foundations

Allow researchers with caring responsibilities ‘promotion pauses’ to make research more equitable

Will the Gates Foundation’s preprint-centric policy help open access?

News 04 APR 24

The corpse of an exploded star and more — March’s best science images

News 28 MAR 24

How papers with doctored images can affect scientific reviews

High-Level Talents at the First Affiliated Hospital of Nanchang University

For clinical medicine and basic medicine; basic research of emerging inter-disciplines and medical big data.

Nanchang, Jiangxi, China

The First Affiliated Hospital of Nanchang University

POSTDOCTORAL Fellow -- DEPARTMENT OF Surgery – BIDMC, Harvard Medical School

The Division of Urologic Surgery in the Department of Surgery at Beth Israel Deaconess Medical Center and Harvard Medical School invites applicatio...

Boston, Massachusetts (US)

Director of Research

Applications are invited for the post of Director of Research at Cancer Institute (WIA), Chennai, India.

Chennai, Tamil Nadu (IN)

Cancer Institute (W.I.A)

Postdoctoral Fellow in Human Immunology (wet lab)

Join Atomic Lab in Boston as a postdoc in human immunology for universal flu vaccine project. Expertise in cytometry, cell sorting, scRNAseq.

Boston University Atomic Lab

Research Associate - Neuroscience and Respiratory Physiology

Houston, Texas (US)

Baylor College of Medicine (BCM)

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

Have a language expert improve your writing

Run a free plagiarism check in 10 minutes, automatically generate references for free.

• Knowledge Base
• Dissertation
• 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.

Instantly correct all language mistakes in your text

Be assured that you'll submit flawless writing. Upload your document to correct all your mistakes.

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.

The only proofreading tool specialized in correcting academic writing

The academic proofreading tool has been trained on 1000s of academic texts and by native English editors. Making it the most accurate and reliable proofreading tool for students.

Correct my document today

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 .

Cite this Scribbr article

If you want to cite this source, you can copy and paste the citation or click the ‘Cite this Scribbr article’ button to automatically add the citation to our free Reference Generator.

McCombes, S. (2022, June 07). What is a Literature Review? | Guide, Template, & Examples. Scribbr. Retrieved 2 April 2024, from https://www.scribbr.co.uk/thesis-dissertation/literature-review/

Is this article helpful?

Shona McCombes

Other students also liked, how to write a dissertation proposal | a step-by-step guide, what is a theoretical framework | a step-by-step guide, what is a research methodology | steps & tips.

• Essay Guide
• Alex Essay Writing Tool
• Dissertation Guide
• Ask The Elephant

The structure of a literature review

A literature review should be structured like any other essay: it should have an introduction, a middle or main body, and a conclusion.

Introduction

The introduction should:

• define your topic and provide an appropriate context for reviewing the literature;
• establish your reasons – i.e. point of view – for
• reviewing the literature;
• explain the organisation – i.e. sequence – of the review;
• state the scope of the review – i.e. what is included and what isn’t included. For example, if you were reviewing the literature on obesity in children you might say something like: There are a large number of studies of obesity trends in the general population. However, since the focus of this research is on obesity in children, these will not be reviewed in detail and will only be referred to as appropriate.

The middle or main body should:

• organise the literature according to common themes;
• provide insight into the relation between your chosen topic and the wider subject area e.g. between obesity in children and obesity in general;
• move from a general, wider view of the literature being reviewed to the specific focus of your research.

The conclusion should:

• summarise the important aspects of the existing body of literature;
• evaluate the current state of the literature reviewed;
• identify significant flaws or gaps in existing knowledge;
• outline areas for future study;
• link your research to existing knowledge.

Privacy Overview

• USC Libraries
• Research Guides

Organizing Your Social Sciences Research Paper

• 5. The Literature Review
• Purpose of Guide
• Design Flaws to Avoid
• Independent and Dependent Variables
• Glossary of Research Terms
• Reading Research Effectively
• Narrowing a Topic Idea
• Broadening a Topic Idea
• Extending the Timeliness of a Topic Idea
• Academic Writing Style
• Choosing a Title
• Making an Outline
• Paragraph Development
• Research Process Video Series
• Executive Summary
• The C.A.R.S. Model
• Background Information
• The Research Problem/Question
• Theoretical Framework
• Citation Tracking
• Content Alert Services
• Evaluating Sources
• Primary Sources
• Secondary Sources
• Tiertiary Sources
• Scholarly vs. Popular Publications
• Qualitative Methods
• Quantitative Methods
• Insiderness
• Using Non-Textual Elements
• Limitations of the Study
• Common Grammar Mistakes
• Writing Concisely
• Avoiding Plagiarism
• Footnotes or Endnotes?
• Further Readings
• Generative AI and Writing
• USC Libraries Tutorials and Other Guides
• Bibliography

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.

• << Previous: Theoretical Framework
• Next: Citation Tracking >>
• Last Updated: Apr 5, 2024 1:38 PM
• URL: https://libguides.usc.edu/writingguide

How to Write a Literature Review

What is a literature review.

• What Is the Literature
• Writing the Review

A literature review is much more than an annotated bibliography or a list of separate reviews of articles and books. It is a critical, analytical summary and synthesis of the current knowledge of a topic. Thus it should compare and relate different theories, findings, etc, rather than just summarize them individually. In addition, it should have a particular focus or theme to organize the review. It does not have to be an exhaustive account of everything published on the topic, but it should discuss all the significant academic literature and other relevant sources important for that focus.

This is meant to be a general guide to writing a literature review: ways to structure one, what to include, how it supplements other research. For more specific help on writing a review, and especially for help on finding the literature to review, sign up for a Personal Research Session .

The specific organization of a literature review depends on the type and purpose of the review, as well as on the specific field or topic being reviewed. But in general, it is a relatively brief but thorough exploration of past and current work on a topic. Rather than a chronological listing of previous work, though, literature reviews are usually organized thematically, such as different theoretical approaches, methodologies, or specific issues or concepts involved in the topic. A thematic organization makes it much easier to examine contrasting perspectives, theoretical approaches, methodologies, findings, etc, and to analyze the strengths and weaknesses of, and point out any gaps in, previous research. And this is the heart of what a literature review is about. A literature review may offer new interpretations, theoretical approaches, or other ideas; if it is part of a research proposal or report it should demonstrate the relationship of the proposed or reported research to others' work; but whatever else it does, it must provide a critical overview of the current state of research efforts. 

Literature reviews are common and very important in the sciences and social sciences. They are less common and have a less important role in the humanities, but they do have a place, especially stand-alone reviews.

Types of Literature Reviews

There are different types of literature reviews, and different purposes for writing a review, but the most common are:

• Stand-alone literature review articles . These provide an overview and analysis of the current state of research on a topic or question. The goal is to evaluate and compare previous research on a topic to provide an analysis of what is currently known, and also to reveal controversies, weaknesses, and gaps in current work, thus pointing to directions for future research. You can find examples published in any number of academic journals, but there is a series of Annual Reviews of *Subject* which are specifically devoted to literature review articles. Writing a stand-alone review is often an effective way to get a good handle on a topic and to develop ideas for your own research program. For example, contrasting theoretical approaches or conflicting interpretations of findings can be the basis of your research project: can you find evidence supporting one interpretation against another, or can you propose an alternative interpretation that overcomes their limitations?
• Part of a research proposal . This could be a proposal for a PhD dissertation, a senior thesis, or a class project. It could also be a submission for a grant. The literature review, by pointing out the current issues and questions concerning a topic, is a crucial part of demonstrating how your proposed research will contribute to the field, and thus of convincing your thesis committee to allow you to pursue the topic of your interest or a funding agency to pay for your research efforts.
• Part of a research report . When you finish your research and write your thesis or paper to present your findings, it should include a literature review to provide the context to which your work is a contribution. Your report, in addition to detailing the methods, results, etc. of your research, should show how your work relates to others' work.

A literature review for a research report is often a revision of the review for a research proposal, which can be a revision of a stand-alone review. Each revision should be a fairly extensive revision. With the increased knowledge of and experience in the topic as you proceed, your understanding of the topic will increase. Thus, you will be in a better position to analyze and critique the literature. In addition, your focus will change as you proceed in your research. Some areas of the literature you initially reviewed will be marginal or irrelevant for your eventual research, and you will need to explore other areas more thoroughly. 

Examples of Literature Reviews

See the series of Annual Reviews of *Subject* which are specifically devoted to literature review articles to find many examples of stand-alone literature reviews in the biomedical, physical, and social sciences. 

Research report articles vary in how they are organized, but a common general structure is to have sections such as:

• Abstract - Brief summary of the contents of the article
• Introduction - A explanation of the purpose of the study, a statement of the research question(s) the study intends to address
• Literature review - A critical assessment of the work done so far on this topic, to show how the current study relates to what has already been done
• Methods - How the study was carried out (e.g. instruments or equipment, procedures, methods to gather and analyze data)
• Results - What was found in the course of the study
• Discussion - What do the results mean
• Conclusion - State the conclusions and implications of the results, and discuss how it relates to the work reviewed in the literature review; also, point to directions for further work in the area

Here are some articles that illustrate variations on this theme. There is no need to read the entire articles (unless the contents interest you); just quickly browse through to see the sections, and see how each section is introduced and what is contained in them.

The Determinants of Undergraduate Grade Point Average: The Relative Importance of Family Background, High School Resources, and Peer Group Effects , in The Journal of Human Resources , v. 34 no. 2 (Spring 1999), p. 268-293.

This article has a standard breakdown of sections:

• Introduction
• Literature Review
• Some discussion sections

First Encounters of the Bureaucratic Kind: Early Freshman Experiences with a Campus Bureaucracy , in The Journal of Higher Education , v. 67 no. 6 (Nov-Dec 1996), p. 660-691.

This one does not have a section specifically labeled as a "literature review" or "review of the literature," but the first few sections cite a long list of other sources discussing previous research in the area before the authors present their own study they are reporting.

• Next: What Is the Literature >>
• Last Updated: Jan 11, 2024 9:48 AM
• URL: https://libguides.wesleyan.edu/litreview

• Resources Home 🏠
• Try SciSpace Copilot
• Search research papers
• Add Copilot Extension
• Try AI Detector
• Try Paraphraser
• Try Citation Generator
• April Papers
• June Papers
• July Papers

How to Structure Your Literature Review - Quick Guide with Examples

Table of Contents

A literature review is a process of reviewing the existing scholarly literature based on a specific topic. It is one of the critical components of your own research paper. By conducting a thorough literature review, you will get a synopsis of the relevant methods, theories, and research gaps of the existing research on the related topic.

However, writing a good literature review is not as easy as it sounds. It requires rigorous research and extensive exploration of hundreds of journal articles to land on the pertinent information. So, it’s essential to learn the components of a literature review structure before you start writing one.

That’s why this article exists — to help you understand how to structure a literature review in a research paper. Read through the article to get the gist of the components used and how to structure them.

Role of literature review structure in research

Why do you think structuring your literature review is crucial in your research? It plays a significant role in organizing and presenting the research evidence and information effectively to the readers.

A well-structured literature review ensures clarity and coherence in the research which enables readers to follow the logical flow of ideas. It helps researchers to logically present their arguments and findings, making it easier for readers to comprehend the research's context and contribution.

Furthermore, it aids in identifying relationships between diverse studies, identifying key themes, and highlighting any research gaps. In fact, one of the prominent reasons why the proper format of a literature review is important is that it provides a framework for the researchers to present their ideas in a systematic and organized sequence.

Overall, a well structured literature review provides a roadmap for readers to navigate through the existing research or existing knowledge. By clearly indicating the main sections and sub-sections of the research, readers can easily locate the information they are interested in.

It is essential for researchers who are conducting a literature review to gain an overview of a specific topic or to find relevant studies and build a concrete framework for their research.

When should I structure my literature review?

Writing and structuring a literature review imparts the required knowledge to the readers only when you do it at the right time. So, be sure to map out the structure after you conduct a thorough literature review of the existing sources.

You should structure the review once you’re done with reading and digesting the research papers and before you start writing your thesis, dissertation, or research paper. It bridges the gap between reviewing literature and writing a research paper.

In simpler words, once you’ve comprehended the existing literature and gained enough knowledge of the theories, key concepts, and research gaps of your study or topic, you will be in a position to map out a literature review structure. It gives you a boost to set the stage for your research paper writing. Once the structure is ready, you can reiterate or restructure it based on the flow of your research work.

Tip: Use SciSpace Literature Review to compare and contrast multiple research papers on a single screen, saving a significant amount of time. And to comprehend the research papers easily, utilize Copilot which explains even the most complicated nomenclature and context in the simplest way possible. Above all, these tools support 75+ languages making your literature review and research paper reading a breeze.

How to structure a literature review?

A literature review is also one of the chapters or sections in your research paper. The structure varies from one study to another depending on diverse factors. However, a typical structure of a literature review has 3 main parts — an introduction, a body, and a conclusion. Let's get into them in detail.

a) Introduction of the literature review

The literature review introduction should give the readers an overview of what will you cover in the study and how the study is correlated. Ideally, it should provide the outline of your research and also explain the scope of your literature review. The introduction section is the most suitable segment to share your stance or perspective about the research topic and gently convey your contributions to the field through this study.

Since it happens to be the first paragraph, you must include and define its purpose, organization, and critical aspects of your research project.

Your introduction should give the following relevant background information to the readers:

• The “why” of the review? — should provide a reason for why you’re writing the review
• The “takeaway” of the review? — should portray the importance of the research
• Articulate the topics covered in the research in a sequential manner
• “What” of the review? — scope of the review
• How or where your topic is aligned with the niche or subject area

b) Body of the literature reviews

The format and structure of the central body part are of utmost importance in writing a good literature review.. This is the section where you summarize, synthesize, analyze, and critically evaluate your research work. Therefore, you must use sections and subsections to divide the body for each methodological approach or theme aspect of further research.

In this part, you will have to organize and present your discussion in a clear and coherent manner. There are different types of structural approaches to adhere to while organizing the main body part of the literature review. Let’s explore the types based on the length and format of your review.

i) Chronological literature reviews

The chronological approach to building literature review format has been described as one of the most straightforward approaches. It helps you articulate the growth and development of the research topic over time in chronological order.

However, do not restrict yourself to just making a list or summarizing the reference resources. Instead, write a brief discussion and analysis of the critical arguments, research, and trends that have shaped the current status of your research topic.

Additionally, you must provide an interpretation of these events in your curated version. This approach gives you a space to discuss the latest developments, key debates, trends, and gaps focused on your research topic.

Example: Locoregional Management of Breast Cancer: A Chronological Review This chronological review discusses the evolution of locoregional management through some key clinical trials and aims to highlight important points in the time period in which the evidence was generated and emphasize the 10-year outcomes for the comparability of results. Source: SciSpace

ii) Thematic literature review

The thematic literature review is the best way to structure your literature review based on the theme or category of your research. The format of a literature review is structured in sections and sub-sections based on the observed themes or patterns in your review.

Every part stays dedicated to presenting a different aspect of your chosen topic. For example, if you’re working on a topic of climatic conditions in Nigeria, you might find themes such as monsoon climate, tropical savannah climate, and so on. Unlike the chronological approach, the primary focus here is on different aspects of a particular topic, or issue instead of the progression of certain events. Example: A Thematic Review of Current Literature Examining Evidence-Based Practices and Inclusion

This paper provides a thematic summary of current literature combining the topics of evidence-based practices (EBPs) and inclusive settings and summarizes key findings from 27 peer-reviewed articles written in English and published between 2012-2022.

Source: SciSpace

iii) Methodological literature review

The methodological approach helps you formulate the structure of a literature review based on the research methodologies used. These methodologies could be qualitative, quantitative, or mixed. You can present your literature review structure in a form by showing a comparison between crucial findings, gatherings, and outcomes from different research methods.

If you’re working on research derived from different disciplines and methodologies, this approach would be more suitable to structure your literature review. This method majorly focuses on the type of analysis method used in the research (quantitative, qualitative, and mixed).

Example: Methodological review to develop a list of bias items used to assess reviews incorporating network meta-analysis: protocol and rationale

The methodological review aims to develop a list of items relating to biases in reviews with NMA, which will inform a new tool to assess the risk of bias in NMAs, and potentially other reporting or quality checklists for NMAs that are being updated.

iv) Theoretical literature review

Theoretical literature reviews are often used to discuss and analyze vital concepts and theories. Adopting this approach such a way that, you can significantly put forth the relevance and critical findings of a particular field or theoretical method. Proceeding in the same way, you can also outline an entirely new research framework.

Example: Theoretical Review Study: Peran Dan Fungsi Mutu Pelayanan Kesehatan Di Rumah Sakit

This paper analyzes various theories on the role and function of quality management in hospitals, where the authors investigate how the role and functions of the quality of health services in hospitals.

c) Conclusion of the literature review

The conclusion of your literature review must be focused on your key findings, and their results, and an elaborate emphasis on the significance of all aspects. Describing the research gaps and your contributions can be helpful in case you are writing a dissertation or thesis.

Moreover, you must specify the procedure and research methodology for developing the framework of your research topic. Additionally, if the relevant literature review is a standalone assignment for you, present the conclusion centered on the implications and suggestions for future references.

Lastly, you must ensure that your research paper does not lack any critical aspects and must not contain any grammatical or spelling mistakes. For this, you must proofread and edit it to perfection.

Overall, your conclusion should provide the reader with the following information:

• Provide an overview of the literature review.
• Highlight key areas for future research on the topic.
• Establish a connection between the review and your research.

Tip: Keep this checklist handy before writing your literature review!

• Outline the purpose and scope of the study
• Identify relevant and credible scholarly sources (research papers/literature)
• Use AI tools to streamline the literature review process
• Capture the bibliographical details of the sources
• Analyze and interpret the findings
• Identify research gaps in the literature
• Investigate methodologies/theories/hypotheses
• Brainstorm and research multiple standpoints
• Craft an introduction, a body, and a conclusion
• Final proofreading and all set!!

Wrapping up!

If you are working on your thesis, ensure to emphasize structuring your literature reviews and be keen in presenting it in a clear, coherent, and organized manner. The structure of a literature review is critical as it assists researchers in building upon existing knowledge, creating a theoretical framework, identifying relationships between studies, highlighting key concepts, and guiding readers through the research.

Scientific research can be made more accessible, informative, and impactful by structuring the literature review according to the different types of approaches discussed in this blog.

Frequently Asked Questions

When conducting a literature review, it's important to avoid:

1.Disorganization: Keep your review structured and coherent.

2.Lack of alignment: Ensure that your review aligns with your research objectives and questions.

3.Lack of synthesis: Connect and integrate the findings from different sources rather than presenting them in isolation.

Common challenges we encounter while organizing a literature review include:

1.Managing an exhaustive volume of scientific publications.

2.Ensuring coherence and flow between different sections.

3.Striving to maintain objectivity and relevance to your research topic.

When structuring a literature review, you should avoid including irrelevant or outdated sources, biased information, and repetitive content.

No, a literature review is typically not arranged in alphabetical order. Instead, it's usually organized thematically, chronologically, or by relevance to the research topic.

Love using SciSpace tools? Enjoy discounts! Use SR40 (40% off yearly) and SR20 (20% off monthly). Claim yours here 👉 SciSpace Premium

You might also like

AI for Meta Analysis — A Comprehensive Guide

Cybersecurity in Higher Education: Safeguarding Students and Faculty Data

How To Write An Argumentative Essay

Academic Writing

• Strategies for Writing
• Punctuation
• Plagiarism & Self-Plagiarism

How to Build a Literature Review

• PRISMA - Systematic reviews & meta-analyses
• Other Resources
• Using Zotero for Bibliographies
• Abstract Writing Tips
• Writing Assistance
• Locating a Journal
• Assessing Potential Journals
• Finding a Publisher
• Types of Peer Review
• Author Rights & Responsibilities
• Copyright Considerations
• What is a Lit Review?
• Why Write a Lit Review?

Structure of a Literature Review

Preliminary steps for literature review.

• Basic Example
• More Examples

What is a Literature Review?

A literature review is a comprehensive summary and analysis of previously published research on a particular topic. Literature reviews should give the reader an overview of the important theories and themes that have previously been discussed on the topic, as well as any important researchers who have contributed to the discourse. This review should connect the established conclusions to the hypothesis being presented in the rest of the paper.

What a Literature Review Is Not:

• Annotated Bibliography: An annotated bibliography summarizes and assesses each resource individually and separately. A literature review explores the connections between different articles to illustrate important themes/theories/research trends within a larger research area. 
• Timeline: While a literature review can be organized chronologically, they are not simple timelines of previous events. They should not be a list of any kind. Individual examples or events should be combined to illustrate larger ideas or concepts.
• Argumentative Paper: Literature reviews are not meant to be making an argument. They are explorations of a concept to give the audience an understanding of what has already been written and researched about an idea. As many perspectives as possible should be included in a literature review in order to give the reader as comprehensive understanding of a topic as possible.

Why Write a Literature Review?

After reading the literature review, the reader should have a basic understanding of the topic. A reader should be able to come into your paper without really knowing anything about an idea, and after reading the literature, feel more confident about the important points.

A literature review should also help the reader understand the focus the rest of the paper will take within the larger topic. If the reader knows what has already been studied, they will be better prepared for the novel argument that is about to be made.

A literature review should help the reader understand the important history, themes, events, and ideas about a particular topic. Connections between ideas/themes should also explored. Part of the importance of a literature review is to prove to experts who do read your paper that you are knowledgeable enough to contribute to the academic discussion. You have to have done your homework.

A literature review should also identify the gaps in research to show the reader what hasn't yet been explored. Your thesis should ideally address one of the gaps identified in the research. Scholarly articles are meant to push academic conversations forward with new ideas and arguments. Before knowing where the gaps are in a topic, you need to have read what others have written.

As mentioned in other tabs, literature reviews should discuss the big ideas that make up a topic. Each literature review should be broken up into different subtopics. Each subtopic should use groups of articles as evidence to support the ideas. There are several different ways of organizing a literature review. It will depend on the patterns one sees in the groups of articles as to which strategy should be used. Here are a few examples of how to organize your review:

Chronological

If there are clear trends that change over time, a chronological approach could be used to organize a literature review. For example, one might argue that in the 1970s, the predominant theories and themes argued something. However, in the 1980s, the theories evolved to something else. Then, in the 1990s, theories evolved further. Each decade is a subtopic, and articles should be used as examples. 

Themes/Theories

There may also be clear distinctions between schools of thought within a topic, a theoretical breakdown may be most appropriate. Each theory could be a subtopic, and articles supporting the theme should be included as evidence for each one. 

If researchers mainly differ in the way they went about conducting research, literature reviews can be organized by methodology. Each type of method could be a subtopic,  and articles using the method should be included as evidence for each one.

• Define your research question
• Compile a list of initial keywords to use for searching based on question
• Search for literature that discusses the topics surrounding your research question
• Assess and organize your literature into logical groups
• Identify gaps in research and conduct secondary searches (if necessary)
• Reassess and reorganize literature again (if necessary)
• Write review

Here is an example of a literature review, taken from the beginning of a research article. You can find other examples within most scholarly research articles. The majority of published scholarship includes a literature review section, and you can use those to become more familiar with these reviews.

Source:  Perceptions of the Police by LGBT Communities

There are many books and internet resources about literature reviews though most are long on how to search and gather the literature. How to literally organize the information is another matter.

Some pro tips:

• Be thoughtful in naming the folders, sub-folders, and sub, sub-folders.  Doing so really helps your thinking and concepts within your research topic.
• Be disciplined to add keywords under the tabs as this will help you search for ALL the items on your concepts/topics.
• Use the notes tab to add reminders, write bibliography/annotated bibliography
• Your literature review easily flows from your statement of purpose (SoP).  Therefore, does your SoP say clearly and exactly the intent of your research?  Your research assumption and argument is obvious?
• Begin with a topic outline that traces your argument. pg99: "First establish the line of argumentation you will follow (the thesis), whether it is an assertion, a contention, or a proposition.
• This means that you should have formed judgments about the topic based on the analysis and synthesis of the literature you are reviewing."
• Keep filling it in; flushing it out more deeply with your references

Other Resources/Examples

• ISU Writing Assistance The Julia N. Visor Academic Center provides one-on-one writing assistance for any course or need. By focusing on the writing process instead of merely on grammar and editing, we are committed to making you a better writer.
• University of Toronto: The Literature Review Written by Dena Taylor, Health Sciences Writing Centre
• Purdue OWL - Writing a Lit Review Goes over the basic steps
• UW Madison Writing Center - Review of Literature A description of what each piece of a literature review should entail.
• USC Libraries - Literature Reviews Offers detailed guidance on how to develop, organize, and write a college-level research paper in the social and behavioral sciences.
• Creating the literature review: integrating research questions and arguments Blog post with very helpful overview for how to organize and build/integrate arguments in a literature review
• Understanding, Selecting, and Integrating a Theoretical Framework in Dissertation Research: Creating the Blueprint for Your “House” Article focusing on constructing a literature review for a dissertation. Still very relevant for literature reviews in other types of content.

A note that many of these examples will be far longer and in-depth than what's required for your assignment. However, they will give you an idea of the general structure and components of a literature review. Additionally, most scholarly articles will include a literature review section. Looking over the articles you have been assigned in classes will also help you.

• Understanding, Selecting, and Integrating a Theoretical Framework in Dissertation Research: Creating the Blueprint for Your “House” Excellent article detailing how to construct your literature review.
• Sample Literature Review (Univ. of Florida) This guide will provide research and writing tips to help students complete a literature review assignment.
• Sociology Literature Review (Univ. of Hawaii) Written in ASA citation style - don't follow this format.
• Sample Lit Review - Univ. of Vermont Includes an example with tips in the footnotes.

Attribution

Content on this page was provided by Grace Allbaugh

• << Previous: Writing a Literature Review
• Next: PRISMA - Systematic reviews & meta-analyses >>
• Last Updated: Dec 6, 2023 3:23 PM
• URL: https://guides.library.illinoisstate.edu/academicwriting

Additional Links

• Directions and Parking
• Accessibility Services
• Library Spaces
• Staff Directory

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 . 

Paperpal is an AI writing assistant that help academics write better, faster with real-time suggestions for in-depth language and grammar correction. Trained on millions of research manuscripts enhanced by professional academic editors, Paperpal delivers human precision at machine speed.  

Try it for free or upgrade to  Paperpal Prime , which unlocks unlimited access to premium features like academic translation, paraphrasing, contextual synonyms, consistency checks and more. It’s like always having a professional academic editor by your side! Go beyond limitations and experience the future of academic writing.  Get Paperpal Prime now at just US$19 a month!

Related Reads:

• Empirical Research: A Comprehensive Guide for Academics 
• How to Write a Scientific Paper in 10 Steps 
• Life Sciences Papers: 9 Tips for Authors Writing in Biological Sciences
• What is an Argumentative Essay? How to Write It (With Examples)

6 Tips for Post-Doc Researchers to Take Their Career to the Next Level

Self-plagiarism in research: what it is and how to avoid it, you may also like, how to use paperpal to generate emails &..., ai in education: it’s time to change the..., is it ethical to use ai-generated abstracts without..., do plagiarism checkers detect ai content, word choice problems: how to use the right..., how to avoid plagiarism when using generative ai..., what are journal guidelines on using generative ai..., types of plagiarism and 6 tips to avoid..., how to write an essay introduction (with examples)..., similarity checks: the author’s guide to plagiarism and....

• Writing well

How to write a literature review

• Starting well
• How to write an annotated bibliography
• How to write a case study response
• How to write a critique
• How to write an empirical article
• How to write an essay
• How to write a reflective task
• How to write a report
• Finishing well

Structure of a literature review

Determine your purpose.

Work out what you need to address in the literature review. What are you being asked to do in your literature review? What are you searching the literature to discover? Check your assignment question and your criteria sheet to know what to focus on.

Do an extensive search of the literature

Find out what has been written on the topic.

What kind of literature?

Select appropriate source material: Use a variety of academic or scholarly sources that are relevant, current and authoritative. An extensive review of relevant material will include — books, journal articles, reports, government documents, conference proceedings and web resources. The Library would be the best place to search for your sources.

How many resources?

The number of sources that you will be required to review will depend on what the literature review is for and how advanced you are in your studies. It could be from five sources at first year undergraduate level to more than fifty for a thesis. Your lecturer will advise you on these details.

Note the bibliographical details of your sources

Keep a note of the publication title, date, authors’ names, page numbers and publishers. These details will save you time later.

Read the literature

• Critically read each source, look for the arguments presented rather than for facts.
• Take notes as you read and start to organise your review around themes and ideas.
• Consider using a table, matrix or concept map to identify how the different sources relate to each other.

Analyse the literature you have found

In order for your writing to reflect strong critical analysis, you need to evaluate the sources. For each source you are reviewing ask yourself these questions:

• What are the key terms and concepts?
• How relevant is this article to my specific topic?
• What are the major relationships, trends and patterns?
• How has the author structured the arguments?
• How authoritative and credible is this source?
• What are the differences and similarities between the sources?
• Are there any gaps in the literature that require further study?

Write the review

• Start by writing your thesis statement. This is an important introductory sentence that will tell your reader what the topic is and the overall perspective or argument you will be presenting.
• Like essays, a literature review must have an introduction, a body and a conclusion.

Introduction

Your introduction should give an outline of:

• why you are writing a review, and why the topic is important
• the scope of the review — what aspects of the topic will be discussed
• the criteria used for your literature selection (e.g. type of sources used, date range)
• the organisational pattern of the review.

Body paragraphs

Each body paragraph should deal with a different theme that is relevant to your topic. You will need to synthesise several of your reviewed readings into each paragraph, so that there is a clear connection between the various sources. You will need to critically analyse each source for how they contribute to the themes you are researching.

The body could include paragraphs on:

• historical background
• methodologies
• previous studies on the topic
• mainstream versus alternative viewpoints
• principal questions being asked
• general conclusions that are being drawn.

Your conclusion should give a summary of:

• the main agreements and disagreements in the literature
• any gaps or areas for further research
• your overall perspective on the topic.
• outlined the purpose and scope?
• identified appropriate and credible (academic/scholarly) literature?
• recorded the bibliographical details of the sources?
• analysed and critiqued your readings?
• identified gaps in the literature and research?
• explored methodologies / theories / hypotheses / models?
• discussed the varying viewpoints?
• written an introduction, body and conclusion?
• checked punctuation and spelling?

Further information

• HiQ: Managing weekly readings
• HiQ: Notetaking
• HiQ: Structuring your assignment
• RMIT University: Literature review - Overview

Global links and information

• Referencing and using sources
• Background and development
• Changes to QUT cite|write
• Need more help?
• Current students
• Current staff
• TEQSA Provider ID: PRV12079 (Australian University)
• CRICOS No. 00213J
• ABN 83 791 724 622
• Last modified: 07-Mar-2023
• Accessibility
• Right to Information
• Feedback and suggestions

Acknowledgement of Traditional Owners

QUT acknowledges the Traditional Owners of the lands where QUT now stands.

• Franklin University |
• Help & Support |
• Locations & Maps |

• | Research Guides

To access Safari eBooks,

• Select not listed in the Select Your Institution drop down menu.
• Enter your Franklin email address and click Go
• click "Already a user? Click here" link
• Enter your Franklin email and the password you used to create your Safari account.

Continue Close

Literature Review

• Getting Started
• Framing the Literature Review

Literature Review Process

• Mistakes to Avoid & Additional Help

The structure of a literature review should include the following :

• 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 of 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)?
• 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/least convincing?
• Value  -- are the author's arguments and conclusions convincing? Does the work ultimately contribute in any significant way to an understanding of the subject?

Development of the Literature Review

Four stages:.

• Introduce the reader to the importance of the topic being studied . The reader is oriented to the significance of the study and the research questions or hypotheses to follow.
• Places the problem into a particular context  that defines the parameters of what is to be investigated.
• Provides the framework for reporting the results  and indicates what is probably necessary to conduct the study and explain how the findings will present this information.
• Literature search -- finding materials relevant to the subject being explored.
• Evaluation of resources  -- determining which literature makes a significant contribution to the understanding of the topic.
• Analysis and interpretation -- discussing the findings and conclusions of pertinent literature.

Consider the following issues before writing the literature review:

Sources and expectations.  if your assignment is not very specific about what form your literature review should take, seek clarification from your professor by asking these questions:.

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

Find Models.   When reviewing the current literature, examine how authors in your discipline or area of interest have organized their literature reviews. Read not only for information, but also to get a sense of the types of themes you might want to look for in your own research review.

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., consider whether your sources are current and applicable.  s ome disciplines require that you use information that is as current as possible. this is very common in the sciences where research conducted only two years ago could be obsolete. however, when writing a review in the social sciences, a survey of the history of the literature may be what is needed because what is important is how perspectives have changed over 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 consider by scholars to be a "hot topic" and what is not., follow the bread crumb trail.  the bibliography or reference section of sources you read are excellent entry points for further exploration. you might find resourced listed in a bibliography that points you in the direction you wish to take your own research., ways to organize your literature review, chronologically:  .

If your review follows the chronological method, you could write about the materials according to when they were published or the time period they cover.

By Publication:  

Order your sources chronologically by publication date, 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.

Conceptual Categories:

The literature review is 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 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 will still be organized chronologically reflecting technological developments in media. The only difference here between a "chronological" and a "thematic" approach is what is emphasized the most.

Methodological:  

A methodological approach focuses on the methods utilized by the researcher.  A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed.

Sections of Your Literature Review:  

Once you've decided on the organizational method for your literature review, the sections you need to include should be easy to figure out because they arise from your organizational strategy.

Here are examples of other sections you may need to include depending on the type of review you write:

• 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.
• Selection Methods : the 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 articles and journals.
• Standards : 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?

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 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 research problem, whether it is thematic, methodological, or chronological.

Use Quotes Sparingly:  

Some short quotes are okay if you want to emphasize a point, or if what the author said just cannot be rewritten in your own words. Sometimes you may need to quote certain terms that were coined by the author, not common knowledge, or taken directly from the study. Do not use extensive quotes as a substitute your own summary and interpretation of the literature.

Summarize and Synthesize:  

Remember to summarize and synthesize your sources within each 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 their own work.

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.

• << Previous: Getting Started
• Next: Mistakes to Avoid & Additional Help >>
• Last Updated: Oct 3, 2023 2:44 PM
• URL: https://guides.franklin.edu/LITREVIEW

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• J Grad Med Educ
• 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.

Log in using your username and password

• Search More Search for this keyword Advanced search
• Latest content
• Current issue
• Write for Us
• BMJ Journals More You are viewing from: Google Indexer

You are here

• Volume 24, Issue 2
• Five tips for developing useful literature summary tables for writing review articles
• Article Text
• Article info
• Citation Tools
• Rapid Responses
• Article metrics

• http://orcid.org/0000-0003-0157-5319 Ahtisham Younas 1 , 2 ,
• http://orcid.org/0000-0002-7839-8130 Parveen Ali 3 , 4
• 1 Memorial University of Newfoundland , St John's , Newfoundland , Canada
• 2 Swat College of Nursing , Pakistan
• 3 School of Nursing and Midwifery , University of Sheffield , Sheffield , South Yorkshire , UK
• 4 Sheffield University Interpersonal Violence Research Group , Sheffield University , Sheffield , UK
• Correspondence to Ahtisham Younas, Memorial University of Newfoundland, St John's, NL A1C 5C4, Canada; ay6133{at}mun.ca

https://doi.org/10.1136/ebnurs-2021-103417

Statistics from Altmetric.com

Request permissions.

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Introduction

Literature reviews offer a critical synthesis of empirical and theoretical literature to assess the strength of evidence, develop guidelines for practice and policymaking, and identify areas for future research. 1 It is often essential and usually the first task in any research endeavour, particularly in masters or doctoral level education. For effective data extraction and rigorous synthesis in reviews, the use of literature summary tables is of utmost importance. A literature summary table provides a synopsis of an included article. It succinctly presents its purpose, methods, findings and other relevant information pertinent to the review. The aim of developing these literature summary tables is to provide the reader with the information at one glance. Since there are multiple types of reviews (eg, systematic, integrative, scoping, critical and mixed methods) with distinct purposes and techniques, 2 there could be various approaches for developing literature summary tables making it a complex task specialty for the novice researchers or reviewers. Here, we offer five tips for authors of the review articles, relevant to all types of reviews, for creating useful and relevant literature summary tables. We also provide examples from our published reviews to illustrate how useful literature summary tables can be developed and what sort of information should be provided.

Tip 1: provide detailed information about frameworks and methods

• Download figure
• Open in new tab
• Download powerpoint

Tabular literature summaries from a scoping review. Source: Rasheed et al . 3

The provision of information about conceptual and theoretical frameworks and methods is useful for several reasons. First, in quantitative (reviews synthesising the results of quantitative studies) and mixed reviews (reviews synthesising the results of both qualitative and quantitative studies to address a mixed review question), it allows the readers to assess the congruence of the core findings and methods with the adapted framework and tested assumptions. In qualitative reviews (reviews synthesising results of qualitative studies), this information is beneficial for readers to recognise the underlying philosophical and paradigmatic stance of the authors of the included articles. For example, imagine the authors of an article, included in a review, used phenomenological inquiry for their research. In that case, the review authors and the readers of the review need to know what kind of (transcendental or hermeneutic) philosophical stance guided the inquiry. Review authors should, therefore, include the philosophical stance in their literature summary for the particular article. Second, information about frameworks and methods enables review authors and readers to judge the quality of the research, which allows for discerning the strengths and limitations of the article. For example, if authors of an included article intended to develop a new scale and test its psychometric properties. To achieve this aim, they used a convenience sample of 150 participants and performed exploratory (EFA) and confirmatory factor analysis (CFA) on the same sample. Such an approach would indicate a flawed methodology because EFA and CFA should not be conducted on the same sample. The review authors must include this information in their summary table. Omitting this information from a summary could lead to the inclusion of a flawed article in the review, thereby jeopardising the review’s rigour.

Tip 2: include strengths and limitations for each article

Critical appraisal of individual articles included in a review is crucial for increasing the rigour of the review. Despite using various templates for critical appraisal, authors often do not provide detailed information about each reviewed article’s strengths and limitations. Merely noting the quality score based on standardised critical appraisal templates is not adequate because the readers should be able to identify the reasons for assigning a weak or moderate rating. Many recent critical appraisal checklists (eg, Mixed Methods Appraisal Tool) discourage review authors from assigning a quality score and recommend noting the main strengths and limitations of included studies. It is also vital that methodological and conceptual limitations and strengths of the articles included in the review are provided because not all review articles include empirical research papers. Rather some review synthesises the theoretical aspects of articles. Providing information about conceptual limitations is also important for readers to judge the quality of foundations of the research. For example, if you included a mixed-methods study in the review, reporting the methodological and conceptual limitations about ‘integration’ is critical for evaluating the study’s strength. Suppose the authors only collected qualitative and quantitative data and did not state the intent and timing of integration. In that case, the strength of the study is weak. Integration only occurred at the levels of data collection. However, integration may not have occurred at the analysis, interpretation and reporting levels.

Tip 3: write conceptual contribution of each reviewed article

While reading and evaluating review papers, we have observed that many review authors only provide core results of the article included in a review and do not explain the conceptual contribution offered by the included article. We refer to conceptual contribution as a description of how the article’s key results contribute towards the development of potential codes, themes or subthemes, or emerging patterns that are reported as the review findings. For example, the authors of a review article noted that one of the research articles included in their review demonstrated the usefulness of case studies and reflective logs as strategies for fostering compassion in nursing students. The conceptual contribution of this research article could be that experiential learning is one way to teach compassion to nursing students, as supported by case studies and reflective logs. This conceptual contribution of the article should be mentioned in the literature summary table. Delineating each reviewed article’s conceptual contribution is particularly beneficial in qualitative reviews, mixed-methods reviews, and critical reviews that often focus on developing models and describing or explaining various phenomena. Figure 2 offers an example of a literature summary table. 4

Tabular literature summaries from a critical review. Source: Younas and Maddigan. 4

Tip 4: compose potential themes from each article during summary writing

While developing literature summary tables, many authors use themes or subthemes reported in the given articles as the key results of their own review. Such an approach prevents the review authors from understanding the article’s conceptual contribution, developing rigorous synthesis and drawing reasonable interpretations of results from an individual article. Ultimately, it affects the generation of novel review findings. For example, one of the articles about women’s healthcare-seeking behaviours in developing countries reported a theme ‘social-cultural determinants of health as precursors of delays’. Instead of using this theme as one of the review findings, the reviewers should read and interpret beyond the given description in an article, compare and contrast themes, findings from one article with findings and themes from another article to find similarities and differences and to understand and explain bigger picture for their readers. Therefore, while developing literature summary tables, think twice before using the predeveloped themes. Including your themes in the summary tables (see figure 1 ) demonstrates to the readers that a robust method of data extraction and synthesis has been followed.

Tip 5: create your personalised template for literature summaries

Often templates are available for data extraction and development of literature summary tables. The available templates may be in the form of a table, chart or a structured framework that extracts some essential information about every article. The commonly used information may include authors, purpose, methods, key results and quality scores. While extracting all relevant information is important, such templates should be tailored to meet the needs of the individuals’ review. For example, for a review about the effectiveness of healthcare interventions, a literature summary table must include information about the intervention, its type, content timing, duration, setting, effectiveness, negative consequences, and receivers and implementers’ experiences of its usage. Similarly, literature summary tables for articles included in a meta-synthesis must include information about the participants’ characteristics, research context and conceptual contribution of each reviewed article so as to help the reader make an informed decision about the usefulness or lack of usefulness of the individual article in the review and the whole review.

In conclusion, narrative or systematic reviews are almost always conducted as a part of any educational project (thesis or dissertation) or academic or clinical research. Literature reviews are the foundation of research on a given topic. Robust and high-quality reviews play an instrumental role in guiding research, practice and policymaking. However, the quality of reviews is also contingent on rigorous data extraction and synthesis, which require developing literature summaries. We have outlined five tips that could enhance the quality of the data extraction and synthesis process by developing useful literature summaries.

• Aromataris E ,
• Rasheed SP ,

Twitter @Ahtisham04, @parveenazamali

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Read the full text or download the PDF:

• Open access
• Published: 05 December 2023

A scoping review to identify and organize literature trends of bias research within medical student and resident education

• Brianne E. Lewis 1 &
• Akshata R. Naik 2  

BMC Medical Education volume  23 , Article number:  919 ( 2023 ) Cite this article

816 Accesses

1 Citations

2 Altmetric

Metrics details

Physician bias refers to the unconscious negative perceptions that physicians have of patients or their conditions. Medical schools and residency programs often incorporate training to reduce biases among their trainees. In order to assess trends and organize available literature, we conducted a scoping review with a goal to categorize different biases that are studied within medical student (MS), resident (Res) and mixed populations (MS and Res). We also characterized these studies based on their research goal as either documenting evidence of bias (EOB), bias intervention (BI) or both. These findings will provide data which can be used to identify gaps and inform future work across these criteria.

Online databases (PubMed, PsycINFO, WebofScience) were searched for articles published between 1980 and 2021. All references were imported into Covidence for independent screening against inclusion criteria. Conflicts were resolved by deliberation. Studies were sorted by goal: ‘evidence of bias’ and/or ‘bias intervention’, and by population (MS or Res or mixed) andinto descriptive categories of bias.

Of the initial 806 unique papers identified, a total of 139 articles fit the inclusion criteria for data extraction. The included studies were sorted into 11 categories of bias and showed that bias against race/ethnicity, specific diseases/conditions, and weight were the most researched topics. Of the studies included, there was a higher ratio of EOB:BI studies at the MS level. While at the Res level, a lower ratio of EOB:BI was found.

Conclusions

This study will be of interest to institutions, program directors and medical educators who wish to specifically address a category of bias and identify where there is a dearth of research. This study also underscores the need to introduce bias interventions at the MS level.

Peer Review reports

Physician bias ultimately impacts patient care by eroding the physician–patient relationship [ 1 , 2 , 3 , 4 ]. To overcome this issue, certain states require physicians to report a varying number of hours of implicit bias training as part of their recurring licensing requirement [ 5 , 6 ]. Research efforts on the influence of implicit bias on clinical decision-making gained traction after the “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” report published in 2003 [ 7 ]. This report sparked a conversation about the impact of bias against women, people of color, and other marginalized groups within healthcare. Bias from a healthcare provider has been shown to affect provider-patient communication and may also influence treatment decisions [ 8 , 9 ]. Nevertheless, opportunities within medical education curriculum are created to evaluate biases at an earlier stage of physician-training and provide instruction to intervene them [ 10 , 11 , 12 ]. We aimed to identify trends and organize literature on bias training provided during medical school and residency programs since the meaning of ‘bias’ is broad and encompasses several types of attitudes and predispositions [ 13 ].

Several reviews, narrative or systematic in nature, have been published in the field of bias research in medicine and healthcare [ 14 , 15 , 16 ]. Many of these reviews have a broad focus on implicit bias and they often fail to define the patient’s specific attributes- such as age, weight, disease, or condition against which physicians hold their biases. However, two recently published reviews categorized implicit biases into various descriptive characteristics albeit with research goals different than this study [ 17 , 18 ]. The study by Fitzgerald et al. reviewed literature focused on bias among physicians and nurses to highlight its role in healthcare disparities [ 17 ]. While the study by Gonzalez et al. focused on bias curricular interventions across professions related to social determinants of health such as education, law, medicine and social work [ 18 ]. Our research goal was to identify the various bias characteristics that are studied within medical student and/or resident populations and categorize them. Further, we were interested in whether biases were merely identified or if they were intervened. To address these deficits in the field and provide clarity, we utilized a scoping review approach to categorize the literature based on a) the bias addressed and b) the study goal within medical students (MS), residents (Res) and a mixed population (MS and Res).

To date no literature review has organized bias research by specific categories held solely by medical trainees (medical students and/or residents) and quantified intervention studies. We did not perform a quality assessment or outcome evaluation of the bias intervention strategies, as it was not the goal of this work and is standard with a scoping review methodology [ 19 , 20 ]. By generating a comprehensive list of bias categories researched among medical trainee population, we highlight areas of opportunity for future implicit bias research specifically within the undergraduate and graduate medical education curriculum. We anticipate that the results from this scoping review will be useful for educators, administrators, and stakeholders seeking to implement active programs or workshops that intervene specific biases in pre-clinical medical education and prepare physicians-in-training for patient encounters. Additionally, behavioral scientists who seek to support clinicians, and develop debiasing theories [ 21 ] and models may also find our results informative.

We conducted an exhaustive and focused scoping review and followed the methodological framework for scoping reviews as previously described in the literature [ 20 , 22 ]. This study aligned with the four goals of a scoping review [ 20 ]. We followed the first five out of the six steps outlined by Arksey and O’Malley’s to ensure our review’s validity 1) identifying the research question 2) identifying relevant studies 3) selecting the studies 4) charting the data and 5) collating, summarizing and reporting the results [ 22 ]. We did not follow the optional sixth step of undertaking consultation with key stakeholders as it was not needed to address our research question it [ 23 ]. Furthermore, we used Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia) that aided in managing steps 2–5 presented above.

Research question, search strategy and inclusion criteria

The purpose of this study was to identify trends in bias research at the medical school and residency level. Prior to conducting our literature search we developed our research question and detailed the inclusion criteria, and generated the search syntax with the assistance from a medical librarian. Search syntax was adjusted to the requirements of the database. We searched PubMed, Web of Science, and PsycINFO using MeSH terms shown below.

Bias* [ti] OR prejudice*[ti] OR racism[ti] OR homophobia[ti] OR mistreatment[ti] OR sexism[ti] OR ageism[ti]) AND (prejudice [mh] OR "Bias"[Mesh:NoExp]) AND (Education, Medical [mh] OR Schools, Medical [mh] OR students, medical [mh] OR Internship and Residency [mh] OR “undergraduate medical education” OR “graduate medical education” OR “medical resident” OR “medical residents” OR “medical residency” OR “medical residencies” OR “medical schools” OR “medical school” OR “medical students” OR “medical student”) AND (curriculum [mh] OR program evaluation [mh] OR program development [mh] OR language* OR teaching OR material* OR instruction* OR train* OR program* OR curricul* OR workshop*

Our inclusion criteria incorporated studies which were either original research articles, or review articles that synthesized new data. We excluded publications that were not peer-reviewed or supported with data such as narrative reviews, opinion pieces, editorials, perspectives and commentaries. We included studies outside of the U.S. since the purpose of this work was to generate a comprehensive list of biases. Physicians, regardless of their country of origin, can hold biases against specific patient attributes [ 17 ]. Furthermore, physicians may practice in a different country than where they trained [ 24 ]. Manuscripts were included if they were published in the English language for which full-texts were available. Since the goal of this scoping review was to assess trends, we accepted studies published from 1980–2021.

Our inclusion criteria also considered the goal and the population of the study. We defined the study goal as either that documented evidence of bias or a program directed bias intervention. Evidence of bias (EOB) had to originate from the medical trainee regarding a patient attribute. Bias intervention (BI) studies involved strategies to counter biases such as activities, workshops, seminars or curricular innovations. The population studied had to include medical students (MS) or residents (Res) or mixed. We defined the study population as ‘mixed’ when it consisted of both MS and Res. Studies conducted on other healthcare professionals were included if MS or Res were also studied. Our search criteria excluded studies that documented bias against medical professionals (students, residents and clinicians) either by patients, medical schools, healthcare administrators or others, and was focused on studies where the biases were solely held by medical trainees (MS and Res).

Data extraction and analysis

Following the initial database search, references were downloaded and bulk uploaded into Covidence and duplicates were removed. After the initial screening of title and abstracts, full-texts were reviewed. Authors independently completed title and abstract screening, and full text reviews. Any conflicts at the stage of abstract screening were moved to full-text screening. Conflicts during full-text screening were resolved by deliberation and referring to the inclusion and exclusion criteria detailed in the research protocol. The level of agreement between the two authors for full text reviews as measured by inter-rater reliability was 0.72 (Cohen’s Kappa).

A data extraction template was created in Covidence to extract data from included full texts. Data extraction template included the following variables; country in which the study was conducted, year of publication, goal of the study (EOB, BI or both), population of the study (MS, Res or mixed) and the type of bias studied. Final data was exported to Microsoft Excel for quantification. For charting our data and categorizing the included studies, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews(PRISMA-ScR) guidelines [ 25 ]. Results from this scoping review study are meant to provide a visual synthesis of existing bias research and identify gaps in knowledge.

Study selection

Our search strategy yielded a total of 892 unique abstracts which were imported into ‘Covidence’ for screening. A total of 86 duplicate references were removed. Then, 806 titles and abstracts were screened for relevance independently by the authors and 519 studies were excluded at this stage. Any conflicts among the reviewers at this stage were resolved by discussion and referring to the inclusion and exclusion criteria. Then a full text review of the remaining 287 papers was completed by the authors against the inclusion criteria for eligibility. Full text review was also conducted independently by the authors and any conflicts were resolved upon discussion. Finally, we included 139 studies which were used for data extraction (Fig.  1 ).

PRISMA diagram of the study selection process used in our scoping review to identify the bias categories that have been reported within medical education literature. Study took place from 2021–2022. Abbreviation: PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Publication trends in bias research

First, we charted the studies to demonstrate the timeline of research focused on bias within the study population of our interest (MS or Res or mixed). Our analysis revealed an increase in publications with respect to time (Fig.  2 ). Of the 139 included studies, fewer studies were published prior to 2001, with a total of only eight papers being published from the years 1985–2000. A substantial increase in publications occurred after 2004, with 2019 being the peak year where most of the studies pertaining to bias were published (Fig.  2 ).

Studies matching inclusion criteria mapped by year of publication. Search criteria included studies addressing bias from 1980–2021 within medical students (MS) or residents (Res) or mixed (MS + Res) populations. * Publication in 2022 was published online ahead of print

Overview of included studies

We present a descriptive analysis of the 139 included studies in Table 1 based on the following parameters: study location, goal of the study, population of the study and the category of bias studied. All of the above parameters except the category of bias included a denominator of 139 studies. Several studies addressed more than one bias characteristic; therefore, we documented 163 biases sorted in 11 categories over the 139 papers. The bias categories that we generated and their respective occurrences are listed in Table 1 . Of the 139 studies that were included, most studies originated in the United States ( n  = 89/139, 64%) and Europe ( n  = 20/139, 20%).

Sorting of included research by bias category

We grouped the 139 included studies depending on the patient attribute or the descriptive characteristic against which the bias was studied (Table 1 ). By sorting the studies into different bias categories, we aimed to not only quantitate the amount of research addressing a particular topic of bias, but also reveal the biases that are understudied.

Through our analysis, we generated 11 descriptive categories against which bias was studied: Age, physical disability, education level, biological sex, disease or condition, LGBTQ + , non-specified, race/ethnicity, rural/urban, socio-economic status, and weight (Table 1 ). “Age” and “weight” categories included papers that studied bias against older population and higher weight individuals, respectively. The categories “education level” and “socio-economic status” included papers that studied bias against individuals with low education level and individuals belonging to low socioeconomic status, respectively. Within the bias category named ‘biological sex’, we included papers that studied bias against individuals perceived as women/females. Papers that studied bias against gender-identity or sexual orientation were included in its own category named, ‘LGBTQ + ’. The bias category, ‘disease or condition’ was broad and included research on bias against any patient with a specific disease, condition or lifestyle. Studies included in this category researched bias against any physical illnesses, mental illnesses, or sexually transmitted infections. It also included studies that addressed bias against a treatment such as transplant or pain management. It was not significant to report these as individual categories but rather as a whole with a common underlying theme. Rural/urban bias referred to bias that was held against a person based on their place of residence. Studies grouped together in the ‘non-specified bias’ category explored bias without specifying any descriptive characteristic in their methods. These studies did not address any specific bias characteristic in particular but consisted of a study population of our interest (MS or Res or mixed). Based on our analysis, the top five most studied bias categories in our included population within medical education literature were: racial or ethnic bias ( n  = 39/163, 24%), disease or condition bias ( n  = 29/163, 18%), weight bias ( n  = 22/163, 13%), LGBTQ + bias ( n  = 21/163, 13%), and age bias ( n  = 16/163, 10%) which are presented in Table 1 .

Sorting of included research by population

In order to understand the distribution of bias research based on their populations examined, we sorted the included studies in one of the following: medical students (MS), residents (Res) or mixed (Table 1 ). The following distributions were observed: medical students only ( n  = 105/139, 76%), residents only ( n  = 19/139, 14%) or mixed which consisted of both medical students and residents ( n  = 15/139, 11%). In combination, these results demonstrate that medical educators have focused bias research efforts primarily on medical student populations.

Sorting of included research by goal

A critical component of this scoping review was to quantify the research goal of the included studies within each of the bias categories. We defined the research goal as either to document evidence of bias (EOB) or to evaluate a bias intervention (BI) (see Fig.  1 for inclusion criteria). Some of the included studies focused on both, documenting evidence in addition to intervening biases and those studies were grouped separately. The analysis revealed that 69/139 (50%) of the included studies focused exclusively on documenting evidence of bias (EOB). There were fewer studies ( n  = 51/139, 37%) which solely focused on bias interventions such as programs, seminars or curricular innovations. A small minority of the included studies were more comprehensive in that they documented EOB followed by an intervention strategy ( n  = 19/139, 11%). These results demonstrate that most bias research is dedicated to documenting evidence of bias among these groups rather than evaluating a bias intervention strategy.

Research goal distribution

Our next objective was to calculate the distribution of studies with respect to the study goal (EOB, BI or both), within the 163 biases studied across the 139 papers as calculated in Table 1 . In general, the goal of the studies favors documenting evidence of bias with the exception of race/ethnic bias which is more focused on bias intervention (Fig.  3 ). Fewer studies were aimed at both, documenting evidence then providing an intervention, across all bias categories.

Sorting of total biases ( n  = 163) within medical students or residents or a mixed population based on the bias category . Dark grey indicates studies with a dual goal, to document evidence of bias and to intervene bias. Medium grey bars indicate studies which focused on documenting evidence of bias. Light grey bars indicate studies focused on bias intervention within these populations. Numbers inside the bars indicate the total number of biases for the respective study goal. * Non-specified bias includes studies which focused on implicit bias but did not mention the type of bias investigated

Furthermore, we also calculated the ratio of EOB, BI and both (EOB + BI) within each of our population of interest (MS; n  = 122, Res; n  = 26 and mixed; n  = 15) for the 163 biases observed in our included studies. Over half ( n  = 64/122, 52%) of the total bias occurrences in MS were focused on documenting EOB (Fig.  4 ). Contrastingly, a shift was observed within resident populations where most biases addressed were aimed at intervention ( n  = 12/26, 41%) rather than EOB ( n  = 4/26, 14%) (Fig.  4 ). Studies which included both MS and Res (mixed) were primarily focused on documenting EOB ( n  = 9/15, 60%), with 33% ( n  = 5/15) aimed at bias intervention and 7% ( n  = 1/15) which did both (Fig.  4 ). Although far fewer studies were documented in the Res population it is important to highlight that most of these studies were focused on bias intervention when compared to MS population where we documented a majority of studies focused on evidence of bias.

A ratio of the study goal for the total biases ( n  = 163) mapped within each of the study population (MS, Res and Mixed). A study goal with a) documenting evidence of bias (EOB) is depicted in dotted grey, b) bias intervention (BI) in medium grey, and c) a dual focus (EOB + BI) is depicted in dark grey. * N  = 122 for medical student studies. b N  = 26 for residents. c N  = 15 for mixed

Addressing biases at an earlier stage of medical career is critical for future physicians engaging with diverse patients, since it is established that bias negatively influences provider-patient interactions [ 171 ], clinical decision-making [ 172 ] and reduces favorable treatment outcomes [ 2 ]. We set out with an intention to explore how bias is addressed within the medical curriculum. Our research question was: how has the trend in bias research changed over time, more specifically a) what is the timeline of papers published? b) what bias characteristics have been studied in the physician-trainee population and c) how are these biases addressed? With the introduction of ‘standards of diversity’ by the Liaison Committee on Medical Education, along with the Association of American Medical Colleges (AAMC) and the American Medical Association (AMA) [ 173 , 174 ], we certainly expected and observed a sustained uptick in research pertaining to bias. As shown here, research addressing bias in the target population (MS and Res) is on the rise, however only 139 papers fit our inclusion criteria. Of these studies, nearly 90% have been published since 2005 after the “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” report was published in 2003 [ 7 ]. However, given the well documented effects of physician held bias, we anticipated significantly more number of studies focused on bias at the medical student or resident level.

A key component from this study was that we generated descriptive categories of biases. Sorting the biases into descriptive categories helps to identify a more targeted approach for a specific bias intervention, rather than to broadly intervene bias as a whole. In fact, our analysis found a number of publications (labeled “non-specified bias” in Table 1 ) which studied implicit bias without specifying the patient attribute or the characteristic that the bias was against. In total, we generated 11 descriptive categories of bias from our scoping review which are shown in Table 1 and Fig.  3 . Furthermore, our bias descriptors grouped similar kinds of biases within a single category. For example, the category, “disease or condition” included papers that studied bias against any type of disease (Mental illness, HIV stigma, diabetes), condition (Pain management), or lifestyle. We neither performed a qualitative assessment of the studies nor did we test the efficacy of the bias intervention studies and consider it a future direction of this work.

Evidence suggests that medical educators and healthcare professionals are struggling to find the appropriate approach to intervene biases [ 175 , 176 , 177 ] So far, bias reduction, bias reflection and bias management approaches have been proposed [ 26 , 27 , 178 ]. Previous implicit bias intervention strategies have been shown to be ineffective when biased attitudes of participants were assessed after a lag [ 179 ]. Understanding the descriptive categories of bias and previous existing research efforts, as we present here is only a fraction of the challenge. The theory of “cognitive bias” [ 180 ] and related branches of research [ 13 , 181 , 182 , 183 , 184 ] have been studied in the field of psychology for over three decades. It is only recently that cognitive bias theory has been applied to the field of medical education medicine, to explain its negative influence on clinical decision-making pertaining only to racial minorities [ 1 , 2 , 15 , 16 , 17 , 185 ]. In order to elicit meaningful changes with respect to targeted bias intervention, it is necessary to understand the psychological underpinnings (attitudes) leading to a certain descriptive category of bias (behaviors). The questions which medical educators need to ask are: a) Can these descriptive biases be identified under certain type/s of cognitive errors that elicits the bias and vice versa b) Are we working towards an attitude change which can elicit a sustained positive behavior change among healthcare professionals? And most importantly, c) are we creating a culture where participants voluntarily enroll themselves in bias interventions as opposed to being mandated to participate? Cognitive psychologists and behavioral scientists are well-positioned to help us find answers to these questions as they understand human behavior. Therefore, an interdisciplinary approach, a marriage between cognitive psychologists and medical educators, is key in targeting biases held by medical students, residents, and ultimately future physicians. This review may also be of interest to behavioral psychologists, keen on providing targeted intervening strategies to clinicians depending on the characteristics (age, weight, sex or race) the portrayed bias is against. Further, instead of an individualized approach, we need to strive for systemic changes and evidence-based strategies to intervene biases.

The next element in change is directing intervention strategies at the right stage in clinical education. Our study demonstrated that most of the research collected at the medical student level was focused on documenting evidence of bias. Although the overall number of studies at the resident level were fewer than at the medical student level, the ratio of research in favor of bias intervention was higher at the resident level (see Fig.  3 ). However, it could be helpful to focus on bias intervention earlier in learning, rather than at a later stage [ 186 ]. Additionally, educational resources such as textbooks, preparatory materials, and educators themselves are potential sources of propagating biases and therefore need constant evaluation against best practices [ 187 , 188 ].

This study has limitations. First, the list of the descriptive bias categories that we generated was not grounded in any particular theory so assigning a category was subjective. Additionally, there were studies that were categorized as “nonspecified” bias as the studies themselves did not mention the specific type of bias that they were addressing. Moreover, we had to exclude numerous publications solely because they were not evidence-based and were either perspectives, commentaries or opinion pieces. Finally, there were overall fewer studies focused on the resident population, so the calculated ratio of MS:Res studies did not compare similar sample sizes.

Future directions of our study include working with behavioral scientists to categorize these bias characteristics (Table 1 ) into cognitive error types [ 189 ]. Additionally, we aim to assess the effectiveness of the intervention strategies and categorize the approach of the intervention strategies.

The primary goal of our review was to organize, compare and quantify literature pertaining to bias within medical school curricula and residency programs. We neither performed a qualitative assessment of the studies nor did we test the efficacy of studies that were sorted into “bias intervention” as is typical of scoping reviews [ 22 ]. In summary, our research identified 11 descriptive categories of biases studied within medical students and resident populations with “race and ethnicity”, “disease or condition”, “weight”, “LGBTQ + ” and “age” being the top five most studied biases. Additionally, we found a greater number of studies conducted in medical students (105/139) when compared to residents (19/139). However, most of the studies in the resident population focused on bias intervention. The results from our review highlight the following gaps: a) bias categories where more research is needed, b) biases that are studied within medical school versus in residency programs and c) study focus in terms of demonstrating the presence of bias or working towards bias intervention.

This review provides a visual analysis of the known categories of bias addressed within the medical school curriculum and in residency programs in addition to providing a comparison of studies with respect to the study goal within medical education literature. The results from our review should be of interest to community organizations, institutions, program directors and medical educators interested in knowing and understanding the types of bias existing within healthcare populations. It might be of special interest to researchers who wish to explore other types of biases that have been understudied within medical school and resident populations, thus filling the gaps existing in bias research.

Despite the number of studies designed to provide bias intervention for MS and Res populations, and an overall cultural shift to be aware of one’s own biases, biases held by both medical students and residents still persist. Further, psychologists have recently demonstrated the ineffectiveness of some bias intervention efforts [ 179 , 190 ]. Therefore, it is perhaps unrealistic to expect these biases to be eliminated altogether. However, effective intervention strategies grounded in cognitive psychology should be implemented earlier on in medical training. Our focus should be on providing evidence-based approaches and safe spaces for an attitude and culture change, so as to induce actionable behavioral changes.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

• Medical student

Evidence of bias

• Bias intervention

Hagiwara N, Mezuk B, Elston Lafata J, Vrana SR, Fetters MD. Study protocol for investigating physician communication behaviours that link physician implicit racial bias and patient outcomes in Black patients with type 2 diabetes using an exploratory sequential mixed methods design. BMJ Open. 2018;8(10):e022623.

Article   Google Scholar  

Haider AH, Schneider EB, Sriram N, Dossick DS, Scott VK, Swoboda SM, Losonczy L, Haut ER, Efron DT, Pronovost PJ, et al. Unconscious race and social class bias among acute care surgical clinicians and clinical treatment decisions. JAMA Surg. 2015;150(5):457–64.

Penner LA, Dovidio JF, Gonzalez R, Albrecht TL, Chapman R, Foster T, Harper FW, Hagiwara N, Hamel LM, Shields AF, et al. The effects of oncologist implicit racial bias in racially discordant oncology interactions. J Clin Oncol. 2016;34(24):2874–80.

Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, van Ryn M. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev. 2015;16(4):319–26.

Garrett SB, Jones L, Montague A, Fa-Yusuf H, Harris-Taylor J, Powell B, Chan E, Zamarripa S, Hooper S, Chambers Butcher BD. Challenges and opportunities for clinician implicit bias training: insights from perinatal care stakeholders. Health Equity. 2023;7(1):506–19.

Shah HS, Bohlen J. Implicit bias. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023. Copyright © 2023, StatPearls Publishing LLC.

Google Scholar  

Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. In: Smedley BD, Stith AY, Nelson AR, editors. Washington (DC): National Academies Press (US); 2003. PMID: 25032386.

Dehon E, Weiss N, Jones J, Faulconer W, Hinton E, Sterling S. A systematic review of the impact of physician implicit racial bias on clinical decision making. Acad Emerg Med. 2017;24(8):895–904.

Oliver MN, Wells KM, Joy-Gaba JA, Hawkins CB, Nosek BA. Do physicians’ implicit views of African Americans affect clinical decision making? J Am Board Fam Med. 2014;27(2):177–88.

Rincon-Subtirelu M. Education as a tool to modify anti-obesity bias among pediatric residents. Int J Med Educ. 2017;8:77–8.

Gustafsson Sendén M, Renström EA. Gender bias in assessment of future work ability among pain patients - an experimental vignette study of medical students’ assessment. Scand J Pain. 2019;19(2):407–14.

Hardeman RR, Burgess D, Phelan S, Yeazel M, Nelson D, van Ryn M. Medical student socio-demographic characteristics and attitudes toward patient centered care: do race, socioeconomic status and gender matter? A report from the medical student CHANGES study. Patient Educ Couns. 2015;98(3):350–5.

Greenwald AG, Banaji MR. Implicit social cognition: attitudes, self-esteem, and stereotypes. Psychol Rev. 1995;102(1):4–27.

Kruse JA, Collins JL, Vugrin M. Educational strategies used to improve the knowledge, skills, and attitudes of health care students and providers regarding implicit bias: an integrative review of the literature. Int J Nurs Stud Adv. 2022;4:100073.

Zestcott CA, Blair IV, Stone J. Examining the presence, consequences, and reduction of implicit bias in health care: a narrative review. Group Process Intergroup Relat. 2016;19(4):528–42.

Hall WJ, Chapman MV, Lee KM, Merino YM, Thomas TW, Payne BK, Eng E, Day SH, Coyne-Beasley T. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health. 2015;105(12):E60–76.

FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;18(1):19.

Gonzalez CM, Onumah CM, Walker SA, Karp E, Schwartz R, Lypson ML. Implicit bias instruction across disciplines related to the social determinants of health: a scoping review. Adv Health Sci Educ. 2023;28(2):541–87.

Pham MT, Rajić A, Greig JD, Sargeant JM, Papadopoulos A, McEwen SA. A scoping review of scoping reviews: advancing the approach and enhancing the consistency. Res Synth Methods. 2014;5(4):371–85.

Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010;5:69.

Pat C, Geeta S, Sílvia M. Cognitive debiasing 1: origins of bias and theory of debiasing. BMJ Qual Saf. 2013;22(Suppl 2):ii58.

Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32.

Thomas A, Lubarsky S, Durning SJ, Young ME. Knowledge syntheses in medical education: demystifying scoping reviews. Acad Med. 2017;92(2):161–6.

Hagopian A, Thompson MJ, Fordyce M, Johnson KE, Hart LG. The migration of physicians from sub-Saharan Africa to the United States of America: measures of the African brain drain. Hum Resour Health. 2004;2(1):17.

Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, Moher D, Peters MDJ, Horsley T, Weeks L, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–73.

Teal CR, Shada RE, Gill AC, Thompson BM, Frugé E, Villarreal GB, Haidet P. When best intentions aren’t enough: Helping medical students develop strategies for managing bias about patients. J Gen Intern Med. 2010;25(Suppl 2):S115–8.

Gonzalez CM, Walker SA, Rodriguez N, Noah YS, Marantz PR. Implicit bias recognition and management in interpersonal encounters and the learning environment: a skills-based curriculum for medical students. MedEdPORTAL. 2021;17:11168.

Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016;113(16):4296–301.

Mayfield JJ, Ball EM, Tillery KA, Crandall C, Dexter J, Winer JM, Bosshardt ZM, Welch JH, Dolan E, Fancovic ER, et al. Beyond men, women, or both: a comprehensive, LGBTQ-inclusive, implicit-bias-aware, standardized-patient-based sexual history taking curriculum. MedEdPORTAL. 2017;13:10634.

Morris M, Cooper RL, Ramesh A, Tabatabai M, Arcury TA, Shinn M, Im W, Juarez P, Matthews-Juarez P. Training to reduce LGBTQ-related bias among medical, nursing, and dental students and providers: a systematic review. BMC Med Educ. 2019;19(1):325.

Perdomo J, Tolliver D, Hsu H, He Y, Nash KA, Donatelli S, Mateo C, Akagbosu C, Alizadeh F, Power-Hays A, et al. Health equity rounds: an interdisciplinary case conference to address implicit bias and structural racism for faculty and trainees. MedEdPORTAL. 2019;15:10858.

Sherman MD, Ricco J, Nelson SC, Nezhad SJ, Prasad S. Implicit bias training in a residency program: aiming for enduring effects. Fam Med. 2019;51(8):677–81.

van Ryn M, Hardeman R, Phelan SM, Burgess DJ, Dovidio JF, Herrin J, Burke SE, Nelson DB, Perry S, Yeazel M, et al. Medical school experiences associated with change in implicit racial bias among 3547 students: a medical student CHANGES study report. J Gen Intern Med. 2015;30(12):1748–56.

Chary AN, Molina MF, Dadabhoy FZ, Manchanda EC. Addressing racism in medicine through a resident-led health equity retreat. West J Emerg Med. 2020;22(1):41–4.

DallaPiazza M, Padilla-Register M, Dwarakanath M, Obamedo E, Hill J, Soto-Greene ML. Exploring racism and health: an intensive interactive session for medical students. MedEdPORTAL. 2018;14:10783.

Dennis SN, Gold RS, Wen FK. Learner reactions to activities exploring racism as a social determinant of health. Fam Med. 2019;51(1):41–7.

Gonzalez CM, Walker SA, Rodriguez N, Karp E, Marantz PR. It can be done! a skills-based elective in implicit bias recognition and management for preclinical medical students. Acad Med. 2020;95(12S Addressing Harmful Bias and Eliminating Discrimination in Health Professions Learning Environments):S150–5.

Motzkus C, Wells RJ, Wang X, Chimienti S, Plummer D, Sabin J, Allison J, Cashman S. Pre-clinical medical student reflections on implicit bias: Implications for learning and teaching. PLoS ONE. 2019;14(11):e0225058.

Phelan SM, Burke SE, Cunningham BA, Perry SP, Hardeman RR, Dovidio JF, Herrin J, Dyrbye LN, White RO, Yeazel MW, et al. The effects of racism in medical education on students’ decisions to practice in underserved or minority communities. Acad Med. 2019;94(8):1178–89.

Zeidan A, Tiballi A, Woodward M, Di Bartolo IM. Targeting implicit bias in medicine: lessons from art and archaeology. West J Emerg Med. 2019;21(1):1–3.

Baker TK, Smith GS, Jacobs NN, Houmanfar R, Tolles R, Kuhls D, Piasecki M. A deeper look at implicit weight bias in medical students. Adv Health Sci Educ Theory Pract. 2017;22(4):889–900.

Eymard AS, Douglas DH. Ageism among health care providers and interventions to improve their attitudes toward older adults: an integrative review. J Gerontol Nurs. 2012;38(5):26–35.

Garrison CB, McKinney-Whitson V, Johnston B, Munroe A. Race matters: addressing racism as a health issue. Int J Psychiatry Med. 2018;53(5–6):436–44.

Geller G, Watkins PA. Addressing medical students’ negative bias toward patients with obesity through ethics education. AMA J Ethics. 2018;20(10):E948-959.

Onyeador IN, Wittlin NM, Burke SE, Dovidio JF, Perry SP, Hardeman RR, Dyrbye LN, Herrin J, Phelan SM, van Ryn M. The value of interracial contact for reducing anti-black bias among non-black physicians: a Cognitive Habits and Growth Evaluation (CHANGE) study report. Psychol Sci. 2020;31(1):18–30.

Poustchi Y, Saks NS, Piasecki AK, Hahn KA, Ferrante JM. Brief intervention effective in reducing weight bias in medical students. Fam Med. 2013;45(5):345–8.

Ruiz JG, Andrade AD, Anam R, Taldone S, Karanam C, Hogue C, Mintzer MJ. Group-based differences in anti-aging bias among medical students. Gerontol Geriatr Educ. 2015;36(1):58–78.

Simpson T, Evans J, Goepfert A, Elopre L. Implementing a graduate medical education anti-racism workshop at an academic university in the Southern USA. Med Educ Online. 2022;27(1):1981803.

Wittlin NM, Dovidio JF, Burke SE, Przedworski JM, Herrin J, Dyrbye L, Onyeador IN, Phelan SM, van Ryn M. Contact and role modeling predict bias against lesbian and gay individuals among early-career physicians: a longitudinal study. Soc Sci Med. 2019;238:112422.

Miller DP Jr, Spangler JG, Vitolins MZ, Davis SW, Ip EH, Marion GS, Crandall SJ. Are medical students aware of their anti-obesity bias? Acad Med. 2013;88(7):978–82.

Gonzalez CM, Deno ML, Kintzer E, Marantz PR, Lypson ML, McKee MD. A qualitative study of New York medical student views on implicit bias instruction: implications for curriculum development. J Gen Intern Med. 2019;34(5):692–8.

Gonzalez CM, Kim MY, Marantz PR. Implicit bias and its relation to health disparities: a teaching program and survey of medical students. Teach Learn Med. 2014;26(1):64–71.

Gonzalez CM, Nava S, List J, Liguori A, Marantz PR. How assumptions and preferences can affect patient care: an introduction to implicit bias for first-year medical students. MedEdPORTAL. 2021;17:11162.

Hernandez RA, Haidet P, Gill AC, Teal CR. Fostering students’ reflection about bias in healthcare: cognitive dissonance and the role of personal and normative standards. Med Teach. 2013;35(4):e1082-1089.

Kushner RF, Zeiss DM, Feinglass JM, Yelen M. An obesity educational intervention for medical students addressing weight bias and communication skills using standardized patients. BMC Med Educ. 2014;14:53.

Nazione S, Silk KJ. Patient race and perceived illness responsibility: effects on provider helping and bias. Med Educ. 2013;47(8):780–9.

Ogunyemi D. Defeating unconscious bias: the role of a structured, reflective, and interactive workshop. J Grad Med Educ. 2021;13(2):189–94.

Phelan SM, Burke SE, Hardeman RR, White RO, Przedworski J, Dovidio JF, Perry SP, Plankey M, A Cunningham B, Finstad D, et al. Medical school factors associated with changes in implicit and explicit bias against gay and lesbian people among 3492 graduating medical students. J Gen Intern Med. 2017;32(11):1193–201.

Phelan SM, Puhl RM, Burke SE, Hardeman R, Dovidio JF, Nelson DB, Przedworski J, Burgess DJ, Perry S, Yeazel MW, et al. The mixed impact of medical school on medical students’ implicit and explicit weight bias. Med Educ. 2015;49(10):983–92.

Barber Doucet H, Ward VL, Johnson TJ, Lee LK. Implicit bias and caring for diverse populations: pediatric trainee attitudes and gaps in training. Clin Pediatr (Phila). 2021;60(9–10):408–17.

Burke SE, Dovidio JF, Przedworski JM, Hardeman RR, Perry SP, Phelan SM, Nelson DB, Burgess DJ, Yeazel MW, van Ryn M. Do contact and empathy mitigate bias against gay and lesbian people among heterosexual first-year medical students? A report from the medical student CHANGE study. Acad Med. 2015;90(5):645–51.

Johnston B, McKinney-Whitson V, Garrison V. Race matters: addressing racism as a health issue. WMJ. 2021;120(S1):S74–7.

Kost A, Akande T, Jones R, Gabert R, Isaac M, Dettmar NS. Use of patient identifiers at the University of Washington School of Medicine: building institutional consensus to reduce bias and stigma. Fam Med. 2021;53(5):366–71.

Madan AK, Aliabadi-Wahle S, Beech DJ. Ageism in medical students’ treatment recommendations: the example of breast-conserving procedures. Acad Med. 2001;76(3):282–4.

Marbin J, Lewis L, Kuo AK, Schudel C, Gutierrez JR. The power of place: travel to explore structural racism and health disparities. Acad Med. 2021;96(11):1569–73.

Phelan SM, Dovidio JF, Puhl RM, Burgess DJ, Nelson DB, Yeazel MW, Hardeman R, Perry S, van Ryn M. Implicit and explicit weight bias in a national sample of 4,732 medical students: the medical student CHANGES study. Obesity (Silver Spring). 2014;22(4):1201–8.

Van J, Aloman C, Reau N. Potential bias and misconceptions in liver transplantation for alcohol- and obesity-related liver disease. Am J Gastroenterol. 2021;116(10):2089–97.

White-Means S, Zhiyong D, Hufstader M, Brown LT. Cultural competency, race, and skin tone bias among pharmacy, nursing, and medical students: implications for addressing health disparities. Med Care Res Rev. 2009;66(4):436–55.

Williams RL, Vasquez CE, Getrich CM, Kano M, Boursaw B, Krabbenhoft C, Sussman AL. Racial/gender biases in student clinical decision-making: a mixed-method study of medical school attributes associated with lower incidence of biases. J Gen Intern Med. 2018;33(12):2056–64.

Cohen RW, Persky S. Influence of weight etiology information and trainee characteristics on physician-trainees’ clinical and interpersonal communication. Patient Educ Couns. 2019;102(9):1644–9.

Haider AH, Sexton J, Sriram N, Cooper LA, Efron DT, Swoboda S, Villegas CV, Haut ER, Bonds M, Pronovost PJ, et al. Association of unconscious race and social class bias with vignette-based clinical assessments by medical students. JAMA. 2011;306(9):942–51.

Lewis R, Lamdan RM, Wald D, Curtis M. Gender bias in the diagnosis of a geriatric standardized patient: a potential confounding variable. Acad Psychiatry. 2006;30(5):392–6.

Matharu K, Shapiro JF, Hammer RR, Kravitz RL, Wilson MD, Fitzgerald FT. Reducing obesity prejudice in medical education. Educ Health. 2014;27(3):231–7.

McLean ME, McLean LE, McLean-Holden AC, Campbell LF, Horner AM, Kulkarni ML, Melville LD, Fernandez EA. Interphysician weight bias: a cross-sectional observational survey study to guide implicit bias training in the medical workplace. Acad Emerg Med. 2021;28(9):1024–34.

Meadows A, Higgs S, Burke SE, Dovidio JF, van Ryn M, Phelan SM. Social dominance orientation, dispositional empathy, and need for cognitive closure moderate the impact of empathy-skills training, but not patient contact, on medical students’ negative attitudes toward higher-weight patients. Front Psychol. 2017;8:15.

Stone J, Moskowitz GB, Zestcott CA, Wolsiefer KJ. Testing active learning workshops for reducing implicit stereotyping of Hispanics by majority and minority group medical students. Stigma Health. 2020;5(1):94–103.

Symons AB, Morley CP, McGuigan D, Akl EA. A curriculum on care for people with disabilities: effects on medical student self-reported attitudes and comfort level. Disabil Health J. 2014;7(1):88–95.

Ufomata E, Eckstrand KL, Hasley P, Jeong K, Rubio D, Spagnoletti C. Comprehensive internal medicine residency curriculum on primary care of patients who identify as LGBT. LGBT Health. 2018;5(6):375–80.

Aultman JM, Borges NJ. A clinical and ethical investigation of pre-medical and medical students’ attitudes, knowledge, and understanding of HIV. Med Educ Online. 2006;11:1–12.

Bates T, Cohan M, Bragg DS, Bedinghaus J. The Medical College of Wisconsin senior mentor program: experience of a lifetime. Gerontol Geriatr Educ. 2006;27(2):93–103.

Chiaramonte GR, Friend R. Medical students’ and residents’ gender bias in the diagnosis, treatment, and interpretation of coronary heart disease symptoms. Health Psychol. 2006;25(3):255–66.

Friedberg F, Sohl SJ, Halperin PJ. Teaching medical students about medically unexplained illnesses: a preliminary study. Med Teach. 2008;30(6):618–21.

Gonzales E, Morrow-Howell N, Gilbert P. Changing medical students’ attitudes toward older adults. Gerontol Geriatr Educ. 2010;31(3):220–34.

Hinners CK, Potter JF. A partnership between the University of Nebraska College of Medicine and the community: fostering positive attitudes towards the aged. Gerontol Geriatr Educ. 2006;27(2):83–91.

Lee M, Coulehan JL. Medical students’ perceptions of racial diversity and gender equality. Med Educ. 2006;40(7):691–6.

Schmetzer AD, Lafuze JE. Overcoming stigma: involving families in medical student and psychiatric residency education. Acad Psychiatry. 2008;32(2):127–31.

Willen SS, Bullon A, Good MJD. Opening up a huge can of worms: reflections on a “cultural sensitivity” course for psychiatry residents. Harv Rev Psychiatry. 2010;18(4):247–53.

Dogra N, Karnik N. First-year medical students’ attitudes toward diversity and its teaching: an investigation at one U.S. medical school. Acad Med. 2003;78(11):1191–200.

Fitzpatrick C, Musser A, Mosqueda L, Boker J, Prislin M. Student senior partnership program: University of California Irvine School of Medicine. Gerontol Geriatr Educ. 2006;27(2):25–35.

Hoffman KG, Gray P, Hosokawa MC, Zweig SC. Evaluating the effectiveness of a senior mentor program: the University of Missouri-Columbia School of Medicine. Gerontol Geriatr Educ. 2006;27(2):37–47.

Kantor BS, Myers MR. From aging…to saging-the Ohio State Senior Partners Program: longitudinal and experiential geriatrics education. Gerontol Geriatr Educ. 2006;27(2):69–74.

Klamen DL, Grossman LS, Kopacz DR. Medical student homophobia. J Homosex. 1999;37(1):53–63.

Kopacz DR, Grossman LS, Klamen DL. Medical students and AIDS: knowledge, attitudes and implications for education. Health Educ Res. 1999;14(1):1–6.

Leiblum SR. An established medical school human sexuality curriculum: description and evaluation. Sex Relatsh Ther. 2001;16(1):59–70.

Rastegar DA, Fingerhood MI, Jasinski DR. A resident clerkship that combines inpatient and outpatient training in substance abuse and HIV care. Subst Abuse. 2004;25(4):11–5.

Roberts E, Richeson NA, Thornhill JTIV, Corwin SJ, Eleazer GP. The senior mentor program at the University of South Carolina School of Medicine: an innovative geriatric longitudinal curriculum. Gerontol Geriatr Educ. 2006;27(2):11–23.

Burgess DJ, Burke SE, Cunningham BA, Dovidio JF, Hardeman RR, Hou YF, Nelson DB, Perry SP, Phelan SM, Yeazel MW, et al. Medical students’ learning orientation regarding interracial interactions affects preparedness to care for minority patients: a report from medical student CHANGES. BMC Med Educ. 2016;16:254.

Burgess DJ, Hardeman RR, Burke SE, Cunningham BA, Dovidio JF, Nelson DB, Perry SP, Phelan SM, Yeazel MW, Herrin J, et al. Incoming medical students’ political orientation affects outcomes related to care of marginalized groups: results from the medical student CHANGES study. J Health Pol Policy Law. 2019;44(1):113–46.

Kurtz ME, Johnson SM, Tomlinson T, Fiel NJ. Teaching medical students the effects of values and stereotyping on the doctor/patient relationship. Soc Sci Med. 1985;21(9):1043–7.

Matharu K, Kravitz RL, McMahon GT, Wilson MD, Fitzgerald FT. Medical students’ attitudes toward gay men. BMC Med Educ. 2012;12:71.

Pearl RL, Argueso D, Wadden TA. Effects of medical trainees’ weight-loss history on perceptions of patients with obesity. Med Educ. 2017;51(8):802–11.

Perry SP, Dovidio JF, Murphy MC, van Ryn M. The joint effect of bias awareness and self-reported prejudice on intergroup anxiety and intentions for intergroup contact. Cultur Divers Ethnic Minor Psychol. 2015;21(1):89–96.

Phelan SM, Burgess DJ, Burke SE, Przedworski JM, Dovidio JF, Hardeman R, Morris M, van Ryn M. Beliefs about the causes of obesity in a national sample of 4th year medical students. Patient Educ Couns. 2015;98(11):1446–9.

Phelan SM, Puhl RM, Burgess DJ, Natt N, Mundi M, Miller NE, Saha S, Fischer K, van Ryn M. The role of weight bias and role-modeling in medical students’ patient-centered communication with higher weight standardized patients. Patient Educ Couns. 2021;104(8):1962–9.

Polan HJ, Auerbach MI, Viederman M. AIDS as a paradigm of human behavior in disease: impact and implications of a course. Acad Psychiatry. 1990;14(4):197–203.

Reuben DB, Fullerton JT, Tschann JM, Croughan-Minihane M. Attitudes of beginning medical students toward older persons: a five-campus study. J Am Geriatr Soc. 1995;43(12):1430–6.

Tsai J. Building structural empathy to marshal critical education into compassionate practice: evaluation of a medical school critical race theory course. J Law Med Ethics. 2021;49(2):211–21.

Weyant RJ, Bennett ME, Simon M, Palaisa J. Desire to treat HIV-infected patients: similarities and differences across health-care professions. AIDS. 1994;8(1):117–21.

Ross PT, Lypson ML. Using artistic-narrative to stimulate reflection on physician bias. Teach Learn Med. 2014;26(4):344–9.

Calabrese SK, Earnshaw VA, Krakower DS, Underhill K, Vincent W, Magnus M, Hansen NB, Kershaw TS, Mayer KH, Betancourt JR, et al. A closer look at racism and heterosexism in medical students’ clinical decision-making related to HIV Pre-Exposure Prophylaxis (PrEP): implications for PrEP education. AIDS Behav. 2018;22(4):1122–38.

Fitterman-Harris HF, Vander Wal JS. Weight bias reduction among first-year medical students: a quasi-randomized, controlled trial. Clin Obes. 2021;11(6):e12479.

Madan AK, Cooper L, Gratzer A, Beech DJ. Ageism in breast cancer surgical options by medical students. Tenn Med. 2006;99(5):37–8, 41.

Bikmukhametov DA, Anokhin VA, Vinogradova AN, Triner WR, McNutt LA. Bias in medicine: a survey of medical student attitudes towards HIV-positive and marginalized patients in Russia, 2010. J Int AIDS Soc. 2012;15(2):17372.

Dijkstra AF, Verdonk P, Lagro-Janssen AL. Gender bias in medical textbooks: examples from coronary heart disease, depression, alcohol abuse and pharmacology. Med Educ. 2008;42(10):1021–8.

Dobrowolska B, Jędrzejkiewicz B, Pilewska-Kozak A, Zarzycka D, Ślusarska B, Deluga A, Kościołek A, Palese A. Age discrimination in healthcare institutions perceived by seniors and students. Nurs Ethics. 2019;26(2):443–59.

Hamberg K, Risberg G, Johansson EE, Westman G. Gender bias in physicians’ management of neck pain: a study of the answers in a Swedish national examination. J Womens Health Gend Based Med. 2002;11(7):653–66.

Magliano L, Read J, Sagliocchi A, Oliviero N, D’Ambrosio A, Campitiello F, Zaccaro A, Guizzaro L, Patalano M. “Social dangerousness and incurability in schizophrenia”: results of an educational intervention for medical and psychology students. Psychiatry Res. 2014;219(3):457–63.

Reis SP, Wald HS. Contemplating medicine during the Third Reich: scaffolding professional identity formation for medical students. Acad Med. 2015;90(6):770–3.

Schroyen S, Adam S, Marquet M, Jerusalem G, Thiel S, Giraudet AL, Missotten P. Communication of healthcare professionals: Is there ageism? Eur J Cancer Care (Engl). 2018;27(1):e12780.

Swift JA, Hanlon S, El-Redy L, Puhl RM, Glazebrook C. Weight bias among UK trainee dietitians, doctors, nurses and nutritionists. J Hum Nutr Diet. 2013;26(4):395–402.

Swift JA, Tischler V, Markham S, Gunning I, Glazebrook C, Beer C, Puhl R. Are anti-stigma films a useful strategy for reducing weight bias among trainee healthcare professionals? Results of a pilot randomized control trial. Obes Facts. 2013;6(1):91–102.

Yertutanol FDK, Candansayar S, Seydaoğlu G. Homophobia in health professionals in Ankara, Turkey: developing a scale. Transcult Psychiatry. 2019;56(6):1191–217.

Arnold O, Voracek M, Musalek M, Springer-Kremser M. Austrian medical students’ attitudes towards male and female homosexuality: a comparative survey. Wien Klin Wochenschr. 2004;116(21–22):730–6.

Arvaniti A, Samakouri M, Kalamara E, Bochtsou V, Bikos C, Livaditis M. Health service staff’s attitudes towards patients with mental illness. Soc Psychiatry Psychiatr Epidemiol. 2009;44(8):658–65.

Lopes L, Gato J, Esteves M. Portuguese medical students’ knowledge and attitudes towards homosexuality. Acta Med Port. 2016;29(11):684–93.

Papadaki V, Plotnikof K, Gioumidou M, Zisimou V, Papadaki E. A comparison of attitudes toward lesbians and gay men among students of helping professions in Crete, Greece: the cases of social work, psychology, medicine, and nursing. J Homosex. 2015;62(6):735–62.

Papaharitou S, Nakopoulou E, Moraitou M, Tsimtsiou Z, Konstantinidou E, Hatzichristou D. Exploring sexual attitudes of students in health professions. J Sex Med. 2008;5(6):1308–16.

Roberts JH, Sanders T, Mann K, Wass V. Institutional marginalisation and student resistance: barriers to learning about culture, race and ethnicity. Adv Health Sci Educ. 2010;15(4):559–71.

Wilhelmi L, Ingendae F, Steinhaeuser J. What leads to the subjective perception of a ‘rural area’? A qualitative study with undergraduate students and postgraduate trainees in Germany to tailor strategies against physician’s shortage. Rural Remote Health. 2018;18(4):4694.

Herrmann-Werner A, Loda T, Wiesner LM, Erschens RS, Junne F, Zipfel S. Is an obesity simulation suit in an undergraduate medical communication class a valuable teaching tool? A cross-sectional proof of concept study. BMJ Open. 2019;9(8):e029738.

Ahadinezhad B, Khosravizadeh O, Maleki A, Hashtroodi A. Implicit racial bias among medical graduates and students by an IAT measure: a systematic review and meta-analysis. Ir J Med Sci. 2022;191(4):1941–9. https://doi.org/10.1007/s11845-021-02756-3 .

Hsieh JG, Hsu M, Wang YW. An anthropological approach to teach and evaluate cultural competence in medical students - the application of mini-ethnography in medical history taking. Med Educ Online. 2016;21:32561.

Poreddi V, Thimmaiah R, Math SB. Attitudes toward people with mental illness among medical students. J Neurosci Rural Pract. 2015;6(3):349–54.

Mino Y, Yasuda N, Tsuda T, Shimodera S. Effects of a one-hour educational program on medical students’ attitudes to mental illness. Psychiatry Clin Neurosci. 2001;55(5):501–7.

Omori A, Tateno A, Ideno T, Takahashi H, Kawashima Y, Takemura K, Okubo Y. Influence of contact with schizophrenia on implicit attitudes towards schizophrenia patients held by clinical residents. BMC Psychiatry. 2012;12:8.

Banwari G, Mistry K, Soni A, Parikh N, Gandhi H. Medical students and interns’ knowledge about and attitude towards homosexuality. J Postgrad Med. 2015;61(2):95–100.

Lee SY. Obesity education in medical school curricula in Korea. J Obes Metab Syndr. 2018;27(1):35–8.

Aruna G, Mittal S, Yadiyal MB, Acharya C, Acharya S, Uppulari C. Perception, knowledge, and attitude toward mental disorders and psychiatry among medical undergraduates in Karnataka: a cross-sectional study. Indian J Psychiatry. 2016;58(1):70–6.

Wong YL. Review paper: gender competencies in the medical curriculum: addressing gender bias in medicine. Asia Pac J Public Health. 2009;21(4):359–76.

Earnshaw VA, Jin H, Wickersham JA, Kamarulzaman A, John J, Lim SH, Altice FL. Stigma toward men who have sex with men among future healthcare providers in Malaysia: would more interpersonal contact reduce prejudice? AIDS Behav. 2016;20(1):98–106.

Larson B, Herx L, Williamson T, Crowshoe L. Beyond the barriers: family medicine residents’ attitudes towards providing Aboriginal health care. Med Educ. 2011;45(4):400–6.

Wagner AC, Girard T, McShane KE, Margolese S, Hart TA. HIV-related stigma and overlapping stigmas towards people living with HIV among health care trainees in Canada. AIDS Educ Prev. 2017;29(4):364–76.

Tellier P-P, Bélanger E, Rodríguez C, Ware MA, Posel N. Improving undergraduate medical education about pain assessment and management: a qualitative descriptive study of stakeholders’ perceptions. Pain Res Manage. 2013;18(5):259–65.

Loignon C, Boudreault-Fournier A, Truchon K, Labrousse Y, Fortin B. Medical residents reflect on their prejudices toward poverty: a photovoice training project. BMC Med Educ. 2014;14:1050.

Phillips SP, Clarke M. More than an education: the hidden curriculum, professional attitudes and career choice. Med Educ. 2012;46(9):887–93.

Jaworsky D, Gardner S, Thorne JG, Sharma M, McNaughton N, Paddock S, Chew D, Lees R, Makuwaza T, Wagner A, et al. The role of people living with HIV as patient instructors—Reducing stigma and improving interest around HIV care among medical students. AIDS Care. 2017;29(4):524–31.

Sukhera J, Wodzinski M, Teunissen PW, Lingard L, Watling C. Striving while accepting: exploring the relationship between identity and implicit bias recognition and management. Acad Med. 2018;93(11S Association of American Medical Colleges Learn Serve Lead: Proceedings of the 57th Annual Research in Medical Education Sessions):S82-s88.

Harris R, Cormack D, Curtis E, Jones R, Stanley J, Lacey C. Development and testing of study tools and methods to examine ethnic bias and clinical decision-making among medical students in New Zealand: the Bias and Decision-Making in Medicine (BDMM) study. BMC Med Educ. 2016;16:173.

Cormack D, Harris R, Stanley J, Lacey C, Jones R, Curtis E. Ethnic bias amongst medical students in Aotearoa/New Zealand: findings from the Bias and Decision Making in Medicine (BDMM) study. PLoS ONE. 2018;13(8):e0201168.

Harris R, Cormack D, Stanley J, Curtis E, Jones R, Lacey C. Ethnic bias and clinical decision-making among New Zealand medical students: an observational study. BMC Med Educ. 2018;18(1):18.

Robinson EL, Ball LE, Leveritt MD. Obesity bias among health and non-health students attending an Australian university and their perceived obesity education. J Nutr Educ Behav. 2014;46(5):390–5.

Sopoaga F, Zaharic T, Kokaua J, Covello S. Training a medical workforce to meet the needs of diverse minority communities. BMC Med Educ. 2017;17:19.

Parker R, Larkin T, Cockburn J. A visual analysis of gender bias in contemporary anatomy textbooks. Soc Sci Med. 2017;180:106–13.

Gomes MdM. Doctors’ perspectives and practices regarding epilepsy. Arq Neuropsiquiatr. 2000;58(2):221–6.

Caixeta J, Fernandes PT, Bell GS, Sander JW, Li LM. Epilepsy perception amongst university students - A survey. Arq Neuropsiquiatr. 2007;65:43–8.

Tedrus GMAS, Fonseca LC, da Câmara Vieira AL. Knowledge and attitudes toward epilepsy amongst students in the health area: intervention aimed at enlightenment. Arq Neuropsiquiatr. 2007;65(4-B):1181–5.

Gomez-Moreno C, Verduzco-Aguirre H, Contreras-Garduño S, Perez-de-Acha A, Alcalde-Castro J, Chavarri-Guerra Y, García-Lara JMA, Navarrete-Reyes AP, Avila-Funes JA, Soto-Perez-de-Celis E. Perceptions of aging and ageism among Mexican physicians-in-training. Clin Transl Oncol. 2019;21(12):1730–5.

Campbell MH, Gromer J, Emmanuel MK, Harvey A. Attitudes Toward Transgender People Among Future Caribbean Doctors. Arch Sex Behav. 2022;51(4):1903-11. https://doi.org/10.1007/s10508-021-02205-3 .

Hatala R, Case SM. Examining the influence of gender on medical students’ decision making. J Womens Health Gend Based Med. 2000;9(6):617–23.

Deb T, Lempp H, Bakolis I, et al. Responding to experienced and anticipated discrimination (READ): anti -stigma training for medical students towards patients with mental illness – study protocol for an international multisite non-randomised controlled study. BMC Med Educ. 2019;19:41. https://doi.org/10.1186/s12909-019-1472-7 .

Morgan S, Plaisant O, Lignier B, Moxham BJ. Sexism and anatomy, as discerned in textbooks and as perceived by medical students at Cardiff University and University of Paris Descartes. J Anat. 2014;224(3):352–65.

Alford CL, Miles T, Palmer R, Espino D. An introduction to geriatrics for first-year medical students. J Am Geriatr Soc. 2001;49(6):782–7.

Stone J, Moskowitz GB. Non-conscious bias in medical decision making: what can be done to reduce it? Med Educ. 2011;45(8):768–76.

Nazione S. Slimming down medical provider weight bias in an obese nation. Med Educ. 2015;49(10):954–5.

Dogra N, Connin S, Gill P, Spencer J, Turner M. Teaching of cultural diversity in medical schools in the United Kingdom and Republic of Ireland: cross sectional questionnaire survey. BMJ. 2005;330(7488):403–4.

Aultman JM, Borges NJ. A clinical and ethical investigation of pre-medical and medical students’ attitudes, knowledge, and understanding of HIV. Med Educ Online. 2006;11(1):4596.

Deb T, Lempp H, Bakolis I, Vince T, Waugh W, Henderson C, Thornicroft G, Ando S, Yamaguchi S, Matsunaga A, et al. Responding to experienced and anticipated discrimination (READ): anti -stigma training for medical students towards patients with mental illness – study protocol for an international multisite non-randomised controlled study. BMC Med Educ. 2019;19(1):41.

Gonzalez CM, Grochowalski JH, Garba RJ, Bonner S, Marantz PR. Validity evidence for a novel instrument assessing medical student attitudes toward instruction in implicit bias recognition and management. BMC Med Educ. 2021;21(1):205.

Ogunyemi D. A practical approach to implicit bias training. J Grad Med Educ. 2021;13(4):583–4.

Dennis GC. Racism in medicine: planning for the future. J Natl Med Assoc. 2001;93(3 Suppl):1S-5S.

Maina IW, Belton TD, Ginzberg S, Singh A, Johnson TJ. A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Soc Sci Med. 2018;199:219–29.

Blair IV, Steiner JF, Hanratty R, Price DW, Fairclough DL, Daugherty SL, Bronsert M, Magid DJ, Havranek EP. An investigation of associations between clinicians’ ethnic or racial bias and hypertension treatment, medication adherence and blood pressure control. J Gen Intern Med. 2014;29(7):987–95.

Stanford FC. The importance of diversity and inclusion in the healthcare workforce. J Natl Med Assoc. 2020;112(3):247–9.

Education LCoM. Standards on diversity. 2009. https://health.usf.edu/~/media/Files/Medicine/MD%20Program/Diversity/LCMEStandardsonDiversity1.ashx?la=en .

Onyeador IN, Hudson STJ, Lewis NA. Moving beyond implicit bias training: policy insights for increasing organizational diversity. Policy Insights Behav Brain Sci. 2021;8(1):19–26.

Forscher PS, Mitamura C, Dix EL, Cox WTL, Devine PG. Breaking the prejudice habit: mechanisms, timecourse, and longevity. J Exp Soc Psychol. 2017;72:133–46.

Lai CK, Skinner AL, Cooley E, Murrar S, Brauer M, Devos T, Calanchini J, Xiao YJ, Pedram C, Marshburn CK, et al. Reducing implicit racial preferences: II. Intervention effectiveness across time. J Exp Psychol Gen. 2016;145(8):1001–16.

Sukhera J, Watling CJ, Gonzalez CM. Implicit bias in health professions: from recognition to transformation. Acad Med. 2020;95(5):717–23.

Vuletich HA, Payne BK. Stability and change in implicit bias. Psychol Sci. 2019;30(6):854–62.

Tversky A, Kahneman D. Judgment under uncertainty: Heuristics and biases. Science. 1974;185(4157):1124–31.

Miller DT, Ross M. Self-serving biases in the attribution of causality: fact or fiction? Psychol Bull. 1975;82(2):213–25.

Nickerson RS. Confirmation bias: a ubiquitous phenomenon in many guises. Rev Gen Psychol. 1998;2(2):175–220.

Suveren Y. Unconscious bias: definition and significance. Psikiyatride Guncel Yaklasimlar. 2022;14(3):414–26.

Dietrich D, Olson M. A demonstration of hindsight bias using the Thomas confirmation vote. Psychol Rep. 1993;72(2):377–8.

Green AR, Carney DR, Pallin DJ, Ngo LH, Raymond KL, Iezzoni LI, Banaji MR. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22(9):1231–8.

Rushmer R, Davies HT. Unlearning in health care. Qual Saf Health Care. 2004;13 Suppl 2(Suppl 2):ii10-15.

Vu MT, Pham TTT. Gender, critical pedagogy, and textbooks: Understanding teachers’ (lack of) mediation of the hidden curriculum in the EFL classroom. Lang Teach Res. 2022;0(0). https://doi.org/10.1177/13621688221136937 .

Kalantari A, Alvarez A, Battaglioli N, Chung A, Cooney R, Boehmer SJ, Nwabueze A, Gottlieb M. Sex and race visual representation in emergency medicine textbooks and the hidden curriculum. AEM Educ Train. 2022;6(3):e10743.

Satya-Murti S, Lockhart J. Recognizing and reducing cognitive bias in clinical and forensic neurology. Neurol Clin Pract. 2015;5(5):389–96.

Chang EH, Milkman KL, Gromet DM, Rebele RW, Massey C, Duckworth AL, Grant AM. The mixed effects of online diversity training. Proc Natl Acad Sci U S A. 2019;116(16):7778–83.

Download references

Acknowledgements

The authors would like to thank Dr. Misa Mi, Professor and Medical Librarian at the Oakland University William Beaumont School of Medicine (OWUB) for her assistance with selection of databases and construction of literature search strategies for the scoping review. The authors also wish to thank Dr. Changiz Mohiyeddini, Professor in Behavioral Medicine and Psychopathology at Oakland University William Beaumont School of Medicine (OUWB) for his expertise and constructive feedback on our manuscript.

Author information

Authors and affiliations.

Department of Foundational Sciences, Central Michigan University College of Medicine, Mt. Pleasant, MI, 48859, USA

Brianne E. Lewis

Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, 586 Pioneer Dr, Rochester, MI, 48309, USA

Akshata R. Naik

You can also search for this author in PubMed   Google Scholar

Contributions

A.R.N and B.E.L were equally involved in study conception, design, collecting data and analyzing the data. B.E.L and A.R.N both contributed towards writing the manuscript. A.R.N and B.E.L are both senior authors on this paper. All authors reviewed the manuscript.

Corresponding author

Correspondence to Akshata R. Naik .

Ethics declarations

Ethics approval and consent to participate.

Not applicable.

Consent for publication

Competing interests.

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Lewis, B.E., Naik, A.R. A scoping review to identify and organize literature trends of bias research within medical student and resident education. BMC Med Educ 23 , 919 (2023). https://doi.org/10.1186/s12909-023-04829-6

Download citation

Received : 14 March 2023

Accepted : 01 November 2023

Published : 05 December 2023

DOI : https://doi.org/10.1186/s12909-023-04829-6

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Preclinical curriculum
• Evidence of bis

BMC Medical Education

ISSN: 1472-6920

• Submission enquiries: [email protected]
• General enquiries: [email protected]

Ownership Structure and Firm Performance: A Comprehensive Review and Empirical Analysis

• Published: 04 April 2024

Cite this article

• Sanjana Bhakar   ORCID: orcid.org/0000-0002-0936-9651 1 ,
• Priti Sharma 1 &
• Sanjiv Kumar 1  

22 Accesses

Explore all metrics

Ownership structure and firm performance are the two important ingredients for a firm to sustain in the market for a prolonged time. Ample research has statistically proven the significant impact of ownership structure on firm performance. Ergo, this study aims to critically review and analyse the mechanisms of ownership structure (OS) and their impact on the firm performance (FP) with the help of content analysis and systematic literature review (SLR). This study used the combined literature from Scopus and Web of Science databases from 1977 to 2022. A total of 552 relevant documents have been extracted, out of which 40 documents were found suitable based on inclusion and exclusion criteria using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) framework of SLR has been applied using R studio software. Major findings of the study revealed that ownership concentration was found significant in affecting firm performance. However, other mechanisms such as managerial ownership, government ownership, institutional ownership, foreign ownership and family ownership showed mixed results such as positive, negative or insignificant. This study on the one side contributes to the existing literature and also helps the policymakers in maximising the performance of the firm by suggesting ways to reduce conflicts of interest between managers and shareholders and will also be significant to the practitioners, scholars and managers in comprehending dynamics of corporate governance practices. Further, it will help investors give special consideration to a particular type of ownership structure while making investment decisions.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price includes VAT (Russian Federation)

Instant access to the full article PDF.

Rent this article via DeepDyve

Institutional subscriptions

Source: Compiled by the researcher

Abbreviations

Corporate governance

• Ownership structure
• Firm performance
• Ownership concentration

Concentrated ownership

Managerial ownership

Foreign ownership

Family ownership

Government ownership

State-owned

Institutional ownership

Dependent variable

Independent variable

Control variables

Abdullah, M. I., Sarfraz, M., Qun, W., & Chaudhary, M. (2019). Ownership concentration impact on firm financial performance. LogForum, 15 (1), 107–118. https://doi.org/10.17270/J.LOG.2019.317

Article   Google Scholar  

Abdulsamad, A. O., & Yusoff, W. F. W. (2016). Ownership structure and firm performance: A longitudinal study in Malaysia. Corporate Ownership & Control, 13 (2), 432–437. https://doi.org/10.22495/cocv13i2c2p3

Abdurrouf, M. A. (2011). The relationship between corporate governance and value of the firm in developing countries: Evidence from Bangladesh. The International Journal of Applied Economics and Finance, 5 (3), 237–244. https://doi.org/10.3923/ijaef.2011.237.244

Alabdullah, T. T. Y. (2018). The relationship between ownership structure and firm financial performance: Evidence from Jordan. Benchmarking, 25 (1), 319–333. https://doi.org/10.1108/BIJ-04-2016-0051

Alba, P., Claessens, S., & Djankov, S. (1998). Thailand's corporate financing and governance structures (No. 2003). World Bank Publications.

Alfaraih, M., Alanezi, F., & Almujamed, H. (2012). The influence of institutional and government ownership on firm performance: Evidence from Kuwait. International Business Research, 5 (10), 192–200. https://doi.org/10.5539/ibr.v5n10p192

Ali, A., Qiang, F., & Ashraf, S. (2018). Regional dynamics of ownership structure and their impact on firm performance and firm valuation: A case of Chinese listed companies. Review of International Business and Strategy, 28 (1), 128–146. https://doi.org/10.1108/RIBS-02-2017-0017

Ali Ahmed, H., & Wadud, I. K. M. (2011). Market based performance: Do ownership structures, or firm policy choice matter ? Corporate Ownership & Control, 8 (2), 89–95.

Alimehmeti, G., & Paletta, A. (2012). Ownership concentration and effects over firm performance: Evidences from Italy. European Scientific Journal, 8 (22), 39–49.

Google Scholar  

Alkurdi, A., Hamad, A., Thneibat, H., & Elmarzouky, M. (2021). Ownership structure’s effect on financial performance: An empirical analysis of Jordanian listed firms. Cogent Business and Management , 8 (1). https://doi.org/10.1080/23311975.2021.1939930

Al-Matari, E. M., & Al-Arussi, A. S. (2016). The effect of the ownership structure characteristics on firm performance in oman: Empirical study. Corporate Ownership and Control, 13 (2), 93–182. https://doi.org/10.22495/cocv13i2p10

Al-Matari, E. M., Al-Swidi, A. K., Faudziah, H. B., & Al-Matari, Y. A. (2012a). The impact of board characteristics on firm performance: Evidence from nonfinancial listed companies in Kuwaiti Stock Exchange. International Journal of Accounting and Financial Reporting, 2 (2), 310-332. 6. https://doi.org/10.5296/ijafr.v2i2.2384

Al-Matari, Y. A., Al-Swidi, A. K., & Fadzil, F. H. B. (2012b). Audit committee effectiveness and performance of Saudi Arabia listed companies. Wulfenia Journal, 19 (8), 169–188.

Al-Matari, E. M., Al-Matari, Y. A., & Saif, S. A. (2017). Association between ownership structure characteristics and firm performance: Oman evidence. Academy of Accounting and Financial Studies Journal, 21 (1), 11.

Alkurdi, A., Hamad, A., Thneibat, H., & Elmarzouky, M| Collins G. Ntim (Reviewing editor) (2021). Ownership structure’s effect on financial performance: An empirical analysis of Jordanian listed firms, Cogent Business & Management , 8:1, https://doi.org/10.1080/23311975.2021.1939930 .

Amran, N. A., & Ahmad, A. C. (2013). Effects of ownership structure on Malaysian companies performance. Asian Journal of Accounting and Governance, 4 (1), 51–60.

Anderson, R. C., & Reeb, D. M. (2003). Founding-family ownership and firm performance: Evidence from the S&P 500. Journal of Finance, 58 (3), 1301–1328. https://doi.org/10.1111/1540-6261.00567

Balsmeier, B., & Czarnitzki, D. (2017). Ownership concentration, institutional development and firm performance in Central and Eastern Europe. Managerial and Decision Economics, 38 (2), 178–192. https://doi.org/10.1002/mde.2751

Basyith, A., Fauzi, F., & Idris, M. (2015). The impact of board structure and ownership structure on firm performance: An evidence from blue chip firms listed in Indonesian stock exchange. Corporate Ownership & Control , 12 (3). https://doi.org/10.22495/cocv12i4c3p2

Barontini, R., & Caprio, L. (2006). The effect of family control on firm value and performance: Evidence from continental Europe. European financial management, 12 (5), 689–723.

Beatty, A., & Harris, D. (1998). The effects of taxes, agency costs and information asymmetry on earnings man- agement: A comparison of public and private firms. The Review of Accounting Studies, 4 (3/4), 299–326. https://doi.org/10.1023/A:1009642403312

Ben Slimane, S., Coeurderoy, R., & Mhenni, H. (2022). Digital transformation of small and medium enterprises: A systematic literature review and an integrative framework. International Studies of Management & Organization, 52 (2), 96–120. https://doi.org/10.1080/00208825.2022.2072067

Berle, A., & Means, G. (1932). The modern corporation and private property . Macmillan.

Bhatia, S., & Srivastava, A. (2017). Do promoter holding and firm performance exhibit endogenous relationship? An analysis from emerging market of India. Management and Labour Studies, 42 (2), 107–119. https://doi.org/10.1177/0258042X17714073

Bonardo, D., Paleari, S., & Vismara, S. (2007). The non-linear relationship between managerial ownership and firm performance. Corporate Ownership & Control, 4 (4), 18–29. https://doi.org/10.22495/cocv4i4p7

Brown, L. D., & Caylor, M. L. (2004). Corporate governance and firm valuation. Journal of Accounting and Public Policy, 25 (2), 409–434. https://doi.org/10.1016/j.jaccpubpol.2006.05.005

Cai, D., Luo, J. H., & Wan, D. F. (2012). Family CEOs: Do they benefit firm performance in China? Asia Pacific Journal of Management, 29 (4), 923–947. https://doi.org/10.1007/s10490-012-9318-4

Chen, A., Kao, L., Tsao, M., & Wu, C. (2007). Building a corporate governance index from the perspectives of ownership and leadership for firms in Taiwan. Corporate Governance : An International Review, 15 (2), 251–261.

Chen, G., Firth, M., Gao, D. N., & Rui, O. M. (2006). Ownership structure, corporate governance, and fraud: Evidence from China . Journal of corporate finance, 12 (3), 424–448.

Chen, X., Kim, J. B., Wang, S. S., & Xu, X. (2007a). Firm performance and the ownership of the largest shareholder. Corporate Ownership and Control, 4 (3), 126–138. https://doi.org/10.22495/cocv4i3p11

Chen, X., Harford, J., & Li, K. (2007b). Monitoring: Which institutions matter? Journal of Financial Economics, 86 , 279–305.

Cheng, T. Y., & Lai, H. C. (2016). Ownership structure, organization stability and biotechnology company performance. Investment Management and Financial Innovations, 13 (2), 109–116. https://doi.org/10.21511/imfi.13(2).2016.12

Claessens, S., Djankov, S., Fan, J. P. H., & Lang, L. H. P. (2002). Disentangling the incentive and entrenchment effects of large shareholdings. Journal of Finance, 6 , 2741–2771.

Clarke, T. (1998). The stakeholder corporation: A business philosophy for the information age. Long Range Planning, 31 (2), 182–194. https://doi.org/10.1016/S0024-6301(98)00002-8

Cronqvist, H., & Fahlenbrach, R. (2009). Large shareholders and corporate policies. Rev. Financ. Stud., 22 , 3941–3976.

Demsetz, H., & Lehn, K. (1985). The structure of corporate ownership: Causes and consequences. Journal of Political Economy, 93 (6), 1155–1177.

Demsetz, H., & Villalonga, B. (2001). Ownership structure and corporate performance. Journal of Corporate Finance, 7 (3), 209–233. https://doi.org/10.1016/s0929-1199(01)00020-7

Escobar, D. R. O., & Escobar, E. S. O. (2022). Oil and its influence on the creation of a sustainable society: A systematic literature review. Intangible Capital, 18 (3), 402–429. https://doi.org/10.3926/ic.1833

Fama, E. F., & Jensen, M. C. (1983). Agency problems and residual claims. The Journal of Law and Economics, 26 (2), 327–349. https://doi.org/10.1086/467038

Fauzi, F., & Locke, S. (2012). Board structure, ownership structure and firm performance: A study of New Zealand listed-firms. Asian Academy of Management Journal of Accounting and Finance, 8 (2), 43–67.

Fazlzadeh, A., Hendi, A. T., & Mahboubi, K. (2011). The examination of the effect of ownership structure on firm performance in listed firms of Tehran stock exchange based on the type of the industry. Interactional Journal of Business and Management, 6 (3), 249–267.

Fooladi, M., & Nikzad Chaleshtori, G. (2011). Corporate governance and firm performance. In International Conference on Sociality and Economics Development (ICSED 2011), Kuala Lumpur, Malaysia, June . 17–19.

Frijns, B., Gilbert, A., & Reumers, P. (2008). Corporate ownership structure and firm performance: Evidence from the Netherlands. Corporate Ownership and Control, 6 (2), 382–392.

García-Meca, E., & Sánchez-Ballesta, J. P. (2011). Firm value and ownership structure in the Spanish capital market. Corporate Governance: The International Journal of Business in Society, 11 (1), 41–53. https://doi.org/10.1108/14720701111108835

Gaur, S. S., Bathula, H., & Singh, D. (2015). Ownership concentration, board characteristics and fIrm performance: A contingency framework. Management Decision, 53 (5), 911–931. https://doi.org/10.1108/MD-08-2014-0519

Gedajlovic, É., & Shapiro, D. (1998). Management and ownership effects: Evidence from five countries. Strategic Management Journal, 19 (6), 533–553. https://doi.org/10.1002/(sici)1097-0266(199806)19:6

Gough, D., & Elbourne, D. (2002a). Systematic research synthesis to inform policy, practice, and democratic debate. Social Policy and Society, 1 , 225–236.

Gough, D., & Elbourne, D. (2002b). Systematic research synthesis to inform policy, practice and democratic debate. Social Policy and Society, 1 (3), 225–236. https://doi.org/10.1017/S147474640200307X

Hartzell, J. C., Sun, L., & Titman, S. (2014). Institutional investors as monitors of corporate diversification decisions: Evidence from real estate investment trusts. Journal of Corporate Finance, 25 (2), 61–72. https://doi.org/10.1016/j.jcorpfin.2013.10.006

Han, K. C., & Suk, D. Y. (1998). The effect of ownership structure on firm performance: Additional evidence. Review of Financial Economics, 7 (2), 143–155. https://doi.org/10.1016/S1058-3300(99)80150-5

Holderness, C. G. (2009). The myth of diffuse ownership in the united states. Review of Financial Studies, 22 , 1377–1408.  https://doi.org/10.1093/rfs/hhm069

Hess, K., Gunasekarage, A., & Hovey, M. (2008). State-dominant and non-state-dominant ownership concentration and firm performance: Evidence from China. International Journal of Managerial Finance, 6 (4), 264–289. https://doi.org/10.1108/17439131011074440

Irina, I., & Nadezhda, Z. (2009). The relationship between corporate governance and company performance in concentrated ownership systems : The case of Germany. Journal of Corporate Finance, 4 (12), 34–56. https://doi.org/10.17323/j.jcfr.2073-0438.3.4.2009.34-56

International Conference on Sociality and Economics Development (ICSED 2011). Kuala Lumpur, Malaysia, June 17-19, 2011, International Proceedings of Economics Development and Research (IPEDR) vol.10, International Association of Computer Science and Information Technology Press (IACSIT Press), Singa

Jensen, M. C. (1986). Agency Costs of Free Cash Flow, Corporate Finance, and Takeovers. The American Economic Review, 76 (2), 323–329.  http://www.jstor.org/stable/1818789

Jensen, M. C. (2000). Theory of the Firm : Governance, Residual Claims, and Organizational Forms . Cambridge: Harvard University Press

Jensen, M., & Meckling, W. H. (1976). Theory of the firm: Managerial behavior, agency costs, and ownership structure. Journal of Financial Economics, 3 , 305–360. https://doi.org/10.1016/0304-405X(76)90026-X

Kajola, S. O. (2008). Corporate governance and firm performance : The case of Nigerian listed firms. European Journal of Economics, Finance and Administrative Sciences, 14 (14), 16–28.

Kao, M. F., Hodgkinson, L., & Jaafar, A. (2019). Ownership structure, board of directors and firm performance: Evidence from Taiwan. Corporate Governance (Bingley), 19 (1), 189–216. https://doi.org/10.1108/CG-04-2018-0144

Kapopoulos, P., & Lazaretou, S. (2007). Corporate ownership structure and firm performance: Evidence from Greek firms. Corporate Governance: An International Review, 15 (2), 144–158. https://doi.org/10.1111/j.1467-8683.2007.00551.x

Karaca, S. S., & Ekşi, İH. (2012). The relationship between ownership structure and firm performance: An empirical analysis over İstanbul Stock Exchange (ISE) listed companies. International Business Research, 5 (1), 172–181. https://doi.org/10.5539/ibr.v5n1p172

Laporšek, S., Dolenc, P., Grum, A., & Stubelj, I. (2021). Ownership structure and firm performance–The case of Slovenia. Economic Research-Ekonomska Istrazivanja . https://doi.org/10.1080/1331677X.2020.1865827

Lauterbach, B., & Vaninsky, A. (1999). Ownership structure and firm performance: Evidence from Israel. Journal of Management and Governance, 3 , 189–201.

Le, T. V., & Chizema, A. (2011). State ownership and firm performance: Evidence from the Chinese listed firms. Organizations and Markets in Emerging Economies, 2 (2), 72–90. https://doi.org/10.15388/omee.2011.2.2.14282

Lee, S. (2008). Ownership structure and financial performance: Evidence from panel data of South Korea. Corporate ownership and Control, 6 (2), 254–267.

Lepore, L., Paolone, F., Pisano, S., & Alvino, F. (2017). A cross-country comparison of the relationship between ownership concentration and firm performance: Does judicial system efficiency matter? Corporate Governance: The International Journal of Business in Society, 17 (2), 321–340. https://doi.org/10.1108/cg-03-2016-0049

Li, K., Lu, L., Mittoo, U. R., & Zhang, Z. (2015). Board independence, ownership concentration and corporate performance—Chinese evidence. International Review of Financial Analysis, 41 , 162–175. https://doi.org/10.1016/j.irfa.2015.05.024

Liang, C.-J., Lin, Y.-L., & Huang, T.-T. (2011). Does endogenously determined ownership matter on performance? Dynamic evidence from the emerging Taiwan market. Emerging Markets Finance and Trade, 47 (6), 120–133. https://doi.org/10.2753/REE1540-496X470607

Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C., Gøtzsche, P. C., Ioannidis, J. P., et al. (2009). The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: Explanation and elaboration. Journal of Clinical Epidemiology, 62 (10), e1–e34. https://doi.org/10.1016/j.jclinepi.2009.06.006

Lins, K. V. (2003). Equity ownership and firm value in emerging markets. The Journal of Financial and Quantitative Analysis, 38 (1), 159. https://doi.org/10.2307/4126768

Manawaduge, A. S., & De Zoysa, A. (2013). The structure of corporate ownership and firm performance: Sri Lankan evidence. Corporate Ownership and Control, 11 (1), 723–734. https://doi.org/10.22495/cocv11i1c8art3

Mang’unyi, E. E. (2011). Ownership structure and corporate governance and its effects on performance: A case of selected banks in Kenya. International Journal of Business Administration , 2 (3), 2.  https://doi.org/10.5430/ijba.v2n3p2

Masood, F. C. (2011). Corporate governance and firm performance. International Conference on Sociality and Economic Development, 10 , 484–489.

Massaro, M., Dumay, J., & Guthrie, J. (2016). On the shoulders of giants: Undertaking a structured literature review in accounting. Accounting, Auditing & Accountability Journal, 29 (5), 767–801. https://doi.org/10.1108/AAAJ-01-2015-1939

McConnell, J. J., & Servaes, H. (1990). Additional evidence on equity ownership and corporate value. Journal of Financial Economics, 27 (2), 595–612. https://doi.org/10.1016/0304-405x(90)90069-c

Millet-Reyes, B., & Zhao, R. (2010). A comparison between one-tier and two-tier board structures in France. Journal of International Financial Management and Accounting, 21 (3), 279–310. https://doi.org/10.1111/j.1467-646x.2010.01042.x

Mitton, T. (2002). A cross-firm analysis of the impact of corporate governance on the East Asian financial crisis. Journal of financial economics, 64 (2), 215–241.

MoIlah, A. S., & Talukdar, M. B. U. (2007). Ownership structure, corporate governance, and firm’s performance in emerging markets: Evidence from Bangladesh. The International Journal of Finance, 19 (1), 4315–4333.

Morck, R., Shleifer, A., & Vishny, R. W. (1988). Management ownership and market valuation: An empirical analysis. Journal of Financial Economics, 20 , 293–315.

Mrad, M. (2015). Post-privatisation ownership structure and firm performance: What is the matter? International Journal of Monetary Economics and Finance, 8 (1), 85–108. https://doi.org/10.1504/IJMEF.2015.069171

Mugobo, V. V., Mutize, M., & Aspeling, J. (2016). The ownership structure effect on firm performance in South Africa. Corporate Ownership & Control, 13 (2), 461–464. https://doi.org/10.22495/cocv13i2c2p7

Nakano, M., & Nguyen, P. (2013). Foreign ownership and firm performance: Evidence from Japan’s electronics industry. Applied Financial Economics, 23 (1), 41–50. https://doi.org/10.1080/09603107.2012.705425

Nor, F. M., Shariff, F. M., & Ibrahim, I. (2010). The effects of concentrated ownership on the performance of the firm : Do external shareholdings and board structure matter ? Jurnal Pengurusan, 30 , 93–102.

NurulAfzan, N., & Rashidah, A. (2011). Government ownership and performance of Malaysian government-linked companies. International Research Journal of Finance and Economics, 61 , 42–56.

Nuryanah, S., & Islam, S. M. N. (2011). Corporate governance and performance: Evidence from an emerging market. Malaysian Accounting Review, 10 (1), 17–42.

Obiyo, O. C., & Lenee, L. T. (2011). Corporate governance and firm performance in Nigeria. IJEMR, 1 (4), 1–12.

Ongore, V. O. (2011). The relationship between ownership structure and firm performance : An empirical analysis of listed companies in Kenya.

Petticrew, M. (2001). Systematic reviews from astronomy to zoology: Myths and misconceptions. British Medical Journal, 322 , 98–101. https://doi.org/10.1136/bmj.322.7278.98

Petticrew, M., & Roberts, H. (2008). Systematic reviews in the social sciences : A practical guide. John Wiley & Sons.

Qin, Z., & Deng, X. (2009). Ownership structure and performance in family businesses at early development stage : Evidence from China. Corporate Ownership and Control, 7 (1), 135. https://doi.org/10.22495/cocv7i1p13

Queiri, A., Madbouly, A., Reyad, S., & Dwaikat, N. (2021). Corporate governance, ownership structure and firms’ financial performance: Insights from Muscat securities market (MSM30). Journal of Financial Reporting and Accounting, 19 (4), 640–665. https://doi.org/10.1108/JFRA-05-2020-0130

Rashid, M. M. (2020). Ownership structure and firm performance: The mediating role of board characteristics. Corporate Governance (Bingley), 20 (4), 719–737. https://doi.org/10.1108/CG-02-2019-0056

Rumsfeld, Donald (2011). Known and Unknown: A Memoir. New York: Penguin Group. p. xiii. http://slate.msn.com/id/2081042

Rusmin, R., Evans, J., & Hossain, M. (2012). Ownership structure, political connection and firm performance: Evidence from Indonesia. Corporate Ownership and Control, 10 (1), 434–443. https://doi.org/10.22495/cocv10i1c4art4

Saleh, A. S., Halili, E., Zeitun, R., & Salim, R. (2017a). Global financial crisis, ownership structure and firm financial performance: An examination of listed firms in Australia. Studies in Economics and Finance . https://doi.org/10.1108/SEF-09-2016-0223

Saleh, M., Zahirdin, G., & Octaviani, E. (2017b). Ownership structure and corporate performance: Evidence from property and real estate public companies in Indonesia. Investment Management and Financial Innovations, 14 (2 (contin.1)), 252–263. https://doi.org/10.21511/imfi.14(2-1).2017.10

Sanda, A., Mikailu, A. S., & Garba, T. (2005). Corporate governance mechanisms and firm financial performance in Nigeria. xxx, xxx(xxx), 1– 47.

Sanda, A. U., Mikailu, A. S., & Garba, T. (2010). Corporate governance mechanisms and firms’ financial performance in Nigeria. Afro-Asian Journal of Finance and Accounting, 2 (1), 22–39

Setia-Atmaja, L. Y. (2009). Governance mechanisms and firm value: The impact of ownership concentration and dividends. Corporate Governance: An International Review, 17 (6), 694–709. https://doi.org/10.1111/j.1467-8683.2009.00768.x

Shleifer, A., & Vishny, R. W. (1986). Large shareholders and corporate control. Journal of Political Economy, 94 (3), 461–488. https://doi.org/10.1086/261385

Shleifer, A., & Vishny, R. W. (1997). A survey of corporate governance. Journal of Finance, 52 (2), 737–783. https://doi.org/10.2307/2329497

Sun, Q., Tong, W. H., & Tong, J. (2002). How does government ownership affect firm performance? Evidence from China’s privatization experience. Journal of Business Finance & Accounting, 29 (1–2), 1–27.

Tsegba, I. N., & Achua, J. K. (2011). Does ownership structure affect firm performance? Evidence from Nigerian listed companies. Corporate Ownership and Control , 9 (1–5), 503–513.  https://doi.org/10.22495/cocv9i1c5art2

Vincent, O. O. (2011). The relationship between ownership structure and firm performance: An empirical analysis of listed companies in Kenya. African Journal of Business Management, 5 (6), 2120–2128.

Wahla, K., Shah, S. Z. A., & Hussain, Z. (2010). Impact of ownership structure on firm performance evidence from non-financial listed companies at Karachi Stock Exchange. International Research Journal of Finance and Economics , 84 (3), 6–13. https://doi.org/10.5897/AJBM2014.7611

Ward, C., Yin, C., & Zeng, Y. (2018). Institutional investor monitoring motivation and the marginal value of cash. Journal of Corporate Finance, 48 , 49–75.

Vroom, G. & Mccann, B.T. (2009). Ownership structure, profit maximization and competitive behavior : Working paper series, IESE business school university of Navarra.

Warokka, A., Abdullah, H. H., & Duran, J. J. (2012). Ownership structures and firm performance : does East Asian corporate governance’s recovery work. World Review of Business Research, 2 (1), 18–35.

Weir, C., Laing, D., & McKnight, P. J. (2002). Internal and external governance mechanisms: Their impact on the performance of large UK public companies. Journal of Business Finance & Accounting, 29 (5–6), 579–611. https://doi.org/10.1111/1468-5957.00444

Weiss, C., & Hilger, S. (2012). Ownership concentration beyond good and evil: Is there an effect on corporate performance? Journal of Management & Governance, 16 (4), 727–752. https://doi.org/10.1007/s10997-011-9170-9

Welch, E. (2003). The relationship between ownership structure and performance in listed Australian companies. Australian Journal of Management, 28 (3), 287–305. https://doi.org/10.1177/031289620302800304

Yammeesri, J., Lodh, S. C., & Herath, S. K. (2006). Influence of ownership structure and corporate performance precrisis: Evidence from Thailand. International Journal of Electronic Finance, 1 (2), 181–199. https://doi.org/10.1504/ijef.2006.010315

Zeitun, R., & Al-kawari, D. (2012). Government Ownership, Business Risk, Financial Leverage and Corporate Performance: Evidence from GCC Countries. Corporate Ownership & Control, 9 (3), 123–131. https://doi.org/10.22495/cocv9i3art10

Zeitun, R., & Tian, G. G. (2007). Does ownership affect a firm’s performance and default risk in Jordan? Corporate Governance, 7 (1), 66–82. https://doi.org/10.1108/14720700710727122

Zraiq, M. A. A., & Fadzil, F. H. B. (2018). The impact of ownership structure on firm performance: Evidence from Jordan. International Journal of Accounting, Finance and Risk Management, 3 (1), 1–4. https://doi.org/10.11648/j.ijafrm.20180301.12

Download references

Author information

Authors and affiliations.

Department of Commerce, Maharshi Dayanand University, Rohtak, 124001, India

Sanjana Bhakar, Priti Sharma & Sanjiv Kumar

You can also search for this author in PubMed   Google Scholar

Contributions

All authors contributed to the study from inception to the end. Material preparation, data collection and analysis were simultaneously performed equally by the authors.

Corresponding author

Correspondence to Priti Sharma .

Ethics declarations

Competing interests.

The authors declare no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

“As we know, there are known knowns. There are things we know we know. We also know there are known unknowns. That is to say, we know there are some things we do not know. But there are also unknown unknowns, the ones we don’t know we don’t know.”- Donald Rumsfeld, 2002.

Please see Table  3 .

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Bhakar, S., Sharma, P. & Kumar, S. Ownership Structure and Firm Performance: A Comprehensive Review and Empirical Analysis. J Knowl Econ (2024). https://doi.org/10.1007/s13132-024-01893-1

Download citation

Received : 31 May 2023

Accepted : 26 February 2024

Published : 04 April 2024

DOI : https://doi.org/10.1007/s13132-024-01893-1

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Systematic literature review
• Content analysis
• Find a journal
• Publish with us
• Track your research

• Search Menu
• Advance articles
• Editor's Choice
• Supplement Archive
• Article Collection Archive
• Author Guidelines
• Submission Site
• Open Access
• Call for Papers
• Why Publish?
• About Nutrition Reviews
• About International Life Sciences Institute
• Editorial Board
• Early Career Editorial Board
• Advertising and Corporate Services
• Journals Career Network
• Self-Archiving Policy
• Journals on Oxford Academic
• Books on Oxford Academic

Article Contents

• INTRODUCTION
• DEOXYNIVALENOL AND T-2 TOXIN
• ZEARALENONE AND METABOLITES
• ADDITIVE AND SYNERGISTIC EFFECTS OF MULTIPLE-MYCOTOXIN EXPOSURE
• EPIDEMIOLOGICAL STUDIES
• Acknowledgments

Mycotoxins and bone growth: a review of the literature on associations between xenobiotic exposure and bone growth and development

• Article contents
• Figures & tables
• Supplementary Data

Rukshan Mehta, Anthony J Wenndt, Mycotoxins and bone growth: a review of the literature on associations between xenobiotic exposure and bone growth and development, Nutrition Reviews , 2024;, nuae032, https://doi.org/10.1093/nutrit/nuae032

• Permissions Icon Permissions

Mycotoxins are secondary metabolites of fungi that are known to be associated with linear growth faltering because of their impact on inflammation, intestinal damage, inhibition of protein synthesis, and micronutrient absorption. In this narrative review, we aim to extend this analysis to further explore associations between mycotoxins (aflatoxins, ochratoxins, trichothecenes including deoxynivalenol, T-2 toxin, and fumonisins) and long-bone growth, particularly during the saltatory periods of development. Linear growth is a direct function of skeletal development and long-bone growth. We therefore explored biological pathways and mechanisms of impact of these toxins in both animal and human studies, in addition to the epidemiology literature (post-2020). Given what is known of the effects of individual and combinations of mycotoxins based on the animal literature, we have identified a need for further research and examination of how these toxins and exposures may be studied in humans to elucidate the downstream impact on bone-related biomarkers and anthropometric indices used to identify and predict stunting in population-based studies.

Email alerts

Citing articles via.

• Recommend to your Library

Affiliations

• Online ISSN 1753-4887
• Print ISSN 0029-6643
• Copyright © 2024 International Life Sciences Institute
• About Oxford Academic
• Publish journals with us
• University press partners
• What we publish
• New features  
• Open access
• Institutional account management
• Rights and permissions
• Get help with access
• Accessibility
• Advertising
• Media enquiries
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

• Open access
• Published: 23 August 2022

Prognostic risk factors for moderate-to-severe exacerbations in patients with chronic obstructive pulmonary disease: a systematic literature review

• John R. Hurst 1 ,
• MeiLan K. Han 2 ,
• Barinder Singh 3 ,
• Sakshi Sharma 4 ,
• Gagandeep Kaur 3 ,
• Enrico de Nigris 5 ,
• Ulf Holmgren 6 &
• Mohd Kashif Siddiqui 3  

Respiratory Research volume  23 , Article number:  213 ( 2022 ) Cite this article

6315 Accesses

20 Citations

33 Altmetric

Metrics details

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. COPD exacerbations are associated with a worsening of lung function, increased disease burden, and mortality, and, therefore, preventing their occurrence is an important goal of COPD management. This review was conducted to identify the evidence base regarding risk factors and predictors of moderate-to-severe exacerbations in patients with COPD.

A literature review was performed in Embase, MEDLINE, MEDLINE In-Process, and the Cochrane Central Register of Controlled Trials (CENTRAL). Searches were conducted from January 2015 to July 2019. Eligible publications were peer-reviewed journal articles, published in English, that reported risk factors or predictors for the occurrence of moderate-to-severe exacerbations in adults age ≥ 40 years with a diagnosis of COPD.

The literature review identified 5112 references, of which 113 publications (reporting results for 76 studies) met the eligibility criteria and were included in the review. Among the 76 studies included, 61 were observational and 15 were randomized controlled clinical trials. Exacerbation history was the strongest predictor of future exacerbations, with 34 studies reporting a significant association between history of exacerbations and risk of future moderate or severe exacerbations. Other significant risk factors identified in multiple studies included disease severity or bronchodilator reversibility (39 studies), comorbidities (34 studies), higher symptom burden (17 studies), and higher blood eosinophil count (16 studies).

Conclusions

This systematic literature review identified several demographic and clinical characteristics that predict the future risk of COPD exacerbations. Prior exacerbation history was confirmed as the most important predictor of future exacerbations. These prognostic factors may help clinicians identify patients at high risk of exacerbations, which are a major driver of the global burden of COPD, including morbidity and mortality.

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide [ 1 ]. Based upon disability-adjusted life-years, COPD ranked sixth out of 369 causes of global disease burden in 2019 [ 2 ]. COPD exacerbations are associated with a worsening of lung function, and increased disease burden and mortality (of those patients hospitalized for the first time with an exacerbation, > 20% die within 1 year of being discharged) [ 3 ]. Furthermore, patients with COPD consider exacerbations or hospitalization due to exacerbations to be the most important disease outcome, having a large impact on their lives [ 4 ]. Therefore, reducing the future risk of COPD exacerbations is a key goal of COPD management [ 5 ].

Being able to predict the level of risk for each patient allows clinicians to adapt treatment and patients to adjust their lifestyle (e.g., through a smoking cessation program) to prevent exacerbations [ 3 ]. As such, identifying high-risk patients using measurable risk factors and predictors that correlate with exacerbations is critical to reduce the burden of disease and prevent a cycle of decline encompassing irreversible lung damage, worsening quality of life (QoL), increasing disease burden, high healthcare costs, and early death.

Prior history of exacerbations is generally thought to be the best predictor of future exacerbations; however, there is a growing body of evidence suggesting other demographic and clinical characteristics, including symptom burden, airflow obstruction, comorbidities, and inflammatory biomarkers, also influence risk [ 6 , 7 , 8 , 9 ]. For example, in the prospective ECLIPSE observational study, the likelihood of patients experiencing an exacerbation within 1 year of follow-up increased significantly depending upon several factors, including prior exacerbation history, forced expiratory volume in 1 s (FEV 1 ), St. George’s Respiratory Questionnaire (SGRQ) score, gastroesophageal reflux, and white blood cell count [ 9 ].

Many studies have assessed predictors of COPD exacerbations across a variety of countries and patient populations. This systematic literature review (SLR) was conducted to identify and compile the evidence base regarding risk factors and predictors of moderate-to-severe exacerbations in patients with COPD.

• Systematic literature review

A comprehensive search strategy was designed to identify English-language studies published in peer-reviewed journals providing data on risk factors or predictors of moderate or severe exacerbations in adults aged ≥ 40 years with a diagnosis of COPD (sample size ≥ 100). The protocol is summarized in Table 1 and the search strategy is listed in Additional file 1 : Table S1. Key biomedical electronic literature databases were searched from January 2015 until July 2019. Other sources were identified via bibliographic searching of relevant systematic reviews.

Study selection process

Implementation and reporting followed the recommendations and standards of the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) statement [ 10 ]. An independent reviewer conducted the first screening based on titles and abstracts, and a second reviewer performed a quality check of the excluded evidence. A single independent reviewer also conducted the second screening based on full-text articles, with a quality check of excluded evidence performed by a second reviewer. Likewise, data tables of the included studies were generated by one reviewer, and another reviewer performed a quality check of extracted data. Where more than one publication was identified describing a single study or trial, data were compiled into a single entry in the data-extraction table to avoid double counting of patients and studies. One publication was designated as the ‘primary publication’ for the purposes of the SLR, based on the following criteria: most recently published evidence and/or the article that presented the majority of data (e.g., journal articles were preferred over conference abstracts; articles that reported results for the full population were preferred over later articles providing results of subpopulations). Other publications reporting results from the same study were designated as ‘linked publications’; any additional data in the linked publications that were not included in the primary publication were captured in the SLR. Conference abstracts were excluded from the SLR unless they were a ‘linked publication.’

Included studies

A total of 5112 references (Fig.  1 ) were identified from the database searches. In total, 76 studies from 113 publications were included in the review. Primary publications and ‘linked publications’ for each study are detailed in Additional file 1 : Table S2, and study characteristics are shown in Additional file 1 : Table S3. The studies included clinical trials, registry studies, cross-sectional studies, cohort studies, database studies, and case–control studies. All 76 included studies were published in peer-reviewed journals. Regarding study design, 61 of the studies were observational (34 retrospective observational studies, 19 prospective observational studies, four cross-sectional studies, two studies with both retrospective and prospective cohort data, one case–control study, and one with cross-sectional and longitudinal data) and 15 were randomized controlled clinical trials.

PRISMA flow diagram of studies through the systematic review process. CA conference abstract, CENTRAL Cochrane Central Register of Controlled Trials, PRISMA  Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Of the 76 studies, 16 were conducted in North America (13 studies in the USA, two in Canada, and one in Mexico); 26 were conducted in Europe (seven studies in Spain, four in the UK, three in Denmark, two studies each in Bulgaria, the Netherlands, and Switzerland, and one study each in Sweden, Serbia, Portugal, Greece, Germany, and France) and 17 were conducted in Asia (six studies in South Korea, four in China, three in Taiwan, two in Japan, and one study each in Singapore and Israel). One study each was conducted in Turkey and Australia. Fifteen studies were conducted across multiple countries.

The majority of the studies (n = 54) were conducted in a multicenter setting, while 22 studies were conducted in a single-center setting. The sample size among the included studies varied from 118 to 339,389 patients.

Patient characteristics

A total of 75 studies reported patient characteristics (Additional file 1 : Table S4). The mean age was reported in 65 studies and ranged from 58.0 to 75.2 years. The proportion of male patients ranged from 39.7 to 97.6%. The majority of included studies (85.3%) had a higher proportion of males than females.

Exacerbation history (as defined per each study) was reported in 18 of 76 included studies. The proportion of patients with no prior exacerbation was reported in ten studies (range, 0.1–79.5% of patients), one or fewer prior exacerbation in ten studies (range, 46–100%), one or more prior exacerbation in eight studies (range, 18.4–100%), and two or more prior exacerbations in 12 studies (range, 6.1–55.0%).

Prognostic factors of exacerbations

A summary of the risk factors and predictors reported across the included studies is provided in Tables 2 and 3 . The overall findings of the SLR are summarized in Figs. 2 and 3 .

Risk factors for moderate-to-severe exacerbations in patients with COPD. Factors with > 30 supporting studies shown as large circles; factors with ≤ 30 supporting studies shown as small circles and should be interpreted cautiously. BDR bronchodilator reversibility, BMI body mass index, COPD chronic obstructive pulmonary disease, EOS eosinophil, QoL quality of life

Summary of risk factors for exacerbation events. a Treatment impact studies removed. BDR bronchodilator reversibility, BMI body mass index, COPD chronic obstructive pulmonary disease, EOS eosinophil, QoL quality of life

Exacerbation history within the past 12 months was the strongest predictor of future exacerbations. Across the studies assessing this predictor, 34 out of 35 studies (97.1%) reported a significant association between history of exacerbations and risk of future moderate-to-severe exacerbations (Table 3 ). Specifically, two or more exacerbations in the previous year or at least one hospitalization for COPD in the previous year were identified as reliable predictors of future moderate or severe exacerbations. Even one moderate exacerbation increased the risk of a future exacerbation, with the risk increasing further with each subsequent exacerbation (Fig.  4 ). A severe exacerbation was also found to increase the risk of subsequent exacerbation and hospitalization (Fig.  5 ). Patients experiencing one or more severe exacerbations were more likely to experience further severe exacerbations than moderate exacerbations [ 11 , 12 ]. In contrast, patients with a history of one or more moderate exacerbations were more likely to experience further moderate exacerbations than severe exacerbations [ 11 , 12 ].

Exacerbation history as a risk factor for moderate-to-severe exacerbations. Yun 2018 included two studies; the study from which data were extracted (COPDGene or ECLIPSE) is listed in parentheses. CI confidence interval, ES effect size

Exacerbation history as a risk factor for severe exacerbations. Where data have been extracted from a linked publication rather than the primary publication, the linked publication is listed in parentheses. CI confidence interval, ES , effect size

Overall, 35 studies assessed the association of comorbidities with the risk of exacerbation. All studies except one (97.1%) reported a positive association between comorbidities and the occurrence of moderate-to-severe exacerbations (Table 3 ). In addition to the presence of any comorbidity, specific comorbidities that were found to significantly increase the risk of moderate-to-severe exacerbations included anxiety and depression, cardiovascular comorbidities, gastroesophageal reflux disease/dyspepsia, and respiratory comorbidities (Fig.  6 ). Comorbidities that were significant risk factors for severe exacerbations included cardiovascular, musculoskeletal, and respiratory comorbidities, diabetes, and malignancy (Fig.  7 ). Overall, the strongest association between comorbidities and COPD readmissions in the emergency department was with cardiovascular disease. The degree of risk for both moderate-to-severe and severe exacerbations also increased with the number of comorbidities. A Dutch cohort study found that 88% of patients with COPD had at least one comorbidity, with hypertension (35%) and coronary heart disease (19%) being the most prevalent. In this cohort, the comorbidities with the greatest risk of frequent exacerbations were pulmonary cancer (odds ratio [OR] 1.85) and heart failure (OR 1.72) [ 7 ].

Comorbidities as risk factors for moderate-to-severe exacerbations. Yun 2018 included two studies; the study from which data were extracted (COPDGene or ECLIPSE) is listed in parentheses. Where data have been extracted from a linked publication rather than the primary publication, the linked publication is listed in parentheses. CI confidence interval, ES effect size, GERD gastroesophageal disease

Comorbidities as risk factors for severe exacerbations. Where data have been extracted from a linked publication rather than the primary publication, the linked publication is listed in parentheses. CI confidence interval, CKD , chronic kidney disease, ES effect size

The majority of studies assessing disease severity or bronchodilator reversibility (39/41; 95.1%) indicated a significant positive relation between risk of future exacerbations and greater disease severity, as assessed by greater lung function impairment (in terms of lower FEV 1 , FEV 1 /forced vital capacity ratio, or forced expiratory flow [25–75]/forced vital capacity ratio) or more severe Global Initiative for Chronic Obstructive Lung Disease (GOLD) class A − D, and a positive relationship between risk of future exacerbations and lack of bronchodilator reversibility (Table 3 , Figs. 8 and 9 ).

Disease severity as a risk factor for moderate-to-severe exacerbations. Yun 2018 included two studies; the study from which data were extracted (COPDGene or ECLIPSE) is listed in parentheses. Where data have been extracted from a linked publication rather than the primary publication, the linked publication is listed in parentheses. CI confidence interval, ES effect size, FEV 1 f orced expiratory volume in 1 s, FVC , forced vital capacity, GOLD Global Initiative for Obstructive Lung Disease, HR hazard ratio, OR odds ratio

Disease severity and BDR as risk factors for severe exacerbations. ACCP American College of Chest Physicians, ACOS Asthma-COPD overlap syndrome, ATS  American Thoracic Society, BDR bronchodilator reversibility, CI confidence interval, ERS  European Respiratory Society, ES effect size, FEV 1 forced expiratory volume in 1 s, FVC  forced vital capacity, GINA Global Initiative for Asthma, GOLD Global Initiative for Obstructive Lung Disease

Of 21 studies assessing the relationship between blood eosinophil count and exacerbations (Table 3 ), 16 reported estimates for the risk of moderate or severe exacerbations by eosinophil count. A positive association was observed between higher eosinophil count and a higher risk of moderate or severe exacerbations, particularly in patients not treated with an inhaled corticosteroid (ICS); however, five studies reported a significant positive association irrespective of intervention effects. The risk of moderate-to-severe exacerbations was observed to be positively associated with various definitions of higher eosinophil levels (absolute counts: ≥ 200, ≥ 300, ≥ 340, ≥ 400, and ≥ 500 cells/mm 3 ; % of blood eosinophil count: ≥ 2%, ≥ 3%, ≥ 4%, and ≥ 5%). Of note, one study found reduced efficacy of ICS in lowering moderate-to-severe exacerbation rates for current smokers versus former smokers at all eosinophil levels [ 13 ].

Of 12 studies assessing QoL scales, 11 (91.7%) studies reported a significant association between the worsening of QoL scores and the risk of future exacerbations (Table 3 ). Baseline SGRQ [ 14 , 15 ], Center for Epidemiologic Studies Depression Scale (for which increased scores may indicate impaired QoL) [ 16 ], and Clinical COPD Questionnaire [ 17 , 18 ] scores were found to be associated with future risk of moderate and/or severe COPD exacerbations. For symptom scores, six out of eight studies assessing the association between moderate-to-severe or severe exacerbations with COPD Assessment Test (CAT) scores reported a significant and positive relationship. Furthermore, the risk of moderate-to-severe exacerbations was found to be significantly higher in patients with higher CAT scores (≥ 10) [ 15 , 19 , 20 , 21 ], with one study demonstrating that a CAT score of 15 increased predictive ability for exacerbations compared with a score of 10 or more [ 18 ]. Among 15 studies that assessed the association of modified Medical Research Council (mMRC) scores with the risk of moderate-to-severe or severe exacerbation, 11 found that the risk of moderate-to-severe or severe exacerbations was significantly associated with higher mMRC scores (≥ 2) versus lower scores. Furthermore, morning and night symptoms (measured by Clinical COPD Questionnaire) were associated with poor health status and predicted future exacerbations [ 17 ].

Of 36 studies reporting the relationship between smoking status and moderate-to-severe or severe exacerbations, 22 studies (61.1%) reported a significant positive association (Table 3 ). Passive smoking was also significantly associated with an increased risk of severe exacerbations (OR 1.49) [ 20 ]. Of note, three studies reported a significantly lower rate of moderate-to-severe exacerbations in current smokers compared with former smokers [ 22 , 23 , 24 ].

A total of 14 studies assessed the association of body mass index (BMI) with the occurrence of frequent moderate-to-severe exacerbations in patients with COPD. Six out of 14 studies (42.9%) reported a significant negative association between exacerbations and BMI (Table 3 ). The risk of moderate and/or severe COPD exacerbations was highest among underweight patients compared with normal and overweight patients [ 23 , 25 , 26 , 27 , 28 ].

In the 29 studies reporting an association between age and moderate or severe exacerbations, more than half found an association of older age with an increased risk of moderate-to-severe exacerbations (58.6%; Table 3 ). Four of these studies noted a significant increase in the risk of moderate-to-severe or severe exacerbations for every 10-year increase in age [ 25 , 26 , 29 , 30 ]. However, 12 studies reported no significant association between age and moderate-to-severe or severe exacerbation risk.

Sixteen out of 33 studies investigating the impact of sex on exacerbation risk found a significant association (48.5%; Table 3 ). Among these, ten studies reported that female sex was associated with an increased risk of moderate-to-severe exacerbations, while six studies showed a higher exacerbation risk in males compared with females. There was some variation in findings by geographic location and exacerbation severity (Additional file 2 : Figs. S1 and S2). Notably, when assessing the risk of severe exacerbations, more studies found an association with male sex compared with female sex (6/13 studies vs 1/13 studies, respectively).

Both studies evaluating associations between exacerbations and environmental factors reported that colder temperature and exposure to major air pollution (NO 2 , O 3 , CO, and/or particulate matter ≤ 10 μm in diameter) increased hospital admissions due to severe exacerbations and moderate-to-severe exacerbation rates [ 31 , 32 ].

Four studies assessed the association of 6-min walk distance with the occurrence of frequent moderate-to-severe exacerbations (Table 3 ). One study (25.0%) found that shorter 6-min walk distance (representing low physical activity) was significantly associated with a shortened time to severe exacerbation, but the effect size was small (hazard ratio 0.99) [ 33 ].

Five out of six studies assessing the relationship between race or ethnicity and exacerbation risk reported significant associations (Table 3 ). Additionally, one study reported an association between geographic location in the US and exacerbations, with living in the Northeast region being the strongest predictor of severe COPD exacerbations versus living in the Midwest and South regions [ 34 ].

Overall, seven studies assessed the association of biomarkers with risk of future exacerbations (Table 3 ), with the majority identifying significant associations between inflammatory biomarkers and increased exacerbation risk, including higher C-reactive protein levels [ 8 , 35 ], fibrinogen levels [ 8 , 30 ], and white blood cell count [ 8 , 15 , 16 ].

This SLR has identified several demographic and clinical characteristics that predict the future risk of COPD exacerbations. Key factors associated with an increased risk of future moderate-to-severe exacerbations included a history of prior exacerbations, worse disease severity and bronchodilator reversibility, the presence of comorbidities, a higher eosinophil count, and older age (Fig.  2 ). These prognostic factors may help clinicians identify patients at high risk of exacerbations, which are a major driver of the burden of COPD, including morbidity and mortality [ 36 ].

Findings from this review summarize the existing evidence, validating the previously published literature [ 6 , 9 , 23 ] and suggesting that the best predictor of future exacerbations is a history of exacerbations in the prior year [ 8 , 11 , 12 , 13 , 14 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 26 , 29 , 34 , 35 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 ]. In addition, the effect size generally increased with the number of prior exacerbations, with a stronger effect observed with prior severe versus moderate exacerbations. This effect was observed across regions, including in Europe and North America, and in several global studies. This relationship represents a vicious circle, whereby one exacerbation predisposes a patient to experience future exacerbations and leading to an ever-increasing disease burden, and emphasizes the importance of preventing the first exacerbation event through early, proactive exacerbation prevention. The finding that prior exacerbations tended to be associated with future exacerbations of the same severity suggests that the severity of the underlying disease may influence exacerbation severity. However, the validity of the traditional classification of exacerbation severity has recently been challenged [ 61 ], and further work is required to understand relationships with objective assessments of exacerbation severity.

In addition to exacerbation history, disease severity and bronchodilator reversibility were also strong predictors for future exacerbations [ 8 , 14 , 16 , 18 , 19 , 20 , 22 , 23 , 24 , 26 , 28 , 29 , 33 , 37 , 40 , 43 , 44 , 45 , 46 , 48 , 50 , 51 , 52 , 56 , 59 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 ]. The association with disease severity was noted in studies that used GOLD disease stages 1–4 and those that used FEV 1 percent predicted and other lung function assessments as continuous variables. Again, this risk factor is self-perpetuating, as evidence shows that even a single moderate or severe exacerbation may almost double the rate of lung function decline [ 79 ]. Accordingly, disease severity and exacerbation history may be correlated. Margüello et al. concluded that the severity of COPD could be associated with a higher risk of exacerbations, but this effect was partly determined by the exacerbations suffered in the previous year [ 23 ]. It should be noted that FEV 1 is not recommended by GOLD for use as a predictor of exacerbation risk or mortality alone due to insufficient precision when used at the individual patient level [ 5 ].

Another factor that should be considered when assessing individual exacerbation risk is the presence of comorbidities [ 7 , 14 , 16 , 18 , 19 , 20 , 21 , 22 , 24 , 25 , 26 , 27 , 28 , 30 , 33 , 34 , 35 , 40 , 41 , 44 , 45 , 46 , 47 , 48 , 51 , 52 , 53 , 54 , 56 , 58 , 59 , 63 , 64 , 73 , 74 , 76 , 77 , 80 , 81 , 82 , 83 , 84 , 85 ]. Comorbidities are common in COPD, in part due to common risk factors (e.g., age, smoking, lifestyle factors) that also increase the risk of other chronic diseases [ 7 ]. Significant associations were observed between exacerbation risk and comorbidities, such as anxiety and depression, cardiovascular disease, diabetes, and respiratory comorbidities. As with prior exacerbations, the strength of the association increased with the number of comorbidities. Some comorbidities that were found to be associated with COPD exacerbations share a common biological mechanism of systemic inflammation, such as cardiovascular disease, diabetes, and depression [ 86 ]. Furthermore, other respiratory comorbidities, including asthma and bronchiectasis, involve inflammation of the airways [ 87 ]. In these patients, optimal management of comorbidities may reduce the risk of future COPD exacerbations (and improve QoL), although further research is needed to confirm the efficacy of this approach to exacerbation prevention. As cardiovascular conditions, including hypertension and coronary heart disease, are the most common comorbidities in people with COPD [ 7 ], reducing cardiovascular risk may be a key goal in reducing the occurrence of exacerbations. For other comorbidities, the mechanism for the association with exacerbation risk may be related to non-biological factors. For example, in depression, it has been suggested that the mechanism may relate to greater sensitivity to symptom changes or more frequent physician visits [ 88 ].

There is now a growing body of evidence reporting the relationship between blood eosinophil count and exacerbation risk [ 8 , 13 , 14 , 20 , 37 , 48 , 52 , 56 , 59 , 60 , 62 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 ]. Data from many large clinical trials (SUNSET [ 89 ], FLAME [ 96 ], WISDOM [ 98 ], IMPACT [ 13 ], TRISTAN [ 99 ], INSPIRE [ 99 ], KRONOS [ 91 ], TRIBUTE [ 48 ], TRILOGY [ 52 ], TRINITY [ 56 ]) have also shown relationships between treatment, eosinophil count, and exacerbation rates. Evidence shows that eosinophil count, along with other effect modifiers (e.g., exacerbation history), can be used to predict reductions in exacerbations with ICS treatment. Identifying patients most likely to respond to ICS should contribute to personalized medicine approaches to treat COPD. One challenge in drawing a strong conclusion from eosinophil counts is the choice of a cut-off value, with a variety of absolute and percentage values observed to be positively associated with the risk of moderate-to-severe exacerbations. The use of absolute counts may be more practical, as these are not affected by variations in other immune cell numbers; however, there is a lack of consensus on this point [ 100 ].

Across the studies examined, associations between sex and the risk of moderate and/or severe exacerbations were variable [ 14 , 16 , 18 , 20 , 21 , 22 , 23 , 24 , 26 , 27 , 28 , 29 , 37 , 40 , 42 , 44 , 45 , 46 , 47 , 48 , 51 , 52 , 56 , 58 , 59 , 63 , 73 , 74 , 77 , 80 , 83 , 84 , 85 ]. A greater number of studies showed an increased risk of exacerbations in females compared with males. In contrast, some studies failed to detect a relationship, suggesting that country-specific or cultural factors may play a role. A majority of the included studies evaluated more male patients than female patients; to further elucidate the relationship between sex and exacerbations, more studies in female patients are warranted. Over half of the studies that assessed the relationship between age and exacerbation risk found an association between increasing age and increasing risk of moderate-to-severe COPD exacerbations [ 14 , 16 , 18 , 20 , 21 , 22 , 23 , 24 , 26 , 27 , 28 , 29 , 33 , 40 , 42 , 44 , 45 , 47 , 51 , 52 , 54 , 56 , 63 , 73 , 74 , 77 , 80 , 83 , 85 ].

Our findings also suggested that patients with low BMI have greater risk of moderate and/or severe exacerbations. The mechanism underlying this increased risk in underweight patients is poorly understood; however, loss of lean body mass in patients with COPD may be related to ongoing systemic inflammation that impacts skeletal muscle mass [ 101 , 102 , 103 ].

A limitation of this SLR, that may have resulted in some studies with valid results being missed, was the exclusion of non-English-language studies and the limitation by date; however, the search strategy was otherwise broad, resulting in the review of a large number of studies. The majority of studies captured in this SLR were from Europe, North America, and Asia. The findings may therefore be less generalizable to patients in other regions, such as Africa or South America. Given that one study reported an association between geographic location within different regions of the US and exacerbations [ 34 ], it is plausible that risk of exacerbations may be impacted by global location. As no formal meta-analysis was planned, the assessments are based on a qualitative synthesis of studies. A majority of the included studies looked at exposures of certain factors (e.g., history of exacerbations) at baseline; however, some of these factors change over time, calling into question whether a more sophisticated statistical analysis should have been conducted in some cases to consider time-varying covariates. Our results can only inform on associations, not causation, and there are likely bidirectional relationships between many factors and exacerbation risk (e.g., health status). Finally, while our review of the literature captured a large number of prognostic factors, other variables such as genetic factors, lung microbiome composition, and changes in therapy over time have not been widely studied to date, but might also influence exacerbation frequency [ 104 ]. Further research is needed to assess the contribution of these factors to exacerbation risk.

This SLR captured publications up to July 2019. However, further studies have since been published that further support the prognostic factors identified here. For example, recent studies have reported an increased risk of exacerbations in patients with a history of exacerbations [ 105 ], comorbidities [ 106 ], poorer lung function (GOLD stage) [ 105 ], higher symptomatic burden [ 107 ], female sex [ 105 ], and lower BMI [ 106 , 108 ].

In summary, the literature assessing risk factors for moderate-to-severe COPD exacerbations shows that there are associations between several demographic and disease characteristics with COPD exacerbations, potentially allowing clinicians to identify patients most at risk of future exacerbations. Exacerbation history, comorbidities, and disease severity or bronchodilator reversibility were the factors most strongly associated with exacerbation risk, and should be considered in future research efforts to develop prognostic tools to estimate the likelihood of exacerbation occurrence. Importantly, many prognostic factors for exacerbations, such as symptom burden, QoL, and comorbidities, are modifiable with optimal pharmacologic and non-pharmacologic treatments or lifestyle modifications. Overall, the evidence suggests that, taken together, predicting and reducing exacerbation risk is an achievable goal in COPD.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Body mass index

COPD Assessment Test

Chronic obstructive pulmonary disease

Forced expiratory volume in 1 s

Global Initiative for Chronic Obstructive Lung Disease

Inhaled corticosteroid

Modified Medical Research Council

Quality of life

St. George’s Respiratory Questionnaire

World Health Organization. The top 10 causes of death. 2018. https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death . Accessed 22 Jul 2020.

GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet. 2020;396:1204–22.

Article   Google Scholar  

Hurst JR, Skolnik N, Hansen GJ, Anzueto A, Donaldson GC, Dransfield MT, Varghese P. Understanding the impact of chronic obstructive pulmonary disease exacerbations on patient health and quality of life. Eur J Intern Med. 2020;73:1–6.

Article   PubMed   Google Scholar  

Zhang Y, Morgan RL, Alonso-Coello P, Wiercioch W, Bała MM, Jaeschke RR, Styczeń K, Pardo-Hernandez H, Selva A, Ara Begum H, et al. A systematic review of how patients value COPD outcomes. Eur Respir J. 2018;52:1800222.

Global Initiative for Chronic Obstructive Lung Disease. 2022 GOLD Report. Global strategy for the diagnosis, management and prevention of COPD. 2022. https://goldcopd.org/2022-gold-reports-2/ . Accessed 02 Feb 2022.

Müllerová H, Shukla A, Hawkins A, Quint J. Risk factors for acute exacerbations of COPD in a primary care population: a retrospective observational cohort study. BMJ Open. 2014;4: e006171.

Article   PubMed   PubMed Central   Google Scholar  

Westerik JAM, Metting EI, van Boven JFM, Tiersma W, Kocks JWH, Schermer TR. Associations between chronic comorbidity and exacerbation risk in primary care patients with COPD. Respir Res. 2017;18:31.

Vedel-Krogh S, Nielsen SF, Lange P, Vestbo J, Nordestgaard BG. Blood eosinophils and exacerbations in chronic obstructive pulmonary disease. The Copenhagen General Population Study. Am J Respir Crit Care Med. 2016;193:965–74.

Hurst JR, Vestbo J, Anzueto A, Locantore N, Müllerová H, Tal-Singer R, Miller B, Lomas DA, Agusti A, Macnee W, et al. Susceptibility to exacerbation in chronic obstructive pulmonary disease. N Engl J Med. 2010;363:1128–38.

Article   CAS   PubMed   Google Scholar  

Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6:e1000097.

Çolak Y, Afzal S, Marott JL, Nordestgaard BG, Vestbo J, Ingebrigtsen TS, Lange P. Prognosis of COPD depends on severity of exacerbation history: a population-based analysis. Respir Med. 2019;155:141–7.

Rothnie KJ, Müllerová H, Smeeth L, Quint JK. Natural history of chronic obstructive pulmonary disease exacerbations in a general practice-based population with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2018;198:464–71.

Pascoe S, Barnes N, Brusselle G, Compton C, Criner GJ, Dransfield MT, Halpin DMG, Han MK, Hartley B, Lange P, et al. Blood eosinophils and treatment response with triple and dual combination therapy in chronic obstructive pulmonary disease: analysis of the IMPACT trial. Lancet Respir Med. 2019;7:745–56.

Yun JH, Lamb A, Chase R, Singh D, Parker MM, Saferali A, Vestbo J, Tal-Singer R, Castaldi PJ, Silverman EK, et al. Blood eosinophil count thresholds and exacerbations in patients with chronic obstructive pulmonary disease. J Allergy Clin Immunol. 2018;141:2037-2047.e10.

Yoon HY, Park SY, Lee CH, Byun MK, Na JO, Lee JS, Lee WY, Yoo KH, Jung KS, Lee JH. Prediction of first acute exacerbation using COPD subtypes identified by cluster analysis. Int J Chron Obstruct Pulmon Dis. 2019;14:1389–97.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Yohannes AM, Mulerova H, Lavoie K, Vestbo J, Rennard SI, Wouters E, Hanania NA. The association of depressive symptoms with rates of acute exacerbations in patients with COPD: results from a 3-year longitudinal follow-up of the ECLIPSE cohort. J Am Med Dir Assoc. 2017;18:955-959.e6.

Tsiligianni I, Metting E, van der Molen T, Chavannes N, Kocks J. Morning and night symptoms in primary care COPD patients: a cross-sectional and longitudinal study. An UNLOCK study from the IPCRG. NPJ Prim Care Respir Med. 2016;26:16040.

Jo YS, Yoon HI, Kim DK, Yoo CG, Lee CH. Comparison of COPD Assessment Test and Clinical COPD Questionnaire to predict the risk of exacerbation. Int J Chron Obstruct Pulmon Dis. 2018;13:101–7.

Marçôa R, Rodrigues DM, Dias M, Ladeira I, Vaz AP, Lima R, Guimarães M. Classification of Chronic Obstructive Pulmonary Disease (COPD) according to the new Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017: comparison with GOLD 2011. COPD. 2018;15:21–6.

Han MK, Quibrera PM, Carretta EE, Barr RG, Bleecker ER, Bowler RP, Cooper CB, Comellas A, Couper DJ, Curtis JL, et al. Frequency of exacerbations in patients with chronic obstructive pulmonary disease: an analysis of the SPIROMICS cohort. Lancet Respir Med. 2017;5:619–26.

Yii ACA, Loh CH, Tiew PY, Xu H, Taha AAM, Koh J, Tan J, Lapperre TS, Anzueto A, Tee AKH. A clinical prediction model for hospitalized COPD exacerbations based on “treatable traits.” Int J Chron Obstruct Pulmon Dis. 2019;14:719–28.

McGarvey L, Lee AJ, Roberts J, Gruffydd-Jones K, McKnight E, Haughney J. Characterisation of the frequent exacerbator phenotype in COPD patients in a large UK primary care population. Respir Med. 2015;109:228–37.

Margüello MS, Garrastazu R, Ruiz-Nuñez M, Helguera JM, Arenal S, Bonnardeux C, León C, Miravitlles M, García-Rivero JL. Independent effect of prior exacerbation frequency and disease severity on the risk of future exacerbations of COPD: a retrospective cohort study. NPJ Prim Care Respir Med. 2016;26:16046.

Engel B, Schindler C, Leuppi JD, Rutishauser J. Predictors of re-exacerbation after an index exacerbation of chronic obstructive pulmonary disease in the REDUCE randomised clinical trial. Swiss Med Wkly. 2017;147: w14439.

PubMed   Google Scholar  

Benson VS, Müllerová H, Vestbo J, Wedzicha JA, Patel A, Hurst JR. Evaluation of COPD longitudinally to identify predictive surrogate endpoints (ECLIPSE) investigators. Associations between gastro-oesophageal reflux, its management and exacerbations of chronic obstructive pulmonary disease. Respir Med. 2015;109:1147–54.

Santibáñez M, Garrastazu R, Ruiz-Nuñez M, Helguera JM, Arenal S, Bonnardeux C, León C, García-Rivero JL. Predictors of hospitalized exacerbations and mortality in chronic obstructive pulmonary disease. PLoS ONE. 2016;11: e0158727.

Article   PubMed   PubMed Central   CAS   Google Scholar  

Jo YS, Kim YH, Lee JY, Kim K, Jung KS, Yoo KH, Rhee CK. Impact of BMI on exacerbation and medical care expenses in subjects with mild to moderate airflow obstruction. Int J Chron Obstruct Pulmon Dis. 2018;13:2261–9.

Alexopoulos EC, Malli F, Mitsiki E, Bania EG, Varounis C, Gourgoulianis KI. Frequency and risk factors of COPD exacerbations and hospitalizations: a nationwide study in Greece (Greek Obstructive Lung Disease Epidemiology and health ecoNomics: GOLDEN study). Int J Chron Obstruct Pulmon Dis. 2015;10:2665–74.

PubMed   PubMed Central   Google Scholar  

Liu D, Peng SH, Zhang J, Bai SH, Liu HX, Qu JM. Prediction of short term re-exacerbation in patients with acute exacerbation of chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2015;10:1265–73.

Müllerová H, Maselli DJ, Locantore N, Vestbo J, Hurst JR, Wedzicha JA, Bakke P, Agusti A, Anzueto A. Hospitalized exacerbations of COPD: risk factors and outcomes in the ECLIPSE cohort. Chest. 2015;147:999–1007.

de Miguel-Díez J, Hernández-Vázquez J, López-de-Andrés A, Álvaro-Meca A, Hernández-Barrera V, Jiménez-García R. Analysis of environmental risk factors for chronic obstructive pulmonary disease exacerbation: a case-crossover study (2004–2013). PLoS ONE. 2019;14: e0217143.

Krachunov II, Kyuchukov NH, Ivanova ZI, Yanev NA, Hristova PA, Borisova ED, Popova TP, Pavlov PS, Nikolova PT, Ivanov YY. Impact of air pollution and outdoor temperature on the rate of chronic obstructive pulmonary disease exacerbations. Folia Med (Plovdiv). 2017;59:423–9.

Article   CAS   Google Scholar  

Baumeler L, Papakonstantinou E, Milenkovic B, Lacoma A, Louis R, Aerts JG, Welte T, Kostikas K, Blasi F, Boersma W, et al. Therapy with proton-pump inhibitors for gastroesophageal reflux disease does not reduce the risk for severe exacerbations in COPD. Respirology. 2016;21:883–90.

Annavarapu S, Goldfarb S, Gelb M, Moretz C, Renda A, Kaila S. Development and validation of a predictive model to identify patients at risk of severe COPD exacerbations using administrative claims data. Int J Chron Obstruct Pulmon Dis. 2018;13:2121–30.

Crisafulli E, Torres A, Huerta A, Méndez R, Guerrero M, Martinez R, Liapikou A, Soler N, Sethi S, Menéndez R. C-reactive protein at discharge, diabetes mellitus and ≥1 hospitalization during previous year predict early readmission in patients with acute exacerbation of chronic obstructive pulmonary disease. COPD. 2015;12:311–20.

Bollmeier SG, Hartmann AP. Management of chronic obstructive pulmonary disease: a review focusing on exacerbations. Am J Health Syst Pharm. 2020;77:259–68.

Bafadhel M, Peterson S, De Blas MA, Calverley PM, Rennard SI, Richter K, Fagerås M. Predictors of exacerbation risk and response to budesonide in patients with chronic obstructive pulmonary disease: a post-hoc analysis of three randomised trials. Lancet Respir Med. 2018;6:117–26.

Calverley PM, Anzueto AR, Dusser D, Mueller A, Metzdorf N, Wise RA. Treatment of exacerbations as a predictor of subsequent outcomes in patients with COPD. Int J Chron Obstruct Pulmon Dis. 2018;13:1297–308.

Calverley PM, Tetzlaff K, Dusser D, Wise RA, Mueller A, Metzdorf N, Anzueto A. Determinants of exacerbation risk in patients with COPD in the TIOSPIR study. Int J Chron Obstruct Pulmon Dis. 2017;12:3391–405.

Eklöf J, Sørensen R, Ingebrigtsen TS, Sivapalan P, Achir I, Boel JB, Bangsborg J, Ostergaard C, Dessau RB, Jensen US, et al. Pseudomonas aeruginosa and risk of death and exacerbations in patients with chronic obstructive pulmonary disease: an observational cohort study of 22 053 patients. Clin Microbiol Infect. 2020;26:227–34.

Estirado C, Ceccato A, Guerrero M, Huerta A, Cilloniz C, Vilaró O, Gabarrús A, Gea J, Crisafulli E, Soler N, Torres A. Microorganisms resistant to conventional antimicrobials in acute exacerbations of chronic obstructive pulmonary disease. Respir Res. 2018;19:119.

Fuhrman C, Moutengou E, Roche N, Delmas MC. Prognostic factors after hospitalization for COPD exacerbation. Rev Mal Respir. 2017;34:1–18.

Krachunov I, Kyuchukov N, Ivanova Z, Yanev NA, Hristova PA, Pavlov P, Glogovska P, Popova T, Ivanov YY. Stability of frequent exacerbator phenotype in patients with chronic obstructive pulmonary disease. Folia Med (Plovdiv). 2018;60:536–45.

Make BJ, Eriksson G, Calverley PM, Jenkins CR, Postma DS, Peterson S, Östlund O, Anzueto A. A score to predict short-term risk of COPD exacerbations (SCOPEX). Int J Chron Obstruct Pulmon Dis. 2015;10:201–9.

Montserrat-Capdevila J, Godoy P, Marsal JR, Barbé F. Predictive model of hospital admission for COPD exacerbation. Respir Care. 2015;60:1288–94.

Montserrat-Capdevila J, Godoy P, Marsal JR, Barbé F, Galván L. Risk factors for exacerbation in chronic obstructive pulmonary disease: a prospective study. Int J Tuberc Lung Dis. 2016;20:389–95.

Orea-Tejeda A, Navarrete-Peñaloza AG, Verdeja-Vendrell L, Jiménez-Cepeda A, González-Islas DG, Hernández-Zenteno R, Keirns-Davis C, Sánchez-Santillán R, Velazquez-Montero A, Puentes RG. Right heart failure as a risk factor for severe exacerbation in patients with chronic obstructive pulmonary disease: prospective cohort study. Clin Respir J. 2018;12:2635–41.

Papi A, Vestbo J, Fabbri L, Corradi M, Prunier H, Cohuet G, Guasconi A, Montagna I, Vezzoli S, Petruzzelli S, et al. Extrafine inhaled triple therapy versus dual bronchodilator therapy in chronic obstructive pulmonary disease (TRIBUTE): a double-blind, parallel group, randomised controlled trial. Lancet. 2018;391:1076–84.

Lipson DA, Barnhart F, Brealey N, Brooks J, Criner GJ, Day NC, Dransfield MT, Halpin DMG, Han MK, Jones CE, et al. Once-daily single-inhaler triple versus dual therapy in patients with COPD. N Engl J Med. 2018;378:1671–80.

Pasquale MK, Xu Y, Baker CL, Zou KH, Teeter JG, Renda AM, Davis CC, Lee TC, Bobula J. COPD exacerbations associated with the modified Medical Research Council scale and COPD assessment test among Humana Medicare members. Int J Chron Obstruct Pulmon Dis. 2016;11:111–21.

Schuler M, Wittmann M, Faller H, Schultz K. Including changes in dyspnea after inpatient rehabilitation improves prediction models of exacerbations in COPD. Respir Med. 2018;141:87–93.

Singh D, Papi A, Corradi M, Pavlišová I, Montagna I, Francisco C, Cohuet G, Vezzoli S, Scuri M, Vestbo J. Single inhaler triple therapy versus inhaled corticosteroid plus long-acting β 2 -agonist therapy for chronic obstructive pulmonary disease (TRILOGY): a double-blind, parallel group, randomised controlled trial. Lancet. 2016;388:963–73.

Søgaard M, Madsen M, Løkke A, Hilberg O, Sørensen HT, Thomsen RW. Incidence and outcomes of patients hospitalized with COPD exacerbation with and without pneumonia. Int J Chron Obstruct Pulmon Dis. 2016;11:455–65.

Stanford RH, Nag A, Mapel DW, Lee TA, Rosiello R, Schatz M, Vekeman F, Gauthier-Loiselle M, Merrigan JFP, Duh MS. Claims-based risk model for first severe COPD exacerbation. Am J Manag Care. 2018;24:e45–53.

Stanford RH, Lau MS, Li Y, Stemkowski S. External validation of a COPD risk measure in a commercial and medicare population: the COPD treatment ratio. J Manag Care Spec Pharm. 2019;25:58–69.

Vestbo J, Papi A, Corradi M, Blazhko V, Montagna I, Francisco C, Cohuet G, Vezzoli S, Scuri M, Singh D. Single inhaler extrafine triple therapy versus long-acting muscarinic antagonist therapy for chronic obstructive pulmonary disease (TRINITY): a double-blind, parallel group, randomised controlled trial. Lancet. 2017;389:1919–29.

Wei X, Ma Z, Yu N, Ren J, Jin C, Mi J, Shi M, Tian L, Gao Y, Guo Y. Risk factors predict frequent hospitalization in patients with acute exacerbation of COPD. Int J Chron Obstruct Pulmon Dis. 2018;13:121–9.

Whalley D, Svedsater H, Doward L, Crawford R, Leather D, Lay-Flurrie J, Bosanquet N. Follow-up interviews from The Salford Lung Study (COPD) and analyses per treatment and exacerbations. NPJ Prim Care Respir Med. 2019;29:20.

Zeiger RS, Tran TN, Butler RK, Schatz M, Li Q, Khatry DB, Martin U, Kawatkar AA, Chen W. Relationship of blood eosinophil count to exacerbations in chronic obstructive pulmonary disease. J Allergy Clin Immunol Pract. 2018;6:944-954.e945.

Vogelmeier CF, Kostikas K, Fang J, Tian H, Jones B, Morgan CL, Fogel R, Gutzwiller FS, Cao H. Evaluation of exacerbations and blood eosinophils in UK and US COPD populations. Respir Res. 2019;20:178.

Celli BR, Fabbri LM, Aaron SD, Agusti A, Brook R, Criner GJ, Franssen FME, Humbert M, Hurst JR, O’Donnell D, et al. An updated definition and severity classification of COPD exacerbations: the Rome proposal. Am J Respir Crit Care Med. 2021;204:1251–8.

Adir Y, Hakrush O, Shteinberg M, Schneer S, Agusti A. Circulating eosinophil levels do not predict severe exacerbations in COPD: a retrospective study. ERJ Open Research. 2018;4:00022–2018.

Bartels W, Adamson S, Leung L, Sin DD, van Eeden SF. Emergency department management of acute exacerbations of chronic obstructive pulmonary disease: factors predicting readmission. Int J Chron Obstruct Pulmon Dis. 2018;13:1647–54.

Kim V, Zhao H, Regan E, Han MK, Make BJ, Crapo JD, Jones PW, Curtis JL, Silverman EK, Criner GJ, COPDGene Investigators. The St. George’s Respiratory Questionnaire definition of chronic bronchitis may be a better predictor of COPD exacerbations compared with the classic definition. Chest. 2019;156:685–95.

Abston E, Comellas A, Reed RM, Kim V, Wise RA, Brower R, Fortis S, Beichel R, Bhatt S, Zabner J, et al. Higher BMI is associated with higher expiratory airflow normalised for lung volume (FEF25-75/FVC) in COPD. BMJ Open Respir Res. 2017;4: e000231.

Emura I, Usuda H, Satou K. Appearance of large scavenger receptor A-positive cells in peripheral blood: a potential risk factor for severe exacerbation of chronic obstructive pulmonary disease. Pathol Int. 2019;69:187–92.

Erol S, Sen E, Gizem Kilic Y, Yousif A, Akkoca Yildiz O, Acican T, Saryal S. Does the 2017 revision improve the ability of GOLD to predict risk of future moderate and severe exacerbation? Clin Respir J. 2018;12:2354–60.

Han MZ, Hsiue TR, Tsai SH, Huang TH, Liao XM, Chen CZ. Validation of the GOLD 2017 and new 16 subgroups (1A–4D) classifications in predicting exacerbation and mortality in COPD patients. Int J Chron Obstruct Pulmon Dis. 2018;13:3425–33.

Huang TH, Hsiue TR, Lin SH, Liao XM, Su PL, Chen CZ. Comparison of different staging methods for COPD in predicting outcomes. Eur Resp J. 2018;51:1700577.

Jung YH, Lee DY, Kim DW, Park SS, Heo EY, Chung HS, Kim DK. Clinical significance of laryngopharyngeal reflux in patients with chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2015;10:1343–51.

CAS   PubMed   PubMed Central   Google Scholar  

Kim J, Kim WJ, Lee CH, Lee SH, Lee MG, Shin KC, Yoo KH, Lee JH, Lim SY, Na JO, et al. Which bronchodilator reversibility criteria can predict severe acute exacerbation in chronic obstructive pulmonary disease patients? Respir Res. 2017;18:107.

Kobayashi S, Hanagama M, Ishida M, Sato H, Ono M, Yamanda S, Yamada M, Aizawa H, Yanai M. Clinical characteristics and outcomes in Japanese patients with COPD according to the 2017 GOLD classification: the Ishinomaki COPD Network Registry. Int J Chron Obstruct Pulmon Dis. 2018;13:3947–55.

Lee SH, Lee JH, Yoon HI, Park HY, Kim TH, Yoo KH, Oh YM, Jung KS, Lee SD, Lee SW. Change in inhaled corticosteroid treatment and COPD exacerbations: an analysis of real-world data from the KOLD/KOCOSS cohorts. Respir Res. 2019;20:62.

Pavlovic R, Stefanovic S, Lazic Z, Jankovic S. Factors associated with the rate of COPD exacerbations that require hospitalization. Turk J Med Sci. 2017;47:134–41.

Song JH, Lee CH, Um SJ, Park YB, Yoo KH, Jung KS, Lee SD, Oh YM, Lee JH, Kim EK, Kim DK. Clinical impacts of the classification by 2017 GOLD guideline comparing previous ones on outcomes of COPD in real-world cohorts. Int J Chron Obstruct Pulmon Dis. 2018;13:3473–84.

Sundh J, Johansson G, Larsson K, Lindén A, Löfdahl CG, Sandström T, Janson C. The phenotype of concurrent chronic bronchitis and frequent exacerbations in patients with severe COPD attending Swedish secondary care units. Int J Chron Obstruct Pulmon Dis. 2015;10:2327–34.

Urwyler P, Hussein NA, Bridevaux PO, Chhajed PN, Geiser T, Grendelmeier P, Zellweger LJ, Kohler M, Maier S, Miedinger D, et al. Predictive factors for exacerbation and reexacerbation in chronic obstructive pulmonary disease: an extension of the Cox model to analyze data from the Swiss COPD cohort. Multidiscip Respir Med. 2019;14:7.

Wallace AE, Kaila S, Bayer V, Shaikh A, Shinde MU, Willey VJ, Napier MB, Singer JR. Health care resource utilization and exacerbation rates in patients with COPD stratified by disease severity in a commercially insured population. J Manag Care Spec Pharm. 2019;25:205–17.

Halpin DMG, Decramer M, Celli BR, Mueller A, Metzdorf N, Tashkin DP. Effect of a single exacerbation on decline in lung function in COPD. Respir Med. 2017;128:85–91.

Bade BC, DeRycke EC, Ramsey C, Skanderson M, Crothers K, Haskell S, Bean-Mayberry B, Brandt C, Bastian LA, Akgün KM. Sex differences in veterans admitted to the hospital for chronic obstructive pulmonary disease exacerbation. Ann Am Thorac Soc. 2019;16:707–14.

Iyer AS, Bhatt SP, Dransfield M, Kinney G, Holm K, Wamboldt FS, Hanania N, Martinez C, Regan E, Foreman MG, et al. Psychological distress prospectively predicts severe exacerbations in smokers with and without airflow limitation—a longitudinal follow-up study of the COPDGene cohort [abstract]. Am J Respir Crit Care Med. 2017. https://doi.org/10.1164/ajrccm-conference.2017.195.1_MeetingAbstracts.A4709 .

Diamond M, Zhao H, Armstrong HF, Morrison M, Bailey KL, Carretta EE, Criner GJ, Han MK, Bleeker E, Cooper CB, et al. Anxiety and depression, either alone or in combination, are associated with respiratory exacerbations in smokers with and without COPD [abstract]. Am J Respir Crit Care Med. 2017;195:1615–31.

Google Scholar  

Lau CS, Siracuse BL, Chamberlain RS. Readmission After COPD Exacerbation Scale: determining 30-day readmission risk for COPD patients. Int J Chron Obstruct Pulmon Dis. 2017;12:1891–902.

Pikoula M, Quint JK, Nissen F, Hemingway H, Smeeth L, Denaxas S. Identifying clinically important COPD sub-types using data-driven approaches in primary care population based electronic health records. BMC Med Inform Decis Mak. 2019;19:86.

Wei YF, Tsai YH, Wang CC, Kuo PH. Impact of overweight and obesity on acute exacerbations of COPD—subgroup analysis of the Taiwan Obstructive Lung Disease cohort. Int J Chron Obstruct Pulmon Dis. 2017;12:2723–9.

Barnes PJ, Celli BR. Systemic manifestations and comorbidities of COPD. Eur Resp J. 2009;33:1165–85.

Polverino E, Dimakou K, Hurst J, Martinez-Garcia MA, Miravitlles M, Paggiaro P, Shteinberg M, Aliberti S, Chalmers JD. The overlap between bronchiectasis and chronic airway diseases: state of the art and future directions. Eur Respir J. 2018;52:1800328.

Xu W, Collet JP, Shapiro S, Lin Y, Yang T, Platt RW, Wang C, Bourbeau J. Independent effect of depression and anxiety on chronic obstructive pulmonary disease exacerbations and hospitalizations. Am J Respir Crit Care Med. 2008;178:913–20.

Chapman KR, Hurst JR, Frent SM, Larbig M, Fogel R, Guerin T, Banerji D, Patalano F, Goyal P, Pfister P, et al. Long-term triple therapy de-escalation to indacaterol/glycopyrronium in patients with chronic obstructive pulmonary disease (SUNSET): a randomized, double-blind, triple-dummy clinical trial. Am J Respir Crit Care Med. 2018;198:329–39.

Couillard S, Larivée P, Courteau J, Vanasse A. Eosinophils in COPD exacerbations are associated with increased readmissions. Chest. 2017;151:366–73.

Ferguson GT, Rabe KF, Martinez FJ, Fabbri LM, Wang C, Ichinose M, Bourne E, Ballal S, Darken P, DeAngelis K, et al. Triple therapy with budesonide/glycopyrrolate/formoterol fumarate with co-suspension delivery technology versus dual therapies in chronic obstructive pulmonary disease (KRONOS): a double-blind, parallel-group, multicentre, phase 3 randomised controlled trial. Lancet Respir Med. 2018;6:747–58.

Ko FWS, Chan KP, Ngai J, Ng SS, Yip WH, Ip A, Chan TO, Hui DSC. Blood eosinophil count as a predictor of hospital length of stay in COPD exacerbations. Respirology. 2019;25:259–66.

MacDonald MI, Osadnik CR, Bulfin L, Hamza K, Leong P, Wong A, King PT, Bardin PG. Low and high blood eosinophil counts as biomarkers in hospitalized acute exacerbations of COPD. Chest. 2019;156:92–100.

Müllerová H, Hahn B, Simard EP, Mu G, Hatipoğlu U. Exacerbations and health care resource use among patients with COPD in relation to blood eosinophil counts. Int J Chron Obstruct Pulmon Dis. 2019;14:683–92.

Bafadhel M, Greening NJ, Harvey-Dunstan TC, Williams JEA, Morgan MD, Brightling CE, Hussain SF, Pavord ID, Singh SJ, Steiner MC. Blood eosinophils and outcomes in severe hospitalised exacerbations of COPD. Chest. 2016;150:320–8.

Roche N, Chapman KR, Vogelmeier CF, Herth FJF, Thach C, Fogel R, Olsson P, Patalano F, Banerji D, Wedzicha JA. Blood eosinophils and response to maintenance chronic obstructive pulmonary disease treatment. Data from the FLAME trial. Am J Respir Crit Care Med. 2017;195:1189–97.

Vestbo J, Vogelmeier CF, Small M, Siddall J, Fogel R, Kostikas K. Inhaled corticosteroid use by exacerbations and eosinophils: a real-world COPD population. Int J Chron Obstruct Pulmon Dis. 2019;14:853–61.

Watz H, Tetzlaff K, Wouters EFM, Kirsten A, Magnussen H, Rodriguez-Roisin R, Vogelmeier C, Fabbri LM, Chanez P, Dahl R, et al. Blood eosinophil count and exacerbations in severe chronic obstructive pulmonary disease after withdrawal of inhaled corticosteroids: a post-hoc analysis of the WISDOM trial. Lancet Respir Med. 2016;4:390–8.

Pavord ID, Lettis S, Locantore N, Pascoe S, Jones PW, Wedzicha JA, Barnes NC. Blood eosinophils and inhaled corticosteroid/long-acting beta-2 agonist efficacy in COPD. Thorax. 2016;71:118–25.

Singh D. Predicting corticosteroid response in chronic obstructive pulmonary disease. Blood eosinophils gain momentum. Am J Respir Crit Care Med. 2017;196:1098–100.

Vestbo J, Prescott E, Almdal T, Dahl M, Nordestgaard BG, Andersen T, Sørensen TIA, Lange P. Body mass, fat-free body mass, and prognosis in patients with chronic obstructive pulmonary disease from a random population sample: findings from the Copenhagen City Heart Study. Am J Respir Crit Care Med. 2006;173:79–83.

Agustí AGN, Noguera A, Sauleda J, Sala E, Pons J, Busquets X. Systemic effects of chronic obstructive pulmonary disease. Eur Respir J. 2003;21:347–60.

Agustí AGN, Sauleda J, Miralles C, Gomez C, Togores B, Sala E, Batle S, Busquets X. Skeletal muscle apoptosis and weight loss in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2002;166:485–9.

Labaki WW, Martinez FJ. Time to understand the infrequency of the frequent exacerbator phenotype in COPD. Chest. 2018;153:1087–8.

Hartley BF, Barnes NC, Lettis S, Compton CH, Papi A, Jones P. Risk factors for exacerbations and pneumonia in patients with chronic obstructive pulmonary disease: a pooled analysis. Respir Res. 2020;21:5.

Kim Y, Kim YJ, Kang YM, Cho WK. Exploring the impact of number and type of comorbidities on the risk of severe COPD exacerbations in Korean Population: a Nationwide Cohort Study. BMC Pulm Med. 2021;21:151.

Mackay AJ, Kostikas K, Roche N, Frent SM, Olsson P, Pfister P, Gupta P, Patalano F, Banerji D, Wedzicha JA. Impact of baseline symptoms and health status on COPD exacerbations in the FLAME study. Respir Res. 2020;21:93.

Smulders L, van der Aalst A, Neuhaus EDET, Polman S, Franssen FME, van Vliet M, de Kruif MD. Decreased risk of COPD exacerbations in obese patients. COPD. 2020;17:485–91.

Battisti WP, Wager E, Baltzer L, Bridges D, Cairns A, Carswell CI, Citrome L, Gurr JA, Mooney LA, Moore BJ, et al. Good publication practice for communicating company-sponsored medical research: GPP3. Ann Intern Med. 2015;163:461–4.

Putcha N, Barr RG, Han M, Woodruff PG, Bleecker ER, Kanner RE, Martinez FJ, Tashkin DP, Rennard SI, Breysse P, et al. Understanding the impact of passive smoke exposure on outcomes in COPD [abstract]. Am J Respir Crit Care Med. 2015;191:411–20.

Wu Z, Yang D, Ge Z, Yan M, Wu N, Liu Y. Body mass index of patients with chronic obstructive pulmonary disease is associated with pulmonary function and exacerbations: a retrospective real world research. J Thorac Dis. 2018;10:5086–99.

Download references

Acknowledgements

Medical writing support, under the direction of the authors, was provided by Julia King, PhD, and Sarah Piggott, MChem, CMC Connect, McCann Health Medical Communications, funded by AstraZeneca in accordance with Good Publication Practice (GPP3) guidelines [ 109 ].

This study was supported by AstraZeneca.

Author information

Authors and affiliations.

UCL Respiratory, University College London, London, WC1E 6BT, UK

John R. Hurst

Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI, USA

MeiLan K. Han

Formerly of Parexel International, Mohali, India

Barinder Singh, Gagandeep Kaur & Mohd Kashif Siddiqui

Parexel International, Mohali, India

Sakshi Sharma

Formerly of AstraZeneca, Cambridge, UK

Enrico de Nigris

AstraZeneca, Gothenburg, Sweden

Ulf Holmgren

You can also search for this author in PubMed   Google Scholar

Contributions

The authors have made the following declaration about their contributions. JRH and MKH made substantial contributions to the interpretation of data; BS, SS, GK, and MKS made substantial contributions to the acquisition, analysis, and interpretation of data; EdN and UH made substantial contributions to the conception and design of the work and the interpretation of data. All authors contributed to drafting or critically revising the article, have approved the submitted version, and agree to be personally accountable for their own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. All authors read and approved the final manuscript.

Corresponding author

Correspondence to John R. Hurst .

Ethics declarations

Ethics approval and consent to participate.

Not applicable.

Consent for publication

Competing interests.

JRH reports consulting fees from AstraZeneca; speaker fees from AstraZeneca, Chiesi, Pfizer, and Takeda; and travel support from GlaxoSmithKline and AstraZeneca. MKH reports assistance with conduction of this research and publication from AstraZeneca; personal fees from Aerogen, Altesa Biopharma, AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, DevPro, GlaxoSmithKline, Integrity, Medscape, Merck, Mylan, NACE, Novartis, Polarean, Pulmonx, Regeneron, Sanofi, Teva, Verona, United Therapeutics, and UpToDate; either in kind research support or funds paid to the institution from the American Lung Association, AstraZeneca, Biodesix, Boehringer Ingelheim, the COPD Foundation, Gala Therapeutics, the NIH, Novartis, Nuvaira, Sanofi, and Sunovion; participation in Data Safety Monitoring Boards for Novartis and Medtronic with funds paid to the institution; and stock options from Altesa Biopharma and Meissa Vaccines. BS, GK, and MKS are former employees of Parexel International. SS is an employee of Parexel International, which was funded by AstraZeneca to conduct this analysis. EdN is a former employee of AstraZeneca and previously held stock and/or stock options in the company. UH is an employee of AstraZeneca and holds stock and/or stock options in the company.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file1: table s1..

Search strategies. Table S2. List of included studies with linked publications. Table S3. Study characteristics across the 76 included studies. Table S4. Clinical characteristics of the patients assessed across the included studies.

Additional file 2: Fig. S1.

Sex (male vs female) as a risk factor for moderate-to-severe exacerbations. Fig. S2. Sex (male vs female) as a risk factor for severe exacerbations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Hurst, J.R., Han, M.K., Singh, B. et al. Prognostic risk factors for moderate-to-severe exacerbations in patients with chronic obstructive pulmonary disease: a systematic literature review. Respir Res 23 , 213 (2022). https://doi.org/10.1186/s12931-022-02123-5

Download citation

Received : 02 March 2022

Accepted : 20 July 2022

Published : 23 August 2022

DOI : https://doi.org/10.1186/s12931-022-02123-5

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Exacerbations
• Comorbidities
• Hospitalization

Respiratory Research

ISSN: 1465-993X

• General enquiries: [email protected]

• Open access
• Published: 05 September 2022

Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature

• Ashlea Hambleton 1 ,
• Genevieve Pepin 2 ,
• Anvi Le 3 ,
• Danielle Maloney 1 , 4 ,
• National Eating Disorder Research Consortium ,
• Stephen Touyz 1 , 4 &
• Sarah Maguire 1 , 4  

Journal of Eating Disorders volume  10 , Article number:  132 ( 2022 ) Cite this article

17k Accesses

40 Citations

65 Altmetric

Metrics details

Eating disorders (EDs) are potentially severe, complex, and life-threatening illnesses. The mortality rate of EDs is significantly elevated compared to other psychiatric conditions, primarily due to medical complications and suicide. The current rapid review aimed to summarise the literature and identify gaps in knowledge relating to any psychiatric and medical comorbidities of eating disorders.

This paper forms part of a rapid review) series scoping the evidence base for the field of EDs, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021–2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for English-language studies focused on the psychiatric and medical comorbidities of EDs, published between 2009 and 2021. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised.

A total of 202 studies were included in this review, with 58% pertaining to psychiatric comorbidities and 42% to medical comorbidities. For EDs in general, the most prevalent psychiatric comorbidities were anxiety (up to 62%), mood (up to 54%) and substance use and post-traumatic stress disorders (similar comorbidity rates up to 27%). The review also noted associations between specific EDs and non-suicidal self-injury, personality disorders, and neurodevelopmental disorders. EDs were complicated by medical comorbidities across the neuroendocrine, skeletal, nutritional, gastrointestinal, dental, and reproductive systems. Medical comorbidities can precede, occur alongside or emerge as a complication of the ED.

Conclusions

This review provides a thorough overview of the comorbid psychiatric and medical conditions co-occurring with EDs. High psychiatric and medical comorbidity rates were observed in people with EDs, with comorbidities contributing to increased ED symptom severity, maintenance of some ED behaviours, and poorer functioning as well as treatment outcomes. Early identification and management of psychiatric and medical comorbidities in people with an ED may improve response to treatment and overall outcomes.

Plain English Summary

The mortality rate of eating disorders is significantly elevated compared to other psychiatric conditions, primarily due to medical complications and suicide. Further, individuals with eating disorders often meet the diagnostic criteria of at least one comorbid psychiatric or medical disorder, that is, the individual simultaneously experiences both an ED and at least one other condition. This has significant consequences for researchers and health care providers – medical and psychiatric comorbidities impact ED symptoms and treatment effectiveness. The current review is part of a larger Rapid Review series conducted to inform the development of Australia’s National Eating Disorders Research and Translation Strategy 2021–2031. A Rapid Review is designed to comprehensively summarise a body of literature in a short timeframe, often to guide policymaking and address urgent health concerns. The Rapid Review synthesises the current evidence base and identifies gaps in eating disorder research and care. This paper gives a critical overview of the scientific literature relating to the psychiatric and medical comorbidities of eating disorders. It covers recent literature regarding psychiatric comorbidities including anxiety disorders, mood disorders, substance use disorders, trauma and personality disorders and neurodevelopmental disorders. Further, the review discusses the impact and associations between EDs and medical comorbidities, some of which precede the eating disorder, occur alongside, or as a consequence of the eating disorder.

Introduction

Eating Disorders (EDs) are often severe, complex, life-threatening illnesses with significant physiological and psychiatric impacts. EDs impact individuals across the entire lifespan, affecting all age groups (although most often they emerge in childhood and adolescence), genders, socioeconomic groups and cultures [ 1 ]. EDs have some of the highest mortality rates of all psychiatric illnesses and carry a significant personal, interpersonal, social and economic burdens [ 2 , 3 ].

Adding to the innate complexity of EDs, it is not uncommon for people living with an ED to experience associated problems such as psychological, social, and functional limitations [ 2 ] in addition to psychiatric and medical comorbidities [ 4 , 5 , 6 ]. Comorbidity is defined as conditions or illnesses that occur concurrently to the ED. Evidence suggests that between 55 and 95% of people diagnosed with an ED will also experience a comorbid psychiatric disorder in their lifetime [ 4 , 6 ]. Identifying psychiatric comorbidities is essential because of their potential impact on the severity of ED symptomatology, the individual’s distress and treatment effectiveness [ 7 , 8 ].

The mortality rate of EDs is significantly higher than the general population, with the highest occurring in Anorexia Nervosa (AN) due to impacts on the cardiovascular system [ 9 ] and suicide. [ 10 ] Mortality rates are also heightened in Bulimia Nervosa (BN) and Other Specified Feeding and Eating Disorder (OSFED) [ 11 ]. Suicide rates are elevated across the ED spectrum, and higher rates are observed in patients with a comorbid psychiatric disorder [ 10 , 12 ]. Of concern, the proportion of people with an ED not accessing treatment is estimated to be as high as 75% [ 13 ], potentially a consequence of comorbidities which impact on motivation, the ability to schedule appointments or require clinical prioritisation (i.e., self-harm or suicidal behaviours) [ 14 ]. Further, for many of those diagnosed with an ED who access treatment, recovery is a lengthy process. A longitudinal study found approximately two-thirds of participants with AN or BN had recovered by 22 years follow-up [ 15 ]. Although recovery occurred earlier for those with BN, illness duration was lengthy for both groups with quality of life and physical health impacts [ 15 ]. Further, less is known regarding the illness trajectory for those who do not receive treatment.

Medical comorbidities associated with EDs can range from mild to severe and life-threatening, with complications observed across all body systems, including the cardiac, metabolic and gastrointestinal, and reproductive systems [ 5 ]. These comorbidities and complications can place people at increased risk of medical instability and death [ 5 ]. Therefore, understanding how co-occurring medical comorbidities and complications impact EDs is critical to treatment and recovery.

In addition to ED-associated medical comorbidities, EDs often present alongside other psychiatric conditions. Psychiatric comorbidities in people with EDs are associated with higher health system costs, emergency department presentations and admissions [ 16 ]. Comorbidities may precede the onset of the ED, be co-occurring, or result from symptoms and behaviours associated with the ED [ 17 , 18 ]. Individuals with an ED, their carers and care providers often face a complex and important dilemma; the individual with an ED requires treatment for their ED but also for their psychiatric comorbidities, and it can be difficult for treatment providers to determine which is the clinical priority [ 19 ]. This is further complicated by the fact that EDs and comorbidities may have a reciprocal relationship, whereby the presence of one impact the pathology, treatment and outcomes of the other.

The current Rapid Review (RR) forms part of a series of reviews commissioned by the Australian Federal Government to inform the Australian National Eating Disorders Research and Translation Strategy 2021–2031 [ 20 ]. In response to the impact of psychiatric and medical comorbidities on outcomes, this rapid review summarises the recent literature on the nature and implications of psychiatric and medical comorbidities associated with EDs.

The Australian Government Commonwealth Department of Health funded the InsideOut Institute for Eating Disorders (IOI) to develop the Australian Eating Disorders Research and Translation Strategy 2021–2031 [ 20 ] under the Psych Services for Hard to Reach Groups initiative (ID 4-8MSSLE). The strategy was developed in partnership with state and national stakeholders including clinicians, service providers, researchers, and experts by lived experience (both consumers and families/carers). Developed through a two-year national consultation and collaboration process, the strategy provides the roadmap to establishing EDs as a national research priority and is the first disorder-specific strategy to be developed in consultation with the National Mental Health Commission. To inform the strategy, IOI commissioned Healthcare Management Advisors (HMA) to conduct a series of RRs to assess all available peer-reviewed literature on all DSM-5 listed EDs.

A RR Protocol [ 21 ] was utilised to allow swift synthesis of the evidence in order to guide public policy and decision-making [ 22 ]. This approach has been adopted by several leading health organisations including the World Health Organisation [ 17 ] and the Canadian Agency for Drugs and Technologies in Health Rapid Response Service [ 18 ], to build a strong evidence base in a timely and accelerated manner, without compromising quality. A RR is not designed to be as comprehensive as a systematic review—it is purposive rather than exhaustive and provides actionable evidence to guide health policy [ 23 ].

The RR is a narrative synthesis adhering to the PRISMA guidelines [ 24 ]. It is divided by topic area and presented as a series of papers. Three research databases were searched: ScienceDirect, PubMed and Ovid/Medline. To establish a broad understanding of the progress made in the field of EDs, and to capture the largest evidence base from the past 12 years (originally 2009–2019, but expanded to include the preceding two years), the eligibility criteria for included studies were kept broad. Therefore, included studies were published between 2009 and 2021, written in English, and conducted within Western healthcare systems or health systems comparable to Australia in terms of structure and resourcing. The initial search and review process was conducted by three reviewers between 5 December 2019 and 16 January 2020. The re-run for the years 2020–2021 was conducted by two reviewers at the end of May 2021.

The RR had a translational research focus with the objective of identifying evidence relevant to developing optimal care pathways. Searches therefore used a Population, Intervention, Comparison, Outcome (PICO) approach to identify literature relating to population impact, prevention and early intervention, treatment, and long-term outcomes. Purposive sampling focused on high-level evidence studies encompassing meta-analyses; systematic reviews; moderately sized randomised controlled studies (RCTs) (n > 50); moderately sized controlled-cohort studies (n > 50); and population studies (n > 500). However, the diagnoses ARFID and UFED necessitated less stringent eligibility criteria due to a paucity of published articles. As these diagnoses are newly captured in the DSM-5 (released in 2013, within the allocated search timeframe), the evidence base is still emerging, and few studies have been conducted. Thus, smaller studies (n =  ≤ 20) and narrative reviews were also considered and included. Grey literature, such as clinical or practice guidelines, protocol papers (without results) and Masters’ theses or dissertations, were excluded. Other sources (which may not be replicable when applying the current methodology) included the personal libraries of authors, yielding two additional studies (see Additional file 1 ). This extra step was conducted in line with the PRISMA-S: an extension to the PRISMA Statement for Reporting Literature Searches in Systematic Reviews [ 25 ].

Full methodological details including eligibility criteria, search strategy and terms and data analysis are published in a separate protocol paper, which included a total of 1320 studies [ 26 ] (see Additional file 1 : Fig. S1 for PRISMA flow diagram). Data from included studies relating to psychiatric and medical comorbidities of EDs were synthesised and are presented in the current review. No further analyses were conducted.

The search included articles published in the period January 2009 to May 2021. The RR identified 202 studies for inclusion. Of these, 58% related to psychiatric comorbidities (n = 117) and 42% to medical comorbidities (n = 85). A full list of the studies included in this review and information about population, aims and results can be found in Additional file 2 : Tables S3, S4. Results are subdivided into two categories: (1) psychiatric comorbidities and (2) medical complications. Tables 1 and 2 provide high-level summaries of the results.

Psychiatric comorbidities

The study of psychiatric comorbidities can assist with developing models of ED aetiology, conceptualising psychopathology and has relevance for treatment development and outcomes. Given that common psychological factors are observed across psychiatric disorders [ 87 ], it is not surprising that there are high prevalence rates of co-occurring psychiatric conditions with EDs. Comorbidity rates of EDs and other psychiatric conditions are elevated further in ethnic/racial minority groups [ 88 ]. When looking at the evidence from studies conducted with children and young people, one study of children with ARFID found that 53% of the population had a lifetime comorbid psychiatric disorder [ 89 ]. It emerged from the RR that research regarding psychiatric comorbidities generally focussed on the prevalence rates of comorbidities among certain ED subgroups, with some also exploring implications for treatment and ED psychopathology.

Anxiety disorders

Research indicates that EDs and anxiety disorders frequently co-occur [ 8 , 27 ]. The high prevalence rates of anxiety disorders in the general population are also observed in people with EDs; with a large population study finding anxiety disorders were the most frequently comorbid conditions reported [ 8 ]. In a study of women presenting for ED treatment, 65% also met the criteria for at least one comorbid anxiety disorder [ 28 ]. Of note, 69% of those endorsing the comorbidity also reported that the anxiety disorder preceded the onset of the ED [ 28 ]. Another study explored anxiety across individuals with an ED categorised by three weight ranges (individuals whose weight is in the ‘healthy weight’ range, individuals in the ‘overweight’ range and individuals in the ‘obese’ range). While anxiety was elevated across all groups, the authors did note that individuals in the overweight group reported significantly higher rates of anxiety than individuals within the healthy weight group [ 90 ]. One study that explored temperamental factors provided some insight into factors that may mediate this association; anxiety sensitivity (a predictor of anxiety disorders) was associated with greater ED severity among individuals in a residential ED treatment facility [ 29 ]. Further, this association was mediated by a tendency to engage in experiential avoidance—the authors noting that individuals with greater ED symptoms were more likely to avoid distressing experiences [ 29 ].

Generalised anxiety disorder (GAD)

Studies have noted the potential genetic links between EDs and GAD, noting that the presence of one significantly increases the likelihood of the other [ 8 , 30 ]. Further, there appears to be a relationship between the severity of ED behaviours and the co-occurrence of GAD, with comorbidity more likely when fasting and excessive exercise are present, as well as a lower BMI [ 30 ]. The authors noted the particularly pernicious comorbidity of EDs (specifically AN) and GAD may be amplified by the jointly anxiolytic and weight loss effects of food restriction and excessive exercise [ 30 ].

Social anxiety

A meta-analysis of 12 studies found higher rates of social anxiety across all ED diagnoses, with patients with BN demonstrating the highest rate of comorbidity at 84.5%, followed by both BED and AN-BP both at 75% [ 31 ]. High levels of social anxiety were also associated with more severe ED psychopathology [ 31 ] and higher body weight [ 91 ]. This particular comorbidity may also impact on access to treatment for the ED; a large follow-up study of adolescents found that self-reported social phobia predicted not seeking treatment for BN symptoms [ 32 ]. Interestingly, two studies noted that anxiety symptoms improved following psychological treatments that targeted ED symptoms, possibly due to a shared symptom profile [ 29 , 31 ].

Obsessive–compulsive disorder

Similarities between the symptoms of Obsessive–Compulsive Disorder (OCD) and EDs, such as cognitive rigidity, obsessiveness, detail focus, perfectionism and compulsive routines have long been reported in the literature [ 34 ]. Given the symptom overlap, a meta-analysis sought to clarify the lifetime and current (that is, a current diagnosis at the time of data collection) comorbidity rates of OCD and EDs, noting the lifetime comorbidity rate was 18% and current comorbidity rate was 15% [ 33 ]. However, the authors noted that this prevalence may double over longer periods of observation, with some follow-up data demonstrating comorbidity rates of 33% [ 33 ]. Prevalence rates of OCD seemed to be highest among people with AN (lifetime = 19% and current = 14%) compared to other ED subtypes. In addition to the symptom crossover, this RR found evidence of a complex relationship between OCD and EDs, including a potential association between OCD and greater ED severity [ 34 ].

Network analysis found that doubts about simple everyday things and repeating things over and over bridged between ED and OCD symptoms. Further, a pathway was observed between restricting and checking compulsions and food rigidity as well as binge eating and hoarding. However, as the data was cross-sectional, directional inferences could not be made [ 36 ]. An earlier study explored how changes in OCD symptoms impact ED symptoms among an inpatient sample [ 35 ]. As was hypothesised, decreases in OCD symptoms accounted for significant variance in decreases in ED symptoms, and this effect was strongest among ED patients with comorbid OCD. The study also found that irrespective of whether patients had comorbid OCD or not, when ED symptoms improved, so did symptoms of OCD [ 35 ]. The authors concluded that perhaps there is a reciprocal relationship between OCD and ED symptoms, whereby symptoms of both conditions interact in a synergistic, bidirectional manner, meaning that improvement in one domain can lead to improvement in another [ 35 ]. These findings were somewhat supported in a study by Simpson and colleagues (2013), which found exposure and response prevention (a specialised OCD treatment) resulted in a significant reduction in OCD severity, as was expected, and an improvement in ED symptoms. In their study, individuals with BN showed more improvement than those with AN–nevertheless, BMI still increased among those underweight [ 92 ].

Mood disorders

Depression and major depressive disorder (mdd).

This RR also found high levels of comorbidity between major depression and EDs. A longitudinal study of disordered eating behaviours among adolescents found that disordered eating behaviours and depressive symptoms developed concurrently [ 37 ]. Among the sample, over half the adolescent sample had a depressive disorder. Prevalence rates were similar for AN (51.5%) and BN (54%) [ 37 ]. The study also explored the neurological predictors of comorbid depression in individuals with EDs, noting that lower grey matter volumes in the medial orbitofrontal, dorsomedial, and dorsolateral prefrontal cortices predicted the concurrent development of purging and depressive symptoms [ 37 ]. The results suggested that alterations in frontal brain circuits were part of a neural aetiology common to EDs and depression [ 37 ].

This RR found much support for a strong relationship between depression and ED symptomatology. In a study of patients with AN, comorbid MDD was associated with a greater AN symptom severity [ 93 ], and this relationship between the symptoms of MDD and AN was bidirectional in a study of adolescents undergoing treatment for AN, whereby dietary restraint predicted increased guilt and hostility (symptoms of low mood) and fear predicted further food restriction [ 94 ]. Further studies noted the association between BN, BED and NES, with a higher prevalence of depression and more significant depression symptoms [ 95 , 96 , 97 ]. However, other studies have failed to find support for this association–for example, a Swedish twin study found no association between NES and other mental health disorders [ 98 ].

The impact of the relationship between depression and EDs on treatment outcomes was variable across the studies identified by the RR. One study noted the impact of depression on attrition; patients with BN and comorbid depression attending a university clinic had the highest rates of treatment drop-out [ 99 ]. However, in a sample of patients with AN, the comorbidity of depression (or lack of) did not impact treatment outcome and the severity of depression was not associated with changes in ED symptoms [ 100 ]. This finding was supported in another study of inpatients with AN; pre-treatment depression level did not predict treatment outcome or BMI [ 101 ].

Bipolar disorders

Notable comorbidity rates between bipolar disorders (BD) and EDs were reported in the literature reviewed, however evidence about the frequency of this association was mixed. Studies noted comorbidity rates of BD and EDs ranging between 1.9% to as high as 35.8% [ 38 , 39 , 40 ]. In order to better understand the nature of comorbidity, a recent systematic review and meta-analysis found BD (including bipolar 1 disorder and bipolar 2 disorder) and ED comorbidity varied across different ED diagnostic groups (BED—12.5%, BN—7.4%, AN—3.8%) [ 102 ]. However, the authors noted the scant longitudinal studies available, particularly in paediatric samples. An analysis of comorbidity within a sample of patients with BD identified that 27% of participants also met criteria for an ED; 15% had BN, 12% had BED, and 0.2% had AN [ 103 ]. Two other studies noted considerable comorbidity rates of BD; 18.6% for binge eating [ 104 ] and 8.8% for NES [ 105 ]. Some studies suggested the co-occurrence of BD and EDs were seen most in people with AN-BP, BN and BED—all of which share a binge and/or purge symptom profile [ 38 , 106 ]. Specifically, BED and BN were the most common co-occurring EDs with BD [ 40 ], however, these EDs are also the most prevalent in the population. Therefore, it is unclear if this finding is reflective of the increased prevalence of BN and BED, or if it reflects a shared underlying psychopathology between BD and these EDs [ 40 ].

Comorbid ED-BD patients appear to experience increased ED symptom severity, poorer daily and neuropsychological functioning than patients with only a ED or BD diagnosis [ 107 ]. In an effort to understand which shared features in ED-BD relate to quality of life, one study assessed an adult sample with BD [ 108 ]. Binge eating, restriction, overevaluation of weight and shape, purging and driven exercise were associated with poorer clinical outcomes, quality of life and mood regulation [ 108 ]. Additionally, a study of patients undergoing treatment for BD noted patients with a comorbid ED had significantly poorer clinical outcomes and higher scores of depression [ 109 ]. Further, quality of life was significantly lower among patients with comorbid ED-BD [ 109 ]. The comorbidity of ED and BD has implications for intervention and clinical management, as at least one study observed higher rates of alcohol abuse and suicidality among patients with comorbid ED and BD compared to those with BD only [ 40 ].

Personality disorders

This RR identified limited research regarding the comorbidity between personality disorders (PD) and EDs. A meta-analysis sought to summarise the proportion of comorbid PDs among patients with AN and BN [ 41 ]. There was a heightened association between any type of ED and PDs, and this was significantly different to the general population. For specific PDs, the proportions of paranoid, borderline, avoidant, dependant and obsessive–compulsive PD were significantly higher in EDs than in the general population. For both AN and BN, Cluster C PDs (avoidant, dependant and obsessive–compulsive) were most frequent. The authors noted that the specific comorbidity between specific EDs and PDs appears to be associated with common traits—constriction/perfectionism and rigidity is present in both AN and obsessive–compulsive PD (which had a heightened association), as was the case with impulsivity, a characteristic of both BN and borderline PD [ 41 ]. This symptom association was also observed in a study of adolescents admitted to an ED inpatient unit whereby a significant interaction between binge-purge EDs (AN-BP and BN), childhood emotional abuse (a risk factor for PD) and borderline personality style was found [ 110 ].

This comorbidity may be associated with greater patient distress and have implications for patient outcomes [ 41 , 42 ]. Data from a nine-year observational study of individuals with BN reported that comorbidity with a PD was strongly associated with elevated mortality risk [ 111 ]. In terms of treatment outcomes, an RCT compared the one- and three-year treatment outcomes of four subgroups of women with BN, defined by PD complexity; no comorbid PD (health control), personality difficulties, simple PD and complex PD [ 112 ]. At pre-treatment, the complex PD group had greater ED psychopathology than the other three groups. Despite this initial difference, there were no differences in outcomes between groups at one-year and three-year follow up [ 112 ]. The authors suggested this result could be due to the targeting of the shared symptoms of BN and PD by the intervention delivered in this study, and that as ED symptoms improve, so do PD symptoms [ 112 ]. Suggesting that beyond symptom overlap, perhaps some symptoms attributed to the PD are better explained by the ED. This was consistent with Brietzke and colleagues’ (2011) recommendation that for individuals with ED and a comorbid PD, treatment approaches should target both conditions where possible [ 113 ].

Substance use disorders

Comorbid substance use disorders (SUDs) are also often noted in the literature as an issue that complicates treatment and outcomes of EDs [ 114 ]. A meta-analysis reported the lifetime prevalence of EDs and comorbid SUD was 27.9%, [ 43 ] with a lifetime prevalence of comorbid illicit drug use of 17.2% for AN and 18.6% for BN [ 115 ]. Alcohol, caffeine and tobacco were the most frequently reported comorbidities [ 43 ]. Further analysis of SUDs by substance type in a population-based twin sample indicated that the lifetime prevalence of an alcohol use disorder among individuals with AN was 22.4% [ 115 ]. For BN, the prevalence rate was slightly higher at 24.0% [ 115 ].

The comorbidity of SUD is considered far more common among individuals with binge/purge type EDs, evidenced by a meta-analysis finding higher rates of comorbid SUD among patients with AN-BP and BN than AN-R [ 44 ]. This trend was also observed in population data [ 116 ]. Further, a multi-site study found that patients with BN had higher rates of comorbid SUD than patients with AN, BED and Eating Disorder Not Otherwise Specific (EDNOS) (utilised DSM-IV criteria) [ 117 ]. Behaviourally, there was an association between higher frequencies of binge/purge behaviours with high rates of substance use [ 117 ]. The higher risk of substance abuse among patients with binge/purge symptomology was also associated with younger age of binge eating onset [ 118 ]. A study explored whether BN and ED subtypes with binge/purge symptoms predicted adverse outcomes and found that adolescent girls with purging disorder were significantly more likely to use drugs or frequently binge drink [ 119 ]. This association was again observed in a network analysis of college students, whereby there was an association between binge drinking and increased ED cognitions [ 120 ].

Psychosis and schizophrenia

The RR identified a small body of literature with mixed results regarding the comorbidity of ED and psychosis-spectrum symptoms. A study of patients with schizophrenia found that 12% of participants met full diagnostic criteria for NES, with a further 10% meeting partial criteria [ 45 ]. Miotto and colleagues’ (2010) study noted higher rates of paranoid ideation and psychotic symptoms in ED patients than those observed in healthy controls [ 121 ]. However, the authors concluded that these symptoms were better explained by the participant's ED diagnosis than a psychotic disorder [ 121 ]. At a large population level, an English national survey noted associations between psychotic-like experiences and uncontrolled eating, food dominance and potential EDs [ 122 ]. In particular, these associations were stronger in males [ 122 ]. However, the true comorbidity between psychotic disorders and ED remains unclear and further research is needed.

Body dysmorphic disorder

While body image disturbances common to AN, BN and BED are primarily related to weight and shape concerns, individuals with body dysmorphic disorder (BDD) have additional concerns regarding other aspects of their appearance, such as facial features and skin blemishes [ 46 , 123 ]. AN and BDD share similar psychopathology and both have a peak onset period in adolescence, although BDD development typically precedes AN [ 46 ]. The prevalence rates of BDD among individuals with AN are variable. In one clinical sample of female AN patients, 26% met BDD diagnostic criteria [ 124 ]. However, much higher rates were observed in another clinical sample of adults with AN, where 62% of patients reported clinically significant 'dysmorphic concern' [ 125 ].

As the RR has found with other mental health comorbidities, BDD contributes to greater symptom severity in individuals with AN, making the disorder more difficult to treat. However, some research suggested that improved long-term outcomes from treatments for AN are associated with the integration of strategies that address dysmorphic concerns [ 124 , 126 ]. However, there remains little research on the similarities, differences and co-occurrence of BDD and AN, and with even less research on the cooccurrence of BDD and other EDs.

Neurodevelopmental disorders

Attention deficit hyperactivity disorder

Several studies noted the comorbidity between Attention Deficit Hyperactivity Disorder (ADHD) and EDs. A systematic review found moderate evidence for a positive association between ADHD and disordered eating, particularly between overeating and ADHD [ 47 ]. The impulsivity symptoms of ADHD were particularly associated with BN for all genders, and weaker evidence was found for the association between hyperactivity and restrictive EDs (AN and ARFID) for males, but not females [ 47 ]. Another meta-analysis reported a two-fold increased risk of ADHD in individuals with an ED [ 48 ] and studies have noted particularly strong associations between ADHD and BN [ 49 , 50 ]. In a cohort of adults with a diagnosis of an ED, 31.3% had a 'possible' ADHD [ 127 ]. Another study considered sex differences; women with ADHD had a significantly higher lifetime prevalence of both AN and BN than women without ADHD [ 128 ]. Further, the comorbidity rates for BED were considerably higher among individuals with ADHD for both genders [ 128 ].

Further evidence for a significant association between ADHD and EDs was reported in a population study of children [ 51 ]. Results revealed that children with ADHD were more like to experience an ED or binge, purge, or restrictive behaviours above clinical threshold [ 51 ]. Another study of children with ADHD considered gender differences; boys with ADHD had a greater risk of binge eating than girls [ 129 ]. However, the study found no significant difference in AN's prevalence between ADHD and non-ADHD groups. Further, among patients attending an ED specialist clinic, those with comorbid ADHD symptoms had poorer outcomes at one-year follow-up [ 130 ].

Autism spectrum disorder

There is evidence of heightened prevalence rates of autism spectrum disorder (ASD) among individuals with EDs. A systematic review found an average prevalence of ASD with EDs of 22.9% compared with 2% observed in the general population [ 52 ]. With regards to AN, several studies have found symptoms of ASD to be frequently exhibited by patients with AN [ 53 , 54 ]. An assessment of common phenomena between ARFID and ASD in children found a shared symptom profile of eating difficulties, behavioural problems and sensory hypersensitivity beyond what is observed in typically developing children (the control group) [ 55 ]. While research in this area is developing, the findings indicated these comorbidities would likely have implications for the treatment and management of both conditions [ 55 ].

Post traumatic stress disorder

Many individuals with EDs report historical traumatic experiences, and for a proportion of the population, symptoms of post traumatic stress disorder (PTSD). A broad range of prevalence rates between PTSD and EDs have been reported; between 16.1–22.7% for AN, 32.4–66.2% for BN and 24.02–31.6% for BED [ 56 ]. A review noted self-criticism, low self-worth, guilt, shame, depression, anxiety, emotion dysregulation, anger and impulsivity were linked to the association between EDs and trauma [ 57 ]. It was suggested that for individuals with trauma/PTSD, EDs might have a functional role to manage PTSD symptoms and reduce negative affect [ 57 ]. Further, some ED behaviours such as restriction, binge eating, and purging may be used to avoid hyperarousal, in turn maintaining the association between EDs and PTSD [ 57 ].

Few studies have explored the impact of comorbid PTSD on ED treatment outcomes. A study of inpatients admitted to a residential ED treatment service investigated whether PTSD diagnosis at admission was associated with symptom changes [ 56 ]. Cognitive and behavioural symptoms related to the ED had decreased at discharge, however, they increased again at six-month follow up. In contrast, while PTSD diagnosis was associated with higher baseline ED symptoms, it was not related to symptom change throughout treatment or treatment dropout [ 56 ]. Given previous research identified that PTSD and EDs tend to relate to more complex courses of illness, greater rates of drop out and poorer outcomes, a study by Brewerton and colleagues [ 131 ], explored the presence of EDs in patients with PTSD admitted to a residential setting. Results showed that patients with PTSD had significantly higher scores of ED psychopathology, as well as depression, anxiety and quality of life. [ 131 ]. Further, those with PTSD had a greater tendency for binge-type EDs.

Suicidality

Suicide is one of the leading causes of death for individuals with EDs [ 58 ]. In a longitudinal study of adolescents, almost one quarter had attempted suicide, and 65% reported suicidal ideation within the past 6 months [ 37 ]. EDs are a significant risk factor for suicide, with some evidence suggesting a genetic association between suicide risk and EDs [ 59 , 60 ]. This association was supported in the analysis of Swedish population registry data, which found that individuals with a sibling with an ED had an increased risk of suicide attempts with an odds ratio of 1.4 (relative cohort n  = 1,680,658) [ 61 ]. For suicide attempts, this study found an even higher odds ratio of 5.28 (relative cohort n  = 2,268,786) for individuals with an ED and 5.39 (relative cohort n  = 1,919,114) for death by suicide [ 61 ]. A comparison of individuals with AN and BN indicated that risk for suicide attempts was higher for those with BN compared to AN [ 61 ]. However, the opposite was true for death by suicide; which was higher in AN compared to BN [ 61 ]. This result is consistent with the findings of a meta-analysis—the incidence of suicide was higher among patients with AN compared to those with BN or BED [ 62 ].

The higher incidence of suicide in adults with AN [ 132 ] is potentially explained by the findings from Guillaume and colleagues (2011), which suggested that comparative to BN, AN patients are more likely to have more serious suicide attempts resulting in a higher risk of death [ 133 ]. However, death by suicide remains a significant risk for both diagnoses. As an example, Udo and colleagues (2019) study reported that suicide attempts were more common in those with an AN-BP subtype (44.1%) than AN-R (15.7%), or BN (31.4%) [ 134 ]. Further, in a large cohort of transgender college students with EDs, rates of past-year suicidal ideation (a significant risk factor for suicide attempts) was 75.2%, and suicide attempts were 74.8%, significantly higher than cisgender students with EDs and transgender students without EDs [ 135 ]. The RR found that the risk of suicidal ideation and behaviour was associated with ED diagnosis and the presence of other comorbidities. Among a community-based sample of female college students diagnosed with an ED, 25.6% reported suicidal ideation, and this was positively correlated with depression, anxiety and purging [ 136 ]. In support of this evidence, Sagiv and Gvion (2020) proposed a dual pathway model of risk of suicide attempt in individuals with ED, which implicates trait impulsivity and comorbid depression [ 137 ]. In two large transdiagnostic ED patient samples, suicidal ideation was associated with different aspects of self-image between ED diagnoses. For example, suicidal ideation was associated with higher levels of self-blame among individuals with BED, while among patients with AN and OSFED, increased suicidal ideation was associated with a lack of self-love [ 138 , 139 ].

Anorexia nervosa

Amongst adults with AN, higher rates of suicide have been reported amongst those with a binge-purge subtype (25%) than restrictive subtype (8.65%) [ 58 , 140 ]. Further, comorbid depression and prolonged starvation were strongly associated with elevated suicide attempts for both subtypes [ 58 , 140 ]. In another study, the risk of attempted suicide was associated with depression, but it was moderated by hospital treatment [ 93 ]. Further, suicidal ideation was related to depression. A significant 'acquired' suicide risk in individuals with AN has been identified by Selby et al. (2010) through an increased tolerance for pain and discomfort resultant from repeated exposure to painful restricting and purging behaviours [ 141 ].

Bulimia nervosa

Further research among individuals diagnosed with BN found an increased level of suicide risk [ 142 ]. Results from an extensive study of women with BN indicated that the lifetime prevalence of suicide attempts in this cohort was 26.9% [ 143 ]. In one study of individuals diagnosed with severe BN, 60% of deaths were attributed to suicide [ 144 ]. The mean age at the time of death was 29.6 years, and predictive factors included previous suicide attempts and low BMI. Further, in a sample of children and adolescents aged 7 to 18 years, higher rates of suicidal ideation were associated with BN, self-induced vomiting and a history of trauma [ 12 ].

A large population-based study of adolescents and adults explored the frequency and correlates of suicidal ideation and attempts in those who met the criteria for BN [ 145 ]. Suicidal ideation was highest in adolescents with BN (53%), followed by BED (34.4%), other non-ED psychopathology (21.3%) or no psychopathology (3.8%). A similar trend was observed for suicide plans and attempts [ 145 ]. However, for adults, suicidality was more prevalent in the BN group compared to no psychopathology, but not statistically different to the AN, BED or other psychopathology groups [ 145 ].

Consistent with Crow and colleagues’ (2014) results, in a sample of women with BN, depression had the strongest association with lifetime suicide attempts [ 146 ]. There were also associations between identity problems, cognitive dysregulation, anxiousness, insecure attachment and lifetime suicide attempts among the sample. Depression was the most pertinent association, suggesting that potential comorbid depression should be a focus of assessment and treatment among individuals with BN due to the elevated suicide risk for this group [ 146 ]. Insecure attachment is associated with childhood trauma, and a systematic review found that suicide attempts in women with BN were significantly associated with childhood abuse and familial history of EDs [ 58 ].

Binge eating disorder

The RR found mixed evidence for the association between suicidal behaviour and BED. A meta-analysis found no suicides for patients with BED [ 62 ]. However, evidence from two separate large national surveys found that a significant proportion of individuals who had a suicide attempt also had a diagnosis of BED [ 134 , 147 ].

Non-suicidal self injury

Non-suicidal self-injury (NSSI), broadly defined, is the intentional harm inflicted to one’s body without intent to die [ 148 ]. Recognising NSSI is often a precursor for suicidal ideation and behaviour [ 149 ], together with the already heightened mortality rate for EDs, several studies have examined the association between EDs and NSSI. Up to one-third of patients with EDs report NSSI at some stage in their lifetime, with over one quarter having engaged in NSSI within the previous year [ 63 ]. Similarly, a cohort study [ 148 ] found elevated rates of historical NSSI amongst patients with DSM-IV EDs; specifically EDNOS (49%), BN (41%) and AN (26%). In a Spanish sample of ED patients, the most prevalent form of NSSI was banging (64.6%) and cutting (56.9%) [ 63 ].

Further research has explored the individual factors associated with heightened rates of NSSI. Higher levels of impulsivity among patients with EDs have been associated with concomitant NSSI [ 64 ]. This was demonstrated in a longitudinal study of female students, whereby NSSI preceded purging, marking it a potential risk factor for ED onset [ 65 ]. In a study of a large clinical sample of patients with EDs and co-occurring NSSI, significantly higher levels of emotional reactivity were observed [ 150 ]. The highest levels of emotional reactivity were reported by individuals with a diagnosis of BN, who were also more likely to engage in NSSI than those with AN [ 150 ]. In Olatunji and colleagues’ (2015) cohort study, NSSI was used to regulate difficult emotions, much like other ED behaviours. NSSI functioning as a means to manage negative affect associated with EDs was further supported by Muehlenkamp and colleagues’ [ 66 ] study exploring the risk factors in inpatients admitted for an ED. The authors found significant differences in the prevalence of NSSI across ED diagnoses, although patients with binge/purge subtype EDs were more likely to engage in poly-NSSI (multiple types of NSSI). Consistent with these findings, a study of patients admitted to an ED inpatient unit found that 45% of patients displayed at least one type of NSSI [ 151 ]. The function of NSSI among ED patients was explored in two studies, one noting that avoiding or suppressing negative feelings was the most frequently reported reason for NSSI [ 151 ]. The other analysed a series of interviews and self-report questionnaires and found patients with ED and comorbid Borderline Personality Disorder (BPD) engaged in NSSI as a means of emotion regulation [ 152 ].

Medical comorbidities

The impact of EDs on physical health and the consequential medical comorbidities has been a focus of research. Many studies reported medical comorbidities resulting from prolonged malnutrition, as well as excessive exercise, binging and purging behaviours.

Cardiovascular complications

As discussed above, although suicide is a significant contributor to the mortality rate of EDs, physical and medical complications remain the primary cause of death, particularly in AN, with a high proportion of deaths thought to result from cardiovascular complications [ 153 ]. AN has attracted the most research focus given its increased risk of cardiac failure due to severe malnutrition, dehydration and electrolyte imbalances [ 67 ].

Cardiovascular complications in AN can be divided by conduction, structural and ischemic diseases. A review found that up to 87% of patients experience cardiovascular compromise shortly following onset of AN [ 153 ]. Within conduction disease, bradycardia and QT prolongation occur at a high frequency, largely due to low body weight and resultant decreased venous return to the heart. Whereas, atrioventricular block and ventricular arrhythmia are more rare [ 153 ]. Various structural cardiomyopathies are observed in AN, such as low left ventricular mass index (occurs frequently), mitral prolapse and percardial effusion (occurs moderately). Ischemic diseases such as dyslipidemia or acute myocardial infarction are more rare.

Another review identified cardiopulmonary abnormalities that are frequently observed in AN; mitral valve prolapse occurred in 25% of patients, sinus bradycardia was the most common arrhythmia, and pericardial effusion prevalence rates ranged from 15 to 30%. [ 68 ] Sudden cardiac death is thought to occur due to increased QT interval dispersion and heart rate variability. [ 68 ] A review of an inpatient database in a large retrospective cohort study found that coronary artery disease (CAD) was lower in AN patients than the general population (4.4% and 18.4%, respectively). Consistent with trends in the general population, the risk of cardiac arrest, arrhythmias and heart failure was higher in males with AN than females with AN [ 69 ].

Given that individuals with AN have compromised biology, may avoid medical care, and have higher rates of substance use, research has examined cancer incidence and prognosis among individuals with AN. A retrospective study noted higher mortality from melanoma, cancers of genital organs and cancers of unspecified sites among individuals with AN, however, there was no statistically significant difference compared to the general population [ 70 ]. No further studies of cancer in EDs were identified.

Gastrointestinal disorders

The gastrointestinal (GI) system plays a pivotal role in the development, maintenance, and treatment outcomes for EDs, with changes and implications present throughout the GI tract. More than 90% of AN patients report fullness, early satiety, abdominal distention, pain and nausea [ 68 ]. Although it is well understood that GI system complaints are complicated and exacerbated by malnutrition, purging and binge eating [ 154 , 155 ], the actual cause of the increased prevalence of GI disorders and their contribution to ED maintenance remain poorly understood.

To this end, a review aimed to determine the GI symptoms reported in two restrictive disorders (AN and ARFID), as well as the physiologic changes as a result of malnutrition and function of low body weight and the contribution of GI diseases to the disordered eating observed in AN and ARFID [ 156 ]. The review found mixed evidence regarding whether GI issues were increased in patients with AN and ARFID. This was partly due to the relatively limited amount of research in this area and mixed results across the literature. The review noted that patients with AN and ARFID reported a higher frequency of symptoms of gastroparesis. Further, there was evidence for a bidirectional relationship between AN and functional gastrointestinal disorders (FGIDs) contributing to ongoing disordered eating. The review found that GI symptoms observed in EDs develop due to (1) poorly treated medical conditions with GI-predominant symptoms, (2) the physiological and anatomical changes that develop due to malnutrition or (3) FGIDs.

There was a high rate of comorbidity (93%) between ED and FGIDs, including oesophageal, bowel and anorectal disorders, in a patient sample with AN, BN and EDNOS [ 157 ]. A retrospective study investigating increased rates of oesophageal cancer in individuals with a history of EDs could not conclude that risk was associated with purging over other confounding factors such as alcohol abuse and smoking [ 158 ].

Given that gut peptides like ghrelin, cholecystokinin (CCK), peptide tyrosine (PYY) and glucagon-like peptide 1 (GLP-1) are known to influence food intake, attention has focussed on the dysregulation of gut peptide signalling in EDs [ 159 ]. A review aimed to discuss how these peptides or the signals triggered by their release are dysregulated in EDs and whether they are normalised following weight restoration or weight loss (in the case of people with higher body weight) [ 159 ]. The results were inconsistent, with significant variability in peptide dysregulation observed across EDs [ 159 ]. A systematic review and meta-analysis explored whether ghrelin is increased in restrictive AN. The review found that all forms of ghrelin were raised in AN’s acute state during fasting [ 160 ]. In addition, the data did not support differences in ghrelin levels between AN subtypes [ 160 ]. Another study examined levels of orexigenic ghrelin and anorexigenic peptide YY (PYY) in young females with ARFID, AN and healthy controls (HC) [ 161 ]. Results demonstrated that fasting and postprandial ghrelin were lower in ARFID than AN, but there was no difference between ARFID and AN for fasting and postprandial PYY [ 161 ].

Oesophageal and gastrointestinal dysfunction have been observed in patients with AN and complicate nutritional and refeeding interventions [ 155 ]. Findings from a systematic review indicated that structural changes that occurred in the GI tract of patients with AN impacted their ability to swallow and absorb nutrients [ 162 ]. Interestingly, no differences in the severity of gastrointestinal symptoms were observed between AN-R and AN-BP subtypes [ 155 ].

A systematic review of thirteen studies aimed to identify the most effective treatment approaches for GI disorders and AN [ 163 ]. An improvement in at least one or more GI symptoms was reported in 11 of the 13 studies, with all studies including nutritional rehabilitation, and half also included concurrent psychological treatment [ 163 ]. Emerging evidence on ED comorbidity with chronic GI disorders suggested that EDs are often misdiagnosed in children and adolescents due to the crossover of symptoms. Therefore, clinicians treating children and adolescents for GI dysfunction should be aware of potential EDs and conduct appropriate screening [ 164 ]. There has been an emerging focus on the role of the gut microbiome in the regulation of core ED symptoms and psychophysiology. Increased attention is being paid to how the macronutrient composition of nutritional rehabilitation should be considered to maximise treatment outcomes. A review found that high fibre consumption in addition to prebiotic and probiotic supplementation helped balance the gut microbiome and maintained the results of refeeding [ 165 ].

Bone health

The RR found evidence for bone loss/poor bone mineral density (BMD) and EDs, particularly in AN. The high rates of bone resorption observed in patients with AN is a consequence of chronic malnutrition leading to osteoporosis (weak and brittle bones), increased fracture risk and scoliosis [ 166 ]. The negative impacts of bone loss are more pronounced in individuals with early-onset AN when the skeleton is still developing [ 67 ] and among those who have very low BMI [ 71 ], with comorbidity rates as high as 46.9% [ 71 ]. However, lowered BMD was also observed among patients with BN [ 72 ].

A review [ 167 ] explored the prevalence and differences in pathophysiology of osteoporosis and fractures in patients with AN-R and AN-BP. AN-R patients had a higher prevalence of osteoporosis, and AN-BP patients had a higher prevalence of osteopenia (loss of BMD) [ 167 ]. Further, the authors noted the significant increase in fracture risk that starts at disease onset and lasts throughout AN, with some evidence that risk remains increased beyond remission and recovery [ 167 ]. Findings from a longitudinal study of female patients with a history of adolescent AN found long-term bone thinning at five and ten-year follow-up despite these patients achieving weight restoration [ 168 ].

Given this, treatment to increase BMD in individuals with AN has been the objective of many pharmacotherapy trials, mainly investigating the efficacy of hormone replacement [ 169 , 170 ]. Treatments include oestrogen and oral contraceptives [ 169 , 170 , 171 , 172 ]; bisphosphonates [ 169 , 173 ]; other hormonal treatment [ 174 , 175 , 176 , 177 ] and vitamin D [ 178 ]. However, the outcomes of these studies were mixed.

Refeeding syndrome

Nutritional rehabilitation of severely malnourished individuals is central to routine care and medical stabilisation of patients with EDs [ 179 ]. Within inpatient treatment settings, reversing severe malnutrition is achieved using oral, or nasogastric tube feeding. However, following a period of starvation, initiating/commencing feeding has been associated with ‘refeeding syndrome’ (RFS), a potentially fatal electrolyte imbalance caused by the body's response to introducing nutritional restoration [ 180 , 181 ]. The studies identified in the RR focused predominantly on restrictive EDs/on this population group—results regarding RFS risk were mixed [ 73 ].

A retrospective cohort study of inpatients diagnosed with AN with a very low BMI implemented a nasogastric feeding routine with vitamin, potassium and phosphate supplementation [ 182 ]. All patients achieved a significant increase in body weight. None developed RFS [ 182 ], suggesting that even with extreme undernutrition, cautious feeding within a specialised unit can be done safely without RFS. For adults with AN, aminotransferases are often high upon admission, however are normalised following four weeks of enteral feeding [ 183 , 184 ]. Further, the RR identified several studies demonstrating the provision of a higher caloric diet at intake to adolescents with AN led to faster recoveries and fewer days in the hospital with no observed increased risk for RFS [ 75 , 76 , 77 ]. These findings were also noted in a study of adults with AN [ 179 ].

However, the prevalence of RFS among inpatients is highly variable, with one systematic review noting rates ranging from 0 to 62% [ 74 ]. This variability was largely a reflection of the different definitions of RFS used across the literature [ 74 ]. A retrospective review of medical records of patients with AN admitted to Intensive Care Units (ICUs) aimed to evaluate complications, particularly RFS, that occurred during the ICU stay and the impact of these complications on treatment outcomes [ 185 ]. Of the 68 patients (62 female), seven developed RFS (10.3%) [ 185 ].

Although easily detectable and treatable, hypophosphatemia (a low serum phosphate concentration) may lead to RFS which is the term used to describe severe fluid and electrolyte shifts that can occur when nutrition support is introduced after a period of starvation. Untreated hypophosphatemia may lead to characteristic signs of the RFS such as respiratory failure, heart failure, and seizures [ 76 , 179 , 186 , 187 , 188 ]. A retrospective case–control study of inpatients with severe AN identified [ 189 ]. A retrospective study of AN and atypical AN patients undergoing refeeding found that the risk of hypophosphatemia was associated with a higher level of total weight loss and recent weight loss rather than the patient’s weight at admission [ 190 ]. The safe and effective use of prophylactic phosphate supplementation during refeeding was supported by the results from Agostino and colleagues’ chart review study [ 191 ], where 90% of inpatients received supplementation during admission.

Higher calorie refeeding approaches are considered safe in most cases, however the steps necessitated to monitor health status are costly to health services [ 192 ]. The most cost-effective approach would likely involve prophylactic electrolyte supplementation in addition to high calorie refeeding, which would decrease the need for daily laboratory monitoring as well as shortening hospital stays [ 75 , 191 , 192 ]. A systematic review noted that much of the research regarding refeeding, particularly in children and young people, has been limited by small sample sizes, single-site studies and heterogeneous designs [ 181 ]. Further, the differing definitions of RFS, recovery, remission and outcomes leading to variable results. While RFS appears safe for many people requiring feeding, the risk and benefits of it are unclear [ 193 ] due to the limited research on this topic. Following current clinical practice guidelines on the safe introduction of nutrition is recommended.

Metabolic syndrome

Metabolic syndrome refers to a group of factors that increase risks for heart disease, diabetes, stroke and other related conditions [ 194 ]. Metabolic syndrome is conceptualised as five key criteria; (1) elevated waist circumference, (2) elevated triglyceride levels, (3) reduced HDL-C, (4) elevated blood pressure and (5) elevated fasting glucose. The binge eating behaviours exhibited in BN, BED and NES have been linked to the higher rates of metabolic syndrome observed in these ED patients [ 78 , 195 ].

An analysis of population data of medical comorbidities with BED noted the strongest associations were with diabetes and circulatory systems, likely indexing components of metabolic syndrome [ 196 ]. While type 1 diabetes is considered a risk factor for ED development, both BN and BED have increased risk for type 2 diabetes [ 78 ]. A 16-year observation study found that the risk of type 2 diabetes was significantly increased in male patients with BED compared to the community controls [ 78 ]. By the end of the observation period, 33% of patients with BED had developed type 2 diabetes compared to 1.7% of the control group. The prevalence of type 2 diabetes among patients with BN was also slightly elevated at 4.4% [ 78 ]. Importantly, the authors were not able to control for BMI in this study. In another study, BED was the most prevalent ED in a cohort of type 2 diabetes patients [ 197 ]. Conversely, the prevalence of AN among patients with type 2 diabetes is significantly lower, with a review of national data reporting comorbidity rates to be 0.06% [ 198 ].

Metabolic dysfunction was observed in a relatively large sample of individuals with NES, including metabolic syndrome and type 2 diabetes, with women reporting slightly higher rates (13%) than men (11%) [ 199 ]. In another group of adults with type 2 diabetes, 7% met the diagnostic criteria for NES [ 200 ]. These findings suggested a need for increased monitoring and treatment of type 2 diabetes in individuals with EDs, particularly BED and NES. Another study found BED had a significant impact on metabolic abnormalities, including elevated cholesterol and poor glycaemic control [ 201 ].

The RR identified one intervention study, which examined an intervention to address medical comorbidities associated with BN and BED [ 195 ]. The study compared cognitive behaviour therapy (CBT) to an exercise and nutrition intervention to increase physical fitness, decrease body fat percentage and reduce the risk for metabolic syndrome. While the exercise intervention improved participants' physical fitness and body composition, neither group reduced cardiovascular risk at one-year follow-up [ 195 ].

Oral health

Purging behaviour, particularly self-induced vomiting, has been associated with several oral health and gastrointestinal dysfunctions in patients with EDs. A case–control study of ED patients with binge/purge symptomology found that despite ED patients reporting an increased concern for dental issues and engaging in more frequent brushing, their oral health was poorer than controls. [ 79 ] Further, a systematic review and meta-analysis aimed to explore whether EDs increase the risk of tooth erosion [ 80 ]. The analysis found that patients with EDs had more risk of dental erosion, especially among those who self-induced vomiting [ 80 ]. These findings were also found in a large cohort study, where the increased risk for BN was associated with higher rates of dental erosion but not dental cavities [ 81 ].

However, a systematic review of 10 studies suggested that poor oral health may be common among ED patients irrespective of whether self-induced vomiting forms part of their psychopathology [ 202 ]. One study reported that AN-R patients had poorer oral health outcomes and tooth decay than BN patients [ 203 ]. Two studies identified associations between NES and poor oral health, including higher rates of missing teeth, periodontal disease [ 204 , 205 ]. Another study of a group of patients with AN, BN and EDNOS, demonstrated the impact of ED behaviours on dental soft tissue, whereby 94% of patients had oral mucosal lesions, and 3% were found to have dental erosion [ 206 ].

Vitamin deficiencies

The prolonged periods of starvation, food restriction (of caloric intake and/or food groups), purging and excessive exercise observed across the ED spectrum have detrimental impacts on micronutrient balances [ 207 ]. The impact of prolonged vitamin deficiencies in early-onset EDs can also impair brain development, substantially reducing neurocognitive function in some younger patients even after weight restoration [ 82 ]. Common micronutrient deficiencies include calcium, fat soluble vitamins, essential fatty acids selenium, zinc and B vitamins [ 183 ]. One included study looked at prevalence rates of cerebral atrophy and neurological conditions, specifically Wernicke's encephalopathy in EDs and found that these neurological conditions were very rare in people with EDs [ 208 ].

Cognitive functioning

The literature included in RR regarding the cognitive changes in ED patients with AN following weight gain was sparse. It appears that some cognitive functions affected by EDs recover following nutritional restoration, whereas others persist. Cognitive functions, such as flexibility, central coherence, decision making, attention, processing speed and memory, are hypothesised to be impacted by, and influence the maintenance of EDs. A systematic review explored whether cognitive functions improved in AN following weight gain [ 83 ]. Weight gain appeared to be associated with improved processing speed in children and adolescents. However, no improvement was observed in cognitive flexibility following weight gain. Further, the results for adults were inconclusive [ 83 ].

Reproductive health

Infertility and higher rates of poor reproductive health are strongly associated with EDs, including miscarriages, induced abortions, obstetric complications, and poorer birth outcomes [ 84 , 85 ]. Although amenorrhea is a known consequence of AN, oligomenorrhea (irregular periods) was common among individuals with BN and BED [ 86 ]. A twin study found women diagnosed with BN and BED were also more likely to have poly cystic ovarian syndrome (PCOS), leading to menstrual irregularities [ 209 ]. The prevalence of lifetime amenorrhea in this sample was 10.4%, and lifetime oligomenorrhea was 33.7%. An epidemiological study explored the association of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) in women with BN and BED and found prevalence rates as high as 42.4% for PMS and 4.2% for PMDD [ 210 ].

Given the increased rates of menstrual irregularities and issues, questions have been raised regarding whether this complication is reversed or improves with recovery. A review of five studies monitoring reproductive functions during recovery over a 6- to 18-year follow up period [ 211 ] noted no significant difference between the pooled odds of childbirth rates between the AN and general population—demonstrating that if patients undergo treatment for AN, achieve weight restoration, and continue to maintain wellness, reproductive functions can renormalise [ 211 ].

An observational study of women with AN, BN or EDNOS found higher rates of low birth rate, pre-term deliveries, caesarean deliveries, and intrauterine growth restrictions [ 84 ]. Increased caesarean delivery was also observed in a large cohort of women diagnosed with BED [ 212 ]. However, these women had higher birth weight babies [ 212 ]. Further, women with comorbid ED and epilepsy were found to have an increased risk of pregnancy-related comorbidities, including preeclampsia (gestational hypertension and signs of damage to the liver and kidneys ) , gestational diabetes and perinatal depression [ 213 ].

The results from this review identified that the symptomology and outcomes of EDs are impacted by both psychiatric and medical factors. Further, EDs have a mortality rate substantially higher than the general population, with a significant proportion of those who die from an ED dying by suicide or as a result of severe medical complications.

This RR noted high rates of psychiatric and medical comorbidities in people with EDs, with comorbidities contributing to increased ED symptom severity, maintenance of some ED behaviours, compromised functioning, and adverse treatment outcomes. Evidence suggested that early identification and management of psychiatric and medical comorbidities in people with an ED may improve response to treatment and outcomes [ 29 , 35 , 83 ].

EDs and other psychiatric conditions often shared symptoms and high levels of psychopathology crossover were noted. The most prevalent psychiatric comorbidities were anxiety disorders, mood disorders and substance use disorders [ 8 , 100 , 119 ]. perhaps unsurprising given the prevalence of these illnesses in the general population. Of concern is the elevated suicide rate noted across the ED spectrum, the highest observed in AN [ 58 , 140 , 149 ]. For people with AN, suicide attempts were mostly associated with comorbid mood and anxiety disorders [ 136 ]. The review noted elevated rates of NSSI were particularly associated with binge/purge subtype EDs [ 150 ], impulsivity and emotional dysregulation (again, an example of psychopathological overlap).

With regards to PDs, studies were limited to EDs with binge-purge symptomology. Of those included, the presence of a comorbid personality disorder and ED was associated with childhood trauma [ 110 ] and elevated mortality risk [ 111 ]. There appeared to be a link between the clinical characteristics of the ED (e.g., impulsivity, rigidity) and the comorbid PD (cluster B PDs were more associated with BN/BED and cluster C PDs were more associated with AN). There was mixed (albeit limited) evidence regarding the comorbidity between EDs and psychosis and schizophrenia, with some studies noting an association between EDs and psychotic experiences [ 45 ]. Specifically, there was an association between psychotic experiences and uncontrolled eating and food dominance, which were stronger in males [ 122 ]. In addition, the review noted the association between EDs and neurodevelopmental disorders-specifically ADHD—was associated with features of BN and ASD was more prevalent among individuals with AN [ 53 , 54 ] and ARFID [ 55 ].

EDs are complicated by medical comorbidities across the neuroendocrine, skeletal, nutritional, gastrointestinal, dental, and reproductive systems that can occur alongside, or result from the ED. The RR noted mixed evidence regarding the effectiveness and safety of enteral feeding [ 180 , 181 ], with some studies noting that RFS could be safely managed with supplementation [ 191 ]. Research also described the impacts of restrictive EDs on BMD and binge eating behaviour on metabolic disorders [ 78 , 195 ]. Purging behaviours, particularly self-induced vomiting [ 79 ], were found to increase the risk of tooth erosion [ 81 ] and damage to soft tissue within the gastrointestinal tract [ 206 ]. Further, EDs were associated with a range of reproductive health issues in women, including infertility and birth complications [ 84 ].

Whilst the RR achieved its aim of synthesising a broad scope of literature, the absence of particular ED diagnoses and other key research gaps are worth noting. A large portion of the studies identified focused on AN, for both psychiatric and medical comorbidities. This reflects the stark lack of research exploring the comorbidities for ARFID, NES, and OSFED compared to that seen with AN, BN and BED. There were no studies identified exploring the psychiatric and medical comorbidities of Pica. These gaps could in part be due to the timeline utilised in the RR search strategy, which included the transition from DSM-IV to DSM-5. The update in the DSM had significant implications for psychiatric diagnosis, with the addition of new disorders (such as Autism Spectrum Disorder and various Depressive Disorders), reorganisation (for example, moving OCD and PTSD out of anxiety disorders and into newly defined chapters) and changes in diagnostic criteria (including for AN and BN, and establishing BED as a discrete disorder). Although current understanding suggests EDs are more prevalent in females, research is increasingly demonstrating that males are not immune to ED symptoms, and the RR highlighted the disproportionate lack of male subjects included in recent ED research, particularly in the domain of psychiatric and medical comorbidities.

As the RR was broad in scope and policy-driven in intent, limitations as a result of this methodology ought to be considered. The RR only considered ‘Western’ studies, leading to the potential of important pieces of work not being included in the synthesis. In the interest of achieving a rapid synthesis, grey literature, qualitative and theoretical works, case studies or implementation research were not included, risking a loss of nuance in developing fields, such as the association and prevalence of complex/developmental trauma with EDs (most research on this comorbidity focuses on PTSD, not complex or developmental trauma) or body image dissatisfaction among different gender groups. No studies regarding the association between dissociative disorders and EDs were included in the review. However, dissociation can co-occur with EDs, particularly AN-BP and among those with a trauma history [ 214 ]. Future studies would benefit from exploring this association further, particularly as trauma becomes more recognised as a risk factor for ED development.

The review was not designed to be an exhaustive summary of all medical comorbidities. Thus, some areas of medical comorbidity may not be included, or there may be variability in the level of detail included (such as, limited studies regarding the association between cancer and EDs). Studies that explored the association between other autoimmune disorders (such as Type 1 Diabetes, Crohn’s disease, Addison’s disease, ulcerative colitis, and coeliac disease) and EDs [ 215 , 216 ] were not included. Future reviews and research should examine the associations between autoimmune disorders and the subsequent increased risk of EDs, and likewise, the association between EDs and the subsequent risk of autoimmune disorders.

An important challenge for future research is to explore the impact of comorbidity on ED identification, development and treatment processes and outcomes. Insights could be gained from exploring shared psychiatric symptomology (i.e., ARFID and ASD, BN/BED and personality disorders, and food addiction). Particularly in disorders where the psychiatric comorbidity appears to precede the ED diagnosis (as may be the case in anxiety disorders [ 28 ]) and the unique physiological complications of these EDs (e.g., the impact of ARFID on childhood development and growth). Further, treatment outcomes would benefit from future research exploring the nature of the proposed reciprocal nature between EDs and comorbidities, particularly in those instances where there is significant shared psychopathology, or the presence of ED symptoms appears to exacerbate the symptoms of the other condition—and vice versa.

The majority of research regarding the newly introduced EDs has focused on understanding their aetiology, psychopathology, and what treatments demonstrate efficacy. Further, some areas included in the review had limited included studies, for example cancer and EDs. Thus, in addition to the already discussed need for further review regarding the association between EDs and autoimmune disorders, future research should explore the nature and prevalence of comorbidity between cancers and EDs. There was variability regarding the balance of child/adolescent and adult studies across the various comorbidities. Some comorbidities are heavily researched in child and adolescent populations (such as refeeding syndrome) and others there is stark child and adolescent inclusion, with included studies only looking at adult samples. Future studies should also address specific comorbidities as they apply to groups underrepresented in current research. This includes but is not limited to gender, sexual and racial minorities, whereby prevalence rates of psychiatric comorbidities are elevated. [ 88 ] In addition, future research would benefit from considering the nature of psychiatric and medical comorbidity for subthreshold and subclinical EDs, particularly as it pertains to an opportunity to identify EDs early within certain comorbidities where ED risk is heightened.

This review has identified the psychiatric and medical comorbidities of EDs, for which there is a substantial level of literature, as well as other areas requiring further investigation. EDs are associated with a myriad of psychiatric and medical comorbidities which have significant impacts on the symptomology and outcomes of an already difficult to treat, and burdensome illness.

Availability of data and materials

Not applicable—all citations provided.

Abbreviations

Anorexia nervosa—restricting type

Anorexia nervosa—binge-purge type

Avoidant restrictive food intake disorder

Body mass index

Borderline personality disorder

Diagnostic and statistical manual of mental disorders, 5th edition

Eating disorder

Generalised anxiety disorder

International classification of diseases, 11th edition

Major depressive disorder

Night eating syndrome

Other specified feeding or eating disorder

Post-traumatic stress disorder

Rapid review

Brandsma L. Eating disorders across the lifespan. J Women Aging. 2007;19(1–2):155–72.

Article   PubMed   Google Scholar  

van Hoeken D, Hoek HW. Review of the burden of eating disorders: mortality, disability, costs, quality of life, and family burden. Curr Opin Psychiatry. 2020;33(6):521–7.

Article   PubMed   PubMed Central   Google Scholar  

Weigel A, Löwe B, Kohlmann S. Severity of somatic symptoms in outpatients with anorexia and bulimia nervosa. Eur Eat Disord Rev. 2019;27(2):195–204.

Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007;61(3):348–58.

Jahraus J. Medical complications of eating disorders. Psychiatr Ann. 2018;48(10):463–7.

Article   Google Scholar  

Udo T, Grilo CM. Psychiatric and medical correlates of DSM-5 eating disorders in a nationally representative sample of adults in the United States. Int J Eat Disord. 2019;52(1):42–50.

Grenon R, Tasca GA, Cwinn E, Coyle D, Sumner A, Gick M, et al. Depressive symptoms are associated with medication use and lower health-related quality of life in overweight women with binge eating disorder. Womens Health Issues. 2010;20(6):435–40.

Ulfvebrand S, Birgegård A, Norring C, Högdahl L, von Hausswolff-Juhlin Y. Psychiatric comorbidity in women and men with eating disorders results from a large clinical database. Psychiatry Res. 2015;230(2):294–9.

Sachs KV, Harnke B, Mehler PS, Krantz MJ. Cardiovascular complications of anorexia nervosa: a systematic review. Int J Eat Disord. 2016;49(3):238–48.

Smith AR, Zuromski KL, Dodd DR. Eating disorders and suicidality: what we know, what we don’t know, and suggestions for future research. Curr Opin Psychol. 2018;22:63–7.

Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders: a meta-analysis of 36 studies. Arch Gen Psychiatry. 2011;68(7):724–31.

Mayes SD, Fernandez-Mendoza J, Baweja R, Calhoun S, Mahr F, Aggarwal R, et al. Correlates of suicide ideation and attempts in children and adolescents with eating disorders. Eat Disord. 2014;22(4):352–66.

Hart LM, Granillo MT, Jorm AF, Paxton SJ. Unmet need for treatment in the eating disorders: a systematic review of eating disorder specific treatment seeking among community cases. Clin Psychol Rev. 2011;31(5):727–35.

Kaplan AS, Garfinkel PE. Difficulties in treating patients with eating disorders: A review of patient and clinician variables. Can J Psychiatry. 1999;44(7):665–70.

Eddy KT, Tabri N, Thomas JJ, Murray HB, Keshaviah A, Hastings E, et al. Recovery from anorexia nervosa and bulimia nervosa at 22-year follow-up. J Clin Psychiatry. 2017;78(2):184–9.

John A, Marchant A, Demmler J, Tan J, DelPozo-Banos M. Clinical management and mortality risk in those with eating disorders and self-harm: e-cohort study using the SAIL databank. BJPsych Open. 2021;7(2):1–8.

Monteleone P, Brambilla F. Multiple comorbidities in people with eating disorders. In: Comorbidity of mental and physical disorders. vol. 179. Karger Publishers; 2015. p. 66-80. 

Van Alsten SC, Duncan AE. Lifetime patterns of comorbidity in eating disorders: an approach using sequence analysis. Eur Eat Disord Rev. 2020;28(6):709–23.

National Institute of Health and Care Excellence. Managing comorbid health problems in people with eating disorders. United Kingdom: National Institute of Health and Care Excellence. 2019.

Institute InsideOut. Australian Eating Disorders Research and Translation Strategy 2021–2031. Sydney: The University of Sydney; 2021.

Google Scholar  

Virginia Commonwealth University. Rapid review protocol. 2018.

Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395(10227):912–20.

Hamel C, Michaud A, Thuku M, Skidmore B, Stevens A, Nussbaumer-Streit B, et al. Defining rapid reviews: a systematic scoping review and thematic analysis of definitions and defining characteristics of rapid reviews. J Clin Epidemiol. 2020;129:74–85.

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLOS Med. 2009;6(7):1–6.

Rethlefsen ML, Kirtley S, Waffenschmidt S, Ayala AP, Moher D, Page MJ, et al. PRISMA-S: an extension to the PRISMA statement for reporting literature searches in systematic reviews. Syst Rev. 2021;10(1):39.

Aouad P, Bryant E, Maloney D, Marks P, Le A, Russell H, et al. Informing the development of Australia’s national eating disorders research and translation strategy: a rapid review methodology. J Eat Disord. 2022;10(1):31.

Godart N, Radon L, Curt F, Duclos J, Perdereau F, Lang F, et al. Mood disorders in eating disorder patients: prevalence and chronology of ONSET. J Affect Disord. 2015;185:115–22.

Swinbourne J, Hunt C, Abbott M, Russell J, St Clare T, Touyz S. The comorbidity between eating disorders and anxiety disorders: Prevalence in an eating disorder sample and anxiety disorder sample. Aust N Z J Psychiatry. 2012;46(2):118–31.

Espel-Huynh HM, Muratore AF, Virzi N, Brooks G, Zandberg LJ. Mediating role of experiential avoidance in the relationship between anxiety sensitivity and eating disorder psychopathology: a clinical replication. Eat Behav. 2019;34:101308.

Thornton LM, Dellava JE, Root TL, Lichtenstein P, Bulik CM. Anorexia nervosa and generalized anxiety disorder: further explorations of the relation between anxiety and body mass index. J Anxiety Disord. 2011;25(5):727–30.

Kerr-Gaffney J, Harrison A, Tchanturia K. Social anxiety in the eating disorders: a systematic review and meta-analysis. Psychol Med. 2018;48(15):2477–91.

Ranta K, Väänänen J, Fröjd S, Isomaa R, Kaltiala-Heino R, Marttunen M. Social phobia, depression and eating disorders during middle adolescence: longitudinal associations and treatment seeking. Nord J Psychiatry. 2017;71(8):605–13.

Mandelli L, Draghetti S, Albert U, De Ronchi D, Atti A-R. Rates of comorbid obsessive-compulsive disorder in eating disorders: a meta-analysis of the literature. J Affect Disord. 2020;277:927–39.

Finzi-Dottan R, Zubery E. The role of depression and anxiety in impulsive and obsessive-compulsive behaviors among anorexic and bulimic patients. Eat Disord. 2009;17(2):162–82.

Olatunji BO, Tart CD, Shewmaker S, Wall D, Smits JA. Mediation of symptom changes during inpatient treatment for eating disorders: the role of obsessive–compulsive features. J Psychiatr Res. 2010;44(14):910–6.

Vanzhula IA, Kinkel-Ram SS, Levinson CA. Perfectionism and difficulty controlling thoughts bridge eating disorder and obsessive-compulsive disorder symptoms: a network analysis. J Affect Disord. 2021;283:302–9.

Zhang Z, Robinson L, Jia T, Quinlan EB, Tay N, Chu C, et al. Development of disordered eating behaviors and comorbid depressive symptoms in adolescence: neural and psychopathological predictors. Biol Psychiatry. 2020;90(12):853–62.

Thiebaut S, Godart N, Radon L, Courtet P, Guillaume S. Crossed prevalence results between subtypes of eating disorder and bipolar disorder: a systematic review of the literature. L’encephale. 2019;45(1):60–73.

Crow S, Blom TJ, Sim L, Cuellar-Barboza AB, Biernacka JM, Frye MA, et al. Factor analysis of the eating disorder diagnostic scale in individuals with bipolar disorder. Eat Behav. 2019;33:30–3.

McDonald CE, Rossell SL, Phillipou A. The comorbidity of eating disorders in bipolar disorder and associated clinical correlates characterised by emotion dysregulation and impulsivity: a systematic review. J Affect Disord. 2019;259:228–43.

Martinussen M, Friborg O, Schmierer P, Kaiser S, Øvergård KT, Neunhoeffer A-L, et al. The comorbidity of personality disorders in eating disorders: a meta-analysis. Eat Weight Disord Stud Anorex Bulim Obes. 2017;22(2):201–9.

Vrabel KR, Rø Ø, Martinsen EW, Hoffart A, Rosenvinge JH. Five-year prospective study of personality disorders in adults with longstanding eating disorders. Int J Eat Disord. 2010;43(1):22–8.

PubMed   Google Scholar  

Bahji A, Mazhar MN, Hudson CC, Nadkarni P, MacNeil BA, Hawken E. Prevalence of substance use disorder comorbidity among individuals with eating disorders: A systematic review and meta-analysis. Psychiatry Res. 2019;273:58–66.

Calero-Elvira A, Krug I, Davis K, Lopez C, Fernández-Aranda F, Treasure J. Meta-analysis on drugs in people with eating disorders. Eur Eat Disord Rev Prof J Eat Disord Assoc. 2009;17(4):243–59.

Palmese LB, Ratliff JC, Reutenauer EL, Tonizzo KM, Grilo CM, Tek C. Prevalence of night eating in obese individuals with schizophrenia and schizoaffective disorder. Compr Psychiatry. 2013;54(3):276–81.

Hartmann AS, Greenberg JL, Wilhelm S. The relationship between anorexia nervosa and body dysmorphic disorder. Clin Psychol Rev. 2013;33(5):675–85.

Kaisari P, Dourish CT, Higgs S. Attention deficit hyperactivity disorder (ADHD) and disordered eating behaviour: a systematic review and a framework for future research. Clin Psychol Rev. 2017;53:109–21.

Nazar BP, Bernardes C, Peachey G, Sergeant J, Mattos P, Treasure J. The risk of eating disorders comorbid with attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Int J Eat Disord. 2016;49(12):1045–57.

Seitz J, Kahraman-Lanzerath B, Legenbauer T, Sarrar L, Herpertz S, Salbach-Andrae H, et al. The role of impulsivity, inattention and comorbid ADHD in patients with bulimia nervosa. PLoS ONE. 2013;8(5):e63891.

Ziobrowski H, Brewerton TD, Duncan AE. Associations between ADHD and eating disorders in relation to comorbid psychiatric disorders in a nationally representative sample. Psychiatry Res. 2018;260:53–9.

Bleck JR, DeBate RD, Olivardia R. The comorbidity of ADHD and eating disorders in a nationally representative sample. J Behav Health Serv Res. 2015;42(4):437–51.

Huke V, Turk J, Saeidi S, Kent A, Morgan JF. Autism spectrum disorders in eating disorder populations: a systematic review. Eur Eat Disord Rev. 2013;21(5):345–51.

Westwood H, Mandy W, Tchanturia K. Clinical evaluation of autistic symptoms in women with anorexia nervosa. Mol Autism. 2017;8(1):1–9.

Dell’Osso L, Carpita B, Gesi C, Cremone I, Corsi M, Massimetti E, et al. Subthreshold autism spectrum disorder in patients with eating disorders. Compr Psychiatry. 2018;81:66–72.

Dovey TM, Kumari V, Blissett J. Eating behaviour, behavioural problems and sensory profiles of children with avoidant/restrictive food intake disorder (ARFID), autistic spectrum disorders or picky eating: same or different? Eur Psychiatry. 2019;61:56–62.

Mitchell KS, Singh S, Hardin S, Thompson-Brenner H. The impact of comorbid posttraumatic stress disorder on eating disorder treatment outcomes: investigating the unified treatment model. Int J Eat Disord. 2021;54(7):1260–9.

Mitchell KS, Scioli ER, Galovski T, Belfer PL, Cooper Z. Posttraumatic stress disorder and eating disorders: maintaining mechanisms and treatment targets. Eat Disord. 2021;29(3):292–306.

Goldstein A, Gvion Y. Socio-demographic and psychological risk factors for suicidal behavior among individuals with anorexia and bulimia nervosa: a systematic review. J Affect Disord. 2019;245:1149–67.

Pisetsky EM, Peterson CB, Mitchell JE, Wonderlich SA, Crosby RD, Le Grange D, et al. A comparison of the frequency of familial suicide attempts across eating disorder diagnoses. Int J Eat Disord. 2017;50(6):707–10.

Thornton LM, Welch E, Munn-Chernoff MA, Lichtenstein P, Bulik CM. Anorexia nervosa, major depression, and suicide attempts: shared genetic factors. Suicide Life Threat Behav. 2016;46(5):525–34.

Yao S, Kuja-Halkola R, Thornton LM, Runfola CD, D’Onofrio BM, Almqvist C, et al. Familial liability for eating disorders and suicide attempts: evidence from a population registry in Sweden. JAMA Psychiatry. 2016;73(3):284–91.

Preti A, Rocchi MBL, Sisti D, Camboni M, Miotto P. A comprehensive meta-analysis of the risk of suicide in eating disorders. Acta Psychiatr Scand. 2011;124(1):6–17.

Pérez S, Marco JH, Cañabate M. Non-suicidal self-injury in patients with eating disorders: prevalence, forms, functions, and body image correlates. Compr Psychiatry. 2018;84:32–8.

Claes L, Islam MA, Fagundo AB, Jimenez-Murcia S, Granero R, Agüera Z, et al. The relationship between non-suicidal self-injury and the UPPS-P impulsivity facets in eating disorders and healthy controls. PLoS ONE. 2015;10(5):e0126083.

Riley EN, Davis HA, Combs JL, Jordan CE, Smith GT. Nonsuicidal self-injury as a risk factor for purging onset: Negatively reinforced behaviours that reduce emotional distress. Eur Eat Disord Rev. 2016;24(1):78–82.

Muehlenkamp JJ, Claes L, Smits D, Peat CM, Vandereycken W. Non-suicidal self-injury in eating disordered patients: a test of a conceptual model. Psychiatry Res. 2011;188(1):102–8.

Gosseaume C, Dicembre M, Bemer P, Melchior J-C, Hanachi M. Somatic complications and nutritional management of anorexia nervosa. Clin Nutr Exp. 2019;28:2–10.

Cass K, McGuire C, Bjork I, Sobotka N, Walsh K, Mehler PS. Medical complications of anorexia nervosa. Psychosomatics. 2020;61(6):625–31.

Kalla A, Krishnamoorthy P, Gopalakrishnan A, Garg J, Patel N, Figueredo V. Gender and age differences in cardiovascular complications in anorexia nervosa patients. Int J Cardiol. 2017;227:55–7.

Karamanis G, Skalkidou A, Tsakonas G, Brandt L, Ekbom A, Ekselius L, et al. Cancer incidence and mortality patterns in women with anorexia nervosa. Int J Cancer. 2014;134(7):1751–7.

Hofman M, Landewé-Cleuren S, Wojciechowski F, Kruseman AN. Prevalence and clinical determinants of low bone mineral density in anorexia nervosa. Eur J Intern Med. 2009;20(1):80–4.

Robinson L, Aldridge V, Clark E, Misra M, Micali N. A systematic review and meta-analysis of the association between eating disorders and bone density. Osteoporos Int. 2016;27(6):1953–66.

Rizzo SM, Douglas JW, Lawrence JC. Enteral nutrition via nasogastric tube for refeeding patients with anorexia nervosa: a systematic review. Nutr Clin Pract. 2019;34(3):359–70.

Cioffi I, Ponzo V, Pellegrini M, Evangelista A, Bioletto F, Ciccone G, et al. The incidence of the refeeding syndrome. A systematic review and meta-analyses of literature. Clin Nutr. 2021;40(6):3688–701.

Golden NH, Keane-Miller C, Sainani KL, Kapphahn CJ. Higher caloric intake in hospitalized adolescents with anorexia nervosa is associated with reduced length of stay and no increased rate of refeeding syndrome. J Adolesc Health. 2013;53(5):573–8.

Garber AK, Mauldin K, Michihata N, Buckelew SM, Shafer M-A, Moscicki A-B. Higher calorie diets increase rate of weight gain and shorten hospital stay in hospitalized adolescents with anorexia nervosa. J Adolesc Health. 2013;53(5):579–84.

O’Connor G, Nicholls D, Hudson L, Singhal A. Refeeding low weight hospitalized adolescents with anorexia nervosa: a multicenter randomized controlled trial. Nutr Clin Pract. 2016;31(5):681–9.

Raevuori A, Suokas J, Haukka J, Gissler M, Linna M, Grainger M, et al. Highly increased risk of type 2 diabetes in patients with binge eating disorder and bulimia nervosa. Int J Eat Disord. 2015;48(6):555–62.

Conviser JH, Fisher SD, Mitchell KB. Oral care behavior after purging in a sample of women with bulimia nervosa. J Am Dent Assoc. 2014;145(4):352–4.

Hermont AP, Oliveira PA, Martins CC, Paiva SM, Pordeus IA, Auad SM. Tooth erosion and eating disorders: a systematic review and meta-analysis. PLoS ONE. 2014;9(11):e111123.

Hermont AP, Pordeus IA, Paiva SM, Abreu MHNG, Auad SM. Eating disorder risk behavior and dental implications among adolescents. Int J Eat Disord. 2013;46(7):677–83.

Peebles R, Sieke EH. Medical complications of eating disorders in youth. Child Adolesc Psychiatr Clin. 2019;28(4):593–615.

Hemmingsen SD, Wesselhoeft R, Lichtenstein MB, Sjögren JM, Støving RK. Cognitive improvement following weight gain in patients with anorexia nervosa: a systematic review. Eur Eat Disord Rev. 2021;29(3):402–26.

Pasternak Y, Weintraub AY, Shoham-Vardi I, Sergienko R, Guez J, Wiznitzer A, et al. Obstetric and perinatal outcomes in women with eating disorders. J Womens Health. 2012;21(1):61–5.

Linna MS, Raevuori A, Haukka J, Suvisaari JM, Suokas JT, Gissler M. Reproductive health outcomes in eating disorders. Int J Eat Disord. 2013;46(8):826–33.

Martini MG, Solmi F, Krug I, Karwautz A, Wagner G, Fernandez-Aranda F, et al. Associations between eating disorder diagnoses, behaviors, and menstrual dysfunction in a clinical sample. Arch Womens Ment Health. 2016;19(3):553–7.

Clarke E, Kiropoulos LA. Mediating the relationship between neuroticism and depressive, anxiety and eating disorder symptoms: The role of intolerance of uncertainty and cognitive flexibility. J Affect Disord Rep. 2021;4:100101.

Grilo CM, White MA, Barnes RD, Masheb RM. Psychiatric disorder co-morbidity and correlates in an ethnically diverse sample of obese patients with binge eating disorder in primary care settings. Compr Psychiatry. 2013;54(3):209–16.

Kambanis PE, Kuhnle MC, Wons OB, Jo JH, Keshishian AC, Hauser K, et al. Prevalence and correlates of psychiatric comorbidities in children and adolescents with full and subthreshold avoidant/restrictive food intake disorder. Int J Eat Disord. 2020;53(2):256–65.

Balantekin KN, Grammer AC, Fitzsimmons-Craft EE, Eichen DE, Graham AK, Monterubio GE, et al. Overweight and obesity are associated with increased eating disorder correlates and general psychopathology in university women with eating disorders. Eat Behav. 2021;41:101482.

Spettigue W, Obeid N, Santos A, Norris M, Hamati R, Hadjiyannakis S, et al. Binge eating and social anxiety in treatment-seeking adolescents with eating disorders or severe obesity. Eat Weight Disord Stud Anorex Bulim Obes. 2020;25(3):787–93.

Simpson HB, Wetterneck CT, Cahill SP, Steinglass JE, Franklin ME, Leonard RC, et al. Treatment of obsessive-compulsive disorder complicated by comorbid eating disorders. Cogn Behav Ther. 2013;42(1):64–76.

Fennig S, Hadas A. Suicidal behavior and depression in adolescents with eating disorders. Nord J Psychiatry. 2010;64(1):32–9.

Pila E, Murray SB, Le Grange D, Sawyer SM, Hughes EK. Reciprocal relations between dietary restraint and negative affect in adolescents receiving treatment for anorexia nervosa. J Abnorm Psychol. 2019;128(2):129–39.

Touchette E, Henegar A, Godart NT, Pryor L, Falissard B, Tremblay RE, et al. Subclinical eating disorders and their comorbidity with mood and anxiety disorders in adolescent girls. Psychiatry Res. 2011;185(1–2):185–92.

Carriere C, Michel G, Féart C, Pellay H, Onorato O, Barat P, et al. Relationships between emotional disorders, personality dimensions, and binge eating disorder in French obese adolescents. Arch Pediatr. 2019;26(3):138–44.

Kucukgoncu S, Tek C, Bestepe E, Musket C, Guloksuz S. Clinical features of night eating syndrome among depressed patients. Eur Eat Disord Rev. 2014;22(2):102–8.

Lundgren JD, Allison KC, Stunkard AJ, Bulik CM, Thornton LM, Lindroos AK, et al. Lifetime medical and psychiatric comorbidity of night eating behavior in the Swedish Twin Study of Adults: Genes and Environment (STAGE). Psychiatry Res. 2012;199(2):145–9.

Schnicker K, Hiller W, Legenbauer T. Drop-out and treatment outcome of outpatient cognitive–behavioral therapy for anorexia nervosa and bulimia nervosa. Compr Psychiatry. 2013;54(7):812–23.

Calugi S, El Ghoch M, Conti M, Dalle GR. Depression and treatment outcome in anorexia nervosa. Psychiatry Res. 2014;218(1–2):195–200.

Voderholzer U, Witte S, Schlegl S, Koch S, Cuntz U, Schwartz C. Association between depressive symptoms, weight and treatment outcome in a very large anorexia nervosa sample. Eat Weight Disord Stud Anorex Bulim Obes. 2016;21(1):127–31.

Fornaro M, Daray FM, Hunter F, Anastasia A, Stubbs B, De Berardis D, et al. The prevalence, odds and predictors of lifespan comorbid eating disorder among people with a primary diagnosis of bipolar disorders, and vice-versa: systematic review and meta-analysis. J Affect Disord. 2021;280:409–31.

McElroy SL, Crow S, Blom TJ, Biernacka JM, Winham SJ, Geske J, et al. Prevalence and correlates of DSM-5 eating disorders in patients with bipolar disorder. J Affect Disord. 2016;191:216–21.

Boulanger H, Tebeka S, Girod C, Lloret-Linares C, Meheust J, Scott J, et al. Binge eating behaviours in bipolar disorders. J Affect Disord. 2018;225:482–8.

Melo MCA, de Oliveira RM, de Araújo CFC, de Mesquita LMF, de Bruin PFC, de Bruin VMS. Night eating in bipolar disorder. Sleep Med. 2018;48:49–52.

McElroy SL, Frye MA, Hellemann G, Altshuler L, Leverich GS, Suppes T, et al. Prevalence and correlates of eating disorders in 875 patients with bipolar disorder. J Affect Disord. 2011;128(3):191–8.

Thiebaut S, Jaussent I, Maïmoun L, Beziat S, Seneque M, Hamroun D, et al. Impact of bipolar disorder on eating disorders severity in real-life settings. J Affect Disord. 2019;246:867–72.

McAulay C, Mond J, Outhred T, Malhi GS, Touyz S. Eating disorder features in bipolar disorder: clinical implications. J Mental Health. 2021:1–11.

Seixas C, Miranda-Scippa Â, Nery-Fernandes F, Andrade-Nascimento M, Quarantini LC, Kapczinski F, et al. Prevalence and clinical impact of eating disorders in bipolar patients. Braz J Psychiatry. 2012;34(1):66–70.

Spiegel J, Arnold S, Salbach H, Gotti E, Pfeiffer E, Lehmkuhl U, et al. Emotional abuse interacts with borderline personality in adolescent inpatients with binge-purging eating disorders. Eat Weight Disord Stud Anorex Bulim Obes. 2021;27:131–8.

Himmerich H, Hotopf M, Shetty H, Schmidt U, Treasure J, Hayes RD, et al. Psychiatric comorbidity as a risk factor for the mortality of people with bulimia nervosa. Soc Psychiatry Psychiatr Epidemiol. 2019;54(7):813–21.

Rowe SL, Jordan J, McIntosh VV, Carter FA, Frampton C, Bulik CM, et al. Complex personality disorder in bulimia nervosa. Compr Psychiatry. 2010;51(6):592–8.

Brietzke E, Moreira CL, Toniolo RA, Lafer B. Clinical correlates of eating disorder comorbidity in women with bipolar disorder type I. J Affect Disord. 2011;130(1–2):162–5.

Harrop EN, Marlatt GA. The comorbidity of substance use disorders and eating disorders in women: prevalence, etiology, and treatment. Addict Behav. 2010;35(5):392–8.

Baker JH, Mitchell KS, Neale MC, Kendler KS. Eating disorder symptomatology and substance use disorders: prevalence and shared risk in a population based twin sample. Int J Eat Disord. 2010;43(7):648–58.

Root TL, Pisetsky EM, Thornton L, Lichtenstein P, Pedersen NL, Bulik CM. Patterns of co-morbidity of eating disorders and substance use in Swedish females. Psychol Med. 2010;40(1):105–15.

Fouladi F, Mitchell JE, Crosby RD, Engel SG, Crow S, Hill L, et al. Prevalence of alcohol and other substance use in patients with eating disorders. Eur Eat Disord Rev. 2015;23(6):531–6.

Brewerton TD, Rance SJ, Dansky BS, O’Neil PM, Kilpatrick DG. A comparison of women with child-adolescent versus adult onset binge eating: Results from the national women’s study. Int J Eat Disord. 2014;47(7):836–43.

Field AE, Sonneville KR, Micali N, Crosby RD, Swanson SA, Laird NM, et al. Prospective association of common eating disorders and adverse outcomes. Pediatrics. 2012;130(2):e289–95.

Cusack CE, Christian C, Drake JE, Levinson CA. A network analysis of eating disorder symptoms and co-occurring alcohol misuse among heterosexual and sexual minority college women. Addict Behav. 2021;118:106867.

Miotto P, Pollini B, Restaneo A, Favaretto G, Sisti D, Rocchi MB, et al. Symptoms of psychosis in anorexia and bulimia nervosa. Psychiatry Res. 2010;175(3):237–43.

Koyanagi A, Stickley A, Haro JM. Psychotic-like experiences and disordered eating in the English general population. Psychiatry Res. 2016;241:26–34.

Phillipou A, Castle DJ, Rossell SL. Direct comparisons of anorexia nervosa and body dysmorphic disorder: a systematic review. Psychiatry Res. 2019;274:129–37.

Cerea S, Bottesi G, Grisham JR, Ghisi M. Non-weight-related body image concerns and body dysmorphic disorder prevalence in patients with anorexia nervosa. Psychiatry Res. 2018;267:120–5.

Beilharz F, Phillipou A, Castle D, Jenkins Z, Cistullo L, Rossell S. Dysmorphic concern in anorexia nervosa: implications for recovery. Psychiatry Res. 2019;273:657–61.

Beilharz F, Castle D, Grace S, Rossell S. A systematic review of visual processing and associated treatments in body dysmorphic disorder. Acta Psychiatr Scand. 2017;136(1):16–36.

Svedlund NE, Norring C, Ginsberg Y, von Hausswolff-Juhlin Y. Symptoms of attention deficit hyperactivity disorder (ADHD) among adult eating disorder patients. BMC Psychiatry. 2017;17(1):1–9.

Brewerton TD, Duncan AE. Associations between attention deficit hyperactivity disorder and eating disorders by gender: results from the national comorbidity survey replication. Eur Eat Disord Rev. 2016;24(6):536–40.

Bisset M, Rinehart N, Sciberras E. DSM-5 eating disorder symptoms in adolescents with and without attention-deficit/hyperactivity disorder: a population-based study. Int J Eat Disord. 2019;52(7):855–62.

Svedlund NE, Norring C, Ginsberg Y, von Hausswolff-Juhlin Y. Are treatment results for eating disorders affected by ADHD symptoms? A one-year follow-up of adult females. Eur Eat Disord Rev. 2018;26(4):337–45.

Brewerton TD, Perlman MM, Gavidia I, Suro G, Genet J, Bunnell DW. The association of traumatic events and posttraumatic stress disorder with greater eating disorder and comorbid symptom severity in residential eating disorder treatment centers. Int J Eat Disord. 2020;53(12):2061–6.

Bühren K, Schwarte R, Fluck F, Timmesfeld N, Krei M, Egberts K, et al. Comorbid psychiatric disorders in female adolescents with first-onset anorexia nervosa. Eur Eat Disord Rev. 2014;22(1):39–44.

Guillaume S, Jaussent I, Olie E, Genty C, Bringer J, Courtet P, et al. Characteristics of suicide attempts in anorexia and bulimia nervosa: a case–control study. PLoS ONE. 2011;6(8):e23578.

Udo T, Bitley S, Grilo CM. Suicide attempts in US adults with lifetime DSM-5 eating disorders. BMC Med. 2019;17(1):1–13.

Duffy ME, Henkel KE, Joiner TE. Prevalence of self-injurious thoughts and behaviors in transgender individuals with eating disorders: a national study. J Adolesc Health. 2019;64(4):461–6.

Goel NJ, Sadeh-Sharvit S, Flatt RE, Trockel M, Balantekin KN, Fitzsimmons-Craft EE, et al. Correlates of suicidal ideation in college women with eating disorders. Int J Eat Disord. 2018;51(6):579–84.

Sagiv E, Gvion Y. A multi factorial model of self-harm behaviors in Anorexia-nervosa and Bulimia-nervosa. Compr Psychiatry. 2020;96:152142.

Andersén M, Birgegård A. D iagnosis-specific self-image predicts longitudinal suicidal ideation in adult eating disorders. Int J Eat Disord. 2017;50(8):970–8.

Runfola CD, Thornton LM, Pisetsky EM, Bulik CM, Birgegård A. Self-image and suicide in a Swedish national eating disorders clinical register. Compr Psychiatry. 2014;55(3):439–49.

Forcano L, Álvarez E, Santamaría JJ, Jimenez-Murcia S, Granero R, Penelo E, et al. Suicide attempts in anorexia nervosa subtypes. Compr Psychiatry. 2011;52(4):352–8.

Selby EA, Smith AR, Bulik CM, Olmsted MP, Thornton L, McFarlane TL, et al. Habitual starvation and provocative behaviors: two potential routes to extreme suicidal behavior in anorexia nervosa. Behav Res Ther. 2010;48(7):634–45.

Bodell LP, Joiner TE, Keel PK. Comorbidity-independent risk for suicidality increases with bulimia nervosa but not with anorexia nervosa. J Psychiatr Res. 2013;47(5):617–21.

Forcano L, Fernández-Aranda F, Alvarez-Moya E, Bulik C, Granero R, Gratacos M, et al. Suicide attempts in bulimia nervosa: personality and psychopathological correlates. Eur Psychiatry. 2009;24(2):91–7.

Huas C, Godart N, Caille A, Pham-Scottez A, Foulon C, Divac SM, et al. Mortality and its predictors in severe bulimia nervosa patients. Eur Eat Disord Rev. 2013;21(1):15–9.

Crow SJ, Swanson SA, le Grange D, Feig EH, Merikangas KR. Suicidal behavior in adolescents and adults with bulimia nervosa. Compr Psychiatry. 2014;55(7):1534–9.

Pisetsky EM, Wonderlich SA, Crosby RD, Peterson CB, Mitchell JE, Engel SG, et al. Depression and personality traits associated with emotion dysregulation: correlates of suicide attempts in women with bulimia nervosa. Eur Eat Disord Rev. 2015;23(6):537–44.

Brown KL, LaRose JG, Mezuk B. The relationship between body mass index, binge eating disorder and suicidality. BMC Psychiatry. 2018;18(1):1–9.

Olatunji BO, Cox R, Ebesutani C, Wall D. Self-harm history predicts resistance to inpatient treatment of body shape aversion in women with eating disorders: The role of negative affect. J Psychiatr Res. 2015;65:37–46.

Pérez S, Ros MC, Folgado JEL, Marco JH. Non-suicidal self-injury differentiates suicide ideators and attempters and predicts future suicide attempts in patients with eating disorders. Suicide Life Threat Behav. 2019;49(5):1220–31.

Smith KE, Hayes NA, Styer DM, Washburn JJ. Emotional reactivity in a clinical sample of patients with eating disorders and nonsuicidal self-injury. Psychiatry Res. 2017;257:519–25.

Claes L, Klonsky ED, Muehlenkamp J, Kuppens P, Vandereycken W. The affect-regulation function of nonsuicidal self-injury in eating-disordered patients: which affect states are regulated? Compr Psychiatry. 2010;51(4):386–92.

Navarro-Haro MV, Wessman I, Botella C, García-Palacios A. The role of emotion regulation strategies and dissociation in non-suicidal self-injury for women with borderline personality disorder and comorbid eating disorder. Compr Psychiatry. 2015;63:123–30.

Giovinazzo S, Sukkar S, Rosa G, Zappi A, Bezante G, Balbi M, et al. Anorexia nervosa and heart disease: a systematic review. Eat Weight Disord Stud Anorex Bulim Obes. 2019;24(2):199–207.

Bouquegneau A, Dubois BE, Krzesinski J-M, Delanaye P. Anorexia nervosa and the kidney. Am J Kidney Dis. 2012;60(2):299–307.

Benini L, Todesco T, Frulloni L, Dalle Grave R, Campagnola P, Agugiaro F, et al. Esophageal motility and symptoms in restricting and binge-eating/purging anorexia. Dig Liver Dis. 2010;42(11):767–72.

Gibson D, Watters A, Mehler PS. The intersect of gastrointestinal symptoms and malnutrition associated with anorexia nervosa and avoidant/restrictive food intake disorder: Functional or pathophysiologic? A systematic review. Int J Eat Disord. 2021.

Abraham S, Kellow J. Exploring eating disorder quality of life and functional gastrointestinal disorders among eating disorder patients. J Psychosom Res. 2011;70(4):372–7.

Brewster DH, Nowell SL, Clark DN. Risk of oesophageal cancer among patients previously hospitalised with eating disorder. Cancer Epidemiol. 2015;39(3):313–20.

Smith KR, Moran TH. Gastrointestinal peptides in eating-related disorders. Physiol Behav. 2021;238:113456.

Seidel M, Markmann Jensen S, Healy D, Dureja A, Watson HJ, Holst B, et al. A systematic review and meta-analysis finds increased blood levels of all forms of ghrelin in both restricting and binge-eating/purging subtypes of anorexia nervosa. Nutrients. 2021;13(2):709.

Becker KR, Mancuso C, Dreier MJ, Asanza E, Breithaupt L, Slattery M, et al. Ghrelin and PYY in low-weight females with avoidant/restrictive food intake disorder compared to anorexia nervosa and healthy controls. Psychoneuroendocrinology. 2021;129:105243.

Schalla MA, Stengel A. Gastrointestinal alterations in anorexia nervosa—A systematic review. Eur Eat Disord Rev. 2019;27(5):447–61.

West M, McMaster CM, Staudacher HM, Hart S, Jacka FN, Stewart T, et al. Gastrointestinal symptoms following treatment for anorexia nervosa: A systematic literature review. Int J Eat Disord. 2021;54(6):936–51.

Avila JT, Park K, Golden NH. Eating disorders in adolescents with chronic gastrointestinal and endocrine diseases. Lancet Child Adolesc Health. 2019;3(3):181–9.

Ruusunen A, Rocks T, Jacka F, Loughman A. The gut microbiome in anorexia nervosa: relevance for nutritional rehabilitation. Psychopharmacology. 2019;236(5):1545–58.

Zaina F, Pesenti F, Persani L, Capodaglio P, Negrini S, Polli N. Prevalence of idiopathic scoliosis in anorexia nervosa patients: results from a cross-sectional study. Eur Spine J. 2018;27(2):293–7.

Hung C, Muñoz M, Shibli-Rahhal A. Anorexia nervosa and osteoporosis. Calcif Tissue Int. 2021;110(5):562–75.

Mumford J, Kohn M, Briody J, Miskovic-Wheatley J, Madden S, Clarke S, et al. Long-term outcomes of adolescent anorexia nervosa on bone. J Adolesc Health. 2019;64(3):305–10.

Robinson L, Aldridge V, Clark EM, Misra M, Micali N. Pharmacological treatment options for low bone mineral density and secondary osteoporosis in anorexia nervosa: a systematic review of the literature. J Psychosom Res. 2017;98:87–97.

Sim LA, McGovern L, Elamin MB, Swiglo BA, Erwin PJ, Montori VM. Effect on bone health of estrogen preparations in premenopausal women with anorexia nervosa: A systematic review and meta-analyses. Int J Eat Disord. 2010;43(3):218–25.

Lebow J, Sim L. The influence of estrogen therapies on bone mineral density in premenopausal women with anorexia nervosa and amenorrhea. Vitam Horm. 2013;92:243–57.

Maïmoun L, Renard E, Lefebvre P, Bertet H, Philibert P, Sénèque M, et al. Oral contraceptives partially protect from bone loss in young women with anorexia nervosa. Fertil Steril. 2019;111(5):1020–9.

Miller KK, Meenaghan E, Lawson EA, Misra M, Gleysteen S, Schoenfeld D, et al. Effects of risedronate and low-dose transdermal testosterone on bone mineral density in women with anorexia nervosa: a randomized, placebo-controlled study. J Clin Endocrinol Metab. 2011;96(7):2081–8.

Bloch M, Ish-Shalom S, Greenman Y, Klein E, Latzer Y. Dehydroepiandrosterone treatment effects on weight, bone density, bone metabolism and mood in women suffering from anorexia nervosa—a pilot study. Psychiatry Res. 2012;200(2–3):544–9.

Vajapeyam S, Ecklund K, Mulkern RV, Feldman HA, O’Donnell JM, DiVasta AD, et al. Magnetic resonance imaging and spectroscopy evidence of efficacy for adrenal and gonadal hormone replacement therapy in anorexia nervosa. Bone. 2018;110:335–42.

DiVasta AD, Feldman HA, Beck TJ, LeBoff MS, Gordon CM. Does hormone replacement normalize bone geometry in adolescents with anorexia nervosa? J Bone Miner Res. 2014;29(1):151–7.

Fazeli PK, Wang IS, Miller KK, Herzog DB, Misra M, Lee H, et al. Teriparatide increases bone formation and bone mineral density in adult women with anorexia nervosa. J Clin Endocrinol Metab. 2014;99(4):1322–9.

Giollo A, Idolazzi L, Caimmi C, Fassio A, Bertoldo F, Dalle Grave R, et al. V itamin D levels strongly influence bone mineral density and bone turnover markers during weight gain in female patients with anorexia nervosa. Int J Eat Disord. 2017;50(9):1041–9.

Davies JE, Cockfield A, Brown A, Corr J, Smith D, Munro C. The medical risks of severe anorexia nervosa during initial re-feeding and medical stabilisation. Clin Nutr ESPEN. 2017;17:92–9.

Hale MD, Logomarsino JV. The use of enteral nutrition in the treatment of eating disorders: a systematic review. Eat Weight Disord Stud Anorex Bulim Obes. 2019;24(2):179–98.

Rocks T, Pelly F, Wilkinson P. Nutrition therapy during initiation of refeeding in underweight children and adolescent inpatients with anorexia nervosa: a systematic review of the evidence. J Acad Nutr Diet. 2014;114(6):897–907.

Gentile MG, Pastorelli P, Ciceri R, Manna GM, Collimedaglia S. Specialized refeeding treatment for anorexia nervosa patients suffering from extreme undernutrition. Clin Nutr. 2010;29(5):627–32.

Hanachi M, Melchior JC, Crenn P. Hypertransaminasemia in severely malnourished adult anorexia nervosa patients: risk factors and evolution under enteral nutrition. Clin Nutr. 2013;32(3):391–5.

Rosen E, Sabel AL, Brinton JT, Catanach B, Gaudiani JL, Mehler PS. Liver dysfunction in patients with severe anorexia nervosa. Int J Eat Disord. 2016;49(2):151–8.

Vignaud M, Constantin J-M, Ruivard M, Villemeyre-Plane M, Futier E, Bazin J-E, et al. Refeeding syndrome influences outcome of anorexia nervosa patients in intensive care unit: an observational study. Crit Care. 2010;14(5):R172.

Whitelaw M, Gilbertson H, Lam P-Y, Sawyer SM. Does aggressive refeeding in hospitalized adolescents with anorexia nervosa result in increased hypophosphatemia? J Adolesc Health. 2010;46(6):577–82.

Leclerc A, Turrini T, Sherwood K, Katzman DK. Evaluation of a nutrition rehabilitation protocol in hospitalized adolescents with restrictive eating disorders. J Adolesc Health. 2013;53(5):585–9.

Leitner M, Burstein B, Agostino H. Prophylactic phosphate supplementation for the inpatient treatment of restrictive eating disorders. J Adolesc Health. 2016;58(6):616–20.

Brown C, Sabel A, Gaudiani J, Mehler PS. Predictors of hypophosphatemia during refeeding of patients with severe anorexia nervosa. Int J Eat Disord. 2015;48(7):898–904.

Whitelaw M, Lee KJ, Gilbertson H, Sawyer SM. Predictors of complications in anorexia nervosa and atypical anorexia nervosa: degree of underweight or extent and recency of weight loss? J Adolesc Health. 2018;63(6):717–23.

Agostino H, Erdstein J, Di Meglio G. Shifting paradigms: continuous nasogastric feeding with high caloric intakes in anorexia nervosa. J Adolesc Health. 2013;53(5):590–4.

Ridout KK, Kole J, Fitzgerald KL, Ridout SJ, Donaldson AA, Alverson B. Daily laboratory monitoring is of poor health care value in adolescents acutely hospitalized for eating disorders. J Adolesc Health. 2016;59(1):104–9.

Nehring I, Kewitz K, Von Kries R, Thyen U. Long-term effects of enteral feeding on growth and mental health in adolescents with anorexia nervosa—results of a retrospective German cohort study. Eur J Clin Nutr. 2014;68(2):171–7.

National Heat LaBI. Metabolic syndrome: US Department of Health and Human Services. 2020.

Mathisen TF, Sundgot-Borgen J, Rosenvinge JH, Bratland-Sanda S. Managing risk of non-communicable diseases in women with bulimia nervosa or binge eating disorders: A randomized trial with 12 months follow-up. Nutrients. 2018;10(12):1887.

Article   PubMed Central   Google Scholar  

Thornton LM, Watson HJ, Jangmo A, Welch E, Wiklund C, von Hausswolff-Juhlin Y, et al. Binge-eating disorder in the Swedish national registers: Somatic comorbidity. Int J Eat Disord. 2017;50(1):58–65.

Nicolau J, Simó R, Sanchís P, Ayala L, Fortuny R, Zubillaga I, et al. Eating disorders are frequent among type 2 diabetic patients and are associated with worse metabolic and psychological outcomes: results from a cross-sectional study in primary and secondary care settings. Acta Diabetol. 2015;52(6):1037–44.

Jaworski M, Panczyk M, Śliwczyński AM, Brzozowska M, Janaszek K, Małkowski P, et al. A ten-year longitudinal study of prevalence of eating disorders in the general polish type 2 diabetes population. Med Sci Monit Int Med J Exp Clin Res. 2018;24:9204.

Gallant A, Drapeau V, Allison KC, Tremblay A, Lambert M, O’Loughlin J, et al. Night eating behavior and metabolic heath in mothers and fathers enrolled in the QUALITY cohort study. Eat Behav. 2014;15(2):186–91.

Hood MM, Reutrakul S, Crowley SJ. Night eating in patients with type 2 diabetes. Associations with glycemic control, eating patterns, sleep, and mood. Appetite. 2014;79:91–6.

Udo T, McKee SA, White MA, Masheb RM, Barnes RD, Grilo CM. Menopause and metabolic syndrome in obese individuals with binge eating disorder. Eat Behav. 2014;15(2):182–5.

Kisely S, Baghaie H, Lalloo R, Johnson NW. Association between poor oral health and eating disorders: systematic review and meta-analysis. Br J Psychiatry. 2015;207(4):299–305.

Pallier A, Karimova A, Boillot A, Colon P, Ringuenet D, Bouchard P, et al. Dental and periodontal health in adults with eating disorders: a case-control study. J Dent. 2019;84:55–9.

Lundgren JD, Smith BM, Spresser C, Harkins P, Zolton L, Williams K. The relationship of night eating to oral health and obesity in community dental clinic patients. Age (Years). 2010;57(15):12.

Lundgren JD, Williams KB, Heitmann BL. Nocturnal eating predicts tooth loss among adults: results from the Danish MONICA study. Eat Behav. 2010;11(3):170–4.

Panico R, Piemonte E, Lazos J, Gilligan G, Zampini A, Lanfranchi H. Oral mucosal lesions in anorexia nervosa, bulimia nervosa and EDNOS. J Psychiatr Res. 2018;96:178–82.

Setnick J. Micronutrient deficiencies and supplementation in anorexia and bulimia nervosa: a review of literature. Nutr Clin Pract. 2010;25(2):137–42.

Oudman E, Wijnia JW, Oey MJ, van Dam MJ, Postma A. Preventing Wernicke’s encephalopathy in anorexia nervosa: A systematic review. Psychiatry Clin Neurosci. 2018;72(10):774–9.

Ålgars M, Huang L, Von Holle AF, Peat CM, Thornton LM, Lichtenstein P, et al. Binge eating and menstrual dysfunction. J Psychosom Res. 2014;76(1):19–22.

Nobles CJ, Thomas JJ, Valentine SE, Gerber MW, Vaewsorn AS, Marques L. Association of premenstrual syndrome and premenstrual dysphoric disorder with bulimia nervosa and binge-eating disorder in a nationally representative epidemiological sample. Int J Eat Disord. 2016;49(7):641–50.

Chaer R, Nakouzi N, Itani L, Tannir H, Kreidieh D, El Masri D, et al. Fertility and Reproduction after recovery from anorexia nervosa: a systematic review and meta-analysis of long-term follow-up studies. Diseases. 2020;8(4):46.

Bulik CM, Von Holle A, Siega-Riz AM, Torgersen L, Lie KK, Hamer RM, et al. Birth outcomes in women with eating disorders in the Norwegian Mother and Child cohort study (MoBa). Int J Eat Disord. 2009;42(1):9–18.

Kolstad E, Gilhus NE, Veiby G, Reiter SF, Lossius MI, Bjørk M. Epilepsy and eating disorders during pregnancy: prevalence, complications and birth outcome. Seizure. 2015;28:81–4.

Longo P, Panero M, Amodeo L, Demarchi M, Abbate-Daga G, Marzola E. Psychoform and somatoform dissociation in anorexia nervosa: a systematic review. Clin Psychol Psychother. 2021;28(2):295–312.

Zerwas S, Larsen JT, Petersen L, Thornton LM, Quaranta M, Koch SV, et al. Eating disorders, autoimmune, and autoinflammatory disease. Pediatrics. 2017;140(6):e20162089.

Wotton CJ, James A, Goldacre MJ. Coexistence of eating disorders and autoimmune diseases: record linkage cohort study, UK. Int J Eat Disord. 2016;49(7):663–72.

Download references

Acknowledgements

The authors would like to thank and acknowledge the hard work of Healthcare Management Advisors (HMA) who were commissioned to undertake the Rapid Review. Additionally, the authors would like to thank all members of the consortium and consultation committees for their advice, input, and considerations during the development process. Further, a special thank you to the carers, consumers and lived experience consultants that provided input to the development of the Rapid Review and wider national Eating Disorders Research & Translation Strategy. Finally, thank you to the Australian Government—Department of Health for their support of the current project.

National Eating Disorder Research Consortium: Phillip Aouad, Sarah Barakat, Robert Boakes, Leah Brennan, Emma Bryant, Susan Byrne, Belinda Caldwell, Shannon Calvert, Bronny Carroll, David Castle, Ian Caterson, Belinda Chelius, Lyn Chiem, Simon Clarke, Janet Conti, Lexi Crouch, Genevieve Dammery, Natasha Dzajkovski, Jasmine Fardouly, Carmen Felicia, John Feneley, Amber-Marie Firriolo, Nasim Foroughi, Mathew Fuller-Tyszkiewicz, Anthea Fursland, Veronica Gonzalez-Arce, Bethanie Gouldthorp, Kelly Griffin, Scott Griffiths, Ashlea Hambleton, Amy Hannigan, Mel Hart, Susan Hart, Phillipa Hay, Ian Hickie, Francis Kay-Lambkin, Ross King, Michael Kohn, Eyza Koreshe, Isabel Krug, Anvi Le, Jake Linardon, Randall Long, Amanda Long, Sloane Madden, Sarah Maguire, Danielle Maloney, Peta Marks, Sian McLean, Thy Meddick, Jane Miskovic-Wheatley, Deborah Mitchison, Richard O’Kearney, Shu Hwa Ong, Roger Paterson, Susan Paxton, Melissa Pehlivan, Genevieve Pepin, Andrea Phillipou, Judith Piccone, Rebecca Pinkus, Bronwyn Raykos, Paul Rhodes, Elizabeth Rieger, Sarah Rodan, Karen Rockett, Janice Russell, Haley Russell, Fiona Salter, Susan Sawyer, Beth Shelton, Urvashnee Singh, Sophie Smith, Evelyn Smith, Karen Spielman, Sarah Squire, Juliette Thomson, Marika Tiggemann, Stephen Touyz, Ranjani Utpala, Lenny Vartanian, Andrew Wallis, Warren Ward, Sarah Wells, Eleanor Wertheim, Simon Wilksch & Michelle Williams

The RR was in-part funded by the Australian Government Department of Health in partnership with other national and jurisdictional stakeholders. As the organisation responsible for overseeing the National Eating Disorder Research & Translation Strategy, InsideOut Institute commissioned Healthcare Management Advisors to undertake the RR as part of a larger, ongoing, project. Role of Funder: The funder was not directly involved in informing the development of the current review.

Author information

Authors and affiliations.

InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, Charles Perkins Centre (D17), University of Sydney, Camperdown, NSW, 2006, Australia

Ashlea Hambleton, Danielle Maloney, Stephen Touyz & Sarah Maguire

School of Health and Social Development, Faculty of Health, Deakin University, Geelong, VIC, 3220, Australia

Genevieve Pepin

Healthcare Management Advisors, Melbourne, VIC, Australia

Sydney Local Health District, Camperdown, NSW, Australia

Danielle Maloney, Stephen Touyz & Sarah Maguire

You can also search for this author in PubMed   Google Scholar

National Eating Disorder Research Consortium

• Phillip Aouad
• , Sarah Barakat
• , Robert Boakes
• , Leah Brennan
• , Emma Bryant
• , Susan Byrne
• , Belinda Caldwell
• , Shannon Calvert
• , Bronny Carroll
• , David Castle
• , Ian Caterson
• , Belinda Chelius
• , Lyn Chiem
• , Simon Clarke
• , Janet Conti
• , Lexi Crouch
• , Genevieve Dammery
• , Natasha Dzajkovski
• , Jasmine Fardouly
• , Carmen Felicia
• , John Feneley
• , Amber-Marie Firriolo
• , Nasim Foroughi
• , Mathew Fuller-Tyszkiewicz
• , Anthea Fursland
• , Veronica Gonzalez-Arce
• , Bethanie Gouldthorp
• , Kelly Griffin
• , Scott Griffiths
• , Ashlea Hambleton
• , Amy Hannigan
• , Susan Hart
• , Phillipa Hay
• , Ian Hickie
• , Francis Kay-Lambkin
• , Ross King
• , Michael Kohn
• , Eyza Koreshe
• , Isabel Krug
• , Jake Linardon
• , Randall Long
• , Amanda Long
• , Sloane Madden
• , Sarah Maguire
• , Danielle Maloney
• , Peta Marks
• , Sian McLean
• , Thy Meddick
• , Jane Miskovic-Wheatley
• , Deborah Mitchison
• , Richard O’Kearney
• , Shu Hwa Ong
• , Roger Paterson
• , Susan Paxton
• , Melissa Pehlivan
• , Genevieve Pepin
• , Andrea Phillipou
• , Judith Piccone
• , Rebecca Pinkus
• , Bronwyn Raykos
• , Paul Rhodes
• , Elizabeth Rieger
• , Sarah Rodan
• , Karen Rockett
• , Janice Russell
• , Haley Russell
• , Fiona Salter
• , Susan Sawyer
• , Beth Shelton
• , Urvashnee Singh
• , Sophie Smith
• , Evelyn Smith
• , Karen Spielman
• , Sarah Squire
• , Juliette Thomson
• , Marika Tiggemann
• , Stephen Touyz
• , Ranjani Utpala
• , Lenny Vartanian
• , Andrew Wallis
• , Warren Ward
• , Sarah Wells
• , Eleanor Wertheim
• , Simon Wilksch
•  & Michelle Williams

Contributions

DM, PM, ST and SM oversaw the Rapid Review process; AL carried out and wrote the initial review; AH and GP wrote the first manuscript; all authors edited and approved the final manuscript.

Corresponding author

Correspondence to Ashlea Hambleton .

Ethics declarations

Ethics approval and consent to participate.

Not applicable.

Consent for publication

Competing interests.

ST receives royalties from Hogrefe and Huber, McGraw Hill and Taylor and Francis for published books/book chapters. He has received honoraria from the Takeda Group of Companies for consultative work, public speaking engagements and commissioned reports. He has chaired their Clinical Advisory Committee for Binge Eating Disorder. He is the Editor in Chief of the Journal of Eating Disorders. ST is a committee member of the National Eating Disorders Collaboration as well as the Technical Advisory Group for Eating Disorders. AL undertook work on this RR while employed by HMA. A/Prof Sarah Maguire is a guest editor of the special issue “Improving the future by understanding the present: evidence reviews for the field of eating disorders.”

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1..

PRISMA diagram.

Additional file 2.

Studies included in the Rapid Review.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Hambleton, A., Pepin, G., Le, A. et al. Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature. J Eat Disord 10 , 132 (2022). https://doi.org/10.1186/s40337-022-00654-2

Download citation

Received : 08 July 2022

Accepted : 15 August 2022

Published : 05 September 2022

DOI : https://doi.org/10.1186/s40337-022-00654-2

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Psychiatric
• Comorbidities
• Eating disorders

Journal of Eating Disorders

ISSN: 2050-2974

• General enquiries: [email protected]

• Open access
• Published: 29 August 2022

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

8196 Accesses

9 Citations

3 Altmetric

Metrics details

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

United Nations Department of Economic and Social Affairs (UNDESA). Who are Indigenous peoples. 2020. Available from: https://www.un.org/esa/socdev/unpfii/documents/5session_factsheet1.pdf . Assessed 02 Feb 2022.

Google Scholar  

Government of Canada. Indigenous peoples and communities. 2021. Available from: https://www.rcaanc-cirnac.gc.ca/eng/1100100013785/1529102490303 . Assessed 02 Feb 2022.

Allen L, Hatala A, Ijaz S, Courchene ED, Bushie EB. Indigenous-led health care partnerships in Canada. CMAJ. 2020;192(9):E208–16. https://doi.org/10.1503/cmaj.190728 .

Article   PubMed   PubMed Central   Google Scholar  

Latimer M, Sylliboy JR, MacLeod E, Rudderham S, Francis J, Hutt-MacLeod D, et al. Creating a safe space for first nations youth to share their pain. Pain Rep. 2018;3(Suppl 1):e682. https://doi.org/10.1097/PR9.0000000000000682 .

Lopresti S, Willows ND, Storey KE, McHugh TF. Indigenous youth mentorship program: key implementation characteristics of a school peer mentorship program in Canada. Health Promot Int. 2021;36(4):913–23. https://doi.org/10.1093/heapro/daaa090 .

Article   PubMed   Google Scholar  

Statistics Canada. Projections of the Indigenous populations and households in Canada, 2016 to 2041: overview of data sources, methods, assumptions and scenarios. 2021. Ottawa, ON. Cat. No. 17-2-0001. Available from: https://www150.statcan.gc.ca/n1/pub/17-20-0001/172000012021001-eng.htm . Assessed 02 Feb 2022.

Statistics Canada. Indigenous population in Canada – Projections to 2041. 2021. Ottawa, ON. Cat. No. 17-2-0001. Available from: https://www150.statcan.gc.ca/n1/pub/11-627-m/11-627-m2021066-eng.htm . Assessed 02 Feb 2022.

Merati N, Salsberg J, Saganash J, Iserhoff J, Moses KH, Law S. Cree youth engagement in health planning. Int J Indig Health. 2020;15(1):73–89. https://doi.org/10.32799/ijih.v15i1.33985 .

Article   Google Scholar  

Adelson N. The embodiment of inequity: health disparities in Aboriginal Canada. Can J Public Health. 2005;96(Suppl 2):S45–61. https://doi.org/10.1007/BF03403702 .

National Collaborating Centre for Indigenous Health (NCCIH). An overview of Aboriginal health in Canada. 2012. Available from: http://www.nccah-ccnsa.ca/Publications/Lists/Publications/Attachments/101/abororiginal_health_web.pdf . Assessed 02 Feb 2022.

Lemstra M, Neudorf C. Health disparity in Saskatoon: analysis to intervention summary. 2008. Available from: https://www.alliancehealth.ca/wp-content/uploads/2019/06/HD-Summary.pdf . Assessed 02 Feb 2022.

Kirmayer LJ, Brass G. Addressing global health disparities among indigenous peoples. Lancet. 2016;388(10040):105–6. https://doi.org/10.1016/s0140-6736(16)30194-5 .

Kirmayer LJ, Gone JP, Moses J. Rethinking historical trauma. Transcult Psychiatry. 2014;51(3):299–319. https://doi.org/10.1177/1363461514536358 .

Phillips-Beck W, Sinclair S, Campbell R, Star L, Cidro J, Wicklow B, et al. Early-life origins of disparities in chronic diseases among indigenous youth: pathways to recovering health disparities from intergenerational trauma. J Dev Orig Health Dis. 2019;10(1):115–22. https://doi.org/10.1017/S2040174418000661 .

Article   CAS   PubMed   Google Scholar  

Barker B, Sedgemore K, Tourangeau M, Lagimodiere L, Milloy J, Dong H, et al. Intergenerational trauma: the relationship between residential schools and the child welfare system among young people who use drugs in Vancouver, Canada. J Adolesc Health. 2019;65(2):248–54. https://doi.org/10.1016/j.jadohealth.2019.01.022 .

Gray AP, Cote W. Cultural connectedness protects mental health against the effect of historical trauma among Anishinabe young adults. Public Health. 2019;176:77–81. https://doi.org/10.1016/j.puhe.2018.12.003 .

Wilk P, Maltby A, Cooke M, Forsyth J. The effect of parental residential school attendance and parental involvement on indigenous youth's participation in sport and physical activity during school. Int J Indig Health. 2019;14(2):133–49. https://doi.org/10.32799/ijih.v14i2.31929 .

Frohlich KL, Ross N, Richmond C. Health disparities in Canada today: some evidence and a theoretical framework. Health Policy. 2006;79(2–3):132–43. https://doi.org/10.1016/j.healthpol.2005.12.010 .

Greenwood ML, de Leeuw SN. Social determinants of health and the future well-being of Aboriginal children in Canada. Paediatr Child Health. 2012;17(7):381–4. https://doi.org/10.1093/pch/17.7.381 .

Kim PJ. Social determinants of health inequities in indigenous Canadians through a life course approach to colonialism and the residential school system. Health Equity. 2019;3(1):378–81. https://doi.org/10.1089/heq.2019.0041 .

King J, Masotti P, Dennem J, Hadani S, Linton J, Lockhart B, et al. The culture is prevention project: adapting the cultural connectedness scale for multi-tribal communities. Am Indian Alsk Native Ment Health Res. 2019;26(3):104–35. https://doi.org/10.5820/aian.2603.2019.104 .

Smylie J, O'Brien K, Beaudoin E, Daoud N, Bourgeois C, George EH, et al. Long-distance travel for birthing among indigenous and non-indigenous pregnant people in Canada. CMAJ. 2021;193(25):E948–e55. https://doi.org/10.1503/cmaj.201903 .

Pollock NJ, Healey GK, Jong M, Valcour JE, Mulay S. Tracking progress in suicide prevention in indigenous communities: a challenge for public health surveillance in Canada. BMC Public Health. 2018;18(1):1320. https://doi.org/10.1186/s12889-018-6224-9 .

Pollock NJ, Mulay S, Valcour J, Jong M. Suicide rates in Aboriginal communities in Labrador, Canada. Am J Public Health. 2016;106(7):1309–15. https://doi.org/10.2105/AJPH.2016.303151 .

Lucente G, Kurzawa J, Danseco E. Moving towards racial equity in the child and youth mental health sector in Ontario, Canada. Adm Policy Ment Health. 2021:1–4. https://doi.org/10.1007/s10488-021-01153-3 .

Sasakamoose J, Scerbe A, Wenaus I, Scandrett A. First Nation and Métis youth perspectives of health. Qual Inq. 2016;22(8):636–50. https://doi.org/10.1177/1077800416629695 .

Wood L, Kamper D, Swanson K. Spaces of hope? Youth perspectives on health and wellness in indigenous communities. Health Place. 2018;50:137–45. https://doi.org/10.1016/j.healthplace.2018.01.010 .

Bauer GR, Mahendran M, Braimoh J, Alam S, Churchill S. Identifying visible minorities or racialized persons on surveys: can we just ask? Can J Public Health. 2020;111(3):371–82. https://doi.org/10.17269/s41997-020-00325-2 .

Janzen B, Karunanayake C, Rennie D, Katapally T, Dyck R, McMullin K, et al. Racial discrimination and depression among on-reserve first nations people in rural Saskatchewan. Can J Public Health. 2018;108(5–6):e482–e7. https://doi.org/10.17269/cjph.108.6151 .

Kirmayer LJ, Brass GM, Tait CL. The mental health of Aboriginal peoples: transformations of identity and community. Can J Psychiatr. 2000;45(7):607–16. https://doi.org/10.1177/070674370004500702 .

Article   CAS   Google Scholar  

Victor J, Linds W, Episkenew J-A, Goulet L, Benjoe D, Brass D, et al. Kiskenimisowin (self-knowledge): co-researching wellbeing with Canadian first nations youth through participatory visual methods. Int J Indig Health. 2016;11(1):262–78. https://doi.org/10.18357/ijih111201616020 .

Ansloos JP, Wager AC. Surviving in the cracks: a qualitative study with indigenous youth on homelessness and applied community theatre. Int J Qual Stud Educ. 2019;33(1):50–65. https://doi.org/10.1080/09518398.2019.1678785 .

Bombay A, McQuaid RJ, Schwartz F, Thomas A, Anisman H, Matheson K. Suicidal thoughts and attempts in first nations communities: links to parental Indian residential school attendance across development. J Dev Orig Health Dis. 2019;10(1):123–31. https://doi.org/10.1017/S2040174418000405 .

Gabel C, Pace J, Ryan C. Using photovoice to understand intergenerational influences on health and well-being in a southern Labrador Inuit community. Int J Indig Health. 2016;11(1):75–91. https://doi.org/10.18357/ijih111201616014 .

Grande AJ, Elia C, Peixoto C, Jardim PTC, Dazzan P, Veras AB, et al. Mental health interventions for suicide prevention among indigenous adolescents: a systematic review protocol. BMJ Open. 2020;10(5):e034055. https://doi.org/10.1136/bmjopen-2019-034055 .

Hartshorn KJ, Whitbeck LB, Prentice P. Substance use disorders, comorbidity, and arrest among indigenous adolescents. Crime Delinq. 2015;61(10):1311–32. https://doi.org/10.1177/0011128712466372 .

Boksa P, Hutt-MacLeod D, Clair L, Brass G, Bighead S, MacKinnon A, et al. Demographic and clinical presentations of youth using enhanced mental health services in six indigenous communities from the ACCESS open minds network. Can J Psychiatr. 2022;67(3):179–91. https://doi.org/10.1177/07067437211055416 .

Abraham ZK, Sher L. Adolescent suicide as a global public health issue. Int J Adolesc Med Health. 2017;31(4):20170036. https://doi.org/10.1515/ijamh-2017-0036 .

Ansloos J. Rethinking indigenous suicide. Int J Indig Health. 2018;13(2):8–28. https://doi.org/10.18357/ijih.v13i2.32061 .

Anang P, Naujaat Elder EH, Gordon E, Gottlieb N, Bronson M. Building on strengths in Naujaat: the process of engaging Inuit youth in suicide prevention. Int J Circumpolar Health. 2019;78(2):1508321. https://doi.org/10.1080/22423982.2018.1508321 .

Barker B, Goodman A, DeBeck K. Reclaiming indigenous identities: culture as strength against suicide among indigenous youth in Canada. Can J Public Health. 2017;108(2):e208–e10. https://doi.org/10.17269/cjph.108.5754 .

Lemstra M, Rogers M, Moraros J, Grant E. Risk indicators of suicide ideation among on-reserve first nations youth. Paediatr Child Health. 2013;18(1):15–20. https://doi.org/10.1093/pch/18.1.15 .

Plazas PC, Cameron BL, Milford K, Hunt LR, Bourque-Bearskin L, Santos SA. Engaging indigenous youth through popular theatre: knowledge mobilization of indigenous peoples’ perspectives on access to healthcare services. Action Res. 2019;17(4):492–509. https://doi.org/10.1177/1476750318789468 .

Sanchez-Pimienta CE, Masuda J, M'Wikwedong indigenous friendship C. From controlling to connecting: M'Wikwedong as a place of urban indigenous health promotion in Canada. Health Promot Int. 2021;36(3):703–13. https://doi.org/10.1093/heapro/daaa066 .

Leonardi F. The definition of health: towards new perspectives. Int J Health Serv. 2018;48(4):735–48. https://doi.org/10.1177/0020731418782653 .

Snowshoe A, Crooks CV, Tremblay PF, Hinson RE. Cultural connectedness and its relation to mental wellness for first nations youth. J Prim Prev. 2017;38(1–2):67–86. https://doi.org/10.1007/s10935-016-0454-3 .

Auger M, Howell T, Gomes T. Moving toward holistic wellness, empowerment and self-determination for indigenous peoples in Canada: can traditional indigenous health care practices increase ownership over health and health care decisions? Can J Public Health. 2016;107(4–5):e393–e8. https://doi.org/10.17269/cjph.107.5366 .

Brady M. Cultural considerations in play therapy with Aboriginal children in Canada. First Peoples Child Fam Rev. 2015;10(2):95–109.

Rabbitskin N, Ermine, W, Walsh, K, Gilbert, L; in Interagency Coalition on AIDS and Development publications. Case Study: Sturgeon Lake traditional health program. 2010. Available from: http://www.icad-cisd.com/our-resources/icad-publications-and-resources/case-study-sturgeon-lake-traditional-health-program/ . Assessed 23 Sept 2021.

Sturgeon Lake First Nation. Sturgeon Lake First Nation wholistic influenza pandemic planning. 2007. Available from: https://fnpa.ca/wp-content/uploads/2020/03/Sturgeon-Lake-First-Nation-Wholistic-Influenza-Plan.pdf . Assessed 23 Sept 2021.

Sturgeon Lake First Nation. Sturgeon Lake First Nation of Saskatchewan. Available from: http://www.slfn.ca/ . Accessed 23 Sept 2021.

Government of Canada. Sturgeon Lake First Nation-connectivity profile. 2020. Available from: https://www.aadnc-aandc.gc.ca/eng/1357840942279/1360166692704 . Assessed 23 Sept 2021.

Gaspar C. Āhkamēyimowin: walking together [Dissertation, University of Saskatchewan]. 2019. Available from: https://core.ac.uk/download/pdf/226154411.pdf . Assessed 23 Sept 2021.

Ramsden VR, Salsberg J, Herbert CP, Westfall JM, LeMaster J, Macaulay AC. Patient- and community-oriented research: how is authentic engagement identified in grant applications? Can Fam Physician. 2017;63(1):74–6.

PubMed   PubMed Central   Google Scholar  

Ramsden VR, Rabbitskin N, Westfall JM, Felzien M, Braden J, Sand J. Is knowledge translation without patient or community engagement flawed? Fam Pract. 2017;34(3):259–61. https://doi.org/10.1093/fampra/cmw114 .

Woolf SH, Zimmerman E, Haley A, Krist AH. Authentic engagement of patients and communities can transform research, practice, and policy. Health Aff (Millwood). 2016;35(4):590–4. https://doi.org/10.1377/hlthaff.2015.1512 .

Gaspar C, Sundown S, Kingfisher S, Thornton R, Bighead S, Girl Power program participants of Sturgeon Lake First Nation, et al. āhkamēyimowin (perseverance): walking together: codesigned research project resulted in empowering first nations girls. Can Fam Physician. 2019;65(12):930–2.

Wu HC, Kornbluh M, Weiss J, Roddy L. Measuring and understanding authentic youth engagement: the youth-adult partnership rubric. Afterschool Matters. 2016;23:8–17.

Allen ML, Salsberg J, Knot M, LeMaster JW, Felzien M, Westfall JM, et al. Engaging with communities, engaging with patients: amendment to the NAPCRG 1998 policy statement on responsible research with communities. Fam Pract. 2017;34(3):313–21. https://doi.org/10.1093/fampra/cmw074 .

Levac D, Colquhoun H, O'Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010;5:69. https://doi.org/10.1186/1748-5908-5-69 .

Peters MD, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid Based Healthc. 2015;13(3):141–6. https://doi.org/10.1097/xeb.0000000000000050 .

Arksey H, O'Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32. https://doi.org/10.1080/1364557032000119616 .

Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–73. https://doi.org/10.7326/m18-0850 .

Sawyer SM, Azzopardi PS, Wickremarathne D, Patton GC. The age of adolescence. Lancet Child Adolesc Health. 2018;2(3):223–8. https://doi.org/10.1016/s2352-4642(18)30022-1 .

Government of Canada. Canada’s first state of youth report: for youth, with youth, by youth. Ottawa: Canadian Heritage; 2021. Available from: https://www.canada.ca/en/canadian-heritage/campaigns/state-youth/report.html . Assessed 02 Feb 2022

University of Saskatchewan. University of Saskatchewan Indigenous studies portal research tool. Available at: https://iportal.usask.ca/ . Assessed 23 Sept 2021.

Clarivate Analytics. MacOS Endnote X9 version 9.2. [commercial computer software]. New York: Thomson Reuters Corporation; 2019.

Evidence Partners Incorporated. Distiller SR. Systematic Review and Literature Review Software. Ottawa: Evidence Partners Incorporated; 2021.

Microsoft Corporation. Microsoft Excel version 16.32. [commercial computer software]. New York: Microsoft; 2016.

Joanna Briggs Institute. Joanna Briggs Institute critical appraisal tools. 2014. Available from: https://joannabriggs.org/ebp/critical_appraisal_tools . Accessed 23 May 2021.

Crooks CV, Exner-Cortens D, Burm S, Lapointe A, Chiodo D. Two years of relationship-focused mentoring for first nations, Metis, and Inuit adolescents: promoting positive mental health. J Prim Prev. 2017;38(1–2):87–104. https://doi.org/10.1007/s10935-016-0457-0 .

Gaudet JC, Chilton C. Milo Pimatisiwin project: healthy living for Mushkegowuk youth. Int J Indig Health. 2018;13(1):20–40. https://doi.org/10.18357/ijih.v13i1.30264 .

Lys C, Gesink D, Strike C, Larkin J. Body mapping as a youth sexual health intervention and data collection tool. Qual Health Res. 2018;28(7):1185–98. https://doi.org/10.1177/1049732317750862 .

Etter M, Goose A, Nossal M, Chishom-Nelson J, Heck C, Joober R, et al. Improving youth mental wellness services in an indigenous context in Ulukhaktok, Northwest Territories: ACCESS open minds project. Early Interv Psychiatry. 2019;13(Suppl 1):35–41. https://doi.org/10.1111/eip.12816 .

Flicker S, Wilson C, Monchalin R, Oliver V, Prentice T, Jackson R, et al. “Stay strong, stay sexy, stay native”: storying indigenous youth HIV prevention activism. Action Res. 2017;17(3):323–43. https://doi.org/10.1177/1476750317721302 .

Goodman A, Snyder M, Wilson K, Whitford J. Healthy spaces: exploring urban indigenous youth perspectives of social support and health using photovoice. Health Place. 2019;56:34–42. https://doi.org/10.1016/j.healthplace.2019.01.004 .

Hatala AR, Morton D, Njeze C, Bird-Naytowhow K, Pearl T. Re-imagining miyo-wicehtowin: human-nature relations, land-making, and wellness among indigenous youth in a Canadian urban context. Soc Sci Med. 2019;230:122–30. https://doi.org/10.1016/j.socscimed.2019.04.012 .

Hutt-MacLeod D, Rudderham H, Sylliboy A, Sylliboy-Denny M, Liebenberg L, Denny JF, et al. Eskasoni first Nation's transformation of youth mental healthcare: partnership between a Mi'kmaq community and the ACCESS open minds research project in implementing innovative practice and service evaluation. Early Interv Psychiatry. 2019;13(Suppl 1):42–7. https://doi.org/10.1111/eip.12817 .

Lines LA, Yellowknives Dene First Nation Wellness Division, Jardine CG. Connection to the land as a youth-identified social determinant of indigenous peoples’ health. BMC Public Health. 2019;19(1):176. https://doi.org/10.1186/s12889-018-6383-8 .

Loebach J, Tilleczek K, Chaisson B, Sharp B. Keyboard warriors? Visualising technology and well-being with, for and by indigenous youth through digital stories. Vis Stud. 2019;34(3):281–97. https://doi.org/10.1080/1472586x.2019.1691050 .

Camargo Plazas P, Cameron BL, Milford K, Hunt LR, Bourque-Bearskin L, Santos SA. Engaging indigenous youth through popular theatre: knowledge mobilization of indigenous peoples’ perspectives on access to healthcare services. Action Res. 2018;17(4):492–509. https://doi.org/10.1177/1476750318789468 .

Hatala AR, Bird-Naytowhow K. Performing pimatisiwin: the expression of indigenous wellness identities through community-based theater. Med Anthropol Q. 2020;34(2):243–67. https://doi.org/10.1111/maq.12575 .

Njeze C, Bird-Naytowhow K, Pearl T, Hatala AR. Intersectionality of resilience: a strengths-based case study approach with indigenous youth in an urban Canadian context. Qual Health Res. 2020;30(13):2001–18. https://doi.org/10.1177/1049732320940702 .

Saini M, Roche S, Papadopoulos A, Markwick N, Shiwak I, Flowers C, et al. Promoting Inuit health through a participatory whiteboard video. Can J Public Health. 2020;111(1):50–9. https://doi.org/10.17269/s41997-019-00189-1 .

Canadian Institutes of Health Research (CIHR). Elder Jim Dumont, National Native Addictions Partnership Foundation in: Honouring our strengths; Indigenous culture as intervention in addictions treatment project - University of Saskatchewan. 2014. Available from: https://cyfn.ca/wp-content/uploads/2016/10/Honouring-our-strengths-Culture-as-treatment-resource-guide.pdf . Assessed 23 Sept 2021.

Fletcher S, Mullett J. Digital stories as a tool for health promotion and youth engagement. Can J Public Health. 2016;107(2):e183–e7. https://doi.org/10.17269/cjph.107.5266 .

Ramsden VR. Integrated primary health services model research team. Learning with the community. Evolution to transformative action research. Can Fam Physician. 2003;49(2):195–7 200–2.

CAS   PubMed   PubMed Central   Google Scholar  

Ramsden VR, McKay S, Crowe J. The pursuit of excellence: engaging the community in participatory health research. Glob Health Promot. 2010;17(4):32–42. https://doi.org/10.1177/1757975910383929 .

Ramsden VR, Cave AJ. Participatory methods to facilitate research. Can Fam Physician. 2002;48(3):548–9 553–4.

Canadian Institutes of Health Research (CIHR), Natural Sciences and Engineering Research Council of Canada (NSERC), Social Sciences and Humanities Research Council of Canada (SSHRC). Tri-Council policy statement. Ethical conduct for research involving humans. Ottawa: Government of Canada; 2018. Available from: https://ethics.gc.ca/eng/documents/tcps2-2018-en-interactive-final.pdf . Assessed 17 Jan 2022

Kanewiyakiho ED, Sawchuk KF, Ramsden VR. Ask before you ask: co-developing meaningful research questions with indigenous elders. Can Fam Physician. 2021;67(12):947–8. https://doi.org/10.46747/cfp.6712947 .

Flicker S, O'Campo P, Monchalin R, Thistle J, Worthington C, Masching R, et al. Research done in “a good way”: the importance of indigenous Elder involvement in HIV community-based research. Am J Public Health. 2015;105(6):1149–54. https://doi.org/10.2105/AJPH.2014.302522 .

Rowe G, Straka S, Hart M, Callahan A, Robinson D, Robson G. Prioritizing indigenous elders’ knowledge for intergenerational well-being. Can J Aging. 2020;39(2):156–68.

Cooke MJ, Wilk P, Paul KW, Gonneville SL. Predictors of obesity among Métis children: socio-economic, behavioural and cultural factors. Can J Public Health. 2013;104(4):e298–303. https://doi.org/10.17269/cjph.104.3765 .

Truth and Reconciliation Commission of Canada (TRC). Honoring the truth, reconciling for the future: Summary of the Final Report of the Truth and Reconciliation Commission of Canada. 2015. Available from: https://ehprnh2mwo3.exactdn.com/wp-content/uploads/2021/01/Executive_Summary_English_Web.pdf . Assessed 23 Sept 2021.

Truth and Reconciliation Commission of Canada (TRC). Truth and Reconciliation Commission of Canada: Calls to Action. 2015. Available from: https://www2.gov.bc.ca/assets/gov/british-columbians-our-governments/indigenous-people/aboriginal-peoples-documents/calls_to_action_english2.pdf . Assessed 23 Sept 2021.

Download references

Acknowledgements

Not applicable.

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.

Author information

Authors and affiliations.

Health Sciences Program, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, S7N 5E5, Canada

Udoka Okpalauwaekwe

Sturgeon Lake Youth Center, Sturgeon Lake First Nation, Sturgeon Lake, Saskatchewan, S0J 2E1, Canada

Clifford Ballantyne

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

Scott Tunison

Research Division, Department of Academic Family Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, S7M 3Y5, Canada

Vivian R. Ramsden

You can also search for this author in PubMed   Google Scholar

Contributions

UO contributed to the conceptualization, methodology, design, data analysis, original draft writing, review, editing and revision of this study. CB was involved in and contributed to the methodology, data analysis, original draft review and editing of this study. ST was involved in and contributed to the conceptualization, methodology, data analysis, review and editing of several versions of this study. VRR was involved in and contributed to the conceptualization, methodology, data analysis, review and editing of this study. All authors (UO, CB, ST, and VRR) read and approved the final the final manuscript.

Corresponding authors

Correspondence to Udoka Okpalauwaekwe or Vivian R. Ramsden .

Ethics declarations

Ethics approval and consent to participate, consent for publication, competing interests.

The authors report no conflict of interest.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1: supplementary material file 1..

PRISMA-ScR Checklist.

Additional file 2: Supplementary Material File 2.

Summary of critical appraisals of individual sources of evidence.

Additional file 3: Supplementary Material File 3.

List of Terminology.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

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

Download citation

Received : 14 April 2022

Accepted : 18 August 2022

Published : 29 August 2022

DOI : https://doi.org/10.1186/s12889-022-14047-2

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Indigenous youth
• Authentic engagement
• Culture as treatment
• Wellness promotion

BMC Public Health

ISSN: 1471-2458

• Submission enquiries: [email protected]
• General enquiries: [email protected]