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

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

Table of Contents

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

What is a literature review?

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

What is the purpose of literature review?

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

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

Literature review example

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

Literature Review on Climate Change Impacts on Biodiversity:

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

a. Habitat Loss and Species Extinction:

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

b. Range Shifts and Phenological Changes:

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

c. Ocean Acidification and Coral Reefs:

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

d. Adaptive Strategies and Conservation Efforts:

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

How to write a good literature review

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

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

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

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

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

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

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

Conducting a literature review

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

Choose a Topic and Define the Research Question:

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

Decide on the Scope of Your Review:

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

Select Databases for Searches:

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

Conduct Searches and Keep Track:

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

Review the Literature:

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

Organize and Write Your Literature Review:

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

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

Frequently asked questions

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

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

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

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

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

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

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

References 

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

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Writing a Literature Review

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

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

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

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

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

What are the parts of a lit review?

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

Introduction:

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

Conclusion:

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

How should I organize my lit review?

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

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

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

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

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

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

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

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

• University of Texas Libraries

Literature Reviews

• What is a literature review?
• Steps in the Literature Review Process
• Define your research question
• Determine inclusion and exclusion criteria
• Choose databases and search
• Review Results
• Synthesize Results
• Analyze Results
• Librarian Support

What is a Literature Review?

A literature or narrative review is a comprehensive review and analysis of the published literature on a specific topic or research question. The literature that is reviewed contains: books, articles, academic articles, conference proceedings, association papers, and dissertations. It contains the most pertinent studies and points to important past and current research and practices. It provides background and context, and shows how your research will contribute to the field. 

A literature review should: 

• Provide a comprehensive and updated review of the literature;
• Explain why this review has taken place;
• Articulate a position or hypothesis;
• Acknowledge and account for conflicting and corroborating points of view

From  S age Research Methods

Purpose of a Literature Review

A literature review can be written as an introduction to a study to:

• Demonstrate how a study fills a gap in research
• Compare a study with other research that's been done

Or it can be a separate work (a research article on its own) which:

• Organizes or describes a topic
• Describes variables within a particular issue/problem

Limitations of a Literature Review

Some of the limitations of a literature review are:

• It's a snapshot in time. Unlike other reviews, this one has beginning, a middle and an end. There may be future developments that could make your work less relevant.
• It may be too focused. Some niche studies may miss the bigger picture.
• It can be difficult to be comprehensive. There is no way to make sure all the literature on a topic was considered.
• It is easy to be biased if you stick to top tier journals. There may be other places where people are publishing exemplary research. Look to open access publications and conferences to reflect a more inclusive collection. Also, make sure to include opposing views (and not just supporting evidence).

Source: Grant, Maria J., and Andrew Booth. “A Typology of Reviews: An Analysis of 14 Review Types and Associated Methodologies.” Health Information & Libraries Journal, vol. 26, no. 2, June 2009, pp. 91–108. Wiley Online Library, doi:10.1111/j.1471-1842.2009.00848.x.

Meryl Brodsky : Communication and Information Studies

Hannah Chapman Tripp : Biology, Neuroscience

Carolyn Cunningham : Human Development & Family Sciences, Psychology, Sociology

Larayne Dallas : Engineering

Janelle Hedstrom : Special Education, Curriculum & Instruction, Ed Leadership & Policy ​

Susan Macicak : Linguistics

Imelda Vetter : Dell Medical School

For help in other subject areas, please see the guide to library specialists by subject .

Periodically, UT Libraries runs a workshop covering the basics and library support for literature reviews. While we try to offer these once per academic year, we find providing the recording to be helpful to community members who have missed the session. Following is the most recent recording of the workshop, Conducting a Literature Review. To view the recording, a UT login is required.

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

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

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

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

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

There are five key steps to writing a literature review:

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

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

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Table of contents

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

• Quick Run-through
• Step 1 & 2

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

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

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

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

Prevent plagiarism, run a free check.

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

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

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

Download Word doc Download Google doc

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

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

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

Make a list of keywords

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

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

Search for relevant sources

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

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

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

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

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

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

For each publication, ask yourself:

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

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

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

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

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

Take notes and cite your sources

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

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

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

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

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

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

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

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

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

Chronological

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

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

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

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

Methodological

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

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

Theoretical

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

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

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

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

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

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

As you write, make sure to follow these tips:

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

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

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

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

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

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

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

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

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

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Literature Reviews

What this handout is about.

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

Introduction

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

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

What is a literature review, then?

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

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

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

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

Why do we write literature reviews?

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

Who writes these things, anyway?

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

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

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

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

Find models

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

Narrow your topic

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

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

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

Consider whether your sources are current

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

Strategies for writing the literature review

Find a focus.

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

Convey it to your reader

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

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

Consider organization

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

First, cover the basic categories

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

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

Organizing the body

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

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

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

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

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

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

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

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

Begin composing

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

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

Use evidence

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

Be selective

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

Use quotes sparingly

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

Summarize and synthesize

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

Keep your own voice

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

Use caution when paraphrasing

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

Revise, revise, revise

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

Works consulted

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

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

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

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

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

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

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

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How To Write A Literature Review - A Complete Guide

Table of Contents

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

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

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

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

What is a literature review?

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

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

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

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

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

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

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

What is the purpose of a literature review?

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

What is the importance of a literature review?

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

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

How long should a literature review be?

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

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

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

What are the different types of literature reviews?

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

Here are the different types of literature reviews:

Argumentative review

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

Integrative review

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

Methodological review

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

Systematic review

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

Meta-analysis review

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

Historical review

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

Theoretical Review

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

Scoping Review

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

State-of-the-Art Review

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

Can you use the first person in a literature review?

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

Do you need an abstract for a literature review?

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

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

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

Is a literature review written in the past tense?

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

How many sources for a literature review?

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

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

Quick tips on how to write a literature review

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

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

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

1. Outline and identify the purpose of  a literature review

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

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

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

2. Search relevant literature

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

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

• Google Scholar
• Microsoft Academic
• Science.gov

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

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

3. Examine and assess the sources

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

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

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

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

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

4. Discover connections

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

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

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

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

5. Structure planning to write a good literature review

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

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

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

Literature review samples

1. Standalone

2. As a section of a research paper

How SciSpace Discover makes literature review a breeze?

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

Find the right information

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

Assess credibility of papers quickly

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

Get the complete picture in no time

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

Make referring sources super easy

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

Final tips on how to write a literature review

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

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

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

Frequently Asked Questions (FAQs)

1. how to start a literature review.

• What questions do you want to answer?

• What sources do you need to answer these questions?

• What information do these sources contain?

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

2. What to include in a literature review?

• A brief background of the problem or issue

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

• A description of what you will do in your project

• How this study will contribute to research on the subject

3. Why literature review is important?

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

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

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

5. What are the components of a literature review?

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

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

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

6. What are common errors in writing literature review?

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

• Totally relying on secondary data while ignoring primary data.

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

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

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

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

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

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

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

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

8. How many sources should a literature review have?

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

9. Can literature review have diagrams?

• To represent an abstract idea or concept

• To explain the steps of a process or procedure

• To help readers understand the relationships between different concepts

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

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

11. What are the types of literature review?

• Argumentative review

• Integrative review

• Methodological review

• Systematic review

• Meta-analysis review

• Historical review

• Theoretical review

• Scoping review

• State-of-the-Art review

12. Is a literature review mandatory?

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

But before you go,

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

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Libraries | Research Guides

Literature reviews, what is a literature review, learning more about how to do a literature review.

• Planning the Review
• The Research Question
• Choosing Where to Search
• Organizing the Review
• Writing the Review

A literature review is a review and synthesis of existing research on a topic or research question. A literature review is meant to analyze the scholarly literature, make connections across writings and identify strengths, weaknesses, trends, and missing conversations. A literature review should address different aspects of a topic as it relates to your research question. A literature review goes beyond a description or summary of the literature you have read. 

• Sage Research Methods Core Collection This link opens in a new window SAGE Research Methods supports research at all levels by providing material to guide users through every step of the research process. SAGE Research Methods is the ultimate methods library with more than 1000 books, reference works, journal articles, and instructional videos by world-leading academics from across the social sciences, including the largest collection of qualitative methods books available online from any scholarly publisher. – Publisher

• Next: Planning the Review >>
• Last Updated: Jan 17, 2024 10:05 AM
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How To Structure Your Literature Review

3 options to help structure your chapter.

By: Amy Rommelspacher (PhD) | Reviewer: Dr Eunice Rautenbach | November 2020 (Updated May 2023)

Writing the literature review chapter can seem pretty daunting when you’re piecing together your dissertation or thesis. As  we’ve discussed before , a good literature review needs to achieve a few very important objectives – it should:

• Demonstrate your knowledge of the research topic
• Identify the gaps in the literature and show how your research links to these
• Provide the foundation for your conceptual framework (if you have one)
• Inform your own  methodology and research design

To achieve this, your literature review needs a well-thought-out structure . Get the structure of your literature review chapter wrong and you’ll struggle to achieve these objectives. Don’t worry though – in this post, we’ll look at how to structure your literature review for maximum impact (and marks!).

But wait – is this the right time?

Deciding on the structure of your literature review should come towards the end of the literature review process – after you have collected and digested the literature, but before you start writing the chapter. 

In other words, you need to first develop a rich understanding of the literature before you even attempt to map out a structure. There’s no use trying to develop a structure before you’ve fully wrapped your head around the existing research.

Equally importantly, you need to have a structure in place before you start writing , or your literature review will most likely end up a rambling, disjointed mess. 

Importantly, don’t feel that once you’ve defined a structure you can’t iterate on it. It’s perfectly natural to adjust as you engage in the writing process. As we’ve discussed before , writing is a way of developing your thinking, so it’s quite common for your thinking to change – and therefore, for your chapter structure to change – as you write. 

Need a helping hand?

Like any other chapter in your thesis or dissertation, your literature review needs to have a clear, logical structure. At a minimum, it should have three essential components – an  introduction , a  body   and a  conclusion . 

Let’s take a closer look at each of these.

1: The Introduction Section

Just like any good introduction, the introduction section of your literature review should introduce the purpose and layout (organisation) of the chapter. In other words, your introduction needs to give the reader a taste of what’s to come, and how you’re going to lay that out. Essentially, you should provide the reader with a high-level roadmap of your chapter to give them a taste of the journey that lies ahead.

Here’s an example of the layout visualised in a literature review introduction:

Your introduction should also outline your topic (including any tricky terminology or jargon) and provide an explanation of the scope of your literature review – in other words, what you  will   and  won’t   be covering (the delimitations ). This helps ringfence your review and achieve a clear focus . The clearer and narrower your focus, the deeper you can dive into the topic (which is typically where the magic lies). 

Depending on the nature of your project, you could also present your stance or point of view at this stage. In other words, after grappling with the literature you’ll have an opinion about what the trends and concerns are in the field as well as what’s lacking. The introduction section can then present these ideas so that it is clear to examiners that you’re aware of how your research connects with existing knowledge .

2: The Body Section

The body of your literature review is the centre of your work. This is where you’ll present, analyse, evaluate and synthesise the existing research. In other words, this is where you’re going to earn (or lose) the most marks. Therefore, it’s important to carefully think about how you will organise your discussion to present it in a clear way. 

The body of your literature review should do just as the description of this chapter suggests. It should “review” the literature – in other words, identify, analyse, and synthesise it. So, when thinking about structuring your literature review, you need to think about which structural approach will provide the best “review” for your specific type of research and objectives (we’ll get to this shortly).

There are (broadly speaking)  three options  for organising your literature review.

Option 1: Chronological (according to date)

Organising the literature chronologically is one of the simplest ways to structure your literature review. You start with what was published first and work your way through the literature until you reach the work published most recently. Pretty straightforward.

The benefit of this option is that it makes it easy to discuss the developments and debates in the field as they emerged over time. Organising your literature chronologically also allows you to highlight how specific articles or pieces of work might have changed the course of the field – in other words, which research has had the most impact . Therefore, this approach is very useful when your research is aimed at understanding how the topic has unfolded over time and is often used by scholars in the field of history. That said, this approach can be utilised by anyone that wants to explore change over time .

For example , if a student of politics is investigating how the understanding of democracy has evolved over time, they could use the chronological approach to provide a narrative that demonstrates how this understanding has changed through the ages.

Here are some questions you can ask yourself to help you structure your literature review chronologically.

• What is the earliest literature published relating to this topic?
• How has the field changed over time? Why?
• What are the most recent discoveries/theories?

In some ways, chronology plays a part whichever way you decide to structure your literature review, because you will always, to a certain extent, be analysing how the literature has developed. However, with the chronological approach, the emphasis is very firmly on how the discussion has evolved over time , as opposed to how all the literature links together (which we’ll discuss next ).

Option 2: Thematic (grouped by theme)

The thematic approach to structuring a literature review means organising your literature by theme or category – for example, by independent variables (i.e. factors that have an impact on a specific outcome).

As you’ve been collecting and synthesising literature , you’ll likely have started seeing some themes or patterns emerging. You can then use these themes or patterns as a structure for your body discussion. The thematic approach is the most common approach and is useful for structuring literature reviews in most fields.

For example, if you were researching which factors contributed towards people trusting an organisation, you might find themes such as consumers’ perceptions of an organisation’s competence, benevolence and integrity. Structuring your literature review thematically would mean structuring your literature review’s body section to discuss each of these themes, one section at a time.

Here are some questions to ask yourself when structuring your literature review by themes:

• Are there any patterns that have come to light in the literature?
• What are the central themes and categories used by the researchers?
• Do I have enough evidence of these themes?

PS – you can see an example of a thematically structured literature review in our literature review sample walkthrough video here.

Option 3: Methodological

The methodological option is a way of structuring your literature review by the research methodologies used . In other words, organising your discussion based on the angle from which each piece of research was approached – for example, qualitative , quantitative or mixed  methodologies.

Structuring your literature review by methodology can be useful if you are drawing research from a variety of disciplines and are critiquing different methodologies. The point of this approach is to question  how  existing research has been conducted, as opposed to  what  the conclusions and/or findings the research were.

For example, a sociologist might centre their research around critiquing specific fieldwork practices. Their literature review will then be a summary of the fieldwork methodologies used by different studies.

Here are some questions you can ask yourself when structuring your literature review according to methodology:

• Which methodologies have been utilised in this field?
• Which methodology is the most popular (and why)?
• What are the strengths and weaknesses of the various methodologies?
• How can the existing methodologies inform my own methodology?

3: The Conclusion Section

Once you’ve completed the body section of your literature review using one of the structural approaches we discussed above, you’ll need to “wrap up” your literature review and pull all the pieces together to set the direction for the rest of your dissertation or thesis.

The conclusion is where you’ll present the key findings of your literature review. In this section, you should emphasise the research that is especially important to your research questions and highlight the gaps that exist in the literature. Based on this, you need to make it clear what you will add to the literature – in other words, justify your own research by showing how it will help fill one or more of the gaps you just identified.

Last but not least, if it’s your intention to develop a conceptual framework for your dissertation or thesis, the conclusion section is a good place to present this.

Example: Thematically Structured Review

In the video below, we unpack a literature review chapter so that you can see an example of a thematically structure review in practice.

Let’s Recap

In this article, we’ve  discussed how to structure your literature review for maximum impact. Here’s a quick recap of what  you need to keep in mind when deciding on your literature review structure:

• Just like other chapters, your literature review needs a clear introduction , body and conclusion .
• The introduction section should provide an overview of what you will discuss in your literature review.
• The body section of your literature review can be organised by chronology , theme or methodology . The right structural approach depends on what you’re trying to achieve with your research.
• The conclusion section should draw together the key findings of your literature review and link them to your research questions.

If you’re ready to get started, be sure to download our free literature review template to fast-track your chapter outline.

Psst… there’s more!

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

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27 Comments

Great work. This is exactly what I was looking for and helps a lot together with your previous post on literature review. One last thing is missing: a link to a great literature chapter of an journal article (maybe with comments of the different sections in this review chapter). Do you know any great literature review chapters?

I agree with you Marin… A great piece

I agree with Marin. This would be quite helpful if you annotate a nicely structured literature from previously published research articles.

Awesome article for my research.

I thank you immensely for this wonderful guide

It is indeed thought and supportive work for the futurist researcher and students

Very educative and good time to get guide. Thank you

Great work, very insightful. Thank you.

Thanks for this wonderful presentation. My question is that do I put all the variables into a single conceptual framework or each hypothesis will have it own conceptual framework?

Thank you very much, very helpful

This is very educative and precise . Thank you very much for dropping this kind of write up .

Pheeww, so damn helpful, thank you for this informative piece.

I’m doing a research project topic ; stool analysis for parasitic worm (enteric) worm, how do I structure it, thanks.

comprehensive explanation. Help us by pasting the URL of some good “literature review” for better understanding.

great piece. thanks for the awesome explanation. it is really worth sharing. I have a little question, if anyone can help me out, which of the options in the body of literature can be best fit if you are writing an architectural thesis that deals with design?

I am doing a research on nanofluids how can l structure it?

Beautifully clear.nThank you!

Lucid! Thankyou!

Brilliant work, well understood, many thanks

I like how this was so clear with simple language 😊😊 thank you so much 😊 for these information 😊

Insightful. I was struggling to come up with a sensible literature review but this has been really helpful. Thank you!

You have given thought-provoking information about the review of the literature.

Thank you. It has made my own research better and to impart your work to students I teach

I learnt a lot from this teaching. It’s a great piece.

I am doing research on EFL teacher motivation for his/her job. How Can I structure it? Is there any detailed template, additional to this?

You are so cool! I do not think I’ve read through something like this before. So nice to find somebody with some genuine thoughts on this issue. Seriously.. thank you for starting this up. This site is one thing that is required on the internet, someone with a little originality!

I’m asked to do conceptual, theoretical and empirical literature, and i just don’t know how to structure it

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What is a literature review? [with examples]

What is a literature review?

The purpose of a literature review, how to write a literature review, the format of a literature review, general formatting rules, the length of a literature review, literature review examples, frequently asked questions about literature reviews, related articles.

A literature review is an assessment of the sources in a chosen topic of research.

In a literature review, you’re expected to report on the existing scholarly conversation, without adding new contributions.

If you are currently writing one, you've come to the right place. In the following paragraphs, we will explain:

• the objective of a literature review
• how to write a literature review
• the basic format of a literature review

Tip: It’s not always mandatory to add a literature review in a paper. Theses and dissertations often include them, whereas research papers may not. Make sure to consult with your instructor for exact requirements.

The four main objectives of a literature review are:

• Studying the references of your research area
• Summarizing the main arguments
• Identifying current gaps, stances, and issues
• Presenting all of the above in a text

Ultimately, the main goal of a literature review is to provide the researcher with sufficient knowledge about the topic in question so that they can eventually make an intervention.

The format of a literature review is fairly standard. It includes an:

• introduction that briefly introduces the main topic
• body that includes the main discussion of the key arguments
• conclusion that highlights the gaps and issues of the literature

➡️ Take a look at our guide on how to write a literature review to learn more about how to structure a literature review.

First of all, a literature review should have its own labeled section. You should indicate clearly in the table of contents where the literature can be found, and you should label this section as “Literature Review.”

➡️ For more information on writing a thesis, visit our guide on how to structure a thesis .

There is no set amount of words for a literature review, so the length depends on the research. If you are working with a large amount of sources, it will be long. If your paper does not depend entirely on references, it will be short.

Take a look at these three theses featuring great literature reviews:

• School-Based Speech-Language Pathologist's Perceptions of Sensory Food Aversions in Children [ PDF , see page 20]
• Who's Writing What We Read: Authorship in Criminological Research [ PDF , see page 4]
• A Phenomenological Study of the Lived Experience of Online Instructors of Theological Reflection at Christian Institutions Accredited by the Association of Theological Schools [ PDF , see page 56]

Literature reviews are most commonly found in theses and dissertations. However, you find them in research papers as well.

There is no set amount of words for a literature review, so the length depends on the research. If you are working with a large amount of sources, then it will be long. If your paper does not depend entirely on references, then it will be short.

No. A literature review should have its own independent section. You should indicate clearly in the table of contents where the literature review can be found, and label this section as “Literature Review.”

The main goal of a literature review is to provide the researcher with sufficient knowledge about the topic in question so that they can eventually make an intervention.

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

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

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

What are Literature Reviews?

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

Goals of Literature Reviews

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

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

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

What kinds of sources require a Literature Review?

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

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

Types of Literature Reviews

What kinds of literature reviews are written?

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

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

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

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

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

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

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

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

Literature Reviews in the Health Sciences

• UConn Health subject guide on systematic reviews Explanation of the different review types used in health sciences literature as well as tools to help you find the right review type
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A literature review surveys prior research published in books, scholarly articles, and any other sources relevant to a particular issue, area of research, or theory, and by so doing, provides a description, summary, and critical evaluation of these works in relation to the research problem being investigated. Literature reviews are designed to provide an overview of sources you have used in researching a particular topic and to demonstrate to your readers how your research fits within existing scholarship about the topic.

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

Importance of a Good Literature Review

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

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

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

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

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

Types of Literature Reviews

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

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

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

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

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

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

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

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

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

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

Structure and Writing Style

I.  Thinking About Your Literature Review

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

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

The critical evaluation of each work should consider :

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

II.  Development of the Literature Review

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

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

III.  Ways to Organize Your Literature Review

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

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

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

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

IV.  Writing Your Literature Review

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

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

V.  Common Mistakes to Avoid

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

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

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

Writing Tip

Break Out of Your Disciplinary Box!

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

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

Another Writing Tip

Don't Just Review for Content!

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

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

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

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

Yet Another Writing Tip

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

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

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

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

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What is a literature review?

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

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

Why is it important?

A literature review is important because it:

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

APA7 Style resources

APA Style Blog - for those harder to find answers

1. Choose a topic. Define your research question.

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

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

2. Decide on the scope of your review

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

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

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

Make a list of the databases you will search. 

Where to find databases:

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

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

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

Review the literature

Some questions to help you analyze the research:

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

Tips: 

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

• General overview of Literature Reviews
• What should a Literature Review include?
• Examples of Literature Reviews
• Research - Getting Started

What do you need to include?

The content of a literature review is important, and all articles you mention should have some relevance to your paper's topic.

Key things to include in a literature review include:

• Do these results expand on the literature? Does your proposal hypothesis align with the results? If your project is complete, do the results align with your results?
• Are you using the same methodology as the article you're citing? Are there some aspects of the methodology you are changing to be more fitting for your project? Did how they go about the design and distribution of their study help you in creating your study?
• Is the concept or purpose of this article similar to yours?
• Another way to use literature reviews is to mention what other articles have covered in regard to the knowledge of your topic and how you plan to cover the gaps in knowledge. Or to use the knowledge covered in other articles to give the reader a quick review so they can better understand your topic?

What should be the focus of your literature review?

It varies from paper to paper what aspects of an article you should focus on covering in your literature review. But the key thing is what is relevant and what will support the main purpose of your proposal or paper.

For an argumentative review you will want to focus on the arguments presented in your sources. This can be arguments that align with your stance or to present the side you are opposing. The arguments you should focus on in your sources should be either supporting or refuting your stance, be a deeply embedded assumption, or philosophical problem already established in the literature. 

For a historical review you will want to focus on all relevant studies surrounding your topic, discussing what has been covered on your topic all the way from the start to present day. Outlining its evolution throughout its existence in the world of research and show familiarity with state-of-the-art developments and to identify the likely directions for future research for the readers.

For a methodological review the key thing to focus on is the results or how the study was design and conducted. Reason for this is you hypothesize your results will be similar to your sources, or you are using a similar if to exact design to the study you are citing. 

For a theoretical review your literature review is the foundation for the theoretical framework used in the research. It might discuss theories definitions, models, or key concepts; it might argue in favor of a specific theoretical approach, or combine more than one theoretical concept to create the framework for your own research.

Literature Review as a Standalone Assignment

Sometimes, your instructor might ask you to write a literature review as a standalone assignment. A standalone literature review does all the same things that a literature review section in a larger academic paper does: it provides a foundation of knowledge on a topic, while collecting relevant, timely research to synthesize into a cohesive summary of existing knowledge in the field.

• Writing an Literature Review This document is a great step-by-step guide for conducting and writing a literature review.

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How do I Write a Literature Review?: #5 Writing the Review

• Step #1: Choosing a Topic
• Step #2: Finding Information
• Step #3: Evaluating Content
• Step #4: Synthesizing Content
• #5 Writing the Review
• Citing Your Sources

WRITING THE REVIEW 

You've done the research and now you're ready to put your findings down on paper. When preparing to write your review, first consider how will you organize your review.

The actual review generally has 5 components:

Abstract  -  An abstract is a summary of your literature review. It is made up of the following parts:

• A contextual sentence about your motivation behind your research topic
• Your thesis statement
• A descriptive statement about the types of literature used in the review
• Summarize your findings
• Conclusion(s) based upon your findings

Introduction :   Like a typical research paper introduction, provide the reader with a quick idea of the topic of the literature review:

• Define or identify the general topic, issue, or area of concern. This provides the reader with context for reviewing the literature.
• Identify related trends in what has already been published about the topic; or conflicts in theory, methodology, evidence, and conclusions; or gaps in research and scholarship; or a single problem or new perspective of immediate interest.
• Establish your reason (point of view) for reviewing the literature; explain the criteria to be used in analyzing and comparing literature and the organization of the review (sequence); and, when necessary, state why certain literature is or is not included (scope)  - 

Body :  The body of a literature review contains your discussion of sources and can be organized in 3 ways-

• Chronological -  by publication or by trend
• Thematic -  organized around a topic or issue, rather than the progression of time
• Methodical -  the focusing factor usually does not have to do with the content of the material. Instead, it focuses on the "methods" of the literature's researcher or writer that you are reviewing

You may also want to include a section on "questions for further research" and discuss what questions the review has sparked about the topic/field or offer suggestions for future studies/examinations that build on your current findings.

Conclusion :  In the conclusion, you should:

Conclude your paper by providing your reader with some perspective on the relationship between your literature review's specific topic and how it's related to it's parent discipline, scientific endeavor, or profession.

Bibliography :   Since a literature review is composed of pieces of research, it is very important that your correctly cite the literature you are reviewing, both in the reviews body as well as in a bibliography/works cited. To learn more about different citation styles, visit the " Citing Your Sources " tab.

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• v.21(3); Fall 2022

Literature Reviews, Theoretical Frameworks, and Conceptual Frameworks: An Introduction for New Biology Education Researchers

Julie a. luft.

† Department of Mathematics, Social Studies, and Science Education, Mary Frances Early College of Education, University of Georgia, Athens, GA 30602-7124

Sophia Jeong

‡ Department of Teaching & Learning, College of Education & Human Ecology, Ohio State University, Columbus, OH 43210

Robert Idsardi

§ Department of Biology, Eastern Washington University, Cheney, WA 99004

Grant Gardner

∥ Department of Biology, Middle Tennessee State University, Murfreesboro, TN 37132

Associated Data

To frame their work, biology education researchers need to consider the role of literature reviews, theoretical frameworks, and conceptual frameworks as critical elements of the research and writing process. However, these elements can be confusing for scholars new to education research. This Research Methods article is designed to provide an overview of each of these elements and delineate the purpose of each in the educational research process. We describe what biology education researchers should consider as they conduct literature reviews, identify theoretical frameworks, and construct conceptual frameworks. Clarifying these different components of educational research studies can be helpful to new biology education researchers and the biology education research community at large in situating their work in the broader scholarly literature.

INTRODUCTION

Discipline-based education research (DBER) involves the purposeful and situated study of teaching and learning in specific disciplinary areas ( Singer et al. , 2012 ). Studies in DBER are guided by research questions that reflect disciplines’ priorities and worldviews. Researchers can use quantitative data, qualitative data, or both to answer these research questions through a variety of methodological traditions. Across all methodologies, there are different methods associated with planning and conducting educational research studies that include the use of surveys, interviews, observations, artifacts, or instruments. Ensuring the coherence of these elements to the discipline’s perspective also involves situating the work in the broader scholarly literature. The tools for doing this include literature reviews, theoretical frameworks, and conceptual frameworks. However, the purpose and function of each of these elements is often confusing to new education researchers. The goal of this article is to introduce new biology education researchers to these three important elements important in DBER scholarship and the broader educational literature.

The first element we discuss is a review of research (literature reviews), which highlights the need for a specific research question, study problem, or topic of investigation. Literature reviews situate the relevance of the study within a topic and a field. The process may seem familiar to science researchers entering DBER fields, but new researchers may still struggle in conducting the review. Booth et al. (2016b) highlight some of the challenges novice education researchers face when conducting a review of literature. They point out that novice researchers struggle in deciding how to focus the review, determining the scope of articles needed in the review, and knowing how to be critical of the articles in the review. Overcoming these challenges (and others) can help novice researchers construct a sound literature review that can inform the design of the study and help ensure the work makes a contribution to the field.

The second and third highlighted elements are theoretical and conceptual frameworks. These guide biology education research (BER) studies, and may be less familiar to science researchers. These elements are important in shaping the construction of new knowledge. Theoretical frameworks offer a way to explain and interpret the studied phenomenon, while conceptual frameworks clarify assumptions about the studied phenomenon. Despite the importance of these constructs in educational research, biology educational researchers have noted the limited use of theoretical or conceptual frameworks in published work ( DeHaan, 2011 ; Dirks, 2011 ; Lo et al. , 2019 ). In reviewing articles published in CBE—Life Sciences Education ( LSE ) between 2015 and 2019, we found that fewer than 25% of the research articles had a theoretical or conceptual framework (see the Supplemental Information), and at times there was an inconsistent use of theoretical and conceptual frameworks. Clearly, these frameworks are challenging for published biology education researchers, which suggests the importance of providing some initial guidance to new biology education researchers.

Fortunately, educational researchers have increased their explicit use of these frameworks over time, and this is influencing educational research in science, technology, engineering, and mathematics (STEM) fields. For instance, a quick search for theoretical or conceptual frameworks in the abstracts of articles in Educational Research Complete (a common database for educational research) in STEM fields demonstrates a dramatic change over the last 20 years: from only 778 articles published between 2000 and 2010 to 5703 articles published between 2010 and 2020, a more than sevenfold increase. Greater recognition of the importance of these frameworks is contributing to DBER authors being more explicit about such frameworks in their studies.

Collectively, literature reviews, theoretical frameworks, and conceptual frameworks work to guide methodological decisions and the elucidation of important findings. Each offers a different perspective on the problem of study and is an essential element in all forms of educational research. As new researchers seek to learn about these elements, they will find different resources, a variety of perspectives, and many suggestions about the construction and use of these elements. The wide range of available information can overwhelm the new researcher who just wants to learn the distinction between these elements or how to craft them adequately.

Our goal in writing this paper is not to offer specific advice about how to write these sections in scholarly work. Instead, we wanted to introduce these elements to those who are new to BER and who are interested in better distinguishing one from the other. In this paper, we share the purpose of each element in BER scholarship, along with important points on its construction. We also provide references for additional resources that may be beneficial to better understanding each element. Table 1 summarizes the key distinctions among these elements.

Comparison of literature reviews, theoretical frameworks, and conceptual reviews

This article is written for the new biology education researcher who is just learning about these different elements or for scientists looking to become more involved in BER. It is a result of our own work as science education and biology education researchers, whether as graduate students and postdoctoral scholars or newly hired and established faculty members. This is the article we wish had been available as we started to learn about these elements or discussed them with new educational researchers in biology.

LITERATURE REVIEWS

Purpose of a literature review.

A literature review is foundational to any research study in education or science. In education, a well-conceptualized and well-executed review provides a summary of the research that has already been done on a specific topic and identifies questions that remain to be answered, thus illustrating the current research project’s potential contribution to the field and the reasoning behind the methodological approach selected for the study ( Maxwell, 2012 ). BER is an evolving disciplinary area that is redefining areas of conceptual emphasis as well as orientations toward teaching and learning (e.g., Labov et al. , 2010 ; American Association for the Advancement of Science, 2011 ; Nehm, 2019 ). As a result, building comprehensive, critical, purposeful, and concise literature reviews can be a challenge for new biology education researchers.

Building Literature Reviews

There are different ways to approach and construct a literature review. Booth et al. (2016a) provide an overview that includes, for example, scoping reviews, which are focused only on notable studies and use a basic method of analysis, and integrative reviews, which are the result of exhaustive literature searches across different genres. Underlying each of these different review processes are attention to the s earch process, a ppraisa l of articles, s ynthesis of the literature, and a nalysis: SALSA ( Booth et al. , 2016a ). This useful acronym can help the researcher focus on the process while building a specific type of review.

However, new educational researchers often have questions about literature reviews that are foundational to SALSA or other approaches. Common questions concern determining which literature pertains to the topic of study or the role of the literature review in the design of the study. This section addresses such questions broadly while providing general guidance for writing a narrative literature review that evaluates the most pertinent studies.

The literature review process should begin before the research is conducted. As Boote and Beile (2005 , p. 3) suggested, researchers should be “scholars before researchers.” They point out that having a good working knowledge of the proposed topic helps illuminate avenues of study. Some subject areas have a deep body of work to read and reflect upon, providing a strong foundation for developing the research question(s). For instance, the teaching and learning of evolution is an area of long-standing interest in the BER community, generating many studies (e.g., Perry et al. , 2008 ; Barnes and Brownell, 2016 ) and reviews of research (e.g., Sickel and Friedrichsen, 2013 ; Ziadie and Andrews, 2018 ). Emerging areas of BER include the affective domain, issues of transfer, and metacognition ( Singer et al. , 2012 ). Many studies in these areas are transdisciplinary and not always specific to biology education (e.g., Rodrigo-Peiris et al. , 2018 ; Kolpikova et al. , 2019 ). These newer areas may require reading outside BER; fortunately, summaries of some of these topics can be found in the Current Insights section of the LSE website.

In focusing on a specific problem within a broader research strand, a new researcher will likely need to examine research outside BER. Depending upon the area of study, the expanded reading list might involve a mix of BER, DBER, and educational research studies. Determining the scope of the reading is not always straightforward. A simple way to focus one’s reading is to create a “summary phrase” or “research nugget,” which is a very brief descriptive statement about the study. It should focus on the essence of the study, for example, “first-year nonmajor students’ understanding of evolution,” “metacognitive prompts to enhance learning during biochemistry,” or “instructors’ inquiry-based instructional practices after professional development programming.” This type of phrase should help a new researcher identify two or more areas to review that pertain to the study. Focusing on recent research in the last 5 years is a good first step. Additional studies can be identified by reading relevant works referenced in those articles. It is also important to read seminal studies that are more than 5 years old. Reading a range of studies should give the researcher the necessary command of the subject in order to suggest a research question.

Given that the research question(s) arise from the literature review, the review should also substantiate the selected methodological approach. The review and research question(s) guide the researcher in determining how to collect and analyze data. Often the methodological approach used in a study is selected to contribute knowledge that expands upon what has been published previously about the topic (see Institute of Education Sciences and National Science Foundation, 2013 ). An emerging topic of study may need an exploratory approach that allows for a description of the phenomenon and development of a potential theory. This could, but not necessarily, require a methodological approach that uses interviews, observations, surveys, or other instruments. An extensively studied topic may call for the additional understanding of specific factors or variables; this type of study would be well suited to a verification or a causal research design. These could entail a methodological approach that uses valid and reliable instruments, observations, or interviews to determine an effect in the studied event. In either of these examples, the researcher(s) may use a qualitative, quantitative, or mixed methods methodological approach.

Even with a good research question, there is still more reading to be done. The complexity and focus of the research question dictates the depth and breadth of the literature to be examined. Questions that connect multiple topics can require broad literature reviews. For instance, a study that explores the impact of a biology faculty learning community on the inquiry instruction of faculty could have the following review areas: learning communities among biology faculty, inquiry instruction among biology faculty, and inquiry instruction among biology faculty as a result of professional learning. Biology education researchers need to consider whether their literature review requires studies from different disciplines within or outside DBER. For the example given, it would be fruitful to look at research focused on learning communities with faculty in STEM fields or in general education fields that result in instructional change. It is important not to be too narrow or too broad when reading. When the conclusions of articles start to sound similar or no new insights are gained, the researcher likely has a good foundation for a literature review. This level of reading should allow the researcher to demonstrate a mastery in understanding the researched topic, explain the suitability of the proposed research approach, and point to the need for the refined research question(s).

The literature review should include the researcher’s evaluation and critique of the selected studies. A researcher may have a large collection of studies, but not all of the studies will follow standards important in the reporting of empirical work in the social sciences. The American Educational Research Association ( Duran et al. , 2006 ), for example, offers a general discussion about standards for such work: an adequate review of research informing the study, the existence of sound and appropriate data collection and analysis methods, and appropriate conclusions that do not overstep or underexplore the analyzed data. The Institute of Education Sciences and National Science Foundation (2013) also offer Common Guidelines for Education Research and Development that can be used to evaluate collected studies.

Because not all journals adhere to such standards, it is important that a researcher review each study to determine the quality of published research, per the guidelines suggested earlier. In some instances, the research may be fatally flawed. Examples of such flaws include data that do not pertain to the question, a lack of discussion about the data collection, poorly constructed instruments, or an inadequate analysis. These types of errors result in studies that are incomplete, error-laden, or inaccurate and should be excluded from the review. Most studies have limitations, and the author(s) often make them explicit. For instance, there may be an instructor effect, recognized bias in the analysis, or issues with the sample population. Limitations are usually addressed by the research team in some way to ensure a sound and acceptable research process. Occasionally, the limitations associated with the study can be significant and not addressed adequately, which leaves a consequential decision in the hands of the researcher. Providing critiques of studies in the literature review process gives the reader confidence that the researcher has carefully examined relevant work in preparation for the study and, ultimately, the manuscript.

A solid literature review clearly anchors the proposed study in the field and connects the research question(s), the methodological approach, and the discussion. Reviewing extant research leads to research questions that will contribute to what is known in the field. By summarizing what is known, the literature review points to what needs to be known, which in turn guides decisions about methodology. Finally, notable findings of the new study are discussed in reference to those described in the literature review.

Within published BER studies, literature reviews can be placed in different locations in an article. When included in the introductory section of the study, the first few paragraphs of the manuscript set the stage, with the literature review following the opening paragraphs. Cooper et al. (2019) illustrate this approach in their study of course-based undergraduate research experiences (CUREs). An introduction discussing the potential of CURES is followed by an analysis of the existing literature relevant to the design of CUREs that allows for novel student discoveries. Within this review, the authors point out contradictory findings among research on novel student discoveries. This clarifies the need for their study, which is described and highlighted through specific research aims.

A literature reviews can also make up a separate section in a paper. For example, the introduction to Todd et al. (2019) illustrates the need for their research topic by highlighting the potential of learning progressions (LPs) and suggesting that LPs may help mitigate learning loss in genetics. At the end of the introduction, the authors state their specific research questions. The review of literature following this opening section comprises two subsections. One focuses on learning loss in general and examines a variety of studies and meta-analyses from the disciplines of medical education, mathematics, and reading. The second section focuses specifically on LPs in genetics and highlights student learning in the midst of LPs. These separate reviews provide insights into the stated research question.

Suggestions and Advice

A well-conceptualized, comprehensive, and critical literature review reveals the understanding of the topic that the researcher brings to the study. Literature reviews should not be so big that there is no clear area of focus; nor should they be so narrow that no real research question arises. The task for a researcher is to craft an efficient literature review that offers a critical analysis of published work, articulates the need for the study, guides the methodological approach to the topic of study, and provides an adequate foundation for the discussion of the findings.

In our own writing of literature reviews, there are often many drafts. An early draft may seem well suited to the study because the need for and approach to the study are well described. However, as the results of the study are analyzed and findings begin to emerge, the existing literature review may be inadequate and need revision. The need for an expanded discussion about the research area can result in the inclusion of new studies that support the explanation of a potential finding. The literature review may also prove to be too broad. Refocusing on a specific area allows for more contemplation of a finding.

It should be noted that there are different types of literature reviews, and many books and articles have been written about the different ways to embark on these types of reviews. Among these different resources, the following may be helpful in considering how to refine the review process for scholarly journals:

• Booth, A., Sutton, A., & Papaioannou, D. (2016a). Systemic approaches to a successful literature review (2nd ed.). Los Angeles, CA: Sage. This book addresses different types of literature reviews and offers important suggestions pertaining to defining the scope of the literature review and assessing extant studies.
• Booth, W. C., Colomb, G. G., Williams, J. M., Bizup, J., & Fitzgerald, W. T. (2016b). The craft of research (4th ed.). Chicago: University of Chicago Press. This book can help the novice consider how to make the case for an area of study. While this book is not specifically about literature reviews, it offers suggestions about making the case for your study.
• Galvan, J. L., & Galvan, M. C. (2017). Writing literature reviews: A guide for students of the social and behavioral sciences (7th ed.). Routledge. This book offers guidance on writing different types of literature reviews. For the novice researcher, there are useful suggestions for creating coherent literature reviews.

THEORETICAL FRAMEWORKS

Purpose of theoretical frameworks.

As new education researchers may be less familiar with theoretical frameworks than with literature reviews, this discussion begins with an analogy. Envision a biologist, chemist, and physicist examining together the dramatic effect of a fog tsunami over the ocean. A biologist gazing at this phenomenon may be concerned with the effect of fog on various species. A chemist may be interested in the chemical composition of the fog as water vapor condenses around bits of salt. A physicist may be focused on the refraction of light to make fog appear to be “sitting” above the ocean. While observing the same “objective event,” the scientists are operating under different theoretical frameworks that provide a particular perspective or “lens” for the interpretation of the phenomenon. Each of these scientists brings specialized knowledge, experiences, and values to this phenomenon, and these influence the interpretation of the phenomenon. The scientists’ theoretical frameworks influence how they design and carry out their studies and interpret their data.

Within an educational study, a theoretical framework helps to explain a phenomenon through a particular lens and challenges and extends existing knowledge within the limitations of that lens. Theoretical frameworks are explicitly stated by an educational researcher in the paper’s framework, theory, or relevant literature section. The framework shapes the types of questions asked, guides the method by which data are collected and analyzed, and informs the discussion of the results of the study. It also reveals the researcher’s subjectivities, for example, values, social experience, and viewpoint ( Allen, 2017 ). It is essential that a novice researcher learn to explicitly state a theoretical framework, because all research questions are being asked from the researcher’s implicit or explicit assumptions of a phenomenon of interest ( Schwandt, 2000 ).

Selecting Theoretical Frameworks

Theoretical frameworks are one of the most contemplated elements in our work in educational research. In this section, we share three important considerations for new scholars selecting a theoretical framework.

The first step in identifying a theoretical framework involves reflecting on the phenomenon within the study and the assumptions aligned with the phenomenon. The phenomenon involves the studied event. There are many possibilities, for example, student learning, instructional approach, or group organization. A researcher holds assumptions about how the phenomenon will be effected, influenced, changed, or portrayed. It is ultimately the researcher’s assumption(s) about the phenomenon that aligns with a theoretical framework. An example can help illustrate how a researcher’s reflection on the phenomenon and acknowledgment of assumptions can result in the identification of a theoretical framework.

In our example, a biology education researcher may be interested in exploring how students’ learning of difficult biological concepts can be supported by the interactions of group members. The phenomenon of interest is the interactions among the peers, and the researcher assumes that more knowledgeable students are important in supporting the learning of the group. As a result, the researcher may draw on Vygotsky’s (1978) sociocultural theory of learning and development that is focused on the phenomenon of student learning in a social setting. This theory posits the critical nature of interactions among students and between students and teachers in the process of building knowledge. A researcher drawing upon this framework holds the assumption that learning is a dynamic social process involving questions and explanations among students in the classroom and that more knowledgeable peers play an important part in the process of building conceptual knowledge.

It is important to state at this point that there are many different theoretical frameworks. Some frameworks focus on learning and knowing, while other theoretical frameworks focus on equity, empowerment, or discourse. Some frameworks are well articulated, and others are still being refined. For a new researcher, it can be challenging to find a theoretical framework. Two of the best ways to look for theoretical frameworks is through published works that highlight different frameworks.

When a theoretical framework is selected, it should clearly connect to all parts of the study. The framework should augment the study by adding a perspective that provides greater insights into the phenomenon. It should clearly align with the studies described in the literature review. For instance, a framework focused on learning would correspond to research that reported different learning outcomes for similar studies. The methods for data collection and analysis should also correspond to the framework. For instance, a study about instructional interventions could use a theoretical framework concerned with learning and could collect data about the effect of the intervention on what is learned. When the data are analyzed, the theoretical framework should provide added meaning to the findings, and the findings should align with the theoretical framework.

A study by Jensen and Lawson (2011) provides an example of how a theoretical framework connects different parts of the study. They compared undergraduate biology students in heterogeneous and homogeneous groups over the course of a semester. Jensen and Lawson (2011) assumed that learning involved collaboration and more knowledgeable peers, which made Vygotsky’s (1978) theory a good fit for their study. They predicted that students in heterogeneous groups would experience greater improvement in their reasoning abilities and science achievements with much of the learning guided by the more knowledgeable peers.

In the enactment of the study, they collected data about the instruction in traditional and inquiry-oriented classes, while the students worked in homogeneous or heterogeneous groups. To determine the effect of working in groups, the authors also measured students’ reasoning abilities and achievement. Each data-collection and analysis decision connected to understanding the influence of collaborative work.

Their findings highlighted aspects of Vygotsky’s (1978) theory of learning. One finding, for instance, posited that inquiry instruction, as a whole, resulted in reasoning and achievement gains. This links to Vygotsky (1978) , because inquiry instruction involves interactions among group members. A more nuanced finding was that group composition had a conditional effect. Heterogeneous groups performed better with more traditional and didactic instruction, regardless of the reasoning ability of the group members. Homogeneous groups worked better during interaction-rich activities for students with low reasoning ability. The authors attributed the variation to the different types of helping behaviors of students. High-performing students provided the answers, while students with low reasoning ability had to work collectively through the material. In terms of Vygotsky (1978) , this finding provided new insights into the learning context in which productive interactions can occur for students.

Another consideration in the selection and use of a theoretical framework pertains to its orientation to the study. This can result in the theoretical framework prioritizing individuals, institutions, and/or policies ( Anfara and Mertz, 2014 ). Frameworks that connect to individuals, for instance, could contribute to understanding their actions, learning, or knowledge. Institutional frameworks, on the other hand, offer insights into how institutions, organizations, or groups can influence individuals or materials. Policy theories provide ways to understand how national or local policies can dictate an emphasis on outcomes or instructional design. These different types of frameworks highlight different aspects in an educational setting, which influences the design of the study and the collection of data. In addition, these different frameworks offer a way to make sense of the data. Aligning the data collection and analysis with the framework ensures that a study is coherent and can contribute to the field.

New understandings emerge when different theoretical frameworks are used. For instance, Ebert-May et al. (2015) prioritized the individual level within conceptual change theory (see Posner et al. , 1982 ). In this theory, an individual’s knowledge changes when it no longer fits the phenomenon. Ebert-May et al. (2015) designed a professional development program challenging biology postdoctoral scholars’ existing conceptions of teaching. The authors reported that the biology postdoctoral scholars’ teaching practices became more student-centered as they were challenged to explain their instructional decision making. According to the theory, the biology postdoctoral scholars’ dissatisfaction in their descriptions of teaching and learning initiated change in their knowledge and instruction. These results reveal how conceptual change theory can explain the learning of participants and guide the design of professional development programming.

The communities of practice (CoP) theoretical framework ( Lave, 1988 ; Wenger, 1998 ) prioritizes the institutional level , suggesting that learning occurs when individuals learn from and contribute to the communities in which they reside. Grounded in the assumption of community learning, the literature on CoP suggests that, as individuals interact regularly with the other members of their group, they learn about the rules, roles, and goals of the community ( Allee, 2000 ). A study conducted by Gehrke and Kezar (2017) used the CoP framework to understand organizational change by examining the involvement of individual faculty engaged in a cross-institutional CoP focused on changing the instructional practice of faculty at each institution. In the CoP, faculty members were involved in enhancing instructional materials within their department, which aligned with an overarching goal of instituting instruction that embraced active learning. Not surprisingly, Gehrke and Kezar (2017) revealed that faculty who perceived the community culture as important in their work cultivated institutional change. Furthermore, they found that institutional change was sustained when key leaders served as mentors and provided support for faculty, and as faculty themselves developed into leaders. This study reveals the complexity of individual roles in a COP in order to support institutional instructional change.

It is important to explicitly state the theoretical framework used in a study, but elucidating a theoretical framework can be challenging for a new educational researcher. The literature review can help to identify an applicable theoretical framework. Focal areas of the review or central terms often connect to assumptions and assertions associated with the framework that pertain to the phenomenon of interest. Another way to identify a theoretical framework is self-reflection by the researcher on personal beliefs and understandings about the nature of knowledge the researcher brings to the study ( Lysaght, 2011 ). In stating one’s beliefs and understandings related to the study (e.g., students construct their knowledge, instructional materials support learning), an orientation becomes evident that will suggest a particular theoretical framework. Theoretical frameworks are not arbitrary , but purposefully selected.

With experience, a researcher may find expanded roles for theoretical frameworks. Researchers may revise an existing framework that has limited explanatory power, or they may decide there is a need to develop a new theoretical framework. These frameworks can emerge from a current study or the need to explain a phenomenon in a new way. Researchers may also find that multiple theoretical frameworks are necessary to frame and explore a problem, as different frameworks can provide different insights into a problem.

Finally, it is important to recognize that choosing “x” theoretical framework does not necessarily mean a researcher chooses “y” methodology and so on, nor is there a clear-cut, linear process in selecting a theoretical framework for one’s study. In part, the nonlinear process of identifying a theoretical framework is what makes understanding and using theoretical frameworks challenging. For the novice scholar, contemplating and understanding theoretical frameworks is essential. Fortunately, there are articles and books that can help:

• Creswell, J. W. (2018). Research design: Qualitative, quantitative, and mixed methods approaches (5th ed.). Los Angeles, CA: Sage. This book provides an overview of theoretical frameworks in general educational research.
• Ding, L. (2019). Theoretical perspectives of quantitative physics education research. Physical Review Physics Education Research , 15 (2), 020101-1–020101-13. This paper illustrates how a DBER field can use theoretical frameworks.
• Nehm, R. (2019). Biology education research: Building integrative frameworks for teaching and learning about living systems. Disciplinary and Interdisciplinary Science Education Research , 1 , ar15. https://doi.org/10.1186/s43031-019-0017-6 . This paper articulates the need for studies in BER to explicitly state theoretical frameworks and provides examples of potential studies.
• Patton, M. Q. (2015). Qualitative research & evaluation methods: Integrating theory and practice . Sage. This book also provides an overview of theoretical frameworks, but for both research and evaluation.

CONCEPTUAL FRAMEWORKS

Purpose of a conceptual framework.

A conceptual framework is a description of the way a researcher understands the factors and/or variables that are involved in the study and their relationships to one another. The purpose of a conceptual framework is to articulate the concepts under study using relevant literature ( Rocco and Plakhotnik, 2009 ) and to clarify the presumed relationships among those concepts ( Rocco and Plakhotnik, 2009 ; Anfara and Mertz, 2014 ). Conceptual frameworks are different from theoretical frameworks in both their breadth and grounding in established findings. Whereas a theoretical framework articulates the lens through which a researcher views the work, the conceptual framework is often more mechanistic and malleable.

Conceptual frameworks are broader, encompassing both established theories (i.e., theoretical frameworks) and the researchers’ own emergent ideas. Emergent ideas, for example, may be rooted in informal and/or unpublished observations from experience. These emergent ideas would not be considered a “theory” if they are not yet tested, supported by systematically collected evidence, and peer reviewed. However, they do still play an important role in the way researchers approach their studies. The conceptual framework allows authors to clearly describe their emergent ideas so that connections among ideas in the study and the significance of the study are apparent to readers.

Constructing Conceptual Frameworks

Including a conceptual framework in a research study is important, but researchers often opt to include either a conceptual or a theoretical framework. Either may be adequate, but both provide greater insight into the research approach. For instance, a research team plans to test a novel component of an existing theory. In their study, they describe the existing theoretical framework that informs their work and then present their own conceptual framework. Within this conceptual framework, specific topics portray emergent ideas that are related to the theory. Describing both frameworks allows readers to better understand the researchers’ assumptions, orientations, and understanding of concepts being investigated. For example, Connolly et al. (2018) included a conceptual framework that described how they applied a theoretical framework of social cognitive career theory (SCCT) to their study on teaching programs for doctoral students. In their conceptual framework, the authors described SCCT, explained how it applied to the investigation, and drew upon results from previous studies to justify the proposed connections between the theory and their emergent ideas.

In some cases, authors may be able to sufficiently describe their conceptualization of the phenomenon under study in an introduction alone, without a separate conceptual framework section. However, incomplete descriptions of how the researchers conceptualize the components of the study may limit the significance of the study by making the research less intelligible to readers. This is especially problematic when studying topics in which researchers use the same terms for different constructs or different terms for similar and overlapping constructs (e.g., inquiry, teacher beliefs, pedagogical content knowledge, or active learning). Authors must describe their conceptualization of a construct if the research is to be understandable and useful.

There are some key areas to consider regarding the inclusion of a conceptual framework in a study. To begin with, it is important to recognize that conceptual frameworks are constructed by the researchers conducting the study ( Rocco and Plakhotnik, 2009 ; Maxwell, 2012 ). This is different from theoretical frameworks that are often taken from established literature. Researchers should bring together ideas from the literature, but they may be influenced by their own experiences as a student and/or instructor, the shared experiences of others, or thought experiments as they construct a description, model, or representation of their understanding of the phenomenon under study. This is an exercise in intellectual organization and clarity that often considers what is learned, known, and experienced. The conceptual framework makes these constructs explicitly visible to readers, who may have different understandings of the phenomenon based on their prior knowledge and experience. There is no single method to go about this intellectual work.

Reeves et al. (2016) is an example of an article that proposed a conceptual framework about graduate teaching assistant professional development evaluation and research. The authors used existing literature to create a novel framework that filled a gap in current research and practice related to the training of graduate teaching assistants. This conceptual framework can guide the systematic collection of data by other researchers because the framework describes the relationships among various factors that influence teaching and learning. The Reeves et al. (2016) conceptual framework may be modified as additional data are collected and analyzed by other researchers. This is not uncommon, as conceptual frameworks can serve as catalysts for concerted research efforts that systematically explore a phenomenon (e.g., Reynolds et al. , 2012 ; Brownell and Kloser, 2015 ).

Sabel et al. (2017) used a conceptual framework in their exploration of how scaffolds, an external factor, interact with internal factors to support student learning. Their conceptual framework integrated principles from two theoretical frameworks, self-regulated learning and metacognition, to illustrate how the research team conceptualized students’ use of scaffolds in their learning ( Figure 1 ). Sabel et al. (2017) created this model using their interpretations of these two frameworks in the context of their teaching.

Conceptual framework from Sabel et al. (2017) .

A conceptual framework should describe the relationship among components of the investigation ( Anfara and Mertz, 2014 ). These relationships should guide the researcher’s methods of approaching the study ( Miles et al. , 2014 ) and inform both the data to be collected and how those data should be analyzed. Explicitly describing the connections among the ideas allows the researcher to justify the importance of the study and the rigor of the research design. Just as importantly, these frameworks help readers understand why certain components of a system were not explored in the study. This is a challenge in education research, which is rooted in complex environments with many variables that are difficult to control.

For example, Sabel et al. (2017) stated: “Scaffolds, such as enhanced answer keys and reflection questions, can help students and instructors bridge the external and internal factors and support learning” (p. 3). They connected the scaffolds in the study to the three dimensions of metacognition and the eventual transformation of existing ideas into new or revised ideas. Their framework provides a rationale for focusing on how students use two different scaffolds, and not on other factors that may influence a student’s success (self-efficacy, use of active learning, exam format, etc.).

In constructing conceptual frameworks, researchers should address needed areas of study and/or contradictions discovered in literature reviews. By attending to these areas, researchers can strengthen their arguments for the importance of a study. For instance, conceptual frameworks can address how the current study will fill gaps in the research, resolve contradictions in existing literature, or suggest a new area of study. While a literature review describes what is known and not known about the phenomenon, the conceptual framework leverages these gaps in describing the current study ( Maxwell, 2012 ). In the example of Sabel et al. (2017) , the authors indicated there was a gap in the literature regarding how scaffolds engage students in metacognition to promote learning in large classes. Their study helps fill that gap by describing how scaffolds can support students in the three dimensions of metacognition: intelligibility, plausibility, and wide applicability. In another example, Lane (2016) integrated research from science identity, the ethic of care, the sense of belonging, and an expertise model of student success to form a conceptual framework that addressed the critiques of other frameworks. In a more recent example, Sbeglia et al. (2021) illustrated how a conceptual framework influences the methodological choices and inferences in studies by educational researchers.

Sometimes researchers draw upon the conceptual frameworks of other researchers. When a researcher’s conceptual framework closely aligns with an existing framework, the discussion may be brief. For example, Ghee et al. (2016) referred to portions of SCCT as their conceptual framework to explain the significance of their work on students’ self-efficacy and career interests. Because the authors’ conceptualization of this phenomenon aligned with a previously described framework, they briefly mentioned the conceptual framework and provided additional citations that provided more detail for the readers.

Within both the BER and the broader DBER communities, conceptual frameworks have been used to describe different constructs. For example, some researchers have used the term “conceptual framework” to describe students’ conceptual understandings of a biological phenomenon. This is distinct from a researcher’s conceptual framework of the educational phenomenon under investigation, which may also need to be explicitly described in the article. Other studies have presented a research logic model or flowchart of the research design as a conceptual framework. These constructions can be quite valuable in helping readers understand the data-collection and analysis process. However, a model depicting the study design does not serve the same role as a conceptual framework. Researchers need to avoid conflating these constructs by differentiating the researchers’ conceptual framework that guides the study from the research design, when applicable.

Explicitly describing conceptual frameworks is essential in depicting the focus of the study. We have found that being explicit in a conceptual framework means using accepted terminology, referencing prior work, and clearly noting connections between terms. This description can also highlight gaps in the literature or suggest potential contributions to the field of study. A well-elucidated conceptual framework can suggest additional studies that may be warranted. This can also spur other researchers to consider how they would approach the examination of a phenomenon and could result in a revised conceptual framework.

It can be challenging to create conceptual frameworks, but they are important. Below are two resources that could be helpful in constructing and presenting conceptual frameworks in educational research:

• Maxwell, J. A. (2012). Qualitative research design: An interactive approach (3rd ed.). Los Angeles, CA: Sage. Chapter 3 in this book describes how to construct conceptual frameworks.
• Ravitch, S. M., & Riggan, M. (2016). Reason & rigor: How conceptual frameworks guide research . Los Angeles, CA: Sage. This book explains how conceptual frameworks guide the research questions, data collection, data analyses, and interpretation of results.

CONCLUDING THOUGHTS

Literature reviews, theoretical frameworks, and conceptual frameworks are all important in DBER and BER. Robust literature reviews reinforce the importance of a study. Theoretical frameworks connect the study to the base of knowledge in educational theory and specify the researcher’s assumptions. Conceptual frameworks allow researchers to explicitly describe their conceptualization of the relationships among the components of the phenomenon under study. Table 1 provides a general overview of these components in order to assist biology education researchers in thinking about these elements.

It is important to emphasize that these different elements are intertwined. When these elements are aligned and complement one another, the study is coherent, and the study findings contribute to knowledge in the field. When literature reviews, theoretical frameworks, and conceptual frameworks are disconnected from one another, the study suffers. The point of the study is lost, suggested findings are unsupported, or important conclusions are invisible to the researcher. In addition, this misalignment may be costly in terms of time and money.

Conducting a literature review, selecting a theoretical framework, and building a conceptual framework are some of the most difficult elements of a research study. It takes time to understand the relevant research, identify a theoretical framework that provides important insights into the study, and formulate a conceptual framework that organizes the finding. In the research process, there is often a constant back and forth among these elements as the study evolves. With an ongoing refinement of the review of literature, clarification of the theoretical framework, and articulation of a conceptual framework, a sound study can emerge that makes a contribution to the field. This is the goal of BER and education research.

Supplementary Material

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How to write a literature review introduction (+ examples)

The introduction to a literature review serves as your reader’s guide through your academic work and thought process. Explore the significance of literature review introductions in review papers, academic papers, essays, theses, and dissertations. We delve into the purpose and necessity of these introductions, explore the essential components of literature review introductions, and provide step-by-step guidance on how to craft your own, along with examples.

Why you need an introduction for a literature review

When you need an introduction for a literature review, what to include in a literature review introduction, examples of literature review introductions, steps to write your own literature review introduction.

A literature review is a comprehensive examination of the international academic literature concerning a particular topic. It involves summarizing published works, theories, and concepts while also highlighting gaps and offering critical reflections.

In academic writing , the introduction for a literature review is an indispensable component. Effective academic writing requires proper paragraph structuring to guide your reader through your argumentation. This includes providing an introduction to your literature review.

It is imperative to remember that you should never start sharing your findings abruptly. Even if there isn’t a dedicated introduction section .

Instead, you should always offer some form of introduction to orient the reader and clarify what they can expect.

There are three main scenarios in which you need an introduction for a literature review:

• Academic literature review papers: When your literature review constitutes the entirety of an academic review paper, a more substantial introduction is necessary. This introduction should resemble the standard introduction found in regular academic papers.
• Literature review section in an academic paper or essay: While this section tends to be brief, it’s important to precede the detailed literature review with a few introductory sentences. This helps orient the reader before delving into the literature itself.
• Literature review chapter or section in your thesis/dissertation: Every thesis and dissertation includes a literature review component, which also requires a concise introduction to set the stage for the subsequent review.

You may also like: How to write a fantastic thesis introduction (+15 examples)

It is crucial to customize the content and depth of your literature review introduction according to the specific format of your academic work.

In practical terms, this implies, for instance, that the introduction in an academic literature review paper, especially one derived from a systematic literature review , is quite comprehensive. Particularly compared to the rather brief one or two introductory sentences that are often found at the beginning of a literature review section in a standard academic paper. The introduction to the literature review chapter in a thesis or dissertation again adheres to different standards.

Here’s a structured breakdown based on length and the necessary information:

Academic literature review paper

The introduction of an academic literature review paper, which does not rely on empirical data, often necessitates a more extensive introduction than the brief literature review introductions typically found in empirical papers. It should encompass:

• The research problem: Clearly articulate the problem or question that your literature review aims to address.
• The research gap: Highlight the existing gaps, limitations, or unresolved aspects within the current body of literature related to the research problem.
• The research relevance: Explain why the chosen research problem and its subsequent investigation through a literature review are significant and relevant in your academic field.
• The literature review method: If applicable, describe the methodology employed in your literature review, especially if it is a systematic review or follows a specific research framework.
• The main findings or insights of the literature review: Summarize the key discoveries, insights, or trends that have emerged from your comprehensive review of the literature.
• The main argument of the literature review: Conclude the introduction by outlining the primary argument or statement that your literature review will substantiate, linking it to the research problem and relevance you’ve established.
• Preview of the literature review’s structure: Offer a glimpse into the organization of the literature review paper, acting as a guide for the reader. This overview outlines the subsequent sections of the paper and provides an understanding of what to anticipate.

By addressing these elements, your introduction will provide a clear and structured overview of what readers can expect in your literature review paper.

Regular literature review section in an academic article or essay

Most academic articles or essays incorporate regular literature review sections, often placed after the introduction. These sections serve to establish a scholarly basis for the research or discussion within the paper.

In a standard 8000-word journal article, the literature review section typically spans between 750 and 1250 words. The first few sentences or the first paragraph within this section often serve as an introduction. It should encompass:

• An introduction to the topic: When delving into the academic literature on a specific topic, it’s important to provide a smooth transition that aids the reader in comprehending why certain aspects will be discussed within your literature review.
• The core argument: While literature review sections primarily synthesize the work of other scholars, they should consistently connect to your central argument. This central argument serves as the crux of your message or the key takeaway you want your readers to retain. By positioning it at the outset of the literature review section and systematically substantiating it with evidence, you not only enhance reader comprehension but also elevate overall readability. This primary argument can typically be distilled into 1-2 succinct sentences.

In some cases, you might include:

• Methodology: Details about the methodology used, but only if your literature review employed a specialized method. If your approach involved a broader overview without a systematic methodology, you can omit this section, thereby conserving word count.

By addressing these elements, your introduction will effectively integrate your literature review into the broader context of your academic paper or essay. This will, in turn, assist your reader in seamlessly following your overarching line of argumentation.

Introduction to a literature review chapter in thesis or dissertation

The literature review typically constitutes a distinct chapter within a thesis or dissertation. Often, it is Chapter 2 of a thesis or dissertation.

Some students choose to incorporate a brief introductory section at the beginning of each chapter, including the literature review chapter. Alternatively, others opt to seamlessly integrate the introduction into the initial sentences of the literature review itself. Both approaches are acceptable, provided that you incorporate the following elements:

• Purpose of the literature review and its relevance to the thesis/dissertation research: Explain the broader objectives of the literature review within the context of your research and how it contributes to your thesis or dissertation. Essentially, you’re telling the reader why this literature review is important and how it fits into the larger scope of your academic work.
• Primary argument: Succinctly communicate what you aim to prove, explain, or explore through the review of existing literature. This statement helps guide the reader’s understanding of the review’s purpose and what to expect from it.
• Preview of the literature review’s content: Provide a brief overview of the topics or themes that your literature review will cover. It’s like a roadmap for the reader, outlining the main areas of focus within the review. This preview can help the reader anticipate the structure and organization of your literature review.
• Methodology: If your literature review involved a specific research method, such as a systematic review or meta-analysis, you should briefly describe that methodology. However, this is not always necessary, especially if your literature review is more of a narrative synthesis without a distinct research method.

By addressing these elements, your introduction will empower your literature review to play a pivotal role in your thesis or dissertation research. It will accomplish this by integrating your research into the broader academic literature and providing a solid theoretical foundation for your work.

Comprehending the art of crafting your own literature review introduction becomes significantly more accessible when you have concrete examples to examine. Here, you will find several examples that meet, or in most cases, adhere to the criteria described earlier.

Example 1: An effective introduction for an academic literature review paper

To begin, let’s delve into the introduction of an academic literature review paper. We will examine the paper “How does culture influence innovation? A systematic literature review”, which was published in 2018 in the journal Management Decision.

The entire introduction spans 611 words and is divided into five paragraphs. In this introduction, the authors accomplish the following:

• In the first paragraph, the authors introduce the broader topic of the literature review, which focuses on innovation and its significance in the context of economic competition. They underscore the importance of this topic, highlighting its relevance for both researchers and policymakers.
• In the second paragraph, the authors narrow down their focus to emphasize the specific role of culture in relation to innovation.
• In the third paragraph, the authors identify research gaps, noting that existing studies are often fragmented and disconnected. They then emphasize the value of conducting a systematic literature review to enhance our understanding of the topic.
• In the fourth paragraph, the authors introduce their specific objectives and explain how their insights can benefit other researchers and business practitioners.
• In the fifth and final paragraph, the authors provide an overview of the paper’s organization and structure.

In summary, this introduction stands as a solid example. While the authors deviate from previewing their key findings (which is a common practice at least in the social sciences), they do effectively cover all the other previously mentioned points.

Example 2: An effective introduction to a literature review section in an academic paper

The second example represents a typical academic paper, encompassing not only a literature review section but also empirical data, a case study, and other elements. We will closely examine the introduction to the literature review section in the paper “The environmentalism of the subalterns: a case study of environmental activism in Eastern Kurdistan/Rojhelat”, which was published in 2021 in the journal Local Environment.

The paper begins with a general introduction and then proceeds to the literature review, designated by the authors as their conceptual framework. Of particular interest is the first paragraph of this conceptual framework, comprising 142 words across five sentences:

“ A peripheral and marginalised nationality within a multinational though-Persian dominated Iranian society, the Kurdish people of Iranian Kurdistan (a region referred by the Kurds as Rojhelat/Eastern Kurdi-stan) have since the early twentieth century been subject to multifaceted and systematic discriminatory and exclusionary state policy in Iran. This condition has left a population of 12–15 million Kurds in Iran suffering from structural inequalities, disenfranchisement and deprivation. Mismanagement of Kurdistan’s natural resources and the degradation of its natural environmental are among examples of this disenfranchisement. As asserted by Julian Agyeman (2005), structural inequalities that sustain the domination of political and economic elites often simultaneously result in environmental degradation, injustice and discrimination against subaltern communities. This study argues that the environmental struggle in Eastern Kurdistan can be asserted as a (sub)element of the Kurdish liberation movement in Iran. Conceptually this research is inspired by and has been conducted through the lens of ‘subalternity’ ” ( Hassaniyan, 2021, p. 931 ).

In this first paragraph, the author is doing the following:

• The author contextualises the research
• The author links the research focus to the international literature on structural inequalities
• The author clearly presents the argument of the research
• The author clarifies how the research is inspired by and uses the concept of ‘subalternity’.

Thus, the author successfully introduces the literature review, from which point onward it dives into the main concept (‘subalternity’) of the research, and reviews the literature on socio-economic justice and environmental degradation.

While introductions to a literature review section aren’t always required to offer the same level of study context detail as demonstrated here, this introduction serves as a commendable model for orienting the reader within the literature review. It effectively underscores the literature review’s significance within the context of the study being conducted.

Examples 3-5: Effective introductions to literature review chapters

The introduction to a literature review chapter can vary in length, depending largely on the overall length of the literature review chapter itself. For example, a master’s thesis typically features a more concise literature review, thus necessitating a shorter introduction. In contrast, a Ph.D. thesis, with its more extensive literature review, often includes a more detailed introduction.

Numerous universities offer online repositories where you can access theses and dissertations from previous years, serving as valuable sources of reference. Many of these repositories, however, may require you to log in through your university account. Nevertheless, a few open-access repositories are accessible to anyone, such as the one by the University of Manchester . It’s important to note though that copyright restrictions apply to these resources, just as they would with published papers.

Master’s thesis literature review introduction

The first example is “Benchmarking Asymmetrical Heating Models of Spider Pulsar Companions” by P. Sun, a master’s thesis completed at the University of Manchester on January 9, 2024. The author, P. Sun, introduces the literature review chapter very briefly but effectively:

PhD thesis literature review chapter introduction

The second example is Deep Learning on Semi-Structured Data and its Applications to Video-Game AI, Woof, W. (Author). 31 Dec 2020, a PhD thesis completed at the University of Manchester . In Chapter 2, the author offers a comprehensive introduction to the topic in four paragraphs, with the final paragraph serving as an overview of the chapter’s structure:

PhD thesis literature review introduction

The last example is the doctoral thesis Metacognitive strategies and beliefs: Child correlates and early experiences Chan, K. Y. M. (Author). 31 Dec 2020 . The author clearly conducted a systematic literature review, commencing the review section with a discussion of the methodology and approach employed in locating and analyzing the selected records.

Having absorbed all of this information, let’s recap the essential steps and offer a succinct guide on how to proceed with creating your literature review introduction:

• Contextualize your review : Begin by clearly identifying the academic context in which your literature review resides and determining the necessary information to include.
• Outline your structure : Develop a structured outline for your literature review, highlighting the essential information you plan to incorporate in your introduction.
• Literature review process : Conduct a rigorous literature review, reviewing and analyzing relevant sources.
• Summarize and abstract : After completing the review, synthesize the findings and abstract key insights, trends, and knowledge gaps from the literature.
• Craft the introduction : Write your literature review introduction with meticulous attention to the seamless integration of your review into the larger context of your work. Ensure that your introduction effectively elucidates your rationale for the chosen review topics and the underlying reasons guiding your selection.

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• Open access
• Published: 16 April 2024

Review on epidemiology, disease burden, and treatment patterns of IgA nephropathy in select APAC countries

• Omer Zaidi 1 ,
• Zhaoli Tang 2 ,
• Sandipan Bhattacharjee 3 &
• Kristin Pareja 3  

BMC Nephrology volume  25 , Article number:  136 ( 2024 ) Cite this article

214 Accesses

Metrics details

Immunoglobulin type A (IgA) nephropathy is the most common primary glomerulonephritis (GN) worldwide with higher rates in East and Pacific Asia compared to North America and Europe. Despite high reported prevalence of IgAN in these countries, the overall disease prevalence across Asia is not available. Treatment patterns of IgAN patients across Asian countries have also not been summarized. The aim of this study was to review and summarize evidence on IgA nephropathy prevalence, treatment patterns, and humanistic and economic burden in mainland China, Taiwan, South Korea, Japan, and Australia.

A targeted literature review was conducted in PubMed and local databases in China (including Taiwan), South Korea, Japan, and Australia between January 2010-December 2021. Website literature searches were conducted using Google Scholar and Baidu.

Sixty-nine publications and 3 clinical guidelines were included. Incidence ranged from 0 to 10.7 per 100 000 people per year in Australia, Japan, and Taiwan, and ranged from 6.3 to 24.70% among patients who underwent renal biopsy in mainland China. Prevalence and diagnosis rates ranged from 0 to 72.1% in mainland China, South Korea, Taiwan, Japan, and Australia. Mortality rates in mainland China, South Korea, and Japan varied widely. The top 3 commonly used therapies were angiotensin-converting enzyme inhibitor/angiotensin receptor blockers (0.9-99.6%), corticosteroids (3.5-100%), and immunosuppressants (1.6-85.5%) in Japan, mainland China, and South Korea. Patient quality of life was measured by different tools, and annual hospitalization costs ranged from $1 284.73 to $2 252.12 (2015–2018) in China.

Conclusions

The prevalence of IgA nephropathy among the general population in select countries/regions is not commonly available, despite evidence from studies and clinical guidelines. In addition, it is observed across geographic regions that heterogeneity exists in prevalence rates, and large variations exist in treatment patterns. There is need to fill in these gaps to understand the contributing factors behind the differences through population-based, multi-center, and real-world studies.

Peer Review reports

Immunoglobulin type A nephropathy (IgAN), also known as Berger’s disease, is a kidney disease caused by kidney deposition of immunoglobulin type A (IgA) complexes involving galactose-deficient IgA [ 1 ] and resulting in inflammatory tissue damage [ 2 ]. IgAN affects the kidneys by attacking the glomeruli and is characterized by persistent urinary abnormalities including microscopic hematuria, gross hematuria, and/or proteinuria [ 2 , 3 ]. IgAN is the most common form of biopsy-proven primary glomerulonephritis (PGN) worldwide [ 3 ] and is one of the leading causes of chronic kidney disease (CKD) and end-stage renal disease (ESRD) [ 4 ].

Primary treatments for IgAN include angiotensin-converting enzyme inhibitor/angiotensin receptor blockers (ACEIs/ARBs), corticosteroids, and immunosuppressants [ 1 , 4 ]. These treatments aim to address symptoms and manifestations of IgAN but not the underlying cause. Nearly one-third of IgAN patients develop ESRD within 10 years [ 5 ]. On average, patients with IgAN die 6 years earlier than the general population [ 6 ]. In addition, patients’ quality of life (QoL) is greatly impacted due to pain, fatigue, and poor mental health [ 4 ], and indirect caregiver burden is high due to time spent caring for patients who progress to ESRD. Thus, caregivers’ QoL and psychological well-being can also be negatively impacted [ 7 ].

IgAN prevalence is highest in Asia, intermediate in Europe and the US, and lower in African countries [ 8 ]. The overall global incidence is approximately 2.5 per 100,000 people per year [ 2 ]. A higher prevalence of IgAN is seen in countries where routine screening is practiced [ 4 ]. While geographic variations of IgAN have been studied previously [ 3 , 9 ], few recent studies have focused on regional disease burden differences and treatment patterns in among IgAN patients across Asian countries/regions and Australia.

This review aimed to summarize the disease burden and treatment patterns of IgAN in select countries/regions in the Asia-Pacific region, specifically mainland China, Taiwan, South Korea, Japan, and Australia.

Data sources and search strategy

A targeted literature review (TLR) was conducted to identify relevant literature published from January 2010 to December 2021 for mainland China, Taiwan, South Korea, Australia, and Japan. The earliest year of publication was expanded from 2010 to 2001 to capture evidence more comprehensively on outcomes of interest. Medline and Embase were the primary databases for publications in English. For publications in local languages, WANFANG and China National Knowledge Infrastructure (CNKI) databases were searched for publications in Chinese, Korean Medical Database and Korean Information Service System (KISS) databases were searched for publications in Korean, and Scholarly and Academic Information Navigator (CiNii) was searched for publications in Japanese. Supplementary searches for clinical guidelines, conference proceedings, and websites of governmental and non-governmental organizations were conducted using Google, Baidu (for Chinese sources), and Naver (for Korean sources). Publications cited as references were also considered for screening.

Search terms included IgA nephropathy, Berger’s disease, incidence, prevalence, mortality, quality of life, cost, burden, and treatment. Observational studies, reviews, and registry studies were included in the search. Publications that reported prevalence, incidence, mortality, treatment patterns, guidelines, economic, and humanistic burden were included for data extraction. Search terms in English and local languages are listed in Supplementary Table S1 .

Study selection and data extraction

After the search was conducted and duplicates were removed, the title, abstract, and full texts of the remaining publications were screened. A second reviewer conducted the validation and finalization for publications to be included in the data extraction phase. During screening, the inclusion and exclusion criteria mainly focused on outcomes. Systematic reviews, observational studies including registry/database studies and other real-world studies, annual reports were considered for inclusion. Publications that reported evidence regarding epidemiology (incidence, prevalence, and mortality), humanistic and economic burden, and treatment patterns (treatment guidelines, duration, adherence, persistence, switching, and discontinuation) were included for data extraction. Studies that did not include outcomes of interest were excluded, as were studies with a small sample size (< 25). Strict predefined population, intervention, comparators, outcomes, and study design (PICOS) selection criteria and a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram were not used in this study. Study characteristics, patient characteristics, epidemiological outcomes, disease burden, and treatment patterns were extracted.

Study quality assessment

All eligible studies went through a quality assessment (QA) using a recommended checklist, according to the Center for Reviews and Dissemination Guidance for Undertaking Reviews in Health Care recommendations [ 10 ]. Quality assessment was performed for all eligible articles by two reviewers. The checklist consisted of 9 items excluding basic information for the included studies. Because all publications included in this study were observational studies or reviews, only the non-randomized clinical trial checklist was used for observational studies.

Sixty-nine publications were included for this review, among which 38 were from mainland China (2015–2021) [ 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 ], 15 from Japan (2003–2021) [ 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 ], 10 from South Korea (2010–2020) [ 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 ], 3 from Taiwan (2014–2019) [ 74 , 75 , 76 ], and 3 from Australia (2001–2021) [ 77 , 78 , 79 ]; characteristics of the studies are shown in Supplementary Table S2 . Approximately 83% the publications reported a retrospective study design ( n  = 57). For publications from mainland China, sample sizes ranged from 74 [ 37 ] to 4,367,829 [ 47 ], and male percentages ranged from 37.5% [ 17 ] to 97.3% [ 32 ]. For publications from Japan, sample sizes ranged from 52 [ 53 ] to 270,902 [ 63 ]; the male percentage ranged from 37.1% [ 58 ] to 56.96% [ 52 ]. For publications from South Korea, sample sizes ranged from 25 [ 64 ] to 5,114 [ 67 ]; the male percentage ranged from 36% [ 64 ] to 66.6% [ 73 ]. For publications from Taiwan, sample sizes ranged from 91 [ 75 ] to 7,073 [ 76 ]; the male percentage ranged from 45.9% [ 76 ] to 52.7% [ 75 ]. For publications from Australia, sample sizes ranged from 1,147 [ 78 ] to 2,457 [ 79 ]; the male percentage ranged from 60% [ 77 ] to 69.7% [ 79 ]. The Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline [ 1 ] and 2 country-specific guidelines [ 80 , 81 ] were also included for evidence on treatment patterns.

Sixty-eight journal articles were assessed for study quality (all details of the quality assessment are shown in Supplementary Table S3 ); one white paper was not included in the study quality assessment. Approximately 75% (51/68 articles) were deemed to be of good quality (i.e., without inherent flaws). Few studies reported the incidence/prevalence of IgAN directly and percentage of IgAN were extracted from included studies. The appropriateness of the statistical analysis conducted was not clear or not specified in 5 studies, as they did not define P values and the level of significance for all observations. Across studies, outcome measures were generally considered reliable. However, 33 articles stated that the results could be generalized to routine practice. In one case-control study, the similarity of both groups at the outset of the study was not clear.

Six publications provided evidence on IgAN incidence [ 30 , 61 , 63 , 74 , 77 , 78 ] in Australia ( n  = 2), Japan ( n  = 2), mainland China ( n  = 1), and Taiwan ( n  = 1). Most were cross-sectional observational studies ( n  = 4), and sample sizes ranged from 156 [ 74 ] to 270,902 [ 63 ].

In Australia, IgAN incidence was estimated to be 1.41–10.5 per 100,000 people per year [ 77 , 78 ]. According to Briganti 2001 [ 78 ], IgAN incidence in Australia was lowest (0.0 per 100,000 per year) among male children and highest (10.7 per 100,000 per year) among male adults [ 78 ]. In Japan, only 2 studies reporting incidence data among children were identified. Utsunomiya 2003 [ 63 ] reported an incidence rate of 4.5 per 100,000 per year among 270,902 junior high and elementary school students; Kajiwara 2020 [ 61 ] reported a rate of 3.3 per 100,000 per year among 60,816 junior high and elementary school students. Both publications collected urine samples through a school urinary screening system in students 6 to 15 years old. In mainland China, the incidence rate of IgAN was estimated to be 6.3% among elderly patients who underwent renal biopsy and 24.7% among non-elderly patients who underwent renal biopsy [ 30 ]. In Taiwan, IgAN incidence was estimated to be 5.5 per million per year among the general population (around 23.5 million between 2014 and 2016), based on 1,445 renal biopsy records from a registry database [ 74 ]. In general, IgAN incidence was higher in males (5.7 per 100,000 per year) compared with females (2.9 per 100,000 per year) [ 78 ]. IgAN incidence was not reported in Korean populations.

Prevalence and diagnosis rate

IgAN prevalence among the general population was not reported in the included publications. But one cross-sectional study ( n  = 3,623) reported an IgAN prevalence rate of 0.03% among the general Chinese pediatric population [ 34 ]. Thirty-five publications were identified with diagnosis rates among 2 populations: patients who received renal biopsies and PGN patients [ 13 , 14 , 17 , 18 , 19 , 21 , 22 , 24 , 30 , 31 , 33 , 34 , 35 , 36 , 39 , 40 , 43 , 44 , 45 , 46 , 47 , 48 , 52 , 59 , 67 , 68 , 69 , 70 , 71 , 72 , 74 , 75 , 76 , 79 ]. Twenty-one publications were from mainland China [ 13 , 14 , 17 , 18 , 19 , 21 , 24 , 30 , 31 , 33 , 34 , 35 , 36 , 39 , 40 , 43 , 44 , 45 , 46 , 47 , 48 ], 6 from South Korea [ 67 , 68 , 69 , 70 , 71 , 72 ], 3 from Taiwan [ 74 , 75 , 76 ], 3 from Japan [ 52 , 55 , 59 ], and 1 from Australia [ 79 ]. The majority (88%) were cohort studies ( n  = 17) [ 13 , 21 , 31 , 33 , 35 , 36 , 39 , 40 , 43 , 44 , 45 , 46 , 52 , 68 , 69 , 70 , 71 ] and cross-sectional studies ( n  = 13) [ 14 , 17 , 18 , 19 , 21 , 24 , 34 , 37 , 47 , 59 , 67 , 72 , 74 , 79 ], with the remainder being an annual report [ 76 ], a registry study [ 55 ] and a chart review [ 75 ]. Sample sizes ranged from 33 [ 70 ] to 43,67,829 [ 47 ].

In mainland China, the mean diagnosis rate of IgAN was estimated to be 24.1% among patients undergoing renal biopsies (median: 23.0%; range: 6.3-40.9%) [ 13 , 19 , 21 , 22 , 24 , 30 , 46 ] and 27.3% (median: 27.9%; range: 0-72.1%) [ 14 , 19 , 21 , 33 , 36 , 40 , 43 , 44 , 45 , 48 ] among PGN patients (Fig.  1 a); The mean IgAN diagnosis rate was estimated to be 21.7% (median: 17.5%; 17-30.4%) among children who underwent renal biopsy [ 17 , 18 , 35 ]. In Taiwan, the mean diagnosis rate of IgAN was 12.1% (median: 12.2%; range: 10.8-13.2%) among patients undergoing renal biopsies [ 74 , 75 ] and was reported similar (26%) among PGN patients [ 74 , 76 ] (Fig.  1 b). In South Korea, the mean diagnosis rate was 41% (median: 38.1%; range: 25.8-61.9%) among patients undergoing renal biopsies [ 67 , 69 , 71 , 72 ] and around 51.6% (average of 51.3% and 51.9%) among PGN patients [ 68 , 70 ] (Fig.  1 c). In Japan, Hattori 2016 reported a mean estimated IgAN diagnosis rate of 23% (median: 22.9%) among CKD patients [ 59 ]. In addition, the reported IgAN diagnosis rate among patients who underwent renal biopsy was 31%, with 6.9% in patients aged 65 to 80 years old and 10.5% in patients aged 80 years or older [ 52 , 55 ]. In Australia, Lee 2020 reported an IgAN diagnosis rate of 13% among patients undergoing renal biopsy [ 79 ].

IgAN Prevalence in Mainland China, Taiwan and South Korea (Abbreviation: ANS, acute nephritic syndrome; CNS, chronic nephrotic syndrome; NHRI, National Health Research Institute & Taiwan Society of Nephrology; NS, nephritis syndrome(e; PGN, primary glomerulonephritis; RPG, rapidly progressive glomerulonephritis)

Disease progression and mortality

Among included studies, all-cause mortality was mainly reported as deaths due to ESRD. Seven publications from mainland China [ 23 , 26 , 27 , 28 , 29 , 41 , 42 ], 7 from Korea [ 64 , 65 , 66 , 68 , 70 , 71 , 73 ], 4 from Japan [ 50 , 51 , 57 , 62 ], and 1 from Taiwan [ 75 ] reported rate of progression to ESRD in IgAN. These studies varied in the definition of endpoint, patient characteristics, and follow-up duration. In China, the median rate of progression to ESRD was 4.1% [ 28 ] over 6 months, ranged from 1.3 to 15.8% (median: 1.3%) over 40–45 months [ 29 , 41 ], ranged from 6.6 to 15% (median: 8.3%) over 4–10 years [ 23 , 27 , 42 ], and 33% over 15 years [ 42 ]. In Korea, the median rate of progression to ESRD ranged from 2.5 to 39.7% (median: 19%) from 60 to 100 months [ 64 , 65 , 66 , 68 , 70 , 71 , 73 ].

Regarding direct reports on mortality, in mainland China, 0.7% of adult IgAN patients progressed to death according to 1 study of 944 patients from 2003 to 2014 with a median follow-up of 4.2 years [ 23 ]. In South Korea, the median death rate was 5.3% (range: 4.4-5.9%) [ 65 , 66 , 68 ] for 1,364 IgAN patients with a median follow-up of 100 months. In addition, 2 publications reported a standard mortality ratio (expressed as the ratio between the observed and the expected number of deaths in the general population) of 1.43 (95% confidence interval:1.04–1.92) among 1,364 IgAN patients in relation to the general population [ 65 , 68 ]. In Japan, IgAN mortality was estimated to be 0.3 per 100 person-years among non-smokers [ 51 ], 1.3 per 100 person-years among smokers [ 51 ] and 1.2 per 100 person-years among patients who received kidney replacement therapy [ 53 ] based on 2 retrospective studies [ 51 , 53 ]. No mortality data was found among IgAN patients in Taiwan or Australia.

• Treatment patterns

Twenty publications [ 1 , 11 , 15 , 26 , 27 , 29 , 42 , 49 , 50 , 54 , 56 , 57 , 58 , 60 , 62 , 64 , 68 , 71 , 73 , 81 ] and 3 clinical guidelines reported treatment patterns. Nine from mainland China [ 11 , 15 , 26 , 27 , 28 , 29 , 32 , 41 , 42 ], 8 from Japan [ 49 , 50 , 54 , 56 , 57 , 58 , 60 , 62 ], and 4 from South Korea [ 64 , 68 , 71 , 73 ]. 80% publications were retrospective studies ( n  = 16) [ 11 , 15 , 26 , 27 , 29 , 42 , 49 , 56 , 57 , 58 , 60 , 62 , 64 , 68 , 71 , 73 ]. Sample sizes ranged from 25 [ 64 ] to 2,283 [ 50 ]. The KDIGO [ 1 ] and 2 country-specific treatment guidelines, 1 from mainland China [ 80 ] and 1 from Japan [ 81 ], were identified. No treatment guidelines were identified in Taiwan, South Korea, or Australia.

The KDIGO guidelines (2021 version) provide treatment recommendations for adults and children with IgAN [ 1 ]. The guidelines state that the management of IgAN should be multifaceted, optimized with supportive care, and include ACEIs/ARBs as tolerated or allowed, control blood pressure, minimize cardiovascular risk, and adherence to lifestyle changes including dietary counseling, smoking cessation, weight control, and exercise, as appropriate. The guidelines provide specific treatment recommendations according to the variant forms of IgAN, the level of proteinuria, and high-risk rate for progression after maximal supportive care. The main treatment regimens include ACEIs and ARBs, immunosuppressants, cyclophosphamide, tonsillectomy, and lifestyle modification [ 1 ]. Similar to the KDIGO guidelines, the primary treatment recommendations in the Chinese 2017 guidelines for children with IgAN were glucocorticoids, immunosuppressants, and ACEIs/ARBs [ 80 ]. Japanese 2020 guidelines covered children and adults, with different treatment recommendations based on symptoms and subtype of IgAN (the subgroup classification for adults was based on estimated glomerular filtration rate and proteinuria; symptoms among children were classified as mild or severe) [ 81 ].

In mainland China, 6 studies investigated adult populations [ 15 , 26 , 28 , 29 , 32 , 42 ] (Table  1 ) and 3 investigated pediatric populations [ 11 , 27 , 41 ] (Table  2 ). For drug usage among adult patients, ACEIs/ARBs had the largest median percentage at 66.7% (range: 38-90%) [ 15 , 26 , 28 , 29 , 32 , 42 ], followed by steroids, with median of 36% (corticosteroids/prednisone/intravenous methylprednisolone injection, range: 10-100%) [ 15 , 26 , 28 , 29 , 32 , 42 ] and immunosuppressants (including in combination with steroids), with median of 25.9% (cyclophosphamide, tacrolimus and tripterygium wilfordii, range: 1.6-72%) [ 15 , 26 , 28 , 29 , 32 , 42 ]. Among pediatric patients, immunosuppressants (cyclophosphamide/mycophenolate /Tripterygium wilfordii /leflunomide) were the common drugs recommended, with a median of 64% (range: 1.7–72.2%) [ 11 , 27 , 41 ], followed by ACEIs/ARBs, with a median of 49.5% (range: 2.5-70%) [ 11 , 27 , 41 ] and steroids with a median of 45% (range: 25.3-69.3% as sum of oral prednisone and intravenous methylprednisolone) [ 11 , 27 , 41 ].

In South Korea, 3 publications on adult IgAN patients [ 64 , 68 , 71 ] (Table  1 ) and 1 publication among pediatric patients [ 73 ] (Table  2 ) were identified. Among adults, ACEIs/ARBs were the most common treatments (27.7-83.4%) [ 68 , 71 , 73 ], followed by ACEIs/ARBs and corticosteroid combinations (33.9%) [ 64 ] and corticosteroids alone (12.4-28.8%) [ 68 , 71 , 73 ]. Among pediatric patients, the frequency of immunosuppressant use was 50.2% [ 73 ].

In Japan, 7 publications reported IgAN treatment patterns among adults [ 50 , 54 , 56 , 57 , 58 , 60 , 62 ] (Table  1 ) and 2 publications [ 49 , 54 ] among pediatric patients (Table  2 ). Among adults, ACEIs/ARBs were the most common treatment (25-99.6%) [ 50 , 54 , 56 , 57 , 58 , 60 , 62 ], followed by antiplatelet agents (58.1-96.8%) [ 54 ] and corticosteroid-immunosuppressant combination therapy (1.5-74%) [ 62 ]. Notably, the rate of administering steroid-immunosuppressant combination was only 1.5% in a retrospective cohort study that sampled 1,012 IgAN patients with a mean age of 32.96 ± 12 years [ 56 ]. Among pediatric patients, ACEIs/ARBs were the most frequently administered treatments (0.9-95.7%) [ 49 , 54 ], followed by antiplatelet agents (range: 1.2-82.6%) [ 49 , 54 ] and immunosuppressants (range: 4.6-68.5%) [ 49 ]. The frequency of administering treatments varied greatly across different subgroups. For example, the frequency of administering ACEIs/ARBs ranged from 0.9% for the diffuse mesangial proliferation subgroup ( n  = 108) to 50.9% for the focal mesangial proliferation subgroup ( n  = 173) in 1 retrospective study in Japanese children with IgAN from 1990 to 2004 [ 49 ]. Tonsillectomy or tonsillectomy combined with steroid was mostly reported in Japanese studies, with frequencies ranging from 1 to 66.2% across publications (Table  1 ). This is in accordance with the KDIGO 2021 guidelines’ evidence that supports the routine use of tonsillectomy in Japanese high-risk patients with IgAN [ 1 ]. No publications reporting IgAN treatment patterns were identified for Taiwan or Australia.

Humanistic burden

Four publications in China reported QoL, measured by the 36-Item Short Form Health Survey (SF-36) [ 16 , 25 ], Daily Living Ability Rating Scale (DLARS) [ 37 ], and QoL scale (QOLs) combined with Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) [ 38 ]. SF-36 scores reflect physical and mental health based on 8 health concepts, including physical and social functioning, role limitations due to physical and emotional problems, mental health, vitality, bodily pain, and general health (GH) perception [ 82 ]. Two publications evaluated the effects of individualized nursing intervention (INI, one improved nursing intervention which costs more time than routine nursing intervention [RNI]) on the psychological mood and QoL among IgAN patients [ 16 , 25 ]. There were two subgroups, the patients in the control group received RNI and patients in the intervention group received INI [ 16 , 25 ]. The mean GH score was 32.16 [ 16 ] among total IgAN patients ( n  = 98; mean age: 32.74 years; male percentage: 50%) in 2017 and 80.15 increasing from 69.93 at baseline [ 25 ] after intervention among total IgAN patients ( n  = 84; mean age: 33.57 years; male percentage: 60.7%) in 2019. In both publications, the intervention groups had higher mean GH scores than that in the control groups (39.47 vs. 24.84 [ 16 ] and 85.73 vs. 74.56 [ 25 ], respectively). Two other prospective studies assessed the effect of INI for IgAN patients [ 37 , 38 ]. Results showed that both mean DLARS and QOLs scores were higher among the intervention group compared to the control group (88.5 vs. 75.7 and 39.5 vs. 24.8, respectively) [ 37 , 38 ]. SAS and SDS scores were also evaluated by Qi 2021 [ 38 ], the mean SAS score decreased more in the intervention group (49.2 ± 6.3 decreased from 62.1 ± 5.8) than that in the control group (57 ± 4.9 decreased from 62.4 ± 6.1) from baseline. Similarly, the mean SDS score decreased more in the intervention group (43.3 ± 5.2 decreased from 56.2 ± 6) than in the control group (52.6 ± 6.4 decreased from 57 ± 6.2) from baseline [ 38 ].

Economic burden

No publications reported indirect costs, but 3 retrospective studies reported hospitalization costs for IgAN patients in China (see Supplementary Figure S1 ) [ 12 , 20 , 47 ]. Hospitalization cost per patient per year is ¥14,900 ($2,252.12; exchange rate of Chinese Yuan [CNY] and US dollar in 2018 was 6.616 [ 83 ]) as reported by Zheng 2018 [ 20 ], and between ¥9,618 ($1,532.26; exchange rate of CNY and US dollar in 2015 is 6.227 [ 83 ]) and ¥10,019 ($1,608.96) as reported by Peng 2015 [ 12 ]. One large database study covering 54.1% of tertiary hospitals in 31 Chinese provinces from 2010 to 2015 reported a hospitalization cost of ¥8,000/$1,284.73 (¥6,000-¥12,000) [ 47 ]. Drug costs accounted for 28.39% of total hospitalization costs, followed by diagnostic testing costs [ 12 ]. Length of stay per patient per year in China ranged from 10 to 14.3 days across 3 publications [ 12 , 20 , 47 ].

To our knowledge, this is the first TLR to summarize the evidence on IgAN disease burden and treatment patterns in mainland China, Taiwan, South Korea, Japan, and Australia. The findings of this review revealed evidence gaps in IgAN epidemiology and humanistic and economic burden. No incidence data was identified in South Korea; no mortality data was identified in Taiwan and Australia; no country/region-specific treatment guidelines were found for Taiwan, South Korea, or Australia; no evidence on treatment patterns from the publications was identified for Taiwan or Australia; and no humanistic burden or economic data was identified except for mainland China.

The IgAN incidence rates among Japanese, Taiwanese, and Australian populations ranged from 0 to 10.7 per 100,000 people per year, higher than the incidence rate reported in a recent systematic literature review (SLR) by Kwon 2021 [ 84 ] (1.29 per 100,000 people per year). Kwon 2021 [ 84 ] is an SLR focusing on US epidemiology, health-related QoL, and the economic burden of IgAN (the included studies were published from January 2010 to June 2020), similar to our study’s objective. Incidence rates among children and teenagers (0-4.5 per 100,000 per year) were similar to the incidence rate in Venezuela (0.03 per 100,000 per year) [ 85 ] and in Italy (0.31 per 100,000 per year) [ 86 ]. The overall prevalence and diagnosis rates of IgAN were similar across selected countries/regions. The diagnosis rates in this review differed from those found in PGN patients and patients who received renal biopsy in Kwon 2021 [ 84 ]; diagnosis rates of IgAN from our results were higher in PGN patients compared with patients who received renal biopsies since renal biopsies were often performed on PGN patients before diagnosis. This applied to both adult and pediatric populations. Compared to the US population in Kwon 2021 [ 84 ], the diagnosis rate among PGN populations in this review was higher (26-72.1% vs. 9.4-19.7%). The diagnosis rate among populations with renal biopsies was also higher (6.3-61.9% vs. 6.3-14.3%). Notably, though not covered by this review, the pathological profile such as Oxford Classification/MEST classification could also shed light upon disease burden, which could be further explored by future studies.

IgAN treatments primarily consisted of ACEIs/ARBs, and high utilization of steroids was found despite mixed evidence on their benefits and safety. There is limited data on IgAN treatment patterns from Taiwan and Australia. Among the publications that reported treatment patterns, few specified drugs’ generic names. The primary treatment patterns reported among select countries/regions in this study are similar to those in US as reported by Kwon 2021 (frequently used therapies were immunosuppressives, corticosteroids, and ACEIs/ARBs) [ 84 ]. Immunosuppressives were used more by children than adults based on data from mainland China, South Korea, and Japan. According to the KDIGO guideline regarding glomerular diseases, the immunosuppressive therapies including azathioprine, cyclophosphamide, calcineurin inhibitors, and rituximab are not recommended for treating IgAN. Mycophenolate mofetil is recommended in Chinese patients and tonsillectomy is recommended to be used in Japanese IgAN patients [ 1 ]. Only Chinese studies reporting SF-36 scores and other metrics were identified. Therefore, more studies on QoL in IgAN patients and caregivers in other regions are warranted.

Evidence of economic burden was identified only from studies in mainland China; Li 2018 was one retrospective national inpatient database study, which included the major hospitals that covers multiple geographic locations [ 47 ], other two studies used the data from one hospital. The mean cost per patient per year reported by Li 2018 is $1,284.73, while one Canadian retrospective study for costs and healthcare resource utilization reported a mean outpatient medication cost per patient per year of Canadian dollar (CAD) $221 in 2016 [ 87 ]. To control medical costs, hospitals in China are undergoing clinical pathway optimization programs [ 12 ].

Publications reported heterogeneous sample populations where IgAN prevalence/diagnosis rates were evaluated. Among 22 publications that reported IgAN prevalence/diagnosis rates, 15 measured IgAN prevalence for patients who underwent renal biopsy and 9 measured IgAN prevalence for patients diagnosed with PGN. Heterogeneity in IgAN prevalence/diagnosis rates may be attributed to differences in study years, patient race/ethnicity, patient age, treatment method, risk factors, diagnosis, and follow-up duration. Other study design–related factors that could introduce bias include sample size and gender composition.

Finally, differences in IgAN prevalence across regions should be noted. County/region-specific healthcare infrastructure and policies influence the epidemiological evidence of IgAN. systematic urine screening programs among individuals with asymptomatic, persistent microscopic hematuria with/without mild proteinuria are commonly implemented in certain countries/regions. These programs facilitate detection of IgAN patients who would otherwise receive a delayed diagnosis or none at all. Countries/regions where screening programs are performed may therefore have higher reported IgAN prevalence. Screening programs play a crucial role in early diagnosis and early treatment [ 88 ].

To our knowledge, this is the first TLR for IgAN in mainland China, Taiwan, South Korea, Japan, and Australia. However, several limitations should be noted. Due to the targeted nature of this review, the search focused on the most relevant literature, and the publications included in this study were prioritized, which potentially have led to an incomplete picture of IgAN-related epidemiology, treatment patterns and disease burden. Across included publications, the sample sizes varied widely and were not always reported. Additionally, this TLR did not weigh the data from included publications; therefore, biases should be considered when comparing outcomes. Studies came from primarily single institutions, and national-level data was not always available for the selected countries/regions. Moreover, this review only covered select Asia-Pacific countries/regions; future reviews and studies in other countries and regions within Asia-Pacific are therefore warranted. Despite these limitations, the evidence gathered in this literature review may help provide a preliminary understanding of the disease burden of IgAN in the Asia-Pacific region.

This TLR summarized evidence on Immunoglobulin type A nephropathy (IgAN) prevalence, treatment patterns, and humanistic and economic burden. Our results suggest that despite the overall scarcity of information in general, evidence on disease burden and treatment patterns has been reported by some studies and several clinical guidelines. The prevalence of IgAN among the general population is not commonly available, while that among patients receiving renal biopsies and diagnosed with PGN is more frequently reported. Heterogeneity in prevalence rates across geographic regions might be explained by differences in initial diagnosis in some regions due to variation in local screening policy and disease management. There is a need to understand how the disease progression differs by those practices. Treatment patterns have been reported mainly in studies from some Asia areas, but geographic variations are noticeable. There is also a need to generate more evidence to shed light upon the possible explanation to the differences in the treatment patterns across geographic regions. In sum, more real-world studies at national levels across select countries/regions are warranted to fill the evidence gaps, particularly regarding incidence, humanistic burden, and economic burden.

The prevalence of IgA nephropathy among the general population in select APAC countries/regions is not commonly available, despite evidence from studies and clinical guidelines. In addition, it is observed across geographic regions that heterogeneity exists in prevalence rates, and large variations exist in treatment patterns. Future studies are needed to fill in these gaps to understand the contributing factors behind the differences through population-based, multi-center, and real-world studies.

Data availability

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Abbreviations

Angiotensin-converting enzyme inhibitor

Acute nephritic syndrome

Asia Pacific

Angiotensin receptor blockers

Canadian dollar

Chronic kidney disease

China National Knowledge Infrastructure

Chronic nephrotic syndrome

Chinese Yuan

Cyclophosphamide

Daily Living Ability Rating Scale

Diffuse mesangial proliferation

Excerpta Medica Database

End-stage kidney failure

Focal mesangial proliferation

General health

Individualized nursing intervention

The Kidney Disease: Improving Global Outcomes

Korean Information Service System

Mycophenolate mofetil

Not reported

Nephritis syndrome

Primary glomerulonephritis

Population, intervention, comparators, outcomes, and study design

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Quality assessment

Routine nursing intervention

Rapidly progressive glomerulonephritis

Self-Rating Anxiety Scale

Standard deviation

Self-Rating Depression Scale

36-Item Short Form Health Survey

Systematic literature review

Targeted literature review

Taiwan Society of Nephrology

Working Group for National Survey on Status of Diagnosis and Treatment of Childhood Renal Diseases

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This work was supported by Otsuka Pharmaceutical Development & Commercialization, Inc., Princeton, NJ.

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Research conception and/or design: Kristin Pareja, Sandipan Bhattacharjee, Omer Zaidi, Fen Du, and Zhaoli Tang; Literature searching strategy: Omer Zaidi, Fen Du, and Zhaoli Tang; literature screening and data extraction and analysis: Fen Du and Zhaoli Tang; All authors were involved in the drafting and /or substantial revision of manuscript; All authors accept accountability for their contributions and agree as a condition of authorship to ensure resolution of questions about the work. All authors approved the submitted version.

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Zaidi, O., Du, F., Tang, Z. et al. Review on epidemiology, disease burden, and treatment patterns of IgA nephropathy in select APAC countries. BMC Nephrol 25 , 136 (2024). https://doi.org/10.1186/s12882-024-03555-5

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Person-centered care assessment tool with a focus on quality healthcare: a systematic review of psychometric properties

• Lluna Maria Bru-Luna 1 ,
• Manuel Martí-Vilar 2 ,
• César Merino-Soto 3 ,
• José Livia-Segovia 4 ,
• Juan Garduño-Espinosa 5 &
• Filiberto Toledano-Toledano 5 , 6 , 7  

BMC Psychology volume  12 , Article number:  217 ( 2024 ) Cite this article

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The person-centered care (PCC) approach plays a fundamental role in ensuring quality healthcare. The Person-Centered Care Assessment Tool (P-CAT) is one of the shortest and simplest tools currently available for measuring PCC. The objective of this study was to conduct a systematic review of the evidence in validation studies of the P-CAT, taking the “Standards” as a frame of reference.

First, a systematic literature review was conducted following the PRISMA method. Second, a systematic descriptive literature review of validity tests was conducted following the “Standards” framework. The search strategy and information sources were obtained from the Cochrane, Web of Science (WoS), Scopus and PubMed databases. With regard to the eligibility criteria and selection process, a protocol was registered in PROSPERO (CRD42022335866), and articles had to meet criteria for inclusion in the systematic review.

A total of seven articles were included. Empirical evidence indicates that these validations offer a high number of sources related to test content, internal structure for dimensionality and internal consistency. A moderate number of sources pertain to internal structure in terms of test-retest reliability and the relationship with other variables. There is little evidence of response processes, internal structure in measurement invariance terms, and test consequences.

The various validations of the P-CAT are not framed in a structured, valid, theory-based procedural framework like the “Standards” are. This can affect clinical practice because people’s health may depend on it. The findings of this study show that validation studies continue to focus on the types of validity traditionally studied and overlook interpretation of the scores in terms of their intended use.

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Person-centered care (PCC)

Quality care for people with chronic diseases, functional limitations, or both has become one of the main objectives of medical and care services. The person-centered care (PCC) approach is an essential element not only in achieving this goal but also in providing high-quality health maintenance and medical care [ 1 , 2 , 3 ]. In addition to guaranteeing human rights, PCC provides numerous benefits to both the recipient and the provider [ 4 , 5 ]. Additionally, PCC includes a set of necessary competencies for healthcare professionals to address ongoing challenges in this area [ 6 ]. PCC includes the following elements [ 7 ]: an individualized, goal-oriented care plan based on individuals’ preferences; an ongoing review of the plan and the individual’s goals; support from an interprofessional team; active coordination among all medical and care providers and support services; ongoing information exchange, education and training for providers; and quality improvement through feedback from the individual and caregivers.

There is currently a growing body of literature on the application of PCC. A good example of this is McCormack’s widely known mid-range theory [ 8 ], an internationally recognized theoretical framework for PCC and how it is operationalized in practice. This framework forms a guide for care practitioners and researchers in hospital settings. This framework is elaborated in PCC and conceived of as “an approach to practice that is established through the formation and fostering of therapeutic relationships between all care providers, service users, and others significant to them, underpinned by values of respect for persons, [the] individual right to self-determination, mutual respect, and understanding” [ 9 ].

Thus, as established by PCC, it is important to emphasize that reference to the person who is the focus of care refers not only to the recipient but also to everyone involved in a care interaction [ 10 , 11 ]. PCC ensures that professionals are trained in relevant skills and methodology since, as discussed above, carers are among the agents who have the greatest impact on the quality of life of the person in need of care [ 12 , 13 , 14 ]. Furthermore, due to the high burden of caregiving, it is essential to account for caregivers’ well-being. In this regard, studies on professional caregivers are beginning to suggest that the provision of PCC can produce multiple benefits for both the care recipient and the caregiver [ 15 ].

Despite a considerable body of literature and the frequent inclusion of the term in health policy and research [ 16 ], PCC involves several complications. There is no standard consensus on the definition of this concept [ 17 ], which includes problematic areas such as efficacy assessment [ 18 , 19 ]. In addition, the difficulty of measuring the subjectivity involved in identifying the dimensions of the CPC and the infrequent use of standardized measures are acute issues [ 20 ]. These limitations and purposes motivated the creation of the Person-Centered Care Assessment Tool (P-CAT; [ 21 ]), which emerged from the need for a brief, economical, easily applied, versatile and comprehensive assessment instrument to provide valid and reliable measures of PCC for research purposes [ 21 ].

Person-centered care assessment tool (P-CAT)

There are several instruments that can measure PCC from different perspectives (i.e., the caregiver or the care recipient) and in different contexts (e.g., hospitals and nursing homes). However, from a practical point of view, the P-CAT is one of the shortest and simplest tools and contains all the essential elements of PCC described in the literature. It was developed in Australia to measure the approach of long-term residential settings to older people with dementia, although it is increasingly used in other healthcare settings, such as oncology units [ 22 ] and psychiatric hospitals [ 23 ].

Due to the brevity and simplicity of its application, the versatility of its use in different medical and care contexts, and its potential emic characteristics (i.e., constructs that can be cross-culturally applicable with reasonable and similar structure and interpretation; [ 24 ]), the P-CAT is one of the most widely used tests by professionals to measure PCC [ 25 , 26 ]. It has expanded to several countries with cultural and linguistic differences. Since its creation, it has been adapted in countries separated by wide cultural and linguistic differences, such as Norway [ 27 ], Sweden [ 28 ], China [ 29 ], South Korea [ 30 ], Spain [ 25 ], and Italy [ 31 ].

The P-CAT comprises 13 items rated on a 5-point ordinal scale (from “strongly disagree” to “strongly agree”), with high scores indicating a high degree of person-centeredness. The scale consists of three dimensions: person-centered care (7 items), organizational support (4 items) and environmental accessibility (2 items). In the original study ( n  = 220; [ 21 ]), the internal consistency of the instrument yielded satisfactory values for the total scale ( α  = 0.84) and good test-retest reliability ( r  =.66) at one-week intervals. A reliability generalization study conducted in 2021 [ 32 ] that estimated the internal consistency of the P-CAT and analyzed possible factors that could affect the it revealed that the mean α value for the 25 meta-analysis samples (some of which were part of the validations included in this study) was 0.81, and the only variable that had a statistically significant relationship with the reliability coefficient was the mean age of the sample. With respect to internal structure validity, three factors (56% of the total variance) were obtained, and content validity was assessed by experts, literature reviews and stakeholders [ 33 ].

Although not explicitly stated, the apparent commonality between validation studies of different versions of the P-CAT may be influenced by an influential decades-old validity framework that differentiates three categories: content validity, construct validity, and criterion validity [ 34 , 35 ]. However, a reformulation of the validity of the P-CAT within a modern framework, which would provide a different definition of validity, has not been performed.

Scale validity

Traditionally, validation is a process focused on the psychometric properties of a measurement instrument [ 36 ]. In the early 20th century, with the frequent use of standardized measurement tests in education and psychology, two definitions emerged: the first defined validity as the degree to which a test measures what it intends to measure, while the second described the validity of an instrument in terms of the correlation it presents with a variable [ 35 ].

However, in the past century, validity theory has evolved, leading to the understanding that validity should be based on specific interpretations for an intended purpose. It should not be limited to empirically obtained psychometric properties but should also be supported by the theory underlying the construct measured. Thus, to speak of classical or modern validity theory suggests an evolution in the classical or modern understanding of the concept of validity. Therefore, a classical approach (called classical test theory, CTT) is specifically differentiated from a modern approach. In general, recent concepts associated with a modern view of validity are based on (a) a unitary conception of validity and (b) validity judgments based on inferences and interpretations of the scores of a measure [ 37 , 38 ]. This conceptual advance in the concept of validity led to the creation of a guiding framework to for obtaining evidence to support the use and interpretation of the scores obtained by a measure [ 39 ].

This purpose is addressed by the Standards for Educational and Psychological Testing (“Standards”), a guide created by the American Educational Research Association (AERA), the American Psychological Association (APA) and the National Council on Measurement in Education (NCME) in 2014 with the aim of providing guidelines to assess the validity of the interpretations of scores of an instrument based on their intended use. Two conceptual aspects stand out in this modern view of validity: first, validity is a unitary concept centered on the construct; second, validity is defined as “the degree to which evidence and theory support the interpretations of test scores for proposed uses of tests” [ 37 ]. Thus, the “Standards” propose several sources that serve as a reference for assessing different aspects of validity. The five sources of valid evidence are as follows [ 37 ]: test content, response processes, internal structure, relations to other variables and consequences of testing. According to AERA et al. [ 37 ], test content validity refers to the relationship of the administration process, subject matter, wording and format of test items to the construct they are intended to measure. It is measured predominantly with qualitative methods but without excluding quantitative approaches. The validity of the responses is based on analysis of the cognitive processes and interpretation of the items by respondents and is measured with qualitative methods. Internal structure validity is based on the interrelationship between the items and the construct and is measured by quantitative methods. Validity in terms of the relationship with other variables is based on comparison between the variable that the instrument intends to measure and other theoretically relevant external variables and is measured by quantitative methods. Finally, validity based on the results of the test analyses consequences, both intended and unintended, that may be due to a source of invalidity. It is measured mainly by qualitative methods.

Thus, although validity plays a fundamental role in providing a strong scientific basis for interpretations of test scores, validation studies in the health field have traditionally focused on content validity, criterion validity and construct validity and have overlooked the interpretation and use of scores [ 34 ].

“Standards” are considered a suitable validity theory-based procedural framework for reviewing the validity of questionnaires due to its ability to analyze sources of validity from both qualitative and quantitative approaches and its evidence-based method [ 35 ]. Nevertheless, due to a lack of knowledge or the lack of a systematic description protocol, very few instruments to date have been reviewed within the framework of the “Standards” [ 39 ].

Current study

Although the P-CAT is one of the most widely used instruments by professionals and has seven validations [ 25 , 27 , 28 , 29 , 30 , 31 , 40 ], no analysis has been conducted of its validity within the framework of the “Standards”. That is, empirical evidence of the validity of the P-CAT has not been obtained in a way that helps to develop a judgment based on a synthesis of the available information.

A review of this type is critical given that some methodological issues seem to have not been resolved in the P-CAT. For example, although the multidimensionality of the P-CAT was identified in the study that introduced it, Bru-Luna et al. [ 32 ] recently stated that in adaptations of the P-CAT [ 25 , 27 , 28 , 29 , 30 , 40 ], the total score is used for interpretation and multidimensionality is disregarded. Thus, the multidimensionality of the original study was apparently not replicated. Bru-Luna et al. [ 32 ] also indicated that the internal structure validity of the P-CAT is usually underreported due to a lack of sufficiently rigorous approaches to establish with certainty how its scores are calculated.

The validity of the P-CAT, specifically its internal structure, appears to be unresolved. Nevertheless, substantive research and professional practice point to this measure as relevant to assessing PCC. This perception is contestable and judgment-based and may not be sufficient to assess the validity of the P-CAT from a cumulative and synthetic angle based on preceding validation studies. An adequate assessment of validity requires a model to conceptualize validity followed by a review of previous studies of the validity of the P-CAT using this model.

Therefore, the main purpose of this study was to conduct a systematic review of the evidence provided by P-CAT validation studies while taking the “Standards” as a framework.

The present study comprises two distinct but interconnected procedures. First, a systematic literature review was conducted following the PRISMA method ( [ 41 ]; Additional file 1; Additional file 2) with the aim of collecting all validations of the P-CAT that have been developed. Second, a systematic description of the validity evidence for each of the P-CAT validations found in the systematic review was developed following the “Standards” framework [ 37 ]. The work of Hawkins et al. [ 39 ], the first study to review validity sources according to the guidelines proposed by the “Standards”, was also used as a reference. Both provided conceptual and pragmatic guidance for organizing and classifying validity evidence for the P-CAT.

The procedure conducted in the systematic review is described below, followed by the procedure for examining the validity studies.

Systematic review

Search strategy and information sources.

Initially, the Cochrane database was searched with the aim of identifying systematic reviews of the P-CAT. When no such reviews were found, subsequent preliminary searches were performed in the Web of Science (WoS), Scopus and PubMed databases. These databases play a fundamental role in recent scientific literature since they are the main sources of published articles that undergo high-quality content and editorial review processes [ 42 ]. The search formula was as follows. The original P-CAT article [ 21 ] was located, after which all articles that cited it through 2021 were identified and analyzed. This approach ensured the inclusion of all validations. No articles were excluded on the basis of language to avoid language bias [ 43 ]. Moreover, to reduce the effects of publication bias, a complementary search in Google Scholar was also performed to allow the inclusion of “gray” literature [ 44 ]. Finally, a manual search was performed through a review of the references of the included articles to identify other articles that met the search criteria but were not present in any of the aforementioned databases.

This process was conducted by one of the authors and corroborated by another using the Covidence tool [ 45 ]. A third author was consulted in case of doubt.

Eligibility criteria and selection process

The protocol was registered in PROSPERO, and the search was conducted according to these criteria. The identification code is CRD42022335866.

The articles had to meet the following criteria for inclusion in the systematic review: (a) a methodological approach to P-CAT validations, (b) an experimental or quasiexperimental studies, (c) studies with any type of sample, and (d) studies in any language. We discarded studies that met at least one of the following exclusion criteria: (a) systematic reviews or bibliometric reviews of the instrument or meta-analyses or (b) studies published after 2021.

Data collection process

After the articles were selected, the most relevant information was extracted from each article. Fundamental data were recorded in an Excel spreadsheet for each of the sections: introduction, methodology, results and discussion. Information was also recorded about the limitations mentioned in each article as well as the practical implications and suggestions for future research.

Given the aim of the study, information was collected about the sources of validity of each study, including test content (judges’ evaluation, literature review and translation), response processes, internal structure (factor analysis, design, estimator, factor extraction method, factors and items, interfactor R, internal replication, effect of the method, and factor loadings), and relationships with other variables (convergent, divergent, concurrent and predictive validity) and consequences of measurement.

Description of the validity study

To assess the validity of the studies, an Excel table was used. Information was recorded for the seven articles included in the systematic review. The data were extracted directly from the texts of the articles and included information about the authors, the year of publication, the country where each P-CAT validation was produced and each of the five standards proposed in the “Standards” [ 37 ].

The validity source related to internal structure was divided into three sections to record information about dimensionality (e.g., factor analysis, design, estimator, factor extraction method, factors and items, interfactor R, internal replication, effect of the method, and factor loadings), reliability expression (i.e., internal consistency and test-retest) and the study of factorial invariance according to the groups into which it was divided (e.g., sex, age, profession) and the level of study (i.e., metric, intercepts). This approach allowed much more information to be obtained than relying solely on source validity based on internal structure. This division was performed by the same researcher who performed the previous processes.

Study selection and study characteristics

The systematic review process was developed according to the PRISMA methodology [ 41 ].

The WoS, Scopus, PubMed and Google Scholar databases were searched on February 12, 2022 and yielded a total of 485 articles. Of these, 111 were found in WoS, 114 in Scopus, 43 in PubMed and 217 in Google Scholar. In the first phase, the title and abstracts of all the articles were read. In this first screening, 457 articles were eliminated because they did not include studies with a methodological approach to P-CAT validation and one article was excluded because it was the original P-CAT article. This resulted in a total of 27 articles, 19 of which were duplicated in different databases and, in the case of Google Scholar, within the same database. This process yielded a total of eight articles that were evaluated for eligibility by a complete reading of the text. In this step, one of the articles was excluded due to a lack of access to the full text of the study [ 31 ] (although the original manuscript was found, it was impossible to access the complete content; in addition, the authors of the manuscript were contacted, but no reply was received). Finally, a manual search was performed by reviewing the references of the seven studies, but none were considered suitable for inclusion. Thus, the review was conducted with a total of seven articles.

Of the seven studies, six were original validations in other languages. These included Norwegian [ 27 ], Swedish [ 28 ], Chinese (which has two validations [ 29 , 40 ]), Spanish [ 25 ], and Korean [ 30 ]. The study by Selan et al. [ 46 ] included a modification of the Swedish version of the P-CAT and explored the psychometric properties of both versions (i.e., the original Swedish version and the modified version).

The item selection and screening process are illustrated in detail in Fig.  1 .

PRISMA 2020 flow diagram for new systematic reviews including database searches

Validity analysis

To provide a clear overview of the validity analyses, Table  1 descriptively shows the percentages of items that provide information about the five standards proposed by the “Standards” guide [ 37 ].

The table shows a high number of validity sources related to test content and internal structure in relation to dimensionality and internal consistency, followed by a moderate number of sources for test-retest and relationship with other variables. A rate of 0% is observed for validity sources related to response processes, invariance and test consequences. Below, different sections related to each of the standards are shown, and the information is presented in more detail.

Evidence based on test content

The first standard, which focused on test content, was met for all items (100%). Translation, which refers to the equivalence of content between the original language and the target language, was met in the six articles that conducted validation in another language and/or culture. These studies reported that the validations were translated by bilingual experts and/or experts in the area of care. In addition, three studies [ 25 , 29 , 40 ] reported that the translation process followed International Test Commission guidelines, such as those of Beaton et al. [ 47 ], Guillemin [ 48 ], Hambleton et al. [ 49 ], and Muñiz et al. [ 50 ]. Evaluation by judges, who referred to the relevance, clarity and importance of the content, was divided into two categories: expert evaluation (a panel of expert judges for each of the areas to consider in the evaluation instrument) and experiential evaluation (potential participants testing the test). The first type of evaluation occurred in three of the articles [ 28 , 29 , 46 ], while the other occurred in two [ 25 , 40 ]. Only one of the items [ 29 ] reported that the scale contained items that reflected the dimension described in the literature. The validity evidence related to the test content presented in each article can be found in Table  2 .

Evidence based on response processes

The second standard, related to the validity of the response process, was obtained according to the “Standards” from the analysis of individual responses: “questioning test takers about their performance strategies or response to particular items (…), maintaining records that monitor the development of a response to a writing task (…), documentation of other aspects of performance, like eye movement or response times…” [ 37 ] (p. 15). According to the analysis of the validity of the response processes, none of the articles complied with this evidence.

Evidence based on internal structure

The third standard, validity related to internal structure, was divided into three sections. First, the dimensionality of each study was examined in terms of factor analysis, design, estimator, factor extraction method, factors and items, interfactor R, internal replication, effect of the method, and factor loadings. Le et al. [ 40 ] conducted an exploratory-confirmatory design while Sjögren et al. [ 28 ] conducted a confirmatory-exploratory design to assess construct validity using confirmatory factor analysis (CFA) and investigated it further using exploratory factor analysis (EFA). The remaining articles employed only a single form of factor analysis: three employed EFA, and two employed CFA. Regarding the next point, only three of the articles reported the factor extraction method used, including Kaiser’s eigenvalue, criterion, scree plot test, parallel analysis and Velicer’s MAP test. Instrument validations yielded a total of two factors in five of the seven articles, while one yielded a single dimension [ 25 ] and the other yielded three dimensions [ 29 ], as in the original instrument. The interfactor R was reported only in the study by Zhong and Lou [ 29 ], whereas in the study by Martínez et al. [ 25 ], it could be easily obtained since it consisted of only one dimension. Internal replication was also calculated in the Spanish validation by randomly splitting the sample into two to test the correlations between factors. The effectiveness of the method was not reported in any of the articles. This information is presented in Table  3 in addition to a summary of the factor loadings.

The second section examined reliability. All the studies presented measures of internal consistency conducted in their entirety with Cronbach’s α coefficient for both the total scale and the subscales. The ω coefficient of McDonald was not used in any case. Four of the seven articles performed a test-retest test. Martínez et al. [ 25 ] conducted a test-retest after a period of seven days, while Le et al. [ 40 ] and Rokstad et al. [ 27 ] performed it between one and two weeks later and Sjögren et al. [ 28 ] allowed approximately two weeks to pass after the initial test.

The third section analyzes the calculation of invariance, which was not reported in any of the studies.

Evidence based on relationships with other variables

In the fourth standard, based on validity according to the relationship with other variables, the articles that reported it used only convergent validity (i.e., it was hypothesized that the variables related to the construct measured by the test—in this case, person-centeredness—were positively or negatively related to another construct). Discriminant validity hypothesizes that the variables related to the PCC construct are not correlated in any way with any other variable studied. No article (0%) measured discriminant evidence, while four (57%) measured convergent evidence [ 25 , 29 , 30 , 46 ]. Convergent validity was obtained through comparisons with instruments such as the Person-Centered Climate Questionnaire–Staff Version (PCQ-S), the Staff-Based Measures of Individualized Care for Institutionalized Persons with Dementia (IC), the Caregiver Psychological Elder Abuse Behavior Scale (CPEAB), the Organizational Climate (CLIOR) and the Maslach Burnout Inventory (MBI). In the case of Selan et al. [ 46 ], convergent validity was assessed on two items considered by the authors as “crude measures of person-centered care (i.e., external constructs) giving an indication of the instruments’ ability to measure PCC” (p. 4). Concurrent validity, which measures the degree to which the results of one test are or are not similar to those of another test conducted at more or less the same time with the same participants, and predictive validity, which allows predictions to be established regarding behavior based on comparison between the values of the instrument and the criterion, were not reported in any of the studies.

Evidence based on the consequences of testing

The fifth and final standard was related to the consequences of the test. It analyzed the consequences, both intended and unintended, of applying the test to a given sample. None of the articles presented explicit or implicit evidence of this.

The last two sources of validity can be seen in Table  4 .

Table  5 shows the results of the set of validity tests for each study according to the described standards.

The main purpose of this article is to analyze the evidence of validity in different validation studies of the P-CAT. To gather all existing validations, a systematic review of all literature citing this instrument was conducted.

The publication of validation studies of the P-CAT has been constant over the years. Since the publication of the original instrument in 2010, seven validations have been published in other languages (taking into account the Italian version by Brugnolli et al. [ 31 ], which could not be included in this study) as well as a modification of one of these versions. The very unequal distribution of validations between languages and countries is striking. A recent systematic review [ 51 ] revealed that in Europe, the countries where the PCC approach is most widely used are the United Kingdom, Sweden, the Netherlands, Northern Ireland, and Norway. It has also been shown that the neighboring countries seem to exert an influence on each other due to proximity [ 52 ] such that they tend to organize healthcare in a similar way, as is the case for Scandinavian countries. This favors the expansion of PCC and explains the numerous validations we found in this geographical area.

Although this approach is conceived as an essential element of healthcare for most governments [ 53 ], PCC varies according to the different definitions and interpretations attributed to it, which can cause confusion in its application (e.g., between Norway and the United Kingdom [ 54 ]). Moreover, facilitators of or barriers to implementation depend on the context and level of development of each country, and financial support remains one of the main factors in this regard [ 53 ]. This fact explains why PCC is not globally widespread among all territories. In countries where access to healthcare for all remains out of reach for economic reasons, the application of this approach takes a back seat, as does the validation of its assessment tools. In contrast, in a large part of Europe or in countries such as China or South Korea that have experienced decades of rapid economic development, patients are willing to be involved in their medical treatment and enjoy more satisfying and efficient medical experiences and environments [ 55 ], which facilitates the expansion of validations of instruments such as the P-CAT.

Regarding validity testing, the guidelines proposed by the “Standards” [ 37 ] were followed. According to the analysis of the different validations of the P-CAT instrument, none of the studies used a structured validity theory-based procedural framework for conducting validation. The most frequently reported validity tests were on the content of the test and two of the sections into which the internal structure was divided (i.e., dimensionality and internal consistency).

In the present article, the most cited source of validity in the studies was the content of the test because most of the articles were validations of the P-CAT in other languages, and the authors reported that the translation procedure was conducted by experts in all cases. In addition, several of the studies employed International Test Commission guidelines, such as those by Beaton et al. [ 47 ], Guillemin [ 48 ], Hambleton et al. [ 49 ], and Muñiz et al. [ 50 ]. Several studies also assessed the relevance, clarity and importance of the content.

The third source of validity, internal structure, was the next most often reported, although it appeared unevenly among the three sections into which this evidence was divided. Dimensionality and internal consistency were reported in all studies, followed by test-retest consistency. In relation to the first section, factor analysis, a total of five EFAs and four CFAs were presented in the validations. Traditionally, EFA has been used in research to assess dimensionality and identify key psychological constructs, although this approach involves a number of inconveniences, such as difficulty testing measurement invariance and incorporating latent factors into subsequent analyses [ 56 ] or the major problem of factor loading matrix rotation [ 57 ]. Studies eventually began to employ CFA, a technique that overcame some of these obstacles [ 56 ] but had other drawbacks; for example, the strict requirement of zero cross-loadings often does not fit the data well, and misspecification of zero loadings tends to produce distorted factors [ 57 ]. Recently, exploratory structural equation modeling (ESEM) has been proposed. This technique is widely recommended both conceptually and empirically to assess the internal structure of psychological tools [ 58 ] since it overcomes the limitations of EFA and CFA in estimating their parameters [ 56 , 57 ].

The next section, reliability, reports the total number of items according to Cronbach’s α reliability coefficient. Reliability is defined as a combination of systematic and random influences that determine the observed scores on a psychological test. Reporting the reliability measure ensures that item-based scores are consistent, that the tool’s responses are replicable and that they are not modified solely by random noise [ 59 , 60 ]. Currently, the most commonly employed reliability coefficient in studies with a multi-item measurement scale (MIMS) is Cronbach’s α [ 60 , 61 ].

Cronbach’s α [ 62 ] is based on numerous strict assumptions (e.g., the test must be unidimensional, factor loadings must be equal for all items and item errors should not covary) to estimate internal consistency. These assumptions are difficult to meet, and their violation may produce small reliability estimates [ 60 ]. One of the alternative measures to α that is increasingly recommended by the scientific literature is McDonald’s ω [ 63 ], a composite reliability measure. This coefficient is recommended for congeneric scales in which tau equivalence is not assumed. It has several advantages. For example, estimates of ω are usually robust when the estimated model contains more factors than the true model, even with small samples, or when skewness in univariate item distributions produces lower biases than those found when using α [ 59 ].

The test-retest method was the next most commonly reported internal structure section in these studies. This type of reliability considers the consistency of the scores of a test between two measurements separated by a period [ 64 ]. It is striking that test-retest consistency does not have a prevalence similar to that of internal consistency since, unlike internal consistency, test-retest consistency can be assessed for practically all types of patient-reported outcomes. It is even considered by some measurement experts to report reliability with greater relevance than internal consistency since it plays a fundamental role in the calculation of parameters for health measures [ 64 ]. However, the literature provides little guidance regarding the assessment of this type of reliability.

The internal structure section that was least frequently reported in the studies in this review was invariance. A lack of invariance refers to a difference between scores on a test that is not explained by group differences in the structure it is intended to measure [ 65 ]. The invariance of the measure should be emphasized as a prerequisite in comparisons between groups since “if scale invariance is not examined, item bias may not be fully recognized and this may lead to a distorted interpretation of the bias in a particular psychological measure” [ 65 ].

Evidence related to other variables was the next most reported source of validity in the studies included in this review. Specifically, the four studies that reported this evidence did so according to convergent validity and cited several instruments. None of the studies included evidence of discriminant validity, although this may be because there are currently several obstacles related to the measurement of this type of validity [ 66 ]. On the one hand, different definitions are used in the applied literature, which makes its evaluation difficult; on the other hand, the literature on discriminant validity focuses on techniques that require the use of multiple measurement methods, which often seem to have been introduced without sufficient evidence or are applied randomly.

Validity related to response processes was not reported by any of the studies. There are several methods to analyze this validity. These methods can be divided into two groups: “those that directly access the psychological processes or cognitive operations (think aloud, focus group, and interviews), compared to those which provide indirect indicators which in turn require additional inference (eye tracking and response times)” [ 38 ]. However, this validity evidence has traditionally been reported less frequently than others in most studies, perhaps because there are fewer clear and accepted practices on how to design or report these studies [ 67 ].

Finally, the consequences of testing were not reported in any of the studies. There is debate regarding this source of validity, with two main opposing streams of thought. On the one hand [ 68 , 69 ]) suggests that consequences that appear after the application of a test should not derive from any source of test invalidity and that “adverse consequences only undermine the validity of an assessment if they can be attributed to a problem of fit between the test and the construct” (p. 6). In contrast, Cronbach [ 69 , 70 ] notes that adverse social consequences that may result from the application of a test may call into question the validity of the test. However, the potential risks that may arise from the application of a test should be minimized in any case, especially in regard to health assessments. To this end, it is essential that this aspect be assessed by instrument developers and that the experiences of respondents be protected through the development of comprehensive and informed practices [ 39 ].

This work is not without limitations. First, not all published validation studies of the P-CAT, such as the Italian version by Brugnolli et al. [ 31 ], were available. These studies could have provided relevant information. Second, many sources of validity could not be analyzed because the studies provided scant or no data, such as response processes [ 25 , 27 , 28 , 29 , 30 , 40 , 46 ], relationships with other variables [ 27 , 28 , 40 ], consequences of testing [ 25 , 27 , 28 , 29 , 30 , 40 , 46 ], or invariance [ 25 , 27 , 28 , 29 , 30 , 40 , 46 ] in the case of internal structure and interfactor R [ 27 , 28 , 30 , 40 , 46 ], internal replication [ 27 , 28 , 29 , 30 , 40 , 46 ] or the effect of the method [ 25 , 27 , 28 , 29 , 30 , 40 , 46 ] in the case of dimensionality. In the future, it is hoped that authors will become aware of the importance of validity, as shown in this article and many others, and provide data on unreported sources so that comprehensive validity studies can be performed.

The present work also has several strengths. The search was extensive, and many studies were obtained using three different databases, including WoS, one of the most widely used and authoritative databases in the world. This database includes a large number and variety of articles and is not fully automated due to its human team [ 71 , 72 , 73 ]. In addition, to prevent publication bias, gray literature search engines such as Google Scholar were used to avoid the exclusion of unpublished research [ 44 ]. Finally, linguistic bias was prevented by not limiting the search to articles published in only one or two languages, thus avoiding the overrepresentation of studies in one language and underrepresentation in others [ 43 ].

Conclusions

Validity is understood as the degree to which tests and theory support the interpretations of instrument scores for their intended use [ 37 ]. From this perspective, the various validations of the P-CAT are not presented in a structured, valid, theory-based procedural framework like the “Standards” are. After integration and analysis of the results, it was observed that these validation reports offer a high number of sources of validity related to test content, internal structure in dimensionality and internal consistency, a moderate number of sources for internal structure in terms of test-retest reliability and the relationship with other variables, and a very low number of sources for response processes, internal structure in terms of invariance, and test consequences.

Validity plays a fundamental role in ensuring a sound scientific basis for test interpretations because it provides evidence of the extent to which the data provided by the test are valid for the intended purpose. This can affect clinical practice as people’s health may depend on it. In this sense, the “Standards” are considered a suitable and valid theory-based procedural framework for studying this modern conception of questionnaire validity, which should be taken into account in future research in this area.

Although the P-CAT is one of the most widely used instruments for assessing PCC, as shown in this study, PCC has rarely been studied. The developers of measurement tests applied to the health care setting, on which the health and quality of life of many people may depend, should use this validity framework to reflect the clear purpose of the measurement. This approach is important because the equity of decision making by healthcare professionals in daily clinical practice may depend on the source of validity. Through a more extensive study of validity that includes the interpretation of scores in terms of their intended use, the applicability of the P-CAT, an instrument that was initially developed for long-term care homes for elderly people, could be expanded to other care settings. However, the findings of this study show that validation studies continue to focus on traditionally studied types of validity and overlook the interpretation of scores in terms of their intended use.

Data availability

All data relevant to the study were included in the article or uploaded as additional files. Additional template data extraction forms are available from the corresponding author upon reasonable request.

Abbreviations

American Educational Research Association

American Psychological Association

Confirmatory factor analysis

Organizational Climate

Caregiver Psychological Elder Abuse Behavior Scale

Exploratory factor analysis

Exploratory structural equation modeling

Staff-based Measures of Individualized Care for Institutionalized Persons with Dementia

Maslach Burnout Inventory

Multi-item measurement scale

Maximum likelihood

National Council on Measurement in Education

Person-Centered Care Assessment Tool

• Person-centered care

Person-Centered Climate Questionnaire–Staff Version

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

International Register of Systematic Review Protocols

Standards for Educational and Psychological Testing

weighted least square mean and variance adjusted

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This work is one of the results of research project HIM/2015/017/SSA.1207, “Effects of mindfulness training on psychological distress and quality of life of the family caregiver”. Main researcher: Filiberto Toledano-Toledano Ph.D. The present research was funded by federal funds for health research and was approved by the Commissions of Research, Ethics and Biosafety (Comisiones de Investigación, Ética y Bioseguridad), Hospital Infantil de México Federico Gómez, National Institute of Health. The source of federal funds did not control the study design, data collection, analysis, or interpretation, or decisions regarding publication.

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L.M.B.L. conceptualized the study, collected the data, performed the formal anal- ysis, wrote the original draft, and reviewed and edited the subsequent drafts. M.M.V. collected the data and reviewed and edited the subsequent drafts. C.M.S. collected the data, performed the formal analysis, wrote the original draft, and reviewed and edited the subsequent drafts. J.L.S. collected the data, wrote the original draft, and reviewed and edited the subsequent drafts. J.G.E. collected the data and reviewed and edited the subsequent drafts. F.T.T. conceptualized the study and reviewed and edited the subsequent drafts. L.M.B.L. conceptualized the study and reviewed and edited the subsequent drafts. M.M.V. conceptualized the study and reviewed and edited the subsequent drafts. C.M.S. reviewed and edited the subsequent drafts. J.G.E. reviewed and edited the subsequent drafts. F.T.T. conceptualized the study; provided resources, software, and supervision; wrote the original draft; and reviewed and edited the subsequent drafts.

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Bru-Luna, L.M., Martí-Vilar, M., Merino-Soto, C. et al. Person-centered care assessment tool with a focus on quality healthcare: a systematic review of psychometric properties. BMC Psychol 12 , 217 (2024). https://doi.org/10.1186/s40359-024-01716-7

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Electronic Medical Records Management and Administration: Current Trends, Issues, Solutions, and Future Directions

• Review Article
• Published: 20 April 2024
• Volume 5 , article number  460 , ( 2024 )

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• Umar Abdulkadir   ORCID: orcid.org/0000-0002-8118-0626 1 ,
• Victor Onomza Waziri 1 ,
• John Kolo Alhassan   ORCID: orcid.org/0000-0002-9289-0404 2 &
• Idris Ismaila 1  

Electronic Medical Records (EMR) is often used to refer to as electronic personal health (EPH) records or electronic healthcare records (EHR). These are considered vivacious assets of health facilities and patients. The relevance of the EMRs has motivated diverse innovations in the collecting, organizing, managing and administering for purpose of treatment primarily and other reasons. There are various concerns raised about legitimate usages, reproducibility, accuracy, and privacy breaches of EMRs across majority of health and medical facilities globally. This phenomenon became popular due to its support of electronic devices, wireless links, transmission and storage of data in the cloud, and communication across a gateway (or central-point). Therefore, physicians and medical facilities were empowered to undertake virtual consultations to patients through telemedicine applications for the remote treatment and diagnosis. Internet of Things (IoT) systems, medical wearable objects, and sensors were the basic components that collect and transmit patient data on real-time basis to a base station or centralized servers managed by hospitals. However, there is the need to improve creation and adoption of EMRs not without understanding their roles and shortfalls as well possible means of improvement. Consequently, this study conducts a systematic literature review on electronic medical records management and administration under current trends, issues, solutions and future directions. To this end, eighty-one (81) peer-reviewed articles including conferences and journals papers were included in the final stage of the study after applying Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRIMA-P) methodology of records selection. The contributions of this study include: the recognition of the informed consent strategy as the best solution to illegitimate access to patient electronic records; the use of permissioned access strategies provided by blockchain technology as most recent attempt for privacy preservations; the use of lightweight cryptosystems with greater emphasis on Lattice systems; and the need to scale beyond theoretical frameworks to real-life implementations.

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The role of colchicine in the management of COVID-19: a Meta-analysis

• Kholoud Elshiwy 1 ,
• Ghada Essam El-Din Amin 1 , 2 ,
• Mohamed Nazmy Farres 3 ,
• Rasha Samir 3 &
• Mohamed Farouk Allam 1 , 4  

BMC Pulmonary Medicine volume  24 , Article number:  190 ( 2024 ) Cite this article

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The Coronavirus disease 2019 (COVID-19) pandemic has robustly affected the global healthcare and economic systems and it was caused by coronavirus-2 (SARS-CoV-2). The clinical presentation of the disease ranges from a flu-like illness to severe pneumonia and death. Till September 2022, the cumulative number of cases exceeded 600 million worldwide and deaths were more than 6 million. Colchicine is an alkaloid drug that is used in many autoinflammatory conditions e.g., gout, familial Mediterranean fever, and Behçet’s syndrome. Colchicine inhibits the production of superoxide and the release of interleukins that stimulate the inflammatory cascade. Colchicine decreases the differentiation of myofibroblast and the release of fibrotic mediators including transforming growth factor (TGF-β1) that are related to the fibrosis. Moreover, colchicine has been used to traet viral myocarditis caused by CMV or EBV, interstitial pneumonia, and pericarditis resulting from influenza B infection. Additionally, colchicine is considered safe and affordable with wide availability.

The aim of the current study was to assess the evidence of colchicine effectiveness in COVID-19 treatment.

A comprehensive review of the literature was done till May 2022 and yielded 814 articles after ranking the articles according to authors and year of publication. Only 8 clinical trials and cohort studies fulfilling the inclusion criteria were included for further steps of data collection, analysis, and reporting.

This meta-analysis involved 16,488 patients; 8146 patients in the treatment group and 8342 patients in the control group. The results showed that colchicine resulted in a significant reduction in the mortality rate among patients received colchicine in comparison with placebo or standard care (RR 0.35, 95%CI: 0.15–0.79). Colchicine resulted in a significant decrease in the need for O2 therapy in patients with COVID-19 (RR 0.07, 95%CI 0.02–0.27, P  = 0.000024). However, colchicine had no significant effect on the following outcomes among COVID-19 patients: the need for hospitalization, ICU admission, artificial ventilation, and hospital discharge rate. Among the PCR confirmed COVID-19 patients, colchicine decreased the hospitalization rate (RR 0.75, 95%CI 0.57–0.99, P  = 0.042). However, colchicine had no effect on mortality and the need for mechanical ventilation among this subgroup.

Colchicine caused a significant clinical improvement among COVID-19 patients as compared with the standard care or placebo, in terms of the need for O2, and mortality. This beneficial effect could play a role in the management of COVID-19 especially severe cases to decrease need for oxygen and to decrease mortality among these patients.

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Introduction

The Coronavirus disease 2019 (COVID-19) that was caused by coronavirus − 2 (SARS-CoV-2) has significantly impacted the healthcare and economic systems worldwide. The disease first began in Wuhan, China at the end of 2019. Then, it spread worldwide and became a pandemic. The clinical picture of the disease ranges from a flu-like illness to a massive inflammatory response and death [ 1 ]. In 2002 and 2003, there were outbreaks of severe respiratory distress syndrome in China. They occurred by SARS-CoV, another member of the coronavirus family. In 2012, another outbreak was documented in the Middle East and was caused by Middle East respiratory syndrome coronavirus (MERS-CoV) [ 2 ]. The current coronavirus is characterized by higher infectivity and geographical spread in comparison with both SARS and MERS. Therefore, COVID-19 was considered a significant global health threat that required robust efforts to minimize the burden of this pandemic [ 3 ].

The World Health Organization (WHO) announced that COVID-19 is a pandemic on 11 March 2020 [ 4 ]. Since then, the number of COVID-19 patients significantly increased. Till September 2022, the cumulative number of cases exceeded 600 million worldwide and deaths were more than 6 million [ 5 ].

The clinical manifestations of COVID-19 encompass symptoms such as fever, cough, dyspnea, malaise, or anosmia or ageusia, which can aid in early detection of the disease [ 6 ]. The primary mode of COVID-19 transmission is predominantly through exposure to infectious respiratory droplets from close contact with either symptomatic patients or asymptomatic carriers, as well as through aerosol particles that can remain suspended in the air for extended periods [ 7 ]. Additionally, indirect transmission through contaminated fomites, fecal excretion, environmental contamination, and fluid pollution has been documented, with viral viability reaching up to 72 hours after infecting surfaces [ 7 , 8 ].

SARS-CoV-2 is a beta coronavirus that is a positive-stranded enveloped RNA virus. Similar to SARS-CoV and MERS-CoV, it is found in domestic and farm animals [ 9 , 10 ]. The SARS-CoV-2 is characterized by spike proteins called S proteins. These proteins facilitate the viral infection through binding the S proteins and the angiotensin-converting enzyme 2 receptors (ACE2). These receptors are found in many tissues such as pneumocytes, enterocytes, renal cells, and endothelial cells [ 11 ]. SARS-CoV-2 causes marked dysfunction of the epithelial barrier and the endothelial cells of the pulmonary capillaries which triggers the migration and accumulation of inflammatory cells. This initiates the inflammatory cascade by both innate and cell-mediated immunity which significantly influences the alveolar-capillary oxygen transmission and the oxygen diffusion capacity [ 12 ].

In severe cases of COVID-19, fulminant inflammation, stimulation of the coagulation pathways, and consumption of the clotting factors occur in the form of a “cytokine storm”. This happens under the effect of many inflammatory mediators including interleukins, tumor necrosis factor-α (TNF-α), and interferon (IFN-γ). In addition, vasodilators such as bradykinin increase vascular permeability and result in pulmonary edema [ 13 ].

These mechanisms of cell damage represent a target for already existing medications that modulate the immune response. Based on its anti-inflammatory effects, colchicine has gained attention to be utilized in the management of COVID-19 patients. Colchicine is an alkaloid drug that is formed from a plant called “ Colchicum autumnale ”, also named “autumn crocus”. Colchicine is used in many autoinflammatory conditions e.g., gout, familial Mediterranean fever, and Behçet’s syndrome. Colchicine has an anti-inflammatory effect that is mediated through its binding to the tubulins and inhibiting the polymerization of microtubules. Microtubules are a key component of the cytoskeleton and are composed of tubulin heterodimers. These structures are important in different cellular functions including intracellular trafficking, cell shape, cell migration, and division [ 14 ]..

Colchicine inhibits the production of superoxide and the release of interleukin 1β and IL-6. Colchicine also prevents the inflammatory cascade by decreasing the production of inflammasomes that stimulate caspase-1 activation and release of interleukins such as interlukin1β and interleukin IL18 [ 15 , 16 ]. Colchicine decreases the differentiation of myofibroblast and the release of fibrotic mediators including transforming growth factor (TGF-β1) [ 17 , 18 ]. Moreover, colchicine has been used in cardiac conditions caused by a viral infection like myocarditis caused by CMV or EBV, interstitial pneumonia, and pericarditis resulting from influenza B infection. These different mechanisms greatly decrease the inflammatory response that represents a cornerstone in the pathophysiologic process of COVID-19. Besides the aforementioned effects of colchicine, its usage is considered safe and affordable with wide availability [ 19 ].

The ongoing impact of COVID-19 on all life aspects, the scarcity of effective treatments and the emergence of new virus variants resulted in the urgent need to repurpose the already existing drugs and to invent new therapeutic agents. This raised concerns about the effectiveness of colchicine in COVID-19 treatment and the possibility of providing an improvement in the clinical course of the disease.

The aim of the current study was to evaluate the efficacy of colchicine on different clinical outcomes including mortality, duration of COVID-19 illness till recovery, need for hospitalization, need for O2 therapy, need for ICU admission, and need for artificial ventilation.

Methodology

Criteria for considering studies for this meta-analysis, types of studies.

The review was restricted to Clinical Trials and Cohort Studies, which investigated the Colchicine administration in COVID-19 patients, versus standard treatment/placebo.

Types of participants

Participants were adult patients with the diagnosis of COVID-19. Patients were considered to have a definite diagnosis of COVID-19 if they were laboratory-confirmed using reverse transcription polymerase chain reaction (RT-PCR) and/or high-resolution CT chest with CO-RADS 4 or 5. All healthcare settings (community/primary care, hospital outpatient, or long-stay institutional) were considered eligible.

Types of interventions

Clinical trials and Cohort Studies were included. Colchicine was administered in COVID-19 patients, versus standard treatment/placebo.

Types of outcome measures

At least one of these outcomes was considered; Mortality, Duration of COVID-19 illness till recovery, Need for hospitalization, Need for O2 therapy, Need for ICU admission, and Need for artificial ventilation.

Inclusion criteria

(i) Cohort studies. (ii) Randomized and non-randomized clinical trials. Studies conducted on adult human subjects. (iii) Studies conducted on patients diagnosed with COVID-19 confirmed with positive reverse transcription polymerase chain reaction (RT-PCR) and/or high-resolution CT chest with CO-RADS 4 or 5. (iv) Studies conducted in all healthcare settings (community/ primary care, hospital outpatient or long-stay institutional). Studies published in Arabic, English, French or Spanish languages.

Exclusion criteria

Review, opinion studies, Case series, Studies conducted on animals.

Search strategy for identification of studies

Published studies and abstracts on the role of colchicine in the management of COVID-19 were identified through a comprehensive search of electronic databases that included PubMed ( https://pubmed.ncbi.nlm.nih.gov/ ), ScienceDirect ( www.sciencedirect.com ), Scirus ( www.scirus.com/srsapp ), ISI Web of Knowledge ( http://www.isiwebofknowledge.com ), Google Scholar ( http://scholar.google.com ) and CENTRAL (Cochrane Central Register of Controlled Trials ( http://www.mrw.interscience.wiley.com/cochrane/cochrane_clcentral_articles_fs.htm ), using a combination of the following keywords: “Colchicine, COVID-19, Clinical Trail, Cohort Study”.

Methods of the meta-analysis

Locating and selecting studies.

Abstracts of articles identified using the search strategy above mentioned were viewed, and articles that appeared to fulfil the inclusion criteria were retrieved in full. Data on at least one of the outcome measures was included in the study. Each article identified was reviewed and categorized into one of the following groups: Included: Randomized and non-randomized clinical trials, and Cohort studies that met the described inclusion criteria and those where it was impossible to tell from the abstract, title or MESH headings. Excluded: review, opinion studies, case series, and studies conducted on animals. When there was a doubt, a second reviewer (MFA) assessed the article, and a consensus was reached. The literature was reviewed till May 31, 2022 and yielded 814 articles after ranking the articles according to authors and year of publication. Only articles fulfilling the inclusion criteria were included (total 8 articles) for further steps of data collection, analysis, and reporting. The studies that met our inclusion criteria were Deftereos et al., Tardif et al., RECOVERY Collaborative Group, Lopes et al., Sandhu et al., Mareev et al., Brunetti et al. and Scarsi et al. [ 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ]. All were in English and there were no available studies published in Arabic, French or Spanish language.

Data extraction

A copy of each identified paper was obtained, and relevant data was abstracted by the first reviewer for a quantitative overview. We extracted the following study data from full-text articles: first author name, year of publication, study design, study location, eligibility criteria, sample size, age, sex, description of intervention and control groups, primary and secondary outcomes. In case of discrepancies or when the information presented in a study was unclear, abstraction by a second reviewer (MFA) was sought to resolve the discrepancy.

Statistical considerations

Data were abstracted from every study in the form of a risk estimate and its 95% confidence interval. When a risk estimate and its 95% confidence interval were not available from the article, we calculated unadjusted values from the published data of the article, using the Epi Info 6 computer program version 6.04d.

Pooled estimates of relative risks were obtained by weighing each study by the inverse variance of the effect measure on a logarithmic scale. This approach to pool the results assumed that the study populations being compared were similar and hence corresponded to a fixed effect analysis. The validity of pooling the relative risks was tested (test of homogeneity) using chi square test.

A violation of this test suggested that the studies being pooled differed from one another. In the presence of significant heterogeneity of the effect measure among studies being compared, we performed a random effect analysis that was based on the method described by DerSimonian and Laird. The random effect analysis accounted for the interstudy variation. Because the test of homogeneity had low power, we reported the figures of the random effect analysis even with the absence of significant heterogeneity.

All statistical analyses for pooling the studies were performed on the MetaXL Software.

In 6 databases, we identified 814 articles; 499 duplicates were removed. Out of the remaining 315 abstracts, we excluded 298 after screening. Thus, 17 full-text studies were assessed for eligibility and 9 were excluded. Finally, eight studies were included for further qualitative and quantitative analyses (Fig. 1 ).

PRISMA flow diagram showing selection of studies. PRISMA; Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Characteristics of the included studies

Two studies were cohort (Brunetti et al. and Scarsi et al.) while the other studies were four randomized controlled clinical trials (Deftereos et al., RECOVERY Collaborative Group, Lopes et al., and Tardif et al.) and two non-randomized controlled clinical trials (Mareev et al., and Sandhu et al.).

Two studies were multicentre clinical trials (RECOVERY Collaborative Group, and Tardif et al.) . The other six studies were conducted in Greece (Deftereos et al.), Brazil (Lopes et al.), the USA (Brunetti et al. and Sandhu et al.), Russia (Mareev et al.), and Italy (Scarsi et al.) [ 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ].

The studies included both hospitalized and non-hospitalized COVID-19 patients, who were diagnosed either clinically or by laboratory diagnosis with PCR–RT testing and CT chest imaging (Table 1 ).

Table 2 and Fig. 2 showed that the meta-analysis of all included studies showed a significant difference in mortality between the treatment group with colchicine and the control group (RR 0.35, 95% CI: 0.15–0.79). There is significant heterogeneity among the studies (Homogeneity Test X2: 42.219, P -value < 0.000).

Forest plot for the efficacy of colchicine on mortality in patients with COVID-19

The meta-analytical result of the six clinical trials was insignificant between the treatment and control groups (RR 0.48, 95% CI 0.22–1.07). There is significant heterogeneity among the studies (Homogeneity Test X2: 11.562, P -value: 0.000). The meta-analytical result of the two cohort studies was significant between the treatment and control groups (RR 0.17, 95%CI 0.08–0.35).

Duration of COVID-19 illness till recovery

Table 3 shows the efficacy of colchicine on the duration of COVID-19 illness till recovery. Lopes et al. reported that the median duration of COVID-19 illness in the treatment group with colchicine was 7 days vs 9 days in the control group ( P -value =0.003) [ 25 ]. While Sandhu et al., and Mareev et al., demonstrated that colchicine had no significant effect on the illness duration [ 26 , 27 ]. (Table 3 ).

Need for hospitalization

Tardif et al., reported that colchicine did not show a significant effect on the COVID-19 patients’ need for hospitalization RR 0.79, 95% CI 0.60–1.03, P-value =0.081) [ 23 ].

Need for O2 therapy

Lopes et al., demonstrated that colchicine use resulted in a significant decrease in the need for O2 therapy in patients with COVID-19 (RR 0.07, 95% CI 0.02–0.27, P  = 0.000024) [ 25 ].

Need for ICU admission

Table 4 and Fig. 3 show the efficacy of colchicine on need for ICU admission in patients with COVID-19. The meta-analytical result did not show a significant effect (RR 0.29, 95% CI: 0.07–1.17).

Forest plot for the efficacy of colchicine on need for ICU admission in patients with COVID-19

Need for artificial ventilation

Table 5 and Fig. 4 show the efficacy of colchicine on need for artificial ventilation in patients with COVID-19. The meta-analysis of four studies demonstrated that colchicine has no significant effect on the need for artificial ventilation (RR 0.40, 95% CI 0.14–1.13). There is significant heterogeneity among the studies (Homogeneity Test X2: 18.417, P -value: 0.000).

Forest plot for the efficacy of colchicine on need for artificial ventilation in patients with COVID-19

Hospital discharge rate

Table 6 and Fig. 5 show the efficacy of colchicine on hospital discharge rate in patients with COVID-19. The meta-analytical result of the three studies demonstrated that colchicine did not show a significant effect on the hospital discharge rate (RR 0.99, 95%CI 0.12–7.85).

Forest plot for the efficacy of colchicine on hospital discharge rate in patients with COVID-19

The effect of colchicine on the hospital discharge rate in the clinical trials was not significant (RR 0.98, 95%CI 0.12–8.02), while a cohort study reported that colchicine showed a significant effect on the hospital discharge rate (RR 5.0, 95%CI 1.25–20.08, P-value 0.023) [ 28 ].

Subgroup analysis among PCR confirmed COVID-19 patients

Mortality among pcr confirmed covid-19 patients.

Table 7 and Fig. 6 show the efficacy of colchicine on mortality among PCR confirmed COVID-19 Patients. Colchicine did not show a significant effect on mortality among PCR confirmed COVID-19 patients (RR 1.02, 95% CI 0.74–1.41).

Forest plot for the efficacy of colchicine on mortality among PCR confirmed COVID-19 patients

See Fig. 6 .

Hospitalization among PCR confirmed COVID-19 patients

Tardif et al. assessed the efficacy of colchicine on hospitalization and reported that colchicine resulted in decreased hospitalization among the PCR confirmed COVID-19 patients (RR 0.75, 95%CI 0.57–0.99, P 0.042) [ 23 ].

Mechanical ventilation among PCR confirmed COVID-19 patients

Tardif et al. found that colchicine has no significant effect on mechanical ventilation among PCR confirmed COVID-19 Patients (RR 0.50, 95%CI 0.23–1.07, P 0.042) [ 23 ].

In this meta-analysis, the studies investigated the role of colchicine in the management of COVID-19 were reviewed.

After a comprehensive search, eight studies were identified. Two of them were cohort studies (Brunetti et al., and Scarsi et al.) while the other studies were four randomized control trials (Deftereos et al., Recovery Collaborative Group, Lopes et al., and Tardif et al.) and two non-randomized trials (Mareev et al., and Sandhu et al.). The current meta-analysis involved 16,488 patients; 8146 were in the treatment group who received colchicine and 8342 were in the control group who received a placebo or standard treatment [ 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ].

The efficacy of colchicine on mortality

The eight pooled studies evaluated the efficacy of colchicine on mortality among COVID-19 patients and showed a significant reduction in the mortality rate among patients received colchicine in comparison with placebo or standard care. This result coincides with the findings of a recent systematic review that reported a significant decrease in the all-cause mortality in three observational studies [ 28 ]. In addition, a recently published meta-analysis reported that colchicine resulted in decreased mortality among COVID-19 patients. This study pooled four randomized control trials and five observational studies and involved 5522 patients only [ 29 ].

On the other hand, Mehta, et al. and Toro-Huamanchumo, et al. documented that colchicine had no effect on the mortality rate among COVID-19 patients [ 30 , 31 ].

The heterogeneity test between the pooled studies showed a significant difference, which indicates interstudy variation. Pooling of these heterogeneous studies added more useful information.

According to our result, colchicine may have a beneficial effect to decrease mortality among COVID-19 patients. It was obvious that this effect occurred when colchicine was used within the early days of the disease. These findings can be explained by the anti-inflammatory role of colchicine that is mediated through the interaction between colchicine and microtubules which play an important role in cellular division, migration, and adhesion. This effect robustly influences the immune system response and reduces the inflammatory reaction. Also, colchicine decreases the release of cytokines and inflammatory mediators that stimulate the immune cells [ 32 ].

The subgroup analysis of the two cohort studies demonstrated a significant effect of colchicine on mortality among COVID-19 patients. However, the subgroup analysis for the six clinical trials showed that colchicine has no effect on mortality in the management of COVID-19. This result is consistent with the pooled analysis of a recent study where four clinical trials only were included [ 33 ]. This variation could be attributed to difference of the study design, variation in follow up duration and the colchicine regimen used in these studies.

The efficacy of colchicine on the duration of COVID-19 illness till recovery

The efficacy of colchicine on the duration of COVID-19 illness was assessed in three clinical trials. Lopes et al. found that hospitalized COVID-19 patients who received colchicine had a shorter duration of illness till recovery in comparison with the patients who received placebo [ 23 ]. This is similar to the result reported by a recent study [ 34 ]. This finding can be related to the anti-inflammatory and immune modulatory roles of colchicine in the management of COVID-19. On the other hand, two clinical trials reported that colchicine did not affect the duration of COVID-19 illness [ 23 , 25 ]. These findings agree with the results of a recently published study investigated the efficacy of colchicine on the duration of COVID-19 clinical course [ 31 ].

The efficacy of colchicine on need for hospitalization

Tardif et al., investigated the efficacy of colchicine among non-hospitalized COVID-19 patients vs placebo. They found that colchicine did not influence the need for hospitalization among the non-hospitalized patients [ 21 ]. A recent clinical trial was conducted to assess the effect of colchicine on the prognosis of non-hospitalized COVID-19 patients and the results showed no significant effect of colchicine on hospitalization rate of the patients [ 35 ].

The efficacy of colchicine on need for O2 therapy

Lopes et al., assessed the efficacy of colchicine on the need for O2 therapy and the results demonstrated that colchicine use resulted in a significant decrease in the need for O2 therapy in patients with COVID-19 [ 23 ]. This result can be understood based on the beneficial effect of colchicine on the inflammatory response.

The efficacy of colchicine on need for ICU admission

The pooled results of two clinical trials showed that colchicine did not improve the need of ICU admission compared to placebo or standard care. This finding is concomitant with a recent study that included six studies only [ 30 ].

The efficacy of colchicine on need for artificial ventilation

Four pooled studies evaluated the efficacy of colchicine on need for artificial ventilation and showed that colchicine did not decrease the need for artificial ventilation compared to placebo or standard care [ 20 , 21 , 22 , 24 ].

The heterogeneity test between the pooled studies regarding the need for artificial ventilation showed a significant difference, which indicates interstudy variation.

This can be attributed to the variation of duration and dose of colchicine regimens in these studies, and the severity of the disease. Tardif et al., included non-hospitalized COVID-19 patients while the other three studies involved hospitalized patients.

The efficacy of colchicine on hospital discharge rate

Three pooled studies evaluated the efficacy of colchicine on hospital discharge rate and showed that colchicine did not improve the hospital discharge rate in comparison with placebo or standard treatment [ 22 , 24 , 26 ].

Furthermore, the subgroup analysis of the pooled results included two clinical trials and showed that colchicine did not cause a significant improvement in the hospital discharge rate compared to placebo or standard treatment [ 22 , 24 ]. On the other hand, the cohort study demonstrated a beneficial effect of colchicine on the hospital discharge rate compared to standard care [ 26 ].

The variation of the results of the three studies could be attributed to the difference of study design, number of included patients, and the treatment regimens used.

Two pooled studies evaluated the efficacy of colchicine among PCR confirmed COVID-19 patients and showed that colchicine did not significantly decrease mortality among PCR confirmed patients [ 21 , 22 ].

In addition, Tardif et al. assessed the efficacy of colchicine on hospitalization rate among PCR confirmed COVID-19 patients and found that colchicine significantly decreased the hospitalization rate compared to placebo. Also, Tardif et al. evaluated the effectiveness of colchicine on mechanical ventilation rate among PCR confirmed COVID-19 patients and showed no beneficial effect of colchicine on mechanical ventilation in comparison with placebo [ 21 ].

The study demonstrates that colchicine administration leads to a notable reduction in mortality rates and a decrease in the necessity for oxygen therapy among individuals with COVID-19. Although its impact on broader outcomes like hospitalization rates, ICU admissions, and discharge rates remains minimal, there’s a significant finding regarding its efficacy in lowering hospitalizations specifically among PCR-confirmed COVID-19 patients. This detailed understanding highlights the potential of colchicine as a therapeutic intervention for COVID-19, particularly in mitigating mortality risks and oxygen therapy requirements. These results offer valuable insights for clinicians, highlighting the need to consider colchicine as a viable treatment option for COVID-19 patients, while also emphasizing the necessity for further exploration to optimize its clinical utility.

Availability of data and materials

Our study is a Systematic Review/Meta-analysis. The datasets analyzed during the current study are available in the published pooled study. Also, the datasets used and analyzed during the current study available from the corresponding author on reasonable request.

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Kholoud Elshiwy, Ghada Essam El-Din Amin & Mohamed Farouk Allam

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Kholoud Elshiwy: Field work supervision, analysis strategy and design, data management, data analysis and interpretation of results, decision making on content and paper write-up and revision of final draft. Ghada Essam El-Din Amin: Field work supervision, analysis strategy and design, data management, data analysis and interpretation of results, decision making on content and paper write-up and revision of final draft. Mohamed Nazmy: Field work supervision, analysis strategy and design, data management, data analysis and interpretation of results, decision making on content and paper write-up and revision of final draft. Rasha Samir: Field work supervision, analysis strategy and design, data management, data analysis and interpretation of results, decision making on content and paper write-up and revision of final draft. Mohamed Farouk Allam: Field work supervision, analysis strategy and design, data management, data analysis and interpretation of results, decision making on content and paper write-up and revision of final draft.

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Elshiwy, K., Amin, G.E.ED., Farres, M.N. et al. The role of colchicine in the management of COVID-19: a Meta-analysis. BMC Pulm Med 24 , 190 (2024). https://doi.org/10.1186/s12890-024-03001-0

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Dementia care pathways in prisons – a comprehensive scoping review

• Samantha Treacy 1 ,
• Steven Martin 2 ,
• Nelum Samarutilake 3 ,
• Veronica Phillips 4 ,
• Ben R. Underwood 3 , 5 &
• Tine Van Bortel   ORCID: orcid.org/0000-0003-0467-6393 2 , 3  

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The number of older people in prison is growing. As a result, there will also be more prisoners suffering from dementia. The support and management of this population is likely to present multiple challenges to the prison system.

To examine the published literature on the care and supervision of people living in prison with dementia and on transitioning into the community; to identify good practice and recommendations that might inform the development of prison dementia care pathways.

A scoping review methodology was adopted with reporting guided by the PRISMA extension for scoping reviews checklist and explanation.

Sixty-seven papers were included. Most of these were from high income countries, with the majority from the United Kingdom ( n  = 34), followed by the United States ( n  = 15), and Australia ( n  = 12). One further paper was from India.

The literature indicated that there were difficulties across the prison system for people with dementia along the pathway from reception to release and resettlement. These touched upon all aspects of prison life and its environment, including health and social care. A lack of resources and national and regional policies were identified as important barriers, although a number of solutions were also identified in the literature, including the development of locally tailored policies and increased collaboration with the voluntary sector.

To our knowledge, this is the most comprehensive and inclusive review of the literature on dementia care pathways in prison to date. It has identified a number of important areas of concern and opportunities for future research across the prison system, and its operations. This will hopefully lead to the identification or adaptation of interventions to be implemented and evaluated, and facilitate the development of dementia care pathways in prisons.

The number of older people (defined here as those over 50 Footnote 1 ) being held in prison in England and Wales has almost tripled over the last 20 years, and they now represent 17.1% of that population (Ministry of Justice, 2022a ). The growing number of older people has brought with it an increasing number of health and social care problems, reportedly affecting around 85% of older people in prison, with associated costs (Di Lorito, et al., 2018 ; Hayes et al., 2012 , 2013 ; Senior, et al., 2013 ). It has been estimated that 8.1% of those over the age of 50 in prison have mild cognitive impairment or dementia, which is much higher than estimates for this age group in the general population (Dunne et al., 2021 ; Forsyth et al., 2020 ). This pattern of poor health also increased the vulnerability of older people in prison during the pandemic (Kay, 2020 ).

Prison policy and legislation mandates that health and social care be ‘equivalent’ to that provided in the community (Care Act, 2014 ; Department of Health, 1999 ). Despite this, provisions are reportedly inconsistent, and the government has been described as ‘failing’ in its duty of care (Health and Social Care Committee, 2018 ; HM Inspectorate of Prisons & Care Quality Commission, 2018 ). This is likely exacerbated by the suspension and limiting of healthcare services during the pandemic, noted to have had a ‘profound’ impact on people’s health and wellbeing (HM Inspectorate of Prisons, 2021 ). This may be particularly so for people living in prison with dementia (PLiPWD), whereby the difficulties of delivering health and social care are compounded by inappropriate buildings, environments, and prison regimes (rules and regulations). In addition, PLiPWDs may experience an increase in social isolation, including separation from friends and family, all of which may make their time in prison more challenging (Moll, 2013 ; Peacock et al., 2019 ).

There is no current national strategy for older people in prison in England and Wales, including PLiPWD, although the British government recently agreed that there is a need for one (Justice Committee, 2020 ). A ‘Model for Operational Delivery’ for older people has been published by Her Majesty's Prison & Probation Service ( 2018 ) in England and Wales, though this is guidance only and the “properly resourced and coordinated strategy” previously called for has not been produced (Prisons & Probation Ombudsman, 2017 , p7; Brooke and Rybacka, 2020 ; HM Inspectorate of Prisons, 2019 ; Justice Committee, 2020 ). One way of attempting to standardise and improve the quality of treatment and care in the community has been through the use of care pathways (Centre for Policy on Ageing, 2014 ; Schrijvers et al., 2012 ). Care pathways have been defined as “a complex intervention for the mutual decision-making and organisation of care processes for a well-defined group of patients during a well-defined period”, involving an articulation of goals and key aspects of evidence-based care, coordination and sequencing of activities and outcomes evaluation (Vanhaecht, et al., 2007 , p137).

The development of care pathways within the prison system lags behind that of the community, but the National Institute for Health and Care Excellence (NICE) has produced a pathway for prisoner health for England and Wales (National Institute for Health and Care Excellence, 2019 ), and there is a care pathway for older prisoners in Wales (Welsh Government & Ministry of Justice, 2011 ). There has also recently been an overall care pathway developed for people in prison with mild cognitive impairment and dementia, although this has not been implemented as yet, and it does not include any details regarding release and resettlement (Forsyth et al, 2020 ). It has been recommended that care pathways should be developed locally, as they are context-sensitive, should be viewed as processual and flexible, and the needs of the person, their experiences and characteristics need to be taken into account – such as age, gender and race (Centre for Policy on Ageing, 2014 ; Pinder, et al., 2005 ).

Here we review the current literature on people living in prison with dementia. There have been two recent systematic literature reviews conducted on PLiPWD, both of which only included primary research studies that were small in number (Brooke and Rybacka, 2020 ( n  = 10); Peacock et al., 2019 ( n  = 8)), and focused on prevalence, identification (screening and diagnosis), and the need for tailored programming and staff training. Peacock et al., ( 2019 ) identified dementia as a concern and suggested recommendations for improved screening and care practices. Brooke et al. ( 2020 ) noted that, whilst the prevalence of dementia in prison populations was largely unknown, there was a need for national policies and local strategies that support a multi-disciplinary approach to early detection, screening and diagnosis. Neither paper, however, reported on the much more extensive and rich grey literature in this area (Brooke and Rybacka, 2020 ), to help comprehensively identify the systemic and operational problems, barriers and potential solutions that would be useful to consider in developing local dementia care pathways. Therefore, the aim of this paper is to conduct a comprehensive systematic scoping review of the available published literature on the support and management of PLiPWD in prison and upon transitioning into the community, and to identify practice and recommendations that would be useful to consider in the development of a local prison dementia care pathway.

A scoping review methodology using Arksey and O’Malley’s ( 2005 ) five-stage framework was adopted for this review. Reporting was guided by the PRISMA extension for scoping reviews checklist and explanation (Tricco et al., 2018 ). The completed checklist for this review is available in Additional file 1 : Appendix 1.

Identification of relevant reports

The search strategy was formulated by the research team, and included an electronic database search and subsequent hand search. The electronic search involved searching twelve electronic databases: Applied Social Sciences Index and Abstract, Criminal Justice Abstracts, Embase, Medline (OVID), National Criminal Justice Reference Service, Open Grey, Psycinfo, Pubmed, Scopus, Social Services Abstracts, Sociological Abstracts, and Web of Science. The search combined condition-related terms (dementia OR Alzheimer*) AND context-related ones (prison OR jail OR gaol OR penitentia* OR penal OR correctional* OR incarcerat*), with no date or language restrictions, and covered the full range of publications up until April 2022. Additional file 2 : Appendix 2 has an example of the search strategy used.

Electronic searches were supplemented by comprehensive hand searching and reference mining. Searches were also undertaken using: search engines; websites related to prisons and/or dementia (for example, Prison Reform Trust); a database from a previous related literature review (Lee et al, 2019 ); recommendations from academic networking sites; contacting prominent authors in the field directly; government-related websites (for example Public Health England, now called Health Security Agency); recent inspection reports for all prisons in England and Wales from Her Majesty’s Inspectorate of Prisons and the Independent Monitoring Board.

Inclusion and exclusion criteria

Papers were considered suitable for inclusion in this review if they met the following criteria:

Setting: Papers should primarily be set in, or pertain to, prisons. Documents solely referring to community services, hospitals or medical facilities that are not part of the prison system were excluded.

People: Papers involving PLiPWD. Research focused only on older people in prison more generally was excluded, as was research which described the disorienting effects of imprisonment more generally, but which was not related to dementia.

Intervention: Some consideration of the treatment, care, support or management of PLiPWD; this can be health or social-care associated, as well as related to the prison overall, and to any individuals, groups or agencies who visit or work with individuals during their time in prison (including family, friends, charities, probation services). Papers which mostly describe prevalence studies, sentencing practices or profiles were excluded.

Study design: All designs were considered for inclusion. Editorials, book reviews, online blogs, press releases, announcements, summaries, newspaper and magazine articles, abstracts and letters were excluded.

The titles, abstracts and full-text of the papers identified by the searches were screened for inclusion in the review. The screening was undertaken by two independent researchers (ST and NS) for inter-rater reliability purposes (Rutter et al., 2010 ). Any differences of opinion on inclusion were resolved between the researchers (ST, NS and SM), and with the Principle Investigator (TVB).

Charting the data

An extraction template was developed for the review, guided by the PICO formula (Richardson et al., 1995 ) and informed by pathway stages and key areas highlighted in the older prisoner pathways toolkit for England and Wales (Department of Health, 2007 ), and the older prisoner pathway formulated for Wales (Welsh Government & Ministry of Justice, 2011 ). Using this extraction template, all of the data was extracted from the included papers by one member of the research team (ST), with a second researcher extracting data from a third of the papers as a check for consistency (SM). Any unresolved issues were related to the Principle Investigator (TVB) for resolution.

Collating, summarising and reporting results

The review was deliberately inclusive of a wide variety of types of papers, which meant that taking a meta-analytic approach to the data was not feasible. Therefore, a narrative approach to summarising and synthesising the findings and recommendations of the included papers was adopted (Popay et al, 2006 ).

Sixty-seven papers were included in this scoping review. The screening process phases conducted by the research team are shown in Fig.  1 .

PRISMA flow diagram

A brief overview of the key features of each of the papers is presented in Table 1 . All but one of the included papers were from high income countries, with the majority from the United Kingdom ( n  = 34), and then the United States ( n  = 15), Australia ( n  = 12), Canada ( n  = 4), Italy ( n  = 1) and India ( n  = 1). The papers were split into types, with twenty-two guidance and inspection documents, and twenty-seven discussion and intervention description papers. Of the eighteen research and review articles with a defined methodology included there were four literature reviews (one was systematic), nine qualitative studies, four mixed-methods studies (one which followed participants up), and one survey-based study.

Areas to consider in the support and management of PLiPWD during their time in prison and upon their release

The pathway through the prison is shown in Fig.  2 , and typically involves: (i) reception into prison; (ii) assessments, and allocation of the person within prison; (iii) time held in prison; (iv) transfers between prisons, and between prisons and other services such as time spent in hospital; and (v) release and preparations for resettlement in the community. There were also a number of (vi) cross-cutting themes which could potentially impact people with dementia living in prison at each stage across the prison pathway.

Dementia prison pathway considerations

(i) Reception

Upon entry into prison, prisoners are subject to an initial reception screening to identify and support immediate health and social care problems, and those in need of further assessment. An induction to prison rules and regulations also typically occurs at this step.

All papers reported that reception screening with appropriate screening tools was important in identifying cognitive difficulties and in establishing a baseline, but implementation seemed to vary (Peacock et al., 2019 ). One study in England and Wales found only 30% of prisons contacted routinely did this (Forsyth et al., 2020 ). Supporting policy and a service/person to refer to directly for further assessment were also highlighted as useful (Brooke & Jackson, 2019 ; Brooke et al., 2018 ; Gaston & Axford, 2018 ; Inspector of Custodial Services, 2015 ; Patterson et al., 2016 ). Proposed cut-offs for this screening were either 50 years of age ( n  = 7), under 55 years ( n  = 1), or 55 years of age ( n  = 7). One paper reported that only a third of prisoners who were offered this screening accepted it, although the reasons for this were not stated (Patel & Bonner, 2016 ). Another paper suggested that a screening programme could have unintended adverse consequences, that could damage already fragile relationships between staff and people living in prison (Moore & Burtonwood, 2019 ). Whilst many screening tools were mentioned, there are currently no tools validated for use in prisons, and many of those used in the community may be inappropriate (Baldwin & Leete, 2012 ; Brooke et al., 2018 ; du Toit et al., 2019 ; Feczko, 2014 ; Forsyth et al., 2020 ; Moore & Burtonwood, 2019 ; National Institute for Health and Care Excellence, 2017 ; Turner, 2018 ; Williams et al., 2012 ). One validation study found that the Six-item Cognitive Impairment Test (6CIT) was not suitably sensitive for use (Forsyth et al., 2020 ). Other difficulties included the limited amount of time and resources available to screen at reception (Christodoulou, 2012 ; Patterson et al., 2016 ; Peacock et al., 2019 ), and that staff lacked ‘familiarity’ with screening tools (Peacock et al., 2019 ).

Only two papers mentioned the induction process (Her Majesty's Prison & Probation Service, 2018 ; Welsh Government and Ministry of Justice, 2011 ) as important. A need for clearly explained information in a dementia-appropriate format (written and verbal) particularly regarding healthcare, and a recommendation that PLiPWD should be regularly reminded of rules and regulations, were suggested.

(ii) Assessment

Following the screening process, the current recommendation is that an initial healthcare assessment takes place in the first seven days after entering prison. During this initial assessment period, although not necessarily within this timeframe, care plans and allocation decisions may also be made regarding where the prisoner is placed within the prison.

An initial older-person-specific health and/or social care assessment or standard process for assessment has been recommended by ten papers, six of which were from government or related bodies. It was also suggested by some papers, that a cognitive assessment should take place at either 50 years ( n  = 6) or 55 years ( n  = 2), which should be repeated every three months ( n  = 3), six months ( n  = 5) or annually ( n  = 12), with the latter including recommendations from NICE guidelines (National Institute for Health and Care Excellence, 2017 ). One study set in England and Wales found that most prisons (60%) that screened older people, did so between 7–12 months (Forsyth et al., 2020 ). Brief and affordable tools were considered more useful (Garavito, 2020 ; Turner, 2018 ), although the Montreal Cognitive Assessment (MOCA) was recommended in the care pathway developed by Forsyth et al. ( 2020 ).

Typically, assessments were conducted by healthcare staff, GPs or a psychologist ( n  = 6), a specialist in-house assessment unit ( n  = 2), or a specific dementia admissions assessment unit ( n  = 4). For further assessment, some prisons had internal teams to refer to ( n  = 5). Forsyth et al. ( 2020 ) recommend referral to external Memory Assessment Services for assessment. A case finding tool was being piloted in one prison (Sindano & Swapp, 2019 ). Assessments included can be found in Table 2 .

Assessments also explored risk and safeguarding (National Institute for Health and Care Excellence, 2017 ; Patterson et al., 2016 ; Welsh Government and Ministry of Justice, 2011 ), environmental impact (National Institute for Health and Care Excellence, 2017 ), capacity (Prison & Probation Ombudsman, 2016 ), work, education, and drug and alcohol use (Welsh Government and Ministry of Justice, 2011 ) and a person’s strengths (Hamada, 2015 ; National Institute for Health and Care Excellence, 2017 ). Prison staff contributed to some assessments of activities of daily living (ADLs) or prison-modified ADLs (Brooke et al., 2018 ; Brown, 2016 ; Dillon et al., 2019 ; Department of Health, 2007 ; Feczko, 2014 ; Forsyth et al., 2020 ; Gaston, 2018 ; Gaston & Axford, 2018 ; Patterson et al., 2016 ; Turner, 2018 ; Welsh Government and Ministry of Justice, 2011 ; Williams et al., 2012 ). Challenges to Assessment can be found in Table 3 .

Twelve papers described or recommended care planning post-assessment, in collaboration with PLiPWD and primary care, or a multi-disciplinary team (MDT) of health, social care and prison staff with external specialists healthcare proxies charities or family (Brown, 2016 ; Dillon et al., 2019 ; du Toit & Ng, 2022 ; Hamada, 2015 ; Her Majesty's Inspectorate of Prisons, 2014 ; Her Majesty's Prison & Probation Service, 2018 ; Moll, 2013 ; National Institute for Health and Care Excellence, 2017 ; Patterson et al., 2016 ; Prisons and Probation Ombudsman, 2016 ; Welsh Government and Ministry of Justice, 2011 ). However, it was suggested that prison staff be removed from the decision-making process as the dementia progresses, and be part of the ‘duty of care’ of healthcare staff and services (du Toit & Ng, 2022 ). It was recommended too that care plans be disseminated to prison wing staff (Forsyth et al., 2020 ) and peer supporters (Goulding, 2013 ), and that consent be sought for this (Goulding, 2013 ; Her Majesty's Inspectorate of Prisons, 2014 ) An ombudsman report in England and Wales noted that care plans for PLiPWD who had died in prison were inadequate (Peacock et al., 2018 ), and of the varying degrees of care planning found by Forsyth et al ( 2020 ), it was described typically as “rudimentary” (p26). Care plans are described further in Table 4 .

Many papers reported that prisons did or should make decisions about where people should be accommodated within the prison after health assessments (Brown, 2016 ; Feczko, 2014 ; Forsyth et al., 2020 ; Hodel & Sanchez, 2013 ; Inspector of Custodial Services, 2015 ; Mistry & Muhammad, 2015 ; Turner, 2018 ; Welsh Government and Ministry of Justice, 2011 ; Williams et al., 2012 ), taking age and health into account. However, despite recommendations that PLiPWD should be placed on the ground floor on low bunks for instance (Baldwin & Leete, 2012 ; Department of Health, 2007 ; Welsh Government and Ministry of Justice, 2011 ), there were reports that this was not happening (Inspector of Custodial Services, 2015 ). There were also recommendations for allocations to be made across a region to ensure people are appropriately placed in the prison system (Baldwin & Leete, 2012 ; Booth, 2016 ; Gaston & Axford, 2018 ; Welsh Government and Ministry of Justice, 2011 ). Concerns were expressed about the lack of lower category places for PLiPWD (Department of Health, 2007 ), and the lack of guidance regarding placement of people with high support needs (Sindano & Swapp, 2019 ) in England and Wales.

(iii) Within-prison issues

A number of papers reported on a need for policies or frameworks to support staff to identify, assess and support people who may be living with dementia (Brooke et al., 2018 ; Brooke & Jackson, 2019 ; Department of Health, 2007 ; Feczko, 2014 ; Gaston, 2018 ; Gaston & Axford, 2018 ; Patterson et al., 2016 ; Turner, 2018 ; Welsh Government and Ministry of Justice, 2011 ), without which staff have faced difficulties in providing quality care and support (Feczko, 2014 ; Prisons and Probation Ombudsman, 2016 ). Whilst there were some examples of guidance for dementia (Hamada, 2015 ; Patterson et al., 2016 ; Treacy et al., 2019 ; Turner, 2018 ), it was suggested that all policies should be reviewed and amended to ensure that they are appropriate for older people and people living with dementia (Department of Health,  2007 ; Lee et al., 2019 ; Treacy et al., 2019 ). Specific policy areas are described in Table 5 .

Issues around staff training on dementia were discussed in the majority of papers ( n  = 54) Many of these reported that prison staff either lacked training on dementia, or that training was limited ( n  = 16), with one study in England and Wales reporting that only a quarter of prison staff had received such training (Forsyth et al., 2020 ). Perhaps consequently, a number of papers identified that prison staff required some dementia training ( n  = 19). Staff working on a specialist dementia unit reportedly had a comprehensive 40-h training (Brown, 2014 , 2016 ; Gaston & Axford, 2018 ; Hodel & Sanchez, 2013 ; Moll, 2013 ), and it was suggested that more comprehensive training be facilitated for officers, particularly those working with PLiPWD ( n  = 18) and offender managers ( n  = 2). A need for all staff working with PLiPWD to be supervised was also suggested (Gaston & Axford, 2018 ; Maschi et al., 2012 ). Despite a lack of consensus on content and duration (du Toit et al, 2019 ), typically, the staff training undertaken and recommended was in four areas (Table 6 ). It was also recommended that training for healthcare could be more comprehensive and focused on screening, identification, assessment, diagnoses, supervision and intervention training (Baldwin & Leete, 2012 ; Brooke & Jackson, 2019 ; Brown, 2014 ; Gaston & Axford, 2018 ; Her Majesty's Inspectorate of Prisons, 2014 ; Moll, 2013 ; Moore & Burtonwood, 2019 ; National Institute for Health and Care Excellence, 2017 ; Peacock et al, 2019 ; Treacy et al, 2019 ; Turner, 2018 ; Williams, 2014 ). It is of note that only 21% of healthcare staff in one study in England and Wales reported attending training to identify dementia (Forsyth et al., 2020 ), similar to the figures regarding prison staff in the same study.

Much of the training described in the included papers had been formulated and delivered by dementia- or older people-specific voluntary organisations (Alzheimer’s Society, 2018 ; Brooke et al.  2018 ; Brown, 2016 ; Gaston & Axford, 2018 ; HMP Hull, 2015 ; Her Majesty's Prison & Probation Service, 2018 ; Hodel & Sanchez, 2013 ; Moll, 2013 ; Peacock et al., 2018 ; Prisons and Probation Ombudsman, 2016 ; Sindano & Swapp, 2019 ; Tilsed, 2019 ; Treacy et al., 2019 ). Although it has also been recommended to involve health and social care (Goulding, 2013 ; Her Majesty's Prison & Probation Service, 2018 ; Ministry of Justice, 2013 ; Treacy et al., 2019 ; Turner, 2018 ), and officers and peer supporters (Brooke & Jackson, 2019 ; Masters et al., 2016 ; National Institute for Health and Care Excellence, 2017 ; Treacy et al., 2019 ) in developing the training. In one study, prison staff were also trained to deliver dementia information sessions to their peers (Treacy et al., 2019 ). A suggestion of video-training packages was also made (du Toit et al., 2019 ). Dementia training typically lacked robust evaluation (Brooke et al., 2018 ), although those available generally reported benefits in their understanding of dementia, relationships, and diagnoses (Goulding, 2013 ; HMP Littlehey, 2016 ; Masters et al., 2016 ; Sindano & Swapp, 2019 ; Treacy et al., 2019 ). It was also reported that some prison staff were resistant to working with PLiPWD (Moll, 2013 ), and that resource limitations resulted in training cuts (HMP Hull, 2015 ; Treacy et al., 2019 ).

Offering healthcare across the spectrum for PLiPWDs, from acute to chronic care, with a focus on preventative and long-term care as well as palliative care was recommended by some papers (Brown, 2014 ; du Toit & Ng, 2022 ; Gaston, 2018 ; Maschi et al., 2012 ; Mistry & Muhammad, 2015 ; Peacock et al, 2018 ; Welsh Government and Ministry of Justice, 2011 ; Williams et al., 2012 ). The development of care pathways to guide this were also recommended or formulated (du Toit et al., 2019 ; Forsyth et al., 2020 ; Peacock et al., 2019 ), although the majority (69%) of prisons in one study in England and Wales did not have one (Forsyth et al., 2020 ). Clear and formal links with local hospitals, memory clinics, forensic and community teams for planning, training, advice, support and in-reach were also present or recommended by sixteen research and guidance papers. The amount of healthcare cover in prisons in England and Wales reportedly varied with the function of the prison with largely only local prisons having 24-h healthcare staff (Treacy et al., 2019 ), and most other forms of prison having office-type hours’ healthcare cover – including sex offender prisons where the majority of older prisoners are held (Brown, 2016 ; Correctional Investigator Canada, 2019 ; Goulding, 2013 ; Inspector of Custodial Services, 2015 ; Treacy et al., 2019 ). While specialist services or units for PLiPWD exist in a number of jurisdictions (Baldwin & Leete, 2012 ; Brown, 2016 ; Cipriani et al., 2017 ; Gaston & Axford, 2018 ; Goulding, 2013 ; Hodel & Sanchez, 2013 ; Inspector of Custodial Services, 2015 ; Maschi et al., 2012 ; Mistry & Muhammad, 2015 ; Treacy et al, 2019 ), more are reportedly needed (Brooke et al., 2018 ; du Toit et al., 2019 ; Forsyth et al., 2020 ; Welsh Government and Ministry of Justice, 2011 ).

Most healthcare teams were reportedly MDT, or this was recommended, alongside joint health and social care working ( n  = 16). A number of healthcare staff acted as the lead for older people in prisons (Department of Health, 2007 ; Her Majesty's Inspectorate of Prisons, 2014 ; Her Majesty's Inspectorate of Prisons, 2016 ; Moll, 2013 ; Welsh Government and Ministry of Justice, 2011 ), with a recommendation that a dementia-trained nurse should lead any dementia care pathways (Forsyth et al., 2020 ) and indeed it was suggested that healthcare staff in general have training and experience in working with older people (Her Majesty's Inspectorate of Prisons, 2014 ; Her Majesty's Inspectorate of Prisons, 2017b ; Moll, 2013 ; Patterson et al., 2016 ; Public Health England, 2017b ; Treacy et al., 2019 ; Turner, 2018 ; Welsh Government and Ministry of Justice, 2011 ). Whilst one of the recommended roles for healthcare was the prescription and monitoring of medication (Feczko, 2014 ; Her Majesty's Inspectorate of Prisons, 2017b ; Moll, 2013 ), much of the focus was on early identification and diagnosis, and keeping a dementia register (Department of Health, 2007 ; Moll, 2013 ; Patterson et al., 2016 ; Welsh Government and Ministry of Justice, 2011 ), and the use of non-pharmacological approaches. These broadly included: psychological interventions (Goulding, 2013 ; Hamada, 2015 ; Moll, 2013 ; Wilson & Barboza, 2010 ); assistance with ADLs and social care (Feczko, 2014 ; Hamada, 2015 ; Hodel & Sanchez, 2013 ; Maschi, et al., 2012 ; Murray, 2004 ; Prisons and Probation Ombudsman, 2016 ); development and delivery of specialist dementia prison programmes (Brown, 2014 , 2016 ; Hodel & Sanchez, 2013 ; Mistry & Muhammad, 2015 ; Moll, 2013 ; Peacock et al., 2018 ; Wilson & Barboza, 2010 ); reablement and rehabilitation (Welsh Government and Ministry of Justice, 2011 ); relaxation (Wilson & Barboza, 2010 ); safeguarding (Hodel & Sanchez, 2013 ); and cognitive stimulation groups (Moll, 2013 ; Williams, 2014 ). Other possible roles included: training or supporting staff and peer supporters, as reported in fourteen papers, as well as advocacy (Feczko, 2014 ; Peacock et al., 2018 ; Welsh Government and Ministry of Justice, 2011 ), allocation, assessment for offending behaviour groups, risk assessments and disciplinary hearings (Booth, 2016 ; Department of Health, 2007 ; Her Majesty's Prison & Probation Service, 2018 ; Murray, 2004 ; Prisons and Probation Ombudsman, 2016 ). Challenges to Healthcare are noted in Table 7 .

Palliative care

A care pathway for dying people that meets community standards was recommended (Department of Health, 2007 ; Her Majesty's Prison & Probation Service, 2018 ; Welsh Government and Ministry of Justice, 2011 ), as was ensuring that people could choose a preferred place to die (Her Majesty's Prison & Probation Service, 2018 ). Some prisoners were moved to community hospices or hospitals (Brooke & Jackson, 2019 ; Inspector of Custodial Services, 2015 ), or it was felt that they should be (Her Majesty's Prison & Probation Service, 2018 ). Although it was noted that some prisons lack relationships with community hospices or palliative care services and need to foster them (Brooke & Jackson, 2019 ; Brown, 2016 ; Correctional Investigator Canada, 2019 ; Department of Health, 2007 ; Her Majesty's Prison & Probation Service, 2018 ).

A number of prisons also reportedly had hospices, particularly in the United States (Brooke et al., 2018 ; Brown, 2016 ; Feczko, 2014 ; Goulding, 2013 ; Williams et al., 2012 ), although these have not been comprehensively evaluated (Williams et al., 2012 ). It was recommended that these be staffed by MDTs (Her Majesty's Prison & Probation Service, 2018 ), including chaplains and nutritionists (Her Majesty's Prison & Probation Service, 2018 ; Goulding, 2013 ), and many included prisoner peer supporters (Brooke et al., 2018 ; Goulding, 2013 ). The use of independent contractors was also suggested as staff-prisoner relationships were considered problematic in some prisons (Williams et al., 2012 ). Regarding family, many hospices were described as allowing more visits (Brooke & Jackson, 2019 ; Goulding, 2013 ; Her Majesty's Prison & Probation Service, 2018 ), including one prison with family accommodation (Her Majesty's Prison & Probation Service, 2018 ). Whilst re-engaging with family was reportedly encouraged (Brown, 2016 ), a lack of support was noted (Correctional Investigator Canada, 2019 ). Suggested improvements include a family liaison officer, providing a list of counselling options, and hosting memorial services (Her Majesty's Prison & Probation Service, 2018 ).

Social care

A social care strategy for older prisoners and a social care lead for all prisons in England and Wales has been recommended (Department of Health, 2007 ; Prisons and Probation Ombudsman, 2016 ). It was reported that MDTs working with PLiPWD should and increasingly do include social workers including specialist units and hospices (Baldwin & Leete, 2012 ; Brooke et al., 2018 ; Brown, 2016 ; Cipriani et al., 2017 ; Goulding, 2013 ; HMP Littlehey, 2016 ; Her Majesty's Prison & Probation Service, 2018 ; Maschi et al., 2012 ; Prisons and Probation Ombudsman, 2016 ; Sindano & Swapp, 2019 ; Treacy et al., 2019 ; Welsh Government and Ministry of Justice, 2011 ). Social care roles can be found in Table 8 .

The work may be direct or may be through co-ordinating external agencies or peer supporters (Brooke & Jackson, 2019 ; Department of Health, 2007 ; Her Majesty's Prison & Probation Service, 2018 ; Prisons and Probation Ombudsman, 2016 ; Tilsed, 2019 ; Treacy et al., 2019 ; Welsh Government and Ministry of Justice, 2011 ). Clarity in these roles was considered paramount, particularly as uncertainty reportedly continues to exist over who is responsible for meeting prisoners’ social care needs in some prisons in England and Wales despite the passing of the Care Act, 2014 (Dementia Action Alliance, 2017 ; Tilsed, 2019 ; Welsh Government and Ministry of Justice, 2011 ). There was also some ambiguity around the threshold PLiPWD were expected to meet in order to access social care (Forsyth et al., 2020 ). In some instances, personal care was delivered informally by untrained and unsupported prison staff and peer supporters in lieu of suitably trained social care workers (Treacy et al., 2019 ), with issues raised about the unavailability of social care through the night (Forsyth et al., 2020 ). Where social care staff were involved in coordinating personal care for prisoners, it was reported as positive for prisoners and prison staff (Her Majesty's Inspectorate of Prisons, 2016 ; Treacy et al., 2019 ), particularly, in one prison, where social care staff were prison-based (Forsyth et al., 2020 ).

Peer supporters

Prisoner peer supporters were operating in a number of prisons, as reported in 22 papers, and their employment was recommended by a further fourteen. Typically, these were people who had ‘good’ disciplinary and mental health records, and certainly in the US, were longer-serving prisoners. A number of papers indicated the need for peer supporters to receive training in dementia, including awareness and support (Brooke et al., 2018 ; Brooke & Jackson, 2019 ; Brown, 2016 ; Correctional Investigator Canada, 2019 ; Department of Health, 2007 ; Dillon et al., 2019 ; du Toit & Ng, 2022 ; Gaston, 2018 ; Gaston & Axford, 2018 ; Goulding, 2013 ; HMP Hull, 2015 ; HMP Littlehey, 2016 ; Her Majesty's Prison & Probation Service, 2018 ; Inspector of Custodial Services, 2015 ; Maschi et al., 2012 ; Mistry & Muhammad, 2015 ; Sindano & Swapp, 2019 ; Tilsed, 2019 ; Treacy et al., 2019 ). Comprehensive 36–40 h training on dementia was delivered for those working on specialist units, including one leading to a qualification (Brooke & Jackson, 2019 ; Brown, 2016 ; Gaston & Axford, 2018 ; Her Majesty's Prison & Probation Service, 2018 ; Moll, 2013 ). Much of the training was developed and delivered by charities, particularly dementia-related ones, as reported in eleven papers. Ongoing support and supervision was offered or recommended by some prisons, provided largely by health or social care staff or charities (Brooke & Jackson, 2019 ; Brown, 2016 ; Correctional Investigator Canada, 2019 ; Department of Health, 2007 ; Her Majesty's Prison & Probation Service, 2018 ; Gaston & Axford, 2018 ; Maschi et al., 2012 ; Prisons and Probation Ombudsman, 2016 ; Sindano & Swapp, 2019 ; Treacy et al., 2019 ), with informal peer-to-peer support also described (Brown, 2016 ; Gaston & Axford, 2018 ; Treacy et al., 2019 ). The support and supervision received was found to be valuable (Brooke & Jackson, 2019 ; Brown, 2016 ; Treacy et al., 2019 ). Peer-supporter roles are listed in Table 9 .

A number of benefits to: (a) the peer supporters, (b) the prisoners they supported and, (c) the prison, were described, although formal evaluations were lacking (Brown, 2016 ; Christodoulou, 2012 ; Department of Health, 2007 ; du Toit et al., 2019 ; Gaston, 2018 ; Gaston & Axford, 2018 ; Goulding, 2013 ; Treacy et al., 2019 ; Welsh Government and Ministry of Justice, 2011 ). This included: payment, development of skills which could be used on release, positive impact on progression through the system, and on self-confidence and compassion, and the creation of a more humane environment. However, frustration and distress amongst peer supporters largely when untrained and unsupported was also reported (Brooke & Jackson, 2019 ; Brown, 2016 ; Correctional Investigator Canada, 2019 ; Inspector of Custodial Services, 2015 ; Prisons and Probation Ombudsman, 2016 ; Treacy et al., 2019 ), and concerns raised in relation to an over-reliance on peers to do work that it is the statutory duty of health and social care to provide (Prisons and Probation Ombudsman, 2016 ; Treacy et al., 2019 ). This was a particular problem in light of personal care being prohibited for peer supporters in England and Wales (Her Majesty's Prison & Probation Service, 2018 ; Moll, 2013 ). It is also of note that the role of peer supporter may also attract the opprobrium of other prisoners, with reports that they have been seen as ‘snitches’ or ‘dogs’ in some areas (Brown, 2016 ; Goulding, 2013 ). In addition, in some prisons, the peer supporter role was not advocated due to: fear of litigation; fear of replacing staff with peers; belief that people should be acquiring more transferable skills, since many would be unable to undertake care work in the community due to their offence history (Brown, 2016 ; Goulding, 2013 ).

Accommodation

There were mixed views regarding accommodation for PLiPWD. A continuum of prison accommodation was suggested from independent to 24-h care (including assisted living) (Forsyth et al., 2020 ; Gaston & Axford, 2018 ; Williams et al., 2012 ). A number of papers ( n  = 18) recommended that there should be some form of alternative, more appropriate accommodation developed, potentially regional, including secure facilities possibly with a palliative orientation (Hodel & Sanchez, 2013 ; Mistry & Muhammad, 2015 ; Sfera et al., 2014 ). However, there were concerns about the availability, costs and staffing of specialist units, and distances that family would have to travel to visit despite potential benefits (du Toit et al., 2019 ; Moore & Burtonwood, 2019 ). It was also suggested that PLiPWD should be released to live in the community instead (Correctional Investigator Canada, 2019 ).

Within prisons, there was a debate evident within the papers about whether PLiPWD should be accommodated in separate units or integrated within the general prison population, which had generated little clear evidence and mixed views (Brooke & Jackson, 2019 ; Dillon et al., 2019 ; Her Majesty's Prison & Probation Service, 2018 ; Treacy et al., 2019 ). Authors have suggested that specialist or separate wings focused on older people or those with dementia were safer, met peoples’ needs better, and offered better care, support and programmes than integrated units (Brown, 2014 ; Dillon et al., 2019 ; du Toit & Ng, 2022 ; du Toit et al., 2019 ; Goulding, 2013 ; Maschi et al., 2012 ; Murray, 2004 ; Treacy et al., 2019 ; Williams et al., 2012 ), as long as they were ‘opt-in’ for prisoners and staff (Correctional Investigator Canada, 2019 ; Moll, 2013 ; Treacy et al., 2019 ; Williams et al., 2012 ), and opportunities to get off the wing to socialise with others are provided (Treacy et al., 2019 ). The types of ‘specialist’ accommodation that PLiPWD were living in are reported in Table 10 . It is of note that papers reported a highly limited number of beds available in specialist units (Inspector of Custodial Services, 2015 ; Patterson et al., 2016 ; Turner, 2018 ), and that a number of older prisoner-specific prisons were being closed due to costs (Turner, 2018 ).

Four papers described the benefits of older people and those PLiPWD residing within the general prison population (Dillon et al., 2019 ; Her Majesty's Prison & Probation Service, 2018 ; Treacy et al., 2019 ; Williams et al., 2012 ). Those living with dementia reported a benefit from socialising with, and being cared for by, younger people (Dillon et al., 2019 ; Her Majesty's Prison & Probation Service, 2018 ; Williams et al., 2012 ). The presence of older people also reportedly calmed younger prisoners (Dillon et al., 2019 ; Her Majesty's Prison & Probation Service, 2018 ; Williams et al., 2012 ). Importantly, removing people from their prison social networks may have a detrimental effect (Williams et al., 2012 ), and living on specialist units can be stigmatising (Treacy et al., 2019 ).

Regime and activities

The maintenance of prisons regimes is the primary focus of prison officers (Brooke & Jackson, 2019 ). However, there was a reported need ( n  = 19) for PLiPWD to have equal access to activities and services including work, education, gym, library and day centres where they exist, as well as a structured and varied regime on the wing on which they were accommodated, and support to access these. This support could include providing adequate seating (Welsh Government and Ministry of Justice, 2011 ), or giving prisoners more time to accomplish activities, and to assist if needed (Brooke & Jackson, 2019 ; Goulding, 2013 ; Her Majesty's Prison & Probation Service, 2018 ; Hodel & Sanchez, 2013 ). Other recommendations included an overall relaxation of regimes (Gaston & Axford, 2018 ; Treacy et al., 2019 ), an ‘open door’ policy (Brown, 2016 ; Cipriani et al., 2017 ; Goulding, 2013 ; Her Majesty's Inspectorate of Prisons, 2014 ; Her Majesty's Inspectorate of Prisons, 2017b ; Her Majesty's Prison & Probation Service, 2018 ; Treacy et al., 2019 ), more visible staff (The King's Fund, 2013 ), and creating a more communal social environment (Christodoulou, 2012 ). On-wing social activities are described in Table 11 .

Having on-wing work available or alternative means for prisoners who are unable to work to make money was also reportedly important (Christodoulou, 2012 ; Department of Health, 2007 ; Gaston, 2018 ; Gaston and Axford, 2018 ; Her Majesty's Inspectorate of Prisons, 2014 , 2016 , 2017b ; Her Majesty's Prison & Probation Service, 2018 ; Moll, 2013 ; Murray, 2004 ; Treacy et al., 2019 ; Welsh Government and Ministry of Justice, 2011 ). It was suggested that people with dementia should have the chance to work if wanted, and adaptations could be made to work programmes or working days made shorter to facilitate this. Some prisons had specific roles which involved lighter, simple, repetitive tasks such as gardening (Baldwin & Leete, 2012 ; Brooke & Jackson, 2019 ; Inspector of Custodial Services, 2015 ; Moll, 2013 ; Treacy et al., 2019 ). Day centres existed in some prisons, or were thought to be feasible (Department of Health, 2007 ; Her Majesty's Prison & Probation Service, 2018 ; Moll, 2013 ; Treacy et al., 2019 ; Welsh Government and Ministry of Justice, 2011 ), and it was suggested that attendance at these could constitute meaningful paid activity (Her Majesty's Prison & Probation Service, 2018 ). The centres were largely developed and facilitated by charities, and ran a wide variety of social, therapeutic, recreational, arts and advice-centred activities (Her Majesty's Prison & Probation Service, 2018 ; Moll, 2013 ).

Equal access to educational activities, including rehabilitation and offending behaviour programmes, was highlighted as important, particularly where attendance is needed to facilitate people’s progression through the system (Booth, 2016 ; Brooke & Jackson, 2019 ; Dillon et al., 2019 ; Department of Health, 2007 ; Her Majesty's Prison & Probation Service, 2018 ). Some prisons provided, or felt there was a need for, particular educational activities for PLiPWD and adaptations may be, or have been, made to learning materials and equipment, content and pace (Brooke & Jackson, 2019 ; Department of Health, 2007 ; Gaston, 2018 ; Gaston & Axford, 2018 ; Her Majesty's Prison & Probation Service, 2018 ; Treacy et al., 2019 ; Welsh Government and Ministry of Justice, 2011 ). Dedicated library sessions have been designated in some prisons, and some libraries can and do stock specialist resources including books, audiobooks, reminiscence packs and archives of local photos, music and DVDs (Department of Health, 2007 ; Her Majesty's Prison & Probation Service, 2018 ;Treacy et al., 2019 ; Williams, 2014 ). Educational materials could and have been available between sessions to aid memory with distance learning also possible (Brooke & Jackson, 2019 ; Her Majesty's Prison & Probation Service, 2018 ). Suggestions for alternatives for PLiPWD focused on activity and stimulation (du Toit & Ng, 2022 ; Gaston, 2018 ; Her Majesty's Prison & Probation Service, 2018 ), preparing for retirement classes (Department of Health, 2007 ), health promotion (Brooke et al., 2018 ; Christodoulou, 2012 ; Gaston & Axford, 2018 ; Her Majesty's Prison & Probation Service, 2018 ; Maschiet al., 2012 ; Murray, 2004 ; Welsh Government and Ministry of Justice, 2011 ), the arts (Brooke & Jackson, 2019 ) and IT classes (Her Majesty's Prison & Probation Service, 2018 ). Prisoner forums or representative could also be consulted regarding regimes and activities (Moll, 2013 ; Her Majesty's Prison & Probation Service, 2018 ; Welsh Government and Ministry of Justice, 2011 ). Challenges to regimen and activities are described in Table 12 .

Environment

A large number ( n  = 42) of the included papers discussed changes that prisons had made, or should make, to the built environment in order to be more suitable for PLiPWD – in one study in England and Wales, around half of prisons surveyed had made such environmental modifications (Forsyth et al., 2020 ). These focused on: (i) prisoners’ cells, (ii) bathrooms, (iii) dining hall, (iv) outside space and recreation areas, and (v) overall general prison environment (Table 13 ).

Problematically, the age and dementia-inappropriateness of buildings are considered a challenge (Baldwin & Leete, 2012 ; Brown, 2016 ; Dementia Action Alliance, 2017 ; Forsyth et al., 2020 ; Goulding, 2013 ; Inspector of Custodial Services, 2015 ; Mistry & Muhammad, 2015 ; Prisons and Probation Ombudsman, 2016 ; Treacy et al., 2019 ). Difficulties in navigating prisons where everywhere looks the same (Dementia Action Alliance, 2017 ; Murray, 2004 ; Treacy et al., 2019 ), and the lack of budget (HMP Littlehey, 2016 ; HMP Littlehey, 2016 ; Inspector of Custodial Services, 2015 ; Treacy et al., 2019 ) were also reported issues. It was suggested that the use of dementia-friendly environmental checklists could be useful, potentially with input from occupational therapists, health and social care, and dementia charities and in-house education, work and estates departments (Brown, 2014 ; Christodoulou, 2012 ; Dillon et al., 2019 ; Goulding, 2013 ; HMP Littlehey, 2016 ; Her Majesty's Prison & Probation Service, 2018 ; Hodel & Sanchez, 2013 ; Peacock et al., 2018 ; Sindano & Swapp, 2019 ; Treacy et al., 2019 ). Hope was expressed that newly built prisons would be more dementia-friendly (Dementia Action Alliance, 2017 ; Her Majesty's Prison & Probation Service, 2018 ; Williams et al., 2012 ).

Formal policies and procedures should be in place to help maintain links between family and prisoners, and to foster an understanding of the central importance of families particularly for PLiPWD (Her Majesty's Inspectorate of Prisons, 2016 ; Treacy et al., 2019 ). Some papers described how prisons could support contact by: giving help and additional time to make telephone calls and arranging visits in quieter spaces (Her Majesty's Prison & Probation Service, 2018 ; Prisons and Probation Ombudsman, 2016 ; Treacy et al., 2019 ); increasing the number of visits (Jennings, 2009 ); and allowing for accumulated visits or transfers to other prisons for visits closer to home (Her Majesty's Prison & Probation Service, 2018 ). Family communication – additional information can be found in Table 14 .

External organisations

One review suggested that external voluntary agencies were not often contacted or referred to, despite their potential benefits in terms of costs and support for staff and PLiPWDs (du Toit et al., 2019 ). However, other papers reported that charities for PLiPWD, or older people, were involved in (or were recommended to be involved in): designing and/or delivering dementia training; being part of MDTs; informing the design of referral processes, screening, assessment and case finding tools; consulting on environmental design; creating and delivering social care plans (including running activity centres); advice and support; advocacy and; co-facilitating a cognitive stimulation therapy group (Alzheimer’s Society 2018 ; Brooke et al., 2018 ; Brown, 2014 , 2016 ; Correctional Investigator Canada, 2019 ; Department of Health, 2007 ; du Toit & Ng, 2022 ; du Toit et al., 2019 ; Gaston, 2018 ; Gaston & Axford, 2018 ; Goulding, 2013 ; Her Majesty's Inspectorate of Prisons, 2014 ; HMP Hull, 2015 ; Her Majesty's Prison & Probation Service, 2018 ; Hodel & Sanchez, 2013 ; Moll, 2013 ; Peacock et al., 2018 ; Prisons and Probation Ombudsman, 2016 ; Sindano & Swapp, 2019 ; Tilsed, 2019 ; Treacy et al., 2019 ; Williams, 2014 ). It was also recommended that external organisations need to have a better knowledge and understanding of prisons and people living in prison, in order to better manage risk, and for clear information sharing protocols (du Toit & Ng, 2022 ).

(iv) Transfers

During the course of their sentence, people in prison may be transferred to other prisons for various reasons or to receive treatment in hospital. The need for MDT transfer plans to be developed was reported (Welsh Government and Ministry of Justice, 2011 ), as was the need to limit the number of prisoner transfers as moving accommodation is likely to have an adverse effect (Her Majesty's Prison & Probation Service, 2018 ; Patterson et al., 2016 ). It was recommended that transfers should take the distance from family and friends into account (Her Majesty's Prison & Probation Service, 2018 ), and that the ‘receiving’ facility (prison or healthcare setting) should be liaised with regarding health and social care, and risk (Her Majesty's Prison & Probation Service, 2018 ; Welsh Government and Ministry of Justice, 2011 ) to ensure continuity of care (Cipriani et al., 2017 ). A standard document transfer protocol was also postulated as useful, as documents need to be forwarded quickly as well (Brown, 2016 ; Tilsed, 2019 ; Welsh Government and Ministry of Justice, 2011 ). At the receiving facility, it was suggested that assessments and care plans should be reviewed on the day of the transfer (Brown, 2016 ; Her Majesty's Prison & Probation Service, 2018 ; National Institute for Health and Care Excellence, 2017 ; Welsh Government, 2014 ), and for re-inductions to be facilitated for prison transfers (Her Majesty's Prison & Probation Service, 2018 ).

(v) Release and resettlement

Most prisoners will be released from prison at the end of their sentence, although a number may die before their time is served. A number of areas were highlighted regarding the release and resettlement of PLiPWD, including the possibility of early release due to dementia.

Early release

A number of papers advocated for compassionate release policies and their actual use, or alternative custodial placements such as halfway houses or secure nursing homes, that would effectively result in the early release of PLiPWD (Brown, 2016 ; Cipriani et al., 2017 ; Correctional Investigator Canada, 2019 ; Dementia Action Alliance, 2017 ; Department of Health, 2007 ; du Toit & Ng, 2022 ; du Toit et al., 2019 ; Fazel et al., 2002 ; Gaston & Axford, 2018 ; Goulding, 2013 ; Her Majesty's Prison & Probation Service, 2018 ; Hodel & Sanchez, 2013 ; Inspector of Custodial Services, 2015 ; Maschi et al., 2012 ; Mistry & Muhammad, 2015 ; Pandey et al., 2021 ; Turner, 2018 ; Williams et al., 2012 ). Although, it has also been noted that early release may not be a popular idea for some sections of the community (du Toit et al., 2019 ; Garavito, 2020 ), it was also suggested that raising community awareness of dementia may ameliorate this (du Toit & Ng, 2022 ). It was reported that prisoners with dementia should be considered in any criteria set forth for early release, particularly given the high cost/low risk ratio which they represent (Baldwin & Leete, 2012 ; Correctional Investigator Canada, 2019 ; Department of Health, 2007 ; Goulding, 2013 ; Her Majesty's Prison & Probation Service, 2018 ; Inspector of Custodial Services, 2015 ; Maschi et al., 2012 ; Murray, 2004 ; Williams et al., 2012 ). For prisoners who do not understand the aims of prison, continuing to hold them may be a contravention of human rights and equality laws – particularly where health and social care is inadequate (Baldwin & Leete, 2012 ; Dementia Action Alliance, 2017 ; Fazel et al., 2002 ; Gaston & Axford, 2018 ; Murray, 2004 ). It was also emphasised that the existence of units and programmes for PLiPWD should not be used to legitimise prison as an appropriate place for PLiPWD (Correctional Investigator Canada, 2019 ). More information can be found in Table 15 .

Resettlement

Ten different areas were identified in the literature which related to the issues PLiPWD leaving prison may face on their release and resettlement into the community, these were:

(a) In-prison release preparation

Specific pre-release programmes or services for older people or those living with dementia may be required (Department of Health, 2007 ; Williams et al., 2012 ), with prisoners being cognitively screened prior to release (Goulding, 2013 ), although the latter was only found in 10% of prisons in one study (Forsyth et al., 2020 ). Other suggestions for programme content included: self-efficacy, health, staving off dementia and associated anxiety, accessing services, addressing institutionalisation, setting up email addresses, and the provision of information packs on national, regional and local services and resources (Department of Health, 2007 ; Her Majesty's Prison & Probation Service, 2018 ; Williams et al., 2012 ).

It has been suggested that release plans and transitions be facilitated by an MDT including prisoners, the voluntary sector, offender managers, and other appropriate community-based organisations (du Toit et al., 2019 ; Feczko, 2014 ; Goulding, 2013 ; Her Majesty's Prison & Probation Service, 2018 ; Inspector of Custodial Services, 2015 ; Moll, 2013 ; Welsh Government and Ministry of Justice, 2011 ). Recommended plan content included: risk management strategies, health, social care, housing, finance, employment, leisure and voluntary sector considerations (Welsh Government and Ministry of Justice, 2011 ). It was also suggested that Circles of Support and Accountability (CoSA), primarily associated with sex offenders, could be set up for PLiPWD as a means to support those leaving prison and settling back into the community particularly without family support (Her Majesty's Prison & Probation Service, 2018 ).

Challenges to release preparation were identified as: a lack of resources, (Turner, 2018 ) the lack of clarity regarding staff resettlement roles (Inspector of Custodial Services, 2015 ), and the lack of resettlement provision offered at sex offender prisons in England and Wales (Her Majesty's Prison & Probation Service, 2018 ).

A number of papers reported the key role that family and friends can or do play in supporting PLiPWD leaving prison, and that this should be supported or facilitated by prison staff (Brown, 2016 ; Her Majesty's Prison & Probation Service, 2018 ; Goulding, 2013 ). Initially this could include encouraging diagnosis disclosure (Dillon et al., 2019 ), using prison leave to maintain relationships (Her Majesty's Prison & Probation Service, 2018 ), involvement in discharge planning (Welsh Government and Ministry of Justice, 2011 ), and placing prison leavers close to family upon release and ensuring family are supported (Correctional Investigator Canada, 2019 ; Gaston & Axford, 2018 ). Where PLiPWD lack family, setting up CoSAs as described above may be useful (Her Majesty's Prison & Probation Service, 2018 ).

(c) Probation

It was suggested that probation staff should have training to work with older people, and that some offender managers could specialise in this work (Department of Health, 2007 ; Welsh Government and Ministry of Justice, 2011 ). Probation officers or offender managers are or can be involved in resettlement planning, (Her Majesty's Prison & Probation Service, 2018 ; Welsh Government and Ministry of Justice, 2011 ), arranging accommodation (Inspector of Custodial Services, 2015 ), liaising with agencies such as health care or social services, checking that PLiPWD are accessing these services and disseminating reports of to-be released prisoners to relevant parties (Department of Health, 2007 ; Moll, 2013 ; Welsh Government and Ministry of Justice, 2011 ). Importantly, the forwarding of important documents to offender managers by the prison should be routine (Department of Health, 2007 ; Moll, 2013 ). It was also recommended that probation staff should visit people in prison before release if they live out of area (Department of Health, 2007 ). The work of probation services was reportedly hampered by limited resources (Brown, 2016 ).

Continuity of care upon release can be difficult, and it was suggested that it could be a role of prison healthcare to ensure this (including registering with the local GP and dentist (Cipriani et al., 2017 ; Department of Health, 2007 ; Gaston, 2018 ; Gaston & Axford, 2018 ; Her Majesty's Prison & Probation Service, 2018 ; Inspector of Custodial Services, 2015 ; Welsh Government and Ministry of Justice, 2011 ). There appeared to be some differences regarding the distribution of full healthcare reports to offender managers and other appropriate agencies with some prisons sending them, some only if requested, and some not providing them on grounds of confidentiality (Moll, 2013 ). Typically, it was recommended that it was better for to-be released older prisoners if these reports were disseminated (Department of Health, 2007 ). It was also suggested that healthcare staff in prison and from the community form part of multi-disciplinary release planning, and that these plans include health considerations and healthcare staff advice on issues of accommodation (du Toit & Ng, 2022 ; Inspector of Custodial Services, 2015 ; Moll, 2013 ; Welsh Government and Ministry of Justice, 2011 ).

(e) Social care

Some papers reported that social workers can and should be involved in the process of resettlement (Department of Health, 2007 ; Welsh Government and Ministry of Justice, 2011 ) and release preparation (Goulding, 2013 ). Continuity of social care arranged with the local authority was also recommended (Her Majesty's Prison & Probation Service, 2018 ; Welsh Government and Ministry of Justice, 2011 ).

(f) Accommodation

Release planning should include plans for accommodation, and involve housing agencies or care services in the community in that planning (Welsh Government and Ministry of Justice, 2011 ). Importantly, people in prison may need help in registering for housing, and their homes may be in need of adaptation in response to their health or social care needs (Department of Health, 2007 ; Her Majesty's Prison & Probation Service, 2018 ). Nursing homes and other care providing facilities were reported to be reluctant to accommodate people who have been in prison (Brown, 2014 ; Brown, 2016 ; Booth, 2016 ; Correctional Investigator Canada, 2019 ; du Toit et al., 2019 ; Gaston, 2018 ; Garavito, 2020 ; Goulding, 2013 ; Inspector of Custodial Services, 2015 ). This was described as particularly the case for those who were living with dementia (Brown, 2014 ; Correctional Investigator Canada, 2019 ; Dillon et al., 2019 ), with further issues reported in accommodating those who have committed sex offences (Brown, 2014 , 2016 ; Dillon et al., 2019 ; Garavito, 2020 ; Inspector of Custodial Services, 2015 ). Concerns regarding the safety of other residents and the views of their families, and the rights of victims in general, were cited as reasons behind these placement difficulties (Brown, 2014 ; Goulding, 2013 ) – one paper reported that there had been community protests (Brown, 2016 ).

It was suggested that prisons need to build better relationships with care providers in the community, which had reportedly been forged by some (Brown, 2016 ; Goulding, 2013 ; Inspector of Custodial Services, 2015 ), and that they could also provide education and support to these services (Booth, 2016 ). However, it was also noted that there may be a need for specialist residential units to be created in the community for people released from prison with dementia (Inspector of Custodial Services, 2015 ), with an example of a state-run facility for ex-prisoners in the United States (Goulding, 2013 ), and particular attention for younger ex-prisoners with dementia (Brown, 2014 ). A number of papers reported that if accommodation could not be arranged for people, this largely resulted in them remaining in prison until it was (Correctional Investigator Canada, 2019 ; Goulding, 2013 ; Inspector of Custodial Services, 2015 ; Peacock et al., 2018 ; Soones et al., 2014 ).

(g) Finance

Imprisonment likely leads to a loss of income, meaning that older prisoners who may have served more lengthy sentences are likely to be poorer, particularly if unable to work in prison (Baldwin & Leete, 2012 ; Gaston, 2018 ). Therefore, it was suggested that release planning ought to include issues of finance (Welsh Government and Ministry of Justice, 2011 ). Given that it has been suggested that people in prison should be given advice on pensions and welfare benefits, and help to arrange these (Department of Health, 2007 ; Her Majesty's Prison & Probation Service, 2018 ; Goulding, 2013 ), addressing this would seem to be an area of particular use for older people leaving prison who may have additional problems in these areas, and for those who may need assistance in arranging their financial affairs because of their deteriorating health problems.

(h) Employment and education

People’s employment prospects are likely to be impacted upon release from prison, particularly for older people who may have served long sentences (Gaston, 2018 ). Where appropriate, it was recommended that release planning should include issues around employment (Welsh Government and Ministry of Justice, 2011 ), that information packs for people should include sections on education and employment, and that it could be useful to help people make links with the Department for Work and Pensions (Her Majesty's Prison & Probation Service, 2018 ).

(i) Leisure

Leisure activities and resources could be considered in release planning, and included in pre-release information packs for prisoners (Her Majesty's Prison & Probation Service, 2018 ; Welsh Government and Ministry of Justice, 2011 ).

(j) Charities and voluntary sector organisations

It was recommended in a number of papers that charity and voluntary sector organisations working with PLiPWD be involved in release planning (Department of Health, 2007 ; du Toit et al., 2019 ; Her Majesty's Prison & Probation Service, 2018 ; Moll, 2013 ; Welsh Government and Ministry of Justice, 2011 ), continuity of care (Moll, 2013 ), and in providing support during the transition and after (du Toit & Ng, 2022 ; Welsh Government and Ministry of Justice, 2011 ). It was also suggested that in general it would be useful for PLiPWD to have contact with these organisations (Department of Health, 2007 ; Her Majesty's Prison & Probation Service, 2018 ; Inspector of Custodial Services, 2015 ), and that they may be well-placed to develop information packs for prisoners on release regarding local amenities, services and resources (Her Majesty's Prison & Probation Service, 2018 ).

(vi) Cross-cutting themes

Eight more generalised concerns were also described which had a clear impact on the passage of PLiPWD through prison, on release and resettlement in the community, and on the issues raised thus far in the review.

Principles-philosophy

The principles suggested to underpin the support of PLiPWD are that it should be person-centred, holistic, adhere to human rights and dignity principles, proactive, health promoting, and enabling – making choices but supported if needed (Brown, 2014 , 2016 ; Christodoulou, 2012 ; Cipriani et al., 2017 ; Correctional Investigator Canada, 2019 ; Department of Health, 2007 ; Dillon et al., 2019 ; du Toit & Ng, 2022 ; Gaston & Axford, 2018 ; Her Majesty's Inspectorate of Prisons, 2017b ; Her Majesty's Prison & Probation Service, 2018 ; Mackay, 2015 ; Maschi et al., 2012 ; Treacy et al., 2019 ; Welsh Government and Ministry of Justice, 2011 ; Wilson & Barboza, 2010 ). Conversely, clashes in philosophies between prison staff, and health and social care staff have been reported with security trumping care in many cases, which can have a negative impact (du Toit & Ng, 2022 ; Gaston, 2018 ; Gaston & Axford, 2018 ; Goulding, 2013 ; Mackay, 2015 ; Murray, 2004 ; Patterson et al., 2016 ; Prisons and Probation Ombudsman, 2016 ; Treacy et al., 2019 ; Williams, 2014 ). It was suggested that positioning dementia as more than just a health issue and fostering a whole-prison care-custody model or approach, with clearly defined roles for ‘care’ and ‘custody’, may be useful in resolving this (du Toit & Ng, 2022 ; Public Health England, 2017b ; Welsh Government and Ministry of Justice, 2011 ).

A number of papers ( n  = 15) reported that budget and resource limitations had a variety of negative impacts including difficulties in providing: appropriate assessment, support and accommodation to PLiPWD; specialist accommodations, plans for which were then curtailed; delivering programmes and activities; healthcare cover; and, staff training (Booth, 2016 ; Christodoulou, 2012 ; Correctional Investigator Canada, 2019 ; Dementia Action Alliance, 2017 ; Dillon et al., 2019 ; du Toit et al., 2019 ; du Toit & Ng, 2022 ; Goulding, 2013 ; HMP Hull, 2015 ; Jennings, 2009 ; Mackay, 2015 ; Moll, 2013 ; Moore & Burtonwood, 2019 ; Pandey et al., 2021 ; Patterson et al., 2016 ; Peacock et al., 2018 ; Treacy et al., 2019 ; Turner, 2018 ). Ultimately, lack of resources has reportedly led to a system that is not able to cope appropriately with PLiPWD (Moll, 2013 ; Williams et al., 2012 ; Wilson & Barboza, 2010 ), with associated problems transferring out of the prison system into probation and care systems when people are released (Williams et al., 2012 ).

It has been suggested that PLiPWD in prison should be treated as if they have capacity to make decisions such as giving or withholding consent for treatment, unless it is proven otherwise. This is consistent with legislation such as the Mental Capacity Act (Prisons and Probation Ombudsman, 2016 ). It has been recommended that healthcare staff should conduct capacity assessments if there are concerns (National Institute for Health and Care Excellence, 2017 ; Welsh Government and Ministry of Justice, 2011 ), and be trained to do so (Maschi et al., 2012 ; Welsh Government, 2014 ). It is of note that an ombudsman report showed that PLiPWD who died lacked access to mental capacity assessments (Peacock et al., 2018 ). For PLiPWD, who are likely to lack capacity as their condition progresses, early education about, and development of, advance directives has been advocated (Brown, 2016 ; Cipriani et al., 2017 ; Inspector of Custodial Services, 2015 ; Maschi et al., 2012 ; Prisons and Probation Ombudsman, 2016 ), and staff should be trained on this (Maschi et al., 2012 ). It has also been suggested that family members, independent mental capacity advocates or healthcare proxies could or should be used for PLiPWD who lack capacity in making care, welfare and financial decisions (Brown, 2016 ; Soones et al., 2014 ), supported by legislation and oversight, as opposed to prison or healthcare staff making decisions (Correctional Investigator Canada, 2019 ).

The issue of ‘risk’ related to PLiPWD revolves around four areas: (i) assessment, (ii) management, (iii) disciplinary procedures, and (iv) safeguarding. Full details can be found in Table 16 .

There were a number of additional facets to risk concerns regarding PLiPWD described in the papers. There were concerns that the lack of understanding of the impact of dementia on people’s behaviour could ultimately lead to people being held in prison for longer periods on account of seemingly transgressive or aggressive behaviour that could in fact be related to their dementia difficulties (Dementia Action Alliance, 2017 ; Mistry & Muhammad, 2015 ; Treacy et al., 2019 ). In one study, a prisoner with dementia was transferred to another prison because staff felt that they were ‘grooming’ an officer (Treacy et al., 2019 ), likely lengthening their overall prison stay. There was also a recurring issue in fatal incidents investigations in England and Wales of prisoners being restrained whilst dying in hospital, a practice described as unnecessary in light of their likely frail state (Peacock et al., 2018 ; Prisons and Probation Ombudsman, 2016 ). One paper suggested linking future accommodation options and considerations for Release on Temporary Licence to a PLiPWD’s risk of reoffending, as well as the severity of their symptoms (Forsyth et al., 2020 ). Moore and Burtonwood ( 2019 ) also observed that a lack of risk assessment protocols was a barrier to release of PLiPWD., and as Table 16 suggests, a comprehensive risk assessment, applied by appropriately trained staff should make health and its impact on future offending more salient to aid this.

There were recommendations that PLiPWD should have the opportunity to make choices in their treatment and care. This included input into care plans or making informed decisions about their care (Department of Health, 2007 ; du Toit & Ng, 2022 ; National Institute for Health and Care Excellence, 2017 ; Welsh Government and Ministry of Justice, 2011 ), as well as developing advance directives particularly early in a person’s sentence (Brown, 2016 ; Cipriani et al., 2017 ; Inspector of Custodial Services, 2015 ; Maschi et al., 2012 ; Pandey et al., 2021 ; Peacock et al., 2019 ; Prisons and Probation Ombudsman, 2016 ), and choosing ‘preferred’ places to die (Her Majesty's Prison & Probation Service, 2018 ).

Protected characteristics

There was a reported need for culturally appropriate assessments, treatment and activities (Brooke et al., 2018 ; Department of Health, 2007 ; Hamada, 2015 ; Welsh Government and Ministry of Justice, 2011 ), spiritual support (Welsh Government and Ministry of Justice, 2011 ), multilingual information (Welsh Government and Ministry of Justice, 2011 ), and the recognition of gender differences in dementia healthcare needs (Brown, 2014 ; Department of Health, 2007 ; Williams et al., 2012 ). It was also highlighted that racism makes the experience of living with dementia in prison more problematic (Brooke et al., 2018 ; Brown, 2014 ; Correctional Investigator Canada, 2019 ). There were some examples of policy and practice within prisons which considered some protected characteristics: assessment tools in different languages (Patterson et al., 2016 ), additional support for PLiPWD to plan care (Department of Health, 2007 ; Welsh Government and Ministry of Justice, 2011 ), and the development of culturally appropriate care planning (Hamada, 2015 ). Hamada ( 2015 ) also advocated assessment and treatment that was culturally ‘competent’ and respectful, and which acknowledged the importance of culture and diversity.

An overall need to tackle dementia- and age-related stigma was also reported in some papers, and the need to foster cultures that are age-respectful should be reflected in staff training (Department of Health, 2007 ; Treacy et al., 2019 ; Welsh Government and Ministry of Justice, 2011 ), In addition, practices which openly discriminate such as the lack of: dedicated dementia resources (Turner, 2018 ), appropriate lower category prison places (Department of Health, 2007 ; Welsh Government and Ministry of Justice, 2011 ), and appropriate accommodation on release, which at times prevents release, should also be challenged (Correctional Investigator Canada, 2019 ; Forsyth et al., 2020 ; Ministry of Justice, 2013 ; Prisons and Probation Ombudsman, 2016 ). There was also a lack of research into the interaction between protected characteristics and dementia in prison (Brooke & Jackson, 2019 ; Treacy et al., 2019 ; Williams et al., 2012 ).

Collaboration

Many papers advocated the need for prisons and specialist dementia units to adopt a collaborative MDT approach drawing from staff teams across the prison regarding: the identification and support of prisoners with dementia, care planning, the disciplinary process, the development, dissemination and implementation of policy, and in environmental change and the building of new prisons (Brooke et al., 2018 ; Brown, 2014 , 2016 ; Christodoulou, 2012 ; Cipriani et al., 2017 ; Dillon et al., 2019 ; Department of Health, 2007 ; Feczko, 2014 ; Forsyth et al., 2020 ; Gaston & Axford, 2018 ; Her Majesty's Inspectorate of Prisons, 2014 , 2016 ; HMP Hull, 2015 ; HMP Littlehey, 2016 ; Her Majesty's Prison & Probation Service, 2018 ; Inspector of Custodial Services, 2015 ; Moll, 2013 ; Patterson et al., 2016 ; Peacock et al., 2018 ; Peacock, 2019 ; Prisons and Probation Ombudsman, 2016 ; Sindano & Swapp, 2019 ; The King’s Fund 2013 ; Tilsed, 2019 ; Treacy et al., 2019 ; Welsh Government and Ministry of Justice, 2011 , 2014 ; Williams, 2014 ). There were examples of prisoners collaborating with staff in the care of PLiPWD as peer supporters, and having joint staff-prisoner supervision and training (Brooke & Jackson, 2019 ), of joint staff-prisoner wing meetings in one prison (Treacy et al., 2019 ), and of the co-designing of services and activities in others (Her Majesty's Prison & Probation Service, 2018 ; Treacy et al., 2019 ). It was suggested that this collaborative way of working should be supported by an information sharing protocol, clear definitions of staff and peer supporter roles and responsibilities, and training (Brooke & Jackson, 2019 ; Dillon et al., 2019 ; du Toit & Ng, 2022 ; HMP Littlehey, 2016 ; Turner, 2018 ). It was reported that there had been a lack of communication and coordination of this process in some prisons which had a negative impact on all involved (Brooke & Rybacka, 2020 ; Forsyth et al., 2020 ; Moll, 2013 ; Prisons and Probation Ombudsman, 2016 ).

It was also suggested that the prisons collaborate with healthcare, hospice and dementia specialists in the community and with external charitable organisations (Brooke et al., 2018 ; Brown, 2014 ; Cipriani et al., 2017 ; du Toit & Ng, 2022 ; Gaston, 2018 ; Gaston & Axford, 2018 ; Goulding, 2013 ; HMP Hull, 2015 ; HMP Littlehey, 2016 ; Her Majesty's Prison & Probation Service, 2018 ; Moll, 2013 ; Peacock, 2019 ; Prisons and Probation Ombudsman, 2016 ; Sindano & Swapp, 2019 ; Tilsed, 2019 ; Treacy et al., 2019 ; Welsh Government and Ministry of Justice, 2011 ; Williams, 2014 ). In addition, inter-prison networks were recommended to be developed to share good practice across prisons (Dementia Action Alliance, 2017 ; Moll, 2013 ; Peacock et al., 2019 ; Prisons and Probation Ombudsman, 2016 ).

Information-sharing

A number of papers ( n  = 7) recommended the need for a clear information sharing protocol regarding the assessment and support of PLiPWD (Brooke et al., 2018 ; Dillon et al., 2019 ; Department of Health, 2007 ; Goulding, 2013 ; Moll, 2013 ; Tilsed, 2019 ; Welsh Government and Ministry of Justice, 2011 ), or a register (Forsyth et al., 2020 ). Particular attention to the interface between healthcare and prison staff and peer supporters was suggested, where it has been reported that privacy regulations have sometimes prevented contributions to collateral histories (Feczko, 2014 ) and the sharing of care plans, impairing their ability to offer appropriate support (Inspector of Custodial Services, 2015 ). Also, it may be against the wishes of the person with dementia, and informed consent should be sought (Forsyth et al., 2020 ; Moll, 2013 ). This lack of information can have a detrimental effect on a person’s health and wellbeing (Brown, 2014 , 2016 ; Feczko, 2014 ; Inspector of Custodial Services, 2015 ), and so discussion of this was highlighted as important, particularly where the safety of the person or others were concerned (National Institute for Health and Care Excellence, 2017 ). A care plan which gives only very basic information to staff and peer supporters was used in a couple of prisons (Goulding, 2013 ; Williams, 2014 ).

There also appeared to be variance with respect to whether healthcare staff disclose a dementia diagnosis to the person diagnosed with dementia. A couple of prisons’ policy was to share a diagnosis and involve family in doing so (Maschi et al., 2012 ; Welsh Government and Ministry of Justice, 2011 ; Wilson & Barboza, 2010 ), however, in one prison disclosed if a person was judged to be able to cope with it, and another only disclosed if asked (Brown, 2016 ). The importance of disclosure to family allowing them to contribute to assessments, planning and support was also emphasised in some papers (Brown, 2016 ; Dillon et al., 2019 ; National Institute for Health and Care Excellence, 2017 ; Welsh Government and Ministry of Justice, 2011 ).

This review has explored the literature regarding all parts of the custodial process and its impact on people living in prison with cognitive impairment and dementia, which includes: reception, assessment, allocation, training, policy, healthcare, accommodation, adaptation, routine, access to family and external agencies, transfer and resettlement. We found evidence that problems had been identified in each of these parts of the process. We also identified a number of cross-cutting themes which interacted with the issues identified across the prison journey including: principles or philosophy regarding care; capacity; resources; considerations of risk; scope for choice; peoples’ protected characteristics; collaboration; and, information sharing. Broadly, our findings were similar to those found in previous reviews, regarding the problems with the prison process identified, and the lack of robust outcomes, and policy guidance regarding PLiPWD (Brooke and Rybacka, 2020 ; Peacock et al., 2019 ).

The aim of this review was to identify areas of good practice and for recommendations that could inform the development of prison dementia care pathways. There is a considerable breadth to the findings, but the main recommendations that have arisen from the review are:

To screen prisoners for cognitive difficulties at reception, from either 50 or 55 years

An initial older-person specific health and social care assessment, post-screening – from either 50 or 55 years, and repeated (from 3 – 12 months)

A spectrum of healthcare to be delivered including preventative, long-term and palliative care, with continuity of care upon release, and in tandem with social care

Mixed views about appropriate accommodation, but it needs to run along a continuum from independent living to 24-h care, with decisions possibly made after health assessments

Environments need to be made more older-person or dementia friendly, using checklists available, and with the voluntary sector as potential partners

A need for prison staff training on dementia, and further training for healthcare staff

The use of peer supporters was broadly reported positively, and were seemingly frequently used. However, there needs to be adequate training and support, and not to be used to do the work that is the statutory duty of health and social care staff

Equal access to activities and services, especially programmes which help people move through the system (such as offending behaviour), as well as opportunities to earn additional monies, and that provide structure and routine on wings

The maintenance of family links, and for families to be supported, are important for PLiPWD, and may be particularly so on release and resettlement

Prisons may also need to work with external care agencies to ensure placements upon release, or alternative specialist care facilities may need to be created

The main barriers to implementing these recommendations are a lack of policy or guidance at local, regional and national levels to support staff in working with PLiPWD, and also the lack of budget and resources available. The latter would also include infrastructure issues, such that a number of prisons are not appropriate for people living with dementia, and could be expensive to modify to become so, coupled with a lack of currently available alternative facilities for PLiPWD to be released to in the community. The lack of use of compassionate release is also an issue here, including during the COVID-19 pandemic, with only 54 people released (Halliday & Hewson, 2022 ). Lastly, the roles that each professional and peer group had regarding PLiPWD needed clarification in some prisons, including some resolution of the ‘clash’ of philosophies (control v care) underpinning this.

In terms of ‘solutions’, multiple organisations have advocated for years for the need for national policy to assist prisons with older people in prison, including those living with dementia (Cornish et al., 2016 ; HM Inspectorate of Prisons, 2004 , 2019 ; Prisons & Probation Ombudsman, 2016 , 2017 ). This was eventually accepted and commissioned by the UK government, although it has not been released as yet (Justice Committee, 2020 ). It has also been suggested that at a more local level, existing policies could be adapted to be more appropriate for PLiPWD – such as restraint policies for frail prisoners, and disciplinary procedures which reflect the impact that dementia may have on behaviour (Department of Health, 2007 ; Treacy et al., 2019 ). Considerations around capacity and consent would need to be weaved in, as well as a focus on the intersection with other protected characteristics. These adaptations would also need to extend to services and activities to ensure that people have equal access and opportunities. A number of reports highlighted the contribution that greater collaboration with partners in external health and social care teams could have, as well as partnerships with the voluntary sector. These could potentially assist in multiple areas including training staff and peer supporters, providing activities, assisting release preparation, at a relatively low cost, to high benefit. There were some recommendations that prisons adopt a whole-prison approach to dementia that focuses on being person-centred, health and human rights focused that may help to ameliorate some differences in philosophical approach between various staff and peer groups in prisons.

A number of potential areas for future research were also indicated by the literature, which would also support the development of prison pathways. These would include: (i) induction to prison, and (ii) release and resettlement from prison, which are important beginning and end-points, but which are under-researched; (iii) the validation of a screening tool for use in prisons, and the development or adaptation of prison-specific health and social care assessments; (iv) the interaction of protected characteristics and dementia, and the need for more culturally and gender aware pathways; (v) the paucity of research conducted in low and middle-income countries, that needs to be addressed; (vi) dementia and age-related stigma in prisons; and (vii) evaluations of all elements of the prison pathway for PLiPWD to undertaken including training, the role of peer supporters, and targeted programmes.

Strengths and limitations of the review

One key strength of this review is its comprehensiveness, particularly as it includes much grey literature. Given the lack of robust evaluation in this area, it was felt that this was necessary to represent the volume of work that has nonetheless taken place. There are, however, a number of limitations of this review. Firstly, despite the use of broad search terms, there may be the possibility that some relevant research was missed, either because of deficiencies in our searches or because of publication bias. Additionally, whilst there are twenty-two guidance and inspection documents included in this review, it is possible that some grey literature might also remain unidentified, particularly outside of the UK where the review was undertaken. Secondly, this review may be subject to a selection bias, as the yielded search results might have included literature that were excluded but which may have indirectly impacted upon the care pathways elements explored in the review. There is also a language bias, and whilst this may reflect the languages spoken by the review team members, it is also reflective of the “northern epistemic hegemony” (Aas, 2012 ), that also may have resulted in the review being largely populated by papers from high income countries. Thirdly, no formal assessment of study quality was undertaken. This is in keeping with scoping review methodology which focuses on breadth, but is nonetheless an important shortcoming inherent in scoping reviews more generally (Arksey & O’Malley, 2005 ).

We have completed the most comprehensive review of the literature on PLiPWD in prisons to date that we have found, including a synthesis of the extensive grey literature, and found important gaps in the literature. Our review includes a mixture of academic research, policy and position papers which identified an increasing number of prisoners with dementia or cognitive impairment as an issue, but there were more limited descriptions of what should be done, and even less describing implementation of these. Most of the literature came from developed nations where extensive assessment and care services are in place for PWD in the community, although a key question is whether prison populations are given easy access to these existing services or whether bespoke services for prisoners are required. We suggest this literature now needs to be drawn together to inform interventions for PLiPWD in the criminal justice system which can be piloted and evaluated, and inform the development of robust dementia care pathways for prisons.

Availability of data and materials

All data and materials used in this review are included in this article and its appendices.

There is no standard cut-off age for older people living in prison, but it is typically set at least ten to fifteen years lower than the general population. People in prison are thought to age more rapidly due to both pre- and post-imprisonment chaotic lifestyles, substance misuse and less healthcare access and use, as well as the ‘pains of imprisonment’. See Williams et al., ( 2012 ) for further discussion.

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Acknowledgements

We would like to thank all the funders for their contributions towards this review. We also would like to thank the key stakeholders, especially the prison advisors and old age psychiatry and care advisors, who contributed towards shaping and contextualising this evidence review.

This is a summary of research which was partly funded by the National Institute for Health Research (NIHR) Applied Research Collaboration East of England - previously, the Collaboration for Leadership in Applied Health Research and Care East of England – and the Cambridgeshire and Peterborough NHS Foundation Trust (CPFT), as part of the wider prison care programme. The views expressed are those of the author(s).

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Treacy, S., Martin, S., Samarutilake, N. et al. Dementia care pathways in prisons – a comprehensive scoping review. Health Justice 12 , 2 (2024). https://doi.org/10.1186/s40352-023-00252-7

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A robust workforce of locum tenens (LT) physicians is imperative for health service stability. A systematic review was conducted to synthesize current evidence on the strategies used to facilitate the recruitment and retention of LT physicians. English articles up to October 2023 across five databases were sourced. Original studies focusing on recruitment and retention of LT’s were included. An inductive content analysis was performed to identify strategies used to facilitate LT recruitment and retention. A separate grey literature review was conducted from June–July 2023. 12 studies were retained. Over half (58%) of studies were conducted in North America. Main strategies for facilitating LT recruitment and retention included financial incentives (83%), education and career factors (67%), personal facilitators (67%), clinical support and mentorship (33%), and familial considerations (25%). Identified subthemes were desire for flexible contracts (58%), increased income (33%), practice scouting (33%), and transitional employment needs (33%). Most (67%) studies reported deterrents to locum work, with professional isolation (42%) as the primary deterrent-related subtheme. Grey literature suggested national physician licensure could enhance license portability, thereby increasing the mobility of physicians across regions. Organizations employ five main LT recruitment facilitators and operationalize these in a variety of ways. Though these may be incumbent on local resources, the effectiveness of these approaches has not been evaluated. Consequently, future research should assess LT the efficacy of recruitment and retention facilitators. Notably, the majority of identified LT deterrents may be mitigated by modifying contextual factors such as improved onboarding practices.

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Introduction

The shortage of a sustainable and robust physician workforce is a significant healthcare issue across most of the world [ 1 ]. In regions that face persistent challenges in physician availability, the continuity of the healthcare system heavily relies on locum tenens (LT) physicians, commonly referred to as “locums”. These healthcare providers work in a temporary capacity to fill vacancies or provide coverage for permanent physicians [ 2 , 3 ]. Their importance was highlighted during the COVID-19 pandemic as the lack of locums resulted in the suspension of hospital services and emergency department closures due to insufficient staffing [ 4 ].

Physician recruitment strategies primarily focus on filling permanent positions with minimal emphasis on attracting locum providers [ 5 ]. However, strategies aimed at facilitating the recruitment of permanent physicians may not effectively attract locums given fundamental distinctions in their employment preferences and priorities. LTs, for instance, are motivated by factors such as seeking greater autonomy, working part-time, transitioning into partial retirement, and supplementing income [ 6 , 7 ]. Their attraction to working as a locum may be due to advantages including reduced administrative burdens, lower workplace stress, and flexibility for maintaining a desired work–life balance [ 6 , 7 ]. Additional advantages include competitive salaries comparable to permanent positions without a long-term commitment, travel and accommodation stipends, subsidized malpractice insurance, and lower overhead expenses [ 6 , 7 ].

Governments and communities invest substantial financial resources to attract locums in order to sustain healthcare service delivery [ 6 , 8 ]. As such, existing research has investigated locum recruitment and retention factors [ 6 , 7 , 9 , 10 ]. Despite the important role that locums play in sustaining operational healthcare systems, particularly during periods of health human resources strain, there is a lack of consolidated of evidence on the recruitment of LT physicians. Consequently, there is a need for the synthesis of current research on facilitators used in the recruitment and retention of LTs. This will serve to better inform the development of comprehensive, evidence-based recruitment guidelines tailored specifically to LT physicians. Therefore, this study systematically reviewed existing literature to identify and synthesize the approaches used to recruit locum physicians. Ensuing results will provide valuable guidance to policymakers and healthcare organizations, aiding in the development of evidence-based recruitment policies and practices to address the unique needs of locum physicians.

This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [ 11 ]. This research protocol was registered in the PROSPERO database (CRD42022339666).

Search strategy

Between April 26th and April 27th, 2022 we performed a systematic search of the electronic databases Ovid MEDLINE, Cochrane Database of Systematic Reviews, PsycINFO, CINAHL and Web of Science-Core Collection. Examples of the medical subject headings (MeSH) applied include “Contract Services”, “Career Choice”, “Personnel Staffing and Scheduling”, “Personnel Loyalty” and “Physician Incentive Plans”. This initial search has since been followed by an updated search in October of 2023 prior to submission for publication. Keywords were used to collect non-indexed material and those terms not captured by MeSH, such as “locum”. No limits were applied to the searches. Articles not available in English were excluded. Secondary research (e.g., meta‐analyses, dissertations, systematic reviews, case reports, commentaries, grey literature) were excluded from the scholarly search. Reference lists of included studies were searched for additional articles. Details of the scholarly search strategy appear in Additional file 1 : Appendix S1. This search strategy was developed in collaboration with a librarian and peer-reviewed by a second librarian.

Between June 12th and July 16th, 2023 we performed an iterative systematic hand-search of grey literature. This included public search engines (e.g., Google), grey literature repositories (e.g., OpenGrey), health care quality organizations, and data facilities across five countries, Canada, United States of America, United Kingdom, Australia, and India. Examples of the search terms and headings applied include “Locum”, “Contract”, “Temporary”, and “Locum Physician''. Search parameters were restricted to include only articles published in the year 1990 or later. For database searches information beyond the first 150 or 250 search results were not incorporated in the analysis. For full search histories please see Additional file 1 : Appendix S3.

Selection and screening process

A modified version of the PICO (population, intervention, comparison, outcomes) framework was used (Table  1 ) [ 12 ]. We included original qualitative, quantitative or mixed-methods studies focused on recruitment and retention initiatives specific to locums in any country across clinical settings. There was variability in how studies defined locum physicians (Table  2 ). Articles focusing on recruitment and retention of non-locum physicians and healthcare workers without an MD designation (with the exception of medical students training in a MD programme) were excluded, including articles that combined both populations in which individual data for locums could not be extracted. Articles that exclusively incorporated the recruitment and retention of locums in the interpretive context such that locum recruitment and retention initiatives were not prospectively mentioned in the study framework or methodology were excluded.

Retrieved articles were managed using Covidence online systematic review software (Veritas Health Innovation, Melbourne, Australia). Two reviewers independently performed title and abstract screening for relevance. Full texts were then reviewed against eligibility criteria (Table  1 ). In both stages of screening, discussion was used to resolve disagreements. Remaining discrepancies were resolved by a third reviewer.

Data extraction and synthesis

Data extraction took place within Covidence using two independent reviewers. A template was developed and piloted for two studies to ensure reviewer agreement prior to utilization. Outstanding conflicts were resolved by a third author. Extraction parameters included study design, participant characteristics, context of locum assignment, and strategies used to recruit and retain locums. Two authors (NF and OM) performed an inductive content analysis to characterize recurring patterns of the locum recruitment and retention strategies discussed in each paper included in the systematic analysis. Following the identification of these strategies, they were grouped into broader, overarching themes relevant to LT recruitment and retention. Methodologic quality of each study was assessed using the Mixed Methods Appraisal Tool (MMAT) [ 13 ]; two authors (NF and OM) conducted the appraisal independently and any discrepancies in appraisal were resolved by discussion with a third author (EO). Authors of included studies were contacted if data were missing.

Our initial search identified 5390 citations. After the removal of duplicates ( n  = 812), 4578 studies’ titles and abstracts were screened. Following this stage, 242 articles were screened using full-text, and 230 were excluded from the review. Twelve studies [ 2 , 3 , 7 , 8 , 9 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ] fulfilled inclusion criteria and were retained for data extraction. The PRISMA flow diagram detailing the screening procedure is displayed in Fig.  1 . Articles reporting data from the same participant population at separate time points are reported together.

PRISMA flow diagram detailing the selection process

Study characteristics are summarized in Table  3 . Most ( n  = 11, 92%) studies [ 2 , 3 , 7 , 8 , 9 , 13 , 14 , 15 , 17 , 18 , 19 ] were published within the last 20 years of our search. Four (33%) studies [ 7 , 9 , 13 , 19 ] were from the United States and four (33%) [ 8 , 14 , 15 , 16 ] were from the United Kingdom. A smaller portion ( n  = 3, 25%) [ 2 , 3 , 17 ] originated in Canada. One (8%) study [ 18 ] was based in India. Quantitative studies [ 3 , 7 , 9 , 13 , 15 , 16 , 17 ] ( n  = 7, 58%) were cross-sectional ( n  = 6, 50%) [ 3 , 7 , 9 , 13 , 15 , 16 ] or pre–post study ( n  = 1, 8%) [ 17 ] in design. Four (33%) studies [ 8 , 14 , 18 , 19 ] used a qualitative design, including semi-structured interviews ( n  = 2, 17%) [ 18 , 19 ], focus groups ( n  = 1, 8%) [ 14 ], and content analysis ( n  = 1, 8%) [ 8 ]. One (8%) study [ 2 ] adopted a mixed-methods design.

The majority of studies [ 2 , 7 , 8 , 9 , 13 , 15 , 16 , 19 ] ( n  = 8, 67%) specified clinical setting, but did not indicate whether it was rural or urban (Table  3 ). A variety of specialities were reported among locum populations. The majority ( n  = 9, 75%) [ 2 , 3 , 7 , 13 , 14 , 15 , 16 , 18 , 19 ] included primary care physicians, and over half ( n  = 5, 42%) [ 7 , 9 , 13 , 18 , 19 ] included specialists. Three (25%) studies [ 7 , 13 , 19 ] reported a subspecialist population. Two (17%) studies [ 2 , 17 ] included physicians in training, with one (8%) [ 2 ] involving resident physicians and another (8%) [ 17 ] medical students. One (8%) study [ 8 ] did not indicate the specialty of the physician population. A total of six (50%) studies [ 7 , 13 , 14 , 15 , 16 , 19 ] reported years of physician practice experience.

A diversity of locum recruitment approaches were reported across studies, with some ( n  = 2, 17%) [ 7 , 8 ] using more than one method. Four (33%) studies [ 7 , 8 , 9 , 13 ] used a third-party recruitment agency, two (17%) [ 8 , 14 ] used a locum bank, word-of-mouth, or personal networks [ 16 ], informal means [ 7 ], and an unspecified novel recruitment software were each reported once [ 8 ] (8%). Four studies [ 2 , 15 , 18 , 19 ] (33%) did not report a specific method.

Quality assessment

The 2018 version of the MMAT was used to appraise the quality of retained articles [ 20 ]. Overall, nine (75%) of the articles [ 7 , 8 , 13 , 14 , 16 , 17 , 18 , 19 ] met 75–100% of the evaluated criteria, representing high quality. Three (25%) studies [ 2 , 9 , 15 ] met 50–75% of the evaluated criteria, representing moderate quality. Further details regarding the assessment of quality of retained articles appear in Additional file 1 : Appendix S2. Grey literature was assessed using the AACODS Checklist [ 21 ]. Additional information on the appraisal of grey literature can be found in Additional file 1 : Appendix S3 and in the supplemental content titled “Grey Literature Search Strategy, Data Extraction, and Evaluation”.

Facilitators of locum recruitment and retention

Six locum recruitment and retention themes were identified across retained studies (Table  4 ). Five overarching themes emerged for factors that facilitated LT recruitment and retention: financial incentives, familial considerations, educational or career-based factors, personal facilitators, and mentorship/clinical support. One theme focused on deterrents of locum work.

Ten (83%) studies [ 2 , 3 , 7 , 8 , 9 , 13 , 14 , 15 , 16 , 18 ] reported financial incentives with nine individual subthemes identified (Table  5 ). A significant portion ( n  = 4, 33%) of studies’ [ 2 , 14 , 15 , 16 ] did not provide specific details about the nature of the financial incentives provided. Four (33%) of the studies’ [ 2 , 7 , 8 , 13 ] financial incentives referred to an increase in income. Reimbursement for locum travel and lodging was reported three times (25%) [ 3 , 7 , 9 ]. Reimbursement for medical licensure ( n  = 2, 17%) and provision of malpractice insurance ( n  = 2, 17%) were also reported [ 7 , 9 ]. Augmented pay for challenging work conditions [ 18 ], payment assistance for continuing medical education (CME) [ 18 ], supplementation of retirement income [ 13 ], and guaranteed income [ 3 ] were all reported once (8%) each.

Three (25%) studies [ 2 , 7 , 14 ] reported familial considerations as facilitators to recruitment and retention which included accommodating family (17%) [ 2 , 14 ], school accessibility (8%) [ 14 ], and unspecified (8%) [ 7 ]. Furthermore, eight (67%) studies [ 2 , 3 , 7 , 8 , 13 , 14 , 16 , 17 ] reported education or career-based incentives. A total of 13 subthemes related to educational and career-based factors facilitating recruitment and retention were reported (Table  5 ), which included pre-permanent practice scouting [ 2 , 7 , 13 , 17 ] and temporary or transition in employment [ 2 , 7 , 13 , 16 ] both reported four (33%) times. Freedom from administrative responsibilities and transitioning into retirement were reported three (25%) times [ 7 , 13 , 16 ]. Avoiding commitment [ 2 , 16 ], increasing skills and competencies [ 2 , 8 ], and a desire to take on part-time employment [ 7 , 13 ] was reported twice (17%). The remaining career-based facilitators to recruitment and retention were each reported once (8%), including acquiring cross-provincial locum medical licensure [ 3 ], facilitation of hospital credentialing and medical licensure [ 7 ], gaining exposure to running a medical practice [ 2 ], accessing novel CME opportunities [ 3 ], assistance with maintaining medical knowledge [ 14 ], and accessing peer-facilitated educational support [ 14 ].

A total of eight (67%) studies [ 2 , 7 , 8 , 13 , 14 , 15 , 16 , 17 ] reported using personal factors as facilitators of LT recruitment and retention. Within this category, five subthemes were identified (see Table  5 ). Seven (58%) reported using flexible contracts (e.g., suitable availability, work schedule flexibility, and work–life balance) [ 2 , 7 , 8 , 13 , 14 , 15 , 16 ]. Having the ability to travel and experience new communities (locum tourism) was reported five (42%) times [ 2 , 7 , 13 , 16 , 17 ]. Three (25%) studies [ 7 , 14 , 15 ] reported unspecified personal incentives including stress relief [ 14 ], structured support [ 14 ], facility amenities [ 7 ], working conditions [ 7 ], personal safety [ 15 ], and overall facility quality [ 7 ]. Compatibility with post and convenience of the assignment were reported once (8%) each [ 8 ].

Four (33%) studies [ 14 , 15 , 16 , 19 ] reported recruitment and retention facilitators involving mentorship and clinical support with four subthemes. Having a network of supportive colleagues [ 14 , 15 ] and a chance to become familiar with the practice before arrival [ 16 , 19 ] were reported twice (17%) each. Intentional relationship building, whereby the seasoned colleague met with the incoming locum to ensure comfort in the practice was reported once (8%) [ 19 ]. Availability of a back-up physician for support was reported once (8%) [ 19 ].

A total of eight (67%) studies [ 2 , 8 , 9 , 14 , 16 , 17 , 18 , 19 ] addressed deterrents of or barriers to locum work, encompassing a total of 19 reported subthemes. Professional isolation ( n  = 5, 42%) [ 2 , 8 , 14 , 18 , 19 ] was reported most frequently followed by work unpredictability (33%) [ 2 , 8 , 16 , 19 ]. Insufficient patient continuity of care was reported three (25%) times [ 2 , 8 , 16 ]. The following deterrents/barriers were each reported twice (17%): inadequate employee onboarding and orientation [ 8 , 19 ], demanding locum work [ 2 , 17 ], poor job security [ 16 , 18 ], lack of information to make an informed decision about accepting the job post [ 8 , 9 ], and a lack of career advancement [ 16 , 18 ]. The following deterrents/barriers were reported just once (8%): excessive travelling [ 16 ], low patient volume [ 2 ], administrative burden [ 18 ], difficulty accessing time-off [ 18 ], inadequate housing [ 18 ], challenging working conditions [ 18 ], exclusion from pension plans [ 16 ], lack of equitable pay [ 18 ], low salary [ 18 ], feeling distanced from CME and limitations in staying up-to-date [ 14 ], and perceptions of inferior professional status by colleagues [ 16 ].

Facilitators of locum recruitment and retention within grey literature

Grey literature findings closely mirrored the facilitators and deterrents found in peer-reviewed literature. A notable exception captured in the ‘education and career’ theme involved the potential benefits of implementing a national physician licensure, which was absent in the primary literature but present in nearly a third ( n  = 27, 26%) of the grey literature.

Interpretation

We identified 12 English language studies that explored the recruitment and retention of locums in Canada, USA, UK, and India over a 30-year period. Finance, education, and personal factors were the most used LT recruitment strategies while family considerations and clinical/mentorship support were less frequently cited. However, almost all studies [ 2 , 3 , 7 , 8 , 13 , 14 , 15 , 16 ] ( n  = 8, 67%) reviewed reported using a combination of these recruitment approaches. While there is a paucity of evidence on whether employing multiple approaches leads to improved LT recruitment, utilizing a range of methods may still be a reasonable strategy. This approach prevents organizations from becoming overly reliant on a single approach and enables them to adapt their strategy more easily as required to maintain LT recruitment, retention and service. Further, as physicians choose locum positions based on different priorities, utilizing multiple strategies provides a range of incentives with wider appeal.

Across the five LT recruitment strategies, the diverse range of unique approaches used indicates there is no one-size-fits-all method. This suggests that organizations develop their own specific approach tailored to their available resources, location, and the anticipated needs of the LT physicians they aim to recruit. For instance, certain recruitment strategies incentives such as back-up availability, network of supportive colleagues and access to CME may not be feasible for some organizations given their size, location, and resource constraints. This may lead to the development of alternative recruitment approaches and/or increased emphasis on other strategies. Notably, we found that common recruitment and retention strategies used elsewhere, such as providing competitive salaries, were extensively used in the recruitment and retention of locums. However, approaches that seem to be specifically designed to address the unique requirements and preferences of locum physicians were also employed, such as offering reimbursements for travel and accommodation, providing support for family-related needs, offering flexible scheduling, and facilitating access to leisure activities. Although the effectiveness of these strategies is poorly defined, their implementation suggests that organizations recognize that conventional recruitment and retention approaches, effective in the broader health workforce, may not adequately address the unique aspects and challenges associated with the transient and temporary nature of locum work. For example, incentives like competitive compensation, while valued, might not be as appealing to those seeking the flexibility of short-term work assignments or lifestyle benefits. Therefore, acknowledging the appeal of locum work, creating incentives that emphasize these benefits, and addressing the related challenges are likely to enhance recruitment and retention efforts.

The finding that showed sites employed a wide range of recruitment and retention approaches highlights the complexity of this process. However, implementing such a wide range of strategies makes it challenging to identify the most effectives. Consequently, future work should identify optimal recruitment strategies within diverse health contexts and organizational structures. This would enable organizations to streamline their approach, maximizing recruitment success while efficiently utilizing their resources. This may be particularly valuable in resource poor healthcare environments where strategic asset allocation is essential.

Numerous factors were cited as deterrents of locum work, indicating that physicians’ decision to work as a LT is influenced by a variety of considerations. Although some of the cited deterrents were addressed by recruitment strategies, it is unclear whether these approaches were effective. In the studies reviewed, professional isolation and work assignment predictability were the two most cited deterrents to locum work appearing in 42% and 33% of studies, respectively. As temporary workers, there are inherent challenges in developing rapport with colleagues. Moreover, providing coverage introduces uncertainties regarding work schedules and conditions (e.g., hours worked, frequency and duration of assignments). Together these factors can contribute to lower job satisfaction, which may result in a decreased willingness to work as a locum. As a result, recruitment strategies should consider measures to address these deterrents. The wide range of deterrents emphasizes the importance for healthcare organizations to adopt comprehensive recruitment strategies that recognize and respond to the various unique needs of LT physicians. Further, many of these deterrents may be addressed by improving locum onboarding and job conditions, such as enhancing infrastructure quality and minimizing social isolation.

It is important to recognize information on locum recruitment and retention extends beyond peer-reviewed articles to include the grey literature. These non-academic resources contain potential insights into practical approaches for recruitment and retention, thus underscoring the need to evaluate the grey literature in this field. Interestingly, our review of the grey literature generally aligns with the facilitators and deterrents of locum work identified in this systematic review apart from support for a national physician license. Such a measure would enhance the portability of licensure, allowing improved mobility of physicians across regions, reducing administrative burdens and the time required for obtaining proper licensing, hospital privileges, and contractual agreements. This, in turn, may reduce barriers to locum recruitment and more effectively facilitate the transition of locums to their temporary place of practice. This finding, which was not identified in the systematic review, again reiterates the importance of assessing the grey literature to gain a comprehensive understanding on the current strategies being used for recruiting and retaining locum physicians.

Importantly, the success of LT physician recruitment relies on a collaborative effort that extends beyond responsibility of individual healthcare organizations. This is particularly important considering that facilitators of LT recruitment and retainment, such as remuneration, fall beyond the scope of health teams. Therefore, the various stakeholders in health human resources, including educational institutions, regulatory bodies, and professional associations, all play a role in LT recruitment efforts. Recognizing and embracing this shared responsibility will be crucial in fostering a robust and sustainable healthcare workforce that incorporates LT physicians.

Limitations

In the systematic and grey literature reviews, a comprehensive set of keywords related to locum recruitment and retention were used (as detailed in Additional file 1 : Appendices S1 and S3). However, some search terms, such as region-specific terminology used to describe locums, were not included. As a result, it is possible that relevant resources may have been missed during the literature search. However, the use of diverse keywords related to locum recruitment and retention would have captured relevant studies thus reducing the likelihood that relevant resources were missed. As described in the literature search strategies, date limitations were applied to both the systematic and grey literature searches, and only select databases were searched. Therefore, there is a possibility that relevant publications or grey literature produced outside of these date ranges or databases might have been missed. The quality of synthesized evidence was moderate as most of the retained quantitative studies were cross-sectional [ 3 , 7 , 9 , 13 , 15 , 16 ] (50%) or mixed-methods [ 2 ] (8%). Only one study adopted a pre–post study design [ 17 ], which is fraught with internal validity issues. Remaining studies [ 8 , 14 , 18 , 19 ] were qualitative and not inherently generalizable to broad populations. None of the studies were intervention-based, making it difficult to draw conclusions about the effectiveness of various recruitment and retention strategies. Inconsistent reporting on locum (LT) gender limited conclusions regarding differences in motivations for LT practice. Geographies of included studies reported were likely influenced by the methodological choice to include English only articles, limiting the generalizability of the presented findings to other regions. Further, the mix of qualitative and quantitative sources make it challenging to comprehend the cumulative size of the physician population raising each issue, and the relative significance of each issue compared to others.

Conclusions

This systematic review synthesized existing knowledge pertaining to international locum physician recruitment and retention strategies. Locum physicians are essential to the delivery of quality healthcare services across Canada and other parts of the world. We demonstrate that organizations employ five main LT recruitment strategies and deploy these in a variety of ways. Though these may be incumbent on local resources, more concerning is that the effectiveness of these approaches has not been tested. Given the present financial challenges within the global healthcare landscape there is a need to better understand recruitment and retention strategies of LTs so this limited resource can be used most effectively. Findings merit future research into the effectiveness of LT recruitment approaches via prospective methodologies.

Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary information files].

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Acknowledgements

We gratefully acknowledge the help of Jennifer Dumond, Education Services Librarian at NOSM University, for peer-reviewing the search strategy.

Supported by Northern Ontario Academic Medicine Association (NOAMA) Academic Funding Plan (AFP) Innovation Fund Project #A-22-07.

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N.F and O.M were responsible for experimental design, the acquisition, analysis, interpretation of data and writing of the manuscript. A.C was responsible for acquisition, analysis, interpretation of data. I.R.L was responsible for interpretation of data, and the writing and revising of the manuscript. L.D and E.O were responsible for conception and experimental design, data analysis, data interpretation and revising the manuscript. All authors approve of the final version of the manuscript and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All persons designated as authors qualify for authorship, and all those who qualify for authorship are listed.

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Additional file 1. appendix s1.

: Search Strategy. Appendix S2 : Mixed-methods Appraisal Tool (MMAT) quality assessment of included studies. Appendix S3 : Grey Literature Search Strategy, Data Extraction, and Evaluation.

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Ferreira, N., McKenna, O., Lamb, I.R. et al. Approaches to locum physician recruitment and retention: a systematic review. Hum Resour Health 22 , 24 (2024). https://doi.org/10.1186/s12960-024-00906-z

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Ten Simple Rules for Writing a Literature Review

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Affiliations Centre for Functional and Evolutionary Ecology (CEFE), CNRS, Montpellier, France, Centre for Biodiversity Synthesis and Analysis (CESAB), FRB, Aix-en-Provence, France

• Marco Pautasso

Published: July 18, 2013

• https://doi.org/10.1371/journal.pcbi.1003149
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Citation: Pautasso M (2013) Ten Simple Rules for Writing a Literature Review. PLoS Comput Biol 9(7): e1003149. https://doi.org/10.1371/journal.pcbi.1003149

Editor: Philip E. Bourne, University of California San Diego, United States of America

Copyright: © 2013 Marco Pautasso. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: This work was funded by the French Foundation for Research on Biodiversity (FRB) through its Centre for Synthesis and Analysis of Biodiversity data (CESAB), as part of the NETSEED research project. The funders had no role in the preparation of the manuscript.

Competing interests: The author has declared that no competing interests exist.

Literature reviews are in great demand in most scientific fields. Their need stems from the ever-increasing output of scientific publications [1] . For example, compared to 1991, in 2008 three, eight, and forty times more papers were indexed in Web of Science on malaria, obesity, and biodiversity, respectively [2] . Given such mountains of papers, scientists cannot be expected to examine in detail every single new paper relevant to their interests [3] . Thus, it is both advantageous and necessary to rely on regular summaries of the recent literature. Although recognition for scientists mainly comes from primary research, timely literature reviews can lead to new synthetic insights and are often widely read [4] . For such summaries to be useful, however, they need to be compiled in a professional way [5] .

When starting from scratch, reviewing the literature can require a titanic amount of work. That is why researchers who have spent their career working on a certain research issue are in a perfect position to review that literature. Some graduate schools are now offering courses in reviewing the literature, given that most research students start their project by producing an overview of what has already been done on their research issue [6] . However, it is likely that most scientists have not thought in detail about how to approach and carry out a literature review.

Reviewing the literature requires the ability to juggle multiple tasks, from finding and evaluating relevant material to synthesising information from various sources, from critical thinking to paraphrasing, evaluating, and citation skills [7] . In this contribution, I share ten simple rules I learned working on about 25 literature reviews as a PhD and postdoctoral student. Ideas and insights also come from discussions with coauthors and colleagues, as well as feedback from reviewers and editors.

Rule 1: Define a Topic and Audience

How to choose which topic to review? There are so many issues in contemporary science that you could spend a lifetime of attending conferences and reading the literature just pondering what to review. On the one hand, if you take several years to choose, several other people may have had the same idea in the meantime. On the other hand, only a well-considered topic is likely to lead to a brilliant literature review [8] . The topic must at least be:

• interesting to you (ideally, you should have come across a series of recent papers related to your line of work that call for a critical summary),
• an important aspect of the field (so that many readers will be interested in the review and there will be enough material to write it), and
• a well-defined issue (otherwise you could potentially include thousands of publications, which would make the review unhelpful).

Ideas for potential reviews may come from papers providing lists of key research questions to be answered [9] , but also from serendipitous moments during desultory reading and discussions. In addition to choosing your topic, you should also select a target audience. In many cases, the topic (e.g., web services in computational biology) will automatically define an audience (e.g., computational biologists), but that same topic may also be of interest to neighbouring fields (e.g., computer science, biology, etc.).

Rule 2: Search and Re-search the Literature

After having chosen your topic and audience, start by checking the literature and downloading relevant papers. Five pieces of advice here:

• keep track of the search items you use (so that your search can be replicated [10] ),
• keep a list of papers whose pdfs you cannot access immediately (so as to retrieve them later with alternative strategies),
• use a paper management system (e.g., Mendeley, Papers, Qiqqa, Sente),
• define early in the process some criteria for exclusion of irrelevant papers (these criteria can then be described in the review to help define its scope), and
• do not just look for research papers in the area you wish to review, but also seek previous reviews.

The chances are high that someone will already have published a literature review ( Figure 1 ), if not exactly on the issue you are planning to tackle, at least on a related topic. If there are already a few or several reviews of the literature on your issue, my advice is not to give up, but to carry on with your own literature review,

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The bottom-right situation (many literature reviews but few research papers) is not just a theoretical situation; it applies, for example, to the study of the impacts of climate change on plant diseases, where there appear to be more literature reviews than research studies [33] .

https://doi.org/10.1371/journal.pcbi.1003149.g001

• discussing in your review the approaches, limitations, and conclusions of past reviews,
• trying to find a new angle that has not been covered adequately in the previous reviews, and
• incorporating new material that has inevitably accumulated since their appearance.

When searching the literature for pertinent papers and reviews, the usual rules apply:

• be thorough,
• use different keywords and database sources (e.g., DBLP, Google Scholar, ISI Proceedings, JSTOR Search, Medline, Scopus, Web of Science), and
• look at who has cited past relevant papers and book chapters.

Rule 3: Take Notes While Reading

If you read the papers first, and only afterwards start writing the review, you will need a very good memory to remember who wrote what, and what your impressions and associations were while reading each single paper. My advice is, while reading, to start writing down interesting pieces of information, insights about how to organize the review, and thoughts on what to write. This way, by the time you have read the literature you selected, you will already have a rough draft of the review.

Of course, this draft will still need much rewriting, restructuring, and rethinking to obtain a text with a coherent argument [11] , but you will have avoided the danger posed by staring at a blank document. Be careful when taking notes to use quotation marks if you are provisionally copying verbatim from the literature. It is advisable then to reformulate such quotes with your own words in the final draft. It is important to be careful in noting the references already at this stage, so as to avoid misattributions. Using referencing software from the very beginning of your endeavour will save you time.

Rule 4: Choose the Type of Review You Wish to Write

After having taken notes while reading the literature, you will have a rough idea of the amount of material available for the review. This is probably a good time to decide whether to go for a mini- or a full review. Some journals are now favouring the publication of rather short reviews focusing on the last few years, with a limit on the number of words and citations. A mini-review is not necessarily a minor review: it may well attract more attention from busy readers, although it will inevitably simplify some issues and leave out some relevant material due to space limitations. A full review will have the advantage of more freedom to cover in detail the complexities of a particular scientific development, but may then be left in the pile of the very important papers “to be read” by readers with little time to spare for major monographs.

There is probably a continuum between mini- and full reviews. The same point applies to the dichotomy of descriptive vs. integrative reviews. While descriptive reviews focus on the methodology, findings, and interpretation of each reviewed study, integrative reviews attempt to find common ideas and concepts from the reviewed material [12] . A similar distinction exists between narrative and systematic reviews: while narrative reviews are qualitative, systematic reviews attempt to test a hypothesis based on the published evidence, which is gathered using a predefined protocol to reduce bias [13] , [14] . When systematic reviews analyse quantitative results in a quantitative way, they become meta-analyses. The choice between different review types will have to be made on a case-by-case basis, depending not just on the nature of the material found and the preferences of the target journal(s), but also on the time available to write the review and the number of coauthors [15] .

Rule 5: Keep the Review Focused, but Make It of Broad Interest

Whether your plan is to write a mini- or a full review, it is good advice to keep it focused 16 , 17 . Including material just for the sake of it can easily lead to reviews that are trying to do too many things at once. The need to keep a review focused can be problematic for interdisciplinary reviews, where the aim is to bridge the gap between fields [18] . If you are writing a review on, for example, how epidemiological approaches are used in modelling the spread of ideas, you may be inclined to include material from both parent fields, epidemiology and the study of cultural diffusion. This may be necessary to some extent, but in this case a focused review would only deal in detail with those studies at the interface between epidemiology and the spread of ideas.

While focus is an important feature of a successful review, this requirement has to be balanced with the need to make the review relevant to a broad audience. This square may be circled by discussing the wider implications of the reviewed topic for other disciplines.

Rule 6: Be Critical and Consistent

Reviewing the literature is not stamp collecting. A good review does not just summarize the literature, but discusses it critically, identifies methodological problems, and points out research gaps [19] . After having read a review of the literature, a reader should have a rough idea of:

• the major achievements in the reviewed field,
• the main areas of debate, and
• the outstanding research questions.

It is challenging to achieve a successful review on all these fronts. A solution can be to involve a set of complementary coauthors: some people are excellent at mapping what has been achieved, some others are very good at identifying dark clouds on the horizon, and some have instead a knack at predicting where solutions are going to come from. If your journal club has exactly this sort of team, then you should definitely write a review of the literature! In addition to critical thinking, a literature review needs consistency, for example in the choice of passive vs. active voice and present vs. past tense.

Rule 7: Find a Logical Structure

Like a well-baked cake, a good review has a number of telling features: it is worth the reader's time, timely, systematic, well written, focused, and critical. It also needs a good structure. With reviews, the usual subdivision of research papers into introduction, methods, results, and discussion does not work or is rarely used. However, a general introduction of the context and, toward the end, a recapitulation of the main points covered and take-home messages make sense also in the case of reviews. For systematic reviews, there is a trend towards including information about how the literature was searched (database, keywords, time limits) [20] .

How can you organize the flow of the main body of the review so that the reader will be drawn into and guided through it? It is generally helpful to draw a conceptual scheme of the review, e.g., with mind-mapping techniques. Such diagrams can help recognize a logical way to order and link the various sections of a review [21] . This is the case not just at the writing stage, but also for readers if the diagram is included in the review as a figure. A careful selection of diagrams and figures relevant to the reviewed topic can be very helpful to structure the text too [22] .

Rule 8: Make Use of Feedback

Reviews of the literature are normally peer-reviewed in the same way as research papers, and rightly so [23] . As a rule, incorporating feedback from reviewers greatly helps improve a review draft. Having read the review with a fresh mind, reviewers may spot inaccuracies, inconsistencies, and ambiguities that had not been noticed by the writers due to rereading the typescript too many times. It is however advisable to reread the draft one more time before submission, as a last-minute correction of typos, leaps, and muddled sentences may enable the reviewers to focus on providing advice on the content rather than the form.

Feedback is vital to writing a good review, and should be sought from a variety of colleagues, so as to obtain a diversity of views on the draft. This may lead in some cases to conflicting views on the merits of the paper, and on how to improve it, but such a situation is better than the absence of feedback. A diversity of feedback perspectives on a literature review can help identify where the consensus view stands in the landscape of the current scientific understanding of an issue [24] .

Rule 9: Include Your Own Relevant Research, but Be Objective

In many cases, reviewers of the literature will have published studies relevant to the review they are writing. This could create a conflict of interest: how can reviewers report objectively on their own work [25] ? Some scientists may be overly enthusiastic about what they have published, and thus risk giving too much importance to their own findings in the review. However, bias could also occur in the other direction: some scientists may be unduly dismissive of their own achievements, so that they will tend to downplay their contribution (if any) to a field when reviewing it.

In general, a review of the literature should neither be a public relations brochure nor an exercise in competitive self-denial. If a reviewer is up to the job of producing a well-organized and methodical review, which flows well and provides a service to the readership, then it should be possible to be objective in reviewing one's own relevant findings. In reviews written by multiple authors, this may be achieved by assigning the review of the results of a coauthor to different coauthors.

Rule 10: Be Up-to-Date, but Do Not Forget Older Studies

Given the progressive acceleration in the publication of scientific papers, today's reviews of the literature need awareness not just of the overall direction and achievements of a field of inquiry, but also of the latest studies, so as not to become out-of-date before they have been published. Ideally, a literature review should not identify as a major research gap an issue that has just been addressed in a series of papers in press (the same applies, of course, to older, overlooked studies (“sleeping beauties” [26] )). This implies that literature reviewers would do well to keep an eye on electronic lists of papers in press, given that it can take months before these appear in scientific databases. Some reviews declare that they have scanned the literature up to a certain point in time, but given that peer review can be a rather lengthy process, a full search for newly appeared literature at the revision stage may be worthwhile. Assessing the contribution of papers that have just appeared is particularly challenging, because there is little perspective with which to gauge their significance and impact on further research and society.

Inevitably, new papers on the reviewed topic (including independently written literature reviews) will appear from all quarters after the review has been published, so that there may soon be the need for an updated review. But this is the nature of science [27] – [32] . I wish everybody good luck with writing a review of the literature.

Acknowledgments

Many thanks to M. Barbosa, K. Dehnen-Schmutz, T. Döring, D. Fontaneto, M. Garbelotto, O. Holdenrieder, M. Jeger, D. Lonsdale, A. MacLeod, P. Mills, M. Moslonka-Lefebvre, G. Stancanelli, P. Weisberg, and X. Xu for insights and discussions, and to P. Bourne, T. Matoni, and D. Smith for helpful comments on a previous draft.

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